Community-led total sanitation
Community-Led Total Sanitation (CLTS) is an approach to achieve sustained behavior change in mainly rural people by a process of "triggering" leading to spontaneous and long-term abandonement of open defecation practices. It was first applied by Kamal Kar in Bangladesh in around the year 2000. The concept involves provoking shame and disgust about poor sanitation in order to bring about change. It has spread throughout Bangladesh and to many other Asican, African and Latin American countries with support from the World Bank, UNICEF, SNV and other large NGOs.
When CLTS was first introduced in a country NGOs were often in the lead, though India was an exception. As of 2011, CLTS is an established method and governments have taken the initiative in many countries. This change has created a new situation with additional challenges.
An important difference between CLTS and other kinds of sanitation intervention is that it does not involve giving subsidies for hardware (such as toilets) and building toilets like pit latrines for the villagers. Instead, those supporting CLTS believe that by provoking behavior change in the people this will ensure that they take ownership of their own sanitation situation, construct their own toilets (often pit latrines) and pay for necessary improvements themselves. Challenges of CLTS may include possible human rights infringements within the communities, low levels of toilet standards and issues with long-term usage rates.
- 1 Overview
- 2 Challenges and difficulties
- 3 History
- 4 See also
- 5 References
- 6 External links
CLTS focuses on community-wide behavioural change rather than merely toilet construction of individual households. The process raises awareness that as long as even a minority continues to defecate in the open everyone is at risk of disease. CLTS uses community-led methods such as participatory mapping and analyzing pathways between feces and the mouth (fecal-oral transmission of disease) as a means of galvanizing communities into action.
A tool called triggering is used to propel people into taking action. The official handbook used by the CLTS Foundation explains that this takes place over a day in a community with a team of facilitators. The team visits a community which is identified as practicing open defecation and encourages villagers to become aware of their own sanitation situation. This tends to cause disgust in participants, and the faciliators help participants to plan appropriate sanitation facilities.
Using the term "shit" (or other locally used crude words) during triggering events or presentations - rather than feces or excreta - is a deliberate aspect of the CLTS approach, as it is meant to be a practical, straight forward approach rather than a theoretical, academic conversation.
Pre-triggering is the process by which communities are assessed to be suitable for CLTS intervention. This may involve visits and a number of different criteria to use to identify communities likely to respond well to triggering.
The UNICEF manual approved for use in CLTS in Sierra Leone suggests the following steps for the triggering process:
- Visit the community, emphasising that it is for learning about their sanitation situation
- Facilitate 'Kaka Mapping' - which involves drawing the main sites in the village then the main sites for defecation
- Pretend to leave
- Facilitate the 'Walk of Shame' - walking with community to the sites of Open Defecation
- Take a piece of faeces in a bag
- Put faeces on the floor in front of the community and discuss the way flies move between food and faeces
- Wait for the shocked understanding that the community is 'eating' the faeces
- Put some faeces into a water bottle and ask community if they would drink it
- Calculate how much faeces is produced each day and asks where it goes
- Wait for the emergence of "Natural Leaders" to work with to develop a plan of action.
The idea of the triggering process is to stimulate disgust in the villagers by physical demonstration of the sanitation problems. At the 'ignition' phase, the villagers are expected to realise that there is a real sanitation problem and that they need to do something about it. Natural Leaders are people from the community who are engaged by the process and who are seen to be people who can drive change.
After a positive response to the ignition phase, NGO facilitators work with communities to deliver sanitation services by providing information and guidance relevant to the local situation.
The positive outcomes are usually measured in the declarations of "ODF villages", where ODF stands for "open defecation free". A positive outcome would be if the village stays as ODF for many years after the initial triggering and if it may even "move up" on the sanitation ladder.
Comparison of different CLTS programmes
One small study considered the differences and similarities between CLTS programmes. Participants from NGOs involved in delivering CLTS reported that although they included some of the activities described in the guidance materials, they often omitted some and included others depending on the local situation. Some reported that subsidies were included, some offered specific design and construction options.
More recently, CLTS has also been adapted to the urban context (for example in Kenya by the NGO Plan) and even to schools and the surrounding pupil and parent communities, where it is sometimes referred to as "school-led total sanitation".
Challenges and difficulties
CLTS’s behavioral changes process is based on the use of shame. This is meant to promote collective consciousness-raising of the severe impacts of open defecation and trigger shock and self awareness when participants realize the implications of their actions. There is quite some evidence now that the triggering process has seen practices utilized which infringe the human rights of recipients even if this was not intended by the original concept. There have been cases of fines (monetary and non-monetary), withholding of entitlements, public taunting, posting of humiliating pictures and even violence. Some researchers have called it the "dirty truth" that CLTS is based on coercion.
Catarina de Alburquerque, the former United Nations Special Rapporteur on the Right to Water and Sanitation is quoted as saying that "Observers have also recognized that incentives for encouraging behavior change and the construction of latrines are sometimes unacceptable, and include public shaming, including photographing, of those who still practice open defecation."
CLTS does not specify technical standards for toilets. This is a benefit in terms of keeping the costs of constructing toilets very low and allowing villagers to start building their own toilets immediately. However, it can produce two problems: first in flood plains or areas near water tables poorly constructed latrines are likely to contaminate the water table and thus represent little improvement. Second, long-term use of sanitation facilities is related to the pleasantness of the facilities, but dirty overflowing pits are unlikely to be utilised in the longer term. A related issue here is that CLTS does not address the issue of latrine emptying services or where they exist, how they dispose of waste. This has led some researchers to say that the success of CLTS is largely down to the cultural suitability of the way it is delivered and the degree to which supply-side constraints are addressed.
Alternative toilet options
If villagers do not know about alternative toilet options (like urine-diverting dry toilets or composting toilets), and are not told about these options by the facilitators of the CLTS process, they may opt for pour flush pit latrines even in situations where groundwater pollution is a significant problem.
Longer-term usage rates
There is also concern about the number of people who go back to open-defecation some months after having been through the CLTS process. A Plan Australia study from 2013 investigated 116 villages considered Open Defecation Free (ODF) following CLTS across several countries in Africa. After 2 years, 87% of the 4960 households had fully functioning latrines - but these were considered the most basic and none of the communities had moved up the sanitation ladder. 89% of households had no visible excreta in the vicinity, but only 37% had handwashing facilities present. When broader criteria for declaring communities ODF were used an overall "slippage rate" of 92% was found. Some researchers suggest that this means support is needed to support communities to upgrade facilities in ODF villages which have been triggered by CLTS.
Reviews of effectiveness
Another problem relates to the lack of rigorous review about the effectiveness of CLTS. A recent study looking at reports released by NGOs and practitioners (the so-called 'grey' literature) which itself was not in a peer reviewed journal found that there was little review of the impact of local Natural Leaders, that anecdotes were used without assessing impacts and claims were made without supporting evidence. It concluded that these kinds of reports focus on the 'triggering' stage of CTLS instead of the measurable outcomes. A peer-reviewed review  considered the sustainability in the longer term and found that there was little monitoring or evaluation of the impacts of CLTS - even though large international organizations were involved in funding the process.
Lack of effectiveness in a study of similar methods
A randomized study of 80 villages in rural India (Madhya Pradesh) was conducted to determine if India's Total Sanitation Campaign (TSC), an effort to eliminate open defecation, was effective in reducing diarrhea and other gastrointestinal diseases in children. Results showed that TSC did modestly increase the number of households with latrines, and had a small effect in reducing open defecation. However, there was no improvement in the health of children. Although the authors point out that their results are limited as to place (rural Madya Pradesh), type of intervention (TSC), and type of measures (self reported open defecation and child health) they conclude: "these findings highlight the challenges associated with achieving large enough improvement in access to sanitation and correspondingly large reductions in the practice of open defecation to deliver health benefits within large-scale rural sanitation programs." Advocates of CLTS argue that this study should not be used to judge the effectiveness of CLTS as the presence of subsidies would fundamentally change the effectiveness of the process.
Reuse of excreta
Feces are given a strong negative connotation in the CLTS approach, which is also obvious by calling it "shit". This can cause confusion for villagers who are already, or could be in future, using treated human excreta as a fertiliser in agriculture - a process known as reuse of excreta in agriculture.
In 1999 and 2000, Kamal Kar was working in a village called Mosmoil in Rajshahi, Bangladesh, and decided that a system of attitudinal changes by villagers might have a longer-lasting effect than the existing top-down approach involving subsidies from NGOs and government. The Bangladeshi government began a programme of installing expensive latrines in the 1970s, but the government decided this was too costly, and many of the original latrines were abandoned. In the 1990s, a social mobilisation plan was begun to encourage people to demand and install better sanitation systems, but early success did not last, according to Kar. At that point Kar, a participatory development expert from India, was brought in by Wateraid and he concluded that the problem with previous approaches was that local people had not "internalised" the demand for sanitation. He suggested a new approach: abandoning subsidies and appealing to the better nature of villagers and their sense of self-disgust to bring about change. The CTLS Foundation is the organisation set up by Kar to promote these ideas. Kar and Robert Chambers stated in their 2008 CLTS Handbook:
It is fundamental that CLTS involves no individual house-hold hardware subsidy and does not prescribe latrine models.—Kamal Kar, Robert Chambers, CLTS Foundation Handbook, 2008 page 8 
In time, NGOs and governments began to see the value of the approach and ran their own schemes in various countries, some with less aversion to subsidies than Kamal Kar. Community-led Total Sanitation as an idea had grown beyond its founder and was being run in slightly different ways in India, Nepal, Sierra Leone and Zambia.
CLTS as an idea now has many supporters around the world, with Robert Chambers, co-writer of the CLTS Foundation Handbook, describing it this way:
"We have so many "revolutions" in development that only last a year or two and then fade into history. But this one is different. In all the years I have worked in development this is as thrilling and transformative as anything I have been involved in."
The Institute of Development Studies (IDS) coordinated research programme on CLTS since about 2007 and regards it as a "radically different approach to rural sanitation in developing countries which has shown promising successes where traditional rural sanitation programmes have failed".
Today there are many NGOs and research institutes with an interest in CLTS, including for example the CLTS Knowledge Hub of the Institute of Development Studies, the CLTS Foundation led by Kamal Kar, The World Bank, Wateraid, Plan USA, SNV from the Netherlands and UNICEF.
- "The CLTS approach". Community-Led Total Sanitation. 2011. Retrieved 12 March 2015.
- "Lukenya Notes Taking Community Led Total Sanitation to Scale with Quality Outputs from a workshop in Nairobi, Kenya, 24th-27th July 2011" (PDF). wash-liberia.org/. September 2011. pp. 3–4. Retrieved 14 March 2015.
- Galvin, M (2015). "Talking shit: is Community-Led Total Sanitation a radical and revolutionary approach to sanitation?". Wiley Interdisciplinary Reviews: Water. doi:10.1002/wat2.1055.
- Kal, K and Chambers, R (2008) Handbook on Community-led Total Sanitation, Plan UK Accessed 2015-2-26
- UNICEF (2010). CLTS Training manual for natural leaders - UNICEF and Sierra Leone Government, Freetown, Sierra Leone
- Philip Vincent Otieno - Defecation mapping in progress CLTS FIRE IGNITED IN DRC Accessed 2015-02-16
- Bongartz, Petra et al. (eds) (2010) "Tales of shit: Community-Led Total Sanitation in Africa. Vol. 61. IIED, 2010. Accessed 2015-02-26
- Venkataramanan, V (2014) "A Systematic Literature Review of Grey LiteraturePublications on Community-led Total Sanitation" Plan International and the Water Institute at the University of North Carolina at Chapel Hill Accessed 2015-02-16
- Sigler, R; Mahmoudi, L; Graham JP. (2015). "Analysis of behavioral change techniques in community-led total sanitation programs". Health Promot Int. 30 (1): 16–28. doi:10.1093/heapro/dau073.
- Engel, S; Susilo, A (2014). "Shaming and Sanitation in Indonesia: A Return to Colonial Public Health Practices?". Development and Change 45 (1): 157–178. doi:10.1111/dech.12075.
- Bartram, J; Charles,K; Evans, B; O'Hanlon, L; Pedley, S (2012). "Commentary on community-led total sanitation and human rights: Should the right to community-wide health be won at the cost of individual rights?". Journal of Water and Health 10 (4): 499–503. doi:10.2166/wh.2012.205.
- Time to Acknowledge the Dirty Truth Behind Community-led Sanitation by Liz Chatterjee in the Guardian
- Black, M. and B. Fawcett (2008) The Last Taboo: Opening the Door on the Global Sanitation Crisis. London: Earthscan
- Mara, D; Lane, J; Scott, BA; Trouba, D (2010). "Sanitation and Health". PLOS Medicine 7 (11). doi:10.1371/journal.pmed.1000363.
- Tyndale-Biscoe, P, Bond, M, Kidd, R (2013) ODF Sustainability Study, Plan Australia
- Plan USA and The University of North Carolina at Chapel Hill (2014) Testing CLTS Approaches for Scalability Accessed 2015-03-04
- Patil, Sumeet; Arnold, Benjamin; Salvatore, Alicia; Briceno, Bertha; Ganguly, Sandipan; Colford Jr., John; Gertler, Paul (August 26, 2014). "The Effect of India's Total Sanitation Campaign on Defecation Behaviors and Child Health in Rural Madhya Pradesh: A Cluster Randomized Controlled Trial". PLOS Medicine. doi:10.1371/journal. PMID 1001709. Retrieved 14 March 2015.
- "An Open Letter in response to the World Development Report 2015". Retrieved 23 March 2015.
- Ahmed, SA (2008) "Community Led Total Sanitation in Bangladesh:Chronicles of a People’s Movement" IDS Conference paper Accessed 2015-02-27
- UNICEF (2008). "Field Notes: UNICEF Policy and Programming in Practice" (PDF). UNICEF. Retrieved 12 March 2015.
- http://www.theguardian.com/global-development/poverty-matters/2011/may/30/mdg-sanitation-offtrack-but-community-led-approach-is-working by Robert Chambers Accessed 2015-02-27
- 'Beyond Subsidies - Triggering a Revolution in Rural Sanitation' Institute of Development Studies (IDS) In Focus Policy Brief 10 July 2009.
- WEPA (2013) Community-based Sanitation lessons learned from Sanimas Programme in Indonesia Accessed 2015-03-04
- WaterAid (2011) Revitalising Community-led Total Sanitation: A process guide. Accessed 2015-03-04
- UNICEF (2009) Field notes: UNICEF Policy and Programming in Practice - Community Approaches to Total Sanitation Accessed 2015-03-04
- CLTS Knowledge Hub at Institute for Development Studies (IDS) in the UK
- CLTS Foundation by Kamal Kar
- Publications on CTLS in the library of the Sustainable Sanitation Alliance (SuSanA)
- Community-led total sanitation at Appropedia.org
- Evaluating the Impact of Community Led Total Sanitation Programs in Mali (CLTS) Grant request at ClinicalTrials.gov, a service of the U.S. National Institutes of Health
- Research projects about CLTS in SuSanA's project database