Health geographies

A sanitation overview – the significance of CLTS in India

Images of Open Defecation

India’s population accounts for approximately 1/7th of the world’s population. The Government of India has the immense challenge of governing and providing services for over 1.2 billion people.  As we were touching down in Mumbai last week (14th March 2012), and the infamous smell of the city hit our noses, I was reminded of the enormity of the task of governance and service provision for 1/7th of the world. The fact that Rose, Susan and I were in India to learn about the implementation of CLTS in the urban context of Nanded City, meant that we were acutely aware of the relationship between what we were smelling and sanitation service provision in cities in India.

Striking figures: toilets vs mobile phones

The day before our arrival (March 13, 2012), the Census Commissioner of India released census data that reported that 49.8% of the Indian population (about 600 million people!) practice open defecation. This was in stark contrast with the statistic that an estimated 68% of Indians (about 800 million people) own mobile phones – demonstrating that financial barriers were not the major problem, but rather prioritization of investments at household level. However, as one participant pointed out, these statistics need to be understood in terms of livelihoods. Mobile phones are now not only used for personal communication, but have become essential for conducting business, as well as maintaining professional networks in India (and indeed this is a global trend).  Toilets and sanitation, at first glance, do not have the same significance for livelihood (although sanitation does of course have a direct impact on one’s livelihood in terms of health status and ability to work). Given this situation, any social movement that is geared towards improving sanitation would do well to integrate a mobile component, for communication, coordination, monitoring and advocacy.

CLTS in the urban context

So far, CLTS has been implemented primarily in rural areas. The belief has been – even amongst CLTS practitioners – that urban sanitation is far too complicated and not conducive for the strict zero- subsidy approach.  The first attempt to adapt and implement CLTS methodology in an urban area was in the city of Kalyani in West Bengal (near Kolkata, within the Kolkata Metropolitan Development Authority) in India in 2008-2009. The second was in Mathare, village number 10 – an informal area of approximately 20,000 people in Nairobi, Kenya. The third is now Nanded City, with a population of 500,000 people located in Maharashtra State. Due to the sheer scale of the problem of open defecation, the CLTS approach is particularly important in India.

We had been invited by the Nanded-Waghala Municipal Corporation to share experience from Mathare at a sharing and learning workshop on urban CLTS. Kalyani was also represented by the ex-mayor of Kalyani, Dr. Shantanu Jha, a visionary leader and pioneer of urban CLTS.  Hearing about

Government housing for the urban poor

the work in Kalyani and Nanded was indeed inspiring. Kalyani was the first city in India to be declared open defecation free in 2008. After receiving word, the State Government of Kolkata took an interest, and in January 2009 also declared it officially ODF. However, the Indian government has not adopted CLTS as an official policy and as such has no framework for assessing ODF status. Instead, the Indian government is implementing mainly subsidy-focused development projects, such as Basic Services for the Urban Poor (BSUP) which provides low-cost, upgraded housing options for urban populations in informal settlements.

At the time of the urban CLTS work in Kalyani, the then mayor refused funds to build toilets and when he could not refuse BSUP funds, used them to reward those communities who had adopted CLTS and were working towards becoming ODF, once they had made significant progress. In an external evaluation, the World Bank’s Water and Sanitation programme (WSP) pinpointed good governance as a key element in the success of urban CLTS in Kalyani. It is important to note that Kalyani is also a smaller, less densely populated city (approximately 100,000 people) and does not have many of the larger urban informal settlements that we are familiar with in Nairobi. It is a planned city with well laid out infrastructure. These three elements – good governance, relatively sparse population and planning – make it uniquely well-suited for urban CLTS implementation.

The Nanded case is also a story of a charismatic leader, Dr. Nipun Vinayak the Municipal Commissioner for Nanded-Waghala Municipal Corporation. Rather than being an elected official (as in the case of the Kalyani mayor) Nipun is an appointed officer of the local government, allocating and managing the budget for local development. Nipun has long been a champion of CLTS, and brought this with him when he was appointed to the Nanded Corporation about a year and a half ago. As part of his work in facilitating a city sanitation plan – together with the mayor and other local elected leaders (called Corporators – the equivalent of Councillors in Nairobi) – he invited two NGOs with experience in rural CLTS to lead the process of urban CLTS in Nanded who then facilitated urban CLTS pilots in several locations around the city. They had successes and challenges and over several months began to scale up the work in 28 different areas of the city.

Upgraded water treatment facility in Nanded

The urban CLTS work is taking place alongside several large-scale urban development works. Nanded is a holy site for the Sikh community – as the location where the last Sikh Guru made his final ascent. It is a major site for tourism and religious pilgrimage, and funding has been made available to support the development of the area’s tourism, expand roads, upgrade the water treatment facilities and improve sewage treatment in the city. This poses a challenge but also an opportunity for urban CLTS and Nanded would do well to learn from the lessons of Kalyani, where urban CLTS was successfully implemented alongside several large-scale infrastructure projects, such as BSUP.

Monitoring the urban CLTS process

At the workshop I shared my experience as a facilitator for monitoring and evaluation of urban CLTS, using digital technology. I have a keen interest in the CLTS process, the lessons that can be drawn from ‘triggering’ (as applied to different fields), and internal monitoring and external evaluation of CLTS. When integrated with well-established participatory approaches, new technology can be used to evaluate the resources required (eg through baselines surveys), to effectively communicate the sanitation situation and the need for investment in this area and to monitor the progress toward ODF. Work on CLTS has continually highlighted the need for improved monitoring and evaluation – and the proliferation of mobile phones represents an opportunity for citizens to become involved in monitoring the sanitation status of their cities. Of course, the political will also has to be strong to ensure that information is received and acted upon by the relevant authorities.

Sanitation and governance

In light of the scale of the sanitation crisis in India – 600 million open defecators – the approach of government subsidized toilets will fall short. Dr. Shantanu Jha posed the questions: is construction of toilets for 600 million people possible by the government? How? By when? Can the government address this by providing free and subsidized toilets? Despite lessons from elsewhere that have shown this approach to be ineffective, it is still favoured by governments worldwide, including the Government of India.

However change is indeed taking place; CLTS has been implemented in over 51 countries worldwide and as many as 15 governments have adopted CLTS as their national strategy for sanitation. CLTS provides an alternative, relatively low-cost approach but it requires courage and innovation. As Nipun put it: “Like they say, there’s nothing good about democracy except that its alternatives are worse. In the same way, CLTS is not the best approach, but it is better than anything else we know of.” We will look to Nanded over the coming months, to learn how they take this social movement forward and hope the ‘commandos’ and local government take up the call to “leave no one behind” in the improvement of the sanitation situation in the city.

This post was prepared for and originally posted on the CLTS blog.

The Daily Nation and the Standard today both ran 11 page spreads on the fire is the Sinai area of Mukuru slum yesterday. Mukuru is a sprawling informal settlement, stretching the length of Nairobi’s industrial area. Access to the area is facilitated by roads that lead along the backs of factories and warehouses and industrial worksites. The dangers of living in Mukuru slum are apparent as factories bellow out smoke, trucks carrying hazardous materials rumble by and pipes and electrical towers dot the landscape.

Despite the environmental hazards, the push and pull factors that drive rural-urban migration and the expansion of informal settlements around the world are at work every day. Kenyans move to the countries’ cities in search of employment, education, exposure and opportunities that are not available in rural areas. On arriving in ‘the big city’ the lack of adequate, low-cost housing means most Kenyans will find a home in one of the informal settlements – built on marginal land, often close to swamps, dams, rivers (Mathare), dump sites (Dandora) or industrial areas.

Our health is closely related to the social and physical environment in which we live. The environment in an informal settlement is directly related to long-term health problems such as chronic respiratory infections or diarrheal diseases. One direct short-term health impact (and one major cause of mortality among residents in informal settlements) is fire and other accidents that are common due to the proximity of houses to one another, the materials used to build homes and cook within them, and proximity to electrical and industrial hazards.

It is not surprising that several journalists have in the past highlighted the dangers of living close to the gas pipeline in Sinai. It’s also not surprising that the residents in the area were warned of the dangers but chose to stay in the area. When the informal, marginal areas are all you can afford, there’s not much choice.

So what’s the solution? Mugo Kibati, Director General of Kenya’s Vision2030 has suggested that the Vision for a Kenya in 2030 is a country without slums. But what’s the process by which Kenya gets there? How does the government ensure safe and adequate housing for the millions of Kenyans living in informal settlements? Let’s ask the residents themselves and brainstorm solutions together.

A story ran in yesterday’s Daily Nation about the trial of a ‘new’ sanitary product in Nairobi’s Korogocho slums. The product is a menstrual cup – a small, silicone cup that  is inserted into the vagina to catch menstrual blood. Instead of absorbing the blood, like a tampon or sanitary napkin, the cup collects the blood, which is then disposed of in a toilet facility. According to the Diva Cup website (one manufacturer of the menstrual cup) the cup is “emptied, washed and reinserted 2-3 times” every 24 hours.

Diagram of how to insert the Diva cup, from

Is the physical and social environment in slum areas in Kenya conducive to the use of the menstrual cup?

There are a number of challenges to using the menstrual cup in slum areas:

  • access to water & soap (2-3 times a day)
  • access to clean, private, safe toilet facilities (2-3 times a day)
  • acceptability (the young woman must insert her finger into her vagina to position the cup properly)
  • price (1000 shillings is very expensive!)

Will the scale up of the use of the cup solve the issue of school absenteeism for young girls during their menstrual cycle? If they can afford the initial cost of the cup, have access to water & soap and clean, private, safe toilet facilities, and its use is accepted by their female peers – yes. However, I thought the challenge in slum areas was low wages, and lack of clean water and sanitary facilities….

The menstrual cup provides an environmentally friendly and convenient alternative to sanitary pads and tampons – that is if you don’t face barriers to accessing and using the product (see the challenges mentioned above). The pilot study is being carried out by the African Population Health and Research Centre (APHRC) to determine the acceptability and usability of the menstrual cup among young girls and women in informal settlements (slums) in Kenya.

Note: Don’t get me wrong, I’m an advocate of the menstrual cup. Is it going be a great alternative for young girls and women in slum areas? I hope it can be, but we’ll wait and see.

Last Wednesday Jon Gosier and Matthew Griffiths from the SwiftRiver team were at the iHub in Nairobi to present SwiftRiver 101. I could not have been more impressed with the work of the Swift team!

What exactly is SwiftRiver?

According to the website:

“SwiftRiver is a free and open source software platform that uses algorithms and crowdsourcing to validate and filter news.”

SwiftRiver is an initiative of Ushahidi Inc. The project is a response to the challenge of handling large amounts of small pieces of data with limited resources, particularly in crisis situations.

SwiftRiver automates some of the work of an administrator of an Ushahidi website (for example Haiti, Hatari or Voice of Kibera). The application automatically parses out the “who”, “what” and “where” of a short piece of text. The text could come from Twitter, a web form, email, SMS, news headline, etc. The platform is made up of the following components:

  1. SiLCC – Natural Language Processing for SMS and Twitter
  2. SULSa – Location Services
  3. SiCDS – Filters for duplicate information (for example exact re-tweets on Twitter)
  4. River ID – Establish the distributed reputation of an individual source (i.e. how reliable is the information I generate as an individual, from my phone, my Twitter account, my blog….and any other channel through which I submit information)
  5. Reverberations – Measures influence of online content

Not only does the Swift platform parse small pieces of text, but it also stores information about the reliability of different sources of information (see #4). This can serve as a way for Ushahidi administrators to decide whether or not to verify a piece of information coming from an individual source (based on their past history and reliability).

Crowdsourcing and Data Verification

A question that is often asked of Ushahidi deployments is “How do you verify your data?” and “How do you know the information is accurate?

These questions are essentially asking the question: is crowdsourced information reliable? The concept of crowdsourcing relies on information submitted from a dispersed network over time. You may not be able to decide how reliable one single text message or tweet is, however the strength of crowdsourcing lies in the collective wisdom of a group of people. The best known example of crowdsourcing is the online, user-generated Encyclopedia, Wikipedia. Although the accuracy of Wikipedia is constantly being challenged, this constant critique leads to improved content over time. In 2005, Nature magazine published a special report comparing a random sample of 42 scientific entries in Encyclopedia Britannica and Wikipedia. The author finds that there are

“numerous errors in both encyclopaedias, but among 42 entries tested, the difference in accuracy was not particularly great: the average science entry in Wikipedia contained around four inaccuracies; Britannica, about three.”

The author argues that the major advantage of Wikipedia is the ability to update and change entries quickly. This can be likened to near-real-time collection and publication of information through the Ushahidi platform. This near-real-time collection and publication also comes with the responsibility, particularly with controversial or sensitive issues, to have a team that is knowledgeable about an issue to read, possibly edit, approve and/or verify reports – SwiftRiver alone cannot do this job for you.

How do organizations deal with crowdsourced information?

It is the responsibility of each organization to develop standards, or procedures, or a policy based on their knowledge of the issue(s) they are monitoring (it’s up to you!). The Ushahidi platform allows you to APPROVE and/or VERIFY reports, which then show on the map as VERIFIED “YES” or VERIFIED “NO”.

A snap-shot of the administrative side of the platform is below. Note that you can approve but not verify a report, and you can indicate its reliability (reliability is not made public).

SwiftRiver as a standalone tool

SwiftRiver does not necessarily need to be plugged into the Ushahidi platform. The application itself can be used to track and store data from many different sources and store that information over time.

A number of use cases were discussed in one of the breakout sessions of SwiftRiver 101:

  • Brand monitoring – a company or organization could set up the SwiftRiver platform to pull in keywords from Twitter and specific websites to monitor what people are saying about their product(s)or service(s)
  • Disaster risk reduction – monitoring opinions and sentiments about certain issues in a specific geographic area over time. Indications of unrest may be apparent in the discourse, prompting intervention by responsible agencies.

Interested? Have an application for SwiftRiver?

SwiftRiver is currently available in a pre-beta version – Batuque v.0.20.

Download it from or view it here.

Learn more about SwiftRiver through the Swift River 101 slide show and the website.

Data collection is not a walk in the park. Day two of the health services mapping with Map Kibera brought to light two major challenges to systematic data collection.

I do not claim that these challenges are unique, nor that today was the first day the mappers came across these issues (in fact yesterday, and during the previous mapping exercise, the mappers expressed some of the same concerns):

1. Suspicion. People do not want to give up information about the services they are providing. This could be for many reasons (they don’t believe you are who you say you are, they think you are being exploitative, research fatigue, they are not licensed to provide said service, etc).

2. Research fatigue. From my (limited) experience in Kibera (I spent 3 months in the area in 2008 and have been back a few times in 2009 & 2010), the settlement is one of the most over-researched places in Kenya, if not in Africa. As an example, as we were walking around today, I saw 2 groups of researchers walking around with clipboards interviewing people door-to-door. And what ever comes of the research? Does the community see the benefits? Likely not in their eyes. As such, even groups such as Map Kibera doing ‘community research’ are viewed with suspicion…and the cycle continues.

Reviewing the health services data collection form

Map Kibera team reviews printed map (in draft stages) of their work

The second phase of the Map Kibera project kicked off earlier this year. The visionary individuals behind the Map Kibera project are busy creating the first comprehensive map of Kibera, Kenya, one of the largest informal settlements in Africa.  Kibera residents, 13 in total – one from each of the area’s villages – were trained to use global positioning system (GPS) devices and to collect geographic information (including GPS tracts & points of interest) in their own villages. The group leaders are guided by the principles of the Open Source and Open Data communities. All of the information collected is mapped using Open Street Map (OSM), therefore the group also gained hands-on experience using the OSM software.

As the Map Kibera project moves into the second phase, the team’s mapping activities become more focused. For the next week mappers will be collecting Health Service data. They will concentrate on ensuring that all of the information pertaining to Health and Health Services is as detailed as possible and that it is accurate and up-to-date. That’s where I come into the picture. During the previous data collection phase, Health Facility information was collected, however it was not standardized. Using the Kenya Master Facilities List (MFL – a project of the Ministry of Health Services) as a guide, and the Wikipedia article on Healthcare in Kenya, a data collection form was developed to capture information about each individual Health Service located in Kibera.

An interesting point to note is that, at present, the MFL website does not include definitions for each facility type (i.e. what characteristics makes a Health Centre a Health Centre vs a Medical Clinic or a Nursing Home) and the website of the Ministry of Health Services is down. The Wikipedia article contained the most comprehensive information I could locate in terms of definitions. Additionally, the MFL project has not yet determined how to incorporate Community Based service provider data into their classification schema, not-to-mention how to go about collecting this data. The data collection guide the Map Kibera mappers will use is thus a modified version of the MFL classifications, tailored the needs and realities of Health Services in Kibera.

Today, Mikel, Erica and I sat down with the mappers and had an in-depth discussion of the data collection form. It is this discussion of the realities of Health Services in Kibera that really intrigued me. As expected, the most challenging aspect of data collect will be determining which Service (or Facility) Type each point of interest really is.  This is due in part to the lack of a clear, publicly available definition of characteristics for each service type, as well as the discrepancies between the medical community’s definition of each health facility and the community definition of the same facilities. For example, what exactly is a Health Centre? How many clinical officers or medical officers must be on staff at a Health Centre? How is this different from a Dispensary?

The most contested distinction was that of dispensary vs pharmacy vs chemist. In the MFL, only dispensaries are listed. Should all chemists and pharmacies and dispensaries thus be called dispensaries? The mappers were clear that the answer is “no”.

In Kibera, a pharmacy is a dispensing facility, usually located in a hospital; a dispensary can be large – as large as a Health Centre –  and provide diagnostic and treatment services, or a dispensary can be small and serve functions, including but not limited to dispensing (no clear conclusion was reached on this); a chemist is a private operation that dispenses drugs (both prescription and over-the-counter drugs). One caveat – a chemist in Kibera often operates as a Medical Clinic, with an exam room in the back of the facility. The catch is that these ‘chemists’ are not licensed as clinics – often there is not even a certified pharmacist working in the “chemist” and the drugs are supplied to the facility by people who work at the larger hospitals outside Kibera and are seeking to make a profit by selling drugs at a cheaper cost inside the informal settlement.

How can these distinctions be visualized on a map? Should they be? What is the role of such ‘backdoor’ operations? Which definition should be used in order to add value to other on-going processes while also ensuring that the data are valuable to the local community? This is food for thought.

Another point of interest for me is that a Nursing Home (which in North America is a rest home for the elderly) in Kenya functions as a large, well-equipped, privately owned hospital. The mappers all knew exactly what a Nursing Home is, and did not need to hear the Wikipedia definition (which I did not even clearly understand).

This just goes to show, things are not always what you expect them to be.

[Cross posted on the Map Kibera blog]

Cross posted on the KANCO and Ushahidi blogs.

In continuing its commitment to the development of Ushahidi’s work in Kenya, Ushahidi has just completed a six-month pilot project with the Kenya AIDS NGO’s Consortium (KANCO) to  visualize civil society organizations (CSOs) in Kenya providing responses to the HIV/AIDS and tuberculosis (TB) epidemics. The project, in collaboration with AIDSPortal, UK, involved modifying the Ushahidi platform for Crowdsourcing Crisis Information in order for KANCO to map its member organizations. This work contributes to KANCO’s mission, “to provide leadership, promote collaboration and enhance capacity among CSOs and other stakeholders to respond to HIV & AIDS and TB at the community level.”

KANCO provides leadership in community systems strengthening (CSS) and policy and advocacy activities across the country. KANCO has extensive experience leading workshops and training for organizations in the field of HIV/AIDS and TB, and these standards for providing CSS were utilized to develop a workshop curriculum, based on the customized Ushahidi platform. In November, two workshops were conducted with 16 participants to gather feedback on platform’s usability. This feedback informed the final customization and last week, Feb. 9-11, a further 23 participants were trained at the KANCO offices in Nairobi. The workshops introduced the three partner organizations, provided background on the project, website demonstration, and user training. Participants were given an hour and a half to browse the website. In particular, they were instructed to search for organizations on the map, learn who’s doing what, where in Kenya, submit their organization’s profile and subscribe to the alerts feature on the map.

User Testing Guidelines
User Testing Guidelines

Overall, the 3 days of training were a great success. Participants responded positively to the project and enjoyed using the site, especially adding and updating their profiles. Generally participants thought the site was a good tool for networking and partnering, knowledge building, promotion and marketing, advocacy and information sharing. One participant described her experience as, “I have confidence and now I can do it for myself because I have been delegating rather than doing it myself. Others can find us online and may be interested in working with us.”

Workshop Participants adding Organization Profiles
Workshop Participants adding Organization Profiles

Currently the KANCO instance does not have a mobile component, but participants liked idea of adding SMS to the site. They thought SMS would be beneficial to them, especially for keeping up-to-date with KANCO and their constituents, particularly in regards to referrals. Participants commented that people are more likely to check SMS than email on a regular basis and that people are comfortable communicating via SMS.

Established in 1990, KANCO is a networking organization with a cumulative membership of over 1000 CSOs. The partnership between KANCO, Ushahidi, and AIDSPortal was established in early 2009 and the pilot project was supported by a Geochallenge Grant, awarded to the team in August 2009. For updates on the project, keep an eye on the KANCO blog.

Post written by Jamie Lundine and Melissa Tully.