Sanitation and Hygiene: Undernutrition’s Blind Spot

Robert Chambers

The undernutrition of babies, infants and children is horrible and a disgraceful blot on our human record. It is not just the immediate suffering, anguish and death. It is also the lasting impact: when growth is stunted at age 2 the damage is largely irreversible. Stunted children are disadvantaged for life – their cognition and immune systems impaired, and their education and earning prospects reduced. Stunting leads to a 10 per cent decrease in lifetime earning. Stunted children start school 7 months later and attend 0.7 years less than children who aren’t stunted.

So undernutrition cries out for action and there is plenty of action. The normal, commonsense, humane response is direct and visible – to get more nutrients and food into babies, infants and children. To get it into their mouths. Who could be against that? Not me. It is so obvious, so necessary, so important, so urgent, with such immediate results.

But, and it is a monumental but, has this distracted attention from a major cause, and outside famines and acute seasonal crises, I will dare to venture even the main cause: faecally-related infections(FRIs)? Have I lost my senses? Well….

I recently watched  a video of a presentation made by Dr Jean Humphrey in India, and met her, and heard her speak  at the UK Department of International Development (DFID). She works in Zimbabwe and in the Lancet (19 September 2009) famously argued with convincing evidence that environmental enteropathy (EE) is a more significant cause of undernutrition than diarrhoea. EE is a persistent subclinical condition in which infections damage and reduce the absorptive capacity of the gut and at the same time make it permeable so that nutrient energy has to be continuously diverted to make antibodies to fight the infection. EE is a multisystem disorder, a ‘profound immune system disorder’ which moreover weakens the immune system later in life. That Lancet article stirred things up, and she is now engaged on long-term rigorous field research into EE. She and others are now saying that diarrhoea is just the tip of the iceberg. I agree. But what an iceberg, not just EE!

Here are some bullet points. Are they right?

Diarrhoeas
How significant are the diarrhoeas as causes of undernutrition?

• Because among faecally-related infections, they are so dramatic, awful, visible and episodic, and so easily measurable, the diarrhoeas have received and continue to receive the major professional attention. Many other conditions are subclinical, continuous, invisible and hard or impossible to measure. The multiple dimensions of EE are a very significant part of this.
• With oral rehydration therapy, diarrhoeas are less damaging than they were
• There is rapid recovery between bouts of diarrhoea
• Studies of the effect of diarrhoeas on linear growth show effects in the range of only 5-20 per cent, and some show none at all
• In the Gambia where the Dunn Nutrition Laboratory has been doing research for many decades there has been a big drop on the incidence of diarrhoea 1979 – 1993 but no change in stunting. They have found stunting is not explained by inadequate diet or days of diarrhoea!

The misleading conclusion could be drawn that since diarrhoeas are not so much implicated in undernutrition, sanitation and hygiene are not so important either, and that FRIs in general are not so signficiant

Feeding programmes
What is the evidence of the impact of feeding programmes?

• A review of 42 studies of feeding programmes found that the very best solved only one third of the problem and some had no effect at all
• No nutrition intervention has ever normalised linear growth

Faecally-related infections (FRIs)
FRIs are much more than the diarrhoeas and EE.

• The variety and scale of these infections is quite mind-blowing. There are intestinal parasites – bacterial like gardia (extremely widespread), amoebiasis, and worms like ascaris (1.5 billion infected) that steal food and hookworm (over 700 million infected, 200 million in India) which voraciously consumes blood from the host, and tapeworms which come through intermediate hosts. There are hepatitis A, B and E, typhoid fever, polio and other enteroviruses, schistosomiasis (over 200 million, more than half in Africa), liverfluke, trachoma, and various zoonoses from animals (in addition to tapeworms)…..

So there is much, much more to the iceberg of which the diarrhoeas are the tip, than EE. No one so far has been able to point me to a study of how many of these infections are found in any one undernourished infant or child, nor how they interact. So my question to those who work in nutrition and those who work on faecally-related infections, is this: does professional specialisation prevent us seeing the enormity of the whole picture? And is the implication of the whole picture that sanitation and hygiene are not only a huge priority in eliminating undernutrition but even, bar famines and seasonal crises, possibly the main means?

Consider India. The latest data indicate that India has 59.4 per cent, almost three fifths, of the open defecation in the world, a proportion which has risen in the past decade. It also has a third of the undernourished children, a figure which has largely resisted herculean attempts to tackle it directly through the mouth with school meals, ration cards and the like. Imagine if suddenly all FRIs were caught and confined safely just below the anus. How much undernutrition would remain?

Robert Chambers is a Research Associate in the Participation, Power and Social Change research team.

Read other recent blog posts from Robert Chambers:
Ensuring those who are ‘last’ come first: using Reality Checks to inform post-MDGs
Discrimination, duties and low hanging fruit: reflections on equity in CLTS
A passionate family: reflections on the WSSCC Global Forum on Sanitation and Hygiene

Ensuring those who are ‘last’ come first: using Reality Checks to inform post-MDGs

Robert Chambers

The MDGs picked low hanging fruit.  To achieve them,  the incentive has been to go for those who were closest to thresholds or easiest to help, for instance people close to the poverty line, those who are most accessible and so on.   But this precisely leaves out the last, those who are poorest, least able, most marginalised, women most vulnerable to maternal mortality and babies most likely to die.  What this has meant can be shown by UNICEF’s diagram of sanitation in India.  The  Total Sanitation Programme of subsidised toilets was meant for those below the poverty line, roughly the bottom two quintiles.  But they hardly gained at all.  The biggest gains were by those already better off, the third and fourth quintiles.

Let me propose, and add my voice to others who are proposing, that post-MDG the great need and opportunity is to think and act from the other end, with those who are poorest, weakest, and most excluded and marginalised, those who are disadvantaged and lving with physical, mental and/or social disability.  It means aiming to level up from the bottom with equity as the goal and a radical rethink of policies and priorities.

It also means reviewing and focusing systems of monitoring and learning.  Policy-makers need to be closely in touch with what is happening on the ground to those who are worst off, the conditions they experience and their changing realities. It means finding ways in which there can be flows of honest, accurate, insightful and credible information to those in positions of power. This matters more than ever given the rates of change for all people living in poverty, not least with the rapid transformations of global interconnectedness, the mobile phone revolution, and accelerating changes in social conditions and relationships.   Being out of touch and out of date has always been a problem, and has repeatedly led to misfits between policy and field realities.   More than ever before, those in capital cities are finding it challenging to keep up with developments and changes at the grass roots,. This can be expected to be even more pronounced after 2015.

Fortunately, we have a new means for being in touch and up-to-date.  An approach has been pioneered which all countries can and should adopt.  This is the Sida-supported Reality Checks pioneered in Bangladesh.  This is a brilliant and extraordinarily successful innovation.  Many have still not heard of it, but it is beginning to be recognised and spread.  

The Reality Checks are conducted annually at the same time of year by the same teams.  Outsiders spend several days and nights staying in the homes of people living in poverty. Each year they stay with the same families in the same nine representative areas.  The brief for those who take part in Bangladesh is to listen, observe and understand the perspectives of their host families and others in their communities. The focus has been primary education and primary health care, two sectors which Sida supports, but a great deal else has come to light.  The approach lends itself very well to learning about the realities of those who are poorer, weaker and most marginalised.

The insights repeatedly surprise, not least people’s changing experiences, behaviours and priorities. Unrecognised policy issues are raised. Much more is learnt than just about education and health.  The teams have been struck, even astonished, by how much has changed and how fast it has changed since the first Reality Check was conducted in 2007.   The people who live in poverty in all countries deserve that their governments keep themselves in touch in this sort of way. 

A bottom up focus on equity and on those who are ‘last’, and the approach of Reality Checks, combine and support each other well. Emulating Bangladesh, they could and in my view should be adopted and adapted by all governments.  David Cameron could set an excellent and early example by starting Reality Checks in the UK. Though his stay was brief, the Secretary of State, Andrew Mitchell, can testify to the value of staying overnight in a community from his own experience with a poor family in Ethiopia.

We do not need to wait for 2015.  We could start now.  Experience could then be gained across a range of countries and conditions, ready to inspire and inform extensive adoption post 2015 and to make it more feasible for equity and the wellbeing of those who are ‘last’ to come first.

Robert Chambers is a Research Associate in the Participation, Power and Social Change research team at IDS.

Discrimination, duties and low hanging fruit: reflections on equity in CLTS

Robert Chambers

The equity day at the WSSCC Global Forum in Mumbai (October 2011) made a deep impact on me.  I am ashamed to admit this.  I should not have needed this. I have been banging on about ‘putting the last first’ for years, but the fuller implications of this with sanitation only came home to me on this day. Thank you those who came and shared their experiences with us –rehabilitated manual cleaners, slum dwellers, disabled, minorities… and Louisa Gosling, Archana Patkar and Nomathemba Neseni and who pulled scales from my eyes.

I am not proud that when sanitation as a human right first came up, my enthusiasm was muted.  I was so imbued with the CLTS (Community-Led total Sanitation) philosophy of no hardware subsidy and of people digging their own pits and making their own toilets that I feared that a rights focus would encourage dependent attitudes and undermine CLTS.  People might demand that government provide them with everything. Well, how wrong can you be?  It depends how you see rights. Frame them differently and  you can see that poor rural people have a right not to be marginalised by top down standardised hardware subsidy programmes like the Total Sanitation Programme in India, in its usual and classic form. Instead they have a right to be facilitated, to be enabled to do their own appraisal and analysis and collectively come to recognise the gruesome reality that they are ‘eating one another’s shit’ and decide to do something to stop it.  Before the equity day, that was about as far as I had got.

What hit me on this day went further. The pieces were shaken up and settled to fit in a new pattern.  We have rights-holders, to be sure.  But we also have duty-bearers.  And we are duty-bearers. But how are our duties determined? They have been defined in terms of the Millennium Development Goals (MDGs), of building up from the base, of filling the empty glass fuller, of achieving targets.  But even achieving the MDG targets would leave hundreds of millions of people still without even the most basic sanitation, still without hygienic behaviour, still suffering the multiple deprivations of Open Defecation (OD) and the horrendous and often cumulative debilitations and sufferings of multiple faecally-related infections.  Not only that, but what does striving for the MDGs in sanitation imply? It implies going for the easy ones, picking the low-hanging fruit. That’s how you achieve targets (or minimise shortfalls).  And that implies neglecting, leaving out, not serving, the more difficult, more challenging, and more deprived ‘last’ whose need is so often greater.  For achieving targets, those who are last are not cost-effective.

And who are these last?  Well, the UNICEF quintile bar charts show how the poor and rich compare: and among these, the charts for India are a stark and shocking indictment of a decade of programme failure on a mega scale: the last who were meant to be served –like the bottom two quintiles – have been barely touched. Then consider who these last are.  Someone said that half of humankind are in some way disabled or specially vulnerable.  I found that difficult to believe until I began to think it through.  Consider who they include: the very poor and destitute; those with the many forms of physical or mental disabilities; people living with HIV/AIDS; those who suffer discrimination – sex workers, LGBTs, low status minorities…; those exposed to and living in insanitary slums and other ‘places of the poor’;  migrant workers, refugees, internally displaced people, and other distress migrants; the chronically sick; and more and more, the infirm aged (unable to walk or walk far, unable to squat…) who are a growing proportion of humankind.  And then, what about vulnerable children?  And all this before considering discrimination against females, or menstrual hygiene. There are shocking answers to questions too, questions I had not asked myself.  How do blind people manage with OD?  Or people who have to crawl? Do they have to go where others go?  Do they get the stuff on their hands? How do they clean up?

As long as any of these ‘last’ are exposed or deprived in such ways, and lack proper access, are we as duty-bearers discriminating by default?  That was the question Archana threw out at the end.  And it will not go away.

So I am in a new space.  With renewed anger.  And asking what the implications are for CLTS. Two stand out straight away. First, with rural CLTS, triggering and/or early follow up must be facilitated so that people identify the ‘last’ in their communities and what needs to be done that they cannot do or be expected to do for themselves.  For the poorer and less able this is already standard good practice but it must go further, and identify those who face physical and other disabilities, encouraging local actions and innovations to provide what is needed.

Second, with urban  Citizen-Led Total Sanitation, when full or even partial self-provision is not an option, rights-based demands, mobilising to secure support and services from the authorities, has to be a major part of the way forward.

So thank you WSSCC for the equity day and for the whole Forum, and roll on the next; and by then let’s hope we will have seen big shifts with many actors and champions – in communities, in governments, in NGOs …- turning the MDGs on their heads to put equity first by starting with the last.

Robert Chambers is a Research Associate in the Participation, Power and Social Change research team at IDS. . This piece will feature in a forthcoming publication by WSSCC, entitled “WSSCC Global Forum on Sanitation and Hygiene: Insights on leadership, action and change”.

Reflecting back upon the PPSC team’s activities in 2011

Danny Burns

As 2012 begins, I want to take this opportunity to wish you a happy (and stress free) New Year. In this blog I want to talk offer a few flavours of things that members of the team have been working on; others you will see from recent contributions to the blog; more will follow over the next weeks…

An increasing area of interest for development actors at all levels, from grassroots movements to major donors, is how to better understand the complex, shifting and multi-layered social and political environments in which development and change occur. Many organisations are searching for more relevant tools of context analysis. Jethro Pettit and others have been working on new tools for power and political economy analysis. Popular frameworks like the Powercube (developed by John Gaventa) are being adapted and combined with other approaches. Recent learning partnerships on power have included Oxfam, Novib, Hivos, Christian Aid, the Swedish Cooperative Centre, and Trocaire. Work has also been carried out within the UK voluntary and philanthropic sector with the Joseph Rowntree Foundation,  Joseph Rowntree Charitable Trust, and the Carnegie UK Trust, Trust for London. This work has included three, year-long action learning processes with dozens of participants from these foundations and more than 20 of their partner organisations Training modules on power have adapted into Spanish and French and facilitated by IDS staff in universities and workshops in Spain, West Africa and Latin America.

The team’s work around “unruly politics” has been growing steadily through the “Summer of Unruly Reading” group facilitated by Akshay Khanna. We have been building a collective conceptual analysis within the team, and growing a work programme with Hivos and their partners.  We have also been building connections with people in the Occupy movement. Mariz Tadros continues to be closely engaged with the emerging situation in Egypt and other parts of North Africa.

PPSC has been contracted to engage in a number of new programmes this year. These include:

• a three year programme on gender and sexuality funded by SIDA (Sweden)
• a three year programme with SDC (Switzerland) – on participatory methodologies and developing the resource centre as a hub for materials on participatory methodologies
• a three year programme with SDC working with the IDS Governance team to support the work of their Decentralisation and Local Governance Network
• an extension of Gates Foundation funding for our Community Led Total Sanitation Hub

The PPSC team played a major role in designing and delivering the Bellagio initiative on the future of international development and philanthropy in pursuit of human well being which comprised a series of global dialogues, commissioned papers and a major international summit. PPSC fellows – Danny Burns (Delhi and Kinna, Kenya), Patta Scott-Villiers (Kinna, Kenya), Alex Shankland (Sao Paulo) and Mariz Tadros (Cairo) – facilitated four of the global dialogues. Georgina Powell Stevens co-ordinated the summit participation of around 200 participants. In June of this year Alex Shankland and I, will be facilitating another Bellagio conference on Indigenous health with colleagues from KIT (Royal Tropical Institute, Amsterdam).

Rosemary McGee has recently carried out a major review of accountability and transparency initiatives with John Gaventa. Naomi Hossain continues her longitudinal work with Oxfam and others on food price volatility; Joanna Wheeler, Peter Clarke and I are working on a six country action research programme with VSO and the international volunteering network FORUM on the impact of volunteering on poverty; Joanna Wheeler and Tessa Lewin have been working on a range of participatory video initiatives; Marzia Fontana has been working with the Ministry of Industry and Commerce of Lao PDR on a project which has brought Lao-based women’s groups and international organisations into dialogue with each other. Rosalind Eyben has been organising The Big Push Forward – an international initiative that links practitioners and researchers to identify and share strategies and approaches for fair assessment and evaluation. Patta Scott Villiers is leading a programme of action research in Karamoja Northern Uganda funded by Irish Aid. Alex Shankland is opening up new areas of work on the role of emerging powers in reshaping development especially through civil society.

Pathways to Women‘s Empowerment in the Middle East hosted a UN Women organized conference on “Pathways for Women in Democratic Transitions: International Experiences and Lessons Learned” in Cairo. The meeting featured Michele Bachelet and others discussing legal reform, women’s movements and gender-responsive accountability systems. Mariz Tadros was a speaker on the panel “Building Strong Women’s Movements in Democratic Transitions”.

The team has recently published a number of IDS Working Papers and Bulletins and will publish a bulletin on Action Research in International Development this spring.

Finally I want to say a huge thank you and good luck to John Gaventa and Kate Hawkins. John has been an inspiration to the PPSC team for more than a decade. He has joined the Coady Institute in Canada as their new Director. Kate Hawkins our sexuality programme convenor who has initiated and developed a great deal of exciting work within the team will be leaving IDS (but will continue to work with us as a free lancer). I would also like to welcome to the team Research Fellow Jerker Edstrom and Jas Vaghadia who will be working on our gender, masculinities and sexuality programmes. Welcome also to Naomi Vernon who is joining our CLTS team.

As I say, just a few flavours of the many different things that are happening. If you want to find out more, follow the links, or contact us directly.

Danny Burns is the Team Leader for the Participation, Power and Social Change research team at IDS and will be publishing IDS Bulletin 43.3 ”Action Research in Development” in May 2012

A passionate family: Reflections on the WSSCC Global Forum on Sanitation and Hygiene

Robert Chambers

This was the first ever Global Forum on Sanitation and Hygiene. There have been the regional meetings – Sacosans, Africasans and so on, but never one for the whole developing world. Water Supply & Sanitation Collaborative Council (WSSCC) (and most notably Archana Patkar, who got a standing ovation at the end) did a great job in imaginative and thorough planning. The facilitation by Archana, Barbara Evans and others was outstanding. WSSCC had brought together some 450 of us. There was fuller representation of Africa than usual, and fewer Indians than one might have expected. There was a family feel about it for those of us who pitch up for the regional ‘Sans’, and a sense of common purpose and commitment which was stronger than before. That augurs well. I didn’t pick up any sense of institutional rivalries.

What stands out now the four main days are over?

• Passion And it is a common passion. Jon Lane set the tone with an eloquent unscripted introduction in which he drew on Gandhi and Mandela. He mentioned that worldwide about half of the toilets constructed for people were either not used or used for other purposes. Demand-led, not supply led…
• Behaviour change This was a good idea, a plenary in which people from different fields gave their insights into what leads to behaviour change. All of their contributions fitted, supported and helped to explain Community-Led Total Sanitation (CLTS), more or less like these soundbites distilling what they said:
  ‘No health education, please!’ (Yes, that really was said)
  Telling people to send girls to school does not work (Yes that really was said)
  Focus on want, need, desire
  For behaviour to change, experiences have to be ‘radical, real, immediate and dramatic’
  Let choice be compelling so that there is no choice
  When frames of mind change, behaviour change is easy
  For behaviour change, social norms must change
  
• Equity and inclusion. These were big, big themes throughout. We had previously excluded people who here came to talk to us in small groups – rehabilitated manual cleaners, slum dwellers, disabled, minorities. We spent part of a whole morning on this, set up by Louisa Gosling of WaterAid who has written authoritatively on this. Everyone will go away with this firmly imprinted. A lot was said on the shift from the Millennium Development Goals approach (and how well it is filling the glass) – to right-holders and duty bearers, and the concept that as long as the glass is not full, and people are excluded, are we as duty-bearers not guilty of discrimination? This from Archana. And this orientation came across powerfully from my nomination for the wittiest speaker award – she had us in stitches – Nomathemba Neseni, Commissioner, Human Rights Commission, Zimbabwe.
• CLTS Bushfire in Africa was Kamal Kar’s title for his rousing presentation, and that imagery seems increasingly justified. Jane Bevan said she thought those in credibly Open Defecation Free (ODF) communities in Africa might now number not four but five million, sustaining the sense that much spread there is exponential (though of course not everywhere). Sammy Musyoki impressed with his presentations on urban CLTS in Mathare, and on the use of mobiles in monitoring. Kamal and I (mainly Kamal) did a four hour CLTS ‘training’ in which we re-christened a familiarisation. Though in competition with field visits in Mumbai, we still got about 25 people, and had fun taking over and messing up some of the paved area outside the hotel with a role play of triggering and lots of (yuk!) yellow rangoli powder which stayed on your hands. The joint IDS- CLTS Foundation stall was well set up by Andii Paul, and attracted a great deal of attention – much material was picked up, many signed up for the bi-monthly e-newsletter. There were country meetings around CLTS – Nigeria, Uganda, Tanzania,Madagascar. And lots of energy.
• CLTS ‘debate’ or moving forward? A debate had been planned but the atmosphere was different. There isn’t much debate about CLTS – yes or no – now. The sceptics are fewer. It is an extraordinary change, and has happened fast. I noticed the same at the Water Engineering and Development Centre (WEDC) conference a couple of months ago in Loughborough. Instead of a debate we split into topic groups and brainstormed. Old ground had to be covered in the groups to bring people up to date, but that was all right. The PHAST issue seems to have subsided – there doesn’t seem to be much argument there any more – it is so painfully obvious why the PHAST approach is incompatible with and undermines, inhibits, slows, stops CLTS. All the same, we still need practitioners to record their experiences. The concerns now (except still in much of India – the elephant in the room) are how to do better with and through CLTS, and how to go to scale with quality and sustainability. Louis Boorstin of the Gates Foundation called for going straight to scale, without pilots (there is a debate to be had there, but perhaps it’s a question of semantics) and realism ‘call it like it is’ and convened a breakout meeting on going to scale with CLTS and total sanitation – experiences of how to do it.
• Handwashing surprise Steve Luby from the International Centre for Diarrhoeal Disease Research (ICDDR) astonished with his finding from rigorous research in Bangladesh that of the five times when you are meant to wash your hands – after shitting, after handling children’s shit, before eating, before preparing food, and before feeding a child, only two had a significant effect on the incidence of diarrhoea. Which two do you think? The answer is at the end of the blog.
• Nepal number 15 The first 14 countries can welcome a new member to the club. In the week before the Forum, Nepal adopted CLTS as national policy for rural sanitation, making it the 15th country to do so, and the second outside Africa, the other being Indonesia.
• India Still underplayed. The gross enormity of open defacation in India, and its impacts on undernutrition of children, on livelihoods, on poverty, is still not really recognised as it should be. If India still has 56-58 per cent of the open defactation in the world, we need to get our minds around this, and so does the Indian Government. The Hindustan Times carried an article about undernutrition in Mumbai, and quoted IDS Director Lawrence Haddad that India was an economic powerhouse but a nutritional weakling. A third of the children in Mumbai are undernourished.
• Shit transect Visits were organised to slums, one of which didn’t seem from the video to be a slum at all, but it wasn’t necessary to go far. Sammy, Naomi and I walked just ten minutes from our five star hotel to an area I had found when jogging. In the early morning we saw children crapping in the middle of a tarmac road, six  men in a small plot of vegetation where they must surely have been stepping on the stuff, and shit on raised flat concrete surfaces. All gross, disgusting and smelly. And oh a disused toilet block, and another quite dirty one actually in use, all of these apparently draining into a stream that feeds into the (beautiful?) lake of which we had such a good view from our lap of luxury. Back in the hotel, I washed my trainers.
• ‘Shit’ is OK The word was widely used, even in the concluding plenary. This is a watershed passed, a mini but meaningful tipping point from which there is no return. We collected more words for the international glossary.

So, well done and thank you WSSCC, and let’s look forward to a summary from this Forum. May the ripples spread wide. Some may be through the Communities of Practice that were launched (see WSSCC website). And don’t let this be the last Forum but the first, so that we can look forward to the next!

PS: The answer is after shitting, and before preparing food

Robert Chambers is a Research Associate in the Participation, Power and Social Change research team at IDS.

About CLTS

The Community Led Total Sanitation (CLTS) approach is an innovative methodology for mobilising communities to completely eliminate open defecation (OD). Communities are facilitated to conduct their own appraisal and analysis of open defecation (OD) and take their own action to become ODF (open defecation free).

At the heart of CLTS lies the recognition that merely providing toilets does not guarantee their use, nor result in improved sanitation and hygiene. Earlier approaches to sanitation prescribed high initial standards and offered subsidies as an incentive. But this often led to uneven adoption, problems with long-term sustainability and only partial use. It also created a culture of dependence on subsidies. Open defecation and the cycle of fecal–oral contamination continued to spread disease.

In contrast, CLTS focuses on the behavioural change needed to ensure real and sustainable improvements – investing in community mobilisation instead of hardware, and shifting the focus from toilet construction for individual households to the creation of “open defecation-free” villages. 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 change, propels them into action and encourages innovation, mutual support and appropriate local solutions, thus leading to greater ownership and sustainability.

CLTS was pioneered by Kamal Kar (a development consultant from India) together with VERC (Village Education Resource Centre), a partner of WaterAid Bangladesh, in 2000 in Mosmoil, a village in the Rajshahi district of Bangladesh, whilst evaluating a traditionally subsidised sanitation programme. Kar, who had years of experience in participatory approaches in a range of development projects, succeeded in persuading the local NGO to stop top-down toilet construction through subsidy. He advocated change in institutional attitude and the need to draw on intense local mobilisation and facilitation to enable villagers to analyse their sanitation and waste situation and bring about collective decision-making to stop open defecation.