Themes / Topics Rural Poverty & Health
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Water Supply Improvement & Health Promotion Campaigns in Rural Areas — China, 1949−2020

Abstract/Summary: In the 1950s, shortly after the founding of the People’s Republic of China (PRC), the central government created the Patriotic Health Campaign (PHC) in order to standardize and disseminate health focused educational materials intended to control and prevent infectious diseases (1). “Water improvement”, meaning measures aimed at providing safe drinking water for households in China, was an important part of the PHC. After 60 years of water improvement policies, programs, and investments, the rural water supply sanitation and hygiene in China has improved dramatically, and water-related diseases no longer negatively impact the rural population as they once did. In addition to improvements related to the quantity and quality of the rural water supply, water improvement programs also promoted improved hygiene, sanitation, and other health-related behaviors among rural households. Together, such initiatives have improved the quality of life and the health of hundreds of millions of rural residents, while also contributing to economic and social advancement across rural China (2). The purpose of this article is to describe how the PHC served as a foundation for the expansion and improvement of drinking water supply in rural China, and to summarize the key programs, projects, and initiatives that followed over the last 60 years.

Refinement & Finalization of the Multidimensional Poverty Assessment Tool (MPAT)

Following the release of the working-paper User’s Guide for the Multidimensional Poverty Assessment Tool (MPAT) in 2009, a number of agencies and universities used the beta-version of MPAT in a variety of settings. In order to finalize MPAT and develop a comprehensive User’s Guide and associated resources, we built on the lessons learned from early adopters of the the tool (e.g., an NGO in Kenya) and iteratively used and evaluated the tool with IFAD-supported projects in Bangladesh and Mozambique. Details on the participatory expert elicitation methods we used are provided in a Journal of Development Studies paper. We developed an Excel-based data entry platform so users could easily calculate MPAT’s indicators at household, village, and project levels. We also wrote a comprehensive, 300+ page, 2014 MPAT User’s Guide which provides step-by-step instructions for using MPAT as well as training modules and materials, all with the goal of making MPAT an accessible open-source tool. The User’s Guide and accompanying resources were presented at a 2014 launch event in Rome. Since its 2014 release, MPAT has been translated into a number of languages, an optional 11th component focused on climate change was added, and MPAT has been used by a variety of agencies and institutions around the world. MPAT publications and related resources are available at

Evaluating Household-level Drinking Water Treatment in Rural China

After extensive discussion and planning, we started a collaborative research project with colleagues at the NCRWSTG and China CDC to characterize and assess methods of household water treatment (HWT) in low-income regions of rural China. During the first phase of this research, in the summer of 2013, we collected drinking water samples and administered surveys to 450 households across 15 rural villages in Guangxi province. To assess seasonal factors, we undertook a second round of data collection in the winter of 2013/2014 during which time we also affixed remote temperature sensors to kettles and pots to help corroborate reported boiling data. In 2014, under the supervision of China CDC colleagues Director Tao Yong and Dr. Qing Luo, we replicated the study in Henan province, collecting data from 450+ rural households during the summer.  Using a variety of modeling approaches, we evaluated the microbiological effectiveness of the HWT methods used – including bottled water (large 19L bottles) – and isolated socioeconomic predictors associated with HWT and water-related beliefs and behaviors. Among other findings, we observed that indicators of fecal contamination were lowest in drinking water samples from households using electric kettles. Our analyses of boiling-associated air pollution indicated that switching from boiling with pots and solid fuels to boiling with electric kettles would result in a measurable reduction in indoor air pollution. We also observed relatively high rates of microbiological contamination in samples from households using bottled water; and our analyses of socioeconomic factors suggested that rural bottled water use will continue to increase in the future. Results from these studies – as well as a systematic review on boiling and health outcomes – were also used to support and inform the design of an intervention to promote the use of electric kettles in low-income rural communities (see project summary above).

Water Utilities & Intermittent Drinking Water Supply in China

Led by our colleague, Dr. Hongxing Li at the China CDC, this project focused on the management and use of drinking water supply in areas where utilities provide piped drinking water, but for a variety of reasons it is not provided continuously (i.e., piped connections are not supplied with treated drinking water 24 hours a day, 7 days a week). This situation – that of intermittent water supply (IWS) – is relatively widespread in many low- and middle-income countries, as well as in parts of China. This research project, conducted in two Chinese provinces (Shandong and Hubei), assessed and compared management and consumer adaptation strategies, as well as drinking water quality, storage practices, and behaviors and beliefs associated with IWS, with comparison to similar communities living under conditions of continuous water supply (CWS). Water samples (from taps and rooftop storage units) and survey data were collected from 400 households across four villages (2 IWS, 2 CWS) in the two provinces. One of the main reasons the utilities in these regions provided water intermittently was to reduce the electricity costs associated with water supply pumps. Indicators of microbiological contamination were higher in samples from the IWS villages compared with the CWS villages, and we observed higher rates of bottled water use in the IWS villages compared with the CWS villages. As a result of this work, we were able to offer evidence-based recommendations utilities could adopt to reduce water-and-health related risks associated with IWS or transition to CWS.

Bottled Water Safety & Use in Low- & Middle-Income Countries

In the course of our work studying drinking water access, contamination, and treatment in rural areas, we have observed relatively high rates of bottled water use. The reasons for increasing bottled water use in rural areas of low- and middle-income countries are varied, but available data indicates that some of the primary reasons are related to perceptions that bottled water is convenient and safer than available drinking water sources. Results from some of our research studies suggest, however, that bottled water may not always be safe. To better understand increasing use of and reliance on bottled water in LMICs we studied available market data which shows that more than half of the top-ten bottled water consuming countries globally are LMICs, and that bottled water use in LMICs is growing rapidly. With respect to global environmental health this trend is problematic in a number of respects, and, we argue, this increasing reliance on bottled water will likely hamper efforts to provide safe and affordable drinking water for all – one of the key objectives of the UN Sustainable Development Goals. As part of this work, we wish to better understand the nature and extent of bottled water contamination; however, there is relatively little publicly available data on bottled water quality, in LMICs or in high-income countries. To complement one of the only systematic review studies examining bottled water use and safety in LMICs, we conducted a comprehensive systematic review and meta-analysis of publicly available research studies on bottled water quality and associated health outcomes in China. After reviewing 7,000+ Chinese-language records, we extracted and analyzed data from 200+ eligible articles and are now preparing a manuscript for publication.

Boiled or Bottled: Regional and Seasonal Exposures to Drinking Water Contamination and Household Air Pollution in Rural China

Abstract/Summary: We assessed the regional and seasonal prevalence of HWT practices (including bottled water use) in low-income rural areas in two Chinese provinces, evaluated the microbiological safety of drinking water and associated health outcomes, and estimated the air pollution burden associated with the use of solid fuels for boiling. Methods: We conducted cross-sectional surveys and collected drinking water samples from 1,033 rural households in Guangxi and Henan provinces. Temperature sensors affixed to pots and electric kettles were used to corroborate self-reported boiling frequencies and durations, which were used to model household air pollution (HAP) in terms of estimated particulate matter 2.5μm in aerodynamic diameter (PM2.5) concentrations. Results: Based on summer data collection in both provinces, after controlling for covariates, boiling with electric kettles was associated with the largest log reduction in thermotolerant coliforms (TTCs) (0.66log10 TTC most probable number/100mL), followed by boiling with pots (0.58), and bottled water use (0.39); all were statistically significant (p<0.001). Boiling with electric kettles was associated with a reduced risk of TTC contamination [risk ratio (RR)=0.25p<0.001] and reported diarrhea (RR=0.80p=0.672). TTCs were detected in 51% (n=136) of bottled water samples. For households boiling with biomass, modeled PM2.5 concentrations averaged 79μg/m3 (standard deviation=21). Discussion: Our findings suggest that where boiling is already common and electricity access is widespread, the promotion of electricity-based boiling may represent a pragmatic stop-gap means of expanding safe water access until centralized, or decentralized, treated drinking water is available; displacing biomass use for water boiling could also reduce HAP concentrations and exposures. Our results also highlight the risks of increasing bottled water use in rural areas, and its potential to displace other sources of safe drinking water, which could in turn hamper efforts in China and other LMICs toward universal and affordable safe water access.

The Multidimensional Poverty Assessment Tool: A new framework for measuring rural poverty. 

The Multidimensional Poverty Assessment Tool (MPAT) measures fundamental dimensions of rural poverty in order to support poverty-alleviation efforts in the less developed world. This article’s primary purpose is to introduce MPAT and describe its theoretical rationale. It begins with an overview of the importance of creating enabling environments for rural poverty alleviation before describing MPAT’s purpose and structure. The article goes on to address some of the advantages and shortcomings of surveys and indicators as means of measuring poverty, and concludes with a few caveats on using MPAT, and a focus on its added value to practitioners and academics.

InnoWat: IFAD & rural water investments

IFAD is currently engaged in over 230 loan operations in 85 countries. About two thirds of that portfolio is related to community-based natural resource management. Poor rural people and their institutions are at the core of this approach. Water is critical to these men and women pastoralists, fishers, farmers, young and old, part- or full-time, urban or rural, indigenous, tribal or otherwise often marginalized people. Itis the key entry point for improving their livelihoods. Water-related interventions are often linked to the building up or restoring of the asset base – and involve many facets and uses. This holistic view is part of the characterization of IFAD’s approach to water interventions in this fact sheet: rather than considering water solely as an input factor in the production chain, we have preferred to follow water throughout rural people’s livelihoods. This approach, combined with a qualitative analysis of the ongoing 2007/08 loan portfolio, yielded a few surprising insights (table 1).Almost half of all projects (45-50 per cent) involve aspects of water resource management at catchment or watershed levels, and hence beyond the immediate household or community level of use.

InnoWat Topic Sheet: [Pro-poor] Payments for watershed services

Payments for environmental services (PES) are a means of creating a market in environmental/ecosystem services. They link those who value a given service with those who can provide it. Most early PES initiatives were in Latin America, which remains the region with the most PES schemes, followed by Asia, and lastly Africa (figure 1). Payments for watershed functions seek to link upstream land use and management with downstream water use and management to realize benefits for upstream and downstream participants in the scheme and others in the area – not to mention for the environment. The ideal is a voluntary agreement between at least one buyer and one seller of ecosystem services (or land-use changes presumed to provide an ecosystem service). PES schemes have become increasingly popular with donors over the last few years. Yet despite their widespread application, by their nature they are not primarily intended as a tool for poverty reduction. They may be tailored to this purpose, however. From IFAD’s perspective, the problem is that poor rural people lack the prerequisites for participation in PES. Often, they do not have secure land tenure, rewards are easily usurped by the elite, and they lack the assets (human capital, natural resources) to provide the level of service needed to yield the desired impacts. Part of the solution to this stubborn dilemma may be to eschew PES schemes that simply seek market creation. Rather than clinging to economic principles, develop a variant of PES that builds on the reality faced in rural areas. This means allowing for market support, subsidies and a means of directing PES benefits to poor people – in short, developing pro-rural-poor PES.

Synthesis of strategic approaches: Enhancing pro-poor investments in water & rural livelihoods.

The reduction of hunger and poverty depends on improved access to water for poor rural people. Progress in community water supplies and agricultural water management (AWM), particularly irrigation, is one of the success stories of the twentieth century. However, it is disappointing to learn that AWM, by far the largest consumer of water in developing countries, has had little impact on world hunger and poverty. The experience of agency- and government-led interventions has not been good. They often impose ‘blueprint’ methods that ignore important local issues. A critical gap exists between planning and successful implementation. Approaches focus on what needs to be done, rather than on how to do it, and they ignore the complex interactions among individuals, the state and service providers –as well as their limited capacity to translate plans into practice. If poor rural people are not to be the losers again in the struggle for declining water resources, a new, pro-poor water management strategy is needed. It must focus more on how to do it, while still addressing what to do, where and with whom.