Nossal Institute for Global Health - Theses
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ItemCommunity-led Total Sanitation in Manufahi, Timor-Leste( 2019)Water, sanitation and hygiene (WASH) are important for health and wellbeing. In Timor-Leste, the rates of access to WASH are some of the lowest in the world, particularly in remote areas. The national government’s response to improving sanitation in remote areas is a community-based approach called ‘PAKSI’ (Planu Aksaun Komunidade, Saneamentu no Ijiene) which is also implemented by non-governmental organisations. The research documented in this thesis sought to understand the implementation and outcomes of the PAKSI component of the WaterAid program in Manufahi Municipality, Timor-Leste from 2013 to 2014 as part of the ‘WASH for Worms’ cluster-randomised control trial. PAKSI is based on Community-Led Total Sanitation (CLTS): an approach which aims to inspire rural communities to lead themselves to become open defecation free (ODF) through triggering collective feelings of disgust and shame about open defecation. CLTS is popular; however, there are few rigorous studies about the approach, especially in the context of Timor-Leste. Three studies were conducted as part of this research to better understand PAKSI: the Timor-Leste adaptation of CLTS. The first study compared the official descriptions of PAKSI (and CLTS) to the way it was implemented and described by 19 representatives of the government, WaterAid and intervention communities as well as Dr Kamal Kar and Dr Robert Chambers. The findings suggested that, officially, PAKSI and CLTS are quite similar; however, the implementation of PAKSI in the research sites diverged from these official descriptions in that the approach was more facilitator-led than community-led. The second study used quantitative methods with 65 households to measure the changes in sanitation-related knowledge, attitudes and practices after the WaterAid program. Whilst toilet coverage increased over the course of the study, and open defecation decreased, the proportion of participants who reported feeling disgusted at the sight of faeces in the open did not change. This suggests that a) the WaterAid PAKSI intervention did not trigger feelings of disgust (which is what PAKSI and CLTS are officially purported to do) and b) whilst disgust might be a necessary motivator for becoming ODF, on its own it is insufficient. The third study explored the possible factors influencing whether households become or continue to be ODF, through interviews with 21 participants including community leaders, household representatives and implementing staff. The experiences of participants who had a disability, an age-related impairment or were from female-headed households were sought to be included. Several factors were identified, including competing priorities for finances and other resources, and participants feeling like they were doing what they had been ‘told to do’. The 17 behavioural factors in the RANAS model of behaviour change provided a framework for analysing what motivates people in remote parts of Timor-Leste to change their sanitation behaviour. The findings suggest that motivators other than disgust and embarrassment, such as affordability of toilets and ‘being told what to do’, are relevant. Further research should investigate whether other approaches such as government regulation and strengthened sanitation markets are effective for bringing about ODF communities in Manufahi Municipality, Timor-Leste.