The times they are a-changin’. Growing up in what used to be a rural area of Medellín (Colombia), we had no telephone, no paved roads, no sewage system, no day-care in the neighbourhood (and no cable TV!). Medellín grew at a startling rate and urbanisation with all its pros and cons came quickly to our doorstep. By the time I left the city to study abroad, congestion was more of a problem than access on our newly paved but still narrow roads. And yet for too many other areas change is yet to happen. When I look at the immense difficulties people living in remote areas of Colombia face to access services, I realise how access quality services early on in my life shaped my opportunities: what if we couldn’t reach the nearest hospital on time when I became sick? What if my school could not prepare me well enough to pass the examination entrance at a public university?
An unhealthy gap
Despite decades of national progress, rural communities still have difficulty in accessing modern education and health services. In education, about a quarter of primary schools in the world did not have access to basic services such as electricity, drinking water and sanitation in 2020. Gaps in infrastructure tend to be higher in village schools compared to city schools across G20 countries especially in Latin American countries. Meanwhile, recent global estimates of access to healthcare show that more than 40% (3.16 billion people) of the global population cannot reach a healthcare facility within a 1-hour walk. In Colombia, the country with the widest gaps in access to healthcare across G20 countries, people living in rural areas must travel about 6 hours more than people in cities to reach the nearest healthcare facility.
Rural schools have worse physical and digital infrastructure than city schools
Poor access to these services can undermine outcomes. Results from PISA show that comparable students in city schools obtained higher scores in reading than their peers in schools located elsewhere in all but two G20 countries with available data. In some countries, the gap can be as high as the equivalent of a year of schooling. These gaps may lead to lower lifelong employment opportunities, incomes, and wellbeing – gaps that often persist across generations.
In health care, a previous OECD/European Commission report showed that around a third of residents of rural areas reported suffering from debilitating health issues, a larger share than city residents (25%). Yet access to healthcare is more challenging, partly explaining why in the United States and Australia mortality rates increase with distance from cities. Indeed, one in five adults across 23 OECD countries reported postponing or forgoing care due to long waiting times or difficulties with transportation.
Bridging these gaps is costly. It requires constructing and maintaining roads in areas of low traffic, operating sub-scale health and education facilities, and providing relocation incentives for service workers. Yet today digital services are offering a powerful way of overcoming distance and increase the variety of services people living in remote areas can access. Teleconsultations, for instance, can reduce travel and waiting times to nearly zero, resulting in significant time gains for patients and health workers: patients of the Ontario Telemedicine Network avoided travelling 270 million km in 2017 and the network saved over CAD 70 million in travel grants. But most countries still do not have the required digital connectivity to make digital service provision a reality for rural areas. In fact, rural areas are subject to a “double divide” in access, or the simultaneous presence of long travel times to healthcare and low access to high-speed internet. In Argentina, for instance, people in rural areas face 300 p.p. longer travel times to healthcare and over 50 p.p. slower internet speeds than the national average.
Rural areas face a “double divide” of slower internet speeds and larger distances to healthcare compared to cities
Deviations from national averages – G20 and OECD countries, 2021
Getting a grip
Restructuring rural services will require new skills and infrastructure, as well as organisational and cultural change in subnational governments. To promote this, national and subnational governments must act together to pool resources and capacity and identify shared investment opportunities and bottlenecks. National governments must provide financial and non-financial incentives, and platforms for dialogues and co-operation to prompt consolidation and mergers.
And times they are a-changin’ again. As the COVID-19 pandemic propelled city dwellers into a new world of remote and hybrid work, it has also opened new opportunities for rural areas to attract them as a means of revitalising their communities. But only accessible, well-served rural communities will succeed. Governments must invest to make them so – and in the process ensure access to opportunity is not a lottery but a reality for everyone, regardless of where they live.
Our new report Addressing territorial disparities in future infrastructure needs in the wake of the COVID-19 crisis: A G20 perspective assesses territorial inequalities in access to basic education and health care services in G20 countries today and in the future. It calls for timely and smart investments to narrow gaps in access to services within countries.
More work on the rural service delivery program.
Ana Isabel Moreno Monroy is an economist at the Centre for Entrepreneurship, SMEs, Regions and Cities at the OECD. Previously she worked as a Visiting Assistant Professor at the Autonomous University of Barcelona, and as Marie Sklodowska Curie Fellow at the Rovira i Virgili University and the London School of Economics. In her research she uses geo-spatial data and economic and geography methods to contribute to the design of social inclusion policies. She has published in leading academic journals including the Journal of Development Economics and the Journal of Urban Economics. Ana owns a Masters and a PhD in Economics from the University of Groningen.