On Saturday10 October Joséa Ratsirarson wrote on the WSSCC CoP in French, here's the translation:

My name is Joséa Ratsirarson and I am working as Resident Representative of Medical Care Development International which is the executing agency of the GSF programme in Madagascar.

In my experiences, the sustainability of ODF status permeates all phases of CLTS; before even the pre-triggering until stage of maturation of post ODF and beyond. Indeed, the low quality of implementation of any of the main stages of the CLTS will weaken the population’s change of behaviour, which is materialized by the achievement of ODF status. For example, implementers often minimize the importance of pre-triggering even though this step would have already helped identify threats (that we call slippage factors in our jargon) to return to OD status and already remediation measures could have been put in place from the outset. Several speakers in this forum also highlighted the quality of facilitation. The quality of facilitation should not only concern the triggering but the CLTS process as a whole (pre-triggering, triggering, post-triggering follow-up, and post-ODF). A weak triggering would generate a fragile ODF status. In my view, the key to good facilitation generating solid ODF communities is the central use of the message that a community is involuntarily ingesting shit due their current OD practices. Nobody in the world wants to ingest shit and once the idea is deeply rooted in the spirit of the community, the ODF status that will be the result [of this facilitation] is not only ODF in terms of visually observable elements (infrastructure) but more importantly in terms of living by an ODF spirit. It is this ODF-spirit that one must strive for and facilitate and NOT only a visually observable ODF . Once the ODF-spirit is there, the visible ODF becomes strong and lasting.

I'll tell you about an example in the Boeny Region (one of the 22 Region of Madagascar), one of our areas of intervention. In January 2015, this Region was victim of a powerful cyclone. 90% of latrines in our ODF villages were destroyed. Without any intervention from our end to implement corrective measures to regain ODF status, the villagers themselves rebuilt, by their own means, without any external help, 90% of latrines destroyed one month after the passage of the cyclone. The question is why? Well, only because the ODF status was deeply engrained in their mind/behavior and was not a visually observable ODF, it was clear for them that they did not want to eat shit anymore. And even if they were in a situation of absolute emergency, to ingest shit was clearly unacceptable and it was clear to be an absolute priority to prevent any member of the community to do so.

The other point I want to address is the point raised by Matilda on "slippage patterns". During the post-ODF phase, the behavior of communities is actually versatile, passing from ODF to OD status. We particularly noticed that return is conditioned by an unimaginable number of slippage factors. For example, if it rains for a few days the community will have less ash at their disposal for handwashing and cleaning latrines. The consequence is that during this particular period, the community slips back to OD status. Emphasis should be placed on research of these slippage factors to address them before their occurrence. Once identified, facilitators should help the community to find its own solution rather than bringing external solutions to them. We, as external to the community, cannot just solve nor have all the solutions. The problem comes from within the community and therefore the solution should be community-led, our role is to facilitate the process of finding these internal solutions.

And yesterday, Sunday 11 October, Joséa Ratsirarson wrote:

Thanks for the comments. I do not quite agree to always retreating to the stereotype that the main cause of slippage is related to the quality of latrines. This is probably one of the factors in some areas where there are specific climatic and geological conditions but this is only one out of a multitude of causes of slippage. To go more in depth, the elimination of open defecation is not only about constructing latrines but also about behavior change. Sustainability will depend on real behavior change rather than only to the access to a latrine. Very often, we are keen to obtain and to declare ODF status, without verifying that the community had made the step of a real and deep behavior change. It is in this framework that we hasten to solve issues of sustainability through donation, subsidy, technology etc. In reality, the veritable problem is the low quality of our implementation and CLTS facilitation that generates fragile ODF communities, with low levels of actual and engrained behavior change.

More comments added below...

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Hallow. I am Tobias Omufwoko, WSSCC National Coordinator, Kenya.

I want to agree with Vincent that sustainability has a lot to do with ODF slippage and l would like to break this into: quality of triggering, follow up by either government or natural leaders, and peer pressure from certified ODF communities to their colleagues. We need to look at ODF not as an event but a process that leads to better health, and therefore it must be competently triggered, monitored and followed up, and nurtured well after the project life - and not merely counting the 100% coverage of toilets and moving to the next community.

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Dennis Alioni

It's true many of the communities declared ODF do slip back to OD. I think these are some issues to consider:

1. The environmental health staff are wrongly satisfied with communities declared ODF and many times stop any follow up interventions to keep these communities truly ODF such as graduation to improved sanitation. This has caused a lot of slippage.
2. Orlando Hernandez makes valid comments about the appropriate technology. Saying that we should have "basic but fly proof latrines" does not take care of sustainability of the facilities. Basic in most cases refers to available local materials. These are poor and susceptible to poor soils hence collapse, termites and rainy seasons among others. The proper latrines technology needs to be defined and made appropriate for each region.
3. Management of the funds at the local government needs to be tightened to make sure that the community workers at village or sub county actually get the funds budgeted for follow up. In some place where follow up after trigger is supposed to be say 6 times, only funds for 2 follow ups is received. The monitoring from country fund managers needs to be strengthened to make this happen.

In Uganda, all the three points have caused slippage.

The Water and Sanitation Programme piloted an initiative in Uganda to accelerate achievement of access to improved sanitation (durable, easy to clean and sealable latrines - with various technologies) in four pilot districts. BCC was introduced at the CLTS triggering to give communities access to improved sanitation services and products. Entrepreneurs and financial institutions were introduced to provide services and access to finance for improved facilities. This was also followed for some demand creation activities in communities during CLTS follow up among others. As a result improved sanitation improved from 17 to 34% in the pilot districts. Integrating such Programmes in CLTS help minimize slippage and provide long lasting sustainable sanitation.

Dear all, we've received some additional comments from our colleagues on the WSSCC CoP. They're posted below for your ease of reference. Thank you, Tracey

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I am Orlando Hernandez, associated with the USAID-funded WASHplus Project, but also with some experiences studying CLTS programs in Latin America and Francophone Africa implemented by ECOPSIS. Just a couple of points to keep in mind.

One, the ODF status may be obtained not paying necessarily attention to the type of sanitation facility that is constructed. Soil conditions may require constructing pits that can be adequate for sandy, rocky or floodable soils/terrain. There is not always an array of technological options available for communities and even if there is sanitation marketing program to accompany sanitation coverage actions, the type of latrine built may not meet required standards. So, these facilities may be short lived and end up collapsing one or two rainy seasons after installed. Families in these conditions may be reverting to open defecation. One issue then is how do we guarantee that the quality of sanitation installation facilities ensures sustainable practices in the long run?

Two, the support structures to declare a community ODF and to help that community achieve it may not be in place. Donors are often concerned with coverage targets without not much care paid to the quality of the facility constructed. There may be repairs that are needed for installed facilities, and these repairs may be just as important as the first hand installation of the facility. Further, the repairs may be also important because the type of latrine constructed may be polluting the environment and contaminating underground water sources, as in the case in sections of Bangladesh where latrines may suffer from leakage and must be 'enveloped' to prevent it. Efforts associated with pit envelopment go undetected and may be important to keep a functional latrine operational and being mindful of environmental protection.

Third, the presence of a latrine in a household does not guarantee that all family members will use it. Ensuring that family members, young and old, men and women, make use of an installed facilities should remain as an important behavior change concern.

Finally, families must learn to use those facilities for disposing of child feces. Often, families have access to a sanitation facility but continue to dispose of child feces using garbage dumps or waterways.

Slippage considerations must take into account then:

• a concern for the quality of the latrine constructed;
• supporting repairs that be needed to the infrastructure in the long run;
• helping families ensure that all family members make use of existing facilities using an inclusive sanitation perspective; and,
• extending latrine use to the disposal of child feces to prevent them ending up polluting the living environment.

It is interesting to see efforts going in direction of preventing slippage.
However, it would be much more interesting to find out about any efforts that have gone into inducing demand through social and behavioural changes.

For example to prevent 'Slippage of convenience' presented by Jonathan Ekhator, quoted by Tracey Keatman.

Dear Colleagues,

Herewith a sad story from the Nepalese media on slippage.

thehimalayantimes.com/nepal/odf-declarat...results-in-far-west/

actual article content (in case the link disappears):

DIPAYAL: Declaration of open defecation-free (ODF) zone without preparing necessary infrastructures in the Far-Western Development Region has rather produced an opposite result than what was expected.

Instead of making the areas clean and hygienic, the declaration without preparation has resulted in pollution and stinking all around.

The makeshift toilets constructed haphazardly are in pity state. The public complaints are on the rise regarding the pollution created by the poor infrastructures.

VDCs and municipalities of the region have resorted to an unhealthy competition to declare themselves ODF in order to make the whole Region ODF by the end of 2015.

According to Parkash Rawal, Engineer at Regional Monitoring and Supervision Office in Dipayal, public awareness campaigns are underway to maintain hygiene at the makeshift toilets.

Many temporary toilets and drinking water projects in the districts are in the limbo after the declaration of ODF zone, as the supporting agencies stopped supporting them.

Far-Western Regional Administrator and Coordinator of the Regional Water Sanitation and Hygiene Co-ordination Committee, Sharad Raj Bista, emphasized that public awareness is must to sustain the existing projects.

Bajura, Achham and Dadheldura districts of the Region have been declared the ODF zones.

The Regional Monitoring and Supervision Office, Dipayal, has informed that six other districts are all set to be declared the ODF zone.

This is an unconfirmed media quote, but probably true to a large extend.

The reasons for slippage, as I read the article:

1. Unhealthy competition between local governments to meet central government targets, at all (non-financial) cost
2. Too many hastily built toilets and water points, which are neither hygienic nor sustainable.
3. Lack of awareness and motivation in community
4. Lack of well funded follow-up

It should also be noted that this part of the country is known for being water-stressed and poor.

Regards

Marijn

Ouma Vincent, from the WSSCC CoP has added:


Halo Everyone,

My name is Vincent, I work with Amref Health Africa in Kenya on the GSF Programe. Through my work on S&H in communities, I am beginning to think that slippage or non slippage has a lot to do with sustainability measures that we put in place during our walk with communities towards ODF, if measures are weak then slippage is very likely to be witnessed.

The other challenge I have come across is the vulnerable people, in some of the villages we work in, it is difficult to be certified ODF because of some of the community members who are bedridden or suffering from illnesses that make them unable to control their bowel movements, as a result, the village never gets certified ODF, people loose hope and may as well eventually just slip back.

So the measures we put in place during the journey are key, I will be glad to hear how others are handling those two issues

Cheers

Jonathan Ekhator, from the LinkedIn WSSCC CoP has added:

In rural communities in Nigeria, where I am part of a team implementing the GSF supported programme on Sanitation, the issue of slippage is a challenge we are learning from and also seeking innovative ways of mitigating.

I am Jonathan Ekhator, I work with Concern Universal as a technical support officer on WASH.
My comment is on patterns of slippage, factors influencing slippage and its social and health impact on the community.

Three patterns of slippage I have noticed are:

1. Community wide slippage: This is were whole community or large population of the community returns to Open Defecation after attaining ODF. External factors contributing to this type of slippage is weak CLTS Triggering facilitation.
2. Seasonal Slippage: community members defecating in the open during raining season and using household latrine during the dry season. This type of slippage is chiefly the result of collapsing latrine, water filling up latrines dug in swampy areas during the wet season. This season too, WASH facilitators are unable to visit communities hinterland due to wet terrain. This on-and-off slippage is not by whole community but only a few individual households whose latrines are affected.
3. Slippage of convenience: in this pattern, community is ODF and you actually don't find any defecation in the open. But community members are happy to defecate in the open in their farms or any where outside their community. The availability of space, and poor facilitation of community not understanding and realising why they should stop open defecation is responsible for this.

Hello everyone,

Thank you WSSCC and SuSanA for posting this theme. It is great to read about the above organization’s comments and I hope others are able to share their thoughts and experiences so we can all grasp these ideas and inspire sustainability in our ODF villages. I am from Medical Care Development International (MCDI) and we are supporting the GSF program as the Executing Agency in Madagascar and Benin.

My comments specifically address Matilda’s questions 2 and 3, but also touch on the others.

There is a strong need to develop a robust evaluation system in order to maintain the status of an ODF village.

In addition to sustaining the everyday routine of an ODF village, one must evaluate the village to determine where the issues are occurring or even where they are excelling. For example, it would not be very helpful to evaluate these villages with ‘Yes’ or ‘No’ tick boxes; ‘Yes, this village is achieving ‘ODF’ or ‘No, this is not an ODF village’. In a failed village, the ones trying to maintain the new ODF status might not know how to improve or even know where to start based on a yes or no question.

Instead we propose to ask more direct questions such as ‘Why is this village failing?’, ‘Where is the village failing’, and ‘What is the frequency of failure’. This way we can better pin-point the next steps of how to get the village back to ODF.

It’s almost like trying to balance on a see-saw or how a spider spins her web between two blades of grass so it is able to sway with the wind.

As described in Matilda’s introduction there are 3 principles recognized for ODF villages:

1. The village must be not be practicing open defecation,
2. Have fly proof lids, and
3. Villagers must have handwashing stations and be washing hands properly at critical times

Do these principles all have equal weight when evaluating a village? We think no.

For example, let’s say a village fails because they are not washing their hands but after further analysis the reason is there is no water – because it’s the dry season. Now this issue is recognized and the solution can be found. However, what if another village fails because they are practicing open defecation from a relapse of poor behavior? We think this should carry more weight than the first village because of the severity of the issue requiring more planning and resources to find the solution.

How do we show this different weighting? One common but often despised suggestion is the traffic light/stop light matrix. Perhaps this ideology could be incorporated into the critical thresholds of the ODF principles.

In summary, this evaluation system will specifically highlight the issues (positive and negative) and then address any slippage in the system to quickly return the village to ODF.

It would be great to hear about how other villages maintain ODF and what evaluation mechanisms are used to ensure the sustainability of the village.

Looking forward to your replies,
Kimberly McLeod

Hello all, our colleague Carolien van der Voorden from the GSF on the WSSCC CoP has added this information for us to consider:

As a bit of inspiration from the GSF's family of programmes, the FAA programme in Madagascar is GSF's longest running programme and has learnt many lessons on how to work at scale. Inevitably, with over 12000 villages declared ODF so far, the programme also faces its share of slippage. While accepting that this is an inevitable part of any large scale behaviour change programme, they are rigorous in continuing to push for 100% compliance with the ODF criteria over time, and have developed a number of tools and approaches to sustain behaviour change over time. For example, the Follow-up Mandona.

See GSF's recently published case study on 'Sanitation and Hygiene Promotion in Madagascar' for some interesting insights and reflections: wsscc.org/2015/10/02/learning-progress-a...otion-in-madagascar/

Hi everyone,

I work with the Urban Management Centre ( www.umcasia.org ), in some of the urban areas of Gujarat, India. We have partnered with some cities to help them in their efforts to become OD free.

Issue 1:
All the cities are at different stages in implementation of various sanitation projects. These projects include construction of toilets, laying a sewerage network, and constructing treatment plants. consequently there are several communities in these cities which have either of those components missing in their homes, compelling them to defecate in the open. Although, it is not that just the supply is facing issues with production, but also the demand cannot afford the products, eq. urban poor have small dwelling units with hardly any place to allow for construction of toilets. however, problems of smaller of these cities have these problems of a lesser magnitude.

Hence, what is step 1 for effectively planning and phasing sanitation infrastructure in urban areas of developing countries?

I would like to find out about solutions that might have been tested or are successful.

Nanpet Chuktu, from the WSSCC CoP has shared the following:

Thank you for starting this discussion. I am from Nigeria and Concern Universal. We are supporting the GSF programme here as Executing Agency. My comments are on the following:

Patterns of Slippage:
Patterns of slippages we have here are:

• inter and intra communal conflicts which result in displaced households and communities. When families return back they are usually starting all over again. If the terrain is difficult, or water logged, then they struggle to get back to owning and using latrines.
• we also have the case of a community that has made progress hosting internally displaced persons from conflict communities. This has been most difficult to deal with as the new comers stretch the facilities existing and sometime are not willing to obey the existing bye-laws of the host community.
• where we have flooding and households loose their latrines as a result of collapse. It takes a little bit linger for households to put their latrines back.

Local strategy to prevent or mitigate slippage

Clinics - We have tried to put forth more energy in building collective pressure and push for action to become ODF and sustain it, not just for 1-2 villages but for a group of villages (20-30) that have a common heritage of administrative affinity. We have so far held meetings (WASH Clinics) where these groups of communities are represented. An appraisal of the performances of the communities is made and those performing well are praised, while those not performing are shamed and made to realize how they are still eating and drinking their shit. This has made the march to become ODF a competition among communities and also not wanting to be shamed when next they meet at the next meeting.

Task Group on Sanitation - Our progamme has supported a 3rd party - the Local Task Group on Sanitation. A locally based group of senior staff of the Local Government Authority, religious leaders and traditional leaders. They have been trained on the National ODF verification protocol and the criteria expected. Their role is to conduct monthly verification of ODF communities and have been used to advocate to 'stubborn' or lagging communities. They have raised the bar in terms of ODF criteria and tend to stick to it on their visits - No open defecation, presence of a handwashing station, a squat-hole cover that are fly proof and in pit latrines, you need to use ash.

WASHCOMS - Once a community becomes ODF we support them to form a WASH committee (at least 6 men and 6 women). These become the vanguards in their respective communities to sustain the ODF status. They receive basic training on sanitation and hygiene and are led to also understand the ODF criteria as well and also how missing out on any ODF criteria could mean that they are back to eating their shit. These WASHCOMs now seek to ensure that households are supported to have latrines that meet the ODF criteria, help the aged and widows who otherwise cannot build one for themselves.

Good morning. This week I will co-lead the discussion on ODF and slippage together with my colleagues Clara Rudholm and Carolien van der Voorden, also working with the Global Sanitation Fund. Please note that the introduction is divided into two posts. For those of you who prefer French, the post will be in French too. Please feel free to post in either language.

Large-scale behaviour change oriented sanitation programmes often focus on supporting communities to achieve Open Defecation Free (ODF) status, criteria for which are locally defined but often include a complete stop of people defecating in the open, access to basic but fly proof latrines for all community members, and presence of handwashing stations with water and soap or ash close to the latrines. As these programmes mature and when the challenge shifts from bringing communities to ODF to sustaining their ODF status, many are confronted with the issue of slippage – a return to previous unhygienic behaviours or an inability of some or all community members to continue to meet all ODF criteria. However, there is a lack of clarity (or at least acceptable/universal definitions) of what slippage actually is and there is no panacea for how to come to terms with slippage, which is dynamic and context specific. What we do know is that slippage is an expected aspect of sanitation interventions, especially those at scale, and NOT a sign of a failure thereof. So, in this week’s discussion we would like to share some of the experiences and lessons learned of the Global Sanitation Fund, currently funding programmes, in various stages of maturity, in 13 countries. We hope that other partners will be inspired to do the same. The discussion will focus on the following themes:

ODF/slippage definitions
To define and nuance slippage we must first define ODF. There are more or less stringent definitions – is it solely about eradicating faeces in the open? Or is it also a matter of completely cutting the oral-fecal chain through fly-proof latrines and hand-washing facilities? Relatedly does slippage suggest that people return to the practice of OD or is it more commonly about the failure to meet ODF criteria (absence of hand washing facilities and/or lack of their use, absence of squat-hole cover, ash etc.)?

Slippage patterns
Sanitation and hygiene behaviour change is a non-linear process that might look like this: a community is triggered, endeavors to reach ODF, is declared ODF, slips back repeatedly (due to various individual/collective and internal/external factors) to non-ODF status followed by interventions to regain ODF status. A common trend seems to be that the more often interventions are repeated and follow-up support is provided, the less dramatic the slippage will be until eventually a level of maturity is met and behaviours ‘stick’. Experience also suggests that ODF status and slippage are seasonal and this is important to consider for monitoring and verification. But are such patterns similar across regions and countries, are patterns related to levels of internal and/or external support and systems in place, and how much evidence has been collected by programmes on slippage patterns?

Impact of slippage and monitoring
Measuring slippage according to visual observations of technical criteria is an important management tool for programming and monitoring, and the rigour and zero-tolerance for failure to meet ODF criteria must not be compromised if we want to ensure the robustness of our programmes. However, it is crucial to find a way to combine this with an analysis of the level of collective behaviour change and health outcomes in a particular community. For instance, what are the actual impacts of slippage? Are all benefits of interventions lost if a single household is missing soap at the handwashing station or has a latrine with a misplaced squat-hole cover? In order to capture slippage in a more nuanced way, would it be possible to introduce other elements in monitoring and verification alongside the visual observations on infrastructure and ODF criteria? Could it be combined with 1) community perceptions of change; and 2) Health data analysis?

Strategies to mitigate slippage
In most GSF countries, programmes are using specific strategies to strengthen the sustainability of ODF status and thereby to mitigate slippage. For instance this could be a strong focus on quality CLTS facilitation as it is believed that high-quality facilitation leads to stronger behaviour change; action-oriented follow-up techniques; strengthening of community governance structures and empowerment of natural leaders; and positive engagement of local government structures throughout the programme.

Questions for discussion
1.What are the patterns of slippage that you experience in your programmes? Returning to defecation in the open or non-compliance with other ODF criteria such as absence of handwashing and squat-hole covers? What are the external influencing factors?

2.In terms of the impact of slippage, is there a critical threshold for when slippage has an impact on the social or health status of the community, and if so, how can this be determined?

3. As behaviour change and slippage are dynamic processes must we change ways to monitor them? Is it feasible to monitor community perceptions and health data alongside the visual observations as mentioned above? Is verification a one-off event?

4. What are the local strategies that your programme uses to prevent or mitigate slippage?

5.How does your programme integrate learning on slippage to improve interventions?