NFHS-5

‘Subsidised Food Canteens Create Democratic Spaces in Deeply Divided Societies’

The Public Distribution System needs to diversify the food basket it provides, and expand coverage to account for the population increase since 2011, says economist Reetika Khera.

Bengaluru: In 2021, three in four people in India could not afford a healthy diet. In South Asia, the pandemic disrupted work and disproportionately impacted poorer families.

Following the pandemic in 2020, the Indira Rasoi Yojana [now called Shree Annapurna Rasoi Yojana] was started by the Congress-led government in Rajasthan to provide subsidised nutritious meals for the urban poor. This was similar to earlier initiatives in Tamil Nadu, Odisha and Karnataka.

Reetika Khera, economist and faculty at the Indian Institute of Technology Delhi, said that “canteens have fostered the creation of democratic spaces” in societies divided along caste and class lines. One of the biggest shortcomings of the National Food Security Act (NFSA), 2013 is that it did not include a provision for community kitchens or canteens which provide heavily subsidised hot, cooked food, especially in urban areas.

Immediately after the pandemic-induced lockdown, Khera (along with Jean Drèze and Meghana Mungikar) had highlighted the exclusion of 100 million people from the government’s subsidised food grain programme which has more than 800 million beneficiaries. It is exacerbated by the indefinite delay in the population Census 2021, she said.

As India votes for the 18th Lok Sabha, we speak with Khera on various social security schemes including maternity entitlements, healthcare, food-related welfare like community kitchens, which are important in the context of the decline in real wages.

Edited excerpts:

The government’s One Nation One Ration Card (ONORC) scheme, which was expected to improve foodgrain access to migrants, is mostly limited to Delhi NCR. You have talked about community kitchens, their potential in providing nutritious food, and how they alleviate women’s workload in households. How can it support migrant households at a time when there is concern about real wages? Could you share more details based on your research, and the impact it can have in urban areas?

One of the biggest shortcomings of the NFSA as passed in 2013 is that it did not include a provision for ‘community kitchens’ or canteens. Many states have been experimenting with these over time. Canteens provide heavily subsidised hot cooked food especially in urban areas.

Amma’s canteens in Tamil Nadu were the first “on scale” initiative and were set up in 2013 (there have been such initiatives even before that). After this, Indira canteens were set up in Karnataka. Most recently, and perhaps overtaking these two states in terms of scale, was Rajasthan’s Indira Rasoi scheme that began in 2020 in response to the humanitarian crisis created by the Covid-19 lockdown. In November 2023, there were more than 1,100 Indira Rasois in Rajasthan. These canteens provide breakfast/lunch and dinner at Rs 3 to Rs 8 per plate.

In our recent survey in six cities of Rajasthan and three each in Karnataka and Tamil Nadu, we were struck by the wide range of guests at the canteens.

Canteens have fostered the creation of democratic spaces in deeply divided (on caste and class lines) societies. One of the most remarkable was a canteen near a hospital in Jaipur where we saw patients, doctors, lab technicians and cleaning staff among others, eating in the same place. It was quite a moving sight. For some elderly and single persons, canteens have become a welcome daily outing.

On a Sunday in Chennai, I was touched when several men who were having breakfast at the Amma’s unavagams [canteen] said that they were eating there even though they have kitchens at home because they didn’t want to trouble their working wives for breakfast on her weekly holiday. In a few canteens, we also met housewives at lunch time. Canteens are creating opportunities for paid work for women. In Tamil Nadu, the entire team is only women. (Though Odisha’s canteen scheme Aahaar is much smaller in scale, there too, all canteens are run by women’s self-help groups, Mission Shakti.)

For many migrant workers, with or without cooking facilities, there is little ONORC can do that canteens cannot. Many working professionals, mostly men, appreciated the canteens because as migrants living alone in the city, their accommodation did not always have cooking facilities, and even when they do, they often don’t have time.

Across states, many regular guests of canteens across the three states appreciated that the food was like home-cooked food, something they could eat on a daily basis. Monetary savings add up to quite a lot. Most respondents reported incomes between Rs 10,000 and Rs 18,000 per month. A conservative estimate suggests that for those relying on canteens for even one meal per day regularly, monthly savings would be 5% to 10% of their salaries.

Experts have pointed out that the new household consumption survey expenditure is not comparable with the previous ones due to changes in the methodology. But considering the reported reduction in real wages, households would ideally be spending a larger proportion on food. How do you explain the reduction in percentage of expenditure on food to 46.4% per month compared to more than half in rural areas in the previous surveys?

The share of food expenditure in total expenditure is the ratio of absolute expenditure on food (numerator) divided by total expenditure (denominator). For the ratio to decline, either the denominator has to increase or the numerator has to decrease. Or both.

However, absolute food expenditure is the product of food quantity consumed and their prices. A decrease in food quantities or prices can lead to a reduction in absolute food expenditure. (For example, if prices rise and people respond by reducing their intake, absolute food expenditure can decline.) If this is the case, then a decline in the share of food expenditure in total is not necessarily a good thing.

I suspect that when people see that food expenditure share has declined, they are assuming that prices have fallen, but they are not accounting for the possibility that a decline in quantity may be behind the observed decline of food share in total expenditure. It would have been far more informative to have information on quantities and prices.

I am unable to understand why the government released the NSS (National Sample Survey) consumption expenditure data selectively. Why not share the raw/granular data using which these summaries were prepared?

Also read: ‘Growth in Real Wages Virtually Zero Under Modi Government’: Data

Three in four Indians could not afford a healthy diet in 2021. In March 2019, the Supreme Court said that nearly 80 million unorganised workers and migrants who did not have ration cards must be provided one. You, along with Drèze and Mungikar, had calculated the exclusion of 100 million people due to the outdated Census 2011 on which the government relies for the PDS. The government’s Pradhan Mantri Garib Kalyan Anna Yojana now provides priority households with only 5 kg of foodgrains under the PDS, but at no cost [a change from the Rs 2 or Rs 3 per kg for rice and wheat]. What are the present challenges in terms of food security and allocation for households. Does the PDS need to be revamped to include more nutritious food options?

For years, even during the discussions on the NFSA, we have been raising the issue of lack of diversity of food items provided through the PDS. The inclusion of dals and oil is important, as well as diversification out of wheat and rice into millets such as ragi, bajra, etc. In some states, there has been progress on both fronts; for example, Karnataka and Odisha have been giving some ragi (it is not clear how regularly) through the PDS. In Tamil Nadu and Himachal Pradesh, dals and oil have been provided for years, but we have not seen any move from the Union government to learn from these state-level initiatives. (Interestingly, the Congress party has promised to add dal and oil to the PDS in its 2024 election manifesto.)

Besides these older issues, we now have the problem of the exclusion of over 100 million people from the PDS because a fresh census in 2021 did not happen. Both these aspects – diversity of food basket provided through the PDS and expansion of coverage to account for the population increase since 2011 – need to be remedied urgently.

Your survey and research on health centres in Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand and Rajasthan show that the pace of improvement is slow. Your analysis said, “Both NRHM and Ayushman Bharat can be seen as a useful but very limited demonstration of the possibility of improving PHCs.” What are the significant gaps in primary healthcare infrastructure, and what investment must be made to improve primary healthcare access in less developed states?

The usage of public health facilities is much higher than what is popularly believed, and it has been rising in most states. According to NFHS, the proportion of households that report using a public health facility when they are sick has risen from 34% (in 2005-06) to 45% (2015-16) and to 50% in the latest round (2019-21). States like Himachal Pradesh have remained above 80% throughout this period. The most remarkable increase is recorded in Chhattisgarh where it has doubled (from 36% in 2005-06 to 69% in 2019-21).

However, the health services that they get are uncertain (the nurse or doctor, the medicines and tests they need may or may not be available) and remain quite basic when available. Though this did not reflect in the numbers in our survey, my sense was that the appointment of more nurses at the sub-centre has been helpful in bringing very basic health services to people (e.g., for small wounds, cold-cough and fevers, diarrhoea and headaches).

Unfortunately, this [Union] government tends to get too caught up in branding/ rebranding exercises, and that wastes resources everywhere. For instance, sub-centres that were “upgraded” to “Health and Wellness Centres” after 2019 are now to be rebranded as “Ayushman Aarogya Mandirs”. A recent report suggested that funds for Kerala were delayed because the state refused to comply (for linguistic reasons) with rebranding norms issued by the Union government.

You and Drèze analysed the government’s maternity entitlements scheme, Pradhan Mantri Matru Vandana Yojana (PMMVY) and found that it has “gone into reverse gear”. You also mention challenges in accessing data for the scheme. Is the PMMVY particularly concerning in some states? How adequately has the government allocated resources for welfare schemes like PMMVY?

An overarching issue with cash-based entitlements is that they lose value over time because governments do not have a mechanism in place for indexation or ensuring an increase in real terms. The central contribution to some social security pensions has not increased since 2006; it is Rs 200 per month even today. (Again, the Congress manifesto promises to increase the Union government’s contribution to Rs 1000; the BJP manifesto is silent on this.)

As per the NFSA, maternity entitlements were supposed to be Rs 6,000 per pregnancy. When the scheme was operationalised in 2017, using warped logic, the government reduced it to Rs 5,000 and limited it to the first child only. (That restriction has been partially relaxed recently.)

Today, more than 10 years later, the amount remains stuck at Rs 5,000 and Rs 6,000. [In] some states with a better track record on social policy issues, things are somewhat better – Tamil Nadu has Dr Muthulakshmi Reddy scheme for maternity entitlements that provides Rs 18,000 per child. Even in such states, the problem of stagnation of cash benefits remains. In 2021, the manifesto of the Dravida Munnetra Kazhagam promised to increase maternity entitlements to Rs 24,000, but as far as I am aware, this has not been done.

Coming back to PMMVY, the central scheme, it has remained underfunded from day 1. The extent of underfunding is depicted in the accompanying chart – the horizontal line on top is an estimate of the budget that would be required for full coverage and the line at the bottom shows you the actual budget.

If we use the ‘wage compensation’ principle to fix maternity entitlements (as is done for women in the formal sector), then at Rs 400 per day for six months, the PMMVY amount would be Rs 72,000 per pregnancy.

When an entitlement is supposed to be universal but adequate funds are not made available, the government uses (hidden) rationing mechanisms to manage the situation: Aadhaar and the Aadhaar-enabled payments system serve this purpose.

Aadhaar is compulsory for PMMVY. On top of that, women are told to correct/update their demographic details on their Aadhaar cards: Their Aadhaar should have their in-laws’ address (not of their natal village); or “w/o” (wife of) rather than “d/o” (daughter of) on their Aadhaar card. Maternity entitlements are supposed to make their lives easier during pregnancy; they end up giving women a runaround for a token amount that is losing value over time.

The combined result of under-funding and this rationing system is that in 2021-22, less than half of all eligible women actually got their maternity benefits.

At 93 million, the total number of people who demanded MGNREGA work in 2023 was similar to 2019, before the pandemic. The household demand was 6% higher in 2023. Further, in 2023-24, at 59%, women persondays generated in MGNREGA was the highest in a decade. What does the reduced demand for MGNREGA, and more women persondays, indicate in terms of employment and the rural economy?

I do not believe that the “employment demanded” figures on the MGNREGA website are reliable. When the Act was passed, awareness among workers about their right to demand work was poor. The norm was for Gram Panchayats and other implementing agencies to open worksites when budgets were available. In small pockets where there were local workers unions, work was being demanded but there were difficulties in getting either a dated receipt or getting work within 15 days, the time-frame stipulated by the Act.

Under pressure from such groups, the employment demanded feature was introduced in NREGASoft, the MIS for MGNREGA. It became compulsory to first enter demand everywhere – even in areas where work was being provided proactively without anyone demanding it. The right to demand work under MGNREGA became a ‘responsibility’.

MGNREGA functionaries reacted to the new ‘work demand’ module in the MIS by entering the work demanded once work had begun in their village. This protected them from having to pay an unemployment allowance (that kicks in if work is not provided within 15 days of demand). Such retrospective data entry practices render this module of the MGNREGA MIS unreliable.

If demand for MGNREGA work is depressed, the most plausible explanation is that MGNREGA wages are not only below market rates but also below wages for agricultural workers (generally the least paid category of workers) in most states. Recently in rural Barmer, I learnt that for harvesting operations on private land, the wage rate for agricultural labour was Rs 500 per day and on MGNREGA, de facto they get only Rs 250 per day.

If you add the hassles and delays MGNREGA workers face to get paid once they have worked, you can see why they may not want to rely on it.

For women, the story is a bit different: MGNREGA has always been an attractive option for them, because it allows them to combine their household responsibilities with some paid work. It is rare for them to find other forms of paid work outside the house that would allow them to do so. In any case, opportunities for paid work outside the house are not easy to come by.

I believe that if MGNREGA is implemented in spirit – that means, if work is provided close to home, timely payments are assured, etc. – the demand for MGNREGA work and budgets would be much higher than we have seen.

This article was originally published on IndiaSpend.

Govt Accepts Resignation of Scapegoated IIPS Director After Revoking His Suspension for Unflattering NFHS Data

With K.S. James gone, International Institute of Population Sciences faculty say the credibility of upcoming NFHS rounds may go for a toss and the data may not be considered fully reliable. NFHS is a large-scale data collection exercise IIPS conducts for all states/UTs regarding various health and some development indicators and helps track the impact of targeted schemes launched to address them.

New Delhi: The Union health and family welfare ministry has accepted the resignation of K.S. James as the director of the International Institute of Population Sciences (IIPS), which is responsible for preparing the National Family Health Survey (NFHS).

The health ministry had suspended James on July 28, 2023, apparently because it was ‘unhappy with data sets’ in NFHS-5. His suspension was formally revoked last week, only for his resignation – submitted in August – to be accepted hours later.

Copies of the orders revoking his suspension and accepting the resignation are available with The Wire.

“The competent authority, on subsequent review, is of the opinion that in view of material changes in the circumstances, the suspension of Prof. K. S. James may not be extended further,” said the order of the Union health ministry dated October 11, 2023.

Earlier, in July, following his suspension, the ministry had released an unsigned and undated note to the media which claimed that a fact-finding committee found merit, prima facie, in 11 out of 35 complaints allegedly received against James.

“The irregularities were mainly regarding [the] lapses observed in certain appointments, recruitments of faculty, Reservation Roasters, Dead Stock registers, etc. (sic),” it had said.

Even in the note, the ministry did not clarify for what charges the committee found prima facie merit or when the complaints against James were received.

Also Read: Govt Note Cites ‘Charges’ Against IIPS Head, Insiders Say He Was Already Facing Flak For ‘Unflattering’ Data

The report of the fact-finding committee was never made public.

An unnamed source, purportedly from the Union health ministry, told The Print that James had participated in a “China-based webinar”, which apparently raised eyebrows within the ministry.

Now, without clarifying the outcome of the inquiry initiated after his suspension, James’s suspension has been revoked. The Wire has sent an email to the health ministry seeking its response. This article will be updated if and when a response is received.

The Wire has reliably learnt that once James’s suspension was revoked on October 11, he was reinstated formally. Within an hour of his reinstatement, his resignation, tendered on “personal grounds”, was accepted.

A source at the institute confirmed that to date, nobody at IIPS, let alone the director’s office, is aware what were the 11 charges that were found prima facie true in the preliminary report of the ministry and led to the director’s suspension.

Since the director’s office was not made aware of those allegations, there was no response to them. However, James’s suspension continued to remain in place until he tendered his resignation.

When The Wire contacted James for comment, he refrained from going into the details about the events leading up to his suspension, its revocation and his resignation. However, he confirmed that he had resigned in August. Currently, he has accepted the position of a short-term visiting scholar at the International Institute for Applied Systems Analysis, Vienna.

Union health minister Mansukh Mandaviya and K.S. James. In the background are students and faculty at the 2022 convocation of IIPS. Photos: Official Twitter and www.iipsindia.ac.in.

‘India’s loss, IIPS’s loss’

The Wire spoke to two IIPS faculty members – one professor and another associate professor – at two departments. They spoke on condition of anonymity.

“We are angry but we are helpless [about the director’s resignation]. This has never happened before,” said one of the faculty members.

“We can’t resist this,” the professor added.

The faculty member confirmed The Wire‘s earlier report about discomfort within the government about figures on anaemia in NFHS-5, which was released under James’s watch. “There was some pressure… but ultimately it [NFHS-5 data] was published,” he added.

“He held an important position in the committee which finally approves the data before publication and [therefore] he could carry forward the [final] results,” the professor added. The committee consists of several independent domain experts outside the institute. The final stamp of approval, before the data is made publicly available, though comes from the government.

The data showed that anaemia had increased in the NFHS-5 period (2019-21) as compared to the previous round, NFHS-4.

Apart from this, NFHS-5 also revealed that India was not open defecation-free – a claim repeatedly made by the members of the ruling BJP and several Union ministers. The survey showed that in no state or Union Territory (UT), except Lakshadweep, 100% of the population have access to toilet facilities. Similarly, the NFHS-5 data also raised questions about the ‘success’ of the Ujjwala scheme to encourage LPG as cooking fuel.

The professor said there are already talks ongoing of some ‘uncomfortable indicators’ being dropped from the ongoing data collection process for NFHS-6.

The associate professor feared that the credibility of NFHS-6 might go for a toss.

“[The] colleagues working on NFHS-6 are in a tight spot. Some of them do worry about the [data for] indicators [that they are collecting now],” the associate professor said.

NFHS is a large-scale exercise that spans all states and UTs that IIPS undertakes on behalf of the Union health ministry. It provides data on important indicators not just related to health but also other aspects of human development which governments have sought to improve through several targeted schemes. The NFHS data helps understand the ground impact of those schemes and is heavily referenced in academic and policy-making circles at both national and state levels.

Both the faculty members The Wire spoke to also talked about the spillover effect on the institute, especially about various international collaborations that the IIPS could forge.

“Now funding agencies will think twice about sanctioning projects because the message has gone out [that the director was forced to leave for presenting accurate data],” the professor said. Asked to explain further, he said the institute does rigorous surveys not just for the government of India but also partners with agencies such as Unicef and the United Nations Population Fund.

The associate professor said James was successful in launching joint courses with foreign universities. “Several MoUs were signed with them,” the associate professor added. Both of them wondered if that momentum would continue anymore.

One of them said the immediate fallout of James’s resignation is the shifting of the venue for the sixth Asian Population Association Conference that will be held in November next year. It is a coveted conference in the field of demography which will be attended by more than 600 experts from across the globe. Earlier, the conference was to be hosted by IIPS in Mumbai. The associate professor said that until early October, the hosting rights remained with IIPS but it was later changed to an institute in Kathmandu. The Wire could not immediately verify if the change of venue was linked with the ongoing developments at IIPS.

Assessing Manipur’s Healthcare Challenges Amidst the Ongoing Crisis

It is crucial to understand Manipur’s culture and history to get a complete picture of their healthcare system and the various stakeholders involved in its development.

This is the first part of a two-part explainer on the need to assess the healthcare costs and impact of the ongoing Manipur conflict on its state-population. The Centre for New Economics Studies’ InfoSphere team, with the help of its field team, has written this piece. The piece also says that a paucity of local data remains a challenge. The conflict situations exacerbate these challenges, making any data analytical exercise a difficult process. You can access the InfoSphere edition here.

Manipur occupies 22,327 square kilometres of area, with a population of 28,55,794 people, as per the 2011 Census. The state’s healthcare system is backed by the Regional Institute of Medical Sciences, a state hospital, seven district hospitals, one sub-district hospital, 16 community health centres, 80 primary health centres, 413 sub-centres and 33 private hospitals/clinics.

The state also has a fairly decent sex ratio of 987 girls born for every 1,000 boys. The ratio declines to 957 girls for every 1,000 boys for ages below six.

In the 2023-24 budget, the state increased its allocation by 10%, as compared to the previous year, to ramp up health facilities in the state.

However, it is crucial to understand Manipur’s culture and history to get a complete picture of their healthcare system and the various stakeholders involved in its development.

Evolution of healthcare in Manipur – A comparison between NFHS-4 and NFHS-5

Manipur’s healthcare system has gone through several phases of development. In the early years, healthcare was primarily limited to traditional practices and local remedies. However, with the advent of modern medicine, the state saw the establishment of government-run healthcare centres and hospitals.

The introduction of immunisation programmes and family planning initiatives further enhanced healthcare services in the state.

However, Manipur still faces plenty of healthcare issues which add to the socio-economic difficulties faced by its residents. The poor condition of the healthcare system affects some communities more than the others. These include women, children, senior citizens, and people with different ailments. Therefore, it is paramount to look at the statistics when analysing the evolution of the healthcare system in any region.

Public expenditure on healthcare

According to the National Family Health Survey (NFHS)-4, 2015-16, Manipur’s per capita public health expenditure stands at Rs 1,364. This is almost three times that of Uttar Pradesh and double the expenditure of Punjab and the national average of India.

Despite such a high expenditure, the percentage of households with any usual member covered by a health scheme or health insurance is only 3.6%, which is significantly lower than the national average of 28.7%. The coverage is even more limited in the hilly districts, with Senapati, Ukhrul, and Chandel having coverage rates of only 0.6%, 1%, and 1.1%, respectively.

This indicates that a majority of Manipur’s population pays for medical expenses out of their own pockets, leading to financial burden and challenges in accessing quality healthcare.

Source: Team InfoSphere

Source: Team InfoSphere

Source: Infosphere

Health indicators

According to NFHS-4, Manipur’s infant mortality rate (IMR) stands at 22, which is lower than the national average of 41. The figures indicate a better infant health outcome in the state compared to the country as a whole.

Moreover, Manipur has the highest prevalence of HIV among the adult population in the country, with a rate of 1.15%. This is four times the all-India average and indicates a significant public health challenge in the state.

Further, over half of the deliveries in private health facilities in urban Manipur are performed by a caesarean section, while the percentage is lower (30%) in public health facilities.

Also read: Medicine Shortages, Uncertain Educational Futures: Manipur Is Reeling Under Many Impacts of Violence

Health manpower and infrastructure

According to NFHS-4 and District Level Household and Facility Survey 4, Manipur has one of the highest number of nurses per capita in the northeast, after Kerala. This indicates a relatively better availability of nursing staff for healthcare services.

Source: Infosphere

Insights from NFHS-5

Of the total surveyed households in the NFHS, around 72% had access to basic drinking water services. However, only 20.5% of the households had water piped into their dwelling, yard or plot. Around 62% of households in Manipur had basic sanitation service (improved facilities not shared among households) while 32% had limited sanitation services (improved sanitation facilities shared by two or more households).

As few as 0.5% of households in the state had no sanitation facility and used open spaces or fields.

According to NFHS-5, the total fertility rate (TFR) in Manipur was 2.17 children per woman; it was 2.38 in rural areas and 1.84 in urban areas. This was a decline from the TFR of 2.61 children per woman recorded in NFHS-4. Knowledge of contraceptive methods was almost universal in the state.

Among married women, the use of contraception rose steeply from 23.6% in NFHS-4 to 61.3% in NFHS-5. However, only 18.2% of the women used modern methods of contraception such as sterilisation, pill, intrauterine devices, injectables, or condoms.

In NHFS-5, the infant mortality rate (IMR) was 25, (meaning 25 deaths before the age of one per 1,000 live births). In NFHS-4, IMR was 21.7. The under-five mortality rate during the period remained nearly the same at around 30, (meaning 30 deaths before the age of five per 1,000 live births).

Medical teams have been constituted in each of the affected districts in Manipur to provide overall healthcare services to the victims at the designated relief camps. Regular health check-ups are conducted at all the designated relief camps across the state, and those who are seriously ill are promptly transferred to the nearest hospitals by ambulance services.

Additionally, healthcare services for women and children, including lactating mothers and infants, are provided under the maternal health and child health programmes.

Source: Infosphere

The report notes that 68.8% of children in Manipur, aged 12-23 months, received all basic vaccinations against tuberculosis, diphtheria, pertussis, tetanus, polio, and measles. Only around 2.8% of children (aged 12-23 months) in the state had not received any vaccinations.

Nearly 42% of children (aged between six and 59 months) in the state suffered from anaemia – a substantial increase from the NFHS-4 estimate of 22.8%.

The report notes that 63.8% of women used cloth, 80.9% used sanitary napkins, 3.9% used locally prepared napkins, 0.7% used menstrual cups and 0.1% used tampons. Thirty-seven per cent of women (aged between 18 to 49 years) in the state reported having experienced either physical or sexual violence and 4% reported having experienced both. However, only 3% of women who had experienced such violence sought help.

It is important to put some of these numbers in perspective.

A district-level insight from the NFHS surveys and other sources may help provide greater depth to our team’s analysis, however, access to these figures and granular details remains a challenge. Our team also faced these challenges. If we could overcome these challenges, through better (high frequency) data, it would have been helpful for both context and analysis.

Assessing the socio-political and economic situation in a conflict-affected area leads to an understanding of the demographic’s public health scenario, too. In the case of Manipur, too, many issues highlighted in this piece have been exacerbated by the conflict – and its impact on the youth, women, children and elderly, who have all been badly affected by the ethnic violence.

The second part of this series shall reflect more on the role of other factors responsible for the healthcare implications of the ongoing conflict.

Deepanshu Mohan is Professor of Economics and Director, Centre for New Economics Studies (CNES), Jindal School of Liberal Arts and Humanities, O.P. Jindal Global University. Amisha Singh, Aditi Desai, Shalaka Adhikari, Samragnee Chakraborty, Shilpa Santhosh and Vasudevan are Research Analysts with CNES and members of the InfoSphere Team. The authors thank Dr Samrat Sinha for his constant guidance, help and support. The previous field studies from the team’s work on Manipur can be accessed here, here, here, and here.

NFHS Data Reveals Worrying Levels of Malnutrition Among Children in ‘Prosperous’ Gujarat

Four major districts with urban populations – Ahmedabad, Surat, Vadodara, and Rajkot – experienced a sharper increase in stunting, wasting, severe malnutrition, and underweight cases compared to some of the tribal districts between 2015-16 and 2020-21.

The dichotomy between wealth and malnutrition continues to be stark in Gujarat. A prosperous state that drives an entrepreneurial culture and demonstrates leadership in industrial development would be embarrassed – and that’s putting it gently – to read these numbers. The National Family Health Survey-5 (NFHS-5) findings on Gujarat, released in 2022, revealed that over 9.7% of children below five years were underweight.

The government had taken initiatives to tackle malnutrition across the country with schemes like Poshan Abhiyan, Matritva Sahyog Yojana, Integrated Child Development Services, Mid-Day Meal Scheme, Pradhan Mantri Matru Vandana Yojana, National Nutrition Mission, National Food Security Mission, and National Nutrition Strategy. Only last year, the state government informed the Assembly that Gujarat had 1,25,707 malnourished children in 30 districts and steps would be taken to improve the situation. But, as Gujarat’s malnutrition data suggests, changes are yet to reflect on the horizon.

Additionally, the state ranked fourth in stunting (short height compared to age) and second worst in wasting (the body becomes progressively weak) among the major states. The Nextias.com reports: “Assam, Dadra and Nagar Haveli, Gujarat, Jharkhand, Madhya Pradesh and Uttar Pradesh have stunted children higher than the national average of 35.5%.”

According to the study, four major districts with urban populations – Ahmedabad, Surat, Vadodara, and Rajkot — experienced a sharper increase in stunting, wasting, severe malnutrition, and underweight cases compared to some of the tribal districts during the period of 2015-16 to 2020-21. The issue was examined by analysing changes between the two rounds of the NFHS survey.

It emerged that the prevalence of anaemia in children rose by 17% across Gujarat in five years and 12% among young girls.

Somen Saha, a professor at the Indian Institute of Public Health Gandhinagar (IIPH-G), said providing suggestions to address the issue was the aim. “We have proposed several measures, including declaring anaemia and malnutrition as public health challenges, focusing on non-iron deficiency anaemia, establishing a nutrition intelligence unit based on comprehensive data and analytics, identifying high-priority talukas, developing sub-district action plans and targeted strategies, and implementing predictive modelling,” he said.

The study titled Nutritional Indicators for Gujarat, Its Determinants and Recommendations: A Comparative Study of National Family Health Survey-4 and National Family Health Survey-5 was published in the Cureus journal. The research was conducted by Jimeet Soni, Faisal Sheikh, Somen Saha, and Deepak Saxena from the Indian Institute of Public Health (IIPH) Gandhinagar, along with Mayur Wanjari from Jawaharlal Nehru Medical College in Wardha. The analysis also outlined aspects such as improvements in post-delivery care and early childhood care.

This article first appeared on Vibes of India.

Hindu Men Have Highest Number of Multiple Sexual Partners, Sikhs Second: NFHS-5 Data

Comparison of NFHS-4 and 5 data reveals that the trend of having multiple partners is on the rise among men.

New Delhi: Among men of all religions, Hindus rank at the top when it comes to having multiple sexual partners in India. They are followed by Sikhs, Christians, Buddhists, Muslims and Jains, in descending order.

The Wire‘s analysis of National Family Health Survey-5 (NFHS-5) data reveals that Hindu men, who chose to have partners outside of marriage or were in live-in relationships, had 2.2 ‘mean number of sexual partners in their lifetime’.

Sikhs and Christians had 1.9, while Buddhists and Muslims had 1.7, on an average. Jains had the lowest mean number of 1.1.

Those with multiple sex partners and who have unprotected intercourse are at the highest risk of acquiring an infection of the Human Immunodeficiency Virus (HIV) or of getting affected with other sexually transmitted diseases – something that the Survey also states.

The Survey was conducted by Mumbai-based International Institute of Population Studies for the Union government in 2019-20. As many as 1.01 lakh men out of a total of 8.25 lakh respondents across 29 states and seven Union Territories took part in the Survey.

The findings of NFHS-5 are a departure from that of NFHS-4 (conducted between 2015-16). The NFHS-4 had revealed that Christian men (2.4) had the highest mean number of sexual partners followed by Buddhists and Muslims (2.1) and Hindus (1.9).

Overall also, the tendency among men to have multiple partners has gone up from 1.9 in the NFHS-4 period to 2.1 in the NFHS-5 period.

The NFHS-5 also tried to find what percentage of men had intercourse with someone who was neither their wife nor somebody they lived with, in the 12 months preceding the survey. As many as 7.8% of all the participating Buddhist men said yes to this question. They were followed by Sikhs (6.0%), Hindus (4.0%), Christians (3.8%) and Muslims (2.6%). On a whole, the Survey found that 4% of men in India had sexual activity with women who were neither their wives or someone they lived with in the 12 months preceding the survey.

It should be noted here that this question was different from the one with which men were asked about the mean number of sexual partners they have had in their lifetime.

The biggest concern regarding those having multiple sexual partners is that of unprotected sex. Muslim men, who reported having intercourse with multiple partners in the 12 months before the NFHS-5 was conducted, recorded the highest use of condoms – 64.1%. They were followed by Hindus (60.2%), Buddhists (58.2%) and Christians (44.7%).

As far as wealth quintiles and the practice of multiple partners was concerned, there was not much variety. As many as 2.0-2.5% men among ‘lowest’, second, middle and fourth quintiles revealed that they engaged in this practice. Among categories, it was found to be the highest among men belonging to Scheduled Tribes (2.4%) followed by Other Backward Classes (2.2%) and Scheduled Castes (2.1%). Less than 2% men belonging to ‘others’ category in the castes figured in this list, according to NFHS-5.

Among states, Meghalaya ranks at the top followed by Sikkim and Andhra Pradesh.

Men who had multiple sex partners did not necessarily recognise them as spouses. Times of India had reported earlier on the practice of polygny – having more than one wife – having been found to be highest among Muslims (1.9%) but, as The Wire analysis found, Hindu men had the maximum number of sexual partners in their lifetime. Polygny among Hindu men was reported to the tune of 1.3%.

Muslims can legally have more than one wife in India, as per the Special Marriage Act. However, the Hindu Marriage Act prohibits the same for Hindus and others.

A research brief on NFHS-5 has, however, indicated that in contrast with the rising trend of having multiple sexual partners among men, polygny was on the decline, if one compared the NFHS-4 and NFHS-5 numbers. “With the exception of nine states (Chandigarh, Delhi, Punjab, Rajasthan, Jharkhand, Meghalaya, Tripura, Maharashtra, and Puducherry) the rate of polygyny decreased in almost every state from 2015-16 to 2019-21,” the authors noted in the brief.

The highest prevalence of polygynous marriages though was found in Meghalaya (6.1%) and Mizoram (4.1%).

The only parameter on which polygynous marriages were in line with men having multiple sexual partners was the area of residence. On both fronts men living in rural areas reported more instances than their counterparts in urban areas.

NFHS-5 Data Can Help India Become a Truly Open Defecation Free Country

The data shows that it is essential to measure the success of sanitation interventions on adoption, rather than access as representative of the true state of the scenario.

India released the fifth round of the National Family Health Survey (NFHS-5) (2019-21) data on November 24, 2021. Given the independent, high quality, and national as well as sub-national representation of the sanitation data collected in this survey, one can assess the impact of the Swachh Bharat Mission (SBM) on India’s sanitation status and the validity of India’s open defecation free (ODF) status. To answer these, we refer to one indicator reported in the state factsheets: population living in households that use an improved sanitation facility.

In figure 1, we see that at the all-India level, there is remarkable progress in the use of improved sanitation facilities from 49% in NFHS-4 (2015-16) to 70% in NFHS-5 (2019-2021). Since the period between the two surveys coincides with the duration of the SBM (2014-2019), this improvement can be largely attributed to SBM. At the end of the SBM, based on the number of toilets built by the government, India was declared an ODF nation. This implied that all the households had access to toilets.

Figure 1: Percentage of population living in households that use improved sanitation in India.

However, NFHS-5 informs us that while many states are on the path of achieving the ODF status, India cannot yet be claimed as an ODF country. States and UTs like Ladakh, Bihar, Jharkhand and Odisha still have only 42-60% of the population living in households that use improved sanitation facilities. Similarly, besides Kerala and Lakshadweep, every state needs significant improvement in the use of toilets to reach ODF status. For the future, it is essential to measure the success of sanitation interventions on adoption, rather than access, because it represents the true state of sanitation across a country.

The figure also informs us that there is heterogenous progress and prevalence of rural and urban sanitation. Rural sanitation improved from 37% to 65%, while urban improved from 70% to 82% from NFHS-4 to NFHS-5. Rural India needs to bridge the gap of 35%, while urban India 18% to achieve ODF status. This differentiated progress calls for a differentiated approach to success.

Future national sanitation schemes need to address the challenge of stubborn social norms in rural India which lead to the preference for open defecation even in the presence of toilets. Hence, allocation of funds to programs like behaviour change communication (BCC), that can inform the communities about the harms of open defecation and benefits of toilets, will be necessary to upend the practice.

Also Read: Here’s Why India Is Struggling to Be Truly Open Defecation Free

The issues for urban sanitation are different. Here, the challenge is not the BCC aspect but managing the solid and liquid waste (SLW) generated from the higher use of toilets. India is the world’s third-largest generator of solid waste in the world and its management is riddled with sub-optimal collection and disposal as well as limited state funding. Unlike the rural areas, where a twin-pit (no sewage connection required) toilet is built under SBM, new toilets in urban areas need a connection to existing sewage systems. Better management of this system, along with the upgradation of the sewage system after every few decades will encourage more people to install and adopt toilets.

However, it is also important to interpret these statistics with caution. For example, respondents are asked to report the place where the household members usually defecate. The response of one member of the household is extrapolated to generate the sanitation practice of the household or the population living in the household. Given that the research has shown heterogeneity in the use of toilets – adults use it more than children, women more than men – the survey might systematically undermine the presence of open defecation in the nation. We call for a more comprehensive assessment of sanitation practices in the future.

India has a long way to go before achieving universal sanitation. NFHS-5 can play a vital role in reaching that target. NFHS-5 is government sourced, and representative at the district, state and national levels. This can help the authorities identify target locations for intervention. For instance, at the state-level much improvement is needed in Ladakh, Bihar, Jharkhand, Odisha and Manipur. At the district level, 411 out of 707 districts have more than 70% of the population living in households that are using an improved source of sanitation. Focusing rigorous application of sanitation programs in the remaining districts will be beneficial.

Similarly, rural areas will require a differentiated approach from urban areas. Recognition of these diverse challenges and the use of NFHS-5 data to precisely identify the places that need sanitation intervention will help India achieve the goal of becoming an ODF nation.

Payal Seth is an economics researcher at Tata-Cornell Institute, Cornell University and a PhD Scholar at Bennett University and Palakh Jain is an associate professor at Bennett University.

What NFHS-5 Data Tells Us About Indian Women’s Use of Period Products

Gujarat and Meghalaya were the only two states with 65% of women using period products.

Gender inequality is deeply rooted in Indian society. India slipped from the 108th to the 112th position in the World Economic Forum’s Global Gender Gap Index in 2020. Women’s empowerment is one of the crucial factors for any nation to bridge gender inequality. The International Institute of Population Sciences, Mumbai, recently released major findings from the fifth National Family Health Survey (NFHS-5), including multiple indicators of women’s empowerment.

One such indicator is the proportion of women aged 15-24 years who use menstruation-related products – locally prepared napkins, sanitary napkins, tampons and menstrual cups – during their menstrual periods.

Not using period products could lead to poor health outcomes, including reproductive and urinary tract infections.

Figure 1 reports the percentage of women aged 15-24 years using period products in India’s states. Seventeen states and Union Territories (UTs) had 90% or more of their women using period products; in Puducherry and the Andaman and Nicobar Islands, the fraction was 99%.

Figure 1. Percentage of women using period products across states.

In contrast, seven states and UTs – Tripura, Chhattisgarh, Assam, Gujarat, Meghalaya, Madhya Pradesh and Bihar – had 70% or fewer of their women using period products. Bihar was the only state to report a figure lower than 60%.

Also read: A Reminder: Periods Don’t Stop During a Pandemic

Figure 2 shows the top eight states that reported an increase in the percentage of women using period products from NFHS-4 to NFHS-5. While Bihar and Madhya Pradesh ranked first and third from the bottom respectively vis-à-vis the percentage of women using period products, Bihar reported an impressive 90% growth, followed by Odisha (72%) and Madhya Pradesh (61%).

Figure 2. Highest percentage increase in the number of women using period products.

Figure 3 shows the states with the lowest percentage-point increase (<10%) in product usage. Twelve of 14 states already had 80% or more women using them, which could explain the low percentage increase.

Figure 3. States with the lowest percentage increase in the period products.

Gujarat and Meghalaya were the only two states with 65% of women using period products. And Mizoram is the only state where usage decreased from 93.4% to 89.4%. Thus, there is a need for action in these three states to improve period-product use.

Previous studies have shown that women in urban areas use more period products than women in rural areas. As shown in Figure 4, 11 states reported a gap of more than 15% in period-product use across urban and rural India. Madhya Pradesh and Meghalaya had the biggest gap (>25%).

Figure 4. Percentage gap in the number of women using period products across urban and rural India.

Interestingly, Madhya Pradesh and Meghalaya are also two of the three states with the lowest period-product use across India. The state with the lowest use, Bihar, is not far down the list and reported a difference of around 20% between rural and urban areas.

All UTs except Chandigarh show a different trend. Period-product use in the UTs was higher in rural areas than in urban areas, although the difference was minimal (0-5%).

Moving forward

Bihar and Madhya Pradesh have done some great work to improve period-product accessibility through multiple state government schemes. For example, Bihar’s ‘bicycle program’ – in which the state gives a bicycle to girl students who continue into secondary school – improved enrolment by 32%. Madhya Pradesh’s Ladli Lakshmi Yojana benefited over 20 lakh girls vis-à-vis their health and education.

Both these schemes helped improve the enrolment rates of girls at schools, empowering them to educate themselves, understand their bodies and make informed decisions about the use of period products.

However, the overall numbers for these two states were low compared to the national scene. One potential reason could be the lower awareness around menstruation. Based on a meta-analysis of 138 studies from India, researchers from India, the UK and the US concluded that 52% of girls were unaware of menstruation before attaining menarche (the first menstrual cycle).

Another reason is that menstruation is accompanied by multiple taboos and myths which result in shame and stigma, especially in rural areas. As a result of this, girls and women become shy about visiting pharmacies to purchase period products and may hesitate to ask the male members in their families to do so as well. These factors could explain the larger gaps in period-product usage between the urban and rural populations.

To mitigate these and similar problems, the Indian government had launched various schemes to empower girls and women in society. For example, the ‘Beti Bachao, Beti Padao’ scheme reduced dropout rates of girl students. The ‘Swachh Bharat Swachh Vidyalaya’ scheme helped provide improved WASH (water, sanitation and hygiene) facilities. And the ‘Menstrual Hygiene Management’ (MHM) scheme under the National Health Mission increased awareness and improved accessibility to menstrual pads.

However, the last one also prompted a broader discourse around the fact that many menstrual pads are neither affordable nor biodegradable.

Also read: What Is Sustainable Menstruation?

A lack of menstrual awareness, the persistence of taboo and stigma around menstruation and poor access to and affordability of menstrual products contribute to their lower use.

To counter these forces, we need to conduct workshops around menstrual health and hygiene, particularly targeting the socio-cultural aspects of menstruation; move away from using non-environmentally-friendly products and strengthen the MHM scheme to include more than one product and empower girls and women to choose the product that fits their needs best.

Karan Babbar is a PhD scholar in innovation and management in education at IIM Ahmedabad.

NFHS Data Proves ‘Population Explosion’ Is a Myth, Says NGO

The Population Foundation of India said that the total fertility rate is now below the replacement level, asking governments to steer away from coercive measures.

New Delhi: The Population Foundation of India (PFI) has said that the complete set of findings from the fifth round of the National Family Health Survey (NFHS) “busts the myth of population explosion” in India, since the total fertility rate (TFR) now stands below the replacement level.

PFI is an NGO that advocates for the effective formulation and implementation of gender-sensitive population, health and development strategies and policies. The NFHS data, released on November 24 by the Ministry of Health and Family Welfare, provide the “most comprehensive data on health and family welfare issues”, PFI said.

It said that the results of the survey show that the fall in TFR – the average number of children that would be born to a woman over her lifetime – is a significant achievement, highlighting that it had been achieved without “coercive policies”. The TFR now stands at 2.0, which is below the replacement level – the rate at which a population exactly replaces itself from one generation to the next, without migration – of 2.1.

Also Read: PM Modi is Worried About Population Explosion, a Problem Set to Go Away in 2021

“These findings bust the population-explosion myth and show that India must steer away from coercive measures of population control. While the increase in the use of modern contraceptive methods is heartening, an increase in female sterilisation coupled with continued stagnation in male sterilisation uptake shows that the onus of family planning still lies with women,” PFI said in a press release.

After China amended its two-child policy, PFI had issued a statement that it is proof that empowering women and enhancing their capabilities works better than coercive population policies. It hoped that those who have been demanding that India should enforce limits on the number of children will realise their suggestion is misplaced. However, soon after, the Uttar Pradesh government signalled its intention to pass a law to control the state’s population.

Also Read: Why UP’s Population Control Bill Can Prove Disastrous for Women, Poor Families

Commenting on the findings of the NHFS 5, PFI highlighted that while the use of condoms has increased from 5.6-9.5%, its uptake continues to be poor. “This is despite the fact that 82% of men (aged between 15 and 49 years) reported knowledge that consistent condom use can reduce the chance of getting HIV/AIDS,” the release says.

“The government must adopt a targeted social and behaviour-change communication strategy to ensure that men also take responsibility for family planning,” Poonam Muttreja, the executive director of PFI, said. “Most programmes assume that primarily women are contraceptive users. There is a dearth of interventions that focus on improving male engagement in family planning.”

The organisation also highlighted that the NFHS data shows significant progress on “several indicators related to fertility, family planning, age at marriage and women’s empowerment” but there remain a few areas of concern—notably, nutrition, gender-based violence and low levels of digital literacy among women.

Illustration of a family with two kids. Photo: Sandy Millar/Unsplash

It said the data shows some achievements, such as India achieving a TFR of 2, down from 2.2 in 2015-16, as per the NFHS-4 data; a significant increase in current use of any modern contraceptive method, which stands at 56.% in 2019-21 against 47.% in 2015-16.

“The total unmet need for family planning has come down to 9.4% in 2019-21 against 12.9% in 2015-16, though the figure is still high,” the release added, also praising the fact that most respondents felt there was a significant improvement in quality of care in family planning.

The concerns, PFI said, are that anaemia and obesity are growing among women, men, adolescents and children, while child marriage has come down just marginally from 27% in 2015-16 to 23% in 2019-21.

“A third of ever-married women (aged between 18 to 49 years) reported experiencing spousal violence. Only 1.5% of women aged between 18 and 29 reported experiencing sexual violence before the age of 18. This indicates significant underreporting of sexual violence against minors,” PFI said.

What NFHS-5 Says About Violence Against and Empowerment of Bihar’s Women

Why did rates of spousal violence drop by 5% in five years? What factors explain this, and what factors, if any, play truant?

On December 12, 2020, the Government of India released partial data from the fifth National Family Health Survey (NFHS-5) for 17 states and five union territories of India.

Compared to five years ago, in 2019, 1.6 million women in Bihar didn’t face abuse from their husbands. In other words, spousal violence dropped by 5% in five years. This drop in numbers, particularly in a state thought to be developmentally ‘backward’, is significant from the point of view of women’s rights and health.

There is a large amount of evidence to show that spousal violence, also called intimate partner violence, has severe health consequences. In this context, a decrease in experience of spousal violence for 1.6 million women deserves a closer look. By some extrapolating, we can say that many married women have been able to ensure that violence by their husbands didn’t take place or were able to resist it. There is the encouraging possibility that several men made this possible by not becoming perpetrators. we also need to recognise that a set of social changes should have allowed women to become powerful than before.

Also read: What the NFHS-5 Data Says About Women’s Empowerment

Women’s empowerment is measured by, among other indicators, their ability to participate in decision-making within the family. NFHS evaluates the three indicators of women’s decision-making ability: ability to decide their own healthcare, to make major household purchases and their mobility. According to NFHS-5, almost nine in every 10 women have a say in their family decisions (87%).

How did this significant transformation take place? Why did rates of spousal violence drop by 5% in five years? What factors explain this, and what factors, if any, play truant? This article sifts through some indicators of empowerment to explain the reduction in spousal violence in Bihar.

Empowerment indicators

The empowerment indicators include schooling, delayed marriage, uptake of contraceptives and access to finances.

* Schooling – The number of girls in Bihar who completed 10 years of schooling increased from one in 10 to three in 10 between 2015 and 2019. Years of schooling correlates positively with increased empowerment, including delayed marriages, later childbearing, improved uptake of contraceptives. Women with more schooling have a higher chance of working out a gender equitable marital relationship as well. There is also evidence that women with no schooling face the maximum risk of spousal violence. Education is a proven protection against spousal violence.

* Delayed marriage – When girls are in school, until they are 16 or 17 years of age, their age at marriage is pushed back as well, and the incidence of teenage marriages is seen to fall. Studies have shown an inverse correlation between the number of schooling years and teenage marriages. In 2019, two lakh more girls got married after attaining the legal age than in 2015.

* Uptake of contraceptives – Marriages after 18 years of age are both legally safe and positively impact maternal and child health, compared to teenage pregnancies. Women who are better educated and marry at a mature age have an improved chance of taking decisions in the family, and are equipped to plan their sexual and reproductive lives, have gaps between childbirth, and use contraceptive measures. Corroborating this, we see that women’s access to contraceptives have more than doubled, to 45%. Corresponding to increase in contraceptive use, the Total Fertility Rate in Bihar dropped from 3.4 to 3 over the past five years.

* Access to finances – Three in every four women in Bihar have their own bank accounts. Studies have shown that having access to finances does not necessarily imply empowerment – but it doesn’t take away the fact that being able to manage one’s own money is an important starting point for women’s empowerment. In fact, this ability is part of a complex web of social processes and needs to be looked at in the context of a patriarchal societal structure.

Also read: Why NFHS-5 Data Merits Serious Concern and Urgent Action

A combination of these factors can explain why spousal violence has dropped in Bihar. However, this explanation is still partial at best. We have missed 40% of Bihar’s young brides from our calculus: girls who were married before they 18 years old. For data on spousal violence, NFHS-4 surveyed women in the age group 15-49 years. On the other hand, NFHS-5 surveyed women aged 18-49 years, in keeping with the legal marriage age in India. So this time analysis of spousal violence data automatically omits the violence suffered by married women aged 15-18 years.

This omission is even more significant because evidence suggests that marriage in younger ages is a strong risk factor for spousal violence. Marriage in teenage and minor years is associated with negative effects on reproductive, child and mental health as well. Women who are married before 18 years of age have lower chances of rejecting spousal violence, of using contraceptives and of having control over their pregnancies.

This is not to despair. The positive changes are not unreal. Trends in the data indicate that underage marriages and underage pregnancies have been becoming less common. As we await the complete NHFS-5 data, we can shift from being cynical about things changing too slow or not at all to being hopeful.

Rakhi Ghoshal works with a developmental organisation in Bihar on a project on gender-based violence. She has a PhD in cultural studies and is a researcher in the areas of gender, health and ethics.

What the NFHS-5 Data Says About Women’s Empowerment

Eleven of the 22 states in NFHS-5 data reported a decline in the fraction of women owning houses or land, five of them in the northeast.

Note: This article was originally published on December 25, 2020 and is being republished on March 8, 2021 to mark International Women’s Day.

To empower women, give them equal opportunities in every field and give them power in without any discrimination. On December 12, the Indian government released the fifth National Family Health Survey fact-sheet for 17 states and five UTs, including indicators of great importance to India, including those relevant to the sustainable development goal of gender equality (SDG-5).

These indicators include education, educational freedom, economic contribution, economic freedom, household management and decision-making, perceived status within the household, and health – which directly influence the status of women in India. Based on them, we can understand if women are participating in household decisions, if they are allowed a say in decisions related to their health and wellbeing, their ‘status’ in the family and the community, and so on.

Decision making related to health, major household purchases and visiting relatives: Bihar has reported the maximum increase from 75.2% in NFHS-4 (2015-2016) to 86.5% in NFHS-5 (2019-2020). Almost 99% of women in Nagaland participate in household decision-making, followed by Mizoram at 98.8%. On the other hand, Ladakh and Sikkim reported the biggest decrease in women’s participation in decision-making, with a 7-5% drop among married women.

Women owning a house and/or land (alone or jointly): Eleven of the 22 states reported a decline in the fraction of women owning houses or land, five of them in the northeast. Tripura reported the maximum decrease – negative 40% – since NFHS-4. Kerala also reported a 7.6% points decline. Although men and women have equal opportunity on paper to inherit ancestral property in India, women still own very little land or property. Karnataka and Telangana have the most women in their population owning land or houses, respectively 67.6% and 66.6%, aged 15-49 years.

Women who worked in the last 12 months and were paid in cash: Telangana takes the lead, with 45.1% women aged 15-49 years involved in paid work, followed closely by Andhra Pradesh (42.2%) and Manipur (42.1%). Meanwhile, Sikkim reported the biggest positive change, from 19.9% in NFHS-4 to 32.7% in NFHS-5. On the other hand, women’s workforce participation dropped in West Bengal, Tripura and Lakshadweep from 2015.

Women owning mobile phones they use: Smartphone sales worldwide as well as in India have increased manifold in the last decade – and the NFHS-5 data reflects this. More women in all 22 states now own phones. The biggest change has been reported from Jammu and Kashmir, of 21.3% points, followed by Lakshadweep, 19.1% points. Over 91% of women in Goa own phones. Curiously, Gujarat has the lowest percentage of such women (48.8%) – and reported the lowest increase (0.9% points) between NFHS-4 and NFHS-5.

Also read: Why NFHS-5 Data Merits Serious Concern and Urgent Action

Women aged 15-24 years who use hygienic methods of protection during their menstrual period: Many NGOs and governments have been working to improve awareness of hygienic menstruation practices among girls and women, with efforts attempting to shift focus from taboos to empowerment and dignity. In line, the fraction of women using hygienic methods of protection during their periods has increased in almost all states except Mizoram – although it’s still quite low in some states. Only 58.8% of women in Bihar use hygienic methods of protection during their menstrual period. Andaman and Nicobar Islands (98.9%) and Goa (96.8%) top the list on this count.

Women aged 15-49 years with bank or savings accounts that they use: The fraction of women aged 15-49 years who have bank accounts in their names has increased considerably. Bihar has reported the largest increase (50.3%), followed by Manipur (37.1%). On the other hand, Lakshadweep has reported a decline since NFHS-4. Since 2014, Indians have reportedly opened 40 crore bank accounts under the Pradhan Mantri Jan Dhan Yojana; more than 50% of these account-holders are women.

Priya Maurya and Palak Sharma are research scholars at the International Institute for Population Studies, New Delhi.