sanitation in Pakistan

Sanitation refers to public health conditions related to clean drinking water and adequate treatment and
disposal of human excreta and sewage. Preventing human contact with feces is part of sanitation, as is
hand washing with soap.

Pakistan is among the top 10 countries in the world that lack access to clean water. The nonprofit
organization WaterAid conducted a study revealing that 21 million people out of the country’s total
population lack access to clean water. Out of Pakistan’s total population, 79.2 percent of the rural poor
have access to clean water. On the other hand, 98 percent of Pakistan’s rich have access to clean water. 

Most urban and rural water is supplied from groundwater, with over 50% of village households
accessing drinking water from hand-pumps (Lerebours, 2017, p. 31). In saline groundwater areas,
irrigation canals are the main source of municipal water
The lack of proper toilet facilities is a part of 41 million people’s lives in Pakistan. According to The United
Nations International Emergency Children’s Fund (UNICEF), the lack of toilets leaves people with no choice but
to practice open defecation, which can lead to the spread of diseases among communities. Pakistan is the third-
largest country where people practice open defecation. UNICEF is working with the government to help build toilet
facilities for communities that need them to ultimately improve sanitation in Pakistan. These facilities are especially
important for girls to protect them against assault, which happens often during open defecation.

Only two cities in Pakistan — Islamabad and Karachi — have biological waste facilities. These facilities clean
only about 8 percent of wastewater due to limited functioning, even with the already limited number of facilities to
filter wastewater. Industrial waste also pollutes water in Pakistan. Out of 6,000 of the country’s registered
businesses, 1,228 have “highly polluted” water sources. Government officials are working towards improving water
treatment centers. Pakistan established the National Water Policy (NWP) to ensure that the country applies 10
percent of national funding to the development and repair of water infrastructure.

Disparities exist between rural and urban access to safe drinking water. There are also differences
between provinces. For example, in Khyber Pakhtunkhwa (KP) 35% of people use tap water as their
main source of drinking water, compared to 18% in the Punjab (Junaid, 2016).

Across Pakistan, there has been a shift from tap water to motorised pumping, largely due to the
unreliability of government provision leading to households turning to self-provision (Junaid, 2016;
World Bank, 2018). Poorer districts are more likely to rely on hand-pumps than better off districts
(World Bank, 2018). The combination of hand-pumps and pit latrines increases the risk of water
contamination due to seepage of human excreta into the water source (World Bank, 2018).

According to the National Drinking Water Policy (NDWP) of 2009, Pakistan's goal is to provide universal
access to drinking water in an equitable, efficient and sustainable manner by 2025.

Pakistan achieved the 2015 Millennium Development Goal for sanitation, reducing by half the
proportion of people without sustainable access to basic sanitation: this included increasing rural access
to sanitation to 67% from 23% in 1991 (World Bank, 2018b) However, this success masks disparities
between rural and urban areas (World Bank, 2018b)

The World Bank (2018b) and Junaid (2016) state that 21% of people in rural areas practise open
defecation. Ending open defecation involves not only providing facilities but also changing community
behaviour (Junaid, 2016). Flush toilets connected to septic are the dominant access modality for rural
households in KP and the Punjab that have access to improved facilities (World Bank, 2018).

The rural-urban gap also includes access to solid waste management services: an estimated 57% of
households in urban areas and 6% in rural areas have access to a solid waste collection (Junaid, 2016).
Closing the rural-urban gap remains a challenge (World Bank, 2018b).

The World Bank (2018) argues that virtually no investment has been made in the management of faecal
sludge or wastewater. 42% of households in rural Punjab and 60% in rural KP has no drains (World Bank,
2018). Where drains exist, they are commonly open drains with no treatment of effluents, leading to
water and soil contamination (World Bank, 2018). Only 10% of households in rural Punjab and 1% of
households in rural KP has access to covered or underground drains connected to their toilets (World
Bank, 2018). In urbans areas of KP and the Punjab, 4.1% and 59% respectively, have access to toilets
connected to sewer systems: in urban KP households mainly rely on flush toilets connected to septic
tanks (World Bank, 2018). The connection of toilets to drainage systems is a key indicator of their safety
(World Bank, 2018).

In addition to a rural-urban disparity, there are also wealth differentials in terms of access to sanitation:
13% of the poorest have access to improved sanitation compared to 80% amongst. the richest (Junaid,
2016). Differences also exist between the provinces. In 2014-15, Punjab had the highest percentage of
households reporting no toilet out of all the provinces at 16%, whilst in KP 12% reported no toilet
(Junaid, 2016)

The Government’s Pakistan Vision 2025 commits to increasing the proportion of the population with
access to improved sanitation to 90%, halving the incidence of diarrhoea, and halving the food insecure
population (World Bank, 2017).

Pakistan Approach to Total Sanitation

Following the 2010/11 floods, the Government of Pakistan developed the Pakistan Approach to Total
Sanitation (PATS) as a country specific strategy to scale up sanitation programmes, particularly in rural
areas to end open defecation (UNICEF, 2015). PATS endorses several models including community-led
total sanitation, school-led total sanitation, component sharing, sanitation marketing and disaster
response (Edouard-Tiberghien, 2016). It is backed by strong political will and increasing budget
allocations (Edouard-Tiberghien, 2016). In 2014, the Government of Punjab began implementing PATS in
6% of villages across all districts (World Bank, 2017). The provincial government has allocated Pakistani
Rupees (PKR) 400 million (USD 2.97 million) for sanitation (UNICEF, 2015).

PATS involves participatory community facilitation and mobilisation where communities selfanalyse
their sanitation status; awareness raising communications to inculcate hygienic behaviours; and
communities constructing their own latrines at the household level (World Bank, 2017).

School-led total sanitation involves children as change agents, who are able to shift perceptions and
habits at the household and community level; teacher-student WASH clubs that impart hygiene
communication messages at scale; and, training programmes for teachers (EdouardTiberghien, 2016).
Edouard-Tiberghien (2016) argues that school WASH interventions can help mitigate the risk of relapse
into open defecation as students can stimulate new hygiene habits in households and represent the
generation that will move communities from open defecation free (ODF) status towards improved
sanitation. UNICEF (2015) argue that closing equity gaps in sanitation remains a challenge: the majority
of Pakistan’s 25 million open defecators live in poor rural households or insecure informal settlements,
making them the most difficult to reach. To maintain the gains already made and continue progress,
UNICEF (2015) states that increased investment is needed to reach the unreached and sustain the social
norm of no open defecation to ensure gains are sustainable. In UNICEF-funded programmes across
Pakistan, extremely vulnerable families, identified by the communities themselves, are issued sanitation
vouchers to purchase latrine construction materials (UNICEF, 2015). These latrines then act as
‘demonstration’ latrines for the community show-casing acceptable standards and design (UNICEF,
2015). In 2016, UNICEF developed PATS-Plus, a new enhanced programme to combat the risk of relapse
into open defecation (UNICEF, 2016).

Effects of poor sanitation

Poor sanitation is linked to transmission of diseases such as cholera, diarrhoea, dysentery,

hepatitis A, typhoid and polio and exacerbates stunting. Poor sanitation reduces human
well-being, social and economic development due to impacts such as anxiety, risk of sexual
assault, and lost educational opportunities.

Pakistan has made significant progress in improving access to

sanitation yet 25 million people still practice open defecation. Lack of
access to proper sanitation facilities impacts negatively the health and
wellbeing of children.

53,000 Pakistani children under five die annually from

diarrhoea due to poor water and sanitation.
Children suffering from repeated episodes of diarrhoea are likely to fall
behind in school or drop out altogether. Furthermore, it can also cause
stunting that currently affects almost 44 percent of children in Pakistan.

Pakistan’s vulnerability to disasters including earthquakes, floods,

droughts, and internal displacement due to conflict, often leaves
hundreds of thousands of affected people in need of emergency water
and sanitation support. Sustainable access to water, sanitation and
hygiene in health centres and schools also remains a challenge
especially for girls who lack adequate facilities to manage their
menstruation. The effects of climate change and rapid urbanisation also
contribute to challenges of improving access to safe water and
sanitation.
An estimated 70 percent of households still drink
bacterially contaminated water.

The economic impact of inadequate sanitation has been estimated at 344 billion Rupees (US$5.7
billion), equivalent to almost 4 percent of GDP. 87% of the impact is on health, 5% on increased
costs of water supply and 8% are other impacts. The main health impacts are premature mortality
and productivity losses, followed by treatment costs. Water supply costs include higher costs for the
supply of piped water, higher expenses for bottled water and the cost of household water treatment.
Other costs include the cost of increased time for open defecation and the use of shared toilets, and
a relatively small cost of lost tourism revenues. Many intangible costs were not included in the
estimate, such as the lack of privacy, security, status and dignity. The cost of environmental
conditions stemming from poor sanitation was also not included in the estimate
Stunted growth due to unsanitary conditions affects 38 percent of children in Pakistan. The United Nations
International Children’s Emergency Fund (UNICEF) found that unsanitary conditions like drinking and bathing in
unsanitary water stunt growth. In the state of Sindh, stunted growth affects 50 percent of children, which can also
cause cognitive development stunting. The consequences of stunting are irreversible, causing lifelong implications
for the child into adulthood. Working with these communities, the United States Agency for International
Development (USAID) has begun a stunting reduction program to work with families to provide children with clean
water and facilities to fight against poor sanitation in Pakistan.

The misuse of pesticides in Pakistan’s agricultural fields results in an annual death rate of 10,000 people per
year from agrochemical poisoning. Around 500,000 people fall ill annually as a result, although most are fortunate
to recover. When people do not properly use pesticides, they can persist through rain and flooding, eventually
entering water sources. People drink these water sources, in turn causing illness. Training is crucial for agricultural
workers to properly prevent water contamination.

Pakistan’s women and young girls often stay at home rather than partaking in normal activities, due to a lack
of menstruation supplies and proper facilities. According to the United Nations International Children’s
Emergency Fund (UNICEF), 75 percent of women stay at home during menstruation. Due to a lack of resources and
cleaning facilities, many girls have no choice but to use unsanitary methods for managing menstruation, such as
homemade sanitary pads. Further, these methods are prone to cause vaginal infections as a result of reuse. 

Solution

Ending open defecation

To end open defecation, communities must accept using toilets as regular habit in their lives. To
eliminate open defecation by 2025, UNICEF and partners support the government to implement
Pakistan’s Approach to Total Sanitation (PATS) in the country.
Seventy-nine million people in Pakistan do not have access to a proper toilet. According to WaterAid.org,
every two out of five people, or the majority of people living in poor rural areas, do not have access to a toilet. The
lack of adequate facilities can create additional problems for citizens, such as bacterial infection or diarrhea. In fact,
16,800 children under the age of 5 die from diarrhea each year. WaterAid is currently working to combat the
sanitation issue in Pakistan by working with government and local officials to provide proper toilet facilities
throughout disadvantaged communities.

Improving Quality of Water

According to the Pakistan Council of Research in Water Resources (PCRWR), 62 percent of the urban
population and 84 percent of the rural population of Pakistan do not treat their drinking water to prevent
waterborne diseases. The United Nations Educational, Scientific and Cultural Organization (UNESCO)
estimates that 40 percent of all diseases in Pakistan are due to unsanitary drinking water.

UNICEF supports the government with frameworks to plan, prioritize, and budget for safe water
services. The aim is to improve the quality of water supply and ensure access to safe drinking water to
nine percent of the population deprived of it.

Water, Sanitation and Hygiene (WASH) in Schools and Health Facilities

UNICEF believes in providing students with a healthy learning environment. It employs the globally
successful Three Star Approach in schools to ensure healthy habits such as hand washing among
students. UNICEF also supports WASH facilities in health structures to ensure the health of patients as
well as reduce the spread of preventable diseases.

WASH in Emergencies

UNICEF works alongside the government’s disaster management authorities to assist communities in
preparing and coping with the effects of disasters on WASH facilities. In the advent of a natural disaster,
diseases such as diarrhea and typhoid spread rapidly and access to WASH services becomes a critical
lifesaving humanitarian intervention.