The Dual Burden: Child Health Gains and the Rising NCD Crisis
Health Gains, Emerging Burdens, and the
Road Ahead for India
Based on the National Family Health Survey (NFH`S-6), 2023–24
Executive Summary
The National Family Health Survey-6
(NFHS-6), released by India's Ministry of Health and Family Welfare (MoHFW) in
May 2026, is a landmark dataset covering 6.79 lakh households across 715
districts for the survey period 2023–24. As the first comprehensive health
survey conducted after the COVID-19 pandemic, it offers a pivotal snapshot of
India's evolving public health landscape. The picture it paints is
simultaneously encouraging and sobering — a story of triumph and of unfinished
business.
India has made genuine, hard-won progress
in child health, maternal care, immunisation, and demographic transition.
Stunting among children under five has fallen from 35.5% to 29.3%; severe
wasting has more than halved in relative terms; institutional deliveries have
crossed the 90% threshold; and full immunisation coverage for children aged
12–23 months now stands above 87%. India’s Total Fertility Rate (TFR) has
settled at 1.9 — below the replacement level of 2.1 — signalling a historic
demographic shift.
Yet, alongside these gains, the survey
reveals an accelerating dual burden of disease: rising obesity, hypertension,
and diabetes co-exist with persistent undernutrition among children; exclusive
breastfeeding has dropped alarmingly; and C-section rates in urban private
hospitals have soared far beyond WHO-recommended thresholds. These trends, if
unaddressed, threaten to create a health crisis of a different but equally
devastating character in the decades ahead.
This report synthesises the key findings of
NFHS-6, contextualises them against previous survey rounds and international
benchmarks, and identifies priority actions for policymakers at the national,
state, and district levels.
About the NFHS-6 Survey
The National Family Health Survey is one of
the largest cross-sectional household surveys in the world and serves as
India’s primary tool for evidence-based governance and public health planning.
Established in 1992–93, six rounds have now been completed, each providing
multi-level data from the national down to the district level.
Survey Coverage — NFHS-6
at a Glance
|
Indicator |
NFHS-5 (2019-21) |
NFHS-6 (2023-24) |
|
Survey period |
2019–21 |
2023–24 |
|
Households surveyed |
~6.36 lakh |
~6.79 lakh |
|
Districts covered |
707 |
715 |
|
Nodal agency |
IIPS, Mumbai |
IIPS, Mumbai (sole coordinator for first
time) |
|
Indicators tracked |
~100 |
~101 |
For the first time in NFHS history, all
aspects of the survey were coordinated solely by the International Institute
for Population Sciences (IIPS), Mumbai, without external agency collaboration.
Implemented across all states and union territories except Manipur, the survey
covered over 7.16 lakh women and more than one lakh men, making it one of
India’s most comprehensive public health databases.
Section 1: The Gains — Reasons to Celebrate
1.1 Child Nutrition: Turning the Corner
Perhaps the most consequential improvements
in NFHS-6 lie in child nutrition. India has long struggled with some of the
world’s highest rates of child stunting and wasting, earning the nation an
unenviable place in global hunger indices. The new data provide grounds for
cautious optimism.
Child Nutrition
Indicators (Under-5 Children)
|
Indicator |
NFHS-5 (2019-21) |
NFHS-6 (2023-24) |
|
Stunting (height-for-age) |
35.5% |
29.3% (∖17.5%) |
|
Wasting (weight-for-height) |
19.3% |
19.0% (marginal) |
|
Severe wasting |
7.7% |
5.2% (−32.5%) |
|
Underweight |
32.1% |
~28% (est.) |
|
Full immunisation (12–23 months) |
76.4% |
87%+ |
Stunting is a key marker of chronic
malnutrition and is closely tied to irreversible impairments in cognitive and
physical development. A decline from 35.5% to 29.3% — 17 percentage points
reduction in relative terms — represents a significant shift in outcomes,
driven in large part by the POSHAN Abhiyaan (National Nutrition Mission)
launched in 2018, improved ICDS delivery, and better coverage of maternal
nutrition programmes.
Severe wasting, an indicator of acute
malnutrition requiring urgent clinical intervention, dropped from 7.7% to 5.2%.
While the overall wasting rate remained nearly static, the decline in its most
dangerous form suggests that healthcare systems are identifying and treating
the most at-risk children more effectively.
|
POSHAN
Abhiyaan (2018–present) targets convergent interventions across six
ministries to reduce stunting, underweight, low birth weight and anaemia.
NFHS-6 data suggest it is beginning to deliver sustained results, though
absolute levels remain unacceptably high by global standards. |
Full immunisation coverage — defined as
children receiving BCG, measles, and all doses of DPT and polio vaccines — rose
to above 87%, up from 76.4% in NFHS-5. This leap of more than ten percentage
points in three years is remarkable and reflects the reach of the Universal
Immunisation Programme (UIP), including the Mission Indradhanush
intensification campaigns.
1.2 Maternal Health and Institutional Deliveries
India’s maternal health infrastructure has
undergone a dramatic transformation over the past two decades, largely through
targeted government schemes. NFHS-6 confirms that these investments are paying
off.
Maternal Health
Indicators
|
Indicator |
NFHS-5 (2019-21) |
NFHS-6 (2023-24) |
|
Institutional deliveries |
88.6% |
90.6% |
|
Mothers with ≥4 ANC visits |
58.5% |
65.2% |
|
Caesarean section rate (all) |
21.5% |
27.2% |
|
C-section in private facilities |
47.4% |
54.1% |
|
C-section in public facilities |
14.3% |
16.9% |
|
C-section in urban areas |
— |
40.0% |
Institutional deliveries crossing 90.6% is
a milestone that India has been working towards for over a decade, with
landmark initiatives such as the Janani Suraksha Yojana (JSY), Pradhan Mantri
Surakshit Matritva Abhiyan (PMSMA), and Janani Shishu Suraksha Karyakram (JSSK)
providing financial incentives and free services for facility-based childbirth.
The rise in antenatal care (ANC) visits to four or more from 58.5% to 65.2%
reflects improved antenatal health surveillance.
However, the sharp rise in C-section
deliveries — from 21.5% to 27.2% overall — is a cause for serious concern. The
WHO recommends an optimal C-section rate of 10–15%. India’s urban rate of 40%
more than doubles this threshold, and the rate in private hospitals (54.1%) is
approaching the levels seen in countries with the highest medically unnecessary
caesarean rates globally. This points to a commercialisation of childbirth,
particularly in urban private facilities, that requires urgent clinical auditing
and regulatory intervention.
1.3 Demographic Transition: Below Replacement Fertility
India’s Total Fertility Rate (TFR) has
declined to 1.9 in NFHS-6, down from 2.0 in NFHS-5 and well below the
replacement level of 2.1. This marks a historic demographic milestone. For
decades, population growth was a central concern of India’s public health and
development policy. The data now confirm that India has crossed into a new
phase.
Contributing factors include rising female
literacy, greater access to contraception (the contraceptive prevalence rate
rose from 66.7% to 69.1%), and a reduction in child marriages (women aged 20–24
married before age 18 fell from 23.3% to 16.7%). Teenage motherhood has also
continued to decline across most states.
This transition carries profound
implications. As the working-age population swells in the short term (the
‘demographic dividend’), India must invest in human capital, healthcare, and
employment. In the longer term, the decline in fertility will accelerate
population ageing, increasing the demand for geriatric services, pension
systems, and chronic disease management.
|
India’s
TFR at 1.9 is below the replacement level of 2.1 for the first time in
national survey history. This demographic milestone demands a fundamental
shift in health planning priorities — from population control to managing an
ageing population’s health needs. |
1.4 Women's Empowerment and Digital Inclusion
NFHS-6 documents sweeping gains in women’s
social and economic empowerment, which carry long-run benefits for population
health.
•
Women’s internet usage nearly doubled, from 33.3% in
NFHS-5 to 64.3% in NFHS-6
•
Bank account ownership among women rose to 89.0%
•
Women participating in major household decisions:
approximately 89%
•
Health insurance coverage rose from ~41% to 60.2%,
improving healthcare affordability
•
Use of hygienic menstrual protection among women aged
15–24 rose from 77.6% to 79.2%
These gains are not merely social metrics.
Research consistently links women’s education, economic autonomy, and
decision-making power with lower child mortality, better nutrition outcomes,
and delayed marriage — creating virtuous cycles that outlast any single
programme.
Section 2: The Pain — Unguarded Pathways
2.1 The Rising Obesity and NCD Burden
If child undernutrition is the old enemy,
obesity and non-communicable diseases (NCDs) are the new ones. NFHS-6 provides
the most alarming data yet on India’s accelerating transition to a
lifestyle-disease-dominated health profile.
Adult Overweight and
Obesity (BMI ≥25 kg/m²)
|
Indicator |
NFHS-5 (2019-21) |
NFHS-6 (2023-24) |
|
Women aged 15–49 — overweight/obese |
24.0% |
30.7% (↑ 6.7 pp) |
|
Men aged 15–49 — overweight/obese |
22.9% |
27.3% (↑ 4.4 pp) |
|
Urban women — overweight/obese |
— |
42.8% |
|
Rural women — overweight/obese |
— |
25.5% |
|
Urban men — overweight/obese |
— |
36.3% |
The increase in obesity between NFHS-5 and
NFHS-6 is larger than the increase that occurred between NFHS-4 and NFHS-5 —
the problem is not just persisting but accelerating. Nearly one in three Indian
women is now overweight or obese, and in urban areas, the figure approaches one
in two. This is a public health emergency in the making.
Obesity is a primary driver of India’s NCD
cluster: type 2 diabetes, hypertension, cardiovascular disease, certain
cancers, and non-alcoholic fatty liver disease. NFHS-6 data on blood sugar and
blood pressure paint a deeply concerning picture.
NCD Indicators — Blood
Sugar and Hypertension
|
Indicator |
NFHS-5 (2019-21) |
NFHS-6 (2023-24) |
|
Men with high/very high blood sugar or on medication |
15.6% |
20.9% |
|
Women with high/very high blood sugar or on medication |
13.0% |
17.8% |
|
Men with very high blood sugar (>160 mg/dL) |
— |
↑ 3.8 pp |
|
Women with very high blood sugar (>160 mg/dL) |
— |
↑ 2.8 pp |
|
Men with hypertension (mild–moderate) |
— |
~22.1% |
|
Women with hypertension (mild–moderate) |
— |
~19.4% |
Translated into absolute numbers:
approximately 8.15 crore men and 6.42 crore women have very high blood sugar
levels. About 12 crore men and 10.5 crore women suffer from mild to moderately
high hypertension. These staggering absolute numbers demand dedicated chronic
disease management infrastructure at every level of the health system.
The urban–rural divide in NCD burden is
stark: 23.9% of urban men have high blood sugar, compared with 19.7% of rural
men. Yet rural rates are rising rapidly too, as processed foods, motorised
transport, and sedentary occupations penetrate deeper into rural India. If the
current trajectory continues unchecked, the projected medical costs of
obesity-related conditions in India could reach $479 billion by 2060, according
to research cited by the National Centre for Biotechnology Information.
2.2 The Decline in Exclusive Breastfeeding
One of the most troubling reversals in
NFHS-6 is the decline in exclusive breastfeeding (EBF) among infants under six
months, from 63.7% in NFHS-5 to 55.8% in NFHS-6 — a drop of nearly eight
percentage points in just three years.
|
Exclusive
breastfeeding for the first six months of life is one of the most
cost-effective public health interventions available. It reduces infant
mortality, prevents undernutrition, confers long-term immunity, and reduces
the risk of obesity and chronic disease in later life. A reversal of this
indicator is a direct threat to child health gains. |
Crucially, while the proportion of women
initiating breastfeeding within the first hour of birth has increased — driven
by improved institutional delivery and skilled birth attendance — this is not
translating into sustained exclusive breastfeeding at home. The paradox may
reflect a gap in post-discharge support and counselling, aggressive marketing
of infant formula, inadequate maternity leave policies, and insufficient
community-level lactation support.
The overall breastfeeding rate (any
breastfeeding) for children under six months stood at 95.6%, suggesting that
women are not abandoning breastfeeding entirely but are supplementing it with
formula, water, or other foods earlier than recommended. This early weaning
undermines both the nutritional and immunological benefits that make exclusive
breastfeeding such a powerful intervention.
2.3 Persistent Child Undernutrition and Regional Disparities
Despite the national-level gains in
stunting, the absolute prevalence of 29.3% remains deeply alarming by any
international benchmark. Nearly one in three Indian children under five is
still chronically stunted. Regional and state-level disaggregation reveals even
more stark inequalities.
In Madhya Pradesh, for example, nearly one
in three children remains stunted; the share of underweight children actually
rose from 33% to 39.7% between NFHS-5 and NFHS-6; and wasting increased from
18.9% to 23.8%. Only 12% of children aged 6–23 months in the state receive a
minimum acceptable diet. These figures expose the danger of interpreting
national averages as uniform progress.
The double burden of malnutrition —
undernutrition in children and obesity in adults, sometimes within the same
household — reflects the inadequacy and poor quality of the food environment.
As one expert cited in recent coverage observed, the availability of adequate
and good quality food is very low in India, simultaneously contributing to
underweight individuals and those eating unhealthy food that drives obesity.
2.4 The Anaemia Data Gap
NFHS-6 faces significant criticism for one
major methodological departure: the official removal of blood-drawn biomarker
testing for anaemia. Previous rounds used haemoglobin testing to provide
precise, district-level anaemia prevalence data. NFHS-6 replaced this with
self-reported or proxy measures, which are known to underestimate true anaemia
burden.
This is a serious setback for monitoring
the Anaemia Mukt Bharat (AMB) programme, which targets a 3-percentage-point
annual reduction in anaemia across key population groups. NFHS-5 (2019–21) had
found anaemia affecting 57% of women of reproductive age (up from 53% in
NFHS-4), making it one of India’s most persistent public health challenges.
Without robust biomarker data in NFHS-6, it is difficult to accurately assess
on-the-ground iron-deficiency trends or evaluate whether AMB is delivering
results.
Anaemia remains a critical concern,
particularly for women, adolescent girls, and children under five. It impairs
cognitive development in children, reduces maternal health outcomes, increases
obstetric complications, and diminishes economic productivity in adults. The
removal of haemoglobin testing from NFHS-6 should be reversed in the next
survey round.
Section 3: Policy Priorities — What Must Be Done
3.1 Build on Child Health Gains Without Complacency
The improvements in stunting, severe
wasting, and immunisation must be actively sustained. Service delivery gaps
must be identified at the sub-district level and addressed urgently, as
national averages obscure severe intra-state disparities. Particular attention
is needed to last-mile delivery in tribal areas, urban slums, and aspirational
districts.
•
Sustain POSHAN Abhiyaan funding and expand
district-level monitoring
•
Ensure no regression in immunisation coverage — target
universal full immunisation
•
Strengthen community-based nutrition screening and
management (CMAM)
•
Address minimum acceptable diet gap: only ~12% in some
high-burden states
3.2 Tackle the NCD Epidemic with Urgency
The pace at which obesity, diabetes, and
hypertension are rising demands that NCDs be elevated to a first-tier national
health priority, on par with maternal and child health.
•
Set up comprehensive NCD screening programmes at
village, town, and city levels under the Health and Wellness Centres framework
•
Launch a nation-wide behaviour change communication
campaign on diet, physical activity, and metabolic health
•
Fast-track Front-of-Pack Labelling (FOPL) warnings by
FSSAI to help consumers identify unhealthy products
•
Impose higher taxes on sugar-sweetened beverages and
ultra-processed packaged foods
•
Integrate NCD management into the PMJAY/Ayushman Bharat
benefit package to ensure affordability
•
Allocate greater funds in the National Health Mission
for lifestyle disease prevention and management
3.3 Reverse the Breastfeeding Decline
A multi-pronged strategy is needed to
reverse the drop in exclusive breastfeeding:
•
Strengthen post-discharge lactation support — deploy
trained lactation counsellors at all delivery facilities
•
Enforce the Infant Milk Substitutes (IMS) Act against
aggressive formula marketing
•
Extend paid maternity leave and enable workplace
breastfeeding infrastructure
•
Train ASHA workers in community-based breastfeeding
support and early weaning counselling
3.4 Regulate C-Section Rates
The surge in C-sections, particularly in
urban private hospitals, demands immediate regulatory response:
•
Mandate clinical auditing for all private hospitals
exceeding 15% C-section rates
•
Introduce standardised indication protocols and
second-opinion requirements before elective C-sections
•
Expand the Nurse Practitioner Midwife cadre to promote
normal childbirth
•
Publicly report facility-level C-section data to enable
accountability
3.5 Restore Anaemia Tracking
The omission of blood-drawn biomarkers from
NFHS-6 must be treated as an urgent data governance issue:
•
Immediately commission state-level haemoglobin surveys
to fill the anaemia data gap
•
Reinstate biomarker testing in all future NFHS rounds
•
Ensure Anaemia Mukt Bharat monitoring is underpinned by
robust biomarker evidence
3.6 Prepare for a Greying India
With TFR below replacement level, India is
on a trajectory towards significant population ageing within two to three
decades. Transformations are still possible if planned for now:
•
Begin building geriatric care infrastructure and
primary care capacity for age-related conditions
•
Train a pipeline of geriatricians, physiotherapists,
and palliative care professionals
•
Review pension and social protection frameworks in
light of demographic projections
•
Strengthen the SRS and National Health Accounts to
complement NFHS data on NCDs and ageing
Conclusion
NFHS-6 is, in the truest sense, a survey of
two Indias. One India has moved needles that appeared immovable for
generations: children are better nourished, more vaccinated, and more likely to
be born in a health facility than ever before. Fertility is below replacement
level. Women are more empowered, more connected, and more financially included.
These are genuine achievements, and they deserve genuine celebration.
But the other India is gaining weight while
its children remain stunted. It is supplementing breast milk with formula
before six months. It is delivering babies in urban hospitals by C-section at
twice the WHO-recommended rate. It is quietly accumulating hypertension,
diabetes, and the early seeds of cardiovascular disease in a health system that
was designed for infections and malnutrition, not metabolic disorders.
The NFHS, as one of the world’s largest
cross-sectional household surveys, is irreplaceable as a tool for public health
navigation. Its data mandate not just celebration, but honest reckoning. The
most dangerous response to NFHS-6 would be to present only the gains and
overlook the unguarded pathways. Setting up comprehensive NCD screening,
enforcing behaviour change communication, taxing unhealthy products, reversing
the breastfeeding decline, regulating the C-section epidemic, and restoring
biomarker testing for anaemia are not optional refinements — they are essential
responses to a dual burden that, if ignored, will define the healthcare crisis
of the 2030s and 2040s.
The moment for pivoting is now. The data —
both the joy and the pain — have never been clearer.
Annexure: Key NFHS-6 Indicators at a Glance
Comprehensive NFHS-5 vs
NFHS-6 Comparison
|
Indicator |
NFHS-5 (2019-21) |
NFHS-6 (2023-24) |
|
Institutional deliveries |
88.6% |
90.6% |
|
Mothers with ≥4 ANC visits |
58.5% |
65.2% |
|
Caesarean section rate (all) |
21.5% |
27.2% |
|
Stunting (under-5) |
35.5% |
29.3% |
|
Severe wasting (under-5) |
7.7% |
5.2% |
|
Full immunisation (12–23 months) |
76.4% |
87%+ |
|
Exclusive breastfeeding (<6 months) |
63.7% |
55.8% |
|
TFR (Total Fertility Rate) |
2.0 |
1.9 |
|
Women overweight/obese |
24.0% |
30.7% |
|
Men overweight/obese |
22.9% |
27.3% |
|
Men with high blood sugar/medication |
15.6% |
20.9% |
|
Women with high blood sugar/medication |
13.0% |
17.8% |
|
Health insurance coverage |
~41% |
60.2% |
|
Women using internet |
33.3% |
64.3% |
|
Women with bank accounts |
~78% |
89.0% |
|
Contraceptive prevalence rate (CPR) |
66.7% |
69.1% |
|
Child marriage (women 20–24 married <18) |
23.3% |
16.7% |
|
Hygienic menstrual protection (women 15–24) |
77.6% |
79.2% |
Sources
1. Ministry of Health and Family Welfare
(MoHFW), Government of India. National Family Health Survey-6 (NFHS-6), 2023–24
Fact Sheets. Published May 2026.
2. International Institute for Population
Sciences (IIPS), Mumbai. NFHS-6 Report. nfhsiips.in
3. The Hindu. “National Family Health
Survey-6 Findings: Complete Coverage.” June 2026.
4. PIB Press Release. “Union Health
Ministry Releases National Family Health Survey–6.” May 2026.
5. eHealth Magazine. “NFHS-6 Reveals
India’s Mixed Health Transition.” May 2026.
6. The Wire. “Missing Indicators in
NFHS-6.” May 2026.
7. Down to Earth. “NFHS-6: Madhya Pradesh’s
development gains hide deep child nutrition crisis.” June 2026.
8. NCBI/PubMed. Spatiotemporal variations
and determinants of overweight/obesity among women of reproductive age in urban
India. 2023.
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