School Water, Sanitation and Hygiene:
Myths Proved and Disproved
9 August 2011, CARE USA Headquarters
Presenters:
Malaika Wright, Shadi Saboori & Brooks Keene
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
SWASH+: Basic Facts
• What: SWASH+ is a five-year applied research project started in 2006
• Goal: To identify, develop, and test innovative approaches to schoolbased water, sanitation and hygiene in Nyanza Province, Kenya
• Partners: CARE, Emory University, the Great Lakes University of Kisumu,
the Government of Kenya, the Kenya Water for Health Organisation
(KWAHO), and Water.org (formerly Water Partners International)
• Where: Research and implementation conducted in Nyanza Province,
Kenya
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
Why School WASH?
• At baseline, approximately 49% of schools
provided drinking water to pupils
• Only 11% provided water for handwashing.
• In schools selected, there were 79.5 pupils
per latrine on average (GoK ratios are 25:1
for girls, 30:1 for boys)
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
The Three Components Of
SWASH+
• 1) Direct implementation 2)
Research 3) Advocacy/
collaborative learning
Direct implementation
Research
• Direct implementation and
research were started first
• Advocacy and collaborative
learning were incorporated later
Advocacy/Collaborative Learning
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
The Research Context
• Widely acknowledged need for
school WASH investments
• Yet scant evidence base for impact
• Evidence necessary to justify
allocation of scarce resources
• Myth vs. fact
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
Background and Methods
• Cluster randomized trial: 2007-2009
• Base package (45 schools):
– Hygiene promotion + Water Treatment
• Base package + Sanitation (45 schools):
– HP+ WT + Sanitation
• Water package (25 schools):
– HP+ WT + Sanitation+ Water
• Control (70 schools) – to receive
improvements in third year of project
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
1. Does school water, sanitation and hygiene
(WASH) interventions make a difference in
educational achievement?
2. Which kids benefit more from school WASH?
3. Can school WASH do more harm than good?
4. What types of investments in school WASH yield
the most returns?
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
1. Does school water, sanitation and hygiene
(WASH) interventions make a difference in
educational achievement?
2. Which kids benefit more from school WASH?
3. Can school WASH do more harm than good?
4. What types of investments in school WASH yield
the most returns?
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
•Significant reduction for HW+WT (OR=0.43) and HW, WT+San
(OR=0.47)
•Six days less absence per year for girls
•No effect for boys
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
1. Does school water, sanitation and hygiene
(WASH) interventions make a difference in
educational achievement?
2. Which kids benefit more from school WASH?
3. Can school WASH do more harm than good?
4. What types of investments in school WASH yield
the most returns?
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
Effect of WASH Helminth Re-infection
• Followed re-infection rates for
Ascaris, Trichuris and Hookworm
• Ascaris
– 45% reduction in odds overall;
even greater among girls
• Trichuris
– No effects
• Hookworm
– Significant reduction in intensity
of infection for boys
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
1. Does school water, sanitation and hygiene
(WASH) interventions make a difference in
educational achievement?
2. Which kids benefit more from school WASH?
3. Can school WASH do more harm than good?
4. What types of investments in school WASH yield
the most returns?
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
What if key WASH components are missing?
Hand Contamination
•Hand Rinse: sampled
pupils’ hands for fecal
contamination
•Measured for E. coli
•Compared intervention
and control schools
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
What happened?
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
1. Does school water, sanitation and hygiene
(WASH) interventions make a difference in
educational achievement?
2. Which kids benefit more from school WASH?
3. Can school WASH do more harm than good?
4. What types of investments in school WASH yield
the most returns?
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
Reduction in Diarrheal Disease
•Water Package schools
showed a 66% reduction in
diarrheal disease and days
of illness.
•This result was not gender
specific.
•There was no effect seen
for the Base and Base +
Sanitation schools.
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
Reduction in Girls’ Absenteeism
•Significant reduction in girls’ absenteeism in schools
where hand washing and treated drinking water were
present (irrespective of sanitation improvement)
•Software components must not be overlooked
•Vital recurrent costs (i.e. soap, water treatment
products) must be regularly budgeted and provided in
order to ensure sustainability of WASH services
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
•2008 provision of soap = over 30% of schools
•2010 provision of soap = under 8%
School Water, Sanitation and Hygiene:
Myths Proved and Disproved
Sustainability Successes
WASH components not requiring
expenditures by schools are still
sustained in a majority of intervention
schools (nearly 3 yrs after
implementation)
Sustainability Challenges
WASH components requiring
expenditure by schools decreased
dramatically (nearly 3 yrs after
implementation)
Using the Evidence and
Learning: Advocacy
The policy environment
• Current and planned investments in school
WASH
• Interested development partners
• Many policies
• Low capacity for implementing them
• Corruption in the Ministry of Education
Specific Policy Goals
1. Increase O&M Funding
$3.30/pupil/year
2. Improve M&E
Downward, decentralized and
supportive
3. Knowledge and behavior
New curriculum (co-developed
with CDC)
An inside player
Outside Expert
Independent
research
MOE
investments in
school WASH
MOE investments in
school WASH
Inside
learning
partner
Collaborative
learning and
capacity
building
Advocacy Activities
•
•
•
•
•
•
•
Learning presentations
Sign-on letters with other civil society
Media work
Submitted policy briefs
Sustainability charter
Day to day badgering
International level: publishing in academic
journals, issuing briefing notes and
presenting at relevant fora
Measuring Our Progress:
Outcome Mapping
Boundary Partners
Primary actors
Results to Date
• $3.4 million allocated for sanitary pads for school girls this year
• Piloting and openness to new M&E systems, including
agreement on need for unified monitoring tool between
ministries
• Doubling of funds for school WASH ($840,000/year) with
potentially more to come
• Adoption of WASH curriculum and materials for in-service
teacher training
• Agreement to develop a school WASH sustainability charter
• International level – Uncertain impact
Thoughts on the Process
• Evidence-based advocacy works
• Getting to scale through learning + advocacy
(not direct service delivery)
• Trying to do implementation, rigorous learning
and advocacy simultaneously is hard (not
necessary?)
• Can’t be internally-focused
• In-country policy staff are essential