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Study Session 1  Understanding Exclusion from WASH in Ethiopia


Everyone, whoever they are, should have safe water for drinking, access to a toilet or latrine, and handwashing facilities. These services should be inclusive and available for all but, in practice, this is often not the case and many people are excluded.

In this study session you will be introduced to the key concepts of inclusion and exclusion in relation to water, sanitation and hygiene services. You will learn about the people who are most likely to be excluded in Ethiopia and the reasons why. You will also learn about the policies and programmes at both international and national levels that provide the framework for inclusive WASH in Ethiopia.

Learning Outcomes for Study Session 1

When you have studied this session, you should be able to:

1.1 Define and use correctly all of the key terms printed in bold. (SAQ 1.1)

1.2 Identify the people who are most likely to be excluded from WASH services in Ethiopia. (SAQs 1.2 and 1.3)

1.3 Explain the reasons why people are excluded from WASH services. (SAQs 1.2 and 1.3)

1.4 Outline the relevant legal frameworks in international and national contexts. (SAQ 1.4)

1.1 Exclusion and inclusion in WASH

In Ethiopia, millions of people lack access to water, sanitation and hygiene (WASH) services. Lack of access means insufficient, unsafe or distant water, unimproved latrines or open defecation, and inadequate facilities for washing. The three components of water, sanitation and hygiene combine to have a significant impact on human health (as illustrated in Figure 1.1) and on school attendance, productivity, well-being and general quality of life.

Figure 1.1 Image from the front cover of Ethiopia’s National Hygiene and Sanitation Strategy illustrating the importance of water, sanitation and hygiene for good health (MoH, 2005).

In 2015, less than half the total Ethiopian population of nearly 100 million was reported to have access to a basic water supply and only 7% and 1% respectively to basic sanitation and hygiene facilities (JMP, 2017). These data, for the population as a whole, show that the country has a long way to go to improve the availability of WASH services.

  • Imagine you are a young woman living in a rural area who does not have access to WASH services. How could this affect your daily life?

  • There are many possible effects but you may have thought of:

    • spending much of your time collecting water for the family and carrying a heavy jerrycan on your back
    • not having enough water for personal or family washing and household chores
    • waiting until dark to go into the fields to find a place to defecate and feeling vulnerable to attack
    • being unable to wash your hands after defecation or before preparing food
    • suffering from frequent diarrhoea caused by contaminated/unsafe water
    • finding it difficult to keep clean and to wash sanitary pads during your monthly period.

An important part of the challenge ahead for Ethiopia is to ensure that improvements in WASH services will reach everyone and that no one is excluded. Exclusion from WASH means a person or group of people are prevented from having access to water, a toilet or handwashing facility, or where access is very difficult for them. Different people have different needs, but this is not always taken into account by planners, designers and decision makers. When we talk about exclusion, we are talking about people who are left behind in terms of getting access to WASH because their needs have not been recognised or considered important.

Inclusion is the opposite of exclusion. Inclusion in WASH means that everyone has access to safe WASH facilities and the needs of all members of a given community, regardless of who they are and their circumstances, are fully addressed in the design, planning and implementation of WASH services. Everyone benefits from inclusive WASH. To give one example, inclusive latrines in a school would have separate blocks for girls and boys, with flat, level paths and handrails for accessibility, with water and basins for handwashing, and appropriate facilities for menstrual hygiene management. Accessibility, in this context, refers to designs, structures and services that are usable (accessible) by people who have limited mobility (the ability to walk) or other disabilities.

It is important to realise, however, that the process of inclusion is not only about making sure that excluded people have access to services but also about helping them to participate fully in the decisions about those services (Gosling, 2010). If they are fully involved in the process their needs will be recognised and they can realise their rights to water, sanitation and hygiene.

There are therefore two aspects to inclusion: access to services and participation in planning and decision-making processes. It follows from this definition that it is possible to be excluded in a number of different ways. For example, some people may not have access because they are physically unable to turn a water tap or walk up steps to a latrine but others may be excluded because their opinions are not considered important and they are ignored by the people who make decisions.

1.2 Who is excluded?

The people most likely to be excluded are marginalised groups which are overlooked in the planning and programming of WASH services. Marginalised groups are people who, in the opinion of others, are considered to be insignificant or not important and as a result are confined to the outer limits, or margins, of society. They tend to be the poorest people in a community. You may also come across the terms vulnerable people or disadvantaged people used to describe these groups.

If you were asked the question ‘Who would have difficulty with access to a latrine or a public water point?’ your first answer may well be a person with a physical disability. You may have thought of a person who uses a wheelchair or someone who has poor eyesight. However, these are just two examples of the various types of disability that can lead to exclusion from WASH services. The UN Convention on the Rights of Persons with Disabilities (CRPD) defines persons with disabilities as ‘those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in a society on an equal basis with others’ (UN, 2006, p.4). (This definition and the meaning of ‘impairments’ and ‘barriers’, will be explored in Study Session 2.)

Another ‘group’ of people likely to be excluded actually make up half the population of the world! We are talking of women and girls. Women are frequently excluded from planning and decisions that affect their daily lives, even though they are usually the main users of WASH facilities. Traditional and cultural norms assume that men will be the ones with power and influence and consequently, the needs of women and girls are often overlooked. (The roles of women and men and gender issues in WASH are the focus of Study Session 3.)

In addition to these two main groups, other marginalised groups who may be excluded are:

Elderly people: As they get older, women and men may become gradually less able to walk and have increasing difficulty with high steps. In a latrine, they may be less able to squat over the hole.

Small children: WASH facilities designed for the average adult may not be accessible or safe for small children.

Pregnant women: During pregnancy, women may find it uncomfortable to squat and be unable to walk long distances.

People living with long-term illnesses including HIV/AIDS: As well as being physically weak, sick people may need more frequent washing of themselves, their clothes and bedclothes. People living with HIV/AIDS also often suffer from stigma and discrimination by their community.

People living in geographically remote and/or water-scarce areas: Some parts of Ethiopia, particularly in the east and south, have limited natural water resources. This restricts the availability of water for everyone in these areas including those with a nomadic life style.

People living in informal settlements: This group includes street children, slum dwellers and people living in areas where water and sanitation services are not available. Government policy makes it illegal to provide services in these settings.

People living in peri-urban areas and new settlement areas: Many towns are expanding rapidly. New settlement areas frequently lack WASH services because buildings have been constructed before the infrastructure of water supply, pipes, etc. has been developed and installed.

People engaged in marginalised occupations: Some activities such as traditional pottery, working with animal skins, and some textile work (locally called ‘shemane’) may be considered sub-standard and discriminated against.

People staying in refugee camps or institutions e.g. prisons: These places may lack adequate water supplies and sanitation services.

A very important point to remember is that people may belong to more than one of these groups, for example, disabled people include boys, girls, men and women of all ages and they may live in any of the disadvantaged areas identified above. Another point is that, for any individual, their situation may change as they get older or their health status changes.

1.3 What are the reasons for exclusion?

You will realise from the long list in Section 1.2 that there are many different reasons for exclusion. People can be excluded because of who they are, where they live, sociocultural reasons, lack of resources – and frequently a combination of these factors, as shown in Figure 1.2. The overlapping circles in the diagram indicate how there may be more than one reason for exclusion of any individual or group. The following sections explain each of these factors in turn.

Figure 1.2 Factors affecting exclusion of people from WASH services.

1.3.1 Individual and group attributes

Many people are excluded from WASH simply because of who they are and the fact that they belong to one or more of the groups identified in Section 1.2.

Design and construction of WASH facilities often does not take the needs of all individuals into account. For example, if you are a wheelchair user, you may be excluded because a latrine entrance has steps, or the door is too narrow, or the space inside is too small. If you are an elderly woman who cannot squat, you would have difficulty using a toilet without a seat. If you are a small child you may not be able to reach the water taps at school if they have been placed too high. There may also be problems with the route that people take when walking to and from a facility. In many cases, when new water and sanitation facilities are built, the path is not made part of the contract and so the builder does not include it in the construction work.

  • Consider a water point constructed in a steep-sided gorge with a narrow and uneven path leading to it. Which groups of people would not be able to collect water from this facility?

  • Elderly people, persons with disabilities, pregnant women, and people who are ill may not be able to access the water point.

(The reasons how and why personal attributes including ability and gender can lead to lack of accessibility and other forms of exclusion are discussed further in following study sessions.)

1.3.2 Location

The geographical location of the place where you live is a significant factor. People residing in water-scarce areas are excluded mainly because of the unavailability of water resources (surface or ground water). There are also places where there is water resource potential but the site is remote and hard to reach. Lack of appropriate technology and land ownership rights are also important issues in some locations. The exclusion in these cases affects everyone in that location, not just people with disabilities or other marginalised groups.

1.3.3 Attitudes of other people

One of the reasons for exclusion is associated with social traditions and the cultural beliefs of the wider community. Some of these attitudes are gradually improving but this is an underlying cause of exclusion of several groups and can be challenging to try to change.

Some people believe that a person with a disability is a reward for a family that broke the law of God or man, or that they are possessed by an evil spirit (Lema, 2015). They keep their children away, thinking that the evil spirit could affect them. If someone has a disability, they may be hidden away by their own family in a secret place and kept out of sight for fear of social stigma and prejudice. As a result, persons with disabilities are marginalised, isolated and prevented from joining in with family and community level engagements and social gatherings.

Attitudes to the role of women in society may make it more difficult for them to speak up and express their opinions about the design or implementation of WASH services, so they are not included in decisions that deeply affect them.

People living with HIV/AIDS often suffer from prejudice and stigma for two basic reasons, one is the incorrect assumption that they are engaged in activities not appreciated by the wider community (e.g. people assume they are sex workers); secondly, people are afraid of the disease and ignorant of how it is transmitted from one person to another. Similar prejudice and exclusion also affects people suffering from other diseases, such as leprosy and some skin conditions.

1.3.4 Available resources

Providing new WASH services will always require funds for planning, design and construction. The budget available to the provider (e.g. government, regional bureau, charity) will be limited and costs need to be kept to a minimum. This can lead to intentional exclusion if the additional cost of, say, a handrail or ramp is considered to be too great.

Other limitations apply specifically to civil society organisations (CSOs) and nongovernmental organisations (NGOs). The Charities and Societies Proclamation of 2009 (FDRE, 2009a) restricts their role and states they must spend a minimum of 70% of their budget on programmes and no more than 30% on administration. International NGOs are not permitted to engage in rights-based advocacy or work to support the empowerment of vulnerable people and for local NGOs and CSOs this work is considered to be an administrative cost and limited by the 30% rule.

The word ‘resources’ not only refers to budgets and funding but also includes human resources. Sometimes exclusion is a result of lack of knowledge and appropriate training of the people who work for the WASH providers. They may not be aware of the various needs of different people on the one hand, or know about appropriate inclusive design, on the other. Inclusive design (also known as universal design) is design of any product or service that makes it accessible to and usable by as many people as possible, regardless of age, gender and disability. If the design is not inclusive from the outset, this may result in unintentional exclusion where the designed service is inaccessible to some people because the service providers did not have the necessary knowledge and skills.

Financial resources are an issue for service users as well as providers. They may also have limited funds so affordability is another important factor to consider. The majority of rural communities in Ethiopia do not have the resources to cover the construction costs for sanitation or the maintenance costs for water supply for the community as a whole, so inclusion of marginalised groups may not be high on their list of priorities.

1.4 Benefits of inclusive WASH

When WASH facilities are inclusive, everyone in the community benefits especially disabled people of all ages, older men and women, pregnant women, sick or injured people, children, and also the carers of these people. There are social benefits such as better health, improved cleanliness, and increased dignity because people do not have to feel the shame and dishonour of open defecation. Educational improvement is another social benefit. Inclusive WASH in schools results in better attendance and therefore improved educational achievements by the pupils. Case Study 1.1 tells the story of the benefits of inclusive WASH experienced by a pupil at a school in Addis Ababa.

Economic benefits such as increased productivity follow on from the improvements to people’s health and well-being. Healthy people are more productive in their work and do not need to spend money on medicines, which also contributes to higher living standards.

Case Study 1.1 Eniyew Yisma

Eniyew Yisma had polio when he was young which affected his mobility. He uses a wheelchair but can do anything anyone else can do while sitting down. He was a pupil at Bruh Tesfa Primary School in Addis Ababa when new accessible toilet and handwashing facilities were installed (Figure 1.3). Before the new toilets were built, Eniyew had suffered because he could not use the old traditional latrine by himself and had to go home to use the toilet. Most of the time he would skip his food during the day to avoid the problem while at school but sometimes, if he had diarrhoea, he had to ask his class mates to help him use the toilet. He felt bad about himself and his condition but this all changed when the new facilities were built. He could use the toilet on his own, he did not have to ask for help, he could eat his food when he wanted, he felt more dignified and his self-esteem was greatly improved.

Figure 1.3 Eniyew Yisma outside the school latrine block. Note there are no steps and the entrance is wide so there is plenty of room for his wheelchair.
  • Lattu is an old woman who has very poor eyesight. She used to walk to some bushes quite far from her home to find a place for defecation. A family member had to walk with her to guide her but sometimes she would take the risk of going alone. Then a new latrine was built within 15 metres of her home with a path leading to it marked with white stones at the sides. What do you think are the benefits for Lattu?

  • She can use the toilet whenever she needs to and can go there by herself without help. She has privacy, added dignity and better quality of life. The time spent looking for a place to defecate is saved and the risks of walking on her own such as tripping over and falling, or possible attack by an animal, are no longer a problem. There are also benefits for her family who no longer have to accompany her.

1.5 International frameworks

Awareness of the importance of inclusion in WASH has grown throughout the world in recent years resulting in new initiatives at both international and national levels. At international level, the United Nations (UN) has produced several proclamations, protocols and resolutions that promote the principle of access for all. These UN initiatives provide a framework for policies at national level. If individual countries choose to ratify (approve) a specific international agreement, the government has a responsibility to incorporate its principles within their national policies and programmes.

Two of the most significant UN frameworks are the Sustainable Development Goals and the Convention on the Rights of Persons with Disabilities.

1.5.1 Sustainable Development Goals

The Sustainable Development Goals (SDGs) provide a global agenda for change. They were agreed by the members of the United Nations in 2015 with the aim to achieve them by 2030. There are 17 goals covering different aspects of social and economic development (Figure 1.4).

Figure 1.4 Sustainable Development Goals (adapted from UNDP, n.d.).

Many of the goals focus on reaching the vulnerable and emphasise the principle of equality among all people regardless of who they are. As you can see from Figure 1.4, SDG 5 is about gender equality and SDG 6 is about clean water and sanitation. The wording of SDG 6 is to ‘ensure availability and sustainable management of water and sanitation for all’ (UNDP, n.d.). The phrase ‘for all’ makes clear that persons with disabilities and other marginalised groups must be included.

1.5.2 UN Convention on the Rights of Persons with Disabilities

The UN Convention on the Rights of Persons with Disabilities (CRPD) aims:

  • … to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity (UN, 2006, p.4).

It recognises the challenges facing persons with disabilities in terms of their social, economic, political and personal life and encourages UN member states to address these challenges so that these people can enjoy every day of their life. Equality and non-discrimination, awareness raising, accessibility, access to information, and access to improved health are among the areas addressed. This convention was adopted by the UN General Assembly in 2006 and ratified by the government of Ethiopia in 2010.

1.6 National governance and policy frameworks

It may take several more years to achieve inclusive WASH in Ethiopia, but the country is laying the groundwork with legal and policy frameworks to help reach that goal.

1.6.1 Governance

The Ethiopian Constitution is the guiding legal document for enacting sector policies, strategies and programmes. It incorporates principles of equal access to basic services but also acknowledges provision is linked to the economy. Article 90 states ‘to the extent the country’s resources permit, policies shall aim to provide all Ethiopians access to public health and education, clean water, housing, food and social security’ (FDRE, 1995). There is no explicit reference to persons with disabilities or marginalised groups, but the phrase ‘all Ethiopians’ should be interpreted as inclusive of everyone. However, because of a widespread lack of awareness of the needs and rights of marginalised people, this interpretation is not always used in practice.

The Constitution also establishes the framework for gender equality by stating that the ‘Government shall ensure the participation of women in equality with men in all economic and social development endeavours’.

Responsibility for ensuring the rights of persons with disabilities, as defined by the CRPD, lies with the Ministry of Labour and Social Affair (MoLSA) and its line bureaus and offices at regional and district levels. MoLSA is expected to work with the focal persons in all branches of government to ensure disability mainstreaming in all sectors and programmes. Mainstreaming means ensuring that an issue or topic, in this case disability, is at the centre (in the mainstream) of consideration when developing and implementing policy and not left to one side or ignored. In addition to MoLSA’s leadership role, all ministries and bureaus have a responsibility to ensure inclusion of persons with disabilities in their work and budgets.

1.6.2 Policies and programmes

Many Ethiopian WASH sector policies were developed before inclusion was recognised as a priority. The Water Resources Management Policy, for example, was developed in 1999 and gives little space for inclusion although it does refer to gender issues and the full involvement of women (MoWR, 1999). It expects users to pay for the water they use and promotes no subsidy for household sanitation. This means that people who cannot afford to construct their own latrine or pay for water facility maintenance are automatically excluded from the service, which particularly affects people with disabilities because of the links between disability and poverty.

In the last decade or so the situation has changed and inclusion has been on the WASH sector agenda. This was reflected in the WASH Implementation Framework of 2011 which expanded on the phrase ‘for all’ by specifying this included ‘disabled, disadvantaged and low-income communities’ (FDRE, 2011). This was followed by the One WASH National Programme (FDRE, 2013) which promotes social inclusion including gender equity and inclusive WASH services.

Policies and proclamations in other sectors have also incorporated principles of inclusion, for example, public buildings and school WASH facilities must be accessible to persons with disabilities (FDRE, 2009b; MoE, 2015). In 2012, under the leadership of MoLSA, a ten-year National Plan of Action of Persons with Disabilities was published (MoLSA, 2012). This aims to promote and protect persons with disabilities and to ensure that they fully enjoy their fundamental rights, public services and any other opportunities for education and jobs. It also aims to ensure that people with disabilities will fully participate in different events and community engagement processes but unfortunately makes no specific mention of access to WASH services.

Summary of Study Session 1

In Study Session 1, you have learned that:

  1. All people regardless of their personal attributes and circumstances should be able to access water, sanitation and hygiene services.
  2. Inclusion means providing WASH facilities that are accessible to all and involving excluded people in planning and decision processes.
  3. Many different groups of people may be excluded from WASH and some people will belong to more than one group. Persons with disabilities face particular challenges with accessibility.
  4. Individual attributes, location, social and cultural beliefs, and limited financial and human resources are the major reasons for exclusion. These reasons overlap and some people are excluded for several different reasons.
  5. Inclusive WASH brings social and economic benefits to individuals and communities by improving health, well-being and productivity for the whole community.
  6. There are global and national frameworks that could be used as guidance to promote inclusive WASH facilities.
  7. The Ethiopian Constitution and other national policies require the equal participation of men and women in social and economic developments.
  8. The Ministry of Labour and Social Affairs and their regional, zonal and woreda offices have the lead role for matters relating to the rights of people with disabilities.

Self-Assessment Questions (SAQs) for Study Session 1

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions.

SAQ 1.1 (tests Learning Outcome 1.1)

Using the following two lists, match each numbered item with the correct letter.

  1. marginalised group

  2. inclusion

  3. mainstreaming

  4. inclusive design

  5. accessibility

  6. persons/people with disability

  7. WASH

  8. exclusion

  • a.abbreviation used to mean water supply, provision of latrines and facilities for handwashing

  • b.when a person or group of people are prevented from having access to water, a toilet or handwashing facility

  • c.making sure an issue is given due attention at all times and not left to one side or ignored

  • d.characteristics and features of structures and services that define whether they are usable by people with disabilities

  • e.people with long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their participation in society

  • f.when the needs of all members of a given community are fully addressed in WASH services

  • g.people who, in the opinion of others, are considered to be insignificant or not important

  • of a product or service that makes it accessible and usable by everyone

The correct answers are:
  • 1 = g
  • 2 = f
  • 3 = c
  • 4 = h
  • 5 = d
  • 6 = e
  • 7 = a
  • 8 = b

SAQ 1.2 (tests Learning Outcomes 1.2 and 1.3)

Fill in the spaces in the following sentences using the correct terms from the following list:

adolescent girls; anyone who cannot squat comfortably; informal settlement areas; persons with disabilities and older people; women.

  • a. In schools where there is no facility for menstrual hygiene management, ……………. are largely affected.
  • b. ………………….. are excluded if the water facility has high steps.
  • c. A toilet that lacks seat and handrails is not accessible to ……………….
  • d. In ………………….. WASH facilities are not promoted by the government as it is not legal.
  • e. Planning of WASH facilities often does not take account of the ideas and opinions of ………………….


(a) In schools where there is no facility for menstrual hygiene management, adolescent girls are largely affected.

(b) Persons with disabilities and older people are excluded if the water facility has high steps.

(c) A toilet that lacks seat and handrails is not accessible to anyone who cannot squat comfortably.

(d) In informal settlement areas WASH facilities are not promoted by the government as it is not legal.

(e) Planning of WASH facilities often does not take account of the ideas and opinions of women.

SAQ 1.3 (tests Learning Outcomes 1.2 and 1.3)

For each of the following people, consider the four main reasons for exclusion and explain in your own words why they might be excluded from WASH.

  • a.A woman who has very low income and lives in a remote rural community far from a water supply.
  • b.A man with HIV/AIDS living in a newly-built condominium on the outskirts of a large town.


  • a.The woman could be excluded simply because she is a woman and so not allowed to participate in community processes, such as decision making about WASH services (personal attributes and social attitudes). She has a low income and so may not be able to afford the water tariff or to pay for a pit latrine (affordability). She lives in a remote rural area a long way from a water supply, so fetching water would be difficult and time consuming (location).
  • b.Some new development areas do not have the infrastructure for a water supply and sanitation (available resources) so people have to depend on public water points and toilet blocks (location). A man living with HIV/AIDS is likely to be shunned by neighbours and others in the community which could make it difficult for him to use shared facilities (personal attributes and social attitudes).

SAQ 1.4 (tests Learning Outcome 1.4)

Name two international and two national policies or frameworks that support the principles of equality for all people and inclusion for marginalised groups.


International frameworks: Sustainable Development Goals; United Nations Convention on the Rights of Persons with Disabilities.

Implementation Framework 2011; One WASH National Programme 2013; National Plan of Action of Persons with Disabilities 2012.