Overcoming sanitation and hygiene crises is the most vital development challenge in South Asia.

Tackling it will reduce unnecessary deaths, facilitate people to live a more dignified life, improve gender equality, help reduce poverty and protect the environment.

Mushahidullah Khan
Pakistan's Minister for Climate Change

Share this content
Follow us 

Diarrhoea, caused by poor sanitation and hygiene, and unsafe drinking water, remains a major cause of child malnutrition, disease and death in South Asia.
Every year 177,000 children in South Asia die of diarrhea.

Nearly half of the under-five children in India are stunted, with open defecation being a major underlying cause.

Two-thirds of the global population practising open defecation live in South Asia. The region has 558 million open defecators, most of them living in rural areas.


148 million fewer individuals practise open defecation by 2021


By 2030, achieve access to adequate and equitable sanitation and hygiene for all, and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations. Sustainable Development Goal (SDG) 6.2.

UNICEF's Strategic Framework 2018-2021 and the Game plan for Open Defecation set the following targets for UNICEF:
- 60 million people living in open defecation free communities as a direct result of UNICEF programming and
- 150 million new users of basic sanitation services through leveraging government and other partners' resources prioritizing countries with high prevalence of open defecation


Good sanitation practices are essential for reducing child morbidity, mortality and stunting. Poor sanitation, especially the practice of open defecation, is an affront to society and is in stark contrast with the region's rapid economic progress. Toilets at home, at work and in public spaces provide dignity and security, especially for girls and women. Ending open defecation is a priority for UNICEF and key to fulfilling our commitment to equity, so we focus on countries where open defecation rates and inequity between different parts of society are high. While the UNICEF country offices in South Asia will support about 148 million individuals to end open defecation, most of this will come from societal change through the introduction of new social norms around sanitation. This will require efficient, well-funded government sanitation programmes plus civil society and private sector actions, to which UNICEF will contribute. We advocate and support governments and civil society to progressively use Community Approaches to Total Sanitation (CATS), which are effective at reducing open defecation in a sustainable manner. UNICEF country offices have set a number of key output results that will support governments and civil society organizations to carry out effective sanitation programmes.

The three priorities for UNICEF support are: (i) strengthening the enabling environment; (ii) enhancing political accountability; and (iii) establishing robust water, sanitation and hygiene (WASH) behaviours and norms across the region. By providing technical support and developing capacity in these priority areas over the next four years, UNICEF will empower partners to deliver enhanced WASH services at scale and ensure universal WASH access by 2030. This will be achieved through various activities under country-specific strategies.


Despite challenges, there have been considerable successes in improving sanitation in South Asia (see figure below). In Bangladesh, open defecation in rural areas fell from 23 per cent in 2000 to 1 per cent in 2015. Nepal has succeeded in eliminating open defecation in 47 of its 75 districts. Afghanistan has launched a major initiative to eliminate open defecation throughout the country, and Pakistan has seen a major expansion of its Pakistan Approaches to Total Sanitation (PATS) programme. In India, the Swachh Barat Mission aims to ensure a clean India by 2019.

Over the past decade (and especially in the last five years) there have been major developments in the sector that have improved sanitation for hundreds of millions of people in South Asia. The proportion of people practising open defecation fell from 65 per cent to 34 per cent in the region as a whole, with India, Bangladesh, Nepal and Pakistan all achieving a more than 30 per cent reduction since 1990. Governments in South Asia are committed to addressing the lack of sanitation: reducing open defecation is now a priority, and many countries have established national targets.

Sanitation coverage, open defecation rates and sanitation estimates, South Asia, 2000-2015


In 2015, 65.3% of the urban population and 37.2% of the rural population used a basic sanitation service.


In 2015, 5.6 of the urban population and 45% of the rural population practised open defecation.

Sanitation estimates

Sanitation Estimates

Ensuring equity

There is a marked urban-rural divide in the prevalence of open defecation. There are also marked inequities between countries, sub-national regions and according to wealth.

Sanitation coverage

Proportion of population using safely managed, basic, limited, unimproved sanitation services or practising open defecation, 2015

Inequalities in prevalence of open defecation, countries in South Asia region, 20??

Inequalities in open defecation's prevalence

Monitoring systems are inadequate

Given the speed with which open defecation is being eradicated in South Asia, more rapid monitoring systems are needed. UNICEF is therefore supporting the development of an atlas of open defecation which uses a combination of household surveys and administrative data to look at coverage and trends from national to sub-district levels.


Measurable progress has been made in water, sanitation and hygiene (WASH), with substantial reductions in open defecation throughout the region. Against the target of achieving 120 million fewer open defecators for the period 2014-2017, there were 132 million fewer open defecators in the region (50 million of them directly supported by UNICEF) by the end of 2017. We are seeing tremendous increases each year: in 2017 alone UNICEF directly supported over 32 million people to live in communities certified to be open-defecation-free (compared to just under 2 million in 2014).

Forecasts for levels of open defecation suggest an increase in line with population growth followed by significant reductions.

15. How many communities have been "triggered" through CATS/CLTS programmes in the reporting year only as a result of UNICEF direct support? 16. How many communities have been certified free of open defecation in the reporting year only, as a result of UNICEF direct support? 17. What is the total population of the communities that have been certified free of open defecation in the reporting year only, as a result of UNICEF direct support?
2017 48,901 24,714 32,195,923
2016 24,404 9,865 10,249,072
2015 8228 3394 4,824,899
2014 2,619 2,124 1,967,244

Forecast net reduction in open defecation, South Asia

South Asia witnessed a sanitation revolution throughout the region during the period 2014-2017. Initiatives such as the South Asia Conferences on Sanitation (SACOSAN), inspiring advocacy campaigns and political commitment have helped create momentum towards a South Asia where sanitation is for all and open defecation is no longer practised.

The past decade (particularly the past five years) have seen the greatest increase in the use of toilets than in any other time in this region's history: over 240 million additional people now use toilets and have abandoned open defecation. Sanitation is high on the political agenda throughout the region and the sanitation revolution is blossoming across the continent. We see it clearly in Pakistan where over 11 million people have already been reached; the first open-defecation-free (ODF) district will shortly be declared in Bhawalpur.

We see it too in Afghanistan where the first open-defecation-free district in Nili (Daikundi province) has just been declared and where seven more are on their way. In India, the Swachh Bharat Mission (led by the Prime Minister) is changing lives throughout the country and the daily rates of toilet construction and use are enormous.

Map showing forecast prevalence of open defecation in rural areas by end 2017, South Asia

OD in rural areas by end 2017

Indian government committed to end open defecation
The Indian government has committed to ending open defecation by 2019, the 150th anniversary of Mahatma Gandhi's birth. In October 2014, it launched a fully funded national hygiene, sanitation and waste management campaign called Swachh Bharat Mission. The campaign aims to transform rural India through community and people-centred strategies that emphasize holistic sanitation approaches. Sikkim and Kerala are mostly free of open defecation, and Himachal Pradesh is making progress through innovative community mobilization. The campaign is already showing results: Rajasthan, Madhya Pradesh and Odisha, large states with high levels of open defecation, are making notable progress.

Pakistan's approach to total sanitation
Pakistan achieved its Millennium Development Goal (MDG) target for sanitation in 2015, five years after the Pakistan Approach to Total Sanitation (PATS) was launched, following massive floods in 2010. Since then, more than 10 million people have eliminated open defecation in their communities, including 6.5 million as a direct result of UNICEF support. In 2015 alone, UNICEF support ensured that more than 1.3 million people were certified as living in open-defecation-free environments and 1.7 million people received hygiene-related information on preventing childhood illness, especially diarrhoea. In Pakistan, 64 per cent of the population is now using improved sanitation facilities. PATS has created demand for toilets, facilitating supply-side options and enabling duty-bearers to take more responsibility. PATS is used by all sanitation sector stakeholders and has spurred government to commit to ending open defecation by 2025, taking on the challenge of the ambitious SDG 6.2 sanitation target. PATS programmes increasingly focus on equity, the creation of a sustainable social norm for 'no open defecation' and universal use of hygienic toilets. Pakistan has now reached a tipping point, and the use of toilets is fast becoming the new norm.

Nepal's Sanitation Social Movement
In Nepal, open defecation in rural areas fell from 93 per cent in 1990 to 37 per cent in 2015: a remarkable improvement. In 2011, Kaski became the first district to be declared open-defecation-free: 47 of Nepal's 75 districts achieved this status by the end of 2017. Success is due to a change in tactics, from subsidizing toilet construction towards the 'reward and recognition' approach set out in Nepal's 2011 national sanitation and hygiene master plan. A wide range of stakeholders are fully engaged: local bodies, government officials, political parties, civil society, mothers' groups, forest user groups, child clubs and others collaborate to reduce open defecation in their communities. The elimination of open defecation has thus become a social movement rather than a programme or a project. Most remarkably, while open defecation use to be most common among the poorest, the recent Nepal Multiple Indicator Cluster Survey (MICS 2014) showed little difference in sanitation coverage between the poorest and richest quintiles of the population - evidence of an effective social movement.

In communities where open defecation is widespread, residents are more likely to have lower education, belong to disadvantaged minority groups, have more children, have lower access to social services and live further from markets and other services. People who defecate in the open generally walk further to get drinking water and are more likely to rely on unimproved drinking water sources; they are also less likely to use soap when washing their hands.

For five countries in the region the open defecation atlas contains equity trees (down to district level). We can also stratify according to education levels, ethnicity, religion, etc.

Afghanistan Open Defecation Equity Tree (forecast end of 2016)

Afghanistan Open Defecation Equity Tree

The SDG target 6.2 'By 2030, achieve access to adequate and equitable sanitation and hygiene for all, and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations' specifically aims to end the practice of open defecation. As the national governments of all countries in South Asia have adopted the SDGs, it is expected that the reduction of open defecation practices will accelerate in the coming years.


World Health Organization and the United Nations Children's Fund, Progress on drinking water, sanitation and hygiene: 2017 update and SDG baselines, WHO and UNICEF, Geneva, 2017.


Each year thousands of child deaths in Afghanistan could be avoided by using toilets and washing hands. Nili district in central Afghanistan recently celebrated being declared 'open defecation free' - a first in the country. Fatima, 23, is one of the people behind this change, helping to create a healthier environment for children and the entire community.

For 23-year-old Fatima, it took the death of one child to spark a simple but transformational change, to convince the whole village to start using toilets and improve the health of many youngsters.

"People didn't think about using toilets here because of all the ground available," says Fatima at celebrations in Chaw village, Nili district, to mark it being declared 'open defecation free', the first district in the country to achieve this status.

"We needed to take a stand and to reduce the amount of illness and problems as a result of people not using toilets and because people were not washing their hands," she says.
Diarrhoea-related deaths among under-five children total over 9,500 a year in Afghanistan. This means some 26 children die each day as a result of an infection that leads to diarrhoea. Many of these deaths are avoidable.

Confronting open defecation

When health workers visited Chaw, a remote village in the central highlands, Fatima realised she could do something to bring about change. She volunteered with the village health committee, which took part in the district wide 'Community-led Total Sanitation' approach, where families identify areas around their homes that are used as toilets.

Using a combination of shock, shame, pride and disgust, families are encouraged through peer pressure to build a latrine and commit to using it. The process usually lasts three to six months until an entire community has given up defecating in the open, contributing to a healthier environment for everyone.

"There were faeces everywhere but it's cleaner now, people realised they needed to use their toilets," says Mercia, 20, who lives on the edge of the village. The impact has not only been positive for the health of her son Alicina, 3, and daughter Sohaila, 5, but also her bank balance. "We've cut down on the numerous trips to the health clinics and hospitals to treat the children. The transport and treatment costs would add up to 2,000 Afghanis (US$ 30) a month," she explains.

Stopping diarrhoea to prevent malnutrition and stunting

Toilet use and improving hygiene is also at the frontline of efforts to reduce malnutrition and stunting in Afghanistan. Regular bouts of diarrhoea contribute to malnutrition, and a malnourished child is more susceptible to infections that can cause diarrhoea. With 1.3 million children malnourished and 41 per cent of all children in Afghanistan stunted, the country is missing out on one of its most valuable resources - its children.

Fatima is playing a key role, as part of broader nationwide efforts, to build momentum for change. "I wasn't told about the impact of this [not using toilets] when I was young but as a mother I want change for my son," she says. "As a woman, it was very encouraging that I changed the views of people in the community, even men listened to me," Fatima adds with a smile.