Impact of a community-led total sanitation intervention on child health in rural Mali: Evidence from a cluster randomized controlled trial

Globally 2.5 billion people lack access to an improved sanitation facility; only 15% of rural households use improved sanitation in Mali (JMP 2014). Community-led total sanitation (CLTS) uses participatory approaches to mobilize communities to build their own toilets, facilitate sustained behavior change, and eliminate open defecation. Although CLTS has been implemented in over 50 countries, there is a lack of rigorous and objective data on its impacts on sanitation behaviors and child health. This cluster-randomized trial evaluated a CLTS program implemented by the government of Mali with support from UNICEF among 121 villages from the Koulikoro district of Mali. Household survey data (N=4299) collected 1.5 years post intervention delivery revealed that CLTS almost doubled access to private latrines (65% vs. 35%), as well as reduced open defecation rates by over 70% among adults and by 50% among children (p<0.001). CLTS households were half as likely to have human feces observed in courtyards (p<0.001). Latrines in CLTS communities were 3 times more likely to have soap and have a cover over the pit, as well as 20% less likely to have flies visible inside (p<0.001). Among children under five, CLTS did not reduce the case definition of diarrhea (relative risk [RR] 0.96, 95% CI 0.80-1.16), although risk of loose stool as measured by an image chart was reduced by 24% for those children not exclusively breastfeeding (RR 0.76, 95% CI 0.59-0.98). When accounting for baseline height, children under five in CLTS villages were taller (+0.16 height-forage Z-score, 95% CI 0.0-0.32) and less likely to be stunted (RR 0.87, 95% CI 0.75-1.0). Improvements in child weight (+0.09 weight-for-age Z-score, 95% CI -0.04 -0.21) and a reduction in the proportion of children underweight (RR 0.86, 95% CI 0.71-1.04) were observed but were not statistically significant. This study provides evidence that a pure behavioral intervention with no monetary subsidies substantially increased access to sanitation facilities in rural Mali. CLTS may have improved child growth through pathways other than preventing diarrhea, such as lessening the subclinical condition of environmental enteropathy through potential reduced exposure to environmental fecal contamination.