The National Family Health Survey-6 (NFHS-6) report released recently has highlighted the success of government’s interventions in improving maternal and child health parameters and also brought up the threat of rapidly increasing lifestyle diseases. India currently faces the twin challenge of undernutrition and obesity, both representing opposite ends of the malnutrition spectrum and affecting different segments of the population.
The sixth round of the survey conducted in 2023-24 involved a sample of over 6.8 lakh households to deliver pinpoint district-level tracking data. When we take into consideration data from National Health Accounts (NHA) estimates for 2022-23, we get a more comprehensive picture of the state of health of the country.
India has come a long way from the first NFHS conducted in 1992-93, when just a quarter of childbirths took place in institutions, while recent data show it to be 90%. In the same period, the share of underweight children has fallen from 53.4% to 31.8%. Compared to the NFHS-5 (conducted in 2019-21), the proportion of fully vaccinated children increased from 75% to over 96%, a decrease in stunted children under five years from 35.5% to 32.5%, and wasted children under five years from 19.3% to 16.3%.
There has also been a rise in the proportion of pregnant women receiving antenatal care during the first trimester, from 70% to 76%, while overall antenatal care coverage has reached 96%. Maternal nutrition and supplement indicators also show improvement as well as the use of hygienic methods of menstrual protection. These achievements have resulted from flagship initiatives taken by the government under different ministries. There has been an increase in girls attending school, women having their own bank accounts and access to internet, all denoting women’s empowerment. Government initiatives such as digital literacy programmes and direct benefit transfers may also have improved maternal and child health outcomes.
The survey has worrisome findings, too. There is a rapid rise in obesity, diabetes and hypertension across India. Obesity among women aged 15-49 years, has gone up from 24% in NFHS-5 to 30.7% in NFHS-6 and the corresponding figures for men are 22.9% in NFHS-5 to 27.3% in NFHS-6. There is a difference in urban and rural populations, the former being more often affected.
Obesity is linked to other metabolic diseases such as diabetes, fatty liver, disease and is a harbinger for heart disease, stroke and cancer. Diabetes and hypertension, each, afflict one in five Indians now. Obesity prevalence is highest in Punjab, followed by Tamil Nadu and Kerala and diabetes in Kerala and followed by Tamil Nadu and Punjab. Hypertension prevalence is the maximum in Punjab, followed by Kerala and Andhra Pradesh.
States with the lowest undernutrition often have the highest prevalence of lifestyle diseases, reflecting the rising disease burden being associated with changing dietary habits due to affluence. Haryana and Chandigarh rank among the high-burden states/UTs.
The survey also looked at alcohol consumption across different states. Alcohol intake is linked to liver disease, pancreatitis and cancer of the liver, colon, mouth, lungs, etc.
The highest alcohol consumption (50.5%) in men is reported in Arunachal Pradesh, followed by Telangana and Manipur. The national average is 18-19%. Punjab and Chandigarh have some of the highest obesity rates but their alcohol consumption is moderate, suggesting that factors like calorie-rich diet and sedentary lifestyle contribute to their high burden of diabetes and hypertension.
While India has to evolve a strategy to combat lifestyle diseases in some states, it still grapples with undernutrition in others. Overall, 31.8% of children are underweight, with the highest rates in Bihar, Gujarat and Jharkhand. Punjab and Haryana have the lowest child undernutrition rates in India. The data suggest that Punjab and Haryana have largely transitioned from concerns about undernutrition to those related to metabolic disease. On the other hand, states like Bihar have higher poverty rates, poor sanitation and healthcare access and lower agricultural productivity.
A noteworthy finding of the NFHS-6 is that the number of households with any member covered under a health insurance or financing scheme has increased from 41% in 2019-21 to 60% in 2023-24. Interestingly, coverage is higher in rural areas (62%) as compared to urban areas (56%), possibly due to schemes like Ayushman Bharat PM-JAY and state health insurance programmes.
The Health Ministry recently released the (National Health Accounts) estimates which show that the out-of-pocket expenditure (OOPE) as a share of total health expenditure has fallen from 64.2% in 2013-14 to 43.4% in 2022-23. This is attributed to rising public health spending, expansion of the Ayushman Bharat PM-JAY and access to Ayushman Arogya Mandirs. The report also shows major differences in public health spending across states. Uttar Pradesh has one of the lowest per capita government spending at Rs 1,419 while Kerala spent the highest at Rs 3,592. These figures reflect interstate inequalities in healthcare priorities. It also shows greater dependence of affluent states on private healthcare systems.
The share of Government Health Expenditure (GHE) as a percentage of GDP has risen from 1.15% in 2013-14 to 1.43% in 2022-23. But it still is short of the WHO recommendations of 5% share and is not even 50% of the total health expenditure. The share of private hospitals in health expenditure is nearly twice that of government hospitals. India’s healthcare system continues to rely heavily on private providers, contributing to concerns about costs and inequalities in access.
The NFHS-6 and NHA data show that India has made progress, but significant gaps remain. Government health spending must be increased to decrease the burden on households. State-wise inequalities in healthcare access need to be bridged. The dichotomy of the disease burden, obesity and other lifestyle diseases on the one end and undernutrition on the other must be addressed in planning state-wise nutrition-related interventions.
There is a need to increase spending on preventive care, an aspect often not given due importance. There is a need to have public awareness campaigns about lifestyle diseases and incorporate them into school curricula and community programmes. Health education should be a part of “marching towards a healthy India" campaign.
