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Understanding geographic inequalities in coverage of drinking-water supply and sanitation (WSS) will help track progress towards universal coverage of water and sanitation by identifying marginalized populations, thus helping to control a large number of infectious diseases. This paper uses household survey data to develop comprehensive maps of WSS coverage at high spatial resolution for sub-Saharan Africa (SSA). Analysis is extended to investigate geographic heterogeneity and relative geographic inequality within countries. Cluster-level data on household reported use of improved drinking-water supply, sanitation, and open defecation were abstracted from 138 national surveys undertaken from 1991-2012 in 41 countries. Spatially explicit logistic regression models were developed and fitted within a Bayesian framework, and used to predict coverage at the second administrative level (admin2, e.g., district) across SSA for 2012. Results reveal substantial geographical inequalities in predicted use of water and sanitation that exceed urban-rural disparities. The average range in coverage seen between admin2 within countries was 55% for improved drinking water, 54% for use of improved sanitation, and 59% for dependence upon open defecation. There was also some evidence that countries with higher levels of inequality relative to coverage in use of an improved drinking-water source also experienced higher levels of inequality in use of improved sanitation (rural populations r = 0.47, p = 0.002; urban populations r = 0.39, p = 0.01). Results are limited by the quantity of WSS data available, which varies considerably by country, and by the reliability and utility of available indicators. This study identifies important geographic inequalities in use of WSS previously hidden within national statistics, confirming the necessity for targeted policies and metrics that reach the most marginalized populations. The presented maps and analysis approach can provide a mechanism for monitoring future reductions in inequality within countries, reflecting priorities of the post-2015 development agenda. Please see later in the article for the Editors' Summary.

This paper presents country-level estimates of water, sanitation and hygiene (WASH)-related mortality and the economic losses associated with poor access to water and sanitation infrastructure in sub-Saharan Africa (SSA) from 1990 to 2050. We examine the extent to which the changes that accompany economic growth will \"solve\" water and sanitation problems in SSA and, if so, how long it will take. Our simulations suggest that WASH-related mortality will continue to differ markedly across countries in sub-Saharan Africa. In many countries, expected economic growth alone will not be sufficient to eliminate WASH-related mortality or eliminate the economic losses associated with poor access to water and sanitation infrastructure by 2050. In other countries, WASH-related mortality will sharply decline, although the economic losses associated with the time spent collecting water are forecast to persist. Overall, our findings suggest that in a subset of countries in sub-Saharan Africa (e.g., Angola, Niger, Sierra Leone, Chad and several others), WASH-related investments will remain a priority for decades and require a long-term, sustained effort from both the international community and national governments.

Water, energy, and food insecurity are significant challenges that affect both economies and households, particularly in developing countries. These resources have an effect on households wellbeing, businesses, and all sectors of the economy, making them critical to ensuring household well-being, which is frequently measured by quintile welfare. As a result, there has been a significant increase in interest in securitizing these resources in order to mitigate their negative effects on household’s wellbeing This study provides an empirical investigation of the determinants of water, energy, and food (WEF) security and the effect of water, energy, and food security on household well-being in Ghana. This study provides an empirical investigation of the determinants of water, energy, and food (WEF) security and the effect of water, energy, and food security on household well-being in Ghana. The study used a sample of 2,735 households from the Ghana Living Standard Survey (GLSS) Wave 7. We applied an instrumental variable probit, complementary log-log and ordered Probit estimation techniques for analysis. Empirical analysis reveals several important findings. Firstly, factors such as age, credit access, household location, employment status, and livestock ownership positively contribute to household water security, while remittances, water supply management, water bills, and water quantity have negative impacts. Secondly, age, marital status, household size, remittances, and livestock ownership significantly influence household energy security. Thirdly, marital status, household income, credit access, and household size are crucial determinants of household food security, with residence and region of household location exerting negative effects. Additionally, while water and energy security have a relatively lower impact on household well-being, food security emerges as a key driver in promoting household wellbeing. The study recommends that policymakers and stakeholders design and implement robust programs and interventions to sustain households’ water, energy, and food supply.

Background One-third of the population in sub-Saharan Africa does not have access to adequate hygiene and sanitation facilities. Many still lack decent and functional toilets, impacting health, dignity, and development. Therefore, this study aimed to assess the geographical distribution and factors associated with unimproved sanitation facilities in sub-Saharan Africa. Methods This study used Demographic and Health Survey (DHS) data from 500,845 households within 20,492 clusters across 34 sub-Saharan African countries, which were weighted, cleaned, and analysed using STATA version 17. Spatial analyses were conducted using ArcGIS software version 10.7 and Kulldorff’s SaTScan software version 10.1. Multilevel analysis was employed to identify contributing factors, with associations presented as adjusted odds ratios and 95% confidence intervals ( p  < 0.05). Results Significant spatial clustering and hotspots of unimproved sanitation facilities were identified within sub-Saharan Africa. The magnitude of unimproved sanitation facilities in sub-Saharan Africa was 48.88% (95% CI: 48.74–49.02%). The magnitude of unimproved sanitation was lowest in Malawi at 16.70% and highest in Chad at 88.52%. Several individual and community level factors were significantly associated with the utilization of unimproved sanitation facilities. At the individual level, female-headed households and those with access to improved drinking water source were less likely to use unimproved sanitation. In contrast, households headed by individuals aged 11–35 and 36–50 years, divorced households, and households with more than four members were associated with greater use of unimproved sanitation facilities. Additionally, households in the poorest, poorer, middle, and richer wealth categories were also associated with a greater use of unimproved sanitation facilities. Furthermore, households with water sources located in the yard/plot and off-premises had higher odds of using unimproved sanitation. At the community level, rural residence and lack of media exposure were associated with greater use of unimproved sanitation facilities. Conclusion Unimproved sanitation facilities remain a major public health challenge in sub-Saharan Africa, with significant regional disparities and a 48% magnitude. Addressing this issue requires targeted government policies, financial support for sanitation infrastructure, improved water supply, hygiene awareness campaigns, increased media exposure, and better sanitation facilities in rural areas.

As extreme events such as drought and flood are projected to increase in frequency and intensity under climate change, there is still large missing evidence on how drought exposure potentially impacts mortality among young children. This study aimed to investigate the association between drought and risk of infant mortality in Africa, a region highly vulnerable to climate change that bears the heaviest share of the global burden. In this cross-sectional study, we obtained data on infant mortality in 34 African countries during 1992-2019 from the Demographic and Health Surveys program. We measured drought by the standardized precipitation evapotranspiration index at a timescale of 24 months and a spatial resolution of 10 × 10 km, which was further dichotomized into mild and severe drought. The association between drought exposure and infant mortality risk was estimated using Cox regression models allowing time-dependent covariates. We further examined whether the association varied for neonatal and post-neonatal mortality and whether there was a delayed association with drought exposure during pregnancy or infancy. The mean (standard deviation) number of months in which children experienced any drought during pregnancy and survival period (from birth through death before 1 year of age) was 4.6 (5.2) and 7.3 (7.4) among cases and non-cases, respectively. Compared to children who did not experience drought, we did not find evidence that any drought exposure was associated with an increased risk of infant mortality (hazard ratio [HR]: 1.02, 95% confidence interval [CI] [1.00, 1.04], p = 0.072). When stratified by drought severity, we found a statistically significant association with severe drought (HR: 1.04; 95% CI [1.01, 1.07], p = 0.015), but no significant association with mild drought (HR: 1.01; 95% CI [0.99, 1.03], p = 0.353), compared to non-exposure to any drought. However, when excluding drought exposure during pregnancy, the association with severe drought was found to be non-significant. In addition, an increased risk of neonatal mortality was associated with severe drought (HR: 1.05; 95% CI [1.01, 1.10], p = 0.019), but not with mild drought (HR: 0.99; 95% CI [0.96, 1.02], p = 0.657). Exposure to long-term severe drought was associated with increased infant mortality risk in Africa. Our findings urge more effective adaptation measures and alleviation strategies against the adverse impact of drought on child health.

Background More than half of the population in Sub-Saharan Africa (SSA) faces limited access to safe drinking water. Unimproved water sources can pose risks to the health of entire households, particularly women and children. Despite the fact that East African countries have some of the poorest drinking water infrastructures globally, there is a lack of published data on this issue. Consequently, the objective of this study was to examine access to safe drinking water and its determinants among households in East Africa, utilizing recent nationally representative data. Methods This study analyzed data from recent demographic and health surveys conducted in 12 East African nations between 2011 and 2022. Data were gathered from 204,275 households. A stratified two-stage cluster sampling method was employed, with enumeration areas serving as the main sampling units and households serving as the secondary sampling units. Binary and multiple multilevel logistic regression were used to examine the relevant factors associated with the use of different sources of drinking water in the region. In binary regression and multiple regression, P values of ≤ 0.2 and < 0.05, respectively, were used to determine the statistical significance of variables in the final model. Results Approximately 72.62% (95% CI = 72.43, 72.83) of households have utilized improved sources of drinking water. Household heads aged 25–35 years (AOR = 1.09, 95% CI = 1.04, 1.14), 36–45 years (AOR = 1.09, 95% CI = 1.04, 1.14), and > 45 years (AOR = 1.08, 95% CI = 1.04, 1.14), those with secondary/higher education (AOR = 1.24, 95% CI = 1.20–1.29), and individuals in wealth index categories of poorest (AOR = 0.17, 95% CI = 0.16, 0.18), poorer (AOR = 0.21, 95% CI = 0.19, 0.22), middle (AOR = 0.25, 95% CI = 0.24, 0.27), and richer (AOR = 0.36, 95% CI = 0.34, 0.38) were associated with improved sources of drinking water. Additionally, female household leaders (AOR = 1.23, 95% CI = 1.20, 1.26), > 30 min of time taken to access the water source (AOR = 2.00, 95% CI = 1.95, 2.05), improved toilet facilities (AOR = 2.25, 95% CI = 2.19, 2.31), rural residence (AOR = 0.43, 95% CI = 0.42, 0.45), high community wealth (AOR = 1.31, 95% CI = 1.13–1.51), community media exposure (AOR = 1.32, 95% CI = 1.15, 1.51) were associated with improved sources of drinking water, respectively. Conclusion Approximately three-quarters of the population in East Africa has access to improved drinking water, although the quality of water in the region is still considered poor. It is important for relevant organizations to collaborate in order to improve the quality of drinking water, with special attention given to high-risk groups such as communities with high poverty and low literacy rates, poor households, and rural residents. Strengthening women’s empowerment and increasing mass media exposure can also play a crucial role in accelerating the adoption of improved drinking water sources in East Africa.

Cholera has been a global pandemic in past centuries, and its persistent emergence and spread pose a significant public health challenge globally. Despite efforts to contain the disease, recurrent cholera outbreaks in sub-Saharan Africa remain a major health threat. This has attracted substantial research interest, raising questions about the effectiveness of prevention and control methods of cholera spread in sub-Saharan Africa. Addressing this health challenge by adopting a sustainable, convenient, and cost-effective intervention will improve the health, well-being, and productivity of vulnerable populations in sub-Saharan Africa. Household-level solutions, which are characterized by relatively low-cost and independence from potentially insufficient public water supply infrastructure were examined to determine their effectiveness in reducing the incidence of cholera if widely adopted across the continent. We perform a mixed-methods retrospective analysis on the Cholera epidemic data obtained from 2010 to 2016 in sub-Saharan Africa. Using an empirical epidemiological model, we estimate the performance efficacy of a suite of household water treatment (HWT) technologies. We also develop economic estimations to perform benefit–cost analyses to determine the cost effectiveness, convenience of use and durability of these products. We find that—if universally adopted—the HWT technologies evaluated here offer comparable and effective microbiological potential for eradicating cholera disease in sub-Saharan Africa but are potentially not affordable for low-income households that reside in cholera hotspots. As such, household subsidies are necessary in lowering barriers to economic access to these products. This finding provides substantial insights on the efficacy and affordability of these household water treatment technologies—insights which can inform stakeholder decisions on the applicability of this intervention in eradicating cholera.

Background The economic impact of schistosomiasis and the underlying tradeoffs between water resources development and public health concerns have yet to be quantified. Schistosomiasis exerts large health, social and financial burdens on infected individuals and households. While irrigation schemes are one of the most important policy responses designed to reduce poverty, particularly in sub-Saharan Africa, they facilitate the propagation of schistosomiasis and other diseases. Methods We estimate the economic impact of schistosomiasis in Burkina Faso via its effect on agricultural production. We create an original dataset that combines detailed household and agricultural surveys with high-resolution geo-statistical disease maps. We develop new methods that use the densities of the intermediate host snails of schistosomiasis as instrumental variables together with panel, spatial and machine learning techniques. Results We estimate that the elimination of schistosomiasis in Burkina Faso would increase average crop yields by around 7%, rising to 32% for high infection clusters. Keeping schistosomiasis unchecked, in turn, would correspond to a loss of gross domestic product of approximately 0.8%. We identify the disease burden as a shock to the agricultural productivity of farmers. The poorest households engaged in subsistence agriculture bear a far heavier disease burden than their wealthier counterparts, experiencing an average yield loss due to schistosomiasis of between 32 and 45%. We show that the returns to water resources development are substantially reduced once its health effects are taken into account: villages in proximity of large-scale dams suffer an average yield loss of around 20%, and this burden decreases as distance between dams and villages increases. Conclusions This study provides a rigorous estimation of how schistosomiasis affects agricultural production and how it is both a driver and a consequence of poverty. It further quantifies the tradeoff between the economics of water infrastructures and their impact on public health. Although we focus on Burkina Faso, our approach can be applied to any country in which schistosomiasis is endemic. Graphical Abstract

The whole population of Feutap still collects drinking water from two protected springs, some 1 km away from this small rural agglomeration. For many generations, the only improvement has been the protection of the springs during the 1980s. The resulting high incidence of gastrointestinal infections continues to hinder the socioeconomic development of this mountain community. This dynamic wherein “poverty begets disease, and disease begets poverty” seems endless given the number of water improvement programs and other health-focused campaigns in rural areas of Cameroon since the 1960s. Fortunately, the hydrographic regime of Feutap and its geographical situation enable the implementation of the Kilimanjaro Concept (KC), wherein rainwater is quantitatively harvested, partly infiltrated, and largely stored to (i) meet the whole-year water needs of the population, (ii) create new ecosystems, and (iii) enable irrigated agriculture. This communication prepares the implementation of the KC in Feutap, including the creation of irrigation ponds for agriculture and small farm animals (e.g., goats and sheep). The view is promoted that Feutap is a potential viable space in which life and work are possible, using the existing rainfall and the few natural springs in a sustainable manner. The presented concept can be extended to other hilly small communities with similar hydraulic regimes.