A qualitative assessment of disability friendly water and sanitation facilities in primary schools, Rumphi, Malawi

ABSTRACT

Students with disabilities commonly face barriers when accessing water and using sanitation and hygiene facilities at school. International frameworks have prompted governments to enact local policies that enshrine these rights, guarantee equitable access to education and mandate inclusive infrastructure. This research was designed to explore whether Malawi has translated good policies into practice. Data were gathered in Rumphi district, Malawi, through structured field observations in ten schools and interviews with students with a disability (n = 23), teachers (n = 11) and government stakeholders (n = 2). No school had facilities that fully meet the needs of students with disabilities, and private schools were not necessarily better. The cost of bringing existing infrastructure up to standard was on average MK54 000 (US$78). However, proactive consultation with children with a disability is likely to generate alternative low-cost short-term solutions. Increased government support, budgeting and enforcement is necessary to ensure international standards and national policies are met.

KEYWORDS:

• Children
• developing countries
• disability
• water
• sanitation and hygiene
• education

1. Introduction

The United Nations Sustainable Development Goals (2016) committed the world to providing equitable education (Goal 4) and water and sanitation for all (Goal 6). This article looks at the interconnectedness of these goals. It focuses on the institutional water, sanitation and hygiene (WASH) needs of children with disabilities and the challenges of closing the gap between policy and practice in low-resource settings.

Students with a disability are much more likely to be marginalised by the education system, and experience much higher drop-out rates and lower levels of literacy (Groce & Bakhshi, 2009). This is particularly pronounced in low- and middle-income countries (LMIC), where it is estimated that fewer than 5% of children with disabilities attend school (Peters, 2003). A review conducted by Wapling in 2016 summarised some of the barriers that contribute to this statistic: (a) many LMIC are still in the process of scaling up universal education and do not see it as a priority to support the needs of children with a disability; (b) making schools more disability-friendly is not seen as cost-effective; (c) national policies are adopted symbolically and do not clarify how to translate rights-based principles into tangible actions; and (d) those at the lowest level, who are in the best position to make change, do not have sufficient capacity or resources to do so.

Safe and dignified access to water, sanitation and hygiene is one of the major challenges that people with disabilities face in their day-to-day lives (White et al., 2016). Groce et al. (2011) suggested that people with disability face three types of barrier when accessing WASH: physical (e.g. muddy paths, narrow doors, steps, etc.), social (e.g. stigma towards and beliefs about people with disabilities) and institutional (e.g. policies and practices that overlook the needs of people with disabilities or prevent their participation). A recent study in Malawi identified 50 barriers that people with disability face when accessing WASH, many of which are relevant to both children and adults (White et al., 2016). Child and disability friendly WASH guides do exist to overcome these barriers. For example, Jones and Wilbur (2014) provide a range of accessible WASH technologies that utilise local materials and are appropriate for LMIC. Additionally, the World Bank (2017a) has guidelines for including persons with disabilities when designing publically accessible water infrastructure.

Malawi is one of the world’s poorest nations but a push in recent years has led to 97% of children being enrolled in primary education (World Bank, 2017b). An estimated 2.4% of youth in Malawi have a disability (UNICEF, 2013), and for these individuals school attendance remains much lower than the national average. A study by UNICEF (2013) found that this inequity is predominantly due to the physical school environment not being sensitive to the needs of people with disabilities.

Malawi’s national policies are clear on the importance of equitable access to WASH in schools. The National Sanitation Policy states that the nation should ‘provide and maintain improved sanitation facilities, which also cater for people with special needs in all public places’ (Malawi Government, 2008). Specifically, the policy states that, ‘at least one latrine or toilet for boys and girls in all schools is provided with facilities for pupils with disabilities’. The National Water Policy also encourages inclusivity and states that there should be ‘active participation of youth, women, persons with disabilities and vulnerable persons in planning and implementation of rural water supply and sanitation activities’ (Malawi Government, 2005). Additionally, the Malawi National Policy on Equalisation of Opportunities for People with Disabilities promotes the education and training of persons with disabilities and pledges ‘to send children with disabilities to school’ and also to ‘make water and sanitation services and facilities more inclusive and accessible for disabled people’ (Malawi Government, 2006). However, the Disability Act (Malawi Government, 2012) does not make the institutional provision of inclusive WASH legally binding.

In 2013, Erhard et al. conducted an initial exploratory case study on WASH in schools in Malawi. Despite the policy provisions outlined, they found that WASH facilities were sub-standard nationally and that the needs of children with disabilities were being particularly overlooked. In 2013 there was no national tracking or assessment of disability friendly WASH facilities in schools and unfortunately this situation has not changed. This study is therefore designed as a follow up to the work of Erhard et al. (2013). It will explore whether Malawi has translated existing policy into practice and, if not, identify remaining barriers to inclusive WASH access in schools.

In this article ‘children with disabilities’ are defined as:

girls and boys with long-term physical, mental, intellectual or sensory impairments which, in interaction with various barriers, may hinder their full and effective participation in society on an equal basis with others. (Age and Disability Consortium, 2015)

2. Methods

2.1. Study site

This study was conducted in ten primary schools in Rumphi town, in northern Malawi, from January to July 2016. Rumphi town had a 2006 projected population of 22 594 (Rumphi District Assembly, 2009). Rumphi district has a literacy rate of 86%, higher than the national average (ibid.). Information about students with disabilities in the region is inconsistent. According to the Ministry of Education, as of 2015 Rumphi district had 1601 primary school children with special learning needs among 194 district-wide schools (Malawi Government, 2016). But in 2009 the district reported 214 persons (adults and children combined) with disabilities registered with the Social Welfare Department (Rumphi District Assembly, 2009). Within Rumphi town there are seven public and three private schools. The local government of Rumphi has taken some initial steps toward providing disability-inclusive household WASH (Jones et al., 2016). The seven public schools receive funding from the government for day-to-day operations, such as infrastructure and salaries, while the three private schools do not receive any financial or infrastructural support from the government. At a local government level, monitoring accessibility to education is based on a travel time to school of less than 3 km (Rumphi District Assembly, 2009).

2.2. Data collection

The study involved observations of WASH facilities at all ten primary schools in Rumphi town, and interviews with students with a disability, teachers and key stakeholders. Interviews and WASH facility observations at the schools were based on the World Health Organization’s 2009 WASH standards for schools in low-cost settings and focused on the availability of facilities sensitive to the needs of people with disabilities, taking note of distances, dimensions and visual observations of facility conditions and asking about management processes. Interviews were undertaken with formally trained special needs teachers. Where such a person did not exist, a senior member of the teaching staff was interviewed. These teachers then provided a list of all students with disabilities at their school. Purposive sampling was utilised to ensure that the sample was diverse in terms of age, impairment type and gender. Written consent was sought from the teachers of each of the students and assent was provided by each student. A maximum of four students per school were selected; however, one school did not have children with disabilities, in which case no student interviews could be conducted. District officials involved in the education system and the provision of WASH services were also interviewed.

Interviews were recorded, transcribed and anonymised. Observational data was recorded on a checklist and analysed descriptively. Data was coded by hand based on an a priori framework that disaggregated water, sanitation and hygiene barriers, ways of coping and awareness of technologies to improve accessibility.

Ethical approval for the project was obtained from the Republic of Malawi, National Commission for Science and Technology (Protocol No. P.11/15/65).

3. Results

A total of 23 students (12 male and 11 females, 6 to 18 years old) with visual, physical and/or cognitive impairments participated in the study as well as 11 teachers and 2 local government representatives.

3.1. Accessible water facilities

About half (11/23) of the students with disabilities described facing problems with accessing drinking water at their school. Two types of barrier were described by these students: (1) the pathways to/from the water source were uneven and (2) the design of the school hand-pump made it difficult for them to operate it. Students described three ways of coping with these barriers: (1) getting friends to help, (2) keeping quiet, and (3) tolerating the discomfort caused by the barriers.

3.1.1. Barriers

Field observations found that the quality of the water source infrastructure (piped water and/or hand-pumps) available at the primary schools was poor in general (Table 1). Two schools had no water sources available and the majority had hand-pumps only. Private schools had better quality facilities, with all three having piped water. Nearly half (4/10) of the water sources were located more than 30 m from classrooms, with some as far as 350 m away. None of the ten schools had an access ramp and in 70% of the surveyed schools the path to the water source was uneven (e.g. the ground was uneven or lined with stones). None of the schools had supporting rails leading to the water source, and four schools had steps leading to the water source. No school had water facilities in the shade (to help children with albinism). Among the schools with hand-pumps, the platforms ranged in size from 2–4 m², which is an insufficient turning radius for a wheelchair user to enter and turn around. The pumps were all Afridev hand-pumps (Figure 1a), which are common throughout Malawi. Piped water sources were not necessarily more accessible as some were placed too high (e.g. 1.2 m). Four schools had a pedestal near the water source that could be used as a seat.

Figure 1. Water and sanitation facilities in primary schools, Rumphi, Malawi: (a) Afridev hand-pump with uneven pathway and platform, (b) raised seat over the pit latrine squat hole made from local bricks, and (c) municipal piped water tap.

Table 1. Results of accessible water, sanitation and hygiene facilities in study schools.

Indicator	Public school % (n = 7)	Private school % (n = 3)
Sufficient toilets – one per 25 girls and one for female staff; one toilet plus one urinal (or 50 cm of urinal wall) per 50 boys, and one for male staff	14 (1)	0 (0)
Toilets are easily accessible to all, including staff and children with disabilities – no more than 30 m from all users, with male and female toilets separated	14 (1)	0 (0)
Toilets provide privacy and security – presence of walls and doors (not necessarily locking)	43 (3)	33 (1)
Toilets are appropriate to local cultural and social conditions, age and gender appropriate and accessible for children with disabilities or suffering from chronic diseases (i.e. toilets are child-friendly) – indication that toilets are able to be accessed by children with disabilities at the time of the site visit	29 (2)	0 (0)
Toilets are hygienic to use and easy to clean – no presence of flies, faeces, urine or wet floors	0 (0)	0 (0)
Toilets have convenient handwashing facilities close by – presence of water (not necessarily soap)	14 (1)	0 (0)
A cleaning and maintenance routine is in operation, ensuring that clean and functioning toilets are available at all times	100 (7)	100 (3)
Reliable water source at the school – indication of water available at the time of the site visit	71 (5)	100 (3)

Note: Checklist adapted from World Health Organization (2009).

Of the 23 children with disabilities, six (26%) described the terrain or pathways to the water points as the major barrier to accessing water:

Paths to the pump – I can’t see properly if there is too much sunlight and cloud cover. (Child with visual impairment)

The paths are not levelled and have stones which I can’t see properly. (Child with visual impairment)

Fewer children (4/23; 17%) also mentioned that the design of the water source made it difficult for them to use it:

It is difficult for me to operate the hand-pump handle. (Child with physical impairment)

3.1.2. Ways of coping

Children were asked how they dealt with these water access barriers. The most common response (6/13) was that they asked friends to help:

I ask my friend to help me and use paths which are comfortable for me to walk. (Child with physical impairment)

Other answers included keeping quiet or avoiding the need to access water:

I just stay quiet. (Child with physical impairment)

I bring water from home. (Child with visual impairment)

Other children explained that they had learned to just tolerate the challenges:

I cover my eyes with my hands when there is high intensity of light. (Child with visual impairment)

I jump [to the water point] though it’s painful. (Child with physical impairment)

3.2. Accessible sanitation facilities

In general, the quality of sanitation facilities available at the primary schools was poor (Table 1). Pit latrines were available at all schools. Distance from the classrooms to the pit latrines ranged from 2–114 m. The WHO (2009) standards state that facilities should be no more than 30 m from all classrooms. The average distance at public schools was 54 m, whereas the average distance at private schools was 12 m. Only one school (public) had a dedicated sanitation facility sensitive to the needs of people with disabilities, which included a door, a raised seat made from local bricks (Figure 1b) and a ramp. Some pit latrines had no door. None of the schools had drop-hole covers. All (3) of the private schools had concrete floors, whereas fewer (5/7) of the public schools had concrete floors. None of the schools had supporting rails leading to the pit latrine and 6/10 schools had steps at the entrance of the latrines. In all of the schools, the latrine door was less than 1 m wide – and thus not wide enough for a wheelchair user to enter – forcing the user to leave it outside and crawl to use the facility. The pit latrine drop-holes ranged from 0.2–0.3 m in diameter. In addition to the pit latrines, six schools had urinals; however, these were functional at only two schools. Others had deteriorating and blocked drainage systems but were nonetheless being used.

Only one school (public) had a handwashing facility near the toilet, but there was no soap present. None of the schools had toilet tissue on hand for anal cleansing or paper towels for hand-drying.

3.2.1. Barriers

More than half (13/23) of the school children with disabilities interviewed said they experienced problems when visiting the school sanitation facilities. Three types of barrier were described by these students: (1) issues with cleanliness of the sanitation facility infrastructure, (2) the pathways to the facilities were difficult to navigate, and (3) privacy. The primary way of coping with these barriers was to drink or eat less to reduce toilet use.

Wet and dirty floors were the most common challenge the children encountered. This was observed in 8/10 schools and reported by 5/23 of the children interviewed. One child who currently needs to place their hands on the ground in order to access the toilet explained:

My friends just piss everywhere, so it’s difficult for me to urinate and defecate. (Child with a physical impairment)

Similar to the issues reported when accessing water, students also said that the pathways to latrines made them difficult to access:

If there is high intensity of sunlight, I can’t see properly [to get to the latrine]. (Child with visual impairment)

Although not an issue that exclusively affects children with disabilities, the limited privacy provided at the sanitation facilities was raised as an issue:

There is no door so I become afraid that other people might see me. (Child with a visual impairment)

In this child’s case, the absence of a locking door was more unsettling than for the average student because they were unaware of whether other students were watching them.

3.2.2 Ways of coping

When asked about how they deal with the barriers to accessing sanitation facilities, many (10/23; 43%) children reported reducing their food and liquid intake to decrease their need to use latrines during the school day. Children reported they normally would not talk about the sanitation difficulties they faced. In contrast to the coping strategies used to overcome water access barriers, getting teachers or friends to help with access to sanitation facilities was not commonly reported.

3.3. Management of water and sanitation facilities sensitive to the needs of people with disabilities

At public schools, maintenance of facilities is the responsibility of School Management Committees, comprised of parents of the students who form a committee and choose representatives. In practice, this means that a roster of students is responsible for cleaning the sanitation facilities on a daily basis. In private schools, in contrast, maintenance is the responsibility of the school owners and performed by a hired cleaner not the students. Based on observations and comments from students with disabilities, utilisation of a hired cleaner tended to result in cleaner latrines, although beyond visual solid material, sanitising should be the target during cleaning.

In public schools, the parents pay MK500 (less than US$1) annually towards operation and maintenance of the school (for WASH facilities plus general school maintenance). This is a relatively substantial commitment given that the national minimum wage is MK18 000 per month (US$36/month). Apparently, the funds are insufficient or not a priority in the public schools.

3.4. Awareness of accessible infrastructure

Key stakeholders, teachers and children were interviewed about their awareness of accessible infrastructure. Key themes that emerged were: (1) students were unwilling to discuss WASH access issues, which meant these needs were overlooked by key stakeholders and teaching staff; (2) the potential to adapt existing facilities was overlooked, and (3) there was a lack of consultation with students with disabilities or special education teachers.

3.4.1. Unwillingness of students to discuss WASH access issues

While conducting interviews with students, the research team realised that students struggled to articulate the difficulties they faced. For some, this was borne out of a sense of embarrassment, while for others it was due to a normalisation of these challenges. For example, at one school, a girl with visual and physical impairments said she did not encounter problems when going to the hand-pump to collect water. However, the researcher observed that she faced substantial difficulties navigating the uneven path. Since this student probably collects water on a daily basis, what looks difficult to the researcher is now normal for the student. In the absence of students discussing these issues, teachers tended to assume that WASH access must not be a significant need among children with disabilities:

They are using WATSAN [water, sanitation and hygiene] services, e.g. toilets, taps, the same as their friends. There is no difference except for one girl who has cerebral palsy and one boy has short arms and can touch the ground when using these services and his friends help him since he can’t walk and they do escort him. (Teacher at a public school)

It’s [WASH access problems for children with a disability] not excessive. They walk with problems to the toilets and drinking water facility but they are able to walk by themselves. (Teacher at a public school)

3.4.2. Overlooking the potential to adapt existing facilities

Government stakeholders, teachers and students did not recognise the potential to adapt existing facilities and were unaware of potential low-cost technologies (Table 2). Teachers were primarily interested in building new inclusive infrastructure in their schools rather than considering how their existing infrastructure could be adapted to become more accessible. The two local government officials also referenced new infrastructure and the importance of community mobilisation around WASH and disability issues.

Table 2. Suggestions to promote accessible water, sanitation and hygiene facilities in schools.

Suggestions from local government (n = 2)	Suggestions from teachers (n = 11)	Suggestions from children with disabilities (n = 23)
Construct facilities on the initiative of community members Use school sanitation clubs to assist with daily care of facilities Encourage learning visits to other schools Use the district water office for technical support Train special education teachers in each school	Increase number of buckets with taps near or in classrooms Increase number of water sources Provide ramps Raise awareness of accessible pit latrine designs Provide a resource centre for children with disabilities inclusive of WASH and other topics Provide wheelchairs or gloves and glasses for children with disabilities Place water sources closer to classrooms Build new urinals Improve paths to pit latrines and water sources Train general teachers on accessible WASH facilities Ask the child’s parents what to do	Place hand-pump handle at a reachable height Place a cup for drinking at the water source Provide shade at water sources and sanitation facilities Use piped water rather than a hand-pump Clean sanitation facilities daily Ensure presence of doors at each sanitation facility Reduce step height at the facility entrance Place kneepads and hand walkers at the pit latrines for children with leg and arm impairments Build more pit latrines in relation to school population

3.4.3. Failing to consult students and teachers

The interviews with teachers revealed that making WASH facilities accessible for their students with disabilities was not a priority and that there had never been any proactive consultation with students on this topic. Rather than seeking the views of students, teachers thought that consultation with health care professionals, the students’ parents or school management would yield the best information about the students’ WASH needs:

If we were to enrol a child with a disability, we can just visit the hospital for them to help us with a wheelchair or any movement aid … If a child with a disability is enrolled and provided with a wheelchair by the hospital, we can just ask his or her parents about his or her problems. Or ask the owner of the school to decide on what he or she can do. (Teacher in a private school)

These quotes also suggest that teachers conceptualise disability relatively narrowly (i.e. that disability normally refers to a wheelchair user). Also, neither of the district representatives suggested asking children with disabilities about their needs.

However, the interviews with children with disabilities demonstrated the ability of these students to come up with practical solutions to the challenges they face. The most commonly requested solutions were: keeping facilities clean, adding doors for privacy, reducing the height of steps or replacing them with a ramp, replacing hand-pumps with piped water sources and moving the facilities closer to the classrooms.

Most public schools (6/7; 86%) had trained special education teachers, and one school had two. In the three private schools in our study, no special education teacher had received formal training. Within the Malawian education system, special education teachers are a resource for a wide range of learning supports. In some public schools, special education teachers had been trained in providing accessible WASH facilities. These teachers said that the local culture of respecting the workplace hierarchy often meant that they were unable to translate this expertise into action within their schools. One respondent said:

Since in the past people didn’t understand disability and WASH, therefore these things have just been introduced as few people know about these things. And we, special education teachers, report to the headmaster … but there is resistance from the headmaster since they thought we’re changing or disturbing things at the school and they said they will look into it. (Teacher in a public school)

Three of the ten teachers interviewed and one of the government representatives felt that teachers had an important role to play in supporting students to access WASH facilities. Yet students reported that they relied primarily on their peers.

3.5. Options to adapt existing facilities

An assessment was carried out to ascertain how much materials for adapting existing sanitation facilities would cost when sourced in the local market. Possible adaptions included using tree branches to mark the edges of pathways, making drop-hole covers, adding doors, building raised seats from earthen bricks and widening doorways.

Adapting existing sanitation facilities in schools in line with the WHO standards (calculations by the first author [HZ]), using local materials sourced from within the study area, was estimated to cost a minimum of MK28 000 (US$40) to a maximum of MK74 600 (US$107) (median MK54 000 [US$78]) (Table 3).

Table 3. Estimated cost to adapt existing sanitation facilities.

	Public school A	Public school B	Public school C	Public school D	Public school E	Public school F	Public school G	Private school A	Private school B	Private School C
Infrastructure	Cost in MK
Path marker	8821	1500	2500	2536	2981	6767	11375	717	2609	400
Ramp	4000	5000	0	7000	4000	3500	4000	0	5000	4000
Steps	5000	3000	0	0	3500	0	7000	3500	2500	6000
Entrance	2000	2000	5000	4500	12000	5000	10000	5000	4000	2500
Presence of a door	200	0	0	100	400	200	100	100	100	150
Door handles	1000	1000	4000	4000	4000	4000	4000	1000	4000	4000
Internal space	10 000	50 000	40 000	30 000	0	20 000	0	9000	35 000	40 000
Raised seat	1500	2000	2000	1500	1500	1500	1500	2000	1500	1500
Handrails for support	3000	3000	3000	3000	3000	3000	3000	3000	3000	3000
Handwashing station	3000	3000	3000	3000	3000	3000	3000	3000	3000	3000
Clear paths	4000	0	4000	3000	2000	0	4000	0	0	9000
Drop-hole cover	1000	1000	1000	1000	1000	2000	1000	1000	1000	1000
Total	43 521	71 500	64 500	59 636	37 381	48 767	48 975	28 317	61 709	74 550

The factor most commonly mentioned by children (4/23; 17%) regarding improving their access to water was replacing hand-pumps with piped water (Figure 1c); such a change would mean both an initial expensive investment and long-term operational costs for the school.

4. Discussion

In 2013 Erhard et al. documented that school sanitation facilities did not yet meet the needs of children with disabilities in Malawi, despite advances in policy and local guidelines. Five years on, the current research project finds that the situation has not changed substantially and access to water, sanitation and hygiene facilities remains an issue for these students.

Improving the inclusivity of WASH facilities in schools is challenging in low-resource settings where their availability and quality remain sub-optimal in general. However, this can also be viewed as an opportunity. Many of the technologies that would improve access for students with a disability would have benefits for all students (e.g. locking doors, clean cemented surfaces, improved pathways, handwashing facilities and access to piped water) and could easily be incorporated into the building of all new facilities. Findings from this research also indicate an array of ‘easy-wins’ that could be achieved by employing low-cost, locally made adaptions to make existing facilities more inclusive. Currently, none of the schools in the study area meet the WHO standards but it was found that it would be relatively affordable to improve them to such.

By garnering perspectives from students, teachers and government stakeholders, this research has identified four key barriers preventing policy from being translated into practice:

1. Policy changes have increased the number of special needs teachers available in public schools but such positions are not commonly being created at private schools, resulting in an expertise gap and a lack of accountability on the part of such schools in terms of providing inclusive infrastructure.

2. Special needs teachers have a wide mandate and receive only a limited amount of training on inclusive WASH facilities. These time and training limitations, coupled with the hierarchies inherent in the education system, dissuade teachers from attempting to bring about change in this area. Chitiyo et al. (2015) found that teacher training programmes in Malawi require at least one special education course/module. A recommendation emerging from this research would be to strengthen this component and to incorporate inclusive WASH training as part of the national teacher training curriculum so that all teachers are aware of potential barriers and solutions for learners with disabilities. Ideal curriculum topics include how to consult students with a disability regarding their needs and how to adapt existing school infrastructure using low-cost locally available resources. Teachers who do manage to make changes to facilities, with the limited resources available to them, should be recognised and provided with incentives, such as the opportunity to visit other schools and share their expertise.

3. Disability is still conceptualised narrowly in Malawi, with the medical model of disability prevailing in discourse and practice. This has resulted in the greatest resource for potential WASH solutions being overlooked and rarely consulted – the students with disabilities themselves. As a consequence, the burden of WASH access is underestimated and normalised by teachers and government stakeholders. Although this research focused on the availability of physical infrastructure, it has revealed that numerous social barriers also need to be overcome (e.g. addressing stigma and creating spaces and methods which enable open conversations about the WASH needs of all pupils).

4. The lack of national standards and monitoring on WASH infrastructure for schools may have added to a lack of decisive effort by school authorities regarding how to put policy into practice. Although this research found that the cost of improving facilities to the WHO standards was relatively small, in a resource-limited setting this is still substantial and there are no stipulations about who should bear this cost.

5. Study limitations

Many students did not respond to interview questions. This may have been a weakness of the methods (e.g. they need to be adapted to more effectively elicit responses from children). Alternatively, it may reflect the social norm whereby WASH access issues are normalised and thus children are not familar with being asked about such matters and are less able to articulate the barriers they face.

Though the number of schools included in this research was small, the study covered all primary schools in the town and through interviews with students, teachers and government stakeholders we were able to achieve a degree of saturation among their responses.

This research did not involve parents, yet family members are likely to have an important role to play in terms of championing the needs of their children and contributing to committees that may be central to realising change.

6. Conclusion

Although Malawi is the focus of this research, the situation described here is likely to be consistent across many low-resource settings. The value of a nation, like Malawi, enacting policies that state the rights of people with disabilities should not be underestimated. Yet this is rendered meaningless if these rights are not afforded in practice. This research found that over the last five years limited progress has been made on inclusive WASH access in schools. Our observations indicate that the WHO standards may be too ambitious for low- and middle-income countries to achieve right away. Instead, low-cost adaptions, such as those described by Jones and Wilbur (2014), may be a crucial short-term stepping stone to achieving long-term change. In the case of Malawi, both government and community-based action are required. The onus is on the government to take the following actions: put in place realistic national standards; train teachers and government officials on following such standards; monitor adherence to such standards; recognise individuals and schools that have been able to bring about change; and, ultimately, develop a funding strategy to help schools improve their facilities. This research highlighted the important role that community-based committees and structures should play in bringing about change and also identified that proactively consulting children with disabilities can generate a range of appropriate and affordable infrastructural improvements.

Acknowledgements

The authors appreciate the valuable feedback and technical editing provided by Dr Kip McGilliard, Dr Mary Grace Flaherty and Dr Leslie Glickman.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Rochelle H. Holm http://orcid.org/0000-0001-8849-1390