School Water, Sanitation and Hygiene: Myths Proved and Disproved Presenters: Malaika Wright, Shadi Saboori & Brooks Keene 9 August 2011, CARE USA Headquarters

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 school- based 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 and research were started first Advocacy and collaborative learning were incorporated later Research Advocacy/Collaborative Learning Direct implementation

School Water, Sanitation and Hygiene: Myths Proved and Disproved Widely acknowledged need for school WASH investments Yet scant evidence base for impact Evidence necessary to justify allocation of scarce resources Myth vs. fact The Research Context

Cluster randomized trial: 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 Background and Methods 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

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

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

School Water, Sanitation and Hygiene: Myths Proved and Disproved 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 Effect of WASH Helminth Re-infection

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 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?

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 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. Reduction in Diarrheal Disease

School Water, Sanitation and Hygiene: Myths Proved and Disproved 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 Reduction in Girls’ Absenteeism

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

Advocacy 3 High-Level Objectives: 1.Increase funding for operations and maintenance costs in schools 2.Improved monitoring and evaluation for accountability 3.Improved knowledge and behavior change

Specific Policy Goals 1.Increase O&M Funding$3.30/pupil/year 2.Improve M&EDownward, decentralized and supportive 3.Knowledge and behaviorNew curriculum (co-developed with CDC)

An inside player Inside learning partner MOE investments in school WASH Collaborative learning and capacity building MOE investments in school WASH Outside Expert Independent research

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

Monitoring Our Progress (cont) Progress Markers Expect to see: MoE and MoPHS engage SWASH+ as a learning partner on school WASH Like to see: MoE, MoPHS, and MoPW adopt monitoring tools with focus on not only hardware but also O&M of hardware and software, behavioral change, and indicators of future sustainability. Love to see: MoE increases budget request to MoF for school WASH software to at least 33 KES/pupil/year and creates an independent budget line for school WASH software.

Monitoring Our Progress (cont) 1,2,6+ Charles Kanja (in-service department): Briefing him on policy issues where SWASH has interest. Kanja is interested in working with SWASH on training manuals. January 25th, Kanja: his office has a limited budget and cannot support training or printing of the manual SWASH is creating. No budget for for zonal level to do monitoring. January 25th, 2011

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