A Community Approach to Better Public Health in Rural Liberia

A Community Approach to Better Public Health in Rural Liberia
By Russell Sticklor
This artilce originally appeared in USAID’s Global Waters.

Residents of Lofa County’s Vahun district in Liberia gather to discuss strategy for sustaining recent local sanitation improvements. Photo Credit: Global Communities

Liberia is no stranger to difficult times, having weathered a devastating Ebola outbreak and now struggling through a slow economic recovery. Lost amid the headlines from these events is the story of Liberia’s quiet public health victories.

Half of Liberia’s 4.5 million people live in the countryside and roughly the same amount practice open defecation. This practice has jeopardized public health by facilitating the spread of diseases that cause diarrhea, Liberia’s sixth leading cause of death and the primary cause of childhood morbidity and mortality.
However, thanks to two programs that championed community-led sanitation improvements, USAID has now helped 1,500 Liberian communities achieve open defecation-free (ODF) status — fueling optimism about continued public health improvements in the near term.

It Takes A Village
Between 2010 and 2015, USAID’s $10 million Improved Water, Sanitation, and Hygiene (IWASH) program partnered with communities throughout rural Liberia, encouraging them to take ownership of their sanitation futures and stamp out open defecation. IWASH and its follow-on program, the Partnership for Advancing Community-Based Services (PACS), have largely accomplished this feat by employing a methodology known as community-led total sanitation (CLTS).

Originally pioneered in Bangladesh in the late 1990s, CLTS is an organic process for improving sanitation that places local residents in the driver’s seat for developing and implementing sanitation upgrades and undertaking the behavioral changes that lead to ODF.

CLTS prioritizes community engagement and accountability. A participating community receives training on how to upgrade infrastructure and adopt behavioral changes concerning hygiene and sanitation. They do not receive subsidies. To ensure continued progress on the path toward ODF status, community members encourage and assist one another to maintain the lifestyle changes needed to sustain their community’s collective sanitation improvements.

CLTS is practiced today in more than 50 countries worldwide, with varying levels of success. But in Liberia, it has delivered big results: By the time IWASH concluded last year, program targets for open defecation free communities had been surpassed by more than 40 percent, and more than 163,000 rural Liberians were accessing an improved drinking water source.

Hattie Payweyne, a seasoned CLTS professional with Liberia’s Ministry of Public Works, travels by raft in Grand Cape Mount County near the Sierra Leone border as part of a CLTS verification trip to monitor nearby communities’ progress in achieving open defecation-free status. Photo Credit: Global Communities

A Tailor-Made Approach
A three-pronged programming model known as “CLTS+” has fueled the sanitation successes of IWASH and PACS. Custom designed for Liberia, CLTS+ places equal emphasis on low-cost locally sourced technological innovations; active and sustained collaboration with both traditional leaders and government agencies; and the development of Natural Leadership Networks, a 610-strong cadre of dedicated Liberian CLTS advocates.

“Communities reach within themselves and come up with ingenious ways of improving their sanitation.”
—Ochiawunma Ibe, senior community health services advisor for USAID/Liberia

The first programming priority is to encourage inexpensive, local solutions for improving sanitation infrastructure. This unleashes communities’ creativity and resourcefulness resulting in such interventions as constructing sand-rock household filters to remove dirt and odor from water; harvesting tall reeds and refashioning them into water-conserving handwashing devices; and using bamboo as piping for slabless ventilated improved pit latrines. Using local materials to build such infrastructure provides a boost to the local economy, while entrepreneurship trainings further develop local markets for sanitation-related products and services.

“Communities reach within themselves and come up with ingenious ways of improving their sanitation,” says Ochiawunma Ibe, senior community health services advisor for USAID/Liberia. “These inventions are exciting and demonstrate the extent to which the communities have taken ownership of the CLTS process and are truly on the path to sustainable development.”

Sanitation infrastructure improvements, such as this newly installed slabless ventilated improved pit latrine, have helped more than 1,500 communities across rural Liberia achieve open defecation-free (ODF) status. Photo Credit: Global Communities

Building Institutional Capacity for Sustaining WASH Improvements
The second core element of CLTS+ integrates WASH into Liberia’s decision-making structures at the community, district, county, and national levels.

Both programs engaged rural Liberia’s influential clan and district leaders, whose buy-in is critical­ — by tradition they must approve community practices before they are adopted.

At higher levels of government, capacity building for integrating WASH into policymaking has involved close collaboration with county-level officials and national agencies like Liberia’s Ministry for Public Health and Social Welfare and the Ministry of Public Works, resulting in creation of the “Guidelines for Community-Led Total Sanitation Implementation in Liberia” policy handbook, published in 2012.

County Health Teams are then created, which monitor ODF communities to ensure continued compliance, and help local governing bodies navigate budget issues and other administrative hurdles standing in the way of broader CLTS implementation.

Sanitation Ambassadors
Perhaps most of the credit for Liberia’s hard-earned sanitation achievements can be traced to the third core element of CLTS+, the grassroots CLTS champions that make up the country’s Natural Leadership Networks. A joint initiative between IWASH and the Liberian government, the Natural Leadership Networks are comprised of 600 of Liberia’s most charismatic, persuasive, and respected community members, who serve as CLTS’ outspoken proponents.

Part public educators, part community organizers, Natural Leaders receive three days of training on how to “trigger” their own and nearby communities to go ODF. Natural Leaders raise public awareness about the health risks associated with open defecation, and monitor their community’s CLTS progress, and once achieved, they help ensure that the community preserves its ODF status.

Some Natural Leaders then become “sanitation ambassadors” who travel to neighboring communities to rally village support for becoming ODF. After a target community has embraced CLTS and achieved ODF status, the Natural Leaders from that community then become CLTS ambassadors themselves, identifying potential WASH advocates in neighboring communities, and the cycle begins anew. For their efforts, successful Natural Leaders are rewarded financially, receiving roughly $65 for every community they help achieve ODF status.

“If we involve more women in this process, it becomes more sustainable.”
—Elizabeth Geddeh, WASH program manager

Since evidence suggests women are often more receptive to implementing sanitation improvements if fellow females deliver the message, IWASH and PACS have also prioritized female recruitment to fill the ranks of the Natural Leadership Networks. Today, gender mainstreaming has become a strategic priority for the networks, and women have emerged as some of CLTS’ most influential advocates.

“People are appreciating what we are doing, and we are trying to encourage other women to step forward” as community sanitation leaders, says Elizabeth Geddeh, a WASH program manager working with PACS in Nimba and Montserrado counties, who has also led CLTS training for government staff. “If we involve more women in this process, it becomes more sustainable.”

Full Speed Ahead
In Liberia, one CLTS success story begets another. At times, sanitation improvements have even been spurred on by friendly rivalries that have sprung up between neighboring communities. At a December 2015 gathering to honor the first Liberian district to achieve ODF status, chiefs and commissioners from neighboring districts were invited to join the celebration. During the proceedings, several chiefs got up and pledged that theirs would be the next district to become ODF.

Piet deVries, former chief of party for IWASH, said: “There was a great positive competition between them. You got a sense of camaraderie in this adoption of CLTS, and all of them feeling that they were moving ahead, and wanting to be the first to achieve this milestone for their own community.” (Click here to hear deVries speak with Global Waters Radio about Liberia’s sanitation success stories in greater detail.)

Drawing on such public enthusiasm, the USAID-funded PACS program is now harnessing the power of CLTS+ to assist an additional 730 rural Liberian communities in reaching ODF status before the program’s conclusion in 2020. Can this ambitious new milestone be reached?

For some of Liberia’s most outspoken Natural Leaders, the answer is a foregone conclusion — so long as communities remain committed to collectively addressing public health issues and hold each other accountable for maintaining sanitation improvements. CLTS is “like a wildfire spreading from community to community, county to county,” says Geddeh. “And we need to keep it burning.”

Photo Credit: Global Communities