Eliminating open defecation is increasingly seen as a key health outcome, with links to reduced stunting, improved educational and positive health outcomes for children. In Sub Saharan Africa, over 35 countries are implementing some form of CLTS, ranging from TATS in Tanzania to CLTSH in Ethiopia. Since the introduction of CLTS in 2005 in the region, rapid scale-up has been achieved with suggested numbers of ODF communities in the range of 30,000 affecting over 15 million people in Sub-Saharan Africa. Several countries have set aggressive targets for elimination of Open Defecation in rural areas for the next five years which often include not only safe disposal of faeces but handwashing facilities, cleanliness and solid waste management. Sustaining the progress made through the application of the CLTS process is emerging as a challenge with experience suggesting that sustainability is determined by the process followed to achieve ODF. Rapid scale up in SSA is arguably linked to the fact that CLTS is based on the concept of triggering community-wide behaviour change, requires no subsidies and integrates easily into existing health programming structures. Current focus is on ‘triggering’ communities into action; while considerably less resources and emphasis on following up and mentoring of communities ‘post-triggering’. This paper reviews process and protocol for defining, reporting, declaring, certifying ODF and sustaining ODF, highlighting where the process varies between countries and potential determinants of sustainability within the process itself. Critical questions include what elements (should) constitute an ODF protocol, what are the determinants of sustainability and what impact does target-setting have on achievement of ODF goals in country?

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