The good, the bad, or the ugly? What NFHS-6 reveals about Kerala's health

Kerala has long been considered one of India's benchmark healthcare models. From high life expectancy and literacy levels to strong maternal and child health indicators, the state is often cited as a model for the rest of the country. But has Kerala managed to sustain that reputation in the years since NFHS-5? Are its people healthier today? Has progress continued, or are new health challenges emerging beneath the surface? 

The newly released National Family Health Survey (NFHS-6, 2023-24) offers a fresh snapshot of the state's health profile. The data suggests that Kerala continues to perform strongly on many health indicators, particularly in maternal and child health, and vaccination coverage. However, the survey also reveals growing concerns around lifestyle diseases, obesity, diabetes, hypertension, and some emerging social indicators.  

Maternal and child health 

Kerala continues to report some of the strongest maternal and child health indicators in the country, though the latest survey shows that progress has not been uniform across all areas. 

Antenatal care remains highly accessible. The proportion of mothers who had at least one antenatal care visit increased from 88.9% in NFHS-5 to 94.9% in NFHS-6. Similarly, the percentage of mothers receiving at least four antenatal care visits rose from 81.3% to 88.6%. 

However, one indicator moved in the opposite direction. Mothers who had their first antenatal check-up during the first trimester declined from 93.6% in NFHS-5 to 85.5% in NFHS-6, suggesting that early registration of pregnancy may have weakened despite overall improvements in antenatal care coverage. 

Nutritional supplementation during pregnancy has improved considerably. Mothers who consumed iron-folic acid tablets for 100 days or more increased from 80% to 92%, while those consuming supplements for 180 days or more rose from 67% to 83.7%. 

Institutional deliveries remained nearly universal in Kerala. About 99.7% of births took place in health facilities, compared with 99.8% in NFHS-5. Births attended by skilled health personnel also remained virtually universal at 99.8%. 

One issue that continues to stand out is the high prevalence of caesarean deliveries. The percentage of births delivered by caesarean section increased from 38.9% to 41.3%. Caesarean deliveries in private health facilities rose from 39.9% to 42.5%, while those in public facilities increased from 37.2% to 39.3%. 

Commenting on the trend, Dr Sushanta Banerjee, a senior demographer and public health researcher, said, “Nationally, the C-section story is overwhelmingly a private-sector phenomenon with 54.1% taking place in the private sector versus just 16.9% in public sector facilities, which is exactly the pattern Sushanta Banerjee and Sumit Gulati's temporal work since 2010 captures. We are seeing a steady annual rise concentrated in private facilities. But Kerala departs from that pattern. The public sector rate also stands at 39.3%, barely below private (42.5%), and more than double the all-India public figure. In most states the public sector acts as an equalizer. However, in Kerala C-Sections have permeated both sectors, so the surgical-delivery norm has effectively become the default standard of care across the whole system.” 

He added that “this shift in clinical norms is plausibly driven by several factors including financial and scheduling incentives in the private sector (which handles the majority of Kerala's deliveries, only 34.3% of institutional births are public); rising maternal age, lower parity and high maternal overweight/obesity.” 

 “Kerala's adult obesity is among the highest and is potentially a significant influencer in decision-making coupled with declining tolerance for any intrapartum risk in a near-universally institutionalised, highly health-seeking population,” Dr Banerjee said.  

Postnatal care indicators showed modest gains. Mothers receiving postnatal care within two days of delivery increased from 93.3% to 94%, while newborns receiving postnatal care within two days rose from 91.2% to 93.5%. 

Child vaccination coverage also strengthened across most indicators. Full vaccination coverage among children aged 12-23 months increased from 78.4% to 84.9%. Coverage of three doses of polio vaccine rose from 84.1% to 88.6%, while three doses of pentavalent vaccine increased from 85.9% to 88.8%. 

The first dose of the measles-containing vaccine improved from 88.9% to 92.8%. Particularly noteworthy was the rise in coverage of the second dose of the measles-containing vaccine among children aged 24-35 months, which jumped from 31.9% to 83.3%. 

Coverage of the birth dose of the hepatitis B vaccine increased from 81.4% to 86.9%. Rotavirus vaccination recorded one of the most dramatic improvements, rising from just 9.5% in NFHS-5 to 87.2% in NFHS-6, reflecting the expansion of immunisation programmes. 

At the same time, childhood illnesses showed mixed trends. The prevalence of diarrhoea among children under five increased from 4.3% to 5.6%, while severe diarrhoea rose slightly from 0.1% to 0.2%. Symptoms of acute respiratory infection (ARI) increased from 2.4% to 2.8%. 

The proportion of children with fever or ARI symptoms who were taken to a health facility or healthcare provider declined from 86.2% to 79%, suggesting a potential gap in healthcare-seeking behaviour despite Kerala's strong healthcare infrastructure. 

Dr Bipin Gopal, Deputy Director, Directorate of Health Services (DHS) and State Nodal Officer for NCD Control, Kerala, attributed the sharp rise in second-dose measles vaccination coverage to focused public health efforts aimed at measles elimination. 

According to Dr Gopal, Kerala attached significant priority to measles vaccination through initiatives aligned with the World Health Organisation's measles elimination programme. He said special efforts were made to mobilise families who were hesitant about additional vaccines beyond the routine immunisation schedule. 

"There was a kind of drive. People who were not willing to take additional vaccines other than the routine vaccines were mobilised for taking the second dose of the measles vaccine. Health education and awareness activities were carried out in the community, and people themselves came forward for measles vaccination," he said. 

Dr Anish TS, Professor at the School of Public Health, Kerala University of Health Sciences, and Nodal Officer at the Kerala One Health Centre for Nipah Research and Resilience, said Kerala has historically maintained high vaccination coverage, although performance varies across districts. 

He noted that many southern districts have consistently recorded vaccination coverage above 95%, while lower coverage in a few districts has influenced the state's overall averages. According to him, further improvements become increasingly difficult once a state has already achieved high levels of immunisation coverage. 

"Generally, it is very difficult for a good-performing state to improve its status further. When coverage is already high, the remaining unvaccinated population often reflects deeper sociological and behavioural factors, making additional gains harder to achieve," he said. 

However, Dr Anish cautioned that the dramatic increase in second-dose measles coverage should be interpreted carefully. He suggested that at least part of the change may reflect differences in vaccine reporting and policy rather than a sudden surge in uptake alone. 

According to him, Kerala previously administered the second dose through the Measles-Mumps-Rubella (MMR) vaccine, whereas later immunisation schedules shifted to a standalone measles-containing vaccine under the Universal Immunisation Programme. 

"Only 30% coverage of the second dose in Kerala was never very believable. Earlier, many children received the MMR vaccine, which also contained measles protection. It is possible that during previous surveys, this was not always recorded as a second measles dose. So part of the difference may reflect reporting issues rather than a true jump in coverage," he said. 

Child nutrition improves, but diet quality remains a challenge 

The NFHS-6 findings indicate that Kerala has made significant gains in child nutrition and feeding practices, although important gaps remain. Early breastfeeding practices improved substantially. The proportion of children breastfed within one hour of birth increased from 66.7% in NFHS-5 to 82.3% in NFHS-6. 

Exclusive breastfeeding among infants younger than six months also improved markedly, rising from 55.5% to 72.7%. This places Kerala well above the national average and reflects stronger adherence to recommended infant feeding practices. 

Complementary feeding practices improved as well. The proportion of children aged 6-8 months receiving solid or semi-solid food along with breast milk increased from 71.3% to 79.3%. 

The percentage of breastfeeding children aged 6-23 months receiving an adequate diet rose slightly from 23.4% to 24.3%. Among non-breastfeeding children in the same age group, the proportion receiving an adequate diet increased sharply from 22.2% to 43%. 

Overall, the percentage of children aged 6-23 months receiving an adequate diet increased from 23.3% to 26%. 

While this marks progress, the data also means that nearly three-fourths of Kerala's young children still do not meet the minimum acceptable diet standards used in the survey, highlighting that dietary diversity and meal frequency remain challenges even in one of India's better-performing states. 

In the latest findings, the nutritional status of children under five improved across all major indicators. 

The prevalence of stunting, which reflects chronic undernutrition, declined from 23.4% to 20.1%. 

Wasting, an indicator of acute malnutrition, fell significantly from 15.8% to 10.9%, while severe wasting reduced from 5.8% to 2.6%. 

The proportion of underweight children also declined from 19.7% to 17.8%. 

Kerala additionally recorded a reduction in childhood overweight prevalence, from 4% in NFHS-5 to 2.1% in NFHS-6. 

Commenting on the findings, Dr Gopal urged caution in interpreting the adequate diet indicator. He said the finding may not fully reflect the nutritional support available to children in the state and noted that the survey sample could influence such estimates. 

Dr Gopal pointed to Kerala's extensive nutrition support programmes, including school meal initiatives and other government-supported interventions, arguing that many children have access to balanced meals through the state's welfare system. 

"Through the midday meal programme, every child is getting adequate nutrition. The midday meal in Kerala is actually a staple diet that contains balanced nutrition. Even children from poor backgrounds are attending schools, and school coverage is above 95%. So everybody is getting some kind of nutrition at some point of time," he said. 

He added that the NFHS findings on adequate diet require closer examination before definitive conclusions can be drawn about child nutrition in the state. 

Offering another perspective, Dr Anish said the indicator reflects dietary quality and diversity rather than overall nutritional status alone. 

He noted that Kerala's improvements in stunting, wasting and underweight prevalence suggest that children are generally achieving better growth outcomes. However, the survey may be highlighting gaps in dietary diversity and micronutrient intake. 

"If you just look at weight and growth indicators, Kerala is performing better. But when you specifically assess whether children are receiving foods from different food groups, then some concerns emerge," he said. 

Dr Anish added that previous research has found significant micronutrient deficiencies among children in Kerala despite relatively favourable growth indicators. "Sometimes a child may achieve adequate weight and height but may not be getting enough vitamins and micronutrients. This is what we call hidden hunger," he said. 

He suggested that limited dietary diversity, changing food habits and growing consumption of processed foods among children could be contributing to the findings. 

Reflecting on the broader public health and social factors influencing child nutrition, Gandhi added that the contrast between Kerala's strong breastfeeding indicators and the relatively low proportion of children receiving a minimum acceptable diet highlights the complexity of complementary feeding. 

She explained that breastfeeding benefits from sustained support through the healthcare system, including counselling from frontline health workers and repeated messaging about its importance. 

"There is a continuum of care around breastfeeding that is supported by the health system and reinforced through trusted relationships between mothers and the primary healthcare network," she said. 

Gandhi noted that complementary feeding depends on a much wider range of factors, including caregiver knowledge, affordability, food availability, time constraints and family support systems. 

"The world of complementary feeding is a much broader ecosystem that extends beyond the health system. What is available  and accessible to the family where they live may be very different from recommendations in guidelines. States have several important initiatives that support child nutrition, including complementary nutrition programmes including Anganwadi take home ration, Poshan Abhiyan and interventions under the maternal and child nutrition programmes. However, nutrition is not simply about calories. It is about the quality and diversity of food, as well as the body's ability to absorb and utilise nutrients. We also need to consider the caregiver's access to time, along with the affordability, availability and accessibility of nutritious foods," she said.  

She also highlighted the role of gender dynamics in shaping child nutrition outcomes. "We often overlook the gendered dimensions of nutrition. A woman’s time is distributed across a range of paid and unpaid responsibilities, and this directly influences feeding practices and childcare. Nutrition programmes often focus on knowledge and behaviour change, but feeding practices are also influenced by who makes decisions within the household, who controls resources and how caregiving responsibilities are shared. These factors need to be recognised as we work collectively to improve child nutrition outcomes," she said.

According to Gandhi, improving infant and young child nutrition requires coordinated action beyond the health sector, involving national, state and local governments as well as community-level interventions that support caregivers with information, resources and decision-making power.   

Kerala's emerging health challenge: Obesity, diabetes and hypertension 

While Kerala continues to perform strongly on maternal and child health indicators, NFHS-6 highlights the growing burden of non-communicable diseases and lifestyle-related health risks. 

Adult nutritional indicators reveal a worrying rise in overweight and obesity. 

Among women aged 15-49 years, the proportion classified as overweight or obese increased from 38.2% in NFHS-5 to 46.7% in NFHS-6. 

Among men, overweight or obesity rose from 36.4% to 37%. 

At the same time, undernutrition has not disappeared. The proportion of women with a Body Mass Index (BMI) below normal increased from 10.1% to 12%, while the percentage of underweight men rose sharply from 10% to 15.5%. 

This suggests Kerala is increasingly facing a "double burden of malnutrition", where undernutrition and obesity coexist within the same population. 

Dr Goyal said the findings reflect a broader epidemiological transition that has been unfolding in the state over several years. 

According to him, the distinction between urban and rural lifestyles in Kerala has become increasingly blurred, with people across the state adopting more sedentary lifestyles and consumption patterns traditionally associated with urban areas. 

"In Kerala, there is a huge epidemiological shift that is happening. The urban-rural divide is a thin margin. People adopt the urban lifestyle even in the so-called rural areas of the state," he said. 

He attributed the rise in obesity and non-communicable diseases to a combination of changing dietary habits, increasing consumerism, higher vehicle usage, reduced physical activity and growing levels of mental stress. 

"Due to this consumerism, the eating habits have changed. Vehicle density has increased. People are having much mental stress-related issues. All these factors contribute to the rise in non-communicable diseases," he said. 

Dr Gopal noted that Kerala has been witnessing a high burden of lifestyle diseases for several years and that the NFHS-6 findings are consistent with previous research conducted in the state. 

He cited studies by the Achutha Menon Centre for Health Science Studies (AMCHSS) and other research institutions, which found that nearly one in three Keralites had hypertension, while around one in five had diabetes. He also referred to research conducted by the Indian Council of Medical Research (ICMR) and the Indian Institute of Diabetes, which estimated that 24% of adults had diabetes and another 14% had prediabetes. 

"This kind of prevalence has actually been present in Kerala for a long period. It is rising slowly. It is not a sudden shift or sudden spike; it is a gradual increase," he said. 

Dr Gopal also pointed out that Kerala's robust screening and surveillance systems may partly contribute to the higher numbers reported in surveys by improving the detection of previously undiagnosed cases. 

"The surveillance mechanism in Kerala is very strong. Through population-based screening conducted by ASHA workers and health staff, even people who do not regularly visit health facilities are getting screened for hypertension and diabetes. Due to this continuous surveillance, more cases are being picked up from the community," he said. 

The survey also points to a growing diabetes burden. 

Among women aged 15 years and above, the proportion with high or very high blood sugar levels, or taking medication to control blood sugar, increased from 24.8% in NFHS-5 to 28.9%. 

Among men, the figure rose from 27% to 31.9%. 

Very high blood sugar levels alone increased from 13.1% to 16.7% among women and from 13.8% to 18.9% among men. 

Hypertension indicators also remain concerning. Among women, the prevalence of elevated blood pressure or use of blood pressure medication increased slightly from 30.9% to 31.9%. Among men, the increase was more pronounced, rising from 32.8% to 36.6%. 

Although the proportion of people with moderately or severely elevated blood pressure declined somewhat, the overall burden of hypertension remains high. 

The survey also highlights changing health-related behaviours. Tobacco use among women remained stable at 2.2%, while tobacco consumption among men declined slightly from 16.9% to 15.9%. 

Alcohol consumption among women remained low at 0.3%, but alcohol use among men increased from 19.9% to 22.7%. 

Understanding the rise in reported violence 

Beyond physical health, some social indicators present a mixed picture. The proportion of ever-married women aged 18-49 years who reported experiencing spousal violence increased from 9.8% in NFHS-5 to 17.7% in NFHS-6. Women reporting physical violence during pregnancy also rose from 0.5% to 1.7%. 

Reflecting on the findings, Gandhi cautioned against drawing definitive conclusions from the data at this stage. She said it is difficult to determine whether the increase reflects a genuine rise in violence, greater willingness among women to report abuse, or a combination of both. 

"Gender-based violence is a complex issue, and it would be difficult to draw definitive conclusions based solely on early NFHS-6 findings. An increase in reporting does not necessarily indicate a simple increase in incidence. It may also reflect greater awareness, changing social norms, or increased willingness among women to disclose experiences of violence. What is needed is a deeper understanding of the context, drivers and consequences before arriving at informed conclusions or policy responses," she said.  

Gandhi noted that self-reporting of violence is highly sensitive and often influenced by factors such as trust, confidentiality, social stigma and willingness to disclose. According to her, experiences such as violence, abortion or even adolescent sexual and reproductive health are often difficult to measure accurately through surveys because of possible underreporting and social desirability bias.

She also pointed out that “violence extends beyond physical abuse and can take many forms, including emotional, mental and financial violence, all of which can have lasting psychological consequences for women.”  

Gandhi further argued that high literacy rates alone do not necessarily translate into agency. Factors such as awareness of what constitutes violence, trust in the survey process, and broader social attitudes towards gender roles may all influence reporting patterns.

According to Gandhi, it is important to interpret the findings with caution, particularly because NFHS-6 currently provides only fact-sheet level data. "We have to be very mindful that what is reported may not fully reflect the true prevalence of violence.” 

This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS