<p>Global climate warming and intensified human activities have profoundly altered natural hydrological processes and increased the risk of regional water balance deterioration. This study develops an integrated natural-social water balance assessment framework to search the temporal-spatial distribution and evolution law of healthy water cycle pattern in China from 2011 to 2018. Natural–social water cycle flux accounting, system coupling coordination, and elasticity analysis were integrated to address regional water balance health and reflect the contribution of driving factors to spatial and temporal imbalance patterns. China was taken as case study with multi-source hydrological, ecological, and socioeconomic dataset from 2011 to 2018. Spatial and temporal patterns of regional water balance health, the dominant contributions of driving factors, and their seasonal variations were obtained from the framework. The results indicated that regional water balance health patterns exhibited pronounced spatial and temporal heterogeneity, and the national mean unhealthy water balance index reached to 0.33 with persistent hotspots of imbalance in northern basins and relatively stable conditions in the south. Terrestrial water storage and total water use exhibited the most consistent influences, with the contribution in the same direction to unhealthy water balance conditions across 88.99% and 93.25% of the country. Vegetation cover and evapotranspiration were the primary factors shaping water balance states conditions across large areas. The framework provides a quantitative and interpretable basis for diagnosing water balance health and for developing region management strategies.</p> Graphical abstract <p></p> <p>This visual summary serves as a pivotal entry point into the research, providing a concise overview of the study’s core findings and methodologies. This study develops an integrated natural–social assessment framework to diagnose water-balance health across China during 2011–2018. Hydroclimate fluxes characterize the natural water cycle, including precipitation, evapotranspiration, runoff, and groundwater runoff. Human regulation is represented by socioeconomic and water-use information across agricultural, industrial, and domestic sectors. The framework quantifies coupling and coordination among water resources, socioeconomic activities, and ecological conditions. These components are integrated into the Unhealthy Water Balance Index (UWBI), where higher values indicate a less healthy water-balance state. The graphical abstract summarizes national and regional UWBI conditions and visualizes spatiotemporal distribution and consistency. Results reveal pronounced regional heterogeneity, with a national mean UWBI of 0.33 and persistent hotspots in northern China. Dominant drivers are identified using elasticity-based attribution and mapped through factor contributions. Terrestrial water storage and total water use show the most consistent influences, with consistent directions across 88.99% and 93.25% of China. Seasonal-transition diagnostics further highlight shifts in controlling mechanisms across seasons. These findings support region-specific strategies for water-demand management and water-allocation planning.</p>