Necessary, a public health data architecture for India


It would be better to have few comprehensive national surveys than to be too dependent on the NFHS omnibus

It would be better to have few comprehensive national surveys than to be too dependent on the NFHS omnibus

In a country always thirsty for reliable health data, the National Family Health Survey (NFHS) is like an oasis. It contains a large volume of freely accessible data. The NFHS fifth cycle report was recently released (covering Phase 2 states where data collection has been delayed due to the novel coronavirus pandemic). Since then we have had an avalanche of articles from journalists and scientists covering different aspects (malnutrition, fertility, domestic violence to name a few). It is the go-to source for many researchers and policy makers and is frequently used for various rankings by NITI Aayog.

Scope and scope

For the uninitiated, the NFHS is a large survey conducted among a representative sample of households across India which started in 1992-93 and is repeated at an interval of about four to five years. It is the Indian version of the Demographic and Health Surveys (DHS), as it is called in other countries. Currently, the survey provides district-level information on fertility, infant mortality, contraceptive practices, reproductive and child health (RCH), nutrition, utilization and quality of selected health services. Respondents are mostly women of childbearing age (15-49), including husbands. The fifth cycle covered 6,36,699 households, 7,24,115 women and 1,01,839 men across the country. Each survey costs over ₹250 crore and funding for the various rounds of NFHS has been provided by the United States Agency for International Development (USAID), Department for International Development (DFID), Bill and Melinda Foundation Gates (BMGF), UNICEF, the United Nations Population Fund (UNFPA) and the Government of India’s Ministry of Health and Family Welfare.

Over the years, its scope has expanded to include HIV, non-communicable diseases or NCDs (tobacco and alcohol, hypertension, blood sugar, etc.), vitamin D3. It has now become an omnibus train where everyone is free to board for a ride. It offers something for everyone. While there is a level of efficiency in adding certain questions to an existing survey, this was lost long ago in the NFHS. In NFHS-4, the household questionnaire had 74 questions, the female questionnaire had 93 pages with 1,139 questions, and the male questionnaire had 38 pages with 843 questions. The NFHS-5 questionnaire was even longer. The size of the survey has obvious implications for data quality.

Other investigations and purposes

The NFHS is coordinated by the International Institute of Population Sciences (IIPS Mumbai) and the actual survey is outsourced. There is a set of entrenched agencies surviving on this survey. Questions have been raised about the quality of these agencies and their workers. The NFHS is not the only survey conducted by the Department of Health. Over the past five years he has conducted the National Non-Communicable Disease Surveillance Survey (NNMS), National Mental Health Survey (NMHS), Global Adult Tobacco Survey (GATS) , the alcohol survey, the National Comprehensive. Nutrition Survey (CNNS) and many others. Many of these have been implemented by leading academic institutions at costs below ₹25 crore, although none of these have generated district-level estimates.

Some of these surveys are carried out to meet global commitments on targets (NCDs, tobacco, etc.). However, the requirements for monitoring NCD targets are not met by the NFHS, as it covers a different age group than that required for the global set of indicators. Yet efforts to sanction the NNMS have met with stiff resistance, with policymakers believing that the NFHS is enough to answer these questions. As already said, for tobacco, we have another vertical survey. So why do we have questions about this in the NFHS? This is because we confuse research with program monitoring and surveillance needs. Questions about domestic violence and collecting blood for vitamin D3 levels are good examples of this imbalanced thinking.

Alignment is difficult

There have been previous attempts to align these surveys, but they have failed because different advocates have different “demands” and push for inclusion in their set of questions. While the Program Planning, Statistics and Monitoring Department is supposed to take a last call, it lacks the technical capacity and clout to do so and ends up using a please-all approach of accept all requests with some alignment effort. Everyone is happy, except perhaps the actor without bargaining power, the household selected for the survey.

Another reason why these questions are not completely dropped is that the NFHS is the only major survey India used to do on a regular basis. It is unclear if and when the other surveys will be repeated. For example, we have no guarantee that the second round of the NNMS will take place, although it is due. So the general thought is that “do everything possible, because something is better than nothing”. Multiple surveys also raise the issue of different estimates, as is likely due to sampling differences in the surveys. We have noted this for example in the case of tobacco, where differences in estimates of tobacco use from the Global Adult Tobacco Survey (GATS) and the NNMS have required much reconciliation effort. and explanation. Another example is the issue of the large discrepancy in sex ratio at birth reported by the NFHS and the Sample Registration System (SRS). The SRS is a better system for this because it continuously enumerates the population unlike the NFHS which is a cross-sectional survey well known for its recall biases.

There must be a purpose

It is time to challenge this rationale and end the overreliance on an omnibus survey to provide all public health data for India. Experience from the NFHS and other surveys has conclusively demonstrated our ability to conduct large-scale surveys with computer-assisted interviewing and reasonable time and cost. Can we now show that we have the capacity to plan for public health data needs for the country and ensure that this data is collected in an orderly and regular manner with an appropriate budget allocation? This requires clarity of purpose and an uncompromising approach to the issue. Some tough calls will have to be taken, including questioning the need for vertical surveys, regardless of domestic or international funding.

We need to identify a set of indicators and surveys at the national level which will be carried out using national public funds at regular intervals. I propose only three national surveys – an abbreviated NFHS focusing on reproductive and child health (RCH) issues, a behavioral surveillance survey (focusing on HIV, NCDs, water, sanitation and hygiene (WASH ) and other behaviors) and a nutritional-biological survey (collection of data on blood pressure, anthropometry, blood sugar, serology, etc.) carried out every three to five years on a staggered basis. We have to look at other models and choose what works best for us. This does not include mortality and health system data sources.

A roadmap

I also propose, as was done for the NNMS, that we sample at the national level for such surveys and ask states to invest in conducting targeted surveys at the state level. States must become active partners, including by providing financial contributions to these investigations. For a detailed understanding of certain issues, each survey cycle can focus on a specific area of ​​interest. Other important public health questions can be answered by specific studies (which may or may not require a study at the national level), conducted by academic institutions on a research mode based on the availability of funding. It is also very important to ensure that the data from these surveys is in the public domain. This allows different analyzes and viewpoints to be presented on the same data set, which enriches the discussion and unlocks the full potential of the survey.

Are we ready to establish a public health data architecture that a country of our complexity needs? We have the technical capacity to do so. All that is needed now is the political will.

Dr. Anand Krishnan is a Professor at Center for Community Medicine, All India Institute of Medical Sciences, New Delhi. He participated in many of these surveys in an advisory capacity. Opinions expressed are personal


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