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BACKGROUND: Lack of access to functional and hygienic toilets in healthcare facilities (HCFs) is a significant public health issue in low- and middle-income countries (LMICs), leading to the transmission of infectious diseases. Globally, there is a lack of studies characterising toilet conditions and estimating user-to-toilet ratios in large urban hospitals in LMICs. We conducted a cross-sectional study in 10-government and two-private hospitals to explore the availability, functionality, cleanliness, and user-to-toilet ratio in Dhaka, Bangladesh. METHODS: From Aug-Dec 2022, we undertook infrastructure assessments of toilets in selected hospitals. We observed all toilets and recorded attributes of intended users, including sex, disability status, patient status (in-patient/out-patient/caregiver) and/or staff (doctor/nurse/cleaner/mixed-gender/shared). Toilet functionality was defined according to criteria used by the WHO/UNICEF Joint-Monitoring Programme in HCFs. Toilet cleanliness was assessed, considering visible feces on any surface, strong fecal odor, presence of flies, sputum, insects, and rodents, and solid waste. RESULTS: Amongst 2875 toilets, 2459 (86%) were observed. Sixty-eight-percent of government hospital toilets and 92% of private hospital toilets were functional. Only 33% of toilets in government hospitals and 56% in private hospitals were clean. A high user-to-toilet ratio was observed in government hospitals' outpatients service (214:1) compared to inpatients service (17:1). User-to-toilet ratio was also high in private hospitals' outpatients service (94:1) compared to inpatients wards (19:1). Only 3% of toilets had bins for menstrual-pad disposal and <1% of toilets had facilities for disabled people. CONCLUSION: A high percentage of unclean toilets coupled with high user-to-toilet ratio hinders the achievement of SDG by 2030 and risks poor infection-control. Increasing the number of usable, clean toilets in proportion to users is crucial. The findi

The recent (re-)emergence of gender-transformative approaches in the development sector has focused on transforming the gender norms, dynamics, and structures which perpetuate inequalities. Yet, the application of gender-transformative approaches within water, sanitation, and hygiene (WASH) programing remains nascent as compared with other sectors. Adopting a feminist sensemaking approach drawing on literature and practice, this inquiry sought to document and critically reflect on the conceptualization and innovation of gender-transformative thinking in the Australian Government's Water for Women Fund. Through three sensemaking workshops and associated analysis, participants developed a conceptual framework and set of illustrative case examples to support WASH practitioners to integrate strengthened gender-transformative practice. The multi-layered framework contains varied entry points to support multi-disciplinary WASH teams integrating gender equality, as skills and resources permit. Initiatives can be categorized as insensitive, sensitive, responsive or transformative, and prompted by five common motivators (welfare, efficiency, equity, empowerment, and transformative requality). The framework has at its foundation two diverging tendencies: toward instrumental gender potential and toward transformative gender potential. The article draws on historical and recent WASH literature to illustrate the conceptual framework in relation to: (i) community mobilization, (ii) governance, service provision, and oversight, and (iii) enterprise development. The illustrative examples provide practical guidance for WASH practitioners integrating gendered thinking into programs, projects, and policies. We offer a working definition for gender-transformative WASH and reflect on how the acknowledgment, consideration, and transformation of gender inequalities can lead to simultaneously strengthened WASH outcomes and improved gender equality.

In urban Indonesia, 40 million people rely on groundwater self-supply, however the role of self-supply in securing household water provision remains unexplored. This study used a mixed-methods approach to understand the use and management of household self-supply in the Indonesian cities of Bekasi and Metro, where a high proportion of households rely on private wells for water supply. Self-supply was the preferred drinking water source because of its perceived safety, taste and appearance at both study sites. The most important attributes influencing choice of domestic water source were appearance, reliability and safety in Bekasi, and safety followed by convenience and reliability in Metro. Coping strategies to overcome quality and availability problems of self-supply included water treatment, switching from dug wells to deeper boreholes and the use of multiple water sources. All households reported boiling self-supplied water, however, the labor involved was tiring for some households, leading them to resort to alternative water sources. Reasons for non-use of alternative water sources such as refill water and public piped systems included a lack of trust in water quality and perceived poor taste. Regarding self-supply management, responsibilities and decision-making varied across households, but cooperation between men and women concerning workload was common. Women were mostly responsible for household water management, and men were mostly responsible for maintenance and repairs, cleanliness of the water source and financing. To support and regulate self-supply towards a safely managed water service, strategies for improvements should be considered not only at the source, but also at point-of-use, including promotion of safe household water treatment and management. Although self-supply was the main water source at these study sites, alternative sources such as refill water and public piped systems played an important role in supplementing inadequate sup

Efforts to expand the delivery of water, sanitation and hygiene (WASH) services are occurring in the context of increasing pressures on the environmental and resource systems on which WASH services depend. As such, it is imperative to explore how sustainability considerations can be made central to WASH initiatives in ways that strengthen both service delivery and environmental systems. This article contributes insights from a transdisciplinary knowledge co-production process designed to bridge conceptual and practical priorities in a sectoral context – the WASH sector – with the intent to inform transformations at multiple levels from local practice through to global discourse. The co-production process was held online with a select group of WASH professionals from 10 countries. The design involved three components: engaging with worldviews and sustainability concepts; discussing the practical relevance of featured research studies in participant's professional roles; and co-creating ideas about desirable futures and transformation pathways. Findings from the process relate to its method, outcomes and implications for future knowledge co-production across four themes: (i) fostering self-reflection and engaging with purpose; (ii) considering sustainability across scales and contexts; (iii) generating ideas for individual and sectoral action; and (iv) reflecting on researcher power and considerations for future co-production processes. The case demonstrates the potential for co-production in a sectoral context to foster generative self-reflection, shared understandings and practical ideas for action towards sustainability transformations. Methodological insights suggest that future knowledge co-production proponents could beneficially emphasize purpose, work across scales and contexts, and take a reflexive approach to power.

Already climate-related hazards are impacting sanitation systems in Indonesia and elsewhere, and climate models indicate these hazards are likely to increase in frequency and intensity. Without due attention, to maintain existing progress on Sustainable Development Goal 6’s target 6.2 and to increase it to meet ambitions for 2030 will be difficult. City governments need new forms of evidence to respond, as well as approaches to enable them to consider sufficient breadth of strategies to adapt effectively. This paper describes a co-production research process which engaged local governments in four cities in Indonesia experiencing different climate hazards. Local government engagement took place across three stages of (i) inception and design, (ii) participation as key informants and (iii) joint analysis and engagement on the findings. We adapted and simplified a risk prioritisation process based on current literature and employed a novel framework of a ‘climate resilient sanitation system’ to prompt articulation of current and proposed climate change adaptation response actions. In contrast to many current framings of climate resilience in sanitation that focus narrowly on technical responses, the results paint a rich picture of efforts needed by city governments across all domains, including planning, institutions, financing, infrastructure and management options, user awareness, water cycle management and monitoring and evaluation. Local government commitment and improved comprehension on the implications of climate change for sanitation service delivery were key outcomes arising from the co-production process. With strengthened policy and capacity building initiatives from national level, this foundation can be supported, and Indonesian city governments will be equipped to move forward with adaptation actions that protect on-going access to sanitation services, public health and the environment.

The emergence of gender-transformative approaches in the international development sector has ushered in a new paradigm for gender and development, refocusing on core feminist principles. This rise has paralleled the growth of transformative research and a strengthened emphasis on social transformations in the field of international development practice. Gender-transformative approaches aim to reshape gender dynamics by redistributing resources, expectations and responsibilities between women, men, and non-binary gender identities, often focusing on norms, power, and collective action. In this paper, we trace the history of gender-transformative approaches (1990 to March 2022); explore the breadth of applications in development described in both grey and academic literature; and identify five principles to guide future gender-transformative approaches with a focus on interventions. We hope that these clarifying principles will make the rich conceptual contribution of gender-transformative thinking relevant to a broad audience of researchers and practitioners and provide a basis for further academic debate and refinement.

Introduction: Equal access to water, sanitation and hygiene (WASH) for all requires leadership that prioritises and drives inclusion. Inclusive WASH also presents opportunities to advance equality more widely, with WASH a pathway to meaningful participation and empowerment for diverse groups. The concept of gender-transformative leadership-which connects ideas of leadership to transformative models of gender equality in development theory that challenge prevailing power structures-is a relevant lens for exploring inclusive WASH. This article shares findings and reflections from a positive deviance study that aimed to investigate gender-transformative leadership in the WASH sector to explore (i) the factors shaping gender-transformative leadership and the characteristics of gender-transformative leaders; (ii) actions taken by gender-transformative leaders; (iii) the types of outcomes achieved; and (iv) ways to strengthen gender-transformative leadership. Methods: The study was undertaken during the COVID-19 pandemic and consisted of interviews with 19 leaders in Bhutan, Lao People's Democratic Republic, and Nepal. We developed a conceptual framework which considers leaders' (i) personal values and traits; (ii) leadership styles; (iii) actions; and (iv) outcomes, influenced by a range of (v) enabling factors and barriers. Results: Leaders' personal values and traits included a strong learning orientation, social justice values, humility, courage, and altruism. Leadership styles were primarily empathetic, with leaders guided by a mission to lead by example and pursue equality in their professional and personal lives. Exploration of actions and outcomes revealed a range of inclusion-oriented WASH activities responding to pandemic-related challenges, with associated potential outcomes in shifting norms. However, validation of outcomes was not possible due to the study timeframe and complexity of tracing complex social change in a positive deviance study reliant on self-r

Abstract Multi-stakeholder engagement is critical for making progress towards Sustainable Development Goal (SDG) 6 ‘Ensure access to water and sanitation for all’, which is currently off track to be achieved by 2030. The aim of this paper was to investigate mutual accountability and multi-stakeholder platforms in the WASH sector in a diverse range of countries. Data were collected by Sanitation and Water for All (SWA) Research and Learning Constituency partners and collaborators in five SWA member countries: Bangladesh, Indonesia, Kenya, Peru and Somalia. Data collection involved document review, key informant interviews and workshops, and an online questionnaire. Across all the case study countries, there were no clear examples of mutual accountability mechanisms being widely used in the WASH sector. However, the findings indicate that some of the case study countries have active WASH multi-stakeholder platforms involving a range of actors from government, civil society and the private sector; however, these typically function as coordination and communication platforms rather than supporting mutual accountability. Other case study countries did not have multi-stakeholder platforms involving a diverse range of actors, and instead had platforms established for single stakeholder groups such as the private sector or civil society, leaving certain groups out of activities. Overall, the study highlights the importance of establishing strong multi-stakeholder processes and platforms that bring together a range of actors including government, civil society, private sector, research actors, and WASH external support organizations. Such platforms could provide a foundation to enable mutual accountability between these actors by providing a space to set commitments and monitor progress and have potential to strengthen WASH systems both nationally and globally.

Abstract Limited piped water services in low- and middle-income countries (LMICs) are likely to increase the use of multiple water sources, impacting access to safely managed water. The aim of this study was to analyze monthly variations of households' water source preferences in three subdistricts in Bekasi, adjacent to the capital city of Indonesia, through a monthly telephone survey of 87 households during 12 months. Households with 1, 2, and 3–4 drinking water sources formed 70, 27, and 3% of the 755 total responses, respectively. Of the 53 households that completed at least 11 of the 12 monthly surveys, around 32% of households resorted to other water sources as an alternative for drinking water and other domestic purposes. Households switched from borehole water to bottled water for their primary drinking water in the wet season but still used borehole water as their complementary source. Unimproved source use as primary drinking water also increased during the wet season from 6 to 8%. Monitoring and risk assessment of water sources need to consider the use of multiple water sources while balancing out the limited resources to protect the population, especially the vulnerable, from unacceptable health risks.

Despite climate change being a major concern for the sanitation sector, rural sanitation remains neglected in the wider discussions of climate impacts on WASH services. Also, the voices of vulnerable individuals, households, and communities who are experiencing the effects of climate change in relation to sanitation issues are missing. This learning brief presents learnings from a practitioner’s experience of integrating climate risk considerations into a Community-Led Total Sanitation (CLTS) programme. The interventions were piloted across three districts of Savannakhet province with a focus on villages that have frequently experienced heavy rainfall and flooding in the past. The learning brief is intended to provide inspiration and ideas to WASH experts and practitioners with interest in integrating considerations of climate change into rural sanitation programming.

This paper presents the experiences of two household sanitation subsidy initiatives piloted by SNV and WaterSHED targeting poor households in rural Cambodia. Each initiative offered eligible households a subsidy to help manage the upfront costs of constructing new pour-flush latrines. Subsidy uptake by households was limited by affordability of the required household contribution, insufficient time for households to mobilise funds, and unavailability of land. However, when taken up, the subsidies also often mobilised significant household investment. Overall, these experiences point to the need to understand how poor households respond to subsidy opportunities and to adapt subsidy mechanisms accordingly.

Transformative research and evaluation both aim to foster social change as part of the inquiry process, often leveraging participatory and tactile methods with an advocacy objective. One such approach is participatory photography which engages marginalized individuals in image creation and includes activities such as photovoice and photo-elicitation. This article considers opportunities to strengthen the transformative potential of participatory photography activities within the water, sanitation, and hygiene (WASH) sector. The research comprised two components: 1) a systematic literature review of participatory photography activities in the WASH sector (n = 32) and 2) an empirical case of a photovoice evaluation of a staff-focused gender mainstreaming intervention in Cambodia (n = 20), including a structured survey, structured observations of the evaluation process, and three participatory reflection workshops with program leadership. Drawing on the two components, we reflect on the extent to which photography-based approaches in the WASH-sector have been transformative. Our findings indicate that transformative potential can arise from participatory photography’s process and outcomes. The research identified opportunities for the WASH-sector to strengthen participatory photography by 1) purposefully recruiting participants, 2) creating engaging orientation opportunities, 3) supporting participants in ethical image creation, 4) facilitating image interpretation, and 5) progressing photo-stories into advocacy. The study also considers how participatory photography can address gender inequalities inherent in photography, hence seeking gender-transformation. While these insights were derived for participatory photography activities in the WASH sector, the findings and implications have relevance in other sectors that seek to investigate complex change and foster transformations.

Evaluations of gender equality initiatives in development programmes traditionally assess cognitive dimensions such as knowledge, attitudes, and awareness; and often rely solely on women’s perspectives. Leveraging story-based evaluation methods, this article explores the assessment of complex gender-transformations and focuses on effective question prompts to elicit significant and meaningful narratives of change from both women and men. In collaboration with a development programme in Cambodia, a staff assessment process led to a set of criteria for considering the quality of respondent stories and testing the efficacy of four different question prompts (n = 176): verb-, value-, sphere-, and theme-based. Highlighting aspects of embodiment, the study suggests that verb-based prompts were the most effective at eliciting stories that reflect diverse experiences of both women and men in processes of gender-transformation. Findings from our analysis can support evaluators in balancing simplicity and specificity of questions in assessing the unique experiences of individuals undergoing complex change.