“Water is life”: developing community participation for clean water in rural South Africa

Jennifer Hove, Lucia D'Ambruoso* (Corresponding Author), Denny Mabetha, Maria Van Der Merwe, Peter Byass, Kathleen Kahn, Sonto Khoza, Sophie Witter, Rhian Twine, Verbal Autopsy with Participatory Action Research

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

23 Citations (Scopus)
14 Downloads (Pure)


Background: South Africa is a semi-arid country where five 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 existing community assemblies to support this. HDSSs provide important opportunities to routinely connect communities to resource management and service delivery. Developing learning platforms with Government and non-government organisations can enable more effective public participation in decentralised water governance.
Original languageEnglish
Article numbere001377
JournalBMJ Global Health
Issue number3
Early online date11 Jun 2019
Publication statusPublished - Jun 2019

Bibliographical note

We thank the study participants for agreeing to be part of the process, sharing their time and perspectives, and the VAPAR staff of the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt). We also thank the three peer reviewers for the insightful comments which helped improveimproved the paper. Permissions have been secured for the reproduction of all images.
This study was funded by the Health Systems Research Initiative from Department for International Development (DFID)/Medical Research Council (MRC)/Welcome Trust/Economic and Social Research Council (ESRC) (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. The content is solely the responsibility of the authors.


  • South Africa
  • participatory action research
  • photovoice
  • rural
  • water


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