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Sunday, June 30, 2013

GLOBAL HEALTH: ISSUES, CHALLENGES AND MANAGEMENT


Being a lead paper presented at the International Conference on 'Global health: issues, challenges and management, organised by Centre for Women, Gender,  and Development Studies; [CWGDS] and Institute of Environmental Health Technology, IEHT, Federal Univeersity of Technology, Owerri

Introduction
Global health has emerged as a growing field, particularly over the past two decades. Greater recognition of the global AIDS crisis, combined with the appearance and rapid international spread of epidemics such as SARS, anthrax, the Ebola virus, swine flu (H1N1), etc., have reinforced that health threats transcend national borders. While much of the media attention has focused on epidemic of infectious diseases, poverty, environmental pollution and degradation, social inequalities, global health looksat a wider scope of health problems, determinants, and solutions, such as chronic illnesses, accidents  and injuries. Other global health challenges include but not limited to poverty, environmental and health emergencies, gender violence and abuse, substance use and abuse, sex and sexuality, infant and maternal mortalities, terrorism etc.
Health was first defined in Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948; as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. While there have been criticisms of this definition, the WHO has not changed its 1946 definition of health. More contentious, however, has been the definition of “global health.”
On the other hand, Public Health can be defined as the combination of sciences, skills, and beliefs that are directed to the maintenance and improvement of health of all people. The classic definition of public health describes it as  “the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health”
Globally, the overall mission of public health is to "fulfil society's interest in assuring conditions in which people can be healthy." The three core public health functions are:
  •  assessing and monitoring  the health of communities and populations at risk to identify health problems and priorities;
  •  formulating public policies designed to solve identified local and national health problems and priorities;
  •  Assuring that all populations have access to appropriate and cost-effective care, including health promotion and disease prevention services, and evaluation of the effectiveness of that care.
Concept of Global Health
According to the Institute of Medicine, "Global health is the goal of improving health for all people in all nations by promoting wellness and eliminating avoidable diseases, disabilities, and deaths. Global health can be attained by combining clinical care at the level of the individual person with population-based measures to promote health and prevent disease. To achieve global health, an understanding of health determinants, practices, and solutions, as well as basic and applied research concerning risk factors, disease, and disability, is very important. Unlike Public Health, Global Health is more encompassing allowing the contributions of many other professionals in health issues and solutions.
Issues
Since 1950, global health has known quite a lot of improvements. However, this progress has not been equally distributed worldwide. A considerable number of countries primarily in Sub-Saharan Africa, especially Nigeria, lag behind the rest of the world on many health indices. For instance, health care systems are still neither available nor accessible (when and if available) to a great many people in Nigeria; infrastructural decay is common in the available health care systems; non-communicable diseases (such as cardiovascular diseases, cancer, diabetes and chronic lung diseases) are still major threats to Nigerians between the ages of 30 and above; hundreds of children under the age of 5 die from malnutrition, diarrhoea, measles, respiratory diseases and mostly preventable diseases, each year. It is on records that millions of people die of infectious diseases, such as HIV/AIDS, pneumonia, diarrhoea, tuberculosis and malaria annually. Other global issues include man-made and natural disasters (such as landslide; tsunamis; earthquakes; and flooding. The flooding of 2012 in Nigeria affected farming and sustenance of food availability in the nation, and displaced at least 10,000 people; etc.Furthermore terrorism, conflict, gender inequality, poor healthcare financing, emerging and re-emerging diseases, etc are other global health issues confronting Nigeria.
These health indicators continue to have a devastating impact on Nigeria and the world’s poorest countries. They make those countries vulnerable to social instability, economic breakdown, and decrease in population strength, spread of infectious diseases and increase in risk factors for chronic diseases.The vast range of global health issues are not without challenges.

Major Challenges

The biggest challenge in global health is the lack of financial resources to combat the multiple scourges ravaging the world's poor and sick. Today, more funds are needed for pressing heath issues than ever before. Furthermore, funds are needed to support research, build health facilities, train more health personnel, build capacity and competence among health care providers.
Tackling the world's diseases burden has become a key feature of many nations' foreign policies over the last five years, given that microbes know no borders. The focus of those nations is on keeping life expectancy high. That is another major challenge.For example,overall, 35% of Africa's children are now at higher risk of death than they were 10 years ago. Every hour, more than 500 African mothers lose a child. In 2002, more than four million African children died. Those who do make it past childhood are confronted with adult death rates that exceed those of 30 years ago. Life expectancy, that is always shorter here than almost anywhere else, is reducing still. In some African countries, it has been cut by 20 years and life expectancy for men is now less than 46 years.
A third major challenge is how to keep new health threats from emerging. While positive in many respects, urbanization, globalization, and demographic changes have intensified timeless health issues, changed the dynamics of health and resulted in the emergence of new health threats. Although HIV/AIDS, tuberculosis, and malaria are treatable and preventable diseases, meanwhile, many rich and poor countries alike have undergone an epidemiological transition in which non-communicable diseases – including depression, diabetes, cardiovascular disease, and cancers – have replaced infectious diseases as the leading causes of morbidity and mortality. Out of every 10 deaths worldwide, six are due to non-communicable conditions, three to communicable diseases, reproductive issues, or nutritional conditions, and one to injuries.
With increasing urbanization comes increasing violence and crime. In addition, the effects of depression and social exclusion can be more profound. About 14 per cent of the global burden of disease has been attributed to neuropsychiatric disorders, mostly owing to depression and other common mental disorders, alcohol- and substance-use disorders, and psychoses. The burden of major depression is expected to rise to be the second leading cause of loss of disability-adjusted life years in 2030 and will pose a major urban health challenge.
A fourth major challenge global health is confronted with is the manner in which to improve living conditions. Declining living conditions and reduced access to basic services have led to decreased health status. In Africa today, almost half of the population lacks access to safe water and adequate sanitation services. As immune systems have become weakened, the susceptibility of Africa’s people to infectious diseases has greatly increased. Global health initiatives aimed at improving the health and well-being of impoverished, vulnerable, and underserved people worldwide include poverty reduction strategies, disease prevention measures, efforts to improve nutrition and food security, policy to raise environmental standards and living conditions, and the promotion of gender equality.Health disparity between high-income and low-income countries, as well as between individuals within a country, often make this impossible, leaving many people living in unhealthy settings without sufficient access to care.
Management
For the world to begin to address health issues, three principles of action should be considered:
1.    Conditions of daily life have to be improved --- the conditions in which people are born, grow up, live, work and age;
2.    The inequitable distribution of power, money, and otherresources has to be tackled; the structural drivers of those conditions of daily life globally, nationally, and  locally;
3.    Problems have to be measured, actions evaluated, knowledge base expanded; a workforce that is trained in the social determinants of health has to be developed, and a public awareness has to be raised about the social determinants of health.
One framework for addressing global health challenges is the Millennium Development Goals (MDGs). The MDGs were adopted by the Member States of the United Nations in 2000 to achieve demonstrable reductions in poverty and improve specific health and social outcomes by 2015. The outlined goals reach beyond health issues, but four of the eight goals pertain directly to health:
  • Goal 1: Poverty Reduction
  • Goal 4: Reduce child mortality
  • Goal 5: Improve maternal health
  • Goal 6: Combat HIV/AIDS, malaria, and other diseases
The MDGs reflect widespread acknowledgement that improving global health is an integral part of development. However, the midpoint between 2000 and 2015 has passed, and the MDGs remain a distant goal for many countries especially Nigeria. For example, an estimated half-million women continue to die as a result of childbirth each year.  While substantial progress has been made in child health, the global community needs to intensify and sustain efforts in other areas in order to meet the MDG targets.
It is important to note that most health problems are caused not by health issues as such, but by social, political and economic conditions that drive people’s lives.
Conclusion
Poverty exacerbates health issues. Under conditions of poverty, entities such as pharmaceutical companies can wield even more power and influence over poor countries. Some major reasons for unnecessary deaths around the world are, therefore, due to human decisions and politics, not just natural outcomes. Well-intentioned companies, organizations and global action show that humanity and compassion still exists, but tackling systematic problems is paramount for effective universal healthcare that all are entitled to.
Addressing health problems goes beyond just medical treatments and policies; it goes to the heart of social, economic and political policies that provide not only for healthier lives, but also for a more productive and meaningful one that can benefit other areas of society.
The Federal Ministry of Health under President Goodluck Jonathan (GCFR) has in the last two years improved the infrastructure of our Health System for improved service delivery across the nation.
The Ministry is also currently involved in disease control and prevention through sustained routine immunization, health promotional activities, Environmental sanitation, safe motherhood.
In this respect the maternal and infant mortality rates are gradually going down, and hope that it will continue to improve.
This transformational agenda of President DrGoodluck Jonathan (GCFR) has also put in place various empowerment programmes to reduce poverty in Nigeria and this will continue until all global health indices are improved.

Monday, June 17, 2013

INSTITUTIONAL SANITATION: PROBLEMS AND PROSPECT


BY
ZAKARIYA’U ALIYU; M.Sc. fseh
Being a Paper Presented on the Occasion of 2012 World Environment Day Celebration at the International Conference Center,
Federal UNIVERSITY of technology, Owerri
31st July, 2012

BACKGROUND
The rise of the city brought mankind’s first awareness of sanitation. The Romans built splendid public baths and toilets linked to fairly sophisticated water and waste delivery system. The ruins of the pre-Roman phonecian city of kerkouane in today’s Tunisia boast a bathtub in every home. Thereafter, the level of attention to urban sanitation then went into decline.
In the nearly two millennia between the remarkable water and sewage systems of the ancient world and the work of germ theorists and sanitary engineers in modern in times, there were few advances in urban sanitation. By the mid 19th century large areas of the great cities of the west that currently fly the flag of modern civilization and advancement had become filthy, smelly slums. Until London got its first modern sewer in 1853, inhabitants’ would simply dump their chamber pots in the streets. For obvious reasons, the idea of using water to bear away filth caught on quickly. Over the years, wooden troughs were replaced with terra-cotta piping which in turn gave way to large, more efficient brick and concrete sewers.
Pre-independence Nigeria, especially during the early colonial period the urban centers were countable by the fingers (Lagos, Kano, Ibadan, Sokoto, Benin, Zaria, etc.), mostly relic capitals of the ancient caliphates and empires of old. Even then the traditional pit toilets and dumping of refuse at nearby paths were common sanitation practices these methods were not different but rather most prominent in the rural settings of the time. Worst still defecation in open spaces and streams.
Independence, eliticism and boost in commerce and agriculture and later oil economy gave rise to wealth and proliferation of urban settlements and services in Nigeria and later the specific need for institutional sanitation due to increasing number of institutions. Institutional sanitation became more expedient given the peculiarities of most institutions and the need for efficiency and effectiveness insanitation services and diseases prevention. Institutional Sanitation has today assumed an indispensable aspect of our national sanitation system in Nigeria.
MEANING OF SANITATION: 
Traditionally Sanitation refers to the provision of facilities and services for the safe disposal of human urine and feces. It is also explained as the hygiene means of promoting health through prevention of human contact with hazard of wastes (physical, microbiological and chemical). It involves the maintenance of hygienic conditions, through services such as garbage collection and waste disposal. 
However, the modern application of sanitation includes such other preventive interventions food, drinking water, building construction etc (thus, food sanitation, water sanitation, building sanitation etc).

INSTITUTIONAL SANITATION:
An institution is a complete property and its building, facilities, and services, having a social, education, or religious purpose. This  include schools, colleges or universities, hospitals, nursing homes, homes for the aged, jails and prison, reformations, and various types of welfare, mental and detention homes or facilities most institutions are communities unto themselves. They have certain characteristics in common that require careful planning, design, construction, operation and maintenance. In considering institutional sanitation certain important factors need to given prominence:
1.  Site Selection
-      Sub soil investigation (valley, wetland, land fill)
-       Location (proximity to sources of noise, air pollution e.t.c)
2.  Water supply
-      Safe and potable water
-      Water for fire protection
-      Water for other uses e.g. sanitation, gardening
3.  Sewage disposal
-      Sewers/waste water disposal
-      Excrete Disposal system
-      Drainages/storm water disposal system
4.  Solid waste disposal system
5.  Food preparation and service facilities etc.
For the purpose of the presentation we are going to consider the sanitation needs of university only.
UNIVERSITIES:
The national policy guidelines on school sanitation of 2005 do not have universities and other tertiary institutions in focus. However, the essential element of school hygiene and sanitation is captured. For university sanitation programme the requirements and approach is more complex since it may incorporate a full spectrum of facilities and services not unlike a community. In addition to basic facilities such as water supply, swage and other waste water disposal, plumbing, solid waste management, and air quality, are control of food preparation and services, housing, clinic or dispensary, swimming pool, radiation installations and radioisotopes, insect and rodent infestation, and safety and occupational health in structures, laboratories and works areas including fire safety, electrical hazards, noise, and hazardous materials. in view of their complexity and their affect on life and health, universities and by extension other tertiary institutions should have a professionally trained environmental health and safety officer and staff responsible for the enforcement of standards and routine monitoring and inspections of the areas of concern. In the context of Nigeria universities, an ideal inspection checklist form shall take cognizance of the following areas of critical sanitation concern:

1.  Water supply
a.   Quality meets local drinking water standards
b.  Supply adequate for population (8 gallons per capital per day)
c.   Water system (pipe borne, boreholes e.t.c) potable and approved
d.  Adequate protection for drinking water
e.   Clean/ storage and distribution system
f.    Routine quality monitoring

2.  Sewage and Toilet facilities
a.   Adequate number of toilets (1.33ration)
b.  Wash hand basins
c.   Bathroom/shower adequate
d.  Treatment meet stream standard
e.   Qualified plumber
f.     Clean, convenient, free from odors, ventilated and well drained facilities.
3.  Solid waters
a.   Garbage storages and collection
b.  Refuge, collection (sorting)
c.   Disposal method satisfactory
4.  Swimming pool and bathing beach
a.   Life-Saving equipment and life guards
b.  Adequate clarity
c.   Adequate treatment
5.  Dietary
a.   Food source approved
b.  Dry storage clean
c.   Food preparation, handling, cooking proper
d.  Food service temperature and protection satisfactory
e.   Utensil and equipment condition clean and satisfactory
f.    Hand washing facilities adequate and convenient
6.  Structure and grounds
a.   Locations suitable
b.  Buildings and grounds well drained
c.   Accessible by emergency vehicles
d.   Service entrance convenient
e.   Elevators serve all floors
7.  Housing and safety
a.   Rooms clean, lighted and ventilated
b.   Fire escape from rooms
c.   Adequate space for occupancy
d.  Insect and rodent control effective
e.   Cleans bedding
f.    Fire protection adequate
g.   Radiation safety measure where applicable
8.  Aesthetics and general safety
a.   Clean lawns and structures
b.  Weed control and flower beds
c.   Lighting of corridors and ventilation
d.   Control of any danger item or situation.


PROBLEMS
In discussing the problems of institutional sanitation, it is safer that some critical aspects that govern the efficacy of sanitation are appraised, especially in the context of institutional policies, funding and the attitude of the university community.
University policies:
Some universities may not have efficient policy guidelines of facilities actions for effective institutional sanitation. How is sanitation to be managed? What facilities are to be made available? What scheme should be entrenched etc are issues that border on policy. The university ought to have clear cut policy and guidelines on very component of the university sanitation program. For the purpose of clarity, the following components are most important:
Excreta Disposal: The practice of open-air defection is ritualized and bound in some traditions. However, the university community is unique considering the diverse culture and traditions that make it up. It is therefore important to have a guideline on excreta disposal. The guideline will spell out the viable methods, the management/maintenance of the facilities and most cost effective disposal options.
Food Sanitation: The important of food hygiene cannot be over emphasized. Many diseases can be spread through poor food hygiene practices. Most catering services in our universities have been contracted for management by the private sector. Often times there is no certainty of the source of the food, method of handling, preparation and even the utensils used in preparation and service of food. A guideline on university food sanitation program is very important. The caterers need to be guided on the standards of personal hygiene, cleaning of utensils, and quality of water for cooking and washing and periodic medical examination of  food handlers. Clandestine sources of food to the university must be checked and avoided.
Cleaning Services and refuse collection:
Most universities as a matter of policy contract cleaning services to companies. However, most companies are not properly guide with required standards of operation. Example, the need sorting at the collection point the use of standard refuses receptacles and standard equipment for operation etc. All these border on sound policy and guidelines for operation.
Attitude:
All too often latrines built can be broom cupboards or goat sheds most probably due to non-use poor maintenance culture. Latrine users for example, that liter the surrounding or refuse to flush that water carriage (W. C) facility make it difficult for other to use. The chronic scarcity of water supply in most institutions make it difficult for availability of water for sanitation services such as flush water for water carriage (W.C) systems. That should information the authorities on the need for most viable alternatives to affect sanitation.
Education and awareness are very important strategies to making institution sanitation effective. Members of the university community across stake must be made aware of their role in sanitation, the vision and mission of the university sanitation program and the actions expected of each one of them. This very critical to positive attitude to sanitation. Groups societies in the institutions.
Funding:
Funding is very critical to effective sanitation program in institutions. For every policy and program of sanitation in the institutions must as a matter of priority be adequately funded to achieve the desire result. Perhaps, a budget line to sustain sanitations is most desirable. Where funding is too limited, assistance can be sort from donors or partners especially in the provision of infrastructure.

PROSPECTS
With the advent of a regulatory institution for environment health practice in Nigeria (EHORECON), matters of sanitation including institutional sanitation have hope of being streamlined and made more effective.
So far, cleaning services in most universities is being contracted and the council has a regulatory framework and enforcement mechanism in place for cleaning services providers in Nigeria.
Professional sanitations across the country are also increasingly being motivated take on private practice in areas of sanitation which include institutional sanitation for better and more effective sanitation regimes in the country. The future looks brighter for institutional sanitation than ever.


               
     


BASICS OF COMMUNITY – LED TOTAL SANITATION (CLTS)


1 Sanitarian A.N. Amadi Ph.D, Fseh, Frsph(Uk) and2 Olabisi Agberemi
1.  Head, Public Health Technology & Wash Consultant
Federal University of Technology, Owerri
2.  WASH Specialist, UNICEF Abuja

RESUME
ASSAINISSEMENT TOTAL PORTE PAR LACOMMUNAUTE          
L’assainissement total porte par lacommunaute est une method innovatrice qui mobilize des communauties a eliminer completement la defecation en plein air. Petra Banqautz et Robert Chambers I’ ont defini comme etent “une nouvelle approche pour la promotion de l’assainissement qui encourage une analyse personelle communautaire des methodes de et des dangers poses par la defecation en plein air”.
toutetois, cette methode fait face a des defis dont quelques-uns incluent: un suivi inadequat par les unites d’hygiene et d’assainissement d’eau du gouvernement local l’existence d’un grand ecert entre les communautes integrees et celles accomplissant la reduction ou l’eradication de la defecation en plein air.
par consequent, il faut qu’il y ait une formation continue de facilitatuers au niveau du gouvernement local et que les communautes forment des comites de suivi et d’evaluation des programmes de l’assainissement total pote par le communaute.
PREAMBLE
Since the down of civilization, man has been involved in various activities within his environment. Those activities have the propensity of generating waste which is susceptible to making the environment inhabitable, i.e., filthy and unhealthy (Kamal and Roberts, 2004).
This view of waste generation is not only limited to man’s activities. As a matter of fact, it is also extended to man himself. It is hardly credible for man to think of himself as an author of nuisance. However, what he produces, after consuming foods of different sorts, is waste, which is also capable of making the environment inhabitable.
It follows, then, that, whenever humans gather their waste, whether as a result their activities or as by-products of what they consume, also accumulates. This accumulation poses a serious health hazard to man, especially, within his habitat, so it has to be kept in check and, if possible, eradicated for the environment to be neat and healthy. 
Generally, excreta management/sanitation can be divided into on-site and off-site technologies. On-site systems (e.g. latrines) store and/or treat excreta at the point of generation. In off-site systems (e.g. sewerage) excreta are transported to another location for treatment, disposal or use. Some on-site systems, particularly in densely populated areas or with permanent structures, will have off-site treatment components, as well.
On-site disposal: In many places, particular in areas with low population densities, it is common to store and treat waste where they are produced – on-site. There are a number of technical options for on-site waste management which, if designed, constructed, operated and maintained correctly, will provide adequate service and health benefits when combined with good hygiene. On-site systems include ventilated improved pit (VIP) latrines, double vault composting latrines, pour-flush toilets, and septic tanks. Dry sanitation or ecological-sanitation (Eco-San) is an on-site disposal method that requires the separation of urine and faeces. Building and operating these systems is often much less expensive than off-site alternatives. Some on-site systems (e.g., septic tanks or latrines in densely packed urban areas) require sludge to be pumped out and treated off-site. Composting latrines allow waste to be used as a fertilizer after it has been stored under suitable conditions to kill worm eggs and other pathogens.
Off-site disposal: In more densely packed areas, sewerage systems are frequently used to transport waste off-site where it can be treated and disposed of. Conventional centralized sewerage systems require an elaborate infrastructure and large amount of water carry the water away. This type of approach may work well in some circumstances, but is impractical for many other locations- -e.g., Nigeria.
To ensure a neat and healthy environment, consequently, individuals and communities have to embrace the habit of proper disposal of solid and liquid waste through various means and methods. One of such means and methods is Community – Led Total Sanitation (CLTS) (Bwure, 2010).
Community-Led Total Sanitation (CLTS) is one of the latest innovations of encouraging individuals and communities to adapt in order to keep free from any activities injurious to good health, especial for instance, human defecation. This method is based upon the premise that subsidies can slow and inhibit the spread of sanitation.
CONCEPT OF COMMUNITY – LED TOTAL SANITATION
Community-Led Total Sanitation (CLTS) is an innovative methodology for mobilizing communities with a view to eradicating Open Defecation (OD). Also, it can be said to be a new approach to sanitation promotion which encourages community self-analysis of existing defecation patterns and threats, and promotes local solutions to reduce and ultimately eliminate the practice of Open Defecation’ (Petra Banqaitz and Robert Chambers, 2009). This definition entails that (CLTS) processes can precede and lead on to, or occur simultaneously with,
-      Improvement of latrine designs
-      adoption and improvement of hygienic practices
-      Solid waste management
-      Waste water disposal
-      Care
-      Protection and maintenance of drinking water sources, and
-      Other environmental health and sanitation strategies.
In many cases, CLTS initiates a series of new collective local development actions by OD communities. (Kamal Kar 2004 & moore Community-Led Total Sanitation is total and involves or affects everyone in the communities. Collective decision-taking and collective local actions are the keys of CLTS, which enhance social solidarity and cooperation in abundance. At the heart of CLTS lies the recognition that merely providing toilets does not guarantee their use, nor result in improved sanitation and hygiene. Rather, people decide together how they will create a clean and hygienic environment that benefits everyone.


PRINCIPLES AND OBJECTIVES OF CLTS
With a view to achieve total sanitation, that is, Open Defecation free communities led by a sustainable use of safe, affordable and user-friendly solutions and/or technologies,
1.  Total sanitation must include provision of sanitation facilities such as dustbins latrines, urines, adequate bathrooms, hand washing equipment, water, soap, etc. in schools, health centers, markets, dormitories and other public places.
2.  In CLTS, communities must be in charge of the change process and use their capacity to attain their envisioned objectives. Community members themselves must be allowed to play a control role in planning, with special attention to the need of women, children and other vulnerable groups;
3.  Subsidies (in the form of funds, hard wares, etc) are not to be given straight to households. Community rewards and incentives should be acceptable only where they encourage collective action, total sanitation, and are used to attain sustainable use of sanitation facilities (as opposed to the construction of infrastructures without educating people on how to use and maintain them)’
4.  For sustainable CLTS, local communities must be empowered towards more participatory activities;
5.  The visibility of community activities must be strengthened;
6.  Local and international linkages with donor agencies and other stakeholders on sanitation should be strengthened;
7.  There must be improvement upon initiation of community – driven health and sanitation activities such as the one organized by Center for Women, Gender and Development Studies (CWGDS).
8.  There must be capacity building in rural and urban areas through training;
9.  Local and international policies should be made available to communities so that these may contribute to policy debates;
10.              There should be routine tests of self-mobilization of communities;
11.              CLTS must contribute to research in order to enhance community knowledge on the operations of land use Decrees and Acts, etc. (Kamal 2004, Moore & Mckee 2012).
STRATEGIES OF CLTS
In order to attain its objectives, CLTS employs several strategies, which include the following:
1.  Given priority to sanitation and hygiene.
2.  Mobilizing political will.
3.  Requiring good approaches to sanitation and hygiene development.
4.  Building on existing practices.
5.  Paying attentions to gender,
6.  Harmonizing institutional frameworks for service delivery.
7.  Enforcing existing sanitation laws.
8.  Involving NGOs, community-base organizations (CNOs) and private sectors.
9.   Sourcing for more funds, specially for sanitation and hygiene     
ATTRIBUTES OF CLTS
CLTS possesses attributes that depict its actions. it is….
1.  focused: It focuses on stopping open defecation;
2.  Encompassing: It employs and relies on the collective action of the members of a community to stop defecation within the community;
3.  Insightful: It recognize that sanitation is both a public and a private good, and that individual hygiene behavior can affect a whole community;
4.  Unprovisioning: I t does not take the responsibility of building toilet for a community; rather, it mandates households to finance their own toilets;
5.  Promotional: It promotes low cost home – made toilets constructed with local materials (rather than standard toilet designs imposed by outsiders) with provision to climb up the sanitation ladder; 
6.  Improving: It seeks general improvement in personal, household and environmental hygiene (including hand washing);
7.  Additional: It increases ownership and sustainability of hygiene of sanitation activities.

DISEASES ASSOCIATED WITH POOR SANITATION
It is a well known fact that human excreta have been implicated in the transmission of many infectious diseases including cholera, typhoid, infectious hepatitis, polio, cryptosporidiosis and ascariasis. WHO (2004) estimates that about 1.8 million people annually where 90% are children under five, mostly in developing countries.
Poor sanitation gives many infections the ideal opportunity to spread. Common sanitation and hygiene related diseases are Lice, Lymphatic filariasis, Ringworm, Scabies, Soil transmitted helminthiasis and Trachoma.
Others are amebiasis, Buruli Ulcer, Campylobacter, Cholera, Cryptoporidiosis, Cyclosporiasis, Dracunculiasis (guinea-worm disease), Escherichia coli) Fascioliasis, Giardiasis, Hepatitis, Leptospirosis Norovirus, Rotavirus Salmonella, Schistosomiasis, Shigellosis, Typhoid Fever.
Sanitation and hygiene are very important to health, survival and development. A great amount of disease can be prevented and averted through better access to convenient sanitation equipment and better hygiene practices. Improved sanitation facilities (for example, toilets and latrines) allow people to dispose of their waste appropriately, which helps break the infection cycles of many diseases. (Amadi, 2009).
CLTS IN NIGERIA AND CHALLENGES
Community-Led Total Sanitation and its adaptations were piloted in Nigeria from 2004-2007 in a number of communities. The pilot interventions were carried out by such organizations as UNICEF, Water Aid, State and Local Governments. Based upon the outcome of such interventions, CLTS was adopted as a major approach for moral sanitation development.
In 2010, UNICEF engaged DR. Kamal Kar to make a fast evaluation of CLTS implementation in Nigeria and facilitate a national training of master trainers on the effective scaling up of CLTS. The main finding of the evaluation was that the CLTS approach in the project areas had been generally very successful in promoting significant reduction in t he practice of open defecation free status. 
However, many problems are still recorded in the project areas. They are as follows:
1.  The government is not pro-active in following up and monitoring CLTS activities in designated areas.
2.  There is lack of baseline data on community sanitation owing to poor record keeping and documentation.
3.   There are delay in implementing open defecation free guidelines and discrepancies in recording open defecation free status.
4.  The upward movement on the sanitation ladder is very slow.
5.  NGOs scarcely get involved in promoting community-Let Total Sanitation.
6.  Facilities for scaling up CLTS are inadequately skilled.
7.  There is still a big gap between the number of triggered communities and the numbers achieving open defecation free (ODF) (Rukuni, 2010).
There is need for on-going research in the area of CLTS.

REFERENCE
Amadi, A.N (2009) Modern Environmental Sanitation; Owerri, Nationwide Printers & publishing Co. Ltd. Bwure, Buluwa (2010) Breaking Shit Taboos: CLTS in Kenya; participatory learning & Action, 61(1) Pg 91-96.
Da silva Wells, Carmen and Sijbesma Christine (2012) Development in Practice’ 22 (3)P 417-426 Kamal Kar &Robert Chambers (2004) Handbook on Community-led Total Sanitation Development Studies, University of Sussex, UK. 
Moore Tom & Mckee Kiai (2012) Empowering Local Government? An international review of Community Land Trust Housing 27 (20 pg 280-290).
Rukuni Samuel (2010): Challenging Mindsets: CLTS and Government Policies in Zimbabwe’ Participatory Learning and action (10 pg 1141-14).