The provision of sanitation facilities - a basic necessity for human health, well-being, dignity, and development - remains a mammoth challenge for developing countries where the vast majority of the 2.5 billion people without improved sanitation facilities reside. Sub-Saharan Africa (SSA) is one of the regions where decent, dignified, and functional toilet facilities remain largely inaccessible. Most of the countries in SSA will miss the Millennium Development Goal (MDG) for sanitation. There are sharp contradictions in the region between formal and informal sanitation institutions. There is also a disconnect between actors at the macro, meso, and micro governance levels. This paper shows how multi-level governance analysis, path dependency, and institutional inertia can be used to improve understanding of some challenges in the sanitation sector in SSA, and discusses approaches that can contribute to improving the sanitation situation in a sustainable way. In addition, the paper asserts that demand-driven strategies and private sector involvement in the sanitation sector is paramount for establishing new sanitation paradigms and sociotechnical regimes. We conclude that a good understanding of actors at all levels - their various roles, interactions, and the way they interpret and respond to policies - is key to accelerating progress in sustainable sanitation coverage in SSA.

Sanitation lags development achievements in other sectors, and is one of the unmet targets of the Millennium Development Goals (MDGs). This article explores the gap between sanitation policy intentions and outcomes in a comparative study of sanitation sector performance in Rwanda and Uganda with ‘good’ and ‘limited or no’ reported MDG progress respectively. The gap between strong political will, as asserted in policy commitments, statements, reforms and coordination efforts on one hand, and insufficient resources and actual implementation on the other, is examined by drawing on policy and implementation theories in a multi-level governance framework. Progress in Rwanda is explained by stronger political leadership and support for sanitation, stringent performance monitoring, an institutionalised and inclusive community-based approach, and investment in rural sanitation. We further argue that with households having much discretion over private actions for sanitation and hygiene, ‘backward mapping’ can contribute to improve understanding on how to close the implementation gap.

This research explores the use of psychometric techniques to improve understanding of psychological mechanisms underlying judgment of excreta as fertilizer in agriculture including other excreta related activities. Participants consisted of environmental health students, smallholder farmers and traders in rural and urban Rwanda and Uganda. The finding reveals an inverse relationship between risk and benefit judgments. This relationship holds for the three groups of participants with significant risk-benefit correlations of p<.0001. This finding is consistent with other studies showing that affect plays a key role in risk perception, judgment and decision making.Building on this finding, we conclude that individuals with high risk and low benefit judgment for excreta related practices would eschew them or emphasize strict standards. Individuals with a high benefit and low risk judgment would engage in excreta management practices regardless of the actual risks involved. This finding is relevant for risk communication and risk management as it indicates that individuals do not rely only on risk management information they receive concerning excreta and related risks but also depend to an extent on their feelings about these substances when making judgments and decisions regarding the purpose for using excreta as fertilizer and the level of exposure they can tolerate and manage.

The appropriateness and effectiveness of different policy instruments in fostering improved sanitation and hygiene practices in different contexts is debated. ‘Sermons’ inform on recommended behaviours, ‘carrots’ initiate behaviours, and ‘sticks’ restrict, deter, and punish undesirable behaviours. Through the lens of ‘carrots’ ‘sticks’, and ‘sermons’, this article analyses two approaches to sanitation promotion as they have been implemented in Rwanda and Uganda. The Community Health Clubs (CHCs) approach is the policy choice in Rwanda whereas Community-Led Total Sanitation (CLTS) is predominantly promoted in Uganda. Building on a survey of 1173 households in both countries, this article contributes to the ongoing debate with insights on how target populations perceive the options promoted by the different approaches in influencing behaviour change outcomes, or not.  

This study reveals significant differences regarding observed latrines, handwashing facilities, soap and water at the handwashing facility, and reported handwashing with soap and water between most of the study sites with CHC and CLTS intervention and those with no CHC and CLTS intervention. The observed differences are indications of the effectiveness of the interventions in changing behaviours. Similar differences are observed between best performing CLTS (ODF declared) and poor performing CLTS (ODF not yet declared), which underlines the importance of proper implementation. The study suggests support for using a combination of ‘carrots’, ‘sticks’, and ‘sermons’ which are all perceived as effective but for different reasons. Incentives for good sanitation practices and proper hygiene behaviour are perceived by respondents as a source of commitment and competition. Health messages are generally preferred for raising community awareness. However, the application of educational appeals - which are perceived as the most legitimate instruments and predominantly used in CHC and CLTS interventions – is insufficient for achieving universal compliance in the short-term. Other instruments can trigger short-term desired changes but may not be legitimate. This is the case with fines and naming and shaming which are perceived as effective but may compromise social relations and values. Findings also reveal that there is a common understanding among respondents that the responsibility for providing resources for construction and maintenance of sanitation facilities is a shared one. However, respondents’ ability to fulfil this responsibility is partly hampered by poverty and water availability related constraints.