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Providing environmentally-safe sanitation to millions of people is a significant challenge, especially in the world’s second most populated country. The task is doubly difficult in a country where the introduction of new technologies can challenge people’s traditions and beliefs. This discussion paper examines the current state of sanitation services in India in relation to two goals—Goal 7 of the Millennium Development Goals (MDGs), which calls on countries to halve, by 2015, the proportion of people without improved sanitation facilities (from 1990 levels); and India’s more ambitious goal of providing “Sanitation for All” by 2012, established under its Total Sanitation Campaign. This paper discusses recommendations that can help key stakeholders address the significant obstacles in providing universal sanitation coverage in India.