An Evolving Choice in a Diverse Water Market: A Quality Comparison of Sachet Water with Community and Household Water Sources in Ghana.

Inadequate drinking water provision in many regions of the world has given rise to a vibrant packaged-water industry that sells water in single-serving sized bottles and plastic bags.1 In lieu of a piped water connection, low-cost bagged or “sachet” water has been shown around the world to often exhibit the lowest levels of contamination among available drinking water options2 and has become a particularly important drinking water source in West Africa.3 The reclassification of high-quality packaged water as an improved water source would improve progress toward global drinking water targets,1 and the World Health Organization (WHO) is slowly incorporating packaged water into its revised drinking water ladder where appropriate.4 Some of the highest rates of sachet water consumption are in Ghana, where in 2014, 29% of all households nationally (43% of urban households and 12% of rural households) relied on it as the primary drinking water source.5 In Ghana, households must diversify their water sources to meet their consumption needs, a practice long observed throughout sub-Saharan Africa.6,7 Diversifying the households’ water supply makes sense in areas with unreliable infrastructure, as it provides households a hedge against uncertain availability. A recent study of five regions in Ghana found that more than half of households are collecting water from improved sources,8 although they rely on many sources to meet their household water needs. During the rainy season, 76% of households collect rainwater, 24% use public taps, 43% collect from boreholes, and 6% buy sachet water. Because all non-rainwater sources are vended, 46% of households were observed to pay for water in some way.8 Although sachet water has been ubiquitous in urban Ghana for more than a decade, it is increasingly becoming a popular drinking water source in rural areas.9 The formalization of the packaged-water industry has led to increased competition in urban centers, and this has been associated with the increase in product quality as large corporate producers replace smaller cottage-industry players in these large markets. Rural Ghanaian communities are often secondary markets with higher distribution costs, thus cottage-industry producers often continue to operate with less competition, and unfortunately, less regulation, and quality control.3 One nationally representative study in Ghana observed that sachet water had a strong protective effect from Escherichia coli contamination of drinking water relative to other water sources.9 Although the study observed that rural localities were associated with higher contamination rates at the point of consumption in bivariate analysis, urban versus rural disparities were not assessed in multivariable analysis because of multicollinearity between the urban–rural classification and other demographic covariates. The study of packaged water quality remains dynamic but remains focused primarily in dense urban centers with the largest consumer markets. Recent Ghanaian studies from urban areas have identified traditional indicator bacteria10,11 and antibiotic resistance,12 explored differences between brands,13 and evaluated vendor practices.14 Despite significant growth in the number of sachet water quality studies this decade, just a handful have assessed sachet quality in rural contexts where it is a relatively newer product.3 Packaged water is theorized to confer a public health benefit if consumed in lieu of water stored in the household because of limited opportunity for cross-contamination.15,16 The quality of stored water is well known to deteriorate due to improper storage or treatment at home,17 and recent evidence confirms that sachet water tends to be of better quality at the point of consumption.9 But there has been no systematic assessment of how sachet water compares with water from other sources at the point of collection (POC). This approach was piloted in a previous Accra study, where POC and point-of-use (POU) water samples from 15 households were tested along with sachet water samples; a decline in quality was observed from sachet to POC to POU samples.15 This study compares the microbiological quality of sachet water and other drinking water sources tested across a sample of 42 Ghanaian communities in rural and peri-urban areas and small towns. We specifically compare the quality of sachet water sold in communities with water from other POC in those communities and with water stored in households. We hypothesized that in smaller communities located beyond large urban centers such as Accra, Kumasi, Sekondi-Takoradi, Sunyani, and Tamale, where sachet water producers and distributors can more easily evade regulatory scrutiny,3 sachet water will exhibit lower rates of microbiological contamination than POC water samples, which in turn will exhibit lower rates of contamination than POU water samples. Our findings present a rare opportunity to assess Ghana’s evolving sachet water landscape outside of Ghana’s major urban centers.