Children wash their hands before eating in Tanzania.

Children washing their hands before eating in Tanzania. Photo: polepole-tochan / Getty .

The 2030 Agenda for Sustainable Development calls for ‘ensuring availability and sustainable management of water and sanitation for all,’ under Sustainable Development Goal (SDG) 6. To support this agenda, OECD countries allocate over 5 billion USD in Official Development Assistance (ODA) annually to water, sanitation, and hygiene (WaSH) programs (read all aid statistics ).

In recent years, about a third of such aid has been directed toward sub-Saharan Africa (SSA), reflecting disproportionate need in this region. Sweden’s contributions to this sector have been substantial: In 2018, Sweden’s ODA to water supply and sanitation was 184 million USD (1.7 billion SEK); in 2019 Sweden allocated 61 million USD (570 million SEK) to the sector. In keeping with overall trends, countries in SSA have been targeted with a large proportion of such assistance.

However, progress toward achieving key outcomes in this sector has been slow. As of 2020, 3.6 billion people worldwide lack safely managed sanitation services, and nearly half of these people reside in countries in SSA. Moreover, the provision of WaSH facilities and services often fails to translate into meaningful behavioural change. Nearly one in five people in Africa still engage in open defecation and a recent study of 14 low- and middle-income countries found that the majority of respondents in 6 African countries do not regularly wash their hands with soap and water at critical times.

Impact evaluations of WaSH interventions routinely fail to find meaningful effects on long-term public health outcomes, largely due to limited program uptake and high rates of attrition. Eliminating open defecation practices, promoting proper and sustained use of toilet facilities, and instilling handwashing with soap at critical times are key for achieving the SDG 6 on clean water and sanitation. However, these remain complex and multifaceted sociocultural and sociopolitical tasks particularly in Africa. Part of the problem is the tendency for professionals or practitioners in the sanitation sector to impose their reasoning and rationale on target populations. This pertains to cognitive biases of experts and decision-makers in the design and evaluation of interventions.

A variety of participatory community-based approaches to sanitation and hygiene are widely promoted and implemented across developing countries with the intention to create group endorsement for new sanitation and hygiene norms in line with the global development agenda. Some of the most commonly used approaches to change sanitation practices and hygiene behaviours include Community Health Club (CHC), Community-Led Total Sanitation (CLTS), and Sanitation Marketing (SanMark). These approaches are intended to trigger social change, demand for toilets, self-realization and collective action, leadership, and innovation. However, the choice, appropriateness, and effectiveness of some of these approaches and their inherent instruments remains a subject of debate in the sanitation sector.

Understanding the reasons why some of these approaches are not as effective as expected is an essential step towards improving aid effectiveness in the WaSH sector.

Community-Led Total Sanitation (CLTS) is the most widely deployed approach and relies on community self-enforcement to promote healthy sanitation practices. This approach involves the use of community-based Participatory Hygiene and Sanitation Transformation (PHAST) designed to update behaviors by influencing knowledge, attitudes, and norms around water, sanitation, and hygiene.

Community Health Clubs (CHCs) uses group knowledge and peer pressure to disseminate preventive health information and provide a forum for consensus building, behavior change, and collective action.

Sanitation Marketing (SanMark) involves the creation of demand for toilets and strengthening of supply by building capacity of the local private sector. The choice, appropriateness, and effectiveness of these approaches remain a subject of debate in the sanitation sector, and there is limited evidence that these approaches are successfully delivering desired and sustainable outcomes.

The primary aim of this study is to understand how introducing and/or improving stakeholder engagement can contribute to the legitimacy, effectiveness, and sustained impact of WaSH behaviour change interventions. The project will leverage stakeholder engagement activities to elicit input and feedback, encourage behavioural change, share results, and consult over program design, implementation, and follow-up.

Stakeholders include all with an interest in a given WaSH project or are affected by it. These include the intended beneficiaries as well as community leaders, service providers (public and private), government authorities, and funding partners. Specific emphasis is placed on understanding the role of program beneficiaries as key stakeholders, the nature of what motivates them to act, and the social, economic, and political pressures acting on them.

The study examines the engagement and communication between program beneficiaries and program designers/implementers. Taking stakeholders—including their norms, preferences, and incentives—seriously and accounting for their different roles according to their gender, social position and interests, are key. The fact is that we have limited to no evidence on the benefits associated with different modalities of stakeholder engagement in WaSH interventions. The study will contribute to the literature on modalities and effects of stakeholder engagement for WaSH interventions, in an unbiased way that does not limit itself to success stories.

The study is conducted in Tanzania where Community-Led Total Sanitation (CLTS) is a key approach in the national WaSH campaign.

Tanzania offers an apt context for the study of WaSH behavior change approaches for several reasons. While the country is in many ways aligned with broader trends in the region, recent studies suggest it merits special attention when it comes to WaSH behavior change. Access to safely managed sanitation services in Tanzania has increased from 18% to 22% between 2015-2020 (reflecting the overall increase in SSA from 19% to 21% over the same period). However, the proportion of the Tanzanian population practicing open defecation has increased (from 15% to 16%) whereas the region overall has registered a slight decline in such practices (from 22% to 18%). Read all statistics .

Furthermore, a recent study of 14 low- and middle-income countries finds that Tanzanian respondents are the least likely to report handwashing after defecation and before preparing food. Whereas 57% of Malawian respondents report handwashing after both activities, only 18% of Tanzania respondents do so. Such outcomes stand in contrast to the considerable amounts of fundings Tanzania’s WaSH sector receives (1.6 billion SEK in 2020).

Tanzania, and East Africa more broadly, is a focal point for WaSH behaviour change interventions supported either directly or indirectly by funding from Sweden. In addition, multiple members of the study team have pre-existing connections with local implementers and researchers.

The following core research questions are explored:

  1. To what extent and in what ways do current WaSH behavior change interventions in Tanzania incorporate stakeholder engagement?
  2. How do existing approaches to stakeholder engagement contribute to the success and/or failure of WaSH behavior change interventions in Tanzania?
  3. How can stakeholder engagement in Tanzanian WaSH behavior change interventions be improved?

Four case studies of WaSH stakeholder engagement programs are planned in Tanzania. These ground-based case studies are designed to address the second and third core research questions.

This study will be conducted in two steps. First, we will map the implementation of stakeholder engagement programs within the WaSH sector in Tanzania to better understand where stakeholder engagement projects are being implemented, through which modalities, and by whom. The mapping will then inform the selection of four case studies of WaSH behaviour change initiatives in Tanzania to explore how stakeholder engagement is being operationalized on the ground, and what effect it has on project outcomes and participants’ perceptions and expectations.

Mapping stakeholder engagement in WaSH behaviour change interventions

The starting point for the case studies will be a project mapping of WaSH behaviour change interventions in Tanzania, with a focus on the role of stakeholder engagement in each program.

The project mapping will serve three goals:

  1. It will allow us to answer the preliminary research question: To what extent do current WaSH behaviour change interventions in Tanzania incorporate stakeholder engagement?
  2. It will facilitate the identification of WaSH behaviour change interventions for the case studies.
  3. It will help contextualize findings from the case studies and allow the research team to generalize their inferences to Tanzania and East Africa generally.

The OECD Common Reporting Standards (CRS), OpenAid, and SEI AidAtlas databases are being explored to identify all major WaSH behaviour change interventions implemented in Tanzania between 2012 and 2022. We are considering all programs aimed at eliminating open defecation, promoting proper and sustained use of toilet facilities, and instilling handwashing with soap. We are also leveraging our network of contacts in the Tanzanian WaSH sector to identify additional interventions not captured by the databases mentioned above.

Following the mapping exercise,an analysis will be conducted on whether stakeholder engagement components are included in each program and develop a typology of the types of stakeholder engagement strategies employed. The information will be sourced from program documents and online sources, as well as through interviews and email exchanges with program designers, implementers, beneficiaries, and other key stakeholders.

A narrative report will contextualize findings from the case studies and the project mapping activities. This report will be directed to the Swedish Ministry for Foreign Affairs and the Embassy in Tanzania, Sweden’s government agency for development cooperation (Sida), and other Swedish agencies funding research and development in the field of WaSH.

This project is funded by The Expert Group for Aid Studies (EBA). It runs from March 2023 to March 2024.


Stockholm Environment Institute (SEI), Sweden

University of Amsterdam, Netherlands

Ardhi University, Institute of Human Settlement Studies (IHSS), Dar es Salaam, Tanzania

  • Assistant Professor of Political Science at the University of Amsterdam (Netherlands)
  • Research Fellow at Ardhi University in the Institute of Human Settlement Studies (IHSS), Dar es Salaam, Tanzania.