Increasing frequency and intensity of extreme weather events (EWEs) threaten healthcare services globally, with particularly acute risks in low-resource settings. While health system resilience is widely discussed, there is limited empirical evidence on how it is enacted in practice across complex, real-world systems, particularly beyond infectious disease contexts. We analysed 18 case studies from diverse global contexts, examining how EWEs affected four interrelated system levels: healthcare facilities, local health systems, communities, and interconnected infrastructures. We applied fuzzy-set Qualitative Comparative Analysis (fsQCA) to identify configurations of vulnerability, adaptive capacity, and external support associated with two outcomes: service continuity and healthcare facility recovery. Four distinct resilience pathways were identified. These demonstrate that resilience emerges from cross-scale configurations rather than individual system components, with local adaptive capacity playing a key role in maintaining service continuity. Where high vulnerability across multiple system levels exceeded local capacity, resilience depended on external support, which was associated with eventual recovery but not with continuity of services. Across cases, workforce factors—including staff wellbeing, safety, and morale—were critical in shaping system response. This study provides empirical evidence that health system resilience to EWEs is a multi-scalar process. The identified pathways offer practice-based insights for strengthening resilience, highlighting the importance of cross-system coordination, planning for capacity limits and phased operational response escalation, and investing in the health workforce as a central component of effective response and recovery.

Abstract Access to “safe” drinking water is often inferred from single-point measurements or isolated cross-sectional surveys, which do not reflect temporal variability. We examine spatiotemporal variability in Escherichia coli contamination in water systems and evaluate implications for water quality monitoring. Using sequence analysis, a method to evaluate ordered sets of data, we assessed patterns of contamination from longitudinal monitoring of 524 small water supplies (8–12 rounds over 1 year) in Bangladesh, Nepal, and Tanzania. The analysis demonstrated that detectable fecal contamination of drinking water is an intermittent condition rather than a stable condition in up to 95% of small water systems. Isolated cross-sectional surveys underestimated the period prevalence of contaminated sources by factors of 1.4–5. Sampling in wetter weather conditions improved detection of at-risk sources. These findings suggest substantive overestimation of safety in system-specific and national monitoring and assessments of global status and progress toward the Sustainable Development Goals target. For small water systems, we propose a shift to a risk-based operational monitoring approach that prioritizes timing over frequency for efficiency of hazard identification and resource use.

Accurate measurement of sanitation access is essential for tracking progress toward universal sanitation under the Sustainable Development Goals, yet current indicators focus on household-level access and rarely capture how sanitation is used within households or facility quality. We conducted a cross-sectional survey of 36,860 rural households in 14 low- and middle-income countries, assessing differences in open defecation practices among household members and sanitation facility quality. Heads of household reported where adult men, adult women, boys, and girls usually defecated, while enumerators directly observed sanitation facilities. We then developed alternative estimates of sanitation service levels that accounted for these dimensions. Despite access to a sanitation facility, 14.1% of households reported that at least one member practiced open defecation, including 2.9% of households classified as having basic sanitation. Children (12.6%) were more likely than adults (9.2% of men and 8.9% of women) to practice open defecation. Only 2.0% of sanitation facilities met the study's hygiene criteria, largely because 80.1% lacked a nearby handwashing facility with soap and water, 45.4% had visible flies, and 79.9% lacked appropriate anal cleansing materials. Structural deficiencies included cracked or damaged pedestals (26.3%), unusable floors (11.6%), non-functional facilities (5.7%), and lack of privacy (18.8%). Accounting for these factors yielded substantially lower estimates of basic sanitation coverage (2.2%) compared to the standard Joint Monitoring Programme (JMP) classification (31.8%), highlighting a gap between reported access and effective service delivery. Routine collection of disaggregated data on sanitation use and standardized measures of facility quality could improve monitoring of effective sanitation coverage.

Evidence to determine the suitability of water quality standards to prevent illness from recreation exposure in inland waters is limited. We present a secondary analysis of previously unpublished data from four Hungarian freshwater sites included in the Epibathe study, a large randomised controlled trial. A total of 2368 participants were randomly allocated either to bathe for 10 min undertaking at least three head immersions, or to remain on the shoreside without water contact. Concurrent water sampling quantified individual-level faecal indicator organism densities and health outcomes were assessed at one-week follow-up. Generalised estimating equation models quantified the relative risk for adverse health outcomes for bathers versus shoreline-only (non-bather) participants, as well as the change in risk per unit increase in FIO concentration; crude, covariate-adjusted and covariate-adjusted models with multiple imputation are reported. Higher concentrations of Escherichia coli and somatic coliphage were each associated with increased risk of gastrointestinal illness (adj. RR = 1.73; 95% CI 1.13-2.65 and RR = 1.46; 95% CI 1.04-2.04 respectively). Bathing itself, independent of any individual microbial indicator, was associated with increased risk for skin ailments (adj. RR = 2.17; 95% CI 1.55-3.03). Low prevalence of eye, ear or respiratory infections precluded reliable estimation of exposure-response relationships. These findings confirm the value of E. coli and potential of somatic coliphage densities as indicators of freshwater quality relevant to recreation-associated gastrointestinal illness risk. In freshwater settings, E. coli and coliphages appear to be more informative than enterococci as predictors of gastrointestinal illness, contrasting with evidence from marine waters.

Strengthening local government capacity to improve sanitation and other basic services is a challenge in many low resource countries. There is growing interest in peer learning as a mechanism to spread successful practices and increase local government performance in the settings. However, few studies have investigated if peer learning leads to changes in practices and improved results. The study aims to identify and evaluate the causal linkages between peer learning activities and any changes to participants capacity, local government practices and increases in sanitation coverage in rural districts. Contribution Analysis, a theory-based evaluation approach, was used to design a longitudinal study investigating outputs, outcomes and impacts of two peer learning workshops between Open Defecation Free (ODF) Districts and non-ODF Districts in Mozambique alongside the enablers and barriers to change. The research draws on a survey of 66 participants directly after the workshops and 29 semi-structured follow-up interviews nine months later. We found that despite broader structural challenges that hinder progress in sanitation service provision, the workshops enabled the spread of knowledge of good practices (outputs) some of which were replicated (outcomes). There is evidence that these replicated practices accelerated progress towards ODF status (impact) in some districts. We demonstrate that under the right conditions peer learning can nurture local learning, improve knowledge, spread frugal practices and lead to incremental improvements in local government performance. We therefore recommend it be integrated into broader programmes to maximise benefits.

Manganese and iron decrease aesthetic acceptability and chlorine disinfection performance in drinking water, and can be toxic at high doses. We present the first characterization of manganese and iron occurrence in drinking water relative to concentration benchmarks for these three outcomes. Manganese and iron concentrations were evaluated in 261 drinking water samples obtained from boreholes and small groundwater-fed piped systems across large rural regions of Ghana, Mali and Niger. One or both metals exceeded aesthetic benchmark concentrations in 30% of samples and reached concentrations likely to interfere with chlorine disinfection in 5% of samples. Manganese exceeded 2011 WHO health-based benchmarks for drinking water (400 µg/L) in 2% of samples, and exceeded updated provisional health-based benchmark concentrations (80 µg/L) in 13% of samples. Iron occurred at levels exceeding health-based benchmarks in 5% of samples. These results suggest that manganese and iron contribute directly and indirectly to public health problems in a substantive proportion of drinking water sources in the study setting. Implementation of rural drinking water systems reliant on groundwater sources should account for the occurrence of these metals during siting, design, construction, operation, and monitoring/surveillance. Strengthening these capacities, particularly with respect to sampling and testing water sources for these metals, may support management and regulatory efforts to manage the occurrence of these metals in drinking water and their potential adverse effects. Finally, generating and synthesizing additional evidence on the occurrence and effects of iron and manganese in drinking water will support national efforts to manage both contaminants, inform discussions regarding the suitability of current health-based Mn guidelines for protecting sensitive life stages, and underscore the value of monitoring Mn as a priority chemical contaminant under Sustainable Development Goal (SDG) target 6.1: “By 2030, achieve universal and equitable access to safe and affordable drinking water for all.”

Climate change (CC) is altering the working conditions for water suppliers. To enhance preparedness, CC has been emphasised in the risk-based approach (RBA) and water safety planning guidelines. We studied how the RBA approach has been applied in small water supplies in the Nordic countries to mitigate CC related risks and impacts. We interviewed small water supply operators and authorities in each country, followed up by government-level queries on guidelines and legislation. We found that small water supplies have experienced consequential incidents associated with a changing climate. Heavy rains, drought, changes in cold climate hydrology, and landslides were most frequently mentioned. Many of the supplies, however, had not experienced any effects, possibly because groundwater is the main water source for small water supplies in the region. Importantly, the effects of a changing climate were scarcely discussed, and CC receives limited or no attention in governmental guidelines. However, in Norway, the CC preparedness was analysed on a municipal level, and Finland and Sweden have tools for CC preparedness, but separately from the RBA. Small suppliers are concerned about over-burdening with multiple guidelines, frameworks, and tools. Therefore, we conclude that CC would be best addressed through integration into RBA and water safety planning regulation and implementation.

The Syrian civil war displaced more than half of the Syrian population, including over 660,000 registered refugees who fled to neighboring Jordan. Environmental health services (e.g., water, sanitation, hygiene, and solid waste management) are critical for refugee health. Still, they may strain resources in host communities and must evolve in protracted crises. We studied environmental health services in the Azraq refugee camp in Jordan to identify the stakeholders and their roles in service provision, assess stakeholder communication and coordination, and evaluate sustainability. We conducted 25 interviews with stakeholders involved in environmental health service provision. We found that non-governmental and United Nations organizations had well-defined responsibilities, but the roles of donors, the Jordanian government, refugees, and the host community needed clarification. Conflicting standards and mismatched donor expectations with on-the-ground needs sometimes created challenges for coordinated and efficient service provision. The basic needs of refugees were generally met and services improved somewhat over time, but political obstacles and inadequate resources complicated the path toward sustainable services. Early incorporation of sustainability in planning and increased efforts to build the capacity of refugees to contribute and take ownership of environmental health services will likely enhance long-term environmental health service provision and development outcomes.

The European Union Drinking Water Directive aims to protect human health and promote safe water consumption. The 2020 revision, Article 17 in particular, directed member states to provide public access to information on drinking water. This update was a response to citizen initiatives calling for the active participation of end-users in water services and greater transparency from water utilities. Difficulties implementing previous versions of the directive have highlighted divergences between policy purposes, local capacity to implement, and public response. These divergences are explored within eight case studies in Nordic countries and analysed using the policy implementation framework. We employed a mixed-method, multi-stage approach. Policy formulation was characterized through a literature review, policy design by the synthesis of legislative instruments, and policy implementation via an analysis of delivery behaviour based on interviews. We identified the main drivers of the directive's update and contrast these with the ongoing implementation process in the countries of study. Our results point to a differential and highly contextual implementation, which differs from the primary drivers of the policy update, namely, the establishment of public confidence in water services.

Pit latrines are the most common household sanitation system in East African cities. Urbanisation reduces the space available for new latrines to be constructed when pits fill and they increasingly require emptying. But formal services that empty and transport sludge to safe disposal or treatment are often unaffordable to low-income households. Cross-subsidies have been suggested to fund services for low-income households but there are no academic studies assessing this funding mechanism. This study analyses empirical financial and operational data shared by a formal service provider in Kigali, Rwanda who is establishing a cross-subsidy model between corporate and high-income households, and low-income households in informal settlements. A semi-mechanical method is used to serve households which cannot be accessed from the road by an exhauster truck. We find that mechanical emptying is gross profitable when exhauster trucks are fully used, particularly large volume and corporate customers. Transferring sludge between vehicles for efficient transport reduces average cost. Cross-subsidies are found to be a viable funding method and a ten-fold increase in mechanical emptying by the service provider would generate 466,876 Int$ (2022 international dollars) gross profit to fund a cross-subsidy for all low-income households in Kigali which require semi-mechanical emptying. This study highlights the opportunities that city authorities have to organise funding to cross-subsidise emptying for low-income households. In addition, by using data from operational records rather than self-reported estimates the reliability of cost estimates is in improved. Further research is required to understand customer group size, demand and emptying frequencies to determine the structure of a citywide cross-subsidy.

Many forcibly displaced people reside in camps characterised by precarious living conditions, exposing them to numerous health risks. This scoping review elucidated the risk factors and exposure routes implicated in outbreaks of faecal-oral pathogens in camps, as well as the context-specific drivers of transmission that shape these outbreaks. Journal articles were identified from PubMed, Embase, Scopus, and Web of Science. Portals for grey literature were also searched. A total of 48 records, published between 1937 and 2022, were included in the analysis. Cholera outbreaks were the most frequently reported. Risk factors included drinking water from shallow wells and rivers, consuming ice and leftover food, and inconsistent handwashing. These indicate exposure through vehicles of transmission in both public and domestic domains, emphasising the importance of a multipronged approach to outbreak prevention and control. Outbreaks were often exacerbated by extreme weather events and acute population influxes that damage or overwhelm water and sanitation facilities. Such shocks warrant explicit recommendations in preparedness and response guidelines. Development projects and outbreak response measures in surrounding areas may reduce the risk of importing pathogens into camps. Future research could further investigate faecal-oral pathogens other than Vibrio cholerae and analyse the co-occurrence of the identified transmission drivers.

BACKGROUND:In sub-Saharan Africa, rural areas have lower rates of access to safe drinking water compared to urban areas. We investigated predictors of Escherichia coli contamination in drinking water of rural households in Ghana, Malawi, Mozambique, Niger, Rwanda, Uganda, and Zambia. METHODS:We used a population-based, cluster randomized sampling design to select rural households in each country. Household interviews on water access, sanitation, and hygiene (WaSH) practices and demographic characteristics were conducted and water samples from every fifth household were collected and enumerated for E. coli. Negative binomial regression models with survey sampling weights were run to evaluate predictors of E. coli contamination. RESULTS:A total of 18,747 rural household surveys (2,378-2,804 per country) were conducted and a total of 3,848 water samples (460-660 per country) were collected. Of surveyed rural households, 61-78% of households had high (11-100 E. coli cfu/100 mL) or very high (>100 cfu/100 mL) risk water quality in Ghana, Niger, and Uganda. Statistically significant WaSH predictors associated with lower E. coli incidence rates included using an improved-type primary water source (Mozambique), storing water in a narrow-mouthed container or container with a spigot (Niger), having continuous water supply during the dry season (Ghana), paying for water service (Rwanda), having soap or ash at handwashing points (Mozambique), having an improved-type household sanitation facility (Malawi), and attaining an education level greater than primary school (Niger and Zambia). CONCLUSION:This study highlights the variability in WaSH access between rural areas of the study countries in association with microbial drinking water quality.

Shared sanitation facilities have replaced open defecation in many areas, improving sanitation access. Although a broad body of literature has been published regarding the importance of shared sanitation services, it is still unclear how to assess their quality. The objective of this review was to synthesize evidence on the use of shared sanitation facilities in informal settlements and identify indicators for assessing their quality. We conducted a systematic review of relevant studies and a total of 248 studies were included in the final analysis. Findings include a proposed list of indicators for evaluating the quality of shared sanitation such as the number of people sharing facilities, cleanliness, privacy, facility location, accessibility, and safety, and a tool for distinguishing between sanitation facilities that are improved shared, basic shared and unimproved shared. We recommend incorporating the proposed indicators in primary data collection, and routine national and global sanitation monitoring.

The Sustainable Development Goals emphasize coordination and integration between sectors. Solar-powered submersible water pumping systems are versatile technology that help address community drinking water, irrigation, and electricity needs. Stakeholders external to the community, particularly solar photovoltaic experts, are vital in ensuring continued system services; however, there has been no comprehensive assessment of different solar-powered water pumping system support efforts. This review is the first to systematically evaluate external support for solar-powered systems from multiple regions and implementing organizations. We reviewed solar-powered water pumping system literature to identify implemented external support and factors that affect implementation. Publication databases, organization Web sites, and citations were searched. Seventy-four studies were included and evaluated using inductive coding and thematic synthesis. We derived a framework that organized support activities and factors into three nested levels of implementation: system, program, and sector. For support efforts implemented after 2010, most support providers worked at all levels. Each provider type worked at levels aligned with their knowledge and resources and complementary to other providers' work. Drivers of support specific to solar-powered water systems were the existence of solar photovoltaic markets and infrastructure, support providers experienced with solar photovoltaics, and government and community solar advocates. We grouped support factors that study authors associated with system functionality into four categories: location and quality of support, reliability of support arrangements, frequency and timeliness of support, and policy and regulatory environment. No study outlined support for multiple uses of the systems or end-of-lifecycle care of solar panels. Solar-powered water pumping systems provide multiple community services, and their management will be bolstered by support providers collaborating to optimally apply their skill sets and create support plans that comprehensively address system versatility.

Exposure to fecally contaminated drinking water contributes to the global disease burden, especially in sub-Saharan Africa (SSA). We used cross-sectional data and elimination regression analysis to examine factors influencing E. coli contamination in household drinking water samples from 4499 rural households in nine countries in SSA (Malawi, Mozambique, and Zambia in Southern Africa; Ghana, Mali, and Niger in Western Africa; and Kenya, Rwanda, and Tanzania in Eastern Africa). The proportion of household water samples containing E. coli was 71%, ranging from 45% (Malawi) to 89% (Tanzania). Pooled and multi-country predictive logistic regression models showed that using an unimproved-type water source, the absence of a community water committee, and domestic animal ownership were significantly associated with household drinking water contamination. Household water treatment and storage practices, sanitation and hygiene practices, and payment for drinking water were not significantly associated with E. coli contamination in any model. The season was a significant predictor of E. coli in the pooled model; samples collected in the rainy season were 2.3 [2.0, 2.7] times as likely to be contaminated with E. coli. Practitioners and policymakers should prioritize implementing piped on-plot water services, establishing effective local water source management structures, and incorporating animal husbandry practices into water, sanitation, and hygiene interventions.

Universal access to safely managed drinking water (SMDW) is important for human health, well-being, and development. It is reflected in Sustainable Development Goal (SDG) 6. In rural areas of low- and middle-income countries, 1.9 billion people lack access to SMDW. Multiple water source use and seasonal source switching may negate health and development gains from SMDW. Hence, achieving SDG 6 requires a better understanding of how these factors relate to household service levels. We explored this using data from 37,105 household surveys and 6,395 household drinking water samples collected from rural areas of 14 low- and middle-income countries (Ethiopia, Ghana, Honduras, India, Kenya, Malawi, Mali, Mozambique, Niger, Rwanda, Tanzania, Uganda, Zambia, Zimbabwe). A different primary water source was used in the rainy and dry seasons by 10% of households; seasonal source switching was most common in Kenyan households (29%) and least common in Zambian households (3%). Twenty-three percent of households used a secondary water source, and 37% of these secondary sources were unimproved (e.g., unprotected dug wells and surface water). Sixty-nine percent of household water samples contained E. coli. In 11 of 14 countries studied, fecally contaminated water was the water service parameter preventing households from having SMDW free from fecal contamination at the point of use. Overall, 7% of households had access to SMDW free from contamination at the point of use. Our results confirm that the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation, and Hygiene (JMP) substantively overstate the population benefiting from safely managed drinking water, and their reporting statistics should be interpreted with caution. Seasonal source switching and secondary water source use have an important influence in some countries and should be accounted for in monitoring and programming activities.

Outdoor food markets represent important locations where foodborne illnesses and other infectious diseases can spread. Countries in Africa face particular challenges given the importance of these markets in food supply and low rates of access to safely managed water and sanitation. We undertook a scoping review of evidence related to disease transmission in food markets in sub-Saharan Africa, North Africa and identified 46 papers for data extraction and synthesis. Vendor behaviour or awareness was reported in the majority of papers and about half reported on market infrastructure. Fewer studies have been reported on regulatory environments or food contamination. Studies on water supply, sanitation and handwashing facilities focused on the presence of services and did not evaluate quality, thus conclusions cannot be drawn on service adequacy. Studies of vendor behaviour were primarily based on self-reporting and subject to bias. Most studies reported high levels of vendor awareness of the need for hygiene, but where observations were also conducted, these showed lower levels of behaviours in practice. Our findings suggest that there are limited studies on environmental hygiene in outdoor food markets and this is an area warranting further research, including into the quality of services and addressing methodological weaknesses.

In 2021, Nigeria witnessed a severe cholera outbreak that affected Borno state, in which more than 1,600,000 internally displaced persons (IDPs) resided at the time. This rapid appraisal explored factors that facilitate the recurrence of cholera outbreaks in sites hosting IDPs in Northeast Nigeria. Semi-structured interviews were conducted with water, sanitation, and hygiene (WASH), management, and healthcare personnel working in 10 displacement camps in Borno state. The interviews were complemented by transect walks and field observations, measurements of free residual chlorine levels, and publicly available data published by the International Organization for Migration Displacement Tracking Matrix. The recurrence of cholera outbreaks appears to be facilitated by substantial interactions between IDPs and host communities, and suboptimal WASH services in camps. Of particular concern, IDP camps are exposed to extreme weather-related events that damage facilities and subsequently affect WASH practices. WASH services in camps may likewise be severely hindered by an influx of new arrivals. In conclusion, we emphasize the importance of expanding WASH activities to host communities and developing site-specific WASH interventions and chlorination targets. Practical recommendations are needed for the prevention and control of outbreaks following extreme weather-related events and population influxes.