WASH-CLD Article References & Abstracts

Jannette Abalo. 2016. “Sanitation and Health practices: A Positive Deviance study of three Community Led Total Sanitation (CLTS) host villages in Uganda.” Research Thesis submitted in Partial Fulfilment of the Requirements for the award of a Degree in Master of Philosophy in Health Promotion Research Centre for Health promotion (HEMIL) Faculty of Psychology: University of Bergen, Bergen, Norway.

Background: Uganda is hard hit by poor access to clean water, lack of basic sanitary facilities and practices, and the high cost of health care, all contributing to a high toll of infection-related illness. Although Uganda has one of the most advanced, harmonized and coordinated water sectors in Africa, her progress in water supply, and sanitation has stagnated in the last few years. This stagnation factor is strongly attributed to the limited political prioritization of the sector, inadequate funding, poor O&M practices and limited translation of policy into practice at different levels of governance. Responding, in 2010 the Uganda government implemented a Community Led Total Sanitation (CLTS) programme, using a participatory approach to empower communities to achieve better sanitation/health. Much can be learned from the experience of particular households in CLTS communities that managed to achieve significant sanitation improvements, despite ubiquitous deprivation.

Conceptual framework: The study therefore, used the ‘positive deviance (PD)’ method/ approach as a conceptual framework to study such success. PD is an innovative public health strategy to learn from people whose uncommon but successful behaviours or strategies enable them to find better solutions to a problem than their peers, despite facing similar challenges and having no extra resources. In the Global South, earlier evidences point to the successful application of the PD in improving child nutrition and other public health challenges but until now, it had not been used as an approach to address the need for better sanitation. Using PD, this study examined sanitation achievements in households with best practice.

Adenike Adeyeye. 2011. “Gender and Community-Led Total Sanitation: A Case Study of Ekiti State, Nigeria.” Tropical Resources: The Bulletin of the Yale Tropical Resources Institute 30: 18-27. environment.yale.edu/tri.

Abstract: Community-led total sanitation (CLTS) has succeeded all over the world, yet it has struggled in Ekiti State, Nigeria. This report examines the role “gender mainstreaming” plays in the progress of Ekiti State CLTS projects. Interviews with CLTS facilitators, community leaders, and individual households indicate that WaterAid Nigeria focuses on equal representation of men and women within the Water and Sanitation Committees (WASCOMs) and as Volunteer Health Promoters (VHPs), two entities that implement CLTS. However, equal representation does not always translate to equal decision-making power. Without clearly delineated roles within the committees, the committees’ foci naturally turn to issues with which men are most familiar, as men are more vocal than women in public spaces. As a result, issues with which women are more familiar can be overlooked to the detriment of the entire community. !is report suggests that CLTS facilitators present communities with the option of electing individuals to specific roles within the WASCOM, possibly in the form of sub-committees for different aspects of the program, to ensure that all relevant issues are addressed thoroughly. Sub-committees could create a space for women and men to influence decision-making equally.

Evans Banana, Beth Chitekwe-Biti, and Anna Walnycki. 2015. “Co-producing inclusive city-wide sanitation strategies: lessons from Chinhoyi, Zimbabwe.” Environment & Urbanization 27: 35–54. DOI: 10.1177/0956247815569683.

Abstract: This paper explores how communities in Chinhoyi, Zimbabwe have used community-led mapping and enumerations(1) to build partnerships with local government to support the development and co-production of innovative pro-poor city-wide sanitation strategies as part of the SHARE City-Wide Sanitation Project. This action research project is being conducted in four cities across sub-Saharan Africa: Chinhoyi (Zimbabwe), Kitwe (Zambia), Blantyre (Malawi) and Dar es Salaam (Tanzania). This programme of work responds to the failure of conventional approaches to urban sanitation to meet the needs of low-income urban communities in sub-Saharan Africa. Over three years it has supported Shack/Slum Dwellers International affiliates to develop and test pro-poor sanitation strategies that can be adopted and driven by networks of community organizations and residents’ associations, and supported by public authorities and private providers.

Kevin Bardosh. 2015. “Achieving ‘‘Total Sanitation” in Rural African Geographies: Poverty, Participation and Pit Latrines in Eastern Zambia.” Geoforum 66: 53-63. http://dx.doi.org/10.1016/j.geoforum.2015.09.004.

Abstract: Over one billion of the poorest people on earth continue to practice open defecation. A complex assemblage of factors, embedded within prevailing inequities and inequalities, continue to betray efforts to improve this. Subsidy-based projects have had little impact in rural Africa where sanitation remains under-prioritised by the state and donors. Community-led total sanitation (CLTS) offers a new, people-centric approach conceptually grounded in participatory development. But despite its broad appeal, the CLTS policy narrative has become equated with quick results, low-cost, provocative language and the potential for community self-help. Drawing on research in Katete district, Eastern Zambia, this paper explores tensions between CLTS theory, policy, practice and local realities. Rapidly scaled-up by local government, poor management and stakeholder engagement effectively diluted the approach, and continued the ‘‘projectification” of the sanitation sector. Open defecation, both symbolically and practically, represented an embedded marginalisation from the modern Zambian state where multiple barriers to latrine construction coexisted in the context of fragile livelihoods. In such agrarian communities, CLTS cannot be conceptualised as a blanket approach quickly bringing total sanitation to the masses. For its strengths to be realised in contexts of rural poverty, a targeted strategy that builds local institutional capacity and iteratively scales-up over time is needed. But realising this in practice requires moving beyond a prevailing emphasis on ‘‘open defecators” to engage complex issues of power and politics in sanitation governance.

Elijah Bisung, Susan J. Elliott, Bernard Abudho, Diana M. Karanja, and Corinne J. Schuster-Wallace. 2015. “Using Photovoice as a Community Based Participatory Research Tool for Changing Water, Sanitation, and Hygiene Behaviours in Usoma, Kenya.” BioMed Research International Volume 2015: Article ID 903025, 10 pages. http://dx.doi.org/10.1155/2015/903025.

Abstract: Recent years have witnessed an increase in the use of community based participatory research (CBPR) tools for understanding environment and health issues and facilitating social action. This paper explores the application and utility of photovoice for understanding water, sanitation, and hygiene (WASH) behaviours and catalysing community led solutions to change behaviours. Between June and August 2013, photovoice was conducted with eight (8) women in Usoma, a lakeshore community in Western Kenya with a follow-up community meeting (baraza) in May 2014 to discuss findings with the community members and government officials. In the first part of the study, photovoice one-on-one interviews were used to explore local perceptions and practices around water-health linkages and how the ecological and socio-political environment shapes these perceptions and practices. This paper, which is the second component of the study, uses photovoice group discussions to explore participants’ experiences with and (re)action to the photographs and the photovoice project. The findings illustrate that photovoice was an effective CBPR methodology for understanding behaviours, creating awareness, facilitating collective action, and engaging with local government and local health officials at the water-health nexus.

Claire Chase and Francis Ngure. 2016. “Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene.” World Bank Group Water and Sanitation Program Technical Paper. www.wsp.org.

Abstract/Key Points: Global momentum around emerging evidence of the linkages between water, sanitation, and hygiene (WASH) and undernutrition, and high-level policy dialogue advocating for nutrition-sensitive WASH, has created a “window of opportunity” to influence how the World Bank Group approaches lending for WASH projects, and how policies are designed for greater impact on nutrition. Achieving nearly universal coverage of the most effective nutrition interventions in high burden countries would only reduce stunting by 20 percent globally, suggesting a critical role for nutrition-sensitive interventions such as WASH to address the remaining burden. Increased use of geographic and demographic targeting of WASH projects can help reach populations where water and sanitation coverage is low and undernutrition is high. Incorporating state-of-the-art behavior change methods and insights from behavioral economics into World Bank Group operations in the WASH sector, and documenting behavioral outcomes, can provide plausible evidence of impact on nutrition. Institutional levers can be used to align incentives of task teams and senior management toward multisectoral approaches, while results-based incentives can align objectives at the project level. WASH interventions can increase nutritional impact by measuring and monitoring outcomes beyond access to services, such as usage, maintenance of infrastructure, and behavioral change.

Ben Cole, John Pinfold, Goen Ho and Martin Anda. 2014. “Exploring the methodology of participatory design to create appropriate sanitation technologies in rural Malawi.” Journal of Water, Sanitation and Hygiene for Development 4: 51-61. doi: 10.2166/washdev.2013.166.

Abstract: The methodologies of demand-led sanitation programmes (including community-led total sanitation [CLTS] and sanitation marketing) encourage participation of users in the design of appropriate sanitation facilities. There has been limited examination of the application of established methodologies in participatory design in the sanitation sector. This paper describes and reflects upon three case studies that applied established participatory design methodologies to create sanitation technologies in rural Malawi. Participants of the design sessions represented two groups: (i) researcher–designers (government staff); and (ii) users (local builders and householders). The methodology created a space to develop a common language between the two groups and allowed an exploration of tensions about the use of sanitation hardware subsidies. The design sessions created a number of innovations including corbelling structures, trapezium shaped bricks and reinforcement of wooden frame structures with sandbags. The paper critically reflects on the processes of participatory design in relation to power, ownership and continued participation.

Jonny Crocker, Elvis Abodoo, Daniel Asamani, William Domapielle, Benedict Gyapong, and Jamie Bartram. 2016. “Impact Evaluation of Training Natural Leaders during a Community-Led Total Sanitation Intervention: A Cluster-Randomized Field Trial in Ghana.” Environ. Sci. Technol. 50: 8867−8875. DOI: 10.1021/acs.est.6b01557.

Abstract: We used a cluster-randomized field trial to evaluate training natural leaders (NLs) as an addition to a community-led total sanitation (CLTS) intervention in Ghana. NLs are motivated community members who influence their peers’ behaviors during CLTS. The outcomes were latrine use and quality, which were assessed from surveys and direct observation. From October 2012, Plan International Ghana (Plan) implemented CLTS in 60 villages in three regions in Ghana. After 5 months, Plan trained eight NLs from a randomly selected half of the villages, then continued implementing CLTS in all villages for 12 more months. The NL training led to increased time spent on CLTS by community members, increased latrine construction, and a 19.9 percentage point reduction in open defecation (p <0.001). The training had the largest impact in small, remote villages with low exposure to prior water and sanitation projects, and may be most effective in socially cohesive villages. For both interventions, latrines built during CLTS were less likely to be constructed of durable materials than pre-existing latrines, but were equally clean, and more often had handwashing materials. CLTS with NL training contributes to three parts of Goal 6 of the Sustainable Development Goals: eliminating open defecation, expanding capacity-building, and strengthening community participation.

Jonny Crocker, Katherine F. Shields, Vidya Venkataramanan, Darren Saywell, and Jamie Bartram. 2016. “Building capacity for water, sanitation, and hygiene programming: Training evaluation theory applied to CLTS management training in Kenya.” Social Science & Medicine 166: 66-76. http://dx.doi.org/10.1016/j.socscimed.2016.08.008.

Abstract: Training and capacity building are long established critical components of global water, sanitation, and hygiene (WaSH) policies, strategies, and programs. Expanding capacity building support for WaSH in developing countries is one of the targets of the Sustainable Development Goals. There are many training evaluation methods and tools available. However, training evaluations in WaSH have been infrequent, have often not utilized these methods and tools, and have lacked rigor. We developed a conceptual framework for evaluating training in WaSH by reviewing and adapting concepts from literature. Our framework includes three target outcomes: learning, individual performance, and improved programming; and two sets of influences: trainee and context factors. We applied the framework to evaluate a seven-month community-led total sanitation (CLTS) management training program delivered to 42 government officials in Kenya from September 2013 to May 2014. Trainees were given a pre-training questionnaire and were interviewed at two weeks and seven months after initial training. We qualitatively analyzed the data using our conceptual framework. The training program resulted in trainees learning the CLTS process and new skills, and improving their individual performance through application of advocacy, partnership, and supervision soft skills. The link from trainees’ performance to improved programming was constrained by resource limitations and pre-existing rigidity of trainees’ organizations. Training-over-time enhanced outcomes and enabled trainees to overcome constraints in their work. Training in soft skills is relevant to managing public health programs beyond WaSH. We make recommendations on how training programs can be targeted and adapted to improve outcomes. Our conceptual framework can be used as a tool both for planning and evaluating training programs in WaSH.

Oliver Cumming and Val Curtis. 2018. “Correspondence: Implications of WASH Benefits trials for water and sanitation.” The Lancet 6. http://dx.doi.org/10.1016/.

Abstract: At a policy level, these studies suggest that business as usual in the WASH sector will not be enough to significantly improve child growth. At a policy level, these findings lend support to the new, and more ambitious, Sustainable Development Goal (SDG) that calls for progress towards a piped continuous water supply located on premises coupled with a safely managed sanitation service for all. Looking forward, if the prospects of those millions of children still born into poverty, and who too often fail to thrive as they should, are to be improved, then it is clear that this new and ambitious level of service is where we should now be aiming.

Carmen da Silva Wells and Christine Sijbesma. 2012. “Practical innovations for strengthening Community-Led Total Sanitation: selected experience from Asia.” Development in Practice 22, No. 3: 417-426. http://dx.doi.org/I0.1080/09614524.20l2.640984.

Abstract: While Community-Led Total Sanitation (CLTS) is a relative success in a growing number of countries, there are also difficulties in assuring all community members can build and use toilets. This paper draws on experiences of IRC International Water and Sanitation Centre and its partners in strengthening inclusiveness and sustainability in CLTS interventions. It presents practical measures to strengthen gender and poverty equity, community-based monitoring and capacity development for community institutions and the local private sector.

Dominick de Waal and Max Hirn. 2015. “The Intricacies of Attracting and Sustaining Investment in WASH in Fragile States: Lessons from Liberia.” World Bank Group Water and Sanitation Program Report. www.wsp.org.

Abstract/Executive Summary: The choice made early in the post-conflict transition by the international community to directly fund WASH service delivery through non-state actors rather than through the Liberian government undermined both sector policy dialogue and the formation of robust government institutions able to lead and orchestrate service delivery by non-state actors.

The lack of a substantive policy dialogue – particularly in the 2003 to 2007 period – meant that a fragmented institutional setup emerged across a number of ministries with no clear locus of policy authority. An earlier move to funding water, sanitation and hygiene (WASH) service delivery through country systems (for both urban and rural WASH) – as was done in the health sector – would have been a point of leverage to influence institutional reforms and build a nucleus of capacity in the Government of Liberia (GoL’s) institutions responsible for WASH on which future capacity building could have capitalized.

Starting in 2011, the Water and Sanitation Program (WSP), the United States Agency for International Development (USAID) and other development partners provided technical assistance to a multi-stakeholder sector planning process that has played a key role in addressing this early mistake transitioning the sector from one dominated by a humanitarian response approach, to one that is based on a longer-term development approach. This TA has helped build a detailed picture of service delivery and generated clear priorities for capital investments reflected in the Liberia WASH Sector Investment Plan (SIP). The SIP and TA to improve the operational efficiency of sector institutions, specifically the main utility, has mobilized an additional US$30m in investments for WASH in Liberia.

The SIP provided direction to existing sector allocations and has also been a strategic tool that has influenced increased bilateral and multilateral aid into the country following the Ebola virus outbreak, including spurring the World Bank’s re-engagement in Liberia’s WASH sector. These aid flows should seek to better connect policy dialogue within individual sectors to higher-level dialogue on state-building. This will help to resolve bottlenecks beyond WASH specific institutions – such as on decentralization – that have potential to enhance the reach and rate of service delivery. It will also reinforce mutual accountability among domestic and donor sector actors driving up investment levels to those needed for universal access.

This paper aims to inform this new wave of support to Liberia’s WASH sector by looking back at service provision in the country over the period 2003 to 2015 and reflecting on the transition from the post-war emergency response to the nascent development response. The paper first describes key trade-offs encountered by the international community in this transition, describing choices made in Liberia that held back government capacity to orchestrate a national response to service delivery. It then goes on to describe how WSP and other development partners have, since 2011, worked with the government of Liberia to build and attract investment to a country-led WASH development program. The paper presents lessons for sector practitioners operating in post-crisis transition situations – both those in developing country governments and their development partners.

Ria A. Dunkley & Alex Franklin. 2017. “Failing better: The stochastic art of evaluating community-led environmental action programs.” Evaluation and Program Planning 60: 112-122.

Summary/Abstract: This article provides insights into the evaluation of a government-funded action for climate change program. The UK-based program aimed to reduce CO2 emissions and encourage behavioral change through community-led environmental projects. It, thus, employed six community development facilitators, with expertise in environmental issues. These facilitators supported and learnt from 18 community groups over an 18-month period. The paper explores the narratives of the six professional facilitators. These facilitators discuss their experiences of supporting community groups. They also explain their contribution to the wider evaluation of the community-led projects. This paper reflects on the facilitator experience of the program’s outcome-led evaluation process. In turn, it also explores how the groups they supported experienced the process. The facilitator’s narratives reveal that often community-group objectives did not align with predefined outcomes established through theory of change or logic model methodologies, which had been devised in an attempt to align to program funder aims. Assisting community action emerges in this inquiry as a stochastic art that requires funder and facilitator willingness to experiment and openness to the possibilities of learning from failure. Drawing on in-depth accounts, the article illustrates that a reflexive, interpretive evaluation approach can enhance learning opportunities and provides funders with more trustworthy representations of community-led initiatives. Yet, it also addresses why such an approach remains marginal within policy circles.

Nelson Ekane, Nina Weitz, Björn Nykvist, Petter Nordqvist, and Stacey Noel. 2016. “Comparative assessment of sanitation and hygiene policies and institutional frameworks in Rwanda, Uganda and Tanzania: THE SANITATION CHALLENGE AND THE POLICY RESPONSE IN RWANDA, UGANDA AND TANZANIA.” Stockholm Environment Institute. https://www.jstor.org/stable/resrep02758.7.

This section outlines the sanitation and hygiene status in the three countries and the challenges that policies must address. We use WHO/UNICEF (2015) data to show the trend in sanitation coverage in Rwanda, Uganda and Tanzania over the past two decades. This trend is summarized in Table 1. On-site sanitation facilities are predominant in the three countries, and mainly consist of traditional pit latrines of varying standards (Morella et al. 2008). Morella et al. (2008) evaluated progress from open defecation to use of on-site sanitation and reported that Rwanda, Uganda and Tanzania meet six sanitation indicators in the sanitation index. This index is a simple scoring system used to evaluate the progress of reforms and focuses specifically on on-site sanitation systems. The five main indicators are: existence of a hygiene promotion programme; existence of an accepted definition of sanitation; existence of a specific fund for sanitation; involvement of utilities in on-site sanitation; and clear cost recovery policies for on-site sanitation.

NELSON EKANE, BJÖRN NYKVIST, MARIANNE KJELLÉN, STACEY NOEL, and NINA WEITZ. 2014. “Multi-level sanitation governance: understanding and overcoming challenges in the sanitation sector in sub-Saharan Africa.” Waterlines 33, No. 3: 242-256. http://dx.doi.org/10.3362/2046-i887.20t4.024

Abstract: The provision of sanitation facilities – a basic necessity for human health, well-being, dignity, and development – remains a mammoth challenge for developing countries where the vast majority of the 2.5 billion people without improved sanitation facilities reside. Sub-Saharan Africa (SSA) is one of the regions where decent, dignified, and functional toilet facilities remain largely inaccessible. Most of the countries in SSA will miss the Millennium Development Goal (MDG) for sanitation. There are sharp contradictions in the region between formal and informal sanitation institutions. There is also a disconnect between actors at the macro, meso, and micro governance levels. This paper shows how multi-level governance analysis, path dependency, and institutional inertia can be used to improve understanding of some challenges in the sanitation sector in SSA, and discusses approaches that can contribute to improving the sanitation situation in a sustainable way. In addition, the paper asserts that demand-driven strategies and private sector involvement in the sanitation sector is paramount for establishing new sanitation paradigms and socio-technical regimes. We conclude that a good understanding of actors at all levels – their various roles, interactions, and the way they interpret and respond to policies – is key to accelerating progress in sustainable sanitation coverage.

Nelson Ekane, Nina Weitz, Björn Nykvist, Petter Nordqvist, and Stacey Noel. 2016. “Comparative assessment of sanitation and hygiene policies and institutional frameworks in Rwanda, Uganda and Tanzania: COMPARATIVE ANALYSIS OF SANITATION AND HYGIENE POLICY FRAMEWORKS.” Stockholm Environment Institute. https://www.jstor.org/stable/resrep02758.8.

In Rwanda, Uganda and Tanzania, policies and institutional frameworks have evolved to address the challenges of sanitation provision and hygiene promotion. This section assesses the key elements of the current sanitation policy frameworks in more detail, and analyses common patterns and their implications.

Raymond Guiteras, James Levinsohn, and Ahmed Mushfiq Mobarak. 2015. “Encouraging sanitation investment in the developing world: A cluster-randomized trial.” Science 348, No. 6237: 903-906. sciencemag.org

Abstract: Poor sanitation contributes to morbidity and mortality in the developing world, but there is disagreement on what policies can increase sanitation coverage. To measure the effects of alternative policies on investment in hygienic latrines, we assigned 380 communities in rural Bangladesh to different marketing treatments—community motivation and information; subsidies; a supply-side market access intervention; and a control—in a cluster-randomized trial. Community motivation alone did not increase hygienic latrine ownership (+1.6 percentage points, P = 0.43), nor did the supply-side intervention (+0.3 percentage points, P = 0.90). Subsidies to the majority of the landless poor increased ownership among subsidized households (+22.0 percentage points, P < 0.001) and their unsubsidized neighbors (+8.5 percentage points, P = 0.001), which suggests that investment decisions are interlinked across neighbors. Subsidies also reduced open defecation by 14 percentage points (P < 0.001).

HANCHETT, S. et al.. 2011. Sustainability of sanitation in rural Bangladesh. Loughborough University’s Institutional Repository, 6-8.

Abstract: This is a report on a study of 53 Bangladesh unions declared “100% sanitized” more than 4.5 years earlier under the auspices of a broad-based national sanitation campaign. Union Chairmen received awards if their populations achieved the goal. Findings were generally positive, with 89.5% of surveyed households using some type of improved latrine (shared or not). A dramatic change in social norms was found. Two-thirds of union chairmen were still working on sanitation. Other achievements were the emergence of private sector latrine parts producers and an increase in latrine pit cleaning services. A significant problem was the unclean condition of 56% of improved household latrines. Other challenges are discussed. Recommendations include: Establish quality standards for latrine parts manufacture; Monitor sanitation coverage in all unions in the future; Offer low-interest loans to poor households for latrine purchases; and Keep local government involved and responsible for continuing rural sanitation improvements.

Peter A. Harvey. 2011. “Zero subsidy strategies for accelerating access to rural water and sanitation services.” Water, Science, and Technology 63, No. 5: 1037-1043. DOI: 10.2166/wst.2011.287.

Abstract: Community-Led Total Sanitation (CLTS) and Household-Led Water Supply (HLWS) are zero subsidy approaches to water and sanitation service provision that have been recently piloted in Zambia. The increases in access to sanitation and toilet usage levels achieved in one year under CLTS were far greater than any achieved in subsidised programmes of the past. Similarly, HLWS has shown that rural households are willing to invest in their own infrastructure and that they can increase coverage of safe water without external hardware subsidy. The promotion of self-sufficiency rather than dependency is a key component of both approaches, as is the focus on the development of sustainable services rather than the external provision of infrastructure. Zero subsidy strategies have the potential to deliver far more rapid increases in service coverage and higher levels of sustainability than the conventional subsidised approaches that predominate in low-income countries.

Kadam, Chitra. 2016. “Sustaining Development Initiatives: Excogitating on the Role of Capacity Building.” Indian Anthropologist 46, no. 1: 47-62. www.jstor.org/stable/43899792.

Abstract: Addressing the issue of sustainability, the present paper deliberates on the role of capacity building initiatives in achieving sustainable results by accentuating the agency of local actors and community based organizations. Imbued with cognition of development as an issue of rights, capacity building initiatives seek to strengthen the capacity of rights holders to claim their rights and entitlements as well as of duty bearers to fulfill their obligations to provide and protect these rights. Capacity building envisages mobilizing community members for greater participation and ownership , establishing community based organizations for institutionalization of development work and nurturing the agency of people for bringing positive transformation in power relations. Drawing comparisons among two villages of Sehore district of Madhya PradesĶ the main argument of the paper revolves around elucidating how capacity building initiatives produced sustainable results in one village while in the other they conked out due primarily to lack of ownership and institutionalization at local level.

J. Joseph Lawrence, Kojo Yeboah-Antwi, Godfrey Biemba, Pavani K. Ram, Nicolas Osbert, Lora L. Sabin, and Davidson H. Hamer. 2016. “Beliefs, Behaviors, and Perceptions of Community-Led Total Sanitation and Their Relation to Improved Sanitation in Rural Zambia.” Am. J. Trop. Med. Hyg. 94, No. 3: 553–562. doi:10.4269/ajtmh.15-0335

Abstract: Inadequate hygiene and sanitation remain leading global contributors to morbidity and mortality in children and adults. One strategy for improving sanitation access is community-led total sanitation (CLTS), in which participants are guided into self-realization of the importance of sanitation through activities called “triggering.” This qualitative study explored community members’ and stakeholders’ sanitation, knowledge, perceptions, and behaviors during early CLTS implementation in Zambia. We conducted 67 in-depth interviews and 24 focus group discussions in six districts in Zambia 12–18 months after CLTS implementation. Triggering activities elicited strong emotions, including shame, disgust, and peer pressure, which persuaded individuals and families to build and use latrines and handwashing stations. New sanitation behaviors were also encouraged by the hierarchical influences of traditional leaders and sanitation action groups and by children’s opinions. Poor soil conditions were identified as barriers to latrine construction. Taboos, including prohibition of different generations of family members, in-laws, and opposite genders from using the same toilet, were barriers for using sanitation facilities. CLTS, through community empowerment and ownership, produced powerful responses that encouraged construction and use of latrines and handwashing practices. These qualitative data suggest that CLTS is effective for improving sanitation beliefs and behaviors in Zambia.

Christoph Lüthi , Jennifer McConville, and Elisabeth Kvarnström. 2010. “Community-based approaches for addressing the urban sanitation challenges.” International Journal of Urban Sustainable Development 1: 1-2, 49-63. DOI: 10.1080/19463131003654764.

Abstract: Urban sanitation presents one of the most significant service delivery challenges related to poverty alleviation and sustainable development in the developing world. The past decade has witnessed innovations in service delivery approaches for unserved rural and urban settlements with a clear policy shift to community-based approaches that attempt to overcome the supply-led, over-engineered sanitation solutions of the past decades. This article presents two examples of new developments: the urban-focussed household-centred environmental sanitation (HCES) and the rural-focussed community-led total sanitation (CLTS) approaches. The internationally renowned CLTS approach has achieved considerable success since its introduction, by harnessing community and small private sector capacity to solve sanitation problems locally. Experience with validation of the HCES approach in a variety of urban sites in Africa, Asia and Latin America is presented in the second part of the article highlighting some of the lessons learned. The article closes by arguing that a combination of HCES and CLTS, two field-tested methodologies, has the potential to improve the sustainability of sanitation service interventions.

Shirin Madon, Mwele Ntuli Malecela, Kijakazi Mashoto, Rose Donohue, Godfrey Mubyazi, and Edwin Michael. 2018. “The role of community participation for sustainable integrated neglected tropical diseases and water, sanitation and hygiene intervention programs: A pilot project in Tanzania.” Social Science & Medicine 202: 28-37. https://doi.org/10.1016/j.socscimed.2018.02.016.

Abstract: Strategies aimed at reducing the prevalence of neglected tropical diseases (NTDs) in Tanzania including those attributed to water, sanitation and hygiene (WASH) problems have been largely top-down in nature. They have focused on strengthening the governance of NTD-WASH programs by integrating different vertical disease programs and improving the efficiency of report-generation. In this paper, we argue for community participation as an effective strategy for developing sustainable village health governance. We present the results of a pilot undertaken between November 2015 and April 2016 in which we adopted a mixed methods case study approach to implement an Enhanced Development Governance (EDG) model using existing village governance structures. Our results show that the EDG model was associated with a statistically significant reduction in the prevalence of schistosomiasis and diarrhoea, and has led to an increase in awareness of WASH interventions for sustaining gains in NTD control. We identify five key social processes enacted by the EDG model that have led to improved health benefits related to frequency of meetings and attendance, promotion of health and sanitation awareness, income-generating activities, self-organising capabilities, and interaction between village bodies. These findings hold important implications for conceptualising the role of community participation in sustaining NTD-WASH intervention programs and for sensitising institutional and policy reform.

McConville, J. ; Kain, J. ; Kvarnstrom, E. et al.. 2014. “Participation in sanitation planning in Burkina Faso: theory and practice.” Journal of Water Sanitation and Hygiene forDevelopment 4, No. 2: 304-312.

Abstract: Stakeholder participation is commonly promoted as a means to boost outcomes of sanitation improvement projects, in particular in developing countries. However, there is little research on when or how this participation should occur during the process of planning and implementing a sanitation system in order to maximize the effect. This study develops a framework for analysing participation levels of different stakeholders throughout a planning process and applies it to sanitation planning guidelines and case studies from Burkina Faso. This analysis highlights that, particularly during designing of system options and selecting among these options, there exist potential weaknesses regarding who participates and how that participation may influence what type of sanitation is implemented.

Celia McMichael. 2019. “Water, Sanitation and Hygiene (WASH) in Schools in Low-Income Countries: A Review of Evidence of Impact.” Int. J. Environ. Res. Public Health 16: 359. doi:10.3390/ijerph16030359.

Abstract: Many schools in low-income countries have inadequate access to water facilities, sanitation and hygiene promotion. A systematic review of literature was carried out that aimed to identify and analyse the impact of water, sanitation and hygiene interventions (WASH) in schools in low-income countries. Published peer reviewed literature was systematically screened during March to June 2018 using the databases PubMed, Embase, Web of Science, the Cochrane Library, Science Direct, and Google Scholar. There were no publication date restrictions. Thirty-eight peer reviewed papers were identified that met the inclusion criteria. The papers were analysed in groups, based on four categories of reported outcomes: (i) reduction of diarrhoeal disease and other hygiene-related diseases in school students; (ii) improved WASH knowledge, attitudes and hygiene behaviours among students; (iii) reduced disease burden and improved hygiene behaviours in students’ households and communities; (iv) improved student enrolment and attendance. The typically unmeasured and unreported ‘output’ and/or ‘exposure’ of program fidelity and adherence was also examined. Several studies provide evidence of positive disease-related outcomes among students, yet other assessments did not find statistically significant differences in health or indicated that outcomes are dependent on the nature and context of interventions. Thirteen studies provide evidence of changes in WASH knowledge, attitudes and behaviours, such as hand-washing with soap. Further research is required to understand whether and how school-based WASH interventions might improve hygiene habits and health among wider family and community members. Evidence of the impact of school-based WASH programs in reducing student absence from school was mixed. Ensuring access to safe and sufficient water and sanitation and hygiene promotion in schools has great potential to improve health and education and to contribute to inclusion and equity, yet delivering school-based WASH intervention does not guarantee good outcomes. While further rigorous research will be of value, political will and effective interventions with high program fidelity are also key.

Isaac Monney, Amos Baffoe-Kyeremeh and Papa Kofi Amissah-Reynolds. 2015. “Accelerating rural sanitation coverage in Ghana: what are the speed bumps impeding progress?” Journal of Water, Sanitation and Hygiene for Development 5, No. 4: 531-543. DOI: 10.2166/washdev.2015.005.

Abstract: Progress towards the Millennium Development Goal (MDG) sanitation target has generally been slow-paced in Ghana. This is particularly the case in rural areas where access to improved sanitation has increased by just 4% within two decades. This paper examines defecation practices as well as constraints and existing opportunities at both household and institutional levels in promoting in-house toilet construction. The study was conducted in three rural communities in the Tain district and drew on key informant interviews, focus group discussions, field observations and face-to-face interviews of 400 residents selected from 249 houses. The results showed the scarcity of in-house toilets, which means consequently open defecation and use of communal toilets are common practices. The need for in-house toilet facilities is high among property owners without them, mainly driven by the desire for comfort and safety. Barriers at the household level constraining latrine installation include ignorance of low-cost technologies, the perceived high cost of latrines and the low priority given to their ownership. Analysis of expenditure patterns at the local assembly shows low priority afforded to sanitation promotion, which is constrained by low donor support, lack of requisite logistics and poor human resource capacity. Existing opportunities for accelerating sanitation coverage in these study communities are examined both at the household and institutional levels, and best practices discussed.

Synne Movik and Lyla Mehta. 2010. “The Dynamics and Sustainability of Community-led Total Sanitation (CLTS): Mapping challenges and pathways.” STEPS Centre Working Paper. www.steps-centre.org/publications.

Abstract: Community-Led Total Sanitation (CLTS) represents a radical alternative to conventional top-down approaches to sanitation and offers hope of achieving the Millennium Development Goals. In contrast to state-led initiatives to improve sanitation that tend to focus on hardware and subsidies, CLTS emphasises community action and behaviour change as the most important elements to better sanitation. CLTS focuses on enabling the local community to analyse the problems of faecal-oral routes of disease spread, and of finding locally appropriate, rather than externally prescribed, solutions. Through exercises such as transect walks, mapping of open defecation sites, and the various routes of disease spread (e. g. through flies and animals), as well as calculation exercises aimed at drawing villagers’ attention to the amount of faeces they are ingesting, powerful emotions of shame and disgust are triggered. A process is ignited where people are moved into action, drawing on local resources and knowledge to construct sanitary facilities that fit their particular needs and desires, within the constraints of household priorities and resources. Pioneered by Dr. Kamal Kar, an independent development consultant, in Bangladesh in 1999, CLTS is currently being implemented in more than 30 countries across the globe, in Asia, Africa and Latin America. However, like all success stories, CLTS still faces a number of challenges in terms of its scope and impact. There is a need to map out and understand the social, technological and ecological dynamics of CLTS implementation in order to better appreciate the long-term sustainability issues of CLTS and realise its full potential for improving people’s lives and well-being.

MYERS, J., 2015. An update of themes and trends in urban community-led total sanitation projects. IN: Shaw, R.J. (ed). Water, sanitation and hygiene services beyond 2015 – Improving access and sustainability: Proceedings of the 38th WEDC International Conference, Loughborough, UK,b27-31, 6pp.

Abstract: This briefing paper identifies common themes and trends of Urban Community-Led Total Sanitation (UCLTS). The study relies on literature from 14 different projects across India and Africa alongside articles that focused on UCLTS and participation in urban sanitation projects. The hope is to provide an overview for those working in the field by identifying common characteristics, problems and opportunities. The paper ends with a list of recommendations for those currently working on UCLTS projects and those interested in transferring the CLTS model to urban environments.

Jamie Myers. 2016. “Urban community-led total sanitation: a potential way forward for co-producing sanitation services.” Waterlines 35, No. 4, Urban Sanitation: 388-396. http://dx.doi.org/l0.3362/1756-3488.20l6.028.

Abstract: Community-led total sanitation (CLTS) has been proved to be a successful strategy for tackling the challenge of open defecation in poor rural communities across Africa and Asia. This article explores whether a similar approach can be used in peri-urban and urban areas to help co-produce sanitation facilities and services with inputs from communities, duty bearers, and other sanitation stakeholders. It is argued that an urban CLTS approach does not mean a copy and paste of tools and methods which have proved successful in the rural environment but following a set of similar principles. Based on field experiences different steps are suggested that incorporate these principles and respond to the specific urban sanitation problem. This article helps to articulate and better define urban CLTS as well as giving practical guidance for those wanting to use this kind of approach.

Naomi Oates, Ian Ross, Roger Calow, Richard Carter, and Julian Doczi. 2014. “Adaptation to Climate Change in Water, Sanitation and Hygiene: Assessing risks, appraising options in Africa.” Water Policy Programme, Overseas Development Institute (ODI) Report

Executive Summary: This report presents the findings of research into the risks to delivery of WASH results posed by climate change in Africa, drawing on rapid case study reviews of WASH programming in Malawi, Sierra Leone and Tanzania. A separate Case Study Report provides further detail on country background and findings.

Water is predicted to be the main channel through which the impacts of climate change will be felt by people, ecosystems and economies. However, predicting impacts on the availability and quality of freshwater resources, and more so water-dependent services and sanitation, remains difficult. While there is a high level of confidence in the processes linking emissions to warming, much less is known about how warming will manifest itself at the local level through changes in rainfall, runoff, groundwater recharge and climate extremes. This reflects challenges with the down scaling of climate models, but also the significance of intervening factors such as changes in land cover which may have a greater influence on local systems and services than climate change. In general, the level of confidence in climate change projections decreases as their potential utility for making decisions on how to adapt increases (OECD, 2013). Section 1 of this report begins by looking at the WASH landscape,the gains made, but also some of the bottlenecks that hold back progress. Section 2 of the report looks at the risks to delivery of WASH results in three countries: Malawi, Sierra Leone and Tanzania. In each country, the aim was to canvass opinion on a risk screening approach that could be applied by programme designers and implementers to identify and mitigate risks. Section 3 of the report looks at the use of cost-benefit analysis (CBA) as a means of appraising the adaptation options prioritised through the risk screening process. Finally, Section 4 of the report summarises the main conclusions of the project and identifies some next steps in terms of the application of research findings and further research needs.

Service Opare. 2011. “Guarding the Garden of Eden: Community Led Water Resource Management in Rural Ghana.” Bibliothèque Et Archives Canada.

Abstract: Effective management of natural resources is essential for the attainment of the overarching object of sustainable development spelt out in the Millennium Development Goals. The world, however, is increasingly being confronted with problems of excessive resource exploitation and environmental degradation. Water resources, which are the focus of this study, are being over-exploited and contaminated, leading to supply shortages and increased incidence of water related diseases. In contrast, and as exemplified in this research that used a case study of two communities in Ghana, rural communities applied strategies that were based on their own traditions and cultural beliefs toward preservation of their water resources. Water resources were utilized in various ways and a mix of adaptation strategies and purification practices were employed to cope with difficulties associated with dwindling supplies and deteriorating quality conditions. However, the communities were confronted with a number of challenges in the management of their water resources. Water purification strategies were characterized by subjectivity and imprecision which affected their efficacy and potency. Community decision-making processes lacked an inclusive character, and women were sidelined in decision-making, as community leaders who developed meeting agenda and guided the flow of deliberations were predominantly males. This, and other factors such as sociocultural biases and preoccupation with hectic domestic duties contributed to women’s marginal participation in deliberations at community meetings. Introduction of formal education and new religions as well as some external influences have contributed to declining youth interest in traditional belief systems upon which resource management measures were based. Their continued use in the future was unlikely due to youth disinterestedness. In view of these challenges, the study among others suggested policies in three key areas: improving upon water purification measures, refining rainwater harvesting to make it a viable adaptation strategy for minimizing vulnerability to climatic variability and lastly, promoting an inclusive community based resource management in which youth, women and other community groups play pivotal roles. Generally, this research made a case for incorporation of the wealth of resource use knowledge and the range of management approaches utilized by the study communities into water resources use and management schemes in Ghana.

Fred Rosensweig and Derko Kopitopoulos. 2010. “Building the Capacity of Local Government to Scale Up Community-Led Total Sanitation and Sanitation Marketing in Rural Areas.” WBG-WSP Working Paper.

Executive Summary: The World Bank administered Water and Sanitation Program (WSP) recently passed the mid-point of the four-year timeframe for its Global Scaling Up Sanitation Project (TSSM). TSSM tests proven and promising Community-Led Total Sanitation (CLTS) approaches to create community-wide demand for stopping open defecation and improving sanitation. It is coupled with the use of sanitation marketing techniques to further strengthen the demand for sanitation at the household level and improve the supply of affordable sanitation-related goods and services produced by the local private sector for the rural poor. One of the central premises of TSSM is that local governments can provide the vehicle to scale up rural sanitation. In all three TSSM countries—India, Indonesia, and Tanzania—local governments are at the center of the implementation arrangements. Scaling up through local governments is a logical choice because functioning local government administrations exist throughout most countries, and with increased decentralization, have been delegated the mandate for rural sanitation, and that local governments have the necessary infrastructure in place to play this role in terms of staffing and resources. This report looks at the experience to date in three TSSM locations in developing the capacity of local government to carry out its role in rural sanitation.

The report suggests that the role of local government in TSSM be defined in seven specific functions: Strategy and planning, Advocacy and promotion, Capacity building, Supervision, Monitoring and evaluation, Regulation, Coordination. 

The report reviews the role of local government in these areas in the context of the management models that TSSM is using in all three countries. While there are variations in the models that reflect the country contexts, all three countries have placed local governments at the center of the implementation arrangements. In all three countries, the roles and responsibilities of the districts are carried out at three levels of local government—district, sub-district, and village. The study concludes that the model of working through local governments with the support of resource agencies—national or regional non- governmental organizations (NGOs)—to build the capacity of local government, is fundamentally sound.

Russpatrick, Scott & Tiwari, Amy & Markle, Laurie & Musonda, Engervell & Mutunda, Anne & Osbert, Nicolas & Pinfold, John & Winters, Anna & Winters, Benjamin & Larsen, David. 2017. “Mobility up the sanitation ladder following community-led total sanitation in rural Zambia.” Journal of Water Sanitation and Hygiene for Development. 7.

Abstract: Scaling the sanitation ladder decreases exposure to various illnesses including diarrheal disease, soil-transmitted helminths and trachoma. In rural Zambia community-led total sanitation (CLTS) has been deployed to help Zambians scale the sanitation ladder. Analysis of monthly routine surveillance data of village-level sanitation coverage of 13,688 villages shows that villages moved up the sanitation ladder following CLTS intervention with more than one third of villages achieving 100% coverage of adequate sanitation. Villages also moved down the sanitation ladder – approximately half of those achieving 100% coverage of adequate sanitation also dropped from that coverage at some point during monitoring. Larger villages were less likely to achieve 100% coverage, and more likely to drop if they did achieve 100% coverage. Drops were more likely to occur during the wet season. Of those villages dropping from 100% coverage, more than half rebounded to 100% coverage. The adequate latrine components most likely to drop off from 100% coverage were hand washing stations and lids to cover holes, both key components in preventing disease transmission. These results have implications for WASH programming – sustained support may be required to ensure villages move up the sanitation ladder and stay there.

Sanusi, Yekeen. 2010. “Water, sanitation and human development in urban fringe settlements in Nigeria.” Theoretical and Empirical Researches in Urban Management. 5. 14-29.

Abstract: The importance of water and sanitation facilities has been reflected in the measurement of human development and in their inclusion in Millennium Development Goals (MDGs). Water and sanitation facilities attain a unique situation at the urban fringe. This study is focused on the investigation of the supply of water and sanitation facilities in the fringe settlements along a development corridor of Minna, Nigeria. This corridor is attracting development from both federal and state institutions including large scale housing development. The settlements are outside the limits of water mains for the city of Minna and have received little attention in the provision of water and sanitation facilities. The present state of water and sanitation in these settlements connote low human development and stand at risk to the health of the people. The danger of serious impact on health with current urbanization of these settlements calls for re-evaluation of a laissez-faire approach that leaves the residents to informal adjustment. Against these backgrounds, the objectives of this paper are to investigate access to water and sanitation facilities in the urban fringe settlements, to determine the adequacy of these facilities; to investigate coping mechanisms by the people, to understand the burden of water search and how these are likely to affect health and human development and to discuss how integrated community-based efforts could improve water and sanitation facilities in the settlements.

Rachel Sigler, Lyana Mahmoudi, Jay Paul Graham. 2015. “Analysis of behavioral change techniques in community-led total sanitation programs.” Health Promotion International, Volume 30, Issue 1, Pages 16–28, https://doi.org/10.1093/heapro/dau073

Summary: The lack of sanitation facilitates the spread of diarrheal diseases—a leading cause of child deaths worldwide. As of 2012, an estimated 1 billion people still practiced open defecation (OD). To address this issue, one behavioral change approach used is community-led total sanitation (CLTS). It is now applied in an estimated 66 countries worldwide, and many countries have adopted this approach as their main strategy for scaling up rural sanitation coverage. While it appears that many of the activities used in CLTS—that target community-level changes in sanitation behaviors instead of household-level changes—have evolved out of existing behavior change frameworks and techniques, it is less clear how these activities are adapted by different organizations and applied in different country contexts. The aims of this study are to (i) show which behavior change frameworks and techniques are the most common in CLTS interventions; (ii) describe how activities are implemented in CLTS interventions by region and context; and (3) determine which activities program implementers considered the most valuable in achieving open defecation free (ODF) status and sustaining it. The results indicate that a wide range of activities are conducted across the different programs and often go beyond standard CLTS activities. CLTS practitioners ranked follow-up and monitoring activities as the most important activities for achieving an ODF community, yet only 1 of 10 organizations conducted monitoring and follow-up throughout their project. Empirical studies are needed to determine which specific behavioral change activities are most effective at ending OD and sustaining it.

E. Tilley, S. Bieri, P. Kohler. 2013. “Sanitation in developing countries: a review through a gender lens.” Journal of Water, Sanitation and Hygiene for Development 1; 3 (3): 298–314. doi: https://doi.org/10.2166/washdev.2013.090

Abstract: Sanitation has evolved from a purely technical discipline to one that includes social, environmental, economic and, increasingly, gender considerations. However, blurry notions of gender are frequently offered in the sanitation literature. Although it has been recognized that gender-responsive sanitation does not mean ‘toilets for women’, substantial alternatives are rarely debated. We structure our review of sanitation in developing countries along three lines: we start by fine-tuning the concept of gender both from the academic and the practitioner’s perspective, analyse relevant developments in gender-specific policies and programming, and finally review the most appropriate toilet room and menstrual hygiene technologies. We argue that strategies to make technologies gender-responsive need to be based upon a thorough analysis of the social arrangements of the intimate, and how these are negotiated and institutionalized in a specific context. A lack of robust gender-segregated data on sanitation policies and technologies, along with reductionist framings of gender are to blame for limited progress in verifying the need for, and impact of, gender-responsive sanitation. Technology and policy development and implementation would benefit from gender-considerate interpretations of shame, dignity, safety and status. Further progress could be achieved by improving the translation process between different academic framings of the sanitation crisis.

Elizabeth Tilley, Linda Strande, Christoph Lüthi, Hans-Joachim Mosler, Kai M. Udert, Heiko Gebauer, and Janet G. Hering. 2014. “Looking beyond Technology: An Integrated Approach to Water, Sanitation and Hygiene in Low Income Countries.” Environmental Science & Technology 48 (17), 9965-9970 DOI: 10.1021/es501645d

Summary: The challenge of reducing mortality and morbidity associated with endemic diseases, such as malaria, tuberculosis and HIV/AIDS, in low-income (i.e., developing) countries is widely recognized. Significant effort and indeed progress have been made in combating these diseases. In 2010, however, diarrhea and related diseases such as cholera and typhus still accounted for 10% of all childhood deaths on a global basis, which was nearly the same as malaria, measles and AIDS combined.Diarrhea-induced loss of vitamins and nutrients can lead to malnutrition, leaving children in a weakened state and at risk of further infection and stunted development. Progress has been made in combating diarrheal disease, but it persists as a significant contributor to childhood mortality despite simple and widely available treatments and preventative technologies.

International discussion is now ongoing to elaborate the post-2015 Sustainable Development Goals, which will be submitted to the General Assembly of the United Nations (UN) in September 2014. The working document for the UN Open Working Group (OWG) defines a focus area on “Water and Sanitation”, which includes an explicit reference to hygiene. The inclusion of hygiene addresses a key gap in the MDGs and targets important hand-to-food and hand-to-mouth pathways for disease transmission. In addition, the issue of sustainable provision of water and sanitation services is emphasized in a set of recommendations based on international consultations. This emphasis on sustainability and the explicit recognition of the role of the private sector reflect the lesson learned that installing water supply, water treatment and sanitation technologies does not ensure their maintenance and use. Failures have been attributed to inadequate planning and financing as well as a lack of skilled operators and repair capacity.

Clearly, there has been significant development since building and counting toilets and water pumps was the norm. There is now increased recognition of the interconnectedness of water, sanitation, and hygiene (WaSH) as well as of the overlapping goals of human and environmental health. To increase access to sustainable sanitation, however, a more integrated approach is still needed. In this article, we highlight four key aspects that have been developed and used successfully (albeit mostly separately) to address WaSH challenges. We argue here for their joint recognition and implementation. Specifically, we examine the roles of planning, economic opportunities, specialized technology, and behavior change both to highlight the far-reaching efforts that are currently underway and to encourage a broader dialogue in the WaSH sector in order to achieve greater success in post-MDG efforts.

Tiwari, Amy et al.. 2017. “Assessing the Impact of Leveraging Traditional Leadership on Access to Sanitation in Rural Zambia.” The American journal of tropical medicine and hygiene vol. 97,5: 1355-1361. doi:10.4269/ajtmh.16-0612

Abstract: Open defecation is practiced by more than one billion people throughout the world and leads to significant public health issues including infectious disease transmission and stunted growth in children. Zambia implemented community-led total sanitation (CLTS) as an intervention to eliminate open defecation in rural areas. To support CLTS and the attainment of open defecation free communities, chiefs were considered key agents of change and were empowered to drive CLTS and improve sanitation for their chiefdom. Chiefs were provided with data on access to sanitation in the chiefdom during chiefdom orientations prior to the initiation of CLTS within each community and encouraged to make goals of universal sanitation access within the community. Using a survival regression, we found that where chiefs were orientated and mobilized in CLTS, the probability that a village would achieve 100% coverage of adequate sanitation increased by 23% (hazard ratio = 1.263, 95% confidence interval = 1.080–1.478, P = 0.003). Using an interrupted time series, we found a 30% increase in the number of individuals with access to adequate sanitation following chiefdom orientations (95% confidence interval = 28.8–32.0%). The mobilization and support of chiefs greatly improved the uptake of CLTS, and empowering them with increased CLTS knowledge and authority of the program in their chiefdom allowed chiefs to closely monitor village sanitation progress and follow-up with their headmen/ headwomen. These key agents of change are important facilitators of public health goals such as the elimination of open defecation in Zambia by 2020.

WILBUR, J. et al.. 2013. “Undoing inequity: inclusive water, sanitation and hygiene programmes that deliver for all in Uganda and Zambia.” IN: Shaw, R.J. (ed). Loughborough University’s Institutional Repository.

Abstract: This research aims to understand the barriers and opportunities that disabled and older persons with additional access requirements may face using standard WASH facilities. An action research approach is being used, which applies a mixed methods approach to gather evidence before and after WASH interventions in one Ward in Zambia and in two Districts in Uganda, to assess the impact and benefits for the target group. This paper provides an overview of the preliminary baseline data findings, how these have been used to inform the planning and re-design of the WASH programmes to respond to identified barriers and needs, the analytical framework and participatory process used to analyse preliminary findings, as well as some of the key inclusive WASH activities that now form practical action plans in both country programmes.