Visualization and the NFHS

A very quick post today, because the end of the year is proving to be anything but a holiday, alas.

My third post in the series about NFHS was going to be about a pet theme (and peeve) of mine: our inability to get better visualization for our data, and indeed better reporting of data in general. But there is good news on this front, finally – there is now an excellent resource that we can use to visualize the results of the NFHS-5 survey.

Here’s just one chart to whet your appetite: blood sugar level among adult women (high, or very high or taking medicine). Note that the chart for men is largely similar.

https://geographicinsights.iq.harvard.edu/nfhs-tracker-districts

This is great work, and kudos to everybody associated with this visualization project! 🙂

H/T: Shashank Patil

Understanding the idea behind the NFHS

Why should you, as an informed citizen of this country, be aware of how well India is doing in terms of health?

The question isn’t rhetorical. For its own sake is a more than good enough answer, of course, but here are additional reasons for keeping track of how well we’re doing as a country in terms of health:

  • If you think that the Solow model is a good way to start to think about the long term growth prospects of our nation, then thinking about the health of that workforce is important
  • If you think it is possible that different states may have different health outcomes, it makes sense to try and understand whether this is the case.
  • It also makes sense to dig into the data and try and understand the particulars of these differences. (A state may do poorly on life expectancy in comparison to other states, for example, but better along other dimensions. Why might this be so is an excellent question to ask, and this is just one of many possible questions.)
  • This is true for many other ways to “slice” this data. Are there different outcomes by, say, gender? By urban/rural divide?
  • The answers to each of these questions is important because it helps us understand how to build a framework to answer the mot important question of them all: if we have to improve India’s health, where should we start?

And for all of these reasons (and so many more) it makes sense for all of us to be aware of the results of the NFHS survey.


What is the NFHS Survey?

The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted in a representative sample of households throughout India. The NFHS is a collaborative project of the International Institute for Population Sciences(IIPS), Mumbai, India; ICF, Calverton, Maryland, USA and the East-West Center, Honolulu, Hawaii, USA. The Ministry of Health and Family Welfare (MOHFW), Government of India, designated IIPS as the nodal agency, responsible for providing coordination and technical guidance for the NFHS. NFHS was funded by the United States Agency for International Development (USAID) with supplementary support from United Nations Children’s Fund (UNICEF). IIPS collaborated with a number of Field Organizations (FO) for survey implementation. Each FO was responsible for conducting survey activities in one or more states covered by the NFHS. Technical assistance for the NFHS was provided by ICF and the East-West Center.

http://rchiips.org/nfhs/about.shtml

Why is the NFHS important?

Why do we have something like NFHS? To obtain data on health and nutrition, disaggregated to the level of districts. We want to take stock of developmental targets at a single point in time and wish to track improvements (or deterioration) over time.

https://www.newindianexpress.com/opinions/columns/2021/dec/13/nfhs-andwhy-surveys-are-better-than-asking-a-cab-driver-2394809.html

How often is the NFHS carried out?

That’s a little tricky to answer, but I can tell you that there have been five rounds so far. The first one was in 1992-93, the second in 1998-99, the third in 2005-06, the fourth in 2015-16 (and this decade long gap is why this question is a little tricky to answer) and the fifth in 2020-21.

OK, so we can use this data to see how health in India has evolved over time?

Um, not exactly:

To gauge improvements over time, ideally, we should have what statisticians and economists call a panel. In a panel, across time, questions are asked to the same individuals/households. For something like NFHS, that’s not possible. In addition, for NFHS-5, compared to NFHS-4 (2015–16), additional questions have been asked. For those questions, gauging improvements over time is naturally impossible.

https://www.newindianexpress.com/opinions/columns/2021/dec/13/nfhs-andwhy-surveys-are-better-than-asking-a-cab-driver-2394809.html

Then what can we use the data for?

Especially because the answer to the first question in this series included this: “wish to track improvements (or deterioration) over time.”

Well, yes, it did. And we do use this data to see how health in India has evolved over time. But it’s not a perfect comparison, because we aren’t tracking the same households over time, and it therefore isn’t an apples to apples comparison. But the perfect shouldn’t be the enemy of the good, especially in public policy! The fifth round has in fact been structured in such a way so as to make the results as comparable as possible.

How many households are covered?

NFHS-5 fieldwork for India was conducted in two phases, phase one from 17 June 2019 to 30 January 2020 and phase two from 2 January 2020 to 30 April 2021 by 17 Field Agencies and gathered information from 636,699 households, 724,115 women, and 101,839 men

http://rchiips.org/nfhs/NFHS-5_FCTS/India.pdf

What questions are asked in this survey?

That’s a great question to ask!

Four Survey Schedules – Household, Woman’s, Man’s, and Biomarker – were canvassed in local languages
using Computer Assisted Personal Interviewing (CAPI).

In the Household Schedule, information was collected on all usual members of the household and visitors who stayed in the household the previous night, as well as socio-economic characteristics of the household:

water, sanitation, and hygiene; health insurance coverage; disabilities; land ownership; number of deaths in the household in the three years preceding the survey; and the ownership and use of mosquito nets.

The Woman’s Schedule covered a wide variety of topics, including the woman’s characteristics, marriage, fertility, contraception, children’s immunizations and healthcare, nutrition, reproductive health, sexual behaviour, HIV/AIDS, women’s empowerment, and domestic violence.

The Man’s Schedule covered the man’s characteristics, marriage, his number of children, contraception, fertility preferences, nutrition, sexual behaviour, health issues, attitudes towards gender roles, and HIV/AIDS.

The Biomarker Schedule covered measurements of height, weight, and haemoglobin levels for children; measurements of height, weight, waist and hip circumference, and haemoglobin levels for women age 15-49 years and men age 15-54 years; and blood pressure and random blood glucose levels for women and men age 15 years and over. In addition, women and men were requested to provide a few additional drops of blood from a finger prick for laboratory testing for HbA1c, malaria parasites, and Vitamin D3.

http://rchiips.org/nfhs/NFHS-5_FCTS/India.pdf

Whoa, that’s… a lot!

Indeed it is! If you haven’t clicked through to those PDF’s that have been linked to in the previous question, take the time out to go and do so. Conducting one of these surveys isn’t easy. All of these, and across these numbers (636,699 households, 724,115 women, and 101,839 men) is pretty tough, and kudos to the team that did the work.

So how are these households selected?

Another excellent question. From the interview manual (and if you are a student of statistics, this manual ought to be mandatory reading):

All 29 states and seven union territories (UTs) will be included in NFHS-5. NFHS-5 will provide
estimates of most indicators at the district level for all 707 districts in the country as on 1 March
2017.

For NFHS-5, the sample consists of approximately 30,456 clusters (small geographically defined
areas) throughout the country. The households in each of these clusters have recently been listed or
enumerated. A sample of households was then scientifically selected to be included in NFHS-5 from
the list in each of the clusters. Each of these households will be visited and information obtained
about the household using the Household Questionnaire. Women and men within these households
will be interviewed using an Individual Questionnaire. Women age 15-49 years will be interviewed
using the individual Woman’s Questionnaire. Men age 15-54 years will be interviewed using the
individual Man’s Questionnaire. We expect to complete interviews with about 7,45,488 women and
1,19,501 men in 670,032 households in this survey.

http://rchiips.org/NFHS/NFHS5/manuals/NFHS-5%20Interviewer%20Manual_Eng.pdf

And how are the surveys conducted?

During NFHS-5 fieldwork, you will work in a team consisting of one field supervisor, three female
interviewers, and one male interviewer. Each team will be provided with a vehicle and driver for
travelling from one Primary Sampling Unit (PSU) to another to conduct the fieldwork.
In addition, the team will include two health investigators. These individuals will be responsible for
drawing blood from eligible persons for testing for anaemia status, blood pressure, and blood glucose. In
addition, the health investigators will collect blood drops from a finger stick on filter paper cards,
which will be tested for malaria, HbA1c, and Vitamin D3 in ICMR laboratories. They will also be
responsible for the anthropometric measurements of eligible women, men, and children. The supervisors
will also receive some biomarker training so that they can supervise the health investigators and assist
them as needed. All interviewers will be trained to assist the health investigators in taking the
anthropometric measurements(height, weight, and waist and hip circumference measurements).
Each team supervisor will be responsible for his/her team of interviewers and health investigators.
The specific duties of the supervisor are described in detail in the Supervisor’s Manual.

http://rchiips.org/NFHS/NFHS5/manuals/NFHS-5%20Interviewer%20Manual_Eng.pdf

This PDF, the one that I have excerpted from, is 182 pages long. I am not for a moment suggesting that all of you must read every single word. But I’ll say this much: if you are currently studying either statistics or economics, you should go through it more than once. It is one thing to learn from textbooks, and quite another to understand the on the ground realities.


In tomorrow’s post, let’s dig in and take a look at the data itself, and see what the NFHS-5 results tell us about our country’s health.

What is the story that NFHS-5 is telling us?

… is, if you ask me, a question that we should ask ourselves, rather than have this question be answered for us by somebody else.

What I mean by that is that I could tell you what I think of the results, or I could point you to articles written by others that tell you what they think of the results. But the results are out there for us to analyze, easily available and fairly readable in terms of accessibility.

Here is the India fact sheet, and here is where you can access data split by states.


I would recommend that you not take the easy way out, by reading what other folks have written. Sit instead, with these reports, and take a look at the big picture – the all India level data. Then begin with the Indian state that you call home, and check how it is doing. Compare India’s performance and your state’s performance with some states that you think ought to do well, and some that you think might be relative laggards on health parameters.

See if the data matches your intuition. And if it doesn’t, ask if you should suspect the data or your intuition (or both!). Begin to build, no matter how long it takes, a picture of India’s health status in your head.

Ask questions about India’s population, its split by gender, ask about our obesity rates and split those up by states. Ask about whether men are doing better than women on some parameters, and if so which – and eventually, why. Ask if there are major changes between the 4th and the 5th round, and ask if the rate of improvement between the 4th and the 5th is different from the rate of improvement between the 3rd and the 4th. Then ask if these numbers are comparable at all, given that there is a difference of ten years in the latter case, but only 5 in the former.


Try to come up with a list of ten points at the all-India level that seem noteworthy to you. And once you’re done with the list, then take a look at what the newspapers and columnists and op-eds are saying.

Is the story that you have come up with similar to theirs? If not, why? Might it be because they’ve done a better job in highlighting relevant material, or might it because they’re biased in some ways? Do you think they’re biased because of what they’ve written in the past, or because their interpretation of NFHS-5 differs from yours, or both? What is the probability that you are biased against them, rather than they being biased while writing whatever it is that they have written? How can one tell, really?

The bottom-line is this: if you consider yourself a student of economics, don’t form your opinions and biases by mirroring and mimicking the opinions and biases of folks you like. Begin with the data, form your own opinions, and then test them against those of others. Defend your ideas and conclusions by pitting them against those of others, and by engaging in respectful debate.

It’s a good way to study our country! 🙂

Update: Please take a look at this excellent Twitter thread about the history of NFHS. H/T: Sumita Kale.

India’s Demographics and the Total Fertility Rate

For many, many years, this was my slide on India’s TFR in lectures I used to give on India’s demographics:

Wikipedia (Old data)

What is TFR? Here’s Wikipedia:

“The total fertility rate (TFR) of a population is the average number of children that would be born to a woman over her lifetime if:

  1. she were to experience the exact current age-specific fertility rates (ASFRs) through her lifetime
  2. she were to live from birth until the end of her reproductive life.”

Hans Rosling had a better, more intuitive term: babies per women. Here’s an excellent chart from Gapminder, although ever so slightly outdated:

Click here to see the original chart, and please press on the play button to see this change over time

Here’s the excellent Our World In Data page about the topic, and here’s a lovely visualization of how the TFR has changed for the world and for India over time (please make sure to “play” the animation):

(I hope this renders on your screens the way it is supposed to. If not, my apologies, and please click here instead)

But now we have news: India’s TFR has now slipped below the replacement rate. Here’s Vivek Kaul in Livemint explaining what this means:

The recently released National Family Health Survey (NFHS-5) of 2019-2021 shows why. As per the survey, India’s total fertility rate now stands at 2. It was 3.2 at the turn of the century and 2.2 in 2015-2016, when the last such survey was done. This means that, on average, 100 women had 320 children during their child-bearing years (aged 15-49). It fell to 220 and now stands at 200.
Hence, India’s fertility rate is already lower than the replacement level of 2.1. If, on average, 100 women have 210 children during their childbearing years and this continues over the decades, the population of a country eventually stabilizes. The additional fraction of 0.1 essentially accounts for females who die before reaching child-bearing age.

https://www.livemint.com/opinion/columns/the-women-who-went-missing-in-our-demographic-dividend-11652200177580.html

And here’s the breakup by state, updated for the latest results:

By iashris.com – https://indiainpixels.xyz, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=112844699

Of course, as with all averages, so also with this one: you can weave many different stories based on how you slice the data. You can slice it by urban/rural divides, you can slice it by states, you can slice it by level of education, you can slice it by religion – and each of these throws up a different point of view and a different story.

But there are three important things (to me) that are worth noting:

  1. The TFR for India has not just come down over time, but has slipped below the global TFR in recent years.
  2. This doesn’t (yet) mean that India’s population will start to come down right away, and that for a variety of reasons. As Vivek Kaul puts it:
    “So, what does this mean? Will the Indian population start stabilizing immediately? The answer is no. This is primarily because the number of women who will keep entering child-bearing age will grow for a while, simply because of higher fertility rates in the past. Also, with access to better medical facilities, people will live longer. Hence, India’s population will start stabilizing in around three decades.”
  3. The next three to four decades is a period of “never again” high growth opportunity for India, because never again (in all probability) will we ever have a young, growing population.

Demography is a subject you need to be more familiar with, and if you haven’t already, please begin with Our World in Data’s page on the topic, and especially spend time over the section titled “What explains the change in the number of children women have?”