Beyond COP26: Lessons from South Africa on water and community health

This episode is about amplifying community voice through a Participatory Action Research (PAR) process. The intention was to bring communities together and connect them with authorities and service providers in cooperative dialogue and learning. Through PAR, we coproduce evidence, action and learning from action for social change, re-think power structures and advance collective action on health issues.

Show Notes

Water scarcity has become an increasing threat to humans with a serious effect on food production globally. The situation is expected to exacerbate under projected future climate change. South Africa was identified as one of the most vulnerable countries predicted to experience climate change.  COP26 highlighted the need for effective sustainable engagement to deliver social change. The ongoing Verbal Autopsy with Participatory Action Research (VAPAR) programme being conducted in Agincourt Health and Demographic Surveillance Site (HDSS) involves an iterative sequence of action-learning cycles, involving communities in priority setting, decision making and action on issues affecting their lives, and with the intention to empower communities. The process has the potential to improve community control, power, and agency for action on health from a pro- equity and social justice perspective. The VAPAR process for community members offers opportunities to raise a collective voice around local concerns, and to interact with service providers and researchers to drive collective action around issues affecting their lives. 

The University of Witwatersrand, faculty of health sciences in collaboration with the University of Aberdeen presents to you a participatory action research (PAR) with communities in Agincourt HDSS in South Africa. In this second series, the host; Jennifer Hove PhD student at Wits university discuss about ‘Amplifying Community Voice’ to address lack of safe water, a community nominated priority. The aim of the process was to shift responsibility of ownership of health and life in general, encourage multisectoral stakeholder collaboration and creating learning platforms. Jennifer Hove engages Mr Jabulani Mnisi, a community member who has been a participant, a partner in this programme since 2017, together with Mrs Nomsa Ntimane a service provider, an Operational Manager (clinician), at Agincourt Health Centre. In this series, Mr Mnisi shares his experience with PAR process, how his community collaboratively decided on the priority health issues, relationships developed with other stakeholders (service providers), roles and responsibilities and reflection on the action learning.   Mrs Ntimane discusses water and health, “no health without water’. Though the health system has no statutory mandate for water, it is deeply impacted by widespread lack of safe water.  This series was recorded at Agincourt Health centre.  

What is Beyond COP26: Lessons from South Africa on water and community health?

This podcast series shares insights on participatory water governance, from Bushbuckridge sub-district in rural Mpumalanga, South Africa. This work is part of the wider Verbal Autopsy with Participatory Action Research (VAPAR) embedded within the Agincourt Health Demographic Surveillance Site (HDSS) of the University of Witwatersrand in collaboration with Aberdeen University. The VAPAR programme aims to expand the knowledge base through creation of legitimate learning platforms for action health equity. Community stakeholders and local government service providers share the complexities of service delivery and how the lack of community participation in water governance affects marginalized rural communities.

Despite legislative and policy commitments to the right of water, cooperative governance and public participation, there are limited opportunities for communities to participate in public service planning. This especially impacts negatively on marginalized rural communities, relying on public services for health and wellbeing.

Applying participatory methods and tools, community stakeholders identified the lack of safe water to be a priority health concern. Repeated and prolonged periods without piped water; unreliable and unavailable infrastructure,; contaminated water sources; extensive waste, litter and dumping; inadequate service delivery; and poor water supply exacerbated by drought were reported in the local area. Several interconnected social, behavioural and health impacts were associated with this lack of safe water, including infectious diseases, compromised sanitation, hunger and malnutrition, social unrest and service delivery protests.

Community engagement allow community stakeholders to take an active role in priority setting and collective action towards addressing community priorities. When spaces are created for dialogue and collective action, extending beyond passive involvement, trust is established between stakeholders and community power built; allowing for cooperative governance.

This series is hosted by research fellow, Jennifer Hove, reflecting COP 26 and exploring the role of participatory action research in addressing water challenges in rural communities, as part of her doctoral research embedded within the multi-year VAPAR programme.

More information on the VAPAR programme is available at

Speaker 1 [00:00:01] So welcome, everyone. My name is Jennifer Hove, and you are listening to Participatory Action Research. I am a PhD student at the University of Witwatersrand, Faculty of Health Science, and graduate associate of the Aberdeen Centre for Health Data Science in the school of Medicine, Medical Science and Nutrition. My passion is to understand the role of community participation in improving health. Our guests today are Sister Ntimane a service provider, clinician and an operational manager at Agincourt Health Centre and Mr Mnisi is a community member, a service user and a leader from Kildare Village in Agincourt Health and Demographic Surveillance Site in South Africa. Before I leave time for our guests to introduce themselves. I want to tell you a little background about the VAPAR programme. The VAPAR Programme, Verbal Autopsy and Participatory Action Research Programme in which my PhD is embedded, started in 2015 to date in the Agincourt HDSS in South Africa. The aim of the programme is to address exclusion from the health system by connecting service users and providers to co-produce and act on the research evidence. The Verbal Autopsy and Participatory Action Research process seeks to build collective dialogue and action through iterative reflection and action learning cycles. This series is about amplifying community voices in the participatory action research process. The intention is bringing communities together, connecting them with service providers for social change, and also to rethink power structures and health issues. Let's welcome Mr. Mnisi, one of our community participants who have been actively participating in the VAPAR programme since 2017. Baba Mnisi, can you tell us about you in journey with the Verbal Autopsy and Participatory Action Research Programme?

Speaker 2 [00:02:21] Thank you. My name is Jabulani Mnisi from Kildare. I joined this VAPAR group in 2017 whereby we were talking about various topics. But I was for one, I was with water, so I cannot elaborate much, I will hear from you the questions that you will pose for me.

Speaker 1 [00:02:52] Okay, thank you Baba Mnisi. A fundamental premise for participatory research approach is that participants or community experts and power what is deliberately shared and negotiated, and the participants cease to be object of research. Let's go back to how the process started as you have mentioned that your village nominated water as a priority health topic, how did they select to water a health priority?

Speaker 2 [00:03:25] Thank you. They selected to water as a priority yet there were various topics that we were discussing. But when doing the voting system, we choose to vote for water because in our place, in our society, there is scarcity of water.

Speaker 1 [00:03:50] So was everyone happy with water as a priority topic?

Speaker 2 [00:03:55] Yes, everyone was happy since it is scarce it led to everyone to be interested in it as they were given a platform to talk about.

Speaker 1 [00:04:08] Thank you, so this was a collective voice from the participants?

Speaker 2 [00:04:12] That was the collective voice and from the different topic that we're talking about.

Speaker 1 [00:04:17] Okay, thank you. Water scarcity has become an increasing threat to humans with serious effects on food production. Globally, the situation is expected to be worse under projected future climate change. And South Africa was also identified as one of the most vulnerable countries predicted to experience climate change. COP26 highlighted the need for effective sustainable engagement to deliver social change. Why is water important to you and the community at large?

Speaker 2 [00:04:58] Yeah, water is important to me because I value it as the basic need of the people. And without water, there's nothing that we are to do since it helps us to be clean. Good communication, not communication, social communication because I cannot visit my neighbor being filthy. I have to wash myself in order visit my neighbor. Then economically, Also, if ever we have got water, it will help us to make some little gardens each and every household, so that you cannot keep on spending.

Speaker 1 [00:05:51] Okay. So, as you are mentioning that, can you elaborate more on the impacts of water to health.

Speaker 2 [00:06:02] Yeah, there's a lot. There's an impact because water is the beginning of cleanliness. If we talk clean, we talk water. So, therefore, if there's no water, there's no cleanliness. And cleanliness, it helps in our health. And if there's no cleanliness, it is a health hazard hasn't cause it to cause some illness in our living. Besides illness, a lot of places would be filthy because water we need it. Even if we clean the yard, we have to put water first because we have not paved our places because we are living in the rural areas, we put water, then we clean to avoid dust to go further to other people.

Speaker 1 [00:06:52] Okay. So, with regards to social impacts of water, where do people get water when it's not available in taps, where do people get water?

Speaker 2 [00:07:01] We are suffering. People are walking, long journey to go and fetch water in the dams. So, when fetching water, sometimes you find that they are so thirsty to such an extent that they just drink it without cooking it. And that is a health hazard, since the germs are there in that water and that water is dirty. Even if we receive it via water tanks, we are not sure. Of course, we don't know where that water comes from and how clean it is. And people, when they get it, they just drink it without cooking or putting something to clean it.

Speaker 1 [00:07:47] Okay. And what are the economic challenges?

Speaker 2 [00:07:50] The economic challenges as we see? It costs us a lot. Of course, we have to buy. We have to buy water whereby nowadays it's difficult to get money as we are in the rural areas where there's no work. There's nothing except if you are professional. If you are unprofessional, forget about work. So economically it affects us.

Speaker 2 [00:08:13] But if there was water economically, we can be safe. That by, as I said, having some, a little bit plot in the house whereby you plant spinach, tomatoes onions and not buying every day. Mmm.

Speaker 1 [00:08:33] Okay. Thank you, Baba Mnisi. Over to you Sister Ntimane. How is water important to you as a health service provider and how does lack of water affect health and the work that you do every day here at the clinic?

Speaker 3 [00:08:52] So coming to the challenges of water, I would like to say this water as a resource it is very important. Without water, we can't do anything. When you want to touch the patient. You must wash your hands. Before and after the procedure, you must wash your hands. So, lack of water causes a medical hazard because there are more infections. We are carrying the bacteria from one person to another because of the lack of water. So that's why now, even if you want to do, to perform a procedure, water, it's very important when you go to the toilet. Water, it's very important. It's worse, worse, when you come into the patient who is coming from delivery because that person needs a lot of water. After delivery, the patient need water. And then even if she’s admitted for a while she must bath because she's not comfortable. So a lack of water, it's a challenge in the facility. And when coming to how we get to the water, we don't have running water at all. And running water, it's very, very important in the facility. So, if you find that the facility, it's using, the JoJo tank water, so how safe it is to use this water? That water? It's not very sure.

Speaker 1 [00:10:32] Well, thank you Sister Ntimane. So, you are saying the clinic has been operating without running water?

Speaker 3 [00:10:37] There are some days that we do not enough water. You have to phone the Municipality and maybe it would take…. There is another day when it even takes the whole week when we reported that we want water. They waited to refill until we phone the higher levels. So, we don't know their challenges or their protocols, what is happening but during that time when we don't even have the JoJo water it's a problem. Because even as we can't work without even drinking a cup of tea. And during that time when a delivery person would come, it's a problem. So that's why we are suffering a lot, because the JoJo doesn't have a gauge to gauge whether the water is running out or what it is. The time when you are going to open the tap and you find out that here is no water. You have to phone to report, to request for the refill. So now, what we are doing almost everyday we go there and check how is the tank, it is a problem?

Speaker 1 [00:11:55] And that is adding a burden to you as well. So are there times that, you know, you provided services without water at all?

Speaker 3 [00:12:06] Yes.

Speaker 1 [00:12:07] So when you talk about lack of water at the facility, who is affected most?

Speaker 3 [00:12:14] The patient it's affected most, but both of us. Both of us we are affected because the nurse is the one to use the water in most of the time to wash hands before touching the patient, to dilute treatment to give to the patient. For the stat doses, there are treatment that needs to be diluted with water and to take those treatment is a stat dose, there patient need to drink these pills with water.

Speaker 1 [00:12:51] Okay. So also the community developed an action plan. So, whose voice is excluded from action on the issue of water challenges. Baba Mnisi?

Speaker 2 [00:13:11] I can say those who are excluded are the member of the society since they haven't got the platform to express their needs or what they want. And also, I will not say this platform only. Also, power. They have no power, whereby if we have people like Madam Ntimane, as the matron and you Sis as the leader of the VAPAR. Those are stakeholders that are making us to be heard because, us, they wouldn't hear us, but with them we are able to be heard. Even the Municipality, our government and the higher office.

Speaker 1 [00:14:06] Okay. So, you think if people come together, the researchers, the stakeholders and the community, then your voice could be heard?

Speaker 2 [00:14:15] Exactly, our voice can be heard. Because they will know exactly what is affecting us in terms of water because that is the basic need of a person to be fighting against health hazards.

Speaker 1 [00:14:32] Okay, so how did the VAPAR process help you and the committee to understand the water challenges in your communities?

Speaker 2 [00:14:42] As I said, it helped us because it has opened our eyes. Made us to meet people that can hear our voice, like as we're talking now, we have a sister in front of us who is in a higher state of the government, who can tell them that in so and so village there is scarcity of water, and they will listen to her because of her status.

Speaker 1 [00:15:13] Sister Ntimane. How did this process, I know you have also been engaged with VAPAR, how did process of this process of change? You been in the VAPAR process from priority setting, voting, identifying a priority health topic. How did this change you, this VAPAR process?

Speaker 3 [00:15:34] The VAPAR process changed me a lot, because meeting with them, sharing information and giving ideas, training to some of our stakeholders change a lot to our community and to our service.

Speaker 1 [00:15:55] And over to you Baba Mnisi. How were the changes or the action agendas developed in the community?

Speaker 2 [00:16:02] Their agendas or development in the community is that now we are able to sit with stakeholders to say to them what is lacking in their society or communities. And also, the government can now listen to us as well, if ever we have started from our leaders around and then go to them because they've given us a platform to talk with them. Because we have the dialogue with them. We engage with them, to show them or to prove to them how water is affecting people on the ground.

Speaker 1 [00:16:44] Okay. So, were the stakeholders involved in the participatory action research process?

Speaker 2 [00:16:52] Health department, municipalities, government officials, all of them had some meetings with the people of Health. We had some meetings with the government people in Nelspruit. We had municipality meetings in Bushbuckridge where we elaborated the need for this water.

Speaker 1 [00:17:22] Over to you Sister Ntimane. So, what is the plan to resolve the water issue here at the clinic? As you are saying that you operate without running water and you rely on the JoJo tank, what is the plan currently?

Speaker 3 [00:17:35] Okay, the plan currently, the operational manager wrote a requisition issue to the higher authorities to plan for water. So, the municipality promised to come and connect. There is a tank over there, the pipeline is running through this road, passing our facility into the tank. So, what they promised is to come and connect to the pipe so that water could be inside. Okay.

Speaker 1 [00:18:21] So do you think your facilities given priority as a health facility?

Speaker 3 [00:18:26] Yes.

Speaker 1 [00:18:27] Okay. So, what could be done differently to improve community participation Baba Mnisi?

Speaker 2 [00:18:35] What can be done to improve community in these things is meetings or coming together.

Speaker 1 [00:18:49] mmm.

Speaker 2 [00:18:50] Twice or of thrice a year whereby discussing this water and that will help and you from the VAPAR side. You know what is in the villages and where is the shortages. And by so doing, it will make the government to know what they supposed to do, to help people to get water.

Speaker 1 [00:19:15] Why is participating in VAPAR important to you?

Speaker 2 [00:19:23] Participating in VAPAR process is important because, as I've said, it is an eye opener. It opened our eyes and it helped us to get, you know, the chance to talk. Even where we're not supposed to talk, we were not talking. But because of VAPAR, now we can talk. And we would be heard. Because as the VAPAR has been with us since the beginning of 2017 till now, there's a vast change when it comes to water, and I believe it is part of their work.

Speaker 1 [00:20:02] But as a participant, what did you learn from the participatory action research process? What did you learn that you would share with others?

Speaker 2 [00:20:09] I have learnt that… yeah. What I have learnt is that through communication it can help us to get what we are looking for and what can help people. Of course, what we're talking about is the basic needs of the people in order to have free health. Because as we were talking before, there was the higher volume of health hazard because we did know that water need to be cooked before drinking. We were just drinking. We didn't know that going to fetch water in the river sometimes you fetch germs. We did not that water that is brought by tankers are sometimes not clean. We're thinking all that is coming to us because we were not having water is right.

Speaker 1 [00:21:04] Okay. And Sister Ntimane, engaging with the community, how was it to you? Meeting the community stakeholders and sharing information with them, how was it?

Speaker 3 [00:21:24] To meet with the community was very important because the community need information. So, if we share the information, they start to ask questions. They start to open their eyes and their mind to know what is good and what is not good to them. Okay.

Speaker 1 [00:21:49] Thank you very much. Communities are at the frontline of climate change, and they are good policies and guidelines around the lack of water. But there is need to embed this conversation that we are doing today with action to reach where we want to be. Most importantly, including the voice of service users, marginalised and economically disadvantaged people. Thank you for your time and I would like to thank the VAPAR Programme team and the principal investigator, Dr. Lucia D’Ambruoso for providing guidance to this work. Thank you.

Speaker 2 [00:22:27] Thanks.