Innovative construction approaches, local government commitment, and adequate resource allocation can help address geographic and environmental challenges, including soil type and heavy rains that cause low-quality toilets to collapse, that hinder sustainability of household sanitation coverage. n Community health worker programs, which represent local capacity for implementing demand generation and behavior change programming, enabled the sustainability of household sanitation coverage improvements through adapting programs based on cultural norms and dynamics. Community health workers were supported by tailored trainings led by SNV and local governments.

BACKGROUND: Few countries are likely to achieve universal sanitation within the next decade as sustaining sanitation coverage remains a critical challenge. The purpose of this study is to investigate factors that may have supported or hindered sustainability of sanitation coverage 1-2 years after the completion of an integrated, area-wide sanitation program in four countries. METHODS: Between 2014 and 2018, the SSH4A approach was implemented in 15 countries in Africa and Asia, four of which are included in this qualitative study. We conducted focus group discussions and interviews with beneficiaries, implementors, and decision-makers to identify sustainability factors and used household survey data to characterize sub-national sanitation coverage throughout implementation, and 1-2 years after. RESULTS: Our data revealed behavioral, contextual, and service delivery factors that were related to the sustainability of sanitation improvements. Service delivery factors included follow-up hygiene promotion, access to materials (e.g., plastic, cement), local government commitment post-implementation, functioning monitoring systems, uptake of the supply chain by private sector, capacity for innovation. Contextual and behavioral factors included poverty, soil type, road networks, social cohesion, desire for improved latrines, maintenance and cleaning, and knowledge of sanitation benefits. DISCUSSION: The presence or absence of sustainability factors identified through this research may have implications on where certain programmatic approaches will work, and where adaptations may be required. Through comparing sustainability factors with sub-national slippage rates, we were able to illustrate how local service delivery systems may respond to barriers (e.g., poverty, lack of affordable sanitation options, changes in population density) and enablers (e.g., sufficient resource allocation, passionate leadership, social cohesion). Understanding the programmatic and contextual factors that either drive or hinder long-term sanitation coverage may allow for greater program impact through adapting implementation based on existing challenges in service delivery and context.