Presentation by Ashok Dyalchand, Institute of Health Management, Pachod, at the First Global Symposium on Health Systems Research, 17 November 2010.

1. Benefits of rural sanitation implemented
through a
community led social norms approach
Implications for health systems
First Global Symposium on Health Systems Research
(Montreux, Switzerland - Nov 16-19, 2010)
A. Dyalchand
Institute of Health Management, Pachod

2. Study Setting
Study Setting
• Purposive Sample of 9 villages from 3 States
Study Methodology
Compared :
• 3 Villages - TSC Approach
• 3 Villages - CLTS Approach
• 3 Villages - No Sanitation

3. Operational Definitions
Total Sanitation Campaign (TSC) –
• Creates individual demand
• Involves subsidies
• Success measured by No. of individuals with access to toilet
Community Led Total Sanitation (CLTS)
• Behaviour change through social norms approach
• No subsidies
• Success defined by No. of Open Defaecation Free villages
Nirmal Gram Puruskar (NGP)
• National award for villages with 100 % coverage with toilets

4. Research questions
• Which components of communication strategy
influence sanitation behaviours & how are
they mediated?
• What institutional arrangements are required
for sustaining social change?
• What evidence of social and health benefits?

5. Key Findings Contd…
• CLTS modifies existing Perceptions, Attitudes &
Behaviours at Community Level
• Uses emotional appeal (disgust) – to trigger
response
• Triggering alone not sufficient for establishing
individual or collective norms
• Sustained persuasive communication required for
sustaining collective action & behaviour change in
Late Adopters

6. Key Findings Contd…
• Core Group creates impression that everyone in the community
is ready to change (descriptive norms)
• Core Group encourages community to introduce Injunctions
and Sanctions (Injunctive norms)
• Injunctions imposed by Community effective in establishing
Collective Norm
• Injunctions imposed by Administration are often counter
productive
• NGP strong Incentive for communities creates (descriptive
norm) But focuses on Toilet Construction not Utilisation and all
actions stop after NGP award

7. Institutional Arrangements
Institutional Arrangements that Enable or Constrain Sanitation
• District Leadership – the most crucial element
• ‘Core group’ required for implementation
• Public Private Partnership – most effective for Sustainability
• Specific roles and responsibilities – crucial
• Systems development - predictor for scaling up
• Relation-based governance – Transparency, Accountability
• Negative role of monetary subsidies
• Choice of Technology – crucial

8. Access and Use of Toilets by
Sanitation Approach
245
152
164
5
61
146
3
41
139
0
50
100
150
200
250
No Sanit. TSC CLTS
Households
Households w ith Toilet
Toilet use

9. Outcome
Access and Utilisation
• Utilization of Toilets not more than 80 %
• 20 % lowest SES household excluded
Environment
• No change in Water Quality (E- Coli Contamination)
Health Benefits
• No change in Prevalence of Diarrhea and Helminths

10. Outcome
Environmental
• Waste water and solid waste disposal improved
• Villages apparently clean
Behavioural / Cultural
• Inter-generational change in norms
• Other hygiene behaviours influenced also
Social
• Large scale community participation
• Privacy and dignity of women
• Empowerment of Women

11. Implications for Health Systems
• CLTS communication approach applicable to a host
of environmental issues
• Women, youth & children effective change agents
• Equity – Not resolved how to reach the most
marginalized
• Need comprehensive approach integrating several
behaviours
• Inter-sectoral coordination is crucial
• Convergence through NRHM – HR availability

12. Implications for Health Systems Research
Multi-Disciplinary Research Skills Required
Quantitative methods
1. Prevalence studies
2. Laboratory research
Qualitative methods
1. PRA tools
2. Social Norms research
3. Institutional development
Environmental research
1. Technology, maintenance & sustainability
2. Impact of population density on
Policy analysis & Research
1. Subsidies
2. Criteria and Methodology for National Award