The free basic water policy is being unevenly implemented and greater attention needs to be given to meeting the needs of the rural poor and those in poor peri-urban communities who would most benefit from its provision, concludes an HSRC report which examines the extent to which the response to the cholera epidemic of 2000/01 has led to sustained provision of safe water and improved sanitation to the poor. This report, Still Paying the Price: Revisiting the Cholera Epidemic of 2000-2001 in South Africa, suggests there is a clear relationship between cost recovery, indifferent municipal management leading to interruptions in supply, and vandalism. In the period since the epidemic, events have shown that it was not a unique occurrence. The outbreak of typhoid in Delmas during August–October 2005, in which there were five deaths from the disease and 596 cases accompanied by 3 346 cases of diarrhoea, demonstrated the continued vulnerability of poor people in urban and rural settings to water-related disease. The evidence pointed to problems in the management of the bucket sanitation system, affecting the quality of water. The epidemic that spread throughout the eastern coastal region and to other provinces resulted in 265 deaths in five provinces and 117 147 people were infected, the majority in KwaZulu-Natal where it originated. The epidemic was, according to the World Health Organisation, the biggest such outbreak in Africa for the reporting period. The epidemic demanded an urgent review of the state of water provision to the traditional rural areas and informal settlements where it was concentrated. The report begins by attempting to answer a number of questions which emerged from this review: What led to an outbreak becoming an epidemic? How was it that many of the victims were those who were situated within areas where water projects were in operation? The answers came from rural development researchers and later from government itself: the policies of cost recovery had disadvantaged those for whom even a small charge of about R20 a month was too much. At its epicentre it was reported that those who could not afford the new charges being implemented in August 2000 were returning to traditional and untreated water sources and were falling victim to the disease. The emergence of cholera in South Africa highlights two points. The most obvious is that there are significant gaps remaining in service delivery. The immediate response to the epidemic was to focus on sanitation, particularly the construction of tens of thousands of toilets in rural areas. Ongoing work to improve the delivery of water was also intensified. A second, more subtle point is that cholera follows from the country’s persistent uneven development. Although services have been improved in many areas, underlying poverty remains in most of the historically disadvantaged parts of the country. Cholera has affected areas with services as well as those without services in part because these areas are uniformly poor. As a result, one of the most overlooked aspects of the epidemic is that “serviced” areas – i.e. areas with piped water – were also prey to cholera. In fact, the epicentre of the outbreak was not an unserved, deep rural community but a semi-rural community on the outskirts of a major industrial area that had access to piped water. A powerful interpretation of the spread of the epidemic to thousands in many provinces is that the pressure on the poor to pay for water made them turn to untreated sources. For instance, Cottle and Deedat argue that DWAF’s unbending implementation of its cost-recovery policy forced poor households to resort to using unsafe sources of water which increased their chances of being infected with cholera. That there was a link between payment for water and the emergence of cholera was recognised by policymakers shortly after the epidemic and was soon followed by national government’s Free Basic Water FBW) policy in late 2000, offering six kilolitres of free water per month to all South African households (intended to provide a lifeline of at least 25 litres per person per day based on a household of eight people). Although largely implemented in urban metropolitan areas and towns, the extension of FBW to those who needed it most has been limited by systems – or a lack of systems – in place to be able to implement such a policy in semi-urban and rural areas. Ironically, the policy of providing free water is being implemented least in the very areas that were the reason for its formulation. The extension of free basic water to urban townships has also been uneven but in the five years after its announcement, many township households now have access to 200 litres of free water per day through meters (though this is still inaccessible to those unable to afford the water or the card required to use a prepaid system). This study asks: What were the local implications of national, provincial, and local government policies, decisions and action before, during, and after the cholera epidemic? How did communities with access to piped water respond to a service that became costly and irregular? Three main points emerge. First, even though the government health intervention to the epidemic was largely effective, local experiences of powerlessness resulted in a range of unexpected community responses. Second, following the epidemic, important improvements were made that resulted in all those interviewed using piped water, water sources closer to households, and increased access to improved pit latrines (VIPs). However, at the time of fieldwork the FBW policy had not been extended to the areas covered in this study, which meant that access to water was still problematic. People continued to resort to using water from traditional sources, often without treating it. Finally, the combination of having to pay for water and poor water service with frequent interruptions resulted in complex community dynamics related to storing water, problems in payment and vandalism. These issues arise not only from the type of macro-level policies and programmes that are being put into place, but also from local government. The cholera epidemic was handled as an emergency. First, the medical intervention with the help of the army medical corps succeeded in breaking the force of the epidemic and reducing cholera to occasional and limited outbreaks. Second, there was the health promotion carried out by Community Health Workers to publicise the danger of taking water from unsafe sources, to treat water and to wash hands. Third, there was the national government’s promise to provide free water in the amount of six kilolitres a month to every household. Finally, there was a renewed commitment to provide improved sanitation and to end the water backlog. The HSRC research drew on two studies at two sites. In terms of water supply, although administered differently, both areas had access to piped water at the time of the cholera outbreak. Perhaps most importantly, people had to pay for water but argued they were unable to do so due to the pervasive poverty in both areas. The first site was Nqutshini, a semi-rural settlement on the banks of the Mhlatuzi River on the outskirts of the industrial town of Empangeni, which was the epicentre of the cholera epidemic. The area falls under the Umhlatuze local municipality, which is a part of the greater uThungulu district municipality. The other was at Nkobongo, a developing low-cost housing area with informal settlements near Ballito, 40km north of Durban, in the Dolphin Coast municipality. The report compares conditions obtaining during the epidemic in 2000/01 and at the time of fieldwork in 2004. Considerable improvement in access to piped water and toilets had been achieved by 2004. Respondents reported that, although frequently interrupted, they get their water from a piped source even though not all report they are paying for water. Of the 80 respondents, 59 households reported access to communal taps and 21 households (who could afford the expense of installation) had access to yard connections. In addition, the vast majority of households (77 out of 80) now report that their water source is safe to drink. In addition, water sources are now much closer, with 55 households accessing water within 50m. Similarly 46 households also mentioned that the distance to the improved water sources water was reduced to only 15 minutes, compared to only five households with this kind of access in 2000. With the provision of improved piped water, only five households are now collecting water more than three times a day compared to 26 in 2000. There were other improvements. One of the positive responses to the epidemic was a renewed interest in sanitation. At the time of the epidemiconly three households in Nqutshini used VIP latrines. Months after the epidemic, plans were made for the construction of VIPs and DWAF approved R2.8 million to meet the needs of 9 600 households as cholera intervention. A survey was conducted of the precise number of households in the community to ensure that all were included. Toilets were also built in Nkobongo. In 2004, at both sites, 77 households reported that they had VIPs and, unlike access to yard connections, availability of a toilet in 2004 did not depend on income. What has changed since the cholera epidemic? Epidemic (2000) Post-epidemic (2004) (Number of households) Piped water source 2 80 2 80 Water on site or in yard 1 21 Water is safe to drink 18 77 Less than 50m distant from water source 8 55 Less than 15 minutes to water source 5 46 Water collection: more than 3 times a day 26 16 Toilet facility: VIP 3 77 N=80 Yet, other things did not change. Despite many warnings from health authorities during the epidemic that water from the Mhlatuze and Mpangeni rivers was unsafe and should either be boiled or treated with Jik, it is clear that water was only treated for a period after the outbreak of cholera, and that many people stopped treating water as soon as the cholera scare died down. This raises a number of questions about the effectiveness of the health promotion intervention and the receptivity of local residents to the messages. Were those without radios and other forms of communication beyond effective reach or were there impediments to people’s understanding? Since charging for water led people to revert to using traditional water sources, the provision of free basic water was one of the most significant post-epidemic changes. However, this was, ironically, one area where things did not change for the communities in this study. Policy versus practice: Free Basic Water The national FBW policy that arose from the cholera epidemic is part of a long-term intervention aimed at improving access by the poorest to all services. If cholera is a disease of poverty, how can poor people be protected from its ravages by effective and free provision? The question has been raised in public debate, with the then-Minister of Water Affairs and Forestry, Ronnie Kasrils, making the link between the socio-economic conditions of people and the disease, as follows: “My visits to many rural areas highlighted the fact that many of our people are so desperately poor that they cannot afford what may seem to us a very small price for water, but which may represent a considerable percentage of a family’s meagre income…Should they have to pay a mere R10 per month for water, they said, their families would have less to eat. They therefore chose to buy food instead and take their chances in searching for river or ground water. It is a fine principle to say that everybody must pay for services and to stress cost recovery, but we have to understand that the poorest of the poor cannot yet afford to do so… the Cholera outbreak in KwaZulu-Natal would not have happened if all South Africans had access to safe drinking water.” Since poor people cannot afford even the lowest tariffs, universal access is compromised where cost recovery is stressed. Charging for water leads to exclusion and to sharply decreasing health benefits from service delivery. Kasrils’ recognition that charging for water was linked to the epidemic led him to make public statements in support of free basic water within weeks of the outbreak. On 18 September 2000 President Mbeki first announced the FBW policy at a Cosatu conference, and on 19 September Minister Kasrils issued a press statement that there would be a minimum of six kilolitres a month lifeline tariff. Although this has been implemented in many urban municipalities, in the rural areas the lifeline tariff has generally not been implemented. In fact, in Nqutshini and Nkobongo, the provision of water services brought about new demands on the household income. The cost of water still continues to be a major factor in poor people’s access to sufficient safe water. There is evidence that, four years after the outbreak of cholera and the introduction of FBW, none of the households were receiving the free water allocation. Instead, households reported that, compared to the situation during the cholera epidemic, the one noticeable change is that they are now paying for water. Despite Nkobongo being the site of a high level of cholera cases, the prepaid system has continued, and the promise to provide free basic water has not been implemented. In 2004 it was announced that, four years after the FBW policy was announced to benefit poor people, township residents would finally receive what others have had for some time. Although prepaid standpipes were modified to provide 200 litres a day to those with cards, a major obstacle to receiving FBW remains the cost of the card itself. Service issues One of the unexpected features of water delivery in the community (particularly in Nqutshini) is its unpredictability and poor management. In the Madlebe tribal area there has been little or no real improvement despite visits from ministers and departmental intervention. The Madlebe water scheme continues to be administered to some extent by the tribal authority and frequent interruptions in supply are reported. Despite the enormous attention focused on the area as the early centre of cholera, it continues to be common for water to be unavailable from the taps at Nqutshini without reason or notification. In contrast, the operation of the water service by the SAUR concession in Nkobongo appears stable even though the costs of water are comparatively high. When asked the reasons for interruptions to their water supply, most households were able to provide a specific reason. The following table shows that the most common reason given for interruptions was vandalism followed by burst pipes, general maintenance and cutoffs. Reasons for water interruptions in the past year Frequency Percent Vandalism 17 21 Burst pipes 14 18 General maintenance/repairs 12 15 Pump not working 7 9 Non-payment for services (cut off) 6 8 Not enough water in the system 3 4 Water only delivered at fixed times 3 4 No interruptions 1 1 Poor management 1 1 Do not know 16 20 Total 80 100 Although general maintenance and repairs may appear as a positive level of management, people felt it was more of an indication of extensive problems needing intervention. The quality of management of water services can be best assessed by the response rate to problems of water services. While 34% of respondents report repairs being undertaken within a day, the table below shows the remainder report that repairs are made within the same week or longer. It appears from these figures that repairs take some time to be implemented, and that breakdowns lasting days were happening several times a year. Time taken to repair water systems Frequency Percent Not applicable 1 1 The same day 27 34 During the same week 50 63 During the same month 2 3 Total 80 100 The interruptions and other problems were mostly reported to the water committee and headman (in Nqutshini) or to the councillor and the service provider (Siza Water) itself (in Nkobongo). A significant proportion of the people said that they did not report problems. In Nqutshini people pointed out that they are expected to pay the flat rate for the month even when water is not coming out of the taps. They also complain that they are not informed in advance when water is going to be unavailable. Over and above inconvenience and cost, problems with water supply result in the consumption of safe water in many areas being below the basic level of 25 litres per person per day, with continuing vulnerability to disease and low levels of hand-washing. Poverty and Vulnerability to Water Related Disease The two communities studied have roughly the same level of access to water services through public provision, and household income levels in both areas range between poverty and extreme poverty. Under these circumstances, what are the precise relationships between poverty, municipal service and health? Although the communities are both poor and thus generally vulnerable to cholera, the disease is found to be associated with households at the lowest levels of income. The additional factor associated with cholera was found to be increased water storage (reflected in the number of containers used to store water). This storage of water is partly related to dysfunctional water supplies; faced with an uncertain supply people tend to store water for some time which leads to an increased health risk. The survey found the same association with extreme poverty in the incidence of diarrhoea among children in the household. The other factors associated with diarrhoea included problems in accessing sufficient water, the ability to pay for water and the household having prior experience of cholera. All these factors, and in particular the continued cycle of water related disease in households over time, point to poor health conditions and continued vulnerability to disease among those living in extreme poverty. The study concludes, firstly, that the free basic water policy is being unevenly implemented and greater attention needs to be given to meeting the needs of the rural poor and those in poor peri-urban communities who would most benefit from its provision. Second, poor communities need a reliable water service, which requires better municipal management. Third, interruptions lead to long storage of water, which poses a health risk to those who consume this water. There should be greater awareness and publicity about this danger. Fourth, communities and households with a prior experience of water-related diseases seem most vulnerable to recurrence. Health and municipal authorities should give priority to those communities with a history of water- related disease to ensure that the cycle of disease is ended.