Registration of deaths likely missed during Covid pandemic, NFHS-5 data indicates

The latest NFHS-5 first phase data shows health insurance is still low in the surveyed states, and a worrying rise in stunting.

File photo of people carrying the body of a Covid-19 patient to crematorium | Arun Sharma | PTI

New Delhi: The latest National Family Health Survey (NFHS) data has shown low registration of deaths with civil authorities in 11 out of 22 states and Union territories surveyed in the first phase.

The new 2019-20 survey shows that states like Bihar, Manipur and Nagaland saw less than 50 per cent registration of the total deaths in the three years through February 2020.

During the pandemic, the health ministry issued a statement that all Covid and non-Covid deaths were being reported in accordance with the Indian Council of Medical Research and World Health Organization guidelines.

“We found in the initial phase of the pandemic that there certain states which were not reporting Covid deaths of co-morbid patients as Covid deaths. They were reporting them as death having been caused by that comorbid condition. So we clarified that so that there is no confusion and written guidelines were issued,” Health Secretary Rajeev Bhushan in a statement had said earlier.

However, since poor registration of deaths has been a trend in the non-pandemic era, it is highly likely that counting of deaths was missed out on during the Covid outbreak as well.

Public health expert Dr Anand Lakshman said poor registration of deaths has been a “trend in the country for a long time now”.

“There is a possibility that deaths of those not diagnosed with Covid may have been missed due to the lack of diagnosis. In rural areas, often when there are no benefits from the registration of a death (for instance, land record transfer, government compensation, etc.), deaths are often not registered,” he said.

“On the contrary when a patient has undergone Covid tests and has tested positive, there will be some motive for registration of death and medical certification of cause of death, because the district administration may be keeping tabs on such patients. The problem with this is that sero prevalence surveys have shown that we have been able to identify only 1 in 30 cases in the country,” he said.

“This would mean that Covid may have had an impact on all causes of mortality but such trends can surface only when the state and central government conducts robust surveys with big sample size such as the SRS (Sample Registration System),” he added.

According to the survey, the registration was the poorest in Bihar (37.1 per cent), Manipur (42.1), Nagaland (40.3), Meghalaya (54.4) and Assam (65.5). Other states and UTs that didn’t perform well were West Bengal (78.6 per cent), Telangana (73.5), Sikkim (75.5), Jammu and Kashmir (76.2), Ladakh (74.9) and Tripura (79.5).

New data

The latest NFHS-5 data was collected from 17 states and five UTs — Maharashtra, Gujarat, Andhra Pradesh, Assam, Meghalaya, Manipur, Nagaland, Jammu and Kashmir, Himachal Pradesh, Ladakh, Lakshadweep, Andaman and Nicobar Island, Daman and Diu, Telangana, Karnataka, Sikkim, Goa, Tripura, West Bengal, Dadra and Nagar Haveli, Mizoram and Kerala.

This survey collects information on population, health, family planning and nutrition related indicators. The results of the survey’s first phase were published last week.

Work on the second phase, which will cover the remaining 12 states and two UTs, was suspended earlier due to the pandemic. It was resumed in November and is expected to be completed by May 2021.

Health insurance

The survey also found that only eight of the 22 states and union territories had over 50 per cent of the families having any member covered under health insurance — Andhra Pradesh (70.2 per cent), Goa (66), Meghalaya (63.5), Telangana (60.8), Lakshadweep (60.1), Assam (60), Dadra and Nagar Haveli (52) and Kerala (51.5).

Others like Bihar, Gujarat, Himachal Pradesh, Maharashtra and West Bengal fared poorly on this metric.

The low insurance figures come despite the launch of Prime Minister Narendra Modi’s health insurance scheme Ayushman Bharat AB-PMJAY last year, which provides a medical cover of Rs 5 lakh.

“Ayushman Bharat AB-PMJAY and Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) were not fully rolled out and hence, their coverage may not have been factored in the results of indicator 12 (percentage of households with any usual member covered under a health insurance/financing scheme) and indicator 41 (percentage of mothers who received 4 or more antenatal care check-ups),” said the survey.

Stunting

The survey found a worrying rise in stunting of children aged below five, in comparison to NFHS-4 data from 2015-16.

Goa, Gujarat, Himachal Pradesh, Kerala, Maharashtra, Meghalaya, Mizoram, Nagaland, Telangana, Tripura, West Bengal, Lakshadweep, Dadra and Nagar Haveli, and Daman and Diu saw an increase in the number of such children.

Stunting refers to impaired growth among children due to inadequate nutrition, repeated infections and insufficient psychosocial stimulation.

According to the World Health Organization, “Stunting in early life —particularly in the first 1000 days from conception until the age of two — impaired growth has adverse functional consequences on the child. Some of those consequences include poor cognition and educational performance, low adult wages, lost productivity and, when accompanied by excessive weight gain later in childhood, an increased risk of nutrition-related chronic diseases in adult life.”

Poonam Muttreja, director, Population Foundation of India, said it is “deeply concerning to see the reversal in decades worth of gains made by India on the front of child nutrition”.

“Of the 17 states surveyed in phase 1, 11 have shown an increase in stunting and underweight children under 5, while nine states have witnessed an increase in wasting among children under 5,” said Muttreja.

“The health outcomes in NFHS-5 are a reflection of events since the last survey (NHFS-4) like the economic downturn, job losses and demonetisation. Small towns and villages have witnessed high inflation in food prices in recent years which could directly compromise the nutritional needs of the poor and vulnerable populations,” she said.

“We must remember that the NFHS-5 data is pre-pandemic and that should concern us greatly, as the pandemic has only added to the woes of our people, especially the more vulnerable sections,” she added.

Women empowerment

Cases of spousal violence seen by women in the 18-49 age bracket saw an overall fall, the survey found. While 15 states and UTs saw this decline, seven — Assam, Himachal Pradesh, Karnataka, Maharashtra, Sikkim, Jammu and Kashmir and Lakshadweep — saw a rise.

Save for Lakshadweep, all states and UTs also saw a jump in the percentage of women owning and operating a bank account. Bihar nearly tripled this number — from 26.4 per cent in 2015-16 to 76.7 per cent in 2019-20.

Caesarean deliveries

The incidences of deliveries through caesarean sections saw a rise in 20 of the 22 states and UTs surveyed. This rise was more prominently seen in private hospitals in urban areas.

In West Bengal, where the use of C-section grew by 9 per cent from 2015-16, the number of such births in private facilities in urban areas rose from about 70 per cent to 82 per cent.

In Jammu and Kashmir, this figure was 91 per cent in urban areas as compared to 74.4 per cent in rural areas.

Similarly, Andhra Pradesh saw 66.1 per cent such deliveries in urban areas and 61.4 per cent in rural areas. In comparison, C-section deliveries in government hospitals across the state remained 30.9 per cent in urban areas and 25.2 per cent in rural areas.