This is the fourth of our six videos on information treatments as a policy intervention. Both this video and the next one will discuss case three from our topology of information treatments. In this case, households are provided with a one time information treatment, and the agency that is intervening has the explicit objective of changing a specific household behavior. There are numerous examples of this type of policy intervention in the wash sector. I will illustrate case three with one of the most famous, and arguably successful, information treatment interventions. Community Led Total Sanitation or CLTS. Before I describe CLTS in a research study to test its effectiveness, I should emphasize that there is a practice that continuing between one time short term information treatments in periodic long term interventions. It's somewhat arbitrary where one draws the line between short term and long term. CLTS is a short term information treatment in the sense that it's not designed to be repeated indefinitely or continually over a multi-year period. However, in practice, some NGOs have drawn out the intervention to over a year. Let me begin by providing some background information. Improving community level sanitation has long been a challenging collective action problem in the development field. Poor sanitation at the community level is a classic example of what economists call a negative externality. If my household practices poor feces disposal this will negatively affect other households in my community, even if this is not intentional. The Conventional Wisdom in the water sector has been that these negative externalities are larger for sanitation and for water supply. Thus wash professional felt that there was greater justification for subsidies for improved sanitation than for improved water supplies. To end open defecation, for decades the preferred policy intervention of most national governments and donors was to focus on the supply side. This typically entailed a two pronged strategy. First, improve technological options available to households. Second, subsidize the construction of improved household latrines. The behavioral assumptions underpinning subsidies, was that households wanted to use improved latrines, but they were simple too poor to afford them. For decades, donors less experienced with different latrine designs and ways of subsidizing the household level latrine construction. At the risk of over generalization many of this donor led latrine construction projects were failures. Even when improved latrines were given away free, the new latrines were often not used. Many people seem to prefer to defecate in the open or continue to use traditional pit latrines. Even when some households in a community did used donor provide latrines this was unlikely to result in dramatic health improvements because other households were not using the improved latrines. Or the improved latrines filled up or broke down and were not repaired. Partial adoption of improved latrines did not solve the collective action problem. Almost everyone on a community needed to stop defecating on the open if everyone wants to experience the maximum health outcome and improve feces disposal. By the beginning of the 21st century there was widespread dissatisfaction among professionals on the water sector about the lack of progress on open defecation practices and the ineffectiveness of available supply side policy interventions. In 1999, Kamal Kar, a development professional working in Bangladesh, developed a different approach. He effectively turned the conventional wisdom about how to tackle open defecation practices on its head. Kamal Kar developed an information treatment for communities that quickly became known as community-led total sanitation. The intervention involved no hardware subsidies for the construction of the trains. Instead, he developed a set of training materials and participatory group exercises that community facilitators could use to change the mindset of households in a community about open defecation. Kamal Kar's group exercises were designed to tap into an ancient instinct and trigger a sense of disgust and shame. Among households about what was really happening in their community. A quick warning that I will use explicit terminology to describe human fesses because that is what the CLTS group of exercises do. I say that because one of the key messages of these exercises was that you are eating your own shit. The choice of language here is intentional. Just as we saw that the baby chimpanzee's instinctual fear of snakes had to be triggered, Humans' ancient instinct about eating their own shit, had to be triggered by disgust and shock. After the triggering event, Kamal Kar argued that people will be able to find sanitation solutions without outside subsidies. In fact, he argued that subsidies were actually a barrier to ending open defecation because they created an expectation of external support, and a lack of confidence among communities that they could improve their own sanitation problems themselves. The CLTS intervention involves four main group exercises to trigger this sense of shame and disgust. The first is a mapping up of all the places around the community were open defecation occurs. Group participants create a large pictorial image of the location of open defecation sites. Even if people do not want to discuss this, the map reveals to everyone where these sites are the second exercise is known as the walk of shame. It involves visiting the open defecation sites around the community. Group participants visit the open defection site so it's not possible for anyone to deny their existence. The third exercise is a shit calculation to demonstrate to group participants the volume or weight of feces being generated by individuals in the community every day. Participants actually scale up the amount of feces produced by one adult and one child. To the community level to help understand the quantity of feces that must be dispose. Often this volume or weight is compared with the amount of the crops say rice that is produced in the community. This makes it easier to visualize the volume of feces. This group exercise can also involve estimating the community expenditure on treating diarrhea and other fecal oral diseases. The fourth exercise is designed to demonstrate the linkage between open defecation, flies, and food. The facilitator takes two plates, one with food and one with human feces, and places them in close proximity for the group participants to see. Flies quickly land on the feces and on the food, and fly back and forth between the two plates. The group proceeds to discuss something else, besides what is happening on the two plates. After a while, the facilitator offers the plate of food to one of the group participants to eat. Generally, everyone is disgusted with this proposal because it is obvious what has happened. The flies have deposited feces on the food. The facilitator then acts surprised observing that this is what is happening in the community everyday. Sometimes the glass of water demonstration was used to make the same point. This involves touching a hair or a blade of glass to wet feces then dipping it in a glass of water. The facilitator then offers the glass of water to community members to drink. The hair or blade of grass is compared to the leg of a fly. The facilitator tells the community members that they recoil and refuse the water despite the fact that it appears perfectly clean. These participatory exercises involve many members of the community. And these group exercises can be done in different orders. Some CLTS practitioners prefer re-ordering and mixing and matching them to suit local circumstances. The triggering is intended to encourage participants to develop a plan to build their trains. I think with exercises is an information treatments because they provide information that enables households to see the open application practices in their community from a new perspective. The CLTS facilitators are not neutral providers of information, they travel to a community with the explicit purpose of triggering behavioral change and ending open defecation practices. From an economics perspective, you can think of these triggering exercises as a way to create or stimulate demand. After the participatory group exercises and the development of a plan to End-Open Application the CLTS facilitator solicit commitment from the community to implement the plan. After the initial intervention the CLTS facilitators may return to the community for a few months to monitor and encourage behavioral change. They also return to certify if a community has achieved open defecation free status. Receiving this certification is an important part of the CLTS intervention protocol. The CLTS facilitators may host a party to celebrate the end of open defecation in the community as part of the certification process. This ODF certification and subsequent celebration functions as a motivator or a reward at a community level. The previous supply driven interventions targeted households. The CLTS intervention not only affects households but also community dynamics. The hope is that it triggers a demand side effect from peer to peer pressure within a community. This peer to peer influence is linked to community wide triggering. CLTS starts with triggering shame and disgust, but then transitions to trying to create pride and dignity. The ODF certification fosters a feeling of pride, if CLTS is successful. In some cases, certification is done by a third party. For example, where CLTS is part of national policy that government contracts an agency or consultant to carry out certification on their behalf. For example, CLTS was part of the national sanitation program in India and ODF status was rewarded with national recognition. Certification is also sometimes used by governments as the basis for paying NGOs or local government for carrying out CLTS triggering. There's a large literature on CLTS techniques. A good place to start is Kamal Kar and Robert Chambers's handbook on Community-Led Total Sanitation. It is important to emphasize, how radically this demand creation strategy differed from what many donors and national governments were doing. They were looking for supply side solutions and trying to educate people about the health benefits of improve sanitation. Health education was a case to information treatment, who is not focus on triggering shame and disgust. In a world in which many household practicing open defecation actually have cell phones, Kamal Kar argues that the problem was not a lack of money, and that health education was not a sufficient trigger to motivate change. Health education interventions and subsidized latrines were not enough to change people's mindset about open defecation and what was really happening in their community. One anecdote that has been told and retold by Wash professionals is that some open defecation free communities posted signs that said girls from this village do not marry men from communities still practicing open defecation or no toilets no bride. CLTS was first promoted in Bangladesh, where almost all communities in the country have now participated in a CLTS triggering intervention. Kamal Kar now argues that CLTS is responsible for Bangladesh almost completely ending open defecation. This is without a question a huge success story for the wash sector. Naturally, WASH sector professional wanted to expand CLTS from Bangladesh to other countries. Kamal Kar himself participated in some of these efforts. But the CLTS movement grew so quickly that he personally cannot be involved in all these initiatives. CLTS is now been rolled out in over 50 countries around the world. Many countries have written CLTS into their national sanitation policy or guidelines. As this roll out occurred, a whole generation of Walsh professionals has tried to use Kamal Kar 's insights on demand creation, to end open defecation practices in places outside of Bangladesh. They confronted new challenges and they naturally adapted the original CLTS package of interventions to locations that differed in various ways from Bangladesh. There were several major areas where CLTS practitioners found differences from Bangladesh, and made changes to Kamal Kar's original package of interventions. First, some communities were offended by the Bangladesh techniques designed to trigger shame and disgust. CLTS practitioners made some adjustments to make the participatory group bachelor sizes more culturally appropriate. Of course, the whole objective of triggering activities was to generate shame and disgust and create demand for improvement so, modifications might go too far. Second, it was relatively easy for households to dig and build improved pit latrines in the alluvial soils of Bangladesh. Bangladesh had also benefited from almost 20 years of support from various agencies to build up capacity of local masons to build latrines. Bangladesh also has an active indigenous plastics industry which has responded to demand by producing a wide range of very cheap plastic latrine pans and other supplies, which reduce the cost of relatively good quality latrines. In other countries, latrine construction was much more expensive, either because excavation was harder or local materials where not as easily available. In such situation, CLTS practitioners often relax the hardware subsidy rule. Third, the supply chains for materials both to build and to empty latrines differ widely. For example, in some cities, private contractors were easily available to both construct improved latrines and empty pit latrines when they filled with excrement. What role should these private contractors play in the roll out of CLTS in other countries, if any? Required thought and adaptation. Fourth, population densities and the spatial distributions of villages in most countries was different than in Bangladesh. And so spillover effects from over defecation free villages to other villages were different. Fifth, watch professionals rolling out CLTS and other countries confronted different situations with regard to political leadership and institutional support. And six, another major impediment to CLTS success is a community's prior experience with government or donor sanitation projects. If a community has previously received subsidized latrines or been exposed to hire quality latrines, accepting responsibility to build their own latrines may be more difficult. Working in virgin communities generally saved the work better. Households in such communities don't necessarily expect subsidized latrines and are okay with building a cheap pit latrine, rather than waiting until they can afford something much more expensive. Some of the adaptations CLTS practitioners made, would not actually in response to conditions in different locations. Instead adaptations were often specific to an organization. Organizations often wanted to implement their own version of CLTS everywhere they were regardless of whether or not if it's local conditions. One example is the Indian Total Sanitation campaign which includes latrine subsides across India. Another is UNICEF's community approach to total sanitation, which involves subsidies or financial rewards to communities, but not to households. The UNICEF program also involves training masons. The World Bank's WSP Total Sanitation and Sanitation Marketing program involves a heavy focus on marketing. Professionals in water sectors had been keenly interested in the effectiveness of the CLTS roll out in other countries. And what has been learned by the various changes that had been made to the original package of the CLTS interventions. The first important evidence of this comes from research conducted by Subrenu Patiniak and his colleagues in Arisa, India. They found the sanitation intervention similar to CLTS, but with subsidies targeted to the poorest, had important positive outcomes on latrine construction and health. But the effects were not as large as in Bangladesh. We've included professor Paten York's papers and other literature on the subject in your readings. In the next video, I will summarize a recent study that tested how well the original package of CLTS information treatments worked in Mali, in West Africa.
