This is the fifth of the six videos on information treatments as a policy intervention. In this video, we will again discuss community-led total sanitation, or CLTS, by looking at research about the effectiveness of a CLTS intervention in Mali, West Africa. This is an example of case three from our topology of information treatments. This study was led by Amy Pickering, and it involved many co-authors. The study was conducted in 121 randomly selected villages in southwestern Mali. A baseline survey was done from April to June, 2011. It covered 4532 households, with 6862 children under five. The CLTS Intervention was conducted in half of the villages from November 2011 to June 2012. Then a follow-up survey was conducted in both the treatment and control villages from April to June, 2013 to measure outcomes. 4031 households and 6322 children under five participated in this follow-up survey. The communities included in this study were small, made up of between 30 and 70 households. They had low latrine coverage so that open defecation was widely practiced. They had no previous experience with other CLTS programs. And they were at least ten kilometers away from another study village. This minimized the risk of information spreading from the CLTS treatment villages to the control villages. It also minimized the chance that control villages would experience positive health externalities from a reduced open defecation in the treatment villages. The CLTS intervention was conducted by government and UNICEF staff. The CLTS facilitators strictly followed the Kamal Kar's CLTS protocol. The same participatory group exercises were deployed as in Bangladesh, and there were no hardware subsidies. The research team measured four outcomes from the CLTS intervention. I'm going to show you the results for the effects of the CLTS intervention on access to a private latrine, open defecation, hygiene practices and child health. First, the CLTS intervention almost doubled the number of households with private latrines. 65% of households in the treatment villages gained access to a private latrine compared to 33% in the control villages. So the CLTS intervention worked, but there two important caveats. First, the CLTS did not result in universal latrine coverage. And second, the private latrines that were built in response to the CLTS intervention were not necessarily improved latrines. Many were what the JNP would classify as unimproved pit latrines. The CLTS methodology doesn't place special value on improved latrines compared to unimproved latrines. So this finding is actually not surprising. This was also the case in Bangladesh, where open defecation has dropped rapidly but access to improved latrines has risen more slowly. Second, the CLTS intervention reduced open defecation significantly. In the control villages, a third of adults practiced open defecation compared to about 10% in the treatment villages. Open defecation was much more common for children, but this also fell substantially. In the control villages, 83% of the children under five practiced open defecation compared to 41% in the treatment villages. This is, again, good news in the sense that CLTS had a large positive effect, but it did not eliminate open defecation in the treatment villages, especially for children. There is more good news. The research team found that CLTS intervention resulted in improvements on a variety of environmental and hygiene indicators. They found fewer visible feces in the treatment villages, cleaner latrines, and more handwashing with soap. The bad news was the researchers found no reduction in diarrhea in the treatment households. This result is consistent with the hypothesis that a community needs to reach near universal coverage with improved sanitation in order to experience dramatic improvements in wash-related health outcomes. However, the CLTS intervention improved measures of height-to-age and weight-to-age in children, which is, of course, a positive outcome. The improvements in childhood stunting were particularly striking. There was a 13% decrease in stunting in children in treatment households, and a 26% decline in severe stunting. The causal pathways from CLTS to the effects on child growth and mortality are unclear. The researchers speculate the effects may be due to reductions in parasitic infections or environmental enteropathy. This is an inflammation of the intestine that makes it difficult to absorb nutrients from food. Pickering's study in Mali is broadly consistent with the findings from Pattanayak's research in Orissa. My conclusion after reading these and other studies is that Kamal Kar's original insight about the importance of triggering and stimulating demands for improvements in sanitation is applicable in many areas outside Bangladesh. There is, however, considerable heterogeneity in the magnitude of the effects from CLTS both within households and across villages. Some villages achieve universal coverage as a result of CLTS type interventions, but many do not. Presently, we do not understand the reasons for this heterogeneity. Whether or not hardware subsidies should be provided remains an unresolved and contentious issue with strong arguments on both sides. My own view on the hardware subsidy issue is that we should not be too dogmatic. Subsidies may help end open defecation in some places. In other places, Kamal Kar is probably correct that they are counterproductive. Most papers on the effectiveness of CLTS do not report careful estimates or the full cost of providing the intervention. It is thus difficult to assess the costs and benefits of CLTS interventions. As we have seen, there's a divide in the wash sector as in many sectors between planners who trust households generally to make the right choices about wash options for themselves if they're provided with objective information. And on the other hand, planners do not. Both groups have good arguments for their positions. But the success of the CLTS intervention shows, at least in some cases, behavioral change may require aggressive interventions by outside agencies to overcome powerful ancient instincts. And CLTS' efforts to trigger shame and disgust are certainly not restrained by a desire to respect consumer sovereignty.
