Drinking water, sanitation and hygiene in human settlements.
Global access to drinking water, sanitation and
hygiene (WASH) services improved significantly
from 1990 to 2024, although major gaps remain.
According to the World Health Organization (WHO)/
United Nations Children’s Fund (UNICEF) Joint
Monitoring Programme report, between 2015 and
2024, 961 million people gained access to safely
managed drinking water services, increasing global
coverage from 68% to 74%. About 1.2 billion people gained access to safely managed sanitation services, with global coverage increasing from 48% to
58% over the same period. Despite this progress,
as of 2024, 2.1 billion people still lacked safely
managed drinking water, while 3.4 billion lacked
safely managed sanitation services and 1.7 billion lacked basic hygiene services at home.
According to the report, women and girls are most
likely to be responsible for water collection. This can
expose them to physical strain and safety risks,
especially in remote or insecure areas. In addition,
lack of privacy and safety because of poor sanitation
facilities disproportionately affects women and girls,
especially in urban slums and rural areas.
The human rights to water and sanitation entitle all
people access to safe and clean drinking water and
adequate sanitation, provided equally and without
discrimination. Fulfillment of these rights requires
that all obstacles in access to safe drinking water
and sanitation are removed, particularly for the
most marginalized populations. This includes removal of
impediments to equal participation of men and
women in water governance.
Equal participation in WASH decision-making
towards a gender-responsive WASH regime calls
for: equitable representation and voice in water
management bodies (see Chapter 9); consultations
with women to understand their needs; organizing consultations such that women can attend;
sex-disaggregated data to monitor progress; gender-separated meetings
to promote open discussions; raising the profile of
women’s needs and voices in WASH policies; and
recognizing that women in different life stages
and circumstances have different WASH needs. Gender disparities
in women’s access, participation and leadership
remain high in low- and middle-income countries
(LMICs), despite the significant progress made
since 2000 in access to WASH services and WASH
decision-making globally.
Up to 1.8 billion people live in households without
water supplies on the premises. About 700 million
of these people fetch water from improved or
unimproved sources. The
gendered burden of domestic work begins at a
young age, with girls between five and nine years
old spending 30% more time, or 40 million more
hours a day, on household chores than boys in 2016. Women and girls aged 15 years and
up are primarily responsible for water collection
in seven out of ten such households. In addition,
girls under 15 (7%) are more likely than boys under
15 (4%) to fetch water. Globally, women and girls
spend 250 million hours per day collecting water
at the expense of time they could otherwise spend
on education, leisure or economic activities. In addition, carrying water can
cause physical strain and injury. And women and
girls may be confronted with gender-based violence
(GBV) on the way and even in their homes.
Beyond access challenges, household water insecurity and unreliability can be significant stressors
for women and girls. Fetched water may not be safe
to access or use, reliably available nor sufficient for
basic household needs. Rainwater harvesting as
a (cheap and efficient) alternative is generally not
promoted enough. Water insecurity could lead to
food insecurity or poor hygiene. Even piped water supply can be
intermittent in LMICs, meaning storage is needed,
recontamination is possible and household water
may need to be rationed between supply periods.
Social expectations can be such that women
perform the invisible daily labour of managing,
rationing and prioritizing, as well as the labour of
caregiving when unsafe or unreliable water leads
to illness in the household. Women in Uganda
have described how pregnant women, tired but still
expected to fetch water, end up with less food and
water for themselves at a time of high caloric and
water needs. Little data are
available on additional water-related labour once it
has reached the home .
Social norms and taboos on sanitation and hygiene
can have particularly negative impacts on women
and girls. For instance, when there is no toilet
inside the home, women, girls and boys may face
the risks of injury and assault when seeking out
sanitation facilities in the dark). Among countries with available data, women
and adolescent girls in the poorest households
and those older and with disabilities are the most
likely to lack a private place to wash and change. Some cultures across Latin
America and South Asia perceive menstruating
women and girls to be impure, resulting in
restricted access to water for cooking and washing,
thus causing negative health outcomes.
It is still a common practice in development research
and programming to collect and present data with
the household as the unit of analysis, with intrahousehold disaggregated data rarely presented. Even
when a household has water, soap or a toilet, without sex-disaggregated data, intra-household access
inequalities cannot be monitored or mitigated. When access to water is insecure or unreliable, without sex-disaggregated data,
the intra-household burden of that insecurity remains
unknown. Treating the household as a homogeneous
unit can conceal and hinder alleviation of instances
of gender inequality.
Secure land tenure and housing rights are often a
prerequisite for accessing municipal water and sanitation services. Poor housing quality, insecure land tenure and
housing discrimination can disproportionately affect
women. With legal ownership or recognized tenure, residents are in a position to demand
better services, including water and sanitation. Otherwise, residents of informal
settlements may be denied these essential services.
Figure 2.1 demonstrates the cycle of lack of land tenure and housing rights and WASH insecurity
As heads of household, women may face significant
impediments in accessing housing due to discriminatory practices and policies or limited financial
resources. Secure housing tends to come with better infrastructure, including
(more) reliable water supply and sanitation systems. However, in many urban areas, women are more likely
than men to experience insecure tenure and limited
access to essential services. This inequality can exacerbate their vulnerability, limit their opportunities
for advancement and impede secure access to WASH.
Data have consistently shown those in precarious
housing situations in the poorest settlements face
higher costs for water than those connected to
piped network, often relying on informal means
of access.
A study using data from the Nairobi Water and
Sewerage Company for the period 2008–2018
showed residents living in slums often depended
on informal water vendors who charged five to
ten times more per litre. The slum residents were
also four to six times less likely to receive the
recommended 1,500 litres of water per person per
month compared with those in middle- and highincome areas.
Access to safe WASH in schools contributes to
positive health, improved school attendance and,
ultimately, better educational outcomes. Yet, globally, 23% of schools lack
basic drinking water services, 22% of schools
lack basic sanitation services and 33% of schools
do not have basic hygiene services. Sub-Saharan
Africa is the furthest behind; less than half of
schools have access to basic water (45%) and
sanitation (50%), and only two in five schools have
a basic hygiene service (37%). Overall, a twofold
increase is needed to achieve universal access
to basic water and sanitation in schools, and a
fourfold increase to achieve the same for basic
hygiene by 2030.
Without water in schools, children cannot wash
their hands before eating and after using a toilet.
Girls cannot manage their periods with dignity and
privacy. The lack of toilets and water for menstrual
hygiene management can lead to shame-inducing
experiences; menstruating
girls often go home and stay home for the day.
Between 2016 and 2022, more than 10 million
adolescent girls aged 15–19 years across 41 countries
reported missing school, work or social activities
during their last menstrual period. Reliable access
to safe water near to or in toilet facilities is thus
as important for girls’ school attendance and
performance as providing drinking water.
Case studies of WASH initiatives in schools, such
as the joint Action Caring Team/United Nations
Environment Programme/United Nations Human
Settlements Programme effort in Lok Urai, Malaysia,
which introduced low-cost wastewater treatment
systems and upgraded sanitation facilities in local
schools and homes, show water pollution can be
reduced while girls’ school attendance can be
measurably improved with safely managed WASH.
By 2018, 76% of births were in health care facilities,
but poor hygiene conditions could compromise
potential benefits and often dissuade mothers from
delivering at such facilities.
Clean water is known to be crucial for infection
prevention during birth. WASH services provision
was one of the top five maternal and reproductive
health service demands of 1.2 million women in
2020. A 2008 study from
Nepal found neonatal mortality was reduced by 41%
when birth attendants and mothers washed their
hands with soap and water (Rhee et al., 2008). In
Rwanda, a single day without clean water at a health
care facility doubled the likelihood of infections
among caesarean-section deliveries.
Representing 70% of the health workforce, women on the front line are significantly
affected by unsafe working conditions. Nurses and
midwives, who handle most services in maternity
wards, are themselves at risk if there is limited
access to water and toilets. They and their patients
can be exposed to contamination. Sex-separated and well-maintained toilets
should be available for staff and patients, and
should include facilities for menstrual hygiene
management. However, only 78% of health care
facilities in LMICs have the basic water services to
enable good hygiene. By
2020, many of these basic WASH services were not
yet captured in health management information
systems or in facility assessments and building
regulations.
Climate change is exacerbating water scarcity
worldwide, affecting the time, effort and risks
associated with water collection and management.
Water insecurities have significant implications for
health – including mental health – particularly in
rural areas of developing countries, where women
and girls often bear the burden of water collection. Unreliable and unsafe water supplies
can have many negative health consequences. This
section focuses on the health consequences of
inadequate WASH for women and girls.
The burden of water carrying and management (often
rationing), disproportionately borne by women and
girls, can have many physical ill effects. Daily water fetching can contribute to
the occurrence of musculoskeletal injuries (1 litre of
water weighs 1 kg; 50 litres per person per day is often
considered the baseline need). Common complaints
include neck pain, axial compression, upper and lower
back pain, and joint pain.
In 2020, 13% of households across 21 LMICs
reported a water-fetching injury, including from falls,
accidents, animal bites and physical confrontations
when attempting to access water; women were more
likely to report such injuries. Data across multiple countries have shown
water fetching by pregnant women is associated with
seeking less antenatal care.
Moreover, women have been found to experience
bladder and breast cancers, potentially associated
with exposure to arsenic, trihalomethanes and
trichloroethylene in drinking water.
Post-pubescent girls, women and gender nonbinary people need increased WASH services
(among other supplies) when they are menstruating.
Water is required for washing themselves, clothing
and reusable sanitary cloths (if used). The lack of
water and hygiene in these situations can cause
shame and extreme anxiety, given the social taboos
around menstruation in many societies, and has
been linked to urogenital infections. For menstruators, a lack of latrines and/or
toilets with water access is a significant obstacle
to gender equality, restricting mobility and full
participation in public life.
WASH access problems can be compounded by
inadequate infrastructure, low levels of education
and health care on menstruation and reproductive
health, and religious teachings or social and cultural
norms that exclude menstruating women and girls
from community activities.
For example, one report found only two out of
five schools provide menstrual health education. When social silencing
interacts with caste, the consequences can be
especially dire. It is extremely
difficult to design policies, buildings or educational
materials for a topic that it is barely possible to talk
about in public.
When water supplies and sanitation are absent,
risks and discomforts for women and girls include
the drudgery of carrying water, deliberately not
drinking water so they do not need to go to the toilet,
falling in the dark, attacks from animals (e.g. dogs
and snakes) and fear of sexual (verbal and physical)
assault. The risks of sexual
violence, verbal harassment and rape, especially
when walking to sanitation locations, have received
considerable attention. Sexual violence and
sexual harassment are heinous violations of human
rights, generating public health burdens with lasting
physical and psychosocial consequences. Instances often remain under-reported
because of the blame-the-victim stigma and fear of
retaliation, and are therefore understudied within the
WASH context.
Coerced sex can occur when women are deprived
of essential needs or services, at the intersection
of extreme deprivation, extreme powerlessness
and weak legal protection. In the WASH sector, it is enabled by
unequal gender roles, insufficient water points,
inadequate sanitation infrastructure, high prices
and the widespread legacy of devaluing women’s
bodies. Studies
in Bangladesh, Colombia, Kenya and South Africa
have uncovered several cases of threatened or realized sex for services. While
WASH deprivation is hardly the main cause of sexual
coercion, its impacts are long
lasting. It remains under-reported and inadequately
addressed because of shame, fear of retaliation
and unclear legal recognition of its criminal nature.
Secure WASH services provision becomes even
more urgent seen in this light. There has been an
ongoing campaign against coerced sex in Kenya with
legislation in parliament.
Even when water is available at or close to a dwelling,
social norms can dictate women carry out the work
of storing, treating and rationing limited supplies
for domestic needs such as drinking, cooking,
hygiene and cleaning. Organisation for Economic
Co-operation and Development analysis on women’s
economic empowerment concluded a reduction in
physically demanding and time-intensive tasks such
as collecting water leaves women with more time
for paid work and studies, as well as for leisure and
personal care.
Activities that enable sustained water treatment
programmes, such as education, peer-to-peer
outreach or community mobilization, continue to
target women and girls; these programmatic costs
are rarely quantified and the women ‘enablers’
are often unpaid, with the unintended result
of increasing women’s level of ‘unpaid’ work.
Some scholars have argued that when safe
water supplies are sold at market prices, or when
piped water tariffs are aimed at cost recovery
from the users, such ‘reforms’ could exacerbate
intra-household gender inequalities. The WASH
community has often used the term ‘low cost’ to
describe chlorine tablets or ceramic filters, for
instance, without investigating the household’s
ability to pay, the opportunity cost of such payments
or who pays. It is likely that some of these drinking
water approaches are low cost, in part because the
labour associated with use and maintenance goes
unpaid. The affordability of water supply services is usually
measured at the household level, as the ratio of the
cost of water (including treatment) to household
income. However, this simple ratio does not say if
the household is using (or can afford) enough water
for its daily needs; water might be affordable
because consumption is tightly rationed. Moreover,
anthropological research has long argued that the
structure of the household determines affordability,
and the cost of water competes with other essential
needs. In addition, men and women may not have
equal control over the household purse, and many cultures may have
separate, and gendered, spending domains whereby
the ‘women’s purse’ is expected to pay for everyday
expenses such as food, fuel, water or soap. In this last instance, the total household
income would not be relevant for calculating the
affordability ratio.
Affordability is a key dimension of the human rights
to water and sanitation, but remains understudied
and underappreciated as a gendered rather than a
unitary-household phenomenon.
Refugees and internally displaced persons face
severe but understudied WASH problems, including
effects specific to women and girls. For example,
shared standpipes translate into hours being in line,
harassment of women and girls, and less time for
learning, caring for children or earning. Disrupted
services and poor sanitary facilities have resulted
in exposure to waterborne diseases like cholera,
which have highlighted the life-threatening effects
of reduced WASH services (MSF, 2023). In addition
to health, poor menstrual hygiene facilities can
undermine the basic dignity of teenage girls and
cause absenteeism from school.
In Dadaab and Kakuma refugee camps in Kenya,
non-governmental organizations have helped
introduce solar-powered boreholes and chlorination
equipment. This has obviated a reliance on diesel
pumps, providing greater reliability of supply and
reducing the daily tasks for women and girls who
once had to walk great distances to fetch water. In Dadaab camp, the implementation
of prepaid ‘water automated machines’ within
camp markets has provided equal opportunities for
households (particularly women-headed households)
to access affordable, safe water at convenient times
of day, thereby reducing the risks of long queues and
increasing transparency in distribution.
Such initiatives have illustrated the efficacy
of gender-responsive WASH interventions for
enhancing safety, health and human dignity for
girls and women. However, the lessons learned
have not yet been adequately captured in policy
and documents. Systematically incorporating
approaches into humanitarian planning and national
water governance can help to ensure refugee women
and girls do not fall behind in terms of meeting the
human rights to water and sanitation.
The progressive removal of obstacles to access to
water and sanitation, including discrimination, is
required to fully realize the human rights to safe
drinking water and sanitation. These include:
• obstacles to equal participation of men and
women in decisions on water governance;
• the disproportionate burden of collecting
household water, which denies women and
girls the opportunity to engage in productive
or social activities;
• cultural norms that restrict women’s and girls’
access to water and sanitation facilities when
they need them the most;
• the implicit acceptance of GBV, harassment
and other threats to safety while accessing
household water and sanitation facilities; and
• the widespread stigma associated with
menstruation.
Addressing WASH barriers requires responses
that go beyond technical fixes, as these challenges
are rooted in the complex interplay of politics,
economics and culture. Some countries have tried
to empower women in rural and peri-urban areas, by
encouraging their voice and participation in WASH
decision-making bodies on the kind of services they
need or receive, and the location and condition of
their facilities.
As we discussed how gender inequalities
in WASH services occur as part of a pattern of other
inequalities and discriminatory social practices.
These include land and housing discrimination,
legal practices and institutions that have internalized
gender norms and expectations, limited opportunities
for women to exercise leadership (as opposed to
labour) in water management, and widely prevalent
indicators of WASH costs, benefits and affordability
that render women’s specific needs and work
invisible. A range of physical and mental health
consequences disproportionately affect women when
water for WASH services is unable to meet their basic
needs. GBV and domestic violence have also been
linked to WASH insecurities. Strengthening national
policy on menstrual hygiene to give more priority to
WASH in schools, work and public places could allow
more women to participate in community activities.
And widening education to include menstrual hygiene
management could help to overcome the associated
taboos.
Alleviating gendered inequalities in WASH calls
for interventions that go beyond technical fixes to
those that address structural and social inequalities.
Global examples demonstrate that when women’s
participation is designed to encourage leadership and
voice, as opposed to merely checking boxes, women are active agents of
change for gender equality and WASH equity.
As described, concerted
action is urgently required in order to:
• Strengthen legal, institutional and community responses to sexual coercion in
WASH. Legislation should be reviewed to
explicitly define and criminalize sexual coercion. Accountability frameworks should also
be developed to track enforcement.
• Disaggregate data by sex and age at the
household level and integrate gendered
time-use and affordability data into
WASH research and policy frameworks.
WASH affordability assessments should consider women’s limited control over household
finances and their disproportionate responsibility for WASH-related tasks. Research
findings could then inform policy on unpaid
work, care and domestic labour.
• Acknowledge and improve research concerning WASH in refugee settlements and
internally displaced person settings. It is
vital to work directly with refugee women and
girls on research and knowledge-sharing to
enable their voices to shape problem identification and solution development.
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