Sanitation as Cross Cutting

Sanitation as Cross Cutting for Health, Nutrition and Education South Asian Conference on Sanitation 2018, Pakistan


Sanitation is “the collection, treatment and disposal or reuse of human excreta, domestic wastewater and solid waste, and associated hygiene”. Sanitation promotion is one of the most important roles the health sector can have in environmental health planning. Provision of drinking water, adequate sanitation and personal hygiene are vital for the sustainable environmental conditions and human health. Not having access to water and sanitation threatens life, destroys opportunity and undermines human dignity. The inadequate quantity of improved drinking water along with poor quality of sanitation invites the variety of diseases i.e. diarrhoea, hepatitis and other stomach related disorders.

Regional disparities in sanitation coverage are huge as well. 99% of people living in industrialized countries have access to improved sanitation, in developing countries only 53% have such access. Within developing countries, urban sanitation coverage is 71% while rural coverage is 39%. Consequently, at present the majority of people lacking sanitation live in rural areas; this balance will shift rapidly as urbanization increases.

Childhood stunting is becoming a key challenge for the globe. A study “The effect of water and sanitation on child health by Fink, Gunther & Hill, 2011” based on analysis of data set of 171 surveys consists on information of 1.1 million children under the age of 5 years in 70 low and middle-income countries over the period 1986-2007, has concluded with strong causal relation of access to water and sanitation and health consequences. Furthermore, this study measured causal relationship between lower risk of mild or severe stunting and access to improved sanitation as (OR = 0.73, 95% CI 0.71-0.75) through logistic regression model. Education is another contributing factor in improved sanitation practices. Open defecation is common in regions with high rates of illiteracy such as Sub-Saharan Africa (35.7%) and South Asia (29.7%) .

A correlation between stunting, adult literacy rate and open defecation has been built in Figure I. It is evident in country like Sri Lanka where adult literacy rate is highest (92.6% in 2012) have lowest open defecation (0.2% in 2012) and lowest prevalence of stunting among under five children (14.7% in 2012). However, Pakistan with highest prevalence of stunting (45% in 2012) have third high percentage of open defecation (17.9% in 2012) and lowest adult literacy (56.4%). India with second high prevalence of stunting (38.7% in 2014) has highest percentage of open defecation (44.6% in 2014) but second high adult literacy rate (72.2%). Percentages for prevalence of stunting in Afghanistan and Maldives are not available for recent years thus, not included in analysis. Furthermore, same year’s data of stunting prevalence is not available for all the countries therefore, data sets for various years (mentioned with country name) are reflected in figure I.

Figure I: Percentage of Stunting, Literacy and Open Defecation

Economic condition of a person is also a key determinant of his/her access to sanitation. Data sets of various surveys shows least access to sanitation among poorest quintile. Furthermore, strong correlation between access to sanitation and health condition burdens poor with more health expenditures. In figure II, a correlation between poverty (headcount ration at $ 3.1 a day, 2011 PPP), access to sanitation and private health expenses (% of GDP) has been developed from world bank data. Sri Lanka with second lowest poverty ratio (14.6% in 2012) has highest access to sanitation (99.8% in 2012) and second lowest country for paying private health expenditure of GDP percentage (2% in 2012). Bhutan with lowest poverty ratio (13.3% in 2012) has second high coverage of sanitation (97.6% in 2012) and paying least private health expenditures of GDP percentage (1% in 2012). India with highest poverty (58% in 2011) has lowest access to sanitation (51.4% in 2011) and paying second high private health expenditures of GDP percentage (3.2% in 2011). Percentages of poverty headcount ratio in Afghanistan and Maldives are not available for recent years thus, not included in analysis. Furthermore, same year’s data of poverty ratio is not available for all the countries therefore, data sets for various years (mentioned with country name) are reflected in figure II.

Figure II: Percentage of Access to Sanitation, Poverty Ratio and Private Health Expenditures

Water, sanitation and hygiene activities typically incorporate sanitation schools into the scope of work, with hygiene education in particular directly targeting children; the sooner children get in the habit of washing their hands regularly, the better. It is therefore important to ensure that the proposed activities promote child protection policy and to further ensure that sufficient mechanisms are in place to support compliance. Pakistan is significantly weak in terms of maternal secondary education and this lack of education impacts the nutritional status of children. A positive relationship was found between the nutritional status of infants and educational status of mothers. A study revealed that majority of Pakistani infants falling in various degrees of malnutrition belonged to uneducated mothers. Similarly, educated Pakistani mothers were more aware of appropriate frequency of complimentary feeding in every age group. The study concludes that a mother’s education plays a vital role in increasing receptivity to nutritional requirements of their infants and improved complementary feeding practices .

Lack of access to sanitation seems to be the main constraint for many countries. If people are suffering (either from diarrhoea or via environmental enteric dysfunctional) due to poor disposal of faecal matter, then this will undo much of the good that improved diet and care does for growth. Poor sanitation, hygiene, and water are responsible for about 50% of the consequences of childhood and maternal underweight, primarily through the synergy between diarrhoeal diseases and under nutrition, whereby exposure to one increases vulnerability to the other. Under nutrition is estimated to cause 45 percent of all child deaths , and is responsible for 11 percent of the global disease burden. It results in productivity losses to individuals estimated at more than 10 percent of lifetime earnings, and gross domestic product (GDP) losses as high as 2 to 3 percent.


  1. Weak presence of the health sector in advocating for improved access to water and sanitation is incomprehensible and completely short-sighted.
  2. Integration of themes of health, nutrition and education, like ECE and ECCD are not well thought approaches to be tried in program design.
  3. Hygiene promotion to be featured as an important part of the school curriculum from primary level.
  4. Links between national health information systems and sanitation planning and financing, is separate from health in most of the countries.
  5. Other constraints to success in sanitation are population growth and increasingly high population densities in urban and peri urban areas of developing countries.
  6. Poverty; as most of the people who lack improved sanitation live on less than $2 per day, which makes high-cost, high-technology sanitation solutions
  7. inappropriate.

Key Areas of Discussion

  1. What are the key ways and mean of integration for various stakeholders to act as facilitators and regulators for integrated WASH – How to enable systems (health, education, nutrition) to incorporate sanitation and hygiene? What are areas of focus in policy, regulation and strategies that complements operations in the WASH sector to maximize the impact on nutrition outcomes for the poor? What guidance is available on effective ways to integrate WASH with nutrition-specific and other nutrition sensitive intervention?
  2. How gender responsive program design can be introduced?
  3. How to measure the potential impact of activities on nutrition through meaningful outcome indicators, such as infrastructure quality, usage (behaviour), and maintenance? Will it have any role in planning and setting the priority for financial allocation?
  4. Are we ready to shift from centralized supply-led infrastructure provision to decentralized, people-centered demand creation coupled with support to service providers to meet that demand? Employing this strategy means transforming sanitation from a minor grant-based development sector into a major area of human economic activity and inherently addresses the problem of affordability, since people install whatever sanitation systems they can afford and subsequently upgrade them as economic circumstances permit.
  5. Do we see ECE and ECCD as key entry points for WASH and Health and Nutrition? ECCD and ECE interventions are yet not welcomed in WASH sector and currently they are in a nascent phase? Can they be entry point and window of opportunity to ensure health and nutrition? Will this bring in a change in current high morbidity and mortality among under five children?
  6. Is institutional WASH our priority? Are we looking at WASH as a key intervention to reduce maternal mortality and improve MNCH indicators?