PHNOM PENH — There are 13 years to go to reach the Sustainable Development Goals, including SDG 6.2, which mandates the end of open defecation. In the two years since the SDGs launched, only one developing country — Bangladesh — has reached the mark. That leaves 892 million people in scores of countries who are still practicing open defecation. Across the globe, some 4.5 billion people have no access to a safely managed toilet.
Life without a toilet is more than an inconvenience. Open defecation increases the incidents of diarrhea, cholera, malnutrition, and more, raising the rates of stunting, disease, and death. That, in turn, impacts everything from productivity to economic growth. In 2015, Oxford Economics and WaterAid estimated the global cost to the economy of poor sanitation to be $222.9 billion.
For Dr. Kamal Kar, the founder of Community Led Total Sanitation, the next few years will prove a make-or-break time for the issue. “In the next four or five years of SDG, we at least have to have two, three, or four open-defecation-free nations, otherwise forget the dream of ODF world by 2030,” said Kar.
“It’s sustainable because it is focused not on toilet construction, but on total collective behavior change.”— Dr. Kamal Kar, founder of CLTS
In the 17 years since it was first developed, CLTS has become the go-to method applied by WASH organizations globally. Today, CLTS is part of government policy in 70 countries, and is the cornerstone of programs supported by UNICEF, Asian Development Bank, the World Bank, and more. With a focus on community-induced behavioral change, Kar’s method eschews subsidies and top-down delivery.
Instead, with the aid of facilitators, communities come to realize the omnipresence of human feces in their vicinity, the likelihood of their food being contaminated, and the economic cost of their constant illnesses. “Triggered” by the shame and disgust by such realizations, individuals then begin building toilets and policing their neighbors.
The program is not without its detractors. Some have taken aim at the shame element, while others have questioned the long-term sustainability of such programs. Kar, however, remains steadfast that — when implemented properly — CLTS is the only means to achieve an end to open defecation. Last week, CLTS co-hosted with Cambodia a regional conference on fast-tracking ODF in Southeast Asia.
After the conference, he sat down with Devex to discuss his method, the importance of local knowledge, and how best to end open defecation. This interview has been edited for length and clarity.
You’ve spoken in the past about being out in the field and speaking with Indian farmers and being struck by their skills and knowledge. Could you speak about the importance of using local knowledge when you’re developing programs?
We had developed this mainly learning from the farmers, learning from the community. We went to do a kind of appraisal to understand why people defecate in the open.
We used participatory tools to elicit local people's knowledge and understanding, using maps, matrixes, venn diagrams, and traveling around to different places to see the filthy areas. Lots of focus group discussions and all of that. But what came out from the analysis by the people was that the people were defecating everywhere. And they knew it was not a good practice, but they had never discussed this correctly with the whole community.
And when they made the map and calculated the amount of [feces] that every household is producing every day and where it was all going, they were totally disgusted, and they said “we never did it before, we knew it was not good. We were smelling, stinking everything, flies everywhere. And we knew this was causing diarrhea, so many stomach problems, but we never did it together. This is a great eye opener. We cannot just continue to do it, we have to stop it at any cost.” And for that they wanted to get some help from outside.
“There is no scope for any facilitator insulting the community or shaming the community. The facilitator role is to create an environment so that inter-community people can draw their map and analyze and facilitate the process.”—
We said: “Look, we came here just to learn from you. We aren’t able to give you anything.” They said, “Ok, if you cannot support us, we will do whatever we could.” And that was the beginning of CLTS.
One guy stood up and said: “With the analysis we have done now, we cannot live like this for a single day more. We are going to stop it now. But we cannot build such expensive toilets.” There was a bit of a misunderstanding that a toilet was very expensive. And that myth was broken. They said: “We could dig a pit, we can throw some ash, we can use a lid. We are the poorest of the people and we can’t spend any money.” But the feces will be contained. And it will be self-contained and safely confined and it will not be carried to different places by flies and chickens and footsteps and bicycles and everything.
So they did that, exactly. That was a great learning process for me.
The whole CLTS was born from that statement — that it was the external subsidy and supply of money and materials by outside agencies that was stopping them. And that is still the main problem in progress growth of sanitation globally.
The earlier trigger for conventional sanitation used to be that people are poor, give them money. People don’t understand, teach them hygiene sanitation. They cannot construct toilet, teach them prescribed, top-down technology — that all went out of the window.
“They all have self-respect, and they have disgust, they have shame, they have fear and understanding. The factors — the prime movers — became disgust, self-respect, shame; it all comes from their own analysis.”—
When CLTS came, the assumption is that people are poor, they may not be so educated, but they are human beings. And they all have self-respect, and they have disgust, they have shame, they have fear and understanding. The factors — the prime movers — became disgust, self-respect, shame; it all comes from their own analysis. That gives them a trigger, so that’s how it all started in Bangladesh, and now it’s more than 70 countries across Asia, Africa, and Latin America.
How in the early years were you able to take it from an idea launched in one village to something that was replicable and that eventually organizations such as the World Bank would want to be using?
It all started with an evaluation. I was heading an evaluation for WaterAid, so I went to evaluate the country program in Bangladesh. I did a month-long evaluation process and in that, I used participatory impact assessment methodology.
While we were carrying out the evaluation, I realized that people were constructing toilets, the number of toilets was increasing, but open defecation was also going on. I realized it was a partial sanitation — it was not total sanitation. And it was outside-agency led; not community led. Then I thought that every village we went, definitely some of us would have stepped on [feces].
“What is the point of constructing a few toilets when there is no health change?”—
I said then: “What is the point?” There was hardly any change on diarrhea, cholera, anything. What is the point of constructing a few toilets when there is no health change?
In Bangladesh, WaterAid was giving uniform subsidy all over the country and I said: “Poverty in Bangladesh is not the same everywhere. Why do you give the same subsidy?”
WaterAid asked if I could help determine what kind of subsidy was needed. And I told them: “Let me understand why people defecate in the open in the first place.” Which is the trip I mentioned above.
When that was done in the first village, immediately I took my team and the next day we went to another district and did the same thing in another village. Same outcome — they said: “We are going to stop it in one month time.” We were excited. I said, “Ok let’s go to another one.” We went to another district — all in Bangladesh. Two, three, four days, one by one we tried it. Same outcome.
Then I wrote back to WaterAid and I told them the recommendations I have given for different cell subsidy doesn’t hold. We went to villages, I have seen it, now I would say no subsidy.
They were curious if it would work. I said, if it doesn’t work we will go back to subsidy. After six months, there was no looking back. The entire subsidy money was saved, and two or three times more toilets were built. We could reach many people because this thing was started.
So WaterAid came to realize that this is a much more powerful approach, more cost effective, and it’s sustainable because it is focused not on toilet construction, but on total collective behavior change. Nobody was defecating in the open. If someone didn’t have a toilet, they were using the neighbor’s toilet or their relatives’ toilet. But the community imposed a rule that nobody was allowed to defecate in the open. In the whole community, nobody was defecating in the open. Meaning fecal-oral contamination stopped.
“The entire subsidy money was saved, and two or three times more toilets were built. We could reach many people because this thing was started.”—
It could be low cost; it could be a pit and using some ash after every time it is used and covering it so that no flies are coming in and out. That’s how it all began. Once fecal-oral contamination stopped, immediately people started realizing no diarrhea, not as many diseases, no cholera, no medicine, or going to doctors.
These pits started collapsing gradually, but by then, the habit was engrained. And when the toilets collapsed, the demand-driven thing started mobilizing local resources. Because silently the behavior got changed and they wouldn’t go back to the bush again. So that demand brought a lot of family investment for toilet construction and the market came in because huge demand was generated.
Plan International Bangladesh saw it and become interested. They invited me to run training workshops. They stopped subsidy totally and institutionalized CLTS. That was a big breakthrough. After Plan International Bangladesh introduced CLTS in their program, all the Plan countries in Africa and Asia and Middle East came to visit plan Bangladesh. From there, they took it into their whole system and I ran major training workshops in Africa.
UNICEF changed eventually, World Bank, the major actors of sanitation. Not initially, but gradually — as they saw the effect and impact of this, they made those institutional changes. Today CLTS has spread globally, mainly because of its efficiency and demonstrated capacity to create tangible impact on human health. It’s an outcome-focused approach in a very short span of time.
Is there follow up? A year or two or three years after being declared ODF?
CLTS has got four stages. Pre-triggering, then triggering — which is three to four hours max, and from triggering to the day they become ODF — this is generally three months. There are two, three, four times we go. We call it post-triggering follow up. And there are post-ODF activities. Those where you use the village as a learning laboratory. You bring the natural leaders emerging from the village and use them to other villages as community consultants. And bring people from other villages to see for themselves.
Once you develop five to 10 villages as ODF, then you can continuously bring people; it’s people to people.
So once a village is ODF it never goes back to open defecation again?
It can happen. But if the triggering is very good, this is not going to happen. Because if you look at the factors of why people go back to open defecation — it’s because the toilet collapses and it’s a very poor family; they do not have any resources to build the toilets again.
“These pits started collapsing gradually, but by then, the habit was engrained. And when the toilets collapsed, the demand-driven thing started mobilizing local resources.”—
How do you really handle these landless or poor people? There are really many landless in Bangladesh. But what we saw — every village all over the world, they have a social indigenous structure of helping each other.
In Indonesia it is called gotong royong — meaning today you are going to harvest your rice, so everyone comes to harvest paddy in your field. The next day is [someone else’s] field so you come and others come. They help each other. At the end of that, they eat together to celebrate.
So using that structure in CLTS, those who are very poor and landless. They are helped and supported by their own community members because they were all trying to achieve one goal: that nobody defecates in the open. But if they realize that if this disabled person who cannot dig a pit, or this very poor person, if he or she continues to defecate in the open, we are all in danger, so they come and help.
Can you tell me a bit about the role of taking cultural context into account when putting CLTS on the ground?
In Muslim countries — like Sudan, Bangladesh, Indonesia, or Pakistan — what I have seen, the cultural context is so powerful. Immediately, once you do the triggering, there is every likelihood that you will meet the religious leaders. And they all say that it is a part of Islam that if you have to go to prayer, you have to wear clean clothes, wash your hands and feet, and you should be pure. But if you wash your clothes and put it for drying in the sun and a fly comes with [feces], it’s gone — your prayer will not be accepted. Everywhere, we found the next Friday prayer, the whole topic was CLTS.
The same thing has happened in Solomon islands. There were many churches where the church leader started preaching in the Sunday prayer [about CLTS]. It was a different story immediately.
Culturally, scaling up this element is being taken up by the CLTS facilitator extensively.
“It’s not a question of shaming anyone. But it is the facilitation, so that the community comes to know they can do their own analysis.”—
There’s been some criticism about some of the tactics, the stigma, and the use of shame within the triggering process? What do you think about that?
Actually the people, those who say that facilitators shame them, they don’t know the approach at all. There is no scope for any facilitator insulting the community or shaming the community.
The facilitator’s role is to create an environment so that inter-community people can draw their map and analyze and facilitate the process. But from their own analysis when they see there is a lot of [feces] and their house is in the middle of it, he or she feels that we have been ingesting this [feces] — and from there they move on.
You are not shaming anybody. They feel ashamed through their own analysis. So those who say that in CLTS you shame people, they simply do not know. Because outside facilitators are nobody to go in and insult people. You cannot. People will beat you up. So what do they do? They facilitate the process whereby local community people form their own analysis, they do the analysis, and understand that they have been eating their own [feces], and they start talking about that.
It’s not a question of shaming anyone. But it is the facilitation, so that the community comes to know they can do their own analysis.
There’s been mention of urban migration and the fact that when cities expand, there aren’t always the facilities there. How will CLTS be applied in these very new settings without traditional community structures?
In a push to meet the needs of hundreds of thousands of new refugees in Cox's Bazar, much of the emergency latrine construction following the late August influx didn’t adhere to best practices. Now, WASH experts from several organizations on the ground are left literally cleaning up the mess.
We have seen many places, particularly in Bangladesh and some other countries, where the community members are exposed to CLTS. They have started using toilets, but after a few years for some reason or another, they have to move. When the people went to some other place, they migrated with the culture in them not to go back to the bush. The first thing they did is to construct a low-cost toilet. Because they simply did not want to go back to that again.
In Bangladesh, many times monsoon floods destroyed everything. As the flood water receded, what people did was to first construct their own toilets. Whereas in most places you see IDPs or refugees come, settle down in refugee camps, the government tries to give them toilets in order to protect from the spread of diarrhea or cholera, but nobody uses it. When you go, you go with your own habit. So that’s why it is very important to really spread it everywhere — urban, rural, whatever. Because today’s settled population could be tomorrow’s refugees or unsettled population. This investment will not go in vain.
More than 65 million people are displaced. Once they become refugees and are in a camp, the diarrhea, mortality, death goes up like shooting star. But if they came with the right hygiene practice, every chance it is not going to outbreak
Read more Devex coverage on sanitation.