[Individual articles from the Winter 2019 issue of Intersections will be posted on this blog each week. The full issue can be found on MCC’s website.]
Despite decades of targeted foreign aid, Haiti has struggled to make significant progress on curbing infectious waterborne diseases or improving basic water, sanitation and hygiene (WASH). While official statistics (WHO/UNICEF, 2017) report that 24% of Haitians have access to latrines or other improved sanitation (similar to the global average for low-income countries), in most rural areas where MCC works, less than 5% of households have latrines, open defecation is commonplace, handwashing with soap is rare and people are dependent on untreated surface water sources for drinking and washing. This combination of challenges has led to persistently high rates of infectious waterborne diseases (including cholera), high rates of malnutrition and stunting and high mortality. According to the World Health Organization (2016), 41% of Haiti’s total disease burden is due to poor WASH infrastructure and practices (the fifteenth highest in the world). One of the promising innovations in WASH programming globally has been ‘Community Led Total Sanitation’ (CLTS). This approach has been imported to Haiti by major funders in recent years with mixed success. Following Hurricane Matthew in 2016, MCC, along with its local partners in the Artibonite region, piloted an adapted version of CLTS that has been extremely successful, leading to zero new cholera cases in the implementation area in nearly two years since the project began (compared to an estimated 1,818 cases over the prior 18-month period).
CLTS was developed in 2000 by Kamal Kar in rural Bangladesh. The approach was a response to decades of failed WASH programming, which tended to assume that WASH problems could be solved simply by installing infrastructure (latrines, water systems, etc.) along with education by non-local experts on WASH topics. This approach all too often led to extreme waste of resources, underuse/nonuse of latrines and WASH infrastructure and deepening dependence on outside resources and expertise. CLTS works at the community level to facilitate a locally-led analysis of WASH problems leading to a community commitment to ending open defecation and a plan (sometimes with outside subsidy) to develop and install appropriate sanitation infrastructure (latrines, handwashing stations, etc.) and enforce new norms of behavior based on community priorities. When it works, CLTS has been demonstrated to generate community ownership for WASH problems and solutions, be cost-effective from a donor/NGO perspective, create rapid change in health outcomes and produce durable behavior change at the community level. These very positive findings from early CLTS projects have resulted in the approach being zealously promoted by most major health-focused international groups in over the last 15 years.
Unfortunately, CLTS has not proven to be the panacea its promoters hoped for. In many contexts, it has been very challenging to implement and has faced deep cultural resistance from local communities. This resistance is generally produced by the way in which CLTS facilitators mobilize communities and use the power of group norms to push change. Specifically, CLTS relies on strong negative emotions, including guilt, disgust, shame and fear to ‘trigger’ and galvanize communities to eradicate the ‘bad’ behavior of open defecation. In some documented cases this has included shouting insults at and humiliating ‘violators’ for endangering the community. As the CLTS manual explains, the approach specifically “shocks, disgusts, and shames people” as it believes this is more effective than non-judgmental or positive health messaging (Kar 7). This approach is controversial, and in some contexts a cultural non-starter. Additionally, in cases of extreme poverty and immediate post-disaster rebuilding, the demands for locals to bear full responsibility for the costs of WASH changes may be unrealistic, unnecessarily slow the pace of change and potentially humiliate and further marginalize the most vulnerable who are the least able to make the necessary investments.
Haiti is a good example of CLTS failure in recent years, despite millions of dollars in international resources supporting the model. Since 2010, the list of organizations promoting CLTS in Haiti touches all the major players, from various ministries of the Haitian government, to United Nations agencies, to large international non-governmental organizations. However, the vast majority of these efforts have had disappointing results. A Plan International evaluation in 2015 found that only 8% of communities achieved their goals of ending open defecation and/or achieving near universal latrine access. A similar UNICEF evaluation in the Artibonite region (the same area as MCC’s work, described below) found only 15% success in achieving its goals. Both evaluations noted strong resistance from local leaders, local government officials, local health workers and participant communities to the shame and disgust-based approach to motivating change. Others noted that while top governmental and NGO leadership in Haiti’s capital of Port-au-Prince had read the CLTS literature and signed on to the approach, local implementation was weak, and communities refused to enforce the negative norms as required by the model. A UNICEF evaluation team in 2012 concluded that “the key learning here is that a more nuanced understanding of community and individual motivation is required to implement CLTS programmes in future [in Haiti]. A solution to this difficulty has not yet been identified” (Plan International Haiti, 2012).
Following Hurricane Matthew in 2016, MCC began a series of pilot WASH projects in the Artibonite Department of central Haiti. These projects used many CLTS elements but built on the positive Haitian cultural tradition of konbit (a rough equivalent to the Amish barn raising tradition) to build positive and inclusive community engagement rather than taking a negative, shame-based approach. The focus on WASH programming was driven by the communities themselves, who identified the eradication of cholera and other deadly diarrheal diseases as their number one priority for MCC accompaniment. Community-led mapping was done to identify the catchment areas that would maximize impact on community-selected WASH outcomes (in this case prioritizing communities living near to and uphill from shared community water sources). Neighbors were organized in groups of 10 to 15 to jointly contribute the labor for latrine construction (digging the holes, transporting materials and collecting locally available materials such as wood, water, stones and sand), which allowed for disabled, elderly and single parent families to fully participate. Local leaders, government officials and health professionals volunteered to work with MCC staff to facilitate community meetings on latrine construction and maintenance, water source protection, hygiene, disease prevention and the importance of complete community engagement in the project. MCC contributed local staff to lead trainings and conduct home visits and subsidized the purchase of some latrine supplies (cement, metal roofing and piping).
This phase of the project expanded several times, as neighboring communities asked to participate after seeing the plummeting infection rates and strong community engagement. Noting the success of this work, a follow-on project working at the commune level (equivalent to a county in the United States) brought together volunteers from the local hospitals, local water authority, public health department, all local primary schools, local disaster response committees and the local government to implement a larger scale version of this work. This second phase of the project used a similar approach to the prior projects, but also included getting the voluntary support of all 213 primary schools in the commune (representing 26,068 students) to install sanitary handwashing facilities and filtered drinking water stations and provide recurrent education to students on WASH topics.
While direct causality is impossible to prove, the rates of infectious waterborne disease, including cholera, have plummeted in the project catchment area since this WASH intervention began. In the 18 months prior to the project’s start, this area saw 1,818 cases of cholera. The 18 months following implementation have seen zero. By adapting the CLTS approach to the local context and listening to the local cultural priorities of respect, inclusiveness, positive group engagement and mutual solidarity, the project achieved rapid success in making durable change, gathering strong community support and participation, keeping costs low and promoting stronger community cohesion and cooperation. As organizations look to implement ‘best practice’ models like CLTS, the lesson from Haiti has been to take the cultural context seriously and adapt thoughtfully.
Paul Shetler Fast is MCC’s health coordinator, based in Port-au-Prince, Haiti.
Kar, Kamal, and Robert Chambers. Handbook on Community-Led Total Sanitation. London: Institute of Development Studies, 2008.
Bongartz, Petra, Naomi Vernon and John Fox. Sustainable Sanitation for All: Experiences, Challenges, and Innovations. Rugby, Warwickshire, UK: Practical Action Publishing, 2016.
Plan International Haiti. Water, Sanitation and Hygiene in 60 schools and 60 Communities in the North‐East and South‐East Haiti: Narrative Report. Port au Prince, Haiti: Plan International, 2012.
World Health Organization (WHO). Global Health Observatory: Mortality and Burden of Disease from Water and Sanitation. Geneva, Switzerland, 2016.
WHO/UNICEF. JMP Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and SDG Baseline. Available at https://data.unicef.org/topic/water-and-sanitation/sanitation/#data.