Does ‘improved’ sanitation make children healthier? Household pit latrines and child health in rural Ethiopia

Some 250,000 Ethiopian children die each year from poor sanitation, hygiene and water. Ethiopia has ambitious plans to ensure universal access to pit latrines in all rural areas by 2012. But will people use them? Will greater availability of toilets enable children to lead healthier lives?A report from the Young Lives project draws on anthropometric data from a long-term survey of Ethiopian children, recent literature and interviews with children to show that greater access to sanitation will not, by itself, have dramatic child health outcomes.The Millennium Development Goal (MDG) target for sanitation in Ethiopia is to reach 52 percent of all households by 2015. However, the Ethiopian government has set itself the higher challenge of 100 percent coverage. Achieving this will not be easy. In 2005 UNICEF estimated that only 13 percent of Ethiopians had access to sanitation. The government hopes that training tens of thousands of extension workers, promoting healthy behaviour and social mobilisation will lead to massive increase in the use of latrines. It is one thing to build latrines but another to ensure that communities use and maintain them. In 2007 the head of Ethiopia’s environmental health acknowledged that up to 80 percent of pit latrines may not be functional.Young Lives compared two groups of children: those who experienced a change from not having access to a toilet, to using a household pit latrine between rounds of data collection in 2001 and 2006 and those who have continued to defecate in the open. Researchers found no significant difference between the groups in terms of nutritional status as measured by height-for-age (stunting) and weight-for-age (underweight). Clearly, mere access to a pit latrine does not necessarily signal improved methods of waste disposal.Young Lives interviewers found that poor infrastructure and care for pit latrines deter children. They found that many children: • Have been exposed to health education, regard clean toilets as a symbol of well-being and status but regret they do not have access to them • refuse to use toilets in schools as they are so disgusting and often not gender-segregated • greatly fear arriving late at school and being punished by having to clean toilets • believe they will get coughs and other illnesses from using latrines and thus prefer to continue defecating in fields or woods. • Improving access to sanitation and ensuring adequate programmes are in place that address cleanliness practices are central to responding to the health needs of children. Although sanitation infrastructure in Ethiopia may be improving, without changes in attitudes and behaviour towards maintenance and cleanliness, children will not make use of the new facilities.Policymakers, in Ethiopia and elsewhere, should realise that simply increasing access to pit latrines will not block transmission of faecal-oral contaminants and promote better health, especially when sanitation appears less clean than other available options not rush to build sub-optimal latrines just to meet MDG targets or strive to achieve an international standard that does not reflect rural realities develop methods to monitor the quality and use of sanitation infrastructure commission more research into children’s attitudes to pit latrines and personal hygiene.