Household-level indicators overestimate sanitation coverage by masking within-household differences in practices and...

Accurate measurement of sanitation access is essential for tracking progress toward universal sanitation under the Sustainable Development Goals, yet current indicators focus on household-level access and rarely capture how sanitation is used within households or facility quality. We conducted a cross-sectional survey of 36,860 rural households in 14 low- and middle-income countries, assessing differences in open defecation practices among household members and sanitation facility quality. Heads of household reported where adult men, adult women, boys, and girls usually defecated, while enumerators directly observed sanitation facilities. We then developed alternative estimates of sanitation service levels that accounted for these dimensions. Despite access to a sanitation facility, 14.1% of households reported that at least one member practiced open defecation, including 2.9% of households classified as having basic sanitation. Children (12.6%) were more likely than adults (9.2% of men and 8.9% of women) to practice open defecation. Only 2.0% of sanitation facilities met the study's hygiene criteria, largely because 80.1% lacked a nearby handwashing facility with soap and water, 45.4% had visible flies, and 79.9% lacked appropriate anal cleansing materials. Structural deficiencies included cracked or damaged pedestals (26.3%), unusable floors (11.6%), non-functional facilities (5.7%), and lack of privacy (18.8%). Accounting for these factors yielded substantially lower estimates of basic sanitation coverage (2.2%) compared to the standard Joint Monitoring Programme (JMP) classification (31.8%), highlighting a gap between reported access and effective service delivery. Routine collection of disaggregated data on sanitation use and standardized measures of facility quality could improve monitoring of effective sanitation coverage.