papers that study India’s TSC, both of which have attributed large improvements in child heightfor-age to the TSC, and a third working paper that evaluated a large-scale sanitation program in Indonesia. Spears [44] estimated that children living in districts with an average level of TSC implementation had improved height of +0.2 Z-scores and reduced infant mortality by 4 per 1000. This study used administrative monitoring data collected by the TSC to measure program exposure combined with national surveys for child outcome measurements. However, official TSC monitoring data likely overstates actual implementation conditions. For example, in this study the TSC block coordinators reported that village level toilet coverage ranged from 47% to 97% in intervention villages, whereas village level toilet coverage in our study population ranged from 5% to 79% (median 42%). Correlated measurement errors in exposures or confounders usually lead to unpredictable biases that are often non-conservative [44–48].

In a second study from Maharashstra, Hammer and Spears [45] report results from a clusterrandomized trial that evaluated the TSC and was similar in design to the present study. Sixty villages were randomized to control or intervention in February 2004, and outcomes measured in August of 2004 and 2005. At the final measurement, the study reported a modest improvement of 8 percentage points in toilet construction but a strong increase of +0.4 Z in height-for-age among children < 5 years. The effects of the TSC on height-for-age are greater in magnitude than most complementary feeding efficacy trials in infants (mean +0.28 Z, range -0.04, 0.69) and far greater than effects observed in complementary feeding effectiveness trials [46,47]. While the study design is robust and the findings are important, the large effects on height-for-age just 6 months after enrollment when most children are beyond the primary window for growth faltering (0-24 months) [48] will need further research to determine whether the results are biologically plausible.

A companion study to the current evaluation was conducted in East Java, Indonesia [21]. Consistent with our results, the intervention in Indonesia significantly increased toilet installation and reduced open defecation, albeit at rates lower than in this study. Among households with no toilet at baseline (N=941), the Indonesia study documented a small but significant improvement in health outcomes including diarrhea, helminth infection, and anthropometry. However, these results while promising should be viewed with caution as this subsample is small and the experiment was not designed nor powered to examine health impacts in subsamples.

Our findings are broadly consistent with several recent studies of sanitation promotion interventions in South Asia. An earlier randomized evaluation in Orissa, India, between 2005 and 2006 randomly allocated the TSC program to 20 villages (20 reserved as control), and documented a 19-percentage point increase in household toilet ownership 5-7 months after implementation; the investigators found that a significant share of households were in the process of building their toilets, and suggested that later measurement would be helpful to document the full impact of the program. The findings from the present study are also consistent with results from an evaluation of the Sanitation Hygiene Education and Water supply in Bangladesh (SHEWA-B) [49]. The SHEWA-B project had the goal of improving sanitation, 19 / 41