Final WASH Assessment

National Assessment of WASH in Schools - Belize Analysis of 2009 survey data to assess water, sanitation and hygiene in Belizean schools

Christie Chatterley Prepared for the Ministry of Education and UNICEF, Belize May 2011

Executive Summary Data from the 2009 assessment of water, sanitation and hygiene (WASH) in Belizean schools are analyzed and presented with regard to the state of WASH facilities, practices and education Results from the 2011 evaluation of the “WASH Project� in Southern Belize (Chatterley 2011) are included where relevant to validate results from 2009. The principal challenges for WASH in Belizean schools and elements of effective school WASH administration are also presented.

The most common challenges, on a national level, include: Sanitation Access

sufficient quantity of toilets and urinals toilets accessible to students with physical disabilities

Water Management

treating water at schools when water is not treated at the source limiting presence of standing water

Hygiene Management

promotion of hygiene practices such as handwashing with soap provision of soap

Based on quantitative composite indices calculated for each district, there is no statistically significant difference in average WASH access and conditions between districts. District reports are provided including a list of specific WASH needs in each district, but on average, schools challenged by WASH access and management tend to be spread throughout the country. The rural schools typically lag behind urban schools with respect to WASH access, but the condition of WASH facilities and hygiene education indicate that WASH management, on average, is similar between rural and urban schools.

A Summary of WASH Access and Conditions Water: At 5.4% of schools, there is no access to an improved water source (2.3% have no access to water). Moreover, 22% of school water sources are unreliable and 25% of schools report untreated source water. The actual percentage of schools with treated source water may be much lower: the 2011 WASH Project Evaluation found that 58% of schools reported access to chlorinated water, while chlorine residual was identified in only 10%. Coliform bacteria were identified in all non-chlorinated sources and fecal contamination was found in 27% based on 5 mL samples. In the 2009 assessment, 43% of schools report treating source water on school grounds; however this was not observed at the 20 schools visited during the WASH Project Evaluation. Drinking water access and treatment is particularly challenging in the rural areas.

Sanitation: The number of girls per toilet does not meet international recommended standards of 25 girls per toilet in 70% of schools. The number of boys per toilet/urinal does not meet international recommended standards of 50 boys per toilet and urinal in 67% of schools. The quantity of facilities is particularly challenging for the urban schools. Based on the 2011 WASH Project Evaluation, some schools may be able to meet recommended standards simply by ensuring that all usable facilities are used (a number of schools had toilet blocks that were not used despite being in usable condition) or conducting repairs to existing toilets. The toilet structure and fixtures are in need of major repair in many schools. Almost half of the schools in Belize have bathroom doors in some state of disrepair ranging from minor damage to the complete absence of doors. The toilets themselves are in need of repair or are not functioning at

all in almost half the schools. The toilet seat, floor, walls or urinal are unclean or demonstrate improper use in the majority of schools. Only 13% of schools nationwide have toilets that are constructed to accommodate children with physical disabilities. Many physically disabled students have to rely on their peers to assist them when they need to use the toilet. This can lead to embarrassment, students not using the facilities when they need to and compromises their independence.

Hygiene Practices & Education: Approximately half of the schools in Belize would meet standards typically used in Latin America for the number of students per handwashing point.

According to the 2009 assessment data, appropriate sanitary cleansing material, such as toilet paper, are provided in about 60% of schools and 72% provided soap. There may be a discrepancy between reported provisions and actual soap availability as witnessed in the WASH Project Evaluation where soap was reportedly provided at 95%, but observed at only 45%.

Provision of soap and toilet paper is a challenge in both urban and rural areas, with urban schools being less likely to provide (or report provision of) these items.

Elements of successful school WASH: Higher frequency of cleaning and monitoring of facilities, the school administration’s interest in WASH and their leadership, hygiene education, and involvement of the PTA and school management in school WASH are associated with cleaner, better maintained and more properly used facilities. The presence of a PTA does not correlate with WASH conditions at the schools. However, active participation of PTAs and management support for school WASH maintenance correlate with improved conditions of WASH facilities (rpb = 0.181, p = 0.006 for PTA participation and rpb = 0.141, p = 0.014 for management support).

Recommended national standards for WASH in schools are provided along with a short monitoring tool intended for use in the EMIS annual data collection. A map of actors for WASH is schools is presented including recommended roles and responsibilities for each party including students, school staff, parents, and local and national government officials.

Five Key Recommendations 1. Establish a clear set of guidelines for school WASH and monitor annually 2. Establish a clear process for schools to solicit for assistance 3. Establish a clear set of criteria for selecting schools that are not meeting standards to support improvement of their WASH facilities 4. Establish clear roles and responsibilities for school WASH stakeholders that are agreed upon by all government bodies and publicized, including a position or board to ensure each groups compliance with their agreed upon responsibilities. In addition to government and support organizations, stakeholders should include students, PTAs, community members, teachers, principals and school management as key players in the implementation process.

5. Encourage student and local community involvement including school health clubs where students are encouraged to get involved in school WASH including monitoring WASH facilities and promoting healthy practices at school and home Details of these recommendations and the rationale behind them are found in the following report.

Acknowledgements The author would like to thank everyone involved in the demanding work of collecting the data used in the following analysis, as well as the school principals, school managers, Ministry of Education officials, HFLE officers, HECOPAB officers, contractors, engineers and non-profit organization representatives for their time, great insights and incredible assistance during the December 2010 visit to Belize and for their continued support through e-mail communication.

Gratitude is also extended to mentors, both directly and by example, Ned Breslin, Jesus Trelles, Karl Linden, Kate Fogelberg, Mark Duey, Veronica Kaune, Rita Klees, David Silver, and most importantly David Sparkman. Thank you to everyone for their support and guidance over the years in this challenging field.

Contents 1.

2.

3.

4.

Introduction ......................................................................................................................... 1 Background ........................................................................................................................ 1 Analysis Methodology ......................................................................................................... 3 Results – Coverage ............................................................................................................ 5 4.1. Water Supply ............................................................................................................... 5 4.2. Sanitation ..................................................................................................................... 6 4.3. Handwashing Facilities ................................................................................................ 8 4.4. Solid Waste Management ............................................................................................ 8 4.5. School Nutrition ........................................................................................................... 8 4.6. Emergency Shelter Capabilities ................................................................................... 9 5. Results – Conditions ..........................................................................................................10 5.1. Water Supply ..............................................................................................................10 5.2. Sanitation ....................................................................................................................10 5.3. Facilitating Handwashing Practices .............................................................................12 5.4. School Compound ......................................................................................................13 6. Composite Indices for WASH Access and Management ....................................................14 7. WASH Administration ........................................................................................................18 8. WASH-Related Illnesses....................................................................................................20 9. Summary of Significant Associations .................................................................................20 10. Recommended Key Actors for WASH in Schools in Belize ................................................22 11. Recommended Standards for WASH in Belizean Schools .................................................24 12. Recommended Monitoring Tool for EMIS ..........................................................................26 13. Conclusions .......................................................................................................................28 14. Recommendations to Improve WASH in Schools Nationally ..............................................30

Figures Figure 1. Political map of Belize ................................................................................................. 3 Figure 2. Percent of schools with adequate water services ........................................................ 5 Figure 3. Percent of schools with adequate sanitation services.................................................. 6 Figure 4. Examples of "good" school bathrooms .......................................................................11 Figure 5. Examples of "poor" school bathrooms ........................................................................11 Figure 6. Histogram of WASH access and conditions for schools in each of the six districts .....15 Figure 7. Histogram of access and management of school WASH in rural and urban areas .....17

Tables Table 1. Statistical tests used to measure association based on the data type for each variable 3 Table 2. Criteria for the structural condition of toilets .................................................................. 4 Table 3. Criteria used to evaluate the sanitary conditions of the school toilets ........................... 4 Table 4. Average number (and range) of students and teachers per toilet/urinal ........................ 7 Table 5. Designation and capacities for schools used as hurricane shelters .............................. 9 Table 6. Structural condition of student toilets ...........................................................................10 Table 7. Sanitary conditions of student toilets ...........................................................................11 Table 8. Composite Indices for WASH Access and Management .............................................14 Table 9. Composite Indices for WASH Access and Management Disaggregated by District .....15 Table 10. Categories of the Composite Indices where disricts fall below national averages ......16 Table 11. Composite Indices for WASH access and management in rural and urban Schools..17 Table 12. Summary of significant correlations identified in the study .........................................21 Table 13. Roles and Responsibilities of Key Actors for WASH in Belizean Schools ..................22 Table 14. Recommended standards for WASH in Belizean schools..........................................24 Table 15. Minimum WASH facility requirements for schools based on student population ........25

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National Assessment of WASH in Schools - Belize – Analysis Report

1. Introduction The following document provides an analysis of the 2009 survey data for the National Assessment of water, sanitation and hygiene (WASH) in schools in Belize. The assessment aims to inform the Ministry of Education’s mission of “ensuring that all Belizeans are given the opportunity to acquire the knowledge, skills and attitude required for full and active participation in the development of the nation and for their own personal development”. It also follows the goals and strategies outlined in the United Nations Development Assistance Framework (MDG 2015 target), the National Plan of Action for Children and Adolescents (2005-2015) and the UNICEF Belize Country Program Goal to “enhance the quality of education and ensure universal coverage of free basic education in child-friendly environments” (2007-2011). The results presented herein are not meant to assess any specific person or group, but to provide a baseline for addressing WASH in schools in a strategic and sustainable manner so that the WASH situation may be improved for the children of Belize.

The main objectives of this document are to conduct a situational analysis of: – – – –

The physical state of WASH facilities in schools in Belize The principal challenges to providing adequate facilities in a sustainable manner WASH practices and education in schools including the available capacities for delivering WASH education, challenges and existing gaps Elements that facilitate successful school WASH in Belize

2. Background 2.1.

Why WASH in Schools?

There are a number of motivations behind the promotion of WASH in schools, including: The Rights Motive: Children should not be prevented from enjoying their right to education due to a lack of water, adequate sanitation and washing facilities, and hygiene education (UN 1948; UN 1959; UN 2002) The Health Motive: WASH improves health through decreased incidence of diarrhea, intestinal worms and other hygiene-related illnesses (Hodges 1956; Koopman 1978; WHO 2002; WHO 2004).

The Learning Motive: WASH in Schools boosts school attendance and achievement by improving health and keeping students on school grounds when nature calls (Hodges 1956; Nokes and Bundy 1993; Hutton and Haller 2004; ÇelĐksöz, Aciöz et al. 2005).

The Gender Motive: WASH in Schools promotes gender equality by providing safe and hygienic facilities for female students during their menstrual cycle though the extent of this impact is still under investigation (IRC 2005; Oster 2010; UNICEF 2010).

The Child Motive: Children are more receptive to new ideas and behavior change than adults, making school-years crucial for learning hygiene practices (Burgers 2000; UNICEF 2010).

The Community Impact Motive: children can act as agents of change to influence decisions and behaviors at home (WSP 2001; Onyango-Ouma 2005; Fernandez 2008).

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National Assessment of WASH in Schools - Belize – Analysis Report

Based on these motivations, a consortium of organizations, including the United Nations Children’s Fund (UNICEF), WaterAid and the World Health Organization (WHO), has launched and actively engaged in the Global Call to Action for WASH in Schools1 to ensure that every child receives the benefits of WASH in Schools (UNICEF 2010). The document calls on decision-makers to increase investments and for concerned stakeholders to plan and act in cooperation – so that all children go to a school with childfriendly water, sanitation and hygiene facilities (Box 1).

Box 1 (from UNICEF 2010). Because every child deserves to be in a school that offers safe water, healthful sanitation and hygiene education, we call for renewed commitments to: 1. Increase investment in WASH in Schools, mobilizing resources to secure children’s health, now and for generations to follow.

2. Engage those who set policies at the global, national, subnational and local levels to support WASH in Schools.

3. Involve multiple stakeholders – community members, civil society advocates, media, students, school staff, local and regional authorities, national ministries of education, water and health, non-governmental organizations and publicprivate partnerships- in the cooperative plans and actions that sustain WASH in Schools.

4. Demonstrate quality WASH in Schools programs that yield a healthy school environment.

5. Monitor WASH in Schools programs to ensure accountability and evaluate progress.

6. Contribute evidence that provides a solid base for informed decision-making and effective distribution of funds.

The rationale behind WASH in Schools is strong, but the task is challenging and solutions will differ between countries, communities, cultures and economies. Facilities must be appropriate to the needs of children, the local conditions, the management capacities of schools, and the means of communities of institutions who have to sustain the facilities over time (WHO 1994).

2.2.

The Situation of WASH in Schools in Latin America

Unfortunately, the promises of school health and hygiene programs have not always been fulfilled. In many countries, schools are not safe for children (Snel 2004). The schools often suffer from: – Non-existent or insufficient water supply, sanitation and handwashing facilities; – Broken, dirty and unsafe water supply, sanitation and handwashing facilities; – Toilets or latrines that are not adapted to the needs of children, in particular girls; – Children with poor hygiene habits and handwashing practices; – Non-existent or irrelevant health and hygiene education for children; – Unhealthy and dirty classrooms and school compounds In Latin America, 75% of schools have access to potable water and 65% have adequate sanitation facilities (UNESCO 2008). These statistics are averaged over seventeen countries, with the worst situation lying in Nicaragua where less than half the schools have access to clean water and less than one-third have sufficient bathrooms. Belize was not included in the study and there was no official data on WASH in Belizean schools prior to the 2009 assessment presented herein. Typical of rural and urban disparities in service coverage, the rural situation is worse: 74% of schools in rural Central America do not have access to either safe water or adequate sanitation based on estimations from development organizations in El Salvador, Guatemala, Honduras and Nicaragua (MWA 2009). The situation in Latin America not only leaves children with insufficient services and an exiguous understanding of the importance of WASH, but poses a significant risk to their health and growth.

1

For more information in the Global Call to Action visit: www.washinschools.com

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National Assessment of WASH in Schools - Belize – Analysis Report

2.3.

Background of the 2009 National Assessment Survey

Based on the benefits of WASH in Schools and the need for improved facilities and hygiene practices in Latin America, the Ministry of Education Mexico and UNICEF Belize conducted an in-depth nationwide survey of WASH in schools, including all six districts of Belize (Figure 1). A questionnaire was elaborated and surveys were carried out in March and April, 2009 in 264 schools, representing almost 90% of schools nationwide. Surveys were distributed to school principals and the Ministry of Education’s Health and Family Life Education (HFLE) officers supervised and validated responses as well as took photos of the school toilet facilities. Analysis of the 2009 survey Toledo data is presented herein as a baseline assessment of water, sanitation and hygiene conditions in schools across the country. The analysis presented is based on survey data collected in 2009 by HFLE officers and a 4-day visit by Figure 1. Political map of Belize the consultant in December 2010, which included interviews and focus groups with key informants such as Ministry of Education officials, HFLE officers, school principals and teachers, school management, representatives from local development organizations and a Ministry of Health Community Health Educator.

3. Analysis Methodology Data were provided to the consultant in hard copy questionnaires as well as an SPSS2 file. Data entry was double-checked by the consultant based on the hard copy questionnaires, recoded into numerical format to facilitate analysis, and missing values were assigned to account for missing data. SPSS was used to compute frequency data and descriptive statistics (mean, maximum, minimum) for each variable collected in the assessment. Data was split by classification (urban/rural), district, management (grant-aided, government or private) and school type (pre-school only, primary school only, both pre and primary school) and frequency and descriptive analysis was conducted for each disaggregation. New variables were also computed based on the collected data such as ratios of students per toilet, percentage of schools that meet standards, and quantitative composite indices.

Association between variables was evaluated in SPSS based on the variable data types.3 The statistical tests in Table 1 were used to measure the association for each data type combination.

Table 1. Statistical tests used to measure association based on the data type for each variable Nominal Ordinal Scale Nominal Point biserial (rpb) or Phi (ϕ) or Phi (ϕ) or Cramer’s V Cramer’s V Cramer’s V Ordinal Point biserial (rpb) or Kendall’s Tau Beta (τβ) Spearman’s rho (ρ) Scale Pearson’s

2

SPSS is a common statistical software package developed by IBM. Scale data are numeric values on an interval or ratio scale (e.g. age, number of students); ordinal data represent categories with some intrinsic order (e.g. low, medium, high); nominal data represent categories with no intrinsic order (e.g. teachers, principals, PTA) 3

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National Assessment of WASH in Schools - Belize – Analysis Report

The structural and sanitary condition of school toilets were evaluated based on the criteria in Table 2 and Table 3, respectively.

Table 2. Criteria for the structural condition of toilets Condition Criteria All in Good Condition No visible damage no improvement necessary No report of malfunctioning Fair Condition Visible damages or report of malfunctioning minor repairs necessary Functions, but not properly because of this damage Poor Condition Visible damages and report of malfunctioning major repairs required Functions with difficulty, use is not continued Very Poor Condition Complete (re)construction required

Table 3. Criteria used to evaluate the sanitary conditions of the school toilets Criteria Good: Demonstrates Fair/Poor: Demonstrates Very Poor: Requires Category proper use improper use urgent intervention Cleanliness of Absence of dirt, urine or Some presence of dirt, Major presence of dirt, toilet seat fecal matter urine or fecal matter urine or fecal matter Coverage of toilet Presence of cover No hole covering Fully covered hole material, but uncovered available Cleanliness of Absence of trash, urine or Some presence of trash, Major presence of trash, floor fecal matter urine or fecal matter urine or fecal matter Absence of graffiti, urine, Some presence of graffiti, Major presence of graffiti, Cleanliness of wall fecal matter urine, fecal matter urine, fecal matter Smell of the facility Clean smell: no foul odor Slightly intolerable odor Highly intolerable odor Cleanliness of No urine on floor or Small presence of urine on Major amount & smell of urinals beyond receptacles floor or wall urine on floor or wall Type of cleansing Appropriate (toilet paper, Inappropriate (leaves, None material in toilet sanitary tissues) newspaper, corncob, etc)

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National Assessment of WASH in Schools - Belize – Analysis Report

4. Results – Coverage The following analysis elucidates the coverage of WASH facilities in schools on a national level as well as disaggregated by classification (urban/rural) and the six districts of Belize. Coverage is summarized focused on water supply, sanitation, hygiene, solid waste management, school nutrition and emergency shelter capabilities.

4.1.

Water Supply

Percent of Schools (%)

64% of Belizean schools have access to an adequate water supply, defined as an improved4 and reliable source of safe water (Figure 2). Adequate water supply is less common in rural schools (56%) and the districts of Stann Creek (53%) and Toledo (47%).

100 80 60 85

40 64 20

85 56

69

62

71 53

47

0 National Urban

Rural Corozal Orange Belize Walk

Cayo

Stann Toledo Creek

Figure 2. Percent of schools with adequate water services

Water Source Type: Water is piped to the premises of 79% of schools and 13% have access to another form of improved water source such as tube wells or rainwater catchment. 5% collect their water from an unimproved water source such as tanker trucks, surface water, unprotected wells or springs, or bottled water, and 2% do not have any water access on school grounds.

Treatment of Source Water: Despite the high percentage of schools with piped water access, many of these sources are not potable. 75% of schools report that their main water source is treated, but this figure is based on school responses not water quality analysis and is likely a very high estimate of actual treatment. In an evaluation conducted in 2011, chlorine residual was found in only 10% of school water sources despite 58% of schools reporting access to chlorinated water (Chatterley 2011). Additionally, coliform bacteria were found in 5 mL samples of all non-chlorinated sources and E. coli was identified in 27%, indicating fecal contamination.

Reliability: Water supply is reliable throughout the year at 78% of schools. The 2009 assessment did not address daily continuity or water quantity however and fewer schools may have sufficient water sources when these are taken into consideration. Nationwide, 37% of schools have alternative water storage to help alleviate the effect of water shortages.

4

By Joint Monitoring Program definition, improved water sources include piped water to the premises, tube well or borehole, protected dug well, or rainwater collection.

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National Assessment of WASH in Schools - Belize – Analysis Report

Drinking Water Access Points: At the majority of schools (61%), students have access to drinking water in the classroom stored in water buckets or water coolers. Other water collection points include piped water fountains (16%) and directly from the hand pump or storage vat (6%).

Students bring their own water at 12% of schools. At most schools (88%), children use their own cup for drinking water; at 9% children use a shared cup.

Child-Friendly Facilities: Water facilities cater to small children and children with physical disabilities at 70% of schools nationwide. In the Corozal district 90% of schools provide adequately accessible water facilities, but in other districts the percentage is worse such as in the Belize district where 62% of schools provide adequately accessible water facilities.

4.2.

Sanitation

Only 21% of schools have adequate sanitation, defined as access to improved5 toilets where the number of students per facility meet international standards for schools in low-cost settings: 25 girls per toilet and 50 boys per toilet and urinal (Adams 2009) (Figure 3).

Percent of Schools (%)

40 30 20 10

26

21

32

29 21

20 12

9

13

0 National Urban

Rural Corozal Orange Belize Walk

Cayo

Stann Toledo Creek

Figure 3. Percent of schools with adequate sanitation services

Technology Type: Flush toilets are the most common sanitation technology found in Belizean schools and constitute 77% of school bathrooms nationwide: 96% in the urban areas and 69% in the rural areas. 20% of schools have some other type of improved sanitation technology, including pit latrines (12%), Ventilated Improved Pit (VIP) latrines (7%), and composting toilets (1%). 3% have unimproved sanitation such as pit latrines without a slab – all in rural areas.

Urinals are provided at 62% of schools.

Age of Toilets: 39% of school toilets have been constructed within the past five years, while 11% of toilets were constructed over twenty years ago. Surprisingly, toilet age does not significantly correlate with the structural condition of the facilities.

Toilet Quantities: 30% of schools nationwide meet the standard for girls’ toilets and 33% meet the standard for both boys’ toilets and urinals (individually, 60% and 46% meet the standard for boys’ toilets and urinals, respectively). The urban areas struggle the most to provide sufficient 5

Improved sanitation includes flush toilet to piped sewer system or septic tank, ventilated improved pit (VIP) latrine, pit latrine with slab, or composting toilet

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National Assessment of WASH in Schools - Belize – Analysis Report

quantities for their typically larger student population and smaller land area. The national averages for the number of students per toilet/urinal are found in Table 4. For teachers, the standard recommended by the World Health Organization is at least one toilet for male teachers and one for female teachers. 5.4% of schools in Belize do not have separate toilets for teachers.

Though these schools do not comply with recommended standards, some schools report that toilets that are shared between teachers and students remain cleaner and better maintained and the lack of separate facilities for teachers may not be of concern in some cases.6 Table 4. Average number (and range) of students and teachers per toilet/urinal Orange Stann Total Urban Rural Corozal Belize Cayo Toledo Walk Creek 33 Average girls per 43 53 39 42 47 40 53 49 toilet ratio (range) (0-206) (6-145) (0-206) (6-134) (10-206) (7-121) (0-145) (9-143) (3-125) Average boys per toilet ratio (range)

52 67 46 49 51 54 59 58 41 (5-282) (6-194) (5-282) (9-147) (13-141) (5-194) (7-133) (13-151) (6-282)

Average boys per 68 89 55 59 52 77 78 82 45 urinal ratio (range) (2-285) (10-285) (2-191) (12-145) (11-178) (4-230) (2-285) (20-191) (6-141)

Gender Separated Facilities: The majority of schools (94%) provide separate toilets for girls and boys. There is no significant difference in the existence of gender separated facilities between the urban and rural areas.

Toilet Location: 36% and 38% of schools have boys’ and girls’ toilets located within the school building, respectively. Constructing toilets within the school building should be considered as this correlates with better structural condition (rpb=0.241, p<0.001) and cleanliness (rpb=0.189, p<0.001). Urban schools are more likely than rural schools to have toilets within the school building and teachers’ facilities are more commonly found inside than student toilets: 46% and 50% have male and female teacher toilets within the building, respectively. Having indoor toilets is especially important if the school is also used as a hurricane shelter, but only 53% of schools that are designated hurricane shelters have at least one toilet within the building.

Child-Friendly Facilities: School toilets are rarely constructed to accommodate children with physical disabilities: nationwide, only 13% of schools have toilet facilities that are accessible to children with physical disabilities. Toilets accessible to children with physical disabilities are rare in both urban and rural schools, with Cayo and Orange Walk districts having the lowest percentages of schools (2% and 3% respectively) and Stann Creek and Toledo with the highest percentages of schools (26% and 25% respectively). At least 29% of schools report having at least one physically disabled student. In schools without proper facilities, children have to rely on their peers to help them when they need to use the toilet, greatly decreasing their ability to be independent.

6

Based on interviews and school visits conducted by the consultant in December 2010 and March 2011

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National Assessment of WASH in Schools - Belize â&#x20AC;&#x201C; Analysis Report

4.3.

Handwashing Facilities

Type of Facilities: 70% of schools nationwide have handwashing basins equipped with running water. Running water is more common in the urban areas (93%) than the rural areas (60%).

25% of schools, have wash basins with bucket accessed water and 3% have no access to handwashing facilities, mostly in the rural areas.

Location: Handwashing facilities are typically located inside the toilet units (52%), immediately outside the toilet (19%), or inside the classroom (18%). Handwashing facilities that are outside of the toilet stall can be beneficial for monitoring of student handwashing practices and ensuring that students properly use the facilities, but a method to close and lock them should be considered for security reasons as many wash basins outside of the toilet units were reported to have been vandalized after school hours.7 Quantity: There is not a standard for the number of students per handwashing point recommended by the World Health Organization for schools in low-cost settings (Adams 2009) and there is no current standard in Belize. In Colombia, the standard is 25-35 students per device (toilet and handwashing point) (GarcĂ­a 2006), in Peru it is 30 students per handwashing point (Ministerio de Vivienda del Peru 2006), and in El Salvador it is 40 students per handwashing point (Ministerio de Salud de El Salvador 2007). Based on the 2009 assessment data, 48% of Belizean schools would meet a standard of 30 students per handwashing point and 55% would meet a standard of 40. Similar to toilet and urinal facilities, the urban areas are particularly in need of more handwashing facilities: only 32% of urban schools would meet a standard of 40 students per handwashing point compared to 66% in rural areas.

4.4.

Solid Waste Management

Urban schools typically have their rubbish and trash transported away by a municipal disposal system, while rural schools tend to burn their garbage on or next to the school compound. 25% of schools dispose of their garbage within 50 yards of their water source and 2% of these dispose immediately next to the water source. Most schools (74%) have garbage receptacles both in classrooms and on the school compound; 22% have receptacles in the classrooms only, while the remaining schools have garbage receptacles on school premises but insufficient quantities/locations to encourage proper solid waste management.

4.5.

School Nutrition

42% of schools have a school feeding program (where food is available at school, sometimes at a reduced cost or free to some students): the majority of which is in the urban schools where 63% of schools have a feeding program compared to the rural areas where only 31% of schools have a feeding program. Only 15% of schools in the Orange Walk district have a feeding program compared to 59% of schools in the Belize district. Based on interviews conducted during the 2011 Evaluation, teachers report a noticeable improvement in student motivation, aggressiveness and focus when they have a feeding program at the school. At most schools (86% nationwide), food is prepared at the school kitchen. Other schools prepare food under a shed at the school, at a family home, or another location.

7

Based on interviews and school visits conducted by the consultant in December 2010.

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National Assessment of WASH in Schools - Belize â&#x20AC;&#x201C; Analysis Report

4.6.

Emergency Shelter Capabilities

Over half of the schools in Belize are designated hurricane shelters, mostly in the rural areas where 61% of schools serve communities as emergency shelters (Table 5). Only 29% of the schools that serve as designated shelters have a defined shelter capacity. Of those schools who define a number, the average capacity is 176 people, ranging from 12 to 600, with the rural schools typically able to shelter more people than the urban schools as the school is often the only or largest community building in the rural villages (Table 5). Only 25% of schools have a safety plan developed for emergency situations. Additionally, not all safety plans include important details such as the use of the school as shelter (71% of safety plans), how and how long the school is to be used as a shelter (53%), and how to return to normal classes (53%).

Equipment needed for sheltering are insufficient in many schools: alternate power supply is identified in 7% of schools, cooking space (39%), mattresses (3%), kitchen equipment (39%) and tents (1%). Only 16% of schools nationwide report having the human and/or financial resources to prepare the school as a hurricane shelter. Safety planning and sheltering are challenges in both rural and urban schools.

Table 5. Designation and capacities for schools used as hurricane shelters (% of schools) Total Urban Rural Corozal Orange Belize Cayo Stann Toledo Walk Creek School is a designated 56 43 61 56 71 44 66 39 64 hurricane shelter Shelter capacity is defined Shelter capacity, mean (range)

29

13

34

32

16

25

17

40

46

176

118

185

112

140

130

103

163

283

(12-600) (60-210) (12-600) (12-200) (50-250) (50-300) (50-200) (60-400) (50-600)

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National Assessment of WASH in Schools - Belize – Analysis Report

5. Results – Conditions The following results provide insight into the condition and management of facilities on a national level as well as information specific to urban and rural schools or particular districts when figures vary for different areas. Conditions are summarized based on water supply, sanitation, hygiene practices and education, and management of the school compound.

5.1.

Water Supply

Safe Water Storage: Most (88%) schools have clean water storage facilities. The remaining 12% with dirty water storage tanks are all in the rural areas, spread throughout the six districts.

95% of schools properly cover their drinking water containers and the remaining 5% include both rural and urban schools.

Treatment of Unsafe Source Water: Nationwide, 43% of schools report treating water on school grounds if it is not treated at the source. The majority report chlorinating the water (90%), followed by filtering (6%), boiling (3%) and distilling (1%). During the 2011 evaluation however, treatment of water on school grounds was not observed at any of the twenty schools and many people reported an aversion to chlorine. Table 6.

5.2.

Sanitation

Structural Condition: The structural condition of toilets is a challenge in many schools.

Based on the criteria in Table 2, toilets are in good structural condition (including doors, seats, bowls, floor and septic tank all in working order) in 33% of schools for both the boys’ and girls’ facilities and 42% for teachers’ toilets (Table 6). Less than half the schools have boys’ urinals in good condition. At many schools, the toilets doors are broken or nonexistent and the toilet bowls/seats and urinals are often in need of repair.

Table 6. Structural condition of student toilets (% of schools) Component Internal doors External doors Toilet seats Toilet bowls Toilet floor Septic tank Urinals

Good 53 53 56 51 66 62 47

Fair 33 34 29 29 23 21 38

Poor 10 8 10 15 9 9 9

All toilet components are in good condition

Very Poor 4 5 5 5 3 8 7 boys 33% girls 33% teachers 42%

Sanitary Condition / Cleanliness: The sanitary condition of the school toilet facilities are poor in many schools based on the definitions/criteria listed in Table 3. Similar to the structural quality of school toilets, the teachers’ facilities tend to be in better sanitary condition than the student toilets, but there is no significant difference between girls’ and boys’ facilities.

Proper use is demonstrated in all categories (cleanliness of seat, floor and walls, coverage of toilet hole, and smell) for 31% of boys’ toilets, 33% of girls’ toilets and 53% of teachers’ toilets (Table 7).

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National Assessment of WASH in Schools - Belize – Analysis Report

Table 7. Sanitary conditions itions of student toilets toilet At over half of the schools, appropriate (% of schools) sanitary cleansing material, such as toilet paper or sanitary tissues, were found in Component Good Fair/Poor Very Poor the toilet hole/bin (more commonly in the Cleanliness of toilet seat 75 22 3 teachers’ toilets than the students), but Cleanliness of toilet floor 71 27 2 35% and 36% of schools did not have Cleanliness of toilet walls 61 37 2 Smell of facilities 55 38 7 evidence vidence that any sanitary cleansing Coverage of toilet hole 52 36 12 material was used at all for the boys and Cleanliness of urinals 57 38 5 girls toilets, respectively. A small Type of cleansing percentage of schools had evidence of 59 5 36 material in toilet inappropriate materials such as leaves, Boys 31% All toilet components are in good sanitary newspapers, corncobs, etc. During visits Girls 33% condition Teachers 53% to 10 schools in December ber 2010, toilet paper was available in the student toilets at only one school. Most reported that they provide it in the classrooms so that teachers can keep track of it. In the student toilets, toilet paper or other cleansing material is typically placed in a separate container (55% of schools) or inside the toilet receptacle (44%) after use.

Photos Examples of Toilet Facilities Facilities: The following photographs8 taken in Belizean schools provide visual examples of school bathrooms in both “good” (Figure 4)) and “poor” condition (Figure 5).

Figure 4. Examples of "good" school bathrooms: toilets are clean and covered, toilet paper is present, the urinals are clean and of appropriate size size,, the sink functions, and soap and drying materials are provided

Figure 5. Examples of "poor" school bathrooms: toilets are dirty and broken, the hole is not covered, and the sink does not function

8

Photographs from the 2009 assessment are provided by Maria Trujillo, HFLE Officer for the Corozal district.

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National Assessment of WASH in Schools - Belize – Analysis Report

5.3.

Facilitating Handwashing Practices

Soap Provision: Soap is available to students at 72% Box 2. Data on handwashing practices were of schools based on principal response. However, not collected during the 2009 assessment.

Based on the 2011 WASH Project Evaluation: this figure may be a high estimate as reporting of • 95% of schools report providing soap soap tends to be much higher than actual soap • Soap was observed at 45% of schools availability (Box 2) and this soap is not always • After using the toilet, 28% of students with provided at the toilet facilities. Keeping soap in the soap available used it to wash their hands: classroom offers greater supervision by teachers, - 72% when soap was available at the sink - 0% when soap was kept in the classroom but may not encourage its use by students (Box 2).9 There are a handful of schools that do not have soap, water, or reminders for children to wash their hands; all in the rural areas.

Provision of Hand-Drying Material: Almost half (45%) of the schools in Belize do not provide material for drying hands after handwashing. Urban schools are less likely than rural schools to provide hand drying material: 38% and 61%, respectively. The most common type of drying material provided are towels (39%) followed by disposable sanitary paper (15%). One urban school in the Belize district has electric dryers. The importance of the provision of proper hand drying materials was shown by Snelling et al. (2011) who report that “damp hands are actually more likely to attract new bacteria” and students should have access to hygienic hand drying material (paper or clean cloth towels).

Structural Condition of Facilities: Data on the physical condition of sinks for handwashing were not collected in the 2009 assessment Hygiene Promotion: Over 25% of schools nationwide have posters, stickers or other signs that encourage good hygiene visible in the toilets. The Stann Creek and Toledo districts have the largest percentage of schools with hygiene education material in the toilets and this may be in part due to the school WASH intervention conducted in 36 schools within these two districts starting in 2007. Hygiene promotion in the toilets should be encouraged as it correlates with cleaner, properly used facilities (rpb=0.207, p<0.001).

Hygiene Education: Health and Family Life Education (HFLE) curriculum is part of the national curriculum and being implemented in the majority of schools. In the urban and rural schools of the Belize, Toledo and Stann Creek districts, the HFLE curriculum is not being implemented by any teachers in 8%, 7% and 3% of the schools respectively. All schools in the other three districts are implementing the HFLE curriculum to some extent. Most schools (93%) report teaching students the proper way to wash their hands, with a slightly higher percentage in the rural areas (94%) compared to the urban (89%). Less than half of schools nationwide designate a time for all students to wash hands before and after eating or monitor students in the feeding program to ensure hands are washed before and after eating. The Corozal, Stann Creek and Toledo districts have substantially more schools with a designated handwashing time and handwashing monitoring than the Orange Walk, Belize and Cayo districts.

9

Based on interviews with principals and HFLE officers by the consultant in December 2010

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National Assessment of WASH in Schools - Belize – Analysis Report

Dental Hygiene Education: There is a dental hygiene program at 57% of schools nationwide, spread fairly evenly between rural and urban schools.

Food Preparation Hygiene: The food preparation area in most schools (91%) is clean and tidy.

Frequency of food preparation area inspection correlates with cleanliness (ϕ=0.341, p<0.01).

5.4.

School Compound

89% of school compounds appear to be well maintained (defined as the grass being cut low and the compound free of trash) while 10% are poorly maintained (grass needs to be cut, scattered trash) and 1% need urgent intervention (tall and overgrown grass and/or lots of trash). The schools in need of urgent intervention are in the rural areas of Toledo and Cayo districts. Almost 30% of schools have stagnant water on the premises that can serve as a breeding ground for mosquitoes and 19% have heard complaints of mosquitoes from students, teachers and other school staff. The rural areas are more likely than the urban schools to have stagnant water (30% versus 27%) and complaints of mosquitoes (23% versus 11%). The district of Toledo has the greatest percentage of schools with stagnant water (37%) and complaints of mosquitoes (27%). Based on general reporting by principals of WASH-related illness issues at their school in the previous year, the presence of stagnant water on school premises is associated with reports of malaria (ϕ = 0.149, p < 0.05).

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National Assessment of WASH in Schools - Belize – Analysis Report

6. Composite Indices for WASH Access and Management A quantitative composite index (QCI) is developed to facilitate communication of results to individual districts and school managements based on (1) access to WASH facilities and (2) WASH management (measured by the condition of WASH infrastructure and level of hygiene education promoted) as described in Table 8. Each variable score is normalized from zero to one, where zero indicates that intervention is needed and one indicated that standards and expectations for a healthy school environment are being met. Variable weighting is based on areas of key importance from interviews with WASH in Schools actors in Belize and school visits. Missing data were excluded pairwise from the calculation of the Quantitative Composite Index (QCI) for districts, classification (urban/rural) and school management type. These data are meant to provide a rough idea and a starting place but each school’s situation may be unique and considered on a case-by-case basis.

Table 8. Composite Indices for WASH Access and Management Composite Level 2 Indicator Normalized Responses Weight Indices Variable 10 WASH Water 1.Improved water source 1=improved ; 0=unimproved/none 2 Access 2.Water reliability 1=constant throughout the year 2 0.5=not constant some months 0=not constant all months 3.Water treatment at source 1=treated; 0=untreated 1 4.Child-friendly water facilities 1=yes; 0=no 1 11 Sanitation 5.Improved toilets 1=improved ; 0=unimproved/ none 2 6.Number of girls per toilet 1= ≤ 25; 0.5= ≤ 50; 0= >50 1 7. Number of boys per toilet/urinal 1= ≤ 25; 0.5= ≤ 50; 0= >50 1 8.Accessible to students with 1=yes; 0=no 1 physical disabilities Hygiene 9.Handwashing facility type 1=running water; 0.5=collected; 2 0=none 10.Number of students per 1=meets standard of 35 1 handwashing facility 0.5=meets twice standard (70) 0=more than 70 students per sink WASH Water 11.Treated by school if not at source 1=yes; 0=no 2 Management 12.Containers properly covered 1=yes; 0=no 1 13.Type of cup used by students 1=unshared; 0=shared 1 14.Standing water on premises 1=no; 0=yes 1 Sanitation 15.Average structural condition 1=good; 0.5=fair; 0=poor/very poor 2 16.Average cleanliness 1=good; 0.5=fair; 0=poor/very poor 2 17.Sanitary cleansing materials 1=appropriate; 0.5=inapp.; 0=none 1 18.Maintenance of area around toilet 1=good; 0.5=poor; 0=very poor 1 Hygiene 19.Soap provision 1=yes; 0=no 2 20.Use of HFLE curriculum 1=good; 0.5=poor; 0=very poor 1 21.Hygiene promotion in toilets 1=yes; 0=no 1 22.Designated time allotted for 1=yes; 0=no 1 washing hands before & after eating 10

Improved water sources include piped water to the premises, tube well or borehole, protected dug well, rainwater collection. Unimproved sources include unprotected wells/springs, tanker truck, bottled water, surface water.

11 Improved sanitation includes flush toilet to piped sewer system or septic tank, ventilated improved pit (VIP) latrine, pit latrine with slab, or composting toilet. Unimproved sanitation include pit latrine without slab and bucket toilet.

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National Assessment of WASH in Schools - Belize – Analysis Report

The differences in average access and management composite indices between districts are not statistically significant and schools challenged by WASH access and management tend to be spread throughout the country (Table 9, Figure 6). Specific challenges disaggregated by district are presented in Table 10.

The most common challenges, on a national level, include: • Sanitation Access: sufficient quantity; toilets accessible to students with physical disabilities • Water Management: treating water if not treated at source; standing water • Hygiene Management: hygiene promotion; designated handwashing time; soap provision Table 9. Composite Indices for School WASH Access and Management Disaggregated by District Orange Stann National Corozal Belize Cayo Toledo Walk Creek Average WASH Access 0.715 0.653 0.694 0.657 0.672 0.673 0.675 Water Access 0.939 0.867 0.810 0.861 0.812 0.760 0.838 Sanitation Access 0.562 0.558 0.533 0.491 0.602 0.610 0.546 Handwashing Access 0.642 0.533 0.739 0.619 0.601 0.648 0.641 WASH Management 0.621 0.611 0.608 0.600 0.603 0.766 0.632 Water Management 0.651 0.573 0.574 0.581 0.414 0.660 0.602 Sanitation Management 0.632 0.709 0.729 0.714 0.754 0.925 0.719 Hygiene Management 0.578 0.552 0.519 0.506 0.641 0.714 0.577 N (# of cases) 42 35 63 43 35 45 262

Figure 6. Histogram of WASH access and conditions among schools in each of the six districts

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National Assessment of WASH in Schools - Belize – Analysis Report

Table 10. Categories of the Composite Indices where disricts fall below national averages Category WASH Access WASH Management Corozal Sanitation Management • Toilet cleanliness • Provision of toilet paper District

Orange Walk

Handwashing Access • Access to running water handwashing facilities • Quantity of handwashing facilities

Water Management • Treatment of water if not treated at source Sanitation Management • Structural condition of toilets Hygiene Management & Education • Soap provision • Designated time allotted to wash hands before/after eating

Belize

Water Access • Access to improved water source • Access to treated source water • Child-friendly water facilities Sanitation Access • Quantity of toilets • Toilets accessible to students with physical disabilities

Water Management • Treatment of water if not at source • Proper coverage of water buckets Hygiene Management & Education • Use of HFLE Curriculum • Handwashing promotion • Designated time allotted to wash hands before/after eating

Cayo

Water Access • Water reliability (constant access) • Child-friendly facilities Sanitation Access • Access to improved toilets • Quantity of toilets • Toilets accessible to students with physical disabilities Handwashing Access • Quantity of facilities

Stann Creek

Water Access • Access to improved source • Water reliability (constant access) • Access to treated source water Handwashing Access • Quantity of facilities

Water Management • Treatment of water if not at source • Proper coverage of water buckets • Standing water Sanitation Management • Toilet cleanliness • Maintenance of area around toilets Hygiene Management & Education • Soap provision • Handwashing promotion • Designated time allotted to wash hands before/after eating Water Management • Treatment of water if not at source • Use of shared cups • Standing water

Toledo

Water Access • Access to improved source • Water reliability (constant access) • Access to treated source water • Child-friendly facilities

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The rural schools tend to lag behind with respect to WASH access, but the condition of WASH facilities and hygiene education indicate that WASH management, on average, is similar between rural and urban schools (Table 11, Figure 7). District and school management reports with further details are available from the consultant upon request by authorized staff in Belize.

Table 11. Composite Indices for WASH access and management in rural and urban Schools Urban Rural WASH Access 0.710 0.659 Water Access 0.917 0.805 Sanitation Access 0.494 0.565 HW Access 0.718 0.608 WASH Management 0.662 0.636 Water Management 0.756 0.586 Sanitation Management 0.720 0.716 Hygiene Management & Education 0.512 0.607 N (# of cases) 76 180

Figure 7. Histogram of access and management of school WASH in the rural and urban areas

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National Assessment of WASH in Schools - Belize – Analysis Report

7. WASH Administration 7.1.

Involvement of the PTA and School Management

Three-quarters of schools have a Parent Teacher Association (PTA), but only 20% and 30% participate in the maintenance of WASH facilities at urban and rural schools, respectively.

School management typically does not support the maintenance of WASH facilities: only 27% of schools receive management support for WASH maintenance (20% of rural schools). In most schools, principals have to fundraise within the community to collect these funds from parents and local businesses which are often unreliable sources as they are solicited for funds for other school and community needs as well.12 Improved WASH conditions correlate with: ‐ active participation of PTA in WASH maintenance (rpb = 0.181, p < 0.01) ‐ management support of WASH maintenance (rpb = 0.141, p < 0.05) ‐ No correlation with presence of a PTA

7.2.

Water Services

Approximately 37% of schools nationwide have a maintenance plan for school water facilities and at 31% of schools the PTA is involved in the monitoring and maintenance of the water facilities, more frequently in the rural areas (34% versus 22% in the urban schools). Having a maintenance plan does not significantly correlate with better water management, but PTA involvement in monitoring & maintenance of water facilities does (rpb = 0.187, p < 0.01).

7.3.

Sanitation

At the majority of schools (64%), the school administration (principal) is responsible for ensuring that toilet facilities are inspected for misuse and damages, followed by teachers (18%) and school management (9%). The PTA is responsible for ensuring inspection of toilet facilities at 5% of the schools. 79% of schools inspect their toilet facilities at least once per week, while 3% report never inspecting the facilities. The school administration is responsible for ensuring that repairs are made in the toilet facilities when necessary at 68% of the schools, followed by school management (18%), teachers (8%) and the PTA (6%). There is no significant correlation between who is in charge of cleaning and ensuring inspection with toilet cleanliness or structural condition. Cleaning frequency correlates with toilet cleanliness (ρ = 0.211, p < 0.001), but inspection frequency is not statistically correlated with structural condition.

Toilet paper is supplied by school management or the administration at 71% of schools. It is supplied by the class at 22% and personally supplied at 8%. Use of proper sanitary cleansing material, such as toilet paper, correlates with toilet paper provision at the school (ϕ = 0.338, p < 0.001) and relying on students to bring it from home may not encourage proper hygiene.

Frequently, toilet paper is collected from parents at the start of the year and provided to the students by the principal or teachers as needed.13 Students (43% of schools) or hired cleaners (42% of schools) are usually responsible for emptying the bins with used sanitary cleansing 12 13

Based on interviews with school principals by the consultant in December 2010 and March 2011 Based on school visits and interviews conducted by the consultant in December 2010 and March 2011

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National Assessment of WASH in Schools - Belize â&#x20AC;&#x201C; Analysis Report

material (e.g. toilet paper) at schools that do not dispose of cleansing material in the toilet itself.

Teachers empty the waste bins in student toilets at 8% of schools.

The majority of schools clean their toilets at least every other day, though 31% clean the toilets once a week or less frequently. Students and hired cleaners are most frequently responsible for cleaning the toilets: 50% and 38% of schools, respectively. Teachers clean student toilets at 4% of schools.

7.4.

Food Preparation Facilities

20% of schools have written policies in place for food processing, handling, consumption and storage. Nationwide, 17% of school food preparation areas are never inspected; 45% are inspected every week, 10% once per month, 20% once per semester, and 8% are inspected at some other frequency ranging from daily to only when requested. The food preparation area is inspected by a public health inspector in 26% of schools, a HFLE officer in 17% of schools and by another person or group such as teachers, school management or administration in the majority of schools (57%). The person/group that inspects the food preparation area varies greatly between districts though not significantly between rural versus urban areas.

7.5.

School Compound Cleaning and Maintenance

Most schools (71%) clean and maintain their compound at least once per month. There is not a significant difference between cleaning frequencies in the urban and rural areas. Cleaning equipment is not available at all schools: 91% have brooms, followed by buckets (72%), machetes (56%), shovels (56%), lawn mowers (45%) and weed eaters (22%).

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National Assessment of WASH in Schools - Belize – Analysis Report

8. WASH-Related Illnesses Head lice, diarrhea and conjunctivitis are the three most common WASH-related student illnesses reported by principals. Over half of schools nationwide report having issues with head lice in the past year, 40% report diarrhea and 35% report conjunctivitis. WASH-related illnesses tend to be slightly more common in the rural areas and in the Toledo and Corozal districts.

Unfortunately, these data are only meant to provide a general idea of the common WASHrelated illnesses and are not used to determine the impact of WASH facilities due to the long recall time (one year) and general nature of the question that are not recommended for impact studies (Blum 1983). Associations between illness data and school WASH facilities were analyzed, though the reliability of the illness data collected should be considered in the interpretation: the presence of stagnant water on school premises is weakly associated with reports of malaria (ϕ = 0.149, p < 0.05) and the data suggest that students at schools with running water are less likely to have scabies (ϕ = 0.235, p < 0.001).

It has been shown conclusively in previous studies, that health improvements result from the behavior changes facilitated by reliable access to WASH services, and the measurement of these changes is likely to be easier, more reliable, and more useful as a diagnostic tool than attempts to measure health impacts directly (Cairncross 1990). In this context, the data on hygiene practices, including maintenance and cleanliness of facilities, that were collected in the 2009 assessment provide insight into the hygienic conditions that facilitate improvements in children’s health.

9. Summary of Significant Associations Table 12 provides a summary of the statistically significant associations between the administration of school WASH services and the impact on reliable access and hygienic behaviors based on data collected such as maintenance, physical condition, proper usage of toilets, treatment of water. The association between variables is presented as the correlation coefficient and p-value, where the correlation coefficient is a measure of the strength of the association and the p-value is a measure of the strength of statistical significance. This information demonstrates that some elements of WASH administration may lead to improved hygienic conditions for the students.14 Based on these data, elements of effective WASH administration may include high frequency of cleaning and monitoring of facilities (which can be facilitated by facility location), teaching hygiene education such as the HFLE curriculum, and to some extent the involvement of the PTA and school management in the maintenance of WASH facilities. Based on interviews, PTA and management support is most beneficial when the principal is a good leader and has taken a strong interest themselves in ensuring that WASH facilities are acceptable and then have given the community a voice in the issue.

14

Other elements of WASH administration may be associated with improved conditions, but are not presented in the table if their association was not statistically significant.

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National Assessment of WASH in Schools - Belize – Analysis Report

Information regarding children’s involvement in operation and maintenance of facilities and hygiene promotion was not collected in the 2009 assessment and there was no evidence of strong student involvement observed during school visits that could be used to assess impact.

Table 12. Summary of significant correlations identified in the study Input Output Sample Strength of Statistical 15 Size Association Significance Frequency of toilet cleaning Cleanliness of student  = 0.211 p < 0.001 toilets N = 257 (weak) (very strong) Frequency of food preparation area Food preparation area = 0.341 p < 0.01 inspection cleanliness (moderate) (strong) N = 94 Frequency of school compound Maintenance level of  = 0.152 p < 0.05 cleaning and maintenance school compound N = 220 (weak) (associated) Location of toilets (in main building) Structural condition of rpb = 0.241 p < 0.001 student toilets N = 243 (weak) (very strong) Cleanliness of student rpb = 0.189 p < 0.001 toilets N = 254 (weak) (very strong) Good use of the HFLE curriculum Water treatment is = 0.275 p < 0.05 reported N = 92 (weak) (associated) School teaches proper = 0.338 p < 0.001 handwashing N = 245 (moderate) (very strong) Posters, stickers, or other hygiene Cleanliness of toilets rpb = 0.207 p < 0.001 promotion are present in the toilets N = 249 (weak) (very strong) Presence of a PTA WASH Management Score N = 253 No significant correlation PTA actively participates in WASH Management Score rpb = 0.181 p < 0.01 maintenance of WASH facilities N = 195 (weak) (strong) PTA is involved in the monitoring Water Management Score rpb = 0.187 p < 0.01 and maintenance of water facilities N = 232 (weak) (strong) Management supports maintenance WASH Management Score rpb = 0.141 p < 0.05 of WASH facilities N = 247 (weak) (associated) Who is responsible for ensuring Structural condition of No significant correlation maintenance of WASH facilities facilities N = 260

15

Interpretation of the strength of the correlation are based on Cohen, J. (1988). Statistical power analysis for the behavioral sciences, New Jersey: Lawrence Erlbaum

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10.

Recommended Key Actors for WASH in Schools in Belize

Government and non-government organizations working in schools in Belize need to coordinate to limit overlapping activities. Overarching goals and individual organization roles to meet those goals need to be identified and agreed upon by all parties. Based on feedback and suggestions from the December 2010 visit, defined and agreed upon responsibilities and periodic meetings with key actors would limit overlap and improve efficiency. Suggested roles and responsibilities are presented in Table 13. These should be utilized as a starting point for groups to come to a mutual agreement of how responsibilities should be divided. Knowledge of overarching goals and clear responsibilities of each organization will allow groups to work individually in a more efficient manner.

Table 13. Roles and Responsibilities of Key Actors for WASH in Belizean Schools Group Roles & Responsibilities Students Practice and encourage proper use of WASH facilities • Use WASH facilities properly and with respect • Encourage fellow students and community members to use and maintain WASH facilities properly and keep them clean (e.g. through school health clubs) • Participate in the design and construction process School Encourage healthy behaviors and maintain/clean facilities over time Teachers • Provide input during planning/implementation of infrastructure • Organize the care and maintenance of infrastructure over time • Monitor the state and use of school WASH facilities • Encourage children’s proper use of WASH facilities at school and home through hygiene education School Encourage healthy school conditions and liaison between key actors Principals • Provide input during planning/implementation of infrastructure • Ensure liaison with education authorities and other authorities at district and local level • Develop and enforce rules when required • Encourage parent-teacher liaison • Create conditions in which teachers and students are motivated to maintain WASH facilities and ensure proper use PTA and/or Offer upfront input and support maintenance of WASH facilities Communities • Advocate locally for school WASH improvements • Raise funds and help plan school WASH improvements with school directors and teachers • Support maintenance of school WASH facilities • Support provision of soap and toilet paper • Encourage children’s proper use of WASH facilities School Support new construction and maintenance of WASH facilities Management • Support school maintenance of facilities over time • Provide additional parts/facilities as needed • Contribute financially to infrastructure construction Ministry of Provide resources and direction for WASH in schools Education • Water access point infrastructure • Adequate toilets including sufficient quantity and facilities for students with physical disabilities • Handwashing facilities • Provide hygiene education curriculum

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National Assessment of WASH in Schools - Belize – Analysis Report

• Monitor school WASH facilities through the EMIS • Enforce WASH in schools standards • Work through schools to increase community involvement in WASH in schools HFLE officers • Provide training and enforce hygiene education at schools • Encourage school and community involvement in WASH programs • Support liaison between school staff and the MoE district offices • Coordinate with HECOPAB officers District officers • Coordinate with local environmental health services, public works departments, etc. to ensure that sufficient technical support is provided Ministry of Ensure hygienic/healthy conditions Health • Inspect school kitchens, toilets and water quality • Provide health advice to MoE for WASH in Schools programming • Support child nutrition through schools • Child vaccinations, provision of micronutrients, surveillance of preventable diseases HECOPAB officers • Provide training and advice to teachers on healthy school environments and proper hygiene • Encourage school and community involvement in WASH programs • Support liaison between school staff and the MoH district offices • Coordinate with HFLE officers Ministry of Provide potable water infrastructure for rural schools and review designs Works • Provide counsel for infrastructure location and construction • Ensure correct design and construction of school WASH facilities • Ensure correct maintenance and training of local infrastructure maintenance staff Ministry of Provide potable water infrastructure for urban schools Public Utilities • Provide water connection lines Ministry of Support WASH in Schools programs Human • Particularly with respect to ensuring adequate WASH facilities for students with Development physical disabilities Belize National Emergency Management Emergency • Ensure that schools designated as emergency shelters are equipped with Management adequate facilities Organization • Ensure that school facilities function properly when shelters return to regular (NEMO) school operation UNICEF Facilitator/Coordinator • Provide support in the form of financial backing and program guidance • Provide monitoring of stakeholder responsibilities to help improve programming • Coordinate efforts between partners, donors and the MoE to ensure WASH in schools are properly reflected in MoE priorities and partners are moving toward these priorities Other NGOs Implementation Support (such as • Support schools and the MoE by providing planning and technical advice, Rotary, Plenty financial support, and encouraging involvement at the local level Belize, etc) • Coordinate efforts with the MoE to reduce duplicating work that may already be planned or underway at a school

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11.

Recommended Standards for WASH in Belizean Schools

Recommended standards are presented in Table 14 based on international standards for WASH in schools recommended by the world Health Organization (Adams 2009) and national standards used in the Latin American region. Recommended standards are modified and adapted to align with the realities of Belize. Infrastructure quantity standards are scaled to provide fewer students per facility at schools with a small student population and provide an achievable and realistic number of facilities in schools with large student populations.

Table 15 provides a guide to evaluate quantities of WASH facilities available at a school.

Standard 1. Safe water available

Table 14. Recommended standards for WASH in Belizean schools Details 1.1. Access to an improved water source (a source that is likely to provide safe water: including piped water, protected wells/springs, rainwater collection.

Unprotected wells/springs, surface water (rivers/lakes/canals), bottled water and tanker trucks are not improved sources.)

1.2. Water used for drinking and handwashing is treated 1.3. Water used for drinking and handwashing has free chlorine residual or absence of E. coli in 100 mL samples

2. Sufficient 2.1. Water is available throughout the school day and school year quantity of water (for boarding schools, water must be available 24 hours per day throughout the available boarding school year) 2.2. Water quantity is sufficient for school needs and to encourage good hygiene - 5 L/person/day if dry sanitation, 10-20 L/person/day if flush toilets and an additional 20 L/person/day for boarding schools (recommended) 2.3. Sufficient number of safe water access points - 1 for every 150 students 3. Sufficient washing facilities available

3.1. Soap is available to students 16 3.2. Soap is available at the handwashing facilities (recommended) 17 3.3. Sufficient number of running water handwashing facilities - 1 for 1-20 students - 2 for 21-50 students - over 50, add 1 facility for every 100 3.4. Within 10 meters of toilets (recommended) 3.5. For boarding schools, the following additional facilities are also needed: - Laundry facilities with detergent and water - 1 shower for every 20 users

4. Hygiene promotion

4.1. Use of HFLE curriculum 4.2. Evidence of promotion 4.3. Facilities & resources enable good hygiene practices

16

Based on WASH Project evaluation results, soap kept in the classroom is typically not used by students and soap should be kept at the handwashing facilities in parallel with student hygiene education to take care of the soap.

17 Based WASH Project evaluation data, bucket-pour handwashing facilities are typically not used and running water facilities are recommended. A bucket with a tap would be sufficient in place of a sink.

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National Assessment of WASH in Schools - Belize – Analysis Report

5. Adequate toilets 5.1. Access to improved sanitation (private facilities that separate human excreta from human contact; Including pit latrines (if there is a stable concrete or wood slab available between the user and hole), ventilated improved pit (VIP) latrines, flush toilets, pourflush toilets, and composting toilets) that is: 5.2. Clean (free of urine and feces on the seat/floor/walls; inspected & cleaned daily) 5.3. Adequately ventilated (screened ventilation pipes/windows) 5.4. Adequately illuminated (can see clearly with the door closed) 5.5. Functioning properly 5.6. Private & secure 5.7. Accessible to small children 5.8. Accessible to students with physical disabilities 5.9. Culturally and geographically appropriate 5.10. Accessible by a safe and clear walkway and surrounding area 6. Sufficient quantity of toilets

6.1. Sufficient number of facilities for girls - 1 toilet for 1-20 girls - 2 toilets for 21-50 girls - over 50, add 1 toilet for every 50 girls 6.2. Sufficient number of facilities for boys - 1 toilet for 1-20 boys - 1 toilet and 1 urinal for 21-50 boys - over 50, add 1 toilet and 1 urinal for every 100 boys 6.3. Separate facilities are available for boys & girls (recommended)

7. Safe waste disposal

7.1. Classrooms are clean of mold and dust 7.2. Areas are free of sharp objects and other physical hazards 7.3. Solid waste is collected daily from classrooms, kitchen and bathrooms 7.4. Solid waste is disposed of safely (if burned, done when students are not present) 7.5. Wastewater is disposed of quickly and safely

Table 15. Minimum WASH facility requirements for schools based on student population Number Girls Number Boys Boys Total Number Handwashing Water Access † † of Girls Toilets of Boys Toilets Urinals of Students Facilities Points 1-20 1 1-20 1 0 1-20 1 1 21-50 2 21-50 1 1 21-40 2 1 51-100 3 51-150 2 2 41-100 3 1 101-150 4 151-250 3 3 101-200 4 2 151-200 5 251-350 4 4 201-300 5 2 201-250 6 351-450 5 5 301-400 6 3 251-300 7 451-550 6 6 401-500 7 3 301-350 8 551-650 7 7 501-600 8 4 351-400 9 651-750 8 8 601-700 9 5 401-450 10 701-800 10 5 451-500 11 801-900 11 6 501-550 12 901-1000 12 7 551-600 13 1001-1100 13 7 601-650 14 1101-1200 14 8 651-700 15 1201-1300 15 9 † If there are unisex toilets, the total number of toilets should equal the combined number of girls and boys toilets/urinals in the table.

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12.

Recommended Monitoring Tool for EMIS

A monitoring tool is modified from the UNICEF WASH in Schools Monitoring Package to capture areas of specific interest to WASH in Belizean schools and based on proposed standards. The following short monitoring tool is intended for use in the annual EMIS data collection process conducted nationwide. Data will help monitor school WASH services in Belize and identify areas in need of improvement over time. In addition, the annual completion of the survey will serve as a reminder to school principals of the importance of WASH in the school-setting.

Question 1: Does the school have access to an improved water source (a source that is likely to provide safe water)? (check one) Yes -Piped water -Protected well -Protected spring -Rainwater collection

No -Unprotected well -Unprotected spring -Surface water (river/lake/canal) -Bottled water (if primary source) -Tanker truck

Question 2: As far as you know, is the school’s water source treated? (check one) Yes

No

Don’t know

Question 3: Is water treated before drinking at the school? (check one) (treating/purifying water in the school in some way such as boiling, chlorination, bleach, ceramic filters, candle filters or biosand filters.)

Sometimes

Always

Never

Question 4: How often is the water source functional? (check one) Always

Most days

Some days

Rarely or never functional

Question 5: When the water source is functional, does it provide enough water for the needs of the school, including water for drinking, handwashing and food preparation? (check one) Yes

No

Water source is not functional

Question 6: How many water access points are at the school, not including handwashing facilities? (insert number) (A water access point includes classroom water buckets, drinking water fountains, running water taps not used for handwashing, well pumps, and storage tank taps) Functional

Not Functional

Number of water access points at the school Question 7: Does the school have improved toilet facilities (private facilities that separate human excreta from human contact)? (check one) Yes -Pit latrine (if stable concrete or wood slab between user and hole) -Ventilated Improved Pit (VIP) latrine -Flush toilet to sewer or septic tank -Pour-flush toilet to sewer or septic tank

No -Flush or pour-flush toilet not piped to sewer, septic tank or enclosed pit -Pit latrine without slab (open pit) -Bucket -No facilities (fields/bush)

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National Assessment of WASH in Schools - Belize – Analysis Report

Question 8: How many toilets and urinals are there in the school? (insert number) (A toilet is defined as an individual stall/seat/squat-plate/drop-hole where a single child can defecate in private. Functional means that at the time of filling out this questionnaire, the toilets are not broken and can be used by children. Not functional means that the toilet is broken, full, or damaged in such a way that it cannot be used.)

Functional

Not Functional

Exclusively for girls Exclusively for boys For boys or girls (unisex toilets) Boys urinals (50 cm of urinal wall = 1 urinal) Question 9: On average, are the toilets in adequate condition and accessible to all students? (check one for each category) Yes

No

Adequate lighting (can see clearly with the door closed) Adequate ventilation (screened ventilation pipes/windows) Adequate privacy (secure lock and building structure) Clean (no urine or feces on the seat, walls or floor) Child-friendly (smaller toilets/lower handles for younger children) Accessible to students with physical disabilities Walkway to and area around toilet is clean (grass is cut short, etc.)

Question 10: How many handwashing stations are there in the school: (insert number) (If there are no handwashing facilities, enter “0”) Functional

Not Functional

Running water Bucket/scoop-pour water Question 11: Is sufficient soap (or ash) available? (check one) Sometimes

Always

Never

Question 12: Where is the soap (or ash) kept for student use?

At handwashing facilities

In the classroom

Other

There is no soap

Question 13: Is HFLE curriculum taught by ALL teachers at the school? (check one) Yes

No

Question 14: Is solid waste (garbage) collected and disposed daily? (check one) (Check yes if the school collects garbage from classroom, kitchen and bathroom receptacles daily and stores it in a safe place from which it is later disposed.)

Yes

No

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13.

Conclusions

Results from the 2009 national assessment of WASH in Belizean schools are presented to provide a baseline for future programming and inform recommendations. Key actors for WASH in schools in Belize are suggested with recommended roles and responsibilities based on interviews and school visits in Belize. Achievable standards and a short survey tool for use with the annual EMIS data collection are recommended for monitoring WASH in schools.

13.1. Areas of Success The Ministry of Education in Belize recognizes the importance of WASH in schools and is spearheading national-level programming. This is a commendable achievement. A significant percentage of schools have access to some type of improved water source and safe sanitation and hygiene education is included in the national school curriculum and used by most schools.

13.2. Key Challenges Many school WASH facilities are inadequate in terms of quantity, operation, use, cleanliness and quality.

Water Access to reliable drinking water at school: 2.3% of schools do not have access to any water on school grounds (all in the rural areas). Moreover, 22.1% of school water sources are unreliable and in 17.8% of schools, the water is not for drinking. In 11.8% of schools, students bring their drinking water from home or an outside source. Drinking water access is particularly challenging in the rural areas of the Stann Creek, Toledo and Belize districts.

Sanitation Quantity: The number of girls per toilet does not meet international recommended standards in 70% of schools. The number of boys per toilet/urinal does not meet standards in 67% of schools. The quantity of facilities is particularly challenging for the urban schools.

Structural Quality: The toilet structure and fixtures are in need of major repair in many schools.

Almost half of the schools in Belize have bathroom doors in some state of disrepair ranging from minor repairs needed to the complete absence of doors. The toilets themselves are in need of repair or are not functioning in almost half the schools. Less than half the schools report having urinals in good condition.

Cleanliness: Proper use of facilities is a challenge for a number of schools, particularly with respect to covering the toilet hole. The toilet seat, floor, walls or urinal are unclean or demonstrate improper use in the majority of schools.

Accommodating students with physical disabilities: Only 13% of schools nationwide have toilets that are constructed to accommodate children with physical disabilities. Many physically disabled students have to rely on their peers to assist them when they need to use the toilet.

This can lead to embarrassment, students not using the facilities when they really need to and compromises their independence.

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Hygiene Practices & Education Quantity of sinks: Approximately half of the schools in Belize would meet standards typically used in Latin America for the number of students per handwashing point.

Structural condition of sinks: Though data on structural condition of sinks were not collected in the 2009 assessment, during school visits in December 2010 many school sinks were observed to be broken or missing parts entirely. Students are unable to practice proper handwashing if sinks are not functional. Principals reported misuse by the students, vandalism by people outside of the school (where sinks were placed outside of the toilet facility without proper security), and low-quality parts as reasons for the damages.

Student handwashing practice: Data were not collected during the assessment, but the WASH Project evaluation provided evidence that 76% of students washed their hands with soap after using the toilet when running water and soap were available to them at the toilet facilities. Use of soap kept in the classroom was not observed.

Provision of soap and toilet paper: According to the 2009 assessment data, toilet paper is provided in about 60% of schools and 72% provided soap. Of the ten schools visited during the December 2010 visit, only one school provided soap and toilet paper for students at the toilet facilities. Other schools had soap and toilet paper in the classroom, but no child was seen caring either of these items from the classroom to the toilet.

Hand drying: The provision of material for students to dry their hands after washing was reported by 54.7% of schools. Wet hands are more susceptible to attracting germs and children should be provided with a way to dry their hands after washing. Towels are the most common drying material in Belizean schools: 72.1%, of schools that provide hand drying material, provide towels. The provision of hand drying material is a greater challenge in the urban schools.

Emergency preparedness Hurricane shelters: Over half of the schools in Belize are a designated hurricane shelter, but only 24.9% of schools have a school safety plan developed for emergency situations and even fewer include key elements such as how and how long the school is to be used as a shelter, how to return to normal classes. The number of people the school is intended to shelter is only defined at 28.6% of schools and only 16.1% have the human and/or financial resources to prepare for a hurricane. Due to the frequent occurrence of hurricanes in Belize, schools should be prepared for these types of emergency situations.

Toilet location: Nationwide, 48.5% of schools have a toilet of some kind within the school building. During a hurricane, a toilet within the building can become very important and in schools where there is none, people have to leave the school building to walk to the toilet or to find other means to relieve themselves within the school building if the conditions outside are unsafe.

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14.

Recommendations to Improve WASH in Schools Nationally

A budget should be allocated for WASH in Schools programming following the recommendations below and a set of guidelines should be defined nationally through a participatory process including the key actors listed in section 10. It is recommended that the MoE and UNICEF propose a preliminary draft for the budget and guidelines and organize necessary meetings.

5 key recommendations for future strategies to improve WASH in Belizean schools 1. Establish a clear set of guidelines for school WASH and monitor annually • Achieved through the annual EMIS data collection from schools nationwide (Section 11) • To be effective, these data must be processed in a timely fashion and acted upon 2. Establish a clear set of criteria for selecting schools that are not meeting standards to support improvement of their WASH facilities • Schools with inadequate quantity of facilities or without access to improved water or sanitation should be prioritized based on the extent of infrastructure needs • Schools with inadequate condition of facilities should be visited to assess if new facilities are needed or if capacity building for facilities management is needed • Upcoming WASH in schools programming can be based on 2009 assessment data as a starting point and confirmed by school visits.

• It is recommended that infrastructure in the phases 1-3 “WASH Project” schools in the Stann Creek and Toledo districts are completed prior to the start of phase 4 and that Phase 4 includes schools in the Cayo district where many schools have below national average access to facilities.

3. Establish a clear process for schools to solicit for assistance • Schools should be able to solicit for assistance from the Ministry of Education in a clear and fair process to include schools with needs not captured by the EMIS data collection and those who understand the importance of school WASH with initiative to push for improved WASH infrastructure at their school • This should include financial contribution from school management and/or the local community/school 4. Establish clear roles and responsibilities for school WASH stakeholders • Recommended roles are presented in Section 9 as a starting point • Roles should be agreed upon by all government bodies involved • Responsibilities should be clear and publicized • A position or board to ensure each groups compliance with their agreed upon responsibilities is recommended 5. Increase student and local community involvement in WASH in schools • Encourage school health clubs, or other mechanism, where students are encouraged to get involved in school WASH including monitoring WASH facilities and promoting healthy practices at school and home • Involve parents and schools staff in WASH at the schools by encouraging their input and ownership in the design and implementation of facilities

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National Assessment of WASH in Schools - Belize – Analysis Report

Further detailed recommendations based on specific results of the 2009 assessment Increase water access: Work with the management of schools that do not have drinking water available to students on school grounds to remedy this situation (particularly in rural areas).

Solutions can include simple technologies such as rainwater collection and chlorination, but should be based on input from the local community and administration and should consider economic (maintenance costs) and cultural appropriateness. During the 2011 WASH Project Evaluation, many students and staff reported a strong dislike of chlorine and effective alternatives to chlorine such as ceramic or sand filters at the school or classroom level may be a better option for many schools. Alternatives should be explored and presented to schools as part of hygiene education and future intervention. The Ministry of Works should lead this endeavor as they are responsible for rural water supply.

Water quality testing: 75% of schools report that water is treated at the source and 43% report treating water at the school for drinking if untreated from the source, but these data do not provide sufficient information about the actual water quality and simple chlorine testing (for chlorinated water) and microbiological testing would provide insight into the true water quality provided to students. HACH chlorine test strips and Micrology Laboratories Coliscan E. coli and total coliform test kits are recommended for ease of use and low expense. This should be conducted with the Ministry of Health’s public health inspectors.

Increase quantities with quality facilities: Increase the number of toilets, urinals and handwashing points (particularly in the urban areas) to meet standards. If quantities can’t be increased due to space, ensure that facilities are of high quality to reduce the loss of facility use due to disrepair. As in the process of increasing access to drinking water at the schools, additions should be based on input (and preferably some financial contribution) from the local community and administration and should consider economic (maintenance costs) and cultural appropriateness. Less expensive technologies can be used such as VIP latrines and composting latrines, but construction and materials should be of high quality. Where mechanical fixtures are used such as flushing toilets and faucet sinks, commercial grade, high-use fixtures are recommended. Flush toilets are not recommended in water scarce areas or in schools with no local capacities for maintaining facilities. Tiled floors (or similar material) should be installed where possible to limit odor and facilitate cleaning. Oversight of contracted construction is also recommended based on input from the December 2010 visit to ensure that quality and appropriately sized materials are used and properly installed. Collaboration with the Ministry of Works to enforce building standards may be useful in this regard.

Handwashing point security: Sinks located outside of the toilet unit are helpful for monitoring students’ handwashing practices and ensuring proper use, but need proper security to minimize vandalism.

Child-Friendly Facilities: Construct or adapt current facilities to accommodate students with physical disabilities to allow students to have greater independence.

Provision of sanitary cleansing materials, hand cleansing and hand-drying materials: Each item is essential in preventing the spread of germs and disease; they should be easily accessible to

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students at any time of day, students should be reminded of the importance of their proper use and when possible their proper use should be monitored. If soap is unavailable, wood ash is a good substitute. Care should be taken in schools that provide reusable towels to frequently replace them with new clean towels.

Cleaning frequency: Based on the 2009 data, higher cleaning frequency of toilet facilities and the school compound are associated with cleaner and better maintained facilities and school grounds. School facilities should be cleaned at least once per day. Quick and simple checklists may be helpful to ensure adequate cleaning.

Monitoring: Cleaner and better maintained facilities for students were also associated with the frequency of monitoring at the school. Facilities should be monitored within the school (by the principal, teachers, students, etc.) and by people/groups outside of the school such as MoE HFLE officers or MoH health educators. Monitoring should be supported so that HFLE officers or health educators can return in a timely manner (within one week) to check on the school after suggestions are made to the administration on how to improve WASH at the school. If monitoring is not expected by the school, the situation is not likely to improve. Quick and simple checklists would be helpful.

Involvement of administration: Based on the 2009 data and school visits by the consultant in December 2010, administration (school principals) can have a strong impact on WASH at the school. School administration needs to be invested in WASH and include parents, teachers and students under their leadership.

School management support: Support from management is necessary to ensure quality facilities and schools that had support from management for WASH also tended to have better facilities and conditions for the students.

Emergency preparedness: Schools that are designated hurricane shelters should have a safety plan that includes key elements such as how to be used as a shelter, how to return to classes and the number of people intended to shelter. Crucial amenities should be available in the case of emergency: ideally this would include a toilet (at least one within the school building), cooking facilities, alternate energy source, and blankets/bedding.

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