A systems-based management framework for sustained operation and maintenance of sanitation facilities in schools : a case of Kampala City, Uganda

Abstract

Sustaining sanitation service delivery in schools requires effective operation and maintenance (O&M) systems supported by appropriate technologies, reliable resources, and structured management processes. However, in many low- and middle-income urban contexts, the functionality of sanitation facilities tends to decline over time because O&M systems are often inconsistently implemented. This study assessed sanitation service levels in Kampala City schools and developed a validated O&M framework together with a decision support system (DSS) to strengthen service delivery. The study used a sequential mixed-methods design. It began with a cross-sectional assessment of sanitation conditions in 274 schools using structured observations to determine factors associated with sanitation service levels and to examine toilet cleanliness as a core O&M outcome. Findings from this assessment informed the development of preliminary thematic domains. These domains were prioritized by stakeholders through a workshop using the Analytic Hierarchy Process and the SWING method. Five regional workshops involving 205 school Head Teachers and Sanitation Teachers then applied a risk-based assessment guided by the Sanitation Safety Planning framework to identify indicators posing the highest threats to continuity of sanitation services. The prioritized domains and risk findings were synthesized into a school level O&M framework, and a DSS based on this framework was developed and tested in a separate workshop. The results showed that 62% of schools operated at limited sanitation service levels, while 38% achieved basic levels. The O&M factors that significantly predicted sanitation service levels included special sanitation budget (OR = 3.6), cleanliness (OR=2.1), mode of toilet flushing (OR = 1.5), and toilet technology (OR = 1.1). Toilet cleanliness was strongly predicted by the presence of rainwater harvesting systems, handwashing stations, and active health clubs contributing about 50% of the factor of importance. The O&M processes were grouped into six domains: service planning, facility design standards, resource management, service provision, governance, and monitoring and evaluation. Stakeholders ranked service planning, facility design standards, and resource management as the most influential domains for sustaining O&M in schools. Risk based assessment further identified five indicators with the highest likelihood of undermining continuity of sanitation services that included lack of a material supply management system, consistently dirty toilets, absence of preventive maintenance schedules, non-implementation of sanitation budgets, and inadequate menstrual hygiene materials. The synthesis of domains and indicators produced a framework structured around four elements: enablers, service provision processes, O&M outcomes, and monitoring and evaluation. The DSS, which prioritises areas of intervention using status, likelihood, and severity of indicators, demonstrated high acceptability, feasibility and appropriateness with moderate usability. Integration of the decision support system into the Education Management Information System can present an opportunity to institutionalise O&M functions and strengthen accountability in Kampala City schools. This study provides a context specific and evidence-based framework for improving sanitation O&M in resource constrained urban school settings, and offers practical guidance for policymakers, school administrators, and regulators working toward universal basic sanitation.