Community-Led Total Sanitation Research Articles

Narratives of sanitation: Motivating toilet use in India

One of the largest gaps between policy intent and actual public behavior lies in the area of sanitation. Despite well-established health benefits as well as intense government efforts, there remains a continued preference for open defecation (OD) in India. Previously vaunted participatory efforts such as Community Led Total Sanitation (CLTS) have also had limited empirical success. We explore this puzzle in Andhra Pradesh (AP) where large investments in latrines have been accompanied by low take-up rates. A survey of 300 residents reveals that the majority of latrine users are highly satisfied with the experience of using latrines, while the majority of non-users are highly dissatisfied with OD. At the same time, we find little or no resource impediment to the adoption of latrines. To explain these highly paradoxical findings, we conducted a quantitative investigation into the narratives of sanitation and find two key themes; the first describes a “technology society” with discourses on health, modernity and infrastructure; the second a “green society” with discourses on traditions, closeness with nature and practical conduct, which provides a strong defensible narrative for OD. Understanding these competing worldviews of the environment provides policy makers with a good premise for motivating latrine use as India urbanizes. It also explains the failure of CLTS methods which rely on “shame” and “disgust” to motivate long term behavioral change.

Combination Of Extension And Triggering Methods Of Changes In Family Head Attitudes About Stop Open Defecation Free (ODF)

Open defecation free health behavior problems in Indonesia are still prevalent, one of which is in Bumiharjo Village in 2016 ODF behavior is still carried out by 561 families. In 2018 the village of Bumiharjo will start carrying out Community Led Total Sanitation (CLTS) counseling and triggering activities. The combination of counseling and triggering methods for changing attitudes related to ODF has not yet been the basis of this research. This type of quantitative research with a quasi-experimental design. Has been carried out in March - November 2019, research subject of the head of the family who is still doing open defecation. A sample of 60 respondents divided into two groups, the sample taken by purposive sampling. Retrieval of data using a questionnaire with the results found the value of p = 0.001 so that it can conclude there is a change in attitude about stopping Open Defecation Free before and after triggering and counseling to the Head of the Family in Purwosari Village, Natar District, South Lampung Regency. It recommended that counseling and triggering activities carried out on an ongoing basis and the availability of facilities for open defecation free, funds, and collaboration across programs and sectors.

Impact of Community-Led Total Sanitation and Hygiene on Prevalence of Diarrheal Disease and Associated Factors among Under-Five Children: A Comparative Cross-Sectional Study in Selected Woredas of Gamo Gofa Zone, Southern Ethiopia

Background. Diarrheal diseases are still one of the major causes of morbidity in under-five children in sub-Saharan Africa. In Ethiopia, diarrhea is responsible for 9% of all deaths and is the major cause of under-five mortality. Objective. To assess the impact of community-led total sanitation and hygiene on the prevalence of diarrheal disease and factors associated among under-five children in Gamo Gofa Zone. Methods. Community-based comparative cross-sectional study design was used to compare the impact of community-led total sanitation and hygiene intervention on under-five diarrheal disease. Multistage sampling method was employed. The data were collected by using pretested structured questionnaires. Data quality was ensured by daily supervision completeness and consistency. The data were coded, entered, and cleaned by using Epi Info version 7 and were analyzed by using SPSS version 20. Bivariate and multivariable analyses were carried out by using binary logistic regression. Significance was declared by using p value of <0.05 and AOR with 95% confidence intervals. Results. The response rate of this study was 93.3%. The overall diarrhea prevalence was 27.5% (CI = (24.06, 30.97)) which was 18.9% (CI = (14.94, 23.2)) in implemented and 36.2%. (CI = (30.41, 41.59)) in nonimplemented woredas. Children whose age was between 12 and 23 months (AOR = 1.6) and greater than 24 months (AOR = 5), availability of handwashing facilities (AOR = 4), disposal of waste in open field (AOR = 9.7), unimproved source of drinking water (AOR = 6.5), using only water for handwashing (AOR = 6), children who started complementary feeding less than 6 months (AOR = 5.6) and greater than 6 months (AOR = 5.2), and utensils used to feed children such as bottle (AOR = 3.9) were the factors positively associated with diarrhea. Conclusion. The overall prevalence of under-five diarrhea was 27.5%. The prevalence was low in CLTSH woredas as compared with non-CLTSH woredas. The study showed that handwashing facility, using only water for handwashing, open refuse disposal, and unimproved source of drinking water among under-five had a statistically significant association with diarrhea occurrence in CLTSH nonimplemented areas. Integrated efforts are needed from the Ministry of Health together with the WASH Project in improving drinking water, handwashing facilities, and solid waste disposal practices.

Externalities and Spillovers from Sanitation and Waste Management in Urban and Rural Neighborhoods

AbstractProper sanitation and waste management has important health benefits, both directly for the household making the decision and indirectly for its neighbors due to positive externalities. Nevertheless, construction and use of improved sanitation systems in much of the developing world continues to lag. Many recent interventions such as Community Led Total Sanitation (CLTS) have attempted to harness the power of social interactions to increase take‐up of improved sanitation. Most evidence to date mobilizes social pressure in rural areas, yet evidence is more scarce in urban neighborhoods where high population density may lead to larger externalities from poor sanitation decisions. We review the recent literature on how sanitation decisions are inter‐related within neighborhoods: the health externalities that sanitation decisions have on neighbors, and the social decision spillovers that drive take‐up. We explore potential explanations for the low take‐up and maintenance of sanitation systems, including the possibility of nonlinearities and thresholds in health externalities; the roles of social pressure, reciprocity, learning from others, and coordination in decision spillovers; and differences between urban and rural contexts.

Evidence-based policy analysis? The strange case of the randomized controlled trials of community-led total sanitation

AbstractOur purpose in this paper is to review the findings of 14 randomized controlled trials (RCTs) of community-led total sanitation (CLTS) and recent rural sanitation interventions to assess their usefulness and implications for sanitation policy-making in low- and middle-income countries. The results of the RCT research programme to evaluate CLTS and related sanitation interventions suggest that the magnitude of the treatment effects was much smaller and uncertain than proponents once anticipated. For example, of the ten studies that reported results for reductions in childhood diarrhoea, only three found statistically significant decreases. Surprisingly, the RCT research teams and their funders do not seem to have thought about how their multi-million dollar research agenda would support decision-making on sanitation. Information on the parameters needed for cost-effectiveness analysis or benefit–cost analysis was not collected. However, making reasonable assumptions about the missing information on parameter values, we show that cost–benefit analysis may still ‘save’ CLTS because small treatment effects may still yield net positive economic benefits if the costs of implementing CLTS programmes are modest. We also discuss the need to move beyond the desire for sanitation policies that are proven to be effective globally, and the importance of focusing on analysis of the local sanitation situation. We describe the data needed to make this shift in policy focus from the global to the local level and stress the importance of interdisciplinary communication between the proponents of RCTs and ‘evidence-based policy’, and economists who will be responsible for the economic analysis of investments in CLTS and other sanitation interventions. We also argue that the results of these RCTs highlight the importance of coordinating investments in piped water and sanitation with investments in improved housing.

Benefit–Cost Analysis of Community-Led Total Sanitation: Incorporating Results from Recent Evaluations

AbstractWe analyze the economic costs and benefits of “community-led total sanitation” (CLTS), a sanitation intervention that relies on community-level behavioral change, in a hypothetical rural region in sub-Saharan Africa with 200 villages and 100,000 people. The analysis incorporates data on the effectiveness of CLTS from recent randomized controlled trials and other evaluations. The net benefits of this intervention are estimated both with and without the inclusion of a positive health externality, that is, the additional reduction in diarrhea for an individual when a sufficient proportion of other individuals in the community construct and use latrines and thereby decrease the overall load of waterborne pathogens and fecal bacteria in the environment. We find that CLTS interventions would pass a benefit–cost test in many situations, but that outcomes are not as favorable as some previous studies suggest. The model results are sensitive to baseline conditions, including the value of time, income level used to calculate the value of a statistical life, discount rate, case fatality rate, diarrhea incidence, and time spent traveling to defecation sites. We conclude that many communities likely have economic investment opportunities that are more attractive than CLTS, and recommend careful economic analysis of CLTS in specific locations.

The Complementarity of Community-Based Water and Sanitation Interventions: Evidence From Mozambique

We use data on a large-scale water and sanitation program in rural Mozambique, implemented between 2008 and 2013, to investigate the complementarities between a behavior-change-based community-led total sanitation intervention and a community water supply intervention. Our findings indicate that the sanitation intervention increased the adoption of handwashing with soap or ash by 11 percentage points, latrine ownership and use by 8 percentage points, and the use of improved water points by 15 percentage points (conditional on access). Combining the water supply and sanitation interventions increased the treatment effects on all three outcomes. However, we find that the effect on toilet ownership was in large part driven by the selective intervention allocation of the implementing NGOs. These effects are measured up to 4 years after the intervention.

How does Community-Led Total Sanitation (CLTS) promote latrine construction, and can it be improved? A cluster-randomized controlled trial in Ghana

RationaleOpen defecation is connected to poor health and child mortality, but billions of people still do not have access to safe sanitation facilities. Community-Led Total Sanitation (CLTS) promotes latrine construction to eradicate open defecation. However, the mechanisms by which CLTS works and how they can be improved remain unknown. The present study is the first to investigate the psychosocial determinants of CLTS in a longitudinal design. Furthermore, we tested whether CLTS can be made more effective by theory- and evidence-based interventions using the risks, attitudes, norms, abilities, and selfregulation (RANAS) model. MethodsA cluster-randomized controlled trial of 3216 households was implemented in rural Ghana. Communities were randomly assigned to classic CLTS, one of three RANAS-based interventions, or to the control arm. Prepost surveys at 6-month follow-up included standardized interviews assessing psychosocial determinants from the RANAS model. Regression analyses and multilevel mediation models were computed to test intervention effects and mechanisms of CLTS. ResultsLatrine coverage increased pre-post by 67.6% in all intervention arms and by 7.9% in the control arm (p < .001). The combination with RANAS-based interventions showed non-significantly greater effects than CLTS alone. The effects of CLTS on latrine construction were significantly mediated by changes in four determinants: others' behaviour and approval, self-efficacy, action planning and commitment. Changes in vulnerability, severity, and barrier planning were positively connected to latrine construction but not affected by CLTS. ConclusionThis study corroborates the effectiveness of CLTS in increasing latrine coverage, and additional activities can be improved further. Behaviour change techniques within CLTS that strengthened the relevant factors should be maintained. The study also recommends interventions based on the RANAS approach to improve CLTS. Further research is needed to understand the effects of RANAS-based interventions combined with CLTS at longer follow-up

Water supply, sanitation and hygiene interventions and childhood diarrhea in Kersa and Omo Nada districts of Jimma Zone, Ethiopia: a comparative cross-sectional study

BackgroundDiarrhea is a major public health problem that disproportionately affects children in developing countries, including Ethiopia. Most of the diseases can be prevented through safe drinking water supply and provision of basic sanitation and hygiene. However, there is a paucity of information on childhood diarrhea related to interventions in kebeles (smallest administrative structure) where community-led total sanitation (CLTS) implemented and not implemented (non-CLTS). Thus, the aim of this study was to assess and compare the association of water supply, sanitation and hygiene interventions, and childhood diarrhea in CLTS implemented and non-implemented kebeles.MethodA comparative cross-sectional study was conducted in Kersa and Omo Nada districts of Jimma Zone, Ethiopia from July 22 to August 9, 2018. Systematically selected 756 households with under-5 children were included in the study. Data were collected through interview using structured questionnaires. Water samples were collected in nonreactive borosilicate glass bottles. The binary logistic regression model was used; variables with a p value < 0.05 were considered as significantly associated with childhood diarrhea.ResultsThe prevalence of childhood diarrhea in the past 2 weeks was 17.7% (95% CI: 13.9–21.5) in CLTS kebeles and 22.0% (95% CI: 17.8–26.2) in non-CLTS kebeles. The occurrence of childhood diarrhea, increased among children whose families did not treat drinking water at home compared to those who treated in both CLTS (AOR = 2.35; 95% CI: 1.02–05.98) and non-CLTS (AOR = 1.98; 95% CI: 0.82–4.78) kebeles. About 96% of households in CLTS and 91% of households in non-CLTS kebeles had pit latrine with and without superstructure. Children from families that used water and soap to wash their hands were 76% less likely to have diarrhea in CLTS kebeles (AOR = 0.76; 95% CI: 0.31–1.88) and 54% less likely to have diarrhea in non-CLTS kebeles (AOR = 0.54; 95% CI: 0.17–1.72) when compared to children from families who used only water. The odds of having diarrhea was 1.63 times higher among children whose families live in CLTS non-implemented kebeles compared to those children whose families live in CLTS implemented kebeles (AOR = 1.63; 95% CI: 0.98–2.68).ConclusionsNo significant difference was observed in the prevalence of childhood diarrhea between CLTS and non-CLTS kebeles.

The Effect of the Community Led Total Sanitation (CLTS) Method on the Event of Diarrhea in Balita in Banjar District

Diarrhea was ranked second as the leading cause of death in infants. Diarrhea in Indonesia is still an endemic disease and is a potential disease outbreak accompanied by death. Health profile data in 2016 showed that there were 6, 897, 463 estimated cases of diarrhea in health facilities, while those handled only around 2, 544, 084 (36.9%). The cases of diarrhea in South Kalimantan were 107, 725, while those handled were only 9, 986 (9.3%). Banjar Regency is the highest regency, both cases of diarrhea with a total estimated cases of 22, 422, while those treated are 9650 (43%). The influence of the CLTS method which includes open defecation, CTPS (Hand Washing with Soap) behavior, drinking and food water management, waste management and household wastewater management with the incidence of diarrhea in infants in Banjar Regency. The design of this study is analytical, with a cross sectional approach. The population in this study were all mothers who had toddlers in Banjar Regency. The sample hereinafter referred to as the respondent in this study was determined using a purposive sampling technique with a minimum sample size of 100 people. Chi-square statistical test with 95% confidence level. The results of the study of all family members have behaved well with defecation in sanitary ware that is 100% and doing a good CTPS of 100%, there is no significant effect of the influence of drinking water and food with the incidence of diarrhea in infants in Banjar Regency, there is no significant effect between waste management and the incidence of diarrhea in infants in Banjar Regency, there is no significant effect between household wastewater management and the incidence of diarrhea in infants in Banjar Regency.

Lessons learned from the national sanitation campaign in Njombe district, Tanzania

Abstract Sanitation remains one of the Sustainable Development Goals, with slow progress. Tanzania has been implementing the National Sanitation Campaign through a Community-Led Total Sanitation (CLTS) approach since 2012. Njombe District Council (DC) has been identified to be among the best performing councils in the implementation of the sanitation campaign. A qualitative study was conducted to document how the CLTS was carried out in Njombe DC, assess progress on CLTS implementation and define the success factors for CLTS implementation. Findings show that CLTS intervention has resulted in increased coverage of improved latrines at a household level from 7.5% before the intervention in 2011 to 99.8% in September 2018. In addition, households with functional hand washing facilities have increased from 5.1% before the intervention to 94% in September 2018. Involvement of political leaders and government officials from the council level to the lowest governmental unit offered important support for CLTS implementation. The best mix of sanitation education, regulation and enforcement was instrumental in raising community awareness, changing collective behavior, making people comply with the village sanitation laws, and the overall success in the sanitation campaign.

The role of social identification for achieving an open-defecation free environment: A cluster-randomized, controlled trial of Community-Led Total Sanitation in Ghana

Unsafe sanitation practices are a major source of environmental pollution and are a leading cause of death in countries of the Global South. One of the most successful campaigns to eradicate open defecation is “Community-Led Total Sanitation” (CLTS). It aims at shifting social norms towards safe sanitation practices. However, the effectiveness of CLTS is heterogeneous. Based on social identity theory, we expect CLTS to be most effective in communities with stronger social identification, because in these communities individuals should rather follow social norms. We conducted a cluster-randomized controlled trial with 3,216 households in 132 communities in Ghana, comparing CLTS to a control arm. Self-reported open defecation rates and social identification were assessed pre-post. Generalized Estimating Equations showed that CLTS achieved lower open defecation rates compared to controls. This effect was significantly stronger for communities with stronger average social identification. The results confirm the assumptions of social identity theory. They imply that pre-existing social identification needs to be considered for planning CLTS, and strengthened beforehand if needed.

Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection.

Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection.

Policy Diffusion in the Rural Sanitation Sector: Lessons from Community-Led Total Sanitation (CLTS)

Worldwide, 892 million people practice open defecation, most of whom live in rural areas of South Asia and Sub-Saharan Africa. Community-Led Total Sanitation (CLTS) is the most widely deployed approach to generate demand for, and use of sanitation facilities. CLTS relies on behavioral change and community self-enforcement to end open defecation. Since its genesis in Bangladesh in 1999, CLTS has spread to approximately 60 countries, mostly in Asia and Africa, and is employed by the majority of development organizations operating in rural sanitation. This paper uses a qualitative approach to analyze the reasons and processes that drove the wide diffusion of CLTS. We show that CLTS was embraced because it was perceived as a fast and effective solution to the problem of open defecation, one which was in line with the decentralization and community participation paradigms, at a time when donors and governments were looking for strategies to meet the MDG for sanitation. CLTS spread under the leadership of influential donors, NGOs, persuasive practitioners, and academics. Face-to-face interactions among members of this network and local governments at conferences and workshops played a central role in the diffusion of the approach. The use of experiential learning during study tours and workshop field visits has been crucial to persuade government actors at different levels, NGOs, and donors to use the CLTS approach. Notably, robust scientific evidence played little role in the diffusion of CLTS. We conclude by making suggestions to strengthen the evidence base for rural sanitation policies.

The prevalence of schistosomiasis in Uganda: A nationally representative population estimate to inform control programs and water and sanitation interventions.

BackgroundTo improve schistosomiasis control programs in Uganda, where intestinal schistosomiasis is a widespread public health problem, a country-wide assessment of the disease prevalence among all age ranges is needed. Few studies have aimed to quantify the relationships between disease prevalence and water and sanitation characteristics across Uganda to understand the potential to interrupt disease transmission with an integrated package of interventions.Methodology/Principal findingsA nationally representative survey was undertaken that included a household and individual questionnaire followed by disease testing based on detection of worm antigens (circulating cathodic antigen–CCA), diagnosis and treatment. A comprehensive set of questions was asked of randomly sampled individuals, two years of age and above, to understand their water and sanitation infrastructure, open defecation behaviors, exposure to surface water bodies, and knowledge of schistosomiasis. From a set of 170 randomly sampled, geographically diverse enumeration areas, a total of 9,183 study participants were included. After adjustment with sample weights, the national prevalence of schistosomiasis was 25.6% (95% confidence interval (CI): 22.3, 29.0) with children ages two to four most at risk for the disease with 36.1% infected (95% CI: 30.1, 42.2). The defecation behaviors of an individual were more strongly associated with infection status than the household water and sanitation infrastructure, indicating the importance of incorporating behavior change into community-led total sanitation coverage.Conclusions/SignificanceOur results highlight the importance of incorporating monitoring and evaluation data into control programs in Uganda to understand the geographic distribution of schistosomiasis prevalence outside of communities where endemicity is known to be high. The high prevalence of schistosomiasis among the youngest age group, ineligible to receive drug treatment, shows the imperative to develop a child-appropriate drug protocol that can be safely administered to preschool-aged children. Water and sanitation interventions should be considered an essential investment for elimination alongside drug treatment.

Assessment of Community-led Total Sanitation Sustainability in Ejigbo Local Government Area of Osun State, Nigeria

Nigeria is among the nations of the world with the highest number of people practising Open Defecation. This study among others assessed the level of community-led total sanitation (CLTS) in the selected triggered communities and focused on the rationale for the reversion of CLTS programme implemented in some of some rural communities with poor sanitation coverage in Ejigbo Local Government Area of Osun state, Nigeria, with the technical and financial support of donor agencies. The qualitative, semi-structured questionnaires were administered in 296 households in 41 selected communities. Spatial positioning of communities and water points coordinates were collected through the use of a hand-held Global Positioning System- GPS model etrex 10 GARMIN to produce a digital map through the Arc view Geographical Information System software. Two batches of CLTS were conducted in the Local Government Area across 182 communities in 2006 and 2012 with and without subsidy. Communities were triggered and declared open defecation free while some were certified ODF. The majority (75.7%) of the respondents reverted to OD as a result of caved-in of pit latrine due to the use of log of wood, wooden slab as platform over the pit. 5.1% of the respondents improved on CLTS latrine 81.7% of household used the latrine for just two years before defectiveness set in. All respondents agreed to have benefited in the CLTS programme and were willing to return to construct durable latrine provided they get a subsidy or are financially buoyancy. This study revealed that emphasis was on latrine construction while other components of environmental sanitation were not properly addressed as any scalability was near to nothing. Monitoring and follow up was found to be weak among the stakeholders.

Externalities and Spillovers from Sanitation and Waste Management in Urban and Rural Neighborhoods

Proper sanitation and waste management has important health benefits, both directly for the household making the decision and indirectly for its neighbors due to positive externalities. Nevertheless, construction and use of improved sanitation systems in much of the developing world continues to lag. Many recent interventions such as Community Led Total Sanitation (CLTS) have attempted to harness the power of social interactions to increase take-up of improved sanitation. Most evidence to date mobilizes social pressure in rural areas, yet evidence is more scarce in urban neighborhoods where high population density may lead to larger externalities from poor sanitation decisions. We review the recent literature on how sanitation decisions are inter-related within neighborhoods: the health externalities that sanitation decisions have on neighbors and the social decision spillovers that drive take-up. We explore potential explanations for the low take-up and maintenance of sanitation systems, including the possibility of non-linearities and thresholds in health externalities; the roles of social pressure, reciprocity, learning from others, and coordination in decision spillovers; and differences between urban and rural contexts.

Spatial Analysis on Stunting Events Based on Community Led Total Sanitation and Poor families in Cianjur District

Spatial Analysis on Stunting Events Based on Community Led Total Sanitation and Poor families in Cianjur District

Design of a parallel cluster-randomized trial assessing the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia: Andilaye study protocol

BackgroundUnimproved water, sanitation, and hygiene (WASH) behaviors are key drivers of infectious disease transmission and influencers of mental well-being. While WASH is seen as a critical enabler of health, important knowledge gaps related to the content and delivery of effective, holistic WASH programming exist. Corresponding impacts of WASH on mental well-being are also underexplored. There is a need for more robust implementation research that yields information regarding whether and how community-based, demand-side interventions facilitate progressive and sustained adoption of improved sanitation and hygiene behaviors and downstream health impacts. The purpose of this protocol is to detail the rationale and design of a cluster-randomized trial evaluating the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia.MethodsTogether with partners, we developed a theoretically-informed, evidence-based behavioral intervention called Andilaye. We randomly selected and assigned 50 sub-districts (kebeles) from three purposively selected districts (woredas); half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). During baseline, midline, and endline, we will collect data on an array of behavioral factors, potential moderators (e.g., water and sanitation insecurity, collective efficacy), and our primary study outcomes: sanitation and hygiene behaviors and mental well-being. We will perform a process evaluation to assess intervention fidelity and related attributes.DiscussionWhile CLTSH has fostered sanitation and hygiene improvements in Ethiopia, evidence of behavioral slippage, or regression to unimproved practices in communities previously declared open defecation free exists. Other limitations of CLTSH, such as its focus on disgust, poor triggering, and over-saturation of Health Extension Workers have been documented. We employed rigorous formative research and practically applied social and behavioral theory to develop Andilaye, a scalable intervention designed to address these issues and complement existing service delivery within Ethiopia’s Health Extension Program. Evidence from this trial may help address knowledge gaps related to scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond.Trial registrationThis trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.

Projected Behavioural Change in Swachh Bharat Mission: A Public Policy Perspective

The Swachh Bharat Mission (SBM) is the largest behavioural change programme in the world. The mission has shifted its focus from production outputs (i.e. toilet construction) to behavioural outcomes (open-defecation-free [ODF] India). The SBM’s emphasis on behavioural change in rural sanitation at the grassroots level also leads to rigorous verification and sustainability of the benefits accrued to rural communities. The SBM targets to achieve an ODF India by 2019, on the eve of the 150th birth anniversary of Mahatma Gandhi. In addition to this, the mission will also contribute to India reaching the UN Sustainable Development Goal 6, which calls for ensuring availability and sustainable management of water and sanitation for all. It is in this context that the article critically analyses the sanitation services in general and with special reference to SBM in India from a public policy perspective. It seeks to establish the linkages between public health and sanitation and problemetises the issue of open-defecation and its health implications. It provides an analysis of behavioural change techniques in community-led total sanitation (CLTS) and its application in achieving Swachh Bharat (clean India). The article presents a historical account of sanitation situation in colonial and post-independence India, followed by an in-depth analysis of the formulation of the SBM. Lastly, the article examines the current status of implementation of SBM and it also discusses the emerging issues and concerns that could be addressed in achieving ODF India.