• Africa;
  • behaviour change;
  • Community-led Total Sanitation (CLTS);
  • health;
  • institutionalisation;
  • rural development;
  • sanitation;
  • scaling up;
  • training


Open defecation is the norm in rural and urban Africa – only about a third of the population uses improved sanitation facilities – and this contributes in various ways to a heavy disease burden. Community-led Total Sanitation (CLTS), an approach to sanitation which focuses on community-wide behaviour change to completely stop open defecation, began to go to scale in Africa in 2006. Since then, it has spread dramatically and in many countries very successfully, and is now used at some level in at least 26 African countries.

This paper draws on the extensive involvement of Kamal Kar with the spread of CLTS in Africa to describe the early stages of the process, to elaborate on its developments and to outline insights into the circumstances and features which have facilitated its rapid spread. Taking a broadly comparative approach which draws on the somewhat earlier experience of the spread of CLTS in Asia, it identifies aspects of the institutionalisation process and circumstances, including key individuals, that have contributed to the success of the approach in Africa. It also discusses challenges, however, noting several issues which may limit its impact and hinder its dissemination. In particular, the paper discusses some of the many adaptations made to CLTS in response to a wide range of pressures, varying country circumstances and strategy choices. These adaptations, it is claimed, should be made with a clear picture of what may be lost and gained by adopting them. As CLTS progresses further, it will be important to continue to grapple with these issues, to acknowledge the lessons from adaptations that have had little success, and to retain a vision of the potential of CLTS to bring fundamental transformations in sanitation, health and rural lives.