Impact evaluation of community-led total sanitation (CLTS) in rural Mali - Final report

Alzua, M. L. et al. (2015)

Published in: 2015
Pages: 23

Universidad Nacional de La Plata, Argentina

Alzua, M. L. et al.

Uploaded by:
Elisabeth von Muench

Partner profile:
common upload


 Location of library entry

This report covers the main findings of the impact evaluation conducted of a communityled total sanitation (CLTS) campaign implemented by the government of Mali (Direction Nationale de l’Assainissement) with the support of UNICEF. We conducted a clusterrandomized controlled trial among 121 villages randomly selected from the district of Koulikoro in order to evaluate health and non-health program impacts. Baseline data was collected during April-June 2011, the CLTS intervention program was implemented between September-June 2012, and follow-up data was collected in April-June 2013. A total of 4532 households were enrolled at baseline and 4299 were visited at follow up; 89% of baseline households (N=4031) were successfully matched to a household at follow up. The primary outcomes presented in this report are reported for those households present at both baseline and follow up.

The CLTS campaign was highly successful in increasing access to private latrines, improving the quality of latrines, and reducing self-reported open defecation. Access to a private latrine almost doubled among households in CLTS villages (coverage increased to 65% in CLTS villages compared to 35% in control villages). Self-reported open defecation rates fell by 70% among adult women and men, by 46% among older children (age 5-10), and by 50% among children under five. Children too young to use latrines were also more likely to use a child potty in CLTS villages. The program also increased perceived privacy and safety during defecation among women. Observations by field staff support respondent-reported reductions in open defecation, use of cleaner latrines, and improved hygiene in CLTS villages. Latrines in the CLTS households were 3 times more likely to have soap present (prevalence ratio [PR]: 3.17, 95% CI: 2.18-4.61) and 5 times more likely to have water present (PR: 5.3, 95% CI: 3.49-8.05). Latrines at CLTS households were more than twice as likely to have a cover over the hole of the pit (PR: 2.78, 95% CI: 2.24-3.44), and 31% less likely to have flies observed inside the latrine (PR: 0.79, 95% CI: 0.68-0.93). CLTS households were also half as likely to have piles of human feces observed in the courtyard (PR: 0.54, 95% CI: 0.37-0.79).

Statistically significant impacts on child diarrheal or respiratory illness were not observed among children under five years of age when analyzing follow-up data only. It should be noted that even though randomization occurred after baseline data collection was complete and socio-economic characteristics were balanced across groups, most symptoms of diarrheal and respiratory illness were more prevalent in CLTS villages at baseline.

There is evidence that the CLTS program has a positive and significant impact on growth outcomes among children less than five years of age. When accounting for baseline height measurements, children under five years old in CLTS villages were taller (+0.18 height-for-age Z-score, CI: 0.03, 0.32) and 14% less likely to be stunted (RR: 0.86, CI: 0.74, 1.0). Improvements in child weight (+0.09 weight-for-age Z-score, CI: -0.04, 0.22) and a reduction in the proportion of children underweight (RR: 0.88, CI: 0.71, 1.08) were also observed but were not statistically significant. The program also appeared to reduce the prevalence of severe stunting by 22% (CI: 0.60 – 1.02) and the risk of being severely underweight by 35% (CI: 0.46 – 0.93).

We measured self-reported all-cause and cause-specific under-five child mortality among the study population as a secondary outcome. Each household was asked to report the age and gender of any household member that had died in the past 12 months and the cause of death. There was no significant difference in all-cause mortality between control and treatment arms (Poisson regression, robust standard errors at the village level). We found a 53% reduction in diarrheal-related under-five mortality in CLTS villages (RR: 0.47, Robust Std. Err. 0.18, 95% CI: 0.23-0.98; N=23 child diarrheal deaths in control, N=11 child diarrheal deaths in CLTS).

In addition, we designed a series of experimental games to measure the role of cooperation in the success of CLTS. We conducted these games over all 121 communities included in the study sample and at both baseline and follow-up. About one half of households in each community were randomly invited to participate to the games. All games were incentivized using valued items (rather than cash). We find a positive and statistically significant impact of the CLTS program on game contributions, indicating that pro-social behavior increased in these communities.

This study provides evidence that a pure behavioral intervention with no monetary subsidies substantially increased access to sanitation facilities in rural Mali. Latrines were also cleaner and better stocked with handwashing supplies in treatment villages, indicating improved hygiene behavior. Our findings suggest CLTS improved child growth and reduced the prevalence of stunting among children. However, the program did not have a significant impact on self-reported diarrheal illness, thus the program may have impacted child growth and mortality through pathways other than preventing diarrhea, such as reducing the subclinical condition of environmental enteropathy via decreased exposure to environmental fecal contamination.


The intervention was implemented by the Malian government with the support of UNICEF.
Generous funding was provided by the Bill and Melinda Gates Foundation.

This report presents data from a cluster randomized controlled trial (registration at NCT01900912). The study protocol was approved by Institutional Review Boards at Facultad de Ciencias Economicas of Universidad Nacional de La Plata and Stanford University

Bibliographic information

Alzua, M. L. et al. (2015). Impact evaluation of community-led total sanitation (CLTS) in rural Mali - Final report. Universidad Nacional de La Plata, Argentina

Filter tags

English Rural Sub-Saharan Africa

Information on external sites


Final report: Impact evaluation of community-led total sanitation (CLTS) in rural Mali

Format: pdf file
Size: 0.84 MB

Share this page on    

Follow us on    

SuSanA Partners  currently 360 partners

Sanitation events

SuSanA newsletter

Stay informed about the activities of SuSanA and its partners. The SuSanA newsletter is sent out around four times per year. It contains information about news, events, new partners, projects, discussions and publications of the SuSanA network.

Subscribe to newsletter »

Latest tweets mentioning SuSanA

Tweets mentioning SuSanA »

30th SuSanA meeting

The 30th SuSanA meeting - the first virtual of its kind - willl take place from August 17th to August 28th 2020. It is organised by the SuSana Secretariat with support and contributions from SuSanA Partners, Members, Working Groups and Regional Chapters.

Click here to get to the Meeting Page!

SuSanA meetings





Resources and publications

Our library has more than 3,000 publications, factsheets, presentations, drawings etc. from many different organisations. It continues to grow thanks to the contributions from our partners.

Add item to library »

The three links below take you to special groups of items in the library for more convenient access:


The project database contains nearly 400 sanitation projects of many different organizations dealing with research, implementation, advocacy, capacity development etc. Advanced filtering functions and a global map are also available. Information on how and why this database was created is here.

People working for SuSanA partners can add their own projects through their partner profile page. You might need your SuSanA login upgraded for this purpose. Please contact us if you would like to add a project.

Trainings, conference and events materials

Missed important conferences or courses? Catch up by using their materials for self study. These materials have been kindly provided by SuSanA partners.

Regional chapters

Use the map or the search tool to access the most relevant information and knowledge products for your region or country. This includes relevant resources, events, partners or projects.

Shit flow diagrams (SFDs), excreta flow diagrams

Shit flow diagrams (SFDs) help to visualize excreta management in urban settings. Access SFDs and more through the SFD Portal.




Discussion forum

Share knowledge, exchange experiences, discuss challenges, make announcements, ask questions and more. Hint: Your discussion forum login is the same as your SuSanA login. More about the forum's philosophy »

Integrated content

We are hosting content from some other communities of practice and information-sharing portals. This section also provides a link to SuSanA's Sanitation Wikipedia initiative.

Suggest content to add »

SuSanA partners

Not yet a SuSanA partner? Show your organisation's support to SuSanA's vision and engage in  knowledge sharing by becoming partners.

Apply to become a partner »

Individual membership

Register as an individual member of SuSanA free of charge. As a member you can interact with thousands of sanitation enthusiasts on the discussion forum.  You can also get engaged in one of our 13 working groups and our regional chapters. Our FAQs explain the benefits further.

By getting a SuSanA login you can fully participate in the SuSanA community!

Register as a member


Forgot your password?