Water, sanitation and hygiene (WASH) in schools: results from a process evaluation of the National Sanitation Campaign in Tanzania

This study assesses the intermediate outcomes of the Tanzania National Sanitation Campaign (NSC) for schools. A cross-sectional study was designed as part of a process evaluation of the NSC in Tanzania on 70 primary schools and 54 regional and district education of ﬁ cers. Data was collected between August and December 2014 using questionaires, key informant interviews, and desk studies. The results showed that only 50% of schools met the Tanzania guideline of 50 boys per drop hole, while 43% met the guideline of 40 girls per drop hole. In addition, 53% of schools had a reliable water supply, 43% had some functional handwashing stations, but only 29% and 19% had water and soap available at the stations, respectively. Overall, the implementation of the NSC in schools was found to be effective, though poor planning and coordination, inadequate funding, and low technical capacity were identi ﬁ ed as barriers to achieve the intended objectives. The study recommends stronger and coordinated stakeholder partnerships with clearly de ﬁ ned roles including cost sharing. Government and other stakeholders should also consider the impact of increasing funding for both software and hardware components to improve the enabling environment, and to develop a standardised monitoring mechanism for sustainable school water, sanitation and hygiene.


INTRODUCTION
Safe and adequate water supply and sanitation in schools are pre-requisites for the right to basic education for school children (Mooijman ). water and sanitation has also been estimated to result in 1.9 billion school days gained due to a reduction of diarrhoeal diseases among students (Hutton & Haller ).
Despite the potential contribution of improved WASH in schools to students' education and health, evidence shows that these benefits can be extremely heterogeneous (Freeman et  The other collaborators were the National Institute for Medical Research (NIMR) and the National Bureau of Statistics (NBS) in Tanzania. The study assessed the improvements made in SWASH in terms of access to WASH facilities and the presence of an enabling environment that can contribute to better health and quality education in primary schools in Tanzania. As a non-experimental study design, the process evaluation did not allow us to determine attribution of changes in behaviour and outputs to the NSC. Nonetheless, we can provide a representative overview of the prevalent sanitation and hygiene conditions and behaviours in the intervention areas, and develop assumptions that can be tested prior to the design of similar programmes.

METHODS
Drawing on the NSC's theory of change, we developed an evaluation framework. Figure 1 shows the conceptual model of the SWASH component of the NSC evaluation.
The chain represented in Figure 1 suggests that the intended impacts of improved health and education are dependent upon a combination of reduced exposures to pathogens and improved quality of basic services (e.g. more desirable and adequate latrines; a reliable water supply). Reduced exposure, in turn, depends upon two critical child behaviours: washing hands and using facilities for defecation, along with a safe physical environment. A safe physical environment includes sufficient clean latrines, handwashing with soap (HWWS) facilities, and culturally appropriate materials for post-defecation cleaning. Children's behaviour change is dependent upon both active hygiene promotion and the availability of desirable sanitation and hygiene facilities. Finally, the above-described conditions for impacts achievement are also dependent on a set of enabling institutional conditions. These include adequate water for cleaning and handwashing, availability of recurrent costs for consumables such as soap and repairs, clear roles and responsibilities for regular tasks, a system of monitoring and accountability, and active school sanitation and health clubs. We understand that several other exposures including the community and the household environment could all impact on the health and educational outcomes of school children. This study has, however, focused only on the school physical environment and its enabling environment due to the manner in which the campaign was implemented and the evaluation questions that needed to be answered.
The key research questions for the SWASH component were the following: • Are there environmental conditions in place for effective SWASH (i.e. adequate and clean latrines, HWFs with soap, post-defecation materials)?
• Are there enabling conditions in place for effective SWASH (i.e. budget, roles and responsibilities, monitoring and accountability, adequate water)?
A cross-sectional study was designed to collect information from 84 primary schools (sanitation improvements have been made or were ongoing in these schools) targeted    Less than half of the schools (44%) made provision for male urinals. In addition, only 37% of schools reported regularly providing anal cleansing materials for students. The majority of the schools (74%) had no facilities accessible to students with physical disabilities. Although more than half (59%)  (Table 3).
We found no association between the type of toilet technology and the reported cleanliness of the toilets.
Our study found that 66% of the schools had a functional water supply system, though only 53% had a regular supply throughout the year. The most common source of

Proportion of full pits (observation)
All toilets 88 (62) Some of them 6 (4) Observation not possible 6 (4) water supply was the tube well/borehole (20%), while the least was the tanker truck service (1.4%). The study also found that 70% of the schools use their water supply for drinking purposes, though of the main uses of water, using it for drinking purposes was ranked third (19%) compared with using it for cleaning purposes (top of ranking, 34%) or for hand washing (4%, almost the lowest in the ranking, Table 4). Nevertheless, a little over half of the schools (51%) reported providing drinking water for the students during school sessions.
Of the 70 schools, more than half (52.9%) had one or more handwashing stations, with an average number of six ( latrine cleaning (53%), and promotion of hygiene behaviour  and practices through art, drama and/or poetry either in the schools (63%) or in the community (40%).
Duty rosters for cleaning facilities were at least available in some of the schools, though only those for cleaning latrines were available in almost all the schools (97%). Less than 20% of schools had duty rosters for water treatment. The display of duty rosters for WASH activities was uncommon (more than 80% of schools did not display their rosters). Similarly, the promotion of good hygiene practices through the display of messages as posters was uncommon in schools. In the majority of schools (83%), all students (boys and girls) were responsible for cleaning the latrines.

THE ENABLING ENVIRONMENT
The implementation of the SWASH sub-component of the NSC, for which US$7 million was allocated, began later than planned and implementation presented several challenges. The SWASH sub-component was coordinated by the MoEVT/MoEST as the overall lead agency for NSC with the MoHCDGEC playing an advisory role.
As illustrated in Figure 3, the MoEVT was mostly involved in training and knowledge management activities (58%), such as the development of the SWASH guidelines and the training of regional secretariats (RS) and LGAs to implement them, followed by monitoring and supervision activities and advocacy and promotional events.
Interviews with district officials revealed that the main responsibility for planning SWASH activities lay with districts (71% of respondents) and the school management committees (SMCs) (49% of respondents). The results from the REOs were in line with those reported by the DEOs, except that the RS was found to be more active in the planning of SWASH at the regional level.  Table 6).

DISCUSSION
The study found that WASH facilities and an appropriate enabling environment were available in most schools, though they were inadequate to ensure a sustainable Lack of human resource capacities at a local level was also cited as a hurdle to conducting appropriate monitoring of programme outcomes. Quarterly progress documents reported that LGAs were unaware of funds being allocated in their accounts, or it was difficult to discern among those activities conducted under the NSC umbrella and those implemented by other partners. However, another critical hurdle to effective monitoring of the NSC was the delayed development and dissemination of the SWASH guidelines, a comprehensive document produced at central level that was set to guide local and regional governments in implementing and assessing the

CONCLUSIONS
The process evaluation of the NSC provided a comprehensive and representative overview of the prevalent WASH conditions and behavioural determinants in the target population during Phase I implementation. Furthermore, through the analysis of key programmatic documents, this evaluation has highlighted the main barriers that affected Phase I, and provided a clear baseline for defining improvements for the next phase. The study found that although WASH facilities were available in some of the schools, they were inadequate in terms of facility-user ratios, functionality and proper operation and maintenance. There was also active participation in SWASH activities by key actors such as teachers, school children, the community and the various government departments, though poor planning and coordination, inadequate funding and budgeting, and a lack of spare parts for repairs and maintenance were found to be the main challenges to improved WASH in schools in Tanza enumerators who conducted data collection for the process evaluation in 2014, as well as the enumerators who supported with data entry and translation.