Assessment of health impacts of quality water provisioning from groundwater sources: a micro-level study in India

Access to safe water is a fundamental human right and a policy goal in many nations (Bain et al., 2020). The UN Sustainable Development Goals (SDGs) 2030 agenda, inter alia, includes global goals for water, sanitation, and hygiene. For instance, SDG 6 aims to ‘ensure availability and sustainable management of water and sanitation for all’ to address water quality issues. Concerns with water quality are addressed by SDG indicator 6.1, safely managed drinking water (SMDW) services. SMDW services are improved sources of clean, contaminant-free drinking water that is accessible on-site (WHO, 2017; Marchese et al., 2018).

Reportedly, in 2020, 75% of the world's population got access to safe drinking water leaving about 25% without access (WHO & UNICEF, 2022). Furthermore, there is a stark division between urban and rural access to ‘improved’ and ‘safe’ water sources (UNICEF & WHO, 2019). According to the Joint Monitoring Program (JMP), 2 billion people do not have access to SMDW worldwide, with sub-Saharan Africa as well as Central and South Asia having the highest in access rates (WHO & UNICEF, 2017). Development activities pollute both surface and underground water sources (Chandra Mohan et al., 2014). While toxin percolations from the soil to ground water contaminate drinking water (Khan & Srivastava, 2012), polluted water tends to host cholera-causing Vibrio and schistosomiasis (Rahman et al., 2018).

Water quality challenges are addressed in other SDGs as well, such as those dealing with poverty reduction (SDG1), health and wellbeing (SDG3), and sustainable consumption and production (SDG12), due to their links to important environmental, socioeconomic, and development issues. As a result, the emphasis on water quality in multiple SDGs reflects the growing need to improve global water quality (Ezbakhe, 2018).

Like many other countries, India is also facing the major concern of growing threat to groundwater quality posed by anthropogenic activities. Reportedly, in India, which occupies 2.2% of the world's land, 4% of its water resources, and 16% of the global population (Hrvatin et al., 2020), groundwater overexploitation degrades water quality (Nigam & Srivastava, 2019). India faces the most serious water shortage issue in the 21st century. Groundwater quality deterioration in rural India poses significant challenges for safe drinking water because it is the primary source of rural water supply (Kumar et al., 2022). Water quality is deteriorated by bacteria, fluoride, salinity, and arsenic, besides contamination due to nitrates, silica, uranium, lead, and other substances (Rajawat & Madheswaran, 2016; Saleem et al., 2016). Water with high iron content can cause tooth discolouration, diarrhoea, and skin problems (Kumar et al., 2017). Also the use of heavy metal contaminated ground water can cause toxic elements to accumulate in cereals and vegetables, posing human health risks (Jenifer & Jha, 2018; Zhang et al., 2018).

The Government of India spends an amount of Rs. 6,700 crores (USD 805 million) each year for the treatment of people suffering from water and sanitation-related diseases. This amount is barely Rs. 52 crore (USD 6.25 million) lower than the country's Central Health Ministry's annual budget, but more than that allocated for education (Narain, 2002; Khurana et al., 2008).

People in India mostly use public water sources for drinking, domestic, and other non-domestic uses, where these sources mainly include groundwater, public taps, water from nearby rivers, ponds, and harvested rainwater. The reliance on untreated sources is partly attributed to the irregularity and inconsistency of pipe water distribution systems (Yadhunath et al., 2020).

In India and other developing countries, the emphasis is on ensuring universal access to clean water, as water pollution detection is often overlooked due to the limited capacity of local institutions to conduct such tests (Kanyagui & Viswanathan, 2022). Water supply is a national issue, whereas pollution is a local issue with ramifications for policy and actions (Abbaspour et al., 2007). In recent years, pollution control boards in many Indian states have conducted various water quality tests in order to better understand the types of pollution that are harming public health and the economy. This was aimed at a better understanding of the relative impact of various types of pollution in the country (Central Pollution Control Board, 2020).

Kansal et al. (2017) emphasized the importance of protecting and conserving water resources, prioritizing water quality, and implementing integrated planning, demand management, and water pricing to address India's growing water challenges. It was observed that a clear, science-based water resource policy is required at the central and state levels along with an effective legislation for groundwater and surface water regulation at the state level. The need for restructuring and empowering of the existing water institutions at the local level was also highlighted to improve efficiency and sustainability. In this regard, Kumar et al. (2022) observed that government's long-term policies should focus on building scientific capabilities of local agencies, restructuring them to effectively perform water quality management and pollution control, and implementing projects that adequately respond to environmental concerns in rural areas.

Against this backdrop, this study explores the aspects of water quality and household water scarcity in a village (Nagla Chandi) in Mathura district in Uttar Pradesh, India. It evaluates the water quality status of two water supply systems, viz., a hand-dug well fitted with hand pumps and a cutting-edge water filtration system, known as the Jivamritam (meaning, ‘elixir of life’) filtration system. Besides a comparative assessment of the water quality and water delivery aspects of the Jivamritam water filtration system with the hand pump system, this study also examines the potential health impacts and draws relevant insights for public policy and actions, as concerns of water scarcity and security and sustainability pose critical challenges at the national and local levels.

The study adopts a mixed methods approach for assessing water quality parameters and its implications on health outcomes in the study village. Raju et al. (2012) and Ahmed et al. (2020) note that the contamination of water sources can be assessed using qualitative and quantitative methods of defined water quality parameters. A quantitative analysis of data on important water parameters was carried out based on the test results of various mineral contents carried out at an independent environmental and analytical laboratory.

Besides water quality assessment, we also conducted focus group discussions (FGDs) involving women of the Nagla Chandi village along with key informant interviews to discuss the water supply, sanitation, and health outcomes. The FGDs included eight participants carefully chosen for the breadth of their knowledge (Djamba & Neuman, 2002; Coghlan & Brydon-Miller, 2014; Jilcha, 2019) pertaining to water quality and sanitation problems in the village.

The study protocol was approved by our institutional review board, and the subjects were given an informed consent authorization form (Nagla Chandi Village) by the Institute of Medical Sciences Healthcare, Education & Research, Institutional Ethics Committee, Kochi, Kerala (Protocol No. – IEC-AIMS.2O22. ASSD.255 and 05/10/2022).

The rest of the paper is organized as follows. Section 2 discusses the results of the comparative water quality assessments of the two systems. In Section 3, we discuss the health impacts of the water sources. The section then reports the results of the FGDs and key informant interviews concerning water-related illnesses in the study village. Section 4 presents the conclusions and policy suggestions to improve the water delivery services in similar rural contexts.

As the national population census 2011 data do not include Nagla Chandi village, we relied on the headcounts undertaken as part of an ongoing village project. Based on the headcount, the total population of the village in October 2022 was 350 (Kanyagui et al., 2023).

The village's primary water sources include 43 covered hand-dug wells that are installed in homes equipped with pumps. The recently introduced Jivamritam water filtration system is the secondary source for household use, provided by the Amrita Live-in-Labs®'s project, an initiative by Amrita Vishwa Vidyapeetham in India. Amrita Live-in-Labs® is a multidisciplinary experiential learning program that aims to develop sustainable solutions for rural communities' challenges. It breaks classroom and lab barriers, allowing participants to study, observe, and interact with rural populations (Ajith et al., 2022). There is also an old uncovered well in the middle of the village that is not utilized. Water from hand-dug wells is mostly utilized for domestic uses such as laundering, consumption, food preparation, bathing, animal bathing, and construction.

The choice of Nagla Chandi village for the study was based on several considerations, including the fact that it is the only village in the Ral block to have benefited from any Civil Society Organisation (CSO) interventions in the form of the installation of a drinking water system (Ajith et al., 2022). Like many other villages within the block, almost every household has its own borewell. The scenario also provides an opportunity to examine the factors influencing household choices of alternative water sources in relation to water quality, as well as how this affects water system sustainability. Furthermore, it is expected that the lessons learned from the study will help in scaling up of similar intervention within the Ral block and in other rural areas in India, which face water quality problems. Furthermore, while underground water quality tests have been conducted in other villages in the Mathura district (Ahmed et al., 2018), no such tests have been conducted in the study village to determine the suitability of underground water for drinking purposes.

In what follows, we present a comparative analysis of the water quality test results in the case of the handpump water (referred to as raw water), followed by the test results of the water sample drawn from the Jivamritam water filter, which is a new intervention in the village.

The water quality parameters were compared with the required threshold values as per the Indian Standard (IS) 10500: 2012. Table 1 shows the parameters that are within the acceptable limits, and Table 2 shows parameters that are above the acceptable threshold for handpump water.

The results of handpump water quality tests show that test items listed in Table 1 are within the parameters and those listed in Table 2 exceed the limit. Hence, it is observed that the handpump water is unsafe for consumption. The health implications of the water quality from the handpumps will be examined in the Discussion section.

Several NGOs in India work with the governments to meet rural water needs (Asad & Kay, 2014). Jivamritam is a community-based clean drinking water solution, a scaled-up Live-in-Labs® project launched in October 2017, supported by the CSO¹. Phase 1 of the project aims to provide clean drinking water to 10 million people in 5,000 villages in India. When complete, the system is expected to serve 2,000 people a day.

The initiative aims to reduce water-borne diseases by providing a common water source to the water-deprived communities. The initiative focuses on community ownership and management of the water system, with funds generated from operating the system used for operation and maintenance (O&M) and addressing other water issues like scarcity (through conservation). Also, the initiative facilitates the formation of water committees responsible for the O&M of the system. The initiative also organizes sessions and awareness campaigns to educate communities about water-borne diseases. To reduce the increasing dependence on packaged drinking water, which is commercially available in 20-L cans at a high cost, the initiative aims to supply drinking water at a price at least 10 times lower than the commercial water supply (Amrita Vishwa Vidyapeetham, 2020).

Reverse osmosis (RO) is a process that removes impurities in drinking water, including harmful ions, organisms, and pesticide residues (Kumar & Shah, 2006; Ahuchaogu et al., 2018). The Jivamritam dual sand/activated carbon filter eliminates toxic substances like fluoride, fertilizer, pesticide residues, heavy metals, suspended particles, and turbidity. Following that are 5- and 1-μm filters. Each system includes an ultraviolet water purifier to remove infectious agents as well as two storage tanks to preserve filtered and unfiltered water separately and avoid contamination. The system's filtered water tanks are connected to taps for drinking water.

The water quality parameters were compared with the required threshold values as per the IS 10500: 2012. Table 3 shows the results of the test.

The water test results in Table 3 show that the water is of sufficient quality to be used as drinking water by the community when compared to IS 10500:2012. The discussion that follows highlights the definition of the borewell water parameters that exceed the IS 10500:2012 threshold and the associated health implications.

SDG indicator 1.4.1, which measures the percentage of people living in households with access to basic services, is directly impacted by the findings of the water test results. Even though access to potable water has significantly improved in rural India, the situation in Nagla Chandi falls short of the national progress. It is in such situations that the need for effective implementation of schemes such as Jivamritam holds immense potential for implementation to achieve the national targets associated with water and sanitation and related SDGs. Table 4 below provides details of the health implications of the water test result.

The outcomes of the water quality tests carried out as reported above have implications for SDG indicator 3.9.2, which pertains to death rate attributable to poor sanitation, unclean water, or lack of hygiene (Water, Sanitation and Hygiene (WASH)), expressed as the number of deaths per 100,000 persons in a specific population (Biswas et al., 2022). India's death rate due to unsanitary conditions (WASH) was 36 per 100,000 population in 2019 (Global Burden of Disease (GBD) Collaborative Network 2019). The continued reliance on highly contaminated, untreated borewell water has negative effects on attaining the national goal of lowering the death rate owing to water-related diseases by 2030. Kumar et al. (2022) observed that adverse health impacts of poor-quality groundwater are widespread, and preventive and curative measures may not receive priority due to institutional inadequacies in monitoring and preventing groundwater pollution.

We conducted an FGD with a village women's self-help group (SHG) to determine the primary ailments, if any, particularly, water-borne diseases in the community (Figure 4).

The group's biggest complaint about the hand-dug well, which served as their main source of drinking water supply, was that the water tasted salty. The group highlighted a number of common water-borne illnesses, such as skin disorders, hair loss, yellowing of teeth, and diarrhoea. These health issues can be attributed to the high iron content (Tiwari et al., 2016) in the water as shown by the water test results.

The FGD with women SHG also revealed that although the village had a water treatment facility, its frequent breakdowns and remote position from the homes contributed to people preferring untreated water from handpumps within homes as their primary source of water. Water pumps are often regarded as one of the most significant interventions in India, wherein the national and state governments had made huge contributions (with varied impacts) in terms of water supply schemes with aid from multilateral agencies, such as the World Bank and Asian Development Bank.

The group noted that households do not prefer RO water as its use involves payment of user charges. They are forced to rely on the contaminated, free water from the hand-dug well because of their circumstance, which has exacerbated the occurrence of water-borne ailments.

Apart from reporting joint pains that are not directly related to quality of water, most of the other reported diseases are water related. Figure 5 shows that the most common water-related diseases in the village are the reddening of teeth followed by diarrhoea, which is linked to the high iron content of the handpump water. Based on the outcome of the test results, it is evident that the incidence of water-borne infections is likely to decrease over time if households exclusively utilize RO water instead of handpump water for drinking and cooking. This is because the RO water's test results for all parameters are within the safe (permissible) limits. In this regard, Kumar et al. (2022) noted that demineralization using an RO system can remove hazardous impurities from drinking water and is cost-effective in areas with high total dissolved solids (TDS), nitrate, and fluoride levels.

Most rural water schemes face operational challenges due to lack of technical and managerial skills in local institutions, such as Panchayats. Furthermore, due to low income status and the lack of livelihood opportunities for rural communities, they are unable to pay for treated water at appropriate rates to ensure adequate revenue to fund the O&M of community-based water systems. There are also limited resources for educating communities about groundwater quality issues and treatment methods. Various models have been used in various countries to ensure the sustainability of community-based water systems to improve access to treated water. In what follows, we examine three such models to identify best practices, which can help draw parallels with respect to the Jivamritam model and suggest modifications or improvements needed if any.

Whave, a Ugandan social enterprise in Uganda, is an advisory body advocating for improved rural water service delivery through public–private partnerships (Harvey, 2017, 2019, 2021). The enterprise works with local governments to develop regulatory structures and maintenance protocols. As a guaranteed service provider, Whave contracts local handpump mechanics for performance-based payments and ensures water supply functionality. The company works with local governments to develop payment options, including subscriptions (Nyaga, 2020).

The Safe Water Network model (Safe Water Network 2021a, 2021b), used in Ghana and India, is a market-based approach to delivering safe water to communities. The approach involves identifying local water sources, testing for contaminants, and providing capital for treatment systems known as safe water stations. Local community members are trained on station operation and maintenance, and water is sold through ATMs and delivered to households or retailers. User fees cover operating and maintenance costs, while unit costs pay for higher water quality. Technical support is provided by local engineers, and the model focuses on supply chain strengthening. Key performance indicators include cost coverage, financial reserves, and household participation (Nyaga, 2020).

The FundiFix model (REACH 2016) in Kenya aims to maintain rural water infrastructure through a guaranteed service approach. Local maintenance service providers (MSPs) are established in two counties, Kwale and Kitui, as independent social enterprises. These MSPs, equipped with tools, training, and office space, set up annual performance-based contracts with communities and schools. The local government is responsible for asset replacement and major repairs. Smart monitoring data from hand pump sensors is used to inform MSPs of system conditions and repair needs (Goodall & Katilu, 2016; Nyaga, 2020).

The study highlights issues related to the performance and functionality of rural water systems and the need for investment in rural water infrastructure to improve access to treated water. It also emphasizes the need for community sensitization of the sustainability of public utilities and the need for strategic water quality management plans and funding for monitoring water quality in rural areas. A summary of the conclusions, policy suggestions, and future research directions is presented in Table 5.

This project was funded by the E4LIFE International Ph.D. Fellowship Program offered by Amrita Vishwa Vidyapeetham. We extend our gratitude to the Live-in-Labs® academic program for providing all the support. The authors express their immense gratitude to Sri. Mata Amritanandamayi Devi, Chancellor of Amrita Vishwa Vidyapeetham, who motivated the authors to research sustainable development issues in rural communities. The authors also thank the anonymous referees of the journal for the comments offered. The usual disclaimers apply.

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by all authors. The first draft of the manuscript was written by MKK, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.