Sustainability of community-led total sanitation outcomes: Evidence from Ethiopia and Ghana

Abstract

We conducted a study to evaluate the sustainability of community-led total sanitation (CLTS) outcomes in Ethiopia and Ghana. Plan International, with local actors, implemented four CLTS interventions from 2012 to 2014: health extension worker-facilitated CLTS and teacher-facilitated CLTS in Ethiopia, and NGO-facilitated CLTS with and without training for natural leaders in Ghana. We previously evaluated these interventions using survey data collected immediately after implementation ended, and concluded that in Ethiopia health extension workers were more effective facilitators than teachers, and that in Ghana training natural leaders improved CLTS outcomes. For this study, we resurveyed 3831 households one year after implementation ended, and analyzed latrine use and quality to assess post-intervention changes in sanitation outcomes, to determine if our original conclusions were robust. In one of four interventions evaluated (health extension worker-facilitated CLTS in Ethiopia), there was an 8 percentage point increase in open defecation in the year after implementation ended, challenging our prior conclusion on their effectiveness. For the other three interventions, the initial decreases in open defecation of 8–24 percentage points were sustained, with no significant changes occurring in the year after implementation. On average, latrines in Ethiopia were lower quality than those in Ghana. In the year following implementation, forty-five percent of households in Ethiopia repaired or rebuilt latrines that had become unusable, while only 6% did in Ghana possibly due to higher latrine quality. Across all four interventions and three survey rounds, most latrines remained unimproved. Regardless of the intervention, households in villages higher latrine use were more likely to have sustained latrine use, which together with the high latrine repair rates indicates a potential social norm. There are few studies that revisit villages after an initial evaluation to assess sustainability of sanitation outcomes. This study provides new evidence that CLTS outcomes can be sustained in the presence of training provided to local actors, and strengthens previous recommendations that CLTS is not appropriate in all settings and should be combined with efforts to address barriers households face to building higher quality latrines.

Assessing the Impact and Equity of an Integrated Rural Sanitation Approach: A Longitudinal Evaluation in 11 Sub-Saharan Africa and Asian Countries

“…Stalled progress occurred in many of these countries for various reasons, including remaining villages are often more rural and difficult to reach with CLTS campaigns, late adopters are often less interested in the interventions, quality of triggering, supply chain limitations, and scaling strategies and both human and monetary resources are sometimes inadequate [18]. Slippage has also been a considerable problem as CLTS interventions often result in unimproved or low durability latrines [19]. The SSH4A approach implements CLTS-like activities through their demand creation, but the multi-dimensionality of the other three intervention components is meant to address barriers and more effectively scale sanitation interventions in a variety of contexts.…”

“…Ghana. Similar to Ethiopia, in Ghana the national government has named CLTS as one of the preferred rural sanitation approach, and the local government at Metropolitan and Municipal District Assembly level is responsible for the implementation of sanitation related interventions [19]. CLTS as a standalone strategy has not been effective across all contexts in terms of sustaining coverage, and has generally resulted in unimproved latrines with low durability.…”

Development and external validation of a logistic regression derived algorithm to estimate a 12-month post open defecation free slippage risk

“…CLTS is designed to mobilise individuals in action to eliminate open defecation as a whole community (Harter, et al, 2018). It is a participatory approach in which facilitators visit villages and trigger awareness of sanitation and subsequently perform follow-up visits to villages to generate a community-wide effort to become ODF (Crocker, et al, 2017). To build capacity of CLTS facilitators to implement district-wide activities in Luwingu district, CLTS district and sub-district level cadres were trained and periodically followed upon in the CLTS methodology through the District Water Sanitation and Hygiene Education Committee (DWASHE) with the assistance of the CLTS national coaches.…”

“…This study also reinforces the findings from a study in Ghana and Ethiopia on sustainability of CLTS outcomes. The study asserts that CLTS is not an appropriate intervention in cases where the baseline toilet coverage is low and local toilet technologies are poor (Crocker, et al, 2017). Poor quality latrines can cause households to revert back to OD (Tyndale-Biscoe, et al, 2013;Mosler, et al, 2018).…”

PROTOCOL: Community‐led total sanitation in rural areas of low‐ and middle‐income countries: a systematic review of evidence on effects and influencing factors

“…We can refer to the following "family" of four articles on CLTS in Ethiopia and Ghana (Crocker et al 2016a;2016b;2017a;2017b):…”