The results of this study are reflective of evidence-based failure-to-success documentation. Review of on-the-ground implementation of sanitation behaviour change advanced using the impactful Community-led Total Sanitation (CLTS) approach provided the much-needed context reinforced by implementation experience. Moreover, the involvement of a local community-based organisation strengthened the credibility of data and information used and fortified results discussed herein.
Implementation of development assistance programmes is often challenging in rural establishments, given the socio-cultural dynamics, poverty, and dependency syndrome.
The failures experienced in the initial years of implementation are attributable to our ineptitude in identifying rapidly-changing community dynamics and not taking time to reflect on the outcomes of the interventions and initiatives. We, therefore, had to make iterative adaptations and modifications as described in the findings to overhaul and salvage the project from failure. This is consistent with Greaves (2016), who reported that contexts, and other emerging programming themes, may appear to make CLTS more challenging to implement effectively. This calls for more learning about the adaptation of the CLTS process to different settings and diversification of the approach.
The CLTS approach is designed to enable rural open defecators to confront the negative repercussions of this behaviour by triggering collective behaviour change and facilitating collective action to adopt safe and hygienic sanitation behaviour.
Based on the results of this study, we noticed a surge in latrine coverage from a mean of 69.8–87.0% in 2017 and 2018, respectively. These results peaked at a mean of 92.5% at the end of the intervention. With the blend of innovative initiatives such as CLTS learning labs, situation room, and CLTS helpdesks, 93% (37/40) of the triggered villages attained ODF status. This provides evidence that the CLTS approach is instrumental in guiding villages to the desired sanitation status once used effectively. A study documented by USAID concurred with this finding, stating that; the current literature points to the ability of CLTS to generate significant short-term reductions in open defecation as well as increases in latrine coverage and use (USAID, 2018).
The general increment in latrine coverage from baseline in 2016 to 2019 saw an average increase of 27.8% in latrine coverage over four years. This finding surpasses the average of 12% documented in literature and therefore is in line with a study that reported that the success of CLTS could be measured by latrine coverage, the percentage of households within a community that have access to their own latrines. A literature review of sanitation campaigns has reported an average increase in latrine coverage following CLTS of 12%, though not statistically significant (Garn et al, 2016).
Upon completion of the project, the mean latrine coverage across all the sub counties was 92.5%. This corroborates with and Robinson (2016), whose study presented up to 96% latrine coverage in a single case in Malawi.
In the intervention, the integration of other small and doable actions as well as intentional and meaningful community involvement were the game-changers. This is in sync with a study that was in agreement with initiating additional actions hence suggesting that this study corroborates the effectiveness of CLTS in increasing latrine coverage, and additional activities can be improved further (Harter, et al, 2020).
Although we had numerous successes to celebrate, there were some challenges to deal with—slippage was one major factor we grappled with. This was primarily due to poverty vulnerability factors as wells as technological challenges. Whereas the use of CLTS champions was instrumental in addressing slippage, the challenge continues to lay bare the strength of the CLTS approach in sustaining sanitation behaviour change. This finding agrees with WHO (2018) which reported that its success rates vary widely across projects and countries and slippage rates as well as long-term effects have received too little scientific attention so far (WHO, 2018).
The CLTS Helpdesks were real-time, given that toll-free lines numbers were used to enable communities to reach out for information and advise and reports challenges without having to worry about airtime. This initiative helped a great deal in bridging the gap between the project and its beneficiaries. A similar approach reported by USAID through its LEARN mechanism was used in Zambia to ensure corrective actions were taken in a timely fashion.
The DHIS2-based Mobile-to-Web (M2W) monitoring system has been a critical element for Community Approaches to Total Sanitation (CATS) success from the start. The system has increased accountability, enabled feedback and course correction, and generated healthy competition between chiefs and districts. Accountability has increased because it is now evident which community champions (local volunteers) are consistently following up with their communities and which ones may be inactive and may need support or replacement (USAID LEARN, 2018).
To our knowledge, there are not as many studies that document a blend of innovative actions simultaneously incorporated into the traditional CLTS processes. Moreover, not as many studies describe how these work in tandem to break sanitation barriers and influence behaviour change. This study, therefore, lays a firm foundation upon which learnings can be drawn not only for replication but also scale up and innovation in rural sanitation programming anchoring the CLTS model in the approach.
Overall, our results indicate that for the CLTS model to be beneficial, incorporating innovative initiatives and reinforcing community engagement are absolute imperatives.