Testing Community-led Total Sanitation (CLTS) Approaches for Scalability

About the Project

The Challenge: Improving Access to Toilets

Worldwide, about 2.5 billion people do not have safe toilets and as many as 1 billion people practice open defecation due to the absence of sanitation facilities. Compounded with lack of access to safe water and poor hygiene practices, these conditions contribute to the spread of disease, which kills about 1.5 million people per year. Despite the huge health benefits, enabling universal access to sanitation infrastructure will be a difficult and lengthy process. In the interim, innovative approaches for improving access to sanitation have emerged which could help fill the gap and improve people’s health and quality of life.

A Solution: Community-led Total Sanitation

Community-led total sanitation (CLTS) is an approach to sanitation promotion that has spread to countries across South Asia, Latin America and Africa over the past 15 years. This approach seeks to eliminate open defecation and encourage the construction and use of sanitation facilities through “triggering” or grassroots mobilization of communities. When successful, triggering promotes a community-wide commitment to becoming open-defecation free (ODF).

The Research Issue: Working with Local Actors

Successfully mobilizing communities to become ODF appears to depend greatly on the skills of local facilitators. Research is needed to understand the essential aspects of the facilitation and mobilization process and how it could be scaled to national level and/or replicated in other countries.

Plan International USA’s Testing CLTS Approaches for Scalability project aims to advance rural sanitation efforts in Kenya, Ethiopia, Ghana, and worldwide by improving the cost-effectiveness and scalability of the CLTS approach, with a particular focus on the role of local actors, such as teachers, local government staff, and natural leaders.

In collaboration with The Water Institute at the University of North Carolina, this goal will be achieved by collecting, critically evaluating, and disseminating lessons about overcoming common challenges to implementing CLTS at scale, based on applied research from interventions in Kenya, Ghana, and Ethiopia.

Funding for the project is provided by the Bill & Melinda Gates Foundation.

In Kenya

In Kenya, our study takes place in two counties, one located on Lake Victoria and the other located in the Indian Ocean coastal area. We selected four sub-counties and identified a number of government officials to receive our capacity-development program. The program consists of a 1-week training, followed by mentoring and support for their CLTS-related duties. Using qualitative research methods, we will evaluate changes in individual knowledge, attitudes and practices relating to the management and monitoring of CLTS. We expect to complete our activities in Kenya in May 2015.

In Ghana

In Ghana, we are working in the Volta, Central and Upper West regions of the country. Plan Ghana and their partners implemented conventional CLTS in 20 communities from each region, for a total of 60 communities. We randomly assigned 30 of the communities to receive additional training. In these 30 communities, we identified natural leaders to receive training and mentoring in a variety of topics. Natural leaders are community members who demonstrate commitment to making their communities ‘Open Defecation Free’. We will evaluate how the training affected household- and community-level outcomes. Our activities in Ghana are expected to complete by October 2014.

In Ethiopia

In Ethiopia, we are working in the Oromia and the Southern Nations, Nationalities and Peoples’ (SNNP) regions of the country. We selected six kebeles in these two regions. Four kebeles received CLTS led by teachers and two kebeles received CLTS led by health extensions workers (HEWs). We will evaluate and compare household, village, and kebele level outcomes in both the teacher and HEW groups. Our activities in Ethiopia will conclude in October 2014.

Research Themes

In what contexts do local actors work?

Context refers to the settings or circumstances in which local actors carry out their roles and responsibilities. We are interested in learning about what factors help or hinder local actors in contributing to the success of CLTS. For example, a motivated natural leader may only be able to influence their community in settings where sanitation subsidies have never been introduced or in circumstances when traditional leaders have shown that they are supportive.

We are exploring these issues through:

A systematic review of CLTS literature;
Case studies of CLTS approaches in nine countries across Asia, Africa, and the Caribbean;
Situational assessments in Ghana, Kenya, and Ethiopia; and
Implementation and evaluation of CLTS projects in Ghana, Kenya, and Ethiopia.

As we learn from our research, we will share findings through this website. Our work will give a better understanding about which factors matter most for the success of CLTS. This will support decision making by practitioners and policy-makers about where and how to spend time and money.

What is the role of local actors?

The term “local actors” refers to individuals who have a role in CLTS. We are interested in how local actors are involved in CLTS, and how they affect CLTS implementation.The roles of local actors vary from country to country. In this project, we work with natural leaders, schoolteachers, and local government officials in their roles as community motivators, facilitators, and CLTS program managers respectively. Local actors also include others such as children, non-governmental organizations (NGOs), and health workers.

We are exploring the role of local actors through:

In-country implementation and evaluation activities;
A systematic review of CLTS literature;
Case studies of CLTS approaches in nine countries across Asia, Africa, and the Caribbean; and
Situational assessments in Ghana, Kenya, and Ethiopia.

As we learn from our research, we will share our findings with you here. Our work will provide a better understanding of how local actors support CLTS across different countries and contexts, which could help us all make better decisions about programming and policy.

What is the cost of involving local actors?

We are interested in the economic cost of involving local actors, which includes financial and non-financial costs associated with involving local actors in a CLTS project. For example, a CLTS triggering session involves paid facilitator time and unpaid community member time, both of which have a cost. Triggering also includes transportation, food, and possibly phone credit.

Limited data has been collected on the costs of CLTS. Most organizations in the countries included in our research do not track or record spending on CLTS activities. We cannot assess cost-effectiveness of CLTS without this information. This makes it difficult for policy-makers to make decisions on how to allocate resources.

In Ghana, Kenya, and Ethiopia, we are looking at a range of costs, including the cost of training, facilitation, community meetings, and latrine construction.

Through our combined implementation and evaluation, we will show how these costs vary in different settings and for different local actors. A better understanding of CLTS costs will enable us to see how to reduce costs, and to compare cost-effectiveness of different approaches to CLTS and CLTS in different settings.

How do local actors influence results?

One aim of our project is to understand how CLTS outcomes change in Ghana, Kenya, and Ethiopia when we give extra training and mentoring to local actors.

In Ghana, we are evaluating how training natural leaders affects household- and community-level outcomes such latrine construction and behavior change. In Kenya, we are evaluating how training and mentoring local government affects their CLTS knowledge and attitudes, and management of CLTS in their counties. In Ethiopia, we are evaluating teachers as facilitators in comparison to health extension workers using household-, village-, and kebele-level outcomes.

Our recent systematic literature review revealed that while many say natural leaders, teachers, and local government are important for sanitation and hygiene, there is limited evidence for their exact role or how they influence CLTS outcomes. Our findings will be of interest to researchers, practitioners and policy-makers who wish to understand how to improve their projects. We are currently updating the systematic literature review and will share the update on our website soon.

Knowledge Update: Plan International Kenya: CLTS Management Capacity Building for District-Level Officials

Implementation Narrative • November 2015

Download the Implementation Narrative (PDF, 688kb, 18 pp.)

The Testing CLTS Approaches for Scalability project was a four year, sanitation-focused, operational research project that aimed to advance rural sanitation efforts in Kenya, Ethiopia, Ghana and worldwide by improving the cost-effectiveness and scalability of the CLTS approach, with a particular focus on the role of local actors. In Kenya, the project assessed the role that government officials could play in increasing the cost-effectiveness and scalability of CLTS. The project was implemented in two Plan Program Units (PUs), Kilifi and Homa Bay, where CLTS activities were launched in 2007 and 2009, respectively. These two PUs were selected so that the project could build upon the ongoing CLTS activities and to provide a benchmark for comparison to assess the impact of the project.

In each of the pilot evaluation countries, the project team at Plan International document their progress throughout the implementation part of the grant. This Implementation Narrative accordingly reflects this process and introduce project team analysis of factors that enabled and constrained implementation. It is our aim that, should other practitioner oriented organizations be interested in applying this adaptation of the CLTS approach, they can do so by following the steps laid out in this report.

In addition to this Implementation Narrative, a new video highlights the impact of empowering government officials as key stakeholders.

Watch the video:

External Resources

Kar, Kamal, and Robert Chambers. 2008. Handbook on Community-Led Total Sanitation. London, United Kingdom: Plan International UK. http://plan-international.org/about-plan/resources/publications/water-and-sanitation/handbook-on-community-led-total-sanitation

Knowledge Update: Lessons from CLTS Implementation in Seven Countries

Learning Brief • February 2016

Download the Learning Brief (PDF, 709kb, 6 pp.)

Purpose

This learning brief shares key findings that emerged from a cross-country synthesis of CLTS projects implemented by Plan International Country Offices (COs) in Cambodia, Nepal, Indonesia, Lao PDR, Uganda, Niger, and Haiti. Specifically, this research aimed to characterize variations in CLTS implementation through the perspectives of stakeholders, and to identify the roles of local actors in implementing CLTS. Several implications are relevant for consideration by Plan International staff across the seven COs, as well as other sanitation practitioners.

The brief is part of the CLTS Learning Series (LS), a collection of case studies on CLTS implementation, prepared by The Water Institute at the University of North Carolina at Chapel Hill (UNC) as part of the Plan International USA project, Testing CLTS Approaches for Scalability. Research activities conducted between 2012 and 2015, sought to better understand CLTS facilitation and mobilization by rigorously evaluating three distinctive strategies to enhance the roles of local actors in CLTS interventions in Kenya, Ghana and Ethiopia. The seven country case studies referenced in this report were undertaken to complement the three pilot evaluations, and to further explore the role and potential of local actors in CLTS.

Methods

UNC researchers collected data between May 2013 and June 2014 with support from Plan International COs. In-depth interviews were conducted with 293 people, including policymakers, Plan International staff, other non-governmental organization (NGO) partners, local government officials, village-level CLTS facilitators, and community leaders. Policy and programmatic documents were also gathered over the course of two to three weeks in each country. Across all 7 countries, thirty-four communities were visited, 44% of which were declared or certified as open-defecation free (ODF) by the time of the visits. Interview transcripts, field notes, and documents were analyzed qualitatively to identify themes pertaining to different stages of CLTS, from which implications and conclusions were drawn for sanitation practitioners as a whole.

Key Findings

CLTS Triggering in Lao PDR, Photo by Plan International

CLTS was widely perceived as a universally applicable approach in rural communities, despite varying success in outcomes.
Local government, in five of the seven case studies, had insufficient resources and motivation to take ownership of CLTS,
Village volunteers were involved throughout CLTS implementation, but required considerable support from Plan International and local government.
Triggering techniques had been adapted in all seven case studies, but were not always designed with the aim of improving outcomes.
Although community-developed sanctions are encouraged, most examples from the case studies were enacted by village or district government.
Affordability and access to durable latrine mate-rials were key obstacles affecting sustainability of outcomes.
Monitoring of CLTS varied widely across programs, with different indicators of success, ODF definitions, verification guidelines.

Implementation Context

Plan International’s implementation arrangements for CLTS varied between each country, ranging from direct implementation to playing a more supportive role of providing technical and capacity building assistance to local government. The complexity of arrangements depended largely on government support for CLTS and sanitation, as well as the capacity of different actors to participate in the process. Where national government support for CLTS was strong and the approach had been implemented for several years (Nepal, Indonesia, Uganda, and Cambodia), local government played a more important role in facilitating CLTS activities, and arrangements were more complex. These governments were directly investing in CLTS activities to train staff local government counterparts. Where national government support was weaker (Lao PDR, Niger, and Haiti), Plan International played a lead role in implementing CLTS. In all seven programs, community leaders played an important role in implementing CLTS, but mostly in the post-triggering stage.

The policy environment in all seven countries was found to be largely positive towards CLTS. All seven governments recognized the need for demand-led sanitation strategies. However, several national policies, such as those in Lao PDR, Cambodia, and Niger, allowed for targeted hardware subsidies for households or public facilities. In all countries where latrine subsidy projects and CLTS overlapped, CLTS practitioners cited considerable challenges.

CLTS Progress

Across all seven LS countries, Plan International has trig-gered nearly 1,000 communities and is one of the major NGOs implementing CLTS. Self-reported monitoring data revealed a wide range in the presence of ODF communities—from 6% of communities in Haiti being declared ODF to 97% of communities in Indonesia being certified as ODF (Table 1). However, these numbers cannot be directly compared across case studies because ODF definitions and verification processes were not consistent. In terms of household latrine coverage, Plan International programs in Indonesia, Uganda, and Lao PDR appeared to have the best end-line results. Baseline data were available for four of the seven case study programs. Of these, the largest ab-solute increase in household latrine coverage after trig-gering activities occurred in Uganda (44%). However, it is not possible to attribute this progress entirely to CLTS activities, as other factors may have also contributed to the increase in latrine coverage, such as campaigns by government or other organizations.

Table 1. Overview of Plan International’s CLTS outcomes in case study programs, 2013–2015

Key Findings & Implications

Finding 1: CLTS was widely perceived as a universally applicable approach in rural communities, despite varying success in outcomes.

Most CLTS practitioners and several policymakers who were interviewed believed that CLTS could be implemented in all rural settings. Only a few respondents challenged the notion of CLTS as universally relevant, and believed in the need for alternative strategies in settings where CLTS had not worked. This widely-held conviction meant that even in challenging environments, alternatives to CLTS were less likely to be considered. Many respondents believed that CLTS could at least be a “starting point” to generate demand, even in settings where practitioners themselves felt it was unlikely to succeed in ending open defecation by itself.

Some practitioners did recognize that alternative or complementary strategies to CLTS may be needed, but the more prevalent belief in the universal relevance of CLTS seems to have overshadowed the need for targeting appropriate communities with this approach and seeking alternative sanitation strategies for less receptive communities. Practitioners’ perceptions of CLTS are important because they determine how the approach is implemented, specifically the manner in which communities are selected for triggering. The widespread application of CLTS may help explain slow progress in several programs. By not targeting communities to optimal settings for CLTS, it is probable that villages not appropriate for CLTS may have been triggered, leading to slow increases in latrine coverage and low ODF attainment.

Finding 2: Local government, in five of the seven case studies, had insufficient resources and motivation to take ownership of CLTS.

It is widely acknowledged that local government support and capacity are vital for scaling up social and public health programs. In all case studies except Haiti, Plan International worked closely with local government actors, even when local government was not mandated to be involved in CLTS. Local government involvement ranged from leadership in CLTS (Nepal) to requiring considerable assistance from Plan International (Lao PDR) to no involvement at all (Haiti).

Government and NGO respondents cited insufficient local government capacity as a key challenge to increasing the scale of activities. Capacity referred to legal responsibility for local government to provide sanitation services; local government budget for CLTS; sufficient staff time avail-able for sanitation; access to transportation to routinely follow-up in remote areas; and experience and skills for facilitating or managing CLTS on their own.

Slow progress in some countries may be partly explained by local government implementing CLTS with limited capacity, including facilitation skills, resources, and motivation for routine follow-up activities. Where local government capacity is insufficient to lead CLTS, NGOs continue to play a dominant role in all stages of implementation until local government is able to take on a leadership role.

Finding 3: Village volunteers were involved throughout CLTS implementation, but required considerable support from Plan International and local government.

As CLTS is a “community-led” process, a crucial component of the strategy is to involve community leaders to take charge of their own sanitation situation. CLTS programs typically refer to “natural leaders”, who emerge from the triggering process and participate in post-triggering activities.

In the seven case studies, a variety of village volunteers were found to be involved in all stages of CLTS. In Nepal and Haiti, volunteers were involved in the pre-triggering stage itself to mobilize communities. In Indonesia, Nepal, and Uganda, village volunteers were recruited as triggerers. While these volunteers were supposed to ultimately lead triggering events, they were not yet able to do so and were supported by local government or Plan International facilitators.

Village volunteers increase community-level engagement, and can also lower the cost burden for practitioners since fewer follow-up visits may be required. However, costs are then transferred to volunteers. Although volunteers in the case studies appeared to be highly motivated, maintaining this level of engagement in the long run remains a concern and may require additional resources, such as increased numbers of training events, and providing monetary and non-monetary incentives.

Finding 4: Triggering techniques had been adapted in all seven case studies, but were not always designed with the aim of improving outcomes.

Plan International used a variety of approaches to trigger communities to change sanitation behavior. The most commonly cited triggering tools were the transect walk/ “walk of shame,” village mapping, shit calculation, water-feces demonstration, and analysis of medical costs. However, several of these triggering tools did not appear to be used routinely in all programs.

For instance, local government facilitators in Cambodia and Lao PDR hesitated to use strong shaming techniques, reportedly due to cultural reasons, and omitted certain steps, such as the water-feces demonstration, because they themselves were too embarrassed to lead these activities. On the other hand, in two triggering events observed in Nepal, LNGO facilitators insisted strongly on community members’ continued participation, even if they were too ashamed or disgusted to stay in place during the transect walk or the water-feces demonstration. Triggering techniques were also adapted in Niger, where facilitators observed that communities were not as aware of the harms of open defecation; therefore, facilitators emphasized health benefits of ending open defecation, rather than techniques that are meant to incite shame and disgust.

Triggering techniques are likely to strongly influence CLTS outcomes. Adaptations in triggering indicate that Plan International does not follow a set template for CLTS and recognizes the need to modify the approach to suit different contexts. However, all adaptations are not equal. Context-specific adaptations that emerge from community- level observations and experiences can be encouraged. However, certain adaptations may compromise the CLTS approach itself and slow progress in communities, and may need to be modified through improved training and selection of facilitators.

Finding 5: Although community-developed sanctions are encouraged, most examples from the case studies were enacted by village or district government.

In international CLTS guidelines, community-innovated sanctions against open defecation are encouraged and listed as a key indicator for monitoring progress in communities. In the seven case studies, truly community- developed sanctions were only reported in a few instances in Uganda and Lao PDR. It was more common to find sanc-tions developed by village or district government, such as in Indonesia and Nepal where social insurance cards or government donations were withheld from households. These sanctions were often informal in nature, as there was no law or guideline authorizing government to with-hold services based on sanitation status.

Sanctions may be a key component in creating and enforcing social norms. The question is not whether the law has a role to play in sanitation, but rather which form is appropriate, at what stage it is introduced, how it is enforced, and how effective it is at ending open defecation and improving safe and equitable sanitation. Local government-imposed sanctions may lead to increased latrine construction, but it is unclear how they influence long-term changes in social norms. They may also inadvertently harm the most vulnerable sections of society who cannot afford to build latrines.

Finding 6: Affordability and access to durable latrine materials were key obstacles affecting sustainability of outcomes.

In all case studies, practitioners, policymakers, and community leaders cited the poor quality of latrines built as a result of CLTS as the primary challenge for ensuring sustainable use of sanitation. Triggered households constructed a variety of latrine types, but there was a strong preference for water-sealed latrines or durable latrines made of cement. In all seven countries—particularly in Cambodia, Niger, Uganda, Haiti, and Indonesia—Plan International worked to improve access to the supply chain, primarily by training masons or through broader sanitation marketing efforts. However, community leaders cited affordability as the main obstacle for being able to act on behavior change messages. Positive examples of local financing and community support mechanisms were identified in the case studies. However, there were also several examples of different forms of hardware subsidies in triggered communities. While they largely believed that CLTS should be a no-subsidy approach, several policymakers and Plan International staff were in support of targeted financial or material support to vulnerable households. Some acknowledged that CLTS may not be enough to address the supply side of the sanitation problem.

By training masons, implementing sanitation marketing programs, and encouraging local financing mechanisms, Plan International staff have shown that they recognize the importance of improving supply-side conditions in the post- triggering phase. Sanitation marketing in particular may help improve access to the supply chain, serving as a com-plement or as a viable alternative to CLTS. However, the challenge of increasing access to sanitation for vulnerable and marginalized populations may require additional financial or material support, provided that it follows CLTS activities and is targeted to those most in need.

Finding 7: Monitoring of CLTS varied widely across programs, with different indicators of success, ODF definitions, verification guidelines.

CLTS monitoring activities comprised a variety of process and outcome indicators, but ultimately focused on achievement of ODF status, except in Haiti. Most programs had simple monitoring systems that did not systematically capture sufficient data to enable cross-country comparisons. Of the seven case studies, only programs in Lao PDR, Uganda, and Niger consistently captured baseline measurements in communities. Definitions of ODF varied substantially across all seven case studies, underscoring the challenge of measuring behavior change at the community level.

Without baseline measurements and routine assessments, programs cannot measure change or appropriately analyze the effectiveness of their CLTS activities. Furthermore, many programs aimed to measure total sanitation under the definition of ODF by adding indicators on handwashing, safe water practices, and environmental sanitation. This sets a more ambitious goal for ODF attainment than the actual the term ODF would imply. Improved monitoring efforts are especially important when there is no standard ODF definition, thereby making it impossible to compare results across programs.

Recommendations

Role of CLTS

CLTS should be considered as one component of a sanitation strategy. Communities that are more likely to be receptive to CLTS should be targeted systematically so that practitioners can allocate remaining resources to test other approaches, such as sanitation marketing, in communities where CLTS may not be appropriate.

Local government capacity

Where local governments are unable to lead CLTS activities, INGOs could strengthen their capacity through training, mentorship, and targeted technical support, and by engaging local NGOs to trigger communities. They could advocate for increased national government investment in CLTS.

Role of village-level actors

When involving volunteers, resources have to be budgeted for training, financial and in-kind support, recognition, and exchange visits, in order to sustain motivation through the lifetime of the program and beyond.

Adaptations to triggering

Programs could systematically identify adaptations to CLTS and critically analyze whether the adaptations are a result of community context or a result of convenience or logistical constraints. They could attribute results to the actual approach that has been implemented so that rural sanitation stakeholders can better understand the effectiveness of CLTS vis-à-vis other approaches.

Sanctions

CLTS practitioners need to carefully consider which sanctions they actively encourage or passively condone, who enforces the sanctions, and how they are enforced. Sanctions need to be introduced at the right time, in the right manner, and target the right people, so that they do not unevenly affect those who are already marginalized, but rather protect the majority from those who are unwilling to change despite having the ability to do so.

Hardware supply and financing

Plan International could continue improving supply-side conditions in triggered communities, including testing sanitation marketing in more country programs. In countries where government or NGO subsidies are still present, Plan International can help influence the mechanisms by which these subsidies are targeted to ensure that they do not negate CLTS efforts but rather enhance sustainability of outcomes.

Monitoring outcomes

CLTS programs could consider focusing on routinely collecting household-level indicators of sanitation (including baseline measurements) to measure and recognize incremental progress in communities. Improved monitoring of activities will help generate evidence on the potential, the effectiveness, and the limits of CLTS.

Limitations

Findings described in this report are from a qualitative analysis of CLTS implementation and sample sizes are intentionally small to allow in-depth analysis. Although readers may connect these findings to their own CLTS experiences, they should be cautious about generalizing the findings. Furthermore, researchers visited a subset of communities where Plan International implements CLTS, which means the study may not fully capture all aspects of CLTS implementation in Plan International COs.

Acknowledgements

Authors: Vidya Venkataramanan and Alexandra Shannon, The Water Institute at UNC

Knowledge update: From Haiti to Indonesia: What’s Different; What’s the Same in CLTS Implementation?

Learning Series Synthesis Release Announcement • January 2016

In an unprecedented multi-country study, using rigorous research design and independent data collection and evaluation, Plan International USA and the Water Institute at the University of North Carolina at Chapel Hill (UNC) are releasing new findings and results about rural sanitation behavior change processes using the Community-led Total Sanitation (CLTS) approach.

This seven country evaluation of case studies presents common features of CLTS implementation, identifies bottlenecks and enabling conditions, and shares lessons relevant to scaling-up CLTS. The research in question identifies implications for practice and delivers policy recommendations across a range of country contexts, including Haiti, Uganda, Niger, Cambodia, Lao PDR, Nepal and Indonesia. Long-form, individual country reports are complemented by a case study meta-analysis, as well as a briefing paper for rapid review of key insights.

External Resources

Kar, Kamal, and Robert Chambers. 2008. Handbook on Community-Led Total Sanitation. London, United Kingdom: Plan International UK. http://plan-international.org/about-plan/resources/publications/water-and-sanitation/handbook-on-community-led-total-sanitation

Knowledge update: Plan International Ethiopia: Teacher-Facilitated Community-Led Total Sanitation

Implementation Narrative and Project Video • January 13, 2016

The Testing CLTS Approaches for Scalability grant is a four year, sanitation‐focused, operational research project that aims to advance rural sanitation efforts in Kenya, Ethiopia, Ghana and worldwide by improving the cost‐effectiveness and scalability of the CLTS approach, with a particular focus on the role of local actors. In Ethiopia, the project assesses teacher‐facilitated CLTS as an alternative to the conventional facilitation approach led by health extension workers (HEWs). The project was implemented in six Kebeles: teacher‐facilitated in four; HEWs together with Kebele administrators facilitated in the remaining two. Three of the Kebeles were located in Deksis District, Oromia region and three were in Dara District, SNNP region. HEWs were responsible for community triggering, follow‐up and reporting for control Kebeles, while teachers were responsible for the same in the treatment Kebeles.

Knowledge update: Community-led Total Sanitation in Haiti: Findings from an Implementation Case Study

Learning Brief • January 6, 2016

Purpose

This learning brief shares key findings from a case study of community-led total sanitation (CLTS) implementation in Plan International Haiti program areas, focusing on the roles and responsibilities of local actors. Several implications are relevant for consideration by Plan International Haiti and other sanitation practitioners.

The brief is part of the CLTS Learning Series, a collection of seven country case studies on CLTS implementation prepared by The Water Institute at the University of North Carolina at Chapel Hill as part of the Plan International USA project, Testing CLTS Approaches for Scalability. The 4-page brief is based on the 30 page Haiti Country Report.

Methods

In June 2014, a researcher from The Water Institute collected data in the South-East and West Departments (first level administrative subdivisions), including the capital city of Port-au-Prince. Data collection consisted of 20 in-depth interviews with government and non-government stakeholders, visits to seven triggered communities across both departments, and a review of relevant organizational documents and national reports.

Key Findings and Implications

Men Digging Pit Latrine for an Elderly Couple; Photo by Vidya Venkataramanan

Government capacity to implement CLTS in Haiti remains weak, and greater coordination is needed between ministries and INGOs. Plan International Haiti and their INGO partners can help the government by organizing trainings and providing trained facilitators.
Program outcomes thus far indicate that CLTS needs to be better targeted towards appropriate communities. Baseline assessments can help to determine which communities may be more receptive to the CLTS message.
Plan International Haiti’s CLTS projects had strong engagement with village-level actors, especially natural leaders. This approach keeps communities engaged and can empower natural leaders to influence behavior change in their communities.
Financing and affordability of sanitation hardware remains a significant challenge. Plan International Haiti can help build the supply chain by exploring supply-side interventions, including sanitation marketing activities, financing/payment plans, and self-help mechanisms.

Roles of Local Actors

Plan International Haiti first began implementing CLTS in 2011 and serves as one of the main actors involved in the activities presented in this report. At the national level, representatives from Plan International Haiti coordinate activities with the Direction Nationale de l’Eau Potable et de l’Assainissement (National Directorate of Drinking Water and Sanitation, or DINEPA), the Ministère de la Santé Publique et de la Population (Ministry of Public Health and Population, or MSPP), and other international non-governmental organizations (INGOs) through monthly meetings. At the department level, Plan International Haiti works through Program Units (PUs) and recruits a team of facilitators for all aspects of the CLTS process. There was minimal local government participation in CLTS activities at the time of this study. Figure 1 further illustrates the role of Plan International Haiti’s CLTS activities.

CLTS Progress

Table 1 highlights the most recent data obtained from Plan International Haiti’s CLTS projects. UNICEF and the Plan National Offices of Ireland (INO), Germany (GNO), and Japan (JNO) provided funding for CLTS activities described in this study. In the UNICEF/INO-funded project, 20% of households that started building latrines after triggering completed their latrines. In the JNO-funded project, staff estimated they had reached 3,588 households across six communities, aiming for at least 10% of households to construct or rehabilitate latrines. Data on baseline latrine coverage and the size of triggered communities were not available, which makes it difficult to assess progress in communities after triggering.

Table 1. Outcomes of Plan International Haiti’s CLTS projects, 2015

Key Findings

Finding 1: Government capacity to implement CLTS in Haiti remains weak, and greater coordination is needed between ministries and INGOs.

At the time of this study, a national sanitation strategy had been drafted but not yet finalized. The strategy does not allow for household toilet subsidies and emphasizes the enforcement of existing laws, provision of public services, and sensitization on household sanitation. Plan International

Haiti, UNICEF, and DINEPA also produced a facilitator’s guide titled Approche Communautaire pour l’Assainissement Total (Community Approach for Total Sanitation, or ACAT), which closely resembles CLTS methods. However, it is unclear how ACAT will be incorporated into the national strategy. In addition, DINEPA and MSPP, with the help of INGOs, are also trying to rebuild the local health infrastructure by recruiting and training 10,000 multipurpose community health agents (MCHAs) to trigger communities. However, there is currently no pool of master trainers available to meet the demands of training these MCHAs.

Despite growing government recognition and planning around sanitation, documents and interviews with government officials revealed significant obstacles, including poor coordination between INGOs and government institutions and limited access to low-cost sanitation technologies.

Finding 2: Program outcomes thus far indicate that the scope for CLTS in Haiti needs to be well-defined.

In three CLTS projects across 83 communities, Plan International Haiti has not yet been successful in converting communities to open defecation free (ODF) status. One important note here is that ODF achievement is not the ultimate aim of CLTS activities in Haiti; instead, the project focuses on reducing open defecation using the construction and rehabilitation of latrines as an indicator. That said, it was clear that sufficiently stringent criteria to select communities that are appropriate for CLTS was not utilized. For instance, amongst current project staff, many indicated that communities with a history of financial assistance, or those without adequate social cohesion, may not respond to triggering alone; although, the proposed solution was to increase follow-up visits, rather than considering other approaches.

Furthermore, “communities” were not defined clearly. It was unclear whether Plan International Haiti triggered entire localities, communities within localities, or simply groups of households near the schools in which they worked. It is possible that Plan International Haiti has been triggering large groups of households that may not feel a sense of social cohesion, which was cited as a significant challenge in rural communities in Haiti.

Finding 3: Plan International Haiti’s CLTS projects had strong engagement with village-level actors, especially natural leaders.

Plan International Haiti, with help from community leaders, formed hygiene clubs as part of routine hygiene promotion work. For instance, in the first year of the JNO-funded project, four clubs—children, youth, mother, and father—of fifteen people each were formed and trained on hygiene and sanitation messages prior to triggering communities with CLTS. Amongst other activities, these club members also helped identify households without latrines and invited them to triggering events. Some club members were also members of CLTS committees, which are formed after triggering events. CLTS committee members may be considered natural leaders, as they emerged during the triggering process. These leaders were all given additional training on CLTS and sanitation messages, and were then asked to use this training to motivate their community members to stop open defecation.

Finding 4: Financing and affordability of sanitation hardware remains a significant challenge.

The main challenge for successful implementation of CLTS in Haiti is the history and presence of financial assistance for latrine construction. Although Plan International Haiti is now trying to encourage households to build latrines with locally available materials, they and other INGOs have unintentionally fostered a strong preference for cement latrines. One natural leader noted, “People nowadays do not build latrines with wood anymore.” However, the weak supply chain in rural Haiti means that access to this kind of hardware is limited and expensive unless it is brought to communities by INGOs.

There was some indication that Plan International Haiti trained masons in the UNICEF/INO and GNO-funded projects to build latrines using externally-financed materials. In the current JNO-funded project, which does not have a provision for hardware support, Plan International Haiti trains two masons per community on latrine construction. In some communities, these masons work voluntarily, while in others they charge for their services. Whether or not they charge is decided by community members at the outset of CLTS activities. Plan International Haiti has also tried to encourage kombit, a Haitian term which refers to a community working together towards a common goal, to mobilize communities to build latrines, but this requires strong social cohesion.

Implications

This study reviewed aspects of Plan International Haiti’s CLTS process with a specific focus on local actors and their roles in achieving and monitoring impact. The following implications highlight areas where local actors and Plan International Haiti can improve their CLTS activities.

Poor coordination between the national government and INGOs makes it challenging for Plan International Haiti to implement CLTS in communities where financial assistance for hardware may be offered simultaneously. Furthermore, until the local government health infrastructure is established, INGOs will continue to implement CLTS mostly on their own. In addition to helping the government write strategic guidance on CLTS and sanitation strategies, Plan International Haiti and other INGO partners can offer trainings for MCHAs to build local capacity.

By engaging with village-level actors, Plan International Haiti may be able to address some issues of social cohesion by creating bonds around water, sanitation, and hygiene (WaSH) activities. However, reliance on volunteers to implement CLTS means there is no obligation to follow any directives. In future CLTS projects, Plan International Haiti should consider involving a greater variety of local actors in the post-triggering stage, such as local government leaders, to stimulate progress in triggered communities.

To improve CLTS outcomes, Plan International Haiti will need to invest more heavily in pre-triggering activities. They must consider using more stringent criteria when selecting “communities”—the social and geographical boundaries of which need to be defined first—including minimal history of externally- financed latrine building or WaSH projects nearby, and smaller, more cohesive groups of households. Baseline assessments that determine existing sanitation coverage and a history or presence of WaSH projects in or near these communities will allow them to target triggering events to those groups that are more likely to be receptive to the CLTS message.

Plan International Haiti can also consider ways to build the sanitation supply chain by developing and increasing access to low-cost products that masons can use to market their skills and increase latrine access. They may be able to do this through the introduction of sanitation marketing activities, locally-decided financing plans, or through self-help mechanisms like kombit.

Limitations

This study uses qualitative methods and a small sample size. Researchers did not evaluate program effectiveness. Although readers may connect these findings to their own CLTS experiences, they should be cautious about generalizing the findings. Furthermore, researchers visited a subset of communities where Plan International implements CLTS, which means the study may not fully capture all aspects of CLTS implementation in Haiti.

Acknowledgements

Authors: Vidya Venkataramanan and Alexandra Shannon, The Water Institute at UNC

This learning brief was made possible through support from Plan International USA, which received a grant from the Bill & Melinda Gates Foundation. The findings in this brief are derived from the Haiti Country Report, available in our Resource Library at waterinstitute.unc.edu/clts. Data were collected by the Water Institute at UNC with logistical support from Plan International. The findings and conclusions contained within do not necessarily reflect positions or policies of the funder, Plan International USA, or of The Water Institute at the University of North Carolina at Chapel Hill.

Project Resources

Venkataramanan, Vidya. 2015. CLTS Learning Series: Haiti Country Report. Chapel Hill, USA: The Water Institute at UNC.
Venkataramanan, Vidya and Alexandra Shannon. 2016. Community-led Total Sanitation in Haiti: Findings of an Implementation Case Study. Chapel Hill, USA: The Water Institute at UNC.

External Resources

Kar, Kamal, and Robert Chambers. 2008. Handbook on Community-Led Total Sanitation. London, United Kingdom: Plan International UK. http://plan-international.org/about-plan/resources/publications/water-and-sanitation/handbook-on-community-led-total-sanitation

Knowledge update: Capacity Building for CLTS: Lessons in Engaging Local Actors

Water and Health Side Event Summary • October 27, 2015 • Chapel Hill, NC, USA

“One of the key goals of this grant was to invest in understanding what other organizations have done before us, and how we could build on that work to ensure that we reach the outcomes we want to see. With that goal in mind, our [first] question going in was: what works in delivering rural sanitation services at scale?” — Jan Willem Rosenboom, Bill and Melinda Gates Foundation

At the UNC Water and Health Conference, Plan International USA and The Water Institute at UNC convened a half-day event to share findings and implications of operational research on community-led total sanitation (CLTS) across ten countries. This research is part of Plan International USA’s Testing CLTS Approaches for Scalability project, funded by the Bill & Melinda Gates Foundation, which aims to advance rural sanitation efforts by improving the cost-effectiveness and scalability of CLTS. In particular, this research was focused on the role of local actors in CLTS, such as teachers, local government staff, and natural leaders. The session was presented to a packed audience representing governments, non-governmental organizations, academic institutions, businesses, and development organizations, who were keenly interested in how these lessons can be translated into their water, sanitation, and hygiene work. Most importantly, this research has helped identify settings where CLTS is most effective.

In regards to setting, we know that local conditions influence the cost, scale, and sustainability of CLTS. Pilot evaluations in Ghana, Ethiopia, and Kenya incorporated new data collection and analysis tools to understand the cost of CLTS, challenging a misconception that CLTS is a low-cost approach. This project also reveals the impact that training local actors can have on achieving CLTS outcomes. In Kenya, Plan trained local government officials to improve CLTS management. The training improved both the way that staff worked in partnership (across ministries), and their supervision of field staff. In Ghana, training natural leaders demonstrated the potential they have to improve CLTS outcomes, but it also added a large cost that varied strikingly across different regions. In contrast to the project in Ghana, in Ethiopia project staff focused their attention on training local facilitators, which required more time than was used to actually facilitate CLTS in communities.

CLTS Side Event Session at UNC’s Water and Health Conference, 2015; Photo by Tom Fuldner

Complementary to the three pilot evaluations, the team also conducted rapid evaluations in seven countries across Africa, Asia, and the Caribbean and found that CLTS does not offer predictable results. Across the seven countries, 36% of communities had been declared open defecation free after Plan’s interventions. However, it is important to note that latrine coverage tended to vary considerably across countries, further highlighting that the effectiveness of the approach is unique to the setting in which it is implemented. The approach may need to be adapted for certain communities, in which case it is also important that policy makers consider targeting appropriate communities. The approach has, however, been most successful in the very communities most neglected by public health interventions – specifically those which are smaller, more remote, have stable populations, and which do not have a history of receiving financial assistance from government or NGO programs.

Researchers also found that monitoring and reporting the effectiveness of CLTS has been compromised by a focus on open defecation free (ODF) achievement, an indicator that is difficult to standardize and more difficult to measure. Additional findings point to the fact that the complexity of CLTS arrangements in various countries is largely dependent on government support (e.g. through national policies and mandates), capacity of local actors to participate in the implementation process, and the length of time that CLTS has been implemented to date.

The partnership between UNC (a research institution) and Plan USA (an international NGO with a global practice footprint) has proven valuable and is generating recommendations for improving sanitation policy and practice. Findings from the Testing CLTS Approaches for Scalability project from several countries are already available and will be shared through public and private events and online communications in coming months.

Key Highlights

CLTS, as an approach, can have a positive impact on sanitation outcomes.
CLTS works best under very specific conditions; thus, policy makers and practitioners need to consider targeting appropriate communities.
Budgeting for CLTS should account for the full cost of the approach, including facilitator training and follow-up by local actors and community members.
Standardized monitoring approaches that extend beyond ODF achievement can enable comparisons between triggered communities.
Local actors are important catalysts for sanitation behavior change, and careful engagement with them can enhance CLTS outcomes.

Knowledge update: Plan International Ghana: Community-Led Total Sanitation with Capacity Building for Natural Leaders

Implementation Narrative and Project Video • December 9, 2015

Download the Implementation Narrative (PDF, 224kb, 14 pp.)

The Testing CLTS Approaches for Scalability project is a four year, sanitation focused, operational research project that aims to advance rural sanitation efforts in Kenya, Ethiopia, Ghana, and worldwide by improving the cost-effectiveness and scalability of the CLTS approach, with a particular focus on the role of local actors. In Ghana, the project assesses the effectiveness of increasing the capacity of local actors (natural leaders), thereby enabling them to carry out post-triggering activities and reduce their dependency on local non-governmental organizations (LNGOs) for follow-up. The project was implemented in the Volta, Central and Upper West regions of the country. Plan Ghana and their partners implemented conventional CLTS in 20 communities from each region, for a total of 60 communities. 30 of these communities were randomly assigned to receive additional training. In these 30 communities, we identified natural leaders to receive training and mentoring in a variety of topics.

In addition to this Implementation Narrative, a new video highlights the impact natural leaders have in addressing barriers to sanitation behavior change, supporting the achievement of open defecation free status, and reducing the dependency on LNGOs for facilitation in Ghana.

Watch the video:

External Resources

Kar, Kamal, and Robert Chambers. 2008. Handbook on Community-Led Total Sanitation. London, United Kingdom: Plan International UK. http://plan-international.org/about-plan/resources/publications/water-and-sanitation/handbook-on-community-led-total-sanitation

Knowledge update: Community-led Total Sanitation in Niger: Findings from an Implementation Case Study

Learning Brief • December 7, 2015

Download the Learning Brief (PDF, 776kb, 4 pp.)

Download the Country Report (PDF, 379kb, 32 pp.)

Purpose

This learning brief shares key findings from a case study of community-led total sanitation (CLTS) implementation in Plan International Niger program areas, focusing on the roles and responsibilities of local actors. Several implications are relevant for consideration by Plan International Niger and other sanitation practitioners.

Methods

In April 2014, a researcher from The Water Institute collected data in the capital city, Niamey, and in the districts of Dosso and Tillabéri. Data collection consisted of 29 in-depth interviews with government and non-government stakeholders, visits to four triggered villages (two in each district), and a review of relevant organizational documents and national reports.

Key Findings and Implications

Sign Declaring ODF Village in Dosso district, Niger; Photo by Vidya Venkataramanan

Although CLTS has been incorporated into the national sanitation policy, district governments have yet to take ownership of the approach. Formalization of TSCs into government entities with a dedicated budget could build further buy-in and accountability.
Community leaders, including natural leaders, have been trained to build village-level capacity for CLTS. This approach keeps leaders engaged and motivated to influence behavior change and monitor progress in their communities.
ODF verification is challenging due to a lack of benchmarks and standardized verification criteria. This may lead to different interpretations of ODF status, and could make it challenging to compare results across districts.
Access to and affordability of durable latrines remained a significant concern. Plan International Niger can influence the nature of post-CLTS support to communities by training masons, advocating for locally-decided financing mechanisms, and targeting financial assistance to those that need it most.

Roles of Local Actors

Plan International Niger began implementing CLTS in 2010, and remains one of the key non-governmental organizations (NGOs) utilizing this approach in Niger. The Ministère de l’Hydraulique et de l’Assainissement (MHA), or Ministry of Water and Sanitation is responsible for water, sanitation and hygiene (WaSH) in Niger. At the national level, representatives from Plan International Niger coordinate with the MHA, other ministries, and other international NGOs though the “Cluster WaSH” working group.

In Dosso and Tillabéri, Plan International Niger contracted local NGOs (LNGOs) to lead triggering and follow-up activities. They also formed Technical Services Committees (TSC), comprising nine to eleven representatives from the technical services offices of départements, hereafter referred to as district government. TSCs are tasked with assisting LNGOs in triggering, and in certifying communities as open defecation free (ODF). Figure 1 illustrates an institutional map of Plan International Niger’s CLTS activities.

CLTS Progress

Table 1 highlights the most recent data obtained from Plan International Niger’s CLTS projects. By the end of 2013, they had implemented CLTS in 87 villages. Triggered villages in Tillabéri saw a much higher improvement in latrine coverage compared to Dosso; eight villages in Tillabéri had 100% latrine coverage after triggering, while no village achieved higher than 50% latrine coverage at the end of the project in Dosso. This disparity between the two districts may be explained by the fact that in Tillabéri, fewer villages were triggered, so activities were more manageable, or because baseline latrine coverage was higher there at the outset of CLTS activities.

In addition, implementers have noted positive behavior change with the introduction of latrines as part of a bride’s dowry, which is a cultural practice that is now spreading throughout Tillabéri.

Table 1. Outcomes of Plan International Niger’s CLTS Projects, 2013

Key Findings

Finding 1: Although CLTS has been incorporated into the national sanitation policy, district governments have yet to take ownership of the approach.

Advocacy by NGOs through the Cluster WaSH group led to the integration of CLTS in the National Plan. The government’s policy of decentralization of rural sanitation therefore places the responsibility for CLTS on district governments. National recognition of CLTS as one viable approach for sanitation behavior change has enabled Plan International Niger to engage closely with district governments to form TSCs that supervise CLTS activities and certify ODF villages. This has the potential to create greater government accountability and ownership of sanitation.

However, the district government has not yet taken ownership of the CLTS approach, possibly because Plan International Niger still plays the lead financial and programmatic role. For example, TSCs were unable to make ODF verification visits without guaranteed financial assistance from Plan International Niger, suggesting that the government has not yet internalized CLTS as part of its sanitation programming, treating it instead as an NGO project.

Finding 2: Community leaders, including natural leaders, have been trained to build village-level capacity for CLTS.

Natural leaders and other community leaders all mentioned that they had been trained by Plan International Niger after triggering. They were taught techniques to engage with community members, about the importance of latrines and environmental sanitation, and how to monitor progress. In addition to training natural leaders, religious leaders, and community radio broadcasters, Plan International Niger organizes routine exchange visits between leaders from triggered communities. Most respondents recalled quarterly exchange visits, where they heard about progress in other communities and shared lessons learned. This forum was described as a powerful motivational tool for communities. One religious leader observed that the meetings created a sense of competition: “When we came back to our village, we would say, ‘Be careful, the next village has gone ahead of us so we should make a greater effort, so that that village does not pass us.’ ”

Finding 3: ODF verification is challenging due to a lack of benchmarks and standardized verification criteria.

Nationally, ODF status is simply defined as the absence of open defecation in a village at the time of certification. However, Plan International Niger’s monitoring forms list 100% latrine utilization and the absence of excreta around the village as the main criteria for ODF certification. In practice, many respondents believed that a village does not have to achieve 100% latrine coverage to be considered ODF; this is supported by data from Plan International Niger, where household latrine coverage was not necessarily related to ODF status.

In addition to differences in definitions, there were conflicting accounts of the verification process. Some TSC members reported developing their own ODF verification forms, whereas others said that the forms were provided to them by the LNGO. Villages were scored and ranked based on some of these indicators, but no benchmarks were listed, making it hard to know on what basis a community could be certified as ODF.

Finding 4: Access to and affordability of durable latrines remained a significant concern.

Simple pit latrines were the most common latrine type reported in the communities visited. However, the quality of these latrines was cited as the main concern for realizing long term behavior change; for instance, a number of respondents reported that pit latrines tended to collapse during floods. According to one village chief, the biggest barriers to building more resistant latrines were the cost and limited availability of cement and iron.

In an effort to provide access to higher quality latrines, Plan International Niger has trained 109 masons to build latrines using a combination of wood, mud, used tires, barrels, stones, and recycled wood. However, these latrines were not in high demand because they were not perceived to be of the same quality as the cement latrines that had previously been subsidized by NGOs. Although Plan International Niger staff were against the idea of providing financial assistance, the national government policy allows for latrine subsidies, and some TSC members wanted to target subsidies to ODF communities after they had demonstrated sufficient behavior change and were ready for better latrines.

Implications

This study reviewed aspects of Plan International Niger’s CLTS process with a specific focus on local actors and their roles in achieving and monitoring impact. The following implications highlight areas where government actors and Plan International Niger can improve their CLTS activities.

Plan International Niger has demonstrated commitment to strengthening local government capacity, but to build further buy-in and accountability, they need to advocate for TSCs to be formalized into government entities with a dedicated budget. TSCs could become a focal point for other sanitation projects in their districts.

The lack of benchmarks and standardized criteria for certifying villages can lead to different interpretations of ODF, making it difficult to compare progress across districts. Plan International Niger can help influence national sanitation monitoring by improving their own baseline assessments, monitoring, and verification processes to become a model for the government.

The engagement of community leaders and interaction between triggered villages has been novel to sanitation programming in this area. It allows communities to create linkages and to influence each other by generating a sense of competition and learning, which could help Plan International Niger realize greater progress in their triggered villages.

Access to higher quality latrines can help sustain CLTS outcomes. Plan International Niger is in a position to influence the nature of post-CLTS support to communities. In addition to training local masons, they can introduce village-based financing mechanisms through collective financing or self-help groups. In an environment where the government intends to provide latrine hardware subsidies, they can also help the district government target subsidies to those who need it most to ensure that gains made as a result of CLTS are sustained.

Limitations

Acknowledgements

Authors: Vidya Venkataramanan and Alexandra Shannon, The Water Institute at UNC

This learning brief was made possible through support from Plan International USA, which received a grant from the Bill & Melinda Gates Foundation. The findings in this brief are derived from the Niger Country Report, available in our Resource Library at waterinstitute.unc.edu/clts. Data were collected by the Water Institute at UNC with logistical support from Plan International. The findings and conclusions contained within do not necessarily reflect positions or policies of the funder, Plan International USA, or of The Water Institute at the University of North Carolina at Chapel Hill.

Project Resources

Venkataramanan, Vidya. 2015. CLTS Learning Series: Niger Country Report. Chapel Hill, USA: The Water Institute at UNC.
Venkataramanan, Vidya and Alexandra Shannon. 2015. Community-led Total Sanitation in Niger: Findings of an Implementation Case Study. Chapel Hill, USA: The Water Institute at UNC.

External Resources

Kar, Kamal, and Robert Chambers. 2008. Handbook on Community-Led Total Sanitation. London, United Kingdom: Plan International UK. http://plan-international.org/about-plan/resources/publications/water-and-sanitation/handbook-on-community-led-total-sanitation

Knowledge update: Community-led Total Sanitation in Uganda: Findings from an Implementation Case Study

Learning Brief • December 4, 2015

Download the Learning Brief (PDF, 1MB, 4 pp.)

Download the Country Report (PDF, 412kb, 28 pp.)

Purpose

This learning brief shares key findings from a case study of community-led total sanitation (CLTS) implementation in Plan International Uganda program areas, focusing on the roles and responsibilities of local actors. Several implications are relevant for consideration by Plan International Uganda and other sanitation practitioners.

Methods

In November 2013, a researcher from The Water Institute collected data in the capital city, Kampala, and in sub-counties within Tororo district. Data collection consisted of 23 in-depth interviews with government and non-government stakeholders, visits to five triggered villages that had been certified as open defecation free (ODF) across the three sub-counties, and a review of relevant organizational documents and national reports.

Key Findings and Implications

Triggering Activities in Tororo District, Uganda; Photo by Plan International

‍

National government has a policy and budget for sanitation activities that includes CLTS. Monitoring and evaluation guidelines, training guides, and established master trainers help to standardize trainings and improve reporting outcomes across government and other NGO’s CLTS projects.
The national ODF definition and ODF verification criteria are not consistent. Unclear definitions and criteria can lead to different interpretations of ODF status, which makes it difficult to compare CLTS progress across regions.
Village-level volunteers were highly engaged in the CLTS process, but require substantial support from implementers. Additional capacity building support for VHTs and natural leaders via exchange visits and refresher trainings may be necessary to sustain long-term motivation.
Plan International Uganda has trained sanitation entrepreneurs in its CLTS communities, but adequate publicity remained a challenge. The high demand for durable latrines indicates potential for expanding sanitation marketing activities in triggered communities.

Roles of Local Actors

Plan International Uganda established CLTS in Uganda in 2007, and continues to play a supporting role in implementing CLTS. Additional actors involved in CLTS activities are national government, district and sub-county government, village health teams (VHTs), and natural leaders.

The National Sanitation Working Group (NSWG), comprising officials from NGOs, networking organizations, and government, is responsible for coordinating CLTS implementation across ministries and sectors. As a result of the Local Government Act of 2000, district governments are required to provide water and sanitation services at the local level. Thus, Plan International Uganda staff help train health inspectors and sub-county health assistants to oversee activities at the local level. Health assistants then recruit VHTs to trigger communities. These VHTs work with village and parish leadership to promote CLTS with the goal of ending open defecation. The various roles of these actors are illustrated in Figure 1.

CLTS Progress

Table 1 highlights the most recent data obtained from Plan International Uganda’s CLTS projects. As of July 2015, they had implemented CLTS in 173 villages across six sub-counties in two districts. Of all 173 villages, 140 (81%) have been certified as ODF, with latrine coverage ranging from 67% to 100%. Sub-counties with the lowest baseline latrine coverage, Mukuju and Katikamu, had the greatest absolute increase in latrine coverage after CLTS activities. On average, it took communities 12 months to reach ODF status, although this time ranged anywhere from 4 to 31 months.

Table 1. Toilet Coverage and ODF Outcomes in Plan International Uganda CLTS Communities, 2015

Key Findings

Finding 1: National government has a policy and budget for sanitation activities that includes CLTS.

Uganda’s national sanitation policy is guided by the 2010 National Development Plan, which focuses on both CLTS and social marketing. The government has also developed a set of “golden indicators” which not only cover access to household and school sanitation, but also measure hygienic practices and access to water infrastructure. Districts receive sanitation scores based on these indicators, which then allows the national government to assess progress towards improving rural sanitation. In addition, a national training-of-trainers manual and a facilitator’s field guide were introduced in 2011, both of which were adapted from international guidelines.

Despite having these institutional mechanisms in place for water, sanitation, and hygiene (WaSH), coordination between government ministries remains a challenge. The lack of clear separation of institutional roles is evidenced by reports that the Ministry of Water and Environment may trigger communities, but the Ministry of Health is then responsible for verification, and data is not always shared between ministries. Therefore, despite strong national buy-in for CLTS, the roles and responsibilities of ministries in implementing these projects has yet to be clearly defined.

Finding 2: The national ODF definition and ODF verification criteria are not consistent.

National guidelines provide distinct definitions for total sanitation and ODF status. Total sanitation is defined as 100% use of improved latrines, handwashing with soap, safe drinking water storage, and safe solid waste disposal. ODF is defined as 100% household latrine use, lack of open defecation (OD), by-laws for preventing OD, and mechanisms to track construction of improved latrines. However, the national CLTS training manual does not require 100% latrine coverage for ODF status. Meanwhile, ODF verification and certification criteria require 100% latrine coverage and achievement of total sanitation. Interviews and observations in Tororo district suggest that the definition for ODF is interpreted to falls somewhere between absence of OD and all indicators of total sanitation. These inconsistent definitions make it challenging to compare results across communities, sub-counties, districts, and NGO projects.

Finding 3: Village-level volunteers were highly engaged in the CLTS process, but require substantial support from implementers.

Plan International Uganda and local government engage intensively with community-level volunteers, especially VHTs and natural leaders. Their model involves training VHTs to facilitate and follow-up on CLTS activities, with support from natural leaders. Most natural leaders were identified for this role during triggering events, and all VHTs and natural leaders said that they were selected by their communities. Furthermore, the relationship between natural leaders and VHTs was strong; they recognized each other’s importance in CLTS and contributions toward ODF progress.

However, as volunteers, these community leaders may have limited capacity for intensive participation or throughout CLTS implementation. In Plan International Uganda’s program, it appeared that local government facilitators still took the lead in triggering communities. Furthermore, although VHTs and natural leaders appeared in interviews to be highly motivated, maintaining this level of engagement in the long run remains a concern and may require additional resources. For example, both natural leaders and VHTs wanted to receive refresher trainings and the opportunity to participate in exchange visits.

Finding 4: Plan International Uganda has trained sanitation entrepreneurs in its CLTS communities, but adequate publicity remained a challenge.

A key challenge cited by local government, Plan International Uganda staff, and community leaders was the quality of latrines being built. Dry pit latrines were the most common latrine type in communities visited for this study, and a number of respondents cited latrine collapse due to termites or heavy rains, affecting ODF sustainability. In response to this challenge, Plan International Uganda identified and trained 78 masons in construction and entrepreneurship in Tororo district.

However, despite the high demand from respondents for high quality latrines, it was evident from this study, as well as a prior internal evaluation, that not all communities were aware of these trained masons. A 2011 evaluation of CLTS activities revealed that in Tororo district, only 9 out of 32 people interviewed were aware of skilled masons in the area. While there was awareness of this program, there was much greater demand for these programs than Plan International Uganda had thus far been able to implement. Some community leaders suggested that it would be useful for households to know about these durable latrine materials from the beginning of the CLTS process so that the households are sensitized to this option ahead of time.

Implications

This study documented aspects of Plan International Uganda’s CLTS process that may enable or constrain their ability to achieve and monitor their desired impact. The findings suggest several implications for Plan International Uganda and other sanitation practitioners.

Confusion in roles and responsibilities between national government ministries can lead to inefficiencies in sanitation activities at the local government level. Plan International Uganda can use its influential role in the sanitation sector to improve coordination between key national stakeholders.

Inconsistencies between the national ODF definition and verification criteria can lead to different interpretations of ODF status. Plan International Uganda should advocate for standardization of definitions and criteria to enable comparisons across triggered communities. Progress towards ODF can serve as a tool to motivate communities to improve their sanitation status, as originally intended by national guidelines.

The model of recruiting VHTs may help expand the scope of CLTS activities in Plan International Uganda working areas. However, to sustain long-term involvement of these volunteers, Plan International Uganda can consider providing additional capacity building support of VHTs via exchange visits and refresher trainings for both VHTs and natural leaders.

Encouraging community members to build simple pit latrines is unlikely to lead to sustained progress towards achieving ODF status. Given the demand for durable latrines, Plan International Uganda should consider expanding the scope of training for sanitation entrepreneurs to include more sanitation marketing activities. They could introduce permanent latrine options with the help of trained masons in the earlier phases of implementation.

Limitations

This study uses qualitative methods and a small sample size. Researchers did not evaluate program effectiveness. Although readers may connect these findings to their own CLTS experiences, they should be cautious about generalizing the findings. Furthermore, researchers visited a subset of communities where Plan International Uganda implements CLTS, which means the study may not fully capture all aspects of CLTS implementation in Uganda.

Acknowledgements

Authors: Vidya Venkataramanan and Alexandra Shannon, The Water Institute at UNC

This learning brief was made possible through support from Plan International USA, which received a grant from the Bill & Melinda Gates Foundation. The findings in this brief are derived from the Uganda Country Report, available in our Resource Library at waterinstitute.unc.edu/clts. Data were collected by the Water Institute at UNC with logistical support from Plan International. The findings and conclusions contained within do not necessarily reflect positions or policies of the funder, Plan International USA, or of The Water Institute at the University of North Carolina at Chapel Hill.

Project Resources

Venkataramanan, Vidya. 2015. CLTS Learning Series: Uganda Country Report. Chapel Hill, USA: The Water Institute at UNC.
Venkataramanan, Vidya and Alexandra Shannon. 2015. Community-led Total Sanitation in Uganda: Findings of an Implementation Case Study. Chapel Hill, USA: The Water Institute at UNC.

External Resources

Kar, Kamal, and Robert Chambers. 2008. Handbook on Community-Led Total Sanitation. London, United Kingdom: Plan International UK. http://plan-international.org/about-plan/resources/publications/water-and-sanitation/handbook-on-community-led-total-sanitation