Through the University Health System, the Autonomous University of Queretaro organized an integrative care clinic '*Clinica de Atencion* Integral COVID' dedicated to providing COVID-19 services and diagnosing and monitoring patients at home. The goal of this clinical service was to provide multidisciplinary assessment and treatment by a system that included virtual phone-based assessment and clinical home monitoring. The *Clinica de Atencion* Integral COVID offered a multidisciplinary care model in which physicians, nutritionists, physical therapists, pharmacological chemists, psychologists, and other staff members played a role in delivering comprehensive care. A description of the activities in each of the clinic's care areas is provided below.

# *Detection Area*

At the beginning of the pandemic, a group of scientists from the Autonomous University of Queretaro offered SARS-CoV-2 virus detection services to the people through the use of the university's own resources. Detection was carried out by means of a molecular screening test. More than 2,000 free tests were offered to the population at risk. It was found that approximately 80% of infected people did not have symptoms or had mild symptoms. This was an important finding because it made it possible to detect and isolate carriers to prevent the spread of the virus, particularly for those most susceptible.

# *Clinical Household Follow-Up Program*

Carriers of SARS-CoV-2 were invited for clinical follow-up which included a symptoms questionnaire to be administered by telephone screening to find out if the patient was a candidate for follow-up at home. Only patients with low and medium risk were accepted into this program. Patients with high risk were referred to a specialized care service. A series of visits were made to the patient's home to record signs and symptoms such as temperature, oxygenation, an olfactory test, and an antibody test. The first home visit was made by medical personnel. In subsequent visits, a pharmacological chemist obtained a blood sample to measure antibodies and a nutritionist performed a nutritional assessment.

Nutrition plays an important role in the management of COVID-19 [44]. Undernutrition, micronutrient deficiencies, and overnutrition increase the risk of developing serious complications [45]. The aim of the nutritional assessment was to identify nutritional risk in COVID-19 patients and assess its association with disease outcomes. In the beginning, the assessments were focused on identifying the risks of undernutrition. Nutritional assessment was later modified to assess metabolic risk factors. In patients included in this program risk factors like hypertension (30%), obesity BMI > 30 (27%), and diabetes (10%) were also assessed.

# *Rehabilitation: Post-COVID-19 Program*

COVID-19 resulted in several medical, social, and psychological consequences like multi-organ failure of the heart and kidneys and vascular damage [46]. Specific rehabilitation needs to be undertaken for post-COVID-19 patients to achieve respiratory improvement and functional and cognitive recovery, decrease disability, and improve the quality of life [47].

Persistent symptoms were present in patients who had recovered from COVID-19 in Mexico [48]. There was no rehabilitation clinic in the private or the public sector where comprehensive multidisciplinary services could be offered for the treatment sequelae of COVID-19. A multidisciplinary team participated to address cardiopulmonary, nutritional, and psychological sequelae.

The assessment included a clinical history to obtain the patient's sociodemographic data, data related to diabetes, cardiovascular risk factors, and other comorbidities. Information on smoking and alcohol consumption and dietary intake was obtained by using a food frequency questionnaire. A battery of tests were conducted including laboratory testing, testing for respiratory conditions, functional status, quality of life, psychiatric conditions, and nutritional status.

The goal of the nutrition service was to assess the nutritional sequelae of COVID-19 and then to give personalized advice to the patients. Body composition analyses were performed by bioimpedance with a Body Composition Analyzer mBCA 514/ 515 Seca GmbH & Co. KG, Hamburg. This breaks down weight into body compartments (muscle mass, body fat, and visceral fat). As would be expected, the principal nutritional risks found in patients post-COVID-19 were obesity, loss of muscle mass, and a decline in overall physical functioning. However, in our experience, after six weeks, muscle mass and nutritional status improved in these patients. It is important to note that medical and physiotherapists participated in the program.

The assessment also included circadian rhythmic features. It has been repeatedly acknowledged that the adequate functioning of the rhythmical system is essential for maintaining the homeostasis of an organism [49]. Studies focusing on the effects of lockdown as a result of the pandemic showed that human performance and health, especially quality and quantity of sleep [50], nutrition, and physical activity were affected [51]. A recent study shows that the complex pathogenesis of severe acute respiratory syndrome by SARS-CoV-2 infection is related to circadian disruption [52]. Thus, in considering the disturbances of the biological timing for nutritional assessment according to light–dark cycles, timing of food intake, light at night, nocturnal feeding, physical activity, jet lag, and shift work are of prime importance [53].

In conclusion, Mexico is among the countries that have the highest COVID-19 fatality rates. Efforts were made to expand hospital capacity. However, there were significant disruptions in the health services. The health system needs to resume essential services and should catch up on missed preventive care even as the COVID-19 crisis continues in Mexico. A comprehensive assessment is the key factor in the management of COVID-19 and in identifying specific clinical needs for comprehensive and individualized care.

# **References**

**Adriana Aguilar Galarza, PhD** Collaborative Researcher, University Health Program, Universidad Autonoma de Queretaro, Queretaro, Mexico Adriana Aguilar Galarza, a Collaborative Researcher from the University Health Program, Universidad Autonoma de Queretaro, focuses on the impact on health of the university community through integral diagnostics and first level medical care, promoting healthy spaces and forming health promoters. She has worked on epidemiology studies related to metabolic risk in young adults and the impact of circadian rhythms in metabolic health.

**Sandra Celada Martínez, MSc** Collaborative Researcher, University Health Program, Universidad Autonoma de Queretaro, Queretaro, Mexico Sandra Celada Martínez, a collaborator to health programs at the Universidad Autonoma de Queretaro, focuses on the implementation of new areas for healthcare systems oriented to adequate spaces and necessary sanitary measures.

**Dr. Oscar San Roman Orozco** Project Manager, The BORN Project, Universidad Autonoma de Queretaro, Queretaro, Mexico Oscar San Roman Orozco is a medical doctor from the Universidad Autonoma de Queretaro (UAQ), Mexico. He has a Masters in Global Public Health and Advanced Certificate in Public Health Disaster Science, Policy and Practice from the New York University (NYU) School of Global Public Health. He has a University Expert Degree in Hospital Management from the Universidad of Cadiz, Spain. He is the Project Manager of the BORN Project Mexico at the Newborn Foundation. He has been on Expert Advisory Boards for developing interventions like the Masimo Safety Net OPEN and the COVID-19 Clinic at UAQ where he has been actively publishing research on COVID-19 in the Mexican population including mobility measures, relationship with the reproductive number, models for re-opening the university and mental health impact among others. He was awarded the Lewis Blackman Leadership Award by the Patient Safety Movement. He is a member of the Delta Omega Honorary Public Health Society. He is a former Co-coordinator and to date, an Advisor to the Applied Global Public Health Initiative at the NYU School of Global Public Health and its satellite laboratory at the Universidad Autonoma de Queretaro

**Dr. Isidro Amadeo Gutiérrez Álvarez, Professor and Medical Coordinator, Applied Global Public Health Initiatives, Universidad Autonoma de Queretaro, Queretaro, Mexico** is Professor of basic medical genetics at the school of medicine of the Autonomous University of Querétaro and is the academic coordinator of the laboratory of Applied Global Public Health Initiatives UAQ/NYU, a student's organization in Querétaro, México that is dedicated to impacting health equity in underserved communities. He has worked on health communications and policy for more than 30 years when he launched campaigns that focused on knowledge of congenital diseases, immunization, food insecurity, infant mortality, nutrition, and mental health. He is a peaker and author who blogs on congenital disease, environmental impacts on health and the connection between public health policies and clinical practice.

**Izarelly Rosillo Pantoja, PhD, Researcher, Universidad Autonoma de Queretaro, Mexico** Doctor of Law, researcher, and trial lawyer in the field of human rights and the environment. She elaborated 20 local legislations for the Mexican state and three international legislations that impacted on various plans and programs on environmental matters. She drafted the first Circular Economy law for Mexico in the state of Quintana Roo and also for the Dominican Republic. She worked for various international and national organizations including the World Bank, Inter-American Development Bank, ECLAC, UN Environment, German Cooperation Agency (GIZ), Chamber of Deputies in Mexico, and local governments, among others.

She received several distinctions, including an honorary appointment as a member of the World Committee on Sustainable Development of the Organization Founded by Nobel Peace Prize winner Rajenda Kumar Pachauri. She is a member of the National System of Researchers of the National Council of Science and Technology in Mexico. She is the author of several books and articles published in national and international journals.

**Dr. Nuri G. Villaseñor Cuspinera, MSc, School of Medicine, Universidad Autónoma de Queretaro, Mexico** is a full-time teacher-research. She has a Degree in Medicine from the Faculty of Medicine, UNAM, and a Master Degree in Bioethics. She is a Faculty of Bioethics, Universidad Anáhuac. Specialty in Nuclear Medicine. National Medical Center 20 de Noviembre. ISSSTE, PhD student in sciences, Faculty of Medicine, UAQ. She held the position of Tutoring Coordinator of the Faculty of Medicine, UAQ. She is professor of the Bachelor of Medicine, Bachelor of Art Teaching, Bachelor of Mexican Folk Dance, Bachelor of Acting, Faculty of Fine Arts, and Faculty of Medicine, UAQ. She has published extensively on COVID-19 and other important issues in international and national journals.

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# **Bridge Over Troubled Waters: Women-led Response to Maternal and Child Health Services in India Amidst the COVID-19 Pandemic**

**Aastha Kant and Avishek Hazra**

**Abstract** Globally, the COVID-19 pandemic has disrupted the delivery of essential health services in general and reproductive, maternal, newborn, child health, and nutrition (RMNCHN) services in particular. The degree of disruption, however, varies disproportionately. It is more in low- and middle-income countries than in highincome countries. Focusing on India, the authors draw on various demand and supply side factors that hampered the provision of RMNCHN services and thus adversely affected many families across the country. Coupled with the gendered aspects of the social determinants of health, the pandemic intensified social vulnerabilities by impacting pregnant and lactating women and children the most. Modelling studies suggest that the progress India made over a decade on various maternal and child health and nutrition indicators may go in vain unless focused efforts are made to address the slide. Complementing government efforts to mitigate the health risks of the pandemic by strengthening health services, women-led initiatives played an important role in portraying how women's collectives and women in leadership can be like a bridge over troubled waters in the times of a pandemic.

# **Introduction**

Coronavirus disease-2019 (COVID-19) affected the warp and weft of the social fabric globally. The pandemic impacted mortality and morbidity in countries around the world. There is evidence to show that more men were infected with COVID-19 as compared to women. And a higher proportion of hospitalizations, intensive care unit admissions, and deaths occurred among men [1]. The 'tyranny of the urgent' placed

A. Kant (B)

A. Hazra Population Council Consulting, New Delhi, India e-mail<EMAIL_ADDRESS>
© The Author(s) 2023

Maternal and Child Health Center India, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA e-mail<EMAIL_ADDRESS>
S. Pachauri and A. Pachauri (eds.), *Global Perspectives of COVID-19 Pandemic on Health, Education, and Role of Media*, https://doi.org/10.1007/978-981-99-1106-6\_4

immediate biomedical needs over existing social inequities [2]. The indirect impacts of COVID-19 had gendered effects that reverberated across sectors. Women faced the social and economic consequences of the pandemic. The virus disproportionately increased the burden of unpaid care on women. It is estimated that in the formal sector, job loss rates were twice as high among women as compared to men with a high proportion of women experiencing a loss in their earnings within the first month of the pandemic. They faced serious socio-economic consequences [3, 4]. Coupled with the gendered aspects of the social determinants of health, the pandemic intensified social inequities in low- and middle-income countries. Learnings from the Ebola outbreak urge us to go beyond the binary of biomedical and social aspects and to respond with a holistic approach to reach underserved and vulnerable populations. To mobilize this response, an intersectionality approach to the pandemic is a prerequisite [2, 5]. This is likely to enhance our understanding of systemic inequities, role of social determinants of health, and lived experiences in the context of the pandemic.

The chapter begins with a snapshot of the global and local (Indian) context of the impact of the COVID-19 pandemic on reproductive, maternal, newborn and child health, and nutrition (RMNCHN). Using secondary data, we present the status of key maternal and child health indicators in the two decades prior to COVID-19 and discuss how various factors during the pandemic disrupted RMNCHN service provision adversely affecting many families across the country. We highlight the way community health workers supported the health system's effort. We also illustrate the gendered impact of the pandemic and how it had severe negative social and economic consequences for women. We showcase the critical role that women's groups and their federations played in underserved and marginalized communities to supplement government efforts to mitigate the health risks of the pandemic. We present these efforts through Relief, Resilience, and Recovery which we term as the '3R response'. We conclude by highlighting the potential of the '3R response' which can serve as a model for other crisis situations in amplifying the reach of health information and services to vulnerable populations.

# **COVID-19 and Maternal, Newborn, and Child Health**

# *Global Context*

The COVID-19 pandemic adversely affected human life in many ways worldwide. The economic and social disruptions caused by the pandemic were devastating. Tens of millions of people were at risk of falling into extreme poverty. It is estimated that the number of undernourished people, currently about 690 million, could increase by an additional 132 million by the end of the year [6]. The pandemic challenged the resilience of health systems globally. It emerged as a threat to global public health, forcing countries to adopt several different strategies including lockdowns [7].

The health sector was affected in particular—from the provision of services to access and the utilization of health services. COVID-19 posed severe challenges for implementing much needed essential health services. It disrupted the delivery of essential health services in general and MNCH services in particular which compelled healthcare systems to prioritize services provided [8]. Healthcare workers had to cope with the rising number of COVID-19 patients. The degree of disruption, however, varied disproportionately. It was more in the low- and middle-income countries (LMICs) than in the high-income countries. The World Health Organization undertook a 'pulse survey on the continuity of essential health services during the COVID-19 pandemic' to estimate its impact on the delivery of essential health services across the life course [9]. In almost every country 90% of country respondents experienced some degree of service disruption with LMICs experiencing a greater extent of service disruption compared to high-income countries.

The potential effects of the virus on mothers, newborns, and pregnancy outcomes were of significant concern [10]. Research showed that nationwide lockdowns disrupted health services in many countries. And the fear of accessing health facilities affected the wellbeing of pregnant women and their babies [4, 11, 12]. Studies which modelled the indirect effects of COVID-19 on maternal and child mortality in LMICs highlighted the consequences of disruption on routine healthcare. A recent meta-analysis shows an increase in maternal mortality, stillbirths, ruptured ectopic pregnancies, pre-term births, and maternal depression during the pandemic which had disproportionate adverse effects in low resource settings [4, 13–15]. A reduction in seeking healthcare as well as reduced provision of maternity services were noted as possible causes [16]. Pregnant women in rural, low resource, and conflict affected settings were at greater risk because they already had inadequate access to quality care [17, 18]. Limitations in the availability of skilled health workers and challenges to using the health system led to lower coverage of ante-natal care (ANC), post-natal care (PNC), and facility and community-based lactation support and counseling for women [19].

A systematic review and meta-analysis published in the Lancet Global Health indicates that the rates of stillbirths and maternal deaths rose by about a third during the COVID-19 pandemic with outcomes showing considerable disparity in stillbirths between high and low resource settings [15]. The review also acknowledged that unequal digital access in LMICs made remote consultations less feasible leading to disruptions in preventive ante-natal care for vulnerable groups. Increase in domestic violence during the pandemic was assumed to be a contributing factor that increased maternal mortality.

The Lancet series of papers highlight the concern on maternal and child nutrition. It was noted that despite some progress, maternal and child undernutrition were a major global health concern as improvements since 2000 may have been countered by the COVID-19 pandemic [20]. The pandemic indirectly threatened breastfeeding practices such as timely initiation, exclusive, and continuous breastfeeding. Reduction in breastfeeding practices during the pandemic were due to limitation in the provision of information and advice and disruptions to the enabling environment [14]. Overall, economic, food, and health system disruptions resulting from the pandemic are expected to exacerbate all forms of malnutrition [21]. Estimates by the International Food Policy Research Institute (IFPRI) suggest that because of the pandemic an additional 140 million people will be thrown into extreme poverty (less than USD 1·90 per day) by 2020 [22].

# *The Indian Context*

The reproductive, maternal, newborn, child, and adolescent health (RMNCH + A) program is at the core of the country's flagship program, the National Health Mission (NHM). Following a call to action summit in 2013, the Government of India took an important step to fulfil its commitment to improve maternal health and child survival through the articulation of a comprehensive approach linking together a set of initiatives and strategies that address each life stage [23]. This was a milestone in the country's health planning for improving the availability of and access to quality healthcare, especially for people residing in rural areas, the poor, women, and children. Innovative strategies were evolved under the national program to deliver evidence-based interventions to various population groups [23]. These included selecting poor-performing districts, prioritizing high impact RMNCH + A health interventions, engaging development partners, and institutionalizing a concurrent monitoring system. This strategy helped in the development of an integrated systems based approach to address public health challenges through a comprehensive framework, defined priorities, and robust partnerships [24].

Over the past two decades, India noted significant improvements in the RMNCH indicators. Data from the National Family Health Survey showed a sharp increase in several indicators including ANC, institutional delivery, newborn care, PNC, child immunization, and child nutrition practices (Fig. 3) [25].

RMNCH services were disrupted in India after March 2020 because of the COVID-19 pandemic induced lockdown and movement restrictions. The health management information system (HMIS), which tracks indicators on the utilization of health services from over 200,000 health facilities—primary health centers to district hospitals in every district of the country and is updated nearly every day showed that health services were severely curtailed in March 2020 as compared to previous months [26]. There were reports of supply chain disruptions due to the lockdown and associated movement restrictions resulting in medicine and vaccine stock-outs. Village health and nutrition days (VHNDs), which are the prime platforms for routine ante-natal and child immunization services, were suspended during the lockdowns. As per the HMIS data, routine check-ups of pregnant women and associated ANC tests that are important for ensuring healthy and safe pregnancy reduced during March 2020 and in the following months (Fig. 4).

*Anganwadi* centers stopped distributing food grains and mid-day meals services were paused as schools were stopped. Mobility restrictions also posed a severe challenge in providing post-natal care to mothers and newborns and monitoring

**Fig. 1** Percentage of countries reporting disruption across entire service groups (n = 105). *Source*  World Health Organization. Pulse Survey on Continuity of Essential Health Services During the COVID-19 Pandemic: Interim Report, 2020

**Fig. 2** Percentage of countries reporting disruption in reproductive, maternal, newborn, child and adolescent health, and nutrition services. *Source* World Health Organization. Pulse Survey on Continuity of Essential Health Services During the COVID-19 Pandemic: Interim Report, 2020

the growth and development of children. The HMIS data indicated that there were reductions in child immunization (Fig. 5).

Multiple barriers decreased service utilization. These barriers were initial movement restrictions and decreased demand due to fear of COVID-19 infection. Several steps were taken by the government to respond to the disruptions caused by the early lockdowns. It moved to a sub-nationally driven localized containment approach that replaced widespread lockdowns with micro-pockets of restrictions determined by the

**Fig. 3** Improvement in key RMNCHN indicators in India (2005–2021). *Source* NFHS-4 and NFHS-5 factsheet

**Fig. 4** Routine ANC check-up during pregnancy in India, July 2019 to June 2020. *Source*  Calculations based on HMIS data

states [27]. There was also greater emphasis on utilizing community health workers in multiple ways which we describe below.

**Fig. 5** Routine immunization for BCG vaccine in India, July 2019 to June 2020. *Source*  Calculations based on HMIS data

# *Community Health Workers' Support to the Health System's Efforts*

Community health workers or frontline health workers—accredited social health activists (ASHAs), a*nganwadi* workers (AWWs), and auxiliary nurse midwives (ANMs)—are women cadres that constitute the healthcare workforce at the grassroots level. It serves as an interface between communities and the public health system. Two million frontline health workers have been engaged in strengthening primary healthcare outreach and community nutrition programs across the country. ASHAs, who are women residents of the village with communication skills, leadership qualities, and social capital were mobilized to engage with the community. They are the first point of contact for maternal and child health related information and services. They mobilize women for ANC services, accompany pregnant women for health facility deliveries, and play an important role in mobilizing women and children for post-natal care services including immunization. In short, ASHAs' mandate is to generate health awareness and mobilize the community for promoting health [28].

AWWs are key personnel under the government's flagship Integrated Child Development Services (ICDS) at a*nganwadi* centers. ICDS aims to promote child development and enhance the capabilities of mothers to look after their children's health and nutrition. The service delivery framework of ICDS includes supplementary nutrition, immunization, health check-ups, and referral services for pregnant and lactating mothers and children below six years of age [29]. ANMs and ASHAs bear the responsibility for immunization services for pregnant women and children, ANC, PNC, basic management of early childhood diseases, and basic services for communicable and non-communicable diseases including disease surveillance. ANMs identify vulnerable populations, assess their needs, and support national and state program activities. Along with ASHAs and AWWs, ANMs organize VHNDs once a month in villages [29].

Community health workers play a vital role in the community by providing access to healthcare especially in the domain of maternal and child health services. There is evidence to suggest that door-to-door counseling and community outreach improved outcomes in health and nutrition behaviors and service uptake such as routine immunization, contraception, and feeding practices of infants and young children [30]. As noted earlier, in the unprecedented times of COVID-19, there was a mandatory lockdown resulting in disruptions in the RMNCH + A services. In this critical situation, the pool of women community health workers was given the additional responsibility of community surveillance by conducting door-to-door visits to identify suspected COVID-19 cases and trace contacts. They were also engaged in providing information about the virus—mode of transmission, symptoms, prevention, and COVID-19 appropriate behaviors. Community health workers were engaged in building community support networks by coordinating with women-led self-help groups (SHGs), youth networks, and *gram pradhans* (village heads) and in connecting them with essential health resources.

During the pandemic, *anganwadi* workers were involved in stitching masks for children and pregnant women. In Vizianagaram, Guntur, Kurnool, and Chittoor districts of Andhra Pradesh. *Anganwadi* workers delivered supplementary nutrition to pregnant and lactating mothers and children below six years of age. In addition to their core mandated responsibilities, *anganwadi* workers were also involved in ensuring the safety of women during the lockdown. Reports show that there was an increase in domestic violence in this period. The government of Tamil Nadu initiated a response system in which the *anganwadi* became the first point of contact for receiving calls about domestic violence and referring those to the concerned officials. In the Rajouri district of Jammu and Kashmir, women could register their domestic violence complaints either at the *anganwadi* center or directly through the distress helpline [29].

Despite the critical role played by frontline women health workers, their own situation had been dismal. Frontline health workers had repeatedly raised their voices regarding inadequate masks, sanitizers, gloves, and personal protective equipment (PPE) kits. In several cases, ASHAs faced violent resistance from the community and so they required protection for their own safety. This was further compounded by delays in receiving their salaries. ASHA workers earn incentives for completing over 60 tasks ranging from Re 1 for every oral rehydration solution (ORS) packet distributed to Rs. 600 for each institutional birth [31]. Due to the pandemic related disruptions in many routine activities related to maternal and child health, ASHAs experienced a decline in their earnings, in some cases to half of their usual income. A study conducted by *Behan*Box between October and December 2020 on the role of frontline workers fighting the COVID-19 crisis in ten states—Assam, Bihar, Haryana, Jharkhand, Karnataka, Maharashtra, Madhya Pradesh, Delhi, Telangana, and Uttar Pradesh, revealed that on an average, work hours for ASHAs increased from 6 to 8 to almost 12–15 h a day during the pandemic [32]. Community health workers were overworked and underpaid during the pandemic.

# **The Gendered Impacts of the Pandemic**

Women contribute a predominant share to the 'care economy' with almost 75% of unpaid care and domestic work at home [33]. Women also engage in the paid economy with high participation in industries. Several of those industries were affected by the pandemic [34]. It is estimated that in the formal sector, job loss rates were twice as high for women than for men [3]. Globally, in the year 2020, women represented 38.8% of all participants in the labor force [35]. As per the Organization for Economic Co-operation and Development (OECD) Center's Gender Index, globally women engaged three times more in care work than men [36, 37]. It is estimated that in the health sector women contribute 5% to the global gross domestic product (USD 3 trillion) annually, of which almost 50% is unrecognized and unpaid [38]. Occupational de-segregated by gender in the health sector is universally seen with a predominance of women health workers belonging to lower social strata. Therefore, they are paid comparatively less and are often in unpaid roles—facing the harsh realities of gender bias. In the health sector, the gender pay gap exists globally affecting women's health outcomes. Women in the healthcare sector earn on an average 28% less than men [39]. The occupational distribution of women tends to be skewed in favor of nursing and midwifery and other 'care' professions such as community health workers. Globally in 2019, of 28.5 million nurses and midwives, about 24 million were women, making them a key stakeholder in the delivery of health services [38].

In India, female labor force participation was on the decline even in the pre-COVID era. Women's earnings were about one-fifth of men's earnings. This situation was further intensified in the informal sector constituting almost 91% of women. Unequal structures, power relations, and societal norms worsened for women during the pandemic. More women lost their jobs and became primary caregivers at home [40]. During the first lockdown in the first quarter of 2020, 47% women lost their jobs and did not return to work by the end of the year as compared to 7% men who lost their jobs and were able to make a recovery. In the informal sector, between March and April 2021, rural women in informal jobs accounted for 80% of the job losses. Overall, in India, the trend shows that men slipped into informal employment while women were forced out of the workforce—further pushing households into poverty and destitution [41].

Extended lockdowns and social distancing norms imposed to curb the pandemic made women more vulnerable to domestic violence. Emerging evidence shows that since the outbreak of COVID-19, reports of violence against women increased in countries where there were lockdowns. Employment insecurity and stress resulted in an increase in gender-based violence. The National Commission for Women (NCW) corroborates that domestic violence complaints almost doubled after the nationwide lockdown was imposed in India. Based on NCW data, a total of 1,477 women complained of domestic violence during the first lockdown between March 25 and May 31, 2021. The highest number of complaints in the last 10 years were recorded in this 68-day period. Among cities, Delhi recorded the highest complaint rate with 32 complaints. Uttar Pradesh recorded the highest number of complaints (600) among all the states in India [42]. Community managed initiatives were undertaken to support civil society organizations along with DAY-NRLM under the Initiative for What Works to Advance Women and Girls in the Economy (IWWAGE). The latter also supported the Study Webs of Active–Learning for Young Aspiring Minds (*SWAYAM)* Project [43]. A center was established to help women voice their grievances. A physical *Lok Adhikar Kendra* (Gender Justice Center) was established with the support of the non-governmental organization *ANANDI* in the Karhal and Sheopur blocks of Sheopur District of Madhya Pradesh. Project Concern International initiated tele-counseling services for women at the Gender Facilitation Center in Odisha [44].

# **Women-led Initiatives to Enhance Maternal and Child Health Services: The 3R Response**

In this section, we showcase the critical role played by women's groups in underserved and marginalized communities to supplement government efforts to mitigate the health risks of the pandemic. These efforts can be viewed through the lens of a '3R response'-Relief, Resilience, and Recovery. We explain this briefly as follows:

The underlying essence of the '3R response' can be understood through various community initiatives that women proactively initiated to address maternal and child health (MCH) needs at the community level during the COVID-19 pandemic. Through the '3R response', we discuss the proactive, innovative, and dynamic responses to the pandemic by women-led initiatives; resilience through collective solidarity by women's groups as they selflessly committed themselves to generating awareness about COVID-19 appropriate behaviors and bridging the supply gap for vulnerable populations. We also sustained efforts of women's groups in facilitating the social and economic recovery of vulnerable populations.

# **Decentralized and Integrated Ways to Generate COVID-19-Related Awareness at the Grassroot Level**

Local responses to the pandemic included generating awareness using creative outlets and digital media. For example, while some SHGs were engaged in graffiti in villages in Chhattisgarh, others made *rangoli* (colored designs) for sensitizing the public about the virus in Uttar Pradesh [45]. In Uttar Pradesh, SHGs of the State Rural Livelihood Mission (SRLM) '*Prerna*' marked the roads with *rangoli* to educate the community about the COVID-19 protocol of physical distancing. They also generated awareness through wall paintings. Women in SHGs used online platforms like TikTok videos and songs to generate awareness about COVID-19 appropriate behavior [46]. In Kerala, *Kudumbshree* disseminated information and checked for misinformation through WhatsApp groups [47]. In Bihar, *JEEViKA* used the mobile *Vaani* platform, an interactive voice response system to spread preventive messages about COVID-19 [47]. *JEEViKA* SHGs developed an innovative comic series, '*Badki Didi*' (big sister), for delivering messages on COVID-19 prevention. In Assam, a vehicle with an amplifier was used by the SHGs to spread messages in the community. In Nagaland, SHGs introduced an innovative method to promote hand hygiene in the community by using locally made bamboo poles [43]. In Jharkhand, a group of rural women journalists called *Patrakar Didis* (journalist sisters) disseminated information on staying safe and accessing healthcare services [43].

SHGs were also involved in enhancing livelihood opportunities for women. In Assam, women were engaged in weaving *Gamusa* (cotton cloth having a cultural significance) fabric for making masks in anticipation of high sales during *Rongali Bihu*, an Assamese festival [43]. Similarly, in the Etawah District of Uttar Pradesh, triple layered masks were made from *khadi* (handloom)*.* In Lucknow, women *chikankari* (embroidery) artisans were involved in making masks. SHGs in the Narayanpet District of Telangana were engaged in making masks from their traditional fabric, *Pochampally*. These products were subsequently marketed by the State Rural Livelihoods Missions [48].

Through their vast networks, SHGs were involved in producing 16 million masks, 500,000 L of sanitizers and 500,000 PPE kits. They also promoted 120,000 community kitchens [49]. Community kitchens provided nutritious food to vulnerable populations, especially to pregnant and lactating mothers and children. Various initiatives were seen across states. Jharkhand initiated the *Mukhya Mantri Didi* Kitchen and *Dal Bhaat Kendras* that were run by *Sakhi Mandals* (SHGs) to provide free meals to vulnerable populations. Bihar started the *Didi Ki Rasoi* and Uttar Pradesh catered to *Prerna* canteens. In Odisha, around seven million women members of 0.6 million Mission *Shakti* SHGs provided necessities like dry rations, groceries, and cooked food to vulnerable populations through community kitchens [45]. In Chhattisgarh, SHGs were engaged in making disposable plates and bowls from paper and dried leaves for the quarantine centers [50]. They also prepared and delivered ready-to-eat *Poshan* (nutrition) kits to pregnant women in quarantine centers in the rural areas of Bemetara District [43].

SHGs also played an instrumental role in crises situations. In Rajasthan, during a crises caused by a drought, the SHG platform was utilized to spread information on capacity building and livelihoods [51, 52]. There are success stories portraying how community-led initiatives for health and food security set an example during the Nipah outbreak in Kerala and cyclone *Phani* in Odisha [51]. Women's collectives have a deep understanding of local communities. They are trusted by the communities which enables them to implement successful initiatives at the community level. At the beginning of the pandemic induced lockdown in India, women SHGs were agile and proactive in pivoting COVID-19 crisis management by reaching out to the last mile and using their social capital to support communities [46]. During the peak of the lockdown, women's collectives, in the form of SHGs, rose to the occasion to provide a decentralized and integrated approach for addressing the health needs of the community. This included generating awareness among pregnant and lactating women as well as among other vulnerable groups to follow COVID-19 protocols and stay safe. They helped in providing nutrition and health services that had been disrupted during the pandemic.

# **SHG and Their Federations in Disseminating MCH and Nutrition Messages in the Community**

In 2011, as part of the National Rural Livelihood Mission, the SHGs and their federations, which were functioning with the support of non-governmental organizations, got a structured government platform. In 2015, the Mission was renamed as *Deendayal Antyodaya Yojana* National Rural Livelihoods Mission. The aim of the Mission is to reduce poverty through gainful self-employment of women. There are 89.91 million households that are mobilized into 8.34 million SHGs. They work across 742 districts and 7073 blocks in 34 states and union territories of India [53].

A systematic review shows that participatory learnings and actions are a costeffective strategy for improving maternal and neonatal survival in low-resource settings [54]. Studies in India show that health interventions with women's groups such as SHGs and their federations helped in improving maternal and child health practices that are supply independent through health behavior change communication interventions [55]. A quasi-experimental study in Uttar Pradesh showed that discussions on key maternal and newborn health practices by trained peer-educators in SHG meetings and community outreach activities organized by SHGs and their federations helped women follow correct healthcare practices [56]. Studies in Bihar demonstrated the effects of pilot interventions around behavior change communication through women's SHGs on improving healthy practices [57, 58]. In three states of India—Bihar, Chattisgarh, and Odisha—*Swabhimaan*, an initiative integrated within the Government of India's flagship poverty alleviation program-*Deendayal Antyodaya Yojana*-National Rural Livelihoods Mission (DAY-NRLM) aims to mobilize women through SHGs to address the nutritional needs of adolescents and women in their communities. Findings from its mid-line evaluation revealed a reduction in thinness among adolescent girls and in women with children under two years of age and an increase in the average mid-upper arm circumference of pregnant women [59].

SHGs were engaged in developing nutri-gardens to promote sustainable ways to boost the immunity of the women and children. This was done by encouraging women to have kitchen gardens in their backyards. They were encouraged to sow different vegetables to address the nutritional needs of pregnant and lactating women and children aged six months to three years. Under the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA), women farmers encouraged families with pregnant women to develop nutri-gardens in their homes in the Koraput District of Odisha [48]. The NRLM advised that *Krishi Sakhis* (agricultural community resource women) support women in making their own kitchen gardens and also engage in poultry as sustainable ways to address their nutritional needs [43]. In Bihar, *JEEViKA* SHGs distributed seeds to households with pregnant women and children who had kitchen gardens. Similarly, in Jharkhand, seeds of pulses and cereals were provided to SHGs. In a few blocks of the Deoghar District in Jharkhand, the district administration distributed sewing machines to women for weaving fishing nets [43].

Another innovative initiative that was undertaken during the lockdown was 'Vegetables on Wheels'. Women in SHGs took it upon themselves to reach fresh vegetables to the vulnerable especially new mothers and children. *Kudumbashree*  started 'floating supermarkets' in the Alappuzha District in the backwaters and canals for delivering essential goods. Five members of two *Kudumbashree* units started operating a 'supermarket' ferry to provide essential daily food supplies. They raised about USD 2,000 for procuring supplies [60]. Ferrying on the *Pampa* river, the supermarket catered to over one hundred families in Kuttanad. In Mizoram, community-operated transport vehicles were used for providing essential services and commodities to underserved areas [48]. In the Bastar District of Chhattisgarh, *Poshan Sakhis* (nutrition sisters) started a tele-counseling service for women on COVID-19 appropriate behaviors, hygiene, and healthy diets. They organized monthly review meetings to assess if appropriate nutrition was being made available during the lockdown to pregnant women, lactating mothers, and children [43].

# *Extending Support to Community Health Workers for Delivering Maternal and Reproductive Health Services*

The lockdown saw a suspension of reproductive, maternal, newborn, child, and adolescent health (RMNCH + A) services across various states of the country. Because *anganwadi* centers were closed, SHGs and other women's collectives stepped in to ensure that pregnant and lactating mothers and children received the services that they needed. Apart from addressing their nutritional needs, SHGs also supported the over-burdened frontline health workers to provide ANC and PNC. They provided iron and folic acid and calcium supplements to women. More than 4,000 pregnant and lactating mothers were reached by over 2,000 SHGs in the states of Bihar, Odisha, and Chhattisgarh. As part of the 'Take Home Ration' (THR) Program, SHGs supported AWWs, ASHAs, and ANMs in Odisha and Chhattisgarh to distribute eggs to children below five years of age and to pregnant and lactating mothers [44]. In some blocks of Odisha, SHGs served the community by tracking pregnant women, lactating mothers, and children to provide routine immunization [61]. They contacted pregnant women who were due for ANC check-ups and extended their support in facilitating ANC visits at health centers [43]. *Kudumbashree* in Kerala ensured that the health supplement *Amrutham* Nutrimix powder reached all infants and children across all the districts of Kerala [43]. The *Swabhimaan* Projects in Bihar, Odisha, and Chhattisgarh was run by the United Nations Children's Fund (UNICEF) and the *ROSHNI* Center for Women Collectives Led Social Action where frontline health workers were supported by SHGs for the delivery of ANC and PNC and for providing micronutrient supplements to under-nourished pregnant women and lactating mothers [44].

*Poshan sakhis* in Bastar, Chhattisgarh worked closely with ASHAs, ANMs, and *Anganwadi* workers in providing counseling on nutritional practices to adolescent girls, pregnant women, and mothers of children under two years of age. They also monitored the beneficiaries receiving essential nutrition services like THR as well as micronutrient supplementation such as iron and folic acid (IFA) and calcium at VHNDs*. Poshan sakhis* in Chhatisgarh and Odisha distributed sanitary napkins, soap, and sanitizers to adolescent girls and generated awareness regarding hand washing with soap [62]. In the Angul District of Odisha, *poshan sakhis* mobilized communities to observe VHNDs while wearing masks and maintaining social distancing [61]. In the Purnea District of Bihar, *kishori sakhis* were engaged in working with adolescent girls through participatory learning and action (PLA) sessions on hygiene and hand washing to prevent COVID-19 infection [43].

Closely associated with SHGs, *poshan sakhis* (friends of nutrition) in Bihar, Chhattisgarh, and Odisha aimed to improve the nutritional status of girls and women through a life cycle approach—starting before conception and ending after childbirth. This included ANC and PNC services and providing micronutrient supplements to malnourished pregnant and lactating mothers [44].

Women in SHGs in Maharashtra distributed sanitary pads through *Asmita* Plus to help meet the demand for sanitary pads during the lockdown. During the lockdown, an SHG from Pune, *Gyaneshwari Samuh Sahayata Samuh* supplied 10,000 packets of *Asmita* Plus sanitary pads to the *Shindhwane gram panchayat* [62]. SHGs under the Chhattisgarh Rural Livelihoods Mission, Bihar Horticulture, Agriculture (BIHAN)—prioritized the distribution of sanitary pads. SHGs also worked very closely with other government initiatives in delivering services to the community during the lockdown. They put their own health at risk as they distributed rations under the Public Distribution System and Take-Home Rations Project implemented through ICDS program [62].

# **Addressing Breastmilk Pleas: Women's Initiatives**

Collaborating with the government, development agencies and civil society organizations provided pathways and opportunities to further the efforts of the women collectives to overcome pandemic related barriers. The second wave of COVID-19 in the country was characterized by a huge shortage of oxygen cylinders, beds, and medications. Thousands of families lost their loved ones. Several pregnant women and new mothers infected; some succumbed to the virus. This led to an increase in pleas for breastmilk. Several community-led organizations came forward to address this concern. Lactating mothers came together voluntarily to support families individually or through human milk banks. Some prominent NGOs, such as *Bachpan Bachao Andolan* and *Protsahan* India Foundation, made efforts to ensure that breastmilk was available to infants in rural and urban areas in the midst of the COVID-19 crisis [63].

In the digital domain, women-led initiatives like *Prachi Pendurkar's Snugbub*  and *Adhunika Prakash's* Facebook group Breastfeeding Support for Indian Mothers posted COVID-related posts on social media for those who were asked to isolate from their babies. Doctors in Mumbai conducted online training in safe breastfeeding for *anganwadi* supervisors in rural Maharashtra. They also set up a helpline for mothers to address their questions on breastfeeding. In addition, they developed a series of Do-It-Yourself tutorials for new mothers [64].

Some state governments also launched initiatives to support breastfeeding. The Delhi Commission for Protection of Child Rights launched a helpline to support children whose caretakers were not available owing to COVID-19 and offered to connect them to women who could donate breast milk. Kerala launched the state's first human milk bank called 'Nectar of Life' at the Ernakulam General Hospital. This facility ensured the availability of abundant breast milk for newborns who could not be breastfed by their own mothers because they were deceased, unwell, or unable to produce sufficient milk [65].

# **Conclusion**

While we recognize the gendered nature and impact of the COVID-19 pandemic, we celebrate the resilience, commitment, and perseverance shown by women-led initiatives in India. Women-led collectives played a critical role in bridging development deficits that were further exacerbated by the COVID-19 pandemic. We believe that the India story was characterized by the '3R response'-Relief, Resilience, and Recovery, led by community women to protect vulnerable groups including pregnant women, lactating mothers, and children who could not receive essential services during the COVID-19 pandemic. The '3R response' can serve as a model in other crisis situations. Women-led initiatives, especially at the grassroots, were able to amplify the voices and priorities of vulnerable groups by bringing them and their concerns center stage. In addition, women's collectives emerged as a sustainable, inclusive, and self-governing community. They demonstrated the effectiveness of participatory development and decentralized governance for building a sustainable gender responsive environment to address the ante-natal and nutritional needs of pregnant women, lactating mothers, and children. Throughout the COVID-19 crisis and the associated lockdowns, these women's groups consistently demonstrated proactive and swift responses and resilience through their selfless dedication and altruism to meet the needs of vulnerable women and children. Pan India narratives of efforts and initiatives of women's collectives discussed in this chapter illustrate that women's leadership can offer hope in times of the COVID-19 humanitarian crisis and beyond—that no matter how troubled the waters are, women champions will continue to build bridges—longer, higher, and stronger—and create pathways for sustainable and inclusive development by serving the underserved and most vulnerable.

# **References**

Government of India. 2020 Apr 13. https://rural.nic.in/en/press-release/community-kitchensrun-shg-women-provide-food-most-poor-and-vulnerable-rural-areas

**Dr. Aastha Kant** is Assistant Director—Research Programs, Maternal and Child Health Center India, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America. Dr. Kant holds a PhD in Social Sciences from the Tata Institute of Social Sciences (TISS). She received her training in Sociology with her Master of Arts (MA) from the University of Pune and Bachelor of Arts (BA) from Lady Shri Ram College for Women, University of Delhi. She previously worked at Harvard T.H. Chan School of Public Health- India Research Center, TISS and the Population Council, India Country Office. She works on gender issues and the social and behavioral aspects of reproductive, maternal, newborn and child health.

**Dr. Avishek Hazra** is the Director, Program and Policy Evaluations at Population Council Consulting Pvt. Ltd., New Delhi, India. He is a monitoring and evaluation specialist with about two decades of research experience in clinical as well as socio-behavioral studies focusing on issues around reproductive, maternal, newborn and child health, nutrition, gender, women's empowerment and mHealth. Over the years he has been leading multi-dimensional large evaluation projects on community mobilization through women's self-help groups, constituted mostly with poor and socially disadvantageous segment of the society. Currently he is leading a unique study that uses implementation science approach to document the effectiveness of interventions supporting women micro-entrepreneurs in 10 states of India. He has published more than 60 articles in peer-reviewed journals and edited books. He has been providing peer review support to many international journals. He is a member of many professional academic forums, global task forces, and served as a technical advisor to the World Health Organization. He holds a MSc in Statistics, and MPhil and PhD in Population Studies.

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# **COVID-19: An Accelerant Toward a Sustainable Health System in Kenya**

**Daniella Munene**

**Abstract** In the face of supply chain inadequacies, human resource constraints, and pervasive false narratives that misinformed the public, the COVID-19 pandemic directed our individual and collective focus on the adequacy of our health system. Was it resilient enough? Had the deficiencies that we were seeing been there all along? Why were they not noticed? Why were voices not raised earlier about the gaps? Perhaps they were. But, why have the proposed changes not been made? Was it resource constraints? Was it poor policies? Was it weak enforcement? These were some of the questions that were going through our minds, the nature of the question reflecting the position each actor had within the system. Action was taken. People organized themselves into task forces and committees, and implemented strategies and work plans. And we started to see results. Face masks and assembling ventilators have now been manufactured in the country. Critical care capacity has been increased. Oxygen plants have been built. Policies have been drafted to spur the growth of the local pharmaceutical manufacturing sector. Drug supply chains have been diversified to prevent stock outs. The general public has tremendously increased its health literacy. Countries are in a much better place than when it began.

# **The Beginning**

Kenya confirmed her first case of COVID-19 on March 12, 2021, in a 27-year-old lady who had traveled from the United States via London [1]. Three days later it was announced that the two passengers that had sat next to her on the airplane had also tested positive. In addition to the trepidation that came with these announcements and given the significant traffic between Kenya and COVID-19 hotspots at the time such as China, there was a healthy skepticism as to whether this was indeed the prime case in our country. Many told of serious 'colds and flus' in the months preceding the announcement. This was the first confirmed case, but in all likelihood was not the

D. Munene (B)

Pharmaceutical Society of Kenya, Nairobi, Kenya e-mail<EMAIL_ADDRESS>
<sup>©</sup> The Author(s) 2023

S. Pachauri and A. Pachauri (eds.), *Global Perspectives of COVID-19 Pandemic on Health, Education, and Role of Media*, https://doi.org/10.1007/978-981-99-1106-6\_5

first case. The concern that coronavirus may have been spreading among us already as the announcement was being made, was valid, and not at all comforting.

# **Evolution of the Pandemic**

Prior to the big announcement, we had been keenly following international news and had heard about the epidemic that had ravaged Wuhan, China as well as Northern Italy. Now our focus shifted to our local networks as daily updates of case numbers were announced by the Ministry of Health in the most somber, and often times stern manner. Numbers of confirmed cases were climbing fast rising to 3,305 in three months. By this time, 90% of cases were locally transmitted [2]. It was no longer an imported disease. There was an established local transmission.

# **Containment Measures**

Strict containment measures followed. Travel by non-residents of Kenya from any country with any case of coronavirus was restricted. Schools and higher learning institutions were closed in March, 2020. People were advised to work from home unless they were providing essential services. Cash transactions were discouraged.

In-person meetings were banned. Visits to hospitals were highly restricted. Every private and public facility was to provide soap and water/hand sanitizers to its patrons. On March 25, 2020, all local and international flights were banned. We were cautioned that if we behaved normally, the coronavirus would treat us abnormally. We were urged to practice hand hygiene, social distancing, and wearing face masks to curb the spread of the virus.

Confirmed cases, whether they were symptomatic or not, were isolated in health facilities. Mandatory quarantine at one's own expense was instituted for case contacts. Dusk to dawn curfew was imposed. Televised cat and mouse games between commuters and police at curfew time became a source of amusement in a tense time. Those arrested were subjected to forced quarantine, a practice that was later abandoned due to its obvious counter-productiveness in preventing the development of stigma to the novel illness.

Life as we knew it changed dramatically. We stocked up on what supplies each person could afford. We worked from home. Our kids stayed home for nine months.

COVID-19 response committees and task forces at national, county, public and private sector levels were constituted. The tasks at hand were risk communication, health promotion, disease surveillance, infection prevention and control, case management, health facility preparation, and resource mobilization.

# **Risk Communication, Health Promotion, and Public Education**

Pervasive false narratives that had already begun to emerge when the disease was first announced by World Health Organization (WHO) in late 2019 began to take root in our country, spreading like wildfire and growing out of proportion. 'The disease was a plot to wipe out the elderly'; "the developed West had hatched a plot to annihilate the populations of poorer countries". On and on the narratives went. They were evocative, emotive, and confusing.

Later when vaccines became available, the perceived fast pace with which they were developed came into question. A new wave of misinformation ensued. It became apparent that it is difficult indeed to have a common understanding when it comes to complex science such as vaccine science.

Science and scientific research for that matter is not a public facing field. Healthcare is visible to the public, sure, but health science and pharmaceutical science are not. Most scientific breakthroughs are attained after years of work by hundreds of scientists working in numerous laboratories, publishing pieces of their work in peer-reviewed scientific journals that are available only to paid subscribers and are presented only in scientific symposia and whose titles do not catch anyone's attention (except the attention of the scientists themselves!).

There was a vaccine that seemed to have come out of the woodwork mysteriously and quickly. How was the scientific establishment to plausibly explain that there had been decades of work leading to the timely breakthrough? 'Nobody had heard' of these 'so called' mRNA vaccines. Attempts to bridge the information gap between the scientists and the public became a challenging undertaking indeed. How can one package the science of nucleic acid therapeutics in public-friendly and believable language?

Efforts to combat the pervasive false narratives were notable but not as effective as expected. This was largely because they were undertaken by the same 'suspect' people from the health science 'establishment'. Vaccine experts could then not successfully advance effective counterclaims to the misleading propaganda as this would further alienate the intended audience. Influencers from the entertainment industry and community lay leaders had much better success. We enlisted them in our risk communication and public education strategy.

# **Disease Surveillance**

In those early days, contact tracing was paramount to disease surveillance. Once a case was identified, all contacts were tested and quarantined. There was also active surveillance in hot spots, which led to useful information that guided geographically limited interventions such as cessation of movement. Quarantine was expensive, and in the early days also fearful, for the quarantined. Later, when self-quarantine and

# **Public Health Cultural Tension**

The country enlisted the help of trained public health officers that had participated in the containment of Ebola in West Africa. This was a prudent move that meant we did not have to reinvent the wheel or unnecessarily use our resources to provide extensive training to new public health teams. At the very onset, we had a trained army of fighters. This, however, had its challenges. Given their experience with the Ebola epidemic, their approach to handling both live cases as well as the remains of COVID-19 patients was, at least at the onset, overreaching. Families were not allowed to view the remains of their departed loved ones if they had succumbed to COVID-19. Public health teams, in full protective suits, buried bodies in hurriedly dug graves, sometimes in the cover of night and without participation of the deceased's family members. Video footage of such burials quickly made the rounds. People were appalled. Affected families, lay leaders, and even Members of Parliament protested to the authorities, questioning whether such drastic measures were warranted. WHO released guidelines on handling COVID-19 human remains and the strict burial practices were relaxed. The period of time allowed between death and burial still remained 72 h—a period that is way too short for burial rites which would otherwise last up to two weeks in some communities.

# **Impact on Mental Health**

Kenya has a high burden of mental illness due to ill health, psychosocial disability, and premature mortality. Depression and anxiety disorders are the leading mental illnesses in Kenya. Huge gaps exist in access to mental healthcare. This bleak scenario was exacerbated by the effects of COVID-19 [3]. Lost livelihoods, the fear of contracting COVID-19, the out-of-reach hospital bills for families of those hospitalized with COVID-19, sudden deaths of colleagues and loved ones, and the disrupted social order where children were not going to school, were some of the factors that had a negative impact on mental wellbeing.

Cases of suicide rose. It was reported that more than 500 people in the country took their lives in the first six months of 2021, more than in all of 2020 [4]. Judging from the timing of this sharp rise, it is imaginable that the disheartening trend was due to the deleterious effects of the pandemic.

His Excellency the President had ordered the formation of a task force on mental health in June 2019, mandating its members to study the status of this issue and make appropriate recommendations for health system reform to better address mental health problems. The task force report in October 2019 made strong recommendations around mental health. The principal recommendation was to declare mental ill health as a national public health emergency. Other key strategies recommended were to raise mental health awareness and to increase the capacity to detect and treat mental health illness.

In terms of COVID-19 and mental health, the task force report observed that COVID-19 containment measures, particularly restriction of movement, threatened the already marginal access to mental health services. This was resulting in undiagnosed mental illness as well as the worsening of existing disease particularly in rural communities.

The mental health impact of COVID-19 was notable amongst healthcare professionals. There was a new infectious disease, about which so little was known. They were expected to have answers for the inquisitive public while their own practice guidelines were constantly changing due to the evolving, and sometimes contradictory, published findings. There were times when the supplies of personal protective equipment were so strained, they had to improvise with non-optimal methods of protection to keep themselves safe. Many lost their jobs due to the decline in the business of healthcare establishments. For those who kept their jobs, their workload particularly during the surges, was grueling. Even as the disease was taking out their most valiant frontline soldiers, they were expected to relentlessly carry on the battle. They were concerned for themselves but most of all for their families. Some would spend the night in their vehicles for fear of passing on the virus to their loved ones.

# **Impact on Availability of Medicines and Health Commodities**

One of the first negative impacts of the pandemic even before it arrived in our country was a strain on global medical supplies availability. As a country, we import more than half of our medicines and medical supplies, largely sourced from India and China. Hubei Province, China, a global hub for pharmaceutical raw materials, was locked down for months. A lot of medicines sourced from India are dependent on China for their active pharmaceutical ingredients. India ring fenced threatened supplies for their local use. The effect of this double jeopardy was a shortage of pharmaceuticals and other health supplies in our market.

This shortage revealed our over-dependence on imports for our pharmaceutical and medical device supplies. We were faced with the inadequacy of our capacity to locally produce not just complex medicines, but even simpler technologies like personal protective equipment. There was also a self-induced artificial shortage of essential medicines when we scrambled to buy and hoard perceived coronavirus therapies, a behavior fueled by misinformation on the internet.

The pandemic necessitated massive procurement of commodities such as hazmat suits, ventilators, and personal protective equipment that would otherwise be procured in much smaller quantities. The rushed procurement process bypassed established protocols of public procurement, for good reason, but naturally attracted shrewd business entities wanting to benefit from this state of a public health emergency. Public procurement scandals ensued, revealing gaps in the governance of our public health institutions.

# *Oxygen Woes*

The third and fourth waves of COVID-19 saw a sharp rise in hospitalizations and consequently in the number of patients needing oxygen. The life-saving gas that is the mainstay of managing hospitalized COVID-19 patients was in ultra-high demand. Hospitals began to look for ways to increase their oxygen capacity. It was not easy to do this overnight.

# **Effect on Human Resources for Health**

No country in the world has adequate human resources for health. According to estimates by the World Health Organization, the global health worker shortage is estimated to rise to 18 million by 2030. This has led to policy initiatives around task shifting and task sharing in order to maximize the utilization of each cadre of health workers.

The pandemic brought these issues to the fore. There was heightened demand for intensive care nurses, anesthetists, pulmonologists, medical officers, pharmacists, laboratory technologists, and many other healthcare workers. The need for health workers was compounded by the need to quarantine COVID-exposed health workers. We had to urgently assess our health human resource capacity if we were to adequately combat the ravaging pandemic.

# **Health Facility Preparedness**

Initially, all confirmed cases of COVID-19 were isolated in health facilities. Later on, as we embraced home-based isolation and care, we reserved hospitals for moderately to severely ill patients. As each wave came, more wards were converted to isolation wards, or new ones built from scratch. Building and equipping more intensive care units was, however, not that easy. We had a few sleepless nights having realized that we had less than 500 critical care beds during the first three months of the pandemic, and even less ventilators. We however breathed a collective sigh of relief when the first wave did not overwhelm our capacity. Estimates by experts showed that we would have several waves of infection before we could achieve herd immunity, and so we still needed to quickly expand our critical care surge capacity.

# **Economic Impact**

During the initial months of the pandemic, business slumped in many sectors. The private for-profit sector suffered the most. Many establishments shut down. Hotels closed their doors for lack of customers. Private schools could not keep up with the overheads needed to maintain the schools in the absence of students. People were afraid to go to the hair salon, to the open-air market, and even to the hospital. The hospitality industry suffered the biggest blow. Airlines downsized. Staff were subjected to pay cuts—these were the lucky ones. Many people lost their livelihoods altogether.

A World Bank report in November 2020 indicated that most households had lost income with unemployment increasing five-fold between October 2019 and October 2020. Families were mitigating this lost income largely by reducing consumption such as by skipping meals. One in four adults did not have enough food to eat and female-headed households were disproportionately affected. COVID-19 was not just a medical issue, it was a social and economic issue [5, 6].

# **Impact on Health Targets**

# *Contraception*

Family Planning (FP) 2020 goals support the rights of women and girls to freely decide for themselves when, whether, and how many children they want to have. Kenya had made FP2020 commitments which they exceeded. Kenya surpassed its target of contraceptives prevalence rate among married women of reproductive age of 58%, attaining 61% by November 2019 [7, 8].

There were concerns that the gains made in our family planning strategy would be lost due to the negative effects of COVID-19 on the availability of health commodities as well as the hesitancy of family planning clients to access health facilities for fear of contracting COVID-19.

# *HIV*

By 2020, 90% of all people living with HIV will know their HIV status. By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy. By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression. These were the ambitious global targets to help end the AIDS epidemic. By mid-2020, Kenya had made significant strides in achieving these targets, performing at 90%, 82%, and 92%, respectively [9, 10].

Kenya has 1.2 million Kenyans on life-long anti-retroviral (ARV) medication, the mainstay of HIV treatment [10]. There was a period of time in 2021 when due to insufficiency of supplies, patients would get a one-month dose or less of ARVs, rather than the usual 90-to-180-day dose. This was because supplies were stretched but thankfully had not run out. Patients had to make more frequent trips to the clinic to pick up refills.

COVID-19 clearly affected every facet of our lives, impacting us socially, and economically, and not sparing our mental and physical health.

# **Collective Action to Build Back Better**

The response to the pandemic, though it was largely led by government ministries of internal security and health, enlisted input from all of the government and all of society. Individuals, families, communities, health professionals, civic leaders, lay leaders, religious leaders, and the private and public sectors continue to combine efforts to minimize, mitigate, and combat the negative effects of the pandemic.

The giant telecommunication companies donated their expertise in providing mass communication on protective measures and public health education. They sponsored text messaging that gave tips on how to report a suspected case of COVID-19, where to get psychosocial support, and how to protect oneself from contracting the disease. In a country with pervasive use of mobile phones, this method of mass communication was effective and far-reaching.

Religious leaders, in an act of self-regulation, penned the guidelines by which their faithful would safely gather for congregational worship. They spoke together as a unified voice regardless of their creed, collectively negotiating with the government to allow in-person worship services. They bargained successfully and were allowed to open places of worship in strict conformance to the guidelines they had developed, bearing the responsibility of enforcing the guidelines on their faithful. This demonstrated the power of unity and the appeal of self-regulation.

To address mental health among healthcare professionals, various health professional associations combined efforts to ease the mental and psychosocial burden of COVID-19 on health workers by setting up a call center manned "by health workers for health workers". This call center provided psychological first-aid and directed health workers to further care as needed. It raised the morale of health workers a great deal and was a heartening example of inter-cadre collaboration.

The way healthcare is delivered evolved. Digital health interventions were embraced as a way to contain the spread of the virus in the process of accessing healthcare. The 'call a doctor' types of mobile and web-based applications proliferated, and hospitals, pharmacies, and laboratories increased their home care services. A notable innovation was the Wheels for Life Initiative which was formed to respond to pregnancy-related emergencies during curfew hours and across the locked down county boundaries. This initiative brought together private sector partners and healthcare professionals to provide a hotline for pregnant women to consult an obstetrician and to get a paid cab or ambulance should they require to visit a health facility. By October 2021, 10,570 mothers had been assisted by doctors through telehealth consultations, 1,322 cabs were dispatched, and 899 emergency ambulance trips were done, resulting in hundreds of women having safe deliveries [11].

Kenya is second only to China in the usage of mobile money for financial transactions [12]. The already pervasive mobile money grew by leaps and bounds fueled by reduced transaction charges and the demand for cashless modes of transacting money. Mobile money transactions rose to USD 32.6 million between January and June 2021 compared to USD 30.6 million between July and December 2020 [13].

To ease the financial strain on businesses occasioned by COVID-19, the government committed to expedite pending bills owed to the business community. These were the bills of monies owed by the government to the private sector for services and products rendered. These bills would accrue and accumulate a great deal due to the bureaucratic nature of government. The need to cushion businesses against the effects of COVID-19 caused a positive shift in the speed of settling these debts. One hundred and forty million dollars in pending bills were cleared by the government between January and March 2021, easing cash flows and injecting life into numerous businesses that were on the brink of collapse.

The Kenyan textile industry rose to the rising demand for face masks. The government placed orders for masks with local suppliers who had passed quality checks from the Kenya Bureau of Standards. By the end of April 2020, we were able to locally produce as many surgical and cloth masks as were required, without a need to import. In addition to this, local entities began to manufacture full personal protective gear such as aprons, face shields, goggles, and full-body suits at prices comparable to imported ones. Furthermore, with partnerships between institutions of higher learning and the private sector, we started to assemble ventilators.

# *Oxygen Supply*

It takes significant investment to install an oxygen production plant—some reports put the initial minimum capital outlay at one million US dollars. Hospitals could not install oxygen plants overnight to take care of patients already in their isolation wards and intensive care units. They needed quick and innovative solutions.

As hospitals scrambled desperately for oxygen to manage the surge of moderate to severe COVID-19 patients during the second and third waves, it was realized that steel manufacturers produce high quantities of oxygen as a necessary part of their production process and they had plenty of industrial oxygen gas to spare. They generously offered the life-saving gas free of cost to hospitals in need. All that the hospitals needed to do was to find cylinders and the steel plants would fill them with oxygen. Medical gas regulators worked with the steel industry to put in place an abbreviated set of requirements to ensure that the donated gas was safe for medical use. Meanwhile, medium to large-sized hospitals began the process of oxygen plant installation and piping, and smaller hospitals purchased more cylinders to refill from their larger counterparts.

# *Donor Support*

During the time of the pandemic, we experienced diminishing support from donors for our health programs, in part due to our achieving the status of a lower middleincome country, and in part due to the global economic shrinkage occasioned by the COVID-19 pandemic. This brought the idea of sustainable financing of our health system to the fore. The triple threat of non-communicable diseases, communicable diseases, and epidemics needed to be largely funded by our exchequer. Advocacy was in high gear to ensure that we took care of some of the previously heavily donordependent budget lines in our health sector. This was even more important seeing as we are at the last mile of reaching several important targets across many health areas including contraceptive prevalence, neglected tropical diseases, and HIV. We must be in control of our pace at this critical time to reach these targets.

# **Going Forward**

Multi-stakeholder collaboration continues. The private sector, organized under the Kenya Private Sector Alliance (KEPSA), which is the apex body of the private sector in Kenya, continues to donate both cash and health equipment to national and county governments as well as to private and public health facilities. KEPSA also continues to support the government in the procurement of vaccines by raising funds from members to complement the government's orders of vaccines. As a result, tens of thousands more vaccines were shot in the arms of Kenyans.

Local COVID-19 vaccine production plans began in earnest, aimed at easing access amidst global supply constraints. This production will start in the form of 'form and fill' where we will package already made vaccine into primary and secondary packaging [14].

Efforts are intense to ensure gains made in meeting health targets prior to the pandemic are not eroded. For instance, to preserve the upward trajectory of the prevalence of modern contraception and to mitigate the effects of fear of accessing health facilities, the Ministry of Health directed that women be given longer refills of their preferred contraceptive method.

A lot continues to be done to achieve greater self-reliance in medicines and medical commodities. Looking into the future, we have drafted policies to spur the growth of our local pharmaceutical manufacturing sector and have diversified our drug supply chains to prevent stock outs.

The general public tremendously increased its health literacy. Vaccine hesitancy dramatically declined. As of October 30, 2021, a total of 5,307,181 COVID-19 vaccine doses were administered across the country, with demand outstripping the supply [15].

COVID positivity rate went below 1% in October 2021, a clear indication that containment measures were successful. A concerted effort by a multiplicity of stakeholders created a sense of national pride in increasing our self-sufficiency in managing the pandemic. COVID-19 has been a rough and painful journey for our health system. One thing, however, is certain; we are in a much better place than where we began. The lessons we have learned have made us build back better, stronger, and together.

# **References**

**Dr. Daniella Munene** Vice President Governance, Pharmaceutical Society of Kenya, Kenya A health professional with extensive experience in quality assurance, organizational regulatory compliance and health sector advocacy. Daniella has created and managed quality management systems in the pharmaceutical distribution supply chain throughout her career. Armed with a passion for health promotion, education, and people empowerment, Daniella has also mobilized the pharmacy profession in Kenya to successfully advocate for change in health policies to ensure enhanced reach of primary healthcare. In this regard she has been part of developing various health policy documents at a global as well as country level.

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

# **Politics, Economics, and Education**

# **COVID-19 and the Indian Economy: Constructing Roadmaps to an Inclusive Recovery**

**Mitali Nikore, Charmi Mehta, and Akshay Kanikar**

**Abstract** The COVID-19 pandemic has driven the highest share of economies into recession in modern times and is expected to bring about the largest contraction in global GDP per capita since World War II. The uncertainty it has spawned is driving governments and institutions into a conundrum, as they are tasked with charting out a course for recovery is immense. While India's GDP contracted 7.3% in FY 2020–21, COVID-19 deepened and exposed the fault lines of the economy. The authors highlight the phase of slowdown in India prior to the pandemic and how COVID-19-related lockdowns reinforced the slowdown. They demonstrate historical trends for a set of indicators for three sectors: agriculture, manufacturing, and services and display the extent of damage that the pandemic induced economic slowdown caused while also identifying underlying factors that existed pre-COVID. Finally, the authors present a macro-economic outlook covering trends and linkages across demand drivers, employment, and investment. They conclude with a roadmap for inclusive growth advocating strategies that seek to advance equality of access, sustainability of resources, and state capacity for governance.

# **Introduction**

The COVID-19 pandemic has caused unprecedented damage to the global economy, pushing over 160 countries into recession, the highest in the history of recorded economic data [1]. Several differences exist in the challenges posed by the pandemic when compared to previous crises like the Global Financial Crisis in 2008. First,

C. Mehta · A. Kanikar Nikore Associates, Mumbai, India e-mail<EMAIL_ADDRESS>
A. Kanikar e-mail<EMAIL_ADDRESS>
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M. Nikore (B) Economist and Founder, Nikore Associates, Mumbai, India e-mail<EMAIL_ADDRESS>
<sup>©</sup> The Author(s) 2023 S. Pachauri and A. Pachauri (eds.), *Global Perspectives of COVID-19 Pandemic on Health, Education, and Role of Media*, https://doi.org/10.1007/978-981-99-1106-6\_6

there were regions (East Asia and Pacific, South Asia, and Sub-Saharan Africa) that managed to maintain or marginally grow their gross domestic product (GDP) even during the crisis year of Financial Year (FY)09.1 In 2020, however, every region suffered slowdowns. Second, recovery trajectories are likely to diverge. All regions (barring developed nations where the crisis originated in 2008) experienced growth in FY10, but recovery post-2020 is expected to be slower and uneven. Finally, the magnitude of the pandemic's impact and associated uncertainty complicate a return to normalcy.

COVID-19 has severely impacted lives and livelihoods. Over 4.4 million deaths occurred globally and are rising. An estimated, 130 million people were pushed back into poverty. And, there is an ensuing global recession. Countries relied on fiscal packages to power economic activity through 2020, as vaccine precarity kept demand revival expectations low. Consequently, successful vaccine trials made returning to normalcy the target for 2021. The global economy is poised to grow at 5.6% in FY21 [2]. There were strong rebounds by China and the US, but output is still expected to remain at pre-COVID-19 levels, largely due to emerging market economies where slow vaccination rates are holding up recovery.

No different from the rest of the world, India was also hit hard by the pandemic. Long drawn lockdowns magnified the ongoing economic slowdown. Of the four instances of national income decline seen in India (FY58, FY66, FY73, and FY80), FY80 was the worst at a 5.2% contraction [3]. This steep GDP plunge of 23.4% for the April-June, 2020 quarter and with the overall economy contracting by 7.3% in FY21, makes 2020 the year that underwent the severest economic contraction in the country's history. Sustained vaccine shortages in early 2021 meant that both the health of dense, unvaccinated populations and economic hardships from a prolonged pandemic were neglected.

After an urban centered first wave,2 India faced a devastating second wave which affected most of rural India. In this chapter, the authors study the impact of COVID-19 on the economy in the context of India's pre-pandemic economic slowdown. Even as India's vaccination program offers a path to ease the health crisis, there is a need to actively address the pandemic's medium-term economic impact to spur green, resilient, and inclusive growth while safeguarding macro-economic stability [4]. The authors also highlight concerns regarding imbalanced growth while illustrating the lack of inclusivity in economic opportunities and threats posed by climate change.

<sup>1</sup> Financial year (FY): A 12-month period beginning on 1st April and ending on 31st March. For instance, FY04 indicates the period 1 April 2003–31 March 2004.

<sup>2</sup> Time periods for the first and second wave are as follows: First wave—Mar–June 2020; Second wave—Mar–June 2021.

# **Methodology**

This chapter follows a mixed methods approach. Secondary data analysis was undertaken to capture historical trends for macro-economic indicators. All India time series data over the last seven decades (1950–2018) was analyzed to examine trends across the Gross Domestic Product (GDP), consumption, investment, public investment, exports, and imports. This data was obtained from numerous sources such as the Ministry of Statistics and Program Implementation (MOSPI), Government of India (GOI), the Center for Monitoring Indian Economy (CMIE), Economic Outlook Database, and the States of India Database.

Studies by Dvara Research, Azim Premji University (State of Working India Report-2021), Information Handling Services (IHS) Markit Economics, and Pew Research Center on the impact of COVID-19 on India's economy were used to demonstrate the same. Extensive analysis by Nikore Associates on gendered and differential employment statistics is also referenced. A literature review, complemented by consultations with agricultural bodies, industry groups, non-governmental organizations (NGOs), and sector experts assisted in contextualizing the findings and developing a progressive policy outlook.

# *Unearthing Realities–A Review of India's Macroeconomic Performance Since Liberalization*

The culmination of demand supply shocks, mobility restrictions, and a high degree of uncertainty makes recovering from COVID-19 the greatest defining challenge of the 2020s decade so far [1]. Multilateral organizations like the World Bank, Asian Development Bank (ADB), and the International Monetary Fund (IMF) are constantly revising their growth outlooks, due to vaccine-coverage being slower than anticipated and consecutive infection waves. Table 1 shows wide-ranging estimates. Even the January 2021 estimates are unable to predict growth and recovery trajectories.

The pandemic emerged as a health crisis that placed great strain on public and personal resources in India. Wage laborers and temporary workers bore the brunt of unemployment as mobility restrictions constrained their ability to overcome joblessness. Successive waves brought to the fore deep inequalities within society, caused by rising income inequality and a shrinking middle class [5]. Poverty is estimated to have more than doubled with numerous estimates forecasting 75–230 million Indians falling into poverty post the first wave of the pandemic, thereby reversing decades of efforts toward poverty reduction [6–8]. This, combined with a large informal workforce, poor public health indicators, and a collapsing health infrastructure left the average Indian extremely vulnerable to pandemic induced shocks [9].

As the pandemic continued, the world was also grappling with climate disasters caused by global warming and catalyzed by human impact. India, alongside the rest of the world, must now not only recover from the pandemic, but must also do so

**Table 1** Estimates of Indian growth: FY21

*Source* Asian Development Outlook (ADB figures), Global Economic Prospects (World Bank figures), and World Economic Outlook (IMF figures) release

sustainably to meet its Intended Nationally Determined Contributions (INDC) and net zero targets.

# *Growth in GDP and Per Capita Income*

India's GDP grew six times post-liberalization from USD 507 billion in 1990 to USD 2.9 trillion in 2019 [10]. During the same period, per capita-gross national income (PC-GNI) only grew 3.5 times from USD 574 in 1990 to USD 2131.8 in 2019 [10]. This growth was primarily the result of two high growth spells: FY04 to FY08 and FY14 to FY17 (Fig. 1). The first spell of growth was powered by exports and investments which grew at an average rate of 17.8% and 15.3%, respectively. The second growth spell of FY12 and FY17 was driven by Private Final Consumption Expenditure (PFCE).

GDP growth had been declining between FY17 and FY20 reaching 4% prior to COVID-19 induced shocks. This was primarily attributed to governance and policy shocks such as demonetization. Although secondary to structural shocks, cyclical trends of lean economic activity based on seasonality and business cycle flows also impacted growth [11].

India's GDP drastically declined by 23.4% in Q1 of FY21 as an immediate effect of COVID-19 related mobility restrictions resulting from nationwide lockdowns (Fig. 2). Recovery stagnated through FY21. Strong rebounds in consumer spending through a surge in automobile sales, fuel consumption, exports, and core imports enabled a V-shaped recovery with 20.1% growth in Q1-FY22 despite a coinciding second wave [12].

 **Trends in growth rate of GDP and PC-GNI at constant prices (2011-12) (in percentage)**

**Fig. 1** Trends in growth rate of GDP and PC-GNI at constant prices (2011–12) (in percentage). *Source* Ministry of Statistics and Program Implementation, Government of India [10]

 **Trends in growth rate of quarterly GDP at constant prices 2011-12 (in percentage)**

**Fig. 2** Trends in growth rate of quarterly GDP at constant prices 2011–12 (in percentage). *Source*  Ministry of Statistics and Program Implementation, Government of India [10]

# *Sectoral Time Series Trends*

The economic impact of COVID-19 was not experienced equally across all sectors of the Indian economy. The share of agriculture and industry in overall Gross Value Added (GVA) declined between FY04 and FY21, with the service sector overtaking the erstwhile dominant sectors (Table 2). Service-led growth was aided by liberalization, privatization, and globalization (LPG)-era reforms from 1991 onwards [13], which eased the influx of Foreign Direct Investment (FDI) and private sector growth to create a favorable business ecosystem (Tables 3 and 4).

Despite its shrinking share in the GVA, agriculture, which employs 48.3% of all Indian households, was largely insulated from the debilitating impact of the first national lockdown. Proactive and timely exemptions from lockdown restrictions

**Table 2** Sectoral share in GVA and growth rates over the years (in percentage)

*Source* Calculations based on Ministry of Statistics and Program Implementation data [10]

facilitated uninterrupted cropping making agriculture the only sector to show positive growth across all quarters (Fig. 3), successfully riding out shocks from the first wave and recording a 3.6% growth (year-on-year (Y-o-Y)) in FY21 [14, 15].

On the other hand, industry and service sectors were severely impacted owing to mobility restrictions and the contact intensive nature of services (Fig. 3). Overall, the growth in industry declined by 7.0% and the growth in services declined by 8.4% in FY21. Mining saw negative growth across FY21 and manufacturing saw capacity utilization falling to 47.3% in Q1 FY21 (Y–o-Y) [16]. Trade, hotels, transport, and communication shrank by a massive 48.1% in Q1 FY21, with an estimated 30–35% of restaurants closing permanently by the end of the second wave [17]. The hospitality sector, severely damaged by the pandemic, also showed significant growth from the previous quarter. The industry and services sub-sectors bounced back only in Q3 and Q4 of FY21 [10].

Comparing Q1-FY22 (June 2021) growth to the average Q1-growth over FY15- FY21, reveals that all three sectors were performing below FY17 and FY18 levels (Fig. 4). Sub-sector level analysis illustrates that that mining, manufacturing, construction, hotels, and transport suffered the greatest declines and were most susceptible to growth shocks.

**Table 3** Sectoral share in GVA and growth rates over the year for industry sub-sectors over the years (in percentage)

*Source* Calculations based on Ministry of Statistics and Program Implementation data [10]

The Services Purchaser's Manufacturing Index (PMI)3 nosedived to its lowest level of 5.4 in April 2020 recovering to 56 only in March 2021, indicating dismal prospects for the sector in the near future (post the first wave) [18]. The Index of Industrial Production (IIP) for Core 84 also reached record lows in April 2020 recovering to pre-COVID-19 levels only in February 2021.5

<sup>3</sup> The Services PMI provides investors an insight into business conditions and economic trend for markets within the sector. IHS Markit Economics carries this out by surveying about 350 PSEs. A PMI reading over 50 indicates growth and that under 50 suggests contraction as compared to the previous month.

<sup>4</sup> The Eight Core Industries comprise 40.27% of the weight of items included in the Index of Industrial Production (IIP). They are coal, crude oil, natural gas, refinery products, fertilizers, steel, cement, and electricity.

<sup>5</sup> Economic Survey 2020–21 calculations based on Ministry of Statistics and Programme Implementation and Office of Economic Advisor's data.

**Table 4** Sectoral share in GVA and growth rates over the year for services sub-sectors over the years (in percentage)

*Source* Calculations based on Ministry of Statistics and Program Implementation data [10]

# *Growth Drivers of the Economy*

Consumption6 and investment7 have been the major drivers of India's growth over the last fifteen years. The average share of private final consumption expenditure (PFCE) in GDP stood at 58% in the 2010's decade, while that of investment was 34%. However, these have been in decline since FY12. The share of government final consumption expenditure (GFCE) remained flat, averaging 11%, while the average share of exports was 21.5% for the same period.

The Global Financial Crisis of 2008 resulted in accumulation of corporate debt and over leveraged financials. The impact of this was worsened by the twin balance sheet crisis that exposed growing non-performing assets of the banking sector, together reducing the scope for corporate borrowings. Table 5 shows the tapering of investments and exports post FY09 as a result of both crises.

Following the COVID-19 crisis, PFCE contracted by 9.1% in FY21 (Table 5). PFCE showed negative growth in the first three quarters of FY21, recovering marginally in Q4 (Fig. 7). Most notably, per capita consumption expenditure (PCCE) fell below FY18 levels (Fig. 8). Government expenditure was the only component of the GDP which registered positive growth at 2.9% for FY21, crucially aiding recovery.

<sup>6</sup> Consumption is indicated by 2 variables: Private final consumption expenditure (PFCE) and Government final consumption expenditure (GFC).

<sup>7</sup> Investment is indicated by gross fixed capital formation (GFCF).

**Fig. 3** Sectoral Impact of COVID-19: trends in quarterly growth rates (Y-o-Y) of sectoral GVAs at constant prices (2011–12) for the year FY20 and FY21 (in percentage). *Note* Year-on-year growth rates are calculated, compared to previous year's same quarter figures. *Source* Ministry of Statistics and Program Implementation, Government of India [10]

Gross fixed capital formation (GFCF)8 declined by 47.7% in Q1 FY21 and contracting overall by 10.1% in FY21 (Table IV, Fig. 6). Announcements of new domestic investment projects fell by 23.5% in FY21 (Fig. 9), where barring Q2, all quarters saw this fall on a Y-o-Y basis (Fig. 10). Revival in investments will depend on an upswing in demand and capacity utilization which were below 70% throughout FY21 [15].

<sup>8</sup> Domestic investment is a measure of the amount of money that domestic businesses invest within their own country, whereas foreign investment involves capital flows from one country to another, granting the foreign investors extensive ownership stakes in domestic companies and assets. Here, the changes in investments refer to both domestic and foreign investment combined.

**Fig. 4** Trends in sectoral GVA (INR million). *Source* Ministry of Statistics and Program Implementation, Government of India [10]

**Fig. 5** Index for industry production (IIP) and eight core growth (in percentage). *Source* Economic Survey 2020–21 calculations based on Ministry of Statistics and Program Implementation and Office of Economic Advisor's data [10]

**Fig. 6** Services purchasing managers' index (PMI) (in percentage). *Source* Press Release, IHS Markit Economics, August 2021 [19]

Though domestic investment was weak, India emerged as a preferred investment destination for foreign investors attracting USD 81,722 million foreign direct investment (FDI) flows in FY21. This figure was up 10% from the previous year, of which FDI equity inflows grew by 19% [21]. Singapore was the highest equity FDI investor, followed by USA, Mauritius, and UAE [21]. Computer software and hardware saw the highest equity FDI inflows followed by construction, services, and infrastructure sectors. Among states, Gujarat (35.6%), Maharashtra (26.3%), Karnataka (12.5%), Delhi (8.9%), and Tamil Nadu (3.8%) received an overwhelming majority of the equity FDI inflows [21] (Fig. 11). Gujarat and Maharashtra were the first ones to recover in speed and volume while other states experienced gradual FDI inflows.

Imports and exports contracted by 40.9% and 21.9%, respectively in Q1 FY21 remaining negative through Q2 and Q3 and only recovering in Q4 (Fig. 12). Overall, imports shrank more than exports in FY20 generating a current account surplus equal to 0.9% of GDP. Trade deficit in goods widened from 1.9% of GDP in Q1 FY20 to 4.4% in Q1 FY21 while the trade surplus in services grew by 8.1% (Y–o-Y) in Q1 FY21, down from double digit growth a year earlier [22].

When comparing Q1-FY22 (June 2021) growth to the average Q1-growth across FY15-FY21, it was evident that consumption and investment in FY21 were below FY15 levels. Even in FY22, these levels remained below those of FY18 (Fig. 11). Exports and imports, on the other hand, recovered, remaining just below FY19 levels despite disruptions associated with the second wave.

**Table 5** Components of GDP and growth across the years (in percentage)

*Source* Calculations based on Ministry of Statistics and Program Implementation data [10]

# *Impact on Employment*

COVID-19 shocked a country where approximately 83% of the labor force works in the unorganized sector in low-productivity, low-income jobs. Despite rapid economic growth over the last two decades driven by high-skilled service sectors, India did not witness significant employment growth. Since the economic reforms of 1991, employment in the informal sector as compared to the formal sector had widened. Besides the agriculture sector, the construction sector created the second highest number of jobs During the COVID-19 crisis, millions of informal and casual laborers were among the worst affected groups as they were unskilled and without social security safety nets.

As India recovers from the lasting effects of COVID-19, policy priorities are shifting from securing health to reviving economic growth. India needs to avoid a

 **Sectoral impact of COVID-19: Trends in growth rates (Y-o-Y) of quarterly estimates of GDP at**

**Fig. 7** Sectoral impact of COVID-19: Trends in growth rates (Y–o-Y) of quarterly estimates of GDP at constant prices (2011–12) in FY20 and FY21 (in percentage). *Note* Year-on-year growth rates are calculated compared to previous year's same quarter figures. *Source* Ministry of Statistics and Program Implementation, Government of India [10]

### **Per capita PFCE (Rupees)**

**Fig. 8** Per capita PFCE (Rupees). *Source* Ministry of Statistics and Program Implementation, Government of India [10]

K-shaped recovery in which white collar sectors bounce back while other sectors are left to languish. The focus must shift to expanding the formal job market and enhancing social security for informal workers.

 **New investment projects**

**Fig. 9** New investment projects announced (Quarterly). *Source* Economic Outlook Database 2020– 21, Center for Monitoring Indian Economy (CMIE) [20]

**Fig. 10** New investment projects announced (Annual). *Source* Economic Outlook Database 2020– 21, Center for Monitoring Indian Economy (CMIE) [20]

# *Pre-COVID-19 Employment Structure*

Between 1977 and 2017, India's economy witnessed a surge in output from services (39% to 53%) and a decrease from agriculture (39% to 20%) and industry (33% to 27%) [23]. Structural changes in sectoral outputs were complimented with crosssectoral shifts in employment. However, this structural transformation9 was far greater for men as compared to women (Fig. 14) [24].

<sup>9</sup> Structural transformation in the context of a developing country involves two distinct processes—a decline in the share of agriculture in employment (and a rise in non-farm work) and a decline in the share of the informal sector (and a rise in the scale of production).

**Fig. 11** State-wise foreign direct investment inflows in Indian rupees– Quarterly (All figures in INR millions). *Source* Department for Promotion of Industry and Internal Trade, Ministry of Finance 2021 [21])

**Fig. 12** Sectoral impact of COVID-19: Quarterly trends for exports and imports within GDP at constant prices (2011–12) in FY20 and FY21 (in percent). *Source* Ministry of Statistics and Programme Implementation, Government of India [10]

In the 15 years between 1994 and 2010, women received less than 19% of all new employment opportunities generated in India's ten fastest growing occupations [25]. This had profound implications for rural women, for whom the proportion of employment in agriculture fell by just 13% in the last 42 years (88.1% in 1977–78 to 75.7% in 2019–20), while it reduced by 25% for rural men (80.6–55.4%) for the same period. Construction and hospitality absorbed a large proportion of rural males.

**Fig. 13** Trends in components of GDP (INR million). *Source* Ministry of Statistics and Programme Implementation, Government of India [10]

 **Employment trends from FY77 to FY19, by area, gender, and sector (in percentage)**

Females

Females

**Fig. 14** Employment trends from FY77 to FY19, by area, gender, and sector (in percentage). *Source*  Ministry of Statistics and Program Implementation, Government of India [10]

Other Services

The unavailability of steady employment opportunities and social stigma restricted rural women to agriculture [26].

Thus, the absolute increase in female employment primarily occurred in low productivity sectors (agriculture being one such example). If women had access to the same work opportunities as men, the absolute increase in female employment would have been upto three times higher for this period [27].

The influx of youth in the job market from FY12 to FY18 [28] highlighted the dearth of non-agricultural jobs for this group as 30–59-year-old men took up 92% of all new non-agricultural jobs, disadvantaging women and young job seekers.

# *Impact of COVID-19*<sup>10</sup>

Following the nationwide lockdown, the labor force contracted from 433 to 369 million i.e., by 14.7% between March and April 2020. The labor force recovered to March 2020 levels only in February 2021 (427 million), before contracting to 425 million in April 2021 due to the second wave of COVID-19. Recovery from the second wave was observed in August 2021 (434 million), a labor force figure which matched pre-COVID-19 levels in March 2020.

About 113.6 million persons lost their jobs as the number of employed individuals contracted from 396 million in March to 282 million in April 2020. By September 2020, the number of employed individuals were back to March levels at 398 million. The impact of the second wave was felt between April and May 2021, when the number of employed persons shrank by 15 million. The recovery was quick. The total number of employed individuals was back at 398 million in August 2021. The unemployment rate rose to 23.5% in April 2020 compared to 8.8% in March 2020. Unemployment gradually declined, recovering to March 2020 levels by July 2020 and declining further to 7.4% by August 2020. Following the second wave, unemployment rose again in May 2021 (11.8%). However, it recovered soon thereafter. In August 2021, the unemployment rate stood at 8.3%.

# *Impact on Employed Persons by Gender and Area*

Of the 113.6 million workers who suffered job losses between March and April 2020, 15.4 million were women. The proportionate fall for women was higher as 37.1% of women lost their jobs, versus 27.7% men. Unlike the first wave, women bore not only a higher proportion but also a higher number of absolute job losses during the second wave. About 7.4 million persons suffered job losses in April, 2021, 5.4 million women versus 1.9 million men. Thus, women suffered 73% job losses (Fig. 15).

<sup>10</sup> This section utilizes Center for Monitoring Indian Economy (CMIE) data.

### **Total number of employed persons during 2019-2021, by area and gender (in millions)**

**Fig. 15** Total number of employed persons during 2019–2021, by area and gender (in millions). *Source* Center for Monitoring Indian Economy (CMIE) Economic Outlook [20]

Urban female employment fell from 11.8 million in March 2020 to 8.3 million in April 2020, a drop of 29.2%11 versus 32.4% for urban men. By March 2021, the number of employed urban women was also 20.9% lower than in March 2020, whereas the corresponding decline was only 0.3% for urban men. Rural female employment shrank by 40.2% versus 25.5% drop for rural men. Box 1 presents the results of consultations held with women's groups, enterprises, farmer producer organizations, and informal workers on the impact of COVID-19 on their employment.

<sup>11</sup> The change in employment between two months has been calculated in relative sense using the rate of change formula: {{previous month/current month} \* 100}

### **Box 1**

### **Impact of COVID-19 on working women: Women's perspective**

Women's overrepresentation in the sectors hardest hit by the pandemic, such as accommodation, food services, and the manufacturing sector, led them to suffer disproportionate job and income losses during COVID-19. Nikore Associates conducted consultations during the first and second waves with over 50 NGOs and community-based organizations (CBOs) that work to empower women.

In rural areas, women working in the agriculture sector were displaced due to the reverse migration of men to the city. Even if they held onto their jobs, it was difficult for them to sell their produce due to disrupted supply chains.

The presence of male relatives and children at home (due to closure of workplaces and schools) led to an increase in unpaid care work for women. The double burden of household chores and office work led to difficulties for women entrepreneurs and women in the corporate sector. For example, self-help groups (SHGs) mobilizer in Telangana shared that the women in her community were unable to attend trainings and SHG meetings owing to domestic work.

Women employed in the urban, informal sector faced prolonged income losses negatively impacting their family income. For example, a CBO in Madhya Pradesh revealed that families were reluctant to employ domestic helpers due to the fear of virus transmission. Flower vendors in Tirupati lost their livelihoods due to the absence of devotees at the temple.

Finally, the pandemic broadened the gender digital divide. As most activities shifted to the online sphere, consultations showed that low ownership of smartphones and a lack of digital literacy affected the economic participation of women. For example, a Mumbai based NGO shared that large family sizes necessitated mobile sharing. Coupled with financial constraints that limited the purchase of internet packages, male members of the family were given preferential treatment for usage of these facilities, leaving women behind.

# *Impact on Employed Persons by Occupation Groups*

Between March and April 2020, small traders and wage laborers were the worst affected group, losing 79 million jobs, of which 59 million were in rural areas and 19 million in urban areas. Among salaried workers, 14 million jobs were lost, of which 10 million were in rural areas. About 18 million fewer urban business persons were employed, while 3 million fewer rural business persons were employed. While urban farmers increased by about 2 million, a similar number of rural farmers lost their jobs.

As trade and mobility restrictions eased, employment for small traders, wage laborers, and farmers recovered and crossed March 2020 levels by July 2020. In comparison, recovery in the business sector was slow as jobs could only recover above the March level by August 2020. On the other hand, urban salaried workers reached March 2020 employment levels only in January 2021, while rural salaried workers remained below March 2020 level even a year later.

Farmers faced the immediate impact of the second wave, where six million farmers lost their jobs between March and April 2021. Urban salaried employees were least affected by the second wave and their employment actually grew, whereas 3 million rural salaried employees lost their jobs. Impact on the business sector reflected in May 2021 as businesspersons fell to 68 million as against 74 million in March 2021. Impact on small traders and wage laborers was felt in June 2021 when 20 million lost jobs between March and June 2021. Of these, about 17 million were from rural areas (Fig. 16).

# *Impact on Employed Persons by Industry Groups*

The number of persons employed in the industry sector contracted by 66.7% between March 2020 (96 million) to April 2020 (32 million). About 15 million persons lost their jobs in the agriculture sector (10%) compared to 33 million (22.1%) in the service sector (Fig. 17).

Recovery in the agriculture sector was swift as compared to the service and industry sectors. Agriculture recovered above the March 2020 level by June 2020 while the industry sector matched March 2020 level only by September 2020 and the services sector recovered only by October 2020.

The impact of the second wave was observed in the agriculture sector between February and March 2021 when the number of employed fell by 14 million. In the service sector, employed persons shrank by 10 million compared to 14 million in industry between April and May 2021. Recovery in agriculture and services was quick as they could reach March 2021 levels by May/June 2021. However, employment in the industry sector could not recover to February/March 2021 levels even by August 2021.

When considering industry sub-sectors, it can be seen that real estate and construction suffered the deepest job losses between March to April 2020 with employment contracting by 87.3% from 55 to 7 million. The manufacturing sector saw the number of employed individuals contract by 44.7%. Within manufacturing, the number of employed individuals contracted in cement and construction (57.3%), textile and leather (42.5%), and handicraft (38.1%) between March and April 2020. The real estate and construction sectors recovered soon as the number of employed persons matched March 2020 levels by July 2020. The impact of the second wave was observed in May 2021 as the number of employed people contracted in mining (<1 million), manufacturing (3 million), real estate, and construction (12 million)

 **Impact of COVID-19 on employed persons: As per occupation groups**

**Fig. 16** Impact of COVID-19 on employed persons: As per occupation groups. *Source* Center for Monitoring Indian Economy (CMIE) Economic Outlook [20]

**Employed persons: By major industry groups (in millions)**

**Fig. 17** Employed persons: By major industry groups (in millions). *Source* Center for Monitoring Indian Economy (CMIE) Economic Outlook [20]

between April and May 2021. Notably, manufacturing did not recover to March 2020 levels even by August 2021 (Fig. 18).

Alternatively, among the sub-sectors of the services sector, it can be noted that employment in the hotel and tourism industry contracted by 40.7%, education by 28.1%, and wholesale and retail trade contracted by 20.2% between March and April 2020. Employment in the wholesale and retail trading industry recovered above March 2020 levels by August 2020, whereas the hotel and tourism industry could only recover by October 2020. Employment in the education sector continues to be lower in August 2021 than in March 2020. Following the second wave, employment in wholesale and retail trade fell by 13.9% and in the hotel and tourism industry by

**Fig. 18** Employed persons: In industry (in millions). *Source* Center for Monitoring Indian Economy (CMIE) Economic Outlook [20]

 **Employed persons: Service sector (in millions)**

**Fig. 19** Employed persons: Service sector (in millions). *Source* Center for Monitoring Indian Economy (CMIE) Economic Outlook [20]

17.1% between April and May 2021. However, employment in both sectors recovered by June 2021 (Fig. 19).

The wholesale and retail trading industry recovered above March 2020 levels by August 2020, (64.6 million in August compared to 60.3 million in March), whereas the hotel and tourism industry could only recover by October 2020, 25.6 million in October compared to 24.6 million in March.

The impact of the second wave was observed on the number of employed individuals in wholesale and retail trading (contraction of 8.9 million) and the hotel and tourism industry (contraction of 3.8 million) between April and May 2021. However, recovery was rapid as hotel, tourism, wholesale, and trading sectors added to the job market.

Micro, small, and medium enterprises (MSMEs) were among the worst hit in both the manufacturing and services sub-sectors; they suffered heavy job losses. Box 2 presents a closer look at the industry perspective of the impact on MSMEs.

### **Box 2**

### **Impact of COVID-19 on MSMEs—Industry perspective**

Pre-COVID, the MSME sector faced a lack of cost competitiveness and many small firms were stuck in cycles of low productivity and informality. The sector was already struggling with demonetization, GST, and a slowing economy when COVID-19 hit.

The pandemic dealt a heavy blow to MSMEs stunting their growth and exacerbating pre-existing issues. The size and scale of MSMEs led to lower bargaining power resulting in delayed payments for goods and services supplied. This malaise continued to plague the growth of the sector in spite of legal remedies. Further, delayed payments resulted in a working capital crunch. Thus, MSMEs had to utilize cash reserves to resolve payment issues with difficulties in borrowing from formal sources.

The Global Alliance for Mass Entrepreneurship LEAD micro-enterprise survey found that 57% of micro-enterprises had no cash reserves, while 65% had to dip into personal savings to manage their operations [29]. Another issue plaguing MSMEs was order cancellations [30]. This added to the inventory stock and to the cost of managing piled up inventory, further leading to working capital constraints.

An April 2020 survey by The Federation of Indian Chambers of Commerce & Industry (FICCI) found that 73% of MSME businesses reported a drop in orders, while 50% indicated that their inventory levels were up by over 15% [30]. The pandemic also disrupted the expansion plans of MSMEs. Many had to restructure their operations and plan a new trajectory for growth. Plans for their future also remained uncertain due to the lack of safety nets.

While some MSMEs used creative methods such as technological upgrades to survive, many had to shut down due to disrupted supply chains and transformed consumer habits; 30–40% of MSMEs in India may cease to exist as the pandemic continues [31].

Personal Protective Equipment (PPE) manufacturing emerged, on the other hand, as a key growth driver for MSMEs. Nearly 1,100 indigenous manufactures from textile clusters across India pivoted toward PPE manufacturing. This led to India emerging as the second largest manufacturer of PPE in the world within just two months of the onset of the pandemic—with a daily production rate of over 500,000 kits by May, 2020 [32].

 **Change in average monthly household per capita income during November 2019 to October 2020 (in percentage)**

**Fig. 20** Change in average monthly household per capita income during November 2019 to October 2020 (in percentage). *Source* State of Working India 2021 calculations based on CMIE-CPHS data [33]

# *Impact of COVID-19 on Incomes*

Average monthly household per capita income (PCI) showed a declining trend even before the COVID-19 lockdown, falling from INR 6,401 in October 2019 to INR 4,929.6 in March 2020. Per capita income then fell sharply to INR 3,453.6 in April 2020. It only recovered by October 2020 (Fig. 20).

While the permanent salaried class was shielded, with their monthly incomes dropping only 5%, casual workers saw their monthly income shrink by 13% in 2020. This was the outcome of lay-offs and no social security safety nets. Similarly, the incomes of self-employed and temporary workers also shrank by 18% and 17% (Fig. 21).<sup>12</sup>

Mobility restrictions and shortage of essentials due to disrupted supply chains had an immense impact on the prices of essential commodities. Rising inflation and higher cumulative income losses among the vulnerable workforce segments worsened the effects of income disparity creating a survival crisis (Fig. 22).

<sup>12</sup> Temporary salaried workers are predominantly support staff, industrial workers and nonindustrial technical employees as compared to permanent salaried who are engaged in primary activities of the firm. Casual/daily wage workers are those depending on freelance jobs. Self-employed are those not drawing salaries from another entity.

 **Change in monthly earnings in 2019-20 by employment category (in percentage)**

**Fig. 21** Change in monthly earnings in 2019–20 by employment category (in percentage). *Source*  State of Working Capital 2021 calculations based on CMIE-CPHS data [33]

**Fig. 22** Monthly inflation rates. *Source* Ministry of Statistics and Program Implementation, Government of India [10]

# **Poverty and Increasing Inequality**

# *Rising Poverty*

Between FY10 and FY11, the proportion of the population earning less than USD 1.90/day fell from 63% to 22.5%. India was among the only fours countries which halved their Multidimensional Poverty Index (MPI) value in a span of

**Table 6** Estimates for number of people pushed into poverty in 2021

*Note* Extreme poverty is measured as the number of people living on less than USD 1.90 per day; 2017 was the last year with official global poverty estimates

*Source* Poverty and Shared Prosperity 2020, PovcalNet for Global; State of Working India 2021, Azim Premji University, Author's calculations based on Consumer Pyramids Household Survey (CPHS) data by the Center for Monitoring Indian Economy (CMIE) for India [40–43]

10 years (FY06–FY16) with the greatest drop of 273 million in its number of multidimensionally poor people [34, 35]. The infant mortality rate13 dropped from 66.7 per 1,000 live births in 2000 to 28.3 in 2019 and literacy rates rose as access to primary and secondary schooling accelerated. Secondary school enrollment increased from 45% in 2000 to 74% in 2019 [10]. This facilitated inter-generational impacts on education and healthcare.

Post-COVID-19, however, initial estimates suggest that South Asia and India in particular will witness rising poverty. The World Bank estimates that global poverty<sup>14</sup> will rise for the first time in twenty years, with South Asia contributing to 49% of this increase [36]. Estimates from the Asian Development Bank show that number of poor are set to increase by 75–80 million across Asia [37]. Researchers from the Azim Premji University estimated that poverty in India was expected to drop by 5% in rural areas and 1.5% in urban areas between 2019 and 2020, lifting approximately 50 million people above the national minimum-wage threshold-line of INR 375/day [38, 39]. Instead, the pandemic led to an anticipated rise in poverty by 15.6% in rural areas and 19.7% in urban areas, respectively pushing an additional 230 million persons into poverty [39] (Table 6).

# *Growing Income Inequalities*

India's growth experience has been in line with cross-country evidence15 wherein income inequality has risen in good and bad times.16 The share of national income accruing to the top 10% of the population increased from 36% in 1992 to 57% in

<sup>13</sup> Deaths per 1,000 live births of children under one year of age.

<sup>14</sup> As per the USD 1.90/day line.

<sup>15</sup> OECD three-part flagship series on trends, causes and remedies to growing inequalities. Part 1—Growing unequal? (2008).

Part 2—Divided we stand: why inequality keeps rising (2011).

Part 3 – In it together: why less inequality benefits all (2015).

<sup>16</sup> Incomes of the richest 10% when compared to the poorest 10% stood at a ratio of 7:1 in the 1980's, growing to 8:1 in the 1990's, and to 9:1 in the 2000s.

 **Average value of assets (000' Rs.) by decile class of asset holding as on 30.06.2018**

**Fig. 23** Average value of assets (000' Rs.) by decile class of asset holding as on 30.06.2018. *Source*  All India Debt and Investment Survey, NSSO 2019–20 [48]

2019. In the same period, the share of the middle 40% fell from 46 to 30% and that of the poorest 50% dropped from 21 to 12%—indicating polarized post-liberalization growth [18, 46]. As of 2019, the richest 10% in India owned over 50% of the total assets, whereas the bottom 50% owned 10%. The average value of assets owned also demonstrates exceptionally large disparities not just between the top and bottom decile classes, but also between decile 8 or 9 and decile class 10 (Fig. 23).