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MONITORING COMMUNITY APPROACHES TO TOTAL SANITATION (CATS)

T3 UNICEF-NYHQ2008-1069crop-Nesbitt

 

 

This topic begins with an overview of monitoring Community Approaches to Total Sanitation (CATS) and then explores each of the key components in turn.

There are three components to be monitored in CATS:

  1. Elimination of open defecation (OD).
  2. Disposal of children’s faeces.
  3. Handwashing with soap.

 

What is CATS?

Over 53 countries are implementing some form of community approach to eliminate open defecation, collectively called Community Approaches to Total Sanitation (CATS). CATS is an umbrella term developed by UNICEF sanitation practitioners in 2008 to encompass a wide range of community-based sanitation programming, including Community-Led Total Sanitation (CLTS), School-Led Total Sanitation (SLTS) and Total Sanitation Campaigns (TSC).

As a direct result of UNICEF support, as of June 2013 over 25 million people now live in around 37,000 open defecation free (ODF) communities. Through indirect support, such as technical assistance for policy and standards development, advocacy and capacity building, a further 92 million people are living in ODF communities around the world. See ‘CATS Field Notes based on case studies from India, Nepal, Sierra Leone, Zambia’, available here.

 

Monitoring CATS

Different levels, different information needs

Different monitoring data are needed and collected at the community, subnational, national, continental and regional/global levels. Data collected at community and subnational levels feeds into national data that in turn contributes to global/regional data as illustrated in the figure below.

 

Figure: Levels of CATS monitoring

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Source: UNICEF, Monitoring CLTS presentation

 

Information from monitoring tools, such as the ODF Monitoring Protocol, can be used at community, subnational and national levels.

A good ODF Protocol should outline the indicators to be monitored at community, subnational and national levels, along with the recommended processes for data collection, compilation, analysis and verification. At community level, data collected should show the effect of CATS programmes on target populations. At subnational level, data collected should be used to monitor the quality of the design and implementation of CATS programmes. At national level, the consolidated data should be able to provide an overview of the efficacy of national strategies.

Monitoring tools, such as the Country Status Overview (CSO), WASH bottleneck analysis tool (WASH-BAT), UN‑water Global Analysis and Assessment of Sanitation and Drinking Water (GLAAS) and Multiple Indicator Cluster Surveys (MICS), also indicate whether or not national ODF/CATS strategies are working. Tools, such as the eThekwini commitments and Sanitation and Water for All (SWA), and tools measuring achievements of the Millennium Development Goals (MDGs), such as the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP), provide a basis for comparison between countries.

Monitoring information from the community level needs to be fed into analysis of monitoring information at the subnational level, which is, in turn, fed into the analysis of monitoring at national and global levels.

Specific information and tools are needed at different levels to answer key monitoring questions

 

Table: Information and tools needed to answer key monitoring questions

 
Community
Subnational/Provincial
National
Regional/Global
Need to know
Effect on target population
  • Baseline practices – OD, HWWS, disposal of children’s faeces
  • Changes in behaviour over time
  • Contribution to other outcomes, such as health and socioeconomic factors
Quality of design and implementation
  • Costing data
  • Performance compared among districts
  • Triggering to ODF ratios (quality)
  • OD status of all communities
Are national strategies working?
Consolidated data on sector performance – ODF population, investment, contribution to other social/health outcomes
How do we compare with other countries?
Progress on high-level commitments (e.g. eThekwini) against increased expenditure, leadership, coordination, and equity and gender issues
Tools
  • ODF Protocol
  • Health information systems data
ODF Protocol (number of ODF communities, number of communities triggered, etc.)
  • CSO
  • WASH-BAT
  • GLAAS
  • MICS/DHS
  • Regional sanitation processes (i.e. AfricaSan, SACOSAN, EASAN, LatinoSan)
  • SWA

 

Monitoring and evaluation (M&E) systems for CATS at scale must be in line with national policies and country capacity and budgets, which will require attention to make ODF (and post-ODF) monitoring cost efficient.

Monitoring of CATS at the community level needs to address these questions (ideally these should be incorporated into a national ODF Protocol):

  • What is your definition of ODF? (i.e. What are the indicators for verifying ODF claims?) Typically, the absence of OD, presence of HWWS facilities and safe disposal of children’s faeces are the three critical indicators?
  • What type of baseline data is needed? (i.e. Which indicators show change in community OD behaviour?)
  • Which indicators will you choose to measure process quality? (e.g. Are the facilitators performing?)
  • How will you monitor sustainability? What kind of ongoing support and monitoring is needed in the community? Who can provide this over the long term? Will you have a second tier ODF status (i.e. ODF+)?
  • What kind of coordination and information management system is needed to link information at different levels?

 

Figure: Questions to monitor CATS at community level and guide the development of a national ODF Protocol

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Source: UNICEF, Monitoring CLTS presentation

 

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1 Monitoring the elimination of open defecation (OD)

Level: Country, subnational and community

 

 

Eliminating open defecation (OD) is important for human health and is directly linked to reduced stunting and improved educational and health outcomes for children. Open defecation free (ODF) means that there is no faeces openly exposed in a community. It also means that all members of the community have access to and are using a latrine.

 

Defining open defecation free (ODF)

Countries often have definitions of ‘ODF’ and ‘improved sanitation’ that differ from the JMP definitions. There is a need to harmonize monitoring and indicators around national goals and targets.

 

Table: Examples of minimum standards for ODF certification in different countries

Country
Definition of minimum standards for ODF certification
Angola
100% ODF
Bangladesh
Basic sanitationFlushed and pour-flushed toilets/latrines with piped sewer system or septic tankPit latrines with slab and water seal or lid or flapPit latrines with slab, but no water seal, lid or flapVentilated improved pit latrinesComposing latrines
Eritrea
100% of the community stopped defecating in the open and the latrines have handwashing facilities (as a proxy indicator for handwashing)
Ethiopia
ODF: 100% reduction in open defecation
Ghana
  • No visible signs of human excreta within the community (total absence of faecal matter that is visible to the eye or able to be accessed by houseflies, including faeces in toilet facilities, chamber pots, surrounding bushes/shrubs, refuse dumps etc.)
  • All community members, including children, dispose of their faecal matter in an acceptable manner that does not perpetuate faeco-oral disease transmission
  • ‘Acceptable manner’ in this context means that faeces should:
-       be covered
-       not be accessible to flies
-       not be stored in a polythene bag
-       be put in a latrine
-       be buried deep enough to prevent animals from exposing it.
India
No open defecation at any time – all households, schools and pre-schools use a functional toilet
Indonesia
  • All households (and schools) defecate only in improved latrines
  • No human excrement is seen in their surroundings
  • The community imposes sanctions, regulations or other efforts to prevent OD
  • The community establishes a monitoring mechanism to achieve access of 100% of households to their own improved latrines
  • There are clear, written efforts or strategies to achieve total sanitation
Kenya
Households should have a toilet that is seen to be in use; toilets used have hole covers and there should be no active OD sites (i.e. no human excrement in the open)
Malawi
ODF: No open defecation; 100% toilet coverage (sharing acceptable)
ODF++: no OD; 100% toilet coverage (sharing acceptable); 100% drop hole covers; 100% handwashing facilities; all institutions ODF++
Nepal
No OD; 100% toilet coverage; one household one toilet; toilet in all institutions (schools, government offices, community centres); toilets in public places
Nigeria
No faeces openly exposed to the environment; use of any form of latrine that prevents exposure of faeces to the environment; handwashing practice and provision of institution latrines
Uganda
No OD; 100% latrine coverage; 100% handwashing facilities
Zambia
Complete stoppage of OD practices with One Family, One latrine

Source: Author’s compilation

 

Verifying and certifying ODF is a crucial part of the ODF monitoring process.

There are excellent examples of protocols and tools for verifying and certifying ODF:

Sustaining ODF is emerging as a critical challenge. The current focus on triggering communities into action needs to be complemented by consistent follow-up and mentoring to support communities after triggering. CATS programmes will need to ensure that planning and resource allocations take this into consideration.

It is important that programme plannersrecognize that the achievement of ODF status through CATS brings programmes to the end of one phase (ODF certification) and to the start of the next phase (post-ODF achievement of sustainable sanitation and stabilization of the new social norm).

Key recommendations to address sustainability include:

  • ensuring follow-up support and ongoing hygiene promotion beyond ODF certification, focusing on reinforcing the new ODF social norm and using various channels of communication and platforms, such as engagement with: i) faith-based organizations; ii) community and natural leaders; iii) school children and iv) mass media. This will require post-ODF programming with commensurate investments;
  • establishing stronger links with community health strategies and other relevant development programmes, such as Water Safety Planning;
  • establishing ongoing monitoring of ODF status, through decentralised national systems wherever possible; where this is not feasible, monitoring ODF-certified villages at least annually through sustainability checks to see whether they have relapsed;
  • enabling households to move up the sanitation ladder by increasing availability and affordability of durable and desirable sanitation products and services through sanitation marketing (SanMark).

The Community-Led Total Sanitation (CLTS) Follow-Up Guidelines (reference: Follow-Up Guidelines for CLTS prepared May 2010 by Engineers Without Borders, Canada. They are based on the insightful contributions of district CLTS leaders across Malawi) provide information for effective follow up visits after CLTS triggering to:

  • document specific aspects of progress and change;
  • support and motivate those involved in CLTS on the ground;
  • learn about the process of change since the triggering.

The table below provides guidance for monitoring change. Further information on supporting, motivating and learning can be found in the CLTS Follow-Up Guidelines.

 

Table: Guidance for monitoring change after CLTS triggering

Human faeces Facilities Behaviour Action plan

Visit the OD area and note if there is any evidence of faeces.

Use all senses: look, smell and listen for flies.

Is there less faecal matter than before?

Have people diverted to new OD areas?

Away from home, are there places where people OD? (e.g. field, road, church, school)

Note presence of new sanitation facilities, built since triggering.

How many new latrines have been built?

How many latrines are in the process of being constructed? (i.e. pits dug, etc.)

Are there any new handwashing facilities?

Do you notice any latrine improvements? (e.g. drop hole covers, etc.)

Do any latrines meet standards for basic sanitation? (e.g. safe, private, functional, safe distance from water points)

Do any latrines meet standards of improved sanitation?

When you record the number of new sanitation facilities, remember that it only counts if it is ‘in use’.

What evidence do you look for that show latrines are being used?

What shows that handwashing facilities are being used?

Are drop hole covers actually covering the entire hole? Is it possible for any flies to go in and out?

Compare what the community committed to at triggering (i.e. the Action Plan) to what has been done so far.

By what date did the community want different changes to occur?

Are the different changes in the community happening faster or slower than planned?

Are the local leaders keeping track of the community’s progress?

 

Examples of ODF Protocols

UNICEF’s ‘Monitoring Protocol for the Elimination of Open Defecation in Sub-Saharan Africa’ (2013) paper reviews the processes and protocols for defining, reporting, declaring, certifying and sustaining ODF. It also addresses questions about sustaining ODF and provides ideas for country ODF Protocols.

 

Suggestions for making the most out of an ODF Monitoring Protocol

  • Develop one consistent protocol for the WASH sector in-country by building consensus for a common approach to defining and monitoring ODF.
  • Develop a monitoring framework that includes both process and output outcomes to reflect such parameters as facilitator quality, data reliability, etc.
  • Investigate the use of mobile/smartphone/GPS technologies which may enable more ‘real-time’ monitoring of the situation on the ground and allow for increased versatility in data presentation and mapping.
  • Consider ways of recognizing communities that do not involve subsidized awards to communities so as not to undermine the CLTS approach.
  • Include a time lag between reporting of ODF by communities and certification to help ensure that the new behaviour is being sustained.
  • Aim for a second level of ODF (e.g. ‘ODF+’) to ensure continued follow-up after certification and to increase the likelihood of sustainability of the new behaviours.
  • Include and budget for follow-up visits with communities to achieve sustainable/improved latrines as part of the CATS process and not as an add-on.
  • Consider the certification and sustainability of ODF as the main outcome, not the initial ODF reporting.
  • Incorporate handwashing with soap (HWWS) and safe disposal of children’s faeces into the triggering process to strengthen health outcomes. This is key to maintaining an ODF environment.

 

Country examples

Taking global guidance and local contexts and standards into account, countries have developed their own protocols that provide useful examples for the development of an ODF Protocol in your country.

 

Examples of CLTS monitoring tools and findings

 

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2 Monitoring the disposal of children’s faeces

Level: Country, subnational and community

 

 

While the impact of poor sanitation is often measured by the effects on children, most sanitation interventions target adults. Global monitoring of sanitation coverage against the MDGs generally also overlooks sanitation among young children. Total sanitation means that all people’s faeces are disposed of safely, including those of young children. Although child faeces are most likely to have pathogens, in many cultures children’s faeces are considered less harmful than other faeces. See http://sanitationupdates.wordpress.com/2013/07/01/washplus-weekly-focus-on-sanitation-for-preschool-age-children for a recent summary of knowledge on sanitation for preschool-age children. Another useful article on the effectiveness of Total Sanitation Campaigns (TSCs) on the disposal of children’s faeces can be found at  http://practicalaction.metapress.com/content/07hn455776t14103/?genre=article&id=doi%3a10.3362%2f1756-3488.2008.026.

Analysis using the household surveys, MICS and DHS, shows that many households using improved sanitation still practice unsafe child faeces disposal, with rates worst among more marginalized households. For example, less than 20 per cent of children’s faeces are disposed of safely in the majority of countries in Africa.

 

Figure: Safe/improved disposal of children’s faeces in countries in Africa 

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Source: Null, Clair, and Heather Reese, ‘Improving Sanitation for All: Safe Child Feces Disposal’, UNICEF and WASH presentation, September 2013, available here

 

As with adult sanitation, safe disposal of children’s faeces should ensure both separation of the stool from human contact and an uncontaminated household environment. Instances where a child uses a toilet or latrine or their faeces are put or rinsed into a toilet or latrine are considered safe while other methods are considered unsafe.

 

Figure: Proportion of the under-five population in 79 developing countries, by child faeces disposal method 

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Sources: DHS/MICS

 

Monitoring indicators

Information on the disposal of children’s faeces is collected through MICS Indicator 4.4, which assesses the disposal of children’s faeces.

For any children under 3 years old, the survey question asks: The last time [name] passed stools, what was done to dispose of the stools?

When calculating the proportion of children’s faeces which were safely disposed of, the numerator is the number of children under the age of 3 years whose last stools were disposed of safely, and the denominator is the total number of children under the age of 3 years.

Standard responses are:

  • Child used toilet/latrine
  • Put/rinsed into toilet/latrine
  • Put/rinsed into drain or ditch
  • Thrown into garbage (solid waste)
  • Buried
  • Left in the open
  • Other
  • Don’t know.

These standard responses are important because:

  • harmonized questions and a standard set of responses allows for easier comparison between datasets;
  • the use of diapers or potties may be common in some countries, but are only an intermediary step in the disposal process;
  • the final disposal location best determines the safety of the faeces disposal practice.

It is important that the verification of the safe disposal of children’s faeces is incorporated into the ODF verification process.

 

Table: Examples of indicators used to monitor the safe disposal of children’s faeces

Element Type Indicators
Safe disposal of children’s faeces Knowledge Percentage of caretakers who are aware of the risk of the unsafe disposal of children’s faeces
Percentage of caretakers who know which disposal techniques are considered safe
Practice (ODF certification criteria) Percentage of children age 0–3 years whose (last) stools were disposed of safely (MICS)
Percentage of children who are not autonomous in using a latrine whose (last) stools were disposed of safely
Exposure (total sanitation) The percentage of ODF communities where the 100% safe disposal of children’s faeces has been incorporated in the certification criteria

 

Country data and reports

Useful country reports on the safe disposal of children’s faeces can be found in ‘Table EN.6: Disposal of Child's Faeces’ at www.childinfo.org/mics_available.html. Data is disaggregated by rural/urban, region, wealth quintile and caretaker’s education, providing a wealth of information for designing and monitoring promotion campaigns. The Demographic Heath Surveys (DHS) also enquire about the care practices of children under the age of 3. The latest DHS survey of your country is available at www.measuredhs.com/countries.

Click on the links for interesting, visual information from MICS data on the safe disposal of children’s faeces in Vietnam, the Democratic Republic of the Congo and Bolivia.

Additional country profiles, using the available MICS and DHS data, have been developed by UNICEF and WSP. These can be found at www.wsp.org/childfecesdisposal.

 

Strategies going forward

Interrupt faecal transmission at two points:

  1. Sanitary disposal of child’s faeces.
  2. Caregiver contact with child’s faeces (handwashing with soap).

Increasing improved disposal of faeces can be incorporated into many existing initiatives.

  • CATS: emphasize that a community is not open defecation free unless everyone, including young children, are defecating in a safe location or their faeces are disposed of safely.
  • Encourage the use of potties for young children, the placement of the potty in a latrine/toilet area, and the subsequent disposal of faeces into a toilet/latrine.
  • If washable diapers are used, encourage the safe disposal of the wash water (i.e. not in the household yard).
  • Promote handwashing with soap after handling a child’s faeces or cleaning an infant’s bottom.

 

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3 Monitoring handwashing with soap (HWWS)

Level: Country, subnational and community

 

 

There is strong evidence that handwashing with soap (HWWS) reduces the main causes of child mortality and a range of diarrhoeal and respiratory infections. Different types of handwashing promotion programmes and initiatives have different goals, including advocacy, behaviour change, education, health impact or combinations of these.

The UNICEF Handwashing Monitoring and Evaluation Toolkit (see http://globalhandwashing.org/resources/general/unicef-handwashing-monitoring-evaluation-toolkit) is a thorough guide to planning and implementing monitoring and evaluation (M&E) for handwashing promotion programmes.

 

Figure: Programme phases and monitoring and evaluation activities

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Source: Prepared by Vujcic, Jelene and Ram, Pavani K, Handwashing Promotion. Monitoring and Evaluation Module, UNICEF, October 2013, p. 16.

 

The user-friendly guide is designed to be adaptable to a variety of programmes, and introduces the reader to:

  • the seven major steps of monitoring and evaluating handwashing promotion;
  • choosing indicators appropriate to the programme’s objectives;
  • collecting the necessary data and sample questions for indicators relevant to handwashing advocacy, education and behaviour change;
  • designing evaluation plans, including the advantages and disadvantages of different methods for undertaking quantitative assessments (e.g. comparison against baseline; comparison groups; randomized control trials (RCTs); stepped wedge design and propensity score matching);
  • health impact measurement and caveats for the inclusion of health impact assessment as part of an M&E plan. There is little evidence about the effects of large-scale WASH programmes on population health and well-being. Measuring health impacts has a range of challenges, however, including the need for large sample sizes and repeated measures; the costs of data collection; confounding factors (e.g. malnutrition, socioeconomic status); complicated design and analysis; and the need for epidemiological and statistical expertise.