Beyond access: WASH, public health, and sustainable development priorities in Africa—a narrative review

BACKGROUND: Water, sanitation, and hygiene [WASH] are core determinants of public health, health equity, and sustainable development in Africa. Despite progress in service coverage, major gaps persist in safety, reliability, affordability, quality, and sustainability. However, evidence remains fragmented on how these challenges collectively affect public health and sustainable development across African settings. AIM: This narrative review synthesizes current evidence to address fragmented knowledge on how these challenges influence public health and sustainable development across African settings. METHODS: A narrative review was conducted using peer-reviewed articles, reviews, global health reports, policy documents, and technical resources identified through PubMed, Scopus, Web of Science, Google Scholar, WHO, UNICEF, UN-Water, and WaterAid. Evidence was synthesized thematically across five domains: WASH inequalities, public health burden, social and system-level barriers, governance and infrastructure sustainability, and evidence-based priorities. RESULTS: WASH inequalities extend beyond service coverage to include deficiencies in safety, reliability, affordability, and sustainability. Unsafe water, inadequate sanitation, and poor hygiene remain major contributors to preventable disease and health-system vulnerability. Persistent social, behavioral, and system-level barriers, along with governance, financing, infrastructure maintenance, and climate vulnerability, hinder sustainable improvements in WASH. Strengthening governance, resilient infrastructure, community participation, and multisectoral collaboration emerged as key priorities for improving public health and sustainable development. CONCLUSIONS: Africa's WASH agenda must move beyond access toward safe, reliable, equitable, climate-resilient, and sustainable services. Integrated WASH action can reduce preventable disease, protect vulnerable populations, strengthen health-system resilience, and accelerate progress toward the Sustainable Development Goals.