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March 08, 2007
The hygiene factor
It is important to understand the link between hygiene and sanitation for child survival and development. According to Unicef, children under five are most vulnerable to the effects of insufficient sanitation and hygiene, writes
Huma Khawar
The WHO/Unicef Joint Monitoring Programme which has reviewed progress between 1990 and 2004, shows that access to improved sanitation in South Asia has more than doubled from 17 per cent to 37 per cent. The current state of affairs, however, is that coverage is still among the lowest in the world as two out of three people in the region still lack basic sanitation.
Despite achievements and all-out efforts, more than 900 million people in the region do not have access to a toilet and represent one-third of the global population. South Asia has the highest rural-urban disparity in the world. Although the average urban coverage is twice as much as the rural one, due to rapid urbanisation the number of people without toilets in cities has increased from 139 million in 1990 to 153 million in 2004.
Like other South Asian nations, Pakistan also shares a joint commitment for achieving Millennium Development Goal 7, Target 10 –– to reduce by half the proportion of people without access to basic sanitation. Sanitation efforts contribute directly to five additional MDGs. It helps to reduce child and maternal mortality (MDG 4 and 5), and combating disease (MDG 6).
There are many challenges in achieving this target. Poor access to adequate sanitation resulting in the practice of widespread open defecation has negative health and social impacts on communities. One of the key reasons for lack of safe hygiene practices in Pakistan is the lack of awareness about, and understanding of, linkages between unsafe excreta disposal and its health impact leading to diarrhoea and other diseases. People want latrines for reasons of convenience, privacy and status, rather than sanitation and health.
It is important to understand the link between hygiene and sanitation for child survival and development. According to Unicef, children under five are most vulnerable to the effects of insufficient sanitation and hygiene.
“Every year, diarrhoea resulting from inadequate and unsafe water, poor sanitation, and lack of hygiene kills more than 1.5 million children under the age of five. It is closely linked to under-nutrition, a condition that is associated with more than half of under-five deaths and half of all of the malnourished children in the world, living in our region,” said Cecilia Lotse, Regional Director UNICEF South Asia, in her keynote address at the South Asian Conference on Sanitation held in Islamabad late last year.
Hygiene and basic sanitation are essential for the health and development of children. “If you do not provide these basic necessities, many other interventions will be undermined. So for Unicef, given this evidence base, the priority areas within the broader definition of sanitation, is safe excreta disposal and the promotion of improved hygiene behaviours, especially hand washing at household and school levels,” Lotse further emphasised. New research indicates that hand washing with soap may also have a significant effect on the reduction of Acute Respiratory Infections (ARI). Preliminary findings from a study in Karachi indicate that the reduction may be as high as 40 per cent.
Hand washing with soap at critical times (before cooking, eating food and after defecation) can decrease diarrhoea by over 47 per cent. Such improvements can save children’s lives. ARI and diarrhoea are the two leading killers of children worldwide. Thus, hand washing with soap is by far the most cost-effective intervention for the reduction of child mortality.
Across South Asia, considerable public funds have been deployed in the sanitation sector ––– predominantly targeted towards the government subsidies for toilet construction. However, in spite of the significant public resources deployed in the sector, the results are poor ––– with less than 40 per cent of the population of South Asia having access to safe sanitation and an extremely low percentage of villages that are safe from the menace of ‘open defecation’.
With the promulgation of LGO-2001 on August 14, 2001, the responsibility for the delivery of sanitation has been decentralised to the tehsil tier of the local government. While the provision of water is the top agenda item for many teshil governments, sanitation is often a low priority.
This is reflected in the poor coverage figures of sanitation (as compared to water supply), with an estimated 54 per cent of the population having access to sanitary latrines (86 per cent urban and 30 per cent rural). This data on the low access to sanitary latrines disguises even lower usage of latrines in Pakistan ––– especially in the rural areas.
The second South Asian Conference on Sanitation (SACOSAN-2) hosted by Pakistan last year, brought water and sanitation on top of the country’s development agenda. “The Ministry of Environment is taking concrete measures for promotion of improved hygiene behaviours and implementation of various water and sanitation projects in line with Millennium Development Goals and Islamabad Declaration of the second South Asian Conference on Sanitation,” said Sami-ul Khilji, Additional Secretary, Ministry of Environment.
The Ministry, he said, is currently developing a comprehensive strategy and an action plan for implementation of the National Sanitation Policy which was approved by the federal cabinet in October 2006. The sanitation week is being observed to accelerate our progress on water and sanitation in line with the objective of the National Sanitation Policy.
A joint event is being organised by the Ministry of Environment, Unicef and the Local Government. The week is being observed in 13 districts of the country from March 5-10, 2007. “The major objective of the week,” according to Khilji, “is to create awareness on three key issues: Practicing hand washing with soap, promoting open defecation-free areas in communities by building and using household latrines and using safe water.”
During the sanitation week, TMA and the city governments, DCO, district and tehsil nazims and civil society groups (NGOs and CBOs), academia and journalists will help in raising awareness at the local level by making public aware of the complex issues and need for institutionalising new mechanisms and instruments.
Across South Asia, supply driven, infrastructure focused sanitation programmes have delivered poor sanitary results. New approaches to sanitation have been introduced in India, Bangladesh and Pakistan. These community-led, demand-driven and outcome oriented approaches have not only successfully overcome the problem of low demand for sanitation, they have also delivered significant changes in collective behaviour thus resulting in improved health for all.
Community-Led Total Sanitation (CLTS) is based on igniting a collective sense of disgust and shame among community members as they realise the consequences of open defecation and its negative impacts on the entire community. The basic assumption is that no human being can stay unmoved once he has learned that he is ingesting faeces. Generally, communities react strongly and instantly try to find ways to change this through their own effort.
The CLTS approach was first pioneered in 1999 by Kamal Kar working with the Village Education Resource Centre (VERC) in a small community of Rajshahi district in Bangladesh. Since then the approach has continued to spread within Bangladesh and has been introduced in a number of Asian and African countries.
“CLTS involves no subsidy as it only induces an attitude of external expectation and dependence. Neither does it prescribe latrine models. Rather, it encourages the initiative and capacity of the community. The aim is to ignite and encourage a self-motivated desire to change behaviour,” explains Kar.
“You can often start discussion with a few community members during an informal walk through the village,” he further elaborates. “The aim is to motivate people to carry out a more substantial sanitation analysis involving the whole community.” There are many different ways of initiating a discussion on open defecation and village sanitation.
The most important element of CLTS, according to Kamal Kar, is not the knowledge of health hazards but the element of disgust, shame and the sense of un-cleanliness and impurity. It is this feeling that compels the people to shift from haphazard open defecation to fixed-point defecation in a covered pit that stops the routes of contamination.
Gaining popularity in many jurisdictions across South Asia, CLTS was first started in Pakistan, in the last quarter of 2004 in tehsil Takht Bhai. The strategies and approaches are still foreign to the majority of the key stakeholders in the country. Integrated Regional Support Programme (IRSP), an NGO, was implementing a Unicef funded water and environmental sanitation focusing on latrine construction in Mardan, earlier.
While implementing the project Shah Nasir, IRSP’s executive director, happened to attend a workshop on water and sanitation organised by WSP-SA, in Bhurban in which Kamal Kar presented a new idea of CLTS focusing on behavioural changes in which the people take measures to stop open defecation.
“The idea was picked by the Unicef, and shared with us. In close liaison with TMA Takht Bhai, IRSP changed its strategy to CLTS and started mobilising people not to defecate in the open. Open defecation was stopped and people not only constructed latrines but also started using them.
IRSP successfully involved different stakeholders such as the department of health, education, union councils, religious leaders, trade unions, sanitary shop owners and built their capacity in sanitation promotion.
The campaign started in 10 villages of five union councils in 2004 and became successful in declaring five communities as Open Defecation Free (ODF). In 2005, another six communities were declared ODF and the programme was extended to other union councils.
Up till now 23 locations in eight union councils have been declared 100 per cent ODF, while in the rest of the 37 locations the progress varies from 30 per cent to 90 per cent. In these villages IRSP convened mass awareness campaigns to sensitise the community and mobilise them. The local people, after sensitisation, constructed their household latrines costing 500–600 rupees using local resources.
To promote safe sanitation, TMA gave rewards as incentives for the ODF community such as hand pumps. Now, TMA Takht Bhai, with the active support of the Tehsil Nazim, in its budget for CLTS has earmarked Rs0.2 millions as a reward for the community.—H.K.
• Provincial Strategies to be developed defining the legislative & regulatory framework
• The goal of creating an ‘open defecation free’ environment
• Sector domain for sanitation includes solid waste and liquid waste
• That service provision responsibility should lie with the tehsil / City District Local Government
• The adoption of rewards for improved sanitary outcomes.—H.K.
• No open defecation or open latrine use.
• Effective hand washing after defecation and before eating/taking or handling food.
• Covering of food and water.
• Good personal hygiene practices, such as brushing teeth and trimming nails.
• Latrines are well-managed.
• Slippers are worn when defecating.
• Clean courtyards and roadsides.
• Garbage is disposed off in a fixed place, such as a pit.
• Safe water use for all domestic purposes.
• Water points are well-managed.
• Waste water is disposed off down drains or in a fixed place. No spitting in public places.— H.K.
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