Context: Despite efforts to ramp up covid-19 testing, India remains among countries with the lowest testing rate. 

  • A new article in The Lancet recommends that India use the National Family Health Survey (NFHS) mechanism to monitor the spread of covid-19 in the population.

Current state of COVID-19 testing in India:

  • Lagging behind: While experts clamour for universal testing, reports suggest that India has tested till now five people out of every million Indians for the virus. South Korea in comparison has tested 140,000 people.
    • In comparison with five other countries that conducted at least 10 lakh Covid-19 tests, India has the least number of positive cases while Spain had recorded the highest, according to the Press Information Bureau.
  • The Indian Council of Medical Research (ICMR’s) circular made it mandatory to test only symptomatic persons (who have cough, fever), people over 60 years of age who are high-risk contacts of Covid-positive patients, whether they are showing symptoms or not; healthcare workers, pregnant women and patients on dialysis and chemotherapy
    • Asymptomatic high-risk contacts of positive patients can get tested if they develop symptoms.
  • Testing has also been increased:While India had largely limited its testing initially to foreign travellers and their contacts and health workers who are symptomatic, it eventually included all those with flu-like symptoms, regardless of travel or contact history, in the hotspots.
    • Currently, there are 419 laboratories, including about 100 in the private sector, which conduct the tests – there were just about 20-30 in March.


  • Demerits of selective testing: Though civic officials opine that the decision to test only symptomatic cases was taken to avoid false reporting of positive cases, health activists alleged that it was implemented to underreport the number of cases.
  • Inaccurate results: In 2002, the National Intelligence Council of the US projected 25 million HIV-positive cases for India, with a 3-4% prevalence rate in Indian adults, based on such a strategy. 
    • NFHS estimates showed much lower morbidity (2.5 million HIV-positive cases) and a prevalence rate of only 0.28% in adults. This discrepancy shows the shortcomings of extrapolating disease risk from selective testing, the researchers argue.
  • No credible estimate: The lack of surveillance has meant that there is no credible estimate of the true number of infected individuals in India

How can NFHS be used in tackling COVID-19 crisis?

  • Alternative for universal testing: In the absence of universal testing, a random sample-based framework  of NFHS should be used for testing. 
  • NFHS Sampling framework: Since NFHS has a ready sampling framework and the required infrastructure, using the same for covid-19 data collection would keep operational costs low. 
    • The minimum sample of individuals who would need to be tested would depend on the anticipated rate of covid-19 prevalence in a region. 
    • The lower the anticipated prevalence, the higher would be the minimum sample needed to reliably estimate the true prevalence.
  • The only major expense would be the laboratory costs for testing samples.

Benefits of using NFHS sampling framework

  • Estimates based on such wider samples would be more reliable than those based on the testing of selected at-risk individuals: those with influenza-like symptoms, those who have had contact with infected individuals, healthcare professionals, or those with a travel history to an affected region.

What is NFHS?

  • The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted in a representative sample of households throughout India. 
  • The survey provides state and national information for India on fertility, infant and child mortality, the practice of family planning, maternal and child health, reproductive health, nutrition, anaemia, utilization and quality of health and family planning services. 


Each successive round of the NFHS has had two specific goals: 

  • to provide essential data on health and family welfare needed by the Ministry of Health and Family Welfare and other agencies for policy and programme purposes, and 
  • to provide information on important emerging health and family welfare issues. 

Agencies involved

  • The Ministry of Health and Family Welfare (MOHFW), Government of India, designated the International Institute for Population Sciences(IIPS) Mumbai, as the nodal agency, responsible for providing coordination and technical guidance for the survey. 
  • IIPS collaborated with a number of Field Organizations (FO) for survey implementation. 
  • Each FO was responsible for conducting survey activities in one or more states covered by the NFHS.
  • Technical assistance for the NFHS was provided mainly by ORC Macro (USA) and other organizations on specific issues
  • The funding for different rounds of NFHS has been provided by USAID, DFID, the Bill and Melinda Gates Foundation, UNICEF, UNFPA, and MOHFW, GOI.

Recent NFHS 4 survey

The National Family Health Survey 2015-16 (NFHS-4), the fourth in the NFHS series, provides information on population, health and nutrition for India and each State / Union territory. NFHS-4, for the first time, provides district-level estimates for many important indicators.

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