Feed the children, raise income security

The national family health survey gives a rounded picture of the state of the nation’s health. The fifth and the latest one, recently released, captures the details as they prevailed during 2019-21. Importantly, the field work for the survey has been conducted in two phases — June 2019 to January 2020 and then from January 2020 to April 2021.

This means that the critical changes that took place in the health of the nation as a result of the Covid pandemic have been only partly captured in the second phase. Plus, there are always data issues in such large surveys, covering over eight lakh people from over six lakh households, many of whose responses have been accessed even as the pandemic has been on. Keeping these caveats in mind, the survey results can be examined for the insights they contain.

From the insights, various policy issues will emerge which call for action. As different aspects of health influence one another, the policy imperatives that appear on the radar can likely be combined into an overall policy stance. This can help us answer the question: what should be the contours of health and economic policies so as to keep strengthening the nation’s health?

The foremost finding is that for the first time, the national fertility rate (the number of children that a woman can bear in her lifetime) has gone down to 2.0, which is below the replacement rate of 2.1 at which a headcount plateaus. This is unlikely to be a flash in the pan as the rate has been steadily falling along almost a straight line from 5.6 in 1970. As at the current rate, the national headcount will actually be falling, the whole idea of having a family planning programme whose aim is to bring down the rate of growth of population and which India has pursued for over half a century needs to be re-examined.

Over time, India could well emerge in the company of countries like Japan, South Korea, and most recently, China which have to reckon with the consequences of a dwindling, and therefore, aging population. If that be so, then what happens to the demographic dividend which emerges when a young nation’s working age population keeps growing, as opposed to the dependents, like the very young and the aged, and enabling a more rapid rise in income? So, is India’s good fortune of foreseeing a demographic dividend coming its way disappearing even before it fully arrives?

But before we jettison the family planning programme, we have to remember that the national figure is an aggregate, containing states whose fertility rates are above as well as below the national average. So, India cannot have a uniform policy, which a smaller and more homogeneous country can live by. Bihar (3) and UP (2.4) with high fertility rates will definitely need to continue with the family planning programme as opposed to West Bengal (1.6) and Kerala (1.8) which may have to ponder over whether they need to take steps to give a push to the total number of babies that arrive in a year.

And if these states also have large numbers of skilled and unskilled workers migrating out, then what are the implications of becoming a remittance economy? When something like a pandemic hits, the workers may have to return home and the remittances can dry up, causing a more debilitating economic impact than would otherwise have been the case.

This apart, the national picture that emerges from the latest survey is positive in many ways. The sex ratio has improved from 991 (females per 1,000 males) in 2015-16 (the previous survey) to 1,020 in the latest (2019-21), indicating that the social attitudes of preferring boys may be changing. The infant mortality rate (per 1,000 live births) has improved, that is, it has gone down from 40.7 to 35.2; more people are practising family planning (from 53.5 per cent to 66.7 per cent); and institutional births indicating access to proper healthcare have risen from 52.1 per cent to 61.9 per cent.

When it comes to children, the picture is almost dismal. The proportion of anaemic children has gone up (from 58.6 per cent to 67.1 per cent). This is not surprising as only an abysmally low 11.3 per cent get an adequate diet. So, public policies to deliver nutritional aid to children have not just to continue but also expand.

The status of women presents a mixed picture. The proportion of women who have their own bank accounts which they themselves operate has gone up sharply from 53 per cent to 78.6 per cent, and it is likely the impact of the Jan Dhan Yojana. There is also good news, though not as dramatic as with bank accounts, on the proportion of women with mobile phones which they themselves use going up from 45.9 per cent to 54 per cent.

But the proportion of women who worked in the last 12 months and were paid in cash has gone up just marginally from 24.6 per cent to 25.4 per cent. Since this figure is from the second phase of the survey which overlaps with the lockdown that rendered a lot of poor people jobless, the employment guarantee programme should have been able to make a larger impact and have delivered cash wages to more poor women who were without work.

Even as India’s poor struggle, a small section shows signs of adequate income, giving rise to an unhealthy lifestyle. The proportion of men and women who are obese has gone up from around 20 per cent to 24 per cent.

The overall policy prescription that emerges from this data is that public expenditure on healthcare and generating employment among the poor should increase even as family planning should continue to be promoted selectively. As incomes rise and the poor feel more secure, they will on their own decide to have fewer children.