Another hole in India’s data tapestry

Govt’s decision to exclude anaemia indicator raises concerns about gender data gap.

The Ministry of Health and Family Welfare, Government of India (GoI), has made a decision to exclude anaemia as an indicator of women’s and children’s health from the National Family Health Survey, 2023–24. The NFHS, scheduled for this month, is a comprehensive study conducted at the household level to gain insights into population, health, and nutrition, with a special focus on women and children in India. It serves as a report card for the GOI’s interventions and achievements in managing critical health indicators of the population.

Despite the GOI’s “Anaemia Mukt Bharat” (Anaemia-Free India) scheme launched in 2018, the prevalence of anaemia among women and children in India has risen, according to the NFHS 2019–21. It currently affects 57% of women and 67% of children. The GOI argues that the methodology used by the NFHS to conduct anaemia tests, involving finger-prick blood samples from over seven lakh Indian households in the past five surveys, including the inaugural NFHS in 1991, is flawed and has led to inflated and exaggerated numbers. The GOI claims that anaemia rates can be better reflected by drawing blood samples from veins instead of fingertips. GOI plans to do exactly that through its newly launched ‘Diet and Biomarkers Survey’ (DABS-I). This move is in sharp contrast to the methodology followed by more than 90 countries that conduct district- and household-level surveys like the NFHS for the purpose of public health research.

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Given this government’s past track record and obsession with doubting data collection methods when the results are not to their liking, often eponymously termed the ‘No Data Available,’ government, dropping anaemia altogether from the list of health indicators arguably creates gender data gaps, perpetuating gender discrimination and apathy towards women’s healthcare needs.

Caroline Perez, in Invisible Women: Data Bias in a World Designed for Men, discusses that on most occasions, the existence of the gender data gap is considered an objective scientific approach, a mere coincidence, or ‘a by-chance omission’. It is nothing more! However, she argues that, “the gender data gap is both a cause and a consequence of the type of unthinking that conceives of humanity as almost exclusively male”. In the absence of data on women, “male data” or the accepted universal data would be the basis of all policies, even those that affect women’s lives, health, and wellbeing.

Echoing Perez, a 2019 Harvard study published in the British Medical Journal found that there is tremendous gender discrimination in access to healthcare in India. Sadly, this disparity is not adequately discussed due to a lack of “reliable data” available to conduct in-depth studies and suggest possible policy outcomes. So, although there is data on female sterilisations, without data on anaemia, it will be difficult to build a correlation between the two indicators, thereby affecting quality health policy advice and better interventions. If this is not clear enough justification for the government to rethink its decision, let us see, by example of female sterilisation, how not having data on anaemia will adversely affect women’s health as well as hamper the creation of sound and targeted interventions. Simply put, dropping anaemia from the NFHS eliminates the opportunity to conduct trend analyses and ask the right question: what are the primary causes of anaemia among Indian women, and what is the correlation between female contraceptive choice and anaemia?

According to United Nations data from 2011, India alone is responsible for 36% of female sterilisation worldwide. Further, as per the NFHS 2019–21, the total percentage of anaemic non-pregnant women between the ages of 15 and 49 stood at 57.2%. The figures for anaemic pregnant women in the same age group stood at 52.2%. Rather than a decline in the numbers, anaemia seemed to have increased among women almost by four percentage points in non-pregnant women and by two percentage points among pregnant women. It is worth noting that in the same study, another indicator associated with women—female sterilisations—also increased markedly. The percentage of female sterilisations in India increased by almost two percent and stood at 37.9%, with rural India recording a higher number than its urban counterpart. In stark contrast, the percentage of male sterilisations remained stagnant at 0.3% across India.

Contrary to the overarching belief that poor nutrition or low iron consumption in food is the primary cause of anaemia among women and children, as highlighted in the government’s ‘Anaemia Mukt Bharat’ scheme and DABS-I, female sterilisations, as mandated by the government, can also be a major source of anaemia among Indian women. A 2022 study titled ‘Identifying risk factors in explaining women’s anaemia in limited resource areas: evidence from West Bengal, India, and Bangladesh emphatically concluded that “sterilisation, vegetarian diet, and open defecation” were the primary causes of anaemia among women.

Unlike other countries where permanent sterilisation among females is prohibited, India, under its population control strategy or the Family Planning Indemnity Scheme, pays individuals opting for permanent sterilisation. Women undergo tubal ligation or tubectomy, wherein the fallopian tubes are ruptured to restrict the flow of eggs to the uterus to get fertilised. For this procedure, the government pays an amount of Rs 400 to every woman. For a vasectomy or male sterilisation procedure, the tubes carrying sperm are cut, and the amount paid for the procedure is the same.

Between the two procedures, the medical community recommends vasectomy, as it only requires local anaesthesia and the risks associated with it are limited and less serious. Despite this, data from the NFHS shows that it is women who are undergoing the sterilisation procedures, as there is widespread misinformation among Indian men that getting sterilised reduces one’s sexual prowess or virility, loss of which can render an Indian man ‘unmanly’. Several studies suggest that female sterilisation procedures, mostly common in developing countries, result in abnormal uterine bleeding among women or menstrual disorders that lead to anaemia and eventually premature death.

In Devika Biswas v. Union of India (2016), the Supreme Court pulled up the GOI for its apathetic approach towards female sterilisation, which results in hundreds of deaths every year due to blood loss. The NFHS survey comes at a crucial time when the country is gearing up for general elections in 2024. It would be wise for political parties to guarantee women voters their reproductive health rights.

(Prerna Dhoop is an assistant professor at the National Law School of India University, Bengaluru. Vandana Dhoop is an independent consultant working on forest governance, gender, and politics)