Sanitation ladder and undernutrition among under-five children in Pakistan


While the state of sanitation in Pakistan has improved in the last decade, a significant proportion of its population is still using inadequate sanitation or no toilet facility at all. Open defecation has decreased over the years; however, it has been replaced by poor quality sanitation in rural areas that might still cause diarrhoea and undernutrition. The research regarding inadequate sanitation in Pakistan, especially in terms of the sanitation ladder, remains limited. The present research thus fills this research gap by assessing the impact of different types of sanitation on the prevalence of stunting and underweight (moderate as well as severe) among under-five children in Pakistan using the nationally representative micro survey, Pakistan Demographic and Health Survey (2017-18). The sanitation ladder comprises of piped to sewer (highest level, base) followed by flush to septic tank, flush to pit latrine, other improved, unimproved sanitation, and open defecation. In order to estimate the adjusted and unadjusted odds ratios of the determinants, this research uses logistic regressions are used to estimate adjusted and unadjusted odds ratios of the determinants. We show that toilets connected to piped sewerage network are rare in the rural areas of Pakistan and a large segment of the rural population is still practicing open defecation. The logistic regressions show that piped sewerage network and flush to septic tanks are associated with lowest odds (both adjusted and unadjusted) of stunting and underweight among under-five children. In multivariate regressions, pit latrines are associated with even higher adjusted odds of severe and moderate and severe stunting as well as underweight among under-five children, showing that poor quality pit latrines may bring the source of faecal contamination to the doorstep of the households. Therefore, interventions targeting reduction in open defecation should promote good quality toilets for sustainable long-term improvements in child health.

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  1. 1.

    Data source: Joint Monitoring Program (JMP, 2017). Website:, accessed on December 24, 2020.

  2. 2.

    Data is taken from Joint Malnutrition Estimates (JME) of UNICEF, World Bank and WHO. Data can be accessed through the following link: For Afghanistan, Bangladesh and Pakistan the data is for the year 2018, for India 2017 and for Nepal and Sri Lanka, 2016. The JME report does not include the recent estimates of malnutrition for Bhutan and Maldives.

  3. 3.

    Data source: Joint Monitoring Program of UNICEF, World Bank and WHO. Website:

  4. 4.

    Data source: PSLM 2018-19


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Authors are grateful to the DHS office for provision of data and faculty members of the department of economics at School of Social Sciences and Humanities, National University of Sciences and Technology, Islamabad, during the presentation of this paper in October 2020.

Availability of data and materials

The datasets generated and/or analysed during the current study are available in the Demographic and Health Survey repository,

Author information




All three authors jointly came up with the concept of the study. AK and KF prepared the first draft of this research including literature review and data analysis. MA revised the manuscript and improved the data analysis and write-up.

Corresponding author

Correspondence to Muhammad Ali.

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This study uses Demographic and Health Survey which provides anonymous unit level data. The authors obtained permission from DHS to use their data for this study.

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The authors declare that they have no competing interests

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Table 6 Determinants of stunting: adjusted odds ratios (full model)
Table 7 Determinants of underweight: adjusted odds ratios (full model)

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Khan, A.Y., Fatima, K. & Ali, M. Sanitation ladder and undernutrition among under-five children in Pakistan. Environ Sci Pollut Res (2021).

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  • Inadequate sanitation
  • Improved sanitation
  • Under-five children
  • Stunting
  • Underweight