Can open-defecation free (ODF) communities be sustained? A cross-sectional study in rural Ghana

Abstract

Community-led total sanitation (CLTS) is a widely used approach to reduce open defecation in rural areas of low-income countries. Following CLTS programs, communities are designated as open defecation free (ODF) when household-level toilet coverage reaches the threshold specified by national guidelines (e.g., 80% in Ghana). However, because sanitation conditions are rarely monitored after communities are declared ODF, the ability of CLTS to generate lasting reductions in open defecation is poorly understood. In this study, we examined the extent to which levels of toilet ownership and use were sustained in 109 communities in rural Northern Ghana up to two and a half years after they had obtained ODF status. We found that the majority of communities (75%) did not meet Ghana’s ODF requirements. Over a third of households had either never owned (16%) or no longer owned (24%) a functional toilet, and 25% reported practicing open defecation regularly. Toilet pit and superstructure collapse were the primary causes of reversion to open defecation. Multivariate regression analysis indicated that communities had higher toilet coverage when they were located further from major roads, were not located on rocky soil, reported having a system of fines to punish open defecation, and when less time had elapsed since ODF status achievement. Households were more likely to own a functional toilet if they were larger, wealthier, had a male household head who had not completed primary education, had no children under the age of five, and benefitted from the national Livelihood Empowerment Against Poverty (LEAP) program. Wealthier households were also more likely to use a toilet for defecation and to rebuild their toilet when it collapsed. Our findings suggest that interventions that address toilet collapse and the difficulty of rebuilding, particularly among the poorest and most vulnerable households, will improve the longevity of CLTS-driven sanitation improvements in rural Ghana.

The Impact of Pro-Poor Sanitation Subsidies in Open Defecation-Free Communities: A Randomized, Controlled Trial in Rural Ghana

“…4 , 11 , 14 , 18 – 26 At a maximum, previous studies have found up to 57% of households not using latrines in formerly ODF communities, 19 although such figures usually relied on limited data. 4 , 44 We found substantial evidence that deterioration was related to the collapse of nondurable toilets with no pit lining, especially when those toilets were located in areas with unstable soils. Collapse has also been found to be common in numerous other contexts such as Bangladesh, Malawi, and Mozambique, sometimes due to heavy rains and flooding.…”

“…21 , 47 , 48 Further analysis of the sanitation declines observed in our study, particularly with regard to the time period from ODF attainment to our baseline surveys, can be found in Delaire et al. 44 …”

“… 35 Timing is also crucial, given that sanitation declines often happened quickly after ODF achievement. 44 Integrating the program into follow-up visits shortly after ODF attainment may be especially useful and provide opportunities to reduce implementation costs while also not interfering with the internal behavior change approach of CLTS to reach ODF status. Sustained follow-up is often a factor that reduces deterioration back to open defecation, although budgets for follow-up visits are often limited.…”

“…To estimate the specific impacts of the subsidy program, we conducted several multivariate logistic regressions on the endline data with adjusted standard errors to account for community clustering. 44 We also considered adjusted standard errors for clustering at the compound level; models with community clustering were more conservative with respect to statistical inference, so we moved forward with community clustering. We computed models among a ) all households, b ) voucher-eligible households, and c ) noneligible households.…”

“…In each model, the primary explanatory variable was whether a household was in a subsidy community, where community consultation and voucher distribution were fully implemented. We also controlled for 13 additional household-, compound-, and community-level variables ( Table 2 ) that had potential relationships with sanitation outcomes at baseline 44 and endline based on bivariate regression models (Table S2). These covariates included household size; wealth quintile, derived from reported asset ownership; whether children of age were present; whether the household head had completed primary education; whether the head was female; whether the head was vulnerable, defined here as elderly, physically or mentally challenged, or chronically ill; the number of households in the compound; the time since the community’s ODF verification; the distance from the community to a road; the presence of rocky soil in the community; whether the community had a village savings and loan association (VSLA) at endline; whether the community had fines for open defecation at endline; and whether the community previously had fines for open defecation but no longer did at endline.…”