The incidence of poverty declined significantly in Pakistan, where Khyber Pakhtunkhwa (KP) saw the largest decline in poverty, followed by Punjab and Sindh while Balochistan remained the poorest province in the country, with a headcount poverty rate of almost 57 percent, says the World Bank (WB).

The WB in its latest report titled, “When Water Becomes a Hazard: The State of Water Supply, Sanitation and Poverty in Pakistan and its Impact on Child Stunting”, states that Pakistan has made significant progress on reducing poverty; improving dietary diversity and reducing open defecation. Despite this, critical markers of child health – rates of diarrhea and stunting – still do not show any real improvement.

“The incidence of poverty declined significantly in Pakistan over the past decade and a half, falling from 64 percent in 2001 to about 30 percent in 2014. The reduction was coupled with an increase in asset ownership and dietary diversity, with substantial gains in both in the bottom quintile. Khyber Pakhtunkhwa (KP) saw the largest decline in poverty, followed by Punjab and Sindh. Balochistan remained the poorest province in the country, with a headcount poverty rate of almost 57 percent in 2014”, maintained in the report.

The report states that the alarming state of water supply and sanitation in Pakistan is creating major health hazards for the entire population and young children are particularly at risk.

The report finds that bacterial contamination of surface and groundwater is on the rise because of the lack of treatment of human waste. Rural areas where the majority of poor households reside are the worst affected. Contamination levels are much higher in poorer and more rural districts and there is virtually no treatment of water at the household level.

Fecal waste is also finding its way into the surface soil and into the water used for crop irrigation. This is turn contaminates food supplies which find their way into urban centers posing health hazards for millions of city dwellers. Young children are most at risk due to diarrhea as well as growth faltering due to environmental enteropathy, which limits the absorption of nutrients even during periods when the child shows no signs of diarrhea—eventually leading to stunting.

“This report provides timely evidence and clear policy advice on the importance of safe water and sanitation for addressing malnutrition”, said Illango Patchamuthu, World Bank Country Director for Pakistan in a message. “Stunting is a serious problem in Pakistan. It severely impacts the learning of children which puts them at a permanent disadvantage in the age of the knowledge economy. This requires urgent attention to the treatment of water and investment in the management of fecal waste”, he added.

Given the gravity of the problem and the levels of investment required, the report recommends a targeted and multi-tiered approach. Investments in fecal waste management systems as well as in the provision of safe drinking water need to begin on an urgent basis but these will take time to reach scale. In the meantime, there are a number of relatively low-cost interventions that can be started immediately and at scale, to protect young children. These include efforts to encourage the point of use treatment of water and community and neighborhood-based interventions to contain exposure to fecal waste so that the oral-fecal route for the transmission of disease can be weakened, if not broken.

“There are huge disparities across the country in the quality of water and sanitation infrastructure. Rural areas across Pakistan have seen little or no investment in publicly provided piped drinking water, sewer connections or the treatment of human waste”, said Dr. Ghazala Mansuri, the author of the report. “But even the most developed urban areas are not immune. Untreated wastewater is mixed with ground and surface water to irrigate crops, so these pathogens also find their way to urban households. The key issue is that in such a context no one is protected”.

Targeting available resources to the poorest and least well-served districts would not only maximize the direct impact of public spending, but it would also reduce the negative spillovers created by poor quality sanitation and water to neighboring non-poor areas creating a virtuous win-win cycle for all.

“Pakistan’s long-term aim must be adequate and safe piped water supply with metering and realistic tariffs”, said Farhan Sami, also an author of the report. “To accomplish this, we will need to safely move fecal waste away from human settlements and treat it adequately”.

Advisor to Prime Minister said that Pakistan is facing the highest ratio of 45 percent of stunting growth rate compared to average 39 percent in the region. He further said that the government wants to change budget priority and make it performance based. He further said PM has launched clean and green Pakistan campaign which is based on five pillars including tree, solid waste management, sanitation, and safe drinking water.

He further said that after the 18th Constitutional amendment, there are capacity challenges. He said that in collaboration with provinces would be devised to overcome climate change, increasing population, sanitation and water challenges, but the federal government does not want to set unrealistic targets. He further said that the private sector would be engaged as public sector alone could not achieve its milestone.

The report states that the 18th Constitutional amendment has shifted all responsibilities in the water and sanitation sector from the federal to provincial and local governments, which weakens the federal role of setting common policy standards across the country. The report states that four out of five poor Pakistanis still live in rural areas, and there are large differences in the level and rate of progress on poverty reduction across districts.

Rural areas continue to lag behind their urban counterparts in terms of both poverty and access to basic services like health and education and the gaps persist across all quintiles of the income distribution. District-level poverty is equalizing over time, but there is a clear north-south divide. Both within and across provinces, the poorest districts registered the largest declines in poverty, but most of the poorest districts are in Balochistan, followed by Sindh and southern Punjab.

A north-south divide is also evident within the two most populous provinces of the country, with the bordering districts of southern Punjab and northern Sindh registering the highest poverty rates within the two provinces.

Urbanization is positively correlated with poverty reduction, but significant pockets of high poverty exist in better-off districts and large urban centers. Within districts, urbanization tends to be positively correlated with the pace of poverty reduction.

The districts of Hyderabad in Sindh and Musakhel and Killa Abdullah in Balochistan increased their urban share by about 23 and 25 percentage points, respectively, for example, and saw the largest reductions in poverty. But, pockets of high poverty exist within better-off areas.

Pakistan continues to lag behind its neighbors and income peers in terms of child nutritional outcomes. Despite reductions in poverty and increases in WASH access, stunting rates remain high. Indeed, stunting rates were somewhat higher in 2011 (44 percent) than in 2001 (42 percent). At the provincial level, 38 percent of all children in Punjab, 47 percent in Sindh, 49 percent in KP, and 53 percent in Balochistan were stunted in 2011. Although the rate of stunting is lowest in Punjab, a majority of Pakistan’s stunted children live there, due to its large population share. More recent data for Punjab and Sindh from the Multiple Indicator Cluster Survey shows no improvement in these rates. The incidence of diarrhea—a critical factor behind immediate weight loss, intestinal damage, and malabsorption of nutrients—also remained at 22 percent between 2006 and 2012 and again shows no improvement in the more recent MICS for Punjab and Sindh.

Higher income and good hygiene and care practices can moderate the impact of low-quality water and sanitation on nutritional outcomes. The decline in poverty has likely prevented health outcomes like stunting from worsening. An increase in household consumption is associated with a reduction in the risk of stunting and diarrhea, especially among older children, because richer households can afford better preventive care (use of oral rehydration salts or other treatment of diarrhea) and a more nutritious diet.

To make matters worse, resource allocation is not aligned with sector needs. Moreover, despite insufficient capacity, there is little effort to engage the private sector in service delivery. Without the technical capacity and the financial budget for Operations and Maintenance (O&M), these communities, which are poor and lack capacity, are set to fail in managing local infrastructure. Unsurprisingly, about a third of all schemes are nonfunctional. Fourth, inadequate information management systems mean that data on service delivery are not systematically collected.