“You don’t expect a man to make good policies that affect women’s health”: Exploring barriers and opportunities to gender transformative policymaking and programming in Ghana’s health and WaSH sectors.

Abstract

Gender inequality is a prevailing global issue, particularly in Sub-Saharan Africa (SSA), a region highly influenced by patriarchal structures. Gender, a socially constructed concept that encompasses the roles, behaviors, customs, norms, and characteristics identified with men and women, significantly influences life choices, including those associated with health and wellbeing. In an attempt to perform socially ascribed gender roles in SSA relating to Water Sanitation and Hygiene (WaSH), women's health and wellbeing are substantially, typically adversely, impacted. Despite efforts by policymakers and other stakeholders to address gender inequalities in health and WaSH these issues persist. These efforts have been criticized for either lacking a gender focus and/or not deliberately addressing the root causes of gender inequalities or often only focusing on infrastructure access. There have been calls to adopt the Gender Integration Framework (GIF)1 to assess how gender policies address gender norms and inequalities from policy formulation to implementation, and the impacts of these policies in transforming harmful gender norms. Ghana has made progress in formulating gender-related policies and programs in both the health and WaSH sectors; however, gender inequalities persist, especially in rural communities. While research has begun to examine gender-transformative policymaking in the health and WaSH sectors, there has been a limited focus on the perspectives of stakeholders to ascertain their level of awareness of gender-transformation and the opportunities in adopting gender-transformative approaches to address these challenges on the ground. Through a qualitative case-study research design, the thesis begins to fill this gap by exploring stakeholders' knowledge and perspectives about gender transformation as well as identifying barriers and opportunities to gender transformative policymaking and programming in Ghana's health and WaSH sectors. Specifically, the research addressed the following objectives: (1) To explore stakeholders' knowledge and perspectives of gender transformative policymaking and programming in Ghana; (2) To identify barriers to gender transformative policymaking and programming across Ghana's health WaSH sectors. (3) To explore the opportunities within existing government policies to break down barriers to women's empowerment in WaSH. Semi-structured interviews with stakeholders (n=30) in three districts in the Upper West Region of Ghana were conducted from July to August 2024. Participants were purposely sampled from government agencies (n=11), civil service organizations (n=7), and community leaders (n=12). Interviews were digitally recorded and transcribed verbatim for subsequent thematic analysis. The results revealed a significant awareness among stakeholders regarding gender-transformative policymaking and programming in Ghana's health and WaSH sectors. This awareness is attributed to their educational status and/or experience in gender-related fields. Despite the awareness, the findings showed a lack of consensus on what gender transformation entails, as stakeholders approach gender-transformative policymaking and programming based on their institutional goals and visions. Participants also revealed institutional and community-level barriers impeding the full potential of gender transformative policies and programs; these included, at the community level: socio-cultural, financial, logistics, monitoring and evaluation, and corruption. Institutional barriers included: bureaucracy, political commitment, women’s representation, and consultation. The National Health Insurance Scheme, Community-based Health and Planning Services, Community Water and Sanitation Program, and Mother-to-Mother Support Initiative were identified as existing gender-transformative policies and programs with significant potential to transform harmful gender norms and empower women. The results of this thesis research contribute to the broader discussion on gender-transformative policies and programming and their potential to address gender inequalities in health and WaSH. They also contribute to the evidence of the shortfalls of the identified gender-transformative policies and programs, which can inform policy and practice review. Future research that can build on these results includes women empowerment in WaSH, gender norms and gender-based violence, among others.