The release of the National Family Health Survey-6 fact sheets on May 29 offers good news. Institutional deliveries have risen. NFHS-6 shows that maternal healthcare indicators have improved. Immunisation coverage remains strong in large parts of the country. By conventional measures, India’s public health system is moving in the right direction.
Yet NFHS-6 also points to a harder problem. India is becoming healthier, but its health challenges are becoming more complex. The system built to fight infectious disease, malnutrition and maternal mortality must now deal with chronic illness, mental health, ageing, environmental risk and rising healthcare costs.
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NFHS-6 and India’s health transition
The older public health bargain was easier to measure. More vaccinations, fewer maternal deaths and wider institutional access produced visible gains. The next phase will not be so simple. Diabetes and hypertension require monitoring, follow-up and adherence. Mental health needs community support. Ageing requires sustained and coordinated care. Climate-linked health risks need preparedness at the local level.
Hospitals cannot carry this burden alone. Nor can insurance. India’s health debate is still dominated by infrastructure and coverage. Both matter. Neither is enough.
NFHS-6 deserves to be read less as a national scorecard and more as a map of uneven capacity. The important message lies not only in national averages, but in disparities across states and districts. These differences are usually attributed to resources. That is only part of the story. Some regions do better because local institutions work better.
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Local governance and public health
Health outcomes are produced in communities, not in ministries. A functioning Primary Health Centre, a panchayat that can coordinate sanitation and nutrition, and frontline workers who detect local vulnerabilities can matter as much as budgetary allocation. Money matters. So does the machinery that turns money into services.
The quality of governance determines whether public spending becomes public health.
This is the central lesson from recent work on decentralised healthcare governance. Local governments often know community needs better than distant authorities. They can respond faster and tailor interventions. But decentralisation does not automatically produce equity. Stronger districts use autonomy well. Weaker ones fall further behind.
NFHS-6 indirectly exposes this gap. District disparities are not just statistical variations. They are signs of uneven administrative capacity.
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Decentralisation without capacity
The problem is not whether health responsibilities should move downward. They already have. Local governments are expected to handle chronic disease, mental health, palliative care, ageing and environmental risks. Many lack the staff, funds and technical capacity to do so.
This creates an ethical problem. Decentralisation may improve efficiency where institutions are strong, but deepen inequality where they are weak. A district with better doctors, data systems and local administration will absorb new responsibilities. A poorer district will struggle with the same mandate.
As India’s disease burden shifts from episodic illness to long-term vulnerability, this gap will become more important. Public health reform must therefore ask a sharper question: not just who is responsible, but whether the responsible institution can deliver.
Kerala and India’s ageing future
India’s health transition is also a demographic transition. Several states are ageing rapidly. Family structures are changing. Migration is separating older parents from younger caregivers. Traditional support systems are weakening just as care needs are becoming more complex.
Kerala shows what lies ahead. It remains a public health success story. But its current problems — non-communicable diseases, mental health concerns, population ageing and rising healthcare expenditure — are not signs of failure. They are the next stage of health development.
Kerala’s experience suggests that success does not end governance problems. It changes their nature.
Public health beyond hospitals
India’s next health reform must focus as much on institutions as on infrastructure. The debate cannot stop at the number of hospitals built or the number of people covered by insurance. It must ask whether local governments have the administrative, financial and technical capacity to manage chronic disease, ageing, environmental health risks and inequality.
This is a governance question. Health outcomes are still treated as products of medical systems. Increasingly, they are products of institutional systems: local coordination, frontline responsiveness, data use, public trust and the ability to reach vulnerable households.
NFHS-6 should be read as a reminder of an unfinished agenda. India has made large gains in expanding access. The next challenge is to build institutions capable of governing health in a society that is older, richer, more unequal and more exposed to new risks. The future of public health will depend not only on what happens inside hospitals, but on the quality of governance outside them.
Megha Jacob is Assistant Professor, Department of Economics, Jesus and Mary College, University of Delhi. Sukanya Das is Professor, Department of Policy and Management Studies and Dean (Research & Partnerships), TERI School of Advanced Studies, New Delhi.