Risk-based prioritization of operation and maintenance indicators for school sanitation decision support in Kampala City, Uganda.

UNLABELLED: Effective operation and maintenance (O&M) of sanitation facilities are vital for ensuring consistent service delivery in schools, yet many low- and middle-income contexts continue to face challenges stemming from reactive maintenance practices and weak management systems. This study developed and applied a risk-based approach to identify and prioritize O&M processes that most threaten the continuity of sanitation services in Kampala City schools. Using a cross-sectional workshop-based design, 106 head teachers and 99 sanitation teachers from 205 schools assessed the status, likelihood, and severity of failure for 33 indicators across six O&M domains. Risk scores were computed following the adapted World Health Organization's Sanitation Safety Planning framework, and indicators were ranked using median (P50) and upper-quartile (P75) statistics to identify priority areas. The results showed that 46% of the indicators were rated as low risk, 24% as medium risk, and 30% as high risk, with no indicator classified as very high-risk. Material supply and use management, toilet cleanliness, preventive maintenance schedules, menstrual hygiene material provision, and sanitation budget-line implementation were identified as the most critical areas requiring attention. Although several monitoring and evaluation indicators ranked as lower risk, this reflects their strong current performance rather than a reduced importance in sustaining sanitation services. The findings highlight that the main threats to sanitation service reliability arise from weak O&M practices and resource management processes rather than infrastructure deficits. Targeting preventive maintenance, supply management, and budget execution provides a practical pathway for strengthening the functionality, reliability, and continuity of sanitation services within resource-limited school environments. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43832-026-00412-4.