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BMJ Glob Health. 2019 Jun 11;4(3):e001377. doi: 10.1136/bmjgh-2018-001377. eCollection 2019.

'Water is life': developing community participation for clean water in rural South Africa.

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MRC/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.
Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland, UK.
Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK.
Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
Department of Health, Mpumalanga Provincial Government, Mbombela, South Africa.
Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, Scotland, UK.



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.


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.


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.


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.


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

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