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1. JIMMA UNIVERSITY
FACULTY OF PUBLIC HEALTH
DEPARTMENT OF ENVIRONMENTAL HEALTH SCIENCES AND
TECHNOLOGY
Systematic Review on:
ODF Reversion: Safe pathways to Recover ODF
Thomas Ayalew1
(BSc, MPH)
1
Department of Water, Sanitation and Hygiene, Lay Volunteer International association, Afar,Ethiopia
ayalewthomas@gmail.com
Dr. Abebe Beyene2
, Dr. Gudina Terefe2,
2
Department of Environmental Health sciences, Jimma University, Jimma, Ethiopia
(abebebh2003@yahoo.com :Abebe Beyene) (guditerefe@yahoo.com Gudina Terefe)
January, 2019

2. i
TABLE OF CONTENTS PAGE NUMBER
TABLE OF CONTENTS.................................................................................................................... I
ACRONYMS.................................................................................................................................... Ii
1. BACKGROUND AND INTRODUCTION...................................................................................1
2. OBJECTIVE OF REVIEW..........................................................................................................4
3. METHODS.................................................................................................................................4
3.1 STUDY ELIGIBILITY........................................................................................................4
3.2 SEARCH AND STUDY SELECTION..................................................................................4
4 RESULT AND DISCUSSION.....................................................................................................6
4.1 CLTSH AND WASH RELATED DISEASE.........................................................................6
4.2 SUBSIDIES VERSUS CLTSH.............................................................................................6
4.3 LONG LASTING CLTSH FOLLOW UP..............................................................................8
4.4 CLTSH VERSUS SOLIDARITY .........................................................................................8
4.5 VALIDITY of ODF CERTIFICATION ................................................................................9
4.6 SOCIAL INTERACTION AND NATURAL LEADERS .......................................................9
4.7 GENDER MAINSTREAMING..........................................................................................10
4.8 QUALITY AND SUSTAINABILITY OF SANITATION FACILITY ..................................11
4.9 COONSIDERATION IN FACILITATION .........................................................................13
4.10 INFRINGEMENTS TO BASIC HUMAN RIGHTS.............................................................13
4.11 LEADERSHIP AND INVOLVEMENT IN ODF.................................................................14
5 CONCLUSION.........................................................................................................................15
6 LIMITATION:..........................................................................................................................16
7 RECOMMENDATION.............................................................................................................17
6. REFERENCES.........................................................................................................................18

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ACRONYMS
CLTSH Community led total Sanitation and Hygiene
FGD Focus Group Discussion
FMOH Federal Ministry of Health
NGOs Non-Government Organizations
NGP Nirmal Gram Puraskar
OD Open Defecation
ODF Open-Defection-Free
SDG Sustainable Development Goals
VERC’s Village Education Resource Center)
WASH Water, Sanitation and Hygiene
WHO World Health Organization

4. 1
1. BACKGROUND AND INTRODUCTION
Neglected sanitation rests a major risk to development of the 21st century, affecting
countries' progress in health, education, gender equity, and social and economic
development worldwide. According to WHO, Globally 2.5 billion people do not use
improved sanitation; 1.2 billion, practice open defecation and 83 percent of whom live in
13 countries most of them are sub-Saharan. Each year, 200 million tons of human waste
goes uncollected and untreated around the world and estimated 1.5 million deaths of
children under the age of five, 5 billion productive days lost, 443 million school days lost
are attributed to diarrheal disease globally. People in rural areas, children, Women,
adolescent girls, children, and infants suffer most from inadequate hygiene and sanitation
related a consequences. (1, 2)
Fig 1: Open Defecation for Sub Saharan Africa in 2005.
To meet the Sustainable Development Goals (SDG) (Goal 6 target 2) by 2030, United
Nation has planned to achieve access to adequate and equitable sanitation and hygiene for

5. 2
all and to end open defecation by paying special attention to the needs of women and
girls and those in vulnerable situations (3)
Until CLTSH (Community led total Sanitation and Hygiene) process turned in, the gains
from customary approaches have remained constricted in terms of their success in pull
together entire communities to effect sustained behavioral change and devastating
consequences of poor sanitation were continued. Moreover, the pace of change has been
too slow to achieve universal access within the stated time frame. (4)
The CLTS approach originates from Kamal Kar‟s evaluation of Water Aid Bangladesh
and their local partner organization – VERC‟s (Village Education Resource Center) is a
local NGO (Non-Governmental Organization) traditional water and sanitation program
and his subsequent work in Bangladesh in late 1999 and into 2000. (5)
The term CLTSH defined by different scholars is more likely similar:
According to Franti sek Ficek and Josef Novotn; CLTS is a behavior change approach
that aims to ignite community action and make OD socially unacceptable without
providing any external financial or material support to individual households. (6)
Kar and Chambers, described CLTS is as an integrated approach to sanitation to achieve
and sustain Open-Defection-Free (ODF) status through the facilitation of the
community‟s analysis of their sanitation profile and their practice of defecation and its
consequences, which are expected to lead to collective action to become ODF (5).
Community-Led Total Sanitation (CLTS) is a revolutionary approach in which
communities are facilitated to conduct their own appraisal and analysis of open
defecation (OD) and take their own action to become ODF (open defecation-free).(7)
According to Jamie et al. CLTS represents a major shift for sanitation projects and
programs in recognizing the value of stopping open-defecation across the whole
community, even when the individual toilets built are not necessarily wholly hygienic. (8)

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Community-led total sanitation and Hygiene (CLTSH) is now practical in an estimated
66 countries worldwide and many countries have adopted this approach as their main
strategy for scaling up rural sanitation coverage.(9)
Fig 2: Sanitation management building on the concept of „Community Led Total Sanitation
(cited from http://www.communityledtotalsanitation.org)
A recent reports and studies showed widespread reversion to open defecation resulted in
many countries, CLTS Sustainability challenges are happening and post-ODF dynamics
in CLTS moving up to the sanitation ladder is being reversed. It is investigated high
levels of microbiological contamination of the water supplies in ODF villages. Many
ODF villages is still practicing open field defecation resulting in the transmission of
hookworms through the human-soil-human contamination route as well as an increased
prevalence of hookworm infestation as well as ODF Community members continued to
openly defecate. [11-15]
As Jenkins & Curtis analyzed ending ODF is not just a matter of access to sanitation
facilities, it also encompasses what motivates decision making such as household status,
well-being, and situational .There is no justification for the continuation of this OD,
because they have a latrine, any minor challenge caused by the latrine should rectify.(16)

7. 4
The reason behind why we eagerly review the literature is that to give some highlight the
statusdesigning or modifying existing sanitation technology options and promotion tool
and innovating other alternative sanitation technology options by concerned bodies as
well as open the get or invites to further research.
2. OBJECTIVE OF REVIEW
The objective of this review is to assess the outcomes and impacts of ODF in CLTSH
interventions:
 Does an ODF intervention reduce disease outbreaks?
 What are the Programme design and implementation characteristics that are
associated?
 What are the obstacles and reversion to ODF interventions?
 Can We Maintain ODF reversion?
 What is the way forward for effective ODF implementation?
3. METHODS
3.1 Study eligibility
A protocol was developed a prior and is available upon request. To assess the therapies
for Open Defecation Free Reversion based on our objective, we used all design types,
including both experimental and observational designs and both qualitative and
quantitative studies.
3.2 Search and study selection
This review includes literature published between Nov 2007 and December, 2018. We
attempted to Minimize reporting bias by including studies published in English, Spanish,
Portuguese, French, German or Italian and by carrying out a comprehensive search
strategy that included published, unpublished, in press and grey literature.
We searched the following electronic databases: Acta Tropica, African Journal of
Environmental Science and Technology , American Chemical Society , BMC Public
Health, World Health Organization, Dove press, East African Medical Journal , Elsevier ,

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Jurnal Pengabdian Kepada Masyarakat , Environmental Health Perspectives
,Environmental Science & Technology, , "Hindawi, Journal of Environmental and Public
Health, IDS Bulletin, Imprimerie Nouvelle GONNET, Indian journal Community
Medicine ,International Journal of Environmental Resource and Public Health,
International Journal of Hygiene and Environmental Health, IWAP Online, JAMBA,
Development and Communication Studies, Journal of Water and Health, Lancet Glob
Health, Oxford University Press, participatory learning and action, PLOS Medicine,
PLOS One, Practical Action Publishing, Science Journal of Public Health, Science of the
Total Environment, Science Selection, Social Science & Medicine, Waterlines, WIREs
Water, British Library for Development Studies, Campbell Library, clinicaltrials.gov,
Cochrane Library, EMBASE, EBSCO (CINHAL, PsychInfo), LILACS, POPLINE,
Research for Development, Sanitary Engineering and Environmental Sciences
(REPIDISCA), Social Science Research Network (SSRN), Sustainability Science
Abstracts (SAS), Web of Science, and 3ie International Initiative for Impact Evaluation.
We also searched the following organizations: ‟Indian Statistical Institute-Delhi,
University of Texas, R.I.C.E. Gupta: University, Charles University, Loughborough
University, CLTS Foundation, FMOH, The American Society of Tropical Medicine and
Hygiene, University of North Carolina at Chapel Hill and Plan International, WHO,
Carter Center, Center for Disease Control and Prevention, Global WASH, International
Water Association, Menstrual Hygiene Management in WASH in Schools Virtual
Conference, Stockholm Environment Institute, Stockholm World Water Week
Conference, University of North Carolina Water and Health Conference, UNICEF Water,
Sanitation and Hygiene, UNICEF WASH in Schools, USAID Environmental Health
Project, WASH plus, World Bank Water and Sanitation Program. We finally included
relevant studies that were found during the database search of the other systematic
reviews.

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4 RESULT AND DISCUSSION
The initial search yielded 424 titles and abstracts that were screened for eligibility, and
then 183 full texts Assessed for eligibility of these, a total of 48 studies met our
eligibility criteria and were extracted (Fig.2)
Fig 2: Schematic Abstract screening flow with
eligibility criteria.
4.1 CLTSH AND WASH RELATED DISEASE
According to many studies CLTSH extremely reduce prevalence and intensity of
Diarrhea, Soil Transmissible Helminthiasis, Trachoma and other WASH related
disease.[17-21,55-56] So it is possible to reduce many WASH related disease and
medical expenses through implementation of CLTSH approach.
4.2 SUBSIDIES VERSUS CLTSH
There are two controversial or debate ideas or issues are rising on the topics of hardware
Subsidies: these extremities are:
I .Subsidy is Bad Practice: in this case it belief that there shouldn‟t be Provision of
subsidy for toilet construction which did not necessarily translate to the use of toilet.
People must achieve ODF conditions without subsidies but this thought did not favor
poorer beneficiaries. There is the saying in old CLTSH facilitation approach that No
424: publication identified
 Electronic search and grey paper:395
 Publication outside recommendation:2
 Publication anotherSystematic review: 14
 Publication hand Search:3
183 Full texts assessedforeligibility
135 excludedfrom based on full text
 Not CLTSH or ODF :108
 Review: 5
 Duplication:20
 Not available:2
48 Use studies included in review
241: articles excluded based on title abstract
 Irrelevant:190
 Duplication:50
 Ineligible language:1

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external individual household hardware subsidy. Communities install their own latrines
or toilets with their own resources. Those who are better off help those who are too weak
or poor to help themselves. When we saw this in real scenario people who are under
poverty line were constrained to access the facility due to unknown case. [17-18, 22]
II. Subsidy should be harmonized with CLTSH: this modern approach which
doesn‟t affect the CLTSH model. It provides evidence on the effectiveness of a social
mobilization strategy that combines shaming with subsidies for poor households.
Since the poor are less likely to adopt public health technologies (in this case needing
to spend 85% of their monthly income on a full-price latrine), subsidies clearly
helped. Encouraging and promoting private sector and self-help group supply of
hardware materials and encouraging assistance to the poor and weak. However, the
favorable response seen among households above the poverty line suggests that
subsidies are not necessary to spur action and that shame alone can be very effective
in this population. Even if CLTS is excellent tool, it needs various modifications
according to local social and natural environments so that it can go against the core

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principles of CLTS like no subsidies and no technical assistance principles. [6, 21,
23]
4.3 LONG LASTING CLTSH FOLLOW UP
As it is known CLTSH without follow up is bad practice. By now CLTS more
championed by non-government organizations (NGOs) with all of its challenges..
Plausible factors such as inadequate monitoring of the CLTS process, inadequate
funding of CLTS programming and conflicting work demands on the CLTS facilitators
This is the lack of a formal and sustainable system for monitoring, lack of a common
criterion for validating ODF status and leading to reduced momentum. CLTS which
equipped full monitoring tool can declare ODF early. The Post-ODF follow-up of the
CLTSH approach is limited. There is no clear guideline for post-ODF follow-up in
communities. Opportunity to monitor sustained behavior change this strategy may help
address the challenges in CLTS monitoring as well as reversion to open defecation post-
CLTS. Monitoring of ODF status after CLTS may be strengthened through the
formulation of clear policies. WASH organizations to institutionalize a sustainable
system for monitoring and evaluation of CLTS outcome indicators, as part of ensuring
the sustainability of the CLTS approach. Behavior change as the key to sustainability of
ODF can best be monitored by the community itself or natural leaders will take care of it.
This argument is not going on because CLTSH couldn‟t achieve ODF sustainably
without support of expertise and professional person. Evidence Based Reporting(EBR)
can be collected qualitative data on hygiene practices should also be incorporated to
ensure that monitoring is not only limited to counting latrines. CLTS is not
founded on the stick of coercion or the carrot of reward but on a balloon of awareness
and self-realization that raises communities out of dependency. [5, 15, 17, 25-27]
4.4 CLTSH VERSUS SOLIDARITY
The community solidarity and sense of achievement from a successful CLTS process can
be an entry point for other initiatives. There have been examples of communities coming
together to build embankments to prevent flooding and crop loss, following CLTS
triggering and action. They have also tackled the annual hunger season in other ways,
with the aim of achieving hunger-free communities. In Cairo, Plan Egypt has facilitated
led to community mobilization, negotiations with the authorities, community

12. 9
participation in helping remove the garbage, and sustainably clean tunnels with children‟s
paintings on the walls. Moreover Evidence on the contributions of CLTS not only to
attaining ODF but also to sustainable behavior change and improvements in disease
prevention and nutritional status. [17-18]
4.5 VALIDITY of ODF CERTIFICATION
In implementation of CLTSH it is well known process that to certifying communities as
ODF and reporting such certifications as success indicators. There are ample of
Diversified protocols for defining, declaring, and certifying ODF status in communities,
yet no protocol has been recognized as the global standard. ODF status has often been
exaggerated and estimates of numbers of ODF communities inflated. In India, the
numbers of local government entities certified for the Nirmal Gram Puraskar (NGP)
award has taken us into realms of unreality. As well as Bangladesh, reports and
impressions were misleading. Estimates may have been made in good faith but were
unreal. Where there have been rewards for achieving ODF status, as with the Nirmal
Gram Puraskar scheme in India. In Maharashtra, rewards for achieving ODF status were
an ingenious way round the problem of having to spend big budgets for hardware
subsidy, but gave incentives for false claims and certifications, reportedly rampant more
widely with the NGP. In these circumstances, some claims and statistics lack credibility
and may be set to become a source of embarrassment, if they are not already. But in
Kenya and Ethiopia to date, with small-scale and careful verification, the numbers of
ODF Certified Communities have been more credible. At one time in Ethiopia, of 240
communities claiming ODF status, only 21 had been certified (though this could have
been because certification could not keep up with claims). And in between these two
poles lie many other degrees of accuracy and credibility. [17-18, 28-30]
4.6 SOCIAL INTERACTION AND NATURAL LEADERS
This indicates that people that perceive their community as having a higher collective
ambition to reduce open defecation, greater solidarity within the village, higher trust
between the residents, and a stronger sense of cohesion and inclusion within the village
are all associated with the individual likelihood of open defecation free status which
provide the basis on which CLTS can work successfully. Positive social context factors
seem to be a prerequisite for a successful CLTS process. Natural leader (or opinion

13. 10
leader) training targeting socially cohesive Communities have the largest impact on
sanitation facility construction from durable materials. Natural leaders are active through
the processes of construction, innovation, monitoring, developing and implementing
community norms and rules, spreading construction and practices within the community
and spreading beyond the community. Their role is crucial at all stages. Natural leaders
also facilitate the linkages between the weaker and poorer and those who are better off
and willing to help them. Natural Leaders can be old, young, relatively poor or rich,
women or men, and variously teachers, students, farmers, laborers, people with small
businesses, religious leaders, village medical practitioners, and others. So ODF greatly
depend on active involvement of Natural leaders in CLTSH process. Natural leaders are
the backbone of communities‟ behavior change dynamics. [4, 18, 31-34]
4.7 GENDER MAINSTREAMING
Many literatures concluded that in the ODF communities of women played a lead role in
initiating and driving sanitation and hygiene behavior change in their communities during
the CLTS process resulted in better health outcomes, due not least to the benefits of
improved sanitation furthermore, other changes, which included the reduction of womens
safety risks, an increase in their social status and involvement in decision-making and
leadership processes both within the household and the community, led to the enhanced
social and psychological well being of women, contributing to their overall health.
Women‟s have active role when the health workers were women, they were able to
mobilize women more easily to create demand and follow through on becoming ODF.
One possible negative outcome of improved sanitation is an additional burden of work,
which often falls upon women. Additional activity related to sanitation should be shared
fairly between women and men. If the level of women participation in triggering
meetings is low it can impair the sustainability of CLTSH process. The participation is
low due to nobody asked them to speak and husbands expected to speak on behalf of their
ladies. Integrating Menstrual Hygiene Management component within any CLTS activity
is crucial to ensure that women and girls are facilitated to fully participate in social and
economic activities and are not limited by practical obstacles, taboos, shame or
inconvenience. A gender study component should be included to learn more on how
CLTS can be used most effectively to improve gender relations and what the impact of

14. 11
this is on ODF sustainability. Gender advisors should be involved within all projects
and work closely together with the WASH advisors to ensure that the focus on gender
isn't limited to counting the number of women active in CLTS activities. [23, 27, 35-36]
4.8 QUALITY AND SUSTAINABILITY OF SANITATION
FACILITY
In the CLTS approach, households are empowered to choose and build latrine facilities.
This led the build insecure or poor facilities and materials used to construct latrines are
not durable beyond two years which sooner or later may collapse especially during the
rainy season, they may have filled up, the shelter may have fallen down, emit offensive
smell, become fertile ground for fly propagation or may not bring about improved
health impacts. The primary purpose of CLTS is eliminating open defecation interpreted
to the implementation of cheap, non-durable latrines are built and hand washing is not
fully addressed
Households may have prioritized maintenance and care for facilities over investments in
hardware, possibly due to a lack of market availability of construction materials and
latrine components. To reduce open defecation, many implementers use the intervention
strategies of Community-Led Total Sanitation (CLTS). But CLTS focuses on latrine
construction and does not include latrine maintenance and repair damage or collapse.
Some households rebuild their latrine while others return to open defecation. The reasons
why are unknown. The analysis showed that, of five psycho social factors that help to
account for latrine rebuilding; only three are changed by CLTS participation. The
addition of data-based behavior change strategies could improve effectiveness even more.
I. Risk factors: which represent a person's understanding and awareness of
health risks, person‟s positive or negative stance towards a behavior,
II. Attitude: person's positive or negative stance towards a behavior,
III. Norm factors form: the third block; they represent the perceived social
pressure towards that behavior,

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IV. The ability: factors form the fourth block. They denote a person's confidence
in her or his ability to practice the behavior,
V. Self-regulation factors form: the last block they represent a person's attempts
to plan and self-monitor their performance of the behavior and to manage
conflicting goals and distracting cues.
People should think about their responsibility when defecating in the open. If this
awareness is strong, people show higher levels of rebuilding behavior. Secondly, people
need to have strong confidence in their own ability to repair or rebuild a broken latrine;
then they are more likely to do so. CLTS still lacks effective means to support and
strengthen this belief.
The issue of poor quality latrine construction with limited technical inputs resonate
s as a major concern CLTS, There are possibilities that following a successful trig
gering, communities will naturally follow the sanitation ladder and build acceptable lev
els of facilities later in to the process. If sufficient flexibility is not permitted, institutional
settings can be barriers against new design innovations and initiatives which will help
communities to move up the sanitation ladder.
CLTS is spreading fast, it is important to ensure that CLTS is scaled-up with quality and
institutionalized appropriately within governments and bureaucracies. This means going
beyond counting ODF villages to mainstreaming CLTS across programs and districts.
This includes institutional capacity, training and facilitation, but also understanding the
dynamics of creating an enabling environment to shift from top-down sanitation
implementation to bottom-up processes that are sustainable and inclusive.
Programs including a combination of demand creation, removal of perceived constraints
through community support mechanisms, and continued encouragement to pursue higher
levels of services with post-ODF follow-up, could stabilize social norms and help to
sustain longer-term latrine usage in study communities. Further investigation and at a
larger scale, would be important to strengthen these findings. [5, 12, 23, 28, 32, 37-42]

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4.9 COONSIDERATION IN FACILITATION
Facilitators, facilitation and training are central and fundamental part of CLTSH. Other
Participatory Methodology trainers and facilitators are encouraged to facilitate in a
sensitive manner. With classical CLTS triggering there is a sort of cultural insensitivity in
broaching an unmentionable subject, and teasing, fun and laughter as well as provoking
disgust. Kamal Kar has said that “a good facilitator should be someone who can sing and
dance” in reality singing and dancing are not essential for CLTS, but they indicate a type
of person. So more time and budget is needed to make a very thorough selection for the
right CLTS facilitator. The best results have been achieved when facilitators are full-time
and strongly motivated. Other issue that must be considered is the time of facilitation;
studies depict that most convenient time for facilitating triggering activities was during
the morning hours which also coincided with the school going hours. Children who
missed participating in triggering activities were more likely to continue open defecation
practices. During the CLTS process it is important to consider existing social customs
and cultural sensitivities so that the facilitators do not offend community members during
the CLTS process. [18, 23, 27, 43]
4.10 INFRINGEMENTS TO BASIC HUMAN RIGHTS
Poorest and weakest members of society should be potential beneficiaries from CLTSH
process without any infringements to their basic human rights. There are reported cases
that can condemn the basic right of people. We think Dr. Kamal Kar will be annoyed by
this and will provide us some additional precautionary supplies after reading this article.
Personally we were participated more than 10 ODF kebeles certification process but we
didn‟t go through this undisciplined measures. We have to put some of finding from
some study to elaborate it clearly and to analyze whether this system of implementation
fit to CLTSH model.
Natural leaders started extremes coercion and punishment of those defecating in the open
if the crime and collecting money from livelihood of these individuals. So this violence is
not reported as crime or been denied by judicial bodies and forced victims to accept it.
Throw stones to the people who are openly defecating. Women were photographed and
their pictures displayed publicly while they were openly defecating. Cut off households‟

17. 14
water and electricity supplies until their owners had signed contracts promising to build
latrines. Collect a woman‟s feaces and dumped it on her kitchen table if she were
defecating openly. No arbitration would be held if the young women and adolescent girls
of the household were raped during defecating outside. Even though experts‟ arguments
consider CLTS an effective tool for improving sanitation and are satisfied with its
application. They are aware of its limitations and possibilities of human rights violations,
though some had objected these claims. It is also common to modify CLTS, as only a
minority of interviewed practitioners applied the pure form. Urge for modifications
strongly resonated in practitioner‟s calls for constant improvements of the approach in
respect to various local social and natural environments. Practitioners also endorse
modifications and improvements which go against core principles of CLTS, such as
provision of subsidies, sanitation hardware or technical assistance. Practitioners have
overall good experiences with subsidies since they carefully target the very poor or in
other ways disadvantaged people. This way sanitation can reach single mothers or people
with disabilities, whose needs are often overlooked. [49-51]
4.11 LEADERSHIP AND INVOLVEMENT IN ODF
Support for better sanitation and hygiene from political leadership was reported as
deficient or fragile in most respects. Continued engagement of leadership figures in to
CLTS illustrated here will support communities. In particular the support of political
leaders like the First ladies of Katsina and Osun States to advocate for CLTS at the
national level will enhance scaling up across the country.
• Traditional leaders enable communes to change age-old practices
and social norms to embrace sanitation.
• Religious leaders invoke Biblical and Koranic texts to further enhance
the process of change through religious teachings.
• Political leaders enhance and support the process of change through
advocacy at local government and state levels.
Big challenge that health workers and teachers face in leading the promotion of
community-wide sanitation behavior change is that they excluding leaders. For example
kebele leaders carried the most authority and influence during the ODF interventions

18. 15
more than teachers and health workers can do. It was also observed that CLTS is not only
about engaging community level health workers, but rather all segments of a society
from Kebele leaders, agricultural workers, school teachers, students, women and
children. In this way, the approach advances itself for integration and collaboration
of many stakeholders and also promoted inclusion of women, children and men. This
further lends itself to greater ownership and buy in by everyone not a few in the
community. Lack of coordination between Non-Governmental Organizations (NGOs)
leads to slow improvement of sanitation coverage. It is recommended that there should be
coordination between partners for harmonization of messages and an integration of the
CLTS and other approaches. [11, 39, 52-54]
5 CONCLUSION
Encouraging and promoting private sector and self-help group supply of hardware
materials and encouraging assistance to the poor and weak people in CLTSH process is
Effective social mobilization strategy that combines shaming with subsidies
Strategy Such as Opportunity to monitor sustained behavior change helps to address the
challenges in CLTS monitoring as well as reversion to open defecation post-CLTS.
The community solidarity and sense of achievement from a fruitful CLTS process and
reduced open defecation can be an entry point for higher collective ambition and other
initiatives.
Many literatures concluded that in the ODF communities of women played a lead role in
initiating and driving sanitation and hygiene behavior change in their communities during
the CLTS process resulted in better health outcomes.
The issue of poor quality latrine construction with limited technical inputs resonate
s as a major concern CLTS, There are possibilities that following a fruitful triggeri
ng, communities will naturally follow the sanitation ladder and build acceptable levels
of facilities later in to the process.

19. 16
In fruitful CLTS process it is important to consider existing social customs and cultural
sensitivities so that the facilitators do not offend community members during the CLTS
process as well as Poorest and weakest members of society should be potential beneficiaries
from CLTSH process without any infringements to their basic human rights.
Dr. Kamal final confirmed that CLTSH Could be no more rigid so CLTS is a nonstop, looping
process of developing innovation and building on progress as it emerges. Unless the
government mode of operation can build in an appreciation of the nature of this continuous
learning and improving process, the gains made here may remain vulnerable.CLTS action which
is strong in nurturing principles of local knowledge and community empowerment has the
power to stop open defecation, bring health benefits and inspire social and economic
development.
Based on current trends, the goal of ending open defecation in the majority of sub-
Saharan African countries by 2015 will not be achieved. For the future it is necessary to
conduct high quality research is required to identify the root cause of ODF reversion and
specific factors to maintain open defecation free by using appropriate research design.
Investigation and research is also required on introducing improved CLTSH process and
sanitation facility options based on the sanitation ladder amongst the communities using
the social marketing approach after the demand is created by the CLTS triggering
process.
6 LIMITATION:
While the 48 studies analyzed provided concrete information to produce comments, there were
Some limitations of the evidence, including:
 None include high quality evidence relating specifically to ODF reversion while they
show consistent findings.
 Most are low quality cross-sectional study designs, only six randomized controlled trials
are included in the review
 None of them provide ODF reversion analysis „especially qualitative‟ ways.
 The potential for reporting bias, search bias, recall and courtesy bias,
 The use of proxy indicators and Inconsistent outcome reporting

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7 RECOMMENDATION
1) Protocols for defining, declaring, and certifying ODF status in communities should be
globally standardized and recognized by all actors
2) A choice of alternative sanitation technology options must be developed or innovated to
integrate it with CLTSH.
3) Combined appropriate hygiene promotion must be undertaken. (RBSA will be coming
soon together with CLTSH) and
4) It should better to get concrete data on Safe pathways to ODF by conducting Rigorous
and tiresome qualitative research and Field trial experiments. This continuous field trial
should be conducted and the result should be disseminated for ODF implementing
partners.
5) To give strong justification on ODF reversion there should be necessary to conduct
qualitative research. Then it will be simple and easy to curb all of ODF deterioration
professionally.
6) There should be the exchange of experience sharing and updating any new trend around
the globe.

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