Physics and Chemistry of the Earth 114 (2019) 102795

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Physics and Chemistry of the Earth

journal homepage: www.elsevier.com/locate/pce

Exploring the sanitation success, sanitation technology and diarrhoeal T

mortality nexus in Sub-Saharan Africa
Muchaneta Munamatia, , Innocent Nhapib, Shepherd Misia
⁎

a
Department of Civil Engineering, University of Zimbabwe, Box MP167, Mt. Pleasant, Harare, Zimbabwe
b
Department of Environmental Engineering, Chinhoyi University of Technology, P. Bag 7724, Chinhoyi, Zimbabwe

ARTICLE INFO ABSTRACT

Keywords: Previous research on the determinants of sanitation success has largely focused on economic, environmental,
Diarrhoeal mortality political and social factors at the expense of technological factors. Therefore, this paper explores the relationship
Environmental protection between improved sanitation technologies and sanitation success, and further investigates the impact of im-
Improved sanitation technology proved sanitation technologies on diarrhoeal mortality in 46 Sub-Saharan African (SSA) countries. Cross-country
Public health
regression analyses were done using publicly available data. The dependent variables ‘proportion of 2015 po-
Sanitation success
Sub-saharan Africa
pulation that gained access to sanitation since 2000’ (GAINACC), ‘access to improved sanitation as a percentage of the
2015 population’ (ACCSAN) and diarrhoeal mortality rates were regressed against six different types of improved
sanitation technologies commonly used in SSA. Significant relationships were observed between GAINACC and
flush toilets connected to septic tanks in the rural sample (p < 0.001). In addition, significant relationships were
obtained between ACCSAN and coverage of flush toilets connected to piped sewer, septic tanks and pit latrines
for all samples (all p-values < 0.05). The findings also showed negative significant relationships between all
flush toilets and diarrhoeal mortality rates (all p-values < 0.05). These results suggest that successful countries
in SSA had higher access to flush toilets than other improved sanitation technologies and diarrhoeal mortality
was lower in areas with higher coverages of flush toilets than those without. These results imply that investment
in flush toilets, where possible, must be encouraged. However, sanitation success must be accompanied with an
improvement in human health. These findings provide important information that could inform new strategies
for achieving the Sustainable Development Goals (SDGs) and help in the drive to improved sanitation and health.

1. Introduction
The world failed to meet the Millennium Development Goal (MDG)
sanitation target of 77% by 9 percentage points. The Joint Monitoring
Programme (JMP) for Water Supply and Sanitation reports that in
2015, approximately 68% of the global population had access to im-
proved sanitation (WHO/UNICEF, 2017). This figure, however, hides
the disparities between and across countries and regions. For example,
in the same year, the Sub-Saharan Africa (SSA) region had the lowest
sanitation coverage of 28% compared to other regions. Thus, 72% of
the 1.1 billion population in SSA did not have access to improved sa-
nitation in 2015 (UN, 2017; WHO/UNICEF, 2017). The region thus
failed to meet its 62% MDG sanitation target.
However, out of the 52 mainland countries and island states in SSA
only 14 countries and island states performed well, though at different
levels, while the majority of the SSA member countries, made limited or
no progress at all (WHO/UNICEF, 2015a, b; Munamati et al., 2016).
The prevailing poor sanitation situation in SSA was reported to be the
cause of 60% of diarrhoeal mortality in 2017 (IHME, 2019). Ironically,
some SSA countries with high sanitation coverages also had high pre-
valence of diarrhoeal diseases. For example, out of the 14 countries that
were said to have been successful in terms of sanitation provision,
several countries recorded diarrhoeal deaths that were above the re-
gional average of 10%. These countries are Angola, Botswana, Malawi
and South Africa, with under-5 diarrhoeal mortality rates of 12%, 14%,
15% and 16% respectively. In contrast, there are countries which had
very low diarrhoeal mortality rates, but they were considered not
performing well in terms of sanitation. These countries included
Equatorial Guinea, Gabon and Ghana with diarrhoeal mortality rates of
4% each.
Besides other issues, the above scenario could be attributed to the
types of improved sanitation technologies used in the different coun-
tries. An improved sanitation technology is a sanitation facility which
hygienically separates human excreta from human contact (WHO/

⁎
Corresponding author.
E-mail addresses: mismuchie@gmail.com, muchiemunamati@yahoo.com (M. Munamati).

https://doi.org/10.1016/j.pce.2019.08.003
Received 30 May 2019; Received in revised form 5 August 2019; Accepted 10 August 2019
Available online 13 August 2019
1474-7065/ © 2019 Elsevier Ltd. All rights reserved.
M. Munamati, et al.
Abbreviations and acronyms
ACCSAN Access to improved sanitation as a percentage of the 2015
population
ACCSANrural Access to improved sanitation as a percentage of the
2015 rural population
ACCSANurban Access to improved sanitation as a percentage of the
2015 urban population
AMCOW African Ministers' Council on Water
ANOVA Analysis of Variance
CT Composting toilet
DHS Demographic Health Surveys
DV Dependent Variable
FPPL Flush/pour-flush toilet connected to pit latrine
FPPS Flush/pour-flush toilet connected to piped sewer
FPST Flush/pour-flush toilet connected to septic tank
UNICEF, 2015b). Improved sanitation technologies include: flush or
pour-flush toilet/latrine connected to either piped sewer system (FPPS),
septic tank (FPST) or pit latrine (FPPL), Ventilated Improved Pit (VIP)
latrine; pit latrine with slab (PLS) and the composting toilet (CT)
(Fig. 1). Improved sanitation technologies offer different health benefits
with findings from research studies showing that flush toilets especially
those connected to sewer connections could greatly reduce diarrhoeal
morbidity and mortality compared to dry toilets like the VIP latrines
(Günther and Fink, 2013; WHO, 2014).
While it is important to consider the public health and environ-
mental protection functions of sanitation technologies (Kvarnström
et al., 2011; Beyene et al., 2015), the selection of improved sanitation
technologies in SSA is likely to be influenced by other factors. These
factors include the country's socio-economic, physical, national
Fig. 1. The sanitation ladder used by the JMP in monitoring sanitation. Adapted from (WHO/UNICEF, 2015a).
2
Physics and Chemistry of the Earth 114 (2019) 102795
GAINACC Proportion of 2015 population that gained access to sa-
nitation since 2000
GAINACCrural Proportion of 2015 rural population that gained ac-
cess to sanitation since 2000
GAINACCurban Proportion of 2015 urban population that gained
access to sanitation since 2000
IHME Institute for Health Metrics and Evaluation
JMP Joint Monitoring Programme
MDG Millennium Development Goals
MICS Multiple Indicator Cluster surveys
PLS Pit latrine with slab
SDG Sustainable Development Goals
SSA Sub-Saharan Africa
VIP Ventilated Improve Pit
WHO/UNICEF World Health Organisation/United Nations
Children's Fund
sanitation policies and strategies and settlement patterns (Murphy
et al., 2009; Parkinson et al., 2014; Munamati et al., 2017). A recent
study by Munamati et al. (2017) found that in SSA, selection of sani-
tation technologies was influenced by income, population, population
density and urban population as sanitation technologies have different
capital and operation and maintenance costs and different space re-
quirements. Physical factors such as steep slopes, soil types and depth,
depth to the groundwater table and the presence of low-lying areas
(Henriques and Louis, 2011; Malekpour et al., 2013) are also likely to
influence selection of sanitation technologies as different technologies
have different technical requirements, which must be matched with the
prevailing physical conditions. The differences in rural and urban set-
tlements also influence the types of sanitation technology which are
used in different settlements because of the differences in socio-
M. Munamati, et al. Physics and Chemistry of the Earth 114 (2019) 102795

economic and physical conditions (Lüthi et al., 2011; McGranahan,
2015). Sanitation policies and strategies play a major role in the se-
lection of improved sanitation technologies because as legal and reg-
ulatory framework, they provide technical standards and codes at na-
tional and municipal levels (Henriques and Louis, 2011; Parkinson
et al., 2014; Tilley et al., 2014; Nakagiri et al., 2016). Some countries
thus prohibit usage of dry toilets in urban areas while other countries
promote use of the same (Government of Rwanda, 2010; World Bank,
2011; Government of Zimbabwe, 2012).
Improved sanitation technologies were first used as an indicator for
monitoring sanitation performance during by the JMP during the MDG
period (1990–2015) and have since been carried over to the Sustainable
Development Goals (SDGs) (WHO/UNICEF, 2015a). However, the sa-
nitation monitoring approach used by JMP has been criticized for its
inflexibility and its failure to accommodate other innovative sanitation
options such as ecological sanitation (Kvarnström et al., 2011). In ad-
dition, the approach overlooked the primary functions of sanitation
namely environmental protection and public health protection (Baum
et al., 2013; Beyene et al., 2015; Munamati et al., 2015). However, the
issue of environmental protection with regards to faecal waste treat-
ment has been addressed in the SDGs through the introduction of a
sanitation target 6.3 on wastewater treatment (WHO/UNICEF, 2015a).
Despite the shortfalls of the JMP sanitation monitoring approach, it
is however important to note that the sanitation performance of
countries has, until now, depended on their access to improved sani-
tation technologies as provided in the JMP sanitation ladder (Fig. 1). It
is thus appropriate to assess the impact of improved sanitation tech-
nologies on sanitation success during the MDG period, with a view of
contributing towards the improvement of measuring sanitation per-
formance in the post-2015 development agenda.
A relatively large body of literature which highlights the reasons for
poor sanitation performance worldwide and that of SSA exists
(Hopewell and Graham, 2014; Adams et al., 2015; Munamati et al.,
2016). Findings from these studies provide critical information which
could help address the underlying causes of poor sanitation perfor-
mance in SSA. However, while commendable efforts have been made in
identifying the determinants of sanitation success, debate on the subject
has largely been centred on the effect of economic, environmental,
social and political factors. The impact of improved sanitation
technologies on sanitation success has not been given priority, yet this
is central in monitoring sanitation performance. The sanitation situa-
tion in SSA, could only be well understood and improved, if the tech-
nological factors, with regards to the different types of improved sa-
nitation technologies used in different countries, are also included in
the investigations.
Moreover, there seems to be lack of information linking sanitation
success to the public health function of sanitation. It is argued in this
paper that a country's sanitation success must translate to public health
benefits such as reductions in prevalence of diarrhoeal diseases and
diarrhoeal mortality. Prevalence of diarrhoeal diseases and diarrhoeal
mortality have been found to be associated with the types of sanitation
technologies used (Günther and Fink, 2013; WHO, 2014). Therefore, it
can be argued that a country which is successful in terms of sanitation
must also be performing well with regards to the public health function
of sanitation. In this regard, there seems to be an inextricable linkage
between sanitation success, sanitation technology and diarrhoeal mor-
tality. Thus, an understanding of a country's sanitation success must go
beyond access to sanitation technologies but include a country's per-
formance in the different functions of sanitation such as public health
represented by diarrhoeal mortality rates in this paper.
An understanding of the relationship between improved sanitation
technology and sanitation success is crucial for several reasons. Firstly,
it diverts attention from the usual debate of sanitation success which
focuses on economic, environmental, social and political factors and
identifies the improved sanitation technologies which have led to either
sanitation success or failure especially in the SSA context. Secondly,
there are also economic and policy implications tied to gaining such
knowledge, considering that improved sanitation technologies have
different investment costs and health benefits (Günther and Fink, 2013;
WHO, 2014). It is also important to understand the meaning of sani-
tation success as currently measured in the context of public health
protection, as this has policy and sanitation monitoring implications.
Considering the above discussion, this paper is aimed at in-
vestigating the relationship between sanitation success and improved
sanitation technologies. The paper also provides an analysis of the re-
lationship between improved sanitation technologies and diarrhoeal
mortality. In this paper ‘sanitation success’ is used to refer to countries
that made considerable sanitation gains in terms of the absolute

Table 1
Data sources for individual SSA countries.
Country Data source Country Data source

Angola MIS2011 Liberia DHS2013

Benin DHS 2011-12 Madagascar MIS2013
Botswana JMP country file-MIS2007 Malawi DHS2013
Burkina Faso DHS2014 Mali DHS 2012-13
Burundi MIS2012 Mauritania MICS2011
Cameroon DHS2011 Mauritius JMP country file-Census 2011
Cape Verde JMP country file-IMC2012 Mozambique DHS2011
Central African Republic MICS2010 Namibia DHS2013
Chad MICS2010 Niger DHS2012
Comoros DHS2012 Nigeria DHS2013
Congo Republic DHS 2011-12 Rwanda MIS2013
Cote d’Ivoire DHS 2011-12 Sao Tome and Principe DHS2008
Democratic Republic of Congo DHS2013 Senegal DHS2014
Djibouti JMP country file-MIS2009 Seychelles JMP country file-HSS2011-12
Equatorial Guinea JMP country file-DHS2011 Sierra Leone DHS2013
Eritrea JMP country file-PHS2010 South Africa JMP country file-IES2011
Ethiopia DHS2011 Swaziland MICS2010
Gabon DHS2012 Tanzania AIS 2011-12
Ghana DHS2014 The Gambia JMP country file-MICS2010
Guinea DHS2012 Togo DHS 2013-14
Guinea-Bissau JMP country file-DHS2006 Uganda DHS2011
Kenya DHS2010 Zambia DHS 2013-14
Lesotho DHS2009 Zimbabwe MICS2014

Notes: DHS-Demographic Health Survey; MICS-Multiple Indicator Cluster Survey; PHS-Population and Health Survey; IES-Income and Expenditure Survey; IMC-
Inquerito Multiobjectivo Continuo, MIS-Malaria Indicator Survey; AIS-AIDS Indicator Survey; –Data unavailable.

3
M. Munamati, et al. Physics and Chemistry of the Earth 114 (2019) 102795

number of people using the index; ‘proportion of 2015 population that
gained access to sanitation since 2000’ (GAINACC). For comparative
purposes, another success indicator, ‘access to improved sanitation as a
percentage of the 2015 population’ (ACCSAN) will also be used. Thus, the
dependent variables used in the analysis are the two sanitation success
indicators (GAINACC and ACCSAN) and diarrhoeal mortality while the
independent variables are the different types of improved sanitation
technologies namely FPPS, FPST, FPPL, VIP, PLS and CT. The
dependent variable ‘diarrhoeal mortality’, is used to understand sanita-
tion success in the context of public health protection, one of the pri-
mary functions of sanitation. This objective intends to answer the
question: ‘Is sanitation success achieved by the different countries indicative
of the actual sanitation situation?’

Table 2
Summary data for 46 sub-Saharan countries used in the analysis.
Countries Dependent Variables (%) Independent Variables (%)

GAINACC ACCSAN FPPS FPST FPPL VIP PLS CT Diarrhoeal mortality rate (% of Total deaths)

Total Mortality Under-5 Infant (5–14 years)

Angola 32 52 7.6 10.5 5.5 0.8 17.4 2.2 8.1 11.6 10.5
Benin 12 20 5.2 18.3 3.6 5.1 41.2 3.6 4.7 6.4 5.1
Botswana 23 63 0.6 3.3 0.3 31.6 17.8 0.2 3.3 13.5 5.4
Burkina Faso 12 20 2.5 8.5 0.5 0.4 82.8 0.1 9.2 13.1 6.5
Burundi 20 48 1.6 0.1 0.0 0.0 4.6 0.0 7.8 9.5 9.1
Cameroon 16 46 1.3 14.3 1.0 1.3 42.9 0.0 5.0 8.7 4.4
Cape Verde 35 72 21.0 52.0 0.0 0.0 0.0 0.0 1.0 6.4 2.3
CAR 8 22 0.1 0.2 0.9 1.3 4.2 0.4 8.5 12.4 10.3
Chad 6 12 1.9 1.8 8.4 0.6 24.0 5.2 15.9 20.4 14.9
Comoros 18 36 6.3 5.8 1.6 0.3 22.3 1.4 5.9 5.5 5.9
Congo Republic 6 15 3.8 12.2 2.6 1.4 21.7 0.0 3.9 5.2 4.1
Cote d'Ivoire 9 22 19.9 33.5 3.5 0.3 24.1 0.3 5.1 8.8 4.6
DRC 14 29 0.4 4.1 0.3 0.3 40.7 0.0 12.5 16.7 5.4
Djibouti −2 47 14.0 39.8 3.3 1.2 11.5 0.3 4.5 6.5 14.8
Equatorial Guinea 21 75 7.9 4.1 21.7 5.7 0.0 0.3 2.6 3.7 3.8
Eritrea 8 16 3.5 4.8 1.1 1.8 0.0 0.0 11.0 12.7 10.7
Ethiopia 22 28 1.2 0.9 2.7 2.7 6.5 7.8 7.8 9.7 9.2
Gabon 14 42 54.6 0.0 0.0 3.0 11.6 0.0 2.2 3.7 3.4
Ghana 8 15 25.4 30.9 2.1 18.7 14.1 0.0 2.2 4.0 2.0
Guinea 11 20 4.9 15.9 4.2 4.9 26.7 0.0 5.0 5.6 7.1
Guinea-Bissau 12 21 6.7 3.5 5.1 0.1 0.0 0.0 6.0 9.0 6.4
Kenya 11 30 12.2 3.9 1.3 16.6 17.9 0.1 9.4 13.3 8.1
Lesotho 9 30 2.1 2.4 0.2 18.4 27.9 4.2 6.8 18.6 4.5
Liberia 8 17 3.7 61.2 2.6 17.7 4.3 0.0 6.8 10.8 7.1
Madagascar 5 12 0.8 7.5 0.1 0.8 6.8 0.0 7.9 13.8 9.0
Malawi 18 41 3.9 0.0 0.0 5.4 16.5 0.0 9.4 14.9 6.6
Mali 13 25 2.6 2.3 4.3 1.2 32.0 0.3 10.9 14.3 11.1
Mauritania 24 40 4.3 15.8 26.4 16.1 15.3 0.9 6.1 9.1 7.0
Mauritius 7 93 20.8 6.4 65.8 0.0 0.0 0.0 0.3 1.9 0.8
Mozambiq 11 21 0.0 0.0 0.0 12.8 21.1 0.0 4.7 1.7 3.3
Namibia 13 34 73.1 2.5 3.9 10.0 2.9 0.4 4.6 5.5 5.9
Niger 7 11 3.5 8.8 0.0 5.1 45.1 0.0 13.9 13.8 13.9
Nigeria 5 29 8.5 14.6 5.4 30.7 14.9 0.2 3.6 17.8 2.8
Rwanda 29 62 0.0 0.9 0.6 0.4 61.2 0.3 5.0 7.0 4.6
STP 19 35 0.0 29.8 39.2 16.3 0.0 0.0 2.3 5.5 2.7
Senegal 21 48 7.5 18.5 3.2 3.3 44.3 0.0 6.4 11.0 7.3
Seychelles 11 98 14.0 85.0 0.7 0.0 0.7 0.0 0.3 0.5 0.2
Sierra Leone 6 13 1.4 18.6 3.2 18.2 28.1 0.2 4.1 18.3 4.1
South Africa 20 66 66.4 6.5 0.0 6.2 23.5 0.0 2.5 15.9 2.5
Swaziland 14 57 22.2 7.6 0.0 18.2 44.0 0.0 5.2 15.2 3.3
Tanzania 9 16 0.7 2.1 7.6 1.8 9.4 0.0 6.3 19.0 7.3
Gambia 21 59 2.3 11.2 3.4 3.7 55.8 0.0 5.1 6.8 2.0
Togo 4 12 0.1 46.0 6.7 1.1 26.5 0.3 6.2 9.8 4.3
Uganda 9 19 2.1 0.0 0.0 3.2 26.9 0.3 4.8 10.1 4.8
Zambia 17 44 14.8 6.3 0.6 13.3 15.4 0.0 6.5 6.9 3.5
Zimbabwe 5 37 30.2 6.6 0.5 30.4 22.2 0.2 7.0 10.2 4.6

Notes.
1) GAINACC = proportion of 2015 population that gained access to sanitation since 2000; ACCSAN = access to improved sanitation as a percentage of the 2015
population; FPST=Flush toilets connected to piped sewer; FPST = flush toilets connected to septic tanks; FPPL = flush toilets connected to pit latrines; VIP=
Ventilated Improved Pit; PLS = pit latrine with slab; CT = composting toilet; CAR= Central African Republic; DRC = Democratic Republic of Congo; STP= Sao
Tome and Principe.
2) Data for GAINACC for each country was calculated by subtracting sanitation coverage for 2000 from sanitation coverage of 2015 and dividing it by population in
2015 (Munamati et al., 2016).
3) Sanitation coverage figures (ACCSAN) for each country were taken from JMP report (WHO/UNICEF 2015a).
4) Data for improved sanitation technologies was obtained from the latest surveys on the DHS database, MICS and JMP country files (UNICEF, 2015; USAID, 2015;
WHO/UNICEF, 2015c).
5) Diarrhoeal mortality data was obtained from the Institute of Health Metrics and Evaluation (IHME, 2016).
6) Data for urban and rural areas not shown here but available upon request.

4
M. Munamati, et al.
2. Materials and methods
2.1. Data and data sources
Data on the independent variables, improved sanitation technolo-
gies, used across and within (rural and urban areas) the 46 SSA coun-
tries studied was extracted, after having obtained permission, from the
most recent Multiple Indicator Cluster surveys (MICS) and
Demographic Health Surveys (DHS) (2005–2014) (UNICEF, 2015;
USAID, 2015). The DHS and MICS are nationally representative
household surveys which collect information on various issues such as
water and sanitation and health. In cases where data was either not
available or was outdated in the DHS and MICS surveys, data was ex-
tracted from the JMP country files which report processed data from
DHS, MICS and other household surveys. This applied to countries such
as Central African Republic and South Africa, where the most recent
data available was for 1994–95 and 1998 respectively. There are cases,
however, where the most recent data available in JMP country files was
not used because it was not segregated into the different sanitation
technology categories. In such cases, the next most recent data set with
all the relevant data was used. The data sources including survey years
for the countries used in the analysis are shown in Table 1.
The data for the dependent variables; GAINACC and ACCSAN was
obtained from the 2015 JMP report (WHO/UNICEF, 2015b). The data
for the third set of dependent variable, diarrhoeal mortality, was ex-
tracted from the Institute for Health Metrics and Evaluation (IHME)
database (IHME, 2016). The IHME gathers and provides comprehensive
global population health data. The data for the dependent and in-
dependent variables for the 46 SSA countries used in the analysis is
shown in Table 2.
It must be noted that, the use of improved sanitation technologies
had its challenges. Firstly, while the DHS and MICs household surveys
use harmonized questions and response categories on sanitation to
improve comparability and accuracy of estimates (WHO/UNICEF,
2006) sometimes the response options failed to coincide with the JMP
sanitation facilities (Bartram et al., 2014) (Fig. 1). For example, a tra-
ditional pit latrine is not one of the options in the sanitation ladder, but
it is an option found in many of the household surveys. Secondly, dif-
ferent definitions for improved sanitation facilities are available across
SSA. Although most countries use the JMP definition, there are coun-
tries which have modified the definition. For example, some countries
regard a portion of their traditional pit latrines as improved latrines, as
reflected in the respective JMP country files. While other countries like
Angola include shared facilities in their definition of improved sanita-
tion facilities. Tied to the latter, some surveys made no distinction be-
tween shared and private facilities, this is particularly so for data which
was extracted from the JMP country files.
Against these variations, adjustments and assumptions were made
in order to improve comparability of results across countries. Firstly, all
traditional latrines were treated as unimproved because of the different
definitions used, which range from ‘open pit’, ‘pit with an earth floor’ or
‘unwashable slab’ (Langford and Winkler, 2013; Bartram et al., 2014).
Secondly, where no distinctions were made between private and shared
facilities, all technologies were assumed to be private. This was the case
for countries such as Angola, Djibouti, Gambia and Seychelles.
Besides differences in definitions of improved sanitation technolo-
gies, different definitions are also available for rural and urban areas.
Countries define rural and urban areas differently, either in terms of
facilities available, economic activities, population size or all of the
three (UN-Water, 2012).
2.2. Data analysis
Data analysis was carried out in IBM-SPSS version 20 software. The
DHS and MICS data on improved sanitation technologies was weighted
first according to the Guide to DHS Statistics procedure (Croft et al.,
5
Physics and Chemistry of the Earth 114 (2019) 102795
2018). Weighting using household weights was done to adjust for dif-
ferences in the probability of selection of sample cases introduced by
the sampling design or by accident. Cross-tabulations were used to
summarize the data on improved sanitation technologies for the in-
dividual countries according to type of residential area. Diagnostic tests
were performed to determine whether assumptions of the regression
model were valid.
2.2.1. Regression analysis
To establish the relationships between improved sanitation tech-
nologies and sanitation success and between improved sanitation
technologies and diarrhoeal mortality, multiple regression analysis was
performed. The empirical specification for the regression analysis
model is shown in Equation (1):
DV = 0 + j CTj, i + j PLSj, i + j VIPj, i + j FPSj, i + j FPSTj , i
+ j FPPLj, i ( i = 1..m; j = 1,...n) (1)
Where DV is the dependent variable of interest (sanitation success in-
dicator – GAINACC or ACCSAN and diarrhoeal mortality rates). GAI-
NACC and ACCSAN are sanitation success indicators at the national
level, while GAINACCrural, and ACCSANrural, and GAINACCurban AC-
CSANurban are sanitation success indicators for rural and urban areas
respectively. Three indicators of diarrhoeal mortality rates: under-5,
infant (5–14 age group) or total mortality are used. β0 is the intercept;
βj is the regression coefficient for the different independent variables; i
represents the individual countries. The indicator, GAINACC was cal-
culated using the method adopted by Munamati et al. (2016). The six
independent variables are: CT (an indicator for access to composting
toilet); PLS (an indicator for access to pit latrine with slab); VIP (an
indicator of access to VIP latrine); FPPS (an indicator for access to
flush/pour flush toilet connected to sewer); FPST (an indicator of access
to flush/pour flush toilet connected to septic tank) and FPPL (an in-
dicator of access to flush/pour flush toilet connected to pit latrine).
The analysis was done in three steps. In the first step, the dependent
variables GAINACC, GAINACCrural and GAINACCurban were regressed
against the six independent variables namely FPPS, FPST, FPPL, VIP,
PLS and CT producing three separate equations in the process. Initially,
the analysis was done for the full sample (all SSA countries). This was
followed by an analysis for rural and urban areas. Stratification into the
different types of residential area was done in order to understand the
variations in sanitation success between the urban and rural settings.
Specifically, the paper sought to answer the question, ‘which improved
sanitation technologies were used by successful countries in general and in
rural and urban areas?’ In the second step, the first step was repeated
with the dependent variables GAINACC, GAINACCrural and
GAINACCurban replaced by ACCSAN, ACCSANrural, and ACCSANurban
respectively. In the third step, the three dependent variables of diar-
rhoeal mortality namely; under-5, infant and total mortality were re-
gressed against the six improved sanitation technologies.
2.2.2. Cluster analysis
A hierarchical cluster analysis procedure was performed to classify
countries according to the types of improved sanitation technologies
used as well as sanitation performance. Cluster analysis was done to
reveal hidden characteristics of successful countries with regards to
improved sanitation technologies. Ward's agglomerative clustering al-
gorithm which combines clusters at each step to reduce the within-
cluster variance was used (Kaufman and Rousseeuw, 1990). The
squared Euclidean distance, which is the square of the geometric dis-
tance in multidimensional space (Kaufman and Rousseeuw, 1990), was
used to determine the distance between the clusters. The stability of the
cluster solution was evaluated by changing the order of the variables
and re-running the analysis. One-way Analysis of Variance (ANOVA)
was used to assess whether there were significant differences between
the clusters. Results of the hierarchical clustering were visualised on a
M. Munamati, et al. Physics and Chemistry of the Earth 114 (2019) 102795

dendrogram. success indicator ACCSANrural and FPST (p = 0.027), FPPL (p = 0.019)

and PLS (p = 0.014) in rural areas. These results suggest that countries
3. Results and discussion which achieved higher sanitation success had higher coverage of these
three improved sanitation technologies in rural areas compared to other
3.1. Variations of variables used in the analysis sanitation technologies. The adjusted R2 of 0.511 show a satisfactory
agreement between the observed and modelled estimates.
Table 3 presents statistics for the full sample and sub-samples used
in this paper. The results showed that the SSA region performed poorly 3.2.2. Cluster analysis results
with regards to access to sanitation as evidenced by the 36% average for Having established that there were significant relationships between
the dependent variable, ‘access to improved sanitation as a percentage of sanitation success and some improved sanitation technologies, hier-
the 2015 national population,’ ACCSAN, for the 46 SSA countries used in archical cluster analysis using Ward's method was run on 46 country
the study. There were wide variations in sanitation access across the cases each corresponding to the two sanitation success indicators and
SSA countries with the lowest sanitation coverage of 11% and highest the six different types of improved sanitation technologies. An ex-
coverage of 98%. amination of the different cluster results from two to eight clusters
The results further indicated that for some countries, ‘the proportion showed that five clusters produced the most varied and significant
of the 2015 national population that gained access to sanitation since 2000,’ differences between clusters. The clusters and corresponding cluster
(GAINACC), decreased in 2015 compared to that in 2000 as shown by a members are shown in Fig. 2 while the descriptive statistics of the
minimum of −2%. Huge disparities were observed between rural and clusters is shown in Table 5.
urban areas. For urban areas, the average for proportion of 2015 urban Cluster 1 was comprised of 13 countries. Five countries were from
population that gained access to sanitation since 2000 (GAINACCurban) Southern Africa, three from West Africa, another three from Central
was 20% with a range of −3%–55% while in rural areas the proportion Africa and two from East Africa. This cluster was characterized by the
of 2015 rural population that gained access to sanitation since 2000 highest coverage of VIP latrines (15%) and CT (1%), high coverage of
(GAINACCrural) averaged 8%, ranging from −21% to 27%. FPPL (7%) and high GAINACC (18%), moderate coverage of PLS, low
The same wide variations were observed for under-5 diarrhoeal coverage of FPPS (8%) and FPST (7%). The average values of these
mortality rates. The average under-5 diarrhoeal mortality rate in SSA
was 10% with a minimum and maximum of 0.5% and 20% respectively. Table 3
The average infant diarrhoeal mortality rate was the same as total Summary statistics of variables used in regression analysis.
diarrhoeal mortality rate for all age groups (6%).
Independent N Minimum (%) Maximum (%) Mean ± Std.Dev. (%)
Variables
3.2. Relationship between improved sanitation technologies and sanitation Improved sanitation technologies- Full sample
success across SSA countries FPPS 46 0 73 11 ± 16
FPST 46 0 85 14 ± 18
FPPL 46 0 66 5 ± 11
3.2.1. Multiple regression results
VIP latrine 46 0 39 8 ± 10
The main hypothesis of this study was that there is a positive re- PLS 46 0 83 21 ± 18
lationship between a country's sanitation success and the types of im- CT 46 0 8 1±2
proved sanitation technologies used. Thus, this study presumed that Improved sanitation technologies-Urban sample
FPPS 45 0 89 12 ± 19
sanitation success in SSA is a function of the types of improved sani-
FPST 45 0 58 11 ± 14
tation technologies used in each country. FPPL 45 0 48 4±8
Table 4 presents the results of the multiple regression analysis VIP latrine 45 0 53 5±9
performed to understand the relationships between sanitation success PLS 45 0 52 12 ± 13
and the six improved sanitation technologies which are commonly used CT 45 0 3 0.2 ± 0.6
Improved sanitation technologies-Rural sample
in SSA. Regression analysis produced four significant models, M1 to
FPPS 45 0 44 2±7
M4. The results are presented as follows: the first column shows the FPST 45 0 52 4±9
model M1 produced after regressing the six independent variables FPPL 45 0 83 4 ± 13
against the dependent variable GAINACC. The last three columns show VIP latrine 45 0 30 5±7
the models M2, M3 and M4 produced after regressing the independent PLS 45 0 60 13 ± 14
CT 45 0 7 0.5 ± 1.3
variables against sanitation success indicators ACCSAN, ACCSANurban Dependent Variables
and ACCSANrural respectively. GAINACC 46 −2 35 14 ± 8
Model M1 results showed that GAINACCrural was positively asso- ACCSAN 46 11 98 36 ± 22
ciated with FPST (p < 0.001). This implies that SSA countries which GAINACCurban 45 −3 55 20 ± 10
GAINACCrural 45 −21 27 8±9
were successful in terms of extending sanitation coverage in rural areas
ACCSANurban 45 18 100 47 ± 20
had a high prevalence of FPST compared to the other technologies. In ACCSANrural 45 4 98 25 ± 22
contrast, models for the full and urban samples using the same indicator Under-5 46 0.5 20 10 ± 5
were statistically non-significant (p > 0.05). diarrhoeal
Model M2 showed significant positive relationships between the mortality
Infant 46 0.2 15 6±3
sanitation success indicator ACCSAN on one hand, and FPPS diarrhoeal
(p = 0.046) and FPPL (p = 0.016) on the other hand. Significant re- mortality
lationships were also observed between ACCSANurban and FPPS and Total diarrhoeal 46 0.3 16 6±3
FPPL in model M3. The p-value for both regressions was 0.007. These mortality
results suggest that high investments in FPPS and FPPL relative to other
Notes.
technologies could have contributed to high sanitation performance at
GAINACC = proportion of 2015 population that gained access to sanitation
both at the national level and in urban areas. Adjusted R2 values of since 2000; ACCSAN = access to improved sanitation as a percentage of the
0.442 and 0.313 for models M2 and M3 suggest that besides FPPS and 2015 population; FPST=Flush toilets connected to piped sewer; FPST = flush
FPPL technologies, other factors could have contributed to sanitation toilets connected to septic tanks; FPPL = flush toilets connected to pit latrines;
success. VIP= Ventilated Improved Pit; PLS = pit latrine with slab; CT = composting
Model M4 showed significant relationships between the sanitation toilet.

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M. Munamati, et al. Physics and Chemistry of the Earth 114 (2019) 102795

Table 4 decreased with the use of flush toilets. The coefficient of determination,
Multiple regression results showing impact of improved sanitation technology R2 for the regressions ranged from 0.371 to 0.596. All the models were
on sanitation success in SSA. significant (p < 0.05) indicating that the joint relationship between
Variables GAINACCrural ACCSAN ACCSANurban ACCSANrural the independent variables and dependent variables were significant.
Model M5 demonstrated negative relationships between under-5
Rural (M1) Total (M2) Urban (M3) Rural (M4) diarrhoeal mortality on one hand and FPST (p = 0.025) and FPPL
(p = 0.040) on the other hand. In model M6, negative relationships
FPPS 0.281 (2.056) 0.369 (2.856)
0.046 0.007 were observed between infant diarrhoeal mortality and FPPS
FPST 0.500 (3.823) 0.314 (2.294) (p = 0.040), FPST (p < 0.001) and FPPL (p = 0.025) while positive
< 0.001 0.027 association was shown with CT (p = 0.041). Furthermore, model M7
FPPL 0.343 (2.506) 0.370 (2.861) 0.334 (2.445)
results showed negative association between total diarrhoeal mortality
0.016 0.007 0.019
PLS 0.303 (2.562) and FPPS (p = 0.006), FPST (p = 0.004) and FPPL (p = 0.016).
0.014 The results further showed that in general, the relationships be-
R2 0.313 0.442 0.313 0.511 tween the diarrhoeal mortality on one hand and VIP latrines and PLS on
F-value 9.551 4.226 9.551 7.410 the other hand were non-significant across the different specifications.
N 45 45 45 45
In addition, the regression coefficients had the unexpected positive
p < 0.001 < 0.001 < 0.001 0.002
signs.
Notes.
1) The figures shown in each cell are: b, regression coefficient; t-statistic; p- 4. Discussion
value (p < 0.05) in that order. Only results which are statistically significant
are shown (p < 0.05). 4.1. Variations of variables used in the analysis
2) GAINACC = proportion of 2015 population that gained access to sanitation
since 2000; GAINACCrural = proportion of 2015 rural population that gained The high prevalence of PLS suggest that the technology was selected
access to sanitation since 2000; ACCSAN = access to improved sanitation as a
based on its advantages of low capital costs, and low operational and
percentage of the 2015 population; ACCSANurban = access to improved sani-
maintenance costs, simplicity and non-water usage (Flores et al., 2009;
tation as a percentage of the 2015 urban population; ACCSANrural = access to
improved sanitation as a percentage of the 2015 rural population; FPST=Flush Nakagiri et al., 2016; Munamati et al., 2017) relative to other improved
toilets connected to piped sewer; FPST = flush toilets connected to septic tanks; sanitation technologies such as flush toilets which tend to be more
FPPL = flush toilets connected to pit latrines; PLS = pit latrine with slab. expensive and require water to operate. On the other hand, the low
usage of CT could be influenced by the faecophobic nature of most SSA
variables were higher than the averages for the full sample variables. cultures (Akpabio and Takara, 2014; Whittington, 2016). The large
Cluster 2 was comprised of 21 countries, 10 from West Africa, five variations in the distribution of all improved sanitation technologies
from East Africa, four from Central Africa and two from Southern show that different countries have different technological preferences
Africa. This cluster was characterized by countries which performed which could be influenced by the prevailing environmental and socio-
poorly in both sanitation success indicators with lowest GAINACC (8%) economic conditions (Munamati et al., 2017). The negative sanitation
and ACCSAN (20%) scores. In addition, the cluster had the highest gains indicate a decrease in sanitation coverage from 2000 to 2015,
coverage of CT (1%), high coverage of FPST (15%) and PLS (21%) and coupled with decreases of rural populations in countries such as Dji-
low coverage of FPPL (3%) and VIP latrines (6%) and lowest coverage bouti, Gabon, and Cape Verde for the same period (Munamati et al.,
of FPPS (5%) relative to other clusters. 2016).
Cluster 3 was comprised of six countries namely Burkina Faso,
Cameroon, Rwanda, Senegal, Swaziland and The Gambia. The cluster 4.2. Relationship between improved sanitation technologies and sanitation
was characterized by the highest GAINACC (19%), highest coverage of success across SSA countries
PLS (56%), high ACCSAN (49%), low coverage of FPST (10%) and VIP
latrines (5%) and the lowest coverage of FPPL (1%). The study explored the relationship between sanitation success and
Cluster 4 was comprised of three countries which are Cape Verde, improved sanitation technologies used in SSA countries. The results of
Mauritius and Seychelles. The cluster was characterized by the highest the multiple regression analysis showed no significant differences be-
scores in ACCSAN (88%), FPST (48%), and FPPL (22%), high scores in tween sanitation success indicator GAINACC and improved sanitation
GAINACC (18%) and FPPS (19%) and lowest scores in PLS (0.2%). In technologies for the full sample and urban sample. These results imply
addition, the cluster is conspicuous by the absence of VIP latrines and that countries with more people who gained access to sanitation since
CT. 2000 did so regardless of the sanitation technology they used. It could
Cluster 5 comprised of three countries namely Gabon, Namibia and also mean that sanitation success could have been due to other factors
South Africa is characterized by highest scores in FPPS (65%) and which were not investigated in this study. These factors could include
lowest scores in FPST (3%) and FPPL (1%). Moderate scores were re- national sanitation policies, investment in sanitation infrastructure,
gistered in ACCSAN (47%), VIP (6%) and CT (0.1%) while low scores political will, skills and capacity and proper institutional arrangements
were obtained in GAINACC (15%) and PLS (13%). (Tilley et al., 2014; Lane, 2015). This was however different for the
rural sample which showed a significant relationship between FPST and
the sanitation success indicator, GAINACC. These results suggest huge
3.3. Impact of improved sanitation technologies on diarrhoeal mortality investments in FPST compared to other technologies. While FPST is an
expensive technology and thus not appropriate for most rural areas, it
Table 6 shows the results of the regression analysis performed to must be noted that most countries and island states which scored huge
investigate the impact of improved sanitation technologies on three sanitation gains such as Cape Verde, Mauritius, Sao Tome and Principe
indicators of diarrhoeal mortality: under-5, infant and total diarrhoeal and Seychelles are middle income countries which tend to prefer more
mortality. The first column shows the regression results for the under-5 advanced technologies (Rudra, 2011; IMF, 2017).
(M5), while regression results for the infant and total mortality are In another set of regression estimations using the sanitation success
shown in second (M6) and third (M7) columns respectively. Results indicator, ACCSAN, all the model specifications were statistically sig-
showed that all the coefficients except the coefficient of CT had the nificant. The results seem to be consistent across all model specifica-
expected negative signs, suggesting that diarrhoeal mortality rates tions where it was shown that access to flush toilets (FPPS, FPST and

7
M. Munamati, et al. Physics and Chemistry of the Earth 114 (2019) 102795

Fig. 2. Dendrogram of clustering of SSA countries along coverage of improved sanitation technologies.

8
M. Munamati, et al. Physics and Chemistry of the Earth 114 (2019) 102795

Table 5
Summaries of the full sample and cluster variables.
Variable Name Mean ± Std. (%)

Full Sample (N = 45) Cluster 1 (N = 13) Cluster 2 (N = 21) Cluster 3(N = 6) Cluster 4 (N = 3) Cluster 5 (N = 3)

GAINACC 14 ± 8 18 ± 7 8±4 19 ± 6 18 ± 15 15 ± 4
ACCSAN 36 ± 22 43 ± 14 20 ± 8 49 ± 15 88 ± 14 47 ± 17
FPPS 11 ± 16 8±8 5±7 6±8 19 ± 4 65 ± 3
FPST 14 ± 18 7±5 15 ± 17 10 ± 6 48 ± 39 3±3
FPPL 5 ± 11 7 ± 11 3±3 1±1 22 ± 38 1±2
VIP 8 ± 10 15 ± 14 6±7 5±7 0±0 6±4
PLS 21 ± 18 13 ± 8 21 ± 13 56 ± 15 0.2 ± 0.4 13 ± 10
CT 1±2 1±2 1±2 0.1 ± 0.1 0±0 0.1 ± 0.2

Notes: GAINACC = proportion of 2015 population that gained access to sanitation since 2000; ACCSAN = access to improved sanitation as a percentage of the 2015
population; FPST=Flush toilets connected to piped sewer; FPST = flush toilets connected to septic tanks; FPPL = flush toilets connected to pit latrines; VIP=
Ventilated Improved Pit; PLS = pit latrine with slab; CT = composting toilet.

Table 6 protection offered by flush toilets seem to be influential in the selection

Regression results explaining the impact of improved sanitation technologies on of improved sanitation technologies for urban areas. The successful
diarrhoeal mortality rate in SSA. countries could have selected any of the technologies among the six
Independent Dependent Variables improved sanitation technologies, but they instead chose technologies
Variables (flush toilets) which are more advanced (and thus costly), are more
Under-5 Infant mortality Total mortality aesthetically pleasing and offer higher health benefits than the other
mortality (M5) (M6) (M7)
improved sanitation technologies.
FPPS −0.256 −0.356 However, for the rural areas, the significant relationships between
(−2.118) (−2.876) sanitation success and FPST and FPPL was found to be contrary to ex-
0.040 0.006 pectations. This is so because these improved sanitation technologies
FPST −0.321 −0.471 −0.374
are advanced high-cost technologies which are not affordable to the
(−2.322) (−3.871) (−3.011)
0.025 < 0.001 0.004
majority of the low income people who live in rural areas (Lüthi et al.,
FPPL −0.293 −0.282 −0.311 2010; McGranahan, 2015). The significant results could be explained in
(−2.123) (−2.328) (−2.501) part by the fact that a number of successful countries (such as Cape
0.040 0.025 0.016 Verde, Mauritius, Mauritania, Reunion, Sao Tome and Principe and
CT 0.302 (2.105)
Seychelles) do not have coverage or have low coverage of low-cost
0.041
R2 0.425 0.371 0.596 improved sanitation technologies such as PLS and VIP toilets, but have
F-value 4.737 4.484 6.287 higher coverages of FPPS and FPST (Munamati et al., 2017). Thus, they
N 45 45 45 contributed to the presence of these technologies in the regression es-
p 0.040 0.040 < 0.001 timations. In addition, the different definitions of rural areas used by
different countries have resulted in some areas exhibiting urban char-
Notes.
1) The figures shown in each cell are: b, regression coefficient; t-statistic; p- acteristics being defined as rural. Different types of improved sanitation
value (p < 0.05) in that order. Only results which are statistically significant technologies are thus possible in rural areas as in urban areas.
are shown (p < 0.05). In view of the findings from multiple regression analysis, the study
2) FPST=Flush toilets connected to piped sewer; FPST = flush toilets con- proceeded to cluster countries according to sanitation performance and
nected to septic tanks; FPPL = flush toilets connected to pit latrines; types of improved sanitation technologies used to reveal some hidden
CT = composting toilet. characteristics associated with sanitation success. Results for Cluster 3
showed that countries which had the highest scores in GAINACC were
FPPL) influenced sanitation success while the effects of VIP latrines and characterized by highest coverage of PLS. This result is in contrast with
CT remained non-significant across the different samples and specifi- multiple regression findings which showed no significant relationships
cations. The influence of both on-site and off-site technologies in sa- between GAINACC and any of the technologies except FPST for the
nitation success reflects the different sanitation policies used in dif- rural sample. These results are, however, plausible since PLS is one of
ferent countries, where some countries advocate for on-site the cheapest improved sanitation technologies and thus most countries
technologies while other countries promote off-site technologies can afford to install them in the presence of an enabling environment.
(Government of Rwanda, 2010; Government of Zimbabwe, 2011; Furthermore, cluster analysis revealed that countries which had the
Nakagiri et al., 2016). These results also suggest that to be successful, highest ACCSAN were associated with highest coverages of FPST and
countries did not have to install the cheapest technologies (in order to FPPL and high coverage of FPPS. These results deserve attention since
rapidly increase coverage), as the technologies which influenced sani- they agree with results of multiple regression results where flush toilets
tation success were the most expensive in terms of capital and operation were found to be associated with sanitation success across all model
costs (Munamati et al., 2017). The choice of technologies could thus, classifications. These cluster results could thus be used alongside mul-
have been greatly influenced by the need to protect human health, as tiple regression results to compare sanitation progress along improved
the flush toilets have been found to significantly lower childhood sanitation technologies.
morbidity and mortality compared to other basic technologies like pit
latrines with slabs (Günther and Fink, 2013; WHO, 2014). 4.3. Impact of improved sanitation technologies on diarrhoeal mortality
In addition, the results are in line with expectations as they reflect
the complexity of the urban context which requires the use of different The multiple regression results were consistent across all the model
types of improved sanitation technologies depending on settings specifications. These results demonstrate that promotion and invest-
(Parkinson et al., 2014). While this is so, it is important to note that the ment in flush toilets can be expected to significantly lower diarrhoeal
technological aspects of aesthetics and comfort and human health mortality rates in SSA. These findings are consistent with previous

9
M. Munamati, et al.
research by, for example, Günther and Fink (2013), WHO (2014) and
Wolf et al. (2014); which showed that the use of flush toilets was as-
sociated with great reductions in diarrhoeal morbidity and diarrhoeal
mortality compared to other improved sanitation technologies.
The positive association between the prevalence of CT and infant
diarrhoeal mortality rate was surprising, as it implies that the use of CT
leads to increases in infant mortality rate contrary to earlier findings
(Günther and Fink, 2013; Semba et al., 2011). In addition, the lack of
evidence of association between the prevalence of dry toilets namely
VIP latrine and PLS and the observed positive regression coefficients
was not consistent with expectations, as previous research found re-
duction in diarrhoeal diseases and diarrhoeal mortality as a result of use
of improved latrines (Günther and Fink, 2013; Semba et al., 2011;
WHO, 2014). While generally all the improved sanitation technologies
were expected to lead to reductions in diarrhoeal mortality, but with
varied levels of significance, the results are, however, plausible. The
positive regression coefficients for CT toilets and other dry toilets
namely VIP latrines and PLS could be attributed to the absence of the
Mills-Reincke phenomenon which explains the decrease in waterborne
and some non-waterborne diseases as a result of improvement in water
quality supplies (Kesztenbaum and Rosenthal, 2017; Ogasawara and
Matsushita, 2018). While the toilets might be available, they might not
be used because of cultural reasons (Akpabio and Takara, 2014;
Routray et al., 2015) thereby resulting in high prevalence of open de-
faecation and subsequent faecal contamination of drinking water
sources especially in rural areas. The toilets might also be sited close to
drinking water sources also leading to faecal contamination and
transmission of waterborne diseases. In addition, the coverage of basic
handwashing facilities (15%) in SSA is very low (WHO/UNICEF, 2017)
possibly because of the high prevalence of dry toilets which by design
do not require water to operate unlike flush toilets. Consequently, the
transmission of faecal pathogens through contaminated hands increases
leading to outbreak of diarrhoeal diseases. These results thus, underline
the importance of ensuring safe provision of water supplies and basic
handwashing facilities to ensure maximum health benefits are gained
from using the improved sanitation technologies. Further research is,
however, recommended in order to fully understand these results.
5. Conclusions
This paper used comprehensive data from 46 SSA countries to es-
timate the relationship between improved sanitation technologies and
sanitation success and to examine the impact of improved sanitation
technologies on mortality rates with the view of improving under-
standing of the meaning of sanitation success. This paper concludes that
sanitation success in SSA during the Millennium Development Goal
(MDG) period was influenced by access to flush toilets. The paper also
concludes that the high prevalence of flush toilets in some SSA coun-
tries was associated with low diarrhoeal mortality rates, while high
mortality rates were associated with the prevalence of dry toilets such
as composting toilets. The results from the study imply that investment
in flush toilets, where possible, must be encouraged. In cases where dry
toilets are used, their installation should be accompanied by the pro-
vision of safe and adequate water supplies and basic handwashing fa-
cilities to ensure effective barriers against transmission of faecal pa-
thogens which lead to diarrhoeal diseases. The conflicting results
produced by the two sanitation success indicators used however, in-
dicate the need to formulate a new sanitation success indicator un-
derpinned on the primary functions of sanitation of public health pro-
tection and environmental protection.
Conflicts of interest
None declared.
10
Physics and Chemistry of the Earth 114 (2019) 102795
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial or not-for-profit sectors.
References
Adams, E.A., Boateng, G.O., Amoyaw, J.A., 2015. Socioeconomic and demographic pre-
dictors of potable water and sanitation access in Ghana. Soc. Indic. Res. 126 (2),
673–687.
Akpabio, E.M., Takara, K., 2014. Understanding and confronting cultural complexities
characterizing water, sanitation and hygiene in Sub-Saharan Africa. Water Int. 39 (7),
921–932.
Bartram, J., Brocklehurst, C., Fisher, M.B., Luyendijk, R., Hossain, R., Wardlaw, T.,
Gordon, B., Fisher, J., Luyendijk, R., Hossain, R., et al., 2014. Global monitoring of
water supply and sanitation: history, methods and future challenges. Int. J. Environ.
Res. Public Health 11 (8), 8137–8165.
Baum, R., Luh, J., Bartram, J., 2013. Sanitation: a global estimate of sewerage connec-
tions without treatment and the resulting impact on MDG progress. Environ. Sci.
Technol. 47, 1994–2000.
Beyene, A., Hailu, T., Faris, K., Kloos, H., 2015. Current state and trends of access to
sanitation in Ethiopia and the need to revise indicators to monitor progress in the
Post-2015 era. BMC Public Health 15, 1–8.
Croft, T.N., Marshall, A.M.J., Allen, C.K., 2018. Guide to DHS statistics. Available at:
www.DHSprogram.com , Accessed date: 5 August 2019.
Flores, A., Buckley, C., Fenner, R., 2009. Selecting sanitation systems for sustainability in
developing countries. Water Sci. Technol. 60 (11), 2973–2982.
Government of Rwanda, 2010. National Policy & Strategy for Water Supply and
Sanitation Services. (Kigali).
Government of Zimbabwe, 2011. Strategy to Accelerate Cccess to Sanitation and Hygiene.
Harare.
Government of Zimbabwe, 2012. National Definitions of Access to Water, Sanitation and
Hygiene. Harare.
Günther, I., Fink, G., 2013. Saving a life-year and reaching MDG 4 with investments in
water and sanitation: a cost-effective policy? Eur. J. Dev. Res. 25 (1), 129–153.
Henriques, J.J., Louis, G.E., 2011. A decision model for selecting sustainable drinking
water supply and greywater reuse systems for developing communities with a case
study in Cimahi, Indonesia. Journal of Environmental Management 214–222.
Hopewell, M.R., Graham, J.P., 2014. Trends in access to water supply and sanitation in 31
major sub-Saharan African cities: an analysis of DHS data from 2000 to 2012., BMC
public health. BMC Public Health 14 (1), 1–12.
IHME, 2016. GBD Compare Data Visualization. Institute for Health Metrics and
Evaluation, Seattle, WA.
IHME, 2019. GBD compare | IHME viz hub, Institute for health Metrics and evaluation.
Available at: https://vizhub.healthdata.org/gbd-compare/.
IMF, 2017. Regional Economic Outlook: Sub-saharan Africa Restarting the Growth
Engine. International Monetary Fund, Washington D.C.
Kaufman, L., Rousseeuw, P.J., 1990. In: Kaufman, L., Rousseeuw, P.J. (Eds.), Finding
Groups in Data: an Introduction to Cluster Analysis. John Wiley & Sons, Inc. (Wiley
Series in Probability and Statistics), Hoboken, NJ, USA.
Kesztenbaum, L., Rosenthal, J.-L., 2017. Sewers' diffusion and the decline of mortality:
the case of Paris, 1880–1914. J. Urban Econ. 98, 174–186.
Kvarnström, E., McConville, J., Bracken, P., Johansson, M., Fogde, M., 2011. The sani-
tation ladder – a need for a revamp? J. Water, Sanit. Hyg. Dev. 1 (1), 3–12.
Lane, J., 2015. Barriers and opportunities for sanitation and water for all. as Envisaged by
the New Delhi Statement 43 (2), 13–20.
Langford, M., Winkler, I.T., 2013. Quantifying Water and Sanitation in Development
Cooperation : Power or Perversity ? the Power of Numbers : A Critical Review of MDG
Targets for Human Development and Human Rights. pp. 1–29 May.
Lüthi, C., McConville, J., Kvarnström, E., 2010. Community-based approaches for ad-
dressing the urban sanitation challenges. Int. J. Urban Sustain. Dev. 1 (1–2), 49–63.
Lüthi, C., Panesar, A., Schütze, T., Norström, A., Mcconville, J., Parkinson, J., Saywell, D.,
Ingle, R., 2011. Sustainable Sanitation in Cities: A Framework for Action. First.
Papiroz Publishing House, The Netherlands.
McGranahan, G., 2015. Realizing the Right to Sanitation in Deprived Urban Communities:
Meeting the Challenges of Collective Action, Coproduction, Affordability, and
Housing Tenure, vol. 68. World Development. Elsevier Ltd, pp. 242–253.
Munamati, M., Nhapi, I., Misi, S.N., 2015. Monitoring sanitation performance: unpacking
the figures on sanitation coverage. J. Water, Sanit. Hyg. Dev. 5 (3), 341.
Munamati, M., Nhapi, I., Misi, S., 2016. Exploring the Determinants of Sanitation Success
in Sub-saharan Africa, Water Research, vol. 103. Elsevier Ltd, pp. 435–443 September
2015.
Munamati, M., Nhapi, I., Misi, S.N., 2017. Types and distribution of improved sanitation
technologies in sub-Saharan Africa. J. Water, Sanit. Hyg. Dev. 7 (2), 260–271.
Murphy, H.M., McBean, E.A., Farahbakhsh, K., 2009. Appropriate Technology – A
Comprehensive Approach for Water and Sanitation in the Developing World,
Technology in Society, vol. 31. Elsevier Ltd, pp. 158–167 2.
Nakagiri, A., Niwagaba, C.B., Nyenje, P.M., Kulabako, R.N., Tumuhairwe, J.B., Kansiime,
F., 2016. Are pit latrines in urban areas of Sub-Saharan Africa performing? A review
of usage, filling, insects and odour nuisances, BMC Public Health. BMC Public Health
16 (120), 1–16.
Ogasawara, K., Matsushita, Y., 2018. Public health and multiple-phase mortality decline:
evidence from industrializing Japan. Econ. Hum. Biol. 29, 198–210.
Parkinson, J., Lüthi, C., Walther, D., 2014. Sanitation 21 - A Planning Framework for
M. Munamati, et al.
Improving City-wide Sanitation Services. Dubendorf, London.
Routray, P., Schmidt, W.P., Boisson, S., Clasen, T., Jenkins, M.W., 2015. Socio-cultural
and behavioural factors constraining latrine adoption in rural coastal Odisha: an
exploratory qualitative study Global health. BMC Public Health 15 (880).
Rudra, N., 2011. Openness and politics of potable water. Comp. Pol Stud. 44 (6),
771–803.
Semba, R.D., Kraemer, K., Sun, K., de Pee, S., Akhter, N., Moench-Pfanner, R., Rah, J.H.,
Campbell, A.A., Badham, J., Bloem, M.W., 2011. Relationship of the presence of a
household improved latrine with diarrhea and under-five child mortality in
Indonesia. The American journal of tropical medicine and hygiene. The American
Society of Tropical Medicine and Hygiene 84 (3), 443–450.
Tilley, E., Strande, L., Lu, C., Mosler, H., Udert, K.M., 2014. Looking beyond technology:
an integrated approach to water, sanitation and hygiene in low income countries.
Environ. Sci. Technol. 48, 9965–9970.
UN, 2017. World Population Prospects: the 2017 Revision. United Nations, Department of
Economic and Social Affairs, Population Division Available at: https://esa.un.org/
unpd/wpp/DataQuery/, Accessed date: 8 November 2017.
UN-Water, 2012. 2011 UN-water GLAAS Country Survey. New York.
UNICEF, 2015. UNICEF Multiple Indicator Cluster Survey (MICS). UNICEF.
USAID, 2015. The DHS Program: Demographic and Health Surveys. USAID.
Whittington, D., 2016. Policy note: ‘ancient instincts — implications for water policy in
11
Physics and Chemistry of the Earth 114 (2019) 102795
the 21st century’. Water Economics and Policy 02 (02), 1671002.
WHO, 2014. Preventing diarrhoea through better water, sanitation and hygiene: ex-
posures and impacts in low-and middle-income countries. Geneva. Available at:
http://apps.who.int/iris/bitstream/10665/150112/1/9789241564823_eng.pdf,
Accessed date: 9 August 2017.
WHO/UNICEF, 2006. Core Questions on Drinking Water and Sanitation for Household
Surveys. (Geneva, Switzerland).
WHO/UNICEF, 2015a. Methodological Note : Proposed Indicator Framework for
Monitoring SDG Targets on Drinking-water, Sanitation, Hygiene and Wastewater.
(Geneva).
WHO/UNICEF, 2015b. Progress on Sanitation and Drinking Water: 2015 Update and
MDG Assessment. World Health Organization, Geneva.
WHO/UNICEF, 2017. Progress on Drinking Water. Sanitation and Hygiene, Geneva.
Wolf, J., Prüss-Ustün, A., Cumming, O., Bartram, J., Bonjour, S., Cairncross, S., Clasen, T.,
Colford, J.M., Curtis, V., De France, J., et al., 2014. Assessing the impact of drinking
water and sanitation on diarrhoeal disease in low- and middle-income settings: sys-
tematic review and meta-regression. Trop. Med. Int. Health 19 (8), 928–942.
World Bank, 2011. Water Supply and Sanitation in Zimbabwe:Turning Finance into
Services for 2015 and beyond. An AMCOW Country Status Overview. (Nairobi,
Kenya).