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Community-Led Total Sanitation in Rural Areas: an Approach That Works

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Community-Led Total Sanitation in Rural Areas: an Approach That Works 39669 The Water and Sanitation Program February 2007 is an international partnership for improving water and sanitation sector policies, practices, and capacities to serve poor people Field Note Public Disclosure Authorized Community-Led Total Sanitation in Rural Areas An Approach that Works Public Disclosure Authorized Sanitation programs have, for some time now, incorporated the need to raise awareness and emphasize the benefits of toilet usage. This has been most effectively undertaken by empowered communities motivated to take collective action, with the local governments and other agencies performing a facilitating role. Public Disclosure Authorized Public Disclosure Authorized At the heart of this approach lies a paradigm shift to collective behavior change in creating open defecation-free environments. Executive Summary Why is Rural Sanitation a Sanitation remains one of the biggest development challenges in all developing countries. Improving sanitation is the key to achieving the Concern in South health-related Millennium Development Goals (MDGs) of reducing child mortality and combating disease. However, these outcomes will remain Asia? pressing and persistent concerns for many nations even as they approach the goal of halving the number of the world's poor by 2015, Despite significant progress in which in turn will have considerable bearing on the progress of attaining Bangladesh, and some improvement this goal by itself. A focus on appropriate outcome-oriented approaches in India in recent years, sanitation to rural sanitation is critical, given that a majority of poor households coverage in the rural areas of South continue to live in rural areas. Asia continues to be a matter of concern. It was estimated in 2003 that Conventional approaches in South Asia have attempted to tackle the approximately 653 million people issue of poor sanitation by trying to improve coverage and access with (76 percent of the total population of financial support for constructing toilets. However, for many years it has the region) still lack access to 1 been evident that providing subsidies for construction of individual toilets adequate sanitation. alone does not necessarily translate into usage. Behavior change is a key ingredient for this to occur. Sanitation programs have, for some time The practice of open defecation by now, incorporated the need to raise awareness and emphasize the the majority of people in this region benefits of toilet usage. Even this marketing of sanitation, in order to is one of the most serious create individual demand (often combined with subsidies linked to toilet environmental threats to public construction by households) has not necessarily resulted in significant health. Open defecation and the progress in securing the desired outcomes from sanitation programs in failure to confine excreta safely are the region. primary factors that contribute to the spread of disease and infection It is in this background that the significant results demonstrated by a through the bacteriological recent approach adopted in South Asia have drawn attention. At the contamination of water sources and heart of this approach is a shift away from the provision of subsidy-led the transmission of pathogens toilets for individual households and emphasizing not merely behavior through the fecal-oral route. Improved change by individuals in general but of an entire collective, to achieve hygiene practices by entire 'open defecation-free' villages. The objective is to reduce incidence of communities, including the use of diseases related to poor sanitation and manage the public risks—posed sanitary toilets, can effectively break by the failure to safely confine the excreta of some individuals—at the this cycle of disease transmission. community level. This has been most effectively undertaken by Policy intervention to help achieve empowered communities motivated to take collective action, with the this objective could reduce the government and other agencies performing at best a facilitating role. disease burden by as much as There is a growing recognition that this evolving approach, often referred 50 percent.2 to as Community-Led Total Sanitation (CLTS), offers tremendous potential not only for achieving, but even for surpassing, the relevant 1 Joint Management Programme 2004. 2 Planning Commission of India, Mid-Term Appraisal of the Tenth MDG targets set for 2015. Plan, 2005. 2 UrbanCommunity-Led Water Sector Total in Sanitation South Asia: Benchmarkingin Rural Areas: Performance An Approach that Works Box 1: What are the Outcomes of Hardware-Driven Programs? The Government of Andhra Pradesh has, over the past few years (post-2001), committed considerable funds to a statewide sanitation program providing subsidies for the construction of toilets in rural areas (under the program, each household is given approximately US$ 16 and 100 kg rice coupons). Substantial coverage has been achieved under the program, and some 2.95 million household toilets have been constructed during this period. However, random concurrent evaluation shows that an estimated 50 percent of these subsidized toilets remain unused or are being used for purposes other than sanitation. Similarly, in Maharashtra, 1.6 million Preferred usage of subsidized toilets. subsidized toilets were constructed during 1997-2000 What has Been the Approach So Far? India, till recently, the national but concurrent evaluation by the government provided financial government puts usage at Traditionally, sanitation programs in assistance to identified poor (below around 47 percent. In the small the region have focused on providing poverty line) families for state of Himachal Pradesh, over toilets, usually on a subsidized basis, constructing toilets of a specified 0.3 million toilets have been built rather than on motivating their usage. design. In addition to this through a subsidy-driven Evidence now overwhelmingly points assistance, many state and program in the 1990s, but to the fact that providing subsidized provincial governments across the random evaluation in 2003 toilets does not necessarily lead to South Asia region had introduced showed usage of less than enhanced usage or ensure behavior their own schemes of providing 30 percent. change for all the households or the subsidy, often covering an even entire community. The focus mostly wider segment of the population. Sources: WSP-supported Rural Water Supply and Sanitation Sector Assessment Study in Andhra remains on construction of toilets in For example, in Bangladesh, early Pradesh, 2004; Unpublished reports/official statements from the Government of Maharashtra; WSP-supported rural areas either directly by the initiatives in sanitation focused on study on Rapid Assessment of Rural Sanitation in government or by providing a high the distribution of fully-subsidized Himachal Pradesh, 2003-04. level of subsidy to beneficiaries. In sanitation hardware. 3 The reason why people defecate in the open is not necessarily due to lack of toilets. Key Issues Does Subsidized Construction of Recent studies of statewide sector Can Health Outcomes be Toilets Lead to Usage? assessments in India show that Achieved if Only Some Households most people continue to defecate in Use Toilets? While investment in toilet construction the open not due to a lack of access through the provision of generous to toilets but primarily because they It has been observed that even where subsidies for hardware to households see no reason to change their higher access and usage of sanitation has, to some extent, increased the behavior because awareness of facilities by several households has reported coverage of sanitation in the associated health risks is limited or been reported, improved public health region, subsidy-driven programs do ignored. In fact, usage of toilets is outcomes have not necessarily been not generate motivation for use of the highest where households achieved. This is because even if some facility. Indeed, subsidized toilets are recognize the need for toilets people still continue to practice open often not used or lie abandoned, or and therefore, construct them on defecation, the surroundings are not are being put to alternative uses. their own.3 free from fecal contamination. Public health outcomes can be achieved only Table 1: Individual Sanitation Practices Affect the Entire Community when the entire community adopts improved sanitation behavior, the area is 100 percent open defecation-free, Category Users of Prevalence of and excreta is safely and hygienically toilet (%) diarrhea (%) confined. This is possible only when Open defecation–prevalent villages 29 38 the collective is made aware of the negative effects of poor sanitation, Almost open defecation-free villages 95 26 sensitized about the fecal-oral transmission route, understands the Open defecation-free villages 100 7 link between sanitation and health, The table shows that rural households in Himachal Pradesh with limited abandons the traditional practice of toilet coverage reported a high diarrhea recall (up to 38 percent). Even open defecation for ever, and every villages with close to 100 percent household toilet coverage showed a member of the community has access significantly high recall of diarrhea incidence. Only villages declared to be to, and uses a, sanitary toilet ensuring open defection-free, with 100 percent toilet usage, reported a significant safe disposal of fecal matter. drop in diarrhea recall to 7 percent. What are the Limitations of the In effect,
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