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Nurses’ role in empowering smallholder women in developing countries
Robert Parolin
York University
NURS 4620 - Women’s Health and Women’s Health Movements: Critical Perspectives
Nazilla Khanlou, RN, PhD
April 4, 2016

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Introduction:
Women make up to 60-80% of small farmers in the developing world (UN DESA,
2011). These farms manage 80% of farmland in sub-Saharan Africa and Asia and supply the
same percentage of the food supply in these regions (Altieri and Koohafkan, 2008), yet those
who work on them account for half of the world’s malnourished and the majority of those living
in absolute poverty (IFPRI, 2005). Raising the yields of these smallholder women is therefore
necessary for eliminating hunger, poverty, and their associated ills not only for themselves, but
for their countries. Yet these women face tremendous obstacles related to poverty and its
associated illnesses in order to do so. This paper will examine these obstacles through an
intersectional approach, examining how they are uniquely experienced by these women due to
their gender (McCall, 2005). It will then propose how nurses can work through both practice and
advocacy in order to empower smallholder women so that they may improve their own health
and livelihoods (Frohlich & Potvin, 2010).
Smallholder women face health challenges commonly associated with poverty, which
are compounded due to their gender. In addition to the threat of communicable diseases common
in developing countries, they face the additional risk of perinatal and maternal conditions due to
lack of access to health resources for prenatal care, childbirth, and postal care. As well, in areas
where solid fuels are used for cooking, women and girls are at increased risk for respiratory
conditions from exposure to indoor air pollution due to their roles in preparing food for their
families. These combined risks account for 40% to more than 60% of total women’s deaths
throughout Africa as well as South and Southeast Asia (WHO, 2009). In this way, women’s
gender roles in developing countries intersect with the burden of poverty and illness in order to

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create unique challenges to them (McCall, 2005). This threat of illness also compounds the pre-
existing threat of malnutrition to smallholder women and their families as it hinders their ability
to work.
In addition to the burden of disease, smallholder women’s challenges as farmers are
also compounded by their gender. Ensuring proper nutrition for themselves and their families
depends on the yields of their crops, which requires inputs such as fertilizers and improved seed
varieties. These women usually need loans in order to access these inputs, in addition to
extension services for receiving the most updated information on newer types of inputs.
Unfortunately, they usually have more restricted access to credit and extension services
compared to their male counterparts, with women in sub-Saharan Africa receiving less than 10
percent of credit and 7 percent of extension services in the region (UN DESA, 2011). This is due
to the fact that in many regions, women’s names are not on the titles of the land they farm, either
due to laws or local cultural traditions that require a male family member’s name instead
(Villarreal, 2013). This means that women are not able to put their land up as collateral, which is
usually necessary for loan applications. Extension services are also often inadequate as extension
agents are often overwhelmingly male, do not take into account women’s roles as farmers, or do
not schedule services in a way that accommodate women’s unique work schedules (FAO, 2011).
In this way, these women’s gender roles intersect with the economic and environmental
difficulties faced by many farmers in developing countries in order to produce unique challenges
towards ensuring their proper nutrition and that of their families, as well as their economic
advancement (McCall, 2005).

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Despite the difficulties of improving smallholder women’s health, doing so should
remain a priority of development. If they are able to prevent themselves from becoming ill and
have access to the proper resources for farming, they will also be able to provide for the
nutritional needs of themselves and their families. Additionally, when women control additional
income, they are more likely than men to spend it on caring for the nutritional, health, and
education needs of their children, thus improving the prospects of the next generation (FAO,
2011).
Improving primary care:
In order to provide effective primary care with finite funds in rural areas of developing
countries, especially in the areas of maternal-child health, there are several strategies that may be
employed. These include strengthening of the capacity of nurses and midwives (Koblinsky,
2004), integrating primary health care with rural development in order to address determinants of
health, and district planning and implementation of care (Ekman et. al., 2008). An advantage of
district planning is that when local government has greater authority, there are more
opportunities for the community to be involved in the design, implementation, and assessments
of interventions, especially for those who are socially excluded, such as women (Rosato et. al.,
2008). Examples of programs incorporating these principles include those implemented in rural
Malaysia and Sri Lanka (Pathmanathan et. al., 2003). These initiatives included primary health
care as part of a larger strategy of rural investment, which included infrastructure development in
the areas of transportation, sanitation, and education, as well as economic growth and poverty
alleviation. Care was provided in the areas of maternal, newborn, and child health, as well as
prevention of malaria and other communicable diseases. Midwives and public-health nurses took

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the role of delivering this care, and built partnerships with community leaders and traditional
birth attendants. This initial reliance on midwives and nurses as opposed to physicians enabled
the development of affordable primary health-care system. Citizens were also provided a forum
to join the planning process and hold leaders accountable for demonstrating progress
(Pathmanathan et. al., 2003). The results of these programs were that rural–urban and ethnic
inequities in health outcomes, especially in maternal and child mortality, were reduced, and
maternal mortality rates have been halved every 7–12 years in both countries. Midwives and
public-health nurses have also remained the backbone of rural health in both countries
(Pathmanathan et. al., 2003).
The aforementioned approach to providing primary care to women in rural areas of
developing countries encompasses several roles for nurses in the areas of practice, advocacy, and
policy. As the chief providers of care under these schemes, nurses have the opportunity to make
change for patients not just as practitioners, but as active members in the participatory change
process (Cohen & Reuter, 2007). These opportunities include building partnerships within the
community, joining in the design and assessment process of initiatives, and ensuring that the
most vulnerable members of the community are able participate in forums to voice their
concerns. By undertaking these actions, nurses are able to change broader power relations and
facilitate women’s agency by serving as both agents and subjects in the mutual empowerment
process (Frohlich & Potvin, 2010). At the policy level, nursing organizations have the
opportunity to join civic and non-governmental organizations, human rights organizations, and
women’s empowerment organizations to advocate for policy at the national and international
level (Ekman et. al., 2008). At the national level, nursing organizations can advocate for district

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planning approaches to primary care for rural women, as well as incorporating these initiatives
into larger strategies for rural development in order to address the social determinants of health.
At the international level, the ICN should work with national nursing organizations to lobby
donor countries for greater dedication of funds towards general budget and health sector support.
As it stands now, only 5% of aid is given as such, with the remainder delivered in the form of
separate requests for specific interventions with their own specified goals. These multiple inputs
breed inefficiency and disjointed care, as opposed to providing comprehensive, integrated
primary care (Ekman et. al., 2008).
Improving women’s livelihoods:
As the health of female smallholders in developing countries depends largely on their
livelihood, rural development programs including improved primary should also include
initiatives to improve their livelihoods. One of the most effective means of doing so is through
organization and support of collective groups such as producer organizations, community-
managed savings and credit groups, and enterprise/ marketing cooperatives. Through such
organizations, women are able to advocate for their shared needs, such as improved recognition
of land rights, access to better credit and extension services, and development of necessary
transportation and water infrastructure. In turn, they provide an effective means for larger
organizations to receive feedback on their assistance, as well as a reliable conduit for distributing
information. These groups also help women to achieve economies of scale and gives them
greater access to markets and bargaining power within them, as well as giving them opportunities
to share knowledge and pool finite resources (Tripathi et. al., 2012). Nurses are well placed to
work with other organizations providing support to such women’s groups within a framework of

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rural development including primary care (Ekman et. al. 2008). From a nursing theoretical
standpoint, these groups are also effective means of empowerment, as they operate under the
assumption that women understand their own needs and are able to enact change, and that
outside groups function as mutual change agents (Frohlich & Potvin, 2010).
In places where governments, universities, or NGOs may be interested in helping to
establish women’s agricultural groups, it is often helpful to seek out existing women’s groups
which are interested in becoming professional organizations and to provide whatever support
they may want in order to do so. This approach recognizes the bonds which women in
communities develop with each other and builds on that (Frohlich & Potvin, 2010). Such was the
case with the NutriBusiness Project, a collaboration between the University of Nairobi and 2,500
female farmers in the Rift Valley and Central Provinces of Kenya to establish cooperatives for
processing and selling their crops (Maretzki, 2007). Another example is the Nigerian
government’s Women in Agriculture (WIA) program, which sought to provide support for
existing women’s professional associations (Ogunlela & Mukhtar, 2009).
Women’s agricultural groups have proven effective at advocating for policies that address
their members’ needs. Through formation of the Zembaba Bee Products Development and
Marketing Cooperative Union, female beekeepers in Ethiopia have been able to lobby their
government for access to appropriate technology, as well as accessible and gender-sensitive
training in its use (Anand & Sisay, 2011). NGOMA is an organization for small-scale dairy and
maize farmers representing seven districts in Kenya’s Rift Valley, and part of their mandate
involves developing and advocating for policies at the international level in the areas of
agricultural trade and funding (Muia, 2011). Through the Women’s Land Rights in Southern

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Africa (WOLAR) Project in Malawi, rural women, men, and traditional leaders have been
sensitized on women’s rights and national land policies, and as of 2010, over 2,000 women
gained access to land (Kachika, 2009). Women-only agricultural groups are also working to
improve women’s positions in mixed-gender organizations by advising them on initiatives such
as the creation of gender sensitive by-laws (Anand & Sisay, 2011), establishing quotas and
targets for women in decision-making roles (Tripathi et. al., 2012), allowing non-household
heads and non-land owners to be group members, and timing meetings to accommodate women’s
workloads (Pandolfelli et. al., 2008).
Conclusion:
Though the unique social, health, and economic challenges facing female smallholders in
developing countries are great, the nursing profession has an obligation and ample opportunities
to address these social determinants of health. Nurses should advocate for participatory primary
care initiatives within rural development initiatives which also involve working with women’s
agricultural groups in order to achieve shared health and prosperity goals, and to effectively
empower them. Doing so would not only improve the health and economic well-being of these
women, but of their families, countries, and future generations.

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