Recycling excreta resources through resource-oriented toilet systems (ROTS) holds transformative potential, yet adoption remains limited, especially where benefits could be high. This study aims to understand constraints hindering the adoption of ROTS in one such area in Ethiopia. Based on a survey among 476 households comprising 2393 individuals, we examine the plans to use ROTS and willingness to pay for ROTS and apply structural equation modelling to analyze the drivers of these two outcomes while comparing the explanative power of the extended technology acceptance model, extended theory of planned behaviour, and their combined model. While 40% of households expressed a plan to use ROTS and 20% reported willingness to pay for a subsidized ROTS with a biogas unit, merely 7% revealed both the plan to use and sufficient willingness to pay, highlighting the need to target both these complementary outcomes concurrently. The theory of planned behaviour showed the best explanative power, also revealing that these two outcomes are influenced by partly distinct sets of factors. Findings imply that common efforts to ease objective constraints through subsidies, which incentivize willingness to pay, are necessary but not sufficient for facilitating the adoption of ROTS. To simultaneously enhance intentions to use, it is also recommended to target psychosocial drivers, such as perceived behavioural control and perceived community support, through awareness creation, behaviour change activities, and community engagement techniques.

• Keywords
• Eco-toilet, Ethiopia, Excreta recycling, Resource recovery, Resource-oriented sanitation, Willingness to pay,
• MeSH
• Humans MeSH
• Surveys and Questionnaires MeSH
• Recycling MeSH
• Sanitation * MeSH
• Toilet Facilities MeSH
• Rural Population MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Geographicals
• Ethiopia MeSH

BACKGROUND: The Indian Swachh Bharat Mission (SBM) was launched in 2014 with the goal to make India open defecation (OD) free by October 2019. Although it is known that the ambitious goal was not achieved, the nature of the sanitation change brought about by the SBM in different parts of India is poorly understood. One reason is a dearth of case studies that would shed light on the performance of the SBM simultaneously across its different domains. This article provides an example of such study. Employing a Process, Outcomes, Context approach, the objective is to understand the process and outcomes of the SBM-induced sanitation change in a specific context of rural Jharkhand. METHODS: The study utilizes data collected through field research conducted in the rural areas of Ranchi district, Jharkhand, a state in east-central India. This data was obtained via repeated cross-sectional household surveys conducted at the beginning and at the end of the SBM, supplemented by key informant interviews with SBM stakeholders. FINDINGS: We identified political support of SBM implementation and its acceptance amongst the population. Female community workers became key agents of SBM implementation at local level. The SBM increased toilet coverage in the study area from 15% to 85% and lowered the OD rate from 93% to 26%. It substantially reduced structural inequalities in access to toilets, furthered social sanitation norms, improved some of the attitudes towards toilet use, but impacted less on hygiene and sanitation knowledge. The implementation mainly concentrated on the construction of subsidized toilets but less on improving public understanding of safe sanitation practices. CONCLUSIONS: Although the SBM reduced sanitation inequalities in access to toilets in the study area, the behaviour change component was underplayed, focusing more on spreading normative sanitation messages and less on public education. Sustainability of the observed sanitation change remains a key question for the future. This article calls for more systematic production of geographically situated knowledge on the performance of sanitation interventions.

• Keywords
• Environmental health, Jharkhand, Sanitation, Swachh Bharat Mission,
• MeSH
• Asian People * MeSH
• Aspirations, Psychological MeSH
• Humans MeSH
• Cross-Sectional Studies MeSH
• Sanitation * MeSH
• Check Tag
• Humans MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Geographicals
• India MeSH

Ethiopia increased the availability of latrines notably, but the sanitation facilities rarely meet hygienic standards. Therefore, the market-based sanitation (MBS) programme has been implemented across the country for nearly a decade to expand the market and boost the demand for hygienic sanitation products and services. While it does not seem that the MBS would bring any notable change in sanitation conditions so far, its implementation challenges are not adequately understood. To address this gap, this article delves into the grassroots-level implementation of MBS in the Wolaita zone. The study relies on qualitative data gathered through interviews with various stakeholders, examining both demand- and supply-side challenges. Some issues identified were external to MBS implementation, such as high inflation and an unstable political and security situation in Ethiopia. Additionally, the study reveals that more general deficiencies of the Ethiopian health extension program, including the stress and discouragement of local change agents (health extension workers, health development army members) due to workloads and low remuneration, have adversely impacted MBS delivery. The implementation of MBS has also not effectively addressed the affordability of hygienic sanitation products. On the supply side, economic constraints and organizational inefficiencies have hindered the development of the sanitation market, preventing it from reaching a critical mass. Our research suggests that MBS alone will not suffice to improve sanitation in Ethiopia.

• Keywords
• Ethiopia, demand for sanitation products, latrine quality, market-based sanitation, supply of sanitation products,
• MeSH
• Health Promotion MeSH
• Sanitation * MeSH
• Health Personnel MeSH
• Publication type
• Journal Article MeSH
• Geographicals
• Ethiopia MeSH

BACKGROUND: Within the past two decades, Ethiopia has achieved one of the fastest reductions of open defecation worldwide. This change can be attributed to the implementation of a national sanitation strategy that focused on facilitating community demand for latrine adoption and use of basic self-constructed latrines but less on other preconditions of hygienic sanitation. Recognition of sanitation by policymakers also catalyzed primary research in this area. As such, the synthesis of the available evidence is both warranted and possible. In this article, we thus decided to assess available primary evidence on the household-level sanitation in Ethiopia and its influencing factors. METHODS: We searched primary studies that present findings on the role of factors influencing household-level sanitation outcomes in Ethiopia. We typologically classified sanitation outcomes analyzed in identified literature and computed pooled estimates for the most prevalent ones (measures of latrine availability and use). We characterized thematic types (themes and sub-themes) of influential sanitation drivers and used network analysis to examine the relational patterns between sanitation outcomes and their influencing factors. FINDINGS: We identified 37 studies that met our inclusion criteria-all but one published after 2009. The general latrine coverage pooled across 23 studies was 70% (95% CI: 62-77%), the share of improved latrines pooled across 15 studies was 55% (95% CI: 41-68%), and latrine use pooled across 22 studies was 72% (95% CI: 64-79%). Between-study heterogeneity was high, and no time trends were identified. The identified sanitation outcomes were classified into eight types and factors reported to influence these outcomes were classified into 11 broader themes and 43 more specific sub-themes. Factors around the quality of latrines represented the most frequent sub-theme of consequential drivers. We found that the available research focused predominantly on outcomes concerning the initial adoption and use of basic latrines, emulating the main focus of national sanitation strategy. By contrast, research on drivers of the sustainability of sanitation change and, in particular, on the upgrading of latrines, has been rare despite its urgency. There is a high need to redirect the focus of sanitation research in Ethiopia towards understanding these factors on both the demand and supply side.

• Keywords
• Environmental health, Ethiopia, Latrine adoption, Sanitation, Systematic review,
• MeSH
• Family Characteristics MeSH
• Hygiene MeSH
• Humans MeSH
• Sanitation * MeSH
• Toilet Facilities * MeSH
• Rural Population MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Systematic Review MeSH
• Geographicals
• Ethiopia MeSH