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Many sanitation and hygiene programmes are confronted with slippage, which refers to a return to unhygienic behaviour, or the inability of community members to continue to meet all open defecation free (ODF) criteria. In the second of a seven-part series for water, sanitation and hygiene (WASH) practitioners, WSSCC explores the nuances of slippage. The article is based on a Global Sanitation Fund reflection paper on slippage and sustainability.
Before nuancing slippage we must first define what it means to be open defecation free (ODF). Is ODF solely about eradicating faeces in the open? Or is it also a matter of completely cutting the oral-faecal chain through fly-proof latrines and handwashing facilities? Does slippage suggest that people have returned to the practice of open defecation? Or is it more commonly about the failure to meet ODF criteria (e.g. the absence of handwashing facilities and/or lack of their use, the absence of a squat hole cover, etc.)?
Slippage is intricate because it is hinged on the philosophy and complexity of behaviour change. The global slippage debate sometimes seems to start from the idea that human behaviour is static and predictable. These conversations somehow suggest that humans act with self-awareness and self-interest and that behaviour operates in isolation from the social context, in which they are found. In this way the discussion on slippage is reduced to the quest for numbers and percentages. This is possibly a remnant from the era when what was monitored was the number of latrines constructed and not if and how they were actually used.
The definition of slippage is linked to the definition of ODF. Moreover, countries do not use equally rigorous ODF criteria. In GSF-supported countries such as Benin, Kenya, Madagascar, Nigeria, Togo and Uganda, ODF status is a matter of completely cutting the oral-faecal chain.
This is achieved through three key criteria: there must be no presence of faeces in the open, all latrines must be fly-proof with evidence of continued use, and handwashing facilities must be available with water and soap or ash. As these are the national ODF definitions, they are therefore also used by the GSF-supported programmes, as stipulated in their country programme proposals.
However, in other countries such as Malawi and Tanzania, the national ODF definition and as such the definition used by the GSF refers solely to the elimination of faeces in the open environment. The existence of fly-proof latrines and handwashing facilities may be labeled as ODF+.
The more demanding the ODF criteria are, the more slippage communities can potentially experience. However, it can also be argued that when more demanding ODF criteria are applied, the quality – and even the impact – of the programme intervention is stronger and perhaps more sustainable.
In most programmes, one can discern two levels of slippage: output-level slippage and impact-level slippage. Output-level slippage relates to the strict application of all ODF criteria, such as the elimination of open defecation and the availability of fly-proof latrines and handwashing facilities with evidence of use. Impact-level slippage relates to negative impacts on overall health and wellbeing due to slippage, such as a return to a high prevalence of diseases and epidemics related to poor sanitation and hygiene.
In the GSF-supported programme in Madagascar, the most commonly discerned type of slippage is output-level slippage, where a community fails to be labeled ODF due to at least one latrine not meeting ODF criteria.
If high-quality Community-Led Total Sanitation facilitation is present – one of the keys to truly sustainable behaviour change – very few communities actually return to open defecation in bushes, streams and other areas. Instead, many communities simply fail to meet all of the criteria at once.
Most of the research related to ODF health impact – or impact-level slippage – is linked to interventions that may have led to some evidenced increase in sanitation coverage, but not to full coverage or adherence to specific ODF criteria.
The sector needs more evidence that a complete cut of the oral-faecal chain through the three key criteria mentioned previously does indeed lead to significant health impacts. In addition, after what length of time following ODF achievement can these impacts be felt?
Once the link between output and impact is firmly established, only then can we start to determine what level of output-level slippage leads to impact-level slippage. If output-level slippage is high, it evidently affects impact-level slippage, as the faecal-oral route has not been fully ruptured. But is there a point when output-level slippage has reduced to minimal levels – for example, only a few people in the community do not use fly-proof latrines any longer – and therefore has little or no influence on impact-level slippage? These and other questions relating to the nuances of slippage urgently require more research.