There has always been a criticism that government schemes and programmes are not evaluated rigorously. The idea of having an Independent Evaluation Office to provide “impartial and objective assessment of various public programmes and improve the effectiveness of public interventions” has not moved beyond interviewing a few well-known researchers. And then there were reports that the National Family Health Survey (NFHS) would be discontinued. Though that did not happen, it seems that the fourth and ongoing round of District Level Health Survey (DLHS), DLHS 4, has paid the price for keeping the NFHS.

I just discovered that the household and woman questionnaires of DLHS 4 would not be canvassed in nine ‘low performing’ States – Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Chhattisgarh, Orissa, Rajasthan and Assam[1]. In other words, it means that when it comes to these nine States, DLHS 4 will not tell us anything about trends in antenatal care, institutional deliveries, post-natal care, breast-feeding practices, immunization of the newborns and various other key indicators. Note that these nine States are the ‘low performing’ States (States with very poor health indicators in 2005), and account for about 48 percent of the total population, 59 percent of births, 70 percent of infant deaths, 75 percent of under 5 deaths and 62 percent of maternal deaths in the country.[2] This is bizarre since it completely goes against the very objective of DLHS 4 – “to assess the performance with regard to implementation of various programmes under NRHM at district level.”[3]

More importantly, what this means is that it won’t be possible to evaluate the effect of the National Rural Health Mission (NRHM) on any of the health outcomes it is intended to impact. The reason is as follows: DLHS 3, the previous round of DLHS, was conducted between December 2007 and December 2008. By then, the NRHM was in operation for barely 2-2.5 years. Thus, DLHS 3 would tell us, at the most, what has been the immediate impact of the NRHM. In order to understand the medium-term impact of the NRHM, one would need a survey that is carried out in a similar manner as DLHS 3. But the exclusion of the nine low performing States from DLHS 4 renders this impossible.

Instead, a much bigger ‘Annual Health Survey’ (AHS) has been launched covering all districts in these 9 States, with a sample of about 4.1 million households and 20.1 million individuals. The base-line survey happened in 2010-11, and it would be repeated every year. These numbers make AHS the largest demographic survey in the world. There is no doubt that the AHS would be crucial in keeping track of maternal mortality, neo-natal and infant mortality, etc., at the district-level, which was impossible till now. But its utility in analysing the effect of NRHM is, to be frank, quite limited since there was no baseline, i.e., there was no AHS or any such similar survey either before or immediately after the NRHM was launched.

What was needed was the inclusion of these nine States in DLHS 4 so that we could assess the medium-term impact of NRHM and simultaneous implementation of AHS. I guess, we have lost that opportunity now!

[1] DLHS consists of structured questionnaires for ever married women, husbands of surveyed women, households, and villages. Married women are asked about antenatal care, care during and after birth of the child, breastfeeding, immunization etc.  Household questionnaire collects information about caste, religion of the household, assets of the household and household amenities. For details, see International Institute of Population Sciences (IIPS) 2010, District Level Household and Facility Survey (DLHS-3), 2007-08: India.

[2] Press Release (dated: 16.07.2012), Office of Registrar General of India, Ministry of Home Affairs, Government of India.

[3] DLHS – 4 Bid document, Invitation for the proposal for selection of field agencies for conducting District Level Household and Facility Survey, IIPS, Mumbai.