The World Bank has issued an official response here

Dear Mughal,

of course we have conveyed our concerns directly to the authors as well. If/when there is a response, I will see if it is appropriate to post it here.

Best wishes,
Petra

Dear Elisabeth, I appreciate your positive take on this, but in our opinion, if there is to be this kind of exposure, it needs to get the fact straight. And as we wrote in the letter, it is telling that the report fails to acknowledge the mindsets and behaviour of those behind it and how these bias the content.

Best wishes,
Petra

Dear Petra,

Much as I would sympathize with your predicament, I think, the book has some positive points on CLTS. For example on pp. 17, it says:

A related approach to creating new norms with some promising anecdotal evidence is Community-
Led Total Sanitation (CLTS). One core element of this approach is that CLTS leaders work with community members to make maps of dwellings and the locations where individuals defecate in the open. The facilitator uses a repertoire of exercises to help people recognize the implications of what they have seen for the spread of infections and to develop new norms accordingly. A recent and systematic study of CLTS in villages in India and Indonesia provides evidence of the initiative’s value as well as its limitations. The CLTS programs were found to decrease open defecation by 7 and 11 percent from very high levels in Indonesia and India, respectively, compared to control villages.

Perhaps, it might be helpful, if you convey your concerns directly to the World Bank. I’m sure, Elisabeth, Marijn and myself would love to see their response.

Regards,

F H Mughal

Dear Petra,

Thank you for bringing this report to our attention and for clarifying some of the aspects about CLTS in this report. I can imagine how furstrating and annoying it must be to see some of those facts wrong, after all the time that was probably put into it from your side.

World Development Report 2015 explores "Mind, Society, and Behavior"
www.worldbank.org/en/news/feature/2014/1...society-and-behavior

On a more positive note: I think without CLTS, the report might not have mentioned sanitation (or open defecation) at all. So it is already a great achievement in itself, that via CLTS, the issue of lack of sanitation has been taken up in this report!

I wonder who the readership of such a report is? It seems to be "all actors in the development process". I would have never come across it if you hadn't pointed it out to me.

The example of CLTS even made it to the summary page on their website!

In Asia, a new approach, focused on establishing new norms that holds promise is Community-Led Total Sanitation (CLTS). In CLTS, leaders work with community members to make maps of dwellings and the locations where individuals defecate in the open. The facilitator uses a repertoire of exercises to help people recognize the implications of what they have seen for the spread of infections and to develop new norms to protect against the damaging effects of open defecation. A set of these programs in Indian villages lowered open defecation by 11 percent from very high levels. (Patil and others 2014).

The more I skim through the report the more curious I get about it. Take this statement for example:

The newly launched report argues that development policies based on new insights into how people actually think and make decisions will help governments and civil society more readily tackle such challenges as increasing productivity, breaking the cycle of poverty from one generation to the next, and acting on climate change.

[...]
When it comes to assisting poor people, a key message from WDR 2015 is that poverty is more than a deprivation in material resources. It is also a “cognitive tax.” Take the case of sugar cane farmers in India, who were asked to participate in a series of cognitive tests before and after receiving their harvest income. Their performance was the equivalent of 10 IQ points higher after the harvest, when resources were less scarce.

I think it's good for us from the sanitation sector to learn more about poverty and how people make decisions; and for those who are experts in that to learn from our sanitation sector how CLTS works. --> see a related thread here on the forum: forum.susana.org/forum/categories/71-beh...rest-long-term#12546


So overall, a pity about those details, but I would say overall CLTS is getting some good exposure in this report, and it has ensured that sanitation is a topic of this report which you can be proud about!

Regards,
Elisabeth

P.S.
I copy two more pieces from this report to wet everyone's appetite to read it:

Consider one of the biggest causes of health problems
in the world, open defecation. (p.152)

--> a powerful statement by Worldbank.

Consider the problem of open defecation. About
1 billion people defecate in the open, and defecation
has been linked to infections in children that lead to
stunted growth and in some cases death. A standard
approach is to provide information, along with goods
at a subsidized cost—in this case, to construct toilets.
But even with these changes in place, new sanitation
norms are also needed to end this unhealthy practice.

Government officials in Zimbabwe developed “community
health clubs” to create community structures
that served as a source of group endorsement for new
sanitation norms (Waterkeyn and Cairncross 2005).

A related approach to creating new norms with
some promising anecdotal evidence is CommunityLed
Total Sanitation (CLTS). One core element of this
approach is that CLTS leaders work with community
members to make maps of dwellings and the locations
where individuals defecate in the open. The facilitator
uses a repertoire of exercises to help people recognize
the implications of what they have seen for the spread
of infections and to develop new norms accordingly. (p. 17)

(I agree that "promising anecdotal evidence" doesn't sound as good as it could have)

It is with disappointment and bewilderment that we, the undersigned, write this letter in response to the publication of the latest World Development Report Mind, Society and Behavior.

In the lead up to its publication, Robert Chambers of the CLTS Knowledge Hub at the Institute of Development Studies and Frank Greaves of Tearfund UK were invited to advise on a contribution on Community-led Total Sanitation (CLTS). This was being considered for inclusion in the report as a key example of a behavioural change process. Robert and Frank went to London to take part in a video conference with Washington and drafted text on CLTS, the CLTS approach and how and why it works as an input for the report.

The Report draws on this in describing CLTS on pages 17 and 152-3. However, it finds (page 17) that where CLTS was combined with subsidies for toilet construction, its impact on toilet availability within households was much higher and concludes that these findings suggest that: 'CLTS can complement, but perhaps not substitute for, programs that provide resources for building toilets’. We are shocked and puzzled to read this. It is a damaging misrepresentation of CLTS. It is surprising that the authors of the report, after consulting with Robert Chambers and Frank Greaves, then wrote text on CLTS which they did not check with them for representativeness before going to publication. Had they done so, this would immediately have been corrected. They also did not consider it necessary to further their understanding of CLTS by referring to the considerable literature on the subject or corresponding with Dr. Kamal Kar, the pioneer of the approach.

CLTS is a sustained process, much more than just a triggering exercise, dramatic and critical though triggering can be. For CLTS to go to any scale, it requires an environment which is free of hardware subsidies. It is a worldwide experience that provision of hardware subsidies inhibits self-help and does not lead to collective behaviour change, but only to many toilets which are often not used, used for other purposes, or dismantled. These experiences with hardware subsidies and the requirement of a subsidy free policy environment as fundamental for achieving CLTS at scale, has not been understood. More than 20 Governments have adopted CLTS as national policy. Over 30 million people have been estimated to be living in open-defecation free communities as a result of CLTS implemented in enabling environments which are free of hardware subsidy. On the other hand, CLTS spread has been very limited wherever hardware subsidies prevail. The WDR authors, instead of consulting the very extensive CLTS literature (see e.g. the CLTS Knowledge Hub website ), have based their conclusions on two Randomised Control Trials, one carried out by the World Bank, and one published in PLoSMed.

The first study is of the Total Sanitation and Sanitation Marketing (TSSM) programme in Indonesia. It was an “impact evaluation” with a baseline in late 2008 and an endline assessment just 2 years later in September 2010. It found that while “treatment communities” that received CLTS triggering showed higher numbers of households constructing toilets than “control communities”, the construction activity was mainly driven by non-poor households. The naïve and simplistic inference that this was somehow a result of simply implementing CLTS processes is very far from the truth. CLTS on its own will always target an open Defecation Free (ODF) environment and not toilet construction by some. These results have to be seen in the context of combining CLTS and sanitation marketing and the fact that this survey was done very early on during programme implementation. TSSM-supported market research by Nielsen (2009)1 had found that poor East Java households aspired to the pour-flush toilets with a ceramic pan, which cost twice as much as what the poorest households were willing to invest. Both the Nielsen study and action research in 20 districts (Mukherjee, 2012)2 found that the rural Indonesians preferred to defecate into rivers until they could afford such a toilet, because they believed that unimproved pit latrines are far more unhygienic than defecation in rivers. The TSSM response to the 2009 market research was to develop the desired product options at lower costs and build local market capacity to deliver them at prices the poor could pay. This took time. Thus poor consumers could find such products in local markets in only a few out of the 29 districts by 2010. The hurried endline assessment in September 2010 failed to capture the impact of improved supply of affordable toilets. That large numbers of the poor did gain access to improved sanitation following both CLTS and sanitation marketing interventions of TSSM – is amply illustrated in the 2200 communities in East Java being verified as ODF by 2011 3, when the TSSM closed and was replaced by the Government of Indonesia’s national Sanitasi Total Berbasis Masyarakat (STBM) program modelled on the TSSM approach.

The RCT study conveniently asks the poor why they have not constructed toilets and the response needless to say is that the cost is not affordable! There are countless surveys that will report the same findings. And the official knee-jerk reaction is to recommend a policy to subsidize toilets, without any attempt to understand why the poor say toilets are unaffordable, but find multiple cell phones per household entirely affordable !! (another finding from the 2012 action research: Mukherjee et al ,2012). The end result, as studies in India regularly bring out, are toilets on paper only and/or unused toilets on the ground. Clearly surveys of this kind are designed and carried out with little understanding of the importance of behaviour change in sanitation. On the other hand, surveys of ODF communities (where even the poor have toilets) in a subsidy free policy environment (as in Indonesia, since 2008 and in parts of India (Ahmednagar and Nanded districts of Maharashtra in 2004 and 2005 and the whole of Himachal Pradesh between 2006 and 2012), show that the toilets are constructed because the understanding that everyone's excreta must be confined safely for all to reap the benefit, has been internalized and where necessary the community has come forward to help its poor and less able. With the CLTS approach now present in over 60 countries, it is not difficult to access literature which brings out evidence of collective behaviour change being sustained by communities that recognize sanitation as a problem to be addressed by them on their own. Subsidy from above inevitably focuses attention on toilets and not behaviour change. It conveys the impression that the problem of OD is external to the community and breaks up the community into those who need to confine their excreta (those entitled to toilet subsidies) and those who need not!

The second study is of the Government of India’s Total Sanitation Campaign (TSC) in Madhya Pradesh (Patil et al 2013)4. Central to CLTS is collective behaviour change in a subsidy-free environment. The TSC in practice was based on hardware subsidies to individual households. These subsidies were a major inhibitor of collective behaviour change. The study is based on a comparison of 40 treatment villages and 40 controls. The treatment was not CLTS but described in the study as ‘CLTS-like’. What it did was use some ‘CLTS methods’ – only triggering is mentioned - together with the TSC subsidy. This resulted, as would be expected, in only very modest change - 19 per cent more toilets (32 per cent versus 13 per cent). At the end of the period 74 per cent of adults and 84 per cent of children in the treatment villages were still practising open defecation. 41 per cent of intervention households with improved toilets reported that adults were still practising daily open defecation. No villages became open defecation free. The WDR’s conclusion that ‘where CLTS was combined with subsidies for toilet construction, its impact on toilet availability within households was much higher’ is invalid. To justify that statement would have required comparison with a control which received CLTS without subsidies. But the control communities did not receive any treatment (except 10 out of the 40 towards the end of the period) and if they had it would have been with subsidy as national policy. The implication that this research showed CLTS does better with subsidies could not be more wrong. It is contradicted by world-wide experience in many countries which have adopted CLTS with great success. Many of these countries have used CLTS to achieve thousands of ODF communities through an enabling environment of national policies which abolish hardware subsidies. The evidence of the vast scale of the experience of these countries is more than anecdotal.

In privileging Randomised Control Trials over the mass of evidence and recorded experience concerning CLTS that is in the public domain, in failing to distinguish between the TSC and the radically different CLTS, and in neglecting to check out the text and conclusions in the Report before going to press, the WDR fell short of the levels of professional behaviour and rigour we expect from the World Bank. Not only has CLTS been misrepresented, but the credibility of the WDR as a cutting edge, thorough and evidence-based publication has been undermined. Given the focus on mind-sets and behaviour, it is ironic that the report does not critically reflect on the mindsets and behaviours that underpin the report itself. In this case they have led to an erroneous and damaging conclusion.

Signed by
Robert Chambers and Petra Bongartz, CLTS Knowledge Hub at the Institute of Development Studies, UK

Deepak Sanan, CLTS Foundation and Additional Chief Secretary to the Government of Himachal Pradesh, India

Dr. Nilanjana Mukherjee, independent sector specialist, India

Frank Greaves, WASH Adviser, Tearfund, UK


Footnotes

1 Nielsen (2009). Total Sanitation and Sanitation Marketing Report. Prepared for the World Bank Water and Sanitation Program.

2 Mukherjee N. et al (2012) Achieving and Sustaining Open defecation Free Communities : Learning from action research in 80 communities in East Java. Full report

3 Government of Indonesia’s ODF verification Guidelines require 100 % community households to be owning and using improved sanitation facilities, besides other criteria. That poor households in 2200 ODF communities gained access to improved sanitation , along with their non-poor neighbours, is a verified statistic. Through the TSSM project a total of 1.4 million people gained access to improved sanitation during 2008-11 in East Java province, as verified by the Ministry of Health, Government of Indonesia. CLTS was one of TSSM’s interventions, supplemented with Sanitation Marketing and Enabling Environment building. For details see Results, Impact, and Learning from Improving Sanitation at Scale in East Java, Indonesia (WSP, 2013), on www.wsp.org

4 Patil, S R, Arnold, B F, Salvatore, A et al. (2013) A Randomized, Controlled Study of a Rural Sanitation Behavior Change Program in Madhya Pradesh, India. The Water and Sanitation Program of the World Bank