India has been making steady progress towards its maternal and child health targets set in the Sustainable Development Goals, or the SDGs 2030. The findings of the NFHS-5 Phase 1 survey have been heartening. There is significant improvement in India’s reproductive health indicators, especially in fertility rate. Use of modern contraceptive methods, and maternal and child health indicators have also seen progress. These improvements tell us that the efforts made by the central and state health departments in prioritising public health are moving in the right direction.
Healthy mothers and children are the bedrock of any thriving society. The National Health Mission (NHM) has held reproductive maternal and child health (RMCH) at the core of its primary healthcare delivery. Over the past few years, systematic and significant investments have been made in strengthening the quality of service and delivery of primary healthcare programmes by augmenting supply-side interventions; ensuring availability of adequate medical staff; training healthcare workers; and focusing on behavioural change initiatives. The launch of a data set, of the scale of National Family Health Survey-5, gives us the opportunity to understand which of the efforts are working and which are not; which of these investments are headed in the right direction, and which need to be strengthened further.
NFHS-5 makes a case for continued investment in primary healthcare as a critical component of the integrated public healthcare delivery, in the benefit of maternal and child health. It is yet another reminder of the fundamentals of a functional public health system focusing on service availability, quality, and effective utilisation (inclusive of service utilisation and healthy behaviours).
Improved reproductive and child health
Intensified efforts have been made under the flagship Mission Indradhanush immunisation programme to ensure that no mother and child are deprived of basic vaccines. Across states, 70 to 96 per cent of children aged between 12 and 23 months are now fully vaccinated, based on information in their vaccination card. And in almost three-fourths of the districts, more than 70 per cent children aged 12-23 months are fully vaccinated against childhood diseases. Between 2015-16 and 2019-20, the percentage of children fully vaccinated moved up in Bihar from 61.7 in 2015-16 to 71; from 50.4 to 76.3 in Gujarat; from 69.5 to 89.3 in Himachal Pradesh; and from 62.6 to 84.1 in Karnataka.
Continued focus on outreach by health workers for Reproductive and Child Health (RCH) services is providing dividends. More families are choosing reversible modern contraceptive methods for planning their families. In Bihar, the use of modern methods increased from 23.3 per cent to 44.4 per cent; in Telangana from 57 per cent to 66.7 per cent; in West Bengal from 57 per cent to 60.7 per cent. This shift has been enabled by better outreach of health workers to women in matters of family planning in 15 of the 22 surveyed states/UTs. Effective counselling has resulted in women in 20 states being better informed of the side effects of various modes of modern contraception. The outcome of these efforts is that replacement fertility — the average number of children born per woman — has come down across the country. In fact, of the 22 states and UTs surveyed in this phase of NFHS, except Assam, Mizoram, Bihar, Nagaland, Manipur and Ladakh, all others have already achieved the United Nations SDG target replacement fertility rate of 2.1.
Improvement witnessed in social determinants is the real marker of India’s progress – sex ratio has improved in 14 out of 22 states/UTs surveyed. More girls are staying longer in schools in many states. Significantly, teenage marriage and pregnancy has come down in 17 of the 22 states; spousal violence has declined, the percentage of women with savings accounts has increased across states and UTs, and more women are accessing information on their mobile phones.
Improvement in coverage and quality of services is another critical factor that contributes to decline in mortality, and one that needs continued focus. It is heartening to see improvements in timely (first trimester) registration of pregnancies, institutional deliveries, and postnatal care to mothers. The NFHS-5 data has shown that in 14 states/UTs, more than 90 per cent of babies were delivered in health facilities. The urban-rural divide in maternal health services in most states has declined. Most states have reported at least 60 per cent of new mothers receiving a minimum of four ANC visits by health workers. The government is systematically putting in place programmes like LaQshya (Labour Room & Quality Improvement Initiative) and SUMAN (Surakshit Matritva Aashwasan) to ensure high-quality services to mothers.
Effective service utilisation and healthy behaviour complement service availability and quality, for improvement in health and wellbeing of the population. Targeted communication through frontline workers and other means for available services and importance of healthy behaviours has shown positive uptake. For instance, modern contraceptive use has increased in all except two states; consumption of Iron Folic Acid—intervention to prevent anaemia— increased in most states; and exclusive breastfeeding improved in several states. Likewise, the proportion of women with unmet need for family planning (who want to stop or delay childbearing but are not using any method of contraception) has also declined.
Assisting the states
Lastly, NFHS-5 has also vindicated the National Health Mission’s (NHM) foundational premise –of assisting and strengthening individual states’ contextual health systems and programmes, both financially and technically. Setting nationally relevant clinical, data and technology standards, while encouraging state-specific innovations and refinements, and fostering inter-state collaborations (the latter becoming more relevant in the way the Covid-19 pandemic spread across state borders) will remain cornerstones of the next phase of NHM in the coming years.
Malnutrition estimates in the survey have shown mixed results. Some states saw a decline in wasting between 2015-16 and 2019-20. Nutrition is intergenerational – positive changes in nutrition-related issues like stunting take time to manifest. We stay hopeful the focus that POSHAN Abhiyaan brings to the nutrition programme, by data-led district level interventions, should be able to mend this gap.
Systematic investments in primary healthcare institutions such as Health and Wellness Centres (HWCs) — a government priority initiative — will help replicate positives from reproductive and child health programmes across a wider scope, including non-communicable diseases such as hypertension and diabetes (NFHS-5 data shows that across states/UTs more than 20 per cent women and men have hypertension). The aim is to provide Comprehensive Primary Health Care (CPHC) services to people closer to their homes by setting up 1.5 lakh HWCs by December 2022. One-third of the target has already been met, with over 56,000 centres established.
India is making impressive strides towards delivering universal and comprehensive healthcare to its people, including communicable/infectious disease management and surveillance, which has been exemplified by proactive and pre-emptive Covid-19 pandemic management — a progress that must continue.
Dr. Vinod. K. Paul is member NITI Aayog, Health and Nutrition. Views are personal.
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