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Access to Lifesaving Assets Including Piped Water and Sanitation Largely Reserved for the Wealthy in Lower Income Countries

November 16, 2018

Data from 41 countries find a stark urban-rural divide. Less than 30% of rural poor have mobile phone access.

Oakland, CA (November 16, 2018) — A new study published today in PLOS ONE by the Public Health Institute showed that in low- and middle-income countries (LMICs), access to critical environmental health assets is severely limited for the poorest segments of the population. Among the poorest three-fifths of households, less than 50% had access to piped water, modern cooking fuels, electricity and improved sanitation. Rural households of all wealth levels had lower rates of access to all assets examined, with the exception of bed nets for malaria prevention.

Image courtesty of Global Alliance of Clean Cookstoves

“Lack of access to these basic environmental health assets is known to contribute significantly to the global burden of disease,” said lead author Jay Graham, PhD, MPH, a research director at the Public Health Institute. “This study suggests that if we are to reduce this disease burden, we need additional strategies to target the lowest income homes—particularly in rural areas.”

The researchers included mobile phone access in the study as a comparison variable, as these technologies are considered to have high penetration into poor households within LMICs. Yet they found that fewer than 30% of the poorest households in rural areas had access to mobile phones. In all areas, both rural and urban, mobile phone coverage was lower than bed net ownership and access to improved water for the poorest two-fifths of households.

“Mobile phones are often held up as a miracle technology, with many global health organizations investing in mHealth programs to better reach their target populations,” said Graham. “Surprisingly, our analysis indicates that the reach of mobile phones among poor, rural segments of the population may be much lower than previously thought.”


Image courtesty of Patrick Bentley/SolarAid

Top findings included:

  • Access to many EHAs is very low among the poorest households. Less than 40% of households in the bottom three wealth quintiles had access to piped water, improved fuel, and improved sanitation.
  • There is a stark urban-rural divide in coverage rates. Among urban households, only the bottom wealth quintile had access below 40% for any technology. In rural areas, coverage rates for these three improvements (piped water, improved fuel and improved sanitation) were below 40% in all but the highest wealth quintile.
  • Wealth gaps exist in both rural and urban areas. For both groups, the gap across wealth quintiles was greatest for electricity, mobile phones and sanitation.

“It might seem obvious that access to these assets would vary with wealth, but the patterns we found are worth considering—especially given the establishment of the Millennium Development Goals and now the Sustainable Development Goals, and the substantial efforts governments and nongovernmental organizations have made over the last two decades to increase access among poorer populations,” said Graham.

The study notes that many environmental health technologies, especially infrastructure solutions, are deployed with considerable government investment—creating the expectation that public funding would reduce disparities in access based on wealth.

The researchers evaluated nationally representative Demographic and Health Survey (DHS) data from 41 LMICs to assess household-level access to: 1) improved water supply; 2) piped water supply; 3) improved sanitation; 4) modern cooking fuels; 5) electricity; and 6) bed nets. Ownership levels were then compared across country-specific wealth quintiles. Additional study authors were professor Marc Jeuland from Duke University and Maneet Kaur from the Johns Hopkins Bloomberg School of Public Health.

The study is available online at http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0207339.




If you would like to arrange an interview with Jay Graham, PhD, MPH, contact Jennifer Scroggins at jennifer.scroggins@phi.org



The Public Health Institute, an independent nonprofit organization, is dedicated to promoting health, well-being and quality of life for people throughout California, across the nation and around the world.