For other meanings, see Wash (disambiguation).
WASH is an acronym, standing for "Water, Sanitation and Hygiene," a group of interrelated public health issues that are of particular interest to international development programs. Access to WASH is a key public health issue, especially in many countries in Asia and sub-Saharan Africa. Several international development agencies have identified WASH as an area with great potential to improve health, life-expectancy, student learning, gender equality, and many other key issues of development.
- 1 Background
- 2 Opportunities
- 3 Monitoring
- 4 Challenges
- 5 Failures of water supply systems
- 5.1 Afghanistan
- 5.2 Africa / Sub-Saharan Africa
- 5.3 Bangladesh
- 5.4 Belarus
- 5.5 Bolivia
- 5.6 Cambodia
- 5.7 Central African Republic
- 5.8 Croatia
- 5.9 Czech Republic
- 5.10 Dominican Republic
- 5.11 DR Congo
- 5.12 Ecuador
- 5.13 England & Wales
- 5.14 Ethiopia
- 5.15 Germany
- 5.16 Ghana
- 5.17 Haiti
- 5.18 India
- 5.19 Kenya
- 5.20 Liberia
- 5.21 Macedonia
- 5.22 Madagascar
- 5.23 Malawi
- 5.24 Mali
- 5.25 Mozambique
- 5.26 Multiple countries
- 5.27 Nepal
- 5.28 Nigeria
- 5.29 Pakistan
- 5.30 Peru
- 5.31 Rwanda
- 5.32 Scotland
- 5.33 Sierra Leone
- 5.34 South Africa
- 5.35 South Asia
- 5.36 South Sudan
- 5.37 Swaziland
- 5.38 Tanzania
- 5.39 Timor-Leste
- 5.40 Uganda
- 5.41 Zimbabwe
- 6 Failures of sanitation systems
- 7 See also
- 8 References
- 9 External links
Access to safe water, adequate sanitation, and proper hygiene education can reduce illness and death, and also impact poverty reduction and socioeconomic development. Poor sanitation contributes to approximately 700,000 child deaths every year due to diarrhea, and chronic diarrhea can have a negative effect on child development (both physical and cognitive). In addition, lack of WASH facilities can prevent students from attending school, impose a burden on women, and diminish productivity.
The concept of WASH groups together water, sanitation, and hygiene because the impact of deficiencies in each area overlap strongly, and so need to be addressed together in order to achieve a strong positive impact on public health. The UN’s Millennium Development Goals include improvement of WASH services in Target 7.C: “Halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation.” However, historically, sanitation and hygiene have often received considerably less attention and funding than the issue of access to water in most WASH programmes. This has been slowly changing ever since the United Nation's International Year of Sanitation in 2008 put the spotlight on the worldwide sanitation crisis. The activities of new donors in the field of sanitation, like the Bill and Melinda Gates Foundation, with a strong focus on reuse of excreta, have also helped to increase the focus on sanitation.
Researchers at the Overseas Development Institute have promoted the value of political economy analysis to better understand the complexities of specific contexts when attempting to identify appropriate responses to WASH challenges in developing countries. They argue that 'best-practice' models of WASH service provision are unlikely to work when applied to real-world contexts. According to the researchers, political economy analysis can help to identify 'best fit' solutions that take into account existing institutions, policies and incentives and so stand a better chance of succeeding.
Neglected tropical diseases
Water, sanitation and hygiene interventions are essential in preventing many neglected tropical diseases (NTDs), for example soil-transmitted helminthiasis. A holistic and integrated approach to NTDs and WASH efforts will benefit both sectors along with the communities they are aiming to serve. This is especially true in areas that are endemic with more than one NTD.
A map has been created to help identify areas with high levels of infection with the WASH-impacted NTDs and low levels of rural improved water and sanitation coverage. In addition, WASH practitioners can use the manual "WASH and the Neglected Tropical Diseases: A Manual for WASH Implementers" to target, implement, and monitor WASH program impact on the NTDs.
In August 2015 the World Health Organization (WHO) unveiled a global strategy and action plan to integrate WASH with other public health interventions in order to accelerate elimination of NTDs. The plan aims to intensify control or eliminate certain NTDs in specific regions by 2020. It refers to the NTD roadmap milestones that included for example eradication of dracunculiasis by 2015 and of yaws by 2020, elimination of trachoma and lymphatic filariasis as public health problems by 2020, intensified control of dengue, schistosomiasis and soil-transmitted helminthiases. The plan consists of four strategic objectives: Improving awareness of benefits of joint WASH and NTD actions; monitoring WASH and NTD actions to track progress; strengthening evidence of how to deliver effective WASH interventions; and planning, delivering and evaluating WASH and NTD programmes with involvement of all stakeholders. The aim is to use synergies between WASH and NTD programmes.
Awareness raising for the importance of WASH is regularly carried out by various organizations on some special days of the year, as it is easier to obtain media coverage on those days. These United Nations international observance days include: World Water Day (22 March), Global Handwashing Day (15 October), World Toilet Day (26 November).
Some national and local governments monitor water services regularly. One example is the Sistema de Información de Agua y Saneamiento Rural(Rural Water and Sanitation Information System).
For organizations that work on WASH interventions, monitoring means using indicators to measure effectiveness of a development program. Some organizations or research organizations do "post-implementation monitoring", which occurs after the WASH intervention has been completed.
The Water Point Data Exchange (WPDx), launched in 2015, is a global platform for sharing water point data collected by governments, non-profit organizations, researchers, and others.
Although access to sanitation has in general been improving over the past decades, the World Health Organization estimates that even still, “2.5 billion people – more one third of the global population – live without basic sanitation facilities”. Part of the reason for slow progress in sanitation may be due to the “urbanization of poverty,” as poverty is increasingly concentrated in urban areas. Migration to urban areas, resulting in denser clusters of poverty, poses a challenge for sanitation infrastructures that were not originally designed to serve so many households, if they existed at all.
As poverty becomes more concentrated in urban areas, one increasingly common phenomenon is the expansion of urban slums. Often built illegally in response to a lack of more permanent housing, slums have a specific set of problems associated with them. For instance, the lack of property rights and instability associated with a slum dwelling may mean that the resident would not be willing to invest in WASH services for a building that may not survive a storm, or from which she may be evicted. In addition, “New urban areas may be very heterogeneous—both ethnically and in terms of wealth distribution. They may face a constant influx of new migrants,”. Such heterogeneity may make it difficult to coordinate efforts to build and maintain a shared sanitation system for slum neighborhoods.
A WHO report found that only one-third of the countries surveyed have national WASH plans that are being fully implemented, funded and regularly reviewed. In most countries monitoring was inconsistent and there were critical gaps. Reliable data is essential to inform policy decision, to monitoring and evaluate outcomes, and to identify those who do not have access to WASH. Many countries have WASH monitoring frameworks in place, but most of the data reported was inconsistent, weakening evaluation and outcome data analysis.
The main obstacle in the use and maintenance of improved water and sanitation systems is not the quality of technology, but the failure "in qualified human resources and in management and organization techniques, including a failure to capture community interest".
Failures of water supply systems
National government mapping and monitoring efforts as well as post-project monitoring by NGOs or researchers, have identified the failure of water supply systems (also known as water points, wells, boreholes, or wells) and sanitation systems (one part of sanitation systems are the toilets). The following sections provide examples of those failures sorted by country.
- During a WaterAid-IRC-RWSN webinar in 2013, Leendert Vijselaar of DACAAR said that 35% of 30,182 water points surveyed were non-functional.
- Nationally, 45% of water supply systems in public schools need extensive repair or replacement (2010).
- A 2013 survey of 23 European Community-funded projects in six sub-Saharan countries found:
- Overall, equipment was installed as planned and was in working order. However, fewer than half of the projects examined delivered results meeting the beneficiaries’ needs.
- While the projects examined were sustainable in technical terms, for a majority of projects, results and benefits will not continue to flow in the medium and long term unless non-tariff revenue is ensured; or because of institutional weaknesses (weak capacity by operators to run the equipment installed).
- RWSN (Rural Water Supply Network) estimated in 2010 that only two out of three handpumps are working at any time.
- Figures collated by the RWSN in 2007 indicate an average rate of 36% non-functionality for hand pumps across 21 countries. This level of failure represents a total investment of between $1.2 and $1.5 billion in the last 20 years.
- Almost 40% of sub-Saharan handpumps are not working in 2005.
- Sutton (2004) compiled data on non-functionality for several countries.
- Among 972,865 existing water options for arsenic mitigation, 29% are not active (2009).
- 14.5% of rural water supply systems do not meet microbial quality standards and 30.1% do not meet chemical standards (2011).
- In over 100 communities visited in the rural municipality of Tiraque, fewer than ten had no water system, 17 were functioning per Bolivia government norms, and the rest were providing sub-par services, requiring anywhere from complete rehabilitations to minor repairs to ensure water of adequate quantity, quality, and continuity was being provided to all citizens (2007).
- In 2014 SNV Cambodia found these results after surveying 1008 water points in Chum Kiri District: 12.1% of 672 tubewells were not functional, 5.8% of 13 protected dug wells were not functional, 262 unprotected dug wells, and 1.1% of 94 community ponds were not functional.
Central African Republic
- Only 10% of the wells and boreholes provide safe water despite these being the main source of water for urban dwellers (2011).
- 70% customers of 443 small water supply systems receive water that is not in compliance with the respective quality standards (2008).
- Water quality data from approximately 1700 small public groundwater well supplies and 3300 private wells from the period 1991–1998 showed there was a non-compliance rate with health-related parameters of approximately 70%.
- A 2011 sustainability assessment from of 61 rural water systems found that 18% are unlikely to be sustainable (it is unlikely the community will be able to overcome significant challenges).
- Out of 2,051 water points in three provinces – Bas Congo, Equateur and Kinshasa – non-functionality was highest in Bas Congo at 68%, 24% in Kinshasa and 14% in Equateur. In Bas Congo only 39% of functional water points provided safe drinking water while in Kinshasa it was just 32% (2012).
- A sustainability study conducted by the Secretariat for Water in 2004 found that 13% of the systems were sustainable, 29% had mild problems, 20% had severe problems, and 38% were broken down.
England & Wales
- An analysis of data collected from 150 local water authorities covering approximately 35,000 microbial water quality results for approximately 11,200 private water supply sites from 1996–2003 showed that E. coli (an indicator of fecal contamination) was detected in 19% of samples, with at least one positive sample being detected at 32% of water supply sites (compared to 0.1% of samples from mains water supplies).
- A 2013 survey from of 57 diverse water schemes showed 38.6% were non-functional on the day of the visit.
- A 2012 survey was carried out with 160 household in 16 water supply systems constructed by different organizations. In Mecha Woreda, 20 of the 21 systems (95%) installed without community support were not functioning while only 12 of the 142 systems (8%) installed with community failed.
- 25.5% of more than 93,000 water schemes across the country were non-functional according to the National Water Inventory (2011).
- Of 91 water schemes in Farta and West Estie surveyed, 17.5% were not functioning and 10% were functioning with difficulties (2011).
- Non-functionality of rural water schemes in 10 regions ranges from 18% to 35%, with a national average of 20% (2010).
- Out of the 70 water supply schemes in Mirab Abaya Woreda, 30 (43%) were non-functional (2008).
- It has been estimated that 33% of rural water supply schemes are non-functional at any time (2007).
- 60% of the Somali region’s birkado (cement-lined underground cisterns) are damaged and unused, calling into question the building of new birkado versus rehabilitating existing structures (2007).
- A 2006 survey found that 29% of handpumps and 33% of mechanized boreholes in rural areas were not functioning because of maintenance problems.
- In Baden-Württemberg, 523 samples from approximately 13,500 private wells were analyzed in 2007; non-compliance rates for E. coli (an indicator of fecal contamination) and total coliforms were at 18% and 43%, respectively.
- Of 898 wells surveyed, 20% were not operational at the time of a University of North Carolina study in 2014.
- Ampadu-Boakye and Hebert stated in 2014: "The Atebubu Water System, in the Brong Ahafo Region, served a group of eight urban communities with a total population of 32,000. The system was completely non-functional at the time of our visit—sand filters were overgrown with weeds, standpipes had been shut down, and the chlorinator appeared run down." Because of the failure, "Many residents now obtain water from boreholes installed by the district assembly or by NGOs....However, at the time of our visit some 40% were broken."
- 21% of 1,509 water points were not functioning on the day of visit (2013).
- In three districts (East Gonja, Akatsi, Sunyani West), more than 30% of the surveyed infrastructure was not functional, and as little as 2% was providing the basic level of service for which it was intended (2012).
- By the late 1980s and early 1990s, 33% of the water supply systems had deteriorated greatly or completely broken down due to inadequate funding to carry out maintenance and rehabilitation (1990).
- A 2012 survey of 1096 water kiosks and 2,266 water fountains showed that more than half of existing water kiosks are out of service in four geographical departments: Nord (63%), Sud (60%), Grand’Anse (59%) and Artibonite (53%) and 41.6% of existing water fountains inventoried are not functional.
- In Port-de-Paix there were no functioning public water sources in the city and 14 of 19 different sites throughout the city that investigators tested for water quality were bacterially contaminated (2007).
- Of 2500 households in 80 villages across the country, 53% do not receive an acceptable level of service (2015).
- 25% of India’s water infrastructure is believed to be in need of repair (2004).
- Evaluation in 1989 of a representative sample of 10 water points found that consumers are not receiving protected water of the required quality in any scheme evaluated.
- UNICEF assisted the Government of India with water access by drilling thousands of wells starting in 1967 when a severe drought hit several states in India. Approximately 75% of the installed cast iron pumps were not working in 1974, just seven years later.
- 2010 pilot mapping showed that, of 1011 ‘improved’ water points (all source types), average rates of non-functionality were 28% (West Pokot), 32% (Kyuso), and 20% (Mbeere North).
- Of 100 water systems assessed (built between 2006-2010), 75% are still in use. 45% are affected by minor technical issues, or even serious damages, although they have the potential to be remediated. 14% of the systems are non-functional.
- Only 58% of rural water sources are functional (2009).
- In western Kenya, nearly 50% of borehole wells dug in the 1980s, and subsequently maintained using a community-based maintenance model, had fallen into disrepair by 2000.
- 40% of over 10,000 improved water points mapped nationally were failed or needed repair (2011).
- The first systematic sampling of water points and study of water quality from 2011 in Monrovia found that 57% of the water points were contaminated by E. coli, which is an indicator of widespread fecal contamination.
- 100% of the unprotected hand-dug wells sampled showed the presence of E. coli.
- 75% of the kiosks sampled showed the presence of E. coli.
- 67% of the LWSC city water taps sampled showed the presence of E. coli.
- 52% of the protected hand-dug open wells fitted with hand pumps showed the presence of E. coli.
- 44% of the drilled wells fitted with hand pumps showed the presence of E. coli.
- Local piped water supply systems, used by 54% of the rural population, had a bacteriological failure rate of 23%. Local (non-piped) water sources, used by 13% of the population had a bacteriological failure rate of 30% (2007).
- 27% of water systems were not functional on the day of a survey which was published 2014. Out of 186 communities visited, "nearly half of all systems broke down in the previous year, and a third of them were reported not to have been fixed satisfactorily. So, by implication, one sixth of all rural water systems breaks down and are not properly fixed, per year.While half of all systems were reported to be functional for the most recent year, a tenth didn’t work at all; systems worked for an average of nine months per year. Note that the survey sample was of systems that had been built or rehabilitated within the last five years. So, at any one time, around a quarter of the rural population of Madagascar has no safe water."
- Functionality of existing water points is 90% for boreholes according to a 2009 RWSN report; 20% according to a 2010 baseline survey of the USAID-funded RANO HamPivoatra Project. Actual functionality rate is likely between 40 – 50% nationally.
- In a 2013 survey of 48 villages, 66% of MALDA handpumps installed one year before the visit were recorded as being non-functional."[T]he proportion of fully functional MALDAs was between 29% and 50% in all age cohorts."
- A survey of the water schemes in the early 1980s showed over 90% of taps were functioning, but now (2011) only 42.4% are functioning: in the Northern Region, 74% of 2305 taps from gravity-fed piped water schemes are non-functional; in the Central (1,465 taps) and Southern Regions (10,215 taps), 55% of the taps from piped water systems are non-functional.
- 31% of the improved rural water points are not functioning (2008).
- 49% of all gravity flow system taps were not working (2007).
- In 1997, a survey almost 900 tapstands found that more than 50% of them were not supplying water. This indicated a significant decline since the early 1980s when surveys showed fewer than 10% not functioning.
- In four municipalities, non-functionality of “modern” water points ranged from 14 to 41% (2011).
- The percent of non-functioning water points remains around 20% (2008).
- Data for 126,251 water points across 37 countries that are being monitored with Akvo FLOW in 2015 show that 20% are not functional, and 10% are functional but have problems.
- The National Management Information Project (2013) shows that of 40,000 gravity flow schemes, 82% are not fully functional.
- Of a sample of 192 water points across the country, 26% were found to be non-functional (2012).
- In 2010 Nepal Functionality Thematic Working Group found that out of 38,000 gravity flow water supply systems, about half are partly or totally defunct.
- A 2008 national survey of households in 36,038 wards found only 18% of the population with a water supply are served by well functioning water points/ systems; 39% are served by points that need minor repair, 12% by points that need major repair, 21% by points that need rehabilitation, 9% by points that need reconstruction, and 1.6% by points that cannot be rehabilitated.
- About 80% of all government owned water systems in small towns are non-operational (2000).
- In public schools nationally, 39% of the water supply systems need extensive repair or replacement (2010).
- A 2009 study of Asian Development Bank Independent Evaluation Group’s assistance to rural water supply in the Punjab Province identified, among others, these major concerns:
- 20% of the subprojects are nonfunctional
- only 43% of community based organizations responsible for subprojects are functional and their capacity remains weak.
- In Loreto Region, it is estimated that 34% of water systems do not function (2004).
- In a 2003 study of 104 rural water systems, only 32% were deemed “sustainable”; 66% were deteriorated and 2% were broken down.
- A 2001 study by the National Water and Sanitation Programme revealed only 34.7% of rural water supply systems in rural areas was in good or fair condition.
- In a 2011 baseline survey of 126 water points in the District of Kicukiro, 50% of the water points had been down for more than 1 day in the last month, and 55% of the communities reported that they had no spare parts on hand for the water system.
- An estimated one-third of the rural water infrastructure requires urgent rehabilitation (2006).
- Out of 1750 samples taken from private water supplies in Scotland between 1992 and 1998, 41% failed compliance for total coliforms, 30% failed for E. coli and 15% failed for nitrate. The combined failure rate was 48%.
- A comprehensive water point mapping exercise (28,845 water points) in 2012 showed the rate of damage of public water points is high and rises rapidly with point age: 14.4% were functional but partly damaged, and 17.8% are broken down. Furthermore, up to 40% of protected in-use points providing insufficient water during the dry season.
- A 2010 survey of all existing water access points across three districts (2,859 structures) found only 30% of the structures in place were found to be capable of delivering access to safe water throughout the year.
- In a sample of water and sanitation projects conducted by CSIR in 2007 in all nine provinces, the compliance level for 1067 completed household water projects was only 2.6% – more than 97% of the projects did not comply with policy requirements, norms and standards. The compliance level for 517 completed household sanitation projects was 0% – that is, none of the completed household sanitation projects complied with policy requirements, norms and standards.
- At any time, approximately 50% of handpumps are not working (2000).
- The 2004 World Development Report estimates that more than one-third of existing rural water infrastructure is not functional. (World Bank, 2004).
- 400 of 578 boreholes built between 2006 and 2012 under the Basic Services Fund were surveyed. 23.2% of surveyed boreholes were not fully functional. The main reasons for reduced functionality were difficulties with pumping and an objectionable taste or color. The 31% of the boreholes for which no information was received were mainly the inaccessible boreholes, or the boreholes constructed by NGOs that had withdrawn from the area. These may also have been the boreholes with a higher occurrence of breakdowns or reduced functionality.
- The Water Policy indicated in 2007 that 30-50% of the water points are non-operational at any time in the different States.
- A 2012 pilot water point mapping effort in 8 Tinkhundlas (sub-districts) beginning Nov 2010 showed that out of 2,689 water points, 58.6% are functional, 11.5% are partially functional, and 29.9% are non-functional.
- 22.9% (national) and 27.9% (Lubombo region, the study area) of the water schemes were non-functional (2005).
- National mapping shows 38% of 74,331 water points are not functional, and 7% are functional but need repair (2013).
- A 2013 survey of 43 taps and 4 cattle troughs showed that 11% were not functional on the day of the visit.
- One in four public kiosks were not functional at the time of an interview of 324 residents of Dar es Salaam (2012).
- According to WaterAid (2009):
- Nearly half (46%) of 65,000 public improved water points in rural areas are not functioning.
- Two years after installation, already 25% of public improved water points are non-functional.
- Up to 7.5 million rural Tanzanians lack access to clean and safe water due to functionality problems.
- Mapping 55 of the 132 district showed that 43% of the water points were no longer working, and that 25% of the water schemes had become non-functional within two years of installation (2008).
- An 2008 assessment of all (134) rural water supply systems in Covalima district found: of 54 piped systems, 44% were fully functional, 30% partially functional, and 26% not functioning. Of the 80 hand pumps, 11 were under construction, 41% of completed systems were fully functional and 59% not functioning.
- 36% of 45 surveyed community managed well sites were not functional; another 24% were either semi-functional needing minor repairs or minimally functional needing major repairs (2013).
- 16% of rural improved water points were non-functional (2013).
- In Bundibugyo, 21% of water points are not functional on average. Some subcounties have functionality rates well above 90%, but others like Kanara and Bubandi have functionality rates as low as 33%. These non-functioning systems lead to dry tap stands, resulting in about 45,000 Bundibugyo residents who are reported to be covered but in reality have to walk long distances to the nearest alternative, often an unprotected water source. Bundibugyo has registered an outbreak of either cholera or typhoid fever or both every year for the past 3 years (2013).
- Only about 7% of 377 surveyed households reported that their village hand pumps had never failed, while the rest reported that their pumps failed nearly every month (14.5%), about twice or more in a year (54%) or once a year (15.6%). Some of the non-functional water sources were considered ‘landmarks’ by the village residents (2013).
- A 2013 survey of 151 water schemes showed that 21.2% were not functional on the day of visit.
- 19% of 79,413 water points are not working. Shallow wells have the highest non-functionality rates (approximately 30%), while protected springs have the lowest non-functionality rate (approximately 88%). As many as 2,303 point water sources (2.9%) are considered abandoned, having been non-functional for five or more years (2012).
- On average, close to 70% of all households surveyed in all the eight districts access low or substandard water services (2012).
- 19% of water points across the country are non-functional based on the national water supply atlas (2010).
- Non-functional rural improved water points for the years 2003 to 2006 were 30%, 20%,18% and 17%, respectively.
- In 1980, UNICEF funded a national inventory of boreholes and found that, out of a national stock of 5,089, 75% were not working. An extensive rehabilitation program was undertaken, but three years later the percentage of non-working pumps had only decreased to 67.8%.
- A 2009 study in Mt Darwin District found 38% of the boreholes studied not functioning. Average downtime for the boreholes was 3 weeks.
- Out of 817 deep boreholes, 65% were estimated to be out of order (2005).
Failures of sanitation systems
- Nationally, 45% of toilets in public schools needed extensive repair or replacement in 2012.
- In areas where community-led total sanitation (CLTS) methods were used to promote latrine use, only about 15% of households with a latrine use the toilet regularly, while the rest continue to defecate in the open (results from 2012).
- There was a "dry ecosan" pilot project (i.e. with using dry toilets) using urine-diverting dry toilets (UDDTs) in multi-story buildings together with other technologies to allow resource recovery from excreta. This project was called the Erdos Eco-Town Project in a town called Erdos in the Inner Mongolia Autonomous Region of China. It was a collaboration between the Dongsheng District government in Erdos and the Stockholm Environment Institute and aimed to save water and provide sanitation services in this drought-stricken and rapidly urbanizing area of northern China. For a variety of technical, social and institutional reasons, the UDDTs were removed in 2011 after only a few years and the project failed to deliver in the area of nutrient recovery.
- In a study commissioned by Plan in 2013, nearly 5000 households in 116 villages were re-assessed according to the original open defecation free (ODF) verification criteria of community-led total sanitation. If all five criteria listed below are applied, the overall slippage rate across the study was 92%. In all countries each household was expected to have:
- In Bihar, a common practice once the pit was full was to revert to the practice of open defecation. The percentage of the population going back to open defecation was close to 90% (an educated guess in 2013 as there is no monitoring of latrine usage).
- 43% of villages that had been declared open defecation free (ODF) now are considered by the community as ODF, while only 25% of all villages were ODF at the time of the survey in 2014 (75% failure).
- An informal survey of toilets at schools that fall within four of the National Health Insurance pilot districts found that at all 17 schools the toilets were in a shocking condition in 2013.
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