Interview: Addressing Madagascar’s sanitation crisis through community-led total sanitation

Over the course of 10 years, the WSSCC-funded sanitation and hygiene programme in Madagascar has helped 2.4 million people across 19,800 communities live in an open defecation free (ODF) environment.
Hoby Randrianimanana
Dr Joelina Ratefinjanahary, CLTS Coordinator at the Fonds d’Appui pour l’Assainissement (FAA)

Behind the progress to end open defecation lies a unique method, “community-led total sanitation (CLTS),” an approach widely used by sanitation professionals to encourage and mobilize villagers to take ownership and improve their sanitation and hygiene conditions.  

Dr Joelina Ratefinjanahary, a medical doctor by training, is the CLTS Coordinator for the Fonds d’Appui pour l’Assainissement (FAA) and has been advancing with local partners to implement this CLTS approach. He spoke with WSSCC to discuss key aspects of CLTS and how it has contributed to improving sanitation in Madagascar.

WSSCC: Why do you think community-led total sanitation has been the best approach for improving sanitation in Madagascar?

Dr Joelina Ratefinjanahary, CLTS Coordinator at the Fonds d’Appui pour l’Assainissement (FAA): In Madagascar, we have a fundamental sociocultural value called “hasina” (or “dignity” in English). To earn and keep hasina, people here are willing to make any sacrifice. It is this concept, or value, that makes the implementation of CLTS in Madagascar powerful and effective. 

It is unacceptable for most Malagasies to lose their “hasina” through the ingestion of “shit”, whether intentionally or not. So when we implement CLTS in communities, we unhesitatingly hit on the subject of human dignity by depicting how people can unknowingly ingest their own “shit” when defecating in the open. 

Once they learn that their dignity is at stake through open defecation, community members swiftly take steps to address it. Some make common decisions to end the practice, while some go further by taking immediate actions, including cleaning open defecation sites and establishing action plans and timelines for building latrines. 

Dr Joelina Ratefinjanahary, CLTS Coordinator at the Fonds d’Appui pour l’Assainissement (FAA) speaking to community members
Dr Joelina Ratefinjanahary, CLTS Coordinator at the Fonds d’Appui pour l’Assainissement (FAA) speaking to community members. ©WSSCC/Hoby Randrianimanana

WSSCC: WSSCC is transforming into the Sanitation and Hygiene Fund (SHF) to accelerate progress in providing sanitation and hygiene for all. How do you see CLTS contributing to its efforts to leave no one behind? 

Dr Ratefinjanahary: I think CLTS is a naturally powerful and effective approach to address the issue of leaving no one behind. Its definition as a participatory approach for an entire community to end open defecation calls for an inclusivity in the programming. It’s up to facilitators to craft and incorporate techniques to identify potentially disadvantaged persons in the community during all three phases of CLTS: pre-triggering, triggering and follow-up. Throughout these steps, facilitators should consistently urge community members to take into account vulnerable people and include them in all activities. 

WSSCC: To align itself with the SHF’s strategic objectives, FAA will expand its activities to address sanitation and hygiene in institutions (schools, health centers). What is the added value of CLTS to effective behavior change among leaders at schools and health care facilities?

Dr Ratefinjanahary: CLTS is primarily designed to effect behavior change among community members. However, since institution leaders are themselves humans, CLTS’s basic principle of provoking self-awareness – from learning that they have been unknowingly eating their own “shit” – can be adapted to ignite behavior change in institutions as well.

CLTS is even more effective when institution leaders reside in the community where they work. It is this adaptability and flexibility to include non-conventional actors in the process that make CLTS a valuable sanitation approach. 

WSSCC: CLTS has primarily been used so far in Madagascar for ODF campaigns. What success stories of the CLTS approach in Madagascar are you most excited about, and why?

Dr Ratefinjanahary: I am proud of the innovations we have produced as a result of our implementation of CLTS. These include, among others, the U approach, the Follow Up Mandona (FUM) and the handwashing station AdemaLav2. I am particularly thrilled by the fact that some of these local innovations, including the Follow Up Mandona (FUM), are now widely recognized and used in other countries to advance sanitation work. 

WSSCC: What advice would you give to anyone considering using CLTS approach?

Dr Ratefinjanahary: An important advice for practitioners would be to keep in mind that CLTS relies equally on both practical skills and theoretical knowledge in order to be successful. It is also important for practitioners to establish good coordination between themselves throughout the CLTS cycle.