​The FRESH framework, an intersectoral partnership to Focus Resources on Effective School Health, provides the context for provision of safe water and sanitation facilities for children in schools.  Creating a healthy school environment by provision of safe water and sanitation facilities within schools, to improve children’s health, well being and dignity, is likely to be most effective where it is supported by other reinforcing strategies. These strategies include policies to provide a non-discriminatory safe and secure environment, skills based health education, provision of health and other services, effective referral to external health service providers and links with the community.  The FRESH framework provides this context by positioning provision of safe water and sanitation among its four core components, that should be made available together for all schools:

Safe water and sanitation

Despite all the progress reported worldwide in recent decades, more than 2.3 billion people still live without access to sanitation facilities and are unable to practice such basic hygiene as washing their hands with soap and water. Diseases related to poor sanitation and water availability cause many people to fall ill or even die. Children are the most vulnerable to health hazards and consequently are affected the most. In 1998, 2.2 million people died because of diarrhoeal diseases, of which the vast majority were children . In addition poor sanitation has led to the infection of nearly a billion people - largely children - with a variety of worm infections, with corresponding costs in health and energy.

While the impact of poor sanitation and hygiene is known to be disastrous for infants and young  children, it also has an important impact on the health of school-age children including adolescents. It is obvious that lack of sanitation and hygiene is a public disaster that deserves the highest priority.

Most of these infections which are related to poor sanitation and hygiene, ARE PREVENTABLE. Diseases such as diarrhea and parasitic worm infections need to be tackled by making improvements to water and sanitation facilities. However such improvements must go hand in hand with hygiene behavior change, if the transmission of disease is to be prevented.

Disease is not the only problem caused by poor sanitation in the school environment.  Providing safe and separate sanitation facilities for girls, particularly adolescents, is one of the key factors in promoting greater school attendance by girls, and preventing them from staying away from school, particularly during mentruation.

Access to sanitation facilities is a fundamental right that safeguards health and human dignity. Providing those facilities at schools not only helps to meet that right, it also provides the most favorable setting to encourage behavior change in the school and in the community.

Implementing the right to sanitation is critical to positive outcomes in early childhood care, for young children and adolescents, especially girls.

How sanitary can conditions be when 90 young children in a school are sharing one toilet? Or when 54% of the toilets are not functioning? Primary schools in some of the poorest countries have inadequate sanitation facilities, according to a pilot survey of 14 countries in 1995. The average number of users is often higher than 50 students per toilet in city schools. None of the 14 countries had increased the number of school toilets by more than 8% since 1990, suggesting that they are barely managing to keep up with the rise in student populations. Somewhat better progress had been achieved in providing safe water in schools. Inadequate sanitation and water in schools jeopardize not only students' health but also their attendance. Girls in particular are likely to be kept out of school if there are no sanitation facilities. 
(UNICEF, Progress of Nations 1997, p. 13)

1. Why school hygiene and sanitation: the health perspective

About 400 million school-age children are infected by roundworm, whipworm, hookworm, schistosomiasis and other flukes and/or guinea worm, often with multiple species infections. These parasites consume nutrients from children they infect. In doing so they bring about or aggravate malnutrition and retard children's physical development. This can lead to stunting, underweight and anemia (iron deficiency anemia, IDA).

Recent studies strongly suggests that school-age children suffer from higher levels of stunting than previously acknowledged. Stunting is increasingly being used as an indicator of population well being and indicator for poverty.  Estimates from the WHO global database are that 53% of school-aged children in developing countries are suffering from IDA. When levels of anemia exceed 40% it is defined as a public health problem requiring the provision of iron supplements, a health service included in the FRESH framework together with deworming.

Morbidity and mortality associated with various water and sanitation related diseases

​Disease Type ​Morbidity (no. of cases each year) ​Mortality (deaths each year) ​Population at Risk
​Diarrhoea​<4,000 million​2.5 million ​  <2,000 million
​ Amoebic Dysentery​48,000​70,000 ​   ditto
​ Cholera​145,000 (1996 data)​10,000 (1996 data)   ditto
 Roundworm​ ​250 million ​60,000 ​   ditto
​ Hookworm​151 million​65,000​   ditto
​ Whipworm​​43.5 million​10,000​   ​N/A​
​Guinea Worm​70,000​None​   100 million
​Trachoma ​600 million (6 million blind)​None     ​500 million​ 
​​ Schistosomiasis ​200,000 ​ 20,000     600 million​

Source: World Health Report, 1998

  • Helminth particularly hookworm infection have been shown to cause iron deficiency anemia (IDA), reduce growth and may negatively affect cognition. (Stoltzfus et al, 1997)
  • It is estimated that 210 million schoolchildren suffer from IDA (Del Rosso and Marek, 1996).
  • There is substantial evidence that IDA in children is associated with decreased physical and mental development and impaired immune function.
  • Inadequate water and sanitation facilities can contribute to high rates of transmission of helminth infections, that in turn contribute to iron deficiency anemia.
Figure 1. shows that the highest rate of roundworm and whipworm infections are often demonstrated in groups of 5-9 and 10-14 years old.

 worm prevalence.jpg

Worm infection by age graph

Figure 1. Worm infection by age (adapted from Bundy, 1988)

Global prevalence and number of cases of intestinal helminth infection in school-age children are estimated at: Roundworm 35% (320 million); Whipworm 25% (233 million); Hookworm 26% (239 million).  (Partnership for Child Development, 1997.)

As most of the worm infections are preventable, the emphasis should be on key interventions to break the transmission of these diseases:

The safe, efficient and hygienic disposal of faeces, particularly child faeces.
The safe, efficient and hygienic management of water from extraction, through transport and storage to use (particularly for drinking and hand-washing).
The regular and effective use of water (with a scouring agent like soap or ash) for hand washing after contact with stools (Curtis, 1998).
Multiple, coordinated strategies produce a greater effect than individual strategies, but these strategies need to be selective and targeted. While treatment of parasitic infections may have an immediate short term impact, a program will only show a sustainable effect when combined with training of teachers and administrators, classroom education and the provision of sanitary facilities all included in the FRESH framework of action.

2. Why school hygiene and sanitation: the learning perspective

As numerous studies show, education and health are inseparable: stunting, nutritional deficiencies, diarrhea and helminth infections affect school participation and learning. It is well known that stunted children enroll late into school and probably are less likely to complete their schooling with long term consequences for educational performance, outcome and productivity. Importantly, many of these issues can be addressed effectively through health, hygiene and nutrition policies and programs for students and staff.

Helminth reduction programmes in schools can have a significant impact on health and learning among school children. De-worming of school-age children can improve both growth and educational achievement, especially for the children most heavily infected.

Data from studies show that the prevalence of stunting increased with age showing a higher proportion of stunted school-age children.   (Partnership for Child Development, 1998).

Studies have shown that linear growth continues beyond the normal puberty growth period. This suggests that school based programmes aimed at improving health and nutrition status may have the potential to bring about catch-up growth in stunted school age children. (Stoltzfus et al. 1997, 1998)

Children with heavy worm burdens are likely to be absent from school for a greater proportion of the time than those who are lightly infected or free from worms (Figure 2).

School absenteeism and helminth infection graph

Figure 2.  School Absenteeism and helminth infection

Worm infection has also been shown to influence children's cognitive ability (see Drake et al, 2000) and school attendence (e.g. Simeon et al., 1995).

3. Why school hygiene and sanitation: the gender perspective

Lack of facilities and poor hygiene affect both girls and boys, although poor sanitation conditions at schools have a stronger negative impact on girls. All girls should have access to safe, clean, separate and private sanitation facilities in their schools. If there are no latrines and hand-washing facilities at school or if they are in a poor state of repair, then many children would rather not attend than use the alternatives. In particular girls who are old enough to menstruate need to have adequate facilities at school and normally separate from those of boys, this is strongly supported by FRESH. If they don’t they may miss school that week and find it hard to catch up, which makes them more likely to drop out of school altogether.

Many children, again mainly girls, miss out on time at school because they are having to walk long distances in order to fetch water. Also in schools, when the schoolteacher sends children to fetch water, it is predominantly girls who are sent.

Lessons learned from a DPHE-UNICEF study in 1994 and 1998 in Bangladesh showed that provision of water and sanitation facilities in schools increased girls’ attendance by 15%. Interaction with family and demand for sanitation facilities at home were seen in 80% of children where those practices were acquired at school.

In addition to the obvious health benefits and time savings (particularly affecting young school-age girls), provision of safe water and sanitation facilities can also have an influence on school enrolment and attendance. The lack of adequate, separate sanitary facilities in schools is one of the main factors preventing girls from attending school, particularly when menstruating. In Bangladesh, a school sanitation program increased girls' enrolment by 11%, a level that is beyond the reach of conventional educational reform (Cairncross, 1998).

When other family members become sick (often due to sanitation related diseases), girls are more likely to be kept home to help. This can lead to reduced school attendance by girls and can result in an increase in drop-out rates. This situation will become even more critical in communities hard hit by the HIV/AIDS pandemic.​

4. Why school hygiene and sanitation: the child's perspective

Children spend long hours in schools. The school environment will partly determine these children’s health and well–being by providing a healthy or unhealthy environment. Compared to adults, children are often more receptive to new ideas and can more easily change their behavior and/or develop new long-term behaviors as a result of increased knowledge and facilitated practices.

Depending on the culture, children and youth, may question existing practices in the household and become agents of change within their families and communities. Teachers as professionals and influential individuals, supported by the school management, can play an important role in the development of pupils through training and providing a role model in the communities.

Life skills training (LST) as promoted by FRESH and used in water and sanitation education can help children make informed decisions and avoid risky situations and behaviors and give them opportunity to practice these skills. They are more effective than traditional teaching methods in influencing behavior rather than just imparting knowledge. These skills are best acquired through learner-centered, participatory, experimental programmes (e.g. WHO, 1996)

Children are future role models and parents. What they learn at school is likely to be passed on to their peers and to their own children. It is obvious that all sanitation facilities and educational programs should be adapted to the different physical and cultural needs of girls and boys at different ages, key aspects enshrined in the concept of child friendly schools.​
5. School sanitation facilities are not enough

Although there is an urgent need for speeding up the installment of appropriate facilities, school sanitation is not only about building child-friendly facilities. Experience shows clearly that mere provision of services, be it within schools or at household level, will not be sustainable. Facilities need to be maintained, and in order to be maintained there must be a recognized need and demand for water as well as sanitation at schools. To improve the sanitation environment of schools, and to ensure benefits from safe and clean facilities, behavioral change is needed, leading to a proper use of the facilities as well as to organized maintenance of the facilities and to sanitation-related behaviors such as hand-washing.

Government officials from 6 different countries in Sub-Saharan Africa gave situation reports on water and sanitation at home and in schools at the Water and Sanitation workshop in October 2000 in Burkina Faso. For most of the countries the assessments showed lower coverage in schools of water and latrines compared to the general population and low state of usage and maintenance. In Cote d’Ivoire, for example, 62% in rural areas had water and 40 % in the capital Abidjan had sanitation. In schools only 30% has water and 32 % latrines. According to a survey in the Yopougon area, Cote d’Ivoire, 62% of WCs do not work and there are about one WC/latrine per 381 students (suggested 1/40 girls and 1/80 boys) and one urinoire per 892 students (suggested 1/50).

Schools are an integral part of a community. Involvement of the local community in school sanitation and hygiene activities increases the effectiveness of the programs. It also promotes the sense of ownership within communities that is needed to sustain the school systems for operation and maintenance, particularly important in the absence of effective local government to provide such services. Although school sanitation and hygiene promotion can bring health benefits for the children and their family members who may improve their sanitation, it is clear that sanitation is a public good and that sanitation improvement has much greater benefit when it is achieved by a whole community. Experience shows that children can act as potential agents of change within their homes and communities through their knowledge and use of sanitation and hygiene practice learned at school.

A recent review of 144 different interventions demonstrated the impact on morbidity of general water, sanitation and hygienic interventions:​
  • 36% median reduction of diarrhea from the safe disposal of faeces
  • 35% median reduction of diarrhea from hand-washing with soap after contact with stools
  • 20% median reduction in diarrhea from protection of water from faecal contamination
  • 26% median reduction in diarrhea from the integration of hygiene education or promotion in water projects (Esrey et al., 1990)
However, without mobilization and motivation of the community as a whole, the impact of a school sanitation and hygiene promotion program may remain limited.

6. Targets for the future

The shared world vision for hygiene sanitation and water supply, based on the recognition of hygienic conditions and adequate access to safe water and sanitation services as fundamental rights, includes school sanitation and hygiene education targets. The suggested school sanitation and hygiene education targets for 2015 are:

80% of primary school children educated about hygiene
all schools equipped with facilities for sanitation and hand-washing
These targets are most effectively implemented within the context of the FRESH Partnership, where provision of safe water and sanitation for schools is positioned as one of the core FRESH activities.

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