Environmental conditions in health care facilities in low- and middle-income countries: Coverage and inequalities

Int J Hyg Environ Health. 2018 Apr;221(3):409-422. doi: 10.1016/j.ijheh.2018.01.004. Epub 2018 Jan 11.


Safe environmental conditions and the availability of standard precaution items are important to prevent and treat infection in health care facilities (HCFs) and to achieve Sustainable Development Goal (SDG) targets for health and water, sanitation, and hygiene. Baseline coverage estimates for HCFs have yet to be formed for the SDGs; and there is little evidence describing inequalities in coverage. To address this, we produced the first coverage estimates of environmental conditions and standard precaution items in HCFs in low- and middle-income countries (LMICs); and explored factors associated with low coverage. Data from monitoring reports and peer-reviewed literature were systematically compiled; and information on conditions, service levels, and inequalities tabulated. We used logistic regression to identify factors associated with low coverage. Data for 21 indicators of environmental conditions and standard precaution items were compiled from 78 LMICs which were representative of 129,557 HCFs. 50% of HCFs lack piped water, 33% lack improved sanitation, 39% lack handwashing soap, 39% lack adequate infectious waste disposal, 73% lack sterilization equipment, and 59% lack reliable energy services. Using nationally representative data from six countries, 2% of HCFs provide all four of water, sanitation, hygiene, and waste management services. Statistically significant inequalities in coverage exist between HCFs by: urban-rural setting, managing authority, facility type, and sub-national administrative unit. We identified important, previously undocumented inequalities and environmental health challenges faced by HCFs in LMICs. The information and analyses provide evidence for those engaged in improving HCF conditions to develop evidence-based policies and efficient programs, enhance service delivery systems, and make better use of available resources.

Keywords: Clinics; Environmental health; Hospitals; Hygiene; Infection prevention; Monitoring and evaluation; Sanitation; Standard precautions; Surveys; Sustainable Development Goals (SDGs); Water.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Developing Countries*
  • Disinfection
  • Drinking Water
  • Hand Disinfection
  • Health Equity*
  • Health Facilities
  • Health Resources*
  • Humans
  • Hygiene*
  • Income
  • Infection Control*
  • Policy
  • Rural Population
  • Sanitation*
  • Socioeconomic Factors
  • Waste Management
  • Water Supply*


  • Drinking Water