Background Paper

Every Child Clean through School Hygiene

An e-conference on School Sanitation and Hygiene Education (SSHE) programmes

Christine van Wijk, IRC International Water and Sanitation Centre, Delft, the Netherlands

“Children of the world are innocent, vulnerable and dependent. They are also curious, active and full of hope. Their time should be one of joy and peace, of playing, learning and growing. Their future should be shaped in harmony and co-operation. Their lives should mature, as they broaden their perspectives and gain new experience (CRC, Convention of the Right of the Child, 1989).

The context

We have all been children. Many of us are a parent or take care of children in other ways. We therefore all know how important it is that children grow up in a safer, fairer and healthier world. Investing in children is the basis for positive change in the world. This knowledge resulted, twelve years ago, in a pledge from national leaders attending the World Summit for Children to protect and promote the rights of children and young people world-wide. In May 2002, a record number of world leaders will gather once again to review the achievement against the original goals, identify the gaps and subscribe to new and more specific goals for the next decade ahead, as outlined in the draft “A World Fit for Children” (www.unicef.org/specialsession/).

Education has been acknowledged as a basic human right since the first human rights convention in 1948. It is confirmed in the Convention on the Rights of the Child, which is the most universally accepted human rights treaty in history. Two of the pledges of the Social Summit, held in Copenhagen in 1995, concern education: equal opportunities for education to girls by 2005 and primary education for all children in 2015. Today, the right to education is high on the political agenda. EFA (“education for all”) is an official UN goal and access to quality basic education for all children, girls as well as boys, is part of the development agenda of the Millennium Declaration.

“Education for all” means ensuring that all children have access to quality education. This implies creating an environment in schools and in basic education programmes in which children are both able and enabled to learn. Quality education is not possible in schools (or more informal places of learning e.g. in factories and workshops) which lack basic hygiene, when in places of learning sanitary facilities and water are missing, when facilities are broken or not properly used. And if children do not have the basic knowledge, attitudes and habits of good hygiene or cannot practice them, education is neither complete nor effective. Even worse, an unsafe school environment may damage their health.

The growing recognition of the importance of quality primary education has inspired UNICEF, WHO, UNESCO and the World Bank to create a partnership to Focus Resources on Effective School Health (FRESH). The issues addressed in FRESH are water and sanitation facilities in all schools, life skills based health and hygiene education, the establishment of school policies for health promotion, and the establishment of school nutrition and health services.

Meanwhile Vision 21, which is part of the action plan of the Second World Water Forum, has set specific school hygiene and sanitation goals. These goals are that by 2015, 80% of primary school children are being educated about hygiene and all schools are equipped with facilities for sanitation and hand washing.

The challenges

While children's access to education has increased, it is by no means universal:

• Nearly 120 million kids of school going age are not in schools;
• One out of three children in developing countries does not complete 5 years of education;
• Sub-Saharan Africa is home to 50 million out-of-school children, 27 million of them girls;
• South Asia is home to 43 million out of school children, including 26 million girls
• In more than 45 countries, fewer than 1 in 4 girls are enrolled in secondary school
• Discrimination on the basis of gender is a worldwide problem and not confined to countries with high numbers of out of school girls
• HIV and Aids is heavily affecting the education systems in the developing world. Children and girls in particular, are staying home to take care of sick relatives. In Sub-Saharan Africa alone nearly 1 million children have lost a teacher. (http://www.unicef.org/pdeduc/education/girlsedu/girls_ed.htm.)

An analysis of UNESCO's data from the Education for All Initiative gives some more data:

• There are now 20 developing countries where - at least on paper- 80% or more of the school age boys enter primary school. Only nine of these countries achieve the same for school age girls;
• In a second group of 25 countries, 50 to 80% of the boys go to primary school;
• In the third group of 22 countries for which statistics are available, less than half of the boy children go to school;
• In groups 2 and 3, only about half of the countries have the same enrollment levels for girls. (For the basic data, see http://www.worldbank.org/data/wdi2001/pdfs/tab2_13.pdf ).

Encouraging in the UNESCO statistics is that countries with higher enrollments of school age children in primary school have a lower drop out before the children reach grade five. The latter is the grade in which children have usually acquired full literacy and numeracy skills. In the three groups mentioned above, the percentage of countries in which 90-100% of the school going children reached grade five, was 15% in group 3, 30% in group 2 and 60% in group 1.

Remarkable is further that in the countries with higher school attendance and more equal school entry opportunities for boys and girls, girls start to achieve even better than boys. In the above mentioned group 3 (less than half of the children entering primary school) the 90-100% score for attaining grade five was equally good for boys and girls in only one country. In group 2, grade five attainments were equally good for boys and girls in two countries while in three countries girls did better. In group 1, grade five attainments was equally good for boys and girls in one country while in seven countries girls did better. This is important for wider development since countries with better education for girls tend to have also later marriages, better spaced and fewer pregnancies, lower infant and maternal mortality, better child nutrition and a greater participation of women in development decisions (United Nations, 2001).

There are no global statistics on the presence of water supply and sanitation in primary and other (nursery and secondary) schools. However, emerging data from studies show that in many developing countries access to water and sanitation facilities in schools is lower than the overall coverage figures for water supply and sanitation (UNICEF 2002). Global information about the presence of hygiene education in the school curricula is also missing. Even less is known if and to what extent school hygiene education programmes are effective and water supply and sanitation facilities are used and maintained.

Fortunately, school sanitation and hygiene education (SSHE) programmes are gaining prominence worldwide. Policy makers, external support organisations and the schools themselves see SSHE increasingly as a vital part of children's rights to education and health. Civil society organisations, governments and external support agencies have now initiated hundreds of SSHE programmes. UNICEF alone is supporting school sanitation, hygiene and water programmes in more than 50 countries in the Americas, Africa and Asia. This number has increased from 35 in 1996. However, many programmes do not yet address both aspects of SSHE: good facilities and healthy practices, or include all four interventions of FRESH. A study in Senegal of over 5000 schools showed that 53% had no water supply and 46% had no sanitation facilities. Only half of the schools had separate facilities for girls and boys (République du Sénegal and UNICEF, 2002.).

The rights of children are clear, but the great task is now to achieve positive results on a large scale. Simply building new sanitation and water facilities is not enough, it is critical that these facilities are properly used and maintained. Even more important, simply giving hygiene lessons in class will not necessarily change children's hygiene behaviour. Revised and better strategies are needed to address the major questions emerging from the adopted children's rights:

• How can, by 2015, sanitation and hygiene conditions in schools allow all children, boys and girls, to go to school in an environment that is safe and healthy?
• How can, by that time, all children not only learn, but also practice hygiene in school, from nursery to secondary school?
• How can, by 2015, all school age girls and boys participate in a meaningful way in the development, implementation and sustainability of school hygiene education and sanitation programs?

Why SSHE programmes?

For many of us - parents, teachers, students, administrators, project workers, and researchers - schools are first and foremost places to acquire scholastic knowledge. However, schools are also places where girls and boys spend a large part of their days. With so many children together, the school environment must be clean and safe to keep children healthy and in the best condition to learn. Of all children between the ages of five and fourteen in the world, 87% live in developing countries. For these children, the risk of death, which is now fourteen times higher than for children of the same age groups in industrialized countries, can be reduced enormously when they stay in a healthy school environment and get used to practicing good hygiene both in and out of school (WHO, 1995)

Safe and healthy school conditions are also essential for better educational achievements. In 1993, Nokes and others showed that both school attendance and educational performance improve when children suffer less from diseases and worm infections. At present, about 400 million school-age children are infected by roundworm, whipworm and/or hookworm. Although they do not die from these infections, they show remarkable spurts in their growth and educational performance when they receive treatment followed by the prevention of re-infection through the introduction of more hygienic practices and better sanitation (WHO, 1997). Eye infections, especially trachoma, are also common among school children. Repeated infection during childhood is an important factor in blindness caused by trachoma and threatens also the children's mothers. They are most frequently in contact with infected children and this is one reason why seventy percent of the blind people are women.

SSHE programmes also provide good opportunities to practice gender equality in health knowledge and the division of tasks. Much can still be done in this respect. The examples will be no exception in many schools. A visit to a school in Senegal brought out that the boys cleaned the schoolyard and the girls the toilets. Because cleaning was done only once a week, the latrines were very dirty. The girls told that this was why they did not use them and why their mothers warned them not to urinate at school. To avoid urination, they tried not to drink during school time. When they did need to urinate, they went somewhere behind the school. In Mexico, when asking why the girls were cleaning the toilets and the boys were playing basketball, the teachers said “Boys don't clean toilets in Mexico” (UNICEF, 2002).

When children learn new knowledge, skills and attitudes on hygiene as part of modern education programmes, they acquire also many other skills that help them cope in life now and later on ? the so-called life skills. Examples of life skills are being able to work in groups, developing investigative and analytical skills, giving and receiving feedback, speaking about sensitive issues, coping with peer pressure and with emotions such as stress and anxiety, and understanding and respecting cultural, economic and gender differences. In Zambia, the participants of a master trainers' workshop on life skills in water supply, sanitation and hygiene developed for example several case studies which - when used in small groups- help students discuss sensitive issues connected with school latrines, such as use during menstruation and misuse for bullying and sexual harassment.

Life skills education uses modern educational methods which are active and participatory. They link the education contents with the children's' daily environment and practices in their homes, schools and communities and make learning more fun, interesting and effective. An example is the “escuelas nuevas” or new schools movement which started in Colombia and now spreads to other countries in South America (Hart, 1997).

Improved sanitation and water supply in schools not only benefits children's health and school achievements, but also direct benefit girls' education. It is already harder for girls to attend and finish school. The presence of sanitation facilities which can be kept clean, offer privacy and, for older girls, are separate from those for boys help parents send girls to school and not stop their education when they reach puberty.

Lessons learned

As seen above there are many reasons to take up SSHE programmes as an important part of the movement for every child to go to school. No less important is to know what makes the SSHE programmes effective and worth the investments. There are too many examples of children who learn about health and hygiene in class while the school toilets are soiled, broken or locked. Children who, in tropical temperatures sit for many hours in class without drinking because, like the girls above, they are afraid that they will have to urinate or because there is no drinking water in school and their parents cannot buy them a flask. Many children and teachers can also not wash their hands after using the toilet or before eating their school canteen meals.

From initiatives such as FRESH and the UNICEF/IRC school sanitation and hygiene manual as well as other country-specific projects and programmes, some important lessons have already been learned about SSHE programmes:

1) The importance of political will and cooperation.

In SSHE programmes, there are many actors. For large programmes, the most important actors are in the Government. Not only the Ministry of Education, but also workers in the Ministries of Health, Community Development and Water or Public Works often have roles to play. However, it is also possible to work more closely with the private sector, from local crafts persons such as mason, potters and soap makers to large companies. The latter can support programmes with finances, research and development (e.g. on child friendly latrines) and special market programmes, e.g. for school soap and disinfectants. Some first experience was gained in a Central American media campaign for the promotion of hand washing in which the region's soap industry worked together with Government departments. NGOs, multi- and bilateral agencies and independent research institutes are important to test new approaches and critically assess cost-effectiveness of programmes in their different stages. These many actors make it crucial that the roles, responsibilities and accountability for results are clearly agreed on from the start.

2) Conceptual clarity and completeness

Many SSHE programmes still focus on either the construction of one type of facilities (usually school latrines) or on health/hygiene education. A good SSHE programme covers however the full spectrum of facilities, also for hand washing, water supply and storage and, where relevant, drainage. It also includes firm arrangements for maintenance and repair of these facilities and their expansion when schools increase in size. And it links the design, construction, maintenance and use of these facilities with effective school hygiene education programmes (see also below), school policies, school management, cooperation between the school, the parents and the communities which the school serves, and monitoring of the programme's performance. Only when a full chain with all elements is in place and strong will a SSHE programme be successful.

3) Participation in a team approach

Just constructing school latrines and water systems has not worked. Participation is important because it enhances that facilities are used and maintained and new learning is acquired. Participation in planning relates not only to the facilities themselves, but also to their maintenance, use and management. Those directly concerned are teachers, girl and boy students, heads of schools, and parents (with children in the school, not elite PTA (Parents-Teachers Association) members whose children are schooling elsewhere). Also concerned are health workers and other local functionaries along with technicians and SSHE programme workers. Making informed and joint decisions ensures that knowledge of all is used. Such decisions relate to which facilities will be installed, how they are made affordable and will be maintained, what is locally the best design, location, materials, quality control, etc. Participation in decisions also makes children and adults more proud of and responsible for what they have created. Moreover, local planning and installation provide good opportunities for boys and girls students to acquire new learning and new technical knowledge and skills, such as the mixing and curing of concrete. Construction workers are often not used to working in a team approach with a development perspective. New procedures and processes for participation have therefore to be worked out. However, many technicians appreciate and enjoy the extra dimension once a different approach has taken roots.

4) More creative learning methods and tools

Many lessons on health and hygiene in class still focus on creating knowledge that is abstract and academic. SSHE lessons typically cover the range of water and sanitation related diseases, their routes of transmission, their symptoms, their treatment and the ways and means of prevention. Their aim is that the children learn this knowledge by heart and can replicate it in class and during exams. More creative learning methods link this more academic knowledge with the children's own environment, their values and practices in school, home and community. Methods are participatory, active and practical. Children learn for example to determine what the locally most prevalent infectious diseases are and how their own conditions and practices make that these infections continue to be spread. They learn to apply this knowledge by making, for example, drawings of their home compounds with good and bad practices in sanitation and in storing and drawing drinking water. The teacher then uses the drawings as a basis for health and hygiene education as well as for arithmetic, e.g. by helping the children to count the number of good and bad practices. The drawings also help start a class discussion that help the children identify and understand why these conditions and practices exist - for example, because of a lack of information, money, too much work and no good equipment for mothers - and what may be done. The use of such creative educational methods and tools helps meet many more education and development goals as described under life skills above. At the same time, the extra costs are limited to the initial costs when the new educational methods and material must be developed and tested and teachers (re) trained.

New insights needed

Although we have gained considerable understanding about how to make more effective SSHE programmes, there is still a lot to be learned. First, there is the political motivation and strategies, which make countries establish SSHE programmes and formulating programmes that are more effective. It is not known exactly why some countries have adopted full or partial programmes and others not.

More can also be learned about ways and means to make existing SSHE programmes more effective and sustainable. Effective programmes are defined here as programmes that achieve good sanitation and hygiene practices and well installed and maintained facilities in all schools. Sustainable programmes are programmes that, along with the already installed sanitation and hygiene facilities and practices, continue to exist over time without ongoing funding from outsiders.

We can also learn more about the meaningful participation of children in SSHE programmes.

“Meaningful participation” is the kind of participation that has a value for the children because it allows them to learn and understand things that are important to them and to acquire and practice new attitudes and skills. In such participation, the interests of the children themselves come first, not the interests of other groups who use the children for their own ends and benefits.

Goal and objectives of the e-conference

As mentioned above, little is known about whether the current documents and initiatives cover the only lessons that can be learned. There may be many more lessons to be learned from the field on the effectiveness of SSHE programmes and the meaningful participation of children. Other issues that affect the effectiveness, sustainability and the increase in coverage in different countries may not be addressed at all and should be included and discussed. Building and sharing experience can help address the questions and help find good solutions.

The general goal of the e-conference is to create a wide public debate between all groups of actors concerned with healthy schools - parents, children, teachers, administrators, policymakers and external support agencies in the water supply and sanitation, education and health sectors on (1) how we can create the large-scale conditions that will enable every child to learn in a healthy and safe school environment, (2) how to influence that environment through children's right to speak and act and as a result master better conditions and practices, and (3) how to spread good sanitation and hygiene practices in and through local schools as well as homes and communities.

More specific objectives are to learn, through the successes and failures, still more about

• the ways to create successful SSHE programmes that are measurably effective and sustainable;
• the forms which meaningful participation of children takes and how we shift to these forms from top-down, non-participatory education in SSHE programmes;
• the routes to realize the goals of Vision 21: what needs to be done to effectively scale up existing SSHE programmes and develop new large-scale programmes to achieve child centered hygiene education and facilities for sanitation and hand washing in all schools.

The three themes around which the e-conference will be organised reflect these specific objectives:

• Theme 1: Making all SSHE programmes work
• Theme 2: Putting the child at the centre
• Theme 3: Overcoming hurdles and scaling up

To make schools healthy for children and children practice and promote hygiene along with other important life skills, we are looking in this e-conference to the participants to share and discuss field experiences and lessons, success stories and failures and the reasons behind them.

References

FRESH (2000). Focusing resources on effective school health: A FRESH start to enhancing the quality and equity of education. Paris/New York/Geneva/ Washington D.C: UNESCO, UNICEF, WHO, World Bank.

Hart, Roger A. (1997). Children's participation: The theory and practice of involving young citizens in community development and environmental care. London: Earthscan Publications.

Nokes, C; Bundy, Donald A. P. 1993. Compliance and absenteeism in school children implications for helminth control. Trans R Soc Trop Med Hyg. 87 (2): 148-52.

République du Sénegal, Ministère de l'Education Nationale et UNICEF, (2002) Mission de micro-planification. Ministère de l'Education et UNICEF.

UNICEF (2002). School Sanitation and Hygiene Education (SSHE): a New Vision - a Renewed Thrust. WaterFront, Issue 15 (in print). New York, UNICEF.

UNICEF/IRC, 1998). A manual on school sanitation and hygiene. New York: UNICEF and Delft: IRC. Available in the SSHE Resources section http://www.irc.nl/page/9583 Hard copies are available from IRC, P.O.Box 2869, 2601CW Delft, The Netherlands, e-mail general@irc.nl

WHO (1995). Improving water and sanitation hygiene behaviour for the reduction of diarrhoeal disease. The report of an informal consultation.WHO/CWS/93.10. Geneva: World Health Organisation.

WHO (1997). Strengthening Interventions to Reduce Helminth Infections: As an Entry Point for the Development of Health-Promoting Schools. WHO Information Series on School Health, Document One. WHO/HPR/SCHOOL/HEP/96.10. Geneva, World Health Organisation