A Review of the Working of National Family Health Survey (NFHS) In India
By Aijaz Ahmad Turrey
The National Family Health Survey (NFHS) is conducted all over India, taking a representative sample of households. It is a broad survey piloted at different levels highlighting information about health for the entire country. Until now three rounds of the survey have been conducted – NFHS-1, NFHS-2, and NFHS-3. The main target of NFHS survey is to provide information about mortality, fertility, infant mortality and child health, family planning methods, anaemia and other diseases, reproductive status, and quality of health services. Each round of the NFHS has two precise objectives:
- “To provide necessary data on health and family welfare needed by the Ministry of Health and Family Welfare (MOHFW) and other agencies for policy and programme purposes”, and
- “To provide necessary information on emerging health and family welfare concerns.”
The Government of India and Ministry of Health has empowered the International Institute for Population Sciences (IIPS) as the nodal agency. This agency will be responsible for providing guidance to technical staff and field organizations and also coordination for successful implementation. The funding for different rounds of NFHS has been provided by USAID (United States Agency for International Development), DFID (Department for International Development), the Bill and Melinda Gates Foundation, UNICEF (United Nations Children’s Fund), UNFPA (United Nations Population Fund formerly United Nations Fund for Population Activities), and Ministry of Health, Government of India.
The first National Family Health Survey (NFHS-1) was conducted in 1992-93. The survey collected a lot of information, particularly on population, health and nutrition, and family planning with an emphasis on women and young children. The data was collected from 25 states including Delhi. Sample of 88,562 households and 89,777 ever-married women in the age group 13-49 were chosen for the purpose of interview. Data collection was carried out in three phases from April 1992 to September 1993. In the NFHS-1, the sample frame was ever-married women, 15-49; anthropometric data were collected from all children under the age of four living with their mother and whose mother completed the women’s questionnaire.
The second National Family Health Survey (NFHS-2) was conducted in 1998-99. The main indicators which were covered by the survey include information on the quality of health and family welfare services, status of women, women’s reproductive health, domestic violence, nutritional status of women, height and weight measurements of all eligible women and young children, blood testing of ever-married women and their children below age three. A sample of about 91,000 ever-married women, age 15-49, from 26 states was covered by the survey in India. In the NFHS-2, the sample frame was ever-married women, 15-49; anthropometric data were collected from women completing the women’s questionnaire and all children under the age of three living with their mother and whose mother completed the women’s questionnaire.
The third National Family Health Survey (NFHS-3) was carried out in 2005-06. In NFHS-3 more than 230,000 women, age 15-49, and men, age 15-54, are interviewed throughout India. Also more than 100,000 women and men were tested for HIV and more than 200,000 adults and young children for anaemia. In the NFHS-3, the sample frame was all women, 15-49; anthropometric (measurement of the size and proportions of the human body) data were collected from women completing the women’s questionnaire and all children under the age of five listed in the household questionnaire.
Fourth National Family Health Survey (NFHS-4) was started in 2014-15 and is still to be completed. It is expected to cover the entire country for the first time. All the states and union territories will be surveyed and most indicators will be selected at district level, covered in 2011 census. The sample size is expected to be approximately 568,200 households. In these households, information on 265,653 children below age 5 will be collected in the survey. Data will be collected using Computer Assisted Personal Interviewing (CAPI) on mini-notebook computers. Like the earlier surveys, it will cover the same range of health-related issues and also new issues such as high-risk sexual behaviour, safe injections, tuberculosis, and malaria, non-communicable diseases, and domestic violence.
The National Family Health Survey (NFHS) is a broad survey providing information regarding number of health issues of the households surveyed. It covers health, family planning, diseases, and much more. The main categories of the coverage include:
- Characteristics of the Household Population.
- Adult Literacy, Education, and Employment
- Marriage and Fertility
- Family Planning Knowledge and Use
- Infant and Child Mortality
- Maternal Health Care
- Coverage and Utilization of ICDS
- Child Nutrition and Child Health
- Women’s and Men’s Nutrition
- Adult Health and Health Care
- HIV/AIDS Knowledge and Sexual Behavior and HIV Prevalence
- Family Life Education
- Women’s Empowerment and Domestic Violence
NFHS mainly uses the following types of questionnaires: the Household Questionnaire, the Woman’s Questionnaire, the Men’s Questionnaire, and the Village Questionnaire. The questionnaires used are mainly bilingual, consisting of questions in both the state language and English. The questionnaire is first translated to local language and then translated back to English once the information is obtained.
- Household Questionnaire: The Household Questionnaire lists all the residents of the household and also those persons who stayed there during night. The basic information of the listed persons such as sex, age, education, marital status, occupation and relationship to the head of the household is also collected. It also covers information on the type of toilet facilities, cooking, source of water, construction, lighting, agriculture, and live-stock. Religion, caste, place and records of birth and death within last two years are also recorded. The main objective of the household questionnaire is to find the women who are eligible to answer to the Women’s Questionnaire, including only ever married women, age 13 – 49 years.
- Women’s Questionnaire: The Women’s Questionnaire used by NFHS highlights the information collected from all ever-married women, usual residents as well as visitors, age 13-49 years. The questionnaire is divided into seven parts. These are:
Respondents Background: Information on age, marital status, age at marriage and education of the eligible women as well as visitors (if any) own household information is covered.
Reproduction: Total number of children that a woman has given birth to, stillbirths and abortions, birth and death history of children, current pregnancy and menstruation status.
Contraception: Use of and attitudes toward various family planning methods.
Health of Children: Births in the year of the survey and previous four calendar years and health of the children.
Fertility Preferences: Desire for additional children, sex composition of children, family size, birth intervals and husbands attitude toward family size.
Husbands Background and Women’s Work: Age, education and work status of the woman and her husband.
Height and Weight: The height and weight of children mostly under age four are measured to check the nutritional status and health of children.
- Men’s Questionnaire: The Men’s Questionnaire is designed to interview men, age 15-54, who are usual residents of the sample household or visitors who stayed in the sample household the nightbefore the survey. It contains a subset of questions that are covered in the Women’s Questionnaire, plus some additional questions only administered to men such as reproductive behavior and intentions, knowledge and use of contraception, male involvement in health care, attitude toward gender roles and sexual life.
- Village Questionnaire: The Village Questionnaire is another important questionnaire used by the NFHS to collect information on various amenities in the villages covered under the NFHS such as water, transport, health, and educational facilities. The Village Questionnaire was managed only in the rural areas.
NFHS discussed its sample design for the first time during a Sample Design Workshop in October 1991, held in Madurai. NFHS uses a uniform sample design in the covered states. It is a systematic design, stratified sample of households, with two stages in rural areas and three stages in urban areas.
No particular sample size is adopted by NFHS in India. It differs with the size of population in different states. Even the three rounds conducted so far used different sample size. However, a target sample size is considered regarding the size of the strata, the resources and the time available for the survey. Initially in 1991, a target sample of 3000 was taken for states having 25 million populations or less and 4000 for states having more than 25 million populations. For UP, it was 8000 and 1000 for Arunachal Pradesh, Manipur, Mizoram, Meghalaya, Nagaland, and Tripura. The sample size increases with the increase in population. However, it is proportionally allocated to the size of the rural-urban populations. Sometimes many small areas are oversampled due to small size.
In rural areas, a two-stage stratified sampling design is used. First a village is selected followed by a selection of households. While selecting a village several variables are considered such as village size, literacy, SC/ST population, distance from town, etc. The stratification varies from 12 (and less) strata for small states and 15 (and less) strata for large states. Probability Proportional to Size (PPS) technique is used for choosing primary sampling units (PSUs) consisting of 30 households on an average. All these households are then approached to collect data and no substitution of a household is allowed by the supervising team consisting of CO, PRC, and field staff in each state.
The process of collecting data and information from the urban areas consists of a three-stage sample design. First cities/towns are selected followed by urban blocks and finally households. The selected cities/towns are then sub-divided into three strata:
- Self-selecting cities (having certainty),
- Towns that are district headquarters, and
- Other towns.
As in rural areas, PPS technique is used to choose PSUs consisting of an average 20 households per block.
Field Staff and Training
The entire fieldwork is carried by a number of interviewing teams in each state. The interviewing team consists of one field supervisor, one field editor, and four interviewers. The number of the teams differs in different states depending upon the size of population, number of samples and sample size. The interviewers are not permanent members but are hired in each state and preference is mostly given to females who can discuss topics with women more comfortably.
The selection of the persons for the purpose is done on the basis of their educational qualification and experience in the relevant field. The entire field-staff is given training for a minimum of twenty days in each state. They are also given instructions on the methods of asking questions, recording answers, using languages, filling questionnaires, weighing and measuring children, error detection and much more. The training and instructions are given in order to ensure uniformity in data collection procedures in different states.
Field Survey Limitations
NFHS is a national survey conducted for the entire country as a whole. Like other surveys, it is also subjected to a variety of field problems. Among the problems encountered, the major ones are highlighted below:
- Security of teams
- Household identification
- Drop-out of members of interviewing teams
- Temporary absenteeism of households
- Unseasonal rains
Survey Results Presentation
When all the required information is obtained from all the selected samples, a survey report is prepared. In this report, the results are shown separately for rural areas, urban areas, and total India. The results from all the covered states is shown and compared. The data is then published and is ready to use by everyone.
NFHS is a national level survey, providing us almost all data regarding health status of India. The information provided by NFHS is used as a secondary source data for almost all studies done in the areas of health. The data is cross sectional in nature and therefore is considered as authentic. Although, since it is a secondary data, it is not entirely free from a few inherent drawbacks. At many places, information on condition of health, service availability, distance, and availability of medicines is not covered because of the limitations given above. Even after three rounds, it is still unable to cover the entire country.
- Dey, D.K. & Mishra, V. (2014), “Determinants of Choice of Healthcare Services Utilization: Empirical Evidence from India”, Indian Journal of Community Health, Vol. 26, Issue No. 04.
- International Institute for Population Sciences (IIPS) & Macro International, (2007), National Family Health Survey (NFHS-3) 2005–06: India, Volume I, Mumbai: IIPS.
Aijaz Ahmad Turrey is Research Scholar, Centre for Studies in Economics and Planning, Central University of Gujarat, Gandhinagar, Gujarat, India.
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