Reduction of stunting by CLTS in Mali: a case study to learn from

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Mali is renowned as the location of the one of the few Community-Led Total Sanitation (CLTS) programmes that has managed to demonstrate a reduction in stunting from increased community-level sanitation coverage. There is much to learn and share from this programme, especially across the West and Central Africa region where similar sanitation challenges are faced and open defecation rates generally remain high.

(Children outside school in Koulikoro, Mali)

During 2011-2013, a cluster-randomised controlled trial (RCT) of a UNICEF Mali CLTS programme found that sanitation access in the CLTS villages increased by 30 per cent (to an average of around 65 per cent), and that children in CLTS villages were taller and less likely to be stunted than children in control villages1 . Further research on the same programme also found that community-level sanitation coverage is more strongly associated with child growth and household drinking water quality than access to a private toilet2.

Analysis of sanitation and health status data from 121 villages from the same Mali CLTS programme found that “community toilet coverage” (defined as coverage within 200m of the household) was significantly associated with higher child height-for-age (measure of stunting); and that child weight-for-age (wasting) and household water quality had positive associations that levelled off when sanitation coverage reached 60 per cent. However, neither child growth nor household water quality was associated with individual household toilet ownership. What does this mean? That, in this context, collective sanitation outcomes had measurable positive impacts on both child growth (stunting and wasting) and water quality, and that these benefits were not linked to whether the individual household used a toilet or not.

The UNICEF Mali CLTS programme was a well designed and implemented rural sanitation programme, which utilised social norms thinking and other approaches to increase the effectiveness and sustainability of the results. The evaluation also found that CLTS households were more than twice as likely to have a cover over the hole of the pit, and less likely to have flies observed inside the toilet; and all toilets seemed to be in regular use, with clear footpaths to the toilets, and toilet floors showing evidence of water from anal cleansing (or from urine) as a marker of recent use. All of these findings suggest that the programme was successful in promoting consistent use of more hygienic toilets. CLTS households were also half as likely to have human faeces observed in the courtyard, animal faeces were less likely to be present, and toilets in CLTS villages were more likely to be stocked with soap and water. Toilet use was also more of a social norm: only 14 per cent of households in CLTS villages reported that “the majority of people in my community do not use latrines for defecation” compared with 48 per cent in non-CLTS villages, and child potty use increased by 35 per cent.

This programme illustrates the importance of a holistic approach to rural sanitation and hygiene, with CLTS used as an entry point to encourage behaviour change, but with significant additional efforts made to encourage hygienic sanitation practices and facilities, promote improved hygiene behaviours, and facilitate wider environmental sanitation improvements (e.g. management of animal excreta and safe household water use).

Photo ‘Mali: School Building in Mali’, taken by GPE/Michelle Mesen.

Andy Robinson is an independent WASH Consultant.

  • 1. Pickering A, Djebarri H, Lopez C, Coulibaly M and Alzua ML (2015) Effect of a community-led sanitation intervention on child diarrhea and child growth in rural Mali: a cluster-randomised controlled trial The Lancet Global Health Vol 3 November 2015 e701-11.
  • 2. Harris M, Alzua ML, Osbert N and Pickering A (2017) Community-level sanitation coverage more strongly associated with child growth and household drinking water quality than access to a private toilet in rural Mali Environmental Science & Technology 2017, 51, 7219-7227.
Date: 11 July 2018