Urban water, sanitation, and hygiene service gaps in Ethiopia: Potential public health risks and policy implications

Objectives The objective of this study is to investigate urban Water, Sanitation and Hygiene (WASH) service gaps, their socio-demographic determinants, and public health and policy implications in Ethiopia Study design Cross-sectional mixed methods study design was conducted. Methods A survey of 384 purposively selected urban households across 16 cities in eight regions and one city administration was conducted using multi-stage stratified sampling. Data was collected via structured questionnaires, 38 institutional surveys of water utilities, 25 key informant interviews, and 70 focus group discussions. Quantitative data were analysed with descriptive statistics, chi-square tests, and binary logistic regression (SPSS v25); qualitative data underwent thematic analysis with methodological triangulation. Results Although 87.8% of households used piped water, 71.2% faced access barriers, 71.4% experienced intermittent supply, and 48.7% consumed <20 L/capita/day. Sanitation relied on pit latrines (80.3%), but 62.4% had never been emptied. Only 26.9% of households had both water and soap at handwashing stations. Significant associations existed between household tenure and sanitation quality (χ 2 = 14.82, p = 0.001), gender and hygiene access (p = 0.013), education and handwashing facilities (OR 2.32, 95% CI 1.52–3.54, p < 0.001), and female-headed households and handwashing (OR 1.66, 95% CI 1.10–2.51, p = 0.015). Conclusions Urban WASH failures exacerbate water-washed and fecal-oral disease risks and violate constitutional rights to a clean environment. Strengthened infrastructure, equitable service delivery to informal settlements, fecal-sludge management, and hygiene subsidies are urgently required.