Background
The JMP estimate suggests a rapid increase in improved sanitation coverage in rural areas from a baseline of 30 per cent in 1990 to 70 per cent in 2015. This is an impressive increase in improved sanitation coverage of 48 per cent in the last 15 years alone. According to the JMP open defecation has reduced from 43 per cent in 1990, to 25 per cent in 2000 and just 1 per cent in 2015. While there has been a significant decrease in open defecation this figure is somewhat misleading as it excludes fish pond latrines and other hanging latrines over rivers, which the Government of Viet Nam defines as unimproved latrines, rather than fixed point open defecation. From the JMP there are an estimated 155,000 rural households (620,000 people) who do not use sanitation facilities, but if fixed point open defecation is included then this number will be higher.

CLTS status and geographic spread
Introduced by SNV in 2008. CLTS has since spread to 20 out of 64 provinces in Viet Nam (31 per cent nationally) in 2015, although in most provinces only selected districts are supported – representing about 15 per cent of the country. Selection of areas for implementation is based on high rates of open defecation, low rate of households with hygienic latrines and ethnic minority areas. With an upcoming World Bank/GOV Payments for Results loan programme – Scaling Up Rural Sanitation and Water Supply (SupRSWS) – support will increase through targeting of 19 of the country’s poorest provinces located in the Northern Mountains and Central Highlands regions.

The Vietnam Health and Environment Management Agency (VIHEMA) of the Ministry of Health is the lead agency for sanitation and a major implementer through seven UNICEF focus provinces and five Plan International supported provinces. VIHEMA provides training materials, low cost latrine designs, and guidelines for CLTS and sanitation marketing. Provincial Centres for Preventative Medicine support facilitator training in these provinces. World Vision is implementing CLTS in nine provinces, with Codespa and Child Fund also having a lead role. Child Fund has implemented CLTS in a total of 19 communes in two northern provinces since 2010. Church World Service (CWS) is implementing in three districts in Lai Chau and Thai Nguyen provinces. Several Viet Nam mass organizations such as Famers Association, Women’s Union, Youth Union are also engaged in CLTS. World Vision implements CLTS in peri-urban areas in Hung Yen province. UNICEF has been instrumental in introducing CLTS within the provincial and national government systems through the DOH and MOH. This has largely helped CLTS as an official strategy for promoting sanitation. UNICEF has also introduced CLTS into the Government of Viet Nam’s Rural Water Supply and Sanitation National Target Programs.

CLTS variations and practice
CLTS is being integrated into:
Rural Water Supply and Sanitation Program National Target Program (NTP), National Patriotic Sanitation Movement; hand washing and sanitation marketing; and a Village Saving Loan programme of Plan International.

ChildFund: CLTS + PHAST
ChildFund is integrating CLTS with PHAST tools in order to provide knowledge about the relationship
between hygiene and health as well as to enhance hand washing with soap practice and hygienic
water usage. In order to raise the rate of households having hygienic latrines, activity will be
combined with saving credits in the livelihood sector to improve economic conditions at the
commune, with health sector to prevent malnutrition and water and environment sanitation related
diseases. In addition, projects have conducted SLTS, CHAST, and activities advocating hand washing with soap at school.

SNV: Sustainable Sanitation and Hygiene for All (SSH4A)
SNV is implementing the SSH4A programme in five countries (Viet Nam, Lao PDR, Cambodia, Nepal
and Bhutan). In Viet Nam, the SSH4A programme targets poor, ethnically diverse villages in the
Northwest, using CLTS with additional components to provide information on sanitation options,
behaviour change communication, increase access to low-cost sanitation goods and services, and
improve WASH governance.

Plan International: Sanitation Marketing
Plan WASH combines CLTS triggering of villages to stop open defecation (OD) with the introduction
of low cost options for sanitation (under Sanmark) to encourage people to make and use hygienic
toilets (particularly pour flush toilets using concrete rings that can be made on-site using a mould from
galvanized iron).

MoH and UNICEF: Community Approaches to Total Sanitation (CATS)
In Viet Nam, CATS is being implemented using interventions on CLTS, School Led Total Sanitation
(SLTS), sanitation marketing and hand washing with soap. Supply chains and sanitation markets in the project areas are strengthened to meet and maintain the sanitation demand triggered by CLTS, and hand washing with soap is included to ensure that this critical faecal-oral disease transmission route is blocked.

CLTS capacity
Large numbers of CLTS facilitators have been trained in Viet Nam. Codespa reports that 700 CLTS facilitators have been trained under its programmes. The Ministry of Health and UNICEF have also supported the training of 900 CLTS facilitators, World Vision 250, Plan International 150, and ChildFund 73, making a total of 2,073 facilitators trained. Of these only 15 per cent are estimated to still be active.

CLTS scale and ODF success rate
More than 2,020 villages have now been triggered using the CLTS approach, with the Ministry of Health efforts accounting for nearly 40 per cent of these triggered villages. CLTS is thought to be one of the most effective community mobilization models in sanitation promotion, and has resulted in a reduction of OD, and increased latrine coverage. Viet Nam’s ODF success rate has improved from 17 per cent in 2012 to 27 per cent in 2015. The number of certified ODF villages reported is 120 for MOH; Plan International reported 188 including self declared villages without formal certification; 63 villages by Codespa, ChildFund 62, and World Vision has not yet conducted an assessment of the ODF villages. Time required to reach ODF is between six to 12 months depending on the location.

Most significant changes since 2012
ODF verification and certification guidelines: Previously there was no official guide on what constitutes ODF and how to verify and certify when this milestone was reached. The introduction of ODF verification and certification guidelines has resulted in a commonly understood and clear definition of the ODF verification process. The guidelines comprehensively deal with faecal sludge management, as well as at commune level, bringing schools and health centres into the formalized certification process. The guidelines have been carefully developed and tested, with input from stakeholders.

Lessons learned
Government commitment needed for scaling up: CLTS is given more attention and support when the Government commits to becoming ODF by 2025 with a detailed plan and roadmap developed to reach this target, World Bank loan project for the scaling up of sanitation is upcoming and CLTS is mainstreamed into the poverty alleviation programmes.

Quality of triggering: The quality of facilitators impacts the quality and effectiveness of triggering sessions, with consistent quality follow-up needed to reach and sustain ODF. Implementing organizations do review facilitator performance at triggering and usually provide support and monitoring of facilitators but this is not systematic and varies between organization. Ensuring quality of follow up is a challenge.

Link with sanitation marketing: CLTS must be implemented together with sanitation marketing to address both supply support and demand creation. The availability of low-cost, socio-culturally appropriate latrine options using locally available materials has helped increase sanitation for a wider range of people with different levels of affordability and make CLTS more effective. Having markets available for sanitation products and services is important, as is involving masons early in the process.

Localize: Viet Nam’s recent experience highlights the importance of using local language (especially for ethnic minority areas) for triggering and other communications. The involvement of opinion leaders/religious leaders within communities can shape attitudes and change behaviour, however the commitment of local leaders is a critical factor in sustaining behaviour change.

Cost efficiencies: The cost of implementing CLTS in a country the size of Viet Nam is expensive and the Government has little budget. Ways to minimize costs include: applying a district-wide approach  to get economies of scale and increase ODF results; combining monitoring with other activities and village visits; optimizing facilitator training.
CLTS weaknesses and bottlenecks

Ability of poor: After triggering, some households do not build latrines, including entry level basic latrines, because they lack money. In some poor areas, the breadwinners of households work away from home, leaving only elderly people and children at home, making it difficult for poor households to physically dig pits and build latrines. There is little evidence of community initiatives to support the poorest members to build a latrine.

Weak capacity at village level: Village heads promote triggering, which means that the activeness of these people affects the triggering quality. Women’s Union members at village level appear unenthusiastic and unskilled even though they have been trained frequently.

Poor follow-up at district level: Currently the district Government is tasked to provide management support to CLTS implementation e.g. triggering, monitoring, and encouragement. However it is difficult for district staff to regularly provide support due to other commitments and distance to communities. The appointment of staff at the commune level to lead and monitor would increase efficiency of CLTS implementation.

atrine solutions for challenging environments: There is still a gap in the availability of lowest cost latrine models that are suitable for hilly areas and the social and cultural conditions of some communes.

CLTS opportunities over the next 3-5 years
Government’s commitment of ODF by 2025: Strong Government commitment to ODF by 2025, with a large loan programme from World Bank on scaling up sanitation with matching funds from the Government.

National ODF Guideline: National ODF Guidelines have been drafted, and when issued by MoH will become the standard for everyone to follow, especially guiding the responsibilities of local governments. The guidelines will also put emphasis on achieving and sustaining ODF rather than building toilets.

Low cost latrine options: Low cost latrine options are being developed by the MoH. Once issued they will provide official guidance on ranges of latrines including low cost hygienic latrines.

(September 2016)