Cash transfers, beneficiaries’ livelihoods, and co-responsibilities in the context of water and sanitation insecurity in Ghana Open Access

The Livelihood Empowerment Against Poverty (LEAP) is Ghana's premiere cash transfer program implemented in 2008 (Ministry of Gender & Social Protection (MoGSP) 2025). The program is designed to use cash transfers and access to social services as a catalyst to improve the welfare of the extremely poor and to foster long-term human capital development. LEAP is managed by the Ministry of Gender, Children, and Social Protection (MoGCSP) and seeks to empower the extremely poor population to ‘leap’ out of extreme poverty (MoGSP 2025). Beneficiaries receive cash grants ranging from GH¢256 (USD16.7) to GH¢424 (USD27.7) as of July 2024. LEAP is an unconditional cash transfer (UCT) program, meaning that beneficiary households receive cash grants without any conditions to satisfy. However, there are co-responsibilities for beneficiary households under the program to fulfill. These co-responsibilities of LEAP beneficiaries include education, health, nutrition, and savings households (Agyemang et al. 2014; Adjei et al. 2020).

Education co-responsibilities involve enrolling children aged 6–15 years in basic school (Primary School to Junior High School) and ensuring they achieve at least 85% attendance in each school term. For health, all household members are expected to improve their nutrition, especially children, by visiting healthcare centers frequently for growth monitoring. Beneficiary households are also expected to enroll in the National Health Insurance Scheme (NHIS), which is renewed annually. By fulfilling these responsibilities, beneficiaries can work toward addressing social risks and economic vulnerability (MMYE 2007), reducing intergenerational transmission of poverty in the long term (Hanlon et al. 2010). The overall aim is that as beneficiaries' lives improve, they will be able to undertake their co-responsibilities and exit the program.

However, while the program addresses economic hardship and poverty, beneficiaries grapple with severe challenges such as access to clean water, adequate sanitation, and proper hygiene (WASH) facilities. Safe drinking water, sanitation, and hygiene are fundamental to human health and well-being (World Health Organization (WHO) 2018). The United Nations (UN) Sustainable Development Goals (SDGs) framework includes a specific goal (SDG 6) for water and sanitation, aiming for universal access by 2030. Targets include achieving affordable drinking water, equitable sanitation and hygiene for all, and ending open defecation, with a special focus on women, girls, and vulnerable populations (United Nations 2019). However, in many parts of the world including the Upper West Region (UWR) of Ghana inadequate WASH infrastructure remains a threat to overall human health and development. WASH is a key area often overlooked and can hinder LEAP beneficiaries' ability to achieve their co-responsibilities and exit the program.

Funding for WASH is increasingly becoming a challenge in Ghana with a sharp drop of 62%, amounting to just 0.14% of gross domestic product (Ministry of Sanitation & Water Resources (MSWR) 2022). This is far below the committed 0.5% to WASH as outlined in the eThekwini Declaration, to which Ghana is a signatory. Currently, the WASH sector in Ghana heavily relies on donor funding, with donor contributions being over 70% of the sector's funding between 2019 and 2021 (MSWR 2022). With the declining trend in donor funding, Ghana is likely to fall short of the SDG 6 targets on water and sanitation. This failure will have a ripple effect on all the SDGs, particularly SDG 1 (no poverty), SDG 2 (no hunger), SDG 5 (gender equality), and SDG 3 (good health).

In the UWR, the poorest households utilize boreholes, wells, rivers, and dams as sources of water (Ghana Statistical Service (GSS) 2014). Government efforts to improve water accessibility in the region led to the establishment of a small-town piped water supply system (STPWSS) in some district capitals. In such cases, those who can afford the cost are able to connect from the STPWSS to their houses (Wa West District Assembly 2018) and this is a factor in assuring household water security (Bisung & Elliott 2018). However, the cost of connecting water hinders the ability of poor households to connect the water. This places households in a situation where they still have to depend on water from open and unimproved sources (Amosah et al. 2023). About 5,750 (32.40%) households in the district are without basic water services (Ghana Statistical Service 2024). In places such as the Wa West district (WWD), good sanitation practices have been neglected. The sanitary facilities in the district are severely inadequate, especially in terms of toilets. Consequently, it is common for people to defecate in the bushes or behind houses (GSS 2014; Wa West District Assembly (WWDA) 2018). According to the Ghana Statistical Service, about 15,432 (87%) households in WWD were without basic sanitation and still practice open defecation as of 2021 (Ghana Statistical Service 2024). Using cash transfers to promote WASH services is crucial as Ghana struggles to achieve the SDG targets. Therefore, using the LEAP as a case study, this research seeks to explore the perceived impact of WASH on beneficiaries' livelihoods and their health and education co-responsibilities.

This study is underpinned by the sustainable livelihood framework (SLF) developed by the Department for International Development to understand the role policies and institutions such as LEAP can play in improving livelihoods and reducing vulnerability such as those related to WASH. The SLF calls for the formulation of development activities that place people at the center, are responsive to their needs, and are able to encourage public participation (Serrat 2017). Key components of the SLF are the vulnerability context, livelihood assets, policies, norms, and processes, livelihood strategies, and outcomes (Serrat 2017).

In SLF, the vulnerability context includes external factors such as seasonal variations and shocks that affect livelihoods and are beyond individual control. For instance, millions of people globally are at risk of severe water scarcity periodically or throughout the year because of climate stressors such as rising temperatures, floods, and drought (Broyles et al. 2023). This affects water availability for domestic, sanitation, and hygiene purposes. Vulnerabilities in WASH exacerbate other social factors such as household income, physical access, and social exclusion of women, potentially undermining the objectives of social protection policies.

The framework identifies five essential assets upon which livelihoods are built. These assets are human, natural, financial, physical, and social (Department for International Development (DFID) 2001). The poor often must make trade-offs and choices about various livelihood assets. For example, with deficiencies in WASH facilities, women and girls most especially must make trade-offs and decisions about their education, health, and level of participation in social and economic activities due to water collection responsibilities.

According to the SLF, policies, norms, and processes have a direct impact on whether people can achieve a feeling of inclusion and well-being. In the Ghanaian context, national policies such as Ghana's National Water Policy and processes influence WASH access. Furthermore, cultural norms for instance influence WASH practices around the world (Kabir 2023). Additionally, gender norms in many cultures enable the belief that securing water is the sole responsibility of women and girls (Cooke 2010). Yet, time spent collecting water significantly impacts their health and education, and increases inequality (Bisung et al. 2015).

Since LEAP is a pro-poor program under the national social protection policies that provide cash grants as a pathway for enhancing people's well-being and inclusion, the theoretical concepts within SLF can be used to explain and understand how WASH may be impacting LEAP.

The approach encourages development practitioners to consider WASH as a potential hindrance to achieving social protection objectives and then incorporating WASH into social protection policies which entails taking actions such as the construction and rehabilitation of WASH infrastructure for livelihood improvement and poverty reduction.

Given that the study objectives are best achieved from in-depth exploration, we used a descriptive case study design to explore how WASH impacts the livelihoods and co-responsibilities of LEAP beneficiaries. The purpose of descriptive case studies is to ‘describe’ a phenomenon in detail in its real-world context (McDonough & McDonough 1997). Thus, participants were all purposefully sampled from LEAP beneficiaries for the study. We used in-depth interviews (n = 44) with women LEAP beneficiaries who had dependents and their dependent girls between the ages of 10 and 18. All the in-depth interviews were conducted in two communities in the WWD. A semi-structured interview guide was designed to collect information from study participants. The interview guide was designed in the English language; however, the interviews were conducted in Daagare (local language) and audio recorded. Interviews lasted between 25 and 30 min. Throughout the data collection process, we made observations and notes as participants described their experiences. The use of in-depth interviews relied on probing strategies to get deep and collect detailed data on the issue being studied (Robinson 2023). The probing strategy allowed the researcher to have a conversation about the impact of WASH on their LEAP co-responsibilities. Participants were recruited and interviewed between 15 November 2023 and 25 January 2024. The Western University Non-Medical Research Ethics Board (NMREB) and Queen's General Ethics Review Board provided ethical clearance for the study.

To ensure confidentiality, participants' identities and names were de-identified using the ‘Letter + Number’ strategy (Wang et al. 2024). In the results section of the study, quotes from the participants are accompanied by letters and numbers, including their age, to provide a clear understanding of the characteristics of the respondents. These alphanumeric codes assigned to the participants correspond to the sequence in which the interviews took place. For instance, ‘AW002, 59’ represents the second adult woman to be interviewed for the study and is 59 years old.

Thematic data analysis was conducted using a deductive approach (Alhojailan 2012). Transcription was done manually at a discourse level, with detailed transcription across all the audio recordings. The authors proofread all the transcripts to ensure accuracy and actual representation of women and girls' experiences. Transcripts were uploaded to NVivo 14 to organize the data and were manually analyzed using Gibbs's framework, which entails transcription and familiarization, code building, theme development, and data consolidation and interpretation. A coding scheme was developed from literature on previous research that focuses on WASH and its impact on women and girls. Codes for the coding scheme were also generated by reading a few transcripts to get a list of themes (Gibbs 2007). The themes were first independently reviewed by the authors and then reviewed together to identify further themes and include themes that might have been omitted. Inconsistencies, where identified, were reconciled. Respondents' narratives were then incorporated throughout the results section to illustrate key issues relevant to WASH and its impact on the co-responsibilities.

The characteristics of the study participants are provided in Table 1. Nineteen of the participants were less than 20 years old. Twenty of the participants had no formal education and 18 of them were married.

Table 2 provides a summary of the responses that emanated from the data analysis. This includes the diverse ways in which WASH impacts LEAP beneficiaries' livelihoods, health, and educational co-responsibilities.

The main source of livelihood in the communities is agriculture. However, the water challenge affects farm work productivity. The women and girls recounted spending less time on the farm for the reason that they had to look for water for their households.

A participant shared their experience on how inadequate water access impacted productivity and the yield they got at the end of the farming season.

Some of the participants engage in petty trading activities as a way of generating income to support their families. However, challenges with water access affected their sale. A participant detailed an account of the negative economic cost associated with limited water accessibility. She described how her customers leave when she is not available.

Women operating informal home-based businesses also described their economic losses resulting from inadequate access to water. Without a formal setup like a shop, a participant described how she depends on her home availability to provide hair braiding services to her customers. However, her absence in the house results in a loss of customers to other service providers.

Aside from WASH impacting beneficiaries' livelihoods, it also has a significant impact on their health and girls' education. Health and education co-responsibilities are expected to be performed under the LEAP program.

Limited access to WASH affects the performance of the health co-responsibilities mandated by LEAP. Participants indicated that affects their ability to practice good personal hygiene which is a key pillar in the co-responsibilities of staying healthy. In terms of hygiene, participants indicated that

A participant who is a mother described how limited water affects their ability to properly bath their children.

This quote above also gives a reflection on how water challenges force parents especially women who are largely responsible for the emotional health of their newborn children. It also highlights the trade-off between securing essential resources (water) and providing direct care to the child, which is another health and caregiving co-responsibility under social protection programs.

Still on hygiene, accessing sanitary pads was also challenging for the girls interviewed. Participants indicated that pads were available in the communities, but that cost remained a barrier to acquiring them. Participants indicated that a pack of sanitary pads was sold at GHC 18.00 (USD 1.2). The comment below indicates that most girls continue to use rags as sanitary items during the period of menstruation.

This was reiterated by one of the girls during the interviews.

Inadequate WASH facilities increase disease burdens among women and girls which has negative implication for the effective performance of their health co-responsibilities. Poor WASH increases exposure to pathogens that cause diseases like cholera and diarrhea which can reduce the ability of participants, especially their children, to stay healthy, leading to noncompliance with the obligations of the program.

This is reiterated by another participant.

Participants mentioned how inadequate access to water affects their food preparation which is directly linked to their health and nutrition co-responsibilities. Women need water to prepare meals for their children but when women and their families struggle to get water to prepare these meals, it compromises their ability to keep their children healthy and properly nourished. According to one of the participants,

With most water sources located outside the household premises, girls face substantial challenges balancing water-fetching responsibilities and their education. According to one of the mothers,

Going to school late attracts punishment and the girls end up doing various corporal punishments which inflict pain on the girls.

Another participant added,

Limited water facilities affect girls' academic performance. One of the women elaborated on how access to water negatively impacted her daughter's class performance.

Without reliable access to water, children face a greater challenge of completing their homework and concentrating on their studies. While discussing these impacts, one of the participants said that

Another woman confirmed this by giving the following account:

Participants stressed the profound repercussions of limited water access, highlighting its role in the punishments they receive for going to school late, and the detrimental impact on their ability to keep up in school. For some, these punishments received become overwhelming, resulting in dropping out of school.

The unavailability of sanitary pads resulted in a decrease in school participation. For some of the girls, inadequate access to sanitary materials became a barrier to regular school attendance.

The participants' responses vividly demonstrate how WASH conditions affect their livelihoods and their health, and educational responsibilities. Their insights highlight the interconnected challenges they face in managing their well-being and education in environments with insufficient WASH infrastructure. These stories emphasize the urgent need for better WASH facilities to promote better health and education.

This study explored the impact of WASH on LEAP beneficiaries' livelihoods and co-responsibilities. From the narratives of the participants, three key themes emerged, and each of the themes offered a unique perspective of the diverse ways through which WASH impacts beneficiaries. These themes are livelihood impact, impact of wash on health co-responsibilities, and impact of wash on educational co-responsibilities. WASH is very important for human health and well-being. It is key to achieving gender equality, good health, and better education outcomes.

In rural Ghana, women often have insecure livelihoods, and inadequate water access has been one of the contributing factors. Agriculture is the main source of livelihood in the WWD. Nonetheless, limited access to water affects productivity and the amount of time beneficiaries spend on their farms (Hejazi et al. 2023). For women and girls, spending less time on farms affects the size of land they can farm and plant crops on. This can make them food insecure at the end of the harvesting season because they will have little to harvest from these farms. Although some beneficiaries operate petty trading activities, the inadequate supply of water constantly interrupts their business, and many lose their customers especially those whose income generation levels depend on their availability. Similar findings are reported in the studies of Fonjong & Ngekwi (2014) highlighting how women's socioeconomic activities are dependent on water and how water scarcity prevents women from operating their economic activities in the Buea Municipality of Cameroon.

Our findings revealed that WASH impacts beneficiaries' health co-responsibilities. As part of health co-responsibilities, LEAP mandates that beneficiaries enroll in the NHIS, regularly visit health facilities for vaccinations and growth monitoring, and also maintain good health. The challenges that inadequate WASH presents have a significant impact on the execution of these health co-responsibilities (Ministry of Manpower Youth & Employment (MMYE) 2007). Without access to water, maintaining basic personal hygiene for the women and their household members including children continues to be a daily struggle. Healthy practices such as bathing are challenging when water is not available (Rhue et al. 2023). This lack of water access will hinder their regular visits to health facilities for vaccinations and growth monitoring programs as recommended by the LEAP program.

The emergence of menstruation as a serious problem related to WASH and its overall impact on LEAP beneficiaries is worth noting. Menstruation hygiene management (MHM) plays a significant role in the reproductive health and well-being of women and adolescent girls. The findings in this study show that some girls were using rugs and clothes as sanitary pads. Reasons for using the clothes and rags were ascribed to their inability to buy the pads at the prices that they were being sold which is consistent with the work of Kambala et al. (2020) who show that girls use pads when there is money available but resort to the use of clothes and blankets when there is no money to buy the pads. The use of the clothes is not recommended because the clothes and rags can easily get soaked and start to leak before the end of the day. The use of rags and cloths acts as a favorable environment through which infections such as bacterial vaginosis (BV), and vulvovaginal candidiasis (VVC) can be introduced to the body (Torondel et al. 2018). LEAP beneficiaries using rags as sanitary pads compromise their health and the attainment of optimal health as recommended by the program. The emotional and mental strain attached to the lack of water and sanitary items can result in missing important health sessions that can impact their health (Bisung & Elliott 2017).

Persistent illness, such as diarrheal diseases, resulting from drinking unsafe water affect participants’ health co-responsibilities. Diarrhea can cause children to experience retarded growth and cognitive functioning (Lauer et al. 2018; Batool et al. 2023). In the study, participants reported difficulties in preparing meals due to poor access to water. This is consistent with findings in a study by Batool et al. (2023) in South Africa where women experience challenges with their ability to cook and prepare meals for their households due to limited water supply. Without access to water for food preparation, ensuring children's physical growth and cognitive development can be affected. Households can cope by consuming less food or changing diets, sometimes replacing preferred foods with less nutrient-dense or more highly processed substitutes that require little or no water to prepare (Achore et al. 2020; Venkataramanan et al. 2020). This at times can cause hunger among children which can lead to fatigue, tiredness, and concentration difficulties, impacting their cognitive development (Jepkemboi 2018).

The impact of WASH on the educational responsibilities of participants emerged as an important problem. For school-going girls, fetching water has a lot of negative implications including going to school late (Innocent et al. 2021). Going to school late attracts punishments such as kneeling, fetching stones, and cutting garden sticks. Water collection also reduces the amount of time that girls have to accomplish schoolwork while at home or for private study (Innocent et al. 2021). Dhital et al. (2022) reported that a 1-h increase in the time spent on a water-fetching trip decreases the probability of girls completing primary school. Cumulative punishments further force girls to drop out of school as reported by some participants. Dropping out of school can lead to a vicious cycle of poverty and vulnerability. Aside from lateness to school and dropouts, lack of access to water also causes absenteeism. Spending a lot of time fetching water means that girls will not have time to attend to very important activities such as attending school (Ruiz 2023). The girls in this study reported missing school because they were unable to access water from crowded water sources such as hand-pumped boreholes. Similar findings have been reported in Jidda Woreda, Ethiopia where 77.4% of female students arrived late to school due to insufficient access to drinking water (Demie et al. 2016). Absenteeism is a hindrance to the 85% of school attendance in the school term outlined by the LEAP program (Ministry of Gender & Social Protection (MoGSP) 2020).

Resonating with the SLF that was employed in the study, deficiencies in access to WASH services and infrastructure compromise valuable livelihood assets such as education, good health, and well-being (Serrat 2017). Education falls under the human capital aspect of the framework that women and girls must compromise due to the limited access to WASH facilities. This affects their ability to fulfill the educational responsibilities that the LEAP outlines for them. Without education, women and girls will be limited in their ability to pursue other livelihood outcomes and improve their self-esteem and participation in decision-making (Kollmair & Gamper 2002). Poverty reduction is a long-term process that needs concerted efforts and includes other needs, not just the provision of cash grants (Jaha & Sika-Bright 2015). A thorough needs assessment is needed to identify the underlying causes of poverty in communities. Without such a thorough analysis, WASH issues can still hinder the potential of cash transfers like LEAP to promote health, nutrition, and food security (Lowe et al. 2019).

This study has a number of limitations. By utilizing a qualitative approach, the study brought to light the impact of WASH on beneficiaries. However, it is important to note that our study was confined to the Wa West in the UWR. Therefore, the findings primarily represent the perspectives of this specific group and cannot be applied universally to demonstrate how WASH may affect the co-responsibilities of other beneficiaries of other social protection initiatives elsewhere. Despite these limitations, the findings have important policy implications as outlined below.

Findings from this study suggest that the failure of LEAP to incorporate components of WASH in the study context has a detrimental impact on women and girls' livelihoods as well as their health and education co-responsibilities specified in LEAP. Without addressing these challenges of WASH, the intended goal of LEAP will remain unachieved. Inadequate WASH affects beneficiaries' ability to stay healthy and girls' educational attainment. To make LEAP more helpful to beneficiaries, the key policy recommendations arising from the findings will be to incorporate WASH as part of the complimentary services provided by LEAP to enhance the capacity of beneficiaries. This can be done by liaising with the institutions responsible for the supply of water into rural areas – Community Water and Sanitation Agency to extend water connections to the households of the beneficiaries and other non-LEAP households in the communities. This will help reduce the time spent collecting water and girls will be able to go to school on time and participate in all schooling activities. The findings from this study illuminate the need for further and deeper longitudinal studies on the challenges social protection beneficiaries face in executing their co-responsibilities while participating in these programs amidst limited access to WASH facilities in developing countries.

We thank all the LEAP beneficiary households for taking the time to participate in the study and the LEAP staff who assisted in participant recruitment and data collection.

This work was supported by the Government of Canada's New Frontiers in Research Fund (NFRF) [NFRF-00594].

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

The authors declare there is no conflict.