on household diarrhea incidence. additional health risks for women further information: menstrual hygiene management women tend to face a higher risk of diseases and illness due to limited wash access. heavily pregnant women face severe hardship walking to and from a water collection site. the consumption of unclean water leading to infection in the fetus accounts for 15% of deaths for women during pregnancy globally. illnesses and diseases that can come from poor menstrual hygiene management become more likely when clean water and toilets are unavailable. in bangladesh and india, women rely on old cloths to absorb menstrual blood and use water to clean and reuse them. without access to clean water and hygiene, these women my experience unnecessary health problems in connection with their periods. health risks for sanitation workers this section is an excerpt from sanitation worker § occupational safety and health. occupational safety and health issues for sanitation workers include: diseases related to contact with the excreta; injuries related to the physical effort of extracting and transporting the waste, including falls from height; injuries related to cuts from non-fecal waste (e.g. glass or needles) disposed of down the toilet. there are also the general dangers of working in confined spaces, including lack of oxygen. many sanitation workers in developing countries work without any form of personal protective equipment (ppe) and no or minimal formal training.: 9 physical and medical conditions directly associated with sanitation work that is carried out unsafely can include: "headaches, dizziness, fever, fatigue, asthma, gastroenteritis, cholera, typhoid, hepatitis, polio, cryptosporidiosis, schistosomiasis, eye and skin burn and other skin irritation, musculoskeletal disorders (including back pain), puncture wounds and cuts, blunt force".: 8 in non-household settings non-household settings for wash include the following six types: schools, health care facilities, workplaces (including prisons), temporary use settings, mass gatherings, and dislocated populations. in schools school toilets at shaheed monumia government secondary school, tejgaon, dhaka, bangladesh) school toilet at iph school and college, mohakhali, dhaka, bangladesh) handwashing stands at a school in mysore district, karnataka, india further information: school hygienemore than half of all primary schools in the developing countries with available data do not have adequate water facilities and nearly two thirds lack adequate sanitation. even where facilities exist, they are often in poor condition. children are able to more fully participate in school when there is improved access to water.: 24 lack of wash facilities can prevent students from attending school, particularly female students. strong cultural taboos around menstruation, which are present in many societies, coupled with a lack of menstrual hygiene management services in schools, results in girls staying away from school during menstruation. reasons for missing or poorly maintained water and sanitation facilities at schools in developing countries include lacking inter-sectoral collaboration; lacking cooperation between schools, communities and different levels of government; as well as a lack in leadership and accountability. outcomes from improved wash at schools wash in schools, sometimes called swash or wins, significantly reduces hygiene-related disease, increases student attendance and contributes to dignity and gender equality. wash in schools contributes to healthy, safe and secure school environments that can protect children from health hazards, abuse and exclusion. it also enables children to become agents of change for improving water, sanitation and hygiene practices in their families and communities. data from over 10,000 schools in zambia was analyzed in 2017 and confirmed that improved sanitation provision in schools was correlated with high female-to-male enrolment ratios, and reduced repetition and drop-out ratios, especially for girls. the study thus confirmed the linkages between adequate toilets in schools and educational progression of girls. methods to improve wash in schools methods to improve the situation of wash infrastructure at schools include on a policy level: broadening the focus of the education sector, establishing a systematic quality assurance system, distributing and using funds wisely. other practical recommendations include: have a clear and systematic mobilization strategy, support the education sector to strengthen intersectoral partnerships, establish a constant monitoring system which is located within the education sector, educate the educators and partner with the school management. the support provided by development agencies to the government at national, state and district levels is helpful to gradually create what is commonly referred to as an enabling environment for wash in schools. this includes sound policies, an appropriate and well-resourced strategy, and effective planning. such efforts need to be sustained over longer time periods as ministries and departments of education are very large organizations, which generally show much inertia and are slow to reform. success also hinges on local-level leadership and a genuine collective commitment of school stakeholders towards school development. developing human and social capital amongst core school stakeholders is important. this applies to students and their representative clubs, headmaster, teachers and parents. furthermore, other stakeholders have to be engaged in their direct sphere of influence, such as: community members, community-based organizations, educations official, local authorities. group handwashing a community handwashing facility in rwanda with sinks for people of different heights. during the covid-19 pandemic in rwanda handwashing was part of a system of public health measures encouraged to reduce transmission. supervised daily group handwashing in schools is an effective strategy for building good hygiene habits, with the potential to lead to positive health and education outcomes for children. this has for example been implemented in the "essential health care program" by the department of education in the philippines. mass deworming twice a year, supplemented by washing hands daily with soap and brushing teeth daily with fluoride, is at the core of this national program. it has also been successfully implemented in indonesia. in healthcare facilities a woman is filling a jerrycan with unsafe drinking water at the boromata well in central african republic. the provision of adequate water, sanitation and hygiene is an essential part of providing basic health services in healthcare facilities. wash in healthcare facilities aids in preventing the spread of infectious diseases as well as protects staff and patients. wash services in health facilities in developing countries are currently often lacking. according to the world health organization, data from 54 countries in low and middle income settings representing 66,101 health facilities show that 38% of health care facilities lack improved water sources, 19% lack improved sanitation while 35% lack access to water and soap for handwashing. the absence of basic wash amenities compromises the ability to provide routine services and hinders the ability to prevent and control infections. the provision of water in health facilities was the lowest in africa, where 42% of healthcare facilities lack an improved source of water on-site or nearby. the provision of sanitation is lowest in the americas with 43% of health care facilities lacking adequate services. in 2019, who estimated that: "one in four health care facilities lack basic water services, and one in five have no sanitation service – impacting 2.0 and 1.5 billion people, respectively." furthermore, it is estimated that "health care facilities in low-income countries are at least three times as likely to have no water service as facilities in higher resource settings". this is thought to contribute to the fact that maternal sepsis is twice as great in developing countries as it is in high income countries.: vii barriers to providing wash in health care facilities include: incomplete standards, inadequate monitoring, disease-specific budgeting, disempowered workforce, poor wash infrastructure.: 14 the improvement of wash standards within health facilities needs to be guided by national policies and standards as well as an allocated budget to improve and maintain services. a number of solutions exist that can considerably improve the health and safety of both patients and service providers at health facilities: availability of safe water for drinking but also for use in surgery and deliveries, food preparation, bathing and showering: there is a need for improved water pump systems within health facilities. improved handwashing practices among healthcare staff must be implemented. this requires functional hand washing stations at strategic points of care within the health facilities, i.e. at points of care and at toilets. waste system management: proper health care waste management and the safe disposal of excreta and waste water is crucial to preventing the spread of disease. hygiene promotion for patients, visitors and staff. accessible and clean toilets, separated by gender, in sufficient numbers for staff, patients and visitors. improving access to hand washing and sanitation facilities in healthcare settings will significantly reduce infection and mortality rates, particularly in maternal and child health. in prisons in developing countries, prison buildings are very often overcrowded and dilapidated.: 12 a report by icrc states that "measures depriving persons of their freedom must in no way, whatever the circumstances, be made more severe by treatment or material conditions of detention which undermine the dignity and the rights of the individual.".: 12 the water supply systems and sanitary facilities in prisons are often insufficient to meet the needs of the prison population in cases where the number of detainees exceeds a prison's capacity. overuse of the facilities results in rapid deterioration. the budget allocated by the state for prisons is often insufficient to cover the detainees' needs in terms of food and medical care, let alone upkeep of water and sanitation facilities.: 12 nevertheless, even with limited funds, it is possible to maintain or renovate decaying infrastructure with the right planning approaches and suitable low-cost water supply and sanitation options. impacts on women impacts on women and girls that come from lack of proper facilities include the burden of time required to collect water from distant water sources when there is no water access on the premises - as well as specific hygiene and privacy needs related to urination, menstruation, pregnancy, and birth. since biological men and boys do not menstruate and can generally urinate in the open without risking their own health and safety, there is a much less frequent need for them to access a potentially dirty toilet stall or outdoor toilet (for defecation). there are also restrictive gender norms for water-related occupations. violence against women is another problem that can come from the fact that to access water or toilets women might have to leave the premises and travel some distances, often alone or in the dark. time required to collect water waiting in line for two hours to collect water from a standpipethe lack of accessible, sufficient, clean and affordable water supply has adverse impacts specifically related to women in developing nations. it is estimated that 263 million people worldwide spent over 30 minutes per round trip to collect water from an improved source.: 3 in sub-saharan africa, women and girls carry water containers for an average of three miles each day, spending 40 billion hours per year on water collection (walking to the water source, waiting in line, walking back).: 14 the time to collect water can come at the expense of education, income generating activities, cultural and political involvement, and rest and recreation.: 2 for example, in low-income areas of nairobi, women carry 44 pound containers of water back to their homes, taking anywhere between an hour and several hours to wait and collect the water.: 733 in many places of the world, getting and providing water is considered "women's work," so gender and water access are intricately linked.: 256 water gathering and supply to family units remains primarily a woman's task in less developed countries where water gathering is considered a main chore.: 256 this water work is also largely unpaid household work based on patriarchal gender norms and often related to domestic work, such as laundry, cooking and childcare.: 5 areas that rely on women to primarily collect water include countries in africa, south asia and in the middle east.: 4 gender norms for occupations gender norms can negatively affect how men and women access water through such behavior expectations along gender lines—for example, when water collection is a woman's chore, men who collect water may face discrimination for performing perceived women's work. women are likely to be deterred from entering water utilities in developing countries because "social norms prescribe that it is an area of work that is not suitable for them or that they are incapable of performing well".: 13 nevertheless, a study by world bank in 2019 has found that the proportion of female water professionals has grown in