Impact of COVID-19 on community-led total sanitation (CLTS) in Ghana: perspectives of implementing partners

More than half of the world's population (about 4.2 billion people) still use sanitation facilities that do not treat faecal matter, thereby threatening environmental sustainability and human health (UNICEF & WHO 2020). In addition, ‘an estimated 673 million people have no toilets at all and practise open defaecation, while nearly 698 million school-age children lacked basic sanitation services at their school’ (UNICEF & WHO 2020: 11). For most of the developing world, the proportion of people using safely managed sanitation is as low as just 10% (WHO 2020). As a result, diseases such as diarrhoea, cholera, typhoid, worm infections, and stunting are common among children and vulnerable groups, especially those living in rural areas and poor neighbourhoods being the most affected (UNICEF & WHO 2020; WHO/UNICEF 2020). For example, the practice of open defaecation and poor disposal of excreta are considered major sources of contamination of drinking water around the world, and about 1.8 billion people drink such contaminated water (WHO/UNICEF 2020).

Subsequently, improved and sufficient sanitation, together with good hygiene, and safe water remain the basis for good health and socio-economic development (Mara et al. 2010). Therefore, to improve sanitation and hygiene, developing countries have employed several approaches to sanitation, some of which are already making the needed impact. One such approach is Community-Led Total Sanitation (CLTS), which employs a participatory approach to increase access to basic sanitation in rural communities across the developing world (Musembi & Musyoki 2016). This approach has been successful in some countries, as evident from the study in Indonesia by Purnama & Susanna (2020), where CLTS was found to be an optimal solution to curbing sanitation challenges since it improved sanitation practices and infrastructure. Similarly, Mwatsahu et al. (2021) found that CLTS leads to improved access to sanitation and hygiene facilities. For instance, the implementation of CLTS in Ethiopia led to the establishment of ‘Chilo clubs’ (faeces eradication clubs) in schools, churches, mosques, and at the district level. The clubs reduced the cost in the facilitation and installation of latrines since communities use their own resources and materials available to them (Sah & Negussie 2009).

Ghana adopted CLTS in 2012 as part of the Rural Sanitation Model and Strategy (RSMS). Since then, eight (8) development partners and international non-governmental organisations (INGOs), including Global Communities, World Vision Ghana, Plan International, Community Water and Sanitation Agency, SNV, Catholic Relief Service, WaterAid, and UNICEF/GoG, have been involved in the implementation of the approach in over 140 districts, leading to a reduction in open defaecation (White et al. 2018).

However, the implementation of CLTS has had its own challenges, including inadequate financial resources for individuals to build toilets, dilapidated toilet structures, and the relapse of open defaecation free (ODF) communities (UNICEF & WHO 2020). These challenges have been worsened by the advent of the COVID-19 pandemic which presented additional complexity to an already challenging landscape. For instance, since the first two coronavirus cases were reported and confirmed in Ghana on 12 March 2020, the pandemic has had a severe impact on many sectors of the economy, including the sanitation sector. The impact of the pandemic on sanitation has been well articulated by UNICEF & WHO (2020:16) as follows:

As a result, the Government of Ghana took measures to contain and prevent the spread, as well as protect and uphold the rights and well-being of Ghanaians. Among the many preventive measures, the government mandated its citizens to observe social distancing, compulsory wearing of a nose mask, limited social gatherings, and reduced time spent in crowded places. These measures helped to contain the COVID-19 in the country, though it had implications on how community-based activities such as CLTS could be carried out. However, the nature and the extent of the impact of the pandemic on the implementation of CLTS remain empirically unclear. Therefore, this study explores the perceptions and experiences of implementing partners about the impact of COVID-19 on the implementation of CLTS in Ghana. This exploratory study is expected to provide some empirical basis for more rigorous studies on the impact of the pandemic on sanitation and how to devise innovative strategies to deal with the challenge.

CLTS was pioneered by Kamal Kar in 2000 in a rural community in Bangladesh. It is a behaviour change approach that uses participatory tools and a series of activities organised by trained local facilitators at the community level (Kar & Chambers 2008), with the aim to motivate and empower community members to take collective action towards ending open defaecation through the construction and use of household toilets and hygiene facilities (Kar & Pasteur 2005; Kar & Chambers 2008). CLTS works by focusing on facilitating a change in people's behaviour by creating awareness of the links between open defaecation and disease. Thus, communities are encouraged to undertake their sanitation situation analysis and take corrective actions for themselves. Since its inception, CLTS has expanded widely and it is practised in more than 66 countries worldwide (Sigler et al. 2014), with many developing countries officially adopting it as the main approach for scaling up access to sanitation in rural areas (Musembi & Musyoki 2016).

A typical CLTS implementation process, as encouraged by the RSMS of Ghana, involves three main stages and other complementary activities. The first of the stages is the pre-triggering stage, which mainly involves baseline data collection on the sanitation situation in the community. At the second stage, i.e. the triggering stage, facilitators encourage communities to carry out their appraisal and analysis of community sanitation situations using various participatory learning and action tools. This often leads communities to recognise the volume of human excreta that is generated in the environment through the practice of open defaecation and how they eventually end up likely ingesting one another's faeces. The resulting disgust and desire for self-respect can induce them to take immediate and comprehensive action by building and using latrines, thereby stopping open defaecation without relying on external support in the form of hardware subsidy (material support). Stage three, post-triggering stage, is the follow-up stage which involves working with communities to implement the actions taken during the triggering stage. This ultimately leads to ending the practice of open defaecation in the communities. The communities at this stage are verified and then certified as ODF. ODF status is attained when the community ends open defaecation with 80% of households constructing and using latrines, and accompanying handwashing facilities (MLGRD 2013).

The study adopted an exploratory research design and employed a purely qualitative approach because understanding people's perceptions about the impact of COVID-19 requires an approach that will allow them ample space and time to narrate their perceptions and experiences in their own words. The study targeted representatives of organisations that are implementing CLTS in Ghana, who participated in the 31st Annual Mole WASH Conference organised by the Coalition of NGOs in Water and Sanitation (CONIWAS) from 3 to 6 November 2020 at Hillview Guest Centre at Abokobi-Teiman (Accra) in the Greater Accra region of Ghana. The Annual Mole WASH Conference, which has been running almost consistently since 1989, is the gathering of policymakers, project implementers, entrepreneurs, and practitioners in the WASH sector of Ghana, where relevant issues on WASH are discussed and solutions proffered through a communique. Therefore, targeting representatives at this conference was deemed appropriate to capture all the relevant stakeholders in the implementation of CLTS in Ghana.

Using a purposive sampling technique, we selected 22 representatives of the eight (8) implementing partners who were willing to speak with us at the time of data collection. Their job titles included WASH Technical Officers, WASH Focal Persons, Behavioural Change Analysts, WASH Programmes Directors, WASH Project Coordinators, CLTS Focal Persons, Monitoring and Evaluation (M&E) Coordinators, CLTS Field Facilitators, and Hygiene Educators.

An in-depth interview guide was developed to solicit the perceptions and experiences of the respondents. The interview guide covered the following broad questions: What has been the negative impact of COVID-19 on your organisation's implementation of CLTS? What has been the positive impact of COVID-19 on CLTS implementation? How can the positive impact be sustained and improved beyond COVID-19?

With expressed permission, and at the convenience, of the respondents, the interview sessions were audio-recorded using a Philips voice recorder and later transcribed. As with many studies that are based on self-reporting, we appreciate the risk of ‘social desirability bias’ (Bergen & Labonté 2020), whereby respondents may present a more favourable or sympathetic account of their situations. In this case, our participants narrated how the pandemic has impacted the implementation of CLTS in their various operational communities. While we appreciate that some may exaggerate to justify their existing failure in the implementation process, we could judge that our respondents were open to sharing with us their experiences. Since the data collection technique employed was a face-to-face in-depth interview, it allowed the researchers to observe the respondents' behaviour and reactions towards answering questions.

The audio recordings were later transcribed manually by listening to the audiotapes over and over again. Then, the transcripts were analysed using NVIVO software and the results were presented based on the emerging themes. We ensured that participation was voluntary and that respondents were given the option to withdraw at any time. For anonymity, all responses were anonymised before analysis, and particular care was taken not to reveal identifiable details of the respondents or their organisations. To ensure confidentially, the recordings were later encrypted to prevent third-party access to the data.

In all, the 22 respondents were made of 21 males and a female; 15 had a bachelor's degree, six (6) had a master's degree, and one (1) person had a diploma.

The results of the study were presented based on the following sections: negative impact of the pandemic on CLTS implementation, positive impact of the pandemic on CLTS implementation, and how to sustain and improve the positive impact of the pandemic for CLTS implementation.

The study sought to identify the negative impacts of COVID-19 preventive measures on the implementation of CLTS. The findings revealed that the COVID-19 preventive measures had a negative impact on CLTS implementation. However, it was observed that the experiences of the negative impact varied from field officers, community leaders to donors/sponsors. Regarding field officers, the COVID-19 preventive measures such as lockdown and work-from-home strategy prevented such field officers from going to the field. For instance, the District Assemblies halted all activities, which prevented field officers from undertaking community mobilisation and sensitisation at the pre-triggering stage of the CLTS. Without the visit of field officers from the implementation partners, most communities relapsed and resorted to open defaecation. Although some participants indicated that they had completed their pre-triggering stage and were not affected by the COVID-19 preventive measures, almost all the participants (20 out of 22) believed that the COVID-19 had had a negative impact on CLTS implementation. For instance, a WASH officer stated that:

This claim was confirmed by a WASH Project Coordinator who indicated that: ‘Because the pre-triggering stage involves engagement with community leaders and collection of household data, field facilitators were unable to conduct pre-triggering because of the ban on movements. This slowed down the process’.

During the triggering stage, most of the participants (16 out of 22) indicated that they could not undertake their CLTS activities due to the ban on mass gatherings. Additionally, some participants (8 out of 22) stated that there was inadequate funding support from donor agencies or partners to procure the needed logistics for triggering the communities. Although a majority of the participants could not undertake the triggering stage, the few participants (6 out of 22) who could conduct the triggering stage had to use the house-to-house engagement, which was not so effective because it required more time and personnel. There was a limitation to the house-to-house engagements due to the fear of contracting the virus, resulting in low patronage because the community members were not willing to receive the field officers in their homes. According to one of the participants: ‘Community meetings could not be organised, so triggering, was not effective. Field officers rather adopted what they termed as ‘house-to-house’ triggering which did not yield much positive results’.

Similarly, the post-triggering stage was said to have halted due to the implications of the COVID-19 containment measures. However, there were few engagements between field officers, community leaders, and community technical volunteers. Even with these few engagements, a Programmes Director indicated that: ‘The inability of field officers, community leaders, community technical volunteers, etc., to access PPEs limited the time spent in the communities’. Other challenges faced in the post-triggering stage were (i) reduced funding because donors had to re-channel resources to COVID-related activities, (ii) reluctant participation by community members and field officers, and (iii) suspension of fieldwork activities. All of these challenges hampered the effective monitoring of CLTS activities. However, some participants used the post-triggering stage to support the sensitisation of the members of the communities on COVID-19 containment protocols. The following excerpts from a CLTS Focal Person are illustrative:

The positive impacts of the pandemic which were evident in the pre-triggering, triggering, and post-triggering stages of CLTS, included mass education through platforms such as community information centres and radio broadcasts. First of all, there was an observable increase in the construction of WASH infrastructure, especially hygiene facilities, at both the household and community levels. For instance, a WASH Technical Officer opined that ‘The period saw an increase in construction of tippy-taps, not only in new communities but also in old ODF communities where tippy-taps had collapsed’, while an Environmental Health and Sanitation (EHS) officer indicated that ‘The pandemic triggered demand for construction and usage of handwashing facilities’.

Second, the pandemic created awareness of the need for proper sanitation and hygiene practices and improved provision of handwashing facilities. Thus, it reinforced the message of the need for proper sanitation and hygiene practices. As mentioned by an M&E Focal Person, ‘To some extent, it has reinforced our message on proper hygiene practices’. A WASH Technical Officer further opined that ‘The COVID-19 sensitisation programmes helped to get some communities to appreciate and adopt some hygiene behaviours such as construction and use of handwashing facilities’. It was also observed that the knowledge of community members in sanitation and public health issues improved. According to a Programmes Director, ‘It has helped increase knowledge on the direct relationship between hygiene and public health’.

To sustain the positive impact of the pandemic on CLTS in Ghana, participants were asked to make suggestions. Broadly, it was suggested that government and donor/development partners should (i) commit more funding support to implementing partners, (ii) develop behaviour change communication messages on hygiene, (iii) promote continuous use of community information centres and radio broadcasts, (iv) institute an award scheme for ODF communities adhering to proper sanitation and hygiene practices, and (v) promote multilevel stakeholder engagements. A typical example came from a Hygiene Educator that ‘it could be sustained by regular monitoring and sensitisation, organising competition among communities, rewarding performing communities, etc.’. Participants suggested that the Government of Ghana should review the involvement and commitment of Metropolitan, Municipal, and District Assemblies (MMDAs) in CLTS, provide financial support to implementing organisations, build capacities of officers of implementing organisations, and implement the rural sanitation strategy which prohibits the construction of communal latrines by MMDAs, political parties, NGOs, and philanthropists. With regards to data on communities, a Behaviour Change Analyst suggested that there should be ‘support for MMDAs to update district sanitation databases. This would help sustain CLTS in our communities’.

The study explored the impacts (both negative and positive) of the COVID-19 pandemic on the implementation of CLTS in Ghana. The study revealed that the pandemic has impacted CLTS in diverse ways, which were either negative or positive, and the impacts were experienced at all the three stages of CLTS implementation (pre-triggering, triggering, and post-triggering). The predominant negative impacts (i.e. halting CLTS activities) resulted from the COVID-19 prevention protocols, such as the ban on mass gatherings, wearing of the PPEs, observing social distancing, and lockdowns. According to UNICEF & WHO (2020) and Blake et al. (2020), the COVID-19 prevention protocols were meant to control the spread of the disease but posed a challenge to citizens in low-income countries such as Ghana. It comes as no surprise that CLTS activities were negatively impacted because each of the CLTS stages relies heavily on community gatherings through group meetings and discussion sessions. This is because CLTS as an approach is built on community cohesion and involvement, with the community leading their own change (Kar & Chambers 2008). Although some organisations continued working during the period of the pandemic, they indicated that the pandemic led to reduced funds for the implementation of CLTS activities. This supports the findings of Marcos-Garcia et al. (2021) and Desye (2021) who reported that expected remittance and funding for WASH activities were reduced due to the COVID-19 pandemic. The findings further resonate with that of Global Wash Cluster (GWC) et al. (2020) who reported that COVID-19 is likely to divert and deprioritise domestic funding away from the WASH sector. In addition, since 71% of employed Ghanaians are in the informal sector (Ghana Statistical Service 2019) without guaranteed monthly income, halting their economic activities for even a day may have negative implications on their finances (Gosselin 2004), hence their inability to construct household toilets. In other words, COVID-19 may have led to a loss of household income and for that matter their ability to pay for WASH commodities and services (GWC et al. 2020). More importantly, halting the monitoring and sensitisation of the implementation of CLTS for a prolonged period may lead to relapse of some households or communities that were already making progress in achieving ODF status. Currently, there are about 5,000 communities that have been declared ODF in Ghana; however, the Nandom District in the Upper West Region of Ghana is the only district to have declared all communities as ODF. Though there is no national target on ODF, Ghana has adopted the Sustainable Development Goal 6.2 towards ending open defaecation by 2030. Therefore, any activity that may lead to a relapse of ODF communities threatens the achievement of SDG 6.2.

Despite challenges presented by the pandemic, our study found some positive impacts of the pandemic on the implementation of CLTS. These included improved handwashing practices, which resulted from the increased construction of handwashing facilities by community members and other stakeholders as a result of the COVID-19 pandemic and its preventive protocols. These findings resonate with recent studies which found that the pandemic and its preventive measures have had positive impacts on sanitation and hygiene practices across the globe, particularly in low- and middle-income countries (Blake et al. 2020; Roy et al. 2020; Islam et al. 2021; Marcos-Garcia et al. 2021). For instance, Desye (2021) opined that COVID-19 has had an impact on the sustainability and continuity of WASH services, while Islam et al. (2021) found that due to COVID-19 and its safety protocols, there has been an improvement in WASH practices. The increase in the construction of handwashing facilities resulted from the evidence that frequent and proper handwashing can stop the transmission of many infectious diseases, including COVID-19 (Mariwah et al. 2012; Oppong et al. 2019; Blake et al. 2020; WHO & UNICEF 2020).

Other positive impacts of COVID-19 brought to the implementation of CLTS were mass education, and sensitisation of community members. Due to the preventive protocols, some CLTS implementing partners used community information centres and radio stations to educate people on sanitation and hygiene practices instead of visiting members in their homes. This also promoted sensitisation and education of a wider audience.

In order to sustain the perceived positive impact of COVID-19 on the implementation of CLTS in Ghana, the study participants suggested more funding support to the activities of implementing agencies, developing text messages on hygiene, and continuous use of community information centres and radio broadcasts. These suggestions confirm the findings that, as a behaviour change communication tool, CLTS thrives on effective communication strategies (Kar & Chambers 2008). In addition, the awareness of good hygiene practices at the individual level can be sustained through the promotion of effective behavioural change messaging through multiple media sources (Hannah et al. 2020).

The study has revealed that the COVID-19 pandemic has negatively impacted on all the stages (pre-triggering, triggering, and post-triggering) of the implementation of CLTS, due mainly to the reduced group interaction and community gatherings. However, the pandemic has also had some positive impacts through increased construction and use of WASH facilities, leading to improved hygiene practices. In order to reduce the negative impacts of the pandemic, implementing partners devised innovative strategies such as community information centres and radio stations to engage households and residents on the need for improved sanitation and hygiene practices, thereby reinforcing the implementation of CLTS. To sustain the gains from the pandemic, implementing partners should leverage the existing community-based mass media outlets such as information centres and radio stations to intensively communicate behaviour change messages of CLTS in Ghana.

The authors declare no conflict of interest.

All relevant data are included in the paper or its Supplementary Information.