Explaining the outcomes of the ‘Clean India’ campaign: institutional behaviour and sanitation transformation in India

Introduction Whilst many less developed countries are struggling to provide universal access to safe sanitation, in the last five years India has almost reached its target of eliminating open defaecation. The object of this study was to understand how the Indian Government effected this sanitation transformation. Methods The study employed interviews with 17 actors in the Government’s ‘Clean India’ programme across the national capital and four states which were analysed using a theory of change grounded in Behaviour Centred Design. Results The Swachh Bharat Mission (Gramin) claims to have improved the coverage of toilets in rural India from 39% to over 95% of households between 2014 and mid 2019. From interviews with relevant actors we constructed a theory of change for the programme in which high-level political support and disruptive leadership changed environments in districts, which led to psychological changes in district officials, which, in turn, led to changed behaviour concerning sanitation programming. The Prime Minister’s setting of the ambitious goal to eliminate open defecation by the 150 th birthday of Mahatma Gandhi (October 2019) galvanised government bureaucracy, while early success in 100 flagship districts reduced the scepticism of government employees, a cadre of 500 young professionals placed in districts imparted new ideas and energy, social and mass media was used to engage and motivate the public and key players, and new norms of ethical behaviour were demonstrated by leaders. As a result, district officials engaged emotionally with the programme and felt pride at their achievements in ridding villages of open defecation. Conclusions Though many challenges remain, Governments seeking to achieve the Sustainable Development Goal of universal access to safe sanitation can emulate the success of India’s Swachh Bharat Mission. SUMMARY BOXES What is already known? At least 47 countries are not on track to reach the Sustainable Development Goal of universal access to safe sanitation by 2030 and some 0.6 billion people are still defecating in the open. It is not clear how governments in low income countries can be galvanised to act to resolve this pressing public health problem. What are the new findings? The experience of the Clean India programme suggests that countries can almost eliminate open defecation. The success of the programme was due to factors including: the setting of ambitious targets; the use of modern communications strategies and monitoring technology; and the provision of visible reward and recognition for employees. What do the new findings imply? Disruptive leadership is needed to create working environments where sometimes jaded civil servants are given an opportunity to make a difference. Politicians who embrace the cause of sanitation may find that there are votes in toilets.