PAKISTAN APPROACH TO TOTAL

SANITATION
(PATS)

MINISTRY OF ENVIRONMENT
GOVERNMENT OF PAKISTAN

March 2011

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1. Background

In 2006, Pakistan hosted the second South Asia Conference on Sanitation (SACOSAN II) which
brought the sanitation agenda on the national level debate. Key stakeholders continuous
efforts resulted in the formulation of National Sanitation Policy which was approved in 2006 by
the Federal Government. The policy highlights social mobilization and behavior change as a key
component in addressing sanitation issues at the household level especially in the rural areas.
The Policy envisions creation of an open defecation free environment with safe disposal of
liquid and solid waste and the promotion of health and hygiene practices in the country using
various total sanitation approaches. One of the objectives of the National Sanitation Policy is to
promote Community Led Total Sanitation model and other approaches for the creation of an
open defecation free environment.

The National Sanitation Policy of Pakistan also provides broad guidelines and support to the
Federal Government, Provincial Governments, Federally Administrated Territories, Local
Governments and other Development Authorities to enhance the sanitation coverage in the
country through formulation of their sanitation policies, strategies, action plans, programmes
and projects. It is provided in the policy that the “Total Sanitation Model” for the provision of
sanitation will be formalized and the procedures and regulations for its implementation will be
developed.

A CLTS core group was notified by the Government of Pakistan in August 2008 with
representation from UNICEF, RSPN, WSP-SA, WaterAid, Plan Pakistan and PIEDAR. RSPN was
given the responsibility to chair the core group. The main objective of the core group was to
operate as a "Think Tank" to advance common understanding of the issues related to scaling up
Community Led Total Sanitation in Pakistan. The CLTS core group was requested by the Ministry
of Environment to propose a Pakistan specific strategy to achieve “Total Sanitation” in Pakistan.

2. Justification of a Pakistan Approach

The rationale to have a specific Pakistan based sanitation approach is linked to the sector
context and prioritizing sanitation. ‘Sector context’ refers to a country’s socio-economic,
political, cultural and historical characteristics, including its development trajectory, occurrence
of frequent disasters and the current development aid architecture. This also involves looking
at political processes within the sanitation sector, the potential links to national political
institutions and stakeholders and the assumptions that underpin sanitation sector investment.

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There is on-going concern of the government that the sector is not devoting enough attention
and resources to sanitation services, particularly when compared to spending on water supply
and other infrastructure services. While there are no general figures showing on- and off-
budget expenditures in the sanitation sector at national levels, evidence illustrates that
investments and expenditures are very low compared to those for water supply and other
infrastructure services. Although in the wake of disasters, considerable resources are made
available for the provision of emergency services through humanitarian assistance. Additionally,
existing sanitation investments and service provision are not always pro-poor. Efforts to
increase access to sanitation infrastructure provision can benefit better-off urban residents at
the expense of the urban poor, slum dwellers or the rural population. Many documents suggest
that governments’ limited sanitation expenditures are determined largely by political, rather
than technical or economic dimensions in the context of competing demands for resources. The
sector demands synergy among all stakeholders from planning to execution of outcomes.
Hence prioritising sanitation has to be anchored on promotion of multiple options that fit well
within the socio-cultural, political and investment climate of Pakistan.

3. Pakistan Approach for Total Sanitation

The Pakistan Approach for Total Sanitation (PATS) is towards achieving and sustaining an open
defecation free environment both in rural and urban context with clear emphasis towards
behavior change and social mobilization enhancing the demand side of sanitation. The
approach endorses the use of a number of branded total sanitation models, having a key role of
communities, which include:

 Community Led Total Sanitation

 School Led Total Sanitation
 Component Sharing
 Sanitation Marketing
 Disaster Response

The above models may be adopted by the provincial and local governments in accordance to
what suits best in their local context and in accordance with the reinforcement values of PATS.
The planning, promotion, implementation, regulation and monitoring will be expected from
municipalities and provincial governments.

The provinces will plan financing the sector which may include own funds, donors and federal
government funds. The federal government will continue supporting through Information,
Education and Communications and coordinating for capacity building among the provinces.
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The approach will be revisited in three years time, it is expected that pilots and implementation
through provincial programmes will provide feedback and learning.

4. Reinforcement Values of Pakistan’s Approach to Total Sanitation

Following are the reinforcement values of Pakistan’s Approach to Total Sanitation which
provide greater programming flexibility in adopting context specific solutions as well as an
opportunity to engage in meaningful discourse to advance the community led process in
Pakistan and attain the desired MDG goals.

I. Integrated Total Sanitation: The Pakistan specific approach seeks to follow the following
components for attaining total sanitation:

 Sanitation Demand Creation Interventions: through Information, Education and

Communications (IEC) Campaigns, Community sensitization through Community
Led Total Sanitation (CLTS), School Led Total Sanitation (SLTS), Marketing of hand
washing etc;

 Sustaining the Demand through Supply Side Interventions: through “Marketing

Sanitation”, supply chain mechanisms, training of masons, construction of
environment friendly latrines for demonstration of technical solutions, trainings
of sanitation entrepreneur and sanitation enterprises, facilitation to develop
linkages with the microfinance institutions and incentivizing outcomes;

 Hygiene Promotion Interventions: through IEC material on active health and

hygiene key massages, behaviour change communications, usage of mass media
campaign and IEC campaigns promoting low-cost appropriate and informed
sanitation solutions etc;

 Drainage and Wastewater Treatment Interventions: through community

participation and component sharing models with the aim to minimize exposure
to human excreta and wastewater management;

II. Launching of a country wide communications campaign to develop a national culture or

social norms for total sanitation;

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 III. Creation of international and in-country partnerships with key development agencies and
organizations such as UNICEF, WSP-SA, WSSCC, RSPN, WaterAid, Plan Pakistan, UN-
Habitat, PIEDAR and others to harmonize and coordinate support to federal and provincial
governments for conceptualizing and rolling out the large scale rural sanitation programs;

IV. Development of an enabling environment at the local, provincial and the national level
through strong evidence based advocacy to ensure that programmatic approaches and
the sanitation development initiatives are well understood, supported, financed and
contributed to long term sustainability;
V. Recognizing that access to adequate sanitation facilities is the fundamental human right
of every individual in disasters, a disaster response approach to be followed for provision
of sanitation services, coupled with appropriate community social mobilization
techniques, at a viable, affordable, cost effective and culturally and environmentally
appropriate manner.

5. Guiding Principles of Pakistan’s Approach to Total Sanitation

The approach emphasizes on the following important guiding principles within PATS
framework:

A. Emphasis on “Total” while using Total Sanitation Approach to change behaviours

(stopping open defecation) on a community-wide bases i.e. achieving 100 % open-
defecation free (ODF) status and working through with the communities after achieving
the ODF status to stimulate and sustain the sanitation demand to achieve the remaining
total sanitation outcomes i.e. sustainability of ODF environment, usage of sanitation
facilities, provision of affordable and informed indigenous solutions, promotion of
health hygiene, introduction to community sanitation ladder initiatives, provision of
drainage facilities with the aim to minimize exposure to human excreta, wastewater
management & the solid waste management;

B. Placing “Communities” at the centre of any planning process for collective action,
behaviour change, application of triggers, follow ups, certification, and the
institutionalization of behaviour change processes;

C. Development of a cadre of local human resource for sensitizing communities on the

adoption of improved sanitation and safe hygiene practices. A cadre of male and female
activists/ Community Resource Persons (CRPs) to be identified at the community level
and developed for making their assigned area open defecation free. These activists can
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 initially work on a service fee and be further transformed into small entrepreneurs and
help expand the capacity of the market to supply services and products;

D. Developing intense engagement with communities including households, schools,

health centres, religious gatherings and other traditional leadership structures to attain
the remaining outcomes of the total sanitation after declaration of the ODF status.
Social mobilization not to be taken as one off activity. The role of CBOs/COs/VOs at the
village level and Local Support Organizations (LSOs) at UC level to be institutionalized;

E. Use of locally designed IEC material to sensitize the communities on sanitation through
hygiene promotion interventions. The messages imparted to be reinforced from time to
time;

F. Integration of “Hygiene ladder” along with the “sanitation ladder” in any of the Total
Sanitation program designs, to maximize the impact, through carefully sequencing the
hygiene promotion components, especially hand washing based on the local context
and through behaviour change communications;

G. Emphasis on “Usage” of sanitation facilities and not specifically on the construction

work to ensure safe disposal of excreta and hygiene practices;

H. Explore options for safe disposal of human excreta through affordable and appropriate
technology and enable communities to take decisions on the materials and designs
which work best for them. A local “support mechanism” be established to provide
communities with the informed and indigenous choices of sanitation technologies and
other infrastructure. Guidance for the infrastructure needs to be extended through
designated community activists/community resource persons and local masons/artisans
to work on technology options with the communities;

I. Quality facilitation and local capacity building to ensure sustainability and scale up
through building a critical mass of master trainers, community facilitators, resource
persons, activists, natural leaders, local masons and artisans. A rigorous training
program for trainers and the Local Government institutions to be introduced on the
methodologies and the philosophical aspects of the approach. Capacity development of
small entrepreneurs and micro financiers to develop a range of technologies and
options for environmental sanitation.

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J. Marketing the sanitation component through involvement with the local market and
local entrepreneurs to further stimulate and sustain demand at the household level and
move up the sanitation ladder through improved sanitation products and supplies;

K. Strengthening the local private sector to offer a wide range of sanitation products and
services that are consumer-responsive (based on a formative research) and affordable
to households with various socio economic incomes including the poor;

L. Provision of subsidies at the outset to be discouraged in any form to the households.

Support extended in the form of in-kind to the poorest of the poor households.
Households with different bands of poverty status be identified through an agreed
criteria;

M. Introduce community rewards and incentives when an outcome based collective action
to achieve “total sanitation” is undertaken and verified and/or sustainable “usage” of
sanitation facilities is maintained through an agreed criteria;

N. Participatory sanitation baseline to be introduced to develop baseline data and help

monitor the post triggering impacts at the village level;

O. Ensure the local government participation from the outset for enhancing the
effectiveness of the PATS, monitoring & evaluation and exploring potential for scale-up
through undertaking their capacity building in a wide range of areas;

P. Results Based Monitoring and ODF Certification Processes to be introduced to sustain

behaviors and rewarding outcomes through the involvement of Local Government
Institutes. The certification mechanism, to monitor the ODF status at any point in time,
be devised which shall take into account the annual renewal of the commitment for
maintaining ODF status.

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 Annex-I

Total Sanitation Models under Pakistan Approach to Total Sanitation

A. Community Led Total Sanitation (CLTS)

Community Led Total sanitation (CLTS) methodology is an entry point to achieve “total
sanitation” and not a total sanitation in itself. It is an effective approach for triggering action to
change defecation behaviours at the community level and to create demand for improved
sanitation facilities. CLTS encourages sanitation, as a whole, to be taken as an entry point for
greater social change and community mobilization. The CLTS process seeks to provoke
communities through their own appraisal and analysis to decide to become open defecation-
free (ODF) and undertake their own efforts to attain this status. CLTS is an approach in which
people in rural communities are facilitated to do their own appraisal and analysis, come to their
own conclusions, and take their own action. They are not instructed or taught. With CLTS in its
classical form, a small team of facilitators conduct triggering. The facilitators may represent
government, NGO or project staff, or Natural Leaders from other communities. The PRA
(Participatory Rural Appraisal) principle that ‘they can do it’ is fundamental to this approach.
Various PRA methods are used including participatory mapping on the ground to show where
people live and where they defecate, transect walks to visit and stand in those places,
calculations of quantities of human faeces (the crude local word is used) produced by each
household and the community, and identifying pathways to the mouth leading to the shocking
recognition that ‘we are eating one another’s shit’. This triggering is designed to lead to a
moment of ignition and a collective decision to end Open Defecation (OD) followed by action to
become Open Defecation Free (ODF). When triggering is successful, Natural Leaders emerge.
People dig pit holes and build latrines. There are no standard models and construction is by
self-help with or without purchase of hardware from the market.

Key steps identified under CLTS includes:

I. Pre-triggering: selecting community and developing a better defined sense of

community
II. Triggering: educating the community regarding the consequences of living in a faecally
contaminated environment until they come to the realization that they are eating,
washing in, and drinking each other’s faeces. Some of the triggering activities include
defecation area transect, mapping of defecation areas, calculations of faeces and
medical expenses, triggering disgust and ignition. The “ignition” captures the moment
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 when the community becomes mobilized to take collective action to stop the ingestion
of each other’s faeces and improve their poor sanitation.
III. Post-triggering: Once communities typically pledge to improve their sanitation by either
becoming open-defecation free or by adopting improved sanitation technologies there
is a danger that these pledges do not come to fruition without follow-up work. Follow-
up activities include immediate follow-up and encouragement, community action
follow-ups i.e engaging with communities to agree furthering action plans to achieve
other sanitation outcomes including external systems, participatory monitoring and
indicators setting, verifying and certifying ODF status, celebrations and the monitoring
and sustaining of ODF status

B. School Led Total Sanitation (SLTS)

School-Led Total Sanitation (SLTS) places children at the centre of catalyzing total sanitation in
schools, homes and communities. Developed and implemented by UNICEF and the Government
of Nepal since 2005, SLTS draws on success elements from a wide range of Community
Approaches to Total Sanitation (CATS) to create a complete package of sanitation and hygiene
programming that begins at the school and extends through the community. Through
participatory approaches, motivational tools, flexibility for innovation and building ownership at
the local level, SLTS is accelerating latrine coverage across Nepal, and creating a social
movement for communities to become open-defecation free (ODF). The main objective of SLTS
is to build on children’s awareness of better sanitation and hygiene practices. This enables
children to promote better practices in joint efforts with community groups and adults in their
school catchments and settlements. This leads to the eradication of open defecation, through
the construction, use and maintenance of latrines by 100% of households/institutions.

C. Sanitation Marketing
Sanitation Marketing is an approach which seeks to capitalize on the strength of various service
providers in the provision of sanitation services using commercial marketing procedures and
techniques and behavior change communication to create and sustain sanitation demand
generated through CLTS and other community approaches. These service providers include
small and medium scale private sector, retailers, entrepreneurs and masons etc.

The main aim is to provide technologically and financially sound sanitary materials, sanitary
services and guidance as per the need of the project intervention areas as the demand for
better sanitation hardware materials goes up, and with the shift in hygiene behaviour. This

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approach is not meant to confine only on the provision of hardware but is meant to extend
further to explain the value, use, and maintenance of latrines to the customers. In this regard,
facilitators help in establishing linkages with local markets. In most cases where CLTS has been
triggered on any scale, demand for sanitary hardware has exceeded supply. Lack of low-cost
hardware can impede progress with CLTS and other community approaches and the
subsequent movement up the sanitation ladder. Very soon after triggering or after achieving
ODF status, those better off in communities tend to move to better quality latrines and improve
the existing ones. Some may decide to move directly to higher-end latrines and skip low-cost
models regardless of cost.

D. Component Sharing Model

In this model, the sanitation project is divided into two components namely internal
component, with the responsibility resting with community for constructing sanitary latrine,
household connection, and lane sewer, and the external component, with the responsibility
resting with the external agency (Government, NGO, etc.) for constructing main sewers and
treatment/disposal works. Rather than sharing the costs of the total system, the responsibility
for components of service provision is clearly allocated between the involved stakeholders. The
component sharing model is designed to rationalize the cost, encourage cost efficiency and
create a sense of ownership as community contributions are substantial, often approaching
50% of the total scheme cost. The Orangi Pilot Project (OPP) is probably the most enduring
success story from Pakistan in the sanitation sector. Developed in the 1980’s, this model has
extended small bore sewerage across the Orangi settlement and various other slums (Katchi
Abadis) of Karachi. The OPP model is based on a ‘component sharing’ arrangement where:

I. Household’s own, finance, operate & maintain their own latrines, interception
chambers up to the point of connection to the lane sewers, while
II. Community organizations (comprised of all households) own, finance, operate &
maintain the point of household connection, the lane and the feeder sewers, while
III. Local government’s own, finance, operate & maintain the trunk sewers and treatment
plants.

E. Disaster Response Approach

In disasters and emergencies, sanitation remains as one of the basic necessities which
contribute to human dignity and quality of life. Disasters also damage existing sanitation
facilities and reverse the process towards achievement of total sanitation. Not only
reconstruction of sanitation facilities back to pre-disaster coverage is a challenge but it is also

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challenging to change behaviors where communities had been practicing open defecation
before the disaster. It is therefore imperative to accord sanitation the highest priority along
with water supply as there are potential risks associated to public health due to lack of or poor
sanitation. Funding through humanitarian assistance comes in context of saving human lives
threatened by disasters and calls for speedy interventions including provision of basic sanitation
in relief phase and rehabilitation of sanitation facilities.

The disaster response approach puts special emphasis on the temporary and intermediate
solutions for the provision of sanitary latrines in camps and affected villages during the relief
operations. With regard to ensuring hygienic conditions and to prevent any ground water
contamination in both camps and affected villages, the approach takes into consideration
promotion of appropriate hygiene promotion messages and delivery of hygiene kits as per need
and local context to the affected families through various campaigns.

For the early recovery and reconstruction phase, the approach stresses the need for having
criteria for appropriate excreta disposal interventions both in temporary and permanent
shelters. The long-term solution during the early recovery and reconstruction phase has two
pronged approach: (a) As the shelter and access to sanitation is closely linked, the first prong
deals with situations where the household latrine is considered as an integral part of any
shelter home to be provided free of cost (b) For those who need to construct their own latrines,
appropriate tools, knowledge and understanding is provided through social mobilization and by
involving affected communities in the design and maintenance of their sanitation facilities. The
approach takes into account the provision of a full or partly subsidy, based on the nature of the
disaster. Provision of hardware through humanitarian assistance for extremely vulnerable and
vulnerable families is not seen as subsidized provision of sanitation rather as an opportunity to
demonstrate low cost sanitation technologies integrated with DRR aspects and its gradual links
with development oriented approaches such as CLTS and sanitation marketing.

The approach also puts special emphasis on other cross cutting issues such as ensuring gender
mainstreaming by addressing gender in all stages from designing, planning, implementation and
evaluation, promoting use of environment friendly technologies, and construction of sanitation
facilities as disaster resilient taking into consideration the disaster risk reduction as a cross
cutting aspect.

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 Annex-II

Rewarding outcomes in the context of National Sanitation Policy:

The proponents of all sanitation programmes and projects should ensure keeping an adequate
provision for rewarding sanitary outcomes. These outcomes will be rewarded at the provincial
and local level after undertaking a thorough certification process to be fully owned by the local
governments. The National Sanitation Policy endorses incentives in shape of rewards at the
following levels/ sanitary outcomes:

 Reward for all “Open Defecation Free” Tehsils/Towns

 Rewards for “100% sanitation coverage” Tehsils/ Towns
 Rewards for the Cleanest Tehsils/Town
 Rewards for the cleanest industrial estates/clusters

These rewards may also be planned at village level or community level. Ideally, rewards may be
of any nature ranging from infrastructure scheme to a standardized hand pump, however,
demand based infrastructure scheme will be a preference especially for public-funded reward
options. Rewards may be a means used by government at all tiers, international organizations,
NGOs and even specific projects to create pilots and a healthy environment in the sector.
However, public funded measures will rely on a government committee at an appropriate level
to recognize and reward.

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