Taps And Toilets Aren't Enough: UB Research Brings People's Voices To Water And Sanitation Monitoring

Public health researcher’s work in schools and health care facilities featured in WHO/UNICEF global monitoring reports

Buffalo, NY — Simply because a school or clinic has basic water and sanitation services doesn’t mean the students or patients who depend on them can quench their thirst or have their needs adequately met, notes a University at Buffalo public health researcher.

That gap is highlighted in two recent reports from the World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP). It monitors global progress toward the United Nations Sustainable Development Goal targets for water, sanitation and hygiene (WASH).

The reports feature research led by Joshua Miller, PhD, assistant professor of epidemiology and environmental health in the School of Public Health and Health Professions and a member of UB’s Center for Climate Change and Health Equity.

Miller served as the lead for the School WASH Insecurity Experiences (School-WISE) and Health Care Facility WASH Insecurity Experiences (HCF-WISE) projects. The two multisectoral, international consortiums developed brief surveys that evaluate whether WASH services are accessible, acceptable and adequate for students, patients and staff.

Led by nongovernmental organizations and local research teams, the projects surveyed more than 4,000 people in schools in Ethiopia, Kenya, Mozambique, Nepal, Pakistan, Peru, Rwanda and Uganda and health care facilities in Ghana, Mozambique, Nepal, Pakistan and Uganda.

User-centered measures

Miller, who joined UB in fall 2025, has focused on user-centered measures since 2018, when he served as study coordinator for the multi-site collaboration that created the Household Water Insecurity Experiences (HWISE) Scale. It is one of the Water Insecurity Experiences (WISE) Scales, which have been used by hundreds of organizations in nearly 100 countries.

“Like food insecurity, water insecurity isn’t just about whether a resource exists,” Miller says. “It’s about whether people can reliably get enough to meet their needs. In schools and health care facilities, that extends to sanitation and hygiene.”

The JMP categorizes WASH services in three tiers — basic, limited, or no service. This is based largely on whether infrastructures such as an improved water source, a toilet or a handwashing station with soap are present and working when surveyed.

Miller’s teams pair these facility observations with surveys of people’s experiences. Both of the JMP reports feature the findings as examples of monitoring beyond basic services.

Each draws on data from Mozambique collected with Helvetas, a Swiss development organization. One in four primary school students surveyed said thirst kept them from concentrating in school, and half of health care staff surveyed said areas where patients received care were dirty — gaps with clear consequences for learning and infection control that service data alone would miss.

Looking beyond ‘basic’

The JMP itself notes that basic service falls short of fully realizing the human right to safe WASH services. Household monitoring already looks beyond “basic” to whether services are “safely managed,” and the JMP is now reviewing indicators that could do the same for schools and health care facilities.

“What gets measured gets fixed,” Miller says. “A tap or toilet can be counted on the day of a survey, but that doesn’t mean people can use it when they need to. Seeing our work on experiential measures featured in the JMP reports is exciting because it signals that future investments must focus not only on infrastructure but on people, and it’s a step toward making their experiences part of how progress is measured.”

In Uganda, for example, all 10 schools the team studied met the WHO/UNICEF basic drinking-water standard. Yet nearly 70% of students said they had been thirsty at school with no safe water to drink in the past week, and 89% said the toilets were dirty, compared with 39% of staff members.

Health workers reported similar gaps.

“In the Mozambique facilities we surveyed, about four in 10 staff said that in the past month they had performed or assisted with a procedure without enough water,” Miller says. “That’s both a patient safety issue and an indignity for the health workers providing care.”

Miller, who spoke at the launch of the health care facilities report at World Water Week in August in Stockholm, is also helping shape how WASH could be monitored beyond basic service levels. He leads the experiences working group in the UNICEF- and JMP-led review for schools and is contributing to the WHO- and JMP-led review for health care facilities.

Insights into who is being left behind

“In these reviews, we’re considering thousands of possible questions and indicators, most of which focus on supply,” he says. “We’re advocating for measures of what people experience, which provide complementary insights into who is being left behind and whether investments are paying off.”

Results from both projects are already helping local decision-makers determine needs and inform future work. The teams are now bringing the surveys to new sites and seeking partners, including in high-income countries.

“Our team at UB leads the analyses across all of the sites,” Miller says. “Next, we’re testing which questions work everywhere, so governments, NGOs, and other agencies can use them for routine monitoring.”

He will present the findings at the UNC Water and Health Conference, Oct. 26-30 in Chapel Hill, N.C., and the teams plan to publish their results and make the final tools publicly available.

“We’re trying to show that people’s experiences are data worth collecting,” he says, “and to get governments and funders using them for monitoring, evaluation and policy.”

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