Study on the quality of water, sanitation and hygiene practices in the schools of Moldova

SUMMARY REPORT
STUDY ON THE QUALITY OF WATER,
SANITATIONAND HYGIENE PRACTICES
IN THE SCHOOLS OF MOLDOVA
The Government of Republic of Moldova

2
SUMMARY
Summary.........................................................................................................................................2
I. Introduction ..................................................................................................................................3
1.1. Study goal................................................................................................................................3
1.2. Study objectives.......................................................................................................................3
II. Methods and materials ...............................................................................................................4
III. Evaluation of schools’ drinking water supply conditions ............................................................5
IV. Evaluation of quality parameters of drinking water in pre-university institutions and level of
students’ exposure to health risks ..................................................................................................7
V. Students’ access to hygiene conditions in schools .....................................................................15
VI. Students’ hygiene practices ......................................................................................................19
Conclusions.....................................................................................................................................22
Recommendations .........................................................................................................................24
Annex. List of the most disadvantaged pre-university institutions in terms of drinking water
quality and conditions of the available drinking water supply and sanitation systems....................26
Authors:
A group of specialists from the National Centre of Public Health, coordinated by Ion Şalaru,
Prime Vicedirector
With the contribution of:
Ghenadie Ţurcanu, Health Policies Programme Coordinator, PAS Centre
Svetlana Stefaneţ, Chief of Programme EquitableAccess to Quality Services, UNICEF
Liudmila Lefter, Education Officer, UNICEF

3
I. INTRODUCTION
The Republic of Moldova, like other Member States of the World Health Organisa-
tion (WHO) in the European Region, has committed to prevent and significantly de-
crease the morbidity and mortality due to gastrointestinal diseases and other health
disorders by ensuring adequate conditions for improving all children’s access to
both safe drinking water at affordable prices and adequate hygiene conditions1
.
Although Moldova has not developed specific actions to ensure children’s univer-
sal access to clean and healthy water so far, the Government has approved policy
documents2
to address the improvement of access of the whole population to bet-
ter water supply and sewerage systems and ensure the control over the quality of
drinking water. This has to some extent led to the improvement of drinking water
distribution systems in pre-university institutions. Children stay at school most of the
day, therefore the quality of dinking water and hygiene conditions in schools have a
direct impact on the formation of children’s health.
To assess the situation of children’s access to water for human consumption and im-
proved hygiene conditions in schools, UNICEF has supported the Ministry of Health,
Ministry of Education and the National Public Health Centre to conduct an expert
Study on Drinking Water Quality and Hygiene Conditions in Pre-university Institu-
tions in the Republic of Moldova.
This document summarises the results of an analytical evaluation of drinking water
quality and hygiene conditions in pre-university institutions, ways of supplying drink-
ing water in schools, as well as students’ hygiene practices.
Study goal:
Assess students’ access to drinking water sources and hygiene conditions in pre-
university institutions in the Republic of Moldova.
Study objectives:
♦ Assess the conditions of drinking water supply in schools.
♦ Survey the quality of drinking water in schools and assess the level of stu-
dents’ exposure to health risks3
.
♦ Estimate students’ access to adequate hygiene conditions in schools.
♦ Assess student’s hygiene practices.
♦ Identify solutions for improving all children’s access to clean water and ad-
equate hygiene conditions in pre-university institutions.
1 The Forth Ministerial Conference on Environment and Health “The Children’s Environment and Health Action Plan for Europe”,
Budapest, Hungary, 23-25 June 2004.
2 Government Decision 487 of 19 June 2001 on approval of the National Plan of Action for Environmental Health; Government
Decision 662 of 13 June 2007 on approval of the Strategy on Water Supply Systems and Sewerage in Settlements of the Republic of
Moldova, and the Government Decision 934 of 15 August 2007 on setting up the Automated Information System “State Register of
Bottled Natural Mineral Water, Drinking Water and Soft Drinks.”
3 Health risk means the likelihood of being exposed to a hazard caused by natural, anthropogenic, biological or social factor and its
consequences as harmful effect on health, and the severity of such effect (Article 2, Law 10 of 3 February 2009 on State Public Health
Surveillance).

4
II. METHODS AND MATERIALS
The study was conducted in all the pre-university institutions (1,526 schools, gym-
nasiums and lyceums4
) of the Republic of Moldova, including residential ones5
.
During the Study, water samples were collected, water supply and sanitation sys-
tems were assessed in each pre-university institution, and interviews with students
in 82 schools were conducted to assess hygiene practices. The sample of inter-
viewed students (4,817 students, of which 57.3% girls and 42.7% boys) was repre-
sentative and covered all the administrative-territorial units countrywide, interviews
being held in one lyceum in each urban and rural area.
Evaluation of drinking water supply and hygiene conditions in schools comprised
the following components: description of the school’s drinking water supply system;
outline of the school’s sanitation system; and evaluation of risk of contamination of
school’s water sources.
Water quality survey was done according to the WHO recommendations6
, which
provide 8 parameters that are more relevant for children’s health, including 7 chemi-
cal parameters: nitrates, nitrites, fluoride, boron, arsenic, pesticides, cyanides and
one microbiologic parameter – microbial pollution (Escherichia coli and Enterococi).
Drinking water quality was checked according to the Sanitation Norms on Drinking
Water Quality7
. The level of students’ exposure to health risks due to consumption
of drinking water depending on its non-conformity in terms of microbiological and
chemical parameters was also estimated according to the WHO recommendations8
.
4 Statistical Yearbook of the Republic of Moldova, 2009, Chisinau 2009, National Bureau of Statistics.
5 Ministry of Health Directive 266/d of 24 April 2009 “On implementing the Study on Drinking Water Quality in School Institutions”.
6 Guidelines for Drinking-water Quality. Third Edition. Volume 1. Recommendations. WHO. Geneva, 2004.
7 Approved through Government Decision 934 of 15 August 2007 on setting up the Automated Information System “State Register
of Bottled Natural Mineral Water, Drinking Water and Soft Drinks.”
8 Guidelines for Drinking-water Quality. Third Edition. Volume 1. Recommendations. WHO. Geneva, 2004

5
III. EVALUATION OF SCHOOLS’
DRINKING WATER SUPPLY
CONDITIONS
In Moldova, children have free access to water supplied for human consumption
in all (100%) pre-university institutions. In terms of drinking water source, over two
thirds of schools use water supply systems and one third use wells9
, springs or wa-
ter transported in water-tanks (Figure 1). Only schools in rural areas use well water,
spring water or water transported in tanks for drinking purposes, for the reason that
about one third of them lack water supply systems.
Figure 1. Distribution of pre-university institutions in urban and rural areas
in terms of type of drinking water source
Half of administrative-territorial units have water supply systems in less than in
60% of schools (Table 1). It means that 2 of 10 students have access only to well
water.
9 Taking into account the UN definition of improved water sources and the current negative well maintenance practices in the
Republic of Moldova, along with the density of constructions, the non-observance of well’s sanitary protection zones, the latter can be
qualified as unprotected sources, have a continuous risk of water microbial contamination.
Share of institutions using transported water
Share of institutions using well water
Share of institutions using water from water supply system
Urban
100 %
90 %
80 %
70 %
60 %
50 %
40 %
30 %
20 %
10 %
Rural Total RM
2,1 3,4
94,5
3,4 2,9
34,4
28
62,2
69,1

6
Table 1. Presentation of administrative-territorial units in terms of share of
schools with water supply systems
Provision of water supply systems
80-100% 60-80% 40-60% 20-40% 0-20%
Chisinau mun.
Balti mun.
Basarabeasca
Anenii Noi
Cahul
Calarasi
Cimislia
Criuleni
Dubasari
ATU Gagauzia
Telenesti
Orhei
Glodeni
Falesti
Causeni
Drochia
Stefan Voda
Taraclia
Ocnita
Floresti
Ialoveni
Briceni
Straseni
Singerei
Soroca
Riscani
Nisporeni
Hincesti
Cantemir
Rezina
Edinet
Donduseni
Leova
Ungheni
Soldanesti
Sanitary protection zone10
of water sources, 80% of which are located in rural ar-
eas, is not observed in one in five schools. Half of schools use unauthorised water
sources for drinking purposes. One in twelve schools has interruptions in water
supply of 4 up to 24 hours a day. Rural schools have even longer water supply inter-
ruptions. Water supply is interrupted 2.7 times more often in the Southern Zone’s
pre-university institutions compared to the situation in the country as a whole, and
6.3 times more frequently than in the Central Zone’ schools (Figure 2), which sup-
posedly have a higher risk of microbial pollution of drinking water.
Figure 2. Pre-university institutions by geographical zones in terms of water
supply interruptions
10 The term “sanitary protection zone” delimits the area around a water source where any activity that exposes water to external
factors favouring so its contamination is prohibited.
25
20
15
10
5
0
North Centre South Total per country
6,3
8,4
3,6
22,5

7
IV. EVALUATION OF QUALITY
PARAMETERS OF DRINKING WATER
IN PRE-UNIVERSITY INSTITUTIONS
AND LEVEL OF STUDENTS’
EXPOSURE TO HEALTH RISKS
Almost one in six drinking water samples collected in pre-university institutions do not
meet the sanitation norms in terms of chemical and microbiological parameters (Table
2). The highest proportion of non-conformity with norms was registered in terms of ni-
trites - one in three non-compliant samples, followed by microbial pollution for which
almost one in four samples did not meet the standards. Concentrations of fluoride and
boron were non-compliant in one in eight and one in fifteen water samples, respectively.
Table 2. Structure of laboratory parameters that were non-compliant with the
standards for drinking water quality in schools
No. Parameter Investigated sample Non-compliant Level of non-conformity,
%
1. Microbial pollution 1,672 395 23.6
2. Nitrates 1,597 505 31.6
3. Nitrites 1,597 31 1.9
4. Fluoride 1,577 210 13.3
5. Boron 504 33 6.5
Total 6,947 1,174 16.9
Schools using mainly well water have as a rule (with some exceptions) the highest
non-conformity level in terms of microbiological parameters (Figure 3).
Figure 3. Proportion of microbial pollution in wells supplying water
for pre-university institutions from various administrative-territorial units
100 %
90 %
80 %
70 %
60 %
50 %
40 %
30 %
20 %
10 %
Microbial pollution, %
Share of well-water users, %

8
Non-compliant drinking water samples by microbiological parameters were regis-
tered in 26% of schools, which host 17% of the total number of students in the coun-
try, from 3411
administrative-territorial units (Figure 4). Therefore almost one in six
students in the country is exposed to health risk of getting acute diarrheal illnesses
as a result of microbe-polluted water consumption. Moreover, water contaminated
by microbes raises the likelihood of epidemics outburst through transmissible hydric
diseases.
Figure 4. Share of students exposed to microbial contamination compared
to the proportion of non-compliant samples by administrative-territorial units
11 In accordance with the Law 764 of 27 December 2001 on Administrative-Territorial Organisation of the Republic of Moldova, the
Right Bank of Nistru River comprises 32 districts, 2 municipalities and the ATU Gagauzia with its 3 districts.
PROPORTION OF MICROBE-POLLUTED WATER
SAMPLES AND NUMBER OF EXPOSED STUDENTS

9
Of note is that, in 2009, the structure of morbidity related to acute diarrheal diseases
considered by age groups shows a share of 75.6% of children aged 0-17, the share
of children aged 0-2 years constituting 69.5%12
. For this reason, the aforementioned
indicators cannot be used to consider the impact of microbial pollution of drinking
water in schools on students’ health.
Data on disease incidence and prevalence in children 7-17 years of age in each
administrative-territorial unit are missing; this fact has not allowed estimating the im-
pact on students’ health condition based on the results of evaluation of water quality
in schools. However we can refer to some national data13
that show an increase in
the incidence of infectious and parasite diseases by 33% in children 15-17 years of
age in 200714
if compared to 2004.
More children (about 21% out of the total number of students) are exposed to health
risks due to consumption of nitrate polluted water. Water samples analysis has re-
vealed that the water is nitrate polluted in 33% of schools in all administrative-ter-
ritorial units, except for Basarabeasca district (Figure 5). Thus almost one in five
students in the country is exposed to the risk of methemoglobinemia and delayed
physical development. Methemoglobinemia15
reduces blood capacity to transport
oxygen due to low haemoglobin level. Symptoms of methemoglobinemia include
skin cyanosis (“blue baby syndrome” – peribuccal cyanosis, cyanosis of hands and
feet), tiredness, dizziness, vomiting and diarrhoea.
Water pollution with nitrates is more frequently registered in schools that use well
water; therefore students in those schools are exposed to a higher health risk.
Like in the case of microbial pollution of drinking water, we could not identify an
eventual connection between the non-compliant water samples in terms of nitrates
and the health indicators for students in those schools during this Study due to
the lack of data on health of children 7-17 years of age by disease categories and
administrative-territorial units. A connection between the high proportion of nitrate-
polluted water samples taken in schools and the share of students identified with
physical retardation during the medical check-ups, which is 2-3 times higher than
the average in the country, was noticed only in two administrative-territorial units
(Ungheni and Rezina districts).16
12 National Public Health Centre “Sanitary-hygiene and Epidemiological Situation in the Republic of Moldova”, 2010
13 Healthcare in the Republic of Moldova, National Bureau of Statistics of the Republic of Moldova, Chisinau, 2008
14 The most recent public data.
15 Source: http://www.who.int/water_sanitation_health/diseases/methaemoglob/en/
16 Public Health in Moldova 2009, National Health Management Centre, Chisinau, 2010.

10
Figure 5. Proportion of students exposed to nitrates compared to the share
of non-compliant samples by administrative-territorial units

In terms of fluoride content, water samples are non-compliant in about 17% of
schools, which host 13.5% of the total number of students, from over two thirds of
administrative-territorial units (Figure 6). Thus, almost one in seven students in the
country is exposed to the risk of developing dental caries and fluorosis, a disease
affecting teeth and bones. It was demonstrated that the fluoride insufficiency in the
body may develop dental caries, and excessive ingestion of it can cause fluorosis.
Clinical dental fluorosis is characterized by staining and pitting of the teeth. Chronic

11
high-level exposure to fluoride can lead to skeletal fluorosis, the main symptoms of
which include stiffness and pain in the joints.17
.
Figure 6. Proportion of students exposed to excessive fluoride in drinking
water compared to the share of non-compliant samples detected in different
administrative-territorial units
The highest concentrations of fluoride were detected in schools from Parlita, Negureni
and Agronomovca villages in Ungheni district – 16.5 mg/l; in Ustia and Dusmani vil-
lages, Glodeni district – 5.3mg/l, in Sipoteni village, Calarasi district – 5.3mg/l, Baurci vil-
17 Source: http://www.who.int/water_sanitation_health/diseases/fluorosis/en/

12
lage – 8.4mg/l and Tomai village from ATU Gagauzia – 5,3mg/l, in Sarata Veche village
– 8.8mg/l, in Risipeni village and in the Falesti railway station, Falesti district – 9-11 mg/l,
which means that the use of those sources for drinking purposes must be prohibited.
A connection between the high proportion of non-compliant water samples in terms of
fluoride content and the proportion of osteoarticular system, muscles, and conjunctive
tissue diseases in children 7-17 years of age, which is 1.4 times higher than the average
in the country, was revealed only in Ungheni and Ciadir-Lunga districts.18
One in 40 students (2.4%) is exposed to health risks due to consumption of non-compli-
ant water in terms of boron content19
. Non-conformity of water samples in terms of boron
content was identified in about one third of administrative-territorial units (Figure 7). Al-
though there are no studies that could show the impact of consumption of non-compliant
drinking water in terms of boron content, the surveys conducted suggest its harmfulness
for heart, blood vessels, liver, reproductive organs and foetus development20
.
Higher boron concentrations were detected in the drinking water in Glodeni and Falesti
districts - between 1 and 1.5 mg-l, and UTA Gagauzia (Ciadir-Lunga district) - up to 3
mg/l. The area of distribution of boron covers the Southern Zone - UTA Gagauzia, Ta-
raclia and Cahul districts, the Northern Zone - Falesti, Singerei and Edinet districts and
the Central Zone - Straseni and Hincesti districts. There is a need for special studies
to estimate the health condition of students exposed to higher boron-related risks com-
pared to that of children from administrative-territorial units where water samples are
non-compliant by all chemical elements. It could be interesting to survey the connec-
tion between the highest proportion of non-compliant water samples in terms of boron
content and the level of chronic hepatitis and hepatic cirrhoses prevalence (1,148.8 per
100,000 inhabitants in 2009) in children 0-17 years of age, which is five times above the
average in the country, registered in Ciadir-Lunga district from ATU Gagauzia.21
In addi-
tion, this district has registered the highest morbidity level in the country (about 3 times
above the average in the country) in terms of congenital malformations, deformations
and chromosomal abnormalities in children 0-17 years of age.22
Fluoride and boron presence in water depends mostly on morpho-geological features of
rocks separating aquiferous layers and are detected especially in underground waters
where the impact of anthropogenic activity is almost non-existent23
. The non-conformity
in terms of fluoride and boron content, which is usually established in schools using
water from water supply system and only in some well-defined geographical zones,
confirm this situation. Consequently, to protect students’ health against the negative ef-
fects of high fluoride and boron concentration, specific water cleaning procedures are
needed, since those are stable and undesirable chemical elements, and their concen-
tration does not change during water distribution from the source to consumer or as a
result of water disinfection. Therefore they cannot be eliminated by means of existing
classical methods of treatment�
.
19 Exposure to large amounts of boron (about 30 g of boric acid) over short periods of time can affect the stomach, intestines, liver,
kidneys, and brain and can eventually lead to death. Source: http://www.atsdr.cdc.gov/tfacts26.pdf
20 Source: http://www.atsdr.cdc.gov/ToxProfiles/tp26.pdf
22 Idem
23 Source: National Public Health Centre.

13
Figure 7. Proportion of students exposed to boron compared to the share of non-
compliant water samples detected in different administrative-territorial units
Of note is that students’ health is not exposed to arsenic, pesticides, and cyanides-
related risks nationally, since no deviation was registered in terms of the respec-
tive chemical parameters after water samples from pre-university institutions were
checked.
Depending on the proportion of students exposed to risk factors determined by mi-
crobial, nitrate, fluoride and boron pollution of water for human consumption,

14
28 %
33 %
17 %
22 %
over two thirds of administrative-territorial units are classified as having a mod-
erate to major health risk�
(Table 4).
Table 4. Distribution of administrative-territorial units depending on stu-
dents’ exposure to risk factors determined by drinking water quality
1st Category –
Insignificant risk
2nd Category –
Minor risk
3rd Category –
Moderate risk
4th Category –
Major risk
5th Category -
Catastrophic risk
Chisinau mun.
Basarabeasca
Dubasari
Drochia
Cahul
Leova
Briceni
Anenii Noi
Orhei
Cimislia
Balti mun.
Glodeni
Singerei
Hincesti
Telenesti
Rezina
Ocnita
Riscani
Floresti
Causeni
Nisporeni
Calarasi
Straseni
Cantemir
Soldanesti
Edinet
Donduseni
Ungheni
Soroca
Atu Gagauzia
(Ciadir-Lunga)
Criuleni
Ialoveni
Stefan Voda
Taraclia
Falesti
The computations have revealed that one in four students is exposed to a major
health risk due to consumption of drinking water at school, one in three students
to a moderate risk, one in six to a minim and one in five to an insignificant risk, re-
spectively (Figure 8). Consequently, 61% of students are exposed to a moderate
to major risk conditioned by the quality of drinking water in schools in the Republic
of Moldova.
Figure 8. Students’ distribution in terms of level of exposure to risk factors
Insignificant risk
Minor risk
Moderate risk
Major risk

15
V. STUDENTS’ACCESS TO HYGIENE
CONDITIONS IN SCHOOLS
Students’ access to hygiene conditions according to the most important components
of the sanitation system - wash basins, soap, single use towels, hand dryers and
WCs - is lower for children in pre-university institutions from rural areas (Figure 9).
Figure 9. Proportion of pre-university institutions from urban and rural areas
lacking basic hygiene conditions
Availability of wash basins was registered in 98.4% of schools, however in 15.2%
of them they were in an unsatisfactory condition. Of note is that students in rural
schools more often lack conditions for hand washing at school than those in urban
schools. Therefore, 232 pre-university institutions lack conditions for hand washing
for the reason that taps are missing or sinks are damaged.
The availability of water basins could not be assessed in terms of their location in
relationship with WCs and access during the school breaks. This would be an objec-
tive for a separate special study. However the fact that water basins are located in
the school does not help students observe the basic hygiene rules of washing hands
before eating and after using the WC, since only 74.8% of schools have taps in can-
teen and only 24.4% in WC (Figure 10). Therefore there is a danger that students
do not manage to wash their hands after using the WC and before eating, being
exposed to the risk of getting diseases spread24
by dirty hands.
24 Infectious and parasite diseases like: Viral Hepatitis A, Bacterial Dysentery, Colitis, Gastroenteritis, Ascaridosis, Enterobiosis, Hyme-
nolepidosis, etc.
100 %
90 %
80 %
70 %
60 %
50 %
40 %
30 %
20 %
10 %
0,3
Proportion of institutions lacking wash basins
Proportion of institutions with unsatisfactory sanitary-technical condition of wash basins
Proportion of institutions lacking soap
Proportion of institutions lacking towels
Proportion of institutions lacking hand dryers
Urban Rural Total RM
2 1,63,7
19,2
15,2
11,8
29,2
24,6
42
56,3
52,3
75,9
88,2
84,6

16
Figure 10. Proportion of pre-university institutions
in terms of water basins’ location
Students’ access to adequate hygiene conditions is inappropriate also due to lack of
liquid or solid soap, since it is missing in one forth of pre-university institutions. The
most disadvantaged are students in schools from Calarasi, Basarabeasca, Cimislia
and Leova districts where soap is lacking in half of schools.
Two thirds of schools in the country at the end of school year 2008/2009 had no
hand dryers. 70% of pre-university institutions in general lack all three facilities:
soap, towels and dryers. In this regard the most disadvantaged are students in
schools from Basarabeasca and Donduseni districts. About 70% of schools in one
third of administrative-territorial units lack two of the three hygiene facilities.
95% of rural schools have only outside WCs on the cesspool. Thus a great majority
of children in rural schools (55% in the total of students in the country) lack inside
WCs (Figure 11.).
74,8
18,8
36,9
24,4
in canteen
in WC
in corridor
in other places

17
Figure 11. Proportion of pre-university institutions in urban and
rural areas where WCs are in an unsatisfactory sanitary-technical
condition and lack toilet paper
24.3% of schools have WCs in an unsatisfactory sanitary-technical condition. Thus
two in ten children use WCs non-compliant with sanitation norms, which poses the
risk of acute diarrheal and parasite diseases. The situation is alarming especially in
terms of toilet paper supply, which lacks in two thirds of WCs in urban schools and
almost in all WCs in rural schools. In outside WCs on the cesspool water basins are
almost non-existing.
100 %
90 %
80 %
70 %
60 %
50 %
40 %
30 %
20 %
10 %
Institutions with WCs in an unsatisfactory sanitary-technical condition
Institutions lacking toilet paper in WCs
Urban Rural Total RM
18,1 26,7 24,3
72,4 95,5 75,9

18
Figure 12. Proportion of schools with outside WCs on the cesspool

19
VI. STUDENTS’ HYGIENE PRACTICES
The lack of opportunities for hand washing at school was confirmed by about 14.1%
of interviewed students from the Southern, 9.2% - Northern and 8.3% - Central
Zones. The assessment of hygiene conditions shows that 15.2% of schools have
water basins in an unsatisfactory condition. The proportion of children who men-
tioned the lack of conditions for hand washing in schools is higher in rural areas
(11.6%) compared to urban ones areas (8.6%), which shows once again that chil-
dren do not enjoy universal access to adequate hygiene conditions in schools.
87% of students wash their hands before eating at home and only 25.9% at school,
with an about equal proportion by areas, sex, geographic zones (Figure 12). Conse-
quently, it proves again that pre-university institutions lack conditions for adequate
hygiene and educating students on hygiene culture.
Figure 13. Proportion of children in urban and rural areas who wash their
hands before eating at school and at home
Only 22.7% of children have taps at home in rural areas, while in urban areas the
proportion of access to these hygiene utilities is 64.5%, which decreases the op-
portunity of children in villages for developing and observing the necessary hygiene
practices.
Nevertheless, 69% of boys and 65% of girls, respectively, in rural areas mentioned
they wash their face and hands compared to 58% of boys and 56% of girls, respec-
tively, in the same groups in urban area. All this happens while the latter enjoy better
sanitation conditions at home. Therefore, children in urban areas have more oppor-
tunities of taking a shower in the morning (girls – 27.4%; boys – 23.7%), compared
to children in rural areas (girls – 16.1%; boys – 13.1%).
100 %
90 %
80 %
70 %
60 %
50 %
40 %
30 %
20 %
10 %
Urban
Rural
before eating, at home before eating, at school
87,4
26,6
84,6
25,2

20
69% of interviewed students brush their teeth in the morning and evening, and 22%
reported they brush their teeth only in the morning, the latter do not observe the
mouth hygiene. Perhaps this state of affairs together with the consumption of drink-
ing water non-compliant in terms of fluoride content defines the high proportion
(35.3% nationally, in 2009) of children who were identified by the medical check-up
as being in need of dental cavity treatment 25
.
Only in 27% of interviewed students mentioned they use WCs provided with water
for hand washing. 15.6% of students in rural areas reported they have access to
WCs provided with water for hand washing, compared to 39%, which is as much as
twice, of children in urban areas. Despite this discrepancy, the provision of adequate
hygiene conditions is below the standard in all pre-university institutions in the coun-
try, both in rural and urban areas.
The evaluation of the level of students’ satisfaction with hygiene conditions shows
that 52% of respondents are not satisfied with school WCs’ condition. 79 - 94% of
children say it is first of all due to the fact that WCs are never provided with toilet
paper. This was reported upon the results of the assessment of hygiene condi-
tions in schools, which showed that 24.3% of schools have WCs with unsatisfactory
sanitary-technical condition.
All the aforementioned pinpoints insufficient measures for providing adequate hy-
giene conditions in pre-university institutions and inadequate conditions of sanita-
tion systems in schools, which is a real danger for children’s health, especially in
relation to the risk of getting infectious and parasite diseases. The situation is wor-
risome, if we take into consideration the fact that the morbidity of infectious and
parasite diseases in children 0-17 years of age increased by 21.6% in 2008 (71,800
children) compared to 2004 (56,300 children).26
25 Public Health in Moldova, National Health Management Centre, Chisinau, 2010.
26 Statistical Yearbook of the Republic of Moldova, 2009, Chisinau 2009, National Bureau of Statistics.

21
Figure 14. The degree of combined risk for child health due to non-compliant
quality of drinking water for the content of boron, fluoride, nitrates, microbe-
pollution and inadequate sanitation

22
CONCLUSIONS
In spite of the expectations, pre-university institutions in the Republic of
Moldova do not ensure universal access for children to safe drinking water
in adequate hygiene conditions, a finding which mostly concerns children in
rural schools.
Those who are more frequently exposed to the risk of illnesses due to con-
sumption of unclean water and poor hygiene conditions in schools are stu-
dents in rural schools. Drinking water is supplied from unprotected and exposed
to the risk of contamination sources in one third of pre-university institutions. Sani-
tary protection zone of the water sources, of which 80% are located in rural areas,
is not observed in one in five schools in the country.
Measures for ensuring disinfection and cleaning of water for human con-
sumption in Moldovan pre-university institutions are insufficient, since 61%
of students are exposed to a moderate to major health risk conditioned by
microbial pollution and excess of nitrate, fluoride and boron in drinking water.
In Moldova, 2 out of 10 students drink only well water at school. Otherwise,
specifically the rural schools, which use well water, have registered the highest
level of non-conformity of drinking water quality in terms of microbial and nitrate
pollution. Therefore, students in rural schools are more often exposed to the risk
of acute diarrheal illnesses and nitrates contamination.
Pre-university institutions experiencing interruptions in water supply sys-
tems face a high risk of microbial pollution of drinking water. And again most
affected by interruptions in water supply are students in rural schools, especially
in the Southern Zone of the country, where this phenomenon occurs more often.
In Moldova almost one in four students is exposed to a major risk and one in
three students to a moderate risk of consuming water that is non-compliant
with the sanitation norms. In total, 20.8% of students drink water oversaturated
with nitrates, 17% - microbe-polluted water, 13.5% - water non-compliant in terms
of fluoride and, to a smaller extent, 2.4% - water in excess of boron.
Insufficient measures for improving access for all children both to safe
water and adequate hygiene conditions in schools are among the causes
preventing the decrease in child morbidity due to infections and parasites.
Moreover, these diseases are spreading among children 15-17 years of age and
increased by 33% in 200727
compared to 200428
. There is also a connection be-
tween the highest proportion of water samples non-compliant in terms of boron
content (Ciadir-Lunga district in ATU Gagauzia) and the prevalence of chronic
hepatitis, hepatic cirrhoses, which is five times above the average per country,
as well as the level of congenital malformations, deformations and chromosomal
27 The most recent public data
28 Health care in the Republic of Moldova, National Bureau of Statistics of the Republic of Moldova, Chisinau, 2008

23
abnormalities, which is three times above the average, in children 0-17 years of
age in 200929
.
Students’ access to water basins, soap, hand dryers and single use hand
towels as well as improved conditions in school WCs is low. The location of
water basins in schools does not help students observe the basic hygiene rules
of washing hands before eating and after using WCs, since only 74.8% of schools
have water basins in canteens and only 24.4% in WCs. In addition, the sanitary-
technical conditions of 24% of WCs in pre-university institutions are awful, which
affects one fifth of the total number of students in the county. Over 55% of students
in rural schools have access only to outside WCs on the cesspool, since this is the
only type of WCs in 95% of rural schools.
Unsatisfactory hygiene conditions in schools pose a risk for students’ health
also due to the fact that they do not help building and further strengthening
children’s hygiene skills, since the condition of the occupational environment,
where the child stays, plays an important part in the development of hygiene prac-
tice.
Children in rural areas have less opportunities of developing and observing
the needed hygiene practice, as they do not have access to taps at home
and at school, which makes them being disadvantaged compared to children
who live in urban areas and who have more opportunities for developing and ob-
serving the basic hygiene practices. According to the Study findings, only 26% of
interviewed students wash their hands before eating at school compared to 87%
who wash their hands at home. A large number of children (52% of interviewees)
are unsatisfied with this situation. Rural schools have the worst conditions, where
only 15.6% of students reported they have access to WCs provided with water for
hand washing.
The results of the Study have clearly highlighted the fact that the conditions
of sanitation systems are much below the standard in most pre-university
institutions in the Republic of Moldova, which does not allow ensuring the uni-
versal access for students to adequate hygiene conditions and building and apply-
ing the hygiene practices.
29 Public Health in Moldova, National Health Management Centre, Chisinau, 2010.

24
RECOMMENDATIONS
Define and approve a new Plan of Actions for Environmental Health in the Re-
public of Moldova, which would include the priorities of Children’s Environment
and Health Action Plan for Europe, adopted by the Forth Ministerial Conference
on Environment and Health held in June 2004 in Budapest, and the Declaration
of the Fifth Ministerial Conference on Environment and Health held in March
2010 in Parma under the motto “Protecting Children’s Health in a Changing En-
vironment”.
Identify among the actions of the Strategy on Water Supply Systems and Sew-
erage in Settlements of the Republic of Moldova or, if needed, supplementing it
with specific measures for developing rural schools’ infrastructure, which would
focus on deferred regions and ensure that all students have access to improved
water supply systems and adequate hygiene conditions.
Promote/Include as a priority the most deferred settlements in terms of quality of
drinking water, water supply factors and students’ access to hygiene conditions
in projects on water supply and sewerage system’s infrastructure modernisation,
supported by international development partners (about 100 schools presented
in Annex).
Ensure the disinfection and cleanness of human consumption water by imple-
menting adequate water treatment technologies to change water properties be-
fore distribution in order to decrease or avoid the risk of water non-conformity
with the value parameters when supplied. Such systems shall be applied prima-
rily in schools that are connected to water supply systems with non-compliant
drinking water quality (over 500 schools were identified during the Study).
Raise the responsibility of education institutions’ managers and specialized cen-
tral and local public administration authorities, which have education institutions
in their subordination, for ensuring children’s access to adequate hygiene condi-
tions in schools, first of all through setting up and modernising sanitation sys-
tems in all pre-university institutions in the country.
Based on regular controls on quality of drinking water in schools, the State Pub-
lic Health Surveillance Service’s institutions should inform the pre-university
institutions’ administration, specialized central and local public administration
authorities, students and parents on the results of water quality controls and
provide counselling on any measure for possible improvements which they will
be required to implement.
Inform and raise students’ and teachers’ awareness on issues related to drinking
water protection and its impact on health, and promote positive hygiene prac-
tices among students.

25
Place the Study results and information on conformity (non-conformity) of water
supplied to students with the Sanitation Norms on Drinking Water Quality30
, as
well as the negative impact of non-compliant water on health, in a visible place
in each pre-university institution in the country.
The State Public Health Surveillance Service’s institutions shall expand and di-
versify measures for adequate and updated consumer’s information on quality of
water for human consumption, also by placing the results of controls on drinking
water from checked water sources on the web-pages of the State Public Health
Surveillance Service’s institutions.
30 Approved through Government Decision 934 of 15 August 2007 on setting up the Automated Information System “State Register
of Bottled Natural Mineral Water, Drinking Water and Soft Drinks.”

26
ANNEX
List of the most disadvantaged pre-university institutions in terms
of drinking water quality and conditions of the available drinking
water supply and sanitation systems
n/o
Institution Quality of drinking
water supplied in
school
Conditions of
school’s drinking
water supply sys-
tems
Conditions of
school’s sanitation
systems
Compli-
ant
Non-
compliant
Adequate Ina-
dequate
Adequate Ina-
dequate
1 Secondary school no. 65, Condrita village, Chisinau mun. X X X
2 Gymnasium, Telita village, Anenii Noi district X X X
3 Gymnasium, Maximovca village, Anenii Noi district X X X
4 Secondary school, Delacau village, Anenii Noi district X X X
5 Theoretical Lyceum, Abaclia village, Basarabeasca district X X X
6 Theoretical Lyceum, Drepcauti village, Briceni district X X X
7 Gymnasium, Balcauti village, Briceni district X X X
8
Secondary school "Nicolae Neculce", Baurci-Moldoveni village,
Cahul district X X X
9
Gymnasium “Mihai Sadoveanu”, Andrusul de Sus village,
Cahul district X X X
10 Gymnasium “Mircea cel Batrin”, Trifesti village, Cahul district X X X
11 Secondary school, Vadul lui Isac village, Cahul district X X X
12 Gymnasium, Capaclia village, Cantemir district X X X
13 Scoala primara, Ghioltosu village, Cantemir district X X X
14 Theoretical Lyceum, Baimaclia village, Cantemir district X X X
15 Theoretical Lyceum, Dereneu village, Calarasi district X X X
16 Gymnasium, Bahmut village, Calarasi district X X X
17 Gymnasium, Hoginesti village, Calarasi district X X X
18 Gymnasium, Baimaclia village, Causeni district X X X
19 Gymnasium, Ursoaia village, Causeni district X X X
20 Gymnasium, Florica village, Causeni district X X X
21 Gymnasium, Cenac village, Cimislia district X X X
22 Gymnasium, Sagaidac village, Cimislia district X X X
23 Theoretical Lyceum, Batir village, Cimislia district X X X
24 Gymnasium, Pohrebea village, Dubasari district X X X
25 Gymnasium, Pascani village, Criuleni district X X X
26 Theoretical Lyceum, Cimiseni village, Criuleni district X X X
27 Secondary school, Hirtopul-Mare village, Criuleni district X X X
28 Gymnasium, Codrenii Noi village, Donduseni district X X X
29 Gymnasium, Pivniceni village, Donduseni district X X X
30 Gymnasium, Donduseni town, Donduseni district X X X
31 Secondary school, Nicoreni village, Drochia district X X X
32 Gymnasium, Macareuca village, Drochia district X X X
33 Gymnasium, Volodeni village, Edinet district X X X
34 Theoretical Lyceum, Brinzeni village, Edinet district X X X
35 Gymnasium, Burnulanesti village, Edinet district X X X
36 Secondary school, Ruseni village, Edinet district X X X
37 Gymnasium, Calugar commune, Falesti district X X X
38 Theoretical Lyceum, Risipeni village, Falesti district X X X
39 Gymnasium, Burghelea, Falesti district X X X
40 Gymnasium, Nicolaevca village, Floresti district X X X
41 Theoretical Lyceum, Sanatauca village, Floresti district X X X
42 Gymnasium, Sevirova village, Floresti district X X X
43 Gymnasium, Fundurii Noi village, Glodeni district X X X

27
44 Gymnasium, Viisoara village, Glodeni district X X X
45 Secondary school, Iabloana village, Glodeni district X X X
46 Gymnasium, Obileni, Hincesti district X X X
47 Theoretical Lyceum, Mingir village, Hincesti district X X X
48 Gymnasium, Dancu village, Hincesti district X X X
49 Gymnasium, Cataleni village, Hincesti district X X X
50 Gymnasium, Sarata-Mereseni village, Hincesti district X X X
51 Gymnasium, Hansca village, Ialoveni district X X X
52 Gymnasium, Vasieni village, Ialoveni district X X X
53 Gymnasium, Pojareni village, Ialoveni district X X X
54 Gymnasium, Carbuna village, Ialoveni district X X X
55 Gymnasium Tochile - Raducani, Leova district X X X
56 Secondary school, Tomai village, Leova district X X X
57 Gymnasium, Covurnului village, Leova district X X X
58 Gymnasium, Hanasenii Noi village, Leova district X X X
59 Gymnasium, Valea-Traisteni village, Nisporeni district X X X
60 Theoretical Lyceum, Seliste village, Nisporeni district X X X
61 Theoretical Lyceum, Varzaresti village, Nisporeni district X X X
62 Gymnasium, Paladea village, Ocnita district X X X
63 Gymnasium, Naslavcea village, Ocnita district X X X
64 Theoretical Lyceum, Biesti village, Orhei district X X X
65 Gymnasium, Discova village, Orhei district X X X
66 Gymnasium, Gordinesti village, Rezina district X X X
67 Theoretical Lyceum, Echimauti village, Rezina district X X X
68 Gymnasium, Horodiste village, Riscani district X X X
69 Gymnasium, Pociumbeni village, Riscani district X X X
70 Gymnasium, Sturzeni village, Riscani district X X X
71 Gymnasium, Tiplesti village, Singerei district X X X
72 Secondary school, Draganesti village, Singerei district X X X
73 Theoretical Lyceum, Radoaia village, Singerei district X X X
74 Gymnasium, Darcauti village, Soroca district X X X
75 Theoretical Lyceum, Vasilcau village, Soroca district X X X
76 Secondary school, Septelici village, Soroca district X X X
77 Gymnasium, Dubna village, Soroca district X X X
78 Secondary school, Panasesti village, Straseni district X X X
79 Gymnasium, Draguseni village, Straseni district X X X
80 Gymnasium, Chirianca village, Straseni district X X X
81 Gymnasium, Fuzauca village, Soldanesti district X X X
82 Theoretical Lyceum, Vadul-Rascov village, Soldanesti district X X X
83 Gymnasium, Poiana village, Soldanesti district X X X
84 Theoretical Lyceum, Ermoclia village, Stefan Voda district X X X
85 Secondary school, Purcari village, Stefan Voda district X X X
86 Theoretical Lyceum, Caplani village, Stefan Voda district X X X
87 Gymnasium Hirtop village, Taraclia district X X X
88 Theoretical Lyceum, Albota de Jos village, Taraclia district X X X
89 Gymnasium, Bogzesti village, Telenesti district X X X
90 Gymnasium, Cucioaia village, Telenesti district X X X
91 Gymnasium, Codru Nou village, Telenesti district X X X
92 Gymnasium, Boghenii Noi village, Ungheni district X X X
93 Gymnasium, Napadeni village, Ungheni district X X X
94 Gymnasium, Untesti village, Ungheni district X X X
95 Gymnasium, Negurenii Vechi village, Ungheni district X X X
96 Theoretical Lyceum, Russcaia-Chiselia village, Comrat district X X X
97 Theoretical Lyceum, Besalma village, Comrat district X X X
98 Secondary school, Cazaclia village, Cadir Lunga district X X X
99 Gymnasium, Gaidar village, Cadir Lunga district X X X
100 Gymnasium, Cismichioi village, Vulcanesti district X X X
101 Primary school, Carbalia village, Vulcanesti district X X X

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