NEW DELHI (AP) — Building toilets in rural India, where hundreds of millions are still defecating outdoors, will not be enough to improve public health, according to a study published Friday.

India is considered to have the world’s worst sanitation record despite spending some $3 billion since 1986 on sanitation programs, according to government figures. The country is now gearing up to spend 10 times that amount, as new Prime Minister Narendra Modi makes garbage and sanitation troubles a key issue for his first year in office.