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Beatrice Lorge Rogers and Nadia Youssef
Rogers and Youssef believe that nutrition programmes "need to recognize explicitly that nutritional problems often have their origins in social and economic systems, and that these problems can be solved only by bringing about changes in these systems, particularly at the household level. "
They state that social services are suffering from a shrinking of government resources in developing countries, and stress that women must draw on their own resources to better their nutritional and health statue
Their proposals promote not only more entrepreneurship for women but also organizations of women, including unions. They also discuss the development of co-operative child-care, which would help women to conserve some of their resources.
Rogers and Youssef assert that women's groups started for economic purposes can be successful forums for nutrition and health education, and they provide examples of groups that have carried out all of these functions.
The objectives of a sound nutrition programme need to go beyond the provision of health and nutrition services. Such programmes need to recognize explicitly that nutritional problems often have their origins in social and economic systems, and that these problems can be solved only by bringing about changes in these systems, particularly at the household level.
Although many nutrition-support programmes are designed at the national level, the effort necessary to improve the nutritional status of given target groups must occur, in the first place, at the local level, within a framework of collective self-reliance. Community self-reliance is becoming more important because of the negative impact that the current economic recession is having on the economies of developing countries.
Government resources are diminishing, and priorities for their allocation are changing accordingly.
Social services are suffering most: their extension towards the periphery has in many cases halted, and in others has even regressed. In this climate it is becoming increasingly clear that the success and permanence of programmes hinge on the willingness and capacity of communities to take an active role in initiating and sustaining activities. They must draw on their own resources, including skills, leadership, organizational structures, and communication networks.
If programmes are focused on health and nutrition, they must rely primarily on women because women have a central role in the health and nutrition of their children. Just as a woman's own health and nutritional status directly affect her child's health during pregnancy, at birth, and in the first years of life, her socioeconomic condition is a vital determinant of the food intake, health, and growth of her children.
In all cultures, women are providers of food as well as caretakers of children. They grow food or earn the money to buy it, they prepare it, and they mediate its distribution among household members. The capacity of women to generate income is often underutilized and even more often unrecognized, but there is some evidence that women in control of household resources demonstrate a preference for ensuring adequate food consumption above other goals. Thus, women's ability to create income and to control resource allocation directly affects the nutritional status of children throughout their growth.
A sound nutritional programme needs to be concerned with and support activities in the following three areas:
The purposes of this paper are to outline the major reasons why nutrition and health-care programmes should include a focus on income-generation for women, to describe some examples of women's groups started for economic purposes that were also successful forums for nutrition and health education, and to identify principle issues in designing and implementing such programmes, including accommodating child-care needs.
Economic programmes for women
Women's income-generating activities
The special health and nutritional needs of women during their childbearing years have been well documented . Pregnancy and lactation elevate the body's need for protein, calories, and micronutrients such as iron and calcium. Repeated pregnancies without adequate time and food intake for recovery jeopardize the health of the mother and any subsequent children. An adequate system of primary health care with referral to more specialized medical services is an important part of any nutrition programme. However, inadequate food intake and the heavy physical work burden of women are both most often related to poverty, so that the solution to these problems is economic.
In approaching the subject of economic activities related to maternal and child health, a distinction must be made from the outset between income-saving and income-producing activities. Income-saving activities represent unpaid work done by women at the household level (such as food production, processing, and conservation); income-producing activities yield cash earnings. Sound nutrition programmes must support the latter by promoting activities that are economically viable and that have a potential for being self-sustaining within a specified period of time. However, since women in many cases will have to continue to devote time to traditional income-saving activities, programme efforts should also be made to facilitate home-production tasks for women through the introduction of simple technology and time-saving devices.
Mobilizing women for economic activities is not only consistent with the goals of a development oriented nutrition programme; it must also be an integral part of the programme if the programme is to have a chance of long-term success. Income-earning activities can increase recognition of the value of women's work time. This awareness, in conjunction with the increased income available, should create a demand for the kinds of support services women need if they are to participate in the work force. Services, such as food-processing, water and firewood delivery, and the organization of child care, can also be the focal point for income-earning projects for an additional number of women. It is quite appropriate for programmes to provide credit for suitable technologies, such as hand or animal carts and mills as well as for the technical assistance needed to organize these services.
Economic activities may themselves be entry points for channels of communication and vehicles by which women can meet their needs . There are many cases in which women's groups, started for economic purposes, became effective vehicles for health and nutrition education, literacy training, and the provision of health care and social security benefits. The Self-Employed Women's Association (SEWA) in Ahmedabad, India-a trade union of over 20,000 women self-employed as cart pullers, junk smiths, garment or vegetable vendors-is one example. The Lijjat Pappad Co-operative in India provides similar benefits to its members.
Another example of an economic activity that led to the spread and acceptance of nutritional and health-care concepts was the Grameen Bank project in Bangladesh. This project trained women, generally those with a relatively high degree of schooling, to assist in organizing groups of women who had ideas for productive businesses, so that these would be reliable investments for the bank's funds. The example of women attending training programmes outside their homes and earning their own salary undoubtedly motivated participation by other village women in meetings to plan credit-worthy, income-generating projects. In these meetings, the group organizers also passed on ideas about sanitation, health care, family planning, and education for children, which they had learned at their own training sessions. The organizers reported a high level of acceptance of many of the new ideas. The fact that the organizers were offering economic opportunity undoubtedly contributed to the acceptance of their other ideas.
Nutrition and health activities in a primary-healthcare context can be developed so that they benefit the local economy. Services can be provided by local women who have been trained. These women will gain prestige from their position as well as the chance, in their work, to establish links among the other women in the community. Since these health workers will be technically trained, earning an income and operating outside the home, they can become important role models, reducing the level of disapproval of an active role for women. This process seems to have occurred in the Grameen Bank project in Bangladesh, where, traditionally, the respectability of women is often equated with the observance of purdah .
Given the high level of prestige that generally attaches to anyone in a village with a medical role, local health and nutrition workers could have an equally high level of credibility. Their training should be broader than simply nutrition or primary health care, however. They should be given some training in techniques of community organization as well, so that they can use the access which they have by virtue of their medical role to initiate a process of social change among women. On the basis of the experience of the Grameen Bank project, it seems that an effective way to ensure that messages are passed along is to make the training of the organizers an ongoing effort, with periodic training over the first year or more of the programme. In this way, the organizers' motivation is maintained, and they need not be overwhelmed with ideas and information all at one time.
Why the focus on women's income?
Both anecdotal and empirically researched evidence suggest that the income women earn is more likely to be spent on food and other basic household needs than is income earned by men and, thus, that it has a greater positive effect on children's nutritional status (see, e.g., refs. 4-6). This is undoubtedly explained at least in part by the fact that women in virtually all parts of the world have traditionally had major responsibility for feeding and caring for children. Further, women in developing countries generally join the work force as a result of severe financial necessity, so that their incomes must be devoted to survival needs. From these facts it follows that even more than an increase in household income per se, an increase in income earned by women is likely to improve the nutritional status of children. Moreover, there is a large proportion of households in which women are the sole or major economic providers as a result of factors such as family dissolution and migration. For these households, women's income is the main determinant of consumption.
Another reason to focus on women's income is that economically active women are more likely to be able to act on many of the ideas given in nutrition and health-education projects than are women whose activities are confined to the household sphere and to income-conservation rather than income-generation.
Finally, there is ample evidence that the expressed priority of women is for programmes that provide economic benefits rather than those that offer social services or the possibility of long-term development [2, 7]. Poor women are universally aware of their precarious economic situation and the need to have some income they control [6, 8, 9]. Thus, the opportunity to earn an income will be a greater initial incentive for women to change traditional patterns of behaviour than will be the less clearly perceptible benefits of improved home-management practices.
The importance of group action
The prime purpose of an economic programme should not only be to empower women economically as individuals. Although this approach may have direct health and nutritional benefits for individual families, it does not offer the potential for providing the social and economic benefits necessary for a community to achieve self-reliance. It is in the interest not only of the community but also of the women themselves to organize collectively for income-earning purposes. Co-operative action is expected to have the following effects.
The design and implementation of income-generation programmes
Several issues need to be taken into account in the design of income-generating activities for women.
Where women and men are located at different starting points in the economic system, it is not always possible to provide equal access to all activities based on ability rather than sex. Clearly, however, this is the long-term goal. In some social settings, then, special programmes for women are necessary to help bridge the existing gap in economic power between the sexes. Such programmes should, however, be linked to the mainstream economy. In this context, one important programme thrust might be to introduce and reinforce a positive bias in favour of women in economic programmes not primarily designed for them, to give them a better chance to perform. Where structural circumstances are more favourable, women should be encouraged to enter into mixed-sex enterprises.
Experience has shown in some cases that, without such a positive bias, women's participation in mixed sex economic enterprises is actually disadvantageous to women, for they are not always able to secure the benefits of production comparable to those of men or to gain equal control over the products of their labour .
Furthermore, women's subordinated status may be perpetuated in such projects since men tend to dominate the management and the decision-making process. An example is the Amul Dairy Project in Gujarat . On the other hand, women-specific programmes in the area of income generation have often been designed as welfare programmes and so have not been entrepreneurially oriented. These have failed to integrate women into the mainstream of the economy and the labour market and, in some instances, have intensified the poverty of their condition.
When enterprises are linked to mainstream development and are managed and staffed by women, the advantages can be manifold. Women secure the benefits of all improvements for themselves; they are in control of their labour and are more likely to control their incomes. They can arrange for training programmes to upgrade their managerial and technical skills when needed, as in the case of the Cattle Project in Kangwong, Korea [ 10], and the Working Women's Forum in Madras, India .
Most important, women-only enterprises enable women to structure the work environment so as to meet their family responsibilities through flexible hours, short shifts, and the possibility of temporarily doing work at or close to the home in order to permit breast feeding. The all-women's Lijjat Pappad Cooperative in India illustrates the feasibility of this approach . There, apprentice rollers of dough have been moved gradually to positions of financial management through training and under a production system organized to maintain physical mobility and time flexibility.
It should not be overlooked that there are examples of successful mixed-sex co-operatives, as in Ethiopia, where the problem of combining work and child care has been solved by setting up child-care facilities managed by women members and assigning women working points for time taken off from work for mothering and nurturing activities (G. Fazzi, personal communication).
Economic activities outside the home
Nutrition programmes should favour economic activities that require some degree of centralization and group production, as distinct from cottage-based industries carried out in the home intermittently as household and childcare tasks permit. There are several reasons for this preference.
Economic activities outside the home provide greater chances than cottage-based industries for women to (a) become visible as workers, (b) perceive and identify themselves as economic beings, (c) become organized. (d) engage in production activities more closely linked to the mainstream economy, (e) receive pay or wages directly and control their earnings, and (f) benefit from productivity-enhancing technology. The fact that activities outside the house often entail the purchase of services and goods to replace women's household work may be seen in a number of cases as a modest but definite step out of the stagnating rural economy. The purchase of services traditionally performed by women at no (visible) cost may also contribute to the social recognition of the economic value of these tasks.
Cottage-based activities, particularly those traditionally performed by women, are often laborious and have low productivity and economic value. They take place outside the mainstream of the national economy and tend to perpetuate the economic marginality of women. Furthermore, they do not encourage the introduction of productivity-enhancing technology for women. As an example, the Dastabar Anjum Association of wool handloom weavers in Jammu and Kashmir introduced improved looms for use by male weavers but did not introduce new technologies for the preweaving processes performed by women. In the same association, payment is channelled through the male head of household regardless of who does the work, so that women do not receive payment directly for their contribution .
These disadvantages of home-based work have been recognized, yet policies continue to promote women's involvement in cottage-based activities on the assumption that these are least threatening both to cultural mores and to the welfare of children. The idea that women's work outside the home is bound to violate cultural norms bears further examination. First, not all societies are characterized by the same cultural constraints, nor is the life of women traditionally confined to the home in all settings and social strata. Conditions in many African and Latin American societies, for example, differ greatly from those in South Asia and the Middle East. And within each of these regions, the influence of differences in economic class on expected behaviour among women is considerable. Second, cultural prescriptions regarding job appropriateness for each sex are not immovable. Examples from Bangladesh, Brazil, Colombia, Nigeria, and Yemen illustrate the fact that traditional customs governing women's behaviour break down when economic pressures are severe  and once the benefits to the household are recognized.
It is also not at all clear that women's work for pay outside the home poses a greater threat to child welfare than women's current activities. There are numerous examples of ways in which the working environment of women can be structured to accommodate child care through the provision of on-site or nearby child care, flexible working hours for mothers, and other means. Moreover, many traditional, unpaid women's activities are not well suited to child care. Examples include cooking at an open hearth, walking long distances carrying water or firewood, and working in flooded rice fields. Thus, compatibility with child care should be a concern of economic projects for women but should not be an excuse for failing to develop such projects.
Building on existing skills and initiating new activities
Market demand and the potential productivity of traditional skills should determine whether an economic project should build on the prevailing male-female division of labour and on traditional women's skills and interests or should introduce new economic activities to women. Unfortunately, many people ask, "What can women do?" when they should ask, "What activities are economically viable?"
The advantage of building on existing skills and abilities is that women can be more rapidly channelled into production without much more training. There are many cases where traditional skills can be used in the larger economy. For example, women's involvement in food production (farming), processing (such as grain pounding), and preparation can be turned to economic use through the sale of crops, prepared food, or services. Often what is needed is simply the development of markets, not new activities. *
However, there are many cases in which women's customary tasks and handcrafts do not have significant income-earning potential, and many successful women's undertakings have been in non-traditional areas. These may have the advantage that they are not associated with traditional women's roles and ways of doing things. They may generate more interest and enthusiasm as well as having the potential for being more productive for the participants. Also, the introduction of productivity-enhancing technology that may modify some of the traditional skills should certainly be encouraged. For example, mechanized grain-processing, the use of carts to transport water and firewood, the use of high-yielding seeds, and modern agricultural inputs can significantly improve the income-generating potential of these tasks. If these are introduced in the context of a women's co-operative, then the risk that these innovations will shift the task to the male domain is diminished. Of course, the two options are not mutually exclusive. Probably the procedure that best minimizes delay is to start organizing on the basis of existing skills if they are marketable and then to develop technical innovations and training programmes in new areas.
Technical assistance in production techniques and entrepreneurial development may be required to transfer an activity from home to market. Some form of credit may also be necessary for technological and other investments. In most cases, credit as well as technical assistance in training, production techniques, and entrepreneurial development should be provided in the project design. The focus of technical assistance should always be on teaching women to take responsibility for their own enterprise, not on performing some of the tasks for them. Also, the feasibility of introducing appropriate technological improvements to facilitate and speed up household chores (e.g., grinders, better stoves, better food-and-water containers, and hand carts) should always be considered to free some of the women's time for economic activities as well as for traditional mothering.
Building on women's organizations
Building on women's groups, particularly those at the local level, is important not only because these organizations help to defend women's interests but also because they can help make women's work and economic contributions visible. These organizations symbolize women's efforts to improve their status independently of men and in collaboration with one another .
The motivation for the formation of women's organizations is as varied as the settings in which they operate. Some groups of women have organized themselves to raise a small amount of capital to initiate an economic activity. Examples include the Collective Women's Garden Group in southern Senegal, a successful venture in the collective production and marketing of vegetables, which was begun with an initial capitalization as low as US$2.50; the Lijjat Pappad enterprise in India, started by seven housewives with a capital of 80 rupees, presently a massive business, marketing its products all over the world ; the Markala Co-operative in Mali , which makes soap and hand-dyed cloth and began with a membership fee of 100 Mali francs (US$0.25) per person.
In other cases, poor women workers have organized themselves into unions to protect their special needs and interests as women and as workers. The formation of SEWA in Ahmedabad and of the Working Women's Forum in Madras (which has brought thousands of poor urban women who are small-scale traders and vendors together around the issue of credit) exemplify this movement .
Organized activities for economic purposes have also been initiated with the help of traditional savings associations already in existence in the community. Among those most successful in meeting poor women's specific credit needs are the susu groups in Kenya, the arisan system in West Java, the njanji credit association in west Cameroon, and the otu-otu contribution clubs in western Nigeria .
In other cases, the development of mixed-sex credit co-operatives by larger public or private organizations has created the incentive for women to organize. This was the case for the Grameen Bank project, which offers low-interest loans to the landless as an encouragement to become organized and develop credit-worthy, income-earning activities . To date, 51,000 landless women have benefited from the credit, with a 99.5% rate of return payments. Other examples include the small-business component sponsored by the Programa Integral de Desarrollo Comunal (PRIDCO) in El Salvador, which provides a revolving line of credit to small-scale entrepreneurs (85% of the borrowers are women), and the Nicaragua Foundation for Development (FUNDE) project directed at encouraging market women to form cooperatives through the extension of credit granted until each co-operative becomes self-sufficient .
Experience has shown that, if there are clearly perceived benefits to group organization, women will be motivated to join, even if they have not done so before, and despite cultural constraints. In settings where local self-help groups do not exist, individuals from the community who are more educated and occupy respected jobs, such as schoolteachers and health workers, can be motivated to serve as initial organizers. Such was the case in the Grameen Bank project, the SEWA trade union, and the Working Women's Forum, among others. The method of organizing women is not so critical as the principals behind such organization: the economic empowerment of women and the fostering of confidence and a sense of self-reliance. Poor women need to feel that they can operate independently in the larger community and can find their own solutions to their problems and those of their families.
Organizing women around economic interests, valuable in its own right, is also one stage in a larger strategy for social change. This strategy expands from addressing economic needs to tackling selected and often more complex social problems of the community. Experience shows that many of the women's groups organized around economic incentives soon develop social support services, such as child care, pre-school education, health centres, and in some cases even roads and maternity centres, resulting in improved well-being, notably in the area of health and nutrition.
Accommodating child-care needs: The support system
Throughout the world, women have primary responsibility for the care of their young children. Therefore, a legitimate concern of programmes aimed at increasing the economic participation of women is that the new economic activities not jeopardize children's well-being by displacing child care. Great stress has been placed on the nutritional importance of breast-feeding infants, which can only be done by the mother. It is now increasingly being recognized that timely supplementation with weaning foods and adequate feeding during the weaning period are at least as critical as breast-feeding to child health and growth. Frequent feeding is essential during this period, since small children have a limited capacity to consume food at any one time. This means that the mother or other caretaker needs to spend time feeding the child at intervals throughout the day.
Against this background, it must be recognized that many of women's traditional tasks, even in the absence of an economic programme, are in conflict with the need to breast-feed, carefully wean, or supervise infants and young children. Farming activities of women often involve arduous labour. For example, rice cultivation in large part occurs in fields distant from home, and much of it takes place when the fields are knee-deep in water. In eastern Thailand it is common for women to fill their infant's stomachs with bulky glutinous rice to keep them from feeling hungry and to leave them in the village all day during the transplanting season, while the women go to the fields (Rogers, personal observation). The carrying of fuelwood and water may require women to travel long distances on foot each way, and their burdens make it difficult for them to carry their infants as well. Women traders often bring their infants with them to the market, which may make it possible for them to breast-feed. However, for older infants and toddlers, the market environment is often dangerous and unsanitary, and the women engaged in selling may not be able to give them close attention or supervision.
Over time, women in poverty have developed strategies that allow them to be productive and at the same time to cope with the demands of childbearing and child care. Searching to balance the demands on their time in a way that maximizes the well-being of children is becoming more difficult because of the decline in traditional sources of support, such as kin groups or neighbourhood and community networks. The burden of the solution is increasingly placed on the nuclear family, most particularly on the working mother. Many of the coping strategies adopted by the poor have serious drawbacks; they include reducing women's sleep and rest to a minimum, dependence on child labour, delegation of home production and nurturing responsibilities to young kin or non-kin, changing household size and composition to ensure child care (including adopting an older child), choosing time flexibility at work at the cost of earnings, and reliance on transfers of income, goods, and services from neighbourhood-based social networks .
Clearly, there is a degree of conflict between mothers' activities away from home and infant and child feeding and care for most active women, even in rural, traditional societies. Such conflict increases with the changing of the family structure from extended to nuclear and with the involvement of women in work outside the home in mixed-sex enterprises that are often insensitive to their needs. One advantage of introducing economic activities in the context of nutrition or economic programmes is that provisions to ensure adequate child care can be built into projects, either by allowing for flexibility in the mother's own work schedule or by concurrently organizing some kind of child-care service. An appropriate objective for a nutrition programme would be to assist in reducing the conflict between work and child care in existing organizations that employ women. Without suggesting that child-care services could be, or even need to be, provided through elaborate, formal day-care centres, a programme might even improve the quality of children's care by means of nutrition and health education and by providing other technical assistance to women who want to provide this service. Immunization and other forms of health supervision could be included in the services offered. Ideally, women's economic and social participation can be increased while, at the same time, the attention to children's needs is improved.
The existence of this important conflict between mothers' work and child care reveals an aspect of maternity often ignored. Mothering is not an instinctive task; it has to be learned. It is also a task that often, in traditional societies, involves persons other than the mother in advisory or supporting roles . In other words, mothering, including breast-feeding, requires a support system under all circumstances, not only when women work outside the home.
As society changes, the traditional support system becomes less available and less relevant and has to be replaced by other forms of support. As the society becomes more sophisticated and industrially more advanced, the support system tends to become more formal and more group-oriented. The creation, preservation, and strengthening of a support system should, therefore, be a focus of activities intended to assist working women in meeting their responsibilities as mothers. In rural societies where a traditional support system still survives, priority should go to encouraging its retention and to improving its quality by introducing health and nutrition education, providing support and training for caretakers, and perhaps providing a clean, safe location for child care. These are appropriate support activities for a nutrition programme whose main focus is the development of income-earning opportunities for women.
For the breast-feeding mother engaged in activities outside the home, the following alternatives exist, at least in the abstract if not in reality:
It is traditional in much of the developing world for a mother to carry her child with her at all times, at least for the first months of the child's life. Together with positive aspects, this practice also has negative ones. The latter include high temperature and humidity of the baby's micro-environment and exposure of the baby's head to the sun during work in the field. Carrying a child also limits a mother's productivity.
Flexible hours are the preferred alternative in many women's projects. In some, child care is organized at the work place, and, therefore, flexible hours are combined with on-site child care. For example, some of the agricultural cooperatives of the Green Zones in Mozambique and Ethiopia combine flexible working hours with child care on the spot. Arrangements for the latter are simple and affordable. Since the number of co-operative members is high, work can continue with a sustained rhythm, and co-operative earnings are not reduced by the movement of mothers (G. Fazzi, personal communication, 1982). On-site child care seems to be more appropriate for industrial situations with mixed-sex staffing in urban settings, provided that transportation to the workplace is not too difficult for mother and child.
Whatever the circumstances, the solution should be relevant to the social and physical environment of the family and the community. In this connection, programme planners should explore the various coping strategies adopted spontaneously by working mothers and should single out areas where improvement and programme support may be needed.
Programme support in this connection may consist of capital investment, equipment, and managerial inputs. Group day-care should also include health measures, such as immunizations to avoid the spread of disease, and health supervision. For weaning children, a weaning food may be left by mothers or may be produced by the care-taker or the community. Aspects required in most if not all cases, however, are training of care-takers and health and nutrition education of mothers.
Summary of options for programme action
The specific type of income-earning activity to be supported will depend on area-specific circumstances. Certain criteria, however, need to be applied to ensure appropriate project selection. Some of these are listed below, with the understanding that not all need to be present in every project. One may say that preference in support is to be given to projects which:
As a broad guideline for the selection of sources for income and work for women the following are some factors to be considered :
Forms of support
Nutrition programmes can provide support to selected economic projects for women by:
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