Published in PLOS One on 2025-12-30, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. HealthSignal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Leonie K. Hyde-Smith, Daniel Ddiba, Sarah Dickin, Domenic Kiogora, Anna L. Mdee, Vanessa Reinfelder, Katy E. Roelich, Barbara Evans
Source: PLOS One • DOI 10.1371/journal.pone.0339272
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
This paper explores the disconnect between policy rhetoric and implementation at the intersection of sanitation equity and climate change in Nairobi, Kenya. To examine the current sanitation adaptation trajectory, we reviewed Nairobi’s sanitation policies, planning, and investment frameworks, focusing on their integration with climate adaptation strategies and consideration of equity in terms of distribution, recognition and processes. We used a socio-technical regime framework to map the current sanitation service configurations in Nairobi and projected their future under different climate change scenarios. Our findings provide evidence for a disconnection between policy rhetoric and implementation, prioritising sewerage development at the expense of other sanitation regimes. Despite recognising equity issues in policy, substantive action towards equitable sanitation governance is lacking. This imbalance hinders the realisation of the constitutionally recognised right to adequate sanitation in the foreseeable future. The anticipated impact of climate change on Nairobi’s sanitation sector suggests an exacerbation of existing service inequalities. Our projection indicates that by 2030, a sizeable portion of Nairobi’s residents will experience poor sanitation services. Our study emphasizes the critical need for a fundamental paradigm shift. It calls for a robust and honest discussion on delivering high-quality, resilient sanitation services at scale including both sewer and non-sewered sanitation and necessitating substantial public investment and support for all systems. This reappraisal is imperative for ensuring equitable and sustainable sanitation solutions in the face of climate change.
Background
The 6th Intergovernmental Panel on Climate Change (IPCC) Assessment Report has highlighted that climate change amplifies inequalities and undermines sustainable development across regions [1, p.1174]. Climate change-driven hazards are poised to (adversely) affect urban sanitation systems across the globe [2], requiring adaptation efforts by governments, local authorities, service providers, and households.
Meanwhile, inequitable access to sanitation service provision is still prevalent globally [3–5] and gained heightened attention during the Covid-19 response [6–8]. However, sanitation investments and funding arrangements are biased towards subsidising capital investment and operational costs of centralised sewerage and treatment systems, which often primarily tend to more affluent parts of the population [9–12]. These systemic biases create what we describe as a business-as-usual approach, where the focus on traditional, centralised systems perpetuates inequalities and limits progress towards universal sanitation access.
There is growing recognition that climate-adaptive sanitation infrastructure is non-negotiable for avoiding the risk of reversing progress towards universal access to safe sanitation services [13,14] and thereby worsening inequalities. However, attention to adaptation needs within urban sanitation systems has been limited and primarily focused on technology solutions [15]. Sanitation adaptation is mainly happening in high-income countries, focusing on retrofitting and upgrading old infrastructure approaching the end of its design life [16,17].
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider financing & policy desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2025 Leonie K. Hyde-Smith, Daniel Ddiba, Sarah Dickin, Domenic Kiogora, Anna L. Mdee, Vanessa Reinfelder, Katy E. Roelich, Barbara Evans. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by HealthSignal. The researchers are the authors of the source study, not members of HealthSignal’s staff.
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