The need of the hour: Providing water in shared toilet facilities for menstrual hygiene management in urban India

India's efforts to achieve universal access to sanitation and Sustainable Development Goal 6 to provide sustainable sanitation services for all have been defined by the Swachh Bharat Mission (SBM), a nationwide programme across rural (Gramin) and urban geographies, which has led to the elimination of open defecation through individual and shared toilet provision. The success of the scheme is reflected in the construction of 10 million household toilets across the country and 600,000 villages across the country declaring themselves open defecation free (Sarkar & Bharat 2021; Ministry of Jal Shakti 2024). The second phase of the SBM (SBM 2.0) seeks to sustain India's open defecation-free (ODF) status by continuing to expand access to sanitation, while also improving septage and wastewater conveyance and treatment and solid waste management to make cities ‘garbage free’ (MoHUA 2021). While viewed as a ‘limited’ level of service according to the WHO Joint Monitoring Programme, shared sanitation, including community toilets (CTs) and public toilets (PTs) as well as household toilets and compound toilets that are shared with other households (Evans et al. 2017), supports in the progress towards achieving the goal of an ODF India.

CT facilities are provided in or near community areas for a defined group of residents or an entire community or settlement, often in low-income or informal settlements where families cannot afford or often lack space to build an individual household toilet. PT facilities, found in markets, train stations, and other public areas, serve floating populations, including those who are in transit, people who work close to the facility such as vendors, and users of CTs whose facilities may be unclean or closed (MoHUA 2018). Yet, CTs and PTs in Indian cities, including those provided through the SBM, continue to face a lack of reliable electricity for adequate lighting, overflow of raw sewage, blocked latrines due to improper disposal of sanitary pads (Sanitation Technology Platform 2016), a lack of doors on cubicles for privacy, and poor ventilation (Koppikar 2017), which must be addressed as part of national efforts to supporting women and girls' menstrual hygiene management (MHM) needs in India. The SBM has placed special emphasis on gender and addresses the inadequate design of shared toilets and their poor maintenance and location for women and girls (MoHUA 2018). One key challenge to address is the limited availability of water in shared urban sanitation facilities, which is vital to supporting menstruating girls and women¹ from menarche (Crofts & Fisher 2012) to perimenopause as women approach the end of menstruation (Bhakta et al. 2021) to wash themselves, reusable menstrual products, and sanitation facilities as required (Sommer & Sahin 2013; UNICEF 2019). A lack of access to water in India's shared urban toilets is hampering efforts to address the MHM needs of women and girls within the 14.74% of India's urban population who currently have ‘limited’ access to sanitation and rely on shared toilets (WHO & UNICEF 2023), 62% of whom use reusable menstrual cloths and cannot wash them properly in shared toilets (Sinha & Paul 2018) due to being unable to afford commercial products (Ghosh & Bose 2021). A total of 48% of Delhi's slum residents rely on CTs built through the SBM (TERI University 2017) that often lack adequate water supply (Chauhan 2017), while in the slums of Mumbai, 78% of CTs have no access to water (Koppikar 2017). As India faces rapid urbanisation and with a projected 50% of the population estimated to be living in cities by 2030 (TERI University 2017) squeezing available space for building household toilets even further, the availability of water for MHM in shared urban toilets is a priority, to support India's efforts to achieve Sustainable Development Goal 5 to ensure gender equality through supporting women and girls' sexual and reproductive health. Menstruation has been recognised as an issue to address through the SBM (Gramin) Guidelines (Ministry of Drinking Water and Sanitation 2017), particularly through the Menstrual Hygiene Management Guidelines (Ministry of Drinking Water and Sanitation 2015), yet more focus is needed on menstruation in the SBM Urban Guidelines which only refer to toilets and bathing facilities ‘for women’ generally (MoHUA 2017). Ensuring that shared sanitation in India fully addresses the rights of menstruating women and girls requires a glance at the ‘need of the hour’, access to water at any time when needed. While ‘menstrual hygiene management’ encompasses the use of water for washing the body as required (Sommer & Sahin 2013) and washing facilities are key to good ‘menstrual health and hygiene’ (UNICEF 2019), these aspects of addressing women and girls' rights are seldom considered in the construction of shared toilets and their connection to regular water supply in India. Whilst it is estimated that 150 L of water per capita per day is needed for citizens living in India's metropolitan areas and megacities (CPHEEO 1999), the ‘standard’ quantity of water required for MHM to wash reusable materials, the body, and the toilet pan collectively has not yet been identified. Yet, the demand for 1–3 L per wash for anal cleansing (Tilley et al. 2014) can provide some indications of the amount of water needed by menstruating women and girls who use shared toilets.

Adequate facilities for MHM are also often lacking in schools and the workplace, and girls and women are more likely to stay at home while menstruating to use community facilities (MoHUA 2018). Ensuring the availability of water in CTs and PTs in India's cities is a key to aiding the utilisation of the facilities by menstruating women and girls in the long term. This article draws on existing academic literature, national policy documents for the expansion of sanitation services, grey literature, and evidence through secondary data from urban India to provide a reflective commentary to outline policy recommendations for the provision of water supply in shared urban sanitation facilities to support menstruating women and girls in India and beyond through the SBM.

The MHM framework for the SBM states that WASH infrastructure is a key component in ensuring the dignity of adolescent girls and women (Ministry of Drinking Water and Sanitation 2015). Despite national efforts to improve sanitation in India, challenges remain around privacy; access to water, soap, and spaces for changing, washing, and drying reusable materials and underwear; and the dignified and safe disposal of menstrual waste for menstruating women and girls (MoHFW, NHM and RKSK 2019). Phase 1 of the SBM (Urban) programme recognised that gender-sensitive sanitation is critical for menstruation and good female reproductive health, in a context where women and girls commonly avoid using toilets due to cultural norms of female modesty and poor access to hygienic facilities and stay at home during menstruation to use household and CTs (MoHUA 2018). SBM 2.0 guidelines encourage urban local bodies (ULBs) to prioritise access to individual household latrines (IHHLs) for all households; yet, due to land constraints, CTs must be provided. The SBM 2.0 guidelines state that all CTs, PTs, and IHHLs constructed should be built in tandem with water supply arrangements in ULBs. The Government of India provides certification to cities for becoming open defecation free as ODF and further providing conveyance and treatment of waste as ODF+ and ODF+ +. Under this certification, there are seven mandatory criteria to be fulfilled, and the availability of water in CTs and PTs is given 20% weightage in assessments (MoHUA 2020). SBM 2.0 mandates provision of disposable menstrual pad vending machines and incinerator facilities, and adequate additional bathing facilities in CTs and PTs (MoHUA 2021) to address menstrual hygiene needs. The provision of the menstrual hygiene products is targeted primarily towards ‘aspirational’ CTs and PTs in tourist destinations where there is high footfall, yet this could be viewed as a mandatory feature for all facilities to ensure MHM needs are met for all women and girls.

Discussions on links between MHM and sanitation have focused on: How shared toilets are used as public spaces; how privacy (Scorgie et al. 2015) and taboos shape the design and use of sanitation (Sommer & Ackatia-Armah 2012); household sanitation as a determinant of MHM choices (Hennegan et al. 2018); and menstrual waste disposal (Elledge et al. 2018). Yet, while the role of water as part of sanitation provisions for effective MHM is largely neglected in these debates, Robinson & Barrington (2021) identified that the quality and availability of running water in and around latrines is a key determinant of menstrual waste disposal practices through their systematic review, in countries such as Bangladesh (Ahmmed et al. 2021), Malawi (Alda-Vidal & Browne 2022), and Uganda (Kemigisha et al. 2020). Most components of MHM require access to water and sanitation facilities to promote the hygienic management of menstruation (Torondel et al. 2022). Evidence from Wai Municipality, Maharashtra, and Greater Warangal Municipality, Telangana, suggest that the unavailability of water and resulting unhygienic conditions pose barriers to use of CTs and PTs by menstruating women dependent on shared facilities in India (CWAS, CEPT University 2022; UNICEF et al. 2018) despite a mandate through the SBM for CTs and PTs to be built in tandem with water supply arrangements in cities (MoHUA 2021). Use of water in toilets for MHM is also determined by the product being used and reproductive life stage. The availability of water for handwashing in the toilet block may suffice for women and girls who use disposable products. Reusable products, however, require washing with larger volumes of water which are also able to meet bathing needs. Water supply for bathing areas in shared facilities warrants attention. Water and soap in toilet cubicles in shared urban toilets are essential for menstruating women and girls to be able to wash their hands, bodies, clothes, and reusable menstrual products (UNICEF et al. 2018; Adams et al. 2021) at any hour of the day or night. This article focuses upon how water in shared urban toilets in India can support the use of reusable products by the majority of women and girls of reproductive age, and recognises how women experiencing heavy periods, such as during the perimenopause, require sufficient additional water to wash themselves and remove menstrual blood stains from toilet slabs and washing areas (Bhakta et al. 2021). Water is particularly important for female users of shared toilets in India, where in states such as Chhattisgarh, pit latrines are more socially accepted than WCs and require water to flush manually (Mahon & Fernandes 2010). Water for MHM does not need to be safe to drink nor does it need to be piped (Loughnan et al. 2016), but should be safe enough for women and girls to reduce the risk of thrush and transmission of hepatitis B through handwashing. PT and CT facilities are ‘female friendly’ when water and soap are available, ideally within the toilet stall or a dedicated stall, but within the toilet block itself. Access to water through a tap or bucket storage for washing the body or menstrual materials inside cubicles is an essential feature of female friendly PTs and CTs, which should be constructed close to water supply networks, drainage, and sewer systems (UNICEF et al. 2018).

In India, a large number of menstruating women and girls need water in shared toilets to wash frequently and wash and reuse menstrual cloths (Dasgupta & Sarkar 2008). Challenges remain particularly in rural areas with ensuring the reusable material is well sanitised, as they are often washed without soap in unclean water and dried indoors away from sunlight and open air (MacRae et al. 2019), leading to urogenital infections among women and girls in states such as Odisha (Torondel et al. 2022). An intervention in this study to provide piped water within the toilet stall or bathing facility to households in 45 villages resulted in women washing their menstrual absorbents within the stall five times more often than women in a separate control group (Torondel et al. 2022).

Adequate water supply along with lighting and proper cleaning is a critical feature that is needed in shared toilets in India. In CTs, this extends to provision of facilities to wash clothes (MoHUA 2018). India has officially declared itself ‘open defecation free’ since the end of the first phase of the SBM in 2019. Yet in reality, land and space constraints continue to prevent 20% of urban households from building toilets at home and therefore practise open defecation in India, highlighting the importance of constructing CTs to address their needs (MoHUA 2017), particularly in slums where increased public investments are needed in sanitation provision to crowd out the effects of private investment (Armand et al. 2020). Evidence shows that access to water in CTs and PTs continues to be lacking in India. In 2017, it was estimated that almost 60% of rural CTs built through the SBM lacked access to water (Chauhan 2017), partly because water-intensive toilets have been built in areas of water scarcity, rendering many facilities unusable (Dutta 2017). In urban areas, the focus of this article, a lack of water in CTs and PTs in poorer parts of cities including Bhopal (Biran et al. 2011), Mumbai (Koppikar 2017), and Delhi (Chauhan 2017) has deterred people from using them. A lack of access to clean water in sanitation facilities has been found to contribute to psycho-social stress among women in urban slums in Odisha (Sahoo et al. 2015). Enough water supply is essential to ensuring women and girls in India can use PT and CT facilities to maintain menstrual hygiene.

Women are a central component of the second phase of the SBM, with emphasis being placed on engaging with women in the process of expanding access to sanitation, encouraging women-led self-help groups, and notably, paying attention to the sanitation needs of urban poor women (MoHUA 2021). As India moves forward to achieve the goals of the SBM, access to water in shared urban toilets for MHM should form part of the strategy for gender-sensitive approaches. Providing water in urban CT and PT facilities in India's expanding cities is a key to addressing the ‘need of the hour’, to ensure women and girls can meet their MHM needs effectively, as and when needed, and fully realise their rights to sanitation services. While access to water in shared sanitation according to norms for water quantities needed during menstruation will improve menstrual hygiene practices and the reproductive health of female users, it will also contribute to achieving the goals of both phases of the SBM to improve access to urban sanitation for poorer women and girls particularly and to reduce menstrual waste in cities by providing sufficient water for sustainable MHM through use of reusable products.

Constructing shared urban toilets in India that are connected to water supply or have clean water ‘available’ such as in a bucket in the shorter term could ensure good reproductive health among women and girls. Guidance for supporting MHM is largely provided through guidelines for SBM (Gramin) for rural areas, and specifies the need for water in girls' toilets in schools. These guidelines for MHM need to feature in the strategy for SBM (Urban), and include availability of water as a universal feature of sanitation, to support poorer women and girls, as well as transient and working populations who particularly rely on them, as well as menstruating women and girls overall.

If reusable products can be washed easily in shared urban toilets, MHM practices among a significant proportion of women and girls on low incomes in India who rely on reusable menstrual products will improve. Evidence from Pakistan has also demonstrated that women and girls were more likely to be able to manage their menstruation more easily and have a better quality of life if they had a water source near to their homes and toilets than those who did not, and also faced challenges where there was a lack of water in public facilities (Khalid 2023). Managing heavier menstrual bleeding intensities after giving birth or during the perimenopause will be easier if soiled menstrual products and clothes can be washed and changed as frequently in shared toilets as required on a 24-h basis, reducing the risk of infections such as thrush and hepatitis B among India's urban poor women and girls. Expanding guidance for SBM (Urban) remains limited to infrastructural recommendations for women and girls in general. The priority given to MHM-related facilities through SBM 2.0 is limited to ‘aspirational’ toilets under the ODF + and ++ certifications, which comprise just 25% of CTs and PTs, leaving the MHM needs of a large proportion of India's women and girls unmet. Moving forward, making water supply a universal feature across all shared toilets in India through SBM 2.0 will improve the reproductive health of women and girls.

In light of the lack of space and available land in India's growing cities to construct IHHTs, a large proportion of poorer menstruating women and girls will continue to use CTs and PTs as part of gender-sensitive sanitation services built through the SBM. PTs should have water available to serve the MHM needs of women and girls from the floating population who use the facilities in cities across India as and when needed. Water should be provided along with spaces for washing menstrual materials and bathing during menstruation, and discrete wastewater and solid waste disposal provisions in shared toilets.

While in the immediate term better disposal facilities in shared toilets are needed to support current trends of promoting the use of disposable MHM products, access to adequate water supply in CTs and PTs may increase the uptake and use of sustainable, reusable MHM products, reduce menstrual waste, and enable strides to be made towards reaching the goal of SBM 2.0 to make India's cities garbage free, as the need for menstrual waste management reduces over the long term. This requires behaviour change at a household level among the 36% of women and girls who use and dispose of 12 billion sanitary pads annually in India (MGSIC 2018). Awareness raising, an expansion of access to appropriate reusable products such as washable pads and menstrual cups, and hygiene promotion on using them safely, will need to complement the provision of water in toilets, to holistically support women and girls' reproductive health needs.

Existing norms provided through the Central Public Health and Environmental Engineering Organisation (1999) cater well for general water needs in India such as drinking, cooking, and bathing. Moving forward, the norms for water supply for shared toilets built through the SBM should consider how much water women require for MHM when using toilets. Further work is needed to estimate the increased demand needed during menstruation for washing materials and bathing, particularly for increased levels of menstrual bleeding at certain life stages such as postpartum and the perimenopause. Water supply norms should also be adequate for cleaning menstrual blood stains left in CT and PT latrine slabs and washing areas for women with particularly heavy menstrual periods (Bhakta et al. 2021). Norms for water supply for MHM in shared sanitation facilities will depend on how it is supplied. While there is a need for further research on this, informal discussions with water engineers have indicated that 3 L could be appropriate for a tap in the toilet, 2 L for a tap immediately outside, whereas 0.5 L could be a good approximation for water that needs to be carried (Reed, pers. comm. 2022).

The SBM has delivered toilets in homes and built shared facilities throughout states across the land. The programme has propelled a country-wide movement in the WASH sector to raise awareness of and to support the MHM needs of women and girls in India by providing hygiene promotion for adolescent girls in schools and facilitating access to sanitary pads. Further action is needed in India to facilitate ‘MHM plus’ responses, moving beyond hygiene promotion and the provision of sanitary pads, towards recognising the need for and providing water in shared public and community sanitation facilities, to address a niche water requirement for menstruating women and girls in India to wash themselves, reusable menstrual products, and changing spaces in the next phase of service expansion. The provision of water in shared urban toilets for MHM can be integrated into existing programming for the SBM and provide lessons for other countries to address this water need in the delivery of shared sanitation facilities.

Water features as part of the definitions of MHM and MHH, yet to date there is scant evidence about women and girls' experiences of using water, particularly in shared toilets, to meet their MHM requirements. This evidence is needed to support effective policymaking and programming for gender-sensitive shared sanitation facilities. Existing MHM programmes in India and beyond need to collect data on the challenges that menstruating women and girls face in the absence of water in shared toilets using participatory methodologies that are sensitive to local taboos around menstruation and raise awareness of these issues. Girls and women using shared toilets should be engaged to share their experiences of MHM when water is and is not provided. Data gathered should be used to develop norms for water supply in shared sanitation facilities to support the majority of menstruating women and girls.

The delivery of shared toilet facilities through national programmes should consider the importance of making water ‘available’ for MHM. In the shorter term, provision of sufficient water for washing, for example, in a bucket in toilet stalls, can ensure availability. Piped connections to shared sanitation facilities should be integral to long-term urban planning. City-level or state-level water and sanitation action plans should be expanded to include the continuous availability of water in public and community facilities to support MHM for the majority of users in the longer term. Lessons for shared urban toilets can be taken from the low-cost (₹45,000, or $565 USD) construction of the ‘Period Room’ facility in shared toilets in Lokmayna Nagar slum in Maharashtra, which includes running water (Arora 2021), and the ‘SHE’ buses in Pune, Hyderabad, and Kerala, which includes a shower, alongside other conveniences for breastfeeding (Saluja 2019).

Awareness raising of the importance of water for MHM in shared sanitation is a key. Primarily, greater emphasis is needed to encourage sustainable MHM among women and girls of reproductive age through hygiene promotion and education on the use of water to support good menstrual hygiene at different life stages, including during phases of menstrual irregularities such as the perimenopause (Bhakta et al. 2021), when bathing becomes a more pertinent feature of MHM, including within shared facilities which may require bathroom spaces to be provided. Hygiene promotion programmes should highlight the importance of water for MHM and enable women and girls to recognise their rights to water in shared toilets. Women and girls should be given a space to voice their water needs for MHM to policymakers to ensure that the expansion of access to PTs and CTs fully addresses their needs.

As shared sanitation facilities increasingly become landmarks in India's communities, mechanisms for monitoring the progress of making water available within them and the impact that it has on MHM can provide a spotlight on access to water as a neglected feature of PTs and CTs. Evaluation mechanisms can be integrated into existing assessment tools. Assessing the availability of water in PTs and CTs either piped or through a bucket as a provision is a start. Monitoring the regularity of piped water in shared toilets over a 24-h basis can help to evaluate whether there are sufficient provisions for ‘MHM plus’ requirements for women who need immediate access to water due to sudden onset of heavy bleeding, such as during the perimenopause. Female users of shared sanitation across different ages should be engaged to evaluate the impact of water provision on their MHM practices and reproductive health issues arising from poor menstrual hygiene. Examining the volume of menstrual waste generated from shared toilets where water has been provided as a menstrual hygiene intervention could provide indications of the uptake of reusable menstrual products that can be washed within the block, and the impact of water provision on MHM practices for menstruating women and girls. The extent to which facilities are connected to wastewater drainage could also provide indications of support for women and girls to safely dispose of and conceal blood-stained wastewater in contexts where menstruation is taboo.

Shared CTs and PTs will be an essential component of India's urban sanitation programme as cities expand, yet to date, the majority of shared facilities, as per the case across many parts of the global South, lack water supply. To meet SDG5, supporting menstruating women and girls reliant on shared toilets in high-density urban areas by providing access to water for washing themselves, their menstrual products and the facility, is a key. Water in shared sanitation can be viewed as the ‘need of the hour’, to support menstruating women and girls from menarche to perimenopause at all times, by being accessible when needed, to ensure their good reproductive health and reduce menstrual waste by promoting sustainable MHM. Providing water supply to shared sanitation does not require new programming. This can be achieved through current national sanitation programmes, by connecting water supply to newly built CTs and PTs in urban India and beyond in the next phases of service expansion, and making water available IN buckets where piped supply is part of long term planning in existing shared toilets, to address this vital, but neglected, aspect of MHM.

Moving forward, the interlinkages and experiences of using water for MHM in shared facilities have been under-explored. Research is needed on the use of water in shared toilets for washing menstrual products, blood-stained latrines and clothes, and bathing to manage menstruation. The creation of evidence-based norms for water for MHM can support existing programmes such as India's SBM to move beyond considerations for MHM in sanitation relating to taboos, privacy, and waste disposal, towards setting an example of highlighting water supply as a critical component of shared sanitation services globally.

The authors thank Prof. Meera Mehta for her useful comments on earlier versions of this paper.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.