In Central and Eastern Europe, about one-third of the population lives in small settlements (<2000 PE). Since the current European Urban Wastewater Treatment Directive (91/271/EEC) does not clearly regulate the collection and treatment of wastewater from these settlements, countries solve the problem individually. Simple and robust technologies such as nature-based treatment systems could be the solution and are widely applied in many EU countries. In this paper, the status of wastewater collection, treatment, and reuse in rural areas of 14 countries in Central and Eastern Europe is presented together with the spread of different nature-based treatment systems. The results show that in the last decade, connection to wastewater treatment plants has increased from 9% to 19% of the total population in small settlements. The use of treated water is rarely applied. Sequencing batch reactors and other types of activated sludge systems predominate in treatment technologies. Nature-based treatment systems (mainly treatment wetlands) are used in all the countries studied. Their implementation is slowly increasing, hampered by lack of acceptance by authorities, lack of good case studies, and misdesigned or misoperated examples from the past. More awareness, formalized training on nature-based treatment systems, and supportive legislation are needed to promote sustainable sanitation solutions in small settlements.