Community-led approaches for development: Linking sanitation and nutrition
Recently I was looking up country data on issues related to sanitation, and was drawn to Bangladesh’s national statistics on nutrition. From reducing its under-5 mortality rate from 144 to 41 and infant mortality rate from 100 to 33 over the last 20 years, the country has made steady progress in its nutritional status, with its achievement being in fact the most remarkable in the region. Furthermore, undernutrition rates dropped from 67% to 37% and stunting rates from 71% to 41% between 1990 and 2013.
Photo: SuSanA Secretariat (CC BY 2.0) (No changes made)
The reason I focus on Bangladesh specifically is because the nation’s improved nutritional status is strongly linked to parallel achievements made in the water and sanitation sector during the same period. Bangladesh increased its sanitation coverage from 34% (in 2003) to 99% (in 2015) , an unparalleled feat in sanitation among the developing countries globally. The open defecation rate in Bangladesh has been reduced to just about 1%, a statistic that the people of the country are collectively working towards erasing by the end of the MDG period in December 2015. This would make Bangladesh the first Open Defecation Free (ODF) nation in the region.
There is a well-documented body of knowledge on the short and long term adverse effects of contaminated water, inadequate access to sanitation and poor hygiene practices on child growth; causing diarrhoea, parasitic infections through soil transmitted helminths and intestinal inflammations through environmental enteropathy; all of which result in undernutrition, stunting and wasting in children. In recent times, growing evidence is emerging on the impact of improved sanitation and hygiene programmes on children’s nutritional outcomes.
For instance, in the decade that Bangladesh made record-breaking sanitation progress, it was recorded that among under-5 children, underweight rates declined from 43% to 35% and stunting rates declined from 51% to 39% . This is not to say that better sanitation alone played a role in increasing the nutritional status of children in Bangladesh. While it is evident that nutritional outcomes achieved in Bangladesh is the product of multiple factors such as increased health care services, better education, provision of nutritional food and supplements and increased awareness of mothers on feeding and caring practices; the stoppage of faecal-oral contamination through improved sanitation plays a key role in optimising the gains made through health and nutritional interventions.
Bangladesh’s sanitation story
A key driver of the unprecedented sanitation progress in Bangladesh was the Community-led Total Sanitation (CLTS) approach, a radical methodology that emerged from a water, sanitation and hygiene (WASH) evaluation led by Dr Kamal Kar in Bangladesh in 2000. Using emotional triggers and a participatory model of community self-analysis, CLTS drew on the community’s collective strength to mobilise indigenous knowledge and resources in the community to collectively change hygiene behaviour and stop open defecation. CLTS not only started a sanitation movement led by the people in Bangladesh but it also transformed traditional bilateral and NGO sanitation policy and practice that had until then spent huge budgets designing and constructing toilets for people with very limited success.
The sanitation story in Bangladesh and that of CLTS is therefore a story of restoring the power of change back to the people. It is a story of community empowerment as the answer to achieving large scale and sustained development outcomes. It is a story of transformation of people’s consciousness and social action to ignite collective behaviour change in the community. Global CLTS experiences suggest that the approach has achieved far more than basic sanitation. The construction and usage of toilets by the community is only a manifestation of their collective sanitation and hygiene behaviour change. Even then, it is merely an output. The true outcome and impact of this collective change process is seen in the long term social, economic, environmental and health benefits experienced by ODF communities. CLTS has in the last 15 years, been implemented in over 65 countries in Asia, Africa and Latin America, contributing widely to the reduction in global open defecation rates. There is however a severe dearth of data that draw a direct link between CLTS and its impact on health in terms of child growth or nutritional outcomes. Those that have emerged, however present compelling evidence.
The findings of an impact evaluation of a rural sanitation programme in Mali suggest that CLTS improved child growth, reduced stunting and reduced child mortality due to diarrhea. The study found a 26% reduction in severe stunting for children under-five years of age, a 35% reduction in severe underweight and a 57% reduction in diarrhea-related under-five mortality in the CLTS villages. Official hospital records in Niando district in Kenya show a drastic reduction (of more than 50% on an average) in cholera and diarrhea cases between 2008 and 2011 due to CLTS intervention. Similarly many cholera endemic zones in Ghana and Zambia have self-reported zero cases of outbreaks since the implementation of CLTS in the respective areas.
Community-led total sanitation as an entry point for enhancing nutritional outcomes
Towards more effective policy and practice, several linkages can be made between sanitation and nutrition. As the above evidence suggests, good sanitation and hygiene provides a clear pathway for positive nutritional outcomes and child growth. CLTS offers a powerful methodology towards creation of sustainable ODF environments – both in the physical and social sense– to promote better nutritional outcomes in the community.
One way is to apply the core principles of community mobilization and empowerment for collective behaviour change in order to trigger individual and community-led actions to promote knowledge, practices and behaviours for improved nutrition.
Second, is to target nutritional outcomes as a part of post-ODF strategies by building upon the collective consciousness and involvement of ‘Natural Leaders’ in the community to drive collective actions for better nutrition. Meaningful engagement of parents and families in a participatory and self-reflective manner should be built into the design of nutritional policies and programmes to generate demand and facilitate better utilization of nutritional and health care services. The key is to ensure that nutrition becomes a ‘felt need’ at both the individual and community level in order to guide and motivate individual parents and the community for action to achieve any significant impact.