Open sky latrines: Comprehensive evaluation of a community-led total sanitation campaign in Orissa, India

Inadequate water and sanitation infrastructure is a major problem in India and throughout the developing world, contributing to severe health problems that limit human and economic development. In order to effectively address these problems, policy makers need a better understanding of “what works” to improve sanitation and health outcomes. This paper presents a comprehensive evaluation of a randomized “Community-Led Total Sanitation” (CLTS) campaign, which focused on changing social norms through a series of social mobilization activities, in Bhadrak District, Orissa. The study evaluates the intervention's overall impact on latrine uptake and child diarrhea rates, as well as the processes generating these outcomes. Difference-in-difference estimators, controlling for a number of household and village characteristics, suggest that latrine uptake increased by about 30% in the CLTS villages as a result of the campaign. Study results also indicate that latrine uptake had a negative impact on child diarrhea rates, although the significance of this result depends on model specification. Quantitative “process” analyses focus on modeling households' latrine adoption decisions as a function of a number of household and village characteristics, some of which were affected by the campaign. In particular, estimates of the impact of social interactions or peer effects in driving demand for latrines in the study area are presented. Further insight comes from qualitative interviews with program officials and village members, as well as field observations. This study highlights the importance of rigorous and comprehensive evaluations to measure program impacts and enable evidence-based policymaking to improve public health.