In Mali, Communities Take Health and Well-Being into their Own Hands
In the center of Simaye village in Mali’s Mopti Region, men, women, and children gather under a large tree to listen. Two USAID-trained facilitators discuss the health challenges facing the village. Only three latrines serve many families, so more than half of the people are practicing open defecation; the water point no longer functions, so most families are pulling dirty water from the river; many of the infants and young children are not benefitting from exclusive breastfeeding or a diversified diet, so they are malnourished.
Holding a glass of clear water and pointing to feces on the ground, the facilitators paint a clear picture of the health risks associated with leaving feces in the open — contaminated drinking sources, diarrheal disease, and poor outcomes for children and their families. Their objective: to trigger a sense of disgust, a determination in the community to control their own health and well-being, and to set in motion plans and solutions to create open defecation free (ODF) communities through a process known as community-led total sanitation (CLTS).
Since 2012, this scene has repeated itself hundreds of times in 15 districts and four regions of Mali — Mopti, Segou, Koulikoro, and Sikasso — most affected by malnutrition, poor access to health care, and substandard water and sanitation services. To address the persistent issues of food insecurity, poverty, and high undernutrition in a country that has among the highest fertility and child mortality rates in the world, USAID is working to improve the nutritional status of pregnant women and children within the critical first 1,000 days of a child’s life.
The strategy is to address the immediate causes of malnutrition — inadequate diet, and infectious diseases such as diarrhea — as well as the underlying causes, among them poor hygiene and inadequate sanitation. And this is where CLTS comes in.
Making it Local — Innovative Latrines
Mali presents some of the world’s most challenging physical environments for latrine construction — so challenging that CLTS activities in the past have chosen to bypass villages with rocky, sandy, or flood-prone terrain. Ignoring the problem does not make it go away, however. In 2010, the Malian Ministry of Health formalized a National Strategy for Behavior Change in Hygiene to reduce diarrheal disease. USAID came on board to help increase the supply of appropriate, affordable, and sustainable water, sanitation, and hygiene (WASH) solutions, increase demand for low-cost options, and improve overall WASH practices.
No one latrine design was going to work in Bankass, a region with sandy soil whose pits collapse in the rainy season; Bandiagara, whose rocky soil is difficult to manually dig; or Mopti, whose pit holes quickly fill with water because of high groundwater levels. So USAID held workshops with local masons in 2014 to devise solutions using local materials that were less expensive than those previously promoted. Handbooks and posters have been distributed far and wide featuring how-to instructions about the different construction techniques designed to compensate for unique geographies. USAID has trained more than 400 masons and women leaders on the new latrine building techniques and improved WASH and nutrition practices.
“I was the most skeptical person about changing behaviors in my municipality’s villages,” said Bankass’s Mayor Allaye Guindo. “Several projects previously came into Bankass district to promote the SanPlat slabs, but had no impact on community behaviors. But, the CLTS approach and improvement of traditional latrines in difficult areas successfully changed the behaviors of people in my municipality in record time.”
Now before each CLTS triggering, two masons in each community are trained in the appropriate context-specific techniques, so that households have support when they become motivated to build their own latrines. This process of training masons in advance of CLTS triggering is now a national policy.
Drissa Djongo, a mason from Allaye-Daga village in Mopti explains his role, “Here we are willing to help households free of charge, even people in neighboring villages, by providing our expertise in the construction of hygienic latrines. Our latrines are built with 100 percent local materials and are affordable.”
But CLTS is not just about building latrines, it’s about putting an end to the practice of open defecation and its associated health risks. The open defecation free (ODF) certification process is the first step in recognizing these benefits and brings some excitement, and pomp and circumstance, into the village. USAID trains local and district level officials to conduct the certification. The presence of handwashing stations at latrines are a critical component in the evaluation process. Monitoring systems are also put in place at the household, village, commune, district, and regional level to provide technical support, maintain momentum, and develop post-ODF plans.
Notable authorities attend the ceremony to celebrate the first village in each district achieving ODF status, as are representatives from nearby villages to catalyze its spread. Hygiene kits with handwashing supplies and cleaning tools are given as prizes, and the achievement is broadcast on the radio. All this attention ignites a healthy village-to-village competition.
In the more urban areas where USAID works, sanitation marketing and microfinance options for improved sanitation are having an impact on the uptake of SanPlat slabs and other pre-manufactured options. USAID facilitates partnerships between Village Savings & Loan Association (VSLA) groups and local masons. The associations operate small shops known as sanicenters that sell locally produced soap, SanPlat slabs manufactured by local masons, and Aquatabs that have been promoted for point-of-use water treatment by USAID-trained outreach workers.
Taking the Village Approach to Behavior Change
Access to clean water is an equally important part of the health equation, and a particular challenge for many villages. USAID support for repair and rehabilitation of water points is tied into achievement of ODF status. USAID trains artisans to make the repairs and to operate and maintain the water points over time. Communities contribute funding to the project, and support is provided to WASH committees to develop a long-term source of operations and maintenance funding to keep the taps flowing.
USAID rounds out the WASH focus by training a cadre of frontline workers — community agents, community health workers, relais (community health volunteers), agriculture agents, elected officials, and women’s associations — to demonstrate, monitor, promote, and reinforce critical hygiene and nutrition behavior change that has led to improved health outcomes and significant drops in open defecation. Their work includes household visits, malnutrition screenings, cooking demonstrations, and post-ODF monitoring.
Key messages are delivered and reinforced in many ways. Djelika Fofana, who lives in the flooded plains of Youwarou Village, can be heard on Dande-deboye radio station explaining how the CLTS process changed her family’s habits and health. “While my family members were washing hands with soap and using a latrine,” habits that she admits she had to encourage on a daily basis, at least at the beginning, “the household was much less sick, especially the kids.”
Advocacy days provide further opportunities to amplify WASH and nutrition messages. The Boundio Village Singer Troop in Sikasso performed this original song at a Global Handwashing Day event:
Adopt hygiene on a day-to-day basis and make sanitation a reality in our lives.
The soap is in the latrine!
The sumps are closed!
Our diseases have diminished!
Our drinking water is purified!
To ensure these gains are maintained over time, USAID is helping the National Directorate for the Control of Pollution and Nuisances develop a nationwide post-ODF database and roll out a national strategy to maintain ODF status. Toward this end, USAID is funding research to explore the differences in uptake of CLTS and why some villages experience what is known as “slippage” over time.
This five-year, $25 million intervention has already yielded significant results for the health of children in the target communities. More than 400 villages have been certified ODF; 100 of them have developed post-ODF plans; over 30,000 women of reproductive age have improved their nutritional status (and 12,000 of their children under 2 have as well).
Says Fatimata Ouattara, USAID/Mali nutrition and WASH advisor, “I believe that this integration activity is a key solution to water-related malnutrition challenges and development overall. Community-led total sanitation as a participatory approach is essential to get support from communities and their leaders. With this approach the communities feel like they are included and their contribution is a key element in improving health outcomes for young and old alike.”
By Wendy Putnam