The importance of sanitation for human health and development is undisputed. Sanitation is now high on the international development agenda and has become a salient issue in most developing countries, Rwanda and Uganda being no exception. However, there are still shortcomings as regards ‘making sanitation happen’ on the ground. The basic institutional environment and the right governance structures are yet to be fully put in place. This is even more important in the new modes of governance wherein increasing numbers of public, private, and philanthropic actors at different levels of society are involved in sanitation provision and hygiene promotion driven largely by global goals and international development agendas. This has engendered top-down pressure to meet prescribed targets which in most cases miss the complexity of context, distort service priorities, and in some cases compromise sustainability.

This thesis disentangles how sanitation policies are articulated at multiple levels of governance and among various actors in the sector, and eventually translate into investment and behaviour change at the community and household levels. This is done by examining sanitation governance structures in Rwanda and Uganda. Specific emphasis is placed on the actors and actions at national, sub-national, community and household levels.

Drawing on multi-level governance as a conceptual framework, qualitative analysis of policy objectives and choices, and quantitative investigations of what motivates hygiene behaviour change at the community and individual levels, this cross-national comparative study is a novel attempt to decipher the complexity surrounding sanitation and to show ‘what makes sanitation happen’.

The insights of this research build on different strands of the literature but most importantly they contribute to the debate in the sanitation sector on what works on the ground, why and where.