Access to safe drinking water, sanitation, and under 5 diarrhea morbidity in South Africa


Background: Universal access to safe drinking water and improved sanitation are paramount sustainable development goals. This is critical for overcoming several health challenges in developing countries. This study analyzed access to safe drinking water and sanitation in relation to diarrhea morbidity among children younger than 5 years in South Africa. Methods: The data were collected by Statistics South Africa during the 2014 General Household Survey and were analyzed using Probit regression. Results: Results showed that majority of the children from this study lived in houses, who access improved drinking water and sanitation, although only 29.68% of households paid for safe drinking water. Lack of water for washing hands was reported by 12.41%, while diarrhea was most prevalent among 1-year-old children (3.34%). Probit regression results showed that air and water pollution significantly increased diarrhea morbidity (P < 0.10), while it reduced with the child’s age. Conclusion: It was concluded that addressing the problems of air and water pollution would reduce diarrhea morbidity among children younger than 5 years.

Keywords: Drinking water, diarrhea morbidity, under 5 children, sanitation, South Africa

How to cite this article:
Oyekale AS. Access to safe drinking water, sanitation, and under 5 diarrhea morbidity in South Africa. Ann Trop Med Public Health 2017;10:187-93


How to cite this URL:
Oyekale AS. Access to safe drinking water, sanitation, and under 5 diarrhea morbidity in South Africa. Ann Trop Med Public Health [serial online] 2017 [cited 2017 Jul 15];10:187-93. Available from:



The war against some diseases ravaging human dignity in developing countries can never be won without adequate access to improved drinking water and sanitation.[1] This emphasizes the premise upon which, in July 2010, access to clean and safe drinking water and improved sanitation was declared by the United Nations General Assembly as one of the fundamental human rights that every citizen should fully enjoy.[2]Although poverty is one of the major access barriers in many African countries, sustainable economic growth and development will equally be pragmatically compromised and substantively illusive without them.[3] This underscores the fact that development efforts targeting poor and deprived households that could not individually afford provision of improved drinking water and sanitation are acceptable, not only for the fulfillment of human rights, but a vital indicator for economic growth and development of a nation.[4]

Some statistical estimations have revealed that, in 2002, 42% of the global population (2.6 billion people) and 17% (1.1 billion) were deprived of improved sanitation and improved drinking water, respectively.[5] In 2011, WHO and United Nations Children Funds estimated that more than 750 million people worldwide were without access to safe drinking water, while about 185 million of these people persistently consumed surface waters from rivers, streams, and other unimproved sources.[6] Recent estimates however indicated that although the set target for Millennium Development Goal (MDG) for water was met since 2010, in 2015, 663 million people still depended on drinking water from unsafe sources, while 2.4 billion used unimproved sanitation.[7] However, sub-Saharan African countries lagged behind from most of the other regions with 328 million and 567 million people lacking access to improved drinking water and sanitation, respectively, in 2008.[4],[8] Moreover, although households in rural areas are more deprived, at the end of 2015, 68.0% of the households from sub-Saharan Africa had access to improved drinking water, while only 30.0% used improved sanitation.[7] These statistics imply that 319 million and 695 million people lacked access to improved drinking water and sanitation, respectively.[9]

It should be emphasized that although many outstanding progresses were recorded in the MDGs targets at the end of 2015,[10] the fight against poverty, ill health, and preventable mortality had been taken to the next level in the sustainable development goals. The reiterated emphases on ensuring healthy lives and promoting well-being for all ages and sustainable provision of water and sanitation for all citizens as the third and six goals, respectively,[11] obviously reflect persistent commitment of the international communities and policy makers to jointly address preventable deaths and poverty decadence in all facets of life and in whichever form. If the set targets are achieved, it is expected that the number of people, especially children, dying from diarrhea morbidity and other water-related diseases would reduce significantly.[5]

Policy makers cannot ignore the calls to reduce child mortality because successes achieved thereby underscore a fundamental economic development indicator and sufficient condition for poverty reduction.[12]More specifically, the duo of unimproved water and sanitation are direct phenomena within poor and socioeconomically deprived households.[13] This cannot be overemphasized given that globally diarrhea accounts for between 15% and 16% of childhood mortality and takes the second position in ranking only after pneumonia.[8],[14],[15] Statistics has also shown that 2.5 billion diarrhea cases are annually recorded among children under the age of 5, with more than 50% of these cases solely reported from Africa and South Asia.[16],[17] Some other facts indicated that in Africa high rate of mortality that is directly associated with diarrhea and other contaminations from water sources accounts for about 85% of the total disease burdens.[18]

During the past two decades, South African government has recorded significant strides in increasing the proportion of the population with access to improved drinking water and sanitation. Specifically, with less than 50% of the population having access to improved sanitation in 1994, the newly elected democratic government inherited an appalling environmental situation, and the black populations were seriously deprived programs for ensuring improved access to basic social services in South Africa since 1994 yielded the desired results with 90% of the household having access to safe drinking water in 2013, while coverage of improved sanitation was 79.5% in 2014.[15] Obviously, in terms of performance, among her peers in other parts of Africa, South Africa rates among top performing countries.[4]

This impressive performance not with standing, the pace of winning battle over water-borne diseases in South Africa remains slow, given that MDG targets on safe drinking water and sanitation were achieved in 2005 and 2008, respectively.[4] The collective action and constitutional mandate of ensuring “a long and healthy life for all South Africans” seems to be elusive in the light of some health challenges facing the country. WHO reported that given that environment-related factors account for about 16% of deaths in South Africa with estimated 69 disability-adjusted life-years (DALYs) per 1 000 persons,[19] the magnitude of environmental burden of diseases in South Africa cannot be overemphasized. Specifically, in 2004, estimated incidence of diarrhea among children under the age of 5 was 128.7 out of 1000, with KwaZulu Natal province having the highest burden of 244.2 of 1000.[5] It had been further estimated that diarrhea remains one of the most common five diseases among South African children, accounting for 16% and 20% of infant and all child deaths in 1995.[20] The objective of this article is to descriptively access provincial incidences of diarrhea among different age groups and determine the effects of access to safe drinking water and improved sanitation on diarrhea morbidity.

Material and Methods

Data and Sampling Procedures

The data used for this study were collected by Statistics South Africa (Stats SA) in 2014 as the General Household Survey (Statistics South Africa, 2014). The survey annually probes into different aspects of households economic and social activities in order to understand where interventions and policies are needed. The sampling procedure for the survey was presented by Stats SA.[21] It was indicated that data collection was implemented with multistage stratified design such that proportional probability was assigned to each of the primary sampling units during the first stage and systematic sampling of the dwelling units at the second stage. After a month long interview, 25,363 households completed the survey. Also, individuals in the households were interviewed. In all, data were obtained from 92,459 individuals of which 9626 were children under 5 years of age, who were participants of this study.

Estimated Model

Probit model was used for data analysis given that the dependent variable is binary with one (1) for children with reported diarrhea and zero (0) otherwise. Bradshaw et al.[22] noted that the estimated model can be specified with F(x′α) defined as the cumulative density function of a standard normal distribution.

The predictive probabilities are limited between 0 and 1 and the maximum likelihood estimation methods are use to estimate the parameters. It is important to compute the marginal parameters that are estimated as the average of the individual marginal effects on the probability of the event occurring. This can be specified as


[Table 1] shows the descriptive statistics of children’s demographic characteristics and their households’ access to safe drinking water and sanitation. The results show that average age of children was approximately 2 years while 46.16% of the household heads were men. The average age of the household heads was 49.42 years and average household size was 6.35. Access to improved toilet was reported for 93.40% of the children’s households, while 12.20% shared toilets. Also, 88.85% indicated that there was access to clean water. The proportion of the children’s households that treated water before drinking was 3.73% while 67.85% indicated that water was in the residence. The proportion of the children’s households that indicated water pollution and air pollution in their communities were 18.31% and 20.17%, respectively. Average asset index was -0.3766 with standard deviation of 0.4671.

Table 1: Descriptive statistics of children’s and households’ variables

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[Table 2] shows the distribution of water and sanitation problems within children’s households. It reveals that more than 87% of the respondents considered the water to be safe for drinking, clear without any odor, good in taste, and free from smell. However, only 29.68% indicated to be paying for water services while 45.90% had their water supply interrupted. The problems associated with sanitation within children’s households are also presented in [Table 2]. It reveals that absence of tap or water to wash hands had the highest percentage (12.41%). This is followed by poor lighting and unsafe to use due to assaults with 10.12% and 10.21%, respectively.

Table 2: Water and sanitation associated problems in under 5 children’s households

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[Table 3] shows the distribution of households across reported incidence of diarrhea. It reveals that 3.45% of the children from rural formal areas reported diarrhea in the previous 3 months of data collection. The table also shows that in terms of frequencies, children from urban formal and tribal areas reported the highest values of 4321 and 4320, respectively, with 2.68% and 2.11% reporting diarrhea. In addition, majority of the children (85.92%) belonged to the African black population, while 9.91% were colored. Also, 50.64% and 49.36% of the children were boys and girls, respectively, with 2.46% and 2.36% reporting diarrhea. The children were almost equally distributed across the age groups, although children age 1 and 2 years reported the highest incidence of diarrhea with 3.34% and 2.83%, respectively.

Table 3: Incidence of diarrhea across children’s socioeconomic groups

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[Table 4] presents the results of Probit regression on the effect of access to safe drinking water, sanitation, and other socioeconomic and environmental factors on incidence of diarrhea among children under 5 in South Africa. The estimated model produced a good fit of the data given that the likelihood ratio χ2 statistics shows statistical significance (P < 0.01). The variables that showed statistical significance (P < 0.10) are Eastern Cape, Northern Cape, Free State, Mpumalanga, clean water, water pollution in the community, air pollution in the community, perception that the water is clean, age of child, and water in residence. Compared with the children from Limpopo/Gauteng, probability of a child reporting diarrhea is significantly higher in Northern Cape, Eastern Cape Mpumalanga, and Free State given that other factors are held constant. Age of the child is with negative sign and implies that probability of reporting diarrhea decreases as the age of child increases. The parameters of access to improved water and water in residence did not have the expected negative sign while access to sanitation did not show statistical significance (P > 0.10). However, air pollution and water pollution have positive signs showing that children who were from households that reported those problems have significantly higher probability of being sick as a result of diarrhea. The parameter of household size also indicated that child’s probability of reporting diarrhea reduced as household size increased.

Table 4: Probit regression results of factors influencing diarrhea morbidity among under 5 children

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The results indicated a very impressive coverage of improved toilet and safe drinking water in South Africa. This obviously reflects positive impacts from efforts already made by South African government in achieving the set goal of ensuring universal access by the end of 2014.[4],[23],[24] It is important to note that only 29.68% of the children’s households were paying for water services. This raises important question of sustainability given that many of the South African water resources were not generating income for the government. Specifically, it was reported that in a survey conducted by the Department of Water and Sanitation, income was not realized from 37% of the municipal water. It was noted that ineffectiveness of the water revenue generating system that is rooted in some cultural issues can hamper sustainable water provision in the future. This should be emphasized given that a study indicated that 65% of national water infrastructure was functioning optimally while Limpopo and Mpumalanga had lower figures of 40% and 39%, respectively.[25] Specifically, concerns for future service delivery can be raised given that the results indicated that 45.90% households had their water supply interrupted.

Moreover, reported diarrhea morbidity was highest among children from rural and urban formal areas with 3.45% and 2.68%, respectively. In South Africa, households in rural areas generally have lower access to safe drinking water and improved sanitation.[23] The results also revealed that children from urban formal and tribal areas reported the highest incidence of diarrhea morbidity with 2.68% and 2.11%, respectively. Siziya et al.[26] noted that persistent poverty in rural areas is able to affect hygienic practices, which are crucial for reducing incidence of diarrhea. Choi[27] submitted that deplorable environmental conditions in which some black South Africans live may lead to higher incidence of diarrhea.Siziya et al.[27] also found that residence in rural area was associated with diarrhea morbidity in Sudan. Similar findings had been reported from Egypt.[28]

Provincially, compared with Gauteng, children from Eastern Cape, Northern Cape, and Mpumalanga had significantly higher probabilities of reporting diarrhea. In a previous study, Choi[28] submitted that due to subtropical climatic factor that facilitate water pollution in the summer, higher incidence of diarrhea had been reported in KwaZulu-Natal and Mpumalanga. Therefore, water treatment becomes very critical when the water source is unsafe for direct consumption. However, the results show that only few proportion of the children’s households (3.73%) were treating water before drinking. However, water and air pollution pose serious threats to safety and health of some households in South Africa with affected population being 18.31% and 20.17%, respectively. Also, exposure of the community to water and air pollution increased the probability of child having diarrhea. Water pollution often results from waste water treatment damages; solid waste accumulation; industrial activities; and mining, agricultural production activities, among others (Republic of South Africa, undated). When households are not well informed, clean water that contains some disease causing pathogens are veritable sources of diseases source as cholera, diarrhea, dysentery, and bilharzias. This becomes critical given that historical record of water cleanliness will not make user to purify it when it is polluted. Similarly, air pollution can add to this problem via conveyance of air-borne pathogens.

Beside the problems that are associated with supply of safe drinking water, inability to get adequate place for hand washing and lack of water were among the major problems associated with sanitation. Obviously, persistence of this problem will undermine the sanity expected of standard toilet because individuals cannot properly get rid of some disease-causing pathogens when water is not available for washing hands.

Also, male children had slightly higher incidence of diarrhea with 2.46% as against 2.36% for female. Some previous studies had reported similar findings,[26]although this contradicts that of el Samani et al.[30] Also, children age 1 and 2 years had the highest incidence of diarrhea with 3.34% and 2.83%, respectively. The probability of having diarrhea also significantly decreases as the age of the children increases. Khatab and Fahrmeir[31] submitted that age of the children can influence morbidity through immunization, which children are expected to have completed by the time they are turning 1 year. The implication is that older children would have completed these immunizations and their immune systems may be stronger than those of younger kids. In addition, less diarrhea morbidity for older children may be explained from the weaning crisis. Conventionally, children are expected to be breast-fed for the first 6 months. The first few months after weaning may be challenging as children change diets. Khatab and Fahrmeir also found persistent decline in the health status of children till they reach 11 months beyond which there were nonlinear decline thereafter.


The global initiative to ensure adequate availability of safe drinking water and improved sanitation for all people is now recognized as one of the fundamental rights of man. South African government had taken significant initiatives to ensure progress form what the situation was in 1994 which marked the end of apartheid government. The results in this study have underscored the need to reevaluate the primary channels of diarrhea infection among under 5 children. This becomes very critical given that availability of safe drinking water and sanitation variables did not give the expected results. However, efforts to reduce water and air pollution hold significant prospects in reducing diarrhea morbidity among children under 5. In addition, interventions to address diarrhea must give preferences to provinces with high infection risks, while children under 2 years of age should be prioritized for some important immune building immunization.


The author is grateful to the Statistics South Africa for granting the permission to use their dataset for this study.

Ethics approval and consent to participate

The data were collected by Statistical South Africa as annual data for evaluating socioeconomic development in the country. All ethical requirements were met and participation was voluntary.

Consent for publication

The author hereby gives the consent to publication to the journal. This article is not under consideration in any other journal.

“Users may apply or process this data, provided Statistics South Africa (Stats SA) is acknowledged as the original source of the data; that it is specified that the application and/or analysis is the result of the user’s independent processing of the data; and that neither the basic data nor any reprocessed version or application thereof may be sold or offered for sale in any form whatsoever without prior permission from Stats SA”.

Availability of data and materials

The data used for this study are available from the author and can as well be requested from Statistics South Africa (

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.



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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.205585

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