Rewa: The sixth round National Family Health Survey (NFHS-6) has some key indicators missing which would have revealed the performances of at least two flagship schemes of the Narendra Modi government.
The NFHS – the largest health survey of the country – is conducted by the International Institute for Population Sciences (IIPS), under the aegis of the Union health ministry. The NFHS-6 was carried out in 2023-24 and NFHS-5 in 2019-21. The factsheets of the NFHS-6 were released on May 29, 2026.
One among them is access to clean cooking fuel.
The NFHS-5 had shown that more than 40% households did not have access to clean cooking fuel – something that questioned the efficacy of the Union government’s Pradhan Mantri Ujjwala Yojana, which was supposed to ease the way for LPG connections to poor women. Similarly, it also showed that India was not close to being open-defecation free – an aim of the Swachh Bharat Mission.
It is noteworthy that after the release of NFHS-5, the then IIPS director K.S. James lost his chair.
What is also missing from NFHS-6 is the sex ratio at birth and infant and child mortality rates – although these two are reflected in other data-collection exercises of the government.
“The NFHSs give district-wise data, unlike other health surveys conducted by the government. This district-wise data is important for fine-tuning policy making for different socio-economic groups and various districts,” a former IIPS faculty-member said, anonymously.
NFHS’ numbers also slightly differed from other health surveys conducted by the government.
The prevalence of anaemia indicator is also missing from this round of the NFHS. The high prevalence, as presented in NFHS-5, of anaemia had made news last time. Now, the government’s National Institute of Nutrition is going to measure its prevalence
through a method different from what was deployed by IIPS. The IIPS’ method, though, was also marked controversial by some experts.
Obesity and other ills
The sixth round of NFHS-6 also indicates a rise in obesity, high blood pressure, and diabetes among both men and women in the country.
The NFHS-6 says that a little less than 30.7% of the female population aged 15 and above – 21.6 crore people – is obese. The jump in these figures in the NFHS-6 from the NFHS-5 is 6.7 percentage points.
Similarly, 27.3% of the male population of the country is obese – a jump of 4.4 percentage points from the figure of the NFHS-5. In absolute numbers, this translates into 20.4 crores males.
The increasing obesity of the male and female population is a continuance of trends as reflected in previous rounds of NFHSs as well. But what is significant is that the rise in obesity levels registered between the NFHS-6 and NFHS-5 is more than the rise which happened between the two previous rounds, i.e, NFHS-5 and NFHS-4.
Obesity, high blood pressure or hypertension, and diabetes are linked with each other. No wonder, therefore, that the proportion of the male population which has ‘very high’ levels of diabetes (more than 160 milligram per decilitre of blood) has risen by 3.8% points. The jump in the female population of this proportion is by 2.8 percentage points. This translates into very high absolute numbers – 8.15 crore crore for males and 6.42 crores for females.
The hypertension picture also presents concern, with about 15% of the women population (10.5 crore) and 16% of the male population (12 crore) of the country suffering from mild to moderately high levels of the disease.
| The standard norm is 120 mm of haemoglobin in systolic pressure and 80 mm of haemoglobin in diastolic pressure. Against this norm, if the levels are 140/90 (systolic/diastolic), it is considered mildly high and if it is more than 160/100, it is moderately high. |
The rising trend of all these diseases, referred to as non-communicable diseases (NCDs), as reported in NFHS, is in line with all international reports on India. The country contributes more than half of the NCD deaths in Southeast Asia.
Though the government runs a dedicated programme to combat NCDs, their prevalence only seems to be going up.
“The bulk of NCD programmes in the public health sector are about measuring parameters like hypertension, diabetes, and monitoring heart problems. But preventive aspects are lacking,” said Indranil, a health economist, who teaches at OP Jindal University.
“The NCD programmes are in nascent stages. It may be adding to the increase of the population being covered in terms of diagnosing these diseases but still quality primary care for NCDs is virtually absent in the public system, the Ayushman Scheme is still at a nascent stage,” he added.
Another correlation, which some of the public health experts draw in this context is of the lack of availability of a healthy diet for pregnant women and obesity.
“[The] offspring become obese if exposed to maternal nutrient-restriction in utero,” says a 2013 study. In turn, when an obese mother gives birth to a child, it may adversely affect the metabolism of the progeny also, in the long-term. In scientific parlance, this is described as fetal programming.
The NFHS also shows that, on the one hand, the levels of obesity are going up and, on the other hand, the prevalence of being underweight is also rising among men and women. About 20% of women and 20% of men are underweight.
What is to be noted here is that the proportion of underweight men and women had declined between NFHS-4 and NFHS-5 periods. But the trend has been reversed in the latest NFHS-6 period.
Rajib Dasgupta, a professor of JNU’s Centre of Social Medicine and Community Health said, in his personal capacity, that this paradox points towards what is called ‘epidemiological polarisation’. In other words, it reflects the double burden of health issues which lie on opposite ends of the spectrum.
“So while one agenda of dealing with the underweight population is unfinished, the other problem of obesity is growing,” he added.
Indranil, meanwhile, points to the affordability of a healthy diet.
“The availability of adequate and good quality food – and not just food – is very low in India. This contributes, on one hand, to underweight men and women, and on the other hand, people being subjected to eating unhealthy food contributing to obesity,” Indranil explained.
Also read: India Makes Significant Progress in Reducing MMR But Is Still Second Highest Global Contributor
Breastfeeding practices
Another trend which has been reversed in the period considered by the latest round of the NFHS is the rise in ‘exclusive breastfeeding’ till six months. This is important to ensure nutrition for a child, development of its long-term immunity, and proper hydration during this time period. The decline in this also indicates early weaning from breastfeeding.
Though the number of women who initiated breastfeeding within the first hour of birth of their child has gone up, the declining trend of exclusive breastfeeding indicates this: While the rise in institutional delivery is leading to ensuring good practices, the trend is not able to continue after the mother goes out of the ambit of the healthcare system.
After the period of exclusive breastfeeding is over, that is six months after birth, the child is also supposed to eat semi-solid food along with their mother’s milk.
One of the most remarkable statistics in NFHS-6 is in this category. Only 15.3% children in the category of 6-23 months are able to get an adequate diet which includes solid or semi-solid foods twice or thrice a day. “There is some improvement but still, access is abysmally low and very worrying,” Dasgupta said.
This can contribute to long-term health problems for a child including malnutrition, low immunity levels, and development of metabolic diseases.
Meanwhile, the use of modern contraceptive methods has declined among women this time, which had actually gone up in the previous two rounds of NFHSs. The modern methods include female sterilisation, male sterilisation, pills, condoms and injectables.
Interestingly, as always, the proportion of female sterilisation far outweighs male sterilisation, thus pointing out the disproportionate burden of family planning on women, as far as this method is concerned.
Other indicators
Health insurance coverage has gone up significantly. As many as 60.2% of households have a member covered under a health insurance or financing scheme as against the 41% previously.
However, despite the increasing insurance coverage, patients’ out-of-pocket expenditure has gone up by 43.4% of the total health expenditure in 2022-23. It also went up from 39.4% in the previous year, as per the National Health Accounts report released by the government on May 28.
Insurance mostly covers admission costs while outpatient department costs remain largely uncovered which contribute to high out-of-pocket expenses. The OPD services form the bulk of healthcare sought by citizens of the country.
The proportion of women receiving four ante-natal health care (ANCs) check-ups during the course of pregnancy has gone up to 65.2% from 58.5%.
“There is an improvement in coverage of four ANC visits but still more than one-third of pregnant women are not getting all four ante-natal care check ups and that is a glaring gap. The National Health Mission funds are being reduced, which constrains further expansions,” Indranil said.
Institutional delivery rates, on expected lines, have gone up to a healthy 90% from 88.6%.
“Institutional delivery is a one-time engagement with the health infrastructure [a woman gets admitted for delivery and comes back] but complete ante-natal check-up, done during the entire course of pregnancy, requires continuous engagement with the health system,” Indranil said.
This reveals that the long-term engagement of women is not as good as the one-time intervention – indicating the status of public health infrastructure, among other factors.
C-section birth rates have also risen in both public and private health facilities. As many as 54.1% of the deliveries in the private sector are done through this method while in public facilities, they remain confined to 16.9%.
“This trend may partly be explained by individuals with high income having better access to insurance schemes or ease of referrals, leading to higher caesarean delivery rates,” says a study published in Lancet Southeast Asia, analysing the results of NFHS-5.
“ [The] high rates are suggestive of overuse without medical necessity, which is associated with higher rates of adverse outcomes (infection, haemorrhage, surgical complications) and misallocation of resources,” it says.
While there is a concern of unnecessary C-sections, the study also points out that the cultural and social factors such as fear of normal childbirth, the desire to deliver on an auspicious day, and a preference for painless deliveries and smaller families, also potentially contribute to higher C-section rates
As per WHO norms, C-section deliveries should not be more than 10-15% of all deliveries.
The WHO clarifies that though there are no country-specific recommendations, in general, its studies say that a proportion beyond this is not beneficial in reducing child or maternal mortality.
“Every effort should be made to provide Caesarean sections to women in need, rather than striving to achieve a specific rate,” the WHO says in the Lancet Southeast Asia study.
State-wise picture
There is large variation among states when it comes to the percentage of deliveries taking place through C-section in private facilities.
It ranges from 81.4% in Assam to 49.3% in Bihar and 47.3% in Uttar Pradesh.
Kerala has an interesting statistic. In almost all states, the percentage of C-section deliveries taking place in private and public health facilities show a sharp gap. It is much higher in private facilities.
But Kerala is an outlier. The percentage there is very close as public health facilities register 39% C-section deliveries (of all deliveries conducted) while private facilities have 42.5%.
The NFHS is revealing when one looks at some of the least developed states of the country, like Bihar, Chhattisgarh, Uttar Pradesh and Odisha.
C-section deliveries in public health facilities are also a function of better health infrastructure and the presence of trained personnel like gynaecologists and anaesthesiologists, especially in primary and secondary healthcare centres. Since Kerala has been traditionally known for good public health infrastructure, the public-private gap is not wide there.
Though Bihar has officially banned alcohol for more than 10 years now, its illicit consumption is often in the news. The consumption of alcohol among men has increased from 18.7% (NFHS-5) to 18.9% (NFHS-6) in Bihar.
Only 63% women aged 15-24 years use hygienic methods of protection during their menstrual period in Bihar.
While women’s participation in the workforce has increased, gender-based violence has also decreased in Bihar.
The percentage of those aged 6-23 months receiving an adequate diet remains abysmally low in Bihar at 11.9%, though there is a jump of 1.1 percentage points.
The prevalence of hypertension has declined in Jharkhand, just like Bihar, but that of diabetes has significantly gone up among both men and women.
The trends of rising undernutrition levels and obesity hold true for Jharkhand also.
In Chhattisgarh, the consumption of tobacco has marginally increased among women while among men it has decreased. The consumption of alcohol among men has marginally increased. Only 72.7% of women in the state use hygienic protection methods during menstruation.
In Odisha, only 43.9% of women have completed 10 or more years of schooling while only 49.1% men have done so.
Banjot Kaur is an independent health journalist.
