Learning to cope positively with one’s living environment can be a question of life or death. In Pakistan, around 250,000 children die of diarrhoea each year. For many of those who survive, mounting garbage heaps and other types of unhygienic environment double the risk for repeated infections that drain away the vital protein their bodies need to grow. As a result, they may never reach their full physical or mental potential.

Many of the hardware solutions in the area of water and sanitation, such as dams and pumps, are costly. They also do not guarantee automatic use by or benefit for those who need them most. Solutions that are most likely to have the greatest impact for the lower cost in one area may not be the same in another. In the Community Voice in Planning initiative, CIET methods were used to look behind the indicators to identify the highest impact action points for defence of children against sanitation risk. Information on what works and what people can do to protect the children in their home environment helped mobilise local response. The findings were fed to planners to make best use of limited resources in their investment options.

Most households that participated in the survey said they throw garbage on the streets or in open places. In the Larkana district of Sindh province, this practice increased the risk of acute diarrhoea by 70 per cent. A more hygienic handling of garbage would be the single most effective intervention to reduce the number of diarrhoea cases in the district. However, a mix of interventions is nearly always necessary. In rural Larkana, lowering the cost of safe water proved to be important, while in urban areas treating tap water could have high health benefits in relation to diarrhoea.

Looking at provincial data for both Sindh and Balochistan, unhygienic disposal of garbage was also found to be strongly linked to hampered child growth and intestinal parasites. In urban areas of the Kalat district in Balochistan, garbage in open spaces was found to nearly triple the risk for dysentery and worms. Promotion of hygienic garbage disposal would be the most effective way to reduce this risk.

The link between a child’s nutritional status and the level of education of the mother was found in both participating provinces. In both Sindh and Balochistan, where nine out of ten women in rural areas are illiterate, any efforts to safeguard the healthy growth of children would have to include efforts to increase female literacy. Community solutions to this problem were explored and built into the planning process during the first phase of the Community Voice in Planning initiative.

In the Loralai district of Balochistan, reducing the time spent on fetching safe water would yield the biggest health benefits in prevention of diarrhoea and worms. This was also the case in the neighbouring Kalat district, while home visits by health workers to promote hygienic practices were found to be the most effective investment in Jhal Magsi, the third focus district in the province.

In Balochistan, nine out of ten rural households do not treat their water before drinking it (83 per cent in urban areas) and only three per cent knew it could be a risk factor for diarrhoea. Some suggested that information on how to treat water should be taught in adult literacy programs and to children at school.

Another household action with considerable health gains is the use of soap when washing the hands. The cost of soap can be offset against what it costs to manage the diarrhoea of one child in the course of the average year.

In Sindh province, the cash savings from avoiding only ten cases of diarrhoea would be enough to pay for the installation of a latrine in the home. If those using open field toilets start using safe latrines instead, this would in turn reduce the number of cases of diarrhoea further. The multiplying effects are considerable.

For each proposed action point, communities were asked what messages and channels could be used to communicate evidence and solutions to those who need to be informed. Many pointed out the financial savings through cleanliness as a good motivation factor, along with the fact that lives can be saved or improved by adopting simple hygienic practices at the household level

Preferred channels for communication were key informants, religious leaders, community health workers, NGOs and mass media. In one area, it was suggested to include messages around hygiene in the Friday prayer. In other areas, “cleanliness committees” were formed to deal with garbage disposal.

Findings were discussed at provincial and district level workshops open to the press, planners, NGOs and community representatives. For the provinces and each focus district, plans of action were created against which progress will be measured over time.