CLTS Learning Series: Lessons from CLTS Implementation in Seven Countries

This report shares key findings that emerged from a cross-country synthesis of rural sanitation behaviour change processes using the Community-led Total Sanitation (CLTS) approach implemented by Plan International Country Offices (COs) in Cambodia, Nepal, Indonesia, Lao PDR, Uganda, Niger, and Haiti. This research aimed to characterise variations in CLTS implementation through the perspectives of stakeholders and to identify the roles of local actors in implementing CLTS. This 7-country evaluation of case studies presents common features of CLTS implementation, identifies bottlenecks and enabling conditions, shares lessons relevant to scaling up CLTS, identifies implications for practice, and delivers policy recommendations across a range of country contexts. (Part of a Bill & Melinda Gates Foundation sponsored applied research project, more findings from the Testing CLTS Approaches for Scalability project (2011-2015) can be found at the Water Institute at the University of North Carolina at Chapel Hill (UNC), which led the project's applied research component.)

CLTS is a behaviour change approach that seeks to eliminate open defaecation and encourage the construction and use of sanitation facilities through "triggering" or grassroots mobilisation of communities. When successful, triggering promotes a community-wide commitment to becoming open-defaecation free (ODF). The process consists of 3 distinct stages: (i) planning and pre-triggering: selecting communities, training facilitators, collecting baseline information, and coordinating community entry; (ii) triggering: organising a mass meeting in communities where facilitators conduct participatory exercises intended to trigger shame and disgust. Attendees are expected to analyse their sanitation situation and be moved to change it on their own; (iii) post-triggering: routine monitoring and follow-up visits by facilitators, technical support on latrine construction, and verification and certification of ODF status in communities. As CLTS is a "community-led" process, a crucial component of the strategy is to involve community leaders to take charge of their own sanitation situation. CLTS programmes typically refer to "natural leaders", who emerge from the triggering process and participate in post-triggering activities. Since its inception in Bangladesh in 2000, CLTS has been adopted by many international non-governmental organisations (INGOs) and is now practiced in over 50 countries.

Plan International's implementation arrangements for CLTS varied between each country, ranging from direct implementation to playing a more supportive role of providing technical and capacity building assistance to local government. The policy environment in all 7 countries was found to be largely positive towards CLTS; all 7 governments recognised the need for demand-led sanitation strategies. However, several national policies, such as those in Lao PDR, Cambodia, and Niger, allowed for targeted hardware subsidies for households or public facilities. In all countries where latrine subsidy projects and CLTS overlapped, CLTS practitioners cited considerable challenges.

UNC researchers collected data between May 2013 and June 2014 with support from Plan International COs. In-depth interviews were conducted with 293 people, including policymakers, Plan International staff, other NGO partners, local government officials, village-level CLTS facilitators, and community leaders. Policy and programmatic documents were also gathered over the course of 2-3 weeks in each country. Across all 7 countries, Plan International has triggered nearly 1,000 communities and is one of the major NGOs implementing CLTS. As part of the research, 34 communities were visited, 44% of which were declared or certified as ODF by the time of the visits. Self-reported monitoring data revealed a wide range in the presence of ODF communities - from 6% of communities in Haiti being declared ODF to 97% of communities in Indonesia being certified as ODF. However, these numbers cannot be directly compared across case studies because ODF definitions and verification processes were not consistent. In terms of household latrine coverage, Plan International programs in Indonesia, Uganda, and Lao PDR appeared to have the best endline results. Baseline data were available for 4 of the 7 case study programmes. Of these, the largest absolute increase in household latrine coverage after triggering activities occurred in Uganda (44%). However, it is not possible to attribute this progress entirely to CLTS activities, as other factors may have also contributed to the increase in latrine coverage, such as campaigns by government or other organisations.

The following themes were identified across the 7 case studies, with related findings and recommendations for CLTS and rural sanitation practitioners:

• Role of CLTS: CLTS was widely perceived as being universally applicable to rural communities, even though outcomes varied depending on community characteristics. Rather than viewing it as a comprehensive solution to rural sanitation, CLTS should be considered as one component of a sanitation strategy. If communities that are more likely to be receptive to CLTS are reached out to more systematically, practitioners can allocate remaining resources to test other approaches, such as sanitation marketing, in other communities less appropriate for CLTS.
• Local government capacity: In 5 of the 7 case studies, local government capacity was found to be insufficient to lead CLTS activities. Where local governments are unable to lead CLTS activities, INGOs can help strengthen their capacity through training, mentorship, and targeted technical support. INGOs should also engage with local NGOs (LNGOs) to trigger communities and strengthen village-level participation. At the same time, all NGOs should advocate for increased investment from national government.
• Role of village-level actors: A variety of village volunteers were implicated in different phases of CLTS, but they needed considerable support from Plan International and local government to motivate communities toward behaviour change. CLTS practitioners need to ensure that an unfair burden is not placed on volunteers. Practitioners should allocate sufficient resources for training, financial and in-kind support, recognition, and exchange visits to sustain volunteer motivation.
• Adaptations to triggering: Triggering techniques had been adapted in all case studies, but adaptations were not always designed with the aim of improving outcomes. The most commonly cited triggering tools were the transect walk/"walk of shame", village mapping, shit calculation, water-faeces demonstration, and analysis of medical costs. However, several of these triggering tools did not appear to be used routinely in all programmes. For instance, local government facilitators in Cambodia and Lao PDR hesitated to use strong shaming techniques, reportedly due to cultural reasons, and omitted certain steps, such as the water-faeces demonstration, because they themselves were too embarrassed to lead these activities. Programmes should systematically identify adaptations to CLTS and critically analyse whether the adaptations are a result of community context or a result of convenience or logistical constraints. Certain adaptations may compromise the CLTS approach itself and slow progress in communities, and may need to be modified through improved training and selection of facilitators.
• Sanctions: Although community-developed sanctions are encouraged in CLTS, most examples identified were enacted by village or district government. CLTS practitioners, including NGOs and government, need to carefully consider the types of sanctions they actively encourage or passively condone, who enforces the sanctions, and how they are enforced in practice. Sanctions may be useful in creating and reinforcing social norms, but they need to be introduced at the right time, in the right manner, and seek to reach the right people.
• Hardware supply and financing: Latrines built as a result of CLTS were often of poor quality, adversely affecting the sustainability of CLTS outcomes. Access to durable materials, technical support, and affordability were key obstacles. Plan International can help influence the nature of post-CLTS support in communities through approaches that maintain the motivational nature of CLTS and also provide access to higher-quality sanitation options, such as sanitation marketing.
• Monitoring outcomes: CLTS monitoring activities comprised a variety of process and outcome indicators, but ultimately focused on achievement of ODF status, except in Haiti. There were differences in indicators of success, ODF definitions, and ODF verification guidelines across all case study countries. Achievement of ODF status can serve as a powerful motivational tool for communities to change their sanitation practices. However, it is less useful as a metric to measure progress; its binary nature suggests that communities that have nearly achieved 100% latrine coverage may still qualify as "not ODF". Therefore, programmes should consider focusing on routinely collecting data (including baseline measurements) on household-level indicators of sanitation so they can measure and recognise incremental progress in communities. Improved monitoring of activities will help generate evidence on the potential, the effectiveness, and the limits of CLTS.

Click here for the 67-page report in PDF format.
Click here for a 6-page learning brief.