Background
The JMP estimate suggests a rapid increase in improved sanitation coverage in rural areas from a low of 17 per cent in 2000 to 56 per cent in 2015. The main contributor to this increase has been the reduction of open defecation. The latest JMP estimates that open defecation sits at 37 per cent, which suggests that 270,000 rural households (1.6 million people) do not use a sanitation facility.

CLTS status and geographic spread
Introduced by WSP and CONCERN Worldwide in 2008, CLTS has since spread to 31 districts out of 143 nationally, in 10 out of the 17 provinces in Lao PDR (59 per cent nationally), although in some provinces CLTS is only being implemented in one district in a limited number of villages. The biggest concentration of effort is by W SP and SNV, and the Nam Saat in Champasak and Sekong provinces, covering 174 villages across 10 districts. During 2015-2016, the Provincial Nam Saat in Champasak and Sekong are planning to carry out CLTS triggering in 250 villages across 10 districts, pending government budget availability.

CLTS is not promoted in urban areas.

Implementation of CLTS remains a relatively a concentrated effort in Lao PDR, however since 2012, the Ministry of Health, Nam Saat, has played a much greater role, especially through direct implementation of CLTS by district health offices (including setting targets, formulation of operational plans, and carrying out CLTS processes such as pre-triggering, triggering, follow-up/supervision, ODF verification). Provincial health offices have the role of management, coordination, providing periodic supervision, training and performance monitoring. UNICEF is a new entrant, having dropped its latrine subsidy programme in 2011. Private sector involvement is a new feature with the Theun Hinboun Power Company, implementing CLTS in selected villages in two districts of Borlikhamxay province. THPC piloted CLTS in Nonxong village, which is home to around 650 people who moved to the village from other areas in 2009, during the expansion of the Theun-Hinboun hydropower project. Nonxong has subsequently become ODF. WSP commissioned two local associations, namely the Community Development and Environment Association (CDEA) and the Lao Biodiversity Association (LBA) to implement CLTS in 40 villages during 2011-2013. More recently, WSP commissioned SNV together with the Participatory Development Training Center (PADECT). Plan implements CLTS in selected districts across three provinces: Bokeo, Oudomxay and Saravanne. WSP is providing technical assistance at the national level (Dept. of Hygiene and Health Promotion and the National Centre for Environmental Health and Water Supply), including capacity building (TOT on CLTS national facilitators), developing CLTS national guidelines, ODF verification, and monitoring frameworks and operational programme guidelines on scaling up rural sanitation in the country. UNICEF, together with development partners, is working with MoH and other ministries to come up with an overarching WASH Policy and implementation strategy, which includes rural sanitation.

CLTS variations and practice
WSP: CLTS + sanitation marketing (+ handwashing with soap): CLTS has been integrated with handwashing with soap (this is in the pilot stage) and is piloting integration of CLTS into the Poverty Reduction Fund (PRF) programme in collaboration with the National Centre for Environmental Health and Water Supply (Central Nam Saat). The PRF pilot project covers 40 villages of six districts across four provinces (Attapeua, Saravan, Sekong and Savannakhet). Sanitation marketing has been carried out by WSP alongside CLTS work in Champasak and Sekong provinces. This has involved strengthening the skills and services of sanitation producers, and integrating informed choice and technical knowledge with CLTS triggering. In addition, WSP, together with East Meet West (EMW), has piloted a sanitation output-based approach. This approach encompasses sanitation marketing with demand generation through CLTS, but adds a suite of innovative features designed to help poor households to overcome financial barriers to accessing improved sanitation and to incentivize communities and community volunteers to become ODF.

SNV: Sustainable Sanitation and Hygiene For All programme (SSH4A): The Sustainable Sanitation and Hygiene for All (SSH4A) programme is implemented in collaboration with the Provincial Rural Development and Poverty Reduction Office in Savannakhet province, together with its subordinate offices in the three target districts (Atsaphon, Phin and Xonabouri). Other programme stakeholders and partners include personnel from the local branches of the ministries of Health, Education, Planning and Investment, Lao Women’s Union, and the Lao Youth Union. SNV provides capacity building, organizational and technical support from its team, which includes associate advisors, consultants and local capacity builders. Provincial and district governments conduct CLTS triggering, post-triggering, ODF verification and declaration based on government standards and guideline. Provincial and district governments develop work-plan and monitoring systems with technical support from SNV.

UNICEF: CTLS was integrated with WASH in schools and linked as a prerequisite for water supply provision.

Plan International: CLTS + SLTS: Plan focused on CLTS in communities and SLTS in schools through four topics, using toilets, handwashing, safe drinking water and clean environments within all target schools and villages for Bokeo and Oudomxay provinces.

CLTS scale and ODF success rate
Due to a reliable database dating back to 2009, data shows that more than 565 villages have been triggered using the CLTS approach since 2009, with a quarter of these in the period between mid-2014 and 2015. Approximately 144 villages have been declared ODF, although not all of the declared ODF villages in 2015 have been certified yet as many were only recently declared ODF. Lao PDR has a moderate ODF success rate: 25 per cent of triggered villages have been declared ODF. However the rate is misleading in that a number of villages were triggered in the period between mid-2014 and early 2015, and are still pending being declared ODF. The length of time to reach ODF
from triggering is 9-10 months, but this depends on factors such as:

• the activeness of village authorities and established village CLTS committees;
• close post-triggering follow-up by facilitators and mobilization work by village CLTS committees; and
• availability of sanitation options/materials/suppliers.

Successful triggers include: disgust, privacy, and stigma of continuing open defecation.

CLTS capacity
A total of 306 CLTS facilitators have been trained in Lao PDR through capacity development activities supported by CONCERN Worldwide, WSP, Plan, SNV and World Vision. The main CLTS trainers have been from the Participatory Development Training Centre (PADETC), SNV and the National Centre for Environmental Health and Water Supply (Nam Saat). Of these, the sector has jointly trained 17 trainers from five provinces who are now certified as national master trainers. Many of the others trained are district-level facilitators (averaging 10 per district). Lao has records of the gender break down on two thirds of the facilitators trained. Where records are available, most of the facilitators are males, with just 29 per cent being female. WSP, SNV and Plan report that of the combined 171 facilitators trained between them, all are still active. For other partners, the number of facilitators still active is unknown.

Most significant changes since 2012

• CLTS guidelines: The development of a standardized set of guidelines and manuals on CLTS for Lao PDR, including a package for the training of trainers, has helped make the approach to CLTS more consistent. An Operational Guideline for Scaling Up Rural Sanitation has also been developed and approved by the Department of Hygiene-Health Promotion (MoH) that helps to guide and unify the sector.
• Wider acceptance of CLTS: Momentum is gaining in the sector and more partners are becoming aware of the progress made using the CLTS approach. More NGOs are applying the approach in their projects. The government is open to and promotes the CLTS approach, recognizing that it is one among other approaches to generate demand for sustainable sanitation.

Lessons learned
Cost efficiencies in scaling up: There are economies of scale when scaling up CLTS. Based on simple cost-efficiency calculations:

• If implementing CLTS in 60 villages, it costs US$ 58,965 (US$ 982/village)
• If implementing in 240 villages, it costs US$ 104,102 (US$ 434/village)

The cost for CLTS is reasonable if compared with the result in changes of behaviour of villagers
from open defecation to ODF.

Government support needed to scale up: To scale up, support is needed from governments to be involved throughout the whole process. Government commitment to sanitation and water supply is an important complement to CLTS as government decisions have legitimacy at community level. The challenge for the future is to make best use of both CLTS and government commitment. Advocacy for the government at senior levels (central and provincial authorities) to allocate funding to support demand creation for rural sanitation is crucial for working at scale.

CLTS stimulates latrine innovation: The introduction of CLTS, and the avoidance of hardware subsidies, has stimulated some innovation in latrine design and construction, and most families have been able to build toilets without employing a mason. However, there remains a strong preference for pour-flush latrines which are unaffordable to most poor households. Technical assistance in the design and marketing of more affordable, hygienic latrines would potentially be very useful and help to make scaling up possible.

Good facilitation skills essential: Good quality training, followed by ongoing mentoring support, is essential for CLTS facilitators and should be incorporated into plans and budgets for scaling up.

Triggering alone is not sufficient: Triggering alone is not enough to secure community-wide, long term change in defecation habits. Substantial follow-up is needed to strengthen community motivation for change and (in some cases) to provide technical advice or logistical support with latrine construction.

Hygiene behaviours need special attention: CLTS is good at delivering ODF communities but does not necessarily impact other hygienic behaviours. There may be scope for including a hygiene promotion component in post-triggering follow-up, focusing as a minimum on the key issues of handwashing with soap or ash at critical times. Experience from other countries indicate that this can be facilitated as a community-led process.

Community leaders are important: Community leaders play a pivotal role in the achievement of ODF status. This role should be nurtured and encouraged, not only to accelerate progress in the leaders’ own villages, but also for scaling up promotion to surrounding communities.

Capacity building takes time: Enhancing local government capacities to fully implement the programme requires continued, long-term commitment.

CLTS weaknesses and bottlenecks
Multiple criteria difficult to meet: In order for communities to be declared ODF there are several criteria which have to be met which are not directly related to ceasing open defecation behaviour. This takes a long time for villages in Lao PDR to meet all these criteria (longer compared to other countries to achieve ODF).

Government lacks money: The government lacks funds to support implementation. Financing systems are needed.

Lack of capacity at district level: There is limited capacity for government agencies (both in quantity and quality) to carry out CLTS work, especially at the district level. The limited number of district staff available in Nam Saat presents a challenge for scaling up. Partnerships with competent INGOs could potentially be very useful if they could deploy additional field workers to support Nam Saat.

More affordable design needed: For the poorest, cost is still the biggest challenge in adopting improved sanitation. Limited availability and range of products in terms of affordability and desirability is a constraint.

High transport costs: Transport costs (both for staff to communities and supplies/suppliers to communities) increases the cost of implementation and puts pressure on scaling up.

Monitoring system missing: Monitoring and evaluation systems and tools are not yet in place, making it difficult to assess progress and gaps.

CLTS opportunities over the next 3-5 years

• WASH Policy and Sanitation Implementation Strategy: UNICEF, together with development partners, is working with MoH and other ministries to devise an overarching WASH policy and implementation strategy. Rural sanitation will be a strong component of the policy. In the UNICEF-Lao Government 2015-2016 work plan, support will be provided to MoH for the development of a National Sanitation Strategy (Sanitation Road Map). This strategy will pave a way to move forward with short, medium and long term action plans to eliminate open defecation.
• Integrate CLTS with nutrition and poverty reduction: The World Bank is in the process of consultation with the Government to develop a new programme of support for the Ministry of Health on Health and Nutrition, as well as to the National Rural Development Office on Poverty Reduction Program, which will have a multi-sectoral approach. Sanitation will be one of the main priority areas of intervention.

(September 2016)