Evaluation of Sustainable Water, Sanitation and Hygiene Systems in Primary Schools in the eThekwini District of South Africa

Water, sanitation, and hygiene (WASH) services are essential for learner health and equitable education. Persistent gaps in WASH infrastructure and hygiene provision remain a major challenge in low- and middle-income countries. We assessed WASH interventions, learner knowledge and perceptions, and implementation challenges and opportunities in five selected primary schools in eThekwini District, South Africa. We conducted a cross-sectional study among Grade 7 learners using a structured questionnaire adapted from the World Health Organization (WHO) Surveillance of WASH in Schools Tool, complemented by observational checklists. Stratified random sampling yielded 129 participants (76 girls and 53 boys), with a 72% response rate. Quantitative data were analysed using Chi-square, Fisher’s exact, and Kruskal–Wallis tests, as appropriate. Although drinking water access was generally reliable, significant gaps were observed in sanitation privacy, soap and toilet paper availability, cleanliness, and menstrual hygiene facilities. Female learners consistently reported poorer conditions than males (p < 0.05). The Hygiene Access Index differed significantly across gender and age groups (p < 0.05), reflecting inequitable provision of hygiene materials. Despite educational initiatives, substantial shortcomings persist in school WASH systems, particularly regarding sanitation privacy, hygiene supplies, and menstrual hygiene management, with potential implications for learner health, educational participation, gender equity, and school attendance. Sustaining gender-responsive WASH systems is essential for improving learner health and promoting equitable educational environments. Sustainable WASH systems refer to the consistent availability, functionality, maintenance, and equitable use of WASH infrastructure and services over time, supported by institutional capacity and behavioural adherence. These findings highlight the need for implementation-focused and systems-oriented approaches to strengthen sustainable WASH service delivery in resource-constrained school settings.