Abstract
Community-led total sanitation (CLTS) is a widely used approach to reduce open defecation in rural areas of low-income countries. Following CLTS programs, communities are designated as open defecation free (ODF) when household-level toilet coverage reaches the threshold specified by national guidelines (e.g., 80% in Ghana). However, because sanitation conditions are rarely monitored after communities are declared ODF, the ability of CLTS to generate lasting reductions in open defecation is poorly understood. In this study, we examined the extent to which levels of toilet ownership and use were sustained in 109 communities in rural Northern Ghana up to two and a half years after they had obtained ODF status. We found that the majority of communities (75%) did not meet Ghana's ODF requirements. Over a third of households had either never owned (16%) or no longer owned (24%) a functional toilet, and 25% reported practicing open defecation regularly. Toilet pit and superstructure collapse were the primary causes of reversion to open defecation. Multivariate regression analysis indicated that communities had higher toilet coverage when they were located further from major roads, were not located on rocky soil, reported having a system of fines to punish open defecation, and when less time had elapsed since ODF status achievement. Households were more likely to own a functional toilet if they were larger, wealthier, had a male household head who had not completed primary education, had no children under the age of five, and benefitted from the national Livelihood Empowerment Against Poverty (LEAP) program. Wealthier households were also more likely to use a toilet for defecation and to rebuild their toilet when it collapsed. Our findings suggest that interventions that address toilet collapse and the difficulty of rebuilding, particularly among the poorest and most vulnerable households, will improve the longevity of CLTS-driven sanitation improvements in rural Ghana.
Highlights
Thirty-nine low-income countries, mostly located in sub-Saharan Africa, are not on track to eliminate open defecation by 2030 [1], the objective set by the United Nations’ Sustainable Development Goals (SDG) under target 6.2 [2]
They were on the higher end of reversions previously observed in Africa: in Ethiopia, a systematic review reported open defecation levels of 7%-28% 0–5 years after open defecation free” (ODF) achievement [8]; and across eight countries, Robinson found open defecation levels ranging from 0%-39% (8% in Ghana) 1–5 years after ODF achievement [10]
Following the introduction of Community-Led Total Sanitation (CLTS), we estimated that community toilet coverage peaked at a median of 87%, decreased by about 12 percentage points annually, and was at a median of 64% at the time of our study (i.e., 3–32 months after ODF verification). These results indicate that CLTS had a positive overall effect on sanitation conditions in Northern Ghana at the time of our study, though these findings highlight the challenges of sustaining ODF communities
Summary
Thirty-nine low-income countries, mostly located in sub-Saharan Africa, are not on track to eliminate open defecation by 2030 [1], the objective set by the United Nations’ Sustainable Development Goals (SDG) under target 6.2 [2]. Governments and international development organizations have implemented CLTS widely across Africa and Asia, and 31 countries have incorporated the approach in their national sanitation improvement guidelines or regulations [5]. While these efforts have helped large numbers of communities, and sometimes entire districts, to be declared ODF [5,6,7], the extent to which these gains are sustained over time is largely unknown. Most CLTS programs do not track sanitation indicators post ODF, and the limited data available indicate that a fraction of the population (ranging from 4%-39% in prior studies) may revert to open defecation in the years following ODF verification [6, 8,9,10,11,12]
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