The research team, led by Joyce Aputere Ndago of the University for Development Studies in Ghana together with Paul Adjorlolo, Martin Nyaaba Adokiya and Micheal Boah, set out to answer a deceptively simple question: how many households in Sub-Saharan Africa actually use improved water sources and improved sanitation facilities, and what determines whether they do? The distinction between access and use matters more than it might seem. A household may technically live within reach of a borehole or a piped connection, yet rely on untreated surface water for drinking. A latrine may exist on the family compound but serve so many people, or fall into such disrepair, that it fails to protect health. By measuring reported use rather than mere infrastructure presence, the study offers a more honest picture of where the region stands.

The numbers tell a story of partial progress and stubborn gaps. Overall, 76.3 percent of households reported access to and use of improved water sources, a category that includes piped water, boreholes, protected wells and protected springs, as opposed to unimproved sources such as unprotected dug wells, tanker trucks or surface water from rivers and ponds. For sanitation, the picture darkens considerably. Only 56.7 percent of households had access to and used improved toilet facilities, which range from flush toilets connected to sewers or septic systems to improved pit latrines with slabs. When the researchers applied the stricter definition of basic sanitation, meaning an improved toilet that is not shared with other households, the figure collapsed to 35.4 percent. Shared facilities, however well constructed, are considered inadequate under international monitoring standards because they are harder to keep clean, harder to maintain, and often inaccessible to women, children and people with disabilities.

Perhaps the most striking feature of the results is the sheer width of the variation between countries. The regional averages conceal enormous disparities, with some nations achieving high coverage of improved water and sanitation while others lag far behind on both indicators. This heterogeneity is not a statistical curiosity; it is a policy signal. It suggests that national context, governance capacity, investment levels and geographic conditions shape outcomes so strongly that a single regional strategy is unlikely to succeed. Countries that have invested in rural water supply infrastructure, for example, have pulled ahead of neighbors facing comparable income levels, while urbanizing nations face a different challenge: keeping sanitation services ahead of the growth of informal settlements.

To move beyond description, the team turned to multivariable Poisson regression with robust variance, a statistical technique well suited to outcomes that are common in a population. Unlike logistic regression, which can produce inflated and unstable effect estimates when a condition affects more than roughly ten percent of respondents, Poisson regression with robust standard errors yields reliable prevalence ratios even for widespread outcomes such as improved water use. The method allowed the researchers to estimate the independent association of each household characteristic with access and use, while holding the others constant, and to do so across a pooled dataset spanning hundreds of thousands of households with widely differing survey designs.

The regression results converge on a clear set of drivers. Household wealth emerged as one of the most consistent predictors, with richer households substantially more likely to use improved toilets and basic sanitation than the poorest. This gradient is unsurprising in economic terms, since building and maintaining a private flush toilet or septic system requires capital that poor families rarely command, but its persistence across 30 countries underscores how deeply sanitation access is stratified by income. Place of residence was equally significant: urban households consistently outperformed rural ones on sanitation indicators, reflecting both the density of infrastructure in cities and the historical concentration of public investment in urban areas. Rural communities, dispersed across difficult terrain and often far from sewer networks or reliable piped systems, remain the region’s sanitation frontier.

Education told a different, and in some ways more hopeful, story. Educational attainment was significantly associated with access to and use of improved water sources, even after accounting for wealth and residence. This suggests that schooling does something beyond raising income: it shapes household preferences, hygiene knowledge and the perceived value of safe water, influencing decisions about where families draw water and how they treat it. The finding aligns with a broader body of evidence showing that maternal education in particular is among the strongest predictors of child health outcomes in low-income settings. For sanitation, however, wealth and residence dominated, implying that knowledge alone cannot overcome the financial and structural barriers to building a private toilet.

The public health stakes of these gaps are difficult to overstate. Unsafe water and inadequate sanitation are major pathways for diarrheal disease, cholera, typhoid, hepatitis A and a constellation of neglected tropical diseases, including soil-transmitted helminth infections that thrive where open defecation persists. Diarrheal illness remains a leading cause of death among children under five in the region, and repeated infections in early childhood contribute to stunting, cognitive impairment and long-term economic loss. The COVID-19 pandemic added a fresh urgency, as handwashing with soap, one of the simplest infection-control measures, depends on exactly the kind of reliable water access that a quarter of households lack. When 35 percent of households share toilets or rely on unimproved facilities, disease transmission is not an occasional crisis but a constant background condition.

The study’s authors argue that governments in Sub-Saharan Africa should prioritize expanding access to water and sanitation, with particular attention to underserved rural areas and poor households. But they also stress that average coverage figures are not enough: targeted strategies are needed to address the disparities driven by socioeconomic and demographic factors that their analysis exposed. In practice, that means subsidies or financing mechanisms that help the poorest families build and maintain private facilities, rural water supply programs designed for dispersed populations, and sanitation marketing approaches that recognize a toilet is a durable household investment rather than a one-time purchase. It also means monitoring systems that track use and equity, not just the construction of infrastructure, so that progress is measured where it matters most, at the household level.

The findings arrive at a critical moment for the Sustainable Development Goals, whose water and sanitation targets call for universal, safely managed services by 2030. On current evidence, Sub-Saharan Africa is far from that trajectory, and the study’s pooled data make clear that closing the gap will require confronting inequality as directly as building infrastructure. The region’s water story is one of real progress, three-quarters of households now use improved sources, a substantial achievement by historical standards. Its sanitation story is one of unfinished business, with basic sanitation reaching barely a third of households and the poorest, most rural families consistently left behind. The data from 465,208 households make the pattern impossible to ignore, and they give governments, donors and public health agencies a precise map of where the work remains.

Subject of Research: Household access to and use of improved water sources and sanitation facilities across 30 Sub-Saharan African countries

Article Title: Access to and use of improved water and sanitation facilities in Sub-Saharan Africa: Analysis of Demographic and Health Survey Data from 30 countries

Article References: Ndago, J. A., Adjorlolo, P., Adokiya, M. N., & Boah, M. (2026). Access to and use of improved water and sanitation facilities in Sub-Saharan Africa: Analysis of Demographic and Health Survey Data from 30 countries. PLOS Global Public Health, 6(10), e0006195. https://doi.org/10.1371/journal.pgph.0006195

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0006195

Keywords: Sub-Saharan Africa, water access, sanitation, Demographic and Health Surveys, Sustainable Development Goals, public health, Poisson regression, household wealth, rural-urban disparities, improved water sources, basic sanitation, health equity