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Review Article: Globalisation and women’s health in Sub-Saharan Africa: Would paying attention to women’s occupational roles improve nutritional outcomes?

Rene Loewenson, Lexi Bambas Nolen and Sarah Wamala

Scand J Public Health 2010 38: 6

DOI: 10.1177/1403494809358276

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Scandinavian Journal of Public Health, 2010; 38(Suppl 4): 6–17

REVIEW ARTICLE

Globalisation and women’s health in Sub-Saharan

Africa: Would paying attention to women’s occupational roles improve nutritional outcomes?

RENE LOEWENSON1, LEXI BAMBAS NOLEN2 & SARAH WAMALA3

1Training and Research Support Centre, 2Center to Eliminate Health Disparities, University of Texas Medical Branch Texas, USA, and 3Swedish National Institute of Public Health and Karolinska Institute, Sweden

Abstract

Aim: This paper explores, through a review of literature, the link between globalisation and nutritional outcomes in Sub-Saharan Africa, focusing on the pathways of women’s occupational roles on the food produced, consumed, and secured for households. Methods: Following a framework linking globalisation and health, we drew evidence from peer reviewed, cross-national or large scale studies, official sources, reviews, online scientific databases, and case studies, published between 1990 and 2009. Results: Publications cite improved technology, information, know how, normative commitments to and resources for human development, returns from access to investment in agriculture for low-income women producers, and urban employment opportunities reducing social discrimination and improving opportunities for household food security, particularly if access to these benefits is reinforced by national policy. However, many more publications cite negative consequences, including in falling national and local food self-sufficiency, livelihood and nutritional losses, widening inequalities, and in declining or insecure access to production inputs, markets, incomes, local foods, and healthcare. These effects are documented to increase time and resource burdens for women, with negative consequences for their own and their families’ health and nutrition. Conclusions: The evidence suggests that globalisation-related economic and trade policies have, on balance, been associated with shifts in women’s occupational roles and resources that contribute to documented poor nutritional outcomes in Africa. These trends call for public policies that address such positive and negative effects for women and for improved monitoring of such gender and socio-economic trends, especially at the household and community level, in the tracking of the Millennium Development Goals.

Key Words: globalisation, women’s health, Sub-Saharan Africa, gender, occupation, nutrition, food security, social inequality

Introduction

The first UN Millennium Development Goal (MDG) target includes the commitment to halve, between 1990 and 2015, the proportion of people who suffer from hunger, and specifically includes halving the prevalence of underweight children. Yet after falling in the 1970s and 1980s, the proportion and absolute number of malnourished children in Africa has actually increased since 1990, particularly in east Africa, with over one-quarter of all African children under 5 years of age being underweight for their age [1,2]. The overall prevalence of population undernutrition has risen in the continent from 29% in 1992 to 30% in 2004 [3]. As shown in Figure 1,

African countries are generally ‘‘seriously off track’’ to meet this MDG.

Nutrition outcomes are an important determinant and indicator of women’s health [4]. The increase in undernutrition in Sub-Saharan Africa directly con-flicts with global commitments and has been called ‘‘a catastrophe for African development’’ [2, p.1]. Policy and programme interventions are being called for, informed by understanding of the determinants and pathways from global contexts to health outcomes.

A number of assertions are already being made on the spectrum of determinants, including conflict, drought, falling agricultural production, falling

Correspondence: Rene Loewenson, Training and Research Support Centre Tanzania, PO Box 93, Bagamoyo, Tanzania. E-mail: rene@tarsc.org

(Accepted 27 November 2009)

2010 the Nordic Societies of Public Health DOI: 10.1177/1403494809358276

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Occupational roles in relation to women’s health in Sub-Saharan Africa7

household food security, poor maternal education, poor access to childcare and primary health care services, and inadequate management of HIV and AIDS [2,5,6]. Gender differentials, and particularly women’s status, access to resources and increases to services are features of many of these determinants, intersecting with deeply rooted structures of gender inequality that are poorly integrated into policy-making [7].

The MDG Africa Steering Group, involving the continental level African Development Bank and African Union together with United Nations and International Finance Institutions, pointed out in 2008 that Africa is the only region in the world where per-capita food production has fallen in the last 30 years [8]. Their policy response has been to call for ‘‘support to African Governments to launch a green revolution to double crop yields, with a focus on providing smallholder farmers with temporary subsidies for fertilizer and better seeds’’, backed by a rise in development assistance to African agricul-ture and assistance for feeding and nutrition pro-grammes [8, p1].

This policy response has been challenged, pointing to the package of technologically driven high yield varieties of seeds, fertilizers, and pesticides in the 1970s’ green revolution approach, which failed to adequately address the social and economic

differentials in the uptake of and benefit from these technologies, or the institutional and political mechanisms for ensuring more sustained agrarian reform [9]. Further, warning is given of the potential for a global-local ‘‘double bind’’, where the demand for national context-specific measures and invest-ments aimed at poverty reduction (in this case for improved production and household food security) contradict global demands for ‘‘sound policy reforms’’ based on macroeconomic stability, liberal-ization, and privatisation [10]. These potential policy conflicts are even more challenging for African countries in the context of globalisation, a process that involves ‘‘greater integration within the world economy through movements of goods and services, capital, technology and (to a lesser extent) labour, which lead increasingly to economic decisions being influenced by global conditions’’ [11, p.1]. Although such globalising processes have existed since the colonial period, characteristics of contemporary globalisation, beginning in the 1970s, that distin-guish it from the past include the scale of exchange, the existence of binding rules such as through trade agreements, the level of corporate power, and the legal commitment of countries to continue towards market liberalisation [12, p. 2]. Globalisation has the potential to affect the more local determinants identified earlier through effects on power, resources,

East Asia and
Pacific
Europe and
Central Asia
Latin America and
CaribbeanNo data
Middle East andSeriously off track
Off track
North Africa
On track
South AsiaAchieved
Sub-Saharan
Africa
Fragile states
–100%–50%0%50%100%

Figure 1. Proportion of countries on track to reduce under-five malnutrition by half in 2008. (Reproduced with kind permission from the World Bank).

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  1. R. Loewenson et al.

labour markets, policy space, trade, financial flows, health systems, and access to essential services and inputs for health. It thus needs to be integrated within the conceptual analysis of the pathways leading to poor nutritional outcomes [13].

Noting the complexity and uncertainty inherent in any analysis of relationships between globalisation and health outcomes, this paper takes a more modest focus. The paper explores, through a review of literature, the link between globalisation and nutri-tional outcomes as an indicator of women’s health in Sub-Saharan Africa, focusing on the pathways of women’s occupational roles, particularly in relation to producing and securing food. The paper draws on the conceptual frameworks of Labonte and Torgerson [13], Hyder et al. [4] and the World Health Organisation (WHO) Commission on the

Social Determinants of Health [14], as summarised and simplified in Figure 2. These frameworks take into account the power relationships, trade mechan-isms, and multi-level dynamics mentioned above that affect nutritional processes and outcomes at the community and household levels.

Methods

The review draws on official sources, systematic and other reviews, and case studies published between 1990 and 2009 and data from online scientific databases, including those of WHO, the World Bank, and the International Labour Organization searched in September 2007, May 2008, and August 2008. The literature was obtained through

Global

context

National

context

Community

context

Household

context

Pathways

Political processes, Macroeconomic policies; Trade agreements and flows; Intermediary Global public goods;

Official development assistance

Domestic politics, policy space and capacity; Economic, labour, Agriculture, food; Public services, Gender income,

price and tax policies

Local government policy space and capacity;

Material conditions: product prices; land tenure;

Service and programme access: health services, nutrition programmes, agricultural credit, services

Social cohesion: civil society organisations; social and family networks

Community capacities:

Household income / wealth distribution Employment; Occupational roles and workloads Household conditions: food quality, storage Household and individual behaviours; work time; food preparation time; dietary patterns; child care; health behaviours

Social position: gender status, autonomy

Household expenditures: food, health, education Biological factors

Health and nutrition

outcomes

Sources: 4, 13, 14

Figure 2.  Women’s occupational roles and resources and pathways between globalisation and nutrition outcomes.

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Occupational roles in relation to women’s health in Sub-Saharan Africa9

web-based libraries, listserves, search engines, insti-tutional websites, online libraries including those in Medline, ELDIS, PubMed, the International Gender and Trade network, and Google, using combinations of search parameters and terminology related to ‘‘globalisation’’, ‘‘gender’’, ‘‘women’’; ‘‘occupation’’, ‘‘health’’, ‘‘Africa’’; ‘‘trade liberalisa-tion’’, ‘‘commercialisation’’; ‘‘nutrition’’, ‘‘food secu-rity’’; ‘‘agriculture’’ and ‘‘MDGs’’. Reference lists in articles found from these searches were also used to yield further publications. A total of 2000 publications were obtained from these sources. Of these, 199 papers were found to focus on globalisation measures and their association with agriculture, women’s occupational roles including domestic roles, and health sector and unpaid care work in Sub-Saharan Africa and were included in the review. Particular attention was paid to articles discussing women and gender issues, health outcomes, food security, and nutrition. This yielded 63 peer-reviewed publications. We also found 136 publications from ‘‘grey’’ literature, including country case studies, reports, and qualita-tive evidence, given the paucity of quantitative analysis and empirical research on globalisation and women’s health, especially in Africa. Cross-national studies, large-scale studies, and syntheses, especially those from peer-reviewed journals, were prioritised for collection and review and, with official data sets, comprise the bulk of literature reviewed and referenced. Additionally, reviews from numerous sites or studies have been used to fill specific knowl-edge gaps. Case studies were used to illustrate particular points or to point to available evidence where there are no large-scale studies and were not given the same weighting as large-scale or multi-country studies in terms of summarising findings.

The paper draws on the conceptual analysis above to explore the global, national, community and household contexts through which the policies and processes associated with globalisation affect the occupational roles women play and resources they command for household food security and how this is associated with nutritional outcomes.

Results

This section presents the findings from the review, summarising these at the end of the section to assess their overall direction in the association between globalisation, women’s occupational roles and nutri-tional outcomes.

Global and national contexts

A substantial review of international evidence on globalisation and the social determinants of health carried out by the Globalisation Knowledge Network of the WHO Commission on the Social Determinants of Health makes clear that globalisa-tion has both positive and negative impacts, but that the benefits are unevenly distributed across groups. The review reported that globalisation’s benefits have been primarily obtained by countries and commu-nities that already have financial, land, physical, institutional, and human capital assets and that globalisation’s rules favour already-rich countries and contexts because they have greater resources and power to influence the design of those rules [13]. Sub-Saharan African countries are found to have experienced increases in inequalities in health and reduced gains in life expectancy, partly due to globalisation policies associated with debt crises, capital flight, and structural adjustment pro-grammes. Globalisation is also suggested to have been accompanied by the reproduction of gender hierarchies and discrimination, with increasing bur-dens of domestic care posing a barrier to economic and employment opportunities. Increased global trade in food products is argued to have brought changes in food availability, accessibility, price, and, through marketing, desirability, thereby shifting demand for home-produced foods or foods pur-chased in traditional markets to increased depen-dence on store-bought foods, especially processed foods, with unclear but potentially negative dietary impacts [13].

This section explores the evidence on how global policies and rules are associated with trends at the national level that have relevance to women’s roles in household food security. The increasing influence of global policies and institutions at national level have led us to treat these two contexts together.

Since the 1980s, national policies and programmes in African countries have been set in the context of increasingly influential global frameworks through conditional loans and supra-national trade agree-ments and policies. Structural adjustment policies promoted by the International Finance Institutions, which made loan and financial investments condi-tional on market liberalisation and export-led pro-duction, as well as the establishment of the World Trade Organisation (WTO) are reported to have brought national trade policy under the increasingly binding constraints of multilateral trade rules that also supercede other policy areas and are relatively unresponsive to national objectives [15,16]. African countries are documented to contend that these

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  1. R. Loewenson et al.

policies have led to substantial losses for their own domestic markets [15]. Enforcement has been slow of measures to level the playing field identified in the 1994 pre-WTO Agreement on Agriculture (AoA), such as of measures requiring governments to elim-inate quantitative import restrictions, lower agricul-tural tariffs, reduce domestic support, and eliminate export subsidies [17,18]. By 2008, distorting sub-sidies in rich countries remained in place, leading to imported foods often being sold at lower prices than local foods. Developed-country agricultural policies were reported to cost developing countries an estimated US $17 billion per year, or five times the current levels of overseas development assistance to agriculture [19].

Trade generally, and these policies specifically, have been largely cast as class- and gender neutral technical processes [16,20]. Their class and gender impacts have, however, been documented in post-hoc evaluations [21-23]. For example, in Zambia, in an attempt to stimulate greater private sector involvement, the World Bank, through struc-tural adjustment reforms, persuaded the Zambian government to replace the Zambian grain marketing authority with the much smaller Food Reserve Agency [22]. However, a lack of infrastructure made it uneconomical for private traders to do business in remote areas and poor farmers lost access to markets through which to sell their produce or buy inputs. An independent IMF evaluation found that liberalisation of the state marketing board contributed to a 30% increase in rural poverty between 1991 and 1994 [22].

Nevertheless, global and national agrarian policies have been reported to have had significant economic and social consequences in Africa. While there have been high rates of urbanisation and inequalities in landownership, Sub-Saharan African countries still have a high level of participation in agriculture and a higher share of income from agriculture compared to other regions [19]. Although research indicates that gross domestic product (GDP) growth originating in agriculture is four times more effective in raising incomes of extremely poor people in Africa than GDP growth originating outside the sector, public spend-ing for farming averages only 4% of total government spending and the sector is taxed at relatively high levels [19]. While these policies benefited some areas of export-led farm production, such as horticulture, through the tax and tariff incentives received, many areas of farming did not benefit [24]. Research and development of appropriate technology, extension services, general infrastructure, and market develop-ment had falling levels of funding in the past three decades in Sub-Saharan Africa [25], with public

funding to agricultural research and development falling after the 1970s. Thirteen of 27 Sub-Saharan Africa countries with data showed further declines in investment after 1990 and investment often focused on more limited specific projects than sectoral needs [19,26]. At the same time, even those countries investing in agricultural export production experi-enced falling returns on commodity prices, shown in Table I, gripping producers in east and southern Africa (ESA) in a price trap demanding increasing production for decreasing revenues [27].

Numerous cross-country reviews of both official data and field surveys indicate that tariff and subsidy imbalances, falling terms of trade, limited develop-ment of internal agricultural markets through research and infrastructure, and service development have been associated with falling domestic agricul-tural output in recent decades in Sub-Saharan Africa, increasing transnational control of the food supply chain with a dramatic escalation in the cost of food [5,19,26,28]. The fall in domestic food production has been marked: since the 1960s, cereal yields have increased significantly in every region globally except Sub-Saharan Africa, and agricultural productivity, measured as growth in agricultural GDP per agricul-tural population, is lowest globally in Africa [19]. Kenya, for example, which more than doubled pro-duction of processed milk between 1980 and 1990, experienced a plummet in domestic milk production after imports of milk powder in 1990 [5]. Globally, food imports have grown fastest in Africa, rising from 8% of world food imports in 1986 to 18% in 2001

  1. At the same time, the value of agricultural output per worker in Africa fell from US$424 in 1980 to about US$365 per worker (constant: 1995 US$) in the late 1990s. A recent UN Department of Economic and Social Affairs review of international data suggests that in this context, reduced agricul-tural subsidies in high-income countries are likely to mainly benefit large, transnational producers in Sub-Saharan Africa and may further increase food costs due to the high volume of imports [30].

Table I. Commodity price declines agricultural commodities, 1980–2001 (US$).

Product, Unit198019902001
Cafe(Robusta)cents/kg411.70118.2063.30
Cocoa cents/kg330.50126.70111.40
Groundnut oil dollars/ton1090.10963.70709.20
Palm oil dollars/ton740.90289.90297.80
Soya dollars/ton376.00246.80204.20
Sugar cents/kg80.1727.6719.90
Cotton cents/kg261.70181.90110.30

Source: 27.

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Occupational roles in relation to women’s health in Sub-Saharan Africa11

Community and household contexts

These outcomes are reported in the literature to have had a particularly profound impact on women, most marked at community and household levels. This section explores how these economic trends at global and national level have been associated with changes in support for women as farmers, in the quality and security of non-farm wage employment, and in demands on women in their household occupational roles.

Women are documented to be responsible for 80% of food production in Africa, including the most labour-intensive work, such as planting, fertilising, irrigating, weeding, harvesting, and marketing. They achieve this despite unequal access to land (less than 1% of land is owned by women), unequal inputs such as credit (<10% of credit provided to small farmers goes to women), poor access to improved seeds and fertilizer, and unequal access to information [4,23,31]. In Sub-Saharan Africa, women are reported to receive no more than 5% of agricultural extension resources and 18% of the region’s total technical assistance and training [32]. Studies report a shift from traditional food crops to export crops, increasing dependency on purchased food and women’s involvement in harmful cash crops such as tobacco, or use of food crops for commercial sales where they do not control the income, such as for alcohol brewing, both of which are associated with food insecurity and undernutrition [16,32,33].

The greater support to large-scale commercial farmers outlined above is reported to have been at the expense of smallholder farmers, particularly women smallholders, increasing the likelihood of women taking on roles as low-wage labour for export-orientated commercial farming concerns [5]. Unequal rights and obligations within the household, as well as more limited time and financial resources, are reported to place much greater constraints on women than on men [19,34]. High fixed-transport costs are estimated to be equivalent of a 15% tax on small farmers with up to 7–10 hours required for time to market, further undermining women’s potential for market entry, fair crop prices, and high yield and thus decreasing household food security and increas-ing work loads [19,34]. None of the papers reviewed reported economic or social gains for women small-holder farmers from these measures. The literature does however give evidence that given equal access to resources and human capital, women farmers can achieve equal, or even, as some studies show, significantly higher, yields than men [35,36]. Where women’s productivity improves, the household gains are also reported to be more likely to be used

to improve the wellbeing of children in the house-hold, with a positive impact on childhood nutritional status [37–39].

Women are not only affected as producers. Household food security is equally affected by the incomes earned in non-farm, urban, and rural formal and informal sector jobs. There is evidence of improved incomes for workers in non-farm employ-ment, except for workers with no education [40]. It is thus possible that globalisation did challenge local dimensions of gender disadvantage by providing economic and social opportunities through non-farm employment. The documented advantages of non-agricultural work for women include greater economic rights and responsibilities such as increased decision making and control over house-hold spending and less pooling of income [40]. A series of studies on agriculture in Sub-Saharan Africa in the past decade found an increasing trend in farmers with very small acreages selling or renting their land out to larger-scale farmers and turning to agricultural wage labour or non-farm activities [40,41]. However, there is also evidence that these urban and rural non-farm jobs are low-skill, insecure forms of employment, with limited rights and benefits [23,41–44]. While new employment oppor-tunities have been provided, particularly to women, through relocation to urban areas, these workers are also reported to experience increased food insecurity due to job and income insecurity, competing demands for spending, higher cost of food purchases, and limited possibilities for people in non-farm jobs to produce food in urban environments [45,46]. A review of published international literature on urban food security and nutrition found a similar range of factors affecting urban nutrition, including negative impacts of a decline in national food self-sufficiency, displacement of local food retailers by corporate chains, food system dynamics favouring processed, high-energy foods, and loss of livelihood options in local food systems [45].

The time and resource demands noted above needed to source, secure, and prepare food add to other demands on household resources and women’s time. In Sub-Saharan Africa, the literature, largely focused on low-income rural and urban women, indicates that these women have a demanding breadth of responsibilities at household level, includ-ing agriculture-related duties, household food prep-aration, fetching water, gathering wood, grinding grains into flour, drying and pounding cassava, transporting and marketing family cash crops, child and family care, washing, breastfeeding, support to other households, and generally all unpaid household labour [4,47]. Studies suggest that women in rural

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  1. R. Loewenson et al.

Africa work up to 16–18 hours per day [48]. Participation in the formal, non-agricultural labour force for many women does not diminish unpaid work and families in Africa are reported to have responded to economic stress by increasing the supply of women’s labour: ‘‘At a basic level, women’s employment, paid and unpaid, may be the single most important factor for keeping many households out of poverty’’ [49, p. 9].

Regardless of their demanding responsibilities, women are reported to generally have less access to land ownership, inheritance rights, capital, credit, inputs and technology for income-generating activ-ities, education, extension services, and community-based support services [7,32,50,51]. They also have low control in decision making over what foods should be produced, consumed, purchased, or sold and face a vicious cycle of increasing work, lack of time, and lack of independent decision making [4].

The nutritional outcomes reported in the first section of this paper suggest that these household burdens and coping strategies are having their own negative consequences for women’s health and for household food security and nutrition. The literature suggests some pathways for this, through:

diminished access to purchased or grown food, competing time demands between food sourcing and preparation and other household activities, increased women’s (and often children’s) physical burdens and energy expenditures and exposure to disease,

mental and emotional stress and neglect by women of their own health and wellbeing,

female children dropping out of school to contribute to household labour, undermining opportunities and capacities for health, and

women’s lack of control over finances and decision making, undermining health-promoting food choices and timely health-seeking behaviours [52–56].

The AIDS epidemic in Sub-Saharan Africa is documented to have added to household ill health and to the time and cost burdens for care, particularly for female children and women [57]. People living with HIV have greater nutritional needs than others, placing demands on family resources and making them particularly vulnerable to health effects of fluctuations and changes in food security and nutri-tion [25,58]. These burdens are reported to have been compounded when countries have responded to market liberalisation policies by commercialising their health services. Reforms that have involved reducing public sector spending and provisioning, raising user charges, and encouraging private provi-ders [31,59,60], together with out-migration of health workers in global labour markets, are reported

to have left peripheral, primary care services under-staffed and under-resourced, raising cost and trans-port barriers for poor communities to access care and adding further to unpaid care burdens and negative health outcomes [14,31].

The summary of these documented trends are shown in Table II. They indicate that globalisation is having both positive and negative effects, but that studies more commonly report negative effects for the rural and urban women from low-income com-munities who are the focus of many of the studies.

Five papers cite the positive outcomes noted in technology, information, and know how as well as normative commitments to and resources for human development, with potential positive impact for food security in Africa given the significant economic role for agriculture at household and national levels, particularly if domestic producers can gain access to these benefits through national policy support. However, nearly five times the number of publica-tions (24) cite negative consequences in terms of widening existing gender inequity in farm produc-tion, falling national and local food self-sufficiency, and livelihood and nutritional losses.

At the community and household level, seven publications indicate returns from access to invest-ment in agriculture to yields for low-income women producers, with gains in household nutrition as well as challenges to gender-related social discrimination from information flows and non-farm employment. However, five times the number of publications (34) cite widening inequalities or declines in access to production inputs, markets, incomes, local foods, and healthcare, associated with weak consideration of gender differentials in trade and economic policy design or implementation. These effects are docu-mented to increase time and resource demands on women, with negative consequences for their own and their family’s health and nutrition. These numbers do not represent any weighting of these positive or negative effects themselves and few studies disaggregate the distribution of these effects across different groups of women or within low-income groups. The frequency of publications does however indicate that a larger share of docu-mented evidence on globalisation measures and women’s occupational roles and nutrition cites neg-ative effects.

Conclusions, policy options, and knowledge gaps

Drawing on published and grey literature, this paper has explored the pathways between globalisation and

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Occupational roles in relation to women’s health in Sub-Saharan Africa13

Table II. Summary of documented outcomes/associations in the pathways between globalisation, women’s occupational roles and health nutrition outcomes.

Documented
outcomes/
associationsFindingsSources cited
Global/national context
LargelyGlobalisation related innovations in technology, information, know how12, 14, 19,
positiveGlobal normative commitments to and resources for human development, universal access to24,
healthcare31(5 cited
Significant economic role for agriculture at household and national levels in Africasources)
Investment in export-oriented farm production; positive returns to national and household level
from investment in agriculture
Increased scale of markets boosts demand
National policy measures can protect domestic producers
Improved opportunities for healthy diets
High returns to yields on investments in women farmers
LargelyEconomic liberalisation and global trade rules constrain national policy space to protect domes-1  5, 8, 9, 12,
negativetic producers1419,
Imbalance in pace of trade liberalisation, market access, and debt crisis favours existing wealth2328,
Declining terms of trade for African agriculture30, 31, 34,
Weak institutional and political mechanisms for agrarian reform in Africa under-investment in45 (24 cited
research and development in agriculture; differential uptake of technologiessources)
Existing gender inequity in assets and access to extension services in African agricultural sector not
addressed by gender neutral trade policy
Fall in African per capita food production and national food self sufficiency; shift to imported foods
Value-added higher in food processing where local food retailers displaced by (largely foreign)
corporate chains
Food system dynamics favouring processed food
Livelihood losses in food markets affecting women
Poor performance on nutrition and health MDGs in Africa
Market liberalisation in healthcare diminishing resources, personnel at peripheral primary care
services raising cost, transport barriers to access in poor communities
Increased inequalities in health and reduced life expectancy gains in Africa
Community/household context
LargelyGreater returns from access to investment in agriculture to yields for low-income producers,31, 3540
positiveespecially women(7 cited
Women responsible for 80% of household food production in Africasources)
Women producers translate improved agricultural returns to household nutritional gains
Increased non-farm employment improves women’s income, social opportunities, and autonomy
Rural-urban migration brings opportunities for employment, service access, and communication
Innovation, information challenges gender-related social discrimination.
LargelyWeak consideration of gender differentials in policy design or implementation means gender4, 5, 7, 12,
negativeinequalities widen16, 17, 19,
Women smallholders have less access to land, credit, fertilizer, information, extension resources,22, 23, 25,
and technical assistance and training3134,
Sale or rent of land by smallholders to large-scale farmers36, 40  54,
Shift to agricultural wage labour and non-farm employment associated with insecure employment/5760(34
income and limited work rights and benefits, competing with time and resource demands forcited
household needssources)
Limited improvements in and increased cost of market infrastructure and services for low-income
communities; rural-to-urban migration associated with job and income insecurity, increased costs

and competing demands for spending, more limited possibilities for food production

Falling availability and accessibility of local foods; increased cost and consumption of imported, processed food

Increasing cost, time demands to source, secure, and prepare food with increased time burdens for women

Women’s lack of control over finances and decision making at household level Women’s neglect of own health and wellbeing to meet time/resource demands

Increased care demands for women and children due to barriers to service access; AIDS epidemic Household food security and nutrition stress associated with diminished access to purchased or grown food; increased physical burdens and energy expenditures and exposure to poorly managed disease

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  1. R. Loewenson et al.

the poor nutritional outcomes in Africa, with a particular focus on women’s occupational roles and resources. While globalisation has indeed increased the flow of goods and services across countries, the changes in agricultural production and marketing and in food availability, accessibility, and prices arising from global trade appear from the literature to have particularly disadvantaged African econo-mies, African agricultural sectors and markets, and African women producers, workers, and caregivers. The literature indicates a recognition, including in UN and International Finance Institution sources, that liberalisation of agricultural production in Africa and concurrent protection (subsidies and tariffs) of developed-country agricultural markets has put African countries, smallholder producers, and women farmers at a disadvantage. This has been compounded by the falling terms of trade, corporate monopolies in the food chains, and weak domestic policies, services, infrastructures, and investments supporting national producers, against a background of economic insecurity for many smallholder produ-cers. Although there is limited documented evidence, the larger share of publications reporting negative outcomes suggest that the changes wrought by globalisation in the agricultural sector may be widening gender inequalities.

The literature indicates that the global policy and national context is linked to community and house-hold determinants of household food security and nutrition through income (amount, type, stability, distribution, and control), labour, (amount available, type, location, energy, and time expended), and changes in access and control of land, water, food markets, infrastructure, and services. Poor outcomes in these determinants in both rural and urban areas adds to other household burdens generally borne by women, such as time demands to source, secure, and prepare food as well as spending and time demands for healthcare, placing stress on household health and wellbeing. A larger share of the literature found gives evidence of the negative impact of these sources of stress on nutritional wellbeing, than of positive changes.

Consistent with the findings of the Globalisation Knowledge Network of the WHO Commission on Social Determinants of Health [13], the evidence from the literature thus suggests that the rules governing globalisation’s market liberalisation and economic integration policies in relation to agricul-ture have been skewed towards protecting high-income country and corporate producers, with limited integration of social or gender issues of low-income countries in Africa in their design or application. Obtaining a more equitable distribution

of the benefits of the technological, information, social, and material advances of globalisation would appear to demand greater gender sensitivity in trade policy and policy space for national measures to ensure that these benefits reach domestic producers in low-income communities.

Trade policies are noted earlier to have largely been cast as class-and-gender neutral. In the same year as the AoA was negotiated, at a separate global plat-form, the Beijing Platform for Action promoted household and national food security through com-mitments to facilitating financial, technical and human resources, and, particularly, women’s access to financial, technical, extension and marketing services, land, and appropriate infrastructure and technology [17]. These positions appear to have had little influence at global trade forums, despite civil society lobbies such as the Network of African Women Economists and the International Gender and Trade Network [16,36]. National trade negotia-tors are reported to have discouraged such linkages, concerned that gender would be used to further circumscribe national policy making [16,36]. Further, the gender ‘‘machineries’’ of many govern-ments are reported to have lacked capacity to bring the gender analysis into trade issues and there is a report of lack of follow through to ensure that these gender concerns inform the final trade policy pro-ducts [36]. This segregation was not unique to gender. Wider public health policies have also had relatively limited influence on trade agendas. The 2001 Doha Round at the WTO did secure flexibilities in patenting rules in the Trade Related Intellectual Property (TRIPs) agreement where this was neces-sary to produce or procure essential drugs to meet public health needs [31]. However, this is an isolated example and was an outcome of significant civil society and state lobbies to the WTO in the context of an AIDS pandemic [31,36]. At the global level, gender issues have thus rather been mainstreamed into plans of action and technical support, monitor-ing, and ‘‘development programmes’’, such as through the Food and Agriculture Organization (FAO) Sustainable Development and Women’s Division (SDW) and the FAO Gender and Development Plan of Action (2002–07) [61], leaving the trade policy domain relatively segregated.

While the evidence from the literature points to the negative implications of globalisation for women’s occupational roles and resources and for nutritional outcomes in Africa, it also suggests that women may provide a turning point for improving nutritional outcomes. The significant labour and time burdens that women face, intensified in the context of global and national policies, and the diminishing resources

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Occupational roles in relation to women’s health in Sub-Saharan Africa15

for farm production and non-farm employment can be addressed through public policies: to enhance access to land, seed, information, transport, and markets, to improve access to water and primary healthcare services, to stimulate smallholder and domestic production, to support marketing of locally produced and consumed foods, and to enhance gender equity and women’s autonomy in control over production and social resources. The literature cited earlier suggests that even partial implementa-tion of such policies gives significant returns for production and greater chances that these returns will be used for household wellbeing and nutrition.

In the introduction to this paper, we quoted the MDG Africa Steering Group [8], which called for African Governments to launch a green revolution. This paper suggests that a technically driven green revolution of the nature promoted by the World Bank in the 1970s in Asia that does not take on the gender and distributional issues raised in this paper could do more harm than good to nutritional outcomes, particularly in the context of an even more liberalised global trade environment. Perhaps a gender revolution in agriculture may be more appro-priate to lever an agrarian transformation that would improve household food security and nutrition outcomes.

While the evidence suggests an important role for women’s work and control over resources in the pathways between globalisation and nutritional out-comes in Africa, we found limited empirical research in Africa. While not a goal of this paper, the gap in documented research calls for dialogue on a research agenda on the gender dimensions of globalisation and health in Africa and support for the capacities and work to address this agenda. There is equally weak documentation in official data globally of this dimension of health and economic outcomes of globalisation. For example, the monitoring of the Millennium Development Goals has weak indicators for understanding the features and trends in the community and household contexts described in this paper. The Gender Equality Goal – to promote gender equality and empower women – focuses on a target related to education and, while some indicators require gender disaggregation (education, wage employment, and participation in government), the dimensions raised in this paper relevant to household and community contexts in Africa are not disaggre-gated by gender or socio-economic status, including poverty and hunger (Goal 1) or those relevant to production (vs. wage employment). There is only one MDG indicator that explicitly refers to tracking improvements and achievement of the goals among socioeconomic groups: proportion of people with

access to secure tenure (urban/rural). Yet analysis suggests that the achievement of the MDGs could occur largely without dramatic improvements among the worst-off in society [62]. As this paper indicates, any weakness in monitoring the distributional trends, whether on gender or socio-economic basis, weakens the ability to capture, understand and, where needed, apply policy corrections for critical trends affecting the achievement of the MDGs and, more impor-tantly, the economic and social justice they intended to achieve.

Acknowledgement

This study is part of the international research project, Globalisation and women’s health in Sub-Saharan Africa, and is financed by the Sida/Sarec. We are indebted to the members and advisors of the research project.

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