A public health data architecture for India

(MainsGS2:Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources, poverty and hunger)

Context:

• The report of the fifth round of the NFHS which was released recently has a large volume of data that is openly accessible.
• It is the go-to source for many researchers and policy makers and is frequently used for various rankings by NITI Aayog.

Brief about NFHS:

• The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted in a representative sample of households throughout India.
• The Ministry of Health and Family Welfare (MOHFW), Government of India, designated the International Institute for Population Sciences (IIPS) as the nodal agency, responsible for providing coordination and technical guidance for the NFHS.
• The 2019-20 National Family Health Survey (NFHS-5), the fifth in the NFHS series, provides district-level information on fertility, child mortality, contraceptive practices, reproductive and child health (RCH), nutrition, and utilisation and quality of selected health services.

Widening the scope:

• Over the years NFHS scope has been expanded to include HIV, non-communicable diseases, or NCDs (tobacco and alcohol use, hypertension, blood sugar, etc.) and Vitamin D3. 
• In NFHS-4, the household questionnaire had 74 questions, the women’s questionnaire was 93 pages long with 1,139 questions and the men’s questionnaire was 38 pages long with 843 questions. 
• The NFHS-5 questionnaire was even longer; thus, the size of the survey has obvious implications for data quality.

Various surveys:

• In the last five years, the Health Ministry has conducted the National NCD Monitoring Survey (NNMS), the National Mental Health Survey (NMHS), the Global Adult Tobacco Survey (GATS), the alcohol survey, the Comprehensive National Nutrition Survey (CNNS) and many others. 
• Some of these surveys are done to meet the global commitments on targets (NCDs, tobacco, etc.). 
• However, the requirements for the monitoring of NCD targets are not met by the NFHS, as it covers an age group different than that needed for the global set of indicators.

Difficulty in Alignment:

• There have been previous attempts to align these surveys but they have failed as different advocates have different “demands” and push for inclusion of their set of questions. 
• While the Department of Planning, Statistics and Programme Monitoring is supposed to take a final call, it lacks the technical capacity and the heft to do so and ends up using a “please-all” approach of accepting all requests with some effort at alignment. 
• Another reason why these questions are not dropped altogether is that the NFHS is the only major survey that India has a record of doing regularly and one does not know if and when the other surveys will be repeated.
• Multiple surveys also raise the problem of differing estimates due to sampling differences in the surveys, for example in tobacco, where differences in tobacco use estimates of the Global Adult Tobacco Survey (GATS) and the NNMS needed a lot of effort at reconciliation and explanation.

End the over-dependence:

• It is time to question the rationale and end the over-dependence on one omnibus survey to provide all public health data for India. 
• The experience of the NFHS and other surveys has conclusively demonstrated our capacity to conduct large-scale surveys with computer-assisted interviews and reasonable quick turnaround and cost.
• India has the capacity to plan the public health data needs for the country and ensure that these data are collected in an orderly and regular manner with appropriate budgetary allocation.
• This requires clarity of purpose and a hard-nosed approach with some tough calls which will question the need for vertical surveys, irrespective of national or international funding.

Look at alternate models:

• Stakeholders have to identify a set of national-level indicators and surveys that will be done using national government funds at regular intervals.
• For comprehensive data India needs just three national surveys — an abridged NFHS focusing on Reproductive and Child Health (RCH) issues, a Behavioral Surveillance Survey (focusing on HIV, NCD, water sanitation and hygiene (WASH)-related and other behaviours) and one nutrition-biological survey (entails collection of data on blood pressure, anthropometry, blood sugar, serology, etc.) to be done every three to five years in a staggered manner.
• Further India needs to take a national-level sample for surveys and ask States to invest in conducting focused State-level surveys, as was done for the NNMS.
• It is also very important to ensure that the data arising from these surveys are in the public domain as this enables different analyses and viewpoints to be presented on the same set of data enriching the discussion and unlocks the full potential of the survey.

Conclusion:

• India needs to establish a public health data architecture that a country of our complexity needs with technical capacity and political will to do so.