Introduction: unsafe water, sanitation and hygiene (WASH) causes millions of deaths and disability-adjusted life years annually, particularly in low- and middle-income countries. Despite the vast sums of money invested, WASH programming continues to fail to improve health outcomes or be sustainable in the longer term, consistently falling short of internal key performance indicators and sometimes negatively impacting the wellbeing of local stakeholders. Although sector experts in high income countries have often provided explanations for such failures, rarely have those implementing WASH programming at the ground level been heard.
Methods: We conducted 96 in-depth interviews with 108 frontline WASH professionals in Malawi, South Africa, Tanzania and Zimbabwe on why they believe WASH failure persists. Through participatory analysis, including framework analysis with additional axial coding, and member-checking of our findings, we determined nine core reasons for WASH failure.
Results: Interviewees reported issues throughout implementation, from the engagement and commitment of intended users to unrealistic and idealistic expectations of funders and implementers, to a general lack of workforce and financial capacity. These reasons coalesce into an overarching problem: the projectization of WASH programming, particularly how it confuses issues of accountability and overly focuses on measurement, places high expectations on intended users, and assumes project ‘handover’ will lead to ongoing maintenance and behavior change.
Conclusion: To achieve sustainable WASH programming that can in turn improve health outcomes, there must be a shift away from projectization led by ‘experts’ in high income countries, to longer term processes driven by local actors. Such programming will require genuine participation of all stakeholders in all aspects of its design, embedding accountability to intended users, and allowing for flexibility and experimentation.