Download - Community-led Total Sanitation (CLTS): Fast tracking an ODF world of healthy and prosperous communities Water and Health Conference 2015 University of

Community-led Total Sanitation (CLTS): Fast tracking an ODF world of healthy and prosperous communities

Water and Health Conference 2015

University of North Carolina

October 27th, 2015

Dr. Kamal Kar

Chairman, CLTS Foundation

Sanitation and the MDGs

The recognition of sanitation as a key element in health outcomes started fairly late in international development

Focus was largely on individual hygiene and sanitation. The understanding of “total sanitation” spanning full communities came much later

Many countries have achieved their MDG water targets yet lag far behind in sanitation. In fact the progress on Goal no 7 (sanitation) has been very poor by most countries in Africa and Asia, which is one of the worst performing goal during the MDGs.

Why is this ?

Global Sanitation Scenario is still Pathetic

• Though 2.1 billion people have gained access to improved sanitation since 1990 and

• Estimated access to improved sanitation increased from 54% to 68 % during MDG, yet MDG target is far from being achieved.

• In 2015, 2.4 billion people still lack improved sanitation facilities

In Southern Asia, 953 million people lack access to improved sanitation facilities

The number in Sub-Saharan Africa is 695 million people

And Eastern Asia has 337 million lacking these facilities

Out of this 1 billion practice OD

Southern Asia – 610 million ( 60%)

Sub Saharan Africa – 229 million (23%)

Top priority is to ensure that these 2.4 billion get access to sanitation

Through most of the MDG period especially at the beginning, a compartmentalised and traditional approach to water and sanitation continued to prevail.

In the mid/latter part of the MDG period the global sanitation community and national leaders started realising that the top down traditional approach of providing toilet as infrastructure to individual households was not yielding the desired results.

This shift in thinking was triggered by the emergence of CLTS Pioneered in 2000 in Bangladesh Spread exponentially throughout countries in Africa,

Asia and Latin America.

Sanitation and the MDGs

Sanitation and the MDGs Led to shift in policy thinking and practice. Towards the middle of

the MDG period many countries started adopting CLTS.

Outcome : 40 million people gained access to sanitation through CLTS

and experienced first hand improvements in basic sanitation reflected in distinct health outcomes.

Some patches of the high endemic zones of cholera, diarrhoea and other enteric diseases started declaring ODF and reported total eradication of these diseases in villages and districts etc. There has also been a reported case of absence of Ebola in 69 ODF zones in Liberia ( this needs more scientific investigation though).

ODF Population Eastern and Southern Africa

Total ODF Population: ~7.6Million

Namibia, Botswana and Lesotho recent initiation of CLTS

Zim

babw

e

Sout

h Su

dan

Som

alia

Ugand

a

Angola

Mad

agas

car

Burun

di

Eritr

ea

Moz

ambiqu

e

Malaw

i

Kenya

Zam

bia

Ethiop

ia

1,675 10,00050,000 59,400

121,015

227,507 241,755

430,000

544,319

639,300

1,026,800

1,308,000

2,469,966

Angola

Benin

Burkina Faso

Botswana

Central African RepublicCote d'Ivoire

Cameroon

Democratic Republic of Congo

Congo Brazzaville

Cape Verde

Djibouti

AlgeriaEgypt

Eritrea

Western Sahara

Ethiopia

Gabon

Ghana

Guinea Conakry

GambiaGuinea-Bissau

Equatorial GuineaKenya

Liberia

Libya

Morocco

Madagascar

Mali

Mozambique

Mauritania

Malawi

Namibia

NigerSudan

Senegal

Sierra Leone

Somalia

South Sudan

Sao Tome and Principe

Swaziland

Seychelles

Chad

Togo

Tunisia

United Republic of Tanzania

Uganda

South Africa

Zimbabwe

Lesotho

Rwanda

Nigeria

Zambia

Burundi

ODF CommunitiesODF Population

7 - 100101 - 250251 - 10001001 - 8443No information

Open defecation free communitiesSince 2010

CLTS - Paradigm Shifts in Policy and Practice

Focus of Intervention

Technology

Extent of Coverage

Monitoring Indicator

Construction of toilet

Top down technology

prescription

Partial coverage

Counting latrines

Collective behaviour

change

Local empowerment

Total (ODF environment)

Counting ODF communities

Leadership Technocrats Political actors

MDGs and CLTS

Source: WHO-UNICEF JMP Report (2015 )

EARLY ADOPTERS OF CLTS :

Open defecation rates (RURAL)

OD Reduction rate

Year of Introduction

1990 2015

Bangladesh 34 1 33 2000

Cambodia 94 60 34 2005

Ethiopia 100 34 66 2006

Pakistan 67 21 46 2004

Indonesia 49 29 20 2005

Met MDG target

Exceptional case

MDGs and CLTS

COUNTRIES THAT ADOPTED CLTS HALF-WAY THROUGH MDGs :

Open defecation rates (RURAL)

OD Reduction rate (RURAL

Year of Introduction

1990 2015

Kenya 22 15 7 2007

Malawi 33 5 28 2008

Vietnam 43 1 42 2008

Madagascar 60 52 8 2008/2011

Mali 37 15 22 2009

Myanmar 4 2010

Thailand 10 0 10 2010

Source: WHO-UNICEF JMP Report (2015 ) Met MDG target

Exceptional case

CLTS in Asia

First introduced in Bangladesh in 2000

Countries that have made notable progress with CLTS :

Bangladesh – sanitation access increased from 34% in 2003 to 97% in 2013

Nepal – reduced open defecation from 84% in 1990 to 40% in 2012

Others include Pakistan, Indonesia, Cambodia and to an extent India.

Bangladesh is now strategizing their journey to Zero OD. Great achievement indeed!

Bangladesh is going to be an ODF Nation very soon! Can we find answers to ODF World

from them?

1985 1990 1995 2000 2005 2010 2015 20200

20

40

60

80

100

120

140

160

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bangladesh: Health and ODF 1995 - 2015

IMR

U5MR

Malnutrition

Stunting

ODF Pop

COUNTRY STATUS

Proportion of the 2015 population that gained access since 1990(%) IMR CMR U-5 Mortality

Rank

MET WATER TARGET LITTLE or NO PROGRESS IN SANITATION

Guinea-Bissau 59 0 78 124 6

Mali 64 18 78 123 7

Nigeria 48 9 74 117 9

Burkina Faso 61 16 64 98 14

Benin 52 17 56 85 24

Ghana 59 11 52 78 28

Djibouti 39 4 57 70 36

India 46 28 41 53 47

Sanitation and Child health

COUNTRIES STILL STRUGGLING

Open defecation rates (RURAL) Comments

1990 2015

India 91 61 First country after Bangladesh. However stiff resistance to no-subsidy and mixed policy has stifled progress. India contributes to 58% of world's OD

Benin 95 76 First introduced in 2009. Reintroduced in 2014. In one year more than 800 localities were made ODF

Burkina Faso 89 75Though one of the earlier adopters in Western Africa, CLTS has been mainstreamed into national policy only as recently as 2014

Chad 93 79 Introduced in 2009, but mainstreamed only after 2012

Cote d'Ivoire 56 51 Introduced in late 2000s, but mainstreamed only much later

MDGs and CLTS

Source: WHO-UNICEF JMP Report (2015 )

Timor-Leste

Unused pour flush latrine provided by donor in a water-scarce village in Liquica district in Kiribati. In the background the community fixed an old dry toilet post-triggering

MDG and CLTS in Africa

Institutionalization and scaling up became more challenging than introduction From a few hundred ODF villages to ODF districts, ODF regions

and ODF nation demanded involvement of another set of actors, triggering and advocacy at a different level

Community’s success on CLTS established and reemphasized that without collective behaviour change improvement in sanitation was not possible. This challenged the national level policy and decision makers who believed in top-down, prescriptive and subsidized/free toilet construction

Challenges

While some nations started realizing the need for behaviour change for sustained health outcomes, changing the mind-set of some donors to modify/correct funding guidelines to accommodate collective behaviour change for sustained health outcome

Weak inter and intra-institutional coordination and lack of functional linkages between organisations and departments blocked effective convergence of efforts among different actors which was needed for large scale scaling up.

Challenges

Governments used to subsidy driven approach resisted making the policy shift towards community empowerment Without policy and a nation wide strategy with roadmap

and adequate resources, institutionalisation and large-scale scaling up was not possible

Mandate for sanitation/WASH rested with ministries focused on infrastructure creation rather than measuring health outcomes Focus on toilet construction continued

Innovative scaling up strategies

Need for abolishing the practice of OD is being stressed by set of new champions emerged at the highest levels of national political leadership ( President, Prime Minister of Madagascar, Timor Leste, Kiribati, Ministers of Ghana, Cote De Ivory, Malawi, Kenya, etc.)

Established organic scaling-up mechanisms Widening network with Natural leaders and Community

Consultants


Emergence of CLTS champions at highest leadership level As the success of communities attracted the

attention of local government, the national level political leadership became interested to show case the success at the country level and emerge as champion at the region. E.g. Malawi, Madagascar, Zambia

His Excellency Mr.Anote Tong,President, Kiribati(2nd

from left)

His Excellency Mr.Hery Rajaonarimampianina,

President,Madagascar(4th from left)

Honourable Mr. Elvis Afriya, Minister of Sports and Youth Affairs, Ghana (front row ;c

entre)

Honourable Mr.Fernando Lasama De Araujo,Vice Prime Minister, Timor Leste

25

Honourable Mr. Roger Kolo,Prime Minister of Madagascar(on right)


Sanitation led by Ministry of Health/Public Health focusing on health outcomes rather than infrastructure creation

Kenya, Ethiopia, Indonesia

Clear national sanitation strategy with ODF target and roadmap

Achieved ODF communes, sub-districts, districts

Successfully created a healthy competition amongst the local governments within the country which triggered national ODF campaign. E.g. Madagascar, Kenya


Establishing appropriate enabling environment helped in converging the efforts of multiple actors towards realizing the national goal rather than disconnected and piecemeal success on CLTS


Innovative funding mechanisms Emergence of new financing mechanisms

like GSF Institutional Triggering

What is institutional triggering?

Institutional triggering is a methodology that has been developed and used by the CLTS Foundation in a number of contexts, and at various different levels to bring about institutional change for improved coordination and greater speed of implementation of CLTS. It has been successfully used at district level during earlier visits to Ghana and has also been used effectively in Madagascar, Timor Leste, Mozambique (recently) and a few other countries.

Timor-Leste

Suco chiefs pledging support to natural leaders in TL

Date: March, 2015

• Presentation by natural leaders

• Date: March, 2015

• Dry Toilet innovations from the community

• Date: March, 2015

What is Institutional Triggering?

Triggering of the highest political and decision making leadership of a nation/organization

What stops the spread and scaling up of a few hundreds of successful ODF communities from spreading all over the nation? Who’s responsibility to spread the success to the entire reging, district or nation? Who is to be blamed?

Is there a clear road map, implementation plan and a budget protocol for achieving an ODF Nation?

Institutional Triggering in Ho, Volta and in Wa in Upper West Regions of Ghana

Can we ensure a better coordination thanWhat is this? Institutional OD?

34

Institutional Triggering in Tamale, Northern Region of Ghana

Attitude &

Behavior

Change

CLTS Tools &Techniq

ues

EnablingEnvironment

Institutio

nal

Professional

Personal

Triggering

Policy Context

National

Protocol/

Budget

Essential Convergence

What do we need?

Inter-Institution

al Coordinati

on

Pre-triggering

Post ODF actions

Post Triggering Follow-up

What is the outcome of Institutional Triggering? Honorable Minister of Volta Region of Ghana making her commitments to fast track ODF coverage

Honorable Minister of Volta Region of Ghana making her commitments to fast track ODF coverage in May, 2015

Ghana

Institutional Triggering – Examples from practice

What is the Outcome? Honorable Ministers from Mozambique, Kenya, Madagascar and Zambia made commitments to fast track coverage by setting national ODF targets, developing road map and allocating budgets.

Impact of CLTS on Health outcomes

CLTS has demonstrated success in increasing access to sanitation enhancing greater coverage, faster uptake by the community due to

internalised behaviour change leading to more sustainable outcomes .

CLTS through better sanitation outcomes have led to better health and reduced medical expenditure and more productivity of ODF communities

Evidence of global health impacts of CLTS is fast emerging. Cases of reduced stunting/wasting ( Mali), reduction in cholera ( Kenya, Ghana) are a few examples.

Impact of CLTS on Health outcomes Additionally the knock on effects of CLTS leads to collective gains for the community in terms of health greater collective consciousness of people towards health care

environmental cleanliness

activating health services and institutions. People start thinking about their overall wellbeing.

In the SDGs it is important to see that policy and practice is geared towards achieving ODF nations

For this institutions and governance have to become responsive greater political will and commitment

Increase budget allocation to sanitation

Madagascar Innovations!

Dry Toilet Models from ODF communities

How do we approach the SDGs?

What can we lean from the successes of countries that have done well?

What lessons can we apply to address the newly emerging challenges ?

How do we scale up CLTS with quality in the next ten years?

How can countries in Africa support each other?

Impact on Health

Nyando Hospital record shows how incidence of diarrhea and cholera dropped dramatically in Niando districts in Kenya – Impact of simple pit latrines on health

Mali – Impact Evaluation

One year after intervention in CLTS villages:

26% reduction in stunting ( U-5)

35% reduction in underweight

57% reduction in diarrhoea-related U5- mortality

46

Direct co-relation of household latrine possession and use in ODF villages in Chad

GUERA

Chari

Bagui

rmi

Salam

atSi

la

Hadjer

Lam

is

Ouadd

ai

Moy

en ch

ari0

2000

4000

6000

8000

10000

12000

14000

16000

18000

CO-RELATION BETWEEN NUMBER OF HOUSEHOLDS AND LATRINES USED IN ODF VILLAGES OF CHAD

No.of households

No.of latrines(CLTS)

REGIONS IN CHAD

HO

US

EH

OL

DS

AN

D L

AT

RIN

ES

IN

NU

MB

ER

S

Guera

Chari

Bagui

rmi

Sala

mat Si

la

Sila

( Goz

Bei

da)

Hadje

r Lam

is

Ouadd

ai

Moyen

Cha

riLa

c0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

CO-RELATION BETWEEN NUMBER OF HOUSEHOLDS AND LATRINES USED IN VILLAGES OF CHAD BEFORE

THE IMPLEMENTATION OF CLTS

No. of householdsNo. of Latrines be-fore CLTS

REGIONS IN CHAD

CLTS was introduced in September 2009 in ChadODF villages in serious cholera endemic zones in Chad reported no single case of cholera when other villages were devastated .

Initiatives for Way Forward

• Ministerial dialogue on CLTS at Africasan on lessons learnt and way forward for SDGs

• Pan-African Ministerial Forum to open CLTS dialogue for identifying common ground for strategic action going forward

• CRAP – CLTS Rapid Appraisal Protocol - Tool to assess the CLTS health in different countries and devise national scaling up strategies

• Institutional Triggering – Tool for nation wide scaling up : From ODF village to ODF district/region/nation

Some of the major economic, health and social impacts of CLTS

Kamal Kar, WHO Technical Report Series, no. 971, 2012

Enhanced income Agriculture

& Livestock Production

Monetary burden of Cystcercosis is > US$ 120 m/year and 200 m Kg of

discarded pork in China alone

Enhanced Nutrition, improved HALYs including

QALYs & DALYs



As we go into SDGs what can we do differently?

More holistic approach to sanitation - in policy making, in programming, in implementation

Sanitation outcomes have to be measure d in terms of health outcomes and not by counting toilets

Make sanitation everyone's business - involvement of diverse stakeholders is required

W ho implements sanitation in nations is important - E.g. in Kenya it is the health ministry

Integration of sanitation in health policies/programmes How to help, advocate and capacitate nations and

governments interested to move ahead and learn from the success and failures of MDG?

Conclusion

Strong linkage of sanitation outcomes on health outcomes is a scientific fact

By 2030, even if all other development targets are achieved , lack of attention to sanitation will not yield desired outcomes on health

Infant and child mortality will continue to be high How can we change this ? And who will change this ? Are we ready to create an ODF world by 2030 ? - The

way we choose to approach the sanitation question in SDGs is critical

Thank YouAfter 2030 would people of our planet be able to say “once up on a time people used to defecate in

the open and there were diseases called cholera and diarrhea”

Visit www.cltsfoundation.org for

updates and news

http://www.cltsfoundation.org/

Download - Community-led Total Sanitation (CLTS): Fast tracking an ODF world of healthy and prosperous communities Water and Health Conference 2015 University of

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