The biggest lesson is that a key to good spread is, at all levels, finding, supporting and multiplying champions, and then their vision, commitment and courage.
Perhaps as many as 2 billion people living in rural areas are adversely affected by open defecation (OD). Those who suffer most from lack of toilets, privacy and hygiene are women, adolescent girls, children and infants.
Sanitation and hygiene in rural areas have major potential for enhancing human wellbeing and contributing to the Millennium Development Goals (MDGs). Approaches through hardware subsidies to individual households have been ineffective. Community-led total sanitation (CLTS) is a revolutionary approach in which communities are facilitated to conduct their own appraisal and analysis of OD and take their own action to become open defecation free (ODF).
In six of the countries where CLTS has spread – Bangladesh, India, Indonesia, Pakistan, Ethiopia and Kenya – approaches to implementation differ, with contrasting combinations of NGOs, projects and governments. Practical elements in strategies for going to scale have included: training and facilitating; starting in favourable conditions; conducting campaigns and encouraging competition; recruiting and committing teams and full-time facilitators and trainers; organising workshops and cross-visits; supporting and sponsoring Natural Leaders and community consultants; inspiring and empowering children, youth and schools; making use of the market and promoting access to hardware; verifying and certifying ODF status; and finding and supporting champions at all levels. To spread CLTS well requires continuous learning, adaptation and innovation.
Yet it also requires major institutional, professional and personal shifts. Opposition at senior levels, pressures to disburse large budgets, demands to go to scale rapidly, and programmes to subsidise hardware for individual rural households have been and remain threats and obstacles.
Issues for review, reflection and research include: diversity, definition and principles; synergies with complementary approaches; scale, speed and quality; creative diversity; and physical, social and policy sustainability. In seeking constructive ways forward, there are four key themes: methodological development and action learning; creative innovation and critical awareness; learning and action alliances and networks; and seeking to seed self-spreading or light-touch movements.