Access to sanitation is a human right, important to human dignity and one of the basic necessities for everyone. Poor sanitation, particularly open defecation, may lead to many transmittable diseases. New evidence is emerging highlighting the link between inadequate sanitation and malnutrition. Last month, a World Bank report linked poverty and stunting growth among children with quality of water and sanitation infrastructure. It is important as PM Khan for long advocating addressing the issues of stunted growth among children. The report suggests that policy focus on improved sanitation and eliminating open defecation without giving due attention to faecal waste management hindering improved health indicators, particularly child health and their stunted growth. The World Bank report further suggests that open defecation as well as no management of faecal waste caused concentration of untreated faecal waste near human settlements contaminated surface and ground water, soil and crop irrigation with negative effects on human health. Although, Pakistan has achieved the Millennium Development Goal target of halving the proportion of people without access to improved sanitation between 1990 and 2015, the country is still a long way from eliminating open defecation. The total population of Pakistan is 207 million as per 2017census, 2015 estimates show that 13 percent defecate in the open. This is an improvement from 49 percent defecating in the open in 1990. According to the UN, it is estimated that 946 million out of 7.4 billion people around the world are still practising open defecation. There are 25 million people (one in eight) defecating in the open in Pakistan, making Pakistan the country with the fifth highest proportion of open defecators in the world. This proportion is unevenly distributed among urban and rural areas. For example, in 2015, Pakistan Bureau of Statistics (PBS) estimated that in Punjab, overall 17.5 percent households defecate in the open i.e. 1.2 percent in urban areas and 25 percent in rural area. In addition, even within rural areas there are variations within districts in Punjab. For example, none of the rural households defecate in the open in rural areas of Lahore district as compared to 59 percent households defecating in the open in rural areas of Rajanpur district. Although, Pakistan has achieved the MDG target access to improved sanitation between 1990 and 2015, the country is still a long way from eliminating open defecation. 2015 estimates show that 13 percent defecate in the open. This is an improvement from 49 percent defecating in the open in 1990 I was recently involved in a research study with a civil society organisation working in the rural areas of Rajanpur district to eliminate open defecation. According to Multiple Indicator Cluster Survey (MICS) 2015, the district of Rajanpur has the highest open defecating rural population in Pakistan. The district is situated in between the Indus River and the Suleman ranges. The eastern part, close to the Indus River, called the Katcha area, while the western part close to Suleman ranges (hilly) is called Pachad locally. The central belt is irrigated and supports agricultural activities. The estimated population of Rajanpur district was 1.6 million in 2015 with about 1.4 million living in rural areas. It is important to note that education and income are two most important determinants associated with sanitation behaviour. Individuals and households involved in open defecation are more likely to be poorer and illiterate. The evidence from the Rajanpur district suggests that constructing a latrine is a low priority for a household in the rural area due to poverty and lack of education. However, people sometimes despite having financial resources do not feel the need for constructing a latrine. It can be easily observed that even in far flung villages people prefer to buy a mobile phone or a motorbike than to spend money on latrine construction. In a patriarchal society reinforcing gender roles, women are most disadvantaged when it comes to sanitation and open defecation. Due to no access to latrines, women go out in the open to relieve themselves either very early in the morning or after dark. It is quite embarrassing for women and young girls to relieve themselves during the daytime if the need arises. Cultural norms do not allow women to go out for defecation during the daytime. The research found out that women are excluded from making decisions for latrine construction in their houses. Even if women want to construct latrines, men do not listen to them as men enjoy greater freedom in terms of defecation time. Men can go out for defecation anytime they want. Poverty and affordability appear to be the biggest reason mentioned by villagers. Being poor is very strongly associated with defecating in the open. During the research it was obvious that people showed their inability to pay for latrine construction however were willing to offer labour if any organisation or agency were willing to pay for construction materials and hardware. In other villages, people also reported poverty as one of the factors, however, they could see the positive outcome of latrine construction and appear to show satisfaction at money well spent. Availability of water is mentioned by almost all villagers in Hilly areas as a factor that reinforces open defecation. Since water is scarce and only available at a distance, using so much water for washing purposes and cleaning latrines is seen as a difficult proposition to comply with. Most of the villagers in Hilly area requested latrine construction as less of a priority than asking for a water supply schemes. It is important to note that only access to latrines is not enough; villagers reported that family members defecating out in the open emerge despite having latrines in their houses. Cultural adaptation sometimes proved difficult and defecating in the open does not go away in a short period of time. It is observed that older men in the household are quite inclined to go back to open defecation practices due to their beliefs and old habits. Households with large family size also reported to have issues with using latrines, as only one person can use the latrine at a given time, thus in the morning, when everyone wants to use the latrine, people waiting prefer to go outside for defecating in the open. There are issues associated with access to and availability of latrines such as proper functioning and perceived supply-side access. The damage, overflow, blockage or any issues that could make latrine non-function compel household members to go back to open defecation. Similarly, if people in villages do not have an idea about where to get the construction materials, hardware and skilled labour to construct a latrine, they would face serious problems in latrine construction. These issues hinder people’s ability to access latrines. There are misconceptions about the cost of contrasting a latrine, particularly among villagers. Some estimates appear to show unrealistically highsums of money. The provision of proper information at the initial stage of projects would counter such issues. The level of knowledge about the benefits of latrines is quite high among villagers throughout the district. On occasions, people in the villages were able to point out the benefits of having a latrine as well as the link between sanitation and health. People in other villages were able to make an economic case where they associated the cost of seeing a doctor as avoidable if a latrine is constructed and used by all family members. The current political commitment in terms of recognising sanitation as an issue and putting it high on the agenda offers an opportunity to take advantage of the situation and lobby the issue at all levels. A greater awareness about realistic estimates on construction costs could reassure the households to think about engaging in the process of latrine construction as oppose to not even thinking about it due to their perception of higher costs based on ill-informed and incorrect information. The role of private sector should be realised and efforts should be made to engage to ensure availability of appropriate and low cost sanitation materials at the nearest markets. The author has a Masters degree from London School of Economics (LSE) and a PhD from Oxford Brookes University and is currently based in the United Kingdom. He worked extensively in Pakistan as an independent consultant. He can be contacted at dr.shakil.ghori@gmail.com Published in Daily Times, December 12th 2018.