Child Feces Disposal in Balochistan and Punjab, 96438 PAKISTAN Key messages: • In 2011, 32 percent of households surveyed in Punjab, and, in 2010, 78 percent of households surveyed in Balochistan reported unsafe disposal of the feces of their youngest child under age three. • Even among households with improved toilets or latrines, 15 percent in Punjab and 73 percent in Balochistan reported unsafe child feces disposal behavior. • Unsafe child feces disposal is more prevalent among households that defecate in the open, those in rural areas, those that are poorer, and those with younger children.1 OVERVIEW Although safe disposal is substantially higher in Punjab than in Balochistan, both provinces report much higher safe disposal in urban Safe disposal of children’s feces is as essential as the safe disposal of than in rural areas: 92 vs. 59 percent in Punjab and 46 vs. 15 percent adults’ feces. This brief provides an overview of the available Multiple in Balochistan. Households practicing open defecation reported the Indicator Cluster Surveys (MICS) data on child feces disposal in lowest prevalence of safe child feces disposal (see Figures 3 and 4). Balochistan and Punjab Provinces of Pakistan and concludes with ideas to strengthen safe disposal practices, based on emerging good In both Punjab and Balochistan, households lacking improved practice. sanitation, those in rural areas, and poorer households—as well as households with younger children—have a higher prevalence of The Joint Monitoring Programme for Water Supply and Sanitation unsafe disposal of child feces. Households practicing open defecation (JMP) tracks progress toward Millennium Development Goal 7 target reported the highest level of unsafe child feces disposal, at 86 percent to halve, by 2015, the proportion of people without sustainable access in Punjab and 93 percent in Balochistan. While it is possible, it is to safe drinking water and basic sanitation. The JMP standardized not probable that households who do not use improved sanitation definition for an improved sanitation facility is one that hygienically themselves deposit their children’s feces into a toilet/latrine (see Data separates human excreta from human contact.2 Sources section for more information). In the latest JMP report, only 48 percent of Pakistan’s population had Within each province, the prevalence of safe feces disposal is fairly access to improved sanitation in 2012.3 This means that 93.9 million uniform across age groups: 63–68 percent of Punjab households individuals in Pakistan lacked improved sanitation in 2012, of which and 16–24 percent of Balochistan households report using safe feces 41.3 million practice open defecation.4 However, these estimates disposal regardless of the age of their youngest child under age three. are based on the household’s primary sanitation facility, and may However, as children age, they are increasingly likely to use a toilet/ overlook the sanitation practices of young children. In many cases, latrine themselves. At these young ages, the behavior of the child’s children may not be able to use an improved toilet or latrine—because caregiver is critical to dispose of their feces safely and shape the child’s of their age and stage of physical development or the safety concerns toilet training. of their caregivers—even if their household has access to one. SUMMARY OF CHILD What Is “Safe Disposal” of a Child’s Feces? FECES DISPOSAL DATA The safest way to dispose of a child’s feces is to help the In 2011, 68 percent of households surveyed in Punjab reported that child use a toilet or latrine or, for very young children, to put the feces of their children under age three were safely disposed of. In or rinse their feces into a toilet or latrine. For the purposes 2010, 22 percent of those surveyed in Balochistan reported safe feces of this brief, these disposal methods are referred to as disposal. “safe,” whereas other methods are considered “unsafe.” By definition, “safe disposal” is only possible where there Only 52 percent of households in Punjab reported that their youngest is access to a toilet or latrine. When a child’s feces is put child’s feces were deposited into an improved sanitation facility, or rinsed into an “improved” toilet or latrine, this is termed according to MICS 2011 (see Figure 1). In contrast, in Balochistan, “improved child feces disposal.” only 14 percent used improved disposal (see Figure 2). March 2015 1 FIGURE 1 In Punjab, 68 percent of households reported that the feces of their children under age three were safely disposed. Percentage of children under age three with each feces disposal type, Punjab, 2011. Unsafe Disposal Safe Disposal Missing, 2% Child used toilet/latrine Other, 0% & household (HH) Left in the used improved open, 4% sanitation, 7% Buried, 1% Improved disposal = 52% Thrown into Child feces put/rinsed garbage, 17% into toilet/latrine & HH used improved Safe Put/rinsed sanitation, 45% disposal = 68% into drain or ditch, 7% Child used toilet/latrine, but HH used unimproved sanitation, 2% Child feces put/rinsed into toilet/latrine, but HH used unimproved sanitation, 14% FIGURE 2 In Balochistan, 22 percent of households reported that the feces of their children under age three were safely disposed. Percentage of children under age three with each feces disposal type, Balochistan, 2010. Unsafe Disposal Safe Disposal Missing, 5% Child used toilet/latrine Other, 3% & household (HH) used improved Left in the sanitation, 3% Improved open, 21% disposal = 14% Child feces put/rinsed into toilet/latrine & HH used improved Safe sanitation, 11% disposal = 22% Buried, 4% Child used toilet/latrine, but HH used unimproved sanitation, 3% Child feces put/rinsed Thrown into into toilet/latrine, but garbage, 29% HH used unimproved sanitation, 4% Put/rinsed into drain or ditch, 15% In both Punjab and Balochistan, safe disposal differs widely across Although there are substantial differences between disposal the wealth asset quintiles.5 In Punjab, households in the least wealthy practices in Punjab and Balochistan, the trends seen are the same quintile have substantially lower safe child feces disposal than in both provinces. For example, in both Punjab and Balochistan, households in the other wealth quintiles. In Balochistan, households households without access to improved sanitation, in rural areas, in the lowest three quintiles are substantially less likely than the and from lower wealth quintiles consistently report lower safe wealthier quintiles to report safe disposal: only 8–17 percent of disposal of child feces. Although this brief only focuses on one the households in the poorest three quintiles report safe disposal. socioeconomic indicator at a time, applying multiple lenses would Further, in Balochistan, the feces of more than a quarter of children show even greater extremes of disparity—with the poorest rural in households in the lowest three quintiles were left in the open. households reporting the greatest prevalence of unsafe disposal. 2 FIGURE 3 In Punjab, households with any sanitation facility (unimproved, shared, or improved) report What Is the Impact of Unsafe Disposal substantially higher safe child feces disposal of Children’s Feces? compared to open defecation households. Reported There is widespread belief that the feces of infants and young feces disposal practice for children under age three, by children are not harmful, but this is untrue. In fact, there is household sanitation facility type, Punjab, 2011. evidence that children’s feces could be more risky than adult feces, due to a higher prevalence of diarrhea and pathogens— 100 2% 2% 1% such as hepatitis A, rotavirus, and E. coli—in children than in 2% 7% 2% 2% 2% 16% 11% 1% 8% 1% 5% 4% adults.6 Therefore, children’s feces should be treated with the 80 3% 7% same concern as adults’ feces, using safe disposal methods % of children 60 that ensure separation from human contact and household 50% 72% 73% contamination. 69% 40 In particular, the unsafe disposal of children’s feces may be 20 14% an important contaminant in household environments, posing 13% 1% 11% 9% 12% a high risk of exposure to young infants.7 Poor sanitation can 0 result in substantial health impacts in children, including a Open Unimproved Shared Improved defecation (5% of (11% of (61% of higher prevalence of diarrheal disease, intestinal worms, (22% of households) households) households) enteropathy, malnutrition, and death. According to the World households) Health Organization (WHO), most diarrheal deaths in the Type of sanitation facility used by household world (88 percent) are caused by unsafe water, sanitation, or hygiene. More than 99 percent of these deaths are in Missing Thrown into garbage developing countries, and about eight in every 10 deaths are Other Put/rinsed into drain or ditch children.8 Diarrhea obliges households to spend significant Left in the open Put/rinsed into toilet/latrine Buried Child used toilet/latrine sums on medicine, transportation, health facility fees, and more, and can mean lost work, wages, and productivity among working household members.9 Stunting and worm FIGURE 4 In Balochistan, even among households infestation can reduce children’s intellectual capacity, which with any sanitation facility, safe child feces disposal affects productivity later in life. The WHO estimates that the is extremely low. Reported feces disposal practice for average IQ loss per worm infection is around 3.75 points.”10 children under age three, by household sanitation facility type, Balochistan, 2010. 100 4% 3% 7% 7% 6% 5% 7% 2% 80 28% 28% 16% 18% % of children 4% 3% 5% 1% 60 21% 27% 26% 40 37% 12% 25% 15% 20 19% 15% 14% 21% 0 4% 4% 12% 7% 6% Open Unimproved Shared Improved defecation (11% of (9% of (54% of (26% of households) households) households) households) Type of sanitation facility used by household Missing Thrown into garbage Other Put/rinsed into drain or ditch Left in the open Put/rinsed into toilet/latrine Buried Child used toilet/latrine IDEAS FOR CONSIDERATION Given the relatively few programs focusing on children’s sanitation In Pakistan, there are few interventions aimed at the safe disposal in Pakistan and globally, there is not a strong evidence base of of children’s feces during the first years of life. In general, sanitation effective strategies for increasing the safe disposal of children’s feces. for children under age three has been a neglected area of policy and Significant knowledge gaps must be filled before comprehensive, program intervention both globally and in Pakistan. practical evidence-based policy and program guidance will be 3 REFERENCES 1 Bureau of Statistics (Punjab), United Nations Children’s Fund (UNICEF), and United Nations Development Programme (UNDP). 2013. Pakistan— Punjab Multiple Indicator Cluster Survey 2011. New York: UNICEF. Bureau of Statistics (Balochistan), United Nations Children’s Fund (UNICEF), and United Nations Development Programme (UNDP). 2012. Pakistan— Balochistan Multiple Indicator Cluster Survey 2010. New York: UNICEF. Please see the “Data Sources” section. 2 The JMP has established a set of standardized definitions to categorize improved sanitation, which are used to track progress toward Millennium Development Goal 7. However, these definitions are not always the same as those used by national governments. See Progress on Drinking Water and Sanitation: Update 2014. 3 WHO/UNICEF Joint Monitoring Programme, 2014. Progress on Drinking Water and Sanitation: Update 2014. Geneva: World Health Organization. 4 WHO/UNICEF, 2014. 5 The wealth indices used to classify households into wealth quintiles include drinking water and sanitation variables. available. Nevertheless, organizations and governments interested in 6 Feachem, R., D. Bradley, H. Garelick, et al. 1983. Sanitation and Disease: improving the management of children’s feces could consider: Health Aspects of Excreta and Wastewater Management. World Bank Studies in Water Supply and Sanitation 3. Chichester, UK: John Wiley & Sons. • Conducting formative research to understand the behavioral 7 Gil, A., C. Lanata, E. Kleinau, and M. Penny. 2004. Children’s Feces Disposal drivers and barriers to safe child feces disposal Practices in Developing Countries and Interventions to Prevent Diarrheal • Strengthening efforts to change the behavior of caregivers through Diseases: A Literature Review. Strategic Report 11. Peru: Environmental programs that encourage cleaning children after defecation, potty Health Project (EHP). 8 WHO. 2009. Global Health Risks: Mortality and Burden of Disease Attributable training children, and using appropriate methods to transport to Selected Major Risks. Geneva: World Health Organization, 23. feces to a toilet/latrine as well as handwashing with soap after fecal 9 Favin, M., G. Naimoli, and L. Sherburne. 2004. Improving Health Through contact and before preparing food or feeding a child Behavior Change: A Process Guide on Hygiene Promotion. Joint Publication 7. • Exploring opportunities to integrate child sanitation into existing Washington, DC: Environmental Health Project (EHP). interventions that target caregivers of young children, such as 10 WHO. 2005. Report of the Third Global Meeting of the Partners for Parasite including key messages in antenatal/newborn care materials and Control: Deworming for Health and Development. Geneva: World Health infant and young child feeding guidance provided to parents, Organization, 15. and ensuring that midwives’ training, as well as early childhood 11 Stanton, B., J. Clemens, K. Azis, and M. Rahamanr. 1987. “Twenty-Four- development materials and preschool programs, include Hour Recall, Knowledge-Attitude-Practice Questionnaires and Direct information on safe child feces disposal Observations of Sanitary Practices: A Comparative Study.” Bulletin of the • Partnering with the private sector to improve feces management World Health Organization. Geneva: World Health Organization. 12 Akhtaruzzaman, M. N., and S. N. Islam. 2011. Nutrition, Health and tools, such as potties, diapers, tools for retrofitting latrines for Demographic Survey of Bangladesh—2011: A Preliminary Report. Bangladesh: child use, and scoopers University of Dhaka, 19. • Improving the enabling environment for management of children’s feces by including specific child feces related criteria in open defecation free (ODF) verification protocols and in national NOTES sanitation policies, strategies, or monitoring mechanisms. We’re interested in your thoughts. Have you found different evidence of what works through your own programming? If you have thoughts to share, or know of a program that is encouraging the safe disposal of child feces, please contact DATA SOURCES WSP at worldbankwater@worldbank.org or UNICEF at WASH@unicef.org so that we can integrate your information into future program guidance. Unless otherwise specified, all analysis in this brief is based on self-reported child feces disposal behavior collected in the 2011 Punjab Multiple Indicator Cluster Survey (MICS) and the 2010 Balochistan MICS, which are the latest ACKNOWLEDGEMENTS MICS or DHS available for Pakistan that record child feces disposal behavior. The MICS and DHS collect data in a generally harmonized manner and hence This brief was developed jointly by WSP and the United Nations Children’s are the basis for this country profile series. However, whereas the DHS collects Fund (UNICEF) as part of a series of country profiles about sanitation for data on the youngest child under age five living with the mother for each children under age three. household, the MICS collects data on all children under age three who live with the respondent (mother or caretaker). To maximize comparability, we The findings, interpretations, and conclusions expressed herein are those of restricted all analysis to children under age three in all figures. the author(s), and do not necessarily reflect the views of the International Bank for Reconstruction and Development / The World Bank and its affiliated It is likely that self-reports overestimate safe disposal.11 In Bangladesh, for organizations, or those of the Executive Directors of The World Bank or the example, although 22 percent of children reportedly either used a toilet/latrine governments they represent, or of UNICEF. or their feces were put or rinsed into the toilet/latrine (according to MICS 2006), a structured observation of behavior conducted under UNICEF’s Sanitation, © 2015 by International Bank for Reconstruction and Development / The Hygiene Education and Water Supply in Bangladesh (SHEWA-B) program in World Bank and UNICEF. 2007 found that only 9 percent of subjects disposed of child feces into a toilet/ specific pit.12 Regardless of this issue, self-reports are currently regarded as the Photo Credits: © UNICEF/PAKA2014-00245/Zaidi (page 1); © UNICEF/ most efficient method for gauging safe disposal of children’s feces. PAKA2014-00212/Zaidi (page 3); © UNICEF/PAKA2014-00321/Zaidi (page 4) 4