The magnitude of the sanitation crisis means that sanitation and hygiene solutions must be delivered sustainably, and on a large scale. This requires the close involvement of government at all levels. A new case study outlines eight lessons from the Global Sanitation Fund (GSF)-supported Uganda programme in coordinating, planning, and implementing Community-Led Total Sanitation (CLTS) at scale through a decentralized government system.
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The GSF supports programmes that focus on national ownership, with the level and type of government involvement adapted to each country context. The GSF-supported Uganda Sanitation Fund (USF) is implemented by 30 District Local Governments, under the overall management of the Ministry of Health. The USF is the largest programme of its kind in Uganda. By September 2016, the programme reported helping over three million people live in open defecation free (ODF) environments.
The development, challenges and overall success of the USF has generated eight key lessons from delivering a sanitation and hygiene programme through a decentralized government system.
Lesson 1: Ensure national ownership is at the centre
Sustainably implementing sanitation and hygiene behaviour change at scale requires strong government ownership. It is critical to anchor programme leadership within government-led national coordinating bodies, and that existing systems are complemented and strengthened.
The USF was designed to closely align with Uganda’s existing policies, sector strategies, and decentralized systems of local governance. A key aim is to embed institutional sustainability and build an enabling environment to expand the USF beyond the GSF-supported programme areas to all 112 districts in the country.
Lesson 2: Maximize existing local government structures
Working with local governments is not only important for sustainability. Rather than creating parallel systems, maximizing the use of existing decentralized governance structures is also an effective means to rapidly achieve scale and reach.
The USF is situated directly within Uganda’s decentralized system of Local Councils, where political leadership and public service delivery at the local level are focused within district, county, and village government structures.
Harnessing these ready-made systems has allowed the USF to reach a large geographical scale – around one quarter of the country – at a significantly reduced cost.
Lesson 3: Balance local management with central support
Working through government means operating through hierarchies. While this allows for greater support and supervision, flexibility, dynamism, and context-specific planning at the local level are important elements for achieving results at scale. Working through government systems means striking a balance between local-level management and support and supervision from the centre.
At the district level, a dedicated USF focal person coordinates a network of health extension workers based at health facilities at the county and sub-county levels. In turn, these extension workers, comprising of Health Inspectors and Health Assistants, support Village Health Teams (VHTs). Alongside emerging Natural Leaders (village-based activists and enthusiasts), VHTs spearhead community initiatives to transform sanitation and hygiene behaviour.
Lesson 4: Go beyond training workshops
Being trained in CLTS does not necessarily equate to having the skills to trigger behaviour change. Rather than limiting CLTS training to formal workshops, it is far more effective to ensure that capacity building activities are demand-driven, context-specific, and as hands-on as possible.
One successful solution has been identifying proven and successful CLTS facilitators among health extension staff, and elevating them to become ‘coaches’ for their peers. Supported by USF Field Officers, coaches work in neighbouring districts to improve CLTS facilitation skills.
Lesson 5: Change attitudes to ensure communities take the lead
An understanding that open defecation is the community’s problem – rather than the external facilitator’s – is essential for fostering the emergence of dynamic local initiatives. This is especially important while working with government staff with a background in enforcement and sensitization.
A key lesson has been to focus on shifting the ingrained attitude of local health extension workers that open defecation is their problem to solve, towards an understanding that it is a community problem that requires community solutions. When extension workers appreciate the importance of ‘triggering the mind’, rather than sensitizing, prescribing, or enforcing, the speed, quality, and sustainability of collective behaviour change is enhanced. The role of extension workers is to facilitate the CLTS journey, by valuing local actors and initiatives.
Lesson 6: Encourage a strong focus on results
A persistent focus on achieving outcomes – rather than only activities – is critical for encouraging dynamic CLTS facilitation and achieving ODF communities at scale.
With work plans and budgets often linked to the completion of activities (e.g. triggering), rather than results (e.g. ODF communities), ensuring a strong focus on outcomes is especially important if local governments are directly implementing CLTS programmes. If guided by a bureaucratic ‘checklist’ mentality, then CLTS facilitation risks becoming undynamic, procedural, and mechanical, resulting in many triggered communities with few attaining ODF status. In contrast, if local government staff are focused on results, rather than just crossing off activities in a rigid work plan, then the quality of CLTS facilitation will improve dramatically.
Lesson 7: Trigger local political support
Passionate political leaders acting as champions for the programme are strategic resources for enhancing coordination, motivating staff, enlisting the support of other actors, and even mobilizing additional resources to reach even greater scale.
One successful way to trigger local political support is to invite local politicians to join health extension workers during CLTS sessions. Not only will they appreciate how open defecation adversely impacts on everyone’s health and dignity, but while taking part in these energetic CLTS events, local leaders can appreciate how communities are already taking the lead.
Institutional Triggering is another powerful approach. Introduced to Uganda by the GSF-supported programme in Madagascar, it is now one of the USF’s standard tools for engaging local leaders. In Pallisa District, an Institutional Triggering session led to the allocation of other local government staff to support health extension workers in communities. In Amuria District, one triggered participant committed to dedicate three hours each week on his local radio station to discuss sanitation and hygiene-related issues.
Lesson 8: Strategically partner with civil society
Local governments cannot do everything on their own. Working at scale means closely collaborating with local civil society organizations that can bring their different strengths to the table.
For local government extension workers, working with local NGOs helps them cover far more ground than they would on their own, with joint-field exercises increasing their exposure to new facilitation strategies.
In Soroti District, the USF is partnering with the international NGO Water for People, in a pilot project to improve the availability and affordability of locally developed sanitation and hygiene technologies. The partnership harnesses the strengths of each organization and builds on lessons from previous sanitation marketing initiatives in the area. While extension workers focus on changing sanitation and hygiene behaviour, or ‘demand creation’ through CLTS, Water for People focuses on supporting emerging sanitation entrepreneurs and developing local supply chains. Through these activities, the partnership aims to ensure that even the most remote areas can access improved sanitation and hygiene technologies.
Eight lessons for effective results
By focusing on the eight lessons, local government health departments working through the USF have greatly enhanced their role as public service providers. As a result, the USF has achieved significant success.
The most comprehensive dataset for comparing sanitation and hygiene outcomes between districts are tracked by the Ministry of Water and Environment’s Annual Sector Performance Report. Based on this data, the graph below clearly shows that the USF has been comparably and consistently effective in achieving ODF communities.
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