Theorizing sustainability performance in Uganda's health and sanitation projects: a multi-theoretical approach

Sustainability performance has become a central benchmark for evaluating the long-term success of public health and sanitation initiatives in low- and middle-income countries (LMICs) (Kyambade et al., 2025). Beyond short-term project outputs, sustainability performance reflects the capacity of interventions to maintain, adapt, and deliver benefits long after initial funding ends. In the health and sanitation sector, sustainability encompasses social, institutional, and environmental dimensions that ensure equitable access, accountability, and resilience of essential services (Ugwu et al., 2025). This multidimensional view is especially critical in fragile contexts such as Uganda, where institutional weaknesses, resource dependency, and governance fragmentation continue to challenge the endurance of development outcomes (Kyambade et al., 2026b; Kyohairwe et al., 2024).

In Uganda, considerable investments have been made in the health and sanitation subsector through partnerships among government agencies, donors, and civil society organizations (Sakaya et al., 2025). These interventions have contributed to improved access to clean water, better hygiene practices, and enhanced community health outcomes. However, despite these achievements, many health and sanitation projects experience a rapid decline following donor withdrawal (Ssegujja et al., 2023). Infrastructure often deteriorates, management systems become inactive, and service delivery diminishes (Lugada et al., 2022), leading to what development practitioners' term “project collapse after funding”. The recurring inability to sustain project gains reflects underlying institutional and systemic issues, including weak leadership accountability, limited stakeholder ownership, poor inter-agency coordination, and low adaptive capacity, that undermine the continuity of benefits and the legitimacy of governance structures overseeing these projects.

Globally, a growing body of empirical literature indicates that sustaining development interventions remains a persistent challenge in many low- and middle-income countries, particularly in health and sanitation systems. Sustainability performance is increasingly understood through the triple bottom line, which emphasizes the ability of projects to maintain economic viability, social benefits, and environmental protection over time (Elkington, 1997; Mensah, 2019; Abu-Rayash and Dincer, 2021). However, studies show that these outcomes are often undermined by weak institutional capacity, fragmented governance arrangements, and limited stakeholder ownership even when significant financial investments are made (Appiah et al., 2022; Anheier et al., 2023). Research on sustainable infrastructure and public service delivery further highlights that long-term sustainability depends not only on technical efficiency but also on effective governance, responsible leadership, and coordinated institutional mechanisms that support accountability and adaptive management (Abu-Rayash and Dincer, 2021). In Sub-Saharan Africa, these challenges are particularly pronounced due to complex governance systems, evolving institutional frameworks, and resource constraints that affect the continuity of development interventions (Anheier et al., 2023; Kyohairwe et al., 2024). Despite these insights, limited empirical studies examine how leadership, stakeholder engagement, institutional governance, and resilience interact to shape the economic, social, and environmental sustainability of health and sanitation projects in Uganda. This gap is particularly significant as it limits the development of contextually grounded and integrative insights needed to explain why health and sanitation projects in Uganda persist or fail, and this study addresses it by providing an in-depth, multi-theoretical exploration of how leadership, governance, stakeholder engagement, and resilience interact to shape sustainability outcomes.

Addressing these challenges requires a deeper understanding of the social and institutional mechanisms that underpin sustainability performance. Recent discourse on sustainable development emphasizes that the persistence of health and sanitation outcomes depends not only on resource availability but also on the quality of governance, responsible leadership behavior, and community participation (Mensah, 2019). Responsible leadership inspires collective commitment and ethical stewardship of resources (Maak, 2007; Gomes et al., 2022), stakeholder engagement fosters inclusivity and shared accountability (Kyambade et al., 2026a), institutional governance provides structure and policy coherence (Kyambade et al., 2026d), while resilience ensures that systems remain functional under stress or crisis (Hanefeld et al., 2018). When these dimensions interact constructively, they create an enabling environment for adaptive learning, innovation, and long-term impact.

However, empirical research examining these interlinkages in Sub-Saharan Africa remains sparse. Existing studies often treat sustainability as a technical or managerial issue, focusing on infrastructure maintenance, cost recovery, or performance indicators (Moslehi and Reddy, 2018; Abu-Rayash and Dincer, 2021). Such approaches tend to overlook the institutional and relational foundations that determine whether projects endure or collapse. Moreover, the predominance of quantitative methodologies has limited the contextual depth needed to understand how actors interpret and enact governance and leadership practices in real-world settings. This gap is particularly evident in Uganda's decentralized health governance system, where multiple stakeholders like government ministries, district authorities, donors, private actors, and community organizations, interact within overlapping and sometimes conflicting mandates.

This study employs a qualitative, storytelling-based approach to examine how responsible leadership, stakeholder engagement, institutional governance, and resilience shape sustainability performance in Uganda's health and sanitation projects. It builds on Kyambade et al. (2025), who synthesized global drivers of sustainability but called for context-specific evidence in fragile settings. By integrating relational leadership theory, stakeholder theory, institutional theory, and resilience theory, the study frames sustainability performance as a dynamic outcome of social relations, governance legitimacy, and adaptive capacity.

The present study contributes to both theory and practice by elucidating how multiple institutional actors negotiate, sustain, and adapt development interventions amid constraints. It advances the argument that sustainability in Uganda's health and sanitation sector is not merely a product of effective project design or funding adequacy, but rather an outcome of coordinated leadership, participatory governance, and institutional resilience.

Sustainability performance has evolved from a peripheral concern in development projects to a central criterion for evaluating effectiveness and accountability (Elkington, 1997; Mensah, 2019). In the context of public health and sanitation, it refers to the capacity of interventions to maintain and adapt services over time while delivering social, economic, and environmental value. The World Health Organization (WHO) (2022) and UN-Water (2022) define sustainability in health and sanitation systems as the continued functioning of services that are affordable, institutionally supported, and environmentally sound. However, in most low- and middle-income countries, particularly across Sub-Saharan Africa, sustaining project benefits remains an enduring challenge due to institutional fragility, resource dependency, and governance deficits (Appiah et al., 2022; Anheier et al., 2023).

In Uganda, numerous government and donor-supported health and sanitation initiatives such as the National Water and Sewerage Corporation (NWSC) programs, community hygiene campaigns, and district-level sanitation improvement projects, have improved access to clean water and basic health services (Ministry of Health Uganda, 2022; UNICEF, 2023). Nonetheless, several studies reveal that many of these projects experience significant performance decline after external support phase out (Ssegujja et al., 2023). Weak institutional capacity, poor leadership accountability, and fragmented coordination between national and district actors are among the most frequently cited barriers to sustainability. Additionally, community disengagement and donor-driven project cycles often result in limited local ownership, making long-term service continuity difficult (Ssegujja et al., 2023).

Globally, sustainability discourse has moved beyond financial and technical parameters to include social equity, institutional legitimacy, and adaptive capacity (Järvelä, 2023). This multidimensional understanding aligns with Elkington's (1997) triple bottom line framework, emphasizing economic viability, social inclusiveness, and environmental protection as interdependent pillars of sustainability. However, empirical studies focusing on the institutional and governance dimensions of sustainability performance in health and sanitation projects remain scarce. While many evaluations focus on short-term outputs such as coverage or service uptake, few examine how leadership, governance, stakeholder engagement, and resilience shape the capacity of these systems to adapt and persist (Cheruiyot and Venter, 2024). This gap is particularly pronounced in Uganda's decentralized system, where the success of public projects relies heavily on local government effectiveness, interagency coordination, and community participation (Kyohairwe et al., 2024).

Therefore, there is growing recognition that sustainability performance must be understood as an institutional and relational phenomenon rooted in leadership behaviors, governance mechanisms, and stakeholder collaboration that collectively enable resilience (Kyambade et al., 2025). The current study builds on these insights, offering a qualitative, multi-theoretical perspective that illuminates how these dimensions interact to determine the long-term viability of Uganda's health and sanitation initiatives.

This study integrates four complementary theories that's relational leadership theory, stakeholder theory, institutional theory, and resilience theory to explain how leadership, governance, and stakeholder interactions shape sustainability performance in Uganda's health and sanitation projects. Together, they offer a holistic lens linking organizational behavior, institutional systems, and adaptive capacity in fragile contexts.

These interrelated perspectives show that sustainability emerges from their interaction: relational leadership fosters trust and ethical collaboration (Uhl-Bien, 2006; Cunliffe and Eriksen, 2011); stakeholder participation enhances legitimacy and shared responsibility (Freeman, 1984; Donaldson and Preston, 1995); institutional governance ensures coordination and accountability (Meyer and Rowan, 1977; Scott, 2017); and resilience enables systems to adapt, learn, and sustain services (Folke, 2006; Holling, 1973). Collectively, sustainability performance arises from these interacting mechanisms rather than isolated factors.

Relational leadership theory provides a foundation for understanding responsible leadership in health and sanitation projects. Rooted in Uhl-Bien (2006) and expanded by Cunliffe and Eriksen (2011), it views leadership as a relational process grounded in trust, collaboration, and mutual respect rather than hierarchy. Responsible leadership extends this by emphasizing ethical accountability, social responsiveness, and stakeholder-oriented decisions (Maak and Pless, 2006). In Uganda's decentralized systems, this is reflected in participatory decision-making, transparent communication, and ethical stewardship of public resources. Leaders act as connectors aligning government, technical teams, and communities toward shared sustainability goals. By fostering dialogue, integrity, and trust, they build shared responsibility and psychological safety, enabling innovation and adaptation during challenges such as funding constraints or disease outbreaks (Lehmeidi, 2025). Thus, relational leadership theory frames responsible leadership as a moral-relational process that integrates collaboration with legitimacy, equity, and accountability to support sustainability performance.

Stakeholder theory (Freeman, 1984; Donaldson and Preston, 1995) posits that organizational effectiveness and legitimacy depend on balancing the interests and expectations of all stakeholders who affect or are affected by organizational activities. In the development sector, this means that sustainability is contingent on how well projects integrate the perspectives of diverse actors including donors, government agencies, civil society, and local communities. In Uganda's health and sanitation landscape, stakeholder collaboration often determines project survival. When community members, local leaders, and beneficiaries are engaged throughout the project cycle from design to monitoring, they develop ownership that sustains initiatives beyond donor withdrawal (Ssegujja et al., 2023). Conversely, exclusionary planning or top-down management often leads to disconnection between project objectives and community realities. Stakeholder theory therefore provides a normative framework for understanding how participatory governance, transparency, and dialogue enhance sustainability performance. This underscores the importance of power balance and shared accountability in building long-term institutional legitimacy.

Institutional theory (Meyer and Rowan, 1977; DiMaggio and Powell, 1983; Scott, 2017) explains how formal rules, norms, and cultural-cognitive beliefs shape organizational structures and behaviors. This suggests that organizations operate within institutional environments characterized by regulative (laws, policies), normative (values, ethics), and cultural-cognitive (shared meanings) pillars that together define legitimacy. In health and sanitation projects, institutional coherence determines whether governance systems can effectively coordinate resources, enforce regulations, and ensure accountability. Uganda's decentralized governance framework provides a relevant setting for institutional analysis. While the 1997 Local Government Act devolved responsibilities for service delivery to district authorities, persistent overlaps between national and local institutions have weakened coordination and policy enforcement (Kyohairwe et al., 2024). From an institutional perspective, sustainability performance depends on the alignment of formal governance structures with informal norms and community expectations. Weak institutional enforcement or fragmented mandates often lead to symbolic compliance, where organizations adopt policies in form but not in function (Kyambade et al., 2026d). This study applies institutional theory to explain how legitimacy, regulatory coherence, and organizational culture interact to sustain or undermine project continuity.

Resilience theory provides an adaptive lens for understanding how systems withstand, recover from, and learn through shocks or disruptions (Folke, 2006; Holling, 1973). In the development and public health sectors, resilience refers to the ability of institutions, communities, and projects to maintain essential functions amid crises such as pandemics, funding interruptions, or policy shifts. It emphasizes adaptability, learning, and transformation as critical attributes for sustainability (Holling, 1973). In Uganda's health and sanitation projects, resilience manifests in the capacity of organizations to adjust strategies, reallocate resources, and mobilize social networks during uncertainty. Projects that embed adaptive planning and feedback mechanisms tend to sustain operations despite contextual volatility (Kyambade et al., 2025). For instance, during the COVID-19 pandemic, some health institutions demonstrated resilience by adopting innovative financing models and cross-sectoral collaborations to maintain service delivery. Resilience theory thus extends sustainability thinking by framing it as a dynamic, ongoing process rather than a static end-state.

Synthesizing these perspectives yields a multi-theoretical framework where sustainability performance emerges from relational, institutional, participatory, and adaptive capacities. Relational leadership theory emphasizes collaboration and ethical conduct, stakeholder theory highlights participation and legitimacy, institutional theory situates these within governance systems, and resilience theory captures adaptability and learning. In Uganda's context, sustainability performance arises when leadership, governance, stakeholder engagement, and adaptive system align, while weaknesses in any dimension undermine outcomes. This integrated perspective underpins the study's qualitative framework.

This study employed a qualitative storytelling narrative design, rooted in interpretivist and constructivist traditions. The approach was selected to capture the lived experiences and reflective accounts of actors engaged in Uganda's health and sanitation projects, allowing their voices to shape a collective story of institutional practices, leadership experiences, stakeholder dynamics, and resilience processes. Storytelling as a form of narrative inquiry enables researchers to document the complexity of social action, reveal the moral and emotional texture of practice, and generate transferable lessons from context-specific experiences (Clandinin and Caine, 2013; Rossetti and Wall, 2017). This aligns with the journal's work-applied philosophy, emphasizing learning from authentic workplace experiences.

The research was conducted in Uganda's health and sanitation projects, encompassing both urban and rural institutional settings in central Uganda. The country's decentralized governance model provides a fertile environment to explore how leadership, stakeholder engagement, institutional governance, and resilience interact to influence sustainability performance. Persistent gaps in policy coherence, funding continuity, and coordination among local governments and implementing agencies underscore the importance of understanding how institutional actors navigate these challenges in practice (Kyohairwe et al., 2024).

The study adopted an interpretivist philosophical stance, recognizing that sustainability and governance realities are socially constructed through actors' interpretations and interactions. This orientation acknowledges multiple perspectives and situates meaning within lived experience rather than external measurement. Consistent with the qualitative paradigm used in prior studies (Kintu, 2025), the researcher analyzed how participants made sense of institutional challenges and leadership decisions within Uganda's decentralized health system.

A purposive sampling strategy was employed to select 21 participants from diverse institutional categories, including government agencies (e.g. Ministry of Health, local councils), public hospitals, private sector projects (e.g. Jibu Water, Cerba Lancet projects), and community-based projects (e.g. First Aid Community Projects). Participants occupied managerial, technical, and frontline roles such as health inspectors, project managers, resource mobilization officers, and technical advisors. The sample included 13 men (61.9%) and 8 women (38.1%), reflecting the gender distribution typical of Uganda's health governance structures. Educational backgrounds ranged from certificates to postgraduate degrees, with nearly half (47.6%) holding master's qualifications in Public Health, Environmental Health, or Project Management. Professional experience ranged from 3 to 27 years (mean = 11 years), allowing for a rich mix of institutional memory and contemporary insight. Saturation was achieved when subsequent interviews yielded no new conceptual information, consistent with qualitative rigor standards (Braun and Clarke, 2006).

Data were collected through semi-structured interviews lasting 45–60 min each. Interviews were guided by open-ended prompts designed to elicit participants' stories about leadership practices, institutional coordination, stakeholder participation, and adaptive responses to challenges. The storytelling narrative framework followed the sequence of context, actions, results, and lessons, enabling participants to describe their institutional journeys in a reflective and experiential manner (Tabala et al., 2024). Probing questions encouraged participants to link specific decisions to broader governance and sustainability outcomes. Field notes and reflective memos were used to document non-verbal cues and contextual insights. All interviews were audio-recorded with consent and later transcribed verbatim for analysis.

Data analysis followed Braun and Clarke's (2006) six-step thematic approach, integrating constant comparison from grounded theory traditions with narrative structuring consistent with the storytelling methodology. The process began with familiarization, where interview transcripts were read and re-read to gain deep immersion in the data and an understanding of participants' lived experiences. This was followed by open coding, during which meaningful statements and patterns related to governance, leadership, stakeholder engagement, and resilience were identified. The third stage involved developing themes by clustering related codes into broader conceptual categories that captured recurring institutional dynamics. In the fourth stage, themes were reviewed across cases to ensure coherence and internal consistency. The fifth stage involved defining and naming themes, articulating how each reflected participants' experiential meanings and linked to sustainability performance. Finally, the interpretation phase integrated theoretical insights from institutional theory, relational leadership theory, stakeholder theory, and resilience theory to explain how these dimensions interacted to influence project outcomes.

NVivo qualitative data analysis software was used to support the systematic organization, coding, and retrieval of qualitative data. NVivo is widely used in qualitative research to enhance analytical transparency by enabling researchers to manage large volumes of textual data, create coding hierarchies, and explore relationships between themes in a structured manner (Bazeley and Jackson, 2013; Castleberry and Nolen, 2018). In this study, NVivo facilitated the organization of codes, matrices, and thematic relationships, while the storytelling framework preserved the narrative flow of findings by situating each theme within the broader sequence of context, action, and lessons learned.

Methodological rigor was ensured using the four criteria of Lincoln and Guba (1985): credibility, dependability, transferability, and confirmability. Credibility was achieved through prolonged engagement, triangulation across institutions, and member checking to validate findings. Dependability was maintained via an audit trail documenting coding and analytical decisions. Transferability was enhanced through thick descriptions of Uganda's health governance context and participant characteristics, enabling contextual applicability. Confirmability was ensured through reflexive journaling and peer debriefing to minimize bias. Together, these strategies strengthened the study's transparency, rigor, and trustworthiness. Ethical approval was obtained, and all procedures followed established standards. Participants were informed of the study's purpose, voluntary nature, and their right to withdraw, with written consent secured before interviews. Confidentiality was maintained through pseudonyms and removal of identifying information from transcripts.

This section presents findings through a storytelling narrative that mirrors the lived experiences of health and sanitation project actors in Uganda. Guided by Smith (2012) and Tabala et al. (2024), the story is structured around four interlinked stages including context, actions, results, and lessons.

Uganda's health and sanitation projects operate within a multilayered institutional ecosystem defined by decentralization, overlapping mandates, and resource dependency. Participants narrated an environment where leadership, coordination, and accountability often intersected with bureaucratic rigidity and limited fiscal autonomy. The complexity of decision-making across ministries, district health offices, and donor agencies created both synergy and strain. One district health inspector explained:

Despite these constraints, participants described a shared sense of duty and innovation, particularly at the project level, where health officers, engineers, and managers continually devised workarounds to sustain services. In their words, sustainability was not just about financial continuity but also about “keeping things running” despite adversity. As one project manager reflected:

In this context, sustainability performance emerged as an institutional and relational achievement, requiring leadership commitment, community trust, and resilience in the face of uncertainty.

Participants' stories revealed four key action domains shaping sustainability performance that is responsible leadership, stakeholder engagement, institutional governance, and resilience building. These intertwined processes were central to how projects endured, adapted, and created long-term social value.

Leadership was described not as command and control but as relational influence, fostering collaboration, ethics, and clarity. Project leaders played the role of mediators and motivators rather than enforcers. A hospital clinical officer recounted:

This participatory style of leadership-built ownership and accountability enables teams to stay focused on service delivery even during periods of financial shortfall. Another health officer elaborated:

Responsible leadership thus fostered a sense of shared responsibility and moral commitment, which participants identified as the emotional foundation for sustainability.

Stakeholder engagement was consistently portrayed as the lifeline of sustainable outcomes. Projects that integrated community representatives, civil society organizations, and district technical teams throughout the project cycle experienced stronger continuity. A district team manager narrated:

Such collaboration went beyond consultation, it was co-production. Participants emphasized that inclusive participation-built legitimacy and reinforced accountability networks across stakeholders. Another respondent echoed this:

Through participation, communities became active custodians rather than passive beneficiaries, an essential ingredient of sustainability performance.

Formal governance systems including standard operating procedures (SOPs), audits, and reporting hierarchies, provide a backbone for accountability and control. These mechanisms helped institutionalize transparency and attract continued donor confidence. A quality assurance officer explained:

However, participants also noted that bureaucratic layers sometimes delayed decision-making. A medical superintendent reflected:

Despite this rigidity, governance structures ensured procedural legitimacy and minimized misuse of resources, balancing accountability with efficiency challenges.

Resilience emerged as a dynamic process of institutional learning and creative problem-solving. Participants described strategies such as internal resource reallocation, interdepartmental collaboration, and risk-informed decision-making as survival tactics in uncertain contexts. One senior health inspector shared:

Similarly, during the COVID-19 pandemic, a project manager explained:

Resilience, therefore, was not an abstract concept but a lived capacity, built through experience, trust, and shared adaptability.

The findings show that the interplay of relational leadership, stakeholder engagement, institutional governance, and resilience produced tangible sustainability outcomes in Uganda's health and sanitation projects. Accountability and transparency were key in building donor trust and ensuring funding continuity, as leaders who kept clear records, upheld ethical standards, and justified expenditures attracted repeat partner support. As one technical advisor explained,

This transparency established credibility and encouraged continuous investment from donors and government agencies.

Community ownership was critical in sustaining project activities beyond external funding, as local leaders mobilized volunteers and resources to maintain infrastructure and ensure continuity. This sense of stewardship acted as a social contract, embedding sustainability in everyday practice, with communities continuing to “defend the project even after donors leave.” Adaptive coordination also strengthened institutional continuity during crises, with organizations using strategies such as internal borrowing, resource reallocation, and staff role rotation to maintain operations, reflecting resilience as a practical, lived response rather than a formal plan.

Trust-based leadership also contributed to enhanced employee morale, reduced turnover, and improved institutional cohesion. Leaders who recognized staff contributions and encouraged open communication fostered a sense of belonging and shared mission. As one project officer observed,

This human-centered leadership approach-built loyalty and commitment, ensuring continuity in project knowledge and performance.

Taken together, these outcomes illustrate that sustainability in Uganda's health and sanitation sector is not solely dependent on financial inputs but is primarily driven by social cohesion, ethical leadership, and adaptive governance. As one health project officer succinctly summarized,

The narratives from participants revealed four interrelated lessons that define what sustains health and sanitation projects in Uganda's complex governance environment.

First, leadership is relational and not positional. Participants emphasized that sustainability is anchored in trust, communication, and ethical leadership rather than authority or rank. Effective leaders were those who created space for dialogue and inclusion, empowering even junior staff to contribute meaningfully to institutional goals. As one respondent noted,

This suggests that relational leadership fosters psychological safety, shared accountability, and a sense of belonging, all of which enhance long-term commitment to project goals.

Second, stakeholder participation builds legitimacy. The study found that projects anchored in inclusive engagement were more likely to survive beyond donor funding cycles. When communities, civil society, and local leaders were meaningfully involved from the design to implementation stages, they developed a sense of ownership and responsibility for sustaining outcomes. As a district health officer observed,

Such participatory governance transforms beneficiaries into partners and co-managers, reinforcing social legitimacy and continuity.

Third, institutional governance ensures stability. Strong systems, standardized procedures, and transparent accountability frameworks emerged as protective mechanisms against political transitions and financial disruptions. Institutionalizing governance through clear policies and oversight structures allows projects to maintain direction and credibility even amid administrative turnover. One quality assurance officer explained,

This underscores the central role of institutional memory and regulatory coherence in sustaining project performance.

Finally, resilience sustains continuity. The ability of institutions to adapt, innovate, and reorganize under stress was seen as essential for survival. Participants described resilience as a mindset that encourages problem-solving, cross-sectoral cooperation, and learning from crises. As one senior health inspector noted,

This highlights the importance of flexibility and adaptive capacity in navigating financial shocks, policy uncertainty, or public health emergencies.

Sustainable performance in Uganda's health and sanitation projects stems from the interaction of relational leadership, participatory engagement, institutional stability, and resilience, which together reinforce continuity, legitimacy, and adaptive learning, demonstrating that sustainability relies as much on relationships as on policies and resources.

The findings show that sustainability performance in Uganda's health and sanitation projects is an emergent, socially embedded outcome of interacting relational, institutional, participatory, and adaptive processes. These processes transform short-term success into lasting value, accountability, and resilience, highlighting that outcomes depend on the interplay of leadership, governance, stakeholder participation, and adaptive capacity. Consistent with prior research (Järvelä, 2023; Cheruiyot and Venter, 2024), the study shows that sustainability is driven by relational and institutional mechanisms, aligning with broader evidence on the role of institutional legitimacy and stakeholder trust in Sub-Saharan Africa (Appiah et al., 2022; Anheier et al., 2023).

The evidence further underscores the role of responsible leadership, as explained by relational leadership theory (Uhl-Bien, 2006), showing that effectiveness lies in building trust, communication, and shared meaning rather than relying on authority. Leaders who treated subordinates as collaborators fostered motivation and cohesion, as reflected in the view: “The superintendent ensures everyone knows their role … clear leadership avoids duplication and confusion.” This supports Hleb et al. (2025), who conceptualize responsible leadership in public health as relational coordination rather than hierarchical control. By promoting accountability, dialogue, and conflict resolution, such leaders turn institutional structures into spaces for collective learning. In Uganda's context of bureaucratic constraints and political patronage, responsible leadership provides the moral and relational foundation for sustainable performance.

The study supports stakeholder theory (Freeman, 1984), showing that sustainability is strengthened when engagement shifts from consultation to co-production. Respondents viewed communities, civil society, and local councils as custodians of continuity, embedding sustainability in local systems. As one noted, “We involve CSOs, religious leaders, and local councils right from the start. That makes the community defend the project even after donors leave.” Consistent with Crossley et al. (2021), this indicates that legitimacy and ownership are stronger drivers of sustainability than funding or donor oversight, enabling projects to evolve into locally institutionalized systems.

From an institutional theory perspective (Scott, 2017; DiMaggio and Powell, 1983), sustainability also reflects institutional legitimacy and coherence. Formal mechanisms such as policies, SOPs, audits, and reporting, anchor accountability and donor trust, while normative and cultural-cognitive elements shape their local enactment. Although bureaucratic rigidity sometimes slowed decisions, governance frameworks preserved stability, reduced misuse, and reinforced trust. This dual role of enforcing accountability and enabling legitimacy extends prior work (Hodgson, 2025), showing that when governance systems align across levels, they sustain service delivery despite leadership changes or donor withdrawal.

Resilience emerged as a complementary dimension of sustainability performance, supporting resilience theory (Folke, 2006). Participants showed that resilience is proactive rooted in foresight, flexibility, and collaboration, evidenced by actions like reallocating resources during COVID-19 or borrowing funds to sustain services. This aligns with studies linking resilience to learning and innovation. In Uganda's fragile governance context, resilience connects institutional stability with operational continuity, bridging rigid systems and adaptive responses. It thus functions as both a mediating and enabling mechanism linking leadership, stakeholder collaboration, and governance into a dynamic sustainability system.

Viewed collectively, the findings show that sustainability performance emerges from the interaction of leadership, stakeholders, institutions, and adaptive capacity. Relational leadership theory explains how ethical leadership fosters trust and collaboration (Uhl-Bien, 2006; Cunliffe and Eriksen, 2011), stakeholder theory highlights participation in building legitimacy and shared responsibility (Freeman, 1984; Donaldson and Preston, 1995), institutional theory situates these within governance structures ensuring accountability and coordination (Meyer and Rowan, 1977; Scott, 2017), and resilience theory explains how systems adapt and sustain services amid shocks (Folke, 2006; Holling, 1973; Kyambade et al., 2026c). In Uganda's decentralized context marked by weak regulation, overlapping mandates, and donor dependence, sustainability is strongest where these elements align, underscoring that lasting outcomes depend on institutional legitimacy, social cohesion, and adaptive learning rather than technical efficiency alone.

Enhancing sustainability in health and sanitation projects requires strengthening relational and ethical leadership to build trust, collaboration, and accountability. Stakeholder participation should be institutionalized to ensure meaningful engagement and long-term ownership, while governance reforms must improve regulatory coherence and reduce bureaucratic inefficiencies. Embedding resilience through flexibility, scenario planning, and cross-sector collaboration is essential, showing that sustainability depends on aligning human capability, institutional systems, and adaptive leadership practices.

In the Ugandan context, policymakers should strengthen accountability and coordination among national ministries, district authorities, and community structures involved in service delivery. Sustainability improves when governance systems provide clear roles, transparent reporting, and regular performance monitoring. Establishing structured coordination platforms between the Ministry of Health, district health offices, and implementing partners can enhance policy coherence and reduce fragmentation after donor funding ends.

For practitioners and project managers, embedding participatory governance in routine operations is critical. This can include community oversight committees, involving local leaders and civil society in monitoring, and creating feedback channels for beneficiaries. Such mechanisms enhance ownership and trust, enabling communities to support maintenance, mobilize resources, and sustain infrastructure even without external support.

Finally, development partners and implementing agencies should integrate resilience into project design and evaluation. This involves allocating contingency resources, strengthening local adaptive decision-making, and promoting cross-sector collaboration across health, water, and environmental institutions. Institutionalizing learning and adaptive management helps projects withstand funding shifts, governance transitions, and public health emergencies while maintaining essential services.

Theoretically, this study advances an integrative understanding of sustainability performance by synthesizing relational leadership theory, stakeholder theory, institutional theory, and resilience theory. Relational leadership theory highlights trust, ethics, and collaboration; stakeholder theory frames sustainability as legitimacy from inclusive participation; institutional theory links governance coherence and regulation to outcomes; and resilience theory explains adaptive capacity as a mediating mechanism under uncertainty. Together, they form a holistic model capturing human and systemic dimensions of sustainability, contributing to public management by showing how leadership, governance, participation, and resilience interact to drive sustainable development in low-resource settings.

This study shows that responsible leadership, stakeholder engagement, institutional governance, and resilience are interdependent drivers of sustainability performance. Evidence from Uganda's health and sanitation sector demonstrates that sustainability is not just a technical or financial process, but a social and institutional process shaped by relationships, legitimacy, and adaptability. When leadership builds trust, engagement fosters ownership, governance ensures coherence, and resilience enables adaptation, projects are more likely to endure beyond donor cycles and policy shifts. These findings highlight the need for coherent governance, participatory leadership, and institutional systems that support learning, collaboration, and responsiveness to achieve sustainable public health outcomes in Uganda and similar contexts.

Despite its contributions, the study has limitations. It draws on qualitative data from 21 participants in Uganda's health and sanitation projects, which may limit its generalizability. Its context-specific focus means that findings may not fully apply to other sectors or countries with different institutional and governance dynamics. Nonetheless, it offers valuable insights into how responsible leadership, governance, stakeholder engagement, and resilience interact to shape sustainability, with relevance for similar developing-country contexts facing governance and resource constraints.

Future research should use mixed-method or quantitative designs to test these relationships, especially the mediating role of resilience. Longitudinal studies could track how leadership, collaboration, and institutional reforms influence sustainability over time, while comparative studies across sectors and countries would refine the model and deepen understanding of how institutional, social, and environmental factors shape sustainable outcomes.