Community-led total sanitation

CLTS triggering process: Community members are drawing the community map of defecation (Ghana)

Community-led total sanitation (CLTS) is an approach to achieve sustained behavior change of people who participate in a guided process of "triggering"; the triggering is intended to lead to spontaneous and long-term change of social behaviours, in particular the abandonment of open defecation. The concept was first developed by Kamal Kar for rural areas in Bangladesh in around the year 2000. The concept originally involved mainly provoking shame and disgust about poor sanitation in order to bring about change. It has been further developed since then by applying the lessons learnt from large scale applications in different rural and urban settings, focussing more on aspects of pride.

CLTS has spread throughout Bangladesh and to many other Asian and African countries (however not significantly in Latin America) with support from the Water and Sanitation Program of the World Bank, DFID and other bilateral donors, Plan International, WaterAid, CARE, UNICEF, SNV and other large INGOs and many national NGOs.^[1] CLTS was successfully included in holistic programs which also included sanitation marketing, governance and sanitation for public institutions with a strong focus on schools using children as messengers of change.

When CLTS was first introduced in a country, NGOs were often in the lead, though India was an exception. Since about 2011, CLTS is an established approach. Governments in many countries have applied it or have even included it in their national policies on sanitation. This change has created a new situation with additional challenges.^[2]

The original concept of CLTS - which made it quite unique at the time - did not include the use of subsidies for hardware (such as toilets) and building toilets for the villagers.^[3] CLTS proponents believed that by provoking behavior change in the people this will ensure that they take ownership of their own sanitation situation, construct their own toilets (often pit latrines) and pay for necessary improvements themselves. Challenges of CLTS may include possible human rights infringements within the communities, low levels of toilet standards and issues with long-term usage rates. This has been counteracted in some programs by successfully applying subsidies for a limited number of users. Rewards may also be given for successful declaration of "open defecation free" (ODF) villages.

Definitions

Open defecation is the practice of defecating outside and not into a designated toilet.

"Open defecation free" (ODF) is a central term for community-led total sanitation (CLTS) programs and primarily means the eradication of open defecation in the entire community. However, it can also include the following additional criteria:^[4]

• Household latrines are hygienic, provide the safe containment of feces, offer privacy, have a lid on the defecation hole or a water seal and a roof to protect the user.
• All household members and all members of the community use these toilets.
• A handwashing facility is nearby with water, soap or ash, and is used regularly.

Even more stringent criteria which may be added to achieve "ODF status" for a community might include:^[4]

• Safe drinking water and storage
• Food hygiene
• Greywater disposal
• Solid waste management
• Provision of toilets at schools, markets and for passers-by

Overview

A facilitator and the community during a triggering in Malda District, West Bengal, India

School-led total sanitation "triggering" event: These school children in West Bengal, India are looking at a glass of water and fresh feces. Flies will pass from the water to the feces and back, which demonstrates how water can get polluted with pathogens.

This is what CLTS tries to stop: Open defecation in rural Bihar, India

CLTS focuses on community-wide behavioural change, rather than merely toilet construction. The process raises the awareness that as long as even a minority continues to defecate in the open, everyone is at risk of disease. CLTS uses community-led methods, such as participatory mapping and analyzing pathways between feces and the mouth (fecal-oral transmission of disease), as a means of teaching the risks associated with OD.

A tool called triggering is used to propel people into taking action. The official handbook used by the CLTS Foundation^[5] explains that this takes place over a day with a team of facilitators. The team visits a community which is identified as practicing open defecation and encourages villagers to become aware of their own sanitation situation. This aims to cause disgust in participants, and the facilitators help participants to plan appropriate sanitation facilities.

Using the term "shit" (or other locally used crude words) during triggering events or presentations - rather than feces or excreta - is a deliberate aspect of the CLTS approach, as it is meant to be a practical, straight forward approach rather than a theoretical, academic conversation.^[3][5]

Phases

Pre-triggering

Pre-triggering is the process by which communities are assessed to be suitable for CLTS intervention. This involves visits and a number of different criteria, which are used to identify communities likely to respond well to triggering.^[5] During pre-triggering, facilitators introduce themselves to community members and begin to build a relationship.^[5]

Triggering

The "CLTS Handbook" from 2008 states that there is no "one way" of doing triggering in CLTS.^[5] A rough sequence of steps is given in this handbook which could be followed. Facilitators are encouraged to modify and change activities depending on the local situation.

The UNICEF manual approved for use of CLTS in Sierra Leone suggests the following steps for the triggering process:^[6]

• Visit the community, emphasising that it is for learning about their sanitation situation
• Facilitate 'Kaka Mapping' - which involves drawing the main sites in the village then the main sites for defecation
• Pretend to leave
• Facilitate the 'Walk of Shame' - walking with community to the sites of Open Defecation
• Take a piece of faeces in a bag
• Put faeces on the floor in front of the community and discuss the way flies move between food and faeces
• Wait for the shocked understanding that the community is 'eating' the faeces
• Put some faeces into a water bottle and ask community if they would drink it
• Calculate how much faeces is produced each day and asks where it goes
• Ignition
• Wait for the emergence of "Natural Leaders" to work with in order to develop a plan of action.

The idea of the triggering process is to stimulate disgust in the villagers by physical demonstration of the sanitation problems. At the 'ignition' phase, the villagers are expected to realise that there is a real sanitation problem and that they need to do something about it.^[7] Natural Leaders are people from the community who are engaged by the process and who are seen to be people who can drive change.^[8][9]

Post-triggering

After a positive response to the ignition phase, NGO facilitators work with communities to deliver sanitation services by providing information and guidance relevant to the local situation.

Comparison of different CLTS programmes

One small study compared different CLTS programmes.^[10] Participants from NGOs involved in delivering CLTS reported that although they included some of the activities described in the guidance materials, they often omitted some and included others depending on the local situation. Some reported that subsidies were included, and some offered specific design and construction options.

Applications to urban situations, schools and other settings

More recently, CLTS has been adapted to the urban context^[11] (for example in Kenya by the NGO Plan and Practical Action),^[12] and has even been used schools and the surrounding communities, which is referred to as "school-led total sanitation".^[13]

Increasingly, there is also discussion about how CLTS could be adapted to post-emergency settings. There has been some experience with this in Haiti, Afghanistan, Pakistan, Philippines and Indonesia. UNICEF has reported in 2014 positive outcomes with CLTS in "fragile and insecure contexts", namely in Somalia and South Sudan.^[14]

Outcomes and health aspects

Millions of people worldwide have benefitted from CLTS. A positive outcome is typically measured by the declarations of "ODF villages", where ODF stands for "open defecation free".

Reviews of effectiveness

There is currently a lack of scientific review about the effectiveness of CLTS, although this has been changing since 2015. A recent study looking at reports released by NGOs and practitioners^[15] found that there was little review of the impact of local Natural Leaders, that anecdotes were used without assessing impacts, and that claims were made without supporting evidence. It concluded that these kinds of reports focus on the 'triggering' stage of CTLS instead of the measurable outcomes. A peer-reviewed article^[3] considered the sustainability of CLTS in the longer term. It found that there was little monitoring or evaluation of the impacts of CLTS, even though large international organizations were involved in funding the process.

Reviews about the effectiveness of CLTS to eliminate open defecation, reduce diarrhea and other gastrointestinal diseases, and decrease stunting in children are currently underway.^[16] In some cases, CLTS has been compared with India's Total Sanitation Campaign (TSC) when assessing the effectiveness of the approach.^[17] However, this comparison may be invalid, as the presence of subsidies in the TSC process may fundamentally change the effectiveness of the CLTS process.^[18]

Health outcomes

A cluster-randomized controlled trial in rural Mali conducted during 2011 to 2013 found that CLTS with no monetary subsidies did not affect diarrhea incidences, but substantially increased child growth (thereby reducing stunting), particularly in children under two years of age.^[19]

Challenges and difficulties

A health worker (centre) gets villagers to draw a map of the area, showing the main features like the road and the river (a village near Lake Malawi, Malawi).

Villagers go to the place where meals are prepared to observe how flies are attracted to human feces and carry diseases by landing on the food (village near Lake Malawi, Malawi)

Villagers making a transect walk or ‘walk of shame’ to the open defecation places, singing ‘let us end open defecation’ (village near Lake Malawi, Malawi)

Human rights

The CLTS behavioral change process is based on the use of shame. This is meant to promote collective consciousness-raising of the severe impacts of open defecation and trigger shock and self-awareness when participants realize the implications of their actions. The triggering process can however infringe the human rights of recipients, even if this was not intended by those promoting CLTS. There have been cases of fines (monetary and non-monetary), withholding of entitlements, public taunting, posting of humiliating pictures and even violence.^[20][21] In some cases CLTS successes might be based on coercion only.^[22] On the other hand, CLTS is in principle compatible with a human rights based approach to sanitation but there are bad practice examples in the name of CLTS.^[23] More rigorous coaching of CLTS practitioners, government public health officials and local leaders on issues such as stigma, awareness of social norms and pre-existing inequalities are important.^[23]

Catarina de Alburquerque, the former United Nations Special Rapporteur on the Right to Water and Sanitation, is quoted as saying that "Observers have also recognized that incentives for encouraging behavior change and the construction of latrines are sometimes unacceptable, and include public shaming, including photographing, of those who still practice open defecation."^[3]

Toilet standards and toilet types

CLTS does not specify technical standards for toilets. This is a benefit in terms of keeping the costs of constructing toilets very low and allowing villagers to start building their own toilets immediately. However, it can produce two problems: first in flood plains or areas near water tables, poorly constructed latrines are likely to contaminate the water table and thus represent little improvement. Second, long-term use of sanitation facilities is related to the pleasantness of the facilities, but dirty overflowing pits are unlikely to be utilised in the longer term.^[24] A related issue here is that CLTS does not address the issue of latrine emptying services or where they exist, how they dispose of waste. This has led some researchers to say that the success of CLTS is largely down to the cultural suitability of the way it is delivered and the degree to which supply-side constraints are addressed.^[25]

If villagers do not know about alternative toilet options (like urine-diverting dry toilets or composting toilets), and are not told about these options by the facilitators of the CLTS process, they may opt for pour flush pit latrines even in situations where groundwater pollution is a significant problem.

Reuse of treated excreta as fertiliser

Feces are given a strong negative connotation in the CLTS approach. This can cause confusion for villagers who are already using treated human excreta as a fertiliser in agriculture and can, in fact, discourage the reuse of human excreta.

Long-term usage rates (sustainability)

There is also concern about the number of people who go back to open-defecation some months after having been through the CLTS process. A Plan Australia study from 2013 investigated that 116 villages were considered Open Defecation Free (ODF) following CLTS across several countries in Africa.^[26] After two years, 87% of the 4960 households had fully functioning latrines - but these were considered the most basic and none of the communities had moved up the sanitation ladder. 89% of households had no visible excreta in the vicinity, but only 37% had handwashing facilities present. When broader criteria for declaring communities ODF was used, an overall "slippage rate" of 92% was found.^[26] Some researchers suggest that this means support is needed to support communities to upgrade facilities in ODF villages which have been triggered by CLTS.^[10]

History

Kamal Kar presented information about CLTS at a meeting of the Sustainable Sanitation Alliance in Sweden in 2010

In 1999 and 2000, Kamal Kar was working in a village called Mosmoil in Rajshahi, Bangladesh, and decided that a system of attitudinal changes by villagers might have a longer-lasting effect than the existing top-down approach involving subsidies from NGOs and government.^[1] The Bangladeshi government began a programme of installing expensive latrines in the 1970s, but the government decided this was too costly, and many of the original latrines were abandoned.^[27] In the 1990s, a social mobilisation plan was begun to encourage people to demand and install better sanitation systems, but early success did not last, according to Kar. At that point Kar, a participatory development expert from India, was brought in by Wateraid and he concluded that the problem with previous approaches was that local people had not "internalised" the demand for sanitation. He suggested a new approach: abandoning subsidies and appealing to the better nature of villagers and their sense of self-disgust to bring about change. The CTLS Foundation is the organisation set up by Kar to promote these ideas. Kar and Robert Chambers stated in their 2008 CLTS Handbook:

It is fundamental that CLTS involves no individual house-hold hardware subsidy and does not prescribe latrine models.

— Kamal Kar, Robert Chambers, CLTS Foundation Handbook, 2008 page 8 ^[5]

In time, NGOs and governments began to see the value of the approach and ran their own schemes in various countries, some with less aversion to subsidies than Kamal Kar.^[3] Community-led Total Sanitation as an idea had grown beyond its founder and is now often being run in slightly different ways, e.g. in India, Pakistan, Philippines, Nepal, Sierra Leone and Zambia.^[28][29]

CLTS as an idea now has many supporters around the world, with Robert Chambers, co-writer of the CLTS Foundation Handbook, describing it this way:

"We have so many "revolutions" in development that only last a year or two and then fade into history. But this one is different. In all the years I have worked in development this is as thrilling and transformative as anything I have been involved in."

— Robert Chambers from Institute of Development Studies, The Guardian, 30 May 2011^[30]

The Institute of Development Studies (IDS) coordinated research programme on CLTS since about 2007 and regards it as a "radically different approach to rural sanitation in developing countries which has shown promising successes where traditional rural sanitation programmes have failed".^[31]

Today there are many NGOs and research institutes with an interest in CLTS, including for example the CLTS Knowledge Hub of the Institute of Development Studies, the CLTS Foundation led by Kamal Kar, The World Bank,^[32] Wateraid,^[33] Plan USA and the Water Institute at UNC,^[34] SNV from the Netherlands and UNICEF.^[35]

See also

• Ecopsychology
• Orangi Pilot Project
• Self-supply of water and sanitation
• Swachh Bharat Abhiyan (Clean India Mission)

References

External links

• CLTS Knowledge Hub at Institute for Development Studies (IDS) in the UK
• CLTS Foundation by Kamal Kar
• Publications on CTLS in the library of the Sustainable Sanitation Alliance (SuSanA)
• Research projects about CLTS in SuSanA's project database
• Testing CLTS Approaches for Scalability