Sanitation is currently high on the international development agenda. But for policy to be effective, basic enabling factors are required – the right institutional environment and the right governance structures – which in many countries are not yet fully in place. It is even more important to get these basic factors right as increasing numbers of public, private, and philanthropic bodies at different levels of society become involved in promoting and providing sanitation, driven largely by global goals and international development agendas. This growing focus on sanitation has led to top-down pressure to meet prescribed targets, which in most cases miss the complexity of context, distort service priorities, and in some cases compromise sustainability. Based on four years of research in Rwanda and Uganda examining sanitation governance structures, the author sets out policy insights on what is needed for sanitation policy to succeed in sub-Saharan Africa.