Where Does CLTS Work Best? Quantifying Predictors of CLTS Performance in Four Countries

Abstract

Improving the effectiveness of rural sanitation interventions is critical for meeting the United Nations’ Sustainable Development Goals and improving public health. Community-led total sanitation (CLTS) is the most widely used rural sanitation intervention globally; however, evidence shows that CLTS does not work equally well everywhere. Contextual factors outside the control of implementers may partially determine CLTS outcomes, although the extent of these influences is poorly understood. In this study, we investigate the extent to which 18 contextual factors from readily available datasets can help predict the achievement and sustainability of open-defecation-free (ODF) status in Cambodia, Ghana, Liberia, and Zambia. Using multilevel logistic regressions, we found that the predictors of CLTS performance varied between countries, with the exception of small community size. Accessibility and literacy levels were correlated with CLTS outcomes, but the direction of correlation differed between countries. To translate findings into practical guidance for CLTS implementers, we used classification and regression trees to identify a “split point” for each contextual factor significantly associated with ODF achievement. We also identified the combinations of factors conducive to a minimum of 50% ODF achievement. This study demonstrates that publicly available, high-resolution datasets on accessibility, socioeconomic, and environmental factors can be leveraged to target CLTS activities to the most favorable contexts.

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

“…Digging toilet pits in rocky soil is difficult without specialized equipment, hindering toilet construction. Two prior studies in Ghana also observed that CLTS programs performed better in remote areas, possibly because communities had been less exposed to prior sanitation subsidies or because social cohesion was stronger in these settings [7,21]. In this study, findings suggest that toilets may have been more durable in communities located further from major roads (S3 Fig) . This may be because robust superstructure construction materials such as wood were more readily available in remote areas, and/or because stronger social cohesion helped ensure that toilets had a higher construction quality.…”

“…One finding however contradicted this trend: households with an uneducated household head were more likely to own a functional toilet (Fig 2). Prior research in Ghana also found a correlation between low education levels and toilet coverage, possibly because uneducated households are more accepting of rudimentary toilets made with local construction materials [7]. However, our findings indicate that higher toilet coverage among uneducated households did not always translate into use, since these households were also more likely to practice some level of open defecation (Fig 2).…”

“…Additionally, this analysis mostly relied on community characteristics reported by chiefs, which may have led to inaccuracies. Finally, other research shows that factors associated with CLTS outcomes are contextspecific [7,26]; therefore, our findings may not be fully generalizable beyond the study region.…”

“…Governments and international development organizations have implemented CLTS widely across Africa and Asia, and 31 countries have incorporated the approach in their national sanitation improvement guidelines or regulations [5]. While these efforts have helped large numbers of communities, and sometimes entire districts, to be declared ODF [5][6][7], the extent to which these gains are sustained over time is largely unknown. Most CLTS programs do not track sanitation indicators post ODF, and the limited data available indicate that a fraction of the population (ranging from 4%-39% in prior studies) may revert to open defecation in the years following ODF verification [6,[8][9][10][11][12].…”

“…Implementers have included Ghana's Community Water and Sanitation Agency (CWSA) as well as international development organizations such as UNICEF, Global Communities, USAID, Plan International, WaterAid, and World Vision [18]. Of the over 5,000 communities that have received CLTS interventions across the country, approximately half have been declared ODF [7], which requires that at least 80% of households have a toilet [19]. With the highest proportion of ODF communities, the northern part of the country appears to have seen the best CLTS results [20], possibly because this region had less exposure to WASH interventions prior to the introduction of CLTS [21].…”