Abstract

Background:

According to the World Health Organization/United Nations International Children’s Fund Joint Monitoring Program, $494\text{\hspace{0.17em}million}$ people practice open defecation globally. After achieving open defecation-free (ODF) status through efforts such as Community-Led Total Sanitation (CLTS), communities (particularly vulnerable households) may revert to open defecation, especially when toilet collapse is common and durable toilets are unaffordable. Accordingly, there is increasing interest in pro-poor sanitation subsidies.

Objectives:

This study determined the impacts of a pro-poor sanitation subsidy program on sanitation conditions among the most vulnerable households and others in the community.

Methods:

In 109 post-ODF communities in Northern Ghana, we conducted a cluster randomized controlled trial to evaluate a pro-poor subsidy program that identified the most vulnerable households through community consultation to receive vouchers for durable toilet substructures. We surveyed households to assess toilet coverage, quality, and use before and after the intervention and tracked program costs.

Results:

Overall, sanitation conditions deteriorated substantially from baseline to endline (average of 21 months). In control communities (not receiving the pro-poor subsidy), open defecation increased from 25% (baseline) to 69% (endline). The subsidy intervention attenuated this deterioration (open defecation increased from 25% to only 54% in subsidy communities), with the greatest impacts among voucher-eligible households. Noneligible households in compounds with subsidized toilets also exhibited lower open defecation levels owing to in-compound sharing (common in this context). CLTS followed by the subsidy program would benefit more households than CLTS alone but would cost 21–37% more per household that no longer practiced open defecation or upgraded to a durable toilet.

Discussion:

Sanitation declines, often due to toilet collapse, suggest a need for approaches beyond CLTS alone. This subsidy program attenuated declines, but durable toilets likely remained unaffordable for noneligible households. Targeting criteria more closely aligned with sanitation inequities, such as household heads who are female or did not complete primary education, may help to generate greater and more sustainable impacts in Northern Ghana and, potentially, other contexts facing toilet collapse and limited market access. https://doi.org/10.1289/EHP10443

中文翻译：

---

有利于穷人的卫生补贴对露天无排便社区的影响：加纳农村的一项随机对照试验

摘要

背景：

根据世界卫生组织/联合国国际儿童基金会联合监测计划，$494\text{\hspace{0.17em}百万}$人们在全球范围内露天排便。在通过社区主导的全面卫生 (CLTS) 等努力实现无露天排便 (ODF) 状态后，社区（特别是弱势家庭）可能会恢复露天排便，尤其是在厕所经常坍塌且耐用厕所难以负担的情况下。因此，人们对有利于穷人的卫生补贴越来越感兴趣。

目标：

这项研究确定了有利于穷人的卫生补贴计划对社区中最脆弱家庭和其他人的卫生条件的影响。

方法：

在加纳北部的 109 个 ODF 后社区，我们进行了一项整群随机对照试验，以评估一项扶贫补贴计划，该计划通过社区咨询确定最脆弱的家庭，以获得耐用厕所底层结构的代金券。我们对家庭进行了调查，以评估干预前后的厕所覆盖率、质量和使用情况，并跟踪项目成本。

结果：

总体而言，卫生条件从基线到终点（平均 21 个月）大幅恶化。在对照社区（未获得扶贫补贴），露天排便从 25%（基线）增加到 69%（终点）。补贴干预减轻了这种恶化（在补贴社区中露天排便的比例从 25% 增加到只有 54%），对有资格获得代金券的家庭影响最大。由于在小区内共享（在这种情况下很常见），在有补贴厕所的小区中不符合条件的家庭也表现出较低的露天排便水平。CLTS 之后的补贴计划将使更多的家庭受益，而不是 CLTS，但每个不再露天排便或升级为耐用厕所的家庭的成本将增加 21-37%。

讨论：

卫生设施下降，通常是由于厕所倒塌，表明需要超越 CLTS 的方法。这项补贴计划减少了下降，但耐用的马桶对于不符合条件的家庭可能仍然负担不起。针对与卫生不公平现象更接近的标准，例如女性户主或未完成小学教育的户主，可能有助于在加纳北部产生更大和更可持续的影响，并可能在其他面临厕所崩溃和市场准入受限的情况下产生更大和更可持续的影响。https://doi.org/10.1289/EHP10443