Is demand creation enough to reach sustainable Open Defecation Free status at scale?

Community Led Total Sanitation (CLTS) is synonymous with demand creation; triggering behavioural change is needed to ensure real and sustainable improvements in eradicating open defecation within communities.

The CLTS approach is anchored in community mobilisation instead of hardware development. By raising awareness that as long as even a minority continues to defecate in the open, everyone is at risk of disease, CLTS triggers the community’s desire for collective change, thereby encouraging people to act and come up with appropriate local solutions. The CLTS approach therefore gained prominence over other methods and currently many organisations use it to ensure communities take lead in their own sanitation and hygiene improvement.

Demand creation is anchored in stimulating communities to understand their need for latrines and stop open defecation. As such, the focus is more on problem identification, educating communities on how to tackle the problem and stressing how they can benefit from the change.

The challenge with this approach as seen in our work under the Sustainable Sanitation and Hygiene for All (SSH4A) Results Programme is that while it is easy to get communities to construct latrines, the quality of the facilities is often not up to par and the sustainability of not practicing open defecation hangs in the balance once the latrines collapse or become unusable. Furthermore, communities relapse if there is no follow up.

The question therefore remains: how do we get communities to stop open defecation and sustain open defecation free (ODF) practices? In this article we explore the findings of the SSH4A project and the actions we took to create lasting open defecation free (ODF) sub-counties in Uganda, without relying on demand creation alone.

The Sustainable Sanitation and Hygiene for All (SSH4A) Results programme is a multi-country programme funded by DFID and implemented by SNV. The project aims to ensure access to sanitation for two million people by April 2020. In Uganda, SNV is implementing the project in 15 districts in Rwenzori and the West Nile regions, seeking to help 510,000 people gain access to sanitation. Implementation started in April 2014.

The project uses the SSH4A approach, which combines work on demand creation (mainly through Community Led Total Sanitation), sanitation supply chain development, hygiene behavioural change communication and governance. In the initial stages of the programme implementation, emphasis was placed on moving communities from open defecation to open defecation free status using community-led total sanitation. Within a period of one year, the project had triggered 1,047 villages (563 in West Nile and 484 in Rwenzori); by the end of 2015, the percentage of people without latrines in the intervention areas had been reduced to 5.5% (from 16% at baseline in 2014). The project had exceeded its 2018 target of 330,000 people – 504,000 people got to live in an open defecation free environment for the first time. The number doubled in 2016, reaching 770,000.

However, capacity development delivery can become a complex process when there are no benchmarks to define the expected changes and the priority areas of intervention. While communities were triggered to construct latrines, the quality of the latrines was questionable, with most latrines on the verge of collapsing and being unhygienically used. Plus, many households had little incentive to improve their hygienic practices. Communities in Dufile sub-county, Moyo District had attained ODF status but relapsed six months after being declared ODF. The weak supply chain for sanitation services and products affected the households' ability to improve or upgrade their latrines. The 2016 mid-term report also showed a stagnation in the open defecation rate at 5.5% across the 15 project districts despite the increase in the number of new latrines.

With this insight into the community challenges, the project started focusing much more on the need to construct quality facilities with technical guidance in order to prevent latrine collapse. Having learnt that most of the households build the latrines themselves, the promotion materials were tailored to guide households on how to construct stable pits. In addition, local solutions like slab materials already available in the community were promoted to ease the cleaning of the latrines. What was interesting to note was the fast adoption by communities ranked in the poorest wealth quantile (ie Nebbi district). Despite the high number of households in the poorest wealth quantile, the districht registered the highest investment in environmentally safe latrines. The lesson we learnt here was that although wealth often influences the choice of technology options, the quality of advice during the construction of the facilities is a critical factor in households' decision making on whether to invest in environmentally safe latrines or not.

Demand creation alone without well-functioning community structures will not sustain ODF status. The initial goal of the project was to get communities to stop open defecation. Thus, emphasis was placed on demand creation and triggering behaviour change, without so much of a focus on building supporting systems, ie developing grassroot leadership and strengthening the supply chain to provide locally sourced sanitation materials. Subsequently, communities built the latrines with the basic minimum and when the latrines collapsed or filled up, they relapsed to their old practices.

Following this lesson, SNV trained village sanitation committees (groups of community members who volunteer to take charge of sanitation and hygiene activities in a particular community) to generate sanitation demand at scale while ensuring quality. The committees are responsible for mobilising their communities, training them on sanitation & hygiene and following up in order to ensure communities act on the agreed plans. Periodic monitoring is carried out by Field Officers and Health Assistants to make sure that the committees are effectively performing their duties.

Another challenge that the project sought to address was the weakness of the sanitation supply chain. We thus developed market-based solutions to improve access to affordable sanitation hardware and services (eg sanitation marketing).

First, we identified enterprising youth within the community, most of whom were already part of village savings groups and trying to start their own businesses. We then trained and mentored them to address the challenges of the sanitation supply. Training included technical aspects of sanitation as well as entrepreneurship and business management to enable them to operate their businesses properly and profitably.

Got Aciku village in Kucwiny Sub-county, Nebbi district is now a community where handwashing with soap has become a norm. All 112 households in the village have improved their sanitary facilities. The results were mainly driven by the young sanitation entrepreneurs who sensitised the communities about the importance of having complete sanitary facilities (latrine with a drop hole cover, handwashing facility and a drying rack), developed local products such as toilet slabs and demonstrated to communities how to construct their tippy taps and drying racks with locally available materials.

The lesson we draw from our practice and implementation of the SSH4A project is that in order to move from open defecation to sustained open defecation free status, a holistic approach to helping communities is needed. While CLTS is a good start, what will sustain the practice of not defecating in the open is the community structures and supporting systems that promote communal accountability for results.