Water, Sanitation and Hygiene
© UNICEF Pakistan
South Asia has made considerable progress over the last 22 years. The proportion of people using improved sanitation has increased by 19 percentage points from 1990 to 2012 (compared to 15 points for the world as a whole). The proportion of people who practice open defecation has dropped by 28 percentage points over the same period, a faster rate of reduction than in any other region. 422 million more people use improved sanitation than 22 years ago. The proportion of schools with adequate sanitation has increased by 23 percentage points from 2008 to 2013, a faster rate than in any other region.
However, substantial challenges remain. A much smaller proportion of people in South Asia use improved sanitation than in the rest of the world. The region is not on track for reaching the MDG sanitation target 65 per cent of the world’s open defecators live in South Asia. The pace of sanitation improvements has not kept up to population growth in India, Nepal, Pakistan and the region taken as a whole: there were 93 million more people without access in the region in 2012 than in 1990. Richer households and urban dwellers are much more likely to use improved sanitation than poorer and rural households. Hand-washing rates are lower in rural areas and among poor households in some countries.
Diarrhoea, caused by poor sanitation and hygiene practices and unsafe drinking water, remains a major cause of child malnutrition, disease and death in many parts of the region.79 Nearly half of India’s underfive children are stunted (too short for their age), with poor sanitation being a major underlying cause. Open defecation also puts the health and safety of women and girls at risk. While the proportion of people practising open defecation is declining, the region is not on track to meet the MDG target for sanitation.
Since 1990, the proportion of people practising open defecation in South Asia has fallen from 68 percent to 41 percent. But the number of people not using a toilet is still huge: it is estimated that there are still 681 million open defecators in the region (there were 771 million in 2000).81 More than a third of the schools in the region do not have toilets, and South Asia sustains significant economic losses due to poor sanitation.
The primary challenge to reducing open defecation is that it is socially accepted behaviour in much of the region. Many consider toilets to be unclean, and some actively prefer to defecate in the open. Perhaps
not surprisingly, the cleaning of toilets in public buildings – including schools and health centres – is often neglected. Compounding this cultural acceptance of open defecation is an acute shortage of
capacity to implement community sanitation programmes. Although promoting sanitation and hygiene might logically fall under the remit of government frontline workers – Auxiliary Nurse-Midwifes, Accredited Social Health Activists, Anganwadi Workers, Female Community Health Workers and the like – their core work priorities mostly prevent them from taking a substantial role.
Despite these twin problems of culture and capacity, there have been some notable successes. In Bangladesh, open defecation in rural areas fell from 23 percent in 2000 to 3 percent in 2012. Nepal has succeeded in eliminating open defecation in 15 of its 75 districts and in more than 1,600 of its village development committees. Governments in South Asia are committed to address sanitation, with open defecation as a priority, and national targets have been set.
The cultural climate may be changing too – a recent survey in Bihar found that there is wide demand for toilets, even in rural areas where almost everyone practises open defecation: 84 percent of households surveyed said they would like a toilet, and 38 percent of these households actually looked into toilet options. But it is interesting to note that the important connection with health has not yet been absorbed: people mentioned convenience, privacy, and the safety of women and children – rather than the prevention of diarrhoeal disease – as the main reasons for wanting a toilet.
India accounts for about 90 percent of the open defecators in the region.87 States with the most rural open defecators are Uttar Pradesh (129 million), Bihar (80 million), Maharashtra (53 million), Madhya Pradesh (52 million), Rajasthan (45 million), West Bengal (38 million) and Odisha (33 million).88 Afghanistan, Bangladesh, Nepal and Pakistan have much smaller numbers of people without toilets, mostly in rural areas. In India, Nepal and Pakistan, few of the poorest rural households have a toilet.
There is a 44 percentage-point difference between the open defecation rates in rural and urban areas in the region as a whole, but there are large in-country disparities, as shown in the graph below. The highest disparity is in India (53 percentage points), although this fell between 1990 and 2011. In 1990, one in four urban residents had no toilet, compared with eight in 10 rural residents. By 2011 there were more toilets, and the difference between urban and rural settings had narrowed slightly – only one in 10 urban residents lacked a toilet, compared with one in two rural residents.
Household wealth is also signifi cant – the poorest households have far less access to improved sanitation than richer households in many South Asian countries. Open defecation rates too are higher for poorer households.
Economic inequalities do not necessarily improve over time. In Nepal, for example, open defecation rates have not fallen evenly across all levels of household wealth: between 2006 and 2011, the poorest households have seen the least improvement.
INNOVATIONS AND IMPACT
INDIA: Nirmal Bharat Abhiyan (Clean India Campaign) and Take the Poo to the Loo campaign
The Government of India has a fully funded national flagship rural sanitation programme, Nirmal Bharat Abhiyan (Clean India Campaign). This programme, which started in 2012, is working to bring sanitation to all rural areas over the decade to 2022 and get rid of open defecation. It is hoped that this transformation of rural India will be achieved via community-led and people-centred strategies that stress the total sanitation approach. Although the programme as a whole has yet to gain momentum, some states (such as Maharashtra, inspired by the work of the social reformer Sant Gadge Maharaj) have achieved considerable progress. Sikkim and Kerala are mostly open defecation-free and Himachal Pradesh is making rapid progress through innovative community mobilization. India’s new Prime Minister has publicly spoken about the importance of addressing sanitation. The private sector is also showing great corporate social responsibility towards sanitation and hygiene.
The Take the Poo to the Loo campaign, supported by UNICEF, is a digitally-led, interactive campaign to create awareness of open defecation, with a focus on young urban dwellers. The aim is to create a sense that open defecation is not acceptable, and that everyone can and should use a toilet. As of June 2014, more than 115,000 people have signed a pledge calling on the President of India to rise to the challenge of making India free of open defecation.
PAKISTAN: Pakistan Approach to Total Sanitation
The Pakistan Approach to Total Sanitation (PATS) initiative was conceived as the country recovered from the devastating floods of 2010. PATS aims to get rid of open defecation through concerted action based on creating demand for toilets through education and raising awareness. Communities and schools lead the activities, which include ‘selling’ the idea of sanitation and promoting handwashing with soap – as a result, there is rising household demand for the supplies and services needed to build toilets. PATS was at first implemented by non-governmental partners with UNICEF funding, but the approach is now being adopted by some provincial governments. The approach has evolved considerably since its inception in 2010, and is now used by all sanitation-sector agencies in Pakistan. By April 2014, PATS had resulted in more than 4,200 communities with a population of more than five million becoming free of open defecation.
NEPAL: A social movement for sanitation
A major diarrhoea outbreak in 2009 triggered a concerted effort – the Aligning for Action to Make Diarrhoea Epidemics History initiative – to tackle sanitation and hygiene. Starting in early 2010, it is a coordinated programme between UNICEF, regional and district government structures, and a range of other stakeholders. To provide a framework for collaborative efforts at all levels, government and partners have developed a comprehensive Sanitation and Hygiene Master Plan. This Cabinet-approved Plan, which is owned by seven line Ministries and the National Planning Commission, was launched by the President of Nepal in 2011.
Partners agreed the programme would operate at several levels – from grassroots to regional – and would involve all the relevant sectors – health, education, water, youth groups, women’s groups, political parties, media and the private sector. The movement seeks to trigger action at all levels, using a range of tools and techniques. Communication channels are many and various – faceto- face interactions, community events, religious institutions, school curriculum, mass media and advocacy. The main emphasis is on changing behaviour by using an adapted version of Community Approaches to Total Sanitation.
The programme is focused on the most disadvantaged communities throughout the country. So far, Nepal has succeeded in eliminating open defecation in 15 of its 75 districts and in more than 1,600 village development committees, as well as 18 municipalities and more than 3,300 school catchment areas.
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