Ladies and latrines – the unspoken development opportunity

Vaishnavi Navalji Dadmal, 9, at her residential toilet in Nagpur, India. Source: UNICEF.

Here’s a stunning fact. Did you know that in some cases, almost 50% of sexual assaults occur when women and girls are forced to defecate outdoors because they lack access to a safe latrine?

While the world has made great strides to improve access to clean drinking water, progress in access to sanitation and hygiene services has been sluggish. To find out what this means, Geneva Solutions interviewed Dr. Elizabeth Wamera, an expert at the Geneva-based Water Supply and Sanitation Collaborative Council (WSSCC). She explains the devastating impacts of poor access to safe sanitation and hygiene services on the lives of women and girls. Bolstering female representation in this traditionally male domain, is key to ensuring new investments meet long-ignored needs of girls and women.

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Dr. Elizabeth Wamera, technical expert at the Geneva-based WSSCC.

GS. We know that improving water, sanitation and hygiene (WASH) services can effectively prevent millions of deaths from water-borne diseases. However, the gender dimensions of WASH aren’t as widely appreciated. Can you describe the link, and why is it important?

When public health services don’t work well, it’s always going to affect some groups more than others. That’s usually girls, women, children, and LGBTIQ groups.

Take open defecation, for instance, which is practised by 15 per cent of the world’s population. While not typically a concern for men and boys, it can be life-threatening for women. In India’s state of Bihar, for example, nearly half of the 870 rape cases in 2012 took place when women defecated outside. And every year, women around the world spend 97 billion hours finding a safe place to relieve themselves. Think about what these women could do if they didn’t have to waste so much time looking for a safe space to defecate. Think about the constant, daily stress of having to defecate outside, especially in contexts where violence against women and girls is rife. That’s why it’s so important for everyone to have access to latrines when they need it, wherever they need it, and as comfortably as possible.

Therefore, we can’t reach WASH targets, nor gender equality targets, nor any of the other Sustainable Development Goals (SDGs), if we don’t address the specific needs of vulnerable populations like girls and women. We cannot deliver WASH services for everyone if we don’t acknowledge that gender is a huge determinant of health, and take that into account during the design, implementation and evaluation of WASH programs.

Source: World Toilet Organization.

Menstrual health and hygiene is another crucial component of WASH. How does achieving menstrual health and hygiene advance the rest of the SDGs?

To achieve WASH targets for 2030, we need adequate menstrual health and hygiene services, and that’s been acknowledged in SDG 6.2. But half a billion women, girls, women, transgender men and non-binary persons of reproductive age still lack access to adequate menstrual hygiene services, despite the fact that menstruation is a natural and monthly occurrence for more than 1.8 billion people.

Inadequate menstrual sanitation options makes women and girls more vulnerable to reproductive tract infections. It also reduces their attendance in schools and participation in community life. In sub-Saharan Africa, one in ten girls miss school because of menstruation, sometimes for up to 15 per cent of the school year. So in fact, I’d say that SDG 6.2 lies at the center of the SDGs. We can’t reach SDG targets if girls can't go to school. WASH is critical for gender equality, but also for social development, health, and economic growth. And WASH has become even more important in times of the pandemic, as hand-washing is still the first line of defense against the coronavirus.

Source: WSCC.

What can we do to change the status quo?

We must embrace the technologies that are already available. Even in Switzerland, there’s a long way to go to improve WASH services - but we need to shift our mindset. Take for instance:

  • Female urinals. For over two decades, female urinals have largely curbed long queues at female bathrooms in the Netherlands, South Africa and Kenya. They are cheap to construct, easy to maintain, and women/girls are largely in favor of urinals when they’re constructed to provide privacy, according to UNICEF Kenya. However, they have not been adopted in most of the world, and that includes Switzerland. In one of the richest countries on earth, a lack of resources cannot explain why female urinals have not been implemented.

  • Sanitary pads in automatic dispensers. Swiss “Selecta” dispensers offer chips, soft drinks, condoms and pregnancy tests, but they still don’t offer sanitary pads, even though these are basic items that should be widely available.

Female urinals can effectively curb large queues for female bathrooms. They are cheap to construct and easy to maintain. Source: David Crosweller.

We need to sell the SDGs as business opportunities. Rather than framing the SDGs as the “holy grail of human rights”, WASH professionals need to start selling the business opportunities,  especially during negotiations with the private sector.

When we [WSCC] speak with soap-makers, we tell them, WASH is fantastic business for you. If you [soap-makers] want to promote your soap, we'll teach people how to wash their hands, and that will help you increase soap sales.

If a shopping mall doesn’t have adequate toilets for women, we explain to property owners that safer and cleaner latrines may help them attract more customers.

We know that global health is delivered by women yet led by men. And presumably this is part of the issue in WASH. What are the benefits of improving female representation in this sector?

Poor female representation is definitely a problem in WASH. In Kenya, where I’m from, nine out of ten public health officers are men and 45 of the 47 regional governors are men. If it’s only men that are leading WASH efforts, interventions won’t be as effective as they could be. That's because men cannot guess the needs of women, girls, and other groups unless they are told what these needs are.

Let's take a pregnant woman's needs, for instance. Her bladder is more loose compared to a woman that’s not pregnant. She also can't use squat toilets. How many men know that?

If we really want to commit to adequate sanitation for all, that means the pregnant woman needs to be able to access toilets where she can sit down, rather than squat toilets. And she needs to be able to access toilets quickly because of her bladder. She can’t be waiting in a long queue before she can relieve herself. But women’s requirements in WASH are diverse. There are women living with other complications like incontinence or fistula, and we need to take those into account when designing WASH programmes.

Global health is delivered by women yet led by men. Source: Women in Global Health.

What are other steps we can take to further the WASH agenda?

One of the solutions is to engage men and boys in WASH; this strategy has had remarkable success in improving sexual and reproductive health, family health, and reducing gender-based violence, among others. Some tips:

  • Re-frame men as allies. Health promotion programmes, including WASH, should frame men and boys as agents of change rather than ‘obstacles’ to gender equality.

  • Target men at the right place & at the right time. Some programmes have successfully boosted male engagement by organizing events in spaces where men gather - like tea stalls in Nepal - or events in the evenings after men finish work.

  • Give men a role without reinforcing existing gender dynamics. Men are also more likely to attend hygiene promotion activities if they are given specific leadership roles, suggests one study published by the International Rescue Committee. But WASH programs should be carefully designed to avoid reinforcing existing gender inequalities.

Unless women explain their realities to men, men won’t know what’s going on and we won’t be able to change the status quo, We need to engage men as partners to change and enablers, rather than perpetrators.

Kenya has a recent success story when it comes to menstrual hygiene. In May 2020, in the midst of Covid-19, the government launched the Menstrual Hygiene Management Policy, the first stand-alone policy of its kind on the whole continent. How was this achieved?

When it comes to menstruation, it’s really important to normalize it. The moment you start speaking about it as a natural bodily function for every woman, then it's no big deal. And when women can comfortably speak about it among themselves, then they're able to discuss it with their husbands, their boyfriends, their sons, and so on. This process, however, is lengthy and challenging, also because decision-makers, most of which are men, don’t want to talk about menstruation at first. But when you start having conversations about it, they eventually have a lightbulb moment and start to appreciate the lived realities of menstruators.

In Kenya, we [WSCC] took a multi-pronged strategy to improve access to menstrual hygiene services:

  1. Societal engagement & capacity building. We trained ministry officials, civil society groups, international NGOs, and the private sector in menstrual health and hygiene. We also engaged them in the design of Kenya’s Menstrual Hygiene Management Policy.

  2. Three-angled approach. We focused on breaking the silence on mensuration by addressing stigma. We also promoted strategies for hygienic menstrual management, as well as the safe reuse and disposal of menstrual products.

  3. Innovative & cheap options for vulnerable groups. To facilitate menstrual hygiene access to vulnerable groups in informal settlements and rural communities, we raised the visibility of various Kenya-based groups that produce reusable and disposable sanitary products, such as the Zana Africa Pads.

We also took a creative approach by working very closely with the governors’ spouses in each of the 47 counties of Kenya. We trained them in menstrual health and hygiene, and they eventually became key influencers within their jurisdictions. They were also able to influence their husbands, who were in charge of budgets and decisions at the county level.

Our work contributes to the national “Beyond Zero” campaign which was set up to ensure that no mother dies during childbirth. It’s led by The First Lady of Kenya Margaret Kenyatta, the president’s wife. This campaign has yielded great results since its inception in 2014. So this also caught the eye of the president, given the campaign is spearheaded by his wife.

The bottom line. By engaging with the right stakeholders, we can speed up progress in WASH - and ensure that women, girls and other vulnerable populations can access safe sanitation and hygiene services when they need it, wherever they need it, and as comfortably as possible.

Source: UNICEF.