Impact of community-led total sanitation on women’s health in urban slums: a case study from Kalyani Municipality.

This Evidence Report seeks to understand the health and other impacts of slum women’s access to sanitation through the Community-led Total Sanitation (CLTS) approach. It draws on findings of a study conducted in the slums of Kalyani a Municipality town located 55km north of Kolkata the capital city of West Bengal state in India. From an area plagued with rampant open defecation the slums of Kalyani were transformed into the first open defecation free (ODF) town in India in 2009. This was achieved through the CLTS model that focused on empowering the community to bring about collective behaviour change in order to achieve ‘total’ sanitation and an ODF environment. This was in sharp contrast to earlier approaches that focused on top-down toilet construction that had failed to ensure ownership or usage by the community. The benefits of CLTS to the community did not remain limited to changed sanitation behaviours and an end of open defecation; it also achieved development and health gains beyond sanitation. The findings of this study indicate that in the ODF communities of Kalyani women played a lead role in initiating and driving sanitation and hygiene behaviour change in their communities during the CLTS process. This resulted in better health outcomes due not least to the benefits of improved sanitation. Furthermore other changes which included the reduction of women’s safety risks an increase in their social status and involvement in decision-making and leadership processes both within the household and the community led to the enhanced social and psychological wellbeing of women contributing to their overall health. Women’s health in this study has been viewed in terms of not just the presence or absence of disease burden on women’s physical health but also their socio-psychological wellbeing. This study seeks to capture an emic account of women’s health and wellbeing in the Kalyani slums building on the accounts and perspectives of local women. It shows that the benefits of sanitation are not limited to merely gaining access to sanitation; the momentum built within the community in the process of CLTS triggering and the ‘Natural Leaders’3 who emerge during the process can be drawn on for engagement in several development projects. In Kalyani the community’s success in improving their sanitation status and the national recognition that the Municipality received as a result paved the way for the Municipality to engage more meaningfully with the slum dwellers by extending basic services to them. The report also provides wider lessons for sanitation in urban and peri-urban contexts and it highlights the importance of recognising the numerous benefits of sanitation interventions which go beyond narrow health outcomes focused largely on diarrhoea reduction (see Loevinsohn et al. 2014). The objectives of the study therefore were: 1. to understand the impact of improved sanitation and specifically of the CLTS process on women’s physical health in terms of reduction in disease burden; and the social and psychological wellbeing of women in selected slums of Kalyani; 2. to understand the impact of the CLTS process on aspects of women’s empowerment and its effect on women’s wellbeing and overall health in selected ODF slums of Kalyani; 3. to understand the external environmental factors that have played a key role in improving sanitation in Kalyani and therefore the health of women. This report is structured as follows. The next section draws on the existing literature to outline the gendered aspects of health and sanitation in the context of urban slums in India. Section 3 provides a background to CLTS implementation in Kalyani and describes the specific objectives of this study. Section 4 explains the methodology pursued and Section 5 sets out the findings of the study. Section 6 briefly outlines the challenges identified and the final section concludes the discussions and arguments made throughout the report.