Why have vital indicators gone missing?

For more than three decades, the National Family Health Survey (NFHS) has been the gold standard for understanding India’s demographic and public health realities. Conducted periodically since the early 1990s, the survey has offered insights into how Indians live, eat, reproduce and access healthcare.

Its rich, district-level data has empowered policymakers, researchers, journalists and civil society groups to identify gaps in health services, monitor welfare programmes and fine-tune interventions. In a country as vast and diverse as India, such granular data often makes the difference between effective policy and administrative guesswork.

It is precisely because of this reputation that the release of the NFHS-6 (2023-24) fact-sheets has triggered an intense debate within the public health community. While the Union government has highlighted improvements in institutional deliveries, immunisation coverage and several other health indicators, critics argue that the most striking aspect of the latest survey is not what it reveals, but what it leaves out.

The omission of key indicators that featured prominently in earlier editions reduces transparency, weakens comparability with previous surveys and makes it harder to independently assess the performance of major government programmes, say public health experts.

Among the most glaring omissions are indicators directly linked to some of the Narendra Modi government’s flagship welfare initiatives.

In NFHS-5, data on household access to clean cooking fuel and sanitation facilities played a crucial role in evaluating the effectiveness of the Pradhan Mantri Ujjwala Yojana and the Swachh Bharat Mission. These allowed researchers to assess not merely whether LPG connections or toilets had been provided, but whether they were actually being used.

Their absence from NFHS-6 is conspicuous at a time when questions are being raised about the long-term sustainability of these schemes.

The number of subsidised LPG cylinders available under the Ujjwala scheme has been cut from nine per year to four. According to the petroleum ministry, around 10.55 crore LPG connections have been provided under the programme. Without district-level data on fuel usage, independent researchers cannot accurately verify these figures or evaluate their benefits.

Equally significant is the exclusion of the Sex Ratio at Birth (SRB) and infant and child mortality indicators. The SRB has long been considered a crucial measure for tracking gender discrimination and assessing the impact of campaigns like Beti Bachao Beti Padhao.

While some information continues to be available through mechanisms such as the Sample Registration System (SRS), experts point out that the NFHS offered something unique: district-level granularity. National or state-level averages often conceal localised failures. Without district-wise data, policymakers lose an important tool for identifying areas where interventions are succeeding, or failing.

Perhaps no omission has generated more discussion than the complete removal of anaemia prevalence estimates. The NFHS-5 had revealed that more than 50 per cent of Indian women and children were anaemic, raising uncomfortable questions about the effectiveness of programmes such as Poshan Abhiyaan.

The government argues that the omission is driven by scientific concerns rather than political considerations. Experts had pointed out that the capillary blood sampling method used in earlier NFHS rounds — commonly known as the finger-prick test — could produce inaccurate estimates because tissue fluids sometimes dilute the blood sample.

Consequently, anaemia measurement shifted to the Diet and Biomarkers Survey in India (DABS-I), which relies on venous blood samples analysed in laboratories using auto analysers — the internationally accepted gold standard.

While scientists generally agree that venous sampling is more accurate, critics argue that accuracy has come at the cost of detail. Unlike the NFHS, DABS-I provides state and national-level estimates, not district-level data.

Health activist Dr A.K. Arun sees a broader pattern in the omissions: “All those indicators that show deficiencies are being omitted, whether it is a deficiency in the health of society or a deficiency in the system.”

For many public health experts, the concern is that the elimination of anaemia from NFHS-6 does not eliminate the crisis, it just makes it less visible.

The omissions are not limited to indicators alone. An entire state is absent from the survey. NFHS-6 collected information from nearly 6.8 lakh households across India but excluded Manipur, where prolonged ethnic violence and instability disrupted fieldwork.

This deliberately creates a blind spot. Manipur has witnessed one of the most severe internal crises in recent Indian history, yet policy-makers, researchers and humanitarian agencies now lack a comprehensive assessment of how the conflict has affected nutrition, maternal health, child health and healthcare access.

Another major casualty is disability data. Disability questions were introduced only in NFHS-5, offering researchers an opportunity to study the relationship between disability and various health out-comes, including maternal health, tuberculosis and access to services. Without updated data, policy-makers have fewer tools to design and assess targeted interventions.

The NFHS-6 debate is also entangled with an earlier controversy involving the International Institute for Population Sciences (IIPS), the Mumbai-based institution responsible for conducting the survey.

As preparations for NFHS-6 were underway in July 2023, the Union government suspended IIPS director K.S. James, citing alleged irregularities in recruitment procedures. Critics claimed that James had earlier been asked to resign because of survey findings that questioned the effectiveness of certain government programmes. When he didn’t, he was suspended.

Though the government maintains that the action was purely administrative, the episode contributed to growing concerns about institutional autonomy and the future independence of large-scale public data collection exercises.

Alarming health trends

Ironically, even as several indicators have disappeared, the data that remains reveals significant challenges.

India now faces what experts describe as the ‘dual burden’ of malnutrition. While roughly one-fifth of adults remain underweight, obesity is rising sharply across both urban and rural populations.

As per the survey, 30.7 per cent women and 27.3 per cent men are now classified as obese or overweight, marking a substantial increase from the previous round.

The trend is accompanied by rising prevalence of high blood sugar and hypertension, signalling a major shift in India’s disease profile. Obesity, increasingly linked to a growing healthcare industry, has become one of the most discussed findings of the survey.

Other concerns include decline in exclusive breastfeeding rates, fall in modern contraceptive usage and rise in caesarean section deliveries. The national C-section rate is 27.2 per cent, soaring to 54 per cent in private healthcare facilities.

The NFHS has always been more than just a dataset. It is a tool of democratic accountability. By making health and welfare out-comes visible at the district level, it enables researchers, citizens and governments to ask difficult questions. Erasing data will not make those questions go away.