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Health and Nutrition of India’s Labour Force and COVID-19 Challenges

Uma Lele ( is a visiting research scholar at the Institute of Economic Growth, New Delhi, and president-elect of the International Association of Agricultural Economists. Sangeeta Bansal ( is with the Centre for International Trade and Development, Jawaharlal Nehru University, New Delhi. J V Meenakshi ( is at the Delhi School of Economics, University of Delhi, New Delhi.

Can the “post-COVID-19 normal” emerge better for India’s food supply and demand management, with a clear goal of zero hunger? Presently contributing one-third of the global undernutrition burden, a daunting challenge that the country must overcome now is of resuming broader based economic growth with a healthy labour force. Given this, India needs a data-driven exit and post-exit strategy from the COVID-19 lockdown that will not only mitigate the immediate food crisis faced by millions of poor households, but also reduce the long-term structural bottlenecks that limit poor households’ access to food.

While handling the COVID-19 crisis, will India make use of the opportunity to address the long-standing challenges of health and nutrition of low-income households, particularly of women and children, which are central to the three prongs of the health sector, food sector, and the macroeconomy? From the macroeconomic perspective, the International Monetary Fund (IMF) has estimated a global gross domestic product (GDP) loss of $9 trillion. A small fraction of that invested in pandemic preparedness would have had a large pay-off.

Better supply and demand management of food would: (i) avoid the immediate food crisis for millions posed by logistical issues between the farm and the plate (Pangestu 2020); (ii) contribute to effective demand by reducing long-term, structural bottlenecks inhibiting supply reaching vulnerable consumers; (iii) contribute to the global sustainable development goals (SDGs) that are important since India presently contributes about one-third of the global undernutrition burden; and (iv) prepare India to avert future disasters while resuming broader based economic growth.

India extended its lockdown beyond 3 May 2020 by two weeks, to contain the spread of COVID-19, buying time to protect its 1.3 billion people from the virus’s uncertain trajectory. Despite enormous hardships, the lockdown appears to have strong public support (Desai and Pramanik 2020). Globally, the reliability of this strategy in bending the curve or reducing future waves of COVID-19 is, by no means, certain. Policy responses are challenging, although global knowledge is accumulating rapidly.

With sudden job losses, the lockdown created acute hardships for millions of ­urban and rural households, most working in the informal sector with no contracts, including 22 million migrants, likely moving from high-income metropolitan locations with higher case rates to areas of migrant origin in poorer states, such as Bihar and Uttar Pradesh, contributing to spread of the virus (Imbert 2020). How much can India’s formal and informal social safety nets be strengthened to deal with the challenge?

The diagnosis and solutions are well-known in India—already working in several cases—but overcoming weak implementation and monitoring, including in the Prime Minister’s extensive agricultural policy reforms announced on 2 May 2020 and the finance minister’s steps announced on 14 May 2020, which will be essential. Implementation remains a challenge, where poverty and undernourishment are acute (Times of India 2020).

The importance of testing, tracing, isolating, and treating those infected with COVID-19 to reduce its spread has huge implications for India. It means India should substantially increase investment in public health, including sanitation and epidemiological research. Concurrently, India should adopt and vigorously implement a “zero hunger” goal. An estimated 194 million were hungry, lacking purchasing power, before COVID-19. The pandemic is projected to increase poverty and hunger by several million. Social safety nets, in-kind and cash transfers, should be increased substantially to create effective demand for food among them. Furthermore, policymakers should prioritise worker safety to assure labour’s return to broad-based, efficient, and productive growth.

Opportunities and Challenges

Fortunately, India’s food production has done well in recent years, with large public sector food stocks of 57 million tonnes, which allows for food distribution (ICAR–NIAP 2020). Strengthened public distribution was already needed, because economic growth had reduced poverty much too slowly and employment growth had slowed even before the pandemic. India’s largely privately traded horticulture production has also grown more rapidly than food production (313.85 million tonnes on 25.49 million hectares in 2018–19), outperforming staple grain production (284.95 million tonnes for the same year) (ICAR–NIAP 2020). India now ranks second globally, behind only China, in fruit and vegetable production (GOI 2018b). Per capita availability of milk in India was 394 grams per day in 2018–19, an increase of 40% since 2009–10, but availability varies substantially across states (NDDB 2019). Smallholder dairy is reportedly adjusting well, switching from the private sector to the cooperative sector in sales and milk processing (Rath 2020).

In short, diets have improved, but India still contributes a third of the global burden of hunger and malnutrition. Also, India has a growing incidence of non-communicable diseases (particularly, diabetes and cancers), increasing the population’s vulnerability to COVID-19, and it has the largest number of the world’s children, 4.3 million, under 18 years.

Persisting undernourishment: Together, women and children comprise about 70% of India’s population. Incidence of undernourishment is higher in women than men (average body mass index ≤ 18.5), varying considerably across states and wealth quintiles, although men fare only slightly better. The prevalence of undernourishment amongst women is as high as 31.6% in Jharkhand, and low as 6.4% in Sikkim. Undernourishment is high in Bihar, Madhya Pradesh, Gujarat, and Rajasthan, which are also the states with high incidence of stunted children. In the lowest health quintile, 36% of women are undernourished, compared to 11.6% in the highest wealth quintile; while among men, these shares are at 32% and 10.6%, respectively (IIPS and IFC 2017).

While under-five stunting, at 37.9%, compares to the developing country ­average of 25%, nearly 21% of children under five show wasting, which is more than twice the developing country average of 8.9%; and 51.4% of women in repro­duc­tive age have anaemia. Again, interstate differences in each dimension are ­considerable. Of the 100 poorly performing districts in stunting, Uttar Pradesh, Bihar, Madhya Pradesh, Jhar­khand, Gujarat, Karnataka, and Rajasthan account for 78% of stunting (Menon et al 2017).

High levels of maternal and child under­nutrition in India persist, despite strong constitutional and legislative policy commitments (Niti Aayog 2017). The National Food Security Act, 2013, mandates food and nutrition entitlements for children, pregnant women and breastfeeding mothers with maternity support; and the Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act, 1992, and the amendment act, 2003, provide a strong policy framework for protecting, supporting, and promoting nutrition interventions—especially during periods of greatest vulnerability for children and women. The National Nutrition Policy, 1993, complemented by other policies, such as the National Health Policy, 2002 and the National Policy for Children, 2013, provides a strong foundation for addressing immediate and underlying determinants of undernutrition through both direct and indirect interventions. The Twelfth Five Year Plan reinforced the commitment to prevent and reduce child undernutrition (underweight prevalence in children 0–3 years), as one of its core monitorable targets, binding multiple sectors and states to collective action (Niti Aayog 2017).

Migrant labour and employment: Temporary and seasonal migration for employment was about 13.6 million annually, seven times larger than permanent and semi-permanent migration (Bhagat and Keshri 2018). Temporary and seasonal migrants belong mainly to poor and lower socio-economic categories, in contrast to permanent/semi-permanent migrants. A large number of migrants return to their places of origin, as part of a circular migration, so contribution of migration to urbanisation and population redistribution remains much lower than expected, based on the historical experience of mobility transition in Western countries.

But, now, return migration poses risks of spread of the virus. On the other hand, high population densities make social distancing nearly impossible, even in rural areas, especially in poorest states, like Bihar and (eastern) Uttar Pradesh. A reported 70.7% of the population is ­rural, according to the labour survey (GOI 2019). The development impact of migration has been positive, but without policy support, and as elsewhere in the world, general perceptions about migration are negative and hostile (Bhagat and Keshri 2018). Poorest households are more widespread, and many are women-headed and lack assets.

The pandemic has had an enormous impact on employment, beyond that seen on migrant labour. The Centre for Monitoring Indian Economy (CMIE 2020) reports that, as in other countries, unemployment rates have skyrocketed, increasing nearly 2.5 times over one month to stand at between 23% and 26% in May 2020. The workforce is comprised of 51.7% of rural males but only 17.5% of rural females, and 53% of urban males but only 14.2% of urban females. The working population ratio (WPR) in current weekly status (CWS) was 49.6% for rural males, 14.8% for rural females, 51.7% for urban males, and 13.3% for urban females. Women’s wages are two-thirds to three-quarters of male wages (IIPS and ICF 2017).

Measures to Overcome Challenges

To improve the undernutrition challenge for better health, a multi-level, multi-stakeholder market and safety net strategy is needed.

Strengthening food supply chains: The need of the hour is to help strengthen food supply chains that move nearly a billion tonnes of food, horticulture, livestock, fisheries production to consumption, removing constraints to production, storage, distribution, processing, packaging, retailing, and marketing, and making the most of institutional diversity in supply chains and information technology.

To this end, the National Institute of Agricultural Economics and Research Policy (NIAP) has already identified areas where quick wins in policy implementation will help foster market linkages, for example, not restricting the farmers to the Agri­cultural Produce Market Committee (AMPC) markets, public information on all public and private storage facilities for surpluses, easy access of market actors to agricultural finance and information to traders linking them to farmers, cash transfers to households using direct banking transfers, creating awareness and, hence, demand for pulses, milk, fruit and vegetables, and the wider use of the public distribution system (PDS) to distribute grain stocks (ICAR–NIAP 2020).

The Delhi government, for example, has supplemented the PDS grains, allowing cash expenditures on other foods, such as milk and vegetables, as prices of milk and vegetables are rising in the wake of supply chain disruptions due to COVID-19. India’s rapid expansion of ­financial inclusion infrastructure (Pradhan Mantri Jan Dhan Yojana) allows for transfer of money ­directly into bank accounts (Lele and Goswami 2017), but the banking infrastructure is much weaker precisely in those states with high incidence of poverty (GOI 2018a). Thus, a disproportionate share of benefits has gone to states with higher incomes. India certainly needs to increase its banking network and digitalisation in less developed states.

Moreover, as the finance minister noted in her speech on 14 May 2020, agriculture, as a state subject, has had its own challenges in a large country like India. Despite the fact that several state-level statutes of the APMC Act have been reformed, so far, they have been unable to create an integrated national agricultural market or address key issues, such as the expansion and modernisation of marketing facilities, improvement in marketing information and communication, and linking of small producers with efficient marketing channels. ­The Prime Minister’s announced reforms will need to be backed by sustained investments in market infrastructure, both by the public and private sectors.

Empowering women in food chains: Women’s empowerment and its effectiveness in their ability to implement decisions needs to increase, especially in the food production and consumption domain, where they play a large role. For example, nearly 85% to 90% of ­menial labour in the dairy sector is done by women.

The food environment, on the other hand, consists of the

food entry points, the physical spaces where food is ­obtained; the built environment that ­allows consumers to access these spaces; personal determinants of food choices including income, education, values, skills, etc and factors that influence food choices, food acceptability and diets [by] physical and economic access to food proximity and affordability; food promotion, advertising and information; and food quality and safety. (HLPE 2017: 11)

India’s institutional diversity in value chains consisting of cooperatives, producer organisations, private sector and self-help groups (SHGs), combined with the PDS, can be gendered to be an asset in the COVID-19 emergency. For example, countries like the United States have seen milk and vegetables ploughed into rivers and the ground (Jeffrey and Newburger 2020). In contrast, in India, the National Dairy Development Board reports liquid milk sales showing signs of steady recovery, based on policy and proactive support from the central and state governments and on measures taken by producer-centric organisations to address supply chain challenges, whereas private sector sales have shown greater disruption (NDDB 2020).

Women empowerment will also enable significant changes in consumer behaviour, including how food is allocated within the household. In times of scarcity, in patriarchal societies, women and children often go hungry and become food-insecure. Prolonged periods of food insecurity translate into long-lasting nutritional deficiencies and poor health. Through several initiatives, this collective change in consumer behaviour can foster sustainable food systems that, at the same time, enhance nutrition security for all.

Strengthening the SHGs: India’s flagship programme, the National Rural Livelihood Mission (NRLM), created in 2010 to reduce poverty by mobilising poor ­rural women in SHGs and building ­community institutions, is addressing COVID-19 challenges.

Some 20,000 SHGs across 27 Indian states are creating employment for women, for example, to produce millions of masks and thousands of litres of sanitiser and handwashing liquid.

Since production is decentralised, these items have reached widely dispersed populations without the need for complex logistics and transportation. With huge numbers of informal workers losing their livelihoods during the lockdown and food supply chains getting disrupted in some areas, SHGs have set up over 10,000 community kitchens across to feed stranded workers, the poor, and the vulnerable. (World Bank 2020)

For example, the Kudumbashree network in Kerala, of nearly 4.4 million women members, has delivered nutritious, cooked meals as needed, operating 1,300 kitchens across the state, in addition to providing food to the bedridden and those in quarantine (World Bank 2020). Kudumbashree is also spearheading the government’s Break the Chain campaign using mobile phones, posters, and weekly meetings to raise awareness about handwashing and social distancing. In one of India’s poorest states, Bihar, the state’s SHG platform JEEViKA is using leaflets, phone messaging, songs, and videos to communicate about handwashing, quarantine, and self-isolation. Additionally, women-run help desks are delivering needed food supplies to the elderly and the quarantined. In Jhar­khand, women are running a dedicated helpline for migrants returning and other vulnerable families. “Women at the centre of development have been an important story in South Asia. In these extra­ordinary times … women’s groups are playing a critical role” (World Bank 2020). Most compelling is the vast literature that suggests that the transfers to women-led SHGs and other measures to empower women have great health multiplier effects.

IT in pandemic management: Information technology (IT) is already profoundly impacting India’s ability to ­respond to the COVID-19 pandemic. IT is particularly important for real-time contact tracing and monitoring of the emergence of hotspots and can play an even more significant role in managing relief measures. As COVID-19 hotspots appear and abate, relief measures can correspondingly be ramped up or dialled down, as necessary. IT will remain vital in targeting health and financial aid.

Public investment in healthcare: Even in normal times, medical expenditures push people into debt and poverty. Over 80% of Indians have no access to health coverage. Despite a health infrastructure that reaches out to primary and community health centres in rural areas, reliance on private health providers is common. Inadequate staffing, accountability, and quality are some of the reasons why private hospitals are preferred. Inpatient expenditures (outside of childbirth) in private hospitals are six to eight times more than in public hospitals. To improve healthcare in the post-COVID-19 environment, more public–private partnerships are needed. Kerala is one state with substantial public investment in the healthcare industry, in addition to crowding-in private health investment.

Concluding Thoughts

It is time for significant change. India is responding to the challenge in several ways; but in the post-COVID-19 normal, by adopting “zero hunger” as an explicit goal, prospects could be a lot better. Comfortable foodgrain stocks and a favourable demographic structure have aided India’s ability to cope with the crisis, but other challenges are daunting. They include high undernutrition prevalence, growing incidence of non-communicable diseases, high population densities, vulnerable migrant labour and daily wage earners, low status of women, low participation rates and lower wages of women in the labour force, and poor health infrastructure.

Most immediately, India needs to prepare an exit strategy from the lockdown. While economic activity should be resumed and supply chains restored and improved, special attention should be paid to protecting income, livelihoods, and food security amongst the vulnerable groups. Removing supply bottlenecks and providing demand stimulus (via incomes) could work in tandem with restoring the economy.

Understanding pattern of spread of the infection, identifying virus-free ­districts, and developing cost-effective testing will lessen the risk of exposure on lifting the lockdown. It will be important to encourage employers to practise socially responsible protocols for worker safety: providing workers with masks, soaps, sanitisers, and clean water, as well as facilitating social distancing. The stigma against COVID-19 needs to be channelled into a constructive way forward. Awareness that most infected people could be cured, if treated in time, would reduce the stigma. The COVID-19 outbreak has made India realise the fragility of its public health infrastructure. India needs to increase and strengthen investments in public hospitals, vaccines, and pharmaceuticals. India has also realised the critical role of epidemiological studies in understanding the spread of the disease. Policymakers should take this opportunity to strengthen its healthcare and food and nutrition research capacity.

When social distancing is so important, policies should also explore the potential of IT for activities ranging from distant learning, implementation of government schemes in efficient, transparent, and accountable manners, to the ­securing of the social safety nets.


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Updated On : 26th May, 2020


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