NFHS-6: Gains in Child Nutrition and Maternal Care
The latest National Family Health Survey shows progress in crucial areas while omitting key indicators like anaemia and mortality rates.
4 mins read
“What gets measured gets managed.” — Peter Drucker
The National Family Health Survey (NFHS) is India's most comprehensive household-level database on health, nutrition, fertility and social indicators. The recently released NFHS-6 (2023-24) records significant improvements in several human development indicators, but has also sparked debate because many long-tracked indicators have been removed from the preliminary fact sheet.
What is NFHS-6?
| Feature | Details |
|---|---|
| Conducted by | International Institute for Population Sciences (IIPS) |
| Commissioned by | Ministry of Health & Family Welfare |
| Coverage | Nearly 6.8 lakh households |
| Exclusion | Manipur |
| Indicators in NFHS-5 | 131 |
| Indicators in NFHS-6 | 101 |
Unlike previous rounds that expanded coverage, NFHS-6 marks the first major contraction in reported indicators.
Key Improvements Recorded
Maternal and Child Health
- Mothers receiving at least four antenatal check-ups increased by nearly 7 percentage points.
- Institutional deliveries improved further.
- Child stunting declined significantly.
- Spousal violence against women declined from 29.3% to 22.3%.
Digital Inclusion
- Women's Internet usage increased substantially.
- Digital literacy and financial transaction indicators were newly introduced.
Examples of Positive Trends
✓ More institutional births
✓ Higher antenatal care coverage
✓ Greater Internet access among women
✓ Reduced child stunting
✓ Decline in spousal violence
Areas of Concern
NFHS-6 also recorded declines in several important indicators:
- Exclusive breastfeeding among infants below six months declined by nearly 8 percentage points.
- Modern contraceptive use fell from 56.4% to 52.7%.
- Overweight and obesity among women increased across all States.
What New Indicators Were Added?
NFHS-6 introduces several contemporary indicators:
| New Additions |
|---|
| Direct Benefit Transfers (DBTs) |
| Self-Help Group participation |
| Digital literacy |
| Digital financial transactions |
| Hepatitis-B testing |
| Hepatitis-C testing |
A major addition is biological testing for Hepatitis among women, men and children.
Notably, HIV testing, dropped in NFHS-5, has been reintroduced.
Which Indicators Were Removed?
The survey shows a net reduction of 30 indicators, resulting from 43 indicators dropped and 13 added.
Major Indicators Removed
| Removed Indicator | Importance |
|---|---|
| Anaemia | Nutritional health |
| Infant mortality | Child survival |
| Under-five mortality | Health outcomes |
| Neonatal mortality | Maternal-child care |
| Sex ratio at birth | Gender equality |
| Sanitation access | Public health |
| Clean cooking fuel use | Energy access |
| Cancer screening indicators | Preventive healthcare |
| Comprehensive HIV knowledge indicators | Disease awareness |
These indicators had been tracked for years and were widely used in policy evaluation.
Why Was Anaemia Removed?
Anaemia remains one of India's biggest nutritional challenges.
NFHS-5 Findings
| Group | Anaemia Prevalence |
|---|---|
| Children | 67.1% |
| Women (15-49 years) | 57% |
| Pregnant women | 52.2% |
Researchers questioned the finger-prick haemoglobin testing method used in NFHS, arguing that it overestimated anaemia levels compared to venous blood testing.
As a result:
- IIPS removed anaemia measurement from NFHS-6.
- Anaemia will now be tracked through the Diet and Biomarkers Survey (DBS) conducted by the National Institute of Nutrition.
Old Method → Finger-prick blood sample
New Method → Venous blood sample
+ Blood biomarkers
+ Urine biomarkers
+ Dietary intake assessment
The DBS was launched in 2022 and data collection has been completed, though results are yet to be released.
Why Do the Missing Indicators Matter?
Several deleted indicators were directly linked to flagship government programmes.
Examples
- Sanitation coverage measured progress of Swachh Bharat Mission.
- Clean cooking fuel use assessed outcomes of Pradhan Mantri Ujjwala Yojana.
- Sex ratio at birth reflected gender discrimination and sex-selective practices.
- Mortality indicators tracked child survival outcomes.
While some indicators are available through other sources like the Sample Registration System (SRS), those sources generally lack:
- District-level estimates
- Socio-economic disaggregation
- Comprehensive household-level analysis
As a result, no single national survey currently provides equivalent data at NFHS scale.
Notable State-Level Trends
- West Bengal recorded the largest rise in health insurance coverage, from 33.7% to 88.2%.
- Andhra Pradesh witnessed the sharpest increase in women's Internet usage, from 21% to 63.6%.
- Haryana recorded the steepest decline in exclusive breastfeeding, from 69.5% to 41.2%.
Way Forward
- Release detailed justification for indicator removals.
- Ensure continuity of long-term health datasets.
- Publish Diet and Biomarkers Survey findings at the earliest.
- Integrate emerging indicators without sacrificing core public health measures.
- Maintain district-level and socio-economic disaggregation for evidence-based policymaking.
Conclusion
NFHS-6 presents a mixed picture of India's development journey. While gains in maternal care, digital inclusion and child nutrition are encouraging, the removal of several foundational indicators raises concerns about data continuity and policy accountability. For a country as diverse as India, comprehensive and transparent health statistics remain essential for informed governance, effective welfare delivery and sustainable human development.
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Quick Q&A
What is the National Family Health Survey and what is its significance for healthcare policy and social development in India?
The National Family Health Survey (NFHS) is India's largest periodic household survey conducted under the Ministry of Health and Family Welfare and implemented by the International Institute for Population Sciences (IIPS), Mumbai. Initiated in 1992-93, the NFHS provides nationally representative data on population, health, nutrition, fertility, mortality, gender and socio-economic indicators. Over successive rounds, the survey has expanded in scope, with NFHS-4 (2015-16) introducing district-level estimates and digital data collection, while NFHS-5 (2019-21) expanded the number of indicators to 131. NFHS-6 (2023-24), covering nearly 6.8 lakh households across all States and Union Territories except Manipur, recorded improvements in maternal healthcare, institutional deliveries and women's Internet usage, although the number of indicators declined to 101. The survey serves as an essential evidence base for policymaking. Programmes such as Poshan Abhiyaan, Ayushman Bharat, Anaemia Mukt Bharat and Mission Indradhanush rely heavily on NFHS findings. The survey also assists international organizations like WHO, UNICEF and UNFPA in monitoring Sustainable Development Goals. For UPSC aspirants, NFHS is relevant to GS-II (Health and Governance), GS-I (Population and Society), GS-III (Human Development) and Essay. By identifying disparities across regions and socio-economic groups, NFHS contributes to evidence-based policymaking, social equity and inclusive development.
Why has the reduction of indicators in NFHS-6 generated concerns among public health experts and policymakers?
The reduction in the number of indicators in NFHS-6 has raised concerns because it creates significant gaps in India's public health database. Unlike earlier rounds that followed an additive approach, NFHS-6 marks the first instance of a net reduction in indicators, with 43 indicators removed and only 13 added. Consequently, the preliminary fact sheet contains 101 indicators compared with 131 in NFHS-5. Several omitted indicators are directly linked to major government programmes and developmental concerns. These include anaemia prevalence, infant mortality, under-five mortality, sanitation coverage, clean cooking fuel use and sex ratio at birth. Such indicators are essential for evaluating flagship schemes such as Anaemia Mukt Bharat, Swachh Bharat Mission and Pradhan Mantri Ujjwala Yojana. Experts argue that alternative data sources such as the Sample Registration System do not provide district-level information and socio-economic disaggregation available through NFHS. This may weaken evidence-based policymaking and obscure inequalities among vulnerable groups. Another concern relates to transparency and accountability, as no detailed rationale has been provided for many omissions. For UPSC preparation, the issue is relevant to GS-II (Health and Governance), GS-III (Human Development) and Ethics, particularly concerning institutional accountability and data governance.
How did methodological concerns influence the removal of anaemia indicators from NFHS-6 and what alternatives have been proposed?
The removal of anaemia indicators from NFHS-6 reflects a methodological debate regarding the accuracy of measurement techniques. Anaemia had emerged as a major public health challenge in India, with NFHS-5 reporting rising prevalence across almost all categories. Child anaemia increased from 58.6% in NFHS-4 to 67.1% in NFHS-5, while anaemia among women aged 15-49 rose from 53.1% to 57%. These trends persisted despite the launch of the Anaemia Mukt Bharat campaign in 2018. NFHS traditionally measured haemoglobin levels using finger-prick blood samples analyzed through portable devices. However, several researchers argued that this method overestimated anaemia prevalence compared with venous blood testing. Consequently, when NFHS-6 fieldwork began in 2023, the anaemia questionnaire was removed. Instead, anaemia assessment was transferred to the Diet and Biomarkers Survey in India, launched in December 2022 by the ICMR-National Institute of Nutrition in Hyderabad. This survey uses venous blood samples and combines dietary intake analysis with blood and urine biomarkers. Supporters view this change as a scientifically superior approach, whereas critics fear disruption in long-term trend analysis. For UPSC aspirants, this issue links with GS-II (Healthcare), GS-III (Science and Technology) and Ethics, highlighting the balance between methodological rigor and continuity in public health surveillance.
What are the implications of excluding indicators such as sanitation, mortality and sex ratio from NFHS-6?
The exclusion of key indicators from NFHS-6 has important implications for healthcare policy, gender justice and developmental planning. Indicators relating to sanitation, clean cooking fuel, neonatal mortality, infant mortality, under-five mortality and sex ratio at birth have historically served as benchmarks for measuring social progress. Sanitation coverage was closely associated with the Swachh Bharat Mission, while clean cooking fuel usage helped assess the performance of the Pradhan Mantri Ujjwala Yojana. Their absence limits the ability to independently evaluate these programmes. The removal of sex ratio indicators is particularly concerning because sex ratio at birth serves as an important measure for detecting sex-selective practices and gender discrimination. Mortality indicators are expected to be tracked through the Sample Registration System, but it lacks district-level and socio-economic disaggregation. Public health experts argue that the absence of these indicators creates blind spots in monitoring inequalities and developmental outcomes. Critics also note that cancer-screening indicators introduced in NFHS-5 were discontinued after only one round, preventing meaningful trend analysis. From a UPSC perspective, this issue relates to GS-II (Health and Welfare), GS-I (Women and Society) and GS-III (Human Development). It raises broader questions concerning transparency, accountability and the importance of continuity in statistical systems supporting evidence-based governance.
What examples from NFHS-6 illustrate changing health and social patterns across Indian States and population groups?
NFHS-6 reveals several encouraging as well as worrying trends that reflect India's changing health and social landscape. One notable improvement is in maternal healthcare. The proportion of women receiving at least four antenatal check-ups increased by approximately seven percentage points compared with NFHS-5. Institutional births also increased, indicating improved access to healthcare services. Women's digital empowerment emerged as another positive trend. Andhra Pradesh recorded one of the largest increases in women's Internet usage, rising from 21% in NFHS-5 to 63.6% in NFHS-6. Health insurance coverage improved dramatically in West Bengal, increasing from 33.7% of households to 88.2%. However, exclusive breastfeeding among infants below six months declined nationally, while Haryana witnessed a sharp fall from 69.5% to 41.2%. Modern contraceptive use also declined from 56.4% to 52.7%, raising concerns regarding reproductive health services. Nutritional indicators showed mixed outcomes. Stunting among children under five declined significantly, indicating progress in combating chronic malnutrition. However, overweight and obesity among women increased across all States, reflecting the growing burden of non-communicable diseases. These examples highlight India's epidemiological transition and emphasize the need for region-specific policies. For UPSC aspirants, these trends are relevant to GS-II (Healthcare), GS-I (Population) and GS-III (Human Development).
How do the evolution and successive rounds of NFHS demonstrate the growing role of evidence-based governance in India?
The evolution of the National Family Health Survey represents an important case study in evidence-based governance and public policy. Since its inception in 1992-93, the survey has continuously expanded to capture changing developmental priorities. NFHS-4 (2015-16) introduced district-level estimates and tablet-based digital interviews, enabling localized policy interventions. NFHS-5 (2019-21) increased the number of indicators from 114 to 131 and incorporated themes such as disability, menstrual hygiene, preschool education, access to toilets and cancer screening. It also extended blood pressure and blood sugar measurements to all adults aged 15 years and above, reflecting growing concerns regarding non-communicable diseases. NFHS-6 (2023-24) added questions on digital literacy, self-help groups, direct benefit transfers and financial transactions, indicating the increasing significance of digital governance and financial inclusion. Biological testing for HIV, Hepatitis-B and Hepatitis-C was also introduced or expanded. These developments demonstrate how surveys evolve alongside socio-economic changes. At the same time, the reduction in indicators in NFHS-6 shows the challenges involved in balancing scientific improvements with continuity in long-term datasets. Internationally, demographic and health surveys are used to monitor Sustainable Development Goals. For UPSC preparation, this case study is relevant to GS-II (Governance), GS-III (Science and Technology) and Essay, emphasizing the importance of reliable and comprehensive data systems.
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