New Delhi: Indian women seem to have finally embarked on their journey to empowerment, the findings of the fourth National Family Health Survey (NFHS) data released by the Union health ministry on Tuesday show.

Though the fertility rate or the number of children each woman has is dropping—a good sign given India’s burgeoning population—the health of women and children remains a major concern, according to NFHS data. However, the overall health of Indians as also the health insurance coverage is in the positive territory, the data shows.

Women empowerment

Data shows a marked increase in the percentage of women in the age group of 15-49 years having a savings account that they use themselves.

Among the 13 states whose data has been released, Goa at 82.8% has the maximum number of women who manage their own finances. However, it is Tamil Nadu which has outdone all other states with the numbers increasing from 15.9% in the third round of NFHS (NHFS-3) done in 2005-2006 to 77% in the fourth round. Tripura, Sikkim and Goa have also registered an increase of 40-42 percentage points from NFHS-3. But states like Bihar at 26.4% still have a long way to go, though the numbers have increased from 8.2% in NHFS-3.

The Jan Dhan Yojana, launched in 2014 to ensure every Indian household has access to a banking facility, also strived to ensure that in most cases, the account is opened in the name of the female member of the household. The government was of the view that women are more responsible and will be more careful in managing finances.

NFHS-4 has added an indicator—women owning a house and/or land (alone or jointly with others). Bihar, which otherwise is at the bottom in other indicators, tops the list with 58.8% women owning some form of property. Tripura finishes second at 57.3%, while West Bengal at 23.8% has the least number of women owning property.

The data also breaks the myth that women do not have a say in decision-making in what is perceived to be an inherently patriarchal society. At 95.3%, Sikkim tops the indicator—in the number of married women who usually participate in household decisions. West Bengal has shown the maximum increase from 70.2% in NFHS-3 to 89.8% in NFHS-4.

Interestingly, the percentage of women participating in household decision-making has fallen from 83.8% to 76.7% and from 87.4% to 84% in Haryana and Tamil Nadu, respectively.

Only 28% women in India own a mobile phone as against 43% men, according to Connected Women 2015, a report by Groupe Speciale Mobile Association (GSMA), an international grouping of mobile operators and related companies. The gender gap of mobile ownership, the report said, is as much as 114 million.

A new category added to the women empowerment section in NFHS-4—women having a mobile phone that they themselves use—shows how this trend might be changing. Goa tops the list with 80.9%, while Sikkim closely follows at 79.8%. Though Meghayala (64.3%), Tamil Nadu (62%) and Uttarakhand (55.4%) show some gains, Madhya Pradesh lags far behind at 28.7%.

Female literacy

On other indicators like the percentage of literate women, Goa again takes the cake with 89% literate women in the age group of 15-49 years. This is closely followed by Sikkim at 86.6%, while Haryana and Madhya Pradesh have had the highest growth from 60.4% and 44.4% in NFHS-3 to 75.4% and 59.4% in NFHS-4, respectively.

In Bihar, the female literacy rate improved from 37% in the last survey to 49.6% in the current one. Haryana, Karnataka and Madhya Pradesh, too, showed a rise in female literacy rates from 60.4% to 75.4%, 59.7% to 71.7% and 44.4% to 59.4%, respectively. In Tamil Nadu, the female literacy rate improved from 69.4% to 79.4% and in West Bengal, it rose to 71% from 58.8%.

Fertility and maternal mortality rates

The fertility rate or the number of children each woman has is dropping, a finding that is expected to bring cheer to policymakers given India’s already sizeable population standing at 1.27 billion population and its youth bulge.

In Bihar, the fertility rate has come down from four children per woman in NHFS-3 to 3.4 in NHFS-4. Some of the sharper declines in fertility rates were found in states with significant populations like Haryana, Madhya Pradesh and West Bengal—with the numbers coming down from 2.7 to 2.1, 3.1 to 2.3 and 2.3 to 1.8, respectively. In Tamil Nadu and Karnataka, other states with a sizeable populations, the decline in fertility rates was marginal from 1.8 to 1.7 and 2.1 to 1.8.

Data also showed that women were taking the lead in the case of adopting family planning methods. The findings showed, for example, that women were the ones opting for methods like sterilization rather than men. In the case of Haryana, the female sterilization rate was 38.1% compared to 0.6% among men. In the case of Bihar, the female sterilization rate was 20.7% compared with nil for men. And the case of West Bengal, the female sterilization rate was 29.3% while for men it was 0.1%.

Institutional deliveries shot up in most states and UTs. In Bihar, it rose threefold—from 19.9% in 2005-06 to 63.8% in 2014-15. Similarly, over the same period, institutional deliveries rose from 35.7% to 80.5% in Haryana and 26.2% to 80.8% in Madhya Pradesh.

Health remains a concern

While the overall health status of Indians has improved, there are glaring gaps in the health condition of children.

In almost all the 13 states and two union territories, nutrition rates among children fared better than NHFS-3. But the number of stunted (height for age) children, a key indicator of malnutrition, in certain states has remained high, even though it has slightly reduced in the past decade. In Bihar, Madhya Pradesh and Meghalaya, more than 40% of children were found stunted. In 2005-06, Bihar had 55.6% of its children stunted, which reduced to 48.3% in 2014-15. In Madhya Pradesh, stunting reduced from 50 to 42 and in Meghalaya from 55.1 to 43.8.

Anaemia continues to haunt children as well as women. In Goa, the percentage of anaemic children has gone up from 38.2% in 2005-06 to 48.3% in 2014-15. In Madhya Pradesh, there has been a marginal decline from 74% to 68.9%.

In Meghalaya, the percentage of anaemic women in productive age has gone up from 46.2% during NFHS-3 to 56.2% in NFHS-4. Haryana follows a similar trend—from 56.1% to 62.7%.

Another worrying factor is reduced awareness among women about HIV/AIDS. The percentage of women with comprehensive knowledge of HIV/AIDS in MP reduced from 20.3% to 18.1% of total women in the state. Similarly, in Bihar, it decreased from 11.7% to 10.1%. Tripura is an exception which saw an increase from 11.8% to 28%. It is pertinent to note here that India’s HIV programme has been facing government apathy in recent times. Last year, massive shortages in medicines of HIV/AIDS in government facilities were reported across the country. It was only after it became a national issue that problems in procuring medicines were resolved.

Wider health insurance net

India has taken big strides improving the health insurance coverage of its citizens in the last 10 years, though many remain deprived of any form of basic health coverage, NHFS data shows.

Efforts of successive governments to improve the social security net of Indians is bearing fruit, though disparities across states remains high. While the Congress-led United Progressive Alliance (UPA) government launched the Rashtriya Swasthya Bima Yojana in 2008 to provide cashless insurance facilities to the country’s poor in hospitals, the present government under Narendra Modi is also looking into designing a health insurance scheme specifically for India’s aged.

For instance, in states like Andhra Pradesh, Telengana, Meghalaya, Tripura and Tamil Nadu, a majority of the households have at least one member under any form of health scheme or health insurance coverage with more than 99% of the households in Meghalaya having health insurance coverage. Though no comparative data is available for the recently bifurcated states of Andhra Pradesh and Telengana, comparing data for other states shows the huge improvement. In Tamil Nadu, 64% of households have some access to health insurance, as per data collected in the fourth round, as against only 4% households in the third round of the survey. In case of Tripura, 58% of households now have health insurance coverage as compared to less than 1% of the households 10 years ago.

However, in an indication of variance across states, the states of Uttarakhand, Bihar, Goa, Haryana, Madhya Pradesh and the union territory of Andaman and Nicobar Islands have less than one-fifth of the households covered under any kind of health scheme or health insurance. Only 12% of the households have health cover in Bihar and Haryana each. For Madhya Pradesh, this number is 17.7%, while its 15% for Goa.

Larger concerns

However, analysts feel that though the numbers are encouraging, a wide gap in women empowerment still needs to be bridged.

“I am extremely delighted to see the data. This only goes to say that women are making progress in the society against all odds. Now it is the system’s turn to keep pace with the aspirations of women who want equal participation in both, the personal and political domain," said Suneeta Dhar, advisor, Jagori, a New Delhi-based women’s resource centre.

On what needs to be done to bridge this gap, Dhar says, “I am really looking forward to the one stop crisis centres proposed by the Women and Child Development Ministry (WCD). Apart from this, budgetary allocations to women empowerment schemes need to be increased with a focus on education and employment opportunities. Gender-specific barriers like domestic violence or violence outside home, high drop-out rates of girls especially after class X, all hinder self-actualization," she said.

Also, experts say, that what the NHFS data does not cover is that increase in institutional deliveries does not automatically translate into reduction in maternal mortality rates (MMR). A PhD thesis submitted in Umea University of Sweden shows low level of correlation between institutional deliveries and MMR in India. Doctoral student Bharat Randive at the Department of Public Health and Clinical Medicine at the university found that the JSY programme successfully increased births at facilities, but due to its implementation in a fragile health infrastructure, it was less effective at reducing fatalities. In his research, Randive looked at 284 districts of nine Indian states and compared access to care and health outcomes in rich and poor areas. The poor areas of these nine less developed states had 135 more maternal deaths for every 100,000 births and the decline in maternal deaths during the programme in these areas was four times slower than in rich areas.

“The cash transfer programmes are by themselves inadequate to improve health outcomes," said Randive. “While the programme can improve service utilization, it will not reduce maternal and neo-natal deaths unless the socioeconomic inequalities in access to facility-based care are also addressed and the care is of good quality."

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