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Globally, an estimated 2.5 billion people lack access to improved sanitation. Unimproved sanitation increases the risk of morbidity and mortality, especially in protracted refugee situ- ations where sanitation is based on pit latrine use. Once the pit is full, waste remains in the pit, necessitating the construction of a new latrine, straining available land and funding resources. A viable, sustainable solution is needed. This study used qualitative and quanti- tative methods to design, implement, and pilot a novel sanitation system in Kakuma refugee camp, Kenya. An initial round of 12 pre-implementation focus group discussions (FGDs) were conducted with Dinka and Somali residents to understand sanitation practices, percep- tions, and needs. FGDs and a supplementary pre-implementation survey informed the development of an innovative sanitation management system that incorporated the provi- sion of urine and liquid-diverting toilets, which separate urine and fecal waste, and a service- based sanitation system that included weekly waste collection. The new system was imple- mented on a pilot scale for 6 weeks. During the implementation, bi-weekly surveys were administered in each study household to monitor user perceptions and challenges. At the end of the pilot, the sanitation system was assessed using a second round of four post- implementation FGDs. Those who piloted the new sanitation system reported high levels of user satisfaction. Reported benefits included odor reduction, insect/pest reduction, the sit- ting design, the appropriateness for special populations, and waste collection. However, urine and liquid diversion presented a challenge for users who perform anal washing and for women who had experienced female genital mutilation. Refugee populations are often cul- turally and ethnically diverse. Using residents’ input to inform the development of sanitation solutions can increase user acceptability and provide opportunities to improve sanitation system designs based on specific needs.

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