World's Largest Health Care Report Card
How do governments, doctors and aid workers decide what is needed to improve public health if they do not have accurate, nationwide information? This was the scenario facing India's public health establishment 15 years ago. Information existed on various health issues plaguing India, but it was not useful for tracking progress, for providing national level updates or for comparing health indices between states.
In 1992, the United States Agency for International Development (USAID) funded a mechanism for collecting more accurate information on health indicators in India. USAID teamed with the East-West Center, Macro International and the United Nations Children's Fund (UNICEF) to launch the first National Family Health Survey (NFHS-1). This household-level survey is now in its third round and is the largest in the world.
The beginning, however, wasn't easy. In 1992, such a large health survey had never been conducted. There was much skepticism regarding the ability to ensure accuracy and control quality. In a large, diverse country like India, creating a survey system that addresses these concerns is difficult. It requires rigorous development, an army of interviewers and an extensive logistics network. NFHS-1 developed just such a system. It covered 24 states and Delhi, interviewing 88,562 households and 89,777 women who had been married. The result: a survey that provided India with accurate nationwide measures of nutritional status, maternal and child health, and reproductive health. The survey also allowed India to conduct state-to-state comparisons and provided a baseline for tracking each state's progress on health issues.
The success of the first National Family Health Survey garnered additional support for the second survey, conducted between 1998 and 1999. It was coordinated by the Mumbai-based International Institute for Population Sciences, endorsed by the Government of India's Ministry of Health and Family Welfare, funded by USAID, and supported by UNICEF and Macro International. As in the earlier survey, the principal objective was to provide state and national estimates of fertility, the practice of family planning, infant and child mortality, maternal and child health, and the utilization of health services provided to mothers and children. It measured the nutritional status of Indian women, and in particular, measured levels of anemia through blood samples. The survey also enquired into domestic violence-allowing India to gauge the amount of abuse taking place in households.
The two surveys furthered the public knowledge of India's health status and gave leaders information on which to base decisions. In India this is crucial, considering that 80 percent of health services are provided by the public sector. By comparing the state-level results from the two surveys, health professionals could measure how well earlier programs had impacted specific states. They also could make informed changes to those programs where necessary.
For the third survey, conducted in 2005-06, there was a marked difference. No longer was USAID footing the bill on its own (it acted as the coordinating body for donor organizations). Other development organizations had recognized the survey's value and funded it. The Government of India played a more direct role and took full ownership of the survey.
The focus of the third survey grew to include testing for HIV, the virus that causes AIDS. For the first time, India will be able to use household-level sampling to determine the country's HIV prevalence rate. The survey also measured attitudes about education and expanded to include men and never married women.
However, the real accomplishment of the survey has not been its findings but its impact. The recent dissemination of the NFHS-3 data has spurred debate in the media. Prime Minister Manmohan Singh has cited it regularly-using it as a tool for focusing India's public health response.
Decision-makers are already drawing conclusions and taking action based on the survey. For example, Health Minister Anbumani Ramadoss referred to the National Family Health Survey finding that the percentage of women and children in India who are anemic had increased to 56 percent and 79 percent respectively since the late 1990s. "This really is a cause of concern for the government," Ramadoss told the Reuters news agency in April. He said the government, among a package of new measures, would intensify deworming among children and provide them with iron tablets to prevent anemia, as well as increase the number of health workers in rural areas to detect and help malnourished infants.
Meanwhile, NFHS-2 findings are the raison d'être for the National Rural Health Mission, a massive initiative to improve the health of the rural population. The surveys were also used for determining the direction of India's 10th Five-Year Plan and are being used in the drafting of the 11th Five-Year Plan. In fact, it is hard to find an Indian health or family welfare policy that does not mention NFHS 1, 2 or 3 findings as the basis for its decision.
Partnerships add value
Thirty-three partner organizations supported the third survey through funding, implementation, testing of samples, technical assistance and data collection.
Thanks to this more robust and diverse funding from private and public sources the third survey is significantly wider in scope and reach. Engaging new partners brought an additional $8 million, and USAID funded the remainder for the $12.5 million project.
The expanding partnership, led by USAID and the Government of India's Ministry of Health and Family Welfare, includes the Bill & Melinda Gates Foundation, UNICEF, the Department for International Development (United Kingdom), and the United Nations Population Fund.
The International Institute of Population Sciences has implemented all three surveys, which "raised the brand identity of the institute," says the director, Dr. P.N. Mari Bhat. "USAID gave us access to survey expertise from around the world. That raised the quality of our work to a higher standard."
New partners such as the Bill & Melinda Gates Foundation were attracted to the NFHS because of its credibility and impact on policy. "We know that the NFHS is the only household survey on health in India. When given the opportunity we wanted to support it and take this chance to get rich data on HIV/AIDS," says Ashok Alexander, director of Avahan, the foundation's India AIDS Initiative. "As partners, our contributions to the greater good increase when we combine the resources of two organizations."
A gigantic undertaking
The third National Family Health Survey was a gigantic exercise in logistics. Research organizations had to interview 124,385 women and 74,369 men in 3,849 villages and urban centers across India.?Some 1,840 individuals and 230 interviewing teams were in the field.
First, workshops, practical sessions and training of trainers on household listing, mapping and data processing were required to ensure quality control. Comprehensive manuals for field workers and supervisors also helped to maintain uniform procedures. Interviewing teams traveled to dangerous areas, working in severe weather and in some cases walking long distances with heavy equipment.
NFHS-3 was the first large scale nationwide survey to collect dried blood samples for HIV testing. Nearly 110,000 women and men were tested for HIV and more than 200,000 adults and young children were tested for anemia. For this, health coordinators and medical personnel had to be trained in blood collection and testing methods. SRL Ranbaxy, with its network of collection centers, conducted the HIV tests. Blood was first collected on filter paper cards and dried overnight. Within five days samples had to be sent to one of 500 Ranbaxy collection centers and then transported overnight to the Ranbaxy laboratory in Mumbai. All samples had to reach Mumbai within seven days of collection. In some cases, that required traversing more than 3,230 kilometers over dirt roads with limited infrastructure to reach Mumbai in time. Thanks to careful planning and logistics, the validity of the findings can withstand scrutiny.
Alex Gainer is a USAID project development officer in India. Kristen Easter, USAID/India's communications officer, and Archana Mirajkar, a USAID communications specialist, contributed to this article.
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Nearly Half of All Indian Children are Malnourished
The third National Family Health Survey revealed that 46 percent of all Indian children are malnourished. The infant mortality rate, though improving, is still high and much worse than other developing countries. This is complicated by the fact that less than half of all Indian women receive care after childbirth and only 40 percent give birth in hospitals or medical centers. USAID food programs reach more than 6.6 million women and children while other programs help increase the consumption of necessary nutrients such as vitamin A and zinc. The use of oral re-hydration salts has increased in USAID focus states, helping to manage childhood diarrhea, a major killer of Indian children.
Survey Tracks Violence Against Women
The third National Family Health Survey found nearly 40 percent of Indian women who have been married have experienced spousal violence. Only 52 percent of married women participate in household decisions. Female feticide and infanticide have resulted in 35 million girls missing from the population. The under-five mortality rate is 50 percent higher for girls than boys.
Reproductive Health and Family Planning Improving but Still Poor
By 2030, India will be the most populous country in the world. The third National Family Health Survey found that less than 30 percent of women in India use modern contraceptive methods. USAID's programs help women in Uttar Pradesh-India's most populous state, with 170 million people-gain greater access to a variety of modern contraception and have helped to nearly double the contraceptive use there. USAID also has helped the state double the use of birth spacing-a family planning method that improves maternal and child health and provides greater reproductive control.
