This study evaluates targeted subsidies as a strategy to improve sanitation infrastructure and behaviours in communities that have reached Open Defecation Free (ODF) status after a Community-Led Total Sanitation (CLTS) program. The investigator's hypothesis is that sanitation subsidies targeted at the most vulnerable households within ODF communities will increase and help sustain latrine coverage, quality, and use amongst the targeted households, and through a spill-over effect, amongst the rest of the community. Half of participating communities will receive the targeted subsidy, while the other half will not receive any treatment.

Community-Led Total Sanitation (CLTS) is a widely used approach to eradicate open defecation in rural communities in developing countries. Using emotional triggers, CLTS promotes community self-help to build household latrines. In Ghana, where CLTS is part of the government's official sanitation strategy, a community is declared "Open Defecation Free" (ODF) when 80 percent of households own a latrine.

There is however evidence that open defecation persists in so-called "ODF" communities, especially as the most vulnerable households (the poorest of the poor) cannot afford to construct or maintain durable latrines. As a result, subsidies for these vulnerable households have been proposed as a strategy to promote the construction of durable latrines and help sustain safe sanitation behaviours in communities having received CLTS.

This study is a cluster randomized controlled trial that will enroll entire communities. Within a community, only specific households will be selected to receive sanitation subsidy vouchers. Outcomes will be measured both for voucher recipients and for the rest of the community.

Inclusion Criteria (for Communities):

• Community was targeted by UNICEF's Community-Led Total Sanitation (CLTS) program in Tatale, Yendi, and Kpandai districts in Ghana.
• Community has Open Defecation Free (ODF) status according to local authorities.
• Community has more than 15 and less than 100 households.

Exclusion Criteria (for Communities):

• Community is located less than 2 kilometers away from a community in the opposite treatment arm.

Inclusion Criteria (for voucher recipients within study communities):

• Household is extremely poor, as identified through community consultation and/or the government's Livelihood Empowerment Against Poverty (LEAP) program.
• Household has at least one vulnerable person, i.e. who meets one of the following criteria: i) older than 65 years old, ii) person with a disability, iii) orphan or vulnerable child, iv) female head of household, v) widow(er), vi) terminally-ill persons, vii) unemployed, viii) outcast groups.

Exclusion Criteria (for voucher recipients within study communities):

• Household owns a functional, individual (non-shared) latrine with durable sub-structure.

De-identified individual participant data for the primary and all secondary outcome measures as well as key confounders (demographics, wealth index, community characteristics) will be made available.

Data will be available within 9 months of study completion.