The Impact of Pro-Poor Sanitation Subsidies in Open Defecation-Free Communities: A Randomized, Controlled Trial in...

Area of Science:

• Global health
• Environmental health
• Sanitation and hygiene

Background:

• Open defecation remains a global challenge, with communities reverting to it after achieving open defecation-free (ODF) status.
• Toilet collapse and unaffordability of durable toilets hinder sustained sanitation, increasing interest in pro-poor sanitation subsidies.

Purpose of the Study:

• To evaluate the impact of a pro-poor sanitation subsidy program on sanitation conditions in vulnerable households in Northern Ghana.
• To assess the effectiveness of targeted subsidies in preventing a return to open defecation post-ODF.

Main Methods:

• A cluster randomized controlled trial was conducted in 109 post-ODF communities in Northern Ghana.
• Vouchers for durable toilet substructures were provided to vulnerable households identified through community consultation.
• Household surveys assessed toilet coverage, quality, and use before and after the intervention, alongside program cost tracking.

Main Results:

• Sanitation conditions significantly deteriorated in both control and subsidy communities over 21 months.
• The subsidy program attenuated the increase in open defecation (from 25% to 54%) compared to control communities (25% to 69%).
• Benefits extended to non-eligible households through in-compound sharing, but durable toilets remained unaffordable for many.

Conclusions:

• Community-Led Total Sanitation (CLTS) alone is insufficient; sanitation subsidies can mitigate declines but do not fully address affordability.
• Improved targeting criteria, focusing on sanitation inequities like female household heads or lower education levels, may enhance sustainability.
• Further interventions are needed to ensure affordable and durable sanitation solutions in contexts with frequent toilet collapse and limited market access.