Without water people cannot survive, but without good sanitation and hygiene practices the water available could become contaminated and lead to disease and death. Every year 1.5 million people, most of them children, die from complications associated with diarrhea that they picked up from dirty water. According to the World Health Organization (WHO) 88% of diarrhea cases worldwide are linked to unsafe water, inadequate sanitation or insufficient hygiene. Diarrhea is caused by bacteria that get into the water system, and one way that this happens is from open defecation.
Some of you may have never heard of open defecation, but it is a reality for a lot of people in developing countries due to the lack of improved sanitation facilities. In India open defecation is practiced by around 638 million people; the most of any country. In Indonesia it is practiced by 63 million people. In Sudan the number rests at 19 million people. And in Afghanistan 89% of the rural population practices open defecation (because of conflict and war no census has been done in Afghanistan since 1979, but from estimates the number of open defecators is around 20 million). From these numbers you can see that open defecation is a big problem, and is one of the contributors to millions of deaths from diarrhea every year.
With that in mind I wanted to talk about a methodology called community-led total sanitation, or CLTS, which aims to eliminate open defecation. With CLTS communities are not just handed a latrine or a hand washing facility to use because it has been found that providing these facilities does not guarantee that people will use them. CLTS recognizes that for any real behavioral change to happen you need to get the community involved and educated. So instead the communities are taught about the facilities. They are told why it is important to use them, and how lack of using them and open defecation can cause disease and death. It also focuses on “open defecation-free” (ODF) communities instead of providing toilets for individual households.
CLTS was originally thought up by Dr. Kamal Kar in 2000 while he was working with Village Education Resource Center (VERC), a partner of WaterAid Bangladesh. Dr. Kar, who had in the past worked on urban poverty, slum improvement, and local governance in India, Mongolia, Bangladesh and
Cambodia was at the time studying the traditional subsidized model for providing sanitation facilities. In realizing that this model was flawed he convinced local NGOs to stop the practice of providing toilets through subsidies, and to instead start implementing the community based approach of CLTS. He worked with these NGOs to start mobilizing and facilitating the villagers to think about their sanitation habits and to come up with solutions to the problem of open defecation on their own.
His first experience with CLTS was in the village of Mosmoil in Bangladesh. Mosmoil had in the past received subsidized toilets from aid agencies but still lived with the problem of open defecation. While there he couldn’t help but notice the piles of human waste throughout the village, often close to water sources, as well as the heavy stench that hung in the air. Once he sat down with the people from the village conversation between them erupted; people wanted a change, but often blamed each other for the problem and asked Dr. Kar to provide more free toilets. However, once he explained to them that he wasn’t there provide toilets the villagers started talking about how they could deal with the problem and after some time came up with real solutions to the problem on their own. By the end of the day children had even begun digging a hole to be used as a latrine in the village.
By engaging a whole community through CLTS a couple of things are accomplished. First, when you explain to a community that they’re getting sick because of open defecation, and even if it’s only a minority of the people practicing it, they are going to hold each other responsible for using good sanitation practices. This education also leads to people wanting to make a change. Imagine if someone came into your village where people had been getting sick and told you the reason they were getting sick and what you could do to stop it. That is a huge motivator.
However, you need to be mindful of how you get this message across. People will often use shame and disgust to compel people to change their ways and stop open defecation. There is debate among those implementing CLTS regarding if shaming people is appropriate or not. While evoking shame does works sometimes it only does if you go about it correctly. There is good shame and bad shame, and whether it turns into good or bad depends on how the message is delivered. If the message is received in a good way then it will lead to people starting to think about how they can make things better, it will expand their value system, and will make them want to elevate their community.
If it’s received in a bad way it can lead to people abandoning the program, low self-esteem, can make people angry, and feeling helpless. You can’t just walk up to someone and tell them they’re disgusting because they practice open defecation. You should explain to them why it’s unsanitary and unhygienic and lead them to realize themselves that a change needs to be made. I’ve seen this point made by placing feces on the ground next to food and having the people watch flies jump from the feces to the food, and then back and forth over and over again. When people see this it’s very easy for them to make the connection between open defecation and sickness without the person who is facilitating saying something offensive like “you’re eating your own feces”.
Also, when working with certain communities you need to realize that for some people this is how they’ve lived their whole life and this is a normal part of their day. Therefore if you tell them they’re disgusting and try and shame them they will be offended and resist any message you’re trying to get across. But if you talk to them and tell them why open defecation is bad they’ll start to realize that open defecation is obnoxious and unhealthy and this will lead to change.
Further, when you get the community involved and let them come up with the solutions it leads to them feeling a sense of ownership over what they’re doing for themselves. Ownership leads to pride, and pride leads to lasting success. Having them come up with their own plan also leads to innovation, and appropriate solutions that they can build, maintain, and repair themselves. This also leads to lasting success because when something breaks or needs to be replaced the community has the means to do it themselves.
Since CLTS was first introduced back in 2000 it has had a lot of success. One of these success stories is from Afghanistan where they started implementing the methodology in 2009. Originally this program only involved people from USAID’s Sustainable Water Supply and Sanitation Project (SWSS). However, because of the past few decades Afghans aren’t particularly trustworthy of new people coming into their country. To gain their trust and speed up the process the SWSS team partnered with one of USAID’s health program partners, Management Sciences for Health, which had already been in the country for a decade working with the people.
After gaining the trust of the Afghans SWSS made sure they were involved in every step of the process in order to ensure that CLTS appealed to local customs, attitudes and values of the Afghans. In order to bring this message to the communities 682 Afghan facilitators were trained, and 3,960 community leaders were trained to promote hygiene within their community. Soon thereafter Family Health Action Groups were formed by women in the communities to help train more woman on how to educate others. Once these women were trained they went out and taught other woman, who in turn taught their families about the importance of health and hygiene, which led to entire communities becoming aware. More or less a snowball effect of education, and it was successful. As of my writing this 394 communities in Afghanistan have been certified ODF, and this number will just continue to grow!
In Malakal, South Sudan 200 latrines have been built in a community of 2,000 households, and while there is still work to be done they are well on their way to becoming ODF. In Kyalugondo Parish, Uganda a community of 3,000 households celebrated their ODF status just this month. In Madhya Pradesh, India they aim to transform all 138 villages to ODF. As of February 2012 sixty three of the villages had accomplished ODF status. In southern Guinea Bissau, in Quinara Region, twenty eight communities were declared ODF in March 2012.
I can go on listing success stories but you get the point; CLTS has been and is working around the world. One thing that I think is important to note is that it has been working in very different cultures. It’s one thing to find a methodology that works for a specific group, but it’s completely different when you find something that can work universally. I’ve also read that after CLTS has been successful in improving sanitation it has led to communities using the basic model to solve other problems such as off season food scarcity in Bangladesh. I think that’s a true sign of a successful methodology.
To date CLTS has spread to 43 countries in Africa, Asia and Latin America benefitting roughly 20 million people. In seven countries CLTS has become the national sanitation strategy. It has also influenced UNICEF to make the decision to not provide household hardware subsidies, which in itself has led to CLTS being implemented in more cases.
Many organizations have picked up the CLTS model and base their sanitation program on it but with some changes. UNICEF calls their program Community Approaches to Total Sanitation, or CATS. UNICEF’s program differs in that they look at both the supply and demand side of the problem. Once people are educated and make decisions as to how they want to implement the program (the demand) CATS starts to look at the supply side. This usually includes things like training local masons to build latrines or setting up sanitation shops that, often with some monetary help from UNICEF, provide low cost materials for building latrines. UNICEF will not give money directly to communities, but instead will provide subsidies to facilitate plans that people in the communities have already come up with on their own.
The World Bank’s Water and Sanitation Program calls it Total Sanitation and Sanitation Marketing, or TSSM. TSSM is a combination of CLTS and what the World Bank calls Sanitation Marketing (SM). SM is basically the same idea as UNICEF’s supply and demand model, create demand and then follow by facilitating the supply.
Up to this point I have been talking about CLTS and its use in rural areas, however in the past several years organizations have been bringing CLTS into urban areas also. There has been some success, but they quickly learned that while the same basic principles remain there are a new set of challenges to overcome when using CLTS in urban areas. One of the biggest challenges is forming partnerships with the politicians in the area so that they will listen to the communities and help facilitate getting what the people need. This is often not at the top of the list of things politicians want to do, especially because the poor are often living in illegal slums that politicians don’t want to support.
Implementing CLTS in a slum area has its own particular set of challenges. Because these people know that at any time they could be evicted from where they’re living they’re less motivated to do something to help the situation. Also, because slums are often densely populated and lack a sense of community it is more challenging to get everyone involved than in a small rural community. The fact that slums don’t have a lot of space also makes it hard for toilets and wash facilities to be constructed there.
Although challenging there has been a few success stories of urban CLTS. Urban CLTS was pioneered in the Kalyani Municipality in India. The town has about 100,000 people of which about half live in its 52 slums that surround the town. Most of these slums do not have any toilet facilities. The history of sanitation in these slums is not a new story. Some of the residents had been given toilets free of charge in the past, and as is usually the case they were not used because there was no education given with the toilets. The rest of the residents that didn’t get toilets yet figured they would at some point so they didn’t take the initiative to solve the sanitation problem themselves.
In 2006 the councilors of Kalyani were persuaded to try CLTS in five of the slums. After having overwhelming success in these five slums they decided to introduce CLTS to the other slums, and by 2008-2009 all 52 slums were declared ODF leading to Kalyani being the first ODF city in India. After seeing how successful CLTS was in dealing with sanitation community leaders from the slums continued to follow its model and improved roads, cleared bush, and made many other improvements in the area. An evaluation of this project by the World Bank’s Water and Sanitation Program identified good and cooperative governance as a key element in the success of CLTS in Kalyani, however the motivation within the community also played a huge role.
In Nanded, Maharashtra, India a CLTS program is ongoing and has been successful up to this point. Currently there is a new initiative in Nairobi to implement CLTS in another urban area. They have just started this past May so it’s still in the planning and training stages but they are getting a lot of support from the local government and people in the communities are very excited to get things going. With all of this support it looks like this will be another successful implementation of urban CLTS.
With all of its success there are still challenges in implementing CLTS in rural and urban areas. Dr. Kar says that the biggest challenge is changing the view by many professionals (engineers, planners, policy makers, etc.) that believe the only way to help the sanitation situation of the poor is by providing them with free toilets. To change their thinking that you need to provide the infrastructure for sanitation and then changes in behavior will follow. CLTS turns this thinking around completely. You have to start with changes in behavior and educating people about sanitation and hygiene before you start constructing anything. Once you educate the people and they understand the problem better they gain the confidence to start implementing their own ideas of how to deal with the problem and create ODF communities.
I read a lot about water and sanitation issues throughout the world, and time and time again I see one thing that is common to most success stories: community involvement. I think it’s so important to educate the communities and get them involved in fixing the problem if there’s going to be any hope of it lasting long term, and that’s why I really like CLTS and expect it to be successful time and time again in the future. I hate to use this old proverb, but it seems so fitting to this situation; “If you give a man a fish you feed him for a day. If you teach a man to fish you feed him for a lifetime.”
As always, thanks for reading, and please leave a comment and let me know what you thought.
World Health Organization. Safer Water, Better Health: Costs, benefits, and sustainability of interventions to protect and promote health. Available at https://whqlibdoc.who.int/publications/2008/9789241596435_eng.pdf
Copenhagen Consensus 2012 Challenge Paper: Water and Sanitation: Frank Rijsberman and Alix Peterson Zwane
USAID – Global Waters – Volume III, Issue II, June 2012