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203 .2 99HY WHO/EOS/94.56Original: ENGLISH
Distr.: LIMITED
HYGIENE EDUCATION ANDENVIRONMENTAL SANITATION IN SCHOOLS
IN FRANCOPHONE WEST AFRICA
The report of an inter-country workshop to identify problemsand options for improvement
EIER, Ouagadougou 19-21 April 1994
It
World Health Organization (WHO)United Nations Children's Fund (UNICEF)
Ecole Inter-Etats des Ingénieurs de l'Equipement Rural (EIER)Swedish International Development Authority (SIDA)
January 1995
Summary
Schools in many parts of the world lack basic sanitation, drinking water facilitiesand hygiene education. The school environment can have considerable influence onchildren's behaviour and provides an opportunity to teach children at an early agebehaviours that can lower their risk of disease.
In April 1994 a workshop was held in Ouagadougou, Burkina Faso to assess thecurrent environmental situation in schools in eight Francophone West African coun-tries, foster improvements and promote the role that improved school environmentsand more effective hygiene education can play in encouraging change in the environ-ment of the community as a whole.
Case studies were conducted in each country to provide background information onthe regional situation. From the case studies, a set of common problems were identi-fied: absence of water points and latrines in schools, lack of personnel qualified inhygiene education, lack of national policies on health education and inadequacy ofresources for schools. Among the reasons identified for this state of affairs are lack ofimportance placed on school sanitation facilities by national ministries and a lack ofharmony between what is taught at school and the realities of life in the home andcommunity. When sanitation structures are available at school, they are often farremoved from anything families could afford to build. A lack of teaching aids andappropriate teaching methods for hygiene is another problem.
The workshop noted that increasingly communities are taking responsibility for theimprovement and maintenance of the school environment This is partly in responseto the financial constraints experienced by Ministries of Education and of Healthwhich mean that they can no longer fulfil this role. It is also because of communities'belief in the importance of education and of a healthy learning environment
The participants identified several possibilities for action that would improve sanita-tion and hygiene education in schools. They stressed the need for political will andappropriate policies. Better coordination between schools, communities, NGOs andgovernment partners in education, health, public works and external donors wereessential. School curricula needs to be focussed more closely on the norms and val-ues of local societies, teachers need to understand the realities of families from whichthe children come and the teaching and facilities should reflect a harmony betweenschool and community. The most effective role of government and concerned NGOsand inter-governmental agencies is to support schools and communities in theirefforts to improve the school environment and the teaching of hygiene.
The workshop recommended that each country create a plan of action to improveschool environments and teaching of hygiene and seek national and internationalpartners to help them implement change.
The workshop was hosted by the Ecole Inter-Etats d'Ingénieurs de l'Equipement Rural and financed withfunds provided by the Swedish International Development Agency {SIDA) to the Rural EnvironmentalHealth Unit of WHO, Geneva.
This report was prepared by Fatoumata Sokona Maiga WHO/Mall and Lucy Clarke and Mayling Simpson-Hébert WHO/HQ/REH, with the help of Mr David Daou, Mr Salissou Kané, Bernadette Kankl, ChristelleLoupforest and Issiya Souley. Most of the photographs in this report formed part of the eight countrycase studies prepared for the workshop. Others were taken by Lucy Clarke.
CONTENTS
A. Workshop Proceedings
1. Purpose of the workshop 1
2. Water, sanitation and hygiene education
in West African schools today 2
3. Key findings of the workshop 8
4. Key recommendations of the workshop 12
B. Country case studies
1. Benin 17
2. Burkina Faso 19
3. Côte d'Ivoire 21
4. Guinea 23
5. Mali 25
6. Niger 26
7. Senegal 28
8. Togo 29
C. Innovative experiences in the region
1. UNICEF 33
2. EAST 34
3. CREPA 36
4. The Saniya Project 37
Annex 1 Programme of the workshop
Annex 2 Case study guidelines
Annex 3 - Resource documents
Annex A\ Participants at the workshop
I > . • :
US
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The views expressed in documents by named authors are solely the responsibility of those authors.
A. WORKSHOP PROCEEDINGS
A1. PURPOSE OF THE WORKSHOP
Water, sanitation, hygiene and health:why schools can make a difference
Many of the diseases which affect children in WestAfrica, and throughout the world, are attributableto a lack of clean water supply and sanitation andaccompanying poor hygiene.
These diseases include diarrhoeal disease, intesti-nal helminths and schistosomiasis. An unhealthyschool environment can actively prevent enrollmentor attendance, when children fall sick, or, for exam-ple, girls are prevented from attending a schoolwhich has no latrines.
It would be over-simplistic to suggest that a healthierschool environment will directly, immediately im-prove the health of school-aged children. We knowthat in many of the countries of West Africa lessthan half of children attend primary school and thosethat do may return to homes without safe water orsanitation. Evidence suggests, however, that an im-proved school environment, combined with healtheducation and efforts to reach the wider commu-nity, can have a long-term effect on the health of thepopulation.
Childhood is the best time to learn hygiene behav-iours. But an effective school environmental healthprogramme does not simply offer children the op-portunity to learn new personal behaviours: it canalso help children to see themselves as importantmembers of the community who can play a role incaring for their environment, their health and thehealth of others. School based health interventionscan affect not only the next generation, our children'schildren, but also the wider community. Their in-volvement in the school's health promotion workand their pride in a healthy school environment canlead to lasting behavioural change and infrastruc-ture improvements.
This workshop
The workshop, which was held at the Ecole Inter-Etats des Ingénieurs de l'Equipement Rural inOuagadougou, Burkina Faso from 19 to 21 April1994, was a collaborative effort of WHO, EIER, andUNICEF. Additional technical support came fromUNESCO and from the Government of BurkinaFaso/London School of Hygiene and Tropical Medi-cine Projet Diarrhées. The workshop was fundedprincipally by the Swedish International Develop-ment Agency (SIDA). Additional financial supportwas provided by UNICEF.
Objectives
The workshop had three objectives:
> To highlight and explain the causes of the cur-rent situation of environmental sanitation andhygiene education in schools in francophoneWest Africa;
> To foster improvements in school environ-ments and hygiene education in schools in theregion;
> To promote the role that improved school en-vironments and more effective hygiene edu-cation can play in fostering change in the en-vironment of the community as a whole.
Preparatory work
Each participating country prepared a national casestudy which reviewed the existing conditions andhygiene education in a number of the country'sschools and provided data on the general health,water and sanitation situation. The preparation ofthese country cases allowed the participants to fo-cus on the issue and permitted an exchange of in-formation between countries. From the case stud-ies the participants developed a regional overviewwhich was the starting point for their discussions.
Key Conclusion
Increasingly, examples can be found of communi-ties taking responsibility for the improvement andmaintenance of the school environment. This ispartly in response to the financial constraints expe-rienced by Ministries of Education and of Healthwhich mean that they can no longer fulfil this role.It is also because of communities' belief in the im-portance of education and of a healthy learning en-vironment.
The most effective role of government and con-cerned NGOs and inter-governmental agenciesis to support schools and communities in theirefforts to improve the school environment andthe teaching of hygiene. Government and itspartners can provide this support through revisedteacher-training, the development of action-oriented curriculum, the dissemination ofmaterials and through a commitment to ensur-ing that all teaching and infrastructure in schoolsare culturally and economically appropriate.
A2. WATER, SANITATION AND HYGIENE EDUCATIONIN WEST AFRICAN SCHOOLS TODAY
77M* section of the report describes water supply,environmental sanitation and hygiene educationin schools, based on the country case studies pre-sented to the workshop and the ensuing discus-sions.
The school environmentThe eight participating countries were asked to un-dertake case studies which would provide a pictureof the current situation in schools in their countryand of the different actors who intervene. Becauseeach country chose to survey different numbers ofschools (from four in Côte d'Ivoire to 240 in Mali),it is difficult to compare their findings on a statisti-cal basis and it should be recognized that the datathey offer on latrine coverage in schools, for exam-ple, cannot always be assumed to be perfectly rep-resentative of the national picture. However, de-spite their specificities, the studies revealed consid-erable similarity between the environmental situa-tion of schools in different francophone West Afri-can countries. The key points held in common bythe studies are presented in this section and sum-marized in the box below. They provide a vivid pic-ture of the problems, needs and potential of schoolsin the region. This picture was confirmed by dis-cussion at the seminar. A resume of each case studycan be found in Section B of this report.
The percentage of children enrolling in schools inWest Africa is low, ranging from 23% in Mali to92% in Togo, but is generally increasing. Table 1on page 3 presents figures for each of the participat-ing countries. Population growth compounds thesefigures; schools face real problems even to provide
enough classroom space for children. The provi-sion of sanitary facilities was seen to represent alower priority than classrooms, teachers and teach-ing materials.
The following paragraphs outline the situation asrevealed in the case studies.
It is worth noting that the problems encountered inday schools are even more acute in boarding schools.Boarding schools are provided in some of the areasof the region which have particularly low popula-tion density or nomadic populations, such as thenorth of Niger. The Niger case study suggests thatthe majority of boarding schools have no dininghalls, showers or latrines.
Drinking water
The provision of safe water in schools echoes thatin communities as a whole, but is generally moresevere. Most schools, particularly in rural areas,have no reliable source of safe drinking water.In Benin, for example, only one in ten schools vis-ited had a piped water supply, whilst three in tenhad a traditional well. All others used surface watersometimes supplemented by water from a spring.During the dry months the lack of drinking waterbecomes an acute problem throughout the region.Teachers and pupils frequently expressed a strongdesire to have access to a permanent adequate sup-ply of safe water.
Even where a water point has been provided, itis frequently no longer in working order. Designis an important issue: pumps may be out of use for
Key points
1. Functional water points providing adequate supplies of safe water are rarely found inschools in the region.
2. Adequate numbers of clean functional latrines were not observed at any of the schoolssurveyed. At least half of the schools surveyed had no latrine. Where latrines exist theyare often out of order and may be inappropriately designed or dirty.
3. Hand washing facilities are very rarely observed in schools.
4. Although hygiene education forms part of all eight national curricula, teachers haveusually not received adequate training to conduct classes effectively and schools veryrarely have any appropriate educational materials.
5. Other environmental issues weigh heavily on the school community, such as the disposalof solid waste and repairs to school buildings.
Table 1. Selected data on water, sanitation and education in eight West African countries
Figures extracted from Human Development Report 1993. UNDP. New York. Oxford University Press, 1993
Country
Benin
Burkina Faso
Côte d'Ivoire
Guinea
Mali
Niger
Senegal
Togo
HumanDevelopmentIndex (HDI)rank (173countriesin total)
1990
162
168
136
173
168
169
150
145
Primaryenrollment
rate (%)
Total1988
71
36
61
32
23
32
52
92
Girls1988
49
28
53
21
17
24
46
83
Pupilscompleting
primaryschooling(as % ofentrants)
1988
40
63
73
48
40
75
81
46
Secondaryenrollment
ratio (gross)
1988-1990
11
8
20
9
6
7
16
22
Population with accessto services:
Safe water(%)
1987-90
50
67
83
33
49
59
53
71
Sanitation
(%)1988-90
41
10
36—
23
9—
23
long periods because a spare part is unobtainable orfinancially out of reach. Fragile standpipes do notwithstand constant use. Water is often lost throughbroken installations, leaving puddles around thewater point which provide an ideal environment forvector breeding.
A water source in workingorder can not itself ensurewater hygiene. A standpipeor pump is difficult to drinkfrom hygienically. Childrenneed water fountains or re-ceptacles from which todrink. But both water pointsand cups or pots must them-selves be kept clean.
What do children do whenno water or insufficient wa-ter is available? When aschool is located in a villageor urban area children andstaff will often use the localwater source, whether or notthe water is safe. This may
mean buying water from vendors as in Côte d'Ivoire,or taking water from the local pump or spring, apractice which may cause disputes, as was noted inBurkina Faso. Additionally, within the school thereis evidently no means to boil water to ensure itssafety. In isolated schools without an adequate wa-ter supply, the school community brings its own
Children and teacher* may b» forced to U M ttw local water sourc», whether ornot the water it safe. (Togo)
Where It is not readily available, teachers may storewater in the classroom, which may quickly becomeInsanitary. (Burkina Faao)
supply of water in gourds or jars. Where water isnot always readily available, teachers may storewater in the classroom in the same way that fami-lies store water in the home. If water storage ves-sels are not covered they may become insanitary.
Sanitation
The case studies indicate that between one quar-ter and one half of schools in the region have func-tional latrines. In Côte d'Ivoire none of the schoolsvisited had latrines in working order. And the exist-ence of a functional latrine does not ensure accessfor children to sanitary facilities: any functional la-trines are often reserved for teachers.
One reason why latrines are often out of order isthat they are frequently inappropriately designed foruse by children. Latrines in the region vary in de-sign from communal four to six hole latrines ob-
served in Togo, to simple pit latrines withsuperstructures made of branches in some schoolsin Côte d'Ivoire. Where latrines are built to a West-ern model, spare parts can be difficult to obtain orprohibitively expensive. Additionally, repairs maybe difficult because local craftsmen are not accus-tomed to the design. The superstructure of latrinesmay be very rudimentary and they are not alwaysroofed. Fragile latrines may prove a disincentive tochildren.
The number of latrines available was without ex-ception insufficient to meet the needs of children,particularly at times of peak usage such as recrea-tion. In Mali, for example, in Koulikoro, the regionsurveyed by the case study, one latrine was avail-able for every 417 children and the study consid-ered that the situation in other regions of the coun-try was even less favourable. In Niger only sevenfuntional latrines were observed in the six schoolssurveyed.
This situation contrasts with the standards gener-ally accepted within the health and education sec-tors which are shown in the box below:
Many schools have latrines that have fallen intodisrepair. (Togo)
How many latrinesdoes a school need?
The provision of one latrine for approxi-mately thirty pupila is generally recom-mended, if urinals are also available. Thisrepresents one latrine for every twentygirls and one for every forty boys.
When planning the number of latrines fora school, certain Issues should beconsidered:
> Are separate urinals available forboys? If so, fewer latrines will beneeded.
What is the proportion of boys togirls? If urinals are available, boysneed fewer latrines.
> Are children allowed to leave theclassroom during classes to use thelatrine? If not, the pressure onlatrines at recreation time will begreat and more latrines will berequired.
Do all children have breaks fromclasses at the same time? If so,more latrines will be required.Could breaks be staggered?
When a school has no latrines, where do childrendefecate? Children have no choice but to defecatein the area around the school. In rural areas thismay mean in the bush, but in urban areas childrenmay have difficulty in finding privacy and the like-lihood of others coming into contact with children'sfaeces is increased.
Hand-washing
Hand washing facilities were very rarely observed,and those available did not allow for hand-washingwith clean water. Soap was almost never observed.
Solid waste disposal
Solid waste disposal is a major problem for schoolauthorities. Schools havedifficulty finding appropri-ate ways to deal with theirown waste and must also inmany cases contend withwaste dumped on the schoolgrounds by the neighbouringcommunity because of thelack of enclosure of theschool compound. Some-times waste is burned, butthis itself may be a cause offurther environmental pollu-tion. In Guinea a solution tothe disposal of solid wastehas been found: the casestudy noted that all schoolsvisited deposited their rub-
enrollment in the face of reduced budgets. Inmany cases these classrooms are wooden frame-works covered with woven matting or corrugatediron panels. Whilst such classrooms may have apositive effect in reducing chronic overcrowd-ing, they are not ideal. They are hot in the warmmonths, cold in the cooler season and generallyhave little or no ventilation. A serious problem isthe poor light, which may ultimately have adetrimental effect on the eyesight of children andteachers. Repairing these and more permanent class-rooms is difficult for schools with no maintenancebudget. Government bodies are unlikely to be ableto maintain the buildings of individual schools,particularly in rural areas, so the school mustlook, with varying success, for support from thecommunity.
bish in pits. Makeshift classrooms may be wooden frameworks covered with woven matting.
Cleaning and building maintenance
Brooms are usually available and classrooms aregenerally kept clean - a sign that teachers and chil-dren are willing to take responsibility for their envi-ronment within the limit of available materials.Monitoring classroom cleanliness often falls withinthe mandate of school inspectors and teachers maybe reprimanded if the classroom is not clean andtidy.
Building maintenance is a perennial problem. Thestructure of school buildings differs greatly, depend-ing on who constructed the school and what materi-als were available to them. Whilst the majority ofclassrooms are solid structures built of brick or con-crete, increasingly schools are erecting makeshiftclassrooms, in order to respond to increased
One problem which affects many schools in the re-gion is that of bat infestation of the roof area. Aswell as being malodorous, bat faeces are highlycorrosive and can cause ceiling panels to rot andfall off.
Hygiene education
The amount of hygiene education offered was feltto be inadequate in almost all of the eight countrieswhich had prepared case studies. Health educationrarely had a real place in the curriculum and the ef-forts of teachers were not often supplemented byvisits by health personnel because of a lack of staff.
The hygiene education given was generally consid-ered to be of little relevance to the community con-
cerned and to be rooted in theory not in practice.The methods used were generally didactic ratherthan participatory, partly because of lack of adequatetraining and dissemination of materials and meth-odologies, and partly because of the lack of sani-tary facilities which makes practical teaching diffi-cult. In Benin it was reported that of the 151 teach-ers surveyed by the case study, only two had receivedany training in health education and communica-tion. One country which has begun to tackle thesetwo problems is Togo where teachers attend a threeday seminar on effective hygiene education andwhere hygiene education is firmly inscribed in thecurriculum.
Although the case studies did not undertake com-prehensive studies of the hygiene behaviours of pu-pils, some did report that pupils did not seem to dis-play many of the behaviours advocated by theirteachers or have a firm grasp of the link betweenhygiene and health. A study in Benin suggested thatwhilst 51 % of junior school children knew thatdrinking water could transmit disease, 44.5% be-lieved that water was not a source of disease, and4.5% were not able to answer.
The picture is not all gloomy, however. Examplesof positive experiences in hygiene education doexist. In 1988, Burkina Faso organized a "cleanestschool competition" which led to considerable ef-forts amongst children and teachers to improve theirenvironment. In Guinea UNICEF and the govern-ment publish a popular school hygiene educationmagazine Ecole propre, Ecole verte ("Clean School,Green School").
The different actors Influencingthe quality of school environmentsIt is often assumed that national and local govern-ment take primary responsibility for the quality ofschool environments. In practical terms, this is rarelythe case. Because of limited resources, both humanand material, they are unable to create or maintainhealthy school environments. This is a situation wecannot hope to improve immediately. Today theburden of responsibility and any hope for changelies with children, teachers, parents and communi-ties, supported whenever possible by NGOs orinter-govemmental organizations. In Section C, be-ginning on page 33, specific information can befound on the experiences of an NGO, a UN agency,a regional inter-govemmental institution and a re'
search group, all working to support schools andtheir communities.
Children and teachers
Children and teachers are at the forefront of the crea-tion of healthy school environments and teachersbear almost sole responsibility for the implementa-tion of hygiene education. The degree of responsi-bility given to school children varies from countryto country and even from school to school.
Children, under their teachers' supervision, aregenerally responsible for sweeping classrooms andthe schoolyard. They may also be expected to cleanthe latrines, either on a voluntary basis or as a pun-ishment. The Senegal and Togo case studies de-scribe how school children organize School HealthCommittees to promote healthy behaviours and ahealthier, safer school. In order to supplement theirincome and to provide environmental education,some schools in the region have created a marketgarden, tended by the children.
School inspectors can play an important role inevaluation of the achievements of teachers and inmonitoring cleanliness. They can also interact be-tween government and communities, disseminatinginformation and supporting community action.
Parents and the local community
Parents and the wider local community bearmuch of the burden of keeping schools function-ing, and several case studies noted that this roleis increasing. The responsibility undertaken byparents and the community depends in part on theirincome, but also on the nature of the community:its cohesiveness, and its degree of acceptance offormal education structures.
Whilst in Côte d'Ivoire government policy has de-manded that communities construct all schools, evenwithin countries the pattern of community involve-ment may differ markedly. Current trends suggestthat national and international financial cutbacksare leading to increasing community involvementin school construction and even community man-agement of school infrastructure. In Benin, forexample, as only very few schools are built by na-tional government, the responsibility for building,maintaining and equipping schools falls primarilyon the local community. In each school a Parents
6
Association meets about twice a year to manage thebudget raised from school fees of 500 CFA per childper year. Problems arise whenever the budget isdepleted. Since 1993 in Benin, in an effort to in-crease female enrollment, the government has ex-onerated girls from school fees, reducing the school'sbudget considerably.
If local communities are playing a significant rolein the construction and maintenance of school in-frastructure, then health education must reach outof the school to the community, allowing them todevelop an undertanding of the need for a healthierschool environment.
NGOs and intergovernmentalorganizations
NGOs and inter-governmental agencies are majorplayers in school hygiene education and environ-mental sanitation and are often seen by schools asthe greatest hope for the construction of latrines andthe provision of educational materials. Their inter-ventions differ, but are often multi-faceted, offeringsupport to hygiene education and to the improve-ment of school environments. The case studies par-ticularly highlight the work of Aide et Action, East,the Association Française des Volontaires pour leProgrès (AFVP) and UNICEF. UNICEF is activein all of the countries of the region, providing schoollatrines, stocked medicine cabinets, pumps and sup-port in the development of hygiene education mate-rials and in teacher training.
The case studies clearly show that, despite theirdynamism, NGOs and UN agencies cannot hope toprovide support to improve the environmental sani-tation of all schools. NGOs and inter-governmen-tal organizations can, however, have national im-pact through their work in teacher training or in edu-cational materials development.
Health personnel
The case studies do not suggest that health person-nel play a major role in ensuring healthy school en-vironments or in promoting healthy behaviours. Thisis chiefly because of the lack of health personnel.In several countries efforts to provide school healthservices have been curtailed because of insufficientresources and may only be available in certain re-gions and at a limited level.
Local and national government
National and local government departments wouldbe more important players if they had greater re-sources available, but in developing countries, evenwhen the state can build sanitary facilities in schools,lack of human and financial resources means thatthe maintenance of facilities by government agen-cies is rarely feasible. Structural adjustment has hitMinistries of Education and Health particularly hard.Consequently they have reduced expenditure onanything not perceived as essential to the function-ing of the school.
Some of the countries surveyed have made a policycommitment to the provision of latrines and safewater points in schools. In Burkina Faso for exam-ple the new Education II plan stresses that everynew school must have sufficient sanitary facilities.But the transition from policy to implementation canbe difficult. Since independence in 1960, the gov-ernment of Côte d'Ivoire has supported rural schoolsby equipping and providing staff for any new schoolbuildings the community could build. Populationincrease coupled with a percentage increase inenrollment has meant that in recent years thegovernment has been unable to keep its side of thebargain.
A3. KEY FINDINGS OF THE WORKSHOP
This section of the report asks why the problemsdetailed in section A2 exist and suggests ways bywhich they might be resolved.
Based on the country case studies and of the ex-perience of different development partners, theparticipants attempted to identify the causes ofthe problems they had found. Next they proposedsolutions to these problems. They found that thefundamental causes for the insanitary schoolenvironments and inadequate hygiene educationin schools in the region fell into four categories:
> Political and policy causes>• Cultural causes>• Educational causes> Institutional and financial causes
Political and policy causesSevere resources constraints oblige governments toprioritize their responsibilities. This in turn hasmeant that, in most of the eight countries, little at-tention has been paid to the development of nationalpolicy on the issues of school environmental sanita-tion or the improvement of hygiene education.Equally, responsibility for different aspects of theschool setting, and their attached resources, may bedivided between different ministries, leading to dif-ficulty in communicating, or acting coherently. Theschool environment and health must be linked indecision-makers minds before this situation willchange.
Any effective environmental action in the schoolsetting requires real commitment from several dif-ferent ministries and close collaboration betweenthese ministries, particularly between the Ministriesof Education and Health. Such broad commitmentand inter-sectoral collaboration are difficult toachieve. Moreover, cooperation is necessary not justbetween different government bodies, but also be-tween all the different development partners. Asshown in Section A2, this means the school itself,the community, NGOs and inter-governmental or-ganizations, local health personnel and local andnational government.
How can these issues be resolved?
The first step towards improvement would be theadoption of a coherent national policy on schoolenvironmental sanitation and hygiene education.Such a policy should clearly demand that all newschools constructed should provide adequate num-
bers of safe water points, latrines and hand washinginstallations. It should also make a commitment tothe improvement of water supply and environmen-tal sanitation in existing schools and map out howthese improvements are to take place. Policy com-mitment is more likely to be forthcoming if thereis a real understanding by all concerned of thelong-term potential for public health impact andof the possibility to take some action even if no in-creased resources can be proposed by government.
Policy would include an acceptance of the need todefine minimum acceptable standards. Flexibleguidelines should be prepared and distributed pro-viding simple guidance on:
• approximately how many latrines, water pointsand hand washing installations should be avail-able for any given number of boys or girls;
• how to make sure that these, and the accompa-nying hygiene education, are culturally appro-priate.
A method must be developed to ensure greater co-ordination between all the different groups con-cerned, including government ministries, NGOs,inter-governmental organizations and external sup-port agencies who assist the sector. Improved coor-dination could be achieved through a national coor-dinating committee on school environments andhygiene education or through a less formal systemof collaboration, through better sharing of informa-tion and planning of joint activities. Coordinationwould be facilitated by a data bank with up-to-dateinformation on the facilities in schools, on trainingpossibilities and on educational materials. The datawould help in planning future work, attracting in-creased resources and monitoring improvement.
Cultural causesBeliefs and practices related to water and sanitationvary considerably, not just from country to country,but also from region to region, even from village tovillage.
The case studies noted that there is little harmonybetween the infrastructure provided in school andthat which is available in the community. Latrines,for example, may not look like those available inthe community and be built of materials unavail-able in the community. The placement of the la-trines may also be culturally alien to the local com-munity, if, for example, boys' and girls' latrines are
8
placed side by side in a community where womentraditionally defecate on the other side of the vil-lage to men. This not only means that the hygienetaught at school seems irrelevant to the home envi-ronment, but also inhibits replication of school in-frastructure by families in their own homes.
It was felt that the hygiene messages transmittedthrough schools could have a much more signifi-cant effect on the wider community, if they weremore relevant to the reality of the community's eve-ryday life. Participants suggested that some currenteducational approaches seem to advocate that thechild, his or her family and his or her communityshould immediately take giant strides forward, bothin terms of facilities and in terms of behaviours.Because such advances may be inconceivable, thelessons can be discouraging.
How can these Issues be resolved?
There are many factors to be considered when try-ing to create culturally appropriate infrastructure andeducation programmes. Although, for example,government can help by providing guidelines on thenumber of latrines or the distance of water pointsfrom latrines, facilities, messages and educationalmethodologies will have to be designed at least atlocal level.
Perhaps the easiest way that governments can en-courage harmony with the local community is toinvolve the community in infrastructure and mes-sage design. Schools are integral parts of thecommunities: school and community are inter-dependent and must support one another. An in-creased role for communities in the management ofschool infrastructure is logical. This is not onlybecause many governments lack resources to un-dertake this role, but also because the greater therole of the community in designing, building ormanaging the facilities, the more chance there willbe that the facilities are culturally appropriate. Waysin which governments can encourage and supportcommunity involvement in school infrastructuremanagement and hygiene education are describedbelow in Institutional and financial.
The role of teachers in the promotion of infrastruc-ture improvement and in the design of appropriatehygiene education should be emphasized. Teachertraining should stress that each community has dif-ferent beliefs and practices related to water and sani-tation and should equip teachers with the ability toadapt their lessons to local circumstances. Teacher
training should equally underline the importance ofsimple appropriate technologies that the communitycan readily attain.
Educational causesFrom the case studies, four major problems emergeas severely affecting the quality of hygiene educa-tion offered by schools in the region. First, teachersalmost never receive adequate training in hygieneeducation. Second, most case studies state thathealth education has no specific slot in the curricu-lum and is not adequately addressed through otherclasses. A third problem which hampers effectivehygiene education is the lack of appropriate teach-ing methodologies and materials at teachers' dis-posal. It is felt that in many countries materials anddocumented methodologies do exist, but they rarelyreach schools and almost never in sufficient num-bers to be used directly by children themselves.Lastly, teachers encounter difficulties teaching hy-giene behaviours which cannot be applied withinthe school, because of a lack of sanitary facilities.A handwashing lesson has little impact when nohandwashing facilities are available at school.
How can these issues be resolved?
It was felt that much could be done immediatelyand at little cost to improve the quantity andquality of hygiene education offered at schoolsin the region. One key measure would be to ensurethat hygiene education was firmly rooted in the cur-riculum. It was not considered necessary to createa slot exclusively for hygiene education. In fact itwas considered that hygiene education would bemost effective if it was integrated into various partsof the curriculum, such as natural science and civiceducation.
A curriculum commitment to hygiene educationmust be accompanied by support to teachers to pro-vide the highest quality of education possible. Animportant early step would be to improve the train-ing of teachers by developing and introducing morerelevant courses into their pre-service training andby ensuring that all teachers can attend in-servicecourses on hygiene education and improvement ofthe school environment. Teachers need to have areal understanding of the links between a hygienicenvironment, hygienic behaviours and good healthbefore they can be expected to teach hygiene effec-tively or promote improvements to the physical en-vironment of the school.
A real understanding of the issues and commitmentto change by teachers was felt to be the foremostelement of improved hygiene education. Neverthe-less, teachers can offer more effective and inspiringclasses if they are familiar with the most appropri-ate educational methodologies. Active health edu-cation which aims for practical behaviour changeshould be the goal. Educational methodologies andmaterials which have proved effective in promotingbehaviour change should be documented and sharedwithin countries and between countries. Certain sim-ple materials, such as soap, can help to make hy-giene education relevant and should be made avail-able whenever possible.
Evaluation of programme effectiveness is clearlynecessary, but the evaluation of educational pro-grammes for their impact on behaviours or on healthis costly and time-consuming. The link betweenhygiene and health is firmly established. Instead ofundertaking difficult evaluation, countries couldchoose simple indicators which tell them whetherthe programme is functioning. Examples of ap-propriate indicators are the availability of soap athand-washing installations or the functioning andcleanliness of latrines.
Activa hMlth education which alms for practical behavioural change should bethe goal. (Benin)
Institutional and financial causesIn almost all developing countries, the water supplyand sanitation sector is seriously under-funded. Thissituation has been exacerbated in recent years inschools, because of the severe restrictions on public
expenditure and of the financial pressures causedby population growth and increased enrollment.Ministries cannot solely bear the burden of schoolenvironments and hygiene education.
Insufficient monitoring and evaluation of activitiesundertaken means that it is difficult to plan effec-tive future programmes and to attract funding.
How can these issues be resolved?
The case for additional funding for the water sup-ply and sanitation and educational sectors is strong.However, when additional funding seems unrealis-tic or will only ever be minimal, low- or no-costsolutions must be sought. Technologies promotedshould not only be culturally appropriate, but alsoeconomically appropriate. The promotion of therole of the schoolchildren and their communityin the management of the school is perhaps themost important step toward change. But not allcommunities can participate equally: some arewealthier than others; those in rural areas may bemore permanent and cohesive than those in urbanareas. How can communities be encouraged to pro-mote change and be supported in their activities?
A bottom-up approachwould see the state encour-aging children to improvetheir own environment andrequesting support whenthey could not act alone.Such an approach could bepromoted through maga-zines which speak directly tochildren and their teachers,through curriculum whichstresses responsibility andthrough educational meth-odologies which stress ac-tion. Competitions for themost hygienic school mayprove an effective motivator.Teachers will become agentsfor change through effectiveand continued training.Communities will be pre-pared to act when they them-
selves are included in hygiene education initiatives.Where Parents Associations are not in place, theircreation should be fostered. Where they are alreadyfunctional, their work should be validated and en-couraged and they should, wherever possible, be
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allowed to take greater responsibility for the man-agement of the school.
Various options exist for providing concrete sup-port to schools and communities who are ready toact. Countries might decide to make available, uponrequest, latrine slabs or other materials, to commu-nities that have already shown a significant com-mitment to the school by repairing the buildings ordigging a well. Countries may decide to offer tech-nical advice on latrine construction or making wa-ter safer. One interesting option would be to assistschools in developing income generating activitiessuch as market gardens. Additional income gener-ated could be spent by the Parents Association toimprove the school setting.
In all the above cases the government bodies con-cerned must be accessible to schools and communi-ties: one way to achieve this accessibility would beto brief school headmasters or mistresses or schoolinspectors and give them documentation with ideasfor action and contact addresses. Practical supportmay be best offered through NGOs or a mix ofNGOs and government. NGOs may be able to spendthe time necessary to follow a school through a pe-riod of change.
As described under the previous heading Educa-tional causes, monitoring is essential if programmesare to continue and to function effectively. Moni-toring also allows communities to evaluate their ownprogress.
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A4. KEY CONCLUSION AND RECOMMENDATIONSOF THE WORKSHOP
This section of the report takes the problems andpossible solutions discussed in the previous twosections and defines an agenda for immediate fea-sible action.
Key ConclusionIncreasingly, examples can be found of commu-nities taking responsibility for the improvementand maintenance of the school environment Thisis partly in response to the financial constraintsexperienced by Ministries of Education and ofHealth which mean that they can no longer fulfilthis role. It is also because of communities' be-lief in the importance of education and of ahealthy learning environment
The most effective role of government and con-cerned NGOs and inter-governmental agenciesis to support schools and communities in theirefforts to improve the school environment andthe teaching of hygiene. Government and itspartners can provide this support through revisedteacher-training, the development of action ori-ented curriculum, the dissemination of materi-als and through a commitment to ensuring thatall teaching and infrastructure in schools areculturally and economically appropriate.
It was felt that, despite financial and human con-straints, much could be done immediately to helpchildren and communities to create and maintainhealthier learning environments and to benefit fromappropriate, effective hygiene education.
Recommendations at national levelThe participants agreed that certain actions couldbe undertaken immediately at national level tobegin improving school environments and hy-giene education. These priority actions fall intothe same four categories which emerged fromdiscussions of the fundamental problems:
>• Political commitment and appropriate policy>• Cultural harmony between school and home>• Improved hygiene education>• Institutional and financial mobilization
Political commitment andappropriate policy1. Ensuring coherent action
A new national coordinating committee shouldbe created, made up of responsible officers ofall ministries concerned and representatives ofteachers, community leaders and any NGOs oragencies involved, such as WHO, UNICEF andUNESCO. The committee would supervise andreview implementation of all future programmesand ensure that all future actions are cultur-ally relevant and community-driven.
2. Gathering informationThe case studies prepared for this workshop pro-vide insights into the current environmental situ-ation and hygiene education provision in schools,but they also revealed the lack of national statis-tics on school facilities. Detailed informationis necessary for the planning of programmes bygovernment, NGOs and agencies. A nation-widesurvey should be undertaken in each country andresults published as a document of the nationalcoordinating committee.
3. Sharing informationThe findings of the workshop and of the nationalsurvey should be shared with decision makersin each of the eight countries. This means theMinistries of Education and Health, and alsoNGOs and agencies which support governmentin programme development and implementation.These different groups must share the informa-tion with schools and communities, who will bethe ultimate agents of change.
4. Development policyGovernments should adopt a national policy onwater supply, environmental sanitation and hy-giene education in schools. This policy shouldinclude:
* A commitment to the involvement of localcommunities in the design, construction,maintenance and management of the schoolenvironment, as well as guidance on how thiscan be supported by government;
• Legislation to ensure that every new schoolbuilding has adequate, appropriate sanitary
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facilities and water points and that, progres-sively, existing schools without water sup-ply and sanitation are provided with this in-frastructure;
Curriculum change to ensure adequate atten-tion to hygiene education, coupled withteacher training and the development and dis-semination of educational methodologies andmaterials for hygiene education.
Cultural harmony between homeand school5. A voice for the community
Parents associations, or any other group whichbrings school and community together, shouldbe encouraged and supported. Their role inschool infrastructure management should be in-creased and they should be involved in the de-sign of hygiene education programmes. Theparents association should have an active voicein wider community development.
6. The school's role in the communityTeachers and pupils should play an importantrole in spreading hygiene education to the com-munity. They could also become involved incommunity activities such as environmental im-provements. Teacher training and curriculumshould reflect this role of the school.
7. Ensuring culturally relevant hygiene educationTo ensure that hygiene education through schoolsis relevant to the realities of community life, theparents association should be involved in thedevelopment of lessons and teachers should betrained to be sensitive to the local situation andadvocate progressive, realistic change. When-ever possible, teachers should learn about localbeliefs and practices, but help children to dis-cover which are beneficial and which might beharmful to their health.
8. Ensuring culturally relevant infrastructureDesign, building and maintenance must takeplace at a local level, in order to ensure that wa-ter, sanitation and handwashing infrastructure atschool is culturally appropriate, will be regularlymaintained and could feasibly be replicated bythe community. School staff should be familiarwith the community's prefered designs. Chil-
dren, the parents association and local craftsmenshould be involved in design selection.
Improved hygiene education9. Strengthening curriculum
• Existing hygiene education programmesshould be reviewed by the national coordi-nating committee, both for their harmonybetween schools and homes and for specifictheoretical and practical objectives. Theplace of hygiene education in the curriculumshould be firmly established, not necessarilyas a separate subject, but as an integral partof other classes;
• The new curriculum should not provide fixedmessages, but rather should stress the role ofthe teacher in adapting messages to fit localbeliefs and practices;
• A strengthened curriculum must include in-dicators for evaluation and information aboutwho should undertake such evaluation. Sim-ple evaluation should be conducted by teach-ers to allow them to monitor their perform-ance and to help their motivation.
10. Strengthening teacher trainingA new approach to hygiene education will re-quire different training for new teachers and ad-ditional training for those already in service.Health education should become a significantcomponent of teacher training. The nationalcoordinating committee should review teachertraining courses and the skills and training oftheir trainers. Efforts should be made to involvehealth personnel and members of NGOs or con-cerned agencies in teacher training.
11. Improving the availability of educationalmethodologies and materialsThose teaching and learning materials alreadyavailable should be gathered, catalogued anddisseminated as widely as possible. At the sametime useful teaching materials produced by in-ternational agencies such as WHO, UNICEF,UNESCO and IRC should be collected, reviewedand made available where needed.
Equally, active educational methodologies whichhave proved effective should be evaluated, docu-mented and shared.
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institutional and financial aspects12. Creating a national plan of action
Based on the nationwide survey, a plan of ac-tion should be made by the national coordinat-ing committee, working as closely as possiblewith community leaders. The plan should setout the environmental and hygiene educationneeds of schools, prioritize these needs, proposea logical and feasible long-term plan for changeand set out which problems the country wishesto tackle first. The plan should clearly defineresponsibilities for all aspects of the school en-vironment and hygiene education. The planshould be a formal joint document of all theministries concerned and should address issuesincluding:
• How communities might be encouraged totake greater responsibility for the manage-ment of school infrastructure, including howcommunities can be assisted in managing afund for school maintenance;
• How action undertaken will be monitored andevaluated for efficiency and effectiveness.
13. Seeking financial and technical support
Ministries and their partners should examinetheir current management of financial, material
and human resources and decide whether thesecannot be better allocated to improve schoolenvironments and facilitate effective hygieneeducation.
Based on the plan of action, a project documentshould be prepared by all the ministries concernedfor submission to development partners, explainingwhere financial or technical support to the actionplan would be welcome. Responsibility for the co-ordination of external support should be defined andan adequate reporting procedure instigated.
Recommendations at regional level1. In order to promote the exchange of materi-
als and educational approaches, one regionalinstitution should be designated as a clearinghouse. The clearing house should gather andreview materials and methodologies and sharethose which are shown to be effective.
2. WHO, UNICEF and UNESCO are requestedto support the countries in their efforts toimprove school environments and hygieneeducation and to play an advocacy role, high-lighting the importance of the issue at a re-gional level.
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B. RESUMES OF COUNTRY CASE STUDIES
1. BENIN
The Republic of Benin has a surface area of112 622 km2 and is bordered by Togo, Burkina Faso,Niger and Nigeria. In 1991, the population of Beninwas estimated at about 4.86 million.
The cas* studyIn 1993, at the request of the government of Benin,the NGO EAST, with financial support form WHO,conducted a study on school environments andschool environmental health education in the Monodepartment in south-west Benin. Of the 427 schoolsin the department, 163 were visited. This study wasused as one case study for the workshop. Anothersurvey was carried out by staff members of the Min-istries of Health and Education in 38 of the 382schools of the Department of Borgou, in the north-east of Benin. The findings of these two studieswill be considered together.
Most of the schools visited highlighted the fol-lowing issues: the need for rehabilitation or con-struction of school buildings; the need for thecreation of canteens; inadequate provision of safewater points; insufficient school furniture; inad-equate teaching materials and essential drugs;and an urgent need for the installation of latrines.
SanitationEnvironmental sanitation is a major problem forschools in Benin: only 23.6% of the schools visitedin the Bourgou department have latrines. These areused by the majority of pupils but are generallypoorly maintained. The remaining 76.4% schoolshave no latrines and children defecate in the opennear the school. In the Mono department 33% ofschools surveyed have latrines. 13% of schools hada dry single pit latrine and 20% had a VIP latrine,generally built during a project undertaken by anNGO or external support agency in collaborationwith the Department of Hygiene and Sanitation(DHA). 80% of existing latrines in Mono are usedand 60% were considered well maintained.
bore hole. A similar picture was observed in Mono.Availability of water is a problem: apart from thefew schools in the urban areas which have pipedwater, most schools suffer acutely from water short-age during the dry season, which lasts from six toeight months in this area. In Mono it was consid-ered that only 40% of schools have a permanentsource of water and only 28% have a source of safewater. In order to ensure a regular supply of drink-ing water, 22% of schools surveyed in Mono keepjars of water in classrooms. These were usuallycovered and well maintained, however the water wasalmost never treated to make it safer to drink.
Buildings, maintenance andcleanlinessThree complaints about infrastructure in schoolswere heard repeatedly during the survey: existingpremises are not maintained and are in poor condi-tion; new classrooms and sanitary facilities areneeded; school canteens to provide a mid-day mealshould be created in order to encourage more chil-dren to come to school.
The structure of school buildings in Benin varies:34% of the schools visited in Bourgou are built ofhard materials, 55.3% of prefabricated materials and10.52% of apatam. All three types of constructioncan be found within the same building. Buildingstandards laid down by government are not alwaysrespected. In some classrooms there is no door, onlyan open doorway and in many schools windows donot let enough air or light into the classrooms.
Schools take responsibility for classroom cleanli-ness: all the classes visited are regularly swept andare kept tidy. 74% of the schools surveyed in Monohave a hygiene committee made up of teachers andpupils that supervises the maintenance of the schoolpremises by the pupils (sweeping, garbage collec-tion, cleaning of latrines, etc.), as well encouragingthe children to look after their personal hygiene andclothing.
Water supplyThe studies show that less than one third of schoolsin Benin have a permanent source of safe water.Particularly in rural areas, the demand for a perma-nent water point near schools is very strong. Only10.52% of the schools visited in Bourgou have apiped water supply, whilst 29% draw water from atraditional well, 26.3% make do with surface waterand 34.4% use both surface water and water from a
Hygiene educationHealth education became an integral part of the cur-riculum in the school year 1993-1994. However itmay be some time before the effects of the new pro-gramme are fully felt, as few teachers have so farbeen trained in health education or given access toappropriate health education materials. Only twoteachers out of 151 surveyed had received any train-ing in hygiene education. Many of the teachers in-
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tcrviewed were hoping to obtain the teaching guidesand supporting illustrative materials for EEC pub-lished by UNICEF.
As part of the survey a test of children's knowledgeof hygiene was carried out among 703 pupils in thefinal class of primary school in Bourgou and gavethe following results: 51 % knew that the water theydrank can transmit diseases, 44.5% felt that watercould not be a source of disease, and 4.5% didnot reply.
Health servicesHealth services are not widely available in schoolsin Benin. Only 17% of schools in Bourgou have astore of essential drugs and only 10% stated thatthey were visited for medical examinations once ayear. In Mono, only 14% of schools have a teacherwho has been trained in primary health care. It wasnoted that health services were more likely to beprovided in schools situated in the chief towns ofsub-districts.
Real attempt* ara being made to increase school attendance by girls. (Benin)
The school and the communityApart from a few schools built at the initiative ofthe national authorities, responsibility for most ofthe work of building, and all the maintenance andequipment of schools lies with the local community.In each school, a parents association meets, on av-erage, twice a year to manage the meager budget ofbetween 500 and 1000 CFA per pupil per year,derived from school fees paid by parents.
Since the beginning of the 1993-1994 school year,concern to increase school attendance by girls hasled the state to exempt girls from school fees. Thisreform has caused difficulties for parents associa-tions which find themselves with insufficient fundsto run their schools properly (already, in Mono, itwas considered that only between 50 and 70% ofparents pay their children's fees). 2105 of the 6164pupils attending the schools surveyed are girls,which means that the number of fee-paying pupilsis only 4059. In practice, each school can count onan income of only about 50 000 CFA. Much de-pends on the income level of the village: in Bourgou,
it was noted that the devel-opment of cotton growing isreducing relative povertyand enabling the villagers tocontribute fairly regularly toparents associations.
About one-third of theschools covered by the sur-vey have a garden or a fieldwhere they can grow pro-duce, however, in general itis felt that local agricultureis well organized and effec-tive, and can readily meet thenutritional needs of schoolchildren without any nutri-tional supplementation fromthe school.
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2. BURKINA FASO
Burkina Faso is a landlocked country situated at theheart of western Africa, in the great bend of the NigerRiver. It has an area of 274 122 km2 and its popula-tion is estimated at about 9 million. Approximately24.6% of children aged 7-12 attend the country's2587 schools, making a total of 530 Oil schoolchil-dren. Schools are not evenly spread throughout thecountry's 30 provinces and the northern provincesin particular are not well served.
The case studyThe study was carried out in the province of Gourma,in the east of the country. This province has61 schools with 184 classes and a total enrollmentof 11 314 pupils, of whom 63.9% are boys and36.1% girls. The study covered 10 schools locatedpartly in the provincial capital and the departmentalcapital, but predominantly in the province's villages.
they may not be used: in Kompienga children saythat they don't use the latrines because the ineffec-tive ventpipes mean that they are very smelly.
Only two schools of the 10 surveyed were observedto have hand washing facilities next to the latrinesand only one had soap available for use by pupils.
Water supplyHalf of the schools surveyed have access to drink-ing water, generally from bore holes equipped withmanual pumps. These are usually shared with theneighbouring community, which can be a source ofdisputes into which the headmaster or mistress maybe forced to intervene. Some of the schools whichhave their own water and sanitation facilities, mustshare these with the local community, which canlead to maintenance problems.
SanitationSanitary facilities vary considerably from one prov-ince to another, both in terms of design and cover-age. Both traditional latrines and ventilated pit la-trines can be found in schools. Four of the10 schools visited had latrines in working order, buttheir design was considered to be inappropriate foruse by the smaller pupils. In rural areas in particu-lar, facilities are rudimentary or rare in schools, echo-ing the situation in the wider community in theseareas. Even when functional latrines are available
Even whan hand washing facilities are available, theymay not be Ideal. (Burkina Faao)
Hygiene educationUntil now, progress in health education has mainlybeen achieved through the hygiene education com-ponent of the national programme to promote waterinfrastructure in the rural areas. The latest govern-ment plan for the development of the education sec-tor, Education II, offers hope both for greater atten-tion to health education and for improvements tothe school sanitary infrastructure. In future everyschool built must provide infrastructure such aswater points and latrines.
In 1988, a hygiene competition was organized inthe schools of Burkina Faso. Each school could enterand was evaluated on the cleanliness of their envi-ronment. The competition was highly successful,motivating schools to undertake major efforts inenvironmental sanitation and hygiene.
School health servicesIn theory, local health personnel working throughschools provide school primary health care services,including: the correction of certain nutritional defi-ciencies; immunization; monitoring of environmen-tal hygiene in schools; and the promotion of healthybehaviours. But in reality, in many parts of BurkinaFaso school health services are paralysed by lack ofresources and are unable to function effectively.Those provinces that have effective health servicesare the provinces which are supported by non-governmental organizations and which have suc-ceeded in bringing together different sectors in a multi-sectorial effort to promote the health of children.
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The school and the communityIncreasingly, the people of Gounna are coming torealize the benefits both of hygiene and of educa-tion for children.
More and more communities are helping with theconstruction of school buildings, generallythrough parents associations some of which nowplay an important role in the management ofschools.
It was noted, however, that whilst all the schoolsvisited officially have a parents association, in somecases the association exists in name only and un-dertakes no activities to support the school. Not allcommunities express the same interest in the schoolenvironment: in the school in Pama, when a teacher
requested a mother to come into school after herson had defecated in a classroom, the mother cleanedup the faeces, but insulted the teacher, telling himthat his own home was not as clean as the school.
The work of NGO» andIntergovernmental agenciesCatholic Relief Services (Cathwel) are the most ac-tive group in supporting schools in this region, pro-viding food for canteens at many of the schools. Oneinteresting partnership has evolved between theschool of La Clusaz in France and the school inPama. The La Clusaz school has sent educationalmaterials and equipment and helped Pama schoolwith the repair of the village pump used by theschool.
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CÔTE D'IVOIRE
Côte d'Ivoire has a surface area of 322 463 km2 anda population estimated at 12.46 million in 1991. Inthe school year 1989-1990, Côte d'Ivoire had 6691primary schools (both public and private) for a totalof 1 405 187 pupils. The greater Abidjan area alonehad 281 386 pupils, or 20% of the overall numberof schoolchildren.
The case studyFour schools were surveyed in the outskirts of thecapital city, Abidjan. It was felt that, contrary towhat might be expected, schools in Abidjan encoun-ter the same problems as those in rural areas. Offi-cial statistics suggest that 27% of all schools inAbidjan have no latrines.
SanitationIn towns, as in rural areas, sanitary facilities havenever been a priority in the design of school infra-structure and it is quite common for a school to beopened without any latrines being planned. Some-times, where the school authorities are aware of therisks inherent in poor hygiene, improvised latrines,often made of branches, have been constructed.When there are no latrines or they are not properlymaintained, the children go outside to defecate.Modern latrines are mainly found in the urban areasand are soon abandoned for lack of maintenance.Schools may thus be without latrines for severalyears.
Two of the four schools visited had no latrines,while the other two had only rudimentary latrinesthat were not in good working order. These weretraditional pit latrines with walls, but without roofs.The majority of the children at all these schools def-ecate directly out of doors in the vicinity of theschool.
Leaves or pages of old notebooks are used for analcleansing and these, as well as the protection usedby girls during their menstrual periods, are thrownon the ground around the school. In fact, the dis-posal of solid waste represents an important prob-lem for schools: in general rubbish is dumped on anopen-air pile near the classrooms, exactly where thechildren go to defecate.
Water supplyIn those villages which have a piped water systeminstalled by the national water distribution company
(Société de Distribution d'Eau en Côte d'Ivoire(SODECI)), the schools have their own meteredwater supply with several taps available to the pu-pils. In villages where there is a village water sup-ply system, the school either has its own standpipeor there is a standpipe in the village from which theschool can draw supplies. Villages with neither ofthese systems continue to draw their water from riv-ers, ditches or wells.
Even if water is available in sufficient quantity,it's quality can be problematic: if there is no freewater point in the school or the community, thechildren buy water sold by vendors, even when itsquality leaves much to be desired. Poor hygienecan cause problems: the water points are notalways properly maintained and drinking from acommon cup or from the tap itself carries risks ofinfection.
Hygiene education and behavioursHealth education is not currently part of the primaryschool programme. The subject is very briefly ad-dressed in a course entitled "Civic and moral edu-cation and environmental studies". The time spenton this subject varies from 15 to 30 minutes a weekdepending on the interest of the teacher.
Because no specific training in health education isgiven to primary-school teachers and as teachers donot have any appropriate teaching aids, the qualityof the hygiene education is variable. A soap com-pany has produced a brochure on hygiene, whichnaturally places considerable emphasis on the useof soap, and this is used by many teachers as a teach-ing aid.
In the four schools surveyed there is a substantialgap between teaching and local practice.
The case study expressed the view that if ruralcommunities are to take responsibility for the en-vironment of schools and devote attention to im-proving sanitary facilities, they should be in-cluded in any environmental hygiene educationthat is given through the school.
The school and the communitySince independence in 1960, the State has pursueda policy promoting the construction of publicschools. In rural areas, policy stated that if any com-munity constructed school buildings and accommo-
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dation for the same number of teachers as there wereclasses, the State would provide teaching staff andthe necessary furniture and equipment. This sys-tem functioned well until the extraordinary growthin demand for primary education of recent years.For some time now, the State has no longer beenable to meet its commitments and schools are nolonger systematically equipped.
In urban areas, the State was responsible for thebuilding of primary schools until 1980 when a sys-tem of municipal authorities was created, amongstwhose responsibilities are the construction and main-tenance of school builidings.
The work of NOOS andIntergovernmental agenciesThe case study noted that very few organizationssupport schools regularly or systematically. Only theWorld Food Programme is a regular supporter, pro-viding assistance to agricultal activities and schoolcanteens. Occasionally clubs, such as Rotary orLions Club, intervene in schools supplying materi-als or supporting repairs.
Most latrines are no longer functional. (BurkinaFaso)
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GUINEA
Guinea has an area of 245 857 km2 and its popula-tion is estimated at about 7 million. Forty-two percent of the population is under the age of 18. Ap-proximately 36% of children attend primary school,although for girls this figure is closer to 24%. Thenumber of pupils enrolled in primary schools is421 869, of which 338 601 are in the urban areasand 83 268 in the rural areas.
The case studyThe survey was carried out in seven schools in thecoastal region. Six of these are in rural areas andone in an urban area. They are situated between 50and 200 km from the capital, Conakry. In total theseven schools have 2 593 pupils, of which 921, or35.5%, are girls. It was noted that the schools situ-ated close to urban areas have a considerably higherpercentage of children of school-age children attend-ing school than those in more rural areas. It wasalso observed that in rural areas no female teachersare employed.
SanitationOnly three of the seven schools surveyed have work-ing latrines. Two have latrines which are no longerfunctional and two others have no latrine at all. Oneschool which currently has no sanitation facilitieswas in the process of building latrines when the casestudy was conducted. The case study noted that itis increasingly rare to see pupils defecate out ofdoors, so it must be assumed that children liide them-selves or make use of facilities in neighbouringhouseholds.
Of the three schools with functional latrines, all hadbeen supplied through external support, one set offacilities by the French NGO Aide et Action and twoby the Red Cross. The sets of latrines supplied bythe Red Cross consist of three latrines: one each forteachers, girls and boys. No material is providedfor anal cleansing, however a basin is located nextto the latrines for handwashing. The case study re-ports that at one of the schools cleaning and main-tenance of the latrines is undertaken twice a weekby the pupils. Since their installation in 1989, noproblems have been reported in the functioning ofthe latrines. This may be in part due to die fact thatthe majority of the children have latrines in theirhomes.
Water supplyDrinking-water is not available in all seven schoolsand provision depends largely on the availability ofa water point near the school. Four of the schoolssurveyed were located near a pump, but one of thesepumps is not currently functional. The NationalWater Service (Service national d'aménagement despoints d'eau (SNAPE)) has only been able to im-prove approximately 50 bore holes for use specifi-cally by schools.
Building maintenance andcleanlinessAll the schools are clean and make efforts to dis-pose of their solid waste, either placing it in gar-bage pits or burning it in the corner of the schoolyard. It was noted that several schools are consid-erably cleaner than the surrounding area and thatconsequently children are happy to spend time atschool. Pupils are responsible for sweeping of theclassrooms and cleaning of the latrines. These ac-tivities generally take place on Saturday morning.Interestingly, it was noted in one school that theburden of latrine cleaning falls most heavily on girlpupils who take turns at cleaning under the super-vision of a female school teacher.
Hygiene education and behavioursIn all the schools visited, curricula officially in-clude courses on hygiene and health education,however the quality of teaching was felt to be lim-ited. A marked discrepancy was observed be-tween the behaviors pupils are taught and theiractual behaviours.
Three issues were raised to explain this situation:teachers have not always received adequate train-ing; in many cases no teaching aids are available;lack of harmony between the behaviours taught inschools and everyday life in the community. Somesupport, in the from of appropriate materials, hascome from the Child-to-Child project and fromNGOs, but tiiese are not widely disseminated.
Health servicesA lack of medical personnel and of financial re-sources means that few school health services canbe offered and the case study revealed that localhealth personnel do not intervene in any of theseven schools surveyed. Few of the schools havea staff member trained in primary health care orfirst aid.
23
The school and the communityAlthough each school theoretically is requested tohave an Association of Parents and Friends of theSchool, these are not always functional and parentsdo not generally play a significant role in the man-agement of the school.
The work of NOOs andIntergovernmental agenciesThree years ago, UNICEF carried out a project incollaboration with local populations to improve en-vironmental hygiene. In an area about 100 km fromthe capital, nine rural schools were equipped withabout 30 double-pit latrines and 10 reservoir tanks
for water. To facilitate the transport of water andpromote hygiene, UNICEF also supplied trolleys,cans, water bottles and soap. Additionally, since1991, UNICEF has contributed to the training ofteachers and the installation of latrines in schools intwo neighbourhoods of Conakry. This project isentitled Ecole propre, école verte (clean school,green school), and includes publication of a healtheducation magazine for schoolchildren.
Other organizations which support schools in thisarea include the NGO Aide et Action and the RedCross which have been active in the construction oflatrines and the Canadian NGO CECI which hasprovided educational materials to schools.
• * ( . .
,.^XSÊAi^ÊSÊ:XÊÊt!M:WSB
BULLETIN D'EDUCATION ENVIRONNEMENTALEDESTINE AUX ELEVES DU PRIMAIRE
SOURCE (MCEF - «SCHNEE
"Je vais à l'écoleet je souris è la vie"
. Une lettre pour tot
, Ton coin sant& :..
.Respectons las règh» d'hygiène
. Billet aux parant! d'ftiivts
. L u r>ol d'or dm Vhyflièn»
, Jaux - R6portse«
. Comptin.
.Çoncoura
. Uiw banàa dsïfttnés ! Soyc
A children's magazine used In Guinea.
24
5. MALI
Mali has an area of I 240 190 km2 and a populationestimated at about 8.29 million. Approximately 28%of children enroll in primary school. 340 573 chil-dren attend state schools in Mali, of which 145 087are girls and 252 061 boys. An additional 56 575children (including 20 680 girls) attend the coun-try's 280 koranic schools. 81% of Mali's schoolpupils and students are in primary schools, howeveronly 35% of the national education budget is de-voted to primary education. 98% of the total sumgiven to primary education is spent on personnel.
The case study240 primary schools in the region of Koulikoro werestudied. This region has the highest level of schoolenrollment in the country at 24.2% of all school agedchildren.
SanitationThe case study revealed that 53% of schools stud-ied have at least one latrine. This means an averagefor the region of one latrine for every 417 pupils. Itis very difficult to determine a national average forschool sanitation, but the rare studies which havebeen undertaken suggest that about one school infive has a latrine.
Water supplyThe case study showed that 39% of the schools sur-veyed have a water point for use by pupils. Thisfigure is probably the highest in the country. Un-fortunately, these collective water points are rarelymaintained and often unhygienic.
Hygiene education and behavioursHealth education, with particular attention topersonal and collective hygiene, has formed partof the primary school curriculum since independ-ence. The case study team felt that teachers makeconsiderable efforts to include hygiene educationin their everyday teaching, but that their effortsare hampered by a lack of teaching aids and bythe absence of sanitary infrastructure in schoolswhich makes any practical teaching difficult.
In recent years attempts have been made to improvethis situation. In 1992 the Ministry of Education, incollaboration with the University of Liège, publisheda health education manual for primary schools, pre-pared with financial support from UNICEF.
The school and the communityThe case study noted a dynamism amongst local
communities and a willingness to contribute finan-cially to the construction of school buildings andthe improvement of school sanitation. This is in parta result of a change in government policy which fa-vours decentralization and increased responsibilityfor local authorities in rural areas. Rural commu-nities increasingly wholly or partly finance andmaintain primary schools and health centres.Additional support sometimes comes from nationalor international NGOs.
The work of NGOs andintergovernmental agenciesThe support fund for primary education financedby the World Bank and USAID is intended to fi-nance the improvement of school infrastructure andincludes provision for the improvement of schoolsanitation.
A number of NGOs and intergovernmental organi-zations have supported the improvement of waterand sanitation facilities in schools in Mali. UNICEFplays a significant role and its 1994-97 programmeof cooperation with the Government of Mali placesa particular accent on the development of primaryschools, including the construction of latrines.
Health servicesUntil 1989 the Ministry of Health had a specific di-vision dealing with school and sport medicine, withan attached centre for school and sports health.Through these structures a system of school healthservices was administered, offering preventative andcurative care through school nurses and stores ofessential drugs located in schools. Where no healthpersonnel were able to intervene in schools and theirwas no school medicine cabinet, children receivedfree health care in local health centres.
Since the advent of the national structural adjust-ment programme, financial constraints have forcedcutbacks and, in 1990, both the department and thecentre of school and sport medicine were closed,effectively halting all provision of health servicesthrough schools. Additionally, although health cen-tres officially provide services to school pupils with-out charge, financial pressure on the centres meanthat children can no longer realistically expect toreceive free care.
In 1992 the national action plan for child survival,protection and development attempted to find a wayforward and a programme for the improvement ofschool environmental sanitation is currently underreview.
25
6. NIGER
Niger is a landlocked country situated in theeast of western Africa in the Saharo-Sahelian belt.It has an area of 1 267 000 km2 and its population isestimated at about 7.9 million. The population isvery unevenly distributed, with three-quartersof the citizens of Niger in one-quarter of thenational territory in the southern strip of thecountry, where the environment is better suited toagriculture.
The traditional school system comprises 2383schools (franco-arab and experimental) with 377 502pupils attending public schools and 8561 in privateprimary schools. The lack of any reliable map ofthe country's schools and the anarchical establish-ment of schools result in considerable disparity be-tween urban and rural areas and hamper the harmo-nious development of the school system. Poor man-agement of the grounds and facilities of the schoolscreate additional problems.
The case studyThe two departments selected for the study aredrawn from different geographical areas and werechosen to present, as far as possible, the differentcultures of the country. The 21 schools chosenwere primary schools, situated exclusively in ruralareas, with the exception of three schools in thecommune of Dosso, regarded as a periurban area,but lacking in any sanitation and water supplyinfrastructure. A total of 2 952 children attendthe schools surveyed, of which 928, or 31.4%, aregirls.
All the problems experienced in Niger's schools areparticularly acutely felt in the schools that have acanteen and where the children live together in aboarding house. These schools generally have norefectories, showers or latrines.
SanitationIn Niger, environmental hygiene is often ne-glected when school infrastructure is designed.Of the 21 schools visited, only six had latrines. Ofthe total of 16 latrines observed, nine were so di-lapidated that they were no longer used. Often thereason for abandoning the latrine was the collapseof the superstructure rather than a full pit. Whenadequate numbers of functional latrines are notavailable, the children defecate in the bush or
around the classrooms. Positive experiences dohowever exist: in the Gatawani school, teachershelped children to build a latrine during theirlesson time on Practical and productive activities.Although this single latrine cannot serve all the 102children at the school, and the lack of a system topump out the waste matter means that the super-structure must be moved each time the pit is full,the example of independent action by the school isencouraging.
The disposal of solid waste can be a problem forschools. (Niger)
Water supplyVery few of the schools surveyed had a water pointwithin the school grounds. In general children hadto collect water from the village pump or well, butin many cases this is not currently functional or issituated at too great a distance from the school forregular water collection to be feasible. Often chil-dren bring their drink in water bottles or cans. The
26
problem of availability of water is especially dras-tic in the regions where the traditional wells do notreach the water table and where for long periods nowater can be obtained.
Hygiene educationAll the schools surveyed made an effort to providehygiene education through lessons such as civic in-struction and natural science. The only educationalmaterials available were standard textbooks in thesesubjects. The quality of the teaching depends largelyon the motivation of the teachers, who are free toconvey hygiene messages as they wish. It was notedthat many try to integrate practical instruction intoclasses, teaching children about cleaning of theschool area and hand washing after defecation andbefore eating. The case study noted, however, thedifficulties encountered by children in applyingthese messages within the school and at home,when in both of these environments latrines andhandwashing facilities may not be available.
Building maintenance andcleanlinessThe case study repeatedly highlighted the prob-lems posed by the lack an enclosure for the schoolgrounds: members of the local community de-posit their solid waste, defecate or allow theiranimals to roam around the school buildings.Solid wastes are generally burnt or dumped nearthe school buildings.
The school and the communityAttitude towards the school differs from commu-nity to community. In a few villages there was hos-tility towards the school, and particularly towardsthe education of girls. However, many communi-ties were ready to support the school within the limitsof their meager revenue. Schools in entirely agri-cultural areas received very little material supportform parents because of their low income. The roleof the community is all the more important when itis considered that, apart from the efforts of UNICEF,the World Food Programme and the European Fundfor Development, little assistance is made availableto Niger's schools through external supportagencies.
27
7. SENEGAL
In 1992, there were 725 496 children in primaryeducation in Senegal, attending 2434 schools, ofwhich 2321 were public and 113 private.
The case studyThe study covered 21 rural schools in the three de-partments of the Tambacounda region in south-eastSenegal. This region covers approximately one thirdof the national territory and has 21 661 childrenenrolled in primary schools.
SanitationThe study highlighted a number of key points re-garding the state of sanitation in schools. Wheresanitary facilities have been built, they are often nolonger functional. The case study suggested that twoof the reasons for the poor rate of functioning of thelatrines were the poor hygiene practices of the chil-dren and the lack of attention to basic maintenance.Care for the latrines falls considerably behind thataccorded to water points. The case study suggeststhat many of the latrines are very simply constructedfrom local materials: this should make basic repairsby the school community possible, however a changeof attitude by pupils would be necessary if they wereto take greater responsibility for the school's sani-tation.
ers are willing to take responsibility for the clean-ing and maintenance of water points and most werereported to be reasonably clean. Where a pipedwater system is in operation, the supply may onlyfunction between certain hours, in which case chil-dren collect water early in the morning in large tra-ditional jars which are stored in the classroom toprovide a ready supply of drinking water.
Health education and behavioursAlthough a health education programme waslaunched in the region surveyed in 1979, the casestudy suggests that in practice there is currently noreal commitment to the teaching of hygiene inschools.
Since 1982, the health education programme hasbeen extended with the help of the French vol-unteer organization, Association Française desVolontaires pour le Progrès (AFVP). The pro-gramme seeks to develop deeply-rooted healthybehaviours among schoolchildren by trainingteachers and providing them with teaching ma-terials in the form of fact sheets or a manual. Atthe same time, health committees, managed andled by the children themselves, are beginning toappear in schools and a child-to-child teachingapproach is being encouraged.
Water supplyAlthough some schools have very good access towater through a piped supply, many schools haveno piped supply, pump or well, and share the waterpoint of the local community. Where pumps do ex-ist, they are often no longer functional due to a lackof parts or because no fuel can be purchased, eitherthrough lack of availability of fuel or lack of funds.The case study stresses that children and their teach-
The school and the communityIn addition to the external financing they receive,the schools raise funds through a variety of activi-ties, such as market gardens, providing services dur-ing harvesting, collecting wood, working in collec-tive fields, theatre, and poultry rearing. Despite theirenterprise, schools are still short of funds and thisproves to be an obstacle to any major improvementto the school environment.
28
8. TOGO
Togo has an area of 56 000 km2 a population esti-mated at about 3.37 million. Approximately 64%of children aged 6 to 11 years were enrolled inschools during the school year 1989-1990. Togohas about 2500 schools.
Togo has not defined any specific policy for socialand sanitary infrastructure in schools. The needs ofschools are theoretically addressed in the overallpolicy for drinking-water supply and sanitation. Theresults of the survey of sanitary facilities carried outin December 1989 by the Department of PrimaryEducation (Direction de l'Enseignement du PremierDegré (DEPD)) revealed that 37.7% of the 1164schools surveyed had access to a water point withina radius of 600 m, while 35.7% had latrines and 12%had urinals.
The public sector has been paralysed for severalyears by the economic crisis. Nevertheless, withthe support of NGOs and international organizations,the situation has somewhat improved, with approxi-mately 40% of schools having access to water and37% having latrines. Significant school absentee-ism on account of infectious diseases such as gas-troenteritis, intestinal parasitoses, diarrhoea,dracunculiasis, etc., is an indirect result of drinkingpolluted water.
The case studyIn Togo, the study was carried out in 10 rural schoolsin the areas covered by two school inspectorates inthe maritime region, about 40 km from Lomé, thecapital. In the 10 schoolsvisited there were 70 teach-ers, of whom five werewomen, and a total of 4744pupils.
SanitationEight schools have latrineswith four to six holes, in-stalled on the initiative of theDepartment of Sanitation,NGOs or international or-ganizations. Most of the la-trines are functional, but inpoor condition. Someschools have constructedurinals using local materials.
Building maintenance andcleanlinessSchool yards are swept regularly, but it was notedthat maintenance of sanitary infrastructures inschools is poor.
Water supplyThere is a general lack of appropriate facilities fordrinking-water supply in schools. Seven of the10 schools visited are supplied with drinking-waterfrom a water point set up by the inhabitants and situ-ated within a radius of 1.5 km from the school. Thewater points are usually wide diameter wells, mostlywithout covers. Schools must share these waterpoints with the local community and, in general, noone takes care of their maintenance.
Containers with drinking-water were observed in theclassrooms of some of the schools. Some schoolsalso have guttering on their roofs to collect rainwa-ter in their cisterns. These rainwater collection res-ervoirs (impluviums) are created by schools them-selves, with some outside assistance. Whilst help-ful, they can rarely satisfy the school's water needsthroughout the year.
Hygiene education and behavioursSchool health education is included in the officialcurriculum within a class entitled "Scientific edu-cation and initiation into practical life". This classlasts 30 minutes a week in the elementary classes(third and fourth years at primary school) and 45 to
A urinal constructed using local material».
29
60 minutes in the middle classes (fifth and sixthyears). Most of the teachers have received threedays of training on the content, objectives and teach-ing approaches of health education, aimed at im-proving the impact of the programme.
The case study noted a lack of interest in healtheducation activities on the part of certain inspec-tors and teachers. This may in part be a result ofa lack of suitable teaching materials and the dif-ficulty in providing action-oriented hygiene edu-cation without adequate sanitary facilities.
Each inspectorate has a supervisory committee com-posed of teachers who have familiarized themselves
with the problems of hygiene. In the school, a chil-dren's school health committee is organized to en-courage hygienic behaviours and the improvementof the school environment.
The work of NGOsCertain organizations have been particularly activein the school setting. In Togo, UNICEF has con-structed 55 latrines, seven wells and four standpipes,and supplied 816 schools with essential drugs. TheNGO Aide et Action has built 27 wells and sevenstandpipes in schools.
30
C. INNOVATIVE EXPERIENCES IN THE REGION
1. UNICEF
The principal objectives of UNICEF, defined by theWorld Summit for Children, are to reduce mortalityamong children under five by one-third; to reducematernal mortality by 50%; to reduce malnutritionby half; to ensure access to drinking-water and hy-gienic systems of excreta disposal; to ensure that50% of children complete primary school; and toreduce the rate of illiteracy among adults. If theseobjectives are to be attained, progress in hygiene,sanitation and drinking-water supply are an abso-lute necessity.
UNICEF is active in all of the countries whichattended the workshop, working in collabora-tion with various national institutions andNGOs. School hygiene and environmental sani-tation is a priority for UNICEF in all of thesecountries.
The programmes established by UNICEF vary fromone country to another, but most include the con-struction of latrines, the improvement of drinking-water supply, and the creation of teaching materialsfor hygiene education. Additionally, UNICEF hasextended its action to the establishment of schoolsupplies of essential drugs, to market gardeningprojects, to the improvement of school buildings andto teacher training in health education.
Over the years, UNICEF has adapted and redefinedits programmes in the region, developing experienceand learning of the difficulties of the sector. Whilstexperiences have been different in each country,certain obstacles to the development of environmen-tal hygiene have been frequently encountered,these include: insufficient support to the develop-ment of a policy for environmental hygiene inschools; difficulties in coordination between thedifferent partners involved; and poor programmefollow-up.
The sustainability of programmes has been foundto be impaired for the following reasons: emphasiswas too often placed on construction; the technolo-gies selected were often costly and not sufficientlyadapted to the needs of the children and the culturaland physical environment; arrangements were notalways made for maintenance.
On the basis of their substantial experience in healtheducation, behavioural change, follow-up of projectsand strengthening of national capacities, UNICEFhas been able to develop multi-sectoral programmesnow based on demand rather than supply. TodayUNICEF is concentrating its efforts on thesustainability of projects and on a stronger relation-ship between schools and communities.
33
2. EAST: THE ROLE AND APPROACH OF AN NGO
The medical NGO EAST (Eau, Agriculture, Santéen Milieu Tropical) has been working in BurkinaFaso since 1983. Initially, EAST'S work was fo-cused on the improvement and monitoring of waterquality in rural areas. The organization sought tohighlight the fact that contamination often occursduring the transport and storage of water.
EAST's attempts to find a simple means to dis-infect water drunk in the home led to the crea-tion of a drinking-water post (poste d'eau pota-ble (PEP)). This water post, made of a traditionalwater pot fitted with a tap, filter and cover andplaced on a simple tripod, allows water to be dis-infected according to simple guidelines for chlo-rination prepared by EAST. The tap and coverprevent contamination of the water.
In 1988 a project waslaunched to disseminate thistechnology, initially by in-troducing the drinking-waterposts into schools. Since1989, this project has devel-oped into an intersectoraldevelopment programme forschools. The programmeincludes health education,drinking-water supply (theconstruction of school drink-ing-water posts), sanitation(the construction of latrines),school health services (thecreation of school stores ofessential drugs) and an in-come-generating activity(the creation of gardens).EAST has contributed toprojects of this type in100 schools in the provinceof Bazega in Burkina Faso.This year a similar type ofproject has been launched in the province ofOubritenga in Burkina Faso and a pilot project hasbeen started in the province of Mono in Benin.
In each case the programme is proposed to all theschools in one educational administration district,and those in charge, whether directors or parents'associations, are free to accept it or not. The pro-gramme launched in January 1994 in Oubritengabuilds on the basis of the previous project, with anumber of interesting developments. Most impor-tantly, a school can only participate in programme
if the majority of parents and all the teachers agreeand make a formal commitment. The programmethen begins with the training of teachers. This train-ing combines theory, which aims to provide teach-ers with a strong understanding of the health educa-tion to be taught, with practice through the demon-stration of the construction and use of sanitation fa-cilities. The teachers also receive a handbook withall the key information provided during the train-ing, including the concept of germs and communi-cable diseases, the importance of waterborne dis-eases and their transmission cycles, and the princi-pal steps that can be taken to prevent these diseases.
Following the training, the project leaders make vis-its to the teachers and assist them by giving demon-stration lessons. A series of educational materials,
l-)««t. «le f i f l-e«.f««
Tho East-designed drinking-water post.
some of them visual, have been prepared for healtheducation classes. In order to raise awarenessamongst the community, parents are included in theinformation campaign as much as possible.
If the school is ready to participate, a number ofimprovements can be made to water and sanitationprovision. A key activity is creation of a drinking-water post. For the creation of each post the com-munity must provide a canari (the traditional waterpot) and provide labour for the installation of thepost. EAST will in turn provide the tripod and the
34
tap and with assist in the installation at a total costof 10,000 CFA a post to the NGO. If the schoolwants to build a rainwater catchment system or im-prove an existing water point, East will provide ce-ment, metal reinforcement for the concrete andskilled labour at a cost of 300 000 CFA to the NGO.The community must undertake to dig the pit, in thecase of the rainwater catchment system, supply sandand gravel and lodge the mason during the buildingperiod. If a community wants to provide a new wa-ter point for the school, EAST will help them tomake contact with another NGO, Eau Vive, who willrequire a 10% contribution from the school beforeundertaking the work.
Latrines can be built if the community is willing todig the necessary pits, supply sand and gravel andhouse the mason. In rural areas EAST suggests theconstruction of single dry pit latrines. In urban ar-eas VIP latrines are suggested. In both cases EASTprovides cement, metal for reinforcement and skilled
labour. EAST estimates that three dry pit latrinescost the NGO 30 000 CFA, and three VIP latrines,650 000.
If parents wish to see the creation of a primary healthcare post in the school, they can form a health com-mittee to raise awareness among other parents, andcollect funds. A volunteer teacher can be trained bythe local health worker to administer basic first aid.An initial stock of medicaments can then be sup-plied if 75% of the necessary funds have been col-lected by the community.
Assistance with the creation of a vegetable gardenmay be given and the teacher may be trained if thereis sufficient commitment from the school commu-nity. Additionally, if the community is prepared tocontribute half the total cost of the renewal of mate-rials, EAST will assist in the replacement of tablesand benches and the repair of the doors and win-dows of classrooms.
35
3. CREPA: DRINKING-WATER ANDSANITATION IN SCHOOLS
The Centre Régional pour l'Eau Potable etl'Assainissement à Faible Coût (Regional Centrefor Low-Cost Drinking Water and Sanitation(CREPA)), is a research and programme supportinstitute, based in Ouagadougou, Burkina Faso. Thecentre works with 14 West African countries to pro-mote appropriate technologies for drinking-waterand sanitation and to support the adoption of amultidisciplinary approach to water and sanitation.CREPA provides support in the development ofhuman resources, conducts applied research, anddisseminates information and documentation forthe exchange of experience within the network ofcountries.
CREPA has experience in the institutional, tech-nical and financial aspects of improving environ-mental sanitation in schools. Many countriesencounter institutional difficulties when they at-tempt to improve school sanitary facilities. Asvf ell as giving technical support to sanitation anddrinking-water supply projects in schools,CREPA provides assistance through the devel-opment of human resources.
Information and training in building techniques,tools for community participation and hygiene edu-cation methods, are offered to the various actors in-volved, including technicians, engineers, labourers,development workers and teachers. CREPA can alsoprovide guidance in the assignment of roles, suchas promotion, construction and evaluation, to thedifferent partners involved.
CREPA have undertaken a number of technical re-search programmes with direct relevance to schoolsin the region. In collaboration with the Ecole Inter-Etats des Technicians Supérieurs de l'Hydrauliqueet de l'Equipement Rural (ETSHER), CREPA haveworked on a system for the continuous chlorinationof wells in rural and peri-urban areas. The processaims to neutralize the chemical and biological tox-
ins found in water taken from traditional wells.Successful results have been obtained and will bepublished very shortly. The system, which allowone month of continuous chlorination, has been in-stalled in the wells of a number of schools on theoutskirts of Ouagadougou.
Excess iron in the water is a major problem in thesahelian region and causes many bore-holes acrossAfrica to be abandoned. CREPA, working jointlywith the trainee engineers of the EIER, has installediron removal systems in many peri-urban and ruralschools. These systems offer a low-cost means ofimproving water quality.
Research and promotion on the collection and stor-age of rainwater is given high priority by the CREPA.In collaboration with the Comité Inter-Africaind'Etudes Hydrauliques (CIEH), rainwater catchmentand collection systems have been built in schools inrural and peri-urban areas of Mali and Burkina Faso.The quality of water from these systems has beenmonitored and work has been done to refine theirdesign and optimize their size when constructed withlocal materials. The conclusions and recommenda-tions of this work are available from the CREPAand were published in the findings of the Interna-tional Conference on Rainwater Catchment, Taiwan,August 1993.
CREPA has also undertaken activities in the fieldof sanitation, building ventilated pit latrines in sev-eral schools on the outskirts of Ouagadougou. Theaccompanying hygiene education is arrangedthrough NGOs such as Enfants du Monde. The la-trines are being monitored, in particular to deter-mine the time they take to fill up. Additionally,CREPA designed latrines, made at a cost of 10 000CFA, are currently being tested in rural areas of theregion.
36
4. THE SANIYA PROJECT:PROMOTION OF TWO FORMS OF HYGIENIC PRACTICE
FOR THE PREVENTION OF DIARRHOEA
The Saniya project is a joint research project of theGovernment of Burkina Faso and the London Schoolof Hygiene and Tropical Medicine. Between 1989and 1991, a Diarrhoea Project attempted to iden-tify risk behaviours for diarrhoea. The SaniyaProject was developed as a follow-up to encouragehygienic behaviours to replace these high-risk prac-tices. Whilst these projects cover the entire com-munity and not just schools, schools are a prioritytarget.
The Diarrhoea Project used several approaches: astudy of the environment; discussions with groupsof women to understand how the populations per-ceive and explain diarrhoeal diseases; a case con-trol study of about 3000 questionnaires; and a struc-tured observation of the hygiene practices of moth-ers. This research resulted in the identification oftwo key high-risk practices:
• most of the stools of young children remain onthe ground, in gutters or on excreta dumps, eventhough 89% of homes have latrines;
• people do not wash their hands systematicallyafter contact with stools and only 5% of moth-ers use soap, although in almost all families, bothchildren and adults follow defecation by wash-ing the anal area with water using the left hand.
Two lessons have been learned from this experience:the usefulness of structured observations in the iden-tification of risk behaviour; and the need for inter-ventions to promote hygienic behaviours using ap-propriate methods. It was felt that in traditional
health education, there has been a discrepancy be-tween the messages given and the beliefs of the com-munity. The Saniya Project was launched to respondto the need to develop an effective hygiene educa-tion approach.
The project is based on a participatory approach.The people questioned are asked to examine ret-roactively the results achieved. What behavioursneed to be changed? What means of communi-cation should be used? What strategy should theproject adopt? In order to find out what couldbe an obstacle to the adoption of new behaviours,a trial campaign was carried out among40 women. This raised a number of importantissues: the difficulty in obtaining soap, breaks insupplies of soap, and the fact that it was impossi-ble for schoolchildren to put the advice beard atschool into practice.
The project set out to tackle these problems. Meet-ings were organized to make contact with schools.Collaboration between all groups working in thisarea was encouraged. In order to adapt messagesfor children, an initiative was undertaken to find outwhat children knew about hygiene. Finally, a projectwas set up in a pilot school to test the messages,teaching aids and ability of schools and schoolchil-dren to disseminate the message within the com-munity.
This process should lead to the implementation of acommunication programme adapted to the needs ofdifferent populations and of which the impact canbe easily measured.
37
ANNEXES
ANNEX 1
PROGRAMME OF THE WORKSHOP
TUesday, 19 April 1994 The problems
Objective: Identification and formulation of the obstacles to development andoperational problems
08:00-09:00 Registration of participants
09:00-09:45 Opening ceremony:• Director of Studies, EIER• Minister of Health• WHO Representative
09:45-10:00 Coffee break
10:00-10:05 Adoption of the programme
10:05-10:10 Words of welcome/explanation of arrangements Mr Chéron (EIER)
10:10-10:25 Introduction of participants
10:25-10:40 Objectives of the workshop Miss Lucy Clarke (WHO, Geneva)
10:40-11:00 Water, sanitation, health education and public health Mr Daou (WHO)
11:00-12:30 Presentation of key points from case studies
• Benin• Burkina Faso• Côte d'Ivoire• Guinea• Mali
12:30-15:00 Lunch
15:00-15:45 Presentation of key points from case studies• Niger• Senegal• Togo
15:45-16:00 Explanation of the "Listeners" system; division into working groups
16:00-16:15 Coffee break
16:15-17:15 Group work
Topic: Definition of obstacles to development and operational problems
17:15-17:45 Presentations of group work in plenary
17:45-18:00 Report of the "Listeners" to the organizing committee
Wednesday, 20 April 1994 Possibilities for action
Objective; Identification of problems for which solutions already exist, and of problemsfor which no solution has yet been found
08:00-08:30 Summary of problems identified on the previous day and definition of the objectivefor the day
08:30-09:30 Presentation of innovative experiences
• UNICEF- Experiences in West Africa (Mrs Lisette Burgers)• EAST- Method of work and role of an NGO (Dr Yannick Pradelles)• CREPA - Appropriate technologies (Dr Cheik Touré)• London School of Hygiene and Tropical Medicine - The study of health behaviour
(Mrs Bernadette Kanki and Mrs Valerie Curtis)• Experiences in Zaire (Mr Lokana Okitangongo)
10:00-12:30 Group work:
1. Political will and policy definition2. Cultural and technical questions3. Health education4. Institutions and finance
12:30-15:00 Lunch
15:00-16:00 Continuation of group work
16:15-18:00 Plenary session
Thursday, 21 April 1994 Orientations
Objective: Definition of priorities and formulation of a strategy
08:00-08:30 Summary of the types of action identified on the previous day definition of the objectiveof the day
08:40-12:30 Group work
1. Political will and policy definition2. Cultural and technical questions3. Health education4. Institutions and finance
12:30-15:00 Lunch
15:00-16:30 Plenary session - adoption of final report
16:30-17:00 Closing ceremony
ANNEX 2
CASE STUDY GUIDELINES
The structure of the case studyThe study should only address primary schools in rural areas and should be structured according to thefollowing plan:
> The introductory section of the case study should begin with a description, of approximately half a page,of the sanitary situation in schools at a national level and of the special characteristics of the regionchosen for the study. Another half page should be given to a summary of the conclusions of the study.More information on this section of the report is provided below, under the heading Information aboutthe national situation.
> A resume of the situation of each school should be provided, in up to half a page per school. The fullreport on each school, as well as any photographs or sketches, will form the last part of the case study.
The report on each school should begin with a presentation of the institution and of the number of pupils.Next, the school's water and sanitation provision should be described. Broad indications should then begiven of the knowledge, attitude and practice of pupils, parents, teachers and health personnel. Currentprovision for health education should also be described. These different elements are explained in moredetail below, under the heading Information about the schools surveyed
Information about the national situationA description should be made of the national water and sanitation provision and of the number and distri-bution of schools. Specific reference should be made to school services in rural areas. The principalendemic diseases which affect the country should be presented. Efforts undertaken or planned in the fieldof hygiene education should be described.
In order to give a clear picture of the division of responsibilities, the roles of the principal institutions in-volved in education, public health and water supply and sanitation at school, district and provincial levelsshould be explained. The role of communities in these different sectors should also be described.
Finally, if at a national level schools suffer from poor environments, these problems, and their effects on healthshould be identified. Such problems may include an insufficient supply of drinking water, inadequate sanitationfacilities or hygiene education, a high prevalence of certain diseases or the continual risk of certain epidemics.Any institutional shortcomings, areas of insufficient resources or other difficulties should be noted.
Information about the schools surveyedInformation about the institution and its location
Sketches > Type of school, for example, primary school open all day or in the mornings only.> Location of the school, for example, in a rural area. The distance from the villages
where the school children live should be specified.> Total number of pupils and numbers of girls and boys.> Number of teachers (male and female).
Photographs > Description of the school: walls (wooden, plastered etc.); roof (metal or other); perimeterfence (maintained or not); maximum and minimum sizes of classrooms; accommodationfor teachers; recreation spaces; immediate environment (forest, bush, ponds, rivers etc.).
> Any difficulties of access to the school for pupils, teachers or others.> Average time for pupils to walk from home to school.> Information on the neighbouring communities surrounding the school: their population; their
role in the life of the school; their socio-economic status of the parents; their occupations.
Information on water supply
Photographs > Description of the water resources within and around the school: springs, traditionalwells, rivers, public pumps, private water points (at mission stations or farms, for exam-ple), others (please specify).
> Quantity and regularity of the water flow (is the average supply sufficient? can the flowbe dangerously high in during flooding? how long does the dry season last?).
> Access to water sources (journey time from school to water point, any difficulties posedby the design of the water point, for example danger for children using a deep wellwithout a sufficiently high surrounding wall).
>• Water quality:• The following should be determined by observation: turbidity, odour, colour• The following should be determined according to the results of any existing studies:
chemical or bacteriological pollution• The following should be determined through discussion with users: taste, any other
characteristics.> General impressions of the cleanliness of the water point: the presence of rubbish,
stagnant water, animals, faeces, waste water; the efficiency of drainage; any improve-ments which have been made to protect the water point.
>• Information on the construction and maintenance of the water point, including: who builtit; under whose supervision; to which, if any, norms does it correspond; who maintainsit; who finances construction and maintenance.
> Usage of the different water points around the school and water disposal.> Any problems in the design, construction or functioning of the water point, for example,
broken parts, a filter which can not be cleaned, bad odours, insect infestation.
Description of the sanitation facilities
Sanitation facilities include any system for the collection and disposal of waste water, excreta, rain-water orsolid waste. At the school level it is particularly important to identify which facilities are used for excretacollection and disposal by children, which by teachers and which by the local community. Nevertheless, theproblems posed by the need for solid waste disposal and waste water evacuation should not be ignored.Mention may also need to be made of provision for rain-water drainage to avoid flooding or the build up ofstagnant water. The following information is fundamental:
Photographs > Description of the installations: the type of latrines; communal or separate latrines; sepa-rate girls and boys latrines or not; latrine ventilation; drainage pipes; arrangements forthe deposit of solid waste.
> Number of latrines already in existence or under construction.>• Do the installations correspond to norms? By whom were they built? By whom are they
maintained? By whom are they cleaned?>• Construction materials: are these local products or purchased at a distance form the
school?> State of the latrines: cleanliness (those areas which are dirty should be described);
odours; any damaged, broken or missing parts; appearance from the outside; appear-ance from the inside; contents of the pit; presence of any insects; ventilation.
>• Is there daylight within the latrine.> Adaptation of the latrine for the needs of children: height; size of the slab and hole;
adequate lighting.> Any handwashing facilities inside, outside or near the latrines.>• Description of any latrine flushing system, of its daily water consumption and of any
receptacles used. Are there any daily or seasonal water shortages?>• Description of any system for the evacuation of waste water and any stagnant water,
ponds, running water and wells in the vicinity of the school.
Usage of the water supply and sanitation facilities
Description of the use of water points
Describe the usage of the water points, for drinking water, for hygiene practices such as hand washing, forcleaning purposes, for small scale agriculture and any other usage:
Photographs > Are there queues at the water points?> Do the children pay attention to the cleanliness of the water point?> Who monitors the cleanliness of the water point?> Who cleans the water point and how many times a day, week or month?>• Does every child have access to a water point?>• Is there any possibility of conflict with other users, for example the neighbouring
community?> What receptacles are used for the transport of water and over what distance? Are they
clean?> Note any handwashing done by children before or after using the latrines, or under any
other circumstances. An estimate should be provided of the proportion of children whouse water for handwashing.
> What percentage of children have easy access to water at school, but not at home.
Description of the use of sanitation facilities
Photographs > Where do children defecate? Do they use latrines? If not, why not? Does each childhave access to a latrine during breaks between class?
>• Are there children who have access to a latrine at school, but not at home?> Are the same latrines used by the children, the teachers and the neighbouring commu-
nity?> Are any of the latrines locked and used only by the teachers?> Who cleans the latrines? Is it ever an enforced duty? Are there class monitors respon-
sible for latrine cleanliness?> Is there any toilet paper, other material, or water available for anal cleansing?> How is the faecal matter removed when the pit of a latrine is full?> Ask the female teachers where women and girls dispose of the protection they use
during their menstrual period.>• Who maintains the latrines? Are there any particular latrine maintenance problems
frequently encountered such as collapse of the pit, the need for repairs to the super-structure, the need for the pit to be emptied.
>• Who is responsible for the purchase of soap, brushes, brooms, disinfectant, etc.?>• Are there any latrines specially designed or located to prevent the embarrassment of
users, notably women or girls? Is there adequate separation between the latrines toprevent sound and odour?
> Does the school have any urinals? If so, have these an adequate drainage system?
Education and attitudes
> Is health education a subject officially taught at the school? If so how much time isgiven to this curriculum item? If not how much time is given in which other lessons tohealth education (prevention of diseases of all kinds) and hygiene education (preven-tion of water- and sanitation-related diseases)?
> Are health education activities managed by teachers themselves, or are they to bebased upon prescribed models?
> Is the hygiene education based upon practical activities such as the construction ormaintenance of a latrine, the cleaning of a water point surround or handwashing?
> Are the messages conveyed realistic? For example, if the importance of handwashingis emphasized, is it certain the water and soap or another cleaning materials areavailable?
> Have the teachers received any training in hygiene education?> What materials are available for hygiene education?> What equipment is available?> Are the children proud of the school for its cleanliness? Is the school more clean or less
clean than its surrounding environment and the children's homes?> Are the children interested in hygiene and water issues? Do they enjoy their health
education lessons? Are the teachers convinced of the importance of health education?Are parents interested in health education? Is it felt that the health education providedat school can have an impact on the wider community, particularly through parents?
> What facilities are available to the teachers and other personnel? Are these facilitiessatisfactory?
V What facilities are available to the children at home? Are these facilities satisfactory?> Describe the system of solid waste collection and disposal and any problems encoun-
tered.> Describe any health services or economic support the school receives from external
sources such as UNICEF, the World Food Programme or any NGOs.
ANNEX 3
RESOURCE DOCUMENTS
Some of the documents listed below can be obtained from WHO:
* Documents that can be obtained from the Information and Documentation Service of the Office ofGlobal and Integrated Environmental Health, WHO, 1211 Geneva.
** Documents that can be obtained from the Distribution and Sales Service of WHO.
Key documents
* Education sanitaire, Eau et Assainissement à l'Ecole en Afrique et dans le Monde. Basic documentfor the inter-country workshop, Ouagadougou, Burkina Faso, 19—21 April 1994. Laugeri L. WHO.Geneva: February 1994.
* Case studies for Benin, Burkina Faso, Côte d'Ivoire, Guinea, Mali, Niger, Senegal and Togo. Preparedfor inter-country workshop on Hygiene Education and Environmental Sanitation in Schools in FrancophoneWest Africa, Ouagadougou, 19-21 April 1994, WHO. Geneva: 1994.
Projet Eau-Assainissement-Santé en milieu scolaire rural dans le Département du Mono, Bénin. Etudede milieu et recommendations. PradellesY. EAST/WHO. Benin: July 1993.
Other documents
** Food, environment and health. A guide for primary school teachers. Williams T., Moon A. andWilliams M. WHO. Geneva: 1990.
* Improving water and sanitation hygiene behaviours for the reduction of diarrhoeal disease. The reportof an informal consultation, Geneva, 18-20 May 1992. WHO. Geneva: June 1993.
Community based workshops for the evaluation and planning of sanitation programmes: a case studyof sanitation in primary schools in Lesotho. Piers Cross. Technical note No. 7 of the Technical Advi-sory Group (TAG). UNDP/World Bank. Washington: July 1986.
* Hygiene education and environmental sanitation in schools in Viet Nam. The report of a project identi-fication and formulation workshop, Hanoi, June 1993. WHO Geneva/WHO Regional Office for WesternPacific (WPRO)/Environmental Health Centre (EHC), Kuala Lumpur. Geneva: May 1994.
* New directions for sanitation and hygiene promotion. The findings of a regional informal consultation,New Delhi, May 1993. WHO Regional Office for South-East Asia. New Delhi; September 1993.
* School Sanitation and Hygiene Education in Latin America. Summary report of a workshop on prob-lems and options for improvement, Cali, Colombia, March 1993. Pan American Health Organization.PAHO/WHO/IRC: March 1993.
ANNEX 4
PARTICIPANTS AT THE WORKSHOP
National participants responsible for the preparation of case studies:
BALDE, Mamadou Mocktar
BARRY, Lamine
CAMARA, Balla
CHABI AGBA, B. Atagara
DRABO, Daniel
GANOU, Yaya
IBO-BAINGUIE, Emmanuel
«ARE, Massiré
PATAMOUSSI, Hermann Marcelin
PRADELLE, Yannick
SIMBOU, Babozou
SOULEY, Issiya
TOURE, Ousmane
Other participants:
ALOUSSENI, Malick
BURGERS, Lizette
CURTIS, Valerie
DE ROOY, Carel
GOCKOUZOU, Adolphe
GOMEZ MEDINA, Maria Pranisca
JEPPENSEN, Kristine ZenthenMARINETTO, MarinaOKITANGONGO, LokanaOUAYORO, Eustache
Secretariat:
CLARKE, Lucy
DAOU, David M'pe
KANE, Mohammed Salissou
KANKI, Bernadette
MAIGA, Fatoumata Sokona
SIMPSON-HEBERT, Mayling
National Water and Sanitation Officer, UNICEF, Conakry, Guinée
Chercheur en Education, Coordonnâtes Education Environnementale,Conakry, Guinée
Chef de la Section Santé Scolaire et Universitaire, Ministère de la SantéPublique et Affaires Sociales, Conakry, Guinée
Inspecteur de l'Enseignement, Bembereke, Bénin
Ministère de l'Enseignement de Base et de l'Alphabétisation de Masse,Ouagadougou, Burkina Faso
Ministère de la Santé, Direction de la Médecine Préventive/Génie Sanitaire, Ouagadougou, Burkina Faso
Consultant sociologist, WHO, Abidjan, Côte d'Ivoire
Chef du Service d'Hygiène de la Région de Tambacounda, Sénégal
Sociologue, Direction de l'Hygiène et de l'Assainissement, Ministère dela Santé, Cotonou, BéninPhysician, Technical Advisor to NGO EAST, Ouagadougou,Burkina FasoCoordonnateur National des Activités d'Education pour la Santé àl'Ecole, Lomé, Togo
Technicien sanitaire, DPSA, Niamey, Niger
Chef, Division de l'Hygiène et de l'Assainissement Direction Nationalede la Santé Publique, Bamako, Mali
UNDP, Water and Regional Development, Ouagadougou, Burkina FasoActing Chief, Water and Sanitation, UNICEF, Burkina Faso
SANIYA Project Manager, London School of Hygiene and TropicalMedicine/Centre Muraz, Bobo Dioulasso, Burkina FasoPlanning advisor, UNICEF Regional Office, Abidjan, Côte d'IvoireChef de Service, Construction et Entretien Scolaire, Ministère desEnseignements, de la Coordination des Recherches et de laTechnologie, Bangui, Centrafrique
Directrice à l'Ecole Normale de Formation des Professeurs, Bissau,Guinea BissauJPO, Water and Sanitation, UNICEF, Guinea BissauNGO C.I.S.C.N.E, Ouagadougou, Burkina FasoMinistère de l'Education Nationale, ZaïreWater and Sanitation, UNDP/World Bank, Ouagadougou, Burkina Faso
Division of Operational Support in Environmental Health, WHO,Geneva, Switzerland
Professor of Sanitary Engineering (WHO/EIER), EIER, Ouagadougou,Burkina FasoProgramme administrator, Water, Sanitation and Environmnetal Health,WHO, NigerSociologist, SANIYA Project, Centre Muraz, Bobo Dioulasso,Burkina FasoWater, Sanitation and Environemental Health, WHO, Bamako, MaliDivision of Operational Support in Environmental Health, WHO,Geneva, Switzerland
