Most diseases that result in ill health are caused by communities polluting the environment through various ways. Open defecation and not washing one’s hands after using the toilet are among the ways in which communities create unsanitary environments favourable for diseases transmission. To prevent disease transmission and keep communities healthy, the Ministry of health and Social Welfare designed the campaign to help increase communities by 50% with access to improved toilets and handwashing facilities. This study evaluated Processes of the National Sanitation Campaign and its effects on increasing improved toilets and handwashing and utilization in Kiteto and Hanang Districts in Manyara Region. METHODS This evaluation adopted a cross sectional study design. The realistic evaluation approach was employed which utilized a mixed methods (qualitative and quantitative) research approach to assess the implementation processes of the National Sanitation Campaign, factors for campaign implementation and campaign effect on the coverage and use of improved toilet and hand washing facilities. The methods of data collection were questionnaire and semi-structured interview guide. Questionnaires were administered to 200 randomly selected respondents. The respondents were head of households. The Semi-structured interviews guide was administered with 12 purposively key informants. The criteria for selection of the key informants were: living in the study area, have good understanding of the sanitation campaign and have been involved in the implementation process. The quantitative data was analyzed by using the STATA version 13.0 while Qualitative data was collected in Kiswahili, transcribed, and translated into English. Thereafter data were analyzed thematically using Atlas.ti software version 7.1 (build 3) RESULTS The campaign implementation involved building capacity of district, masonry and village leaders with the aim of every activity providing synergic effect to another so that they can help in increasing the coverage and utilization of improved toilets. This study revealed that the flow of campaign activities did not favour communities to improve their sanitation status since the demand for sanitation was created but the trained masonry in all districts did not manage to increase sanitation supplies(toilet slabs). In all district demand creation for sanitation through triggering was done before training of masonry which created a gap since sensitized communities did not have supplies to improve their toilets. Campaign design requires regular follow up, among 200 head of households administered questionnaire only 23% in Kiteto and 32% in Hanang were followed up. The results of evaluation provide the evidence of overlap of design of campaign and not achieving its intention. During baseline survey 22% of households were having improved toilet in Hanang while during evaluation among 82 (82%) households with toilets only 22 (22%) have improved toilets and 60 (60%) unimproved toilets. In Kiteto, during baseline survey 5% of households were having improved toilet in Hanang while during evaluation all 42 (42%) households had traditional pit latrines. Among 200 head of household administered questionnaire no household was found with handwashing station while during baseline study only 16 households had hand washing facilities. CONCLUSION The programme has not achieved its target of half of community’s ownership and use improved toilets, since 18% and 58% of households in Hanang and Kiteto respectively still have no toilets. Also 60% and 42% of households in Hanang and Kiteto respectively have unimproved toilets and none of household was found with handwashing station. The campaign implementers should take recommendations from this study and make adjustments to the campaign implementation strategies for attainment Millennium Development Goals target of ensuring 50% of communities own improved sanitation.