The 41st WEDC Conference in Nakuru, Kenya was an open door for Water, Sanitation and Hygiene (WASH) practitioners from different organisations and parts of the world to discuss how to reach the 'last mile', how to involve the most vulnerable individuals and communities in open defecation free (ODF) processes, and to debate the design of, and access to, sanitation facilities which adapt to diverse needs, means and contexts.

(Colourful signboards inform people about good health practices, Jamam refugee camp, South Sudan. Photo by: Alun McDonald/Oxfam)

Last mile people, last mile communities
The expression 'last mile' is commonly applied to refer to those people or communities who are the last and most difficult to be reached by sanitation programming. On the one hand, practitioners who attended the CLTS Knowledge Hub's Sharing and Learning workshop at WEDC identified the last mile people as the extremely poor, the elderly, people with visual, hearing or mobility impairments, people with mental health problems, street vendors, sex workers, landless people, as well as women and children under-five with limited access to sanitation facilities.

On the other hand, last mile communities were recognised as those living at border areas (e.g. migrants in remote areas who are resistant to change their behaviours), settled in geographically isolated areas or in difficult terrains (hard rocky areas or loose soils), with socio-cultural norms which forbid their populations to practice sanitation, and also nomad communities, pastoralists groups and communities with no access to a water source, among others.

Despite the fact that the characteristics presented above are quite broad and at the same time quite narrow (as many more examples could be shared), they help us to understand that within the ‘last mile’ we can talk about whole communities which are marginalised and difficult to reach, as well as about vulnerable often marginalised people in non-vulnerable communities. They also bring new light to the need for Community-led Total Sanitation (CLTS) and WASH programming to be designed taking into account these people’s perspectives and particularities.

Current answers and innovations to reaching the last mile
The challenges to reach the most marginalised people and communities are substantial, inter-related, context-specific, and if they are to be solved require combined efforts from the start. Even with all of these difficulties, several countries are currently implementing more equitable and inclusive CLTS and WASH programmes designed to take different voices and perspectives into account in order to reach and provide adequate, accessible and sustainable solutions for those most in need.

Some of the solutions and innovations identified and shared by participants are presented below:

Further involvement of local level actors
To start with, in Kenya community health workers are considered to play an important role in the triggering process as they have relevant grass-root knowledge and networks, for example: connections with government officials, also with practitioners implementing the sanitation programmes and with each community member. For this reason, some Kenyan counties started to provide motorbikes to their health workers for them to reach everyone in their communities. While not at work, the community health workers can use the motorbikes for their own businesses which empowers them economically and contributes to sustain the work of local level actors. Furthermore, SNV Kenya trains their health workers to be aware and consider the most vulnerable people in their interactions with the community.

In Ethiopia, health extension workers are based in the remote areas, they do the follow-up of the CLTS implementation and reward community members who carry out good implementation practices (e.g. identifying best households and giving soap as a reward or flags to identify Open Defecation Free (ODF) from Open Defecation (OD) households). A similar intervention takes place in remote areas from Malawi where health surveillance assistants are the linkage between the communities and the health system, and work close to improving the sanitary behaviours of mothers and children while contributing to reduce the rates of diarrhoea and under-five mortality.

Another relevant example comes from Dantewada, an insecure district in the Indian state of Chhattisgarh where there are apparently no government agencies working on sanitation, and programmes led by external development agencies have previously been very difficult to implement as communities didn't trust outsiders and had been very resistant to accept any change in their social norms and behaviours. In order to improve sanitation outcomes UNICEF worked with the community to help them understand that without any government sanitation programmes being implemented, sanitation solutions would need to come from local ideas and innovations led by the communities themselves. By applying a CLTS approach, triggering with videos showing some of the major health problems caused by OD, fostering capacity building and institutional strengthening it was possible for UNICEF to disseminate messages on CLTS and WASH, and make the community involved in the ODF process to later declare the area ODF. It was found relevant to further understand the local context and to sensitize local stakeholders in order to have their support to generate sustained sanitation behaviour changes. Now the communities themselves are working on post-ODF strategies.

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(Health Surveillance Assistant, Webster Phiri, leads the triggering for the children. They are also singing: ‘let’s end open defecation’. Photos by WSSCC/Katherine Anderson)

Financing mechanisms to reach the most vulnerable
The 'Financial Inclusion Improves Sanitation and Health in Kenya' (FINISH INK) project in Busia county is a remarkable innovation in Kenya which was designed to provide finances for sanitation and health improvements for previously excluded communities. Amref Health Africa fosters access to finances for the poorest households in Busia county through the creation of a sanitation loan portfolio and a county saving scheme. The Kenyan Government is involved in the project and provides initial funding; financial partners are later linked to the customers and commercial banks are also involved in order to increase the amount of investment to build and improve sanitation facilities.

Ghana presents another case in which the national government designed guidelines to target the most vulnerable people and provided financial support in terms of subsidies for them to build and improve their own toilets.

Making approaches inclusive and products accessible
Thinking about ways in which to involve people with disabilities in the CLTS process, the Water Supply and Sanitation Collaborative Council (WSSCC) started to develop menstrual hygiene management (MHM) interventions for girls and women with hearing impairments in India and Kenya. During the workshop Patricia Mulongo, hearing-impaired MHM trainer in Kenya, highlighted the importance of having professionals who manage sign languages and who can easily understand and depict messages, as family members, care-givers and community health workers usually cannot get the whole message. WSSCC is also producing and distributing MHM materials which are accessible for people with different disabilities.  

Furthermore, the PhD. Candidate Amita Bhakta from Loughbourogh University U.K. is currently running a compelling study on MHM for perimenopausal women in Ghana; a research topic which has been hardly studied during the past years. According to the researcher, there is inadequate access to sanitation infrastructure, sanitation services, financing, and an increase in the demand for water which makes the access to MHM a real challenge for perimenopausal women. This research brings new light on the need to think further about how to find the most vulnerable and also how to reach them with solutions and innovations that adapt to their needs.

Amref Health Africa is also developing a sanitation marketing (SanMark) strategy in Kenya focusing on fostering designs of sanitation products which are context specific and rely on local materials. The organisation understands that toilets have many interfaces (a superstructure, a collection and treatment interfaces and a substructure), and as a consequence there is a need to look at the various contexts and decide what sort of coverage is needed and which interfaces should be put together to suit a particular context.

In Nigeria the EcoSan innovation was developed in delta areas but it was an expensive option and the technology was not inspirational for the communities, so entrepreneurs started to develop local technologies which are cheaper and more acceptable. Entrepreneurs are also starting to offer different options of latrines to reach the most vulnerable and also pushing for the creation of affordable community loans. Furthermore, in Niger WaterAid is designing latrines for nomads. These are suitable for areas with high water tables and are placed in nomadic roads. The latrines contain plastic cans which are placed in the pit to protect the water table and are also a source of water for the nomads and their cattle.

Key learnings and ways forward

In order to involve every single person in the process of reaching ODF status, practitioners identified the importance of involving local level actors, as in the case of Ethiopia, Kenya and Malawi. It is also highlighted the need to identify and work together with key influencers at the community and district level like in India, to develop financing mechanisms, products and technologies that adapt to particular challenging environments and needs like in Ghana, Kenya, Nigeria and Niger, as well as to design and implement triggering process differently, as carried out by WSSCC Kenya, in order to leave no one behind.
Furthermore, it is necessary to understand that individual needs will vary across time, consequently sanitation technologies and designs have to be prepare to face changing requirements. As raised by some of the participants, there is a compelling need to understand that ODF status is not about the toilet as a structure, but about us having the possibility to access that toilet whenever we want it. Moreover, an ODF community should entail the possibility to access the same type of toilet wherever we are.

Florencia Rieiro in an independent WASH consultant