For Cleaner and Healthier Rural Communities

Clean and healthy communities require proper sanitation, but one in every three people in the world still lacks access to a dignified sanitation service. Ghana has also struggled to improve sanitation coverage, and the situation remains challenging, especially in rural communities where private latrines are scarce.

Throughout the entire UN Millennium Development Goals period, between 2000 and 2015, the percentage of rural households practicing open defecation dropped by only one percentage point, to 31%. As of 2017, about 4 million people in rural Ghana still practiced open defecation, and many others rely on facilities shared between more than one household.

The most significant consequence of poor sanitation is the high burden of diarrhea and cholera. In 2017, Ghanaians suffered an estimated 41 million cases of diarrhea and nearly 800 cases of cholera. Over 7,000 deaths were caused by diarrheal disease in the country, and more than 3,500 of them were children.

Sanitation is an urgent issue policymakers need to focus on in order to improve Ghanaians’ overall health, but it’s not the only one. While Ghana has seen impressive economic growth in the last two decades and the government has increased public spending to advance development, resources are always limited and decision-makers need to prioritize the smartest initiatives with the highest likelihood of success.

To improve sanitation in rural communities, a group of researchers for the Ghana Priorities project which aims to highlight the most cost-effective policy proposals for the country, studied the impact of the main community sanitation intervention used in rural Ghana, the Community-Led Total Sanitation (CLTS) model.

The CLTS initiative is a three-step process. First, communities are selected, information is collected to plan the intervention, and the implementers are trained. Second, the program aims to make community members aware of their current unsanitary conditions and practices and motivate them to engage with the program and construct latrines. In the final step, the implementers conduct follow-up visits to assess the success of the program.

The total costs of this intervention on its own were estimated at GH¢ 3.7 million for a nationally representative area of 100 villages and around 80,000 people. With this investment, the researchers predict a 15% average improvement in uptake rates for the latrines. Households that build latrines see a 20% reduction in diarrheal disease, which translates into 31,000 cases of diarrhea and 6 premature deaths avoided over a 10-year period. Additionally, beneficiaries would save 5 minutes a day from not having to find a place to open defecate – a staggering 80,000 hours over a 10-year period for these communities. The total benefits of the CLTS intervention were estimated at GH¢ 4.8 million, meaning every cedi spent on this initiative would produce 1.3 cedis of social benefit.

These figures mask the fact that not all villages respond to CLTS equally, with some greatly increasing the use of latrines and others much less. This difference matters because health benefits are greater when a large proportion of the population in any community takes up improved sanitation. The analysts assume that once latrine coverage reaches 75%, all households would see a reduction in disease rates of up to 35%. This way, even those that don’t have a private latrine can eventually benefit from a successful implementation of the CLTS intervention. 

One important reason households don’t switch to improved sanitation is the cost of a latrine. Providing subsidies can help but because they are expensive, it is important that they are targeted to where they can be most effective. With this in mind, the researchers suggest a second intervention where the 40% poorest households in villages that respond well to CLTS are provided with a subsidy. They estimate this would increase the uptake rate of improved sanitation by 22%. When the traditional CLTS intervention is coupled with the subsidy, the benefit in reduced disease and death also increases, to around 44,000 non-fatal diarrhea cases, and 9 premature deaths averted over the 10-year period. Across the region, more than 94,000 hours could also be saved by adopting the intervention, increasing the potential benefits in improved productivity for the communities. The cost of this intervention, including the subsidy, is GH¢ 4.2 million, and the benefits reach nearly GH¢ 7 million, meaning they’re now 1.7 times higher than the original investment.

The CLTS intervention passes a cost-benefit test both with and without a subsidy, showing that improved sanitation has an important effect on reducing disease and mortality. The initiative may also bring other non-health benefits, including a reduced risk of assault, increased dignity, and better privacy, all of which are especially relevant for women in particular. Cleaner, healthier communities are also more productive, and the access to proper sanitation is key to unlocking their potential.

This article was originally published in Ghana's newspaper of record - The Daily Graphic.