Problem Statement
While visiting many cities across South Asia and Sub-Saharan Africa as part of our project mandate, we repeatedly observed a lack of well-maintained or usable water, sanitation and hygiene (WASH) facilities in schools and healthcare facilities (HCFs). Infrastructure was present in many cases, but usability and maintenance were largely missing across locations.
Global data shows that as of 2020, 43% of schools worldwide lacked access to basic handwashing facilities[1], and 37% had limited or no sanitation facilities[2]. This affects approximately 818 million children, increasing their vulnerability to preventable diseases and absenteeism. For example, a study in Kenya found that improved WASH access led to a 58% reduction in the odds of two-week absences among girls, equating to an average decrease of six days of absence per year[3].
In healthcare settings, the situation is equally concerning. A 2022 report by the World Health Organization (WHO) and UNICEF found that half of healthcare facilities globally lack basic hygiene services (functional, usable facilities with soap and water), affecting around 3.85 billion people. WHO also reports that, on average, 15 out of every 100 patients in low- and middle-income countries acquire at least one healthcare-associated infection (HAI) during their hospital stay. These infections not only prolong hospital stays but also increase morbidity and mortality rates.
Although various support programmes aim to provide this basic infrastructure, one of the core challenges is ensuring that newly implemented systems are not only functional but also operationally sustainable in the long term.
To tackle these challenges, the “Three-Star Approach” (TSA) offers a phased system to progressively improve WASH infrastructure in a way that is manageable, sustainable and effective[4].
The Three-Star Approach (TSA): A Phased Path to Improved WASH
The TSA is a structured model for improving WASH facilities, designed for schools and healthcare settings. Its phased structure allows institutions to improve their facilities incrementally without overwhelming their resources or capacities.
The guiding principle of the TSA is to “Keep it simple, scalable, and sustainable”.
For example, in Mozambique, several project towns under the Small Town Sanitation programme are planning to implement the recommended changes following the TSA. In Mocuba, schools are just starting their journey towards basic sanitation standards, with recommendations to install borewells and gender-segregated twin-pit toilets, while students bring water from home until these improvements are complete. Meanwhile, Alto Molocue is progressing by adding handwashing stations and menstrual hygiene facilities alongside new borewells and rainwater harvesting systems. In Angoche, where over 4,000 students rely on limited facilities, the installation of additional toilets aims to meet both hygiene and privacy needs. Namialo, facing similar challenges with 6,000 students, is implementing a large-scale upgrade, adding toilets and rainwater harvesting to ensure a stable water supply. Healthcare facilities across these towns are also evolving, with Mocuba and Angoche expanding to offer patient and staff toilets and accessible hygiene facilities. Through each incremental improvement, these towns are laying a strong foundation for health, dignity and growth in their communities.
Operation & Maintenance
Effective operation and maintenance (O&M) is the backbone of the TSA, ensuring that WASH facilities remain functional and effective. Schools and healthcare facilities play central roles in this process, supported by active engagement from students, staff and community members.
In Schools: Inspired by Japanese practice, where 93% of students participate in daily cleaning, schools can involve students in maintaining cleanliness and functionality. Activities such as water audits, waste segregation drives and hygiene competitions foster a sense of ownership. Teachers guide these efforts, integrating hygiene into everyday learning through WASH clubs that organise themed activities such as handwashing campaigns and waste reduction projects. The WASHaLOT 3.0 is a prefabricated group handwashing facility designed to promote hygiene practices in schools and communities. It features multiple water outlets designed with scalability (according to group size) and sustainability (reduced water consumption) in mind.
In Healthcare Facilities: The Water and Sanitation for Health Facility Improvement Tool (WASH FIT) is a risk-based management framework that gives facilities a structured approach to assess current conditions, identify hazards and implement targeted improvements across key areas such as WASH, environmental cleaning and healthcare waste management. By integrating WASH FIT into routine operations, healthcare facilities can systematically improve service quality, reduce healthcare-associated infections and promote patient and staff safety. Facility In-Charges and Chief Medical Officers oversee WASH protocols, conducting regular inspections and maintaining feedback systems for staff and patients. Structured training programmes for healthcare workers improve compliance with hygiene standards, while Sanitation Committees, comprising healthcare staff, local representatives and community members, drive long-term sanitation improvements. These committees collaborate with NGOs and government bodies to secure resources and implement new solutions.
Monitoring and Benchmarks: Service level benchmarks (SLBs) provide phased targets for continuous improvement. Facilities start by developing model set-ups within the first two years, achieving One-Star compliance by year three, Two-Star compliance by year five and Three-Star compliance by year seven. These benchmarks are tailored to facility needs, ensuring progress is both measurable and achievable. For example, in Mozambique, towns were targeted to build the model facility in 2 years, bring 100% of schools to One-Star in 4 years and 100% of HCFs to Two-Star in 5 years, and so on.
Awards and Recognition: To encourage excellence, award programmes celebrate achievements in WASH maintenance and innovation. Schools receive awards for best-maintained classrooms, while healthcare facilities are recognised for exceptional hygiene protocols. At the community level, wards or neighbourhoods are rewarded for collective sanitation achievements, fostering a culture of pride and accountability. Recognition is also combined with financial incentives and training programmes to further boost involvement.
Through collaborative and continuous effort, effective O&M ensures that WASH infrastructure remains a catalyst for better health, education and community well-being.
Success Stories from the Past
The TSA has a wide range of success stories in countries such as Kenya, which saw a 35% reduction in school absenteeism, and Egypt and Colombia, which saw reductions of 41% and 20% respectively[5]. (Note that the Kenyan figure here measures overall absenteeism, a different measure from the 58% reduction in the odds of absence among girls cited above.) Bhutan and the Philippines have both adopted the TSA in combination with WASH FIT to better manage operations in healthcare facilities[6]. Madagascar has adopted the Three-Star Approach, with 208 schools and 77 HCFs meeting national standards[7].
Future Outlook
The Three-Star Approach is a practical tool for monitoring and improving WASH performance in schools and healthcare facilities. Scaling this framework to broader levels, whether town, province or state, can drive continuous improvement, encourage sustainable management practices and support the adoption of new solutions based on proven success stories. By encouraging facilities to maintain and improve their ratings, the approach not only ensures better hygiene and sanitation infrastructure but also encourages facilities to sustain their ratings through consistent operation and management.
[3] IRC WASH, resource on the impact of school WASH on absenteeism: school-based water treatment, hygiene and sanitation in Kenya
[4] The TSA as described here is modelled on UNICEF and GIZ (2013), Field Guide: The Three Star Approach for WASH in Schools, and WHO and UNICEF (2022), WASH FIT: A Practical Guide for Improving Quality of Care Through Water, Sanitation and Hygiene in Health Care Facilities, Second Edition
[5] Field Guide: The Three Star Approach for WASH in Schools, UNICEF & GIZ, 2013
[6] WASH FIT: A Practical Guide for Improving Quality of Care Through Water, Sanitation and Hygiene in Health Care Facilities, Second Edition, WHO, 2022
[7] WASH and OR+ Thematic Report, UNICEF, 2019
