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Objective To evaluate the long-term impact of a community-led total sanitation campaign in rural India. Methods Local organizations in Odisha state, India worked with researchers to evaluate a community-led total sanitation campaign, which aimed to increase the demand for household latrines by raising awareness of the social costs of poor sanitation. The intervention ran from February to March 2006 in 20 randomly-selected villages and 20 control villages. Within sampled villages, we surveyed a random subset of households (around 28 households per village) at baseline in 2005 and over the subsequent 10-year period. We analysed changes in latrine ownership, latrine functionality and open defecation among approximately 1000 households. We estimated linear probability models that examined differences between households in intervention and control villages in 2006, 2010 and 2016. Findings In 2010, 4 years after the intervention, ownership of latrines was significantly higher (29.3 percentage points; 95% confidence interval, CI: 17.5 to 41.2) and open defecation was significantly lower (−6.8 percentage points; 95% CI: −13.1 to −1.0) among households in intervention villages, relative to controls. In 2016, intervention households continued to have higher rates of ever owning a latrine (26.3 percentage points; 95% CI: 20.9 to 31.8). However, latrine functionality and open defecation were no longer different across groups, due to both acquisition of latrines by control households and abandonment and deterioration of latrines in intervention homes. Conclusion Future research should investigate how to maintain and rehabilitate latrines and how to sustain long-term behaviour change.

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Impact evaluation (IE) of large infrastructure presents numerous challenges, and investments in urban piped water and sanitation are no exception. Here we present methods for more systematic assessment of the implications of such interventions, discussing tradeoffs between validity, relevance and practicality that arise from alternative approaches. Then, to more clearly illustrate the many issues that typically arise in such IEs, we draw on an example application in Zarqa, Jordan, where the Millennium Challenge Corporation invested about US$275 million to upgrade and extend piped water and sewer networks, as well as increase the capacity of the country's largest wastewater treatment plant. The theory of change for the intervention took a systems view of impacts: the project aimed to improve water supply to urban areas while maintaining flows to irrigators through enhanced wastewater reuse. The case adds valuable evidence on the impacts of large infrastructure investments and illustrates well the challenges of capturing spillovers, mitigating study contamination, maintaining statistical power, and determining overall welfare effects, in situations involving diverse market and nonmarket impacts. These limitations notwithstanding, the case highlights the high value of conducting IEs, and why applied researchers should not give up on pragmatic and interdisciplinary collaborations to evaluation in the face of complex interventions.