This is a brief insider story of my small role in nudging the system to increase the frequency of the National Family and Health survey from once in 10 years to once in five years. It is an interesting case study in public policy where a combination chance and homework, and some perseverance, can lead to a public policy initiative.
The time to narrate it is relevant now with the release of the preliminary results of the much-awaited NFHS-6 survey round. The data will remain in circulation and in public discussions for some time as the district level data getting released in due course.
NFHS data has always engaged the attention of the public health professionals, health and nutrition bureaucracy and political leadership alike. Criticism of the data quality, whenever the indicator is unpalatable, cuts across political ideology, citing in the same breath the favourable results from the NFHS. Nevertheless, everybody accepts the data, even if grudgingly, as a good quality data on maternal and child health and nutrition.
The survey for first three rounds of the NFHS had been conducted with a 10-year interval. Besides, these were representative only at the state level, not below it. The 4th survey round (2015-16) also followed the same decadal gap but with a difference; it was much more granular and also representative at the district level given a much larger sample size.
By this time, I had retired from the Civil Service and had joined my alma mater, IIT Bombay as a full time Professor. This gave me an opportunity to engage with the data at a granular level and appreciate its use for policy and programme intervention. But I also realized, that the next round would be in 2025-26 going by the current pattern. More importantly, most of the policy and programme level discussion will soon term this data as old and go ahead with their business-as-usual approach in programme intervention. Was there a way that these data were collected every five years?
This was also a time of great interest in doing something about child health and nutrition. My association with the UNICEF, other donors and some of the state governments, Maharashtra and Odisha in particular, made me think about the possibility of initiating a discussion about NFHS like surveys every five years. Incidentally, Odisha had done a NFHS like survey, termed the CCM (Concurrent Child Monitoring), right at the block level through DFID support. Surely some states could be persuaded to do a state level survey, between two NFHS rounds. These could be called the SFHS or even NFHS 4.5.
In some of the detailed discussions with the state governments at the level of the Secretary and even the Chief Secretary, the idea was considered interesting. But many doubts arose. Who will do it? What will be the cost? Will central Government allow it? Both Maharashtra and Odisha had shown relatively better performance in the NFHS – 4 indicators. So, giving a shot to the SFHS 4.5 was not considered to be a bad idea. Once the state expresses a favourable view, donor agencies follow suit. So, the funds would not have been an issue. Moreover, if the IIPS, which had handled all the rounds of the NFHS so far agreed to do similar survey, everybody would be comfortable. So IIPS was the next port of call!
I have had a long association with the IIPS, the International (earlier Indian !) Institute of Population studies since 1992-93, given my research on the declining sex ratios in India. I knew the faculty handling the NFHS as well. This helped me ascertain the possibility of their doing a state level survey and the rough costs involved. They were quite enthusiastic.
But while Maharashtra was okay with the idea of the IIPS doing the survey, Odisha was not quite keen on this. Could we look at another agency? Preferably, from within the state?
This was somewhat unexpected. Given my long association with the State as an IAS officer of the Odisha cadre, I was able to find out which agency had done the CCMB survey. It happened to be the ICMR Bhubaneshwar. Would the state government be okay if they do this? ICMR also had an advantage. They could be assigned the task on a nomination basis – there was no need to call for tenders and face any associated issues.
Now the Yaksha Prashna? Will GoI agree? Even if the states were not seeking funds, they would want some explicit nod from the Centre and not rub them the wrong way. This was a fair enough position. Even the potential funding agencies would also favour this view.
Naturally, Secretary MoHFW was the next post of call. I had known him during my tenure in Delhi in the Cabinet Secretariat. So, I sought a time for discussion. We soon met in his office. I briefly explained the idea of an ‘intermediate’ survey, an SFHS or, if the GoI permits a state level NFHS 4.5 if a state wishes to do it with their own resources. This was a rather unusual idea. ‘Which states would want to do it”? he asked.
“Maharashtra and Odisha”, was my response. “Of course, they will certainly like to do so. They are better performing states – one on the eastern coast and one on the west.”
“Why not encourage them then? We don’t want funds. Just your help in seeing that no spanner is put in the works (Paise nahee chaahiye, bus adangaa mat lagaanaa).” Money was not an issue he assured me. But the idea of letting a state do this ….! Why don’t we do this from the Centre, Sir for four states. One from the south and one northern state?”
“I would be delighted” I responded, take one better performing state from the south, like Tamilnadu, and one from the north such as Haryana covering all the four zones!”
To my surprise, he immediately called the Additional Secretary over. “Look at what Sir is saying – a state level survey between the two NFHS rounds”. I explained the idea, also cited the CCMB survey of Odisha which I had used for some internal analysis. The AS, himself from the Odisha Cadre, knew this part. “We should do it Sir, there will then be a uniformity in the approach. We can in fact ask IIPS to do the survey. What’s the point in sitting idle for 10 years (Dus saal khalee baithane me kyaa matlab hai). But…”, he paused, “we will also need to also take one state from the North East”.
The meting concluded on a positive note with an assurance that they will positively think this over. But I should not in the meantime press the matter ahead with the states and give them some time to think through the modalities. I had no reasons to differ.
Few days later I did check with the AS, as to what was happening. He assured me that the idea is being taken ahead. Some days passed. I tried to check again. The AS was on a visit abroad and was likely to be back only after a week.
I decided to try my luck with the JS concerned, whom I happened to know as well. The JS heard my query and laughed. He perhaps was unaware my meeting with the Secretary and the AS. That is not unusual. “What five states sir. There is some confusion. This will be an all India survey!”
I fell from my chair! “Are you saying that there will be a NFHS-5 now? With 5 year interval?” There was an emphatic “Yes” from his side. I was delighted to put it mildly. Rest is history.
This is an interesting case in public policy advocacy. There was a huge element of chance, my being at the right meetings at the right time. The element of I, is purely incidental. I was just lucky. But there is also the element of homework, and of course perseverance.
Why did I then not write this piece after NFHS-5 then?
Well. I am conservative by nature in these matters. Firstly, I did not want to jump the gun. I wanted the NFHS-5 to happen before believing it happened. This was when we had COVID-19. Then the Census of 2021 got deferred. Even after the NFHS-6 actually happened I decided to wait given all the delays in release of the data. Now that the state level fact sheets have been released, I thought penning down this anecdote. Hope you enjoy it.
[PS: Once NFHS-5 got going, I did persuade the Secretary Tribal Welfare, Odisha (May God bless her), to do a Tribal Health and Family Welfare through ICMR Bhubaneshwar. This has since been completed. God willing, similar exercise may happen at all India level entirely at her initiative. I have no role in it. But I am happily keeping my fingers firmly crossed!]