The provision of sanitation facilities – a basic necessity for human health, well-being, dignity and development – remains a mammoth challenge for developing countries, in which the vast majority of the 2.5 billion people without improved sanitation facilities reside. Sub-Saharan Africa (SSA) is one of the regions where decent, dignified and functional toilet facilities remain largely inaccessible. Most countries in SSA will not meet the Millennium Development Goal (MDG) for sanitation. There are sharp contradictions in the region between formal and informal sanitation institutions. There is also a disconnect between actors at the macro, meso and micro governance levels. This paper shows how analysis of multi-level governance, path dependency, and institutional inertia can be used to improve understanding of some of the challenges in the sanitation sector in SSA, and discusses approaches that can contribute to improving the sanitation situation in a sustainable way. In addition, the paper asserts that demand-driven strategies and private sector involvement in the sanitation sector is paramount for establishing new sanitation paradigms and socio-technical regimes.