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‘Water is life’: developing community participation for clean water in rural South Africa
  1. Jennifer Hove1,
  2. Lucia D'Ambruoso2,
  3. Denny Mabetha1,
  4. Maria van der Merwe3,
  5. Peter Byass4,
  6. Kathleen Kahn1,
  7. Sonto Khosa5,
  8. Sophie Witter6,
  9. Rhian Twine1
  1. 1MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
  2. 2Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland, UK
  3. 3Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
  4. 4Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
  5. 5Department of Health, Mpumalanga Provincial Government, Mbombela, South Africa
  6. 6Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, Scotland, UK
  1. Correspondence to Dr Lucia D'Ambruoso; lucia.dambruoso{at}


Background South Africa is a semiarid country where 5 million people, mainly in rural areas, lack access to water. Despite legislative and policy commitments to the right to water, cooperative governance and public participation, many authorities lack the means to engage with and respond to community needs. The objectives were to develop local knowledge on health priorities in a rural province as part of a programme developing community evidence for policy and planning.

Methods We engaged 24 participants across three villages in the Agincourt Health and Socio-Demographic Surveillance System and codesigned the study. This paper reports on lack of clean, safe water, which was nominated in one village (n=8 participants) and in which women of reproductive age were nominated as a group whose voices are excluded from attention to the issue. On this basis, additional participants were recruited (n=8). We then held a series of consensus-building workshops to develop accounts of the problem and actions to address it using Photovoice to document lived realities. Thematic analysis of narrative and visual data was performed.

Results Repeated and prolonged periods when piped water is unavailable were reported, as was unreliable infrastructure, inadequate service delivery, empty reservoirs and poor supply exacerbated by droughts. Interconnected social, behavioural and health impacts were documented combined with lack of understanding, cooperation and trust between communities and authorities. There was unanimity among participants for taps in houses as an overarching goal and strategies to build an evidence base for planning and advocacy were developed.

Conclusion In this setting, there is willingness among community stakeholders to improve water security and there are existing community assemblies to support this. Health and Socio-Demographic Surveillance Systems provide important opportunities to routinely connect communities to resource management and service delivery. Developing learning platforms with government and non-government organisations may offer a means to enable more effective public participation in decentralised water governance.

  • water
  • south africa
  • participatory action research
  • photovoice
  • rural

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  • Handling editor Seye Abimbola

  • Contributors JH led the thematic analysis and drafted the manuscript with LD and RT. DM led the data collection with inputs from LD, RT and JH. LD, RT, MV, PB, SW, SK and KK conceived of the study and made inputs to the collection and interpretation of data. LD, JH and RT revised the manuscript critically. All authors have given approval for the version to be published and agreed to be accountable for the work.

  • Funding This study was funded by the Joint Health Systems Research Initiative from Department for International Development/MRC/Welcome Trust/Economic and Social Research Council (MR/N005597/1 and MR/P014844/1). This work was nested within the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), supported by the University of the Witwatersrand and Medical Research Council, South Africa.

  • Disclaimer The content is solely the responsibility of the authors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study protocol was approved by research ethics committees in the Universities of the Witwatersrand and Aberdeen and the Provincial Health Research Committee gave permission for the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.