In many schools around the world, water, sanitation and hygiene (WASH) facilities and services are inadequate, resulting in preventable diseases such as diarrhoea, acute respiratory diseases, worms and dental caries in children. These common ailments negatively affect children’s ability to learn and reduce their well-being. The Fit for School (FIT) Programme, established in 2011 and running until 11/2021, supports Ministries of Education on national and subnational levels in developing national standards and implementing guidelines for WASH in Schools, based on the basic service level set out in SDGs 6 and 4. The education sector is strengthened in its capacities to take leadership in all aspects related to WASH service provision in schools.

Access to WASH in Schools is the right of every child. Ensuring adequate WASH in Schools as outlined in SDGs 6 and 4 is the responsibility of schools and constitutes the most basic prerequisite for a healthy and conducive learning environment. However, there is still a wide gap between this vision and the reality for many schools around the globe. In order to bridge this gap, the FIT approach has been developed to support schools in incrementally improving hygiene and WASH at schools, by conducting regular hygiene interventions, constructing washing facilities, providing water, establishing operation and maintenance activities to reach the WASH-related SDGs. Even though conceived and implemented long before the adoption, the FIT approach addresses a number of SDGs, particularly SDGs 6 and 4, and contributing to SDGs 1, 2, 3, 5 and 17. The FIT approach brings them to life in an integrated, yet simple framework.
The approach of the FIT programme is intersectoral – bringing together WASH improvements and effective health interventions under the leadership of the education sector. Therefore, it predominantly works with the education sector on different levels to support the development and implementation of minimum standards for WASH in schools in Cambodia, Indonesia, Lao PDR and the Philippines to achieve a broad impact. The approach aims to improve health and learning conditions mainly of primary but extending to pre-primary and secondary school children. Evidence-based and cost-effective preventative measures, such as daily handwashing with soap and brushing teeth with fluoride toothpaste in groups, are promoted to form routine activities, along with school-based deworming according to WHO guidelines. Institutionalizing these interventions addresses some of the most prevalent diseases among school children. To provide a healthy environment, schools need usable WASH facilities and services. These basic school infrastructures are prerequisites for positive hygiene behaviour, and help to address key determinants of health for all children, but particularly for those who might not have access to basic water and sanitation at home. The programme encourages regular operation and maintenance of WASH facilities, and promotes hygiene practices through hard and software tools such as manuals, lists, videos, and packaged supplies for hygiene, cleaning and repair. The aim is for the education sector to integrate cleaning and maintenance of WASH facilities into the core responsibilities of school heads and to improve their capacities to manage the toilets and washing facilities.
Depending on the most challenging ailments of school children, interventions can be extended or adapted. In Lao PDR where stunting among children is prevalent, the feasibility of combining group handwashing with a school lunch programme was successfully demonstrated in collaboration with the Ministry of Education and Sports and the World Food Programme. Promotion of daily hygiene habits, food hygiene and healthy recipes aimed at strengthening the nutrition impact of the daily school lunch.

Interventions are modelled into a template-based package to simplify implementation through education staff and students in the school context with the least extra effort possible. Packages are adaptable to different settings and stages of development and are building on the principles of School-based Management (SBM), the predominant school management approach.
All students of a school benefit from improved WASH, particularly the disadvantaged. In addition, special attention is paid to improving menstrual hygiene management to prevent girls from missing school during their period or dropping out due to inadequate facilities or lack of privacy contributing to gender equality.On the policy level, the programme supports Ministries of Education to integrate WASH in Schools into existing structures of the education sector.

The FIT Programme is implemented in partnership with the Southeast Asian Ministers of Education Organization (SEAMEO), specifically its Regional Centre for Educational Innovation and Technology of the Southeast Asian Ministers of Education Organization (INNOTECH) and its Regional Center for Food and Nutrition (RECFON). SEAMEO INNOTECH’s mandate is to promote development of innovative approaches and capacity development in education.
The FIT Programme provides technical assistance and capacity building to partner governments on national and subnational levels to support policy and programme development. On subnational levels, technical assistance focuses on strengthening implementation of school interventions. In the Philippines, FIT works closely with the Department of Education, in Indonesia with the Ministry of Education and Culture and the Ministry of Religious Affairs, in Lao PDR with the Ministry of Education and Sports, and in Cambodia with the Ministry of Education, Youth and Sport.
Through international and national collaborations with partners, such as UNICEF, WFP, and NGOs, the programme strongly contributes towards alignment of agendas and joint approaches.

The FIT Programme first started around 2008 in the Philippines to address the high burden of tooth decay in school children by introducing daily school-based toothbrushing with fluoride toothpaste. With the emerging pandemics like bird flu in Asia, the importance of handwashing particularly in public schools became more important and led to the development of the broader approach, in the Philippines known as the Essential Health Care Programme (EHCP). Under the EHCP, daily group hand washing and daily group toothbrushing were combined with bi-annual deworming and first prototypes of group handwashing facilities. The programme has led to the development of a national WASH in Schools policy, endorsed by the Department of Education in 2016, to establish a broader nationwide WASH in schools programme, aligning all other WASH partners under a common umbrella.
Learning from the success in the Philippines, other Southeast Asian governments were keen to follow with similar programmes, which led to the development of the FIT Programme. It was launched in 2011 as a joint research and development initiative led by GIZ in partnership with SEAMEO INNOTECH. The programme aims to adapt the FIT approach to the specific national context in Cambodia, Indonesia and Lao PDR, including implementation templates, advocacy and monitoring tools for scale-up and expanded programme coverage.
The FIT programme has been rolled out in three phases. The first phase (4 years) concentrated on adapting the FIT approach to the respective country contexts. Based on experiences in the Philippines, pilots were set up in selected schools in Cambodia, Indonesia and Lao PDR. Instead of covering a large number of schools and providing them with supplies and equipment, the programme aimed at contextualizing the approach for the specific setting of the respective country, identifying what works and is appropriate. This ensured to have a proper model in place before going to scale. The second phase focused on scaling up successful models within the partner countries. The third and current phase concentrates on the strengthening capacities of national structures and processes and increasing knowledge management to prepare for the end of the programme.
Monitoring and research are core component of the FIT Programme to keep implementation on track and to inform advocacy, policy development and decision-making. Regular monitoring has been conducted in all model schools, using the adapted Fit for School monitoring tool. The monitoring process is a self-assessment tool, involving different stakeholders on school and community level and aims to ensure good implementation quality and community involvement. Research collaborations with national and international universities have been established to gain more insights into different aspects of WASH in schools to make it more impactful. This also enhances local research capacities, increases ownership and facilitates south-south learning. Aligned with the WASH-related SDGs, the FIT Programme supports the respective Ministries of Education to include a set of globally agreed indicators into the national Education Monitoring Information Systems and thereby confirm the responsibility of the education sector for WASH in School.

In the Philippines, a longitudinal health outcome study was conducted from 2009 to 2012 to assess the impact of the programme interventions on children’s parasitological, nutritional and oral health status and has shown very positive health effects after just one year: 20% fewer underweight children, 30% less absenteeism, 40% less infections from decayed teeth and 50% less heavy worm infections compared to schools employing traditional health education. A similar study has been conducted in Cambodia, Indonesia and Lao PDR, from 2012 to 2014 focusing on a WASH survey and a handwashing behaviour study. The research was carried out in partnership with several local and international universities. Data were collected by teams of trained personnel from the respective Ministries of Education and health, local universities and local NGOs in each country. Results from Cambodia, Indonesia and Lao showed that daily group toothbrushing with fluoride toothpaste in schools prevented 17 % to 38 % of new caries lesions. After two years, model schools had 8% to 62% functional and clean toilets compared to 0% to 36% in control schools. The percentage of handwashing slots with water & soap per school was higher in model schools ranging from 87% to 95% compared to 10% to 33% in control schools. Encouraged by the programme implementation, model schools even went beyond intended programme objectives and also built handwashing facilities for individual use.
Taking scale as an indicator of success the programme reached about, with a conservative estimation, about 6.7 million children (2020) in approximately 18,000 schools with basic service level of the SDGs for WinS.
In the partner countries, the FIT Programme has contributed to policy development, to the development of implementing guidelines and a stepwise approach to reach national targets for WASH in schools, strengthened monitoring frameworks, and scaling-up beyond pilot areas, and promoted a vivid south-south exchange. With governments allocating and increasing budgets for WASH in schools and school communities taking responsibility, the programme fosters sustainability.
On a global level, the FIT Programme has contributed to the development of the WASH-related core and expanded indicators for the respective target areas of the SDGS under the leadership of the Joint Monitoring Programme of UNICEF/WHO in 2016. Prior to that, the FIT Programme and UNICEF developed the Three Star Approach, a key concept and publication providing guidance to many WASH in Schools programmes around the world, now implemented in over 40 countries! This approach promotes a gradual and stepwise approach to improve the WASH in School status, which is a key principle of the FIT approach. The Three Star Approach guides all schools, even those without additional resources, to identify immediate steps the school community can take to start the journey to reach the national standards. At the same time, it provides a clear pathway for all schools throughout a country to meet national standards, and for all children to have hygiene-promoting and healthy schools. It encourages local action and support from communities and does not depend on expensive hardware inputs from the education system or external support agencies. The FIT programme supports the Department of Education in the Philippines in implementing the Three Star Approach as the monitoring system for the national WASH in Schools policy, collecting data annual data since 2016 for now over 75% of schools, and the localized version "Minimum Requirement Guidelines for WinS" in Cambodia, which started collecting data for 100% of schools from kindergarten through to upper secondary since 2018.

The contexts and conditions for WASH in schools vary within and between the partner countries. Among the main constraints are scarce resources on all levels, insufficient capacities to guide and implement WASH in Schools on subnational levels, competing political priorities and inadequate alignment of actors. Overarching success factors that helped to overcome obstacles for WASH in Schools relate to the core principles of the programme - simplicity, scalability, sustainability and system-orientation.
Simplicity: To achieve significant health impacts, the programme focuses on the most prevalent diseases in school-age children such as hygiene deficiency-related illnesses, dental caries and worm infections. The interventions are simple and evidence-based. By applying a skills-based approach the programme goes beyond the traditional instruction-based health education. By implementing the activities as part of the daily school routine, it supports children in acquiring healthy habits and promotes sustained behaviour change. These interventions are packaged to facilitate implementation, which includes clear and simple guidance and implementation templates that allow school principals and teachers to run the programme with minimal supervision and effort.
Sustainability: Independence from external funding is essential for sustainability. The FIT Programme therefore only covered the costs of an initial start-up and research phase and thereafter commits technical assistance to local or national government partners to establish appropriate budget lines and financing mechanisms for the sustainable funding. The community and parents are actively involved in the construction of the required group washing facilities. In addition, they are engaged in monitoring and evaluation through a simple participatory process. This ensures accountability and transparency, strengthens local ownership and promotes community empowerment.
Scalability: Programme management is kept as lean as possible and is integrated in existing structures of the education sector with support of the health and related sectors. The programme follows a modular structure and uses uniform templates to facilitate implementation and scale-up.
System-orientation: Mobilizing and utilizing resources and existing structures of the education sector aims to keep interventions and implementable and realistic. Sustainability can only be ensured if activities of the programme can be managed independently from external sources.
Other enabling factors include the contribution to supportive policies, multi-level advocacy and fostering an effective link with research institutions to monitor programme performance and assess its impacts on health and education.
With single handwashing facilities, not all students get to wash their hands. To facilitate daily hygiene practices in schools, the FIT Programme has developed a simple group handwashing facility model. It was designed to allow lay people to construct and maintain the facility with an easy construction process and built with locally available materials. Effective hardware designs help schools to use their resources efficiently.
Another very useful tool developed by the FIT Programme are costing templates and fixed module pricing of supply packages necessary to run the programme. This helps schools to estimate and manage their budgets predictably.
Capacity building is at the core of the programme, involving stakeholders of Ministries of Education on national and subnational level, also making use of manuals and videos. The newest innovation are two massive open online courses to strengthen WinS capacities in the Philippines - one for schools, the other for subnational education officials to better understand WinS policy requirements, possible strategies and available tools. After a pilot run, the school-level course was relaunched as part of the COVID-19 response measures with 7,000 participants in July 2020.

The Agenda 2030 asks for universal access to WASH, health and education, which requires interventions that can be sustainably applied and replicated. This thinking is at the core of the FIT approach, thanks to the fundamental principles of simplicity, scalability, sustainability and system-orientation.
The simplicity of the approach has proven to be appealing and opening doors with stakeholders and decision makers who are looking for practical and tangible models for WinS management and implementation at scale. WASH improvements have been successfully delivered in settings with challenging preconditions. For instance, the concept for group handwashing facilities was successfully applied in natural disaster and emergency situations, including the immense devastation after the typhoon Haiyan hit the Philippines in 2013. Improved hygiene contributes to resilience and pandemic preparedness.
As part of the programme, regular learning exchanges are organized to bring a broad range of stakeholders together. Organized jointly with UNICEF, the format of international learning exchanges with stakeholders and government representatives from Asian, African and Pacific Island countries has gained major traction and is now the leading forum to bridge science, evidence, policy and practice related to WASH in Schools. For instance, resulting from such an event and learning from the Philippines, the India mid-day meal programme has integrated handwashing prior to and toothbrushing after lunch, thereby reaching currently 17 million school children on a daily base according to Indian Government
On the international level, the programme was awarded multiple times for its innovative and intersectoral character, as well as for bridging science and practice through promoting evidence-based interventions. Among the major recognitions was the award for Innovation in Global Health from UNDP, World Bank and the WHO in 2009. These international achievements contributed greatly to the international momentum towards improving WASH in Schools, and to scaling-up the reach of programmes using the FIT approach.

The FIT approach and its implementation have demonstrated that improving WASH in Schools is possible, even in challenging settings with poor resources. The FIT approach allows for effective coordination and collaboration across sectors under leadership of the education sector. The positive impacts generally include a stronger supportive policy context, improved capacity of stakeholders to plan, implement, manage and monitor WASH in Schools as requested in SDGs 6 and 4.
The programme has contributed to great progress in WASH in schools in all partner countries, as well as mobilized actors and influenced programming of WASH in Schools on regional and global level to make it more effective and impactful.
The development of Three Star Approach for WASH in Schools was a major step in mainstreaming the innovative concepts of the FIT approach and has since its launch in 2013 changed the thinking and implementation landscape of WASH in Schools, resulting in various adaptations of the approach in different countries. The principle of stepwise improvements, starting with what is available before investing heavily in new WASH facilities, has resonated well with national, regional and international WASH in Schools stakeholders. International recognition through awards and competitions has provided additional momentum in advocacy to achieve universal access to basic WASH services in schools.

Website:
www.fitforschool.international

Youtube channel:
https://www.youtube.com/channel/UCwrvUkhNtZRZUfxyJoImerA/videos

Selected videos:
GIZ. Bridging research and practice - FIT Programme Outcome Study [video]. Manila: GIZ; 2015. Available from: http://www.fitforschool.international/resource/bridging-research-and-practice-fit-program-outcome-study/

GIZ, SEAMEO INNOTECH, WFP. Working Together for Better Nutrition and Hygiene in Schools in Lao PDR [video]. Vientiane: GIZ, SEAMEO INNOTECH, WFP; 2017 Available from: http://www.fitforschool.international/resource/fit-for-school-working-together-for-better-nutrition-and-hygiene-in-schools-in-lao-pdr-with-subtitles/

Philippine Department of Education (DepEd). DepEd WinS Program Overview: Reaching the Stars [video]. Manila: DepEd; 2018. Available from:
http://www.fitforschool.international/resource/deped-wins-program-overview-reaching-the-stars/

Publications:
Ministry of Education, Youth and Sport, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH. Research Update: Cambodia, Kampot Province Scale-up Success Factors. 2018. Available from: http://www.fitforschool.international/resource/research-update-cambodia-kampot-province-scale-up-success-factors/

UNICEF, GIZ. Field Guide: The Three Star Approach for WASH in Schools. 2013. Available from: http://www.fitforschool.international/resource/field-guide-the-three-star-approach-for-wash-in-schools/
Dimaisip-Nabuab et al. Nutritional Status, Dental Caries and Tooth Eruption in Children: A Longitudinal Study in Cambodia, Indonesia and Lao PDR. BMC Pediatrics (2018) 18:300 https://doi.org/10.1186/s12887-018-1277-6. Available from: http://www.fitforschool.international/resource/nutritional-status-dental-caries-and-tooth-eruption-in-children-a-longitudinal-study-in-cambodia-indonesia-and-lao-pdr/

Philippine Department of Education. WASH in Schools Three Star Approach Brochure. Manila: DepEd; 2017. Available from: www.fitforschool.international/resource/philippine-department-of-education-wash-in-schools-three-star-approach-brochure/


GIZ. WinS Knowledge Map: Fit for School in Autonomous Region in Muslim Mindanao. Manila: GIZ; 2017. Available from: www.fitforschool.international/resource/wins-knowledge-map-fit-for-school-in-autonomous-region-in-muslim-mindanao/

GIZ. Fit for School Program Assessment Study Report Short Regional. Manila: GIZ; 2016. Available from: http://www.fitforschool.international/resource/fit-for-school-program-assessment-report-short/

Duijster et al. ‘Fit for School’ – a school-based water, sanitation and hygiene programme to improve child health: Results from a longitudinal study in Cambodia, Indonesia and Lao PDR. BMC Public Health (2017)17:302. DOI 10.1186/s12889-017-4203-1. Available from: http://www.fitforschool.international/resource/fit-for-school-a-school-based-water-sanitation-and-hygiene-programme-to-improve-child-health-results-from-a-longitudinal-study-in-cambodia-indonesia-and-lao-pdr/


Ministry of Education and Sports (MoES) and Ministry of Health (MoH) of the Lao People’s Democratic Republic, GIZ and SEAMEO INNOTECH. Sisattanak District Scale-up Experience in Lao PDR [video]. Vientiane: MoES, MoH, GIZ, SEAMEO INNOTECH: 2018. Available from: http://www.fitforschool.international/resource/sisattanak-district-scale-up-experience-in-lao-pdr/