Galvanising and fostering sub-national government leadership for area-wide sanitation programming

The introduction of the sustainable development goals (SDGs) in 2015 brought a new level of ambition to the water, sanitation and hygiene (WASH) sector. The SDGs commit signatories to reaching everyone with sustainable WASH services by 2030, placing a specific emphasis on women, girls and those in vulnerable situations. To meet this target, new approaches and ways of working are required.

Shifting away from projects that deliver WASH-related outputs (such as through the provision of infrastructure or behaviour change interventions), development partners are increasingly seeking to understand and strengthen the wider social, political, environmental, institutional, financial and technical context – or ‘system’ – in which services are delivered (Casey & Crichton-Smith 2020; Valcourt et al. 2020).

Following widespread decentralisation reforms, including across Africa (Cabral 2011), responsibility for sanitation and hygiene (S&H) in many countries sits with sub-national governments. Sub-national or local government is often the only structure with the mandate and infrastructure required to lead sanitation programmes at the scale needed (Perez et al. 2012). Strengthening systems at this level is, therefore, critical to reach everyone. This paper explores influences on local government leadership and their prioritisation of sanitation as a critical component of sub-national systems strengthening. We draw on practical experiences in three rural sub-national areas in East Africa where an increase in local government action had been identified: Moyo, Uganda, Nyamagabe, District, Rwanda, and Siaya County, Kenya. We then examine how political will and commitments were galvanised and fostered.

Uganda, Rwanda and Kenya all have decentralised structures, with responsibility for sanitation provision sitting with sub-national governments.

Kenya is the largest and most populous of the three countries, with a population of 52.6 m people (World Bank Group n.d.). Constitutional reform approved in 2010 and implemented in 2013 devolved roles and responsibilities from the national government to 47 new elected county governments (Cheeseman et al. 2016). Under this structure, the national government retains decision making powers – creating policies, guidelines and strategies – while the county governments are responsible for implementation. Overall responsibility for sanitation provision rests with county governments. Counties have relatively high amounts of power and central government funding compared to many comparable units in other countries, making ‘the Kenyan system of decentralisation closer to Nigerian federalism than the sort of limited decentralisation practiced in Malawi and Uganda’ (Cheeseman et al. 2016).

Uganda is smaller in size and population with 44.3 m people (World Bank Group n.d.) and divided into 135 Districts and the capital Kampala. Decentralisation was introduced in the 1980s as a means of improving service delivery, devolving extensive central government powers and responsibilities to local governments (Muriisa 2008; Green 2015). However, this level of decentralisation may not have been achieved consistently in practice, with Muriisa (2008) finding that ‘decisions at local government are frequently influenced and/or affected by the financial and political dependence of local governments on the central government’.

Rwanda is the smallest of the three countries, with a population of 12.6 m people (World Bank Group n.d.). Rwanda's four provinces are made up of 30 districts, which are further divided into sectors, cells and villages. Following a history of highly centralised government, decentralisation reforms were introduced in 2000 (Hasselskog & Schierenbeck 2015). However, according to Tsinda et al. (2021), here also ‘districts have not gained the powers and resources to carry out their mandate’. Individual, institutional and collective sanitation and hygiene targets are set centrally by the Rwanda government in a five-year plan but implemented through annual plans led by district councils.

Although decentralisation has been implemented differently in the three contexts and in practice the governments have varying degrees of power to shape programmes, their responsibilities with respect to sanitation are similar allowing for meaningful comparison. Table 1 shows the different levels in the administrative system in Kenya, Rwanda and Uganda. In Kenya, the Country is mandated to provide sanitation services, in Uganda and Rwanda, it is the district level. It is this level we refer to as sub-national or local government throughout the article.

WASH systems strengthening approaches aim to examine the multiple, interrelated and dynamic actors and factors which influence access to and uptake and management of improved WASH services. Proponents recognise that change is often messy, unpredictable and non-linear and seek to address the complexity of reaching everyone with sustainable services by understanding where the system's strengths and weaknesses occur so that programming can be designed accordingly (Huston & Moriarty 2018; Hollander et al. 2020).

Different frameworks have been developed to describe and strengthen the WASH system. These include those used by Agenda for Change (Huston & Moriarty 2018) and Sanitation & Water for All (2020). These frameworks use ‘building blocks’ identified as key elements necessary for positive WASH outcomes in different contexts. Though not referred to explicitly as a WASH systems framework, the Africa Ministers' Council on Water's also use building blocks, describing the Ngor Commitments as ‘areas of the enabling environment that need to be addressed… [and] the building blocks of an effective sanitation and hygiene sector’ (AMCOW n.d.). These frameworks build on previous work linking the WASH enabling environment through a set of core governance functions (building blocks) (Jiménez et al. 2016) and thinking around water systems (Harvey & Reed 2004). While minor variations exist, these ‘building blocks’ – can be summarised as (1) policy, strategy and planning; (2) institutional arrangements; (3) infrastructure and service delivery; (4) monitoring, evaluation and learning; (4) financing; (5) accountability and regulation; (6) capacity development (Huston & Moriarty 2018; Jiménez et al. 2020; SWA n.d.). Each of these blocks requires specific, context-dependent actions to be strengthened. For example, to improve financing, it is likely necessary to develop financing streams, whereas for institutional arrangements, clarifying ambiguities related to roles and responsibilities of different actors may be required (Huston & Moriarty 2018; SWA n.d.).

A key factor that serves as an enabler to the other building blocks is government leadership or political will. The World Bank's Water and Sanitation Program (WSP) outlined the importance of national, state and local governments, alongside the local private sector, communities and households for at scale approaches for sustainable service delivery. Ensuring political will was identified as the ‘first step’ of this process (Perez et al. 2012). Other guidance documents also note how government leadership influences the strength and shape of the building blocks, from creating and arranging institutions related to sector policy and service provision (Agenda for Change n.d.) to ensuring prioritisation of WASH for investment (Casey & Crichton-Smith 2020). In short, it is government leadership that directs and coordinates internal and external resources – ensuring alignment to government policy – to reach scale and ensure no one is left behind (Casey & Crichton-Smith 2020; SWA n.d.).

The importance of government leadership and political will in reaching sanitation goals is also emphasised by academic literature as well. O'Reilly and & Louis (2014), for example, establish a ‘toilet tripod’ model that puts political will as one of the three pillars behind successful toilet adoption by drawing on their work in rural India. Building on this, McMichael (2018) shows how political will at multiple levels were key to toilet adoption in Nepal, and Ekane et al. (2014), after comparing sanitation outcomes between Rwanda and Uganda, conclude that political leadership and commitment in the former contributed to improved sector performance and effective service delivery.

While political will is widely acknowledged to be a key enabler to success, research and guidance on how it can be fostered is limited. Though Perez et al. (2012) acknowledge the importance of political will and the roles, responsibilities, capacity development needs and resources of local governments they do not detail how sub-national political will could be fostered. The Making Rights Real approach is an example of an emerging approach that attempted to do this. Rooted in human rights, the approach fosters interaction between local civil society organisations and local government officials to empower the latter to become ‘heroes’ of human rights to water and sanitation. While traditional rights-based approaches focus on advocacy, placing emphasis on demanding rights and holding duty bearers to account without acknowledging of the duty bearers' (often lack of) capacity, the Making Rights Real approach aims to support government staff to understand the human rights to water and sanitation and their responsibility on a personal level so that they can begin to make realistic, context-adapted changes (Carrard et al. 2020). Institutional triggering is another approach that aims to increase political will. A participatory method based on the Community Led Total Sanitation (CLTS) approach aims to trigger administrative, elected, traditional and community leaders to take action to eliminate open defecation. The approach is dependent on understanding different leaders' motivations and designing activities to tap into these. However, there is limited published guidance on how to do this or the effectiveness of it.

To our knowledge, there is limited research on the ways to foster political will in practice for improved sanitation. Though studies have highlighted there is a sense that local government efficacy was influenced in part by external multi-level pressure from NGOs and donors – forming a ‘multi-scalar political will’ (O'Reilly & Louis 2014) – details of how the local authorities became ‘proactive’ is not included.

This paper aims to fill this gap by providing practical examples and recommendations. Doing so is particularly important given that political motivation has been low for sanitation for many years (Moe & Rheingans 2006; Rosenqvist et al. 2016) and that sanitation governance has been little studied in comparison to water governance (Rosenqvist et al. 2016). As Valcourt et al. (2020) argue, ‘the strong preference of systems approaches to focus on rural water services (48% of all studies) also points to another significant knowledge gap in the existing literature.’

This gap is particularly evident at the sub-national government level. Given that responsibility for implementing sanitation and hygiene improvements often sits at the local rather than national government level (Cabral 2011; Ekane et al. 2014; Jiménez et al. 2014; Carrard et al. 2020), it is important that the local government is motivated and have the capabilities and capacity to lead sanitation improvements. According to Huston & Moriarty (2018), ‘in many cases a particular building block is well developed at the national level and in sector frameworks but remains poorly applied at the district level’. Jiménez et al. (2014) meanwhile note that ‘the combination of these processes (new approach, change of governmental responsibilities and decentralised service delivery) poses a formidable challenge to local governments. Despite the importance of this aspect from the practitioner's point of view, the role of local government in this new service delivery approach has received very little research attention.’

This work, therefore, focuses on practical ways to support sub-national government leadership to prioritise sanitation as an integral element of systems strengthening for improved service delivery.

In late 2020–early 2021, the Sanitation Learning Hub (SLH) worked with UNICEF and Siaya County in Kenya, WaterAid and Nyamagabe District in Rwanda and WSSCC/Uganda Sanitation Fund and Moyo District in Uganda, to explore how to increase sub-national government commitments and leadership for sanitation. Specific local government areas were selected in consultation with WaterAid, WSSCC/Ugandan Sanitation Fund and UNICEF. Selection criteria were that the chosen sub-national government must have demonstrated prioritisation of sanitation and that they were willing and able to participate actively in the case study development process and online analysis workshops. Stakeholders involved in the research process – both in terms of collecting and analysing data – included researchers, sub-national and national government officials and development partners. The process involved two stages:

• 1.

  Case study development

• 2.

  Participatory online analysis workshops

The process was facilitated by the SLH who took an iterative approach to both stages of the research. This included regular reflection and adaption points designed to ensure the approach remained emergent to the needs of participants and evolution of discussions.

Firstly, local government and development partners formed a case study development team to document their experiences relating to the overarching research question: what influenced the local government [county and districts] to increase their leadership and/or prioritisation of sanitation and hygiene? The case studies were later analysed collectively in three online workshops (see the following section). In Uganda, the team was made up of Moyo District representatives, staff from the Uganda Sanitation Fund and an independent consultant, who reviewed quarterly and annual progress reports and interviewed District leaders and staff. In Rwanda, the team included WaterAid Rwanda and staff from Nyamagabe District who used national, sub-national and organisational documents and undertook 18 key informant interviews. In Kenya, the team included UNICEF and government staff from Nairobi and Siaya County who reviewed project documents and undertook 13 key informant semi-structured interviews.

To support case study development teams, SLH developed a case study development guide. This included a suggested process as well as a case study template with examples of questions to consider in each section. This aimed at ensuring a comparable process as well as quality and level of detail. Teams were also provided with a cases study template to ensure they followed a common format to aid subsequent analysis across the cases. The case study development guide also included an annex on data management and confidentiality, a draft participant information sheet, consent form and information about obtaining permission to use third-party images. The guide, annexes and template have been published in the Supplementary Material.

The case study development guide drew on two participatory monitoring and evaluation methods: Most significant change (MSC) (Davies & Dart 2005) and outcome harvesting (Simister & Napier 2017). MSC engages stakeholders involved in a particular process under investigation to identify and agree on a change to record as well as analyse the relevant data (Davies & Dart 2005). Outcome harvesting is a process to identify, describe, verify and analyse change – evidence of a change is collected with harvesters working backwards to assess what contributed to the change (Simister & Napier 2017). Drawing on the MSC method case study teams were first tasked with identifying a change in the prioritisation and leadership around sanitation by answering the following questions: what change had been seen, who has been influenced, what had they changed, when and where did the change take place and what was being done differently. After the change had been identified, outcome harvesting was used to work back from the MSCs – or outcome(s) – and identify what may have contributed to them. Teams were required to identify evidence they already had available as well as list and address questions which would require further investigation through reviewing additional documents and/or interviewing key informants. Appreciative inquiry principles were promoted throughout to encourage participants to be open about their experiences and focus on what had been successful that could be built on (AI Commons n.d.).

Prior to teams undertaking literature reviews, interviews and focus group discussions, they were asked to produce a research plan. SLH provided tailored support to each case study development team throughout this phase based on demand. For most, this involved reviewing research plans, interview guides and draft case studies. Support conducting interviews was also provided for the Kenya team.

Following the development of the case studies, all participants came together to analyse and draw out learning from their experiences in a series of three 3-h online participatory analysis workshops facilitated by SLH. Each workshop was recorded and notes of groupwork taken to ensure discussions were captured to enable subsequent documentation.

The objectives and main topics of discussion for each of these collective analysis workshops are shown in Table 2. These formed the basis within which participants collectively analysed their experiences to draw out common findings, nuances, lessons and recommendations. The collective analysis approach added further rigour to the research, ensuring timely analysis by local experts-by-experience with a range of perspectives (Burns 2018). An inductive approach was used to guide the data analysis with themes emerging from across the case studies.

To inform this adaptive process, facilitators reflected regularly on the process and content of the workshops: debriefing sessions following each workshop were held with facilitators to capture immediate reflections, more in-depth reflection sessions were held periodically to reflect on the overall process to date and a learning diary was kept to record ongoing reflections as they emerged. Participants were also invited to share feedback on each workshop, with space to do so provided in the workshops, via email or through an anonymous online Padlet.

Workshop one took place on 26 November 2020 and workshop two on 14 December 2020. Workshop three was delayed due to the shutting down of internet access in Uganda during the presidential and parliamentary elections, it was rescheduled and took place on 4 February 2021. Workshop participants included SLH researchers, government representatives from Siaya County, Nyamagabe District and Moyo District, the Ministry of Health and Ministry of Water and Sanitation and Irrigation in Kenya, UNICEF Kenya, WaterAid Rwanda and WaterAid UK. The Uganda team was unable to join the first workshop; however, a separate meeting was organised with them and SLH staff to share with them the discussion they missed, and space was provided in workshop two for them to present their case study.

There are some limitations to the methodology described above. Firstly, regarding case study selection, there may be more representative sub-national governments or local administrations that respond to different incentives. However, this is offset by working with three different cases and then exploring commonalities and differences. Secondly, there is no way of knowing if local administrations will successfully sustain progress towards sanitation and hygiene outcomes over the long term. Thirdly, the MSC and outcome harvesting methods include those directly involved in the process under investigation. They are the selectors of the change(s) and primary researchers. Consequently, there is a potential bias in selecting a change and highlighting contributions that portray researchers positively. It is important to note that the change makers (government actors) were directly engaged in this process; however, the findings, discussion and conclusion should be considered as one way and not the only way to galvanise and foster leadership for sanitation.

Through the case study development process, the following significant change(s) were identified.

Changes in Nyamagabe, Rwanda, included improved coordination of activities with the establishment in 2016 of the Human Security Issue Taskforce, who met monthly, to work on sanitation and other human security issues. The district established a Situation Room which compiled monthly achievements and sets new targets. Additional district stakeholders were also involved in S&H programming – for example, the District Business Unit who allocated staff time to support the administration of a revolving fund for S&H for the first time. Furthermore, there was increased planning with the launch in the 2018/2019 fiscal year of the district's first WASH investment plan with targets and strategies for achieving basic services. This plan was incorporated into the District Development Strategic Plan which had previously not included WASH-related targets. These actions have been cited as changes which enabled Nyamagabe to become ODF in 2020.

A baseline survey conducted in 2013 had found that sanitation indicators in Moyo District, Uganda, were lower than the national average with latrine coverage at 64.5% compared to a national average of 72% and no village being ODF. In April 2014, Moyo district's political leadership convened a special council meeting – the highest political making forum in a district – and decided to put sanitation as a priority on their district's development agenda. Sanitation was added as an agenda item to every council session agenda. In addition, the dormant District Water and Sanitation Coordination Committee was re-activated and tasked to give a quarterly update to the council on progress made. Sanitation has remained as an agenda item ever since. The district also made it mandatory for those who receive benefits from livelihood programmes to have and use a toilet. As of June 2020, latrine coverage was 95%, handwashing with soap 65.3% and 130 villages out of 165 declared ODF.

Latrine coverage in Siaya county, Kenya, was only 20% in 2010. Though there had been steady progression, a critical change occurred in 2016 with the county allocating budget to sanitation-related activities. Siaya county invested 5 million shillings, with UNICEF investing 10 million shillings, for CLTS activities in the country for the 2016/2017 financial year. Additionally, the county agreed to continually finance CLTS activities with the governor signing a financial commitment letter to ensure the funds were not redirected to other programmes. The county WASH budget the previous year had been 3 million shillings, however, had been used to tackle a cholera outbreak with minimal funds used for CLTS implementation. Siaya county also implemented performance contracting for Community Public Health Offices and Community Health Volunteers, who were also provided with stipends to motivate them to undertake regular household sanitation-related visits. Siaya county became ODF in the 2017/2018 financial year with latrine coverage at 87%.

The case studies and collective analysis workshops identified advocacy efforts at different administrative levels, data presented in concise and visual ways, engaging multiple actors at the sub-national level, learning exchanges and long-term partnerships all contributed to increasing sub-national government's commitments to sanitation. While documenting and publicising commitments, continuing to display data and regular reporting contributed to continued attention on sanitation.

Advocacy efforts are likely needed at multiple government levels. In all three case studies, a strong enabling environment with clear policies and strategies for sanitation at a national level was key to increasing the prioritisation of sanitation at the county and district levels. In Uganda, advocacy by a range of elected officials and technical staff working with the national WASH parliamentary forum was identified as helping to increase political prioritisation of sanitation at the national level. In Kenya, a series of sanitation conferences helped both national and county governments recommit to their ODF targets. While in Rwanda, the national government declared sanitation a human security issue impacting priorities at the sub-national level.

These advocacy efforts relied on data to achieve political buy-in and leadership at both national and sub-national levels. Data presented included health prevalence statistics, economic impact and data on sanitation access. Our research indicates that presenting compelling sanitation and hygiene-related data that speak to different leaders' motivations in concise, visual ways is a particularly effective way to engage decision makers. Sharing select information concisely was also found to be important when working with busy leaders who have multiple competing demands on their time. The research identified a range of practical ways that this can be done. In both Kenya and Uganda, health data were shared with leaders to emphasise the health benefits of improved S&H, and the long-term cost-effectiveness of disease prevention, helping to increase leaders' prioritisation of sanitation. In Kenya, UNICEF developed short, easily accessible county sanitation profiles using census data. These four-page profiles gave county leaders a snapshot of the county's sanitation situation, their county's position in the sanitation ‘league table’ and an estimated budget for reaching ODF status. In Uganda, institutional triggering of district staff was undertaken by the Ministry of Health. Firstly, staff were presented with photographs displaying good aspects of the district such as tourist attractions and cultural leaders from the district, this was then followed by pictures of open defecation. In an interview the District Chairperson cited, this activity really challenged them to take action on sanitation, leading them to reactivate the District Water and Sanitation Coordination Committee and make sanitation a standing agenda item at quarterly meetings. Similar triggering events were then held with government staff working at lower levels conducted by technical staff from the district.

Learning or exchange visits were also highlighted as valuable to support programme advocacy efforts and increase motivation. In Moyo, Uganda, politicians were taken to different districts on learning journeys to see what others were achieving. While community champions were engaged in learning exchange visits across sub-counties and villages to motivate them. In Kenya, County Public Health Officers were sent to different counties to learn from other's success.

The case studies indicate the need to engage a diverse range of government representatives at the sub-national government level. It was clear that sanitation decision making and programming involves both elected officials and technical staff, sometimes spread across multiple departments, with different motivations and interests. These differences impacted the entry points used to engage sub-national governments. For instance, in Siaya, Kenya, the Ministry of Health targeted mid-level county public health staff first who then worked to increase focus on sanitation at both higher and lower levels. Conversely, in Moyo, Uganda, political and technical leaders at the district (highest local government) level were targeted first to get their buy in and to encourage them to be a role model by improving district sanitation and hygiene facilities, before then leading similar processes at more local levels.

Strong partnerships between sub-national governments and development partners over long periods were found to be key to gaining and maintaining government leadership and increasing political commitments. In the case studies, partnerships had been in place for approximately 10 years.

A number of different activities have been credited with maintaining commitments. In Siaya County, Kenya, for example, to counter-act changes in personnel, leaders were encouraged to document decisions and commitments. This was found to lead to improved continuity across political transitions. Furthermore, a letter from the governor was issued to prevent the redirection of funds committed for sanitation and hygiene. In Nyamagabe, Rwanda, the use of the Situation Room with data displayed visually on the walls and was updated regularly was reported to contribute to continued attention on sanitation with district leaders and the Mayor visiting the room to engage with the data. In Moyo, Uganda, the case study reported ranking political leaders based on their sub-counties progress on sanitation and hygiene, with those not doing well being put on a ‘shame list’ and leaders given warnings from the county leadership, as an effective mechanism.

Each sub-national area still faces challenges. Though attempts have been made to maintain commitments across political leadership transitions, this is still a major stumbling block. It was also noted that maintaining commitments beyond the declaration of ODF status, especially when targets are theoretically met is challenging. Though data is highlighted as key, there are still no adequate resources in place to develop, maintain and update monitoring systems. Furthermore, development partners' still play an active role through providing financial support, leveraging county resources, technical support for county and district sanitation and hygiene plans and monitoring progress.

The aims of this study were to identify practical ideas for how development partners, and national governments, can foster local government prioritisation for sanitation. Reflecting on the findings, there are a number of areas where actions are recommended which can help support the continuous strengthening of the WASH system at a sub-national level.

The results highlight that the sub-national system operates within a larger national system. Sub-national advocacy efforts alone are unlikely to make a substantial impact without a supportive national enabling environment. Therefore, the results suggest advocacy efforts at a sub-national level should not be undertaken without work towards developing strong policies, frameworks and commitments at the national level – this should be a priority for both the national government and development partners operating at this level. National level actors can also support sub-national political will through fostering healthy competition between sub-national levels, by ranking commitment levels and actions or through performance contracts.

Furthermore, our findings highlighted that advocacy efforts are not a one-off activity. Plans and budgets change, new priorities emerge and both political and technical staff move on. Examples from the case studies found that follow-up with leaders is needed to hold them to account and public declarations and the public documentation of decisions and commitments are effective mechanisms to ensure continued support through political transitions. As was the identification and support of champions who will remain in place, and who can lobby new staff (both political and non-political). Linked to this point is the need to engage and work with both technical staff and political appointees – both will need to be engaged in different ways and at different points in time. Different stakeholders are involved in resource allocation and planning activities. An initial stakeholder analysis to determine where advocacy efforts are needed, entry points (mid-level, political leadership) and how to best trigger action could help achieve maximum impact.

In addition, our findings support the idea that longer timelines are needed to see results from this kind of work (Casey & Crichton-Smith 2020). Development partners and national governments, therefore, should be prepared to work with sub-national governments over a longer period of time. However, this comes with challenges as replicating this long-term partnership model at scale is challenging and more research is needed to find ways to strengthen systems with less intensive engagement from non-governmental partners. Investigating the role national-level actors can play in supporting this and how commitments can influence surrounding sub-national areas should be a priority.

A strong message has emerged about how best to use data to support these efforts. It has been recognised as effective across all cases to galvanise support from local officials and maintain this commitment over time. This study identified creative ways for displaying data in a concise and interactive way.

All three cases have provided examples of local governments taking a more of a leading role in service delivery. However, it is important to note that all cases are works in progress, and challenges do remain both in terms of maintaining commitments, especially across political leadership transitions and beyond declarations of ODF. Furthermore, though data are noted as powerful and influencing, decision makers’ resources for the development and maintenance of monitoring systems remain low. Challenges also persist with reaching universal coverage with vulnerable communities and households still underserved. This is especially important when considering the link between a systems approach and a human rights approach and ensuring everyone, everywhere has access to improved sanitation services.

This work was conceived to provide practical examples of ways sub-national governments can be supported to provide both leadership and resources for sanitation programming. By first identifying positive changes in the prioritisation of sanitation by local government, we used a participatory process working with both local government representatives and development partners to analyse what triggered this change. We then brought case study author teams and additional stakeholders involved to cross-examine and identify lessons learnt and practical recommendations.

Our findings indicate that to galvanise commitments, an understanding of the existing sub-national landscape and stakeholders' motivations is key. This should then be followed by ongoing engagement and strong documentation of processes and commitments to hold decision makers to account. Collection and use of timely and relevant sanitation and associated economic health data are also important and serve multiple purposes for sanitation system strengthening, including forming a basis for evidence-based planning and adaptation; informing and strengthen advocacy for resource allocation; and motivating stakeholders to continue (or improve) sanitation efforts. Investment in easy-to-use monitoring and reporting systems that generate ongoing data that can be rapidly analysed and simply presented is essential. This process can help provide an important foundation of which other ‘building blocks’ can then be strengthened.

Data cannot be made publicly available; readers should contact the corresponding author for details.