Coming up short without sanitation : a community sanitation program by the Indian government helped children grow taller and healthier in the State of Maharashtra

Most people living in rural Indian villages defecate openly outside, without using a toilet or latrine. In 2004, as a supplement to its ongoing Total Sanitation Campaign (TSC), the government of Maharashtra conducted a randomized, controlled experiment to study the effect of a sanitation intervention. In Ahmednagar district of Maharashtra, 30 villages were randomly assigned to a community-level sanitation motivation treatment group and 30 villages to a control group. The program caused a modest increase in sanitation coverage. After the experimental intervention, villages in the treatment group achieved more latrine use than villages in the control group, but open defecation remained a practice in almost every village. These results suggest that even incremental improvements in sanitation can lead to better health for children. From 1999 to 2012, the Indian government's flagship program to end rural open defecation was called the TSC. The TSC was implemented after the centrally sponsored rural sanitation programmed of the 1990s, which invested in latrine construction, but did not specifically promote latrine use. In 2004, the Indian state of Maharashtra began the large scale implementation of the TSC. As the TSC was new at the time, there was an opportunity to learn from the implementation experience given that it would be launched in some districts and villages before others. Analysis of this experiment demonstrates that improving sanitation in these villages in Ahmednagar district allowed children to grow taller. However, one of the most important conclusions of this study required neither statistical analysis nor a randomized, controlled trial-in two of the three districts where the state government originally decided to experimentally implement the TSC, no action was taken, illustrating the constraints facing the Indian government, the importance of investing in the capacity of district governments, and the need to ensure that local governments are motivated to carry out programs that can reduce open defecation.