Attention to the needs of women and girls in WASH: An analysis of WASH policies in selected sub-Saharan African countries

ABSTRACT

There has been a push for understanding gendered violence in WASH in recent times. Attention is therefore shifting to how these issues are conceptualised, considering their embeddedness in context. One step primarily is to understand how existing policies in WASH acknowledge the needs of women and girls in WASH. In doing this, we conducted a summative content analysis of selected policy documents on WASH: five at the international level and five each from Ghana, Uganda and Kenya. Findings suggest that existing policies inadequately acknowledge WASH related gender-based violence and pay little attention to the complex ways gender and WASH relations are intimately connected. Generally, a holistic policy approach for addressing gender-based violence in WASH is needed. The paper recommends a system policy approach to address the unique needs of women and girls in WASH in sub-Saharan Africa.

KEYWORDS:

• WASH
• policy
• gender-based violence
• menstrual hygiene
• and sub-Saharan Africa

1. Introduction

The global aspirations for universal Water, Sanitation, and Hygeiene (WASH) coverage are collectively captured in the Sustainable Development Goal (SDG) 6 – clean water and sanitation for all (2015–2030). While tremendous progress has been made in WASH coverage (WHO & UNICEF, 2021), the progress is uneven and significant disparities exist between regions and even within countries. For instance, in 2020, about 30% of the people in sub-Saharan Africa (SSA) had access to safely managed drinking water compared to 96% in Europe and Northern America. Even within SSA, national coverage varied from 6% in Chad to about 94% in Reunion (WHO & UNICEF, 2021). A wide stream of research has associated these disparities to structural and institutional failures (Bisung & Elliott, 2016; Nunbogu & Elliott, 2022), gender inequalities in WASH (Adams et al., 2022; Bisung & Dickin, 2019; Datta & Ahmed, 2020; Nunbogu et al., 2023), environment (Dos Santos et al., 2017), socio-cultural norms and practices (Adams et al., 2022; Dery, 2021) among others. This stream of work has enhanced our understanding of WASH access that acknowledges both the material and social dimensions of access and has also triggered a deeper reflection on the social, cultural, and institutional processes that interact to shape WASH access, use and control in place.

A substantial emerging literature documents how the lack of and inequalities in WASH access (re)inforces women and girls’ exposure to gender-based violence (GBV) in low- and middle-income countries (Nunbogu et al., 2023; Nunbogu & Elliott, 2022; Sommer et al., 2015; Tallman et al., 2023). Nunbogu and Elliott (2022) conceptualised GBV in WASH into four dimensions including structural, physical, psychosocial, and sexual violence. These dimensions of GBV are mutually reinforcing and are shaped by social interactions across multiple scales (Nunbogu & Elliott, 2022). For example, structural violence – which describes the various ways political and institutional processes determine who gets access to WASH, at what time and price – exposes women and girls to other forms of violence (Datta & Ahmed, 2020; Nunbogu et al., 2023; Pommells et al., 2018). The lack of menstrual towels, safe space for changing menstrual towels and the unavailability of water and soap for safe menstrual hygiene management by women and girls resulted in sexual and psychosocial violence (Jewitt & Ryley, 2014; Onyango & Elliott, 2020). Distance to WASH facilities and services also exposes women and girls to multiple risks of GBV (Adams et al., 2022; Kulkarni et al., 2017; Pommells et al., 2018). WASH insecurity constraints women’s engagement in economic activities (Bisung & Elliott, 2016; Wutich, 2009) and also hinders girls’ educational engagement and attainment (Jewitt & Ryley, 2014; Lahme et al., 2018). Despite the disproportionate impacts, women and girls often have less say in WASH governance (Adams et al., 2018).

To address these challenges, SDG target 6.2 emphasises policy attention to the special needs of women and girls in WASH. WASH policy approaches on the needs of women and girls have considerably evolved over the years (Sweetman & Medland, 2017). Recent reviews have explored WASH and gender (Sweetman & Medland, 2017), women empowerment in WASH (Caruso et al., 2022; Dery et al., 2020) and gender equality and social inclusion in WASH (Macura et al., 2023). In essence, these studies provided compelling highlights on the progress of women and girls’ empowerment in WASH. However, there is a paucity of empirical evidence on policies that protect women and girls from violence in WASH. Therefore, our aim in this paper is to examine the extent to which policies on WASH at the international level and in selected countries in sub-Saharan Africa: Ghana, Kenya, and Uganda explicitly focus on women and girls’ experiences of GBV when meeting their WASH needs. In doing this, we conducted a summative content analysis (Hsieh & Shannon, 2005; Wiese et al., 2012) to measure whether these policy documents acknowledge (i.e. actual mention or not) the needs of women and girls in relation to their WASH access.

2. Research context: Overview of WASH in Ghana, Kenya and Uganda

Despite the progress made in WASH access across world regions, populations in SSA still have the lowest access to safely managed water and sanitation and improved hygiene globally (WHO & UNICEF, 2021). Research has also noted that socio-cultural and political factors are major determinants of WASH access in SSA (Adams et al., 2022; Dery, 2021; Ngben & Yakubu, 2023; Nunbogu et al., 2019, 2023; Tutu & Stoler, 2016). For a broader understanding of these dynamics, our study focused on three countries – Ghana in West Africa and Kenya and Uganda in East Africa. The choice of these countries was informed by three main reasons: (1) despite the increase in WASH coverage over the years, these countries still have over 50% of their populations lacking access to safely managed WASH (WHO & UNICEF, 2021), (2) structural and socio-cultural norms are major determinants of WASH access, use and control in these countries (Bisung & Elliott, 2016; Nunbogu et al., 2023), and (3) the ease of accessing documents and the existence of research partners, particularly in Kenya and Uganda also played a part in selecting these countries. Documents were easy to access on WASH-related policies for the purpose of the content analysis on the websites of ministries responsible for WASH. At the time of this study, the staffs of developmental organisations were working remotely due to the Covid-19 lockdowns in SSA. It would have been difficult to recruit participants for this research. However, our research partners in these countries facilitated the recruitment of participants for the second phase of the study.

Ghana is one of the countries in sub-Saharan Africa with increasing inequalities in WASH access. In 2021, the Joint Monitoring Programme (WHO & UNICEF, 2021) reported that 87% of households in the country lacked access to safely managed sanitation, whilst 59% are without access to safely managed water. About 51.5% of households lack handwashing facility with soap and water (Ghana Statistical Service [GSS], 2018). There are significant spatial disparities regarding WASH access across the regions in Ghana. For example, the Upper East Region which is one of the deprived regions in the country has 66% of households practicing open defecation compared to 6.8% in Eastern region (GSS, 2018). Furthermore, compared to national average of 77%, about 91.7% of households in Northern region do not have drinking water on premises and more than 35% of water collectors in this region spend over one hour collecting water per day (Dongzagla et al., 2020; GSS, 2018). Ghana is a patriarchal society and women and girls are primarily responsible for water collection in most households (Dery, 2021; GSS, 2018; Nunbogu et al., 2023). Inequalities in WASH access and the institutionalisation of water rationing and pricing (Fielmua & Dongzagla, 2020; Jambadu et al., 2022) reinforce women and girls’ vulnerabilities to GBV (Nunbogu et al., 2023).

In Kenya, about 38% of households lack basic access to water and about 67% of households do not have basic sanitation access (WHO & UNICEF, 2021). About 73% households lacked access to basic hygiene in Kenya whilst 40% of households are without hand washing facility at home in 2020 (WHO & UNICEF, 2021). As in other SSA countries, rural and urban disparities exist in WASH access. For example, 87% of households in rural Kenya lack access to basic drinking water compared to 52 in urban areas. Like Ghana, inequalities in WASH access coupled with socio-cultural norms in household WASH provision and management have created spaces of GBV in Kenya (Nunbogu & Elliott, 2022). For instance, Winter and Barchi (2016) analysis of the 2008–2009 Kenyan Demographic Health Survey (DHS) data revealed that women who practiced open defecation had 40% more likely of experiencing sexual and physical violence compared to women who did not practice open defecation.

Despite Uganda’s remarkable progress in WASH coverage, about 83% of the population still lacked safely managed water and 80% are without basic sanitation in 2020 (WHO & UNICEF, 2021). About 92% of the population without safely managed water are in rural communities and 57% reside in urban areas. According to the Joint Monitoring Programme (WHO & UNICEF, 2021), only 23% of the population in Uganda had access to basic hygiene facilities and about 45% of the population had no hand washing facilities at home in 2020. Data from a survey by the Ugandan Bureau of Statistics (UBOS) indicate that about 95% women have been victims of violence before the age 15 years (UBOS, 2016). The survey also acknowledges that, though the Government of Uganda has measures in place to address gender-based violence, certain cultural norms and practices were impeding the fight against GBV. Research works have also reported cases of GBV during periods of WASH insecurity. For example, Cooper-Vince et al. (2018) observed that women in water insecurity hotspots are at 70% greater risk of depression than men in rural Uganda. Similarly, Pommells et al. (2018) reported Ugandan women and girls’ experiences of sexual and physical violence when meeting their WASH needs.

3. Research design and methods

Content analysis was used as the primary method for the study. Content analysis is a means of exploring human experiences by analysing textual data in documents (Erlingsson & Brysiewicz, 2017). Documents were selected from international developmental organisations and national policy documents based on an inclusion and exclusion criteria. The search was limited to documents that focused on WASH, menstrual health management and women and girls’ experiences of GBV when meeting their WASH needs. At the international level, we focused on agencies such as United Nations Children Fund (UNICEF) and UN water since they are the leading agencies on the international stage promoting the drive to achieve universal WASH coverage. Desktop searches of key phrases and words like ‘water’, ‘gender-based violence’, ‘gender’, ‘women’, ‘non-governmental organizations and WASH’, ‘WASH’, ‘hygiene’, and ‘sanitation’ was carried out on the websites of UN-Water and UNICEF. At the national level, WASH policy documents in the study countries (i.e. Ghana, Kenya and Uganda) were selected based on searches of ministries tasked with WASH policy implementation. The electronic search for this level was limited to policy documents from 1990 to 2021. This time frame was selected to cover a range of national policy documents. Table 1 highlights the documents that were reviewed for the study.

Table 1. Documents reviewed in this analysis.

Document title	Author	Scale	Type	Year	No. of pages
International
Eliminating discrimination and inequalities in access to water and sanitation	UN Water	Global	Policy	2015	56
UN Water 2030 Strategy	UN Water	Global	Strategy	2019	36
Guidance for Monitoring Menstrual Hygiene and Health	UNICEF	Global	Guidance	2020	130
Strategy for Water, Sanitation and Hygiene 2016–2030	UNICEF	Global	Strategy	2016	75
The Sustainable Development Goal 6 Global Acceleration Framework	UN-Water	Global	Framework	2020	18
Ghana
National Gender Policy	Ministry of Gender, Children and Social Protection	National	Policy	2015	84
National Water Policy	Ministry of Water Resources, Works, and Housing	National	Policy	2007	72
Environmental Sanitation Policy	Ministry of Local Government and Rural Development	National	Policy	2009	41
National Community Water and Sanitation Strategy	Community Water and Sanitation Agency	National	Strategy	2014	66
National Strategy for Community Participation in Management of Urban WASH Services	Ministry of Water Resources, Works, and Housing and Ministry of Local Government and Rural Development	National	Strategy	2012	48
Kenya
National Policy on Gender and Development	Ministry of Public Service, Youth and Gender	National	Policy	2019	62
Strategic Water Plan	Ministry of Water and Sanitation, Kenya	National	Plan	2018	85
Environmental Sanitation and Hygiene Policy	Ministry of Health	National	Policy	2016	134
Framework for monitoring the realisation of the rights to water and sanitation in Kenya	Kenyan Commission on Human Rights	National	Framework	2017	45
Menstrual Hygiene Management Policy	Ministry of Health	National	Policy	2019	42
Uganda
Water and Sanitation Gender Strategy	Ministry of Water and Environment	National	Strategy	2018	87
National Water Policy	Ministry of Water, Lands and Environment	National	Policy	1999	36
Sanitation Policy for Uganda	National Sanitation Taskforce	National	Policy	1997	20
Vulnerable and marginalised groups framework (VMGF) for Uganda	Ministry of Water and Environment	National	Framework	2020	178
Environment and Social safeguards Policy	Ministry of Water and Environment	National	Policy	2018	16

A summative content analysis approach was adopted. This gives a broader understanding of how words are used and within what context (Hsieh & Shannon, 2005; Wiese et al., 2012). After reading the selected documents thoroughly, preliminary analytic codes were developed based on the emerging issues from the documents. This is a process called open coding (Neuman, 2014). The second process involved axial coding which involves a second look at the data to organise code labels for themes. In axial coding, Neuman (2014) recommends that categories or concepts that are similar be grouped into themes. Collectively, we used eleven codes to guide our framing of how policy documents capture WASH-gender-based violence. Specifically, we discussed these using four themes including: (1) distance to WASH facilities, (2) women in WASH governance, and (3) menstrual hygiene management. Though these three themes broadly reflect issues of GBV in WASH (see Nunbogu & Elliott, 2022), we added a fourth theme – gender-based violence to cater for the difference in how GBV is conceptualised in WASH over the years. Initial coding was done by the main researcher, after which another round of coding was done by another researcher. Intercoder reliability test yielded an inter-rater reliability kappa statistic of 0.87, a high inter-rater agreement. Content analysis was done using NVIVO 12.

4. Results

4.1. International policy documents

4.1.1. UN Water 2030 Strategy

In planning to meet the long-term WASH needs of SDG 6, UN-Water sets long-term targets in collaboration with other WASH sector partners (UN Water, 2020). A vital example of this is the UN-Water 2030 Strategy, published in 2020. It acknowledges the right to safe drinking water and sanitation for all and makes reference to the ease of access to water and sanitation fifteen 15 times, respectively (Table 2). The publication also focuses on the role UN-Water will play in advancing global WASH targets. While this is laudable, no mention is made of the need to address the negative experiences of women and girls in WASH access, be it violence or indignity experienced in practicing menstrual health (Table 2). Additionally, no reference is made to the influential role women and girls play in WASH management and the need to include them in WASH governance at all levels (Table 2).

Table 2. Representation of WASH and GBV in international policy documents.

Code	Description of code	Documents (International) (no. of mentions for each code)
		UN-Water 2030 Strategy (2019)	Guidance for Monitoring Menstrual Health Hygiene (2020)	The Sustainable Development Goal 6 Global Acceleration Framework (2020)	Eliminating Discrimination and Inequalities in access to water and sanitation (2015)	Strategy for Water, Sanitation and Hygiene 2016–2030 (2016)	Total
Water	Access to or availability of safe water/ challenges to safe water sources	15	1	1	77	38	132
Sanitation	Ease of access to facilities for safe disposal of human waste/ challenges of waste disposal	15	4	1	74	41	135
Hygiene	Ease of access to handwashing facilities with soap, ash, or acceptable medium and its practice	2	5	3	5	25	40
Women, girls, and WASH	Challenges faced by women and girls in WASH	N/A	1	N/A	15	12	28
WASH, women, girls, and distance	The challenges encountered by women in girls in accessing WASH because of walking long distances on an individual, family, and community level.	N/A	N/A	N/A	N/A	N/A	0
Women and WASH governance	The involvement of women in making decisions or maintenance of WASH facilities at the community or national level.	N/A	N/A	3	11	5	19
Menstrual hygiene/health management (MHM)	MHM is the ability of women and girls to have ease of access to all materials (clean water, clean material to serve as sanitary pads) and information to manage menstrual blood and maintain hygiene.	N/A	43	N/A	10	9	62
MHM, women, and girls	The challenges faced by women and girls in managing MHM in an environment of safety, privacy, and dignity.	N/A	26	N/A	13	6	45
Gender-based violence (GBV)	Any act or omission that results in psychological, physical, or sexual harm associated with expectations based on gender largely due to unequal power relations in society	N/A	1	N/A	1	2	4
GBV, WASH, women, and girls	Violence faced by women and girls in WASH access	N/A	15	N/A	8	4	27
GBV, WASH, distance, women, and girls	Violence faced by women and girls in WASH access because of distance travelled	N/A	1	N/A	1	4	6

4.1.2. Guidance for monitoring menstrual health hygiene

The guidance for menstrual health and hygiene was published by UNICEF in 2020. MHM involves a wide range of facilities including water, soap, and materials to absorb menstrual blood, all required by women and girls to manage their menstrual periods in a manner of dignity devoid of fear, discomfort, or violence (Phillips-Howard et al., 2016; Sommer et al., 2015; UNICEF, 2020). Menstrual health and hygiene (MHH) encompass both MHM and other factors that associate menstruation with wellbeing, health, rights, education, and gender equality (Sommer et al., 2015; UNICEF, 2020). The document aims to support monitoring of MHM, to recommend essential guides and ethical considerations to include in monitoring menstrual health practices and safeguards (UNICEF, 2020). The document is not a prescriptive one but instead puts forth practical suggestions that countries should adopt and implement based on case-specific scenarios (UNICEF, 2020). It stresses in detail the need for women and girls to have access to information and services to menstrual health in an environment of dignity with forty-three (43) references (Table 2). Also, the challenges faced by women and girls in managing menstrual health are referenced twenty-six (26) times (Table 2). The Guidance highlights that women and girls can face violence in WASH was referenced fifteen (15) times because of cultural norms surrounding menstruation (Table 2). However, no reference is made to women in WASH governance (Table 2). The document also references water and sanitation once and four times, respectively (Table 2). The low number of references raises doubts about attention paid to water and sanitation in MHM. The distance from households to water sources and sanitary facilities is also not referenced in the document even though it is worth noting that the greater the distance between the home and any of these services, the greater the probability for violence (Pommells et al., 2018).

4.1.3. The sustainable development goal 6 global acceleration framework

In a bid to accelerate the achievement of SDG 6 targets, the United Nations and UN-Water, developed the Sustainable Development Goal (SDG) 6 Global Acceleration Framework to increase action to meet this SDG by 2030. In the document, neither menstrual hygiene management nor the challenges of MHM are referenced (Table 2). Additionally, challenges women and girls face in accessing WASH such as distance barriers or structural issues, are not acknowledged (Table 2). No reference is made to the problem of GBV in WASH access (Table 2). This is quite surprising because SDG 6 calls for attention to be paid to the needs of women and girls in WASH. Only three (3) references are made to women and WASH governance (Table 2).

4.1.4. Eliminating discrimination and inequalities in access to water and sanitation

In this document, the UN-Water appears to recognise existing discriminatory patterns in WASH (UN Water, 2015). Discrimination in WASH can be based on gender, race, religion, colour, or social origin. Ease of access or challenges to safe water is highlighted seventy-seven (77) times, while ease of access or challenges to sanitation facilities is referenced seventy-four (74) times (Table 2). This, in the long run, enables us to understand how much importance is placed on eliminating discrimination in WASH access by UN-Water. Going further, the policy references the participation of women and girls in WASH governance eleven (11) times (Table 2). This is encouraging because when a platform is created for women and girls to contribute to WASH governance, the complex challenges they encounter will be highlighted and ultimately addressed. The document also makes fifteen (15) references to the challenges women and girls face in WASH access. The ability of women and girls to have ease of access to materials, facilities, and information to manage menstrual blood and maintain personal hygiene is also referenced ten (10) times (Table 2). Most importantly, GBV in WASH is referenced eight (8) times while GBV experienced because of distance travelled by women and girls to access WASH is acknowledged once (Table 2). By referencing these challenges, policy makers and other stakeholders in the WASH sector can carefully re-examine their own local context to see if these challenges exist in their communities and work to address them.

4.1.5. Strategy for water, sanitation, and hygiene

The Strategy is a guide for UNICEF's efforts to advance child rights to WASH in a world that is changing rapidly. The Strategy is a comprehensive document analysed because it references ten (10) out of eleven (11) codes used in the analysis (Table 2). Apart from references to WASH, distance, women, and girls, all other codes are referenced (Table 2). For example, ease of access or challenges to safe water is highlighted thirty-eight (38) times, while ease of access or challenges to sanitation facilities is referenced forty-one (41) times (Table 2). Additionally, ease of access or challenges to handwashing facilities is highlighted twenty-five (25) (Table 2). It is worth noting that the strategy emphasises integrating the different components (water, sanitation, and hygiene) to achieve holistic results rather than treating each component separately. Also, acknowledging the challenges of women and girls in MHM (6) (Table 2) is a step in the right direction in addressing such challenges. Noteworthy is that GBV in accessing WASH is referenced eight (8) times while GBV resulting from distance to WASH facilities is acknowledged once, with five (5) acknowledgements for women in WASH governance (Table 2). The strategy promotes commitment to continue learning emerging challenges from the WASH sector hindering access for women and girls, doing better by leveraging public and private financing, and moving in the right direction to meet the needs of all.

In sum, the WASH needs of women and girls are fairly addressed based on the findings from the documents reviewed. However, they do not advocate for policies to be put in place to protect women and girls from violence in WASH. Nonetheless, the effort to highlight the challenges of women and girls in WASH at the international level has the potential to trickle down to the national level across SSA. A global focus on challenges of women and girls in WASH can form the basis for actors in the WASH sector to recommend change to conform with international standards.

4.2. Findings from national policy documents

4.2.1. Ghana policy documents

Several sector policy documents guide the direction of the Government of Ghana in fulfilling its mandate to ensure access to water, sanitation, and hygiene for all (see Table 3). The National Gender Policy of Ghana (2015) is the country's guide to promoting the rights of women and girls. It emphasises women and girls empowerment based on international development frameworks and commitments (Ministry of Gender Children and Social Protection, 2015). The policy references issues of GBV (female genital mutilation, harmful cultural practices, child trafficking, and denial of education) in society and how it affects women in all spheres of life. Thirty-four references are made to GBV (Table 3). The policy, however, does not address the challenges of women in WASH access, nor does it acknowledge that women are prone to violence in accessing WASH (Table 3). Given that women are primary responsible for households WASH provision and management in many Ghanaian communities (GSS, 2018; Nunbogu et al., 2023), it is worrisome for the policy not to address the challenges of women in WASH governance (Table 3). Challenges of women in managing menstrual management are referenced only twice. This does not exemplify the commitment of the Government of Ghana to address challenges women face in meeting their MHM needs.

Table 3. Representation of WASH and GBV in Ghanaian policy documents.

Code	Description of code	Documents (Ghana) (no. of mentions for each code)
		National Gender Policy (2015)	National Water Policy (2007)	Environmental Sanitation Policy (2009)	National Community Water and Sanitation Strategy (2014)	National Strategy for Community Participation in Management of Urban WASH Services (2012)	Total
Water	Access to or availability of safe water/ challenges to safe water sources	N/A	51	3	53	44	151
Sanitation	Ease of access to facilities for safe disposal of human waste/ challenges of waste disposal	N/A	11	35	38	14	98
Hygiene	Ease of access to handwashing facilities with soap, ash, or acceptable medium and its practice	N/A	3	1	13	8	25
Women, girls, and WASH	Challenges faced by women and girls in WASH	1	6	2	N/A	1	10
WASH, women, girls, and distance	The challenges encountered by women in girls in accessing WASH because of walking long distances on an individual, family, and community level.	N/A	N/A	N/A	N/A	N/A	0
Women and WASH governance	The involvement of women in making decisions or maintenance of WASH facilities at the community or national level.	N/A	8	N/A	2	1	11
Menstrual hygiene/health management (MHM)	MHM is the ability of women and girls to have ease of access to all materials (clean water, clean material to serve as sanitary pads) and information to manage menstrual blood and maintain hygiene.	N/A	N/A	N/A	N/A	N/A	0
MHM, women, and girls	The challenges faced by women and girls in managing MHM in an environment of safety, privacy, and dignity.	2	N/A	N/A	N/A	N/A	2
Gender-based violence (GBV)	Any act or omission that results in psychological, physical, or sexual harm associated with expectations based on gender largely due to unequal power relations in society	34	N/A	N/A	N/A	N/A	34
GBV, WASH, women, and girls	Violence faced by women and girls in WASH access	N/A	N/A	N/A	N/A	N/A	0
GBV, WASH, distance, women, and girls	Violence faced by women and girls in WASH access because of distance travelled	N/A	1	N/A	N/A	N/A	1

The National Water Policy of Ghana (2007) is an integrated water resources management tool that views water as an essential element to development. The Water Policy emphasises expanding water access and discusses the challenges that limit water access by referencing water fifty-one (51) times (Table 3). Ease of access to sanitation and the challenges of sanitation access, however, is referenced eleven (11) times, while ease of access and challenges in hygiene access is also highlighted three (3) times (Table 3). It is worth noting that the policy focuses on water alone without integrating sanitation and hygiene. This has the potential of achieving very little since WASH should be integrated into all aspects to achieve lasting results. Little discussion is placed on women's role in WASH governance, with only eight (8) references (Table 3). Additionally, discussion on the challenges women and girls face in accessing WASH is limited, with only six (6) references (Table 3). However, a single reference is made to GBV because of the distance in accessing WASH (Table 3). The Water Policy makes no mention of the challenges women and girls face in MHM or the difficulties encountered by women and girls because of the distance covered in accessing WASH.

The Environmental Sanitation Policy of Ghana (2009) focuses on sanitation but fails to acknowledge the linkages with water and hygiene and mentions sanitation thirty-five (35) times while water and hygiene are only mentioned thrice and once respectively (Table 3). However, it should be noted that WASH should be approached with an integrated framework to achieve holistic results. While the policy discusses how to handle waste, it does not reference any steps to be taken in managing menstrual hygiene waste (Table 3). This can partly be attributed to the low involvement of women in WASH governance within institutions as the policy makes no mention of the need to incorporate women in WASH governance (Table 3).

The National Community Water and Sanitation Strategy (NCWSS) was published by the Community Water and Sanitation Agency (CWSA) under the Ministry of Sanitation and Water Resources. CWSA is tasked with water, sanitation, and hygiene provision in rural communities. NCWSS seeks to ‘improve the public health and economic well-being of rural and small communities through the provision of sustainable water and sanitation services, and hygiene promotion interventions’. As thoughtful as those sounds, the concerns and challenges of women and girls in the WASH sector are not discussed in the strategy. The strategy does not reference issues of menstrual hygiene or challenges that women and girls face in WASH access (Table 3). The resultant effect is that if the needs of women and girls are not adequately conceptualised, no plans will be put in place to deal with the violence they face because of inadequate WASH access. Water, on the other hand, is referenced fifty-three (53) times against sanitation (38) and hygiene (13) times, respectively (Table 3). Again, the strategy does not holistically approach WASH but adopts a piecemeal approach that will not result in significant changes in terms of leaving no one behind in WASH and specifically the WASH needs of women and girls.

Finally, the National Strategy for Community Participation in Management of Urban WASH Services examines the situational analysis of urban WASH, the role of communities in WASH delivery, governance issues, and the range of governance models used in urban WASH management (Ministry of Water Resources Works and Housing, and Ministry of Local Government and Rural Development, 2012). However, it is regrettable that while the strategy advocates for the involvement of communities in urban WASH management, the participation of women and girls in decision-making is only referenced once (Table 3). Ultimately, the strategy is ‘business as usual’ because it will rely on men to make WASH-related decisions that will not cater to women's and girls’ needs. This is also evident by the failure of the strategy to reference challenges women and girls face in MHM, the need for MHM facilities and services to be made accessible to women and girls, and GBV because of WASH access (Table 3).

4.2.2. Kenyan policy documents

Kenya’s National Policy on Gender and Development (2019) was formulated to achieve gender equality and empower women and girls to participate and contribute to the developmental agenda of Kenya (Ministry of Public Service Youth and Gender, 2019). The Policy aims to achieve this by ensuring gender mainstreaming in all facets of sectoral planning and programmes. An analysis of how gender equality is advanced in the policy reveals that not much has been planned and advocated in the WASH sector. For example, accessing safe water is only referenced three (3) times, while sanitation and hygiene are not referenced at all (Table 4). Additionally, challenges faced by women and girls in WASH are not mentioned (Table 4). While GBV is referenced mainly in the policy twenty-one (21) times (Table 4), it fails to address or acknowledge the need to meet the unique needs of women and girls in WASH. The ability of women to contribute to WASH governance or advocate for their rights to WASH is not addressed. For a policy that advocates gender mainstreaming in all sectors, reference to women in WASH governance is only once (Table 4).

Table 4. Representation of WASH and GBV in Kenyan policy documents.

Code	Description of code	Documents (Kenya) (no. of mentions for each code)
		National Policy on Gender and Development (2019)	Strategic Water Plan (2018)	Environmental Sanitation and Hygiene Policy (2016)	Framework for monitoring the realisation of the rights to water and sanitation in Kenya (2017)	Menstrual Hygiene Management Policy (2019)	Total
Water	Access to or availability of safe water/ challenges to safe water sources	3	20	19	60	5	107
Sanitation	Ease of access to facilities for safe disposal of human waste/ challenges of waste disposal	N/A	21	77	47	3	148
Hygiene	Ease of access to handwashing facilities with soap, ash, or acceptable medium and its practice	N/A	3	37	11	3	54
Women, girls, and WASH	Challenges faced by women and girls in WASH	2	N/A	6	6	12	26
WASH, distance, women, and girls	The challenges encountered by women in girls in accessing WASH because of walking long distances on an individual, family, and community level.	N/A	N/A	N/A	N/A	N/A	0
Women and WASH governance	The involvement of women in making decisions or maintenance of WASH facilities at the community or national level.	1	N/A	N/A	N/A	2	3
Menstrual hygiene/health management (MHM)	MHM is the ability of women and girls to have ease of access to all materials (clean water, clean material to serve as sanitary pads) and information to manage menstrual blood and maintain hygiene.	1	N/A	12	1	72	86
MHM, women, and girls	The challenges faced by women and girls in managing MHM in an environment of safety, privacy, and dignity.	N/A	N/A	14	2	47	63
Gender-based violence (GBV)	Any act or omission that results in psychological, physical, or sexual harm associated with expectations based on gender largely due to unequal power relations in society	21	N/A	1	N/A	1	23
GBV, WASH, women, and girls	Violence faced by women and girls in WASH access	N/A	N/A	2	N/A	1	3
GBV, WASH, distance, women, and girls	Violence faced by women and girls in WASH access because of distance travelled	1	N/A	N/A	N/A	N/A	1

The Environmental Sanitation and Hygiene Policy (2016–2030) from the Ministry of Health commits the Government of Kenya to a robust rights-based approach in achieving the global SDGs with a focus on environmental sanitation. The policy has a section that advocates the menstrual hygiene needs of women and girls. Notably, the policy calls for public institutions to have sanitary facilities designed to ensure the security and dignity of women and girls to dispose of menstrual waste. The importance placed on water (19), sanitation (77), and hygiene (37) are worth noting (Table 4). MHM is referenced twelve (12) times, while the challenges of MHM are referenced fourteen (14) times (Table 4). Additionally, the challenges women and girls encounter in meeting their WASH needs are acknowledged with six (6) references, while GBV in WASH access is also acknowledged with just two (2) mentions (Table 4). However, there is no reference to women in WASH governance (Table 4).

The Framework for monitoring the realisation of the rights to water and sanitation in Kenya (2017) was published by the Kenyan National Commission on Human Rights based on the mandate of the Constitution of Kenya to ensure the right to water and sanitation. The challenges or ease of access to water, sanitation, and hygiene are referenced sixty (60), forty-seven (47), and eleven (11) times, respectively. Reference to challenges women and girls face in WASH is mentioned only six (6) times against general challenges in water (60), sanitation (47), and hygiene (11) (Table 4). A review of the framework reveals that the right to sanitation and water is not being enforced adequately by the state. This is because MHM is only referenced once, while the challenges of accessing MHM by women and girls are referenced twice (Table 4). Other issues like the distance women and girls travel to access WASH, the involvement of women in WASH governance, and the incidence of GBV in WASH are not mentioned at all in the document (Table 4).

Finally, the Menstrual Hygiene Management Policy (2019–2030), by the Ministry of Health, is a policy that seeks to address the gaps in knowledge about menstruation, negative cultural practices, and myths that surround a biological function. It emphasises breaking the misconceptions about MHM by providing information about MHM to both men and women, boys and girls (Ministry of Health Kenya, 2019). The policy is the most significant effort to address the menstrual needs of women and girls by tasking the government to also provide sanitary pads and materials to all adolescent girls in public schools. Additionally, the policy references MHM seventy-two (72) times and the challenges women and girls face in MHM forty-seven (47) times (Table 4). The challenges that women and girls face in accessing WASH are also mentioned twelve (12) times (Table 4). However, the document does not incorporate WASH and MHM holistically because ease or challenges in water, sanitation, and hygiene access are referenced only five (5), three (3), and three (times) respectively (Table 4). Additionally, GBV in WASH access is only referenced once (Table 4). Though the document is aimed at MHM in Kenya, it is important to note that access to water and handwashing facilities are integral in MHM, and greater attention needs to be paid to the two.

The Government of Kenya has worked considerably hard to ensure that the rights of women and girls in WASH are adhered to by advocating for safe environments, access to information, and facilities for women and girls. While not all reviewed documents emphasise the needs of women and girls in WASH, the policy on MHM is a significant step forward in ensuring that structural violence in the WASH sector is addressed.

4.2.3. Ugandan policy documents

In Uganda, the right to water is stipulated in the Constitution under the national objectives and directives principles of state policy (The Government of Uganda, 1995). In 1999, the National Water Policy was formulated to promote an integrated approach to managing water resources beneficial to Uganda. A review of the policy reveals that water is referenced twenty-two (22) times while sanitation is referenced eleven (11) times (Table 5). No reference is made to hygiene (Table 5). Though the focus of the policy is on water, hygiene is integral to making any progress in expanding access to WASH. The policy, unfortunately, does not address the gendered need of women and girls in water access, be it MHM, GBV in WASH, or challenges encountered by women and girls in accessing WASH (Table 5); however, it calls for the inclusion of women in WASH governance by referencing it four (4) times (Table 5). Based on the year the policy was formulated (1999), there is an urgent need to review its objectives and goals to meet current global WASH sector needs.

Table 5. Representation of WASH and GBV in Ugandan policy documents.

Code	Description of code	Documents (Uganda) (no. of mentions for each code)					Total
		Water and Sanitation Gender Strategy (2018)	National Water Policy (1999)	National Sanitation Policy of Uganda (1997)	Vulnerable and marginalised groups framework (VMGF) for Uganda (2020)	Environment and Social safeguards Policy (2018)
Water	Access to or availability of safe water/ challenges to safe water sources	8	22	5	1	3	39
Sanitation	Ease of access to facilities for safe disposal of human waste/ challenges of waste disposal	7	11	20	1	1	40
Hygiene	Ease of access to handwashing facilities with soap, ash, or acceptable medium and its practice	N/A	N/A	6	N/A	N/A	6
Women, girls, and WASH	Challenges faced by women and girls in WASH	6	N/A	2	N/A	N/A	8
WASH, women, girls, and distance	The challenges encountered by women in girls in accessing WASH because of walking long distances on an individual, family, and community level.	N/A	N/A	N/A	N/A	N/A	0
Women and WASH governance	The involvement of women in making decisions or maintenance of WASH facilities at the community or national level.	17	5	3	N/A	N/A	25
Menstrual hygiene/health management (MHM)	MHM is the ability of women and girls to have ease of access to all materials (clean water, clean material to serve as sanitary pads) and information to manage menstrual blood and maintain hygiene.	6	N/A	N/A	N/A	N/A	6
MHM, women, and girls	The challenges faced by women and girls in managing MHM in an environment of safety, privacy, and dignity.	N/A	N/A	1	N/A	N/A	1
Gender-based violence (GBV)	Any act or omission that results in psychological, physical, or sexual harm associated with expectations based on gender largely due to unequal power relations in society	2	N/A	N/A	N/A	N/A	2
GBV, WASH, women, and girls	Violence faced by women and girls in WASH access	2	N/A	N/A	N/A	N/A	2
GBV, WASH, distance, women, and girls	Violence faced by women and girls in WASH access because of distance travelled	4	N/A	N/A	N/A	N/A	4

The National Sanitation Policy of Uganda was published in 1999 and describes the approach to sanitation adopted by the Government of Uganda. A review of the policy reveals that reference to sanitation is made twenty (20) times while water and hygiene are referenced five (5) and six (6) times, respectively (Table 5). The document makes limited references to the challenges women and girls face in WASH access, with only two references (Table 5), while no attention is paid to the distance women and girls cover to access WASH or the GBV in WASH access (Table 5). However, challenges in MHM are referenced once (Table 5). Participation of women in WASH governance is highlighted three (3) times (Table 5).

To ensure the commitment of the Ministry of Water and Environment to gender equality and women empowerment, the Water and Sanitation Gender Strategy (2018–2022) was formulated in 2018. The need for a gender strategy was necessitated by gender imbalances in the management of the water and sanitation sector and insufficient capacity of sector staff to design and implement gender-sensitive programmes (Ministry of Water and Environment, 2018).

The policy mainly emphasises the need for women to be included in WASH governance by tackling and eliminating sociocultural practices that impede the participation of women. This is highlighted by seventeen (17) references for women in WASH governance (Table 5). The policy also references violence in WASH for women and girls two (2) times and highlights that distance covered in accessing WASH, four (4) promotes GBV in WASH (Table 5). The commitment to increase the participation of women in WASH governance is a step worthy of highlighting. However, limited attention is focused on challenges and ease of accessing water and sanitation. Water is referenced eight (8) times, while sanitation is referenced seven (7) times (Table 5). Unfortunately, ease of access to hygiene is not referenced in the document (Table 5).

The Environment and Social Safeguards Policy (2018) guides the integration of environmental and social concerns to development. The policy advocates for a safe environment to encourage sustainable development and enhance healthy living and was published by the Ministry of Water and Environment. The policy barely addresses any of the codes but focuses on climate change, land and soil conservation, pollution prevention, and public health (Table 5). It, however, references water and sanitation three (3) and one time respectively (Table 5).

The Vulnerable and marginalised groups framework (VMGF) for Uganda barely addresses any of the codes. It only refers to water and sanitation once, respectively (Table 5). The document does not address the needs of vulnerable and marginalised populations in Uganda and their challenges in accessing WASH. However, in a publication entitled Eliminating Discrimination and Inequalities in access to water and sanitation, UN-Water highlights that vulnerable and marginalised groups are subject to discrimination in WASH access (UN Water, 2015). UN-Water, on that basis, advocates for pro-poor policies to meet the needs of marginalised and vulnerable groups.

In summary, there is a need for greater action by the Government of Uganda to meet the needs of women and girls in WASH access. This can begin with the formulation of policy and frameworks to conform with international WASH goals. Additionally, water, sanitation, and hygiene need to be integrated and addressed as a single unit rather than being addressed as single units.

5. Discussion and conclusion

This paper provides insight into how WASH policies highlight issues of women and girls’ experiences of GBV when meeting their WASH needs (i.e. the mentions or not). Our findings align with literature on gender and WASH, showing the lack of a holistic policy to address WASH issues (Sweetman & Medland, 2017) which (re)inforces women and girls’ exposure to GBV. There are varied commitments to addressing gender vulnerabilities in WASH across the study countries and some policy documents are outdated. The UN water Acceleration strategy which is supposed to provide a strategic framework for national policies paid less attention to women and girls experiences of GBV in their WASH spaces. The focus is on the material aspect of water access, however, there is growing evidence that the presence of water infrastructure does not eliminate women and girls’ vulnerability to GBV (Nunbogu & Elliott, 2022).

While policies and strategies included in the study made reference to water, sanitation and hygiene, the inter-linkages of these broad areas are not explicitly discussed. Although these policies and strategies are signs of progress, the lack of attention on the embedded interconnectedness in WASH in high level policy documents suggests intersectoral coordination is needed in order not to leave anyone behind. Furthermore, while research has outlined the multi-layered challenges women and girls’ encounter in their WASH spaces, these issues are implicitly referenced. For instance, research findings linked distance to WASH facilities to women and girls’ exposure to GBV (Adams et al., 2022; Nunbogu & Elliott, 2022; Tallman et al., 2022), however, none of the documents reviewed acknowledged this challenge. These implicit referencing lays the foundation for unclear policy interventions on addressing gender inequalities in WASH.

One critical issue is MHM, which is absent in many of the policy documents. The breadth of neglect of MHM is summarised in its absence from most of the policy discourse particularly in Ghana and Uganda. Only 6 out of the 15 policy documents analysed mentioned menstrual health with Kenya recording the most mentions. This may suggest that WASH policy interventions in these countries are yet to prioritised MHM. It may also signify the inadequate incorporation of MHM into infrastructure design for public sanitary facilities and waste disposal interventions in these countries. We also noted there is a weak acknowledgement across all the policy documents of the challenges women and girls face in meeting their menstrual health needs. Simply referencing MHM without recognising the need to address existing challenges hindering MHM practices further heightens the vulnerability of women and girls. For example, research has reported increasing challenges of MHM in many school settings in Uganda (Sommer et al., 2015), Kenya (Jewitt & Ryley, 2014), and Ghana (Rheinländer et al., 2019).

GBV in WASH is multi-dimensional and broader than the issues discussed in this review (see Nunbogu & Elliott, 2021; 2022). However, the limited attention to GBV in the policies reviewed is an indication that WASH interventions have lost sight of the contextual factors that shape violence and point to the narrow framing of GBV in WASH (Nunbogu et al., 2023; Tallman et al., 2023). Furthermore, while engaging women in WASH governance does not eliminate GBV, it opens space for women to make decisions that shape their WASH needs. The Water and sanitation Gender Strategy of Uganda epitomises this direction and countries seeking to promote gender inclusion in WASH should learn from it for tailored policy interventions.

WASH-related GBV needs to be addressed by formulating definite policies on WASH that cater to women's unique needs in their WASH spaces. These policies should be evidence-informed and multisectoral (Phillips-Howard et al., 2016). An evidence-based approach understands local customs and norms surrounding menstrual hygiene. As such, any evidence-based policy should be context dependent and inclusive (Sommer et al., 2015). Since inequalities and vulnerabilities to WASH in sub-Saharan Africa are sometimes reflections of socio-political relations across multiple scale, countries seeking to address GBV in WASH should adopt system perspectives in understanding GBV (Nunbogu & Elliott, 2021). The system approach frames WASH-GBV as an outcome of interdependent elements in WASH which are in a continuous process of interaction and redevelopment.

This study has some limitations which are worth highlighting. First, we acknowledge that the WASH needs of women and girls are not limited to what has been analysed but rather diverse. Secondly, the sample size of documents reviewed (20) has implications on extrapolating findings to other parts of sub-Saharan Africa (SSA). Additionally, since WASH is multidimensional, multiple agencies and ministries have mandates to address it with multiplicity of focus. Given this situation, we acknowledge that the selected documents are not the same and have differences in terms of target areas. However, it is worth noting the documents selected provide enough information for this paper. Furthermore, this paper did not discuss the extent of policy implementation at the national or local level. However, we have comprehensively discussed that in a different manuscript.

Despite these limitations, the findings contribute to the current wealth of knowledge on gender specific needs in WASH as SDG 6 recommended. While these needs are broad, our paper draws policy attention to GBV in WASH. Additionally, the research charts a path that is new and points to how the WASH needs of women and girls are addressed in international and national policies. Undertaking a content analysis with a focus on international and national level sheds new evidence with regards to the disconnect between international WASH policy and the needs of women and girls at the national and local levels. Also, the findings revealed cross-country differences with regards to policies among the study areas and the need for policies to be updated to reflect changing WASH needs. While these differences present learning opportunities, we recommend further studies across SSA to understand the wider context of WASH policies.

Disclosure statement

No potential conflict of interest was reported by the author(s).