Investments aligned with this strategic goal aim to improve access to water, sanitation, and hygiene (WASH) in public places, such as schools and healthcare facilities. This strategic goal could also be applied to other types of public places, including offices, transport systems, and marketplaces.
The sections below include an overview of the strategy for achieving desired goals, supporting evidence, a starter kit of metrics that help measure performance toward goals, and a curated list of resources to support collecting, reporting on, and using data for decision-making.
Investments with this strategic goal aim to support access to clean, safe, and reliable water, sanitation, and hygiene (WASH) services in public facilities, especially in schools and hospitals, health centers, and clinics. For children and adults alike, lack of WASH services in schools and healthcare facilities hinder education and learning outcomes, worsen health, and slow economic growth. According to UNICEF, WASH investments can reduce water-borne diseases in vulnerable populations and keep children in school.
Schools: Access to clean water, toilets, and hygiene solutions is essential to the school learning environment, particularly for girls and children with disabilities. WASH services in schools reduce the risk of serious diseases, provide students a safe and private place to use the toilet, and allow girls to safely, privately, and hygienically manage their menstrual periods. Safe water, sanitation, and hygiene practices in schools also promote the behavioral change necessary to end open defecation.
Healthcare facilities: While no one goes to the doctor to get sick, hundreds of millions of people risk infection by seeking care in health facilities that do not have safe WASH services (1). The lack of WASH services in healthcare facilities not only compromises patient safety and dignity but can also exacerbate the spread of infections and undermine efforts to improve child and maternal health. For example, hygienic postnatal practices can prevent 40% of neonatal mortality from sepsis and tetanus (2).
Sensitive to local context and demand, investments in WASH for public facilities can:
Millions of children attend school every day in unsafe environments with no drinking water, no proper or private toilets, and no soap to wash their hands. The latest report from UNICEF and the World Health Organization found that more than 620 million children worldwide attend schools that lack toilets that are available, functional, and private, and 570 million children attend schools that lack basic water service (3).
Regarding health facilities, an estimated 869 million people use health care services without basic water, and 1.5 billion use facilities without basic sanitation (1). One of six healthcare facilities worldwide lack hand hygiene facilities at points of care and soap and water at toilets (1).
Many girls and women miss hours or days of school or work rather than attempting to manage their menstruation in difficult environments. Inadequate menstrual hygiene management accounts for 1.5 million missed workdays and a corresponding USD 1.28 million economic loss in Vietnam and 13.8 million missed workdays and USD 12 million lost in the Philippines, according to a 2016 study (4).
Children, especially girls: Inadequate WASH facilities in schools lead to disease transmission, missed days of school, and poorer learning outcomes. Girls who are menstruating are more likely to miss school days when they lack adequate places to change or dispose of sanitary pads. Evidence highlights that inadequate menstrual health management can keep girls out of school and public spaces when menstruating, either for lack of safe and private spaces to change or as a result of anxiety (of leaking or staining) and learned shame. Menstrual hygiene management most directly helps women and girls protect their dignity, bodily integrity, and overall life opportunities (5).
In healthcare settings, following hygienic birth and post-birth practices can reduce neonatal mortality by 40% (2). Handwashing with soap can prevent approximately 40% of diarrhea cases—the third-leading cause of under-five mortality—as well as respiratory illnesses, such as pneumonia, which accounts for 13% of global childhood deaths (6,7,8). Sanitation-related diarrhea, which can be greatly reduced by handwashing, often leads to undernutrition, the cause of 45% of under-five child mortality (9). And a comprehensive meta-analysis indicated that handwashing with soap after defecating and before eating can reduce respiratory infection rates by up to 25% (10).
Poor and vulnerable populations: Access to safe water, sanitation, and hygiene solutions in public can encourage people to follow hygienic practices, especially where doing so requires behavioral change.
According to the World Health Organization and UNICEF’s Joint Monitoring Programme, sub-Saharan Africa and Oceania have the broadest extent of no or limited drinking water and sanitation services in schools and healthcare facilities (3). Low levels of service are also common in many of the Least Developed Countries and the Landlocked Developing Countries (3). In general, rural schools have lower coverage of basic drinking water services than do urban schools in almost all countries with disaggregated data (3).
Investments aligned with this strategic goal can:
As noted above, roughly 1.5 billion people use health care facilities with no sanitation, and 620 million children worldwide lack a functional and private toilet at their school (1,3). Regarding water, 869 million people use health care facilities without water service, and more than 570 million children lack a basic drinking water service at their school (1,3).
Those residing in poor urban neighborhoods—especially in informal settlements—often lack typical urban WASH services in their homes (11). Instead, they may depend entirely on public access points rather than having in-home access to piped water connections and toilets (11). The UN estimates that over a third of the global population will be urban by 2050, and cities are struggling to invest in the water and sanitation services needed for the projected population growth (12).
The number of people that can benefit from investments with this strategic goal depends on several contextual factors, including cost requirements and current and potential population served by the target school or health care provider. Concerning school attendance, 56% of girls in a study in Ethiopia were absent from school specifically because they had no sanitary pad, 42% of girls in a study in Bangladesh missed at least one day of school each month due to menstruation, and 19% of school-aged girls responding to a survey in Uganda reported that they had stained their clothes as a result of menstruation (13,14,15).
Inadequate WASH provision in healthcare facilities in low- and middle-income countries may increase the risk of infections contracted through healthcare services (16). Access to safe water and sanitation in public places can protect and save lives. Increasing hand hygiene compliance among healthcare workers from poor (less than 60%) to excellent (90%) reduced the risk of methicillin-resistant, “super-bug” infection by 24% for each 10% level of improvement in compliance (17).
Investments in handwashing facilities are one of the most cost-effective investments in public health, averting the loss of disability-adjusted life years (DALY) associated with diarrheal disease. Averting one DALY through hygiene promotion costs just USD 3.35 (18, 19). Regarding performance at school, 96.8% of schoolgirls participating in a study in Ghana felt “more confident” while wearing pads during their period, and 98.4% felt they were better able to concentrate at school (20).
Impact risk factors identified by experts as material for this Strategic Goal include:
The consequences of these risks are defunct and unused WASH products or improvements. Without quality access to water, removal of waste, and promotion of hygienic practice, individuals may revert to their older methods, nullifying any positive outcomes from the improvement.
ZanaAfrica Group is a hybrid social enterprise based in Nairobi, Kenya, that manufactures and distributes high-quality, low-cost feminine hygiene products. Tested for behavioral change and health outcomes, all ZanaAfrica products are developed with girls using human-centered design. In this way, they meet the demand for affordable, accessible, and aspirational sanitary pad products, as well as providing menstrual health education for girls. ZanaAfrica has secured investment catalyzed by the Grand Challenges Canada, TripAdvisor, and Stewardship Foundation for a total of USD 1.9 million. ZanaAfrica is one of a small number of social enterprises that has successfully transitioned from grants to investment and has reached 150,000 beneficiaries with its sales of pads and underwear.
HappyTap Co. is an independent social business, wholly owned by WaterSHED and headquartered in Vietnam, that designs, manufactures, and sells the HappyTap, a first-of-its-kind portable sink to encourage consistent handwashing with soap. It offers a modern, convenient choice for the aspirational bottom of the economic pyramid. HappyTap has sold 10,000 units in less than three years.
Banka BioLoo is women-led business organization that promotes and develops innovative, environmentally friendly products and services for human waste management. The company has collaborated with the public and private sectors to provide sustainable bio-toilets in communities, schools, homes, institutes, offices, hotels, hospitals, healthcare facilities, and work sites, including trains. Banka BioLoo’s investors are private individuals, including members from the Banka family in India. In 2018, Banka BioLoo installed 800 bio-toilets in schools, reaching more than 40,000 students. As of August 2019, Banka BioLoo had installed more than 200,000 bio-toilets on Indian Railways trains.
Have an investment the GIIN should consider including here? Let us know!
World Health Organization (WHO) and UNICEF Joint Monitoring Programme. WASH in Health Care Facilities: Global Baseline Report 2019. Geneva: WHO, 2019.
Hannah Blencowe, Simon Cousens, Luke C. Mullany, Anne C.C. Lee, Kate Kerber, Steve Wall, Gary L. Darmstadt, and Joy E. Lawn. “Clean Birth and Postnatal Care Practices to Reduce Neonatal Deaths from Sepsis and Tetanus: A Systematic Review and Delphi Estimation of Mortality Effect.” BMC Public Health 11, Suppl. 3 (2011): S11.
World Health Organization (WHO) and UNICEF Joint Monitoring Programme. Drinking Water, Sanitation and Hygiene in Schools: Global Baseline Report 2018. New York: UNICEF, 2018.
Marni Sommer, Sahani Chandraratna, Sue Cavill, Therese Mahon, Penlope Phillips-Howard. “Managing Menstruation in the Workplace: An Overlooked Issue in Low- and Middle-Income Countries.” International Journal for Equity in Health 15 (2016): 86.
World Bank Group. “Menstrual Hygiene Management Enables Women and Girls to Reach Their Full Potential.” News release, May 25, 2018.
Matthew C. Freeman, Meredith E. Stocks, Oliver Cumming, Aurelie Jeandron, Julian P. T. Higgins, Jennyfer Wolf, Annette Prüss-Ustün, Sophie Bonjour, Paul R. Hunter, Lorna Fewtrell, and Valrie Curtis. “Hygiene and Health: Systematic Review of Handwashing Practices Worldwide and Update of Health Effects.” Tropical Medicine & International Health 19, no. 8 (August 2014): 906–16.
WHO and UNICEF Joint Monitoring Programme. Progress on Sanitation and Drinking Water: 2015 Update and MDG Assessment. New York: UNICEF, June 2015.
Lucia Hug, David Sharrow, and Danzhen You. Levels & Trends in Child Mortality: Report 2017. New York: UNICEF, 2017.
WHO, UNICEF, and USAID. Improving Nutrition Outcomes with Better Water, Sanitation and Hygiene: Practical Solutions for Policies and Programs. Geneva: World Health Organization, 2015.
Allison E. Aiello, Rebecca M. Coulborn, Vanessa Perez, and Elaine L. Larson. “Effect of Hand Hygiene on Infectious Disease Risk in the Community Setting: A Meta-Analysis.” American Journal of Public Health 98, no. 8 (August 1, 2008): 1372–81.
M.A.C. Schouten and R.W. Mathenge. “Communal Sanitation Alternatives for Slums: A Case Study of Kibera, Kenya.” Physics and Chemistry of the Earth, Parts A/B/C 35, no. 13–14 (2010): 815–22.
United Nations Department of Economic and Social Affairs. “2018 Revision of World Urbanization Prospects: Multimedia Library.” May 2018. https://www.un.org/development/desa/publications/2018-revision-of-world-urbanization-prospects.html.
Teketo Kassaw Tegegne and Mitike Molla Sisay. “Menstrual Hygiene Management and School Absenteeism among Female Adolescent Students in Northeast Ethiopia.” BMC Public Health 14 (2014): 1118.
Ritu Programme. Baseline Report 2017. Dhaka: Simavi, 2017.
George Miiro, Rwamahe Rutakumwa, Jessica Nakiyingi-Miiro, Kevin Nakuya, Saidat Musoke, Juliet Namakula, Suzanna Francis, Belen Torondel, Lorna J. Gibson, David A. Ross, and Helen A. Weiss. “Menstrual Health and School Absenteeism among Adolescent Girls in Uganda (MENISCUS): A Feasibility Study.” BMC Women’s Health 18 (January 2018): 4.
Maha Bouzid, Oliver Cumming, and Paul R. Hunter. “What Is the Impact of Water Sanitation and Hygiene in Healthcare Facilities on Care Seeking Behaviour and Patient Satisfaction? A Systematic Review of the Evidence from Low-Income and Middle-Income Countries.” BMJ Global Health 3 (May 2018): e000648.
Xiaoyan Song, David C. Stockwell, Tara Floyd, Billie L. Short, and Nalini Singh. “Improving Hand Hygiene Compliance in Health Care Workers: Strategies and Impact on Patient Outcomes.” American Journal of Infection Control 41, no. 10 (October 2013): e101–e105.
Damian G. Walker, Raymond Hutubessy, and Philippe Beutels. “WHO Guide for Standardisation of Economic Evaluations of Immunization Programmes.” Vaccine 28, no. 11 (March 8, 2010): 2356–59.
Global Handwashing Partnership. “Why Handwashing: Economic Impact.” https://globalhandwashing.org/about-handwashing/why-handwashing/economic-impact/.
Paul Montgomery, Caitlin R. Ryus, Catherine S. Dolan, Sue Dopson, and Linda M. Scott. “Sanitary Pad Interventions for Girls’ Education in Ghana: A Pilot Study.” PLoS ONE 7, no. 10 (October 2012): e48274.
This mapped evidence shows what outcomes and impacts this strategy can have, based on academic and field research.
Freeman, Matthew C., Leslie E. Greene, Robert Dreibelbis, Shadi Saboori, Richard Muga, Babette Brumback, and Richard Rheingans. “Assessing the Impact of a School-Based Water Treatment, Hygiene and Sanitation Programme on Pupil Absence in Nyanza Province, Kenya: a Cluster-Randomized Trial.” Tropical Medicine & International Health, 2011. https://doi.org/10.1111/j.1365-3156.2011.02927.x.
Garn, Joshua V., Leslie E. Greene, Robert Dreibelbis, Shadi Saboori, Richard D. Rheingans, and Matthew C. Freeman. “A Cluster-Randomized Trial Assessing the Impact of School Water, Sanitation and Hygiene Improvements on Pupil Enrolment and Gender Parity in Enrolment.” Journal of Water, Sanitation and Hygiene for Development 3, no. 4 (October 2013): 592–601. https://doi.org/10.2166/washdev.2013.217.
Mulogo, Edgar Mugema, Micheal Matte, Andrew Wesuta, Fred Bagenda, Richard Apecu, and Moses Ntaro. “Water, Sanitation, and Hygiene Service Availability at Rural Health Care Facilities in Southwestern Uganda.” Journal of Environmental and Public Health 2018 (2018): 1–7. https://doi.org/10.1155/2018/5403795.
Hayat, Fatima Akram, and Adam Thomas. “The Relationship Between Access to Toilets and School Enrollment in Pakistan.”
“Pilot Study Findings on the Provision of Hygiene Kits with Reusable Sanitary Pads: Testing the Appropriateness and Acceptability of AFRIpads Reusable Sanitary Pads in Southwestern (Ugandan) Refugee Context among Schoolgirls.” Pilot Study Findings on the Provision of Hygiene Kits with Reusable Sanitary Pads: Testing the Appropriateness and Acceptability of AFRIpads Reusable Sanitary Pads in Southwestern (Ugandan) Refugee Context among Schoolgirls, 2018.
Mcmichael, Celia. “Water, Sanitation and Hygiene (WASH) in Schools in Low-Income Countries: A Review of Evidence of Impact.” International Journal of Environmental Research and Public Health 16, no. 3 (2019): 359. https://doi.org/10.3390/ijerph16030359.
Each resource is assigned a rating of rigor according to the NESTA Standards of Evidence.
School Enrollment: Total (PI2389) / Number of toilets