Scandinavian Journal of Public Health, 2010; 38(Suppl 4): 617

REVIEW ARTICLE

Globalisation and womens health in Sub-Saharan

Africa: Would paying attention to womens occupational roles
improve nutritional outcomes?

RENE LOEWENSON1, LEXI BAMBAS NOLEN2 & SARAH WAMALA3

1
Training 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 womens 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 womens 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, womens health, Sub-Saharan Africa, gender, occupation, nutrition, food security, social inequality

Introduction African countries are generally seriously off track

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,
to meet this MDG.
Nutrition outcomes are an important determinant
and indicator of womens 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
 Occupational roles in relation to womens health in Sub-Saharan Africa
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
womens 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
East Asia and
Pacific
Europe and
Central Asia
Latin America and
Caribbean
Middle East and
North Africa
South Asia
Sub -Saharan
Africa
Fragile states
100% 50%
Figure 1. Proportion of countries on track to reduce under-five malnutrition by half in 2008. (Reproduced with kind permission from
the World Bank).
7
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,
No data
Seriously off track
Off track
On track
Achieved
0% 50% 100%
8 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 womens health in
Sub-Saharan Africa, focusing on the pathways of
womens 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

Political processes, Macroeconomic policies; Trade

Global agreements and flows; Intermediary Global public goods;
context Official development assistance

Domestic politics, policy space and capacity; Economic,

National labour, Agriculture, food; Public services, Gender income,
context price and tax policies

Local government policy space and capacity;

Material conditions: product prices; land tenure;

Community Service and programme access: health services, nutrition
Pathways

context 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
Household conditions: food quality, storage
context
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. Womens occupational roles and resources and pathways between globalisation and nutrition outcomes.
 Occupational roles in relation to womens health in Sub-Saharan Africa
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, womens 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
womens 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, womens occupational roles and nutri-
tional outcomes.
9
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 globalisations benefits have
been primarily obtained by countries and commu-
nities that already have financial, land, physical,
institutional, and human capital assets and that
globalisations 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 womens 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
10 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
[29]. 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,
19802001 (US$).
Product, Unit 1980 1990 2001
Cafe(Robusta)cents/kg 411.70 118.20 63.30
Cocoa cents/kg 330.50 126.70 111.40
Groundnut oil dollars/ton 1090.10 963.70 709.20
Palm oil dollars/ton 740.90 289.90 297.80
Soya dollars/ton 376.00 246.80 204.20
Sugar cents/kg 80.17 27.67 19.90
Cotton cents/kg 261.70 181.90 110.30
Source: 27.
 Occupational roles in relation to womens health in Sub-Saharan Africa
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 regions total
technical assistance and training [32]. Studies report
a shift from traditional food crops to export crops,
increasing dependency on purchased food and
womens 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 710 hours required for time
to market, further undermining womens 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
womens productivity improves, the household
gains are also reported to be more likely to be used
11
to improve the wellbeing of children in the house-
hold, with a positive impact on childhood nutritional
status [3739].
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 [23,4144]. 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 womens
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
12 R. Loewenson et al.
Africa work up to 1618 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 womens labour: At a basic level,
womens 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 womens 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 womens (and often childrens) 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
 womens lack of control over finances and decision
making, undermining health-promoting food choices
and timely health-seeking behaviours [5256].
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 familys 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
womens 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
 Occupational roles in relation to womens health in Sub-Saharan Africa 13
Table II. Summary of documented outcomes/associations in the pathways between globalisation, womens occupational roles and health
nutrition outcomes.

Documented
outcomes/
associations Findings Sources cited
Global/national context
Largely Globalisation related innovations in technology, information, know how 12, 14, 19,
positive Global normative commitments to and resources for human development, universal access to 24,
healthcare 31(5 cited
Significant economic role for agriculture at household and national levels in Africa sources)
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
Largely Economic liberalisation and global trade rules constrain national policy space to protect domes- 15, 8, 9, 12,
negative tic producers 1419,
Imbalance in pace of trade liberalisation, market access, and debt crisis favours existing wealth 2328,
Declining terms of trade for African agriculture 30, 31, 34,
Weak institutional and political mechanisms for agrarian reform in Africa under-investment in 45 (24 cited
research and development in agriculture; differential uptake of technologies sources)
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
Largely Greater returns from access to investment in agriculture to yields for low-income producers, 31, 3540
positive especially women (7 cited
Women responsible for 80% of household food production in Africa sources)
Women producers translate improved agricultural returns to household nutritional gains
Increased non-farm employment improves womens income, social opportunities, and autonomy
Rural-urban migration brings opportunities for employment, service access, and communication
Innovation, information challenges gender-related social discrimination.
Largely Weak consideration of gender differentials in policy design or implementation means gender 4, 5, 7, 12,
negative inequalities widen 16, 17, 19,
Women smallholders have less access to land, credit, fertilizer, information, extension resources, 22, 23, 25,
and technical assistance and training 3134,
Sale or rent of land by smallholders to large-scale farmers 36, 4054,
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 for cited
household needs sources)
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
Womens lack of control over finances and decision making at household level
Womens 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
14 R. Loewenson et al.
the poor nutritional outcomes in Africa, with a
particular focus on womens 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 globalisations 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, womens 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 Womens
Division (SDW) and the FAO Gender and
Development Plan of Action (200207) [61], leaving
the trade policy domain relatively segregated.
While the evidence from the literature points to the
negative implications of globalisation for womens
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
 Occupational roles in relation to womens health in Sub-Saharan Africa
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 womens 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
womens 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
15
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 womens 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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