Despite an increasing focus on school-based water, sanitation and hygiene (WASH) interventions in less-developed countries, we lack an understanding of what combinations of conditions are sufficient for their continued maintenance post-implementation. We use a novel method, qualitative comparative analysis, to determine what pathways lead to well-maintained school toilets, as an indicator of continued maintenance of WASH services. Results from 15 case schools in Belize reveal five pathways to well-maintained school sanitation, and three pathways to poorly maintained services. Common conditions in the pathways to well-maintained toilets include local involvement upfront, quality construction, and the presence of a local champion; while conditions common in the pathways to poorly maintained toilets include the absence of the aforementioned conditions, in addition to vandalism and a lack of community support for maintenance. The familiarity of the technology is as common in the pathways to well-maintained toilets as poorly maintained toilets, suggesting that though technology choice is important, quality construction and social conditions may have a stronger influence on maintenance. Qualitative information is presented to support further discussion of the six conditions, including factors linked to their presence that may support improvements in Belize and have implications for school WASH services in other low-income settings.

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