The burden of progress: NFHS-6 readings explain why India is in need of a third health revolution

Historically, rural India has been the most vulnerable to catastrophic health expenses, but now has 62% coverage, slightly more than urban India’s 56%.

It’s one of the fastest expansions of financial risk protection ever seen in a large developing country. Programmes like Ayushman Bharat, along with state insurance schemes, have turned healthcare from a purely private household burden into a partially socialized risk.

India is still far from the levels of universal health coverage achieved by countries such as Thailand or South Korea, but the direction of change is clear.

Women’s empowerment has been the second revolution. The proportion of women who manage their own bank accounts rose from 53% in 2015-16 to 89% in 2023-24. The increase was more dramatic in rural India: from 49% to 89%. Nationally, women’s ownership of mobile phones increased from 46% to 64% and use of hygienic menstrual protection increased from 58% to 79%.

Such changes may seem mundane, but economists increasingly see them as the basic building blocks of development. A woman with a bank account, a mobile phone and control over her own finances has far more agency in healthcare decisions, fertility choices and investments in the well-being of children.

That the rural-urban gap is narrowing is especially striking. In 2005-06, rural women were separated from urban women by wide gaps in access, information and financial services. Differences remain, but had narrowed considerably by 2023-24. Digital identity, direct benefit transfers and financial inclusion programmes have enabled the Indian state to reach populations that were once beyond its administrative reach.

But the success has had an unexpected consequence. India is winning the battle against undernutrition but losing ground against over-nutrition. In 2005-06, 36% of women in India were below normal Body Mass Index. That number had fallen to 20% by 2023-24. Undernutrition among rural women dropped from a shocking 41% to 23%.

That is progress, no doubt. But during this period, the overweight and obesity rate among women soared from 13% to 31%. The rise was even sharper for men, from 9% to 27%. The transformation is especially visible in rural India. The percentage of overweight or obese rural women rose from 7% in 2005-06 to 26% in 2023-24. That of rural men rose from 6% to 23%.

For decades, policymakers have worried about too few calories. Now they have to worry about poor-quality calories. This is like the ‘nutrition transition’ that took place in China, Brazil and Mexico when economic growth, processed foods and less physical activity quickly changed the pattern of diseases. According to the World Health Organization (WHO), obesity is a leading cause of cardiovascular disease, stroke and diabetes globally. India is now at that stage of development.

This transition is nowhere more apparent than in blood sugar levels: 9% of women had high blood sugar in 2015-16. By 2023-24, this had almost doubled to 17%. Urban male prevalence rose from 13% to 22%; rural prevalence from 11% to 19%.

What is scary about these numbers is not only the growth but the pace at which rural India is closing the gap with urban India. Diabetes was earlier regarded as a disease of the rich urban population.

NFHS findings suggest that assumption is no longer true. India is basically exporting urban lifestyles to rural communities and importing urban diseases back.

The story of maternal health presents a similar paradox. Over two decades, institutional deliveries have increased tremendously and helped reduce maternal as well as infant mortality. The rate of deliveries by Caesarean section has risen from 9% nationally in 2005-06 to 17% in 2015-16 and 27% in 2023-24. The increase is particularly pronounced in private health facilities where Caesarean delivery accounts for 54% of births, up from 41% a decade ago and 17% two decades ago.

The WHO has repeatedly said that at the population level, Caesarean rates in excess of about 10–15% do not necessarily translate to better maternal or neonatal outcomes. India’s current trajectory therefore raises questions around medical necessity, provider incentives and healthcare regulation.

Not all behavioural trends are negative. The consumption of tobacco has been steadily declining among all; 37% of men used tobacco in 2005-06, falling to 36% in 2023-24. Female tobacco use dropped from 11% to 8%. Alcohol consumption has also fallen among men from 32% to 19% nationally and remains very low among women.

These improvements illustrate how sustained public health messaging, regulation and social change can change behaviour at scale. The latest NFHS findings reveal that India has gone through three health revolutions in a generation. The first was a fight against poverty. The second was for inclusion. The third—and ongoing—war is against diseases of affluence.

Even as we increase access to healthcare, we must stop diet-related diseases in their tracks. Insurance cards, hospital beds and surgical capacity will count but won’t be enough. India needs to invest in nutrition policy, urban design, preventive screening, food regulation and behavioural change with the same determination as financial inclusion.

The big challenge of the next 20 years will be to ensure Indians live healthier lives. That is what the NFHS indicates. India must translate its rising prosperity into healthy longevity and not let it result in a public health burden.

The author is managing director and chief executive officer of People Research on India’s Consumer Economy.