India needs a public health data structure

In a country always thirsty for reliable health data, the National Family Health Survey (NFHS) is an oasis. It has huge amount of data which is openly accessible. The report of the fifth round of NFHS was released recently (Phase 2 covering states where data collection was delayed due to the novel coronavirus pandemic). Since then, we have had a slew of articles by journalists and scientists covering various aspects (malnutrition, fertility, domestic violence to name a few). It is the most popular source for many researchers and policy makers and is frequently used by NITI Aayog for various rankings.

range and scope

For non-starters, the NFHS is a large survey conducted in a representative sample of households across India that began in 1992-93 and is repeated at intervals of about four to five years. This is the Indian version of the Demographic and Health Survey (DHS), as it is known in other countries. Currently, the survey provides district-level information on fertility, child mortality, contraceptive practices, reproductive and child health (RCH), nutrition, and access and quality of selected health services. The respondents are mainly women of reproductive age group (15-49 years) including husbands. 6,36,699 households, 7,24,115 women and 1,01,839 men were covered across the country in the fifth round. The cost of each survey is over ₹250 crore and funding for the various visits to the NFHS is provided by the United States Agency for International Development (USAID), the Department for International Development (DFID), the Bill and Melinda Gates Foundation (BMGF). UNICEF, United Nations Population Fund (UNFPA), and Ministry of Health and Family Welfare, Government of India.

Over the years its scope has expanded to include HIV, non-communicable diseases, or NCDs (tobacco and alcohol use, high blood pressure, blood sugar, etc.), vitamin D3. It has now become a ubiquitous train where anyone and everyone is free to board along for the ride. It offers something for everyone. While there is a level of efficiency in adding some questions to the existing survey, this is long ago lost in the NFHS. In NFHS-4, the household questionnaire was 74 questions, the women’s questionnaire was 93 pages long with 1,139 questions and the men’s questionnaire was 38 pages long with 843 questions. The NFHS-5 questionnaire was even longer. The size of the survey has a clear impact on data quality.

Other surveys and targets

The NFHS is coordinated by the International Institute of Population Sciences (IIPS Mumbai) and the actual survey is outsourced. There’s a bunch of agencies that are surviving on this survey. Questions have been raised on the quality of these agencies and their staff. The NFHS is not the only survey that the Ministry of Health conducts. Over the past five years, it has conducted National NCD Surveillance Survey (NNMS), National Mental Health Survey (NMHS), Global Adult Tobacco Survey (GATS), Alcohol Survey, comprehensive national Nutrition Survey (CNNS) and many others. Many of these have been implemented by leading educational institutions at a cost of less than ₹25 crore, although none of these are district-level estimates.

Some of these surveys are conducted to meet global commitments on targets (NCD, tobacco, etc.). However, the requirements for monitoring NCD targets are not met by the NFHS, as it covers a different age group than is required for the global set of indicators. Nevertheless, efforts to get the NNMS approved met stiff resistance as decision-makers felt that the NFHS was sufficient to answer those questions. As already said, we have another vertical survey for tobacco. Then why do we have questions on these in the NFHS? This is because we are confusing research with program monitoring and monitoring requirements. Questions on domestic violence and blood collection for vitamin D3 levels are good examples of this one-sided thinking.

alignment is difficult

There have been previous attempts to align these surveys, but they have failed because different advocates have different “demands” and insist on including their own set of questions. While the planning, statistics and program monitoring department has to make the final decision, it lacks the technical capability and ability to do so and ends up using a “please-all” approach of accepting all requests with some effort in alignment. it happens. Everyone is happy, except perhaps the stakeholder who does not have negotiating power – the family selected for the survey.

Another reason not to leave out these questions completely is that the NFHS is the only major survey that India has the record of doing regularly. One does not know when and if the other surveys will be repeated. For example, we have no guarantee that a second round of NNMS will be conducted, although it is payable. So, the general thinking is “do whatever is possible, because something is better than nothing”. Multiple surveys also raise the problem of differing estimates, as is likely due to sample differences among surveys. We noted this for example in tobacco, where differences in estimates of tobacco use from the Global Adult Tobacco Survey (GATS) and the NNMS required much effort to reconcile and clarify. Another example is the issue of wide variation in sex ratio at birth as reported by NFHS and Sample Registration System (SRS). SRS is a better system for this as it continuously calculates the population unlike NFHS which is a cross-sectional survey which is known to have recall bias.

the objective should be

The time has come for us to question this logic and end the over-reliance on a comprehensive survey to provide all public health data for India. The experience of the NFHS and other surveys has conclusively demonstrated our ability to conduct large-scale surveys with computer-aided interviews and reasonable quick turnaround and cost. Can we now show that we have the ability to plan for the country’s needs for public health data and ensure that these data are collected in a systematic and regular manner with appropriate budgetary allocations? It requires clarity of purpose and a rigorous approach to the issue. Irrespective of national or international funding, some difficult decisions will have to be made, including questioning the need for vertical surveys.

We have to identify a set of national level indicators and surveys which will be done at regular intervals using national government funds. I propose just three national surveys – a brief one focusing on NFHS reproductive and child health (RCH) issues, a behavioral monitoring survey (related to HIV, NCDs, Water Sanitation and Sanitation (WASH) and other behaviours). is focused) and a nutrition-biological survey (which includes collection of data on blood pressure, anthropometry, blood sugar, serology, etc.) is carried out every three to five years in a staggered manner. We need to look at alternative models and choose the one that suits us best. It does not include data sources on mortality and the health system.

a road map

I also propose, as was done for NNMS, that we take a national level sample for such surveys and ask the states to invest in conducting focused state level surveys. States have to be active participants in these surveys including providing financial contributions. For a detailed understanding of certain issues, each round of the survey may focus on a specific area of ​​interest. Other important public health questions can be answered by specific studies (which may or may not require national level studies), conducted on a research mode depending on the availability of funding by academic institutions. Is. It is also very important to ensure that the data arising out of these surveys are in the public domain. This enables different analyzes and perspectives to be presented on the same set of data, enriching the discussion and revealing the full potential of the survey.

Are we ready to establish a public health data structure with the complexity we need in a country? We have the technical capability to do so. Now all we need is political will.

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