Consumption of products packaged in plastics is growing in Sub-Saharan African cities, whose populations often lack solid waste management (SWM) services. The informal sector often fills gaps in plastic waste collection and recovery that are not met by formal SWM. To reduce plastic waste mismanagement and its associated health risks, SWM systems are needed that separate plastic waste for reuse or recycling. However, little is known about the contributions and challenges facing the mixed formal-informal enterprises in such cities' SWM chains. This multi-country qualitative study therefore aimed to contrast the specific challenges of plastic waste collectors with those facing general waste collectors. Eleven focus group discussions (FGDs), 6-12 participants per FGD (n = 87 in total), were held with plastic main collectors and sub-collectors (4 FGDs), and general waste collectors (2 FGDs)in Greater Accra, Ghana, and waste sub-collectors (2FGDs), waste intermediaries (2FGDs) and apex plastic traders (1FGD) in Kisumu, Kenya, differentiating business types and plastic from mixed waste enterprises. Barriers, enablers, and solutions were identified through thematic coding and analysis of transcripts. We find differing SWM trajectories in Accra versus Kisumu. Domestic waste separation remains low in Kisumu, whilst Accra's SWM system evolved from flexible to rigid plastic separation. Mixed and plastic waste collectors reported shared challenges, such as lack of crushing or transport equipment, harassment, greater hazardous faecal matter in waste streams, and lack of societal recognition. Additionally, specialist plastic waste workers in Greater Accra reported business-specific challenges, notably price volatility from seasonally variable plastic waste generation and from bulk international waste plastic imports, alongside theft of separated plastics. Accra's informal plastic waste sub-collectors were mostly elderly women who reported occupational health challenges from bending and lifting waste. Our findings highlight the need for context-sensitive plastic SWM programmes, including fair bargaining and price regulation measures, occupational health programmes and safer diaper SWM.

Utility/small-scale service provider partnerships are a pro-poor water service delivery mechanism that also reduce non-revenue water and generate employment. Since 2006, a water utility in Kisumu (Kenya) has operated such a partnership programme, the Delegated Management Model (DMM). Implementation science explicitly examines how setting and individuals’ experiences influence public health programme adaptation, but few studies have applied implementation science to water service delivery. This study aimed to assess how contextual changes and evolving actor relationships have influenced DMM programme adaptation, ongoing effectiveness, and long-term sustainment and sustainability. A mixed methods study combined focus group discussions with programmatic document and utility record analysis. The latter captured tariffs, water production, and non-revenue water between DMM inception and 2022. Ten focus group discussions were held with 99 participants, comprising small-scale water providers, kiosk operators, and households in DMM and non-DMM areas. Discussions examined DMM’s evolution, transferability, and scalability. Participants reported recent reductions in DMM small-scale provider profit margins and higher domestic consumer prices after a long period of implementation process stability. DMM delivered most of its original objectives, expanding service coverage and accounting for 6.2% of Kisumu’s connections in 2008, but 18.1% of connections by 2021. However, utility adoption of additional innovations alongside DMM (e.g. district metering) reduced non-revenue water from 67% in 2006 to 25% in 2021. Given these contextual changes but also DMM’s continued delivery of its objectives, we recommend continued DMM investment but also exploring diversification of small-scale providers’ services, such as developing their expertise to deliver wastewater alongside water services.

Background To attain universal health care, health managers need to monitor progress in service uptake, changes and geographic coverage. Although routine health management information systems are now well established in many resource-constrained countries, such data have not yet been used to examine geographic access trends over time. Objective This study aims to quantify changing patterns of geographic access to healthcare in the Volta Region, Ghana. Methods The repeated cross-sectional ecological spatio-temporal analysis used routine health management information systems data from 2016 to 2022, and geospatial data to examine changes in healthcare accessibility and services provided for population subgroups. Changes in healthcare provision, travel time to services and population coverage were estimated. Results Most health facilities (60.6%) provided the same range of services or added new services between 2016 and 2022. Childhood immunisation services had the highest geographic coverage within 30 min of the nearest health facility from 2016 to 2022 (minimum 97.2%), while Caesarean births had the lowest (maximum 75.2%). More health facilities provide antenatal services (2022: 59.9%) than birthing care (2022: 52.6%). Of all new health facilities, 93.2% were Community Health Planning and Services (CHPS) facilities. The majority of the population lived within 30 min of services in 2016 and 2022 for all the services studied. Conclusion The study provides a new approach to monitoring service changes through routine health data and spatial analysis. The analysis provided evidence to improve geographic accessibility, address gaps in service changes and consolidate the gains of high geographic coverage with quality care.

Slums house nearly one-quarter of the global urban population, yet their spatial and socioeconomic dynamics remain poorly understood, hindering progress toward the United Nations' commitment to 'leave no one behind'. Here, focusing on sub-Saharan Africa, we integrate geospatial data with household surveys to map slum prevalence and asset-based wealth inequalities across 32 countries. We identify that 54.6% of the urban population in these countries live in slums, with lower wealth levels compared with non-slum areas. Despite a reduction in the proportion of slum populations over the past two decades, wealth inequalities have risen, especially in countries with substantial slum populations. This study highlights profound inequalities in urban essential services, living conditions and household wealth in sub-Saharan African countries, emphasizing the importance of fine-scale analysis of slum distributions and associated wealth inequalities to inform inclusive programs.

Mismanaged plastic waste undermines environmental quality, aquatic ecosystems and ultimately public health. Mismanaged plastics increasingly originate from urban populations lacking waste collection services. Household expenditure survey analyses have quantified plastic waste generation among these populations, but only for individual products (e.g. bagged or bottled drinking-water), not for the overall packaging profile of households’ basket-of-goods. This study aims to evaluate how far the international NOVA classification of foods/beverages and commodity classifications by residents predict plastic food packaging. Via a cross-sectional market surveillance survey, packaging was observed for 502 and 396 transactions at selected retail outlets serving low-income areas of Greater Accra, Ghana, and Kisumu, Kenya respectively. In both cities, NOVA processed/ultra-processed food and food/beverage classes created by local residents were significantly associated with greater plastic food packaging, with similar predictive performance. Plastic packaging prevalence was also significantly higher in supermarkets. Plastic packaging use was significantly lower in Kisumu, where single-use carrier bags are banned. Thus, given their international availability and national representativeness, household expenditure surveys have potential for monitoring to inform policy by targeting plastic pollution hot-spots. However, survey-based monitoring should incorporate expert knowledge of national context and the retail environment to reflect the realities of packaging use.

Delegated management (DMM) is a water service delivery model, whereby micro-operators financially and operationally manage underserved areas of a piped network. This post-hoc evaluation aimed to assess the impact of DMM on water safety. Kiosk and household stored water in DMM and matched control areas were tested for microbiological quality, showing comparable, substantial post-collection contamination. DMM increased household piped connections, reducing the need for household water storage and thereby post-collection contamination. However, DMM kiosk users remain exposed to recontaminated water. DMM remains a viable service delivery model, but other strategies are needed to address post-collection contamination of household stored water.

Due to a lack of formal planning and resources, piped networks in low-income African urban areas may develop into an unstructured and chaotic configuration. This makes such areas more vulnerable to service disruptions, with infrastructure harder to maintain and inefficiently configured. The delegated management model (DMM), where a utility provider delegates water service delivery responsibilities to micro-operators, is a proposed solution to this issue, implemented in numerous cities, including Kisumu, Kenya. However, it is unclear empirically whether DMM rationalizes the spatial configuration of piped water networks in slums. This study aims to assess how piped network topology and, thereby, efficiency and interruption vulnerability vary in Kisumu and Kigali based on water service management arrangements and for slum versus non-slum areas. We applied the hierarchical Infomap community detection algorithm to a water pipeline network digital map layer for both cities. Infomap iteratively distinguishes communities as areas of the network where dense connections exist, generating a hierarchical classification based on the network topology. Graph-based analysis highlights the structural characteristics of pipeline networks shaped by the cities' urban planning and development strategies. In both cities, Infomap output differentiates low-income areas from other neighborhoods, so in Kisumu, it further discriminates DMM neighborhoods from other parts of the pipeline network. This suggests that the topology and, therefore, the vulnerability of the pipeline network within DMM neighborhoods demonstrate similarities, and that these are distinct between slum and non-slum areas.

Transect surveys are widely used to quantify mismanaged plastic waste discarded to the environment. However, very few studies have quantified inter-observer reliability in environmental waste surveys. The aim of this study was to assess inter-observer reliability for a set of environmental waste indicators derived from transect surveys in slum areas of two sub-Saharan African cities. Pairs of observers independently recorded counts of scattered waste items, large waste piles, and burnt waste along 64 environmental transects in Kisumu, Kenya, and Greater Accra, Ghana. Concordance correlation coefficients were used to measure inter-observer reliability for derived indicators measuring mismanaged waste density, waste composition, waste origins of policy concern, and waste disposal practices. Evidence across all observers consistently showed that single-use disposable diapers, discarded Personal Protective Equipment, and bagged or bottled water are locally important constituents of mismanaged waste in both cities that should be addressed through urban waste management strategies. In both cities, there was generally excellent inter-observer reliability for density of burnt waste and density of large waste piles (concordance correlation coefficient > 0.9 for all but one observer pair), but weak to moderate inter-observer reliability for scattered waste density and densities of specific waste items such as disposable nappies and discarded Personal Protective Equipment. Our study shows that beach litter survey protocols can be adapted for use in slums. However, to generate robust estimates of scattered waste, its composition, and waste origins of policy concern in slums, assessment of inter-observer reliability should be incorporated into field team training.

Background Dams provide water for industrial, agricultural, and domestic use, particularly in arid regions. However, controlled dam releases due to heavy rainfall may affect downstream communities’ livelihoods and life courses such long-term impacts may be omitted from damage and loss assessments. This study aims to assess the lived experiences and long-term consequences of dam release flooding for downstream populations, comparing these with the typical scope of a damage and loss assessment (DaLA). Methods This research was conducted in two flood-prone districts in the White Volta basin, Ghana, subject to dam spillage. Four Focus Group Discussions (FGDs) with community opinion headers, household heads, chiefs, local politicians, and institutional staff were conducted and analysed, alongside semi-structured interviews with twelve opinion leaders and disaster-related institutions. Results Flood-affected communities struggled to attract partners for marriage due to stigmatisation from flooding impacts. Women outside flooded areas rejected male members’ marriage proposals, while communities offered young girls for marriage to wealthy men for greater financial security. Out-migration of female members to seek better livelihoods frequently led to divorce, subsequently affecting children’s education and well-being. Participants reported long-term trauma from flood-related contact with dangerous wildlife, travel disruption, disease risk, livelihood loss, and accidents. Such life course events and long-term trauma would be omitted from a DaLA exercise. Conclusion Beyond its immediate impacts, flooding undermines family relationships and marriage, impairing children’s education and traumatises affected communities. We recommend livelihood diversification programmes, psychological support and family counselling to address these long-term impacts, with expansion of DaLA’s scope to underpin such support.

Mismanaged disposable diaper (DD) waste is widespread in many African cities. Proposed policy responses range from free DD provision to outright bans. However, African studies examining DD consumption, disposal, and benefits are scarce. This cross-sectional study aimed to assess socio-economic variation in DD consumption, inappropriate DD disposal, and perceived benefits for children's carers. A survey interviewing 440 carers of children aged 0-36 months attending health facilities in Greater Accra, Ghana and Kisumu, Kenya found 95.0 and 94.2% used DD respectively. Median DD consumption in a child's first 36 months was significantly higher in the wealthiest households respectively, compared to the poorest (4,099 versus 2,800 DD and 2,876 versus 1,714 DD, p = 0.015 and <0.001 in Greater Accra and Kisumu, respectively). In Greater Accra, 10.2% of households reported burning, burying, or dumping used DD in latrines or elsewhere, compared to 30.5% in Kisumu. Carers in all wealth quintiles consistently cited DD's convenience and hygiene benefits. This confirms widespread DD consumption among rich and poor households, posing disposal challenges for those lacking waste collection services. Given DD's likely time-saving and reported convenience benefits for children's carers, we recommend waste management programmes that separate DDs for safe disposal as opposed to outright bans.

Disposable diaper use is widespread in many low- and middle-income countries whilst waste collection services are scarce. Despite the potential environmental and public health impacts of disposable diaper consumption by households lacking waste services, an international system for monitoring such consumption is lacking. This study therefore aims to develop and evaluate a method for estimating disposable diaper use based on secondary data, specifically nationally representative household expenditure surveys. Disposable diaper expenditure reported via household expenditure surveys for Nigeria (from 2018–19), Kenya (2015–16) and Ghana (2016–17) was used to estimate national disposable diaper consumption among households lacking waste collection services. To assess plausibility of reported expenditure, consumption-smoothing was examined, and Receiver Operating Curve analysis was used to infer mean toilet-training age. In Ghana, Kenya and Nigeria, households lacking appropriately managed waste services consumed an estimated 19 million, 210 million and 285 million disposable diapers per year (292 child/year, 433 child/year and 59 child/year among nappy-consuming households), respectively. Mean toilet-training ages were 24 to 30 months. Disposable diaper purchasing patterns showed evidence of consumption-smoothing among poorer households. Where commodity coding allows, household expenditure surveys can be used to construct internationally comparable indicators depicting disposable diaper consumption among households lacking waste services. Such indicators could be used to advocate for accelerated diaper product innovation, and target areas with high disposable diaper consumption but low waste service coverage.

Studies have reported widespread disposable diaper (DD) consumption in parts of urban Africa, increasing municipal waste generation and with mismanaged DD waste impacting water quality. However, the DD manufacturing and distribution systems behind this trend are little studied, yet understanding these underlying systems is critical in informing efforts to promote extended producer responsibility. This study therefore aims to assess DD brand preferences and trends in international trade in absorbent hygiene products in two case study Sub-Saharan countries. A cross-sectional survey was undertaken of 440 carers of children aged 0-36 months attending health facilities in Greater Accra, Ghana and Kisumu, Kenya. Survey analysis was supplemented by analysis of international trade in absorbent hygiene products for both countries from 2000-2021. Trade data showed DD imports to Ghana and Kenya increased from 2000-17 particularly from China, but declined thereafter. This coincided with Chinese foreign direct investment establishing DD production facilities within both countries in 2018-19, and increased DD exports from Kenya and Ghana to surrounding countries. Meanwhile, 93.0% and 94.2% of survey respondents in Greater Accra and Kisumu respectively reported using DD. In Greater Accra and Kisumu respectively, 62.4% and 45.3% of survey participants reported using the brand produced by these new domestic manufacturing facilities, with 29.8% and 40.9% using imported brands. In Greater Accra, approximately half of reported imported brands were unregistered with the regulator. Given its market dominance, we therefore recommend engagement with the leading manufacturer to identify product or waste management innovations to address water pollution from DD waste. We also recommend similar engagement with imported brand manufacturers and greater DD import regulation in Ghana, given lack of imported brand registration.

Water, Sanitation and Hygiene (WASH) are commonly grouped for service delivery planning, monitoring and policy, reflecting their many interconnecting impacts, but few studies articulate household-level WASH-solid waste interactions. We aim to assess mismanaged solid waste interactions with WASH that affect urban households and whether integrated waste-WASH indicators can be constructed to monitor these interactions. Via literature review, we identify three trade-offs and seven synergies between WASH and waste management for urban households. Trade-offs arise from consumption of water packaged in bottles or bags and disposable diapers (DDs), whilst synergies include opportunities for households with water services to wash separated waste or cloth diapers. One trade-off (packaged water consumption) has grown rapidly in southeast Asia and West Africa. Household surveys for Ghana and Kenya demonstrate that the urban population lacking waste collection services overlaps strongly with those lacking WASH services. In Kenya, 3.3 million people simultaneously lacked waste collection, hygiene, and basic sanitation services. Finally, we construct indicators from household survey micro-data to measure DD and packaged water consumption in households lacking waste services. Case studies show that from 2012-13 to 2016-17, packaged water consumption grew among Ghanaian households burning or dumping waste, whilst most urban Nigerian households consuming DD lack waste collection services. We conclude that household survey micro-data can be used to construct trade-off measures to inform policy and target services towards populations simultaneously exposed to uncollected waste and lacking WASH services. However, such analyses require an institutional mechanism to coordinate cross-goal monitoring and greater survey data harmonisation. In countries where large populations lack both waste collection and WASH services or with growing DD or packaged water consumption, balanced evidence is needed on DD and packaged water’s impacts from both WASH and solid waste management perspectives.

UN-Habitat estimates that 51.3% of the urban population in sub-Saharan Africa (SSA) resided in slums in 2020, and future projections indicate continued growth. However, limited information on the spatial distribution and evolution of slums in the region underestimates the challenges they present. This study investigates the use of urban morphology to map slums in 95 cities across Nigeria, Kenya, Ghana, and Malawi. The approach employed an unsupervised classification and a tree-based clustering framework, integrating morphological and socio-economic indicators, as well as comprehensive sampling points for slums. Our findings indicate that morphological clusters with compact, small buildings are indicative of a high prevalence of slums, with an accuracy rate of 83.6%. Moreover, these morphological slum clusters exhibit significant correlations with socio-economic indicators, exhibiting lower GDP and wealth index compared to neighbouring clusters. Notably, larger and older slums demonstrate improved economic well-being and enhanced infrastructures services. Our findings underscore the potential of utilizing urban morphology to comprehend the diversity and dynamics of urban slums and socioeconomic development. These results provide a foundation for large-scale identification of slums and urban deprivation, offering support for targeted solutions to address the challenges associated with slums in developing countries.

Among other focus areas, the global Sustainable Development Goals (SDGs) 3 and 11 seek to advance progress toward universal coverage of maternal, neonatal, and child health (MNCH) services and access to safe and affordable housing and basic services by 2030. Governments and development agencies have historically neglected the health and well-being associated with living in urban slums across major capital cities in sub-Saharan Africa since health policies and programs have tended to focus on people living in rural communities. This study assessed the trends and compared inequities in MNCH service utilization between slum and non-slum districts in the Greater Accra region of Ghana. It analyzed information from 29 districts using monthly time-series Health Management Information System (HMIS) data on MNCH service utilization between January 2018 and December 2021. Multivariable quantile regression models with robust standard errors were used to quantify the impact of urban slum residence on MNCH service utilization. We assessed the inequality of MNCH coverage indicators between slum and non-slum districts using the Gini index with bootstrapped standard errors and the generalized Lorenz curve. The results indicate that rates of vaccination coverage and antenatal care (ANC) attendance have declined significantly in slum districts compared to those in non-slum districts. However, skilled birth delivery and postnatal care (PNC) were found to be higher in urban slum areas compared to those in non-urban slum areas. To help achieve the SDGs’ targets, it is important for the government of Ghana and other relevant stakeholders to prioritize the implementation of effective policies, programs, and interventions that will improve access to and utilization of ANC and immunization services among urban slum dwellers.

Objectives To investigate how the quality of maternal health services and travel times to health facilities affect birthing service utilisation in Eastern Region, Ghana. Design The study is a cross-sectional spatial interaction analysis of birth service utilisation patterns. Routine birth data were spatially linked to quality care, service demand and travel time data. Setting 131 Health facilities (public, private and faith-based) in 33 districts in Eastern Region, Ghana. Participants Women who gave birth in health facilities in the Eastern Region, Ghana in 2017. Outcome measures The count of women giving birth, the quality of birthing care services and the geographic coverage of birthing care services. Results As travel time from women’s place of residence to the health facility increased up to two2 hours, the utilisation rate markedly decreased. Higher quality of maternal health services haves a larger, positive effect on utilisation rates than service proximity. The quality of maternal health services was higher in hospitals than in primary care facilities. Most women (88.6%) travelling via mechanised transport were within two2 hours of any birthing service. The majority (56.2%) of women were beyond the two2 -hour threshold of critical comprehensive emergency obstetric and newborn care (CEmONC) services. Few CEmONC services were in urban centres, disadvantaging rural populations. Conclusions To increase birthing service utilisation in Ghana, higher quality health facilities should be located closer to women, particularly in rural areas. Beyond Ghana, routinely collected birth records could be used to understand the interaction of service proximity and quality.

Roads have major impacts on wildlife, and the most direct negative effect is through deadly collisions with vehicles, i.e., roadkill. Amphibians are the most frequently road-killed animal group. Due to the significant differences between urban and rural environments, the potential urban-rural differences in factors driving amphibian roadkill risks should be incorporated into the planning of mitigation measures. Drawing on a citizen-collected roadkill dataset from Taiwan island, we present a MaxEnt based modelling analysis to examine potential urban-rural differences in landscape features and environmental factors associated with amphibian road mortality. By incorporating with the Global Human Settlement Layer Settlement Model—an ancillary human settlement dataset divided by built-up area and population density—amphibian roadkill data were divided into urban and rural data sets, and then used to create separate models for urban and rural areas. Model diagnostics suggested good performance (all AUCs > 0.8) of both urban and rural models. Multiple variable importance evaluations revealed significant differences between urban and rural areas. The importance of environmental variables was evaluated based on percent contribution, permutation importance and the Jackknife test. According to the overall results, road density was found to be important in explaining the amphibian roadkill in rural areas, whilst precipitation of warmest quarter was found to best explain the amphibian roadkill in the urban context. The method and outputs illustrated in this study can be useful tools to better understand amphibian road mortality in urban and rural environments and to inform mitigation assessment and conservation planning.