Are piped water services reaching poor households? Empirical evidence from rural Viet Nam

Accepted Manuscript Are piped water services reaching poor households? Empirical evidence from rural Viet Nam Naomi Carrard, Ben Madden, Joanne Chong, Melita Grant, Tuyen Nghiem, Ly Bui Ha, Ha Thi Thu Hue, Juliet Willetts PII:

S0043-1354(19)30070-3

DOI:

https://doi.org/10.1016/j.watres.2019.01.026

Reference:

WR 14392

To appear in:

Water Research

Received Date: 23 June 2018 Revised Date:

21 December 2018

Accepted Date: 13 January 2019

Please cite this article as: Carrard, N., Madden, B., Chong, J., Grant, M., Nghiem, T., Ha, L.B., Thu Hue, H.T., Willetts, J., Are piped water services reaching poor households? Empirical evidence from rural Viet Nam, Water Research, https://doi.org/10.1016/j.watres.2019.01.026. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT

Are piped water services reaching poor households? Empirical evidence

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from rural Viet Nam

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Naomi Carrarda [email protected] (corresponding author)

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Ben Maddena [email protected]

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Joanne [email protected]

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Melita Granta [email protected]

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Tuyen Nghiemb [email protected]

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Ly Bui Hab [email protected]

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Ha Thi Thu Hueb [email protected]

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Juliet Willettsa [email protected]

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a

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Hanoi, Viet Nam

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Abstract

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The delivery of water services to the poor is lagging, yet local causes and manifestations of this are

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not well understood. Better data is needed to identify inequalities where they occur, explore

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underlying reasons, and develop strategies to achieve more equitable access. A focus on the local

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scale is important because this is where water services are delivered, and inequalities in access can

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be best observed. This paper presents a mixed-methods study of poor households’ access to piped

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water in rural Viet Nam, providing insight into local dynamics of the water/poverty nexus. Findings

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pointed to lower rates of piped water access for poor households across areas served by

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government, private and community service providers. Connection fees were found to be the

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primary barrier to poor households accessing available piped services. The study also found that

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where financial support is provided, poor households can achieve comparable or even higher rates

Institute for Sustainable Futures, University of Technology Sydney, PO Box 123 Broadway NSW 2007, Australia

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Central Institute for Natural Resources and Environmental Studies, Viet Nam National University, 19 Lê Thánh Tông,

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ACCEPTED MANUSCRIPT of access. Key implications of the study are the demonstrated value of, and yet challenges associated

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with, rigorous local-level monitoring to ensure equitable, quality service delivery.

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Keywords

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Water services; poverty; piped water; Viet Nam; mixed-methods

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1

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Global monitoring of access to water indicates persistently lower rates of access to improved

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sources for the poor compared with other groups, a situation particularly evident in rural areas

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(WHO/UNICEF 2017). The need to focus efforts on ensuring water services reach the poorest and

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most marginalised has been recognised by the international community. Sustainable Development

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Goal (SDG) 6 calls for the achievement of universal and equitable access to safe and affordable

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drinking water for all by 2030, in line with the Agenda 2030 commitment to “leave no one behind”

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(United Nations 2015). This aligns with efforts to realise the Human Rights to Water and Sanitation

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for all, without discrimination (UN Special Rapporteur 2014).

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To achieve universal, equitable access to water services, sharper focus is needed on inequalities in

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access between groups such as rich and poor, rural and urban, or potentially disadvantaged groups

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versus the general population. Disaggregated and higher resolution data is needed to identify

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inequalities where they occur, explore underlying reasons, and develop strategies for improving

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equality of access. Recent efforts by the WHO/UNICEF Joint Monitoring Program (JMP) have made

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advances in this area, with country and global datasets now incorporating wealth quintile and sub-

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national differences in access to services (WHO/UNICEF 2017).

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Yet knowledge gaps remain, particularly at local levels where inequalities translate into lived

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experiences, and where ultimate responsibility for ensuring universal water services lies (Pati and

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Neumeyer 2018; Keatman et al. 2016). There is a need for data that provides insight into the local

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dynamics of poverty and water access, including identifying reasons for non-uptake of available

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services, and exploring outcomes associated with different models of service delivery. Research on

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private and social enterprise service delivery has found that programs might monitor the

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participation of poor households in program activities, but there is a gap in data on actual outcomes

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for the poor (Gero et al. 2014). Such data will provide critical information towards development of

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strategies to address current inequities and work towards achievement of universal water access.

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Introduction

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ACCEPTED MANUSCRIPT Yet this data is notoriously difficult to collect, with challenges compounded in developing country

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contexts where water services can often evolve ad hoc without coordinated planning (Grant et al.

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2016), resulting in challenges related to defining service area boundaries and identifying rates of

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connection.

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Seeking to address the data gap on local level water inequality, this paper reports on a mixed-

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methods study of poor households’ access to piped water in rural Viet Nam, and illustrates how the

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methodological challenges in doing so can be overcome. The objectives of the study were twofold:

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(i) to determine the extent to which piped water services are reaching poor households; and (ii) to

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identify explanatory reasons for non-connection of poor households. With reference to both of

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these objectives, we also sought to compare the relative success (or otherwise) of different service

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provider types in reaching poor households, looking across government, private and community-

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based models.

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We first provide a brief overview of water and poverty dynamics in Viet Nam. We then present

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materials and methods used including qualitative and statistical analysis components. The

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methodology applied was tailored to facilitate rigorous analysis of the kind of ‘fuzzy data’ typically

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available in developing country contexts, and as such, offers both an approach with potential for

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further application in comparable situations, and insight into the particular challenges and

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limitations faced. The results of the analysis are presented and discussed, including relative rates of

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water access between poor and non-poor households and reasons for non-connection. Finally, we

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consider how this research might inform efforts to better understand disadvantage as the world

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strives for universal and equitable access to safe and affordable water by 2030.

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In 2018 the Government of Viet Nam released its response to the Sustainable Development Goals,

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emphasising its commitment to achieving Goal 6 of the SDGs, with a focus on pricing and

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affordability (Government of Viet Nam, 2017). This is important, since at the national level in Viet

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Water poverty in Viet Nam

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ACCEPTED MANUSCRIPT Nam, a quarter of the poorest wealth quintile in rural areas are without access to an improved water

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source, compared with near universal access for the highest wealth quintiles (Figure 1). The figures

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are even more pronounced for piped water in particular. Access to piped water is an important

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measure, given global research indicating that piped supplies are significantly less likely to be

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contaminated between source and household storage compared with non-piped supplies (Shields et

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al. 2015) and that water piped to premises results in a 75% reduction in diarrheal illness, higher than

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any other water, sanitation or hygiene intervention (Wolf et al. 2018). Only 5% of the poorest wealth

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quintile in rural Viet Nam have access to piped water, compared with 47% of the wealthiest quintile.

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Figure 1 Proportion of household population by water supply type by wealth quintile in rural Viet Nam 2014 (General Statistics Office and UNICEF 2015)

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Possible reasons for lower poor-household connection rates have been outlined in research focused

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on private enterprise water service delivery (Batzella and Ljung 2014; Grant et al. 2016). These

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include the cost of connection (particularly when fees are set on a cost-recovery basis) and the

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location of poor households, in a context where service delivery evolves in a piecemeal and

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opportunistic fashion. This study sought to contribute further evidence by analyzing rates of

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connection between poor and non-poor households and comparing the relative success of different

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types of service providers across private, government and community-based models.

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The need to consider the relative success of different service provider types in reaching poor

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households is critical, given the current Government of Viet Nam policy focus on increasing the role of private providers in service delivery in rural areas. A national Government policy (Circular 131)

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establishes incentives for private water service providers in the form of co-financing, land and tax

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exemptions (Grant et al. 2016; Willetts et al. 2017). Yet application of this policy by provincial

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governments has been partial, and in some cases processes for enterprises to access the incentives

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is complex, limiting their uptake (Willetts et al. 2017). Nonetheless, there are an increasing number

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of private providers, and their effectiveness in reaching the poor must be compared with other

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existing service provider types, namely government (or government-owned enterprises) and

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community managed systems.

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3.1

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The study addressed two research questions:

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Material and methods

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Research questions and overall approach

1. To what extent are piped water services reaching poor households?

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2. In cases where disparities exist between rates of poor and non-poor household connection,

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why are poor households not connected to piped water supplies?

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Research question 1 (RQ1) was considered at two scales: (i) commune (village) wide; and (ii) water

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service areas within communes. Communes are a local administrative boundary in Viet Nam. There

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can be one or more water service areas within a commune, and water service areas can also cross

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commune boundaries, though this was less common in case study locations. Looking at an entire

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commune, we first investigated the location of poor households with reference to water service area

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boundaries. For the study, ‘water service area’ was defined by water service providers (during

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ACCEPTED MANUSCRIPT interviews) as the area within reasonable geographic reach of a service provider's piped network,

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within which households would typically have the option to connect. Secondly, focusing within

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water service areas, we investigated rates of connection of poor households and compared these

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with overall connection rates.

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To answer research question 2 (RQ2), insights from literature on possible explanatory reasons for

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non-connection were tested through interviews with service providers and poor households.

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Interviews also included more open-ended discussion about the history of water service provision

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and any specific efforts made to reach poor households. Topic areas guiding interviews are provided

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in Appendix B.

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Across both research questions, analysis (described further below) involved comparison of service

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provider types (government, private, community). This assessed the relative success of different

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provider types in reaching poor households (RQ1), and considered explanatory reasons related to

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the different business models (RQ2). Different business models represented in case study

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communes included state-owned enterprises, private enterprises (ranging in size from medium-large

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corporations to household businesses) and various community-based models including cooperatives

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and water user associations.

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The study approach draws from a body of literature on mixed-methodologies which asserts the

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value of ‘methodological pluralism’ for addressing complexity (Onwuegbuzie and Leech 2017). It

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followed a pragmatic approach to research, prompting the selection of quantitative and qualitative

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methodologies best able to answer the research question(s) (Johnson and Onwuegbuzie 2013).

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Key steps in the research process are summarised in Figure 2 including interviews, data collection

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and analysis activities. Ethical approval for the study was secured through standard University of

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Technology Sydney - Institute for Sustainable Futures ethics procedures. A detailed presentation of

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study location, data collection and sampling as well as statistical and qualitative analysis processes is

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provided below.

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ACCEPTED MANUSCRIPT Interviews with water service providers

Interviews with commune officials

Mapping water service area boundaries (including ground truthing)

Identification of poor households

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Collation of data on total # households in commune, # households in each water service area and total # connected households

Analysis to determine whether poor households located within a water service area are less likely to be connected to piped water services

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Analysis to determine whether poor households are less likely to be located in a water service area

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RQ1: To what extent are piped water services reaching poor households?

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Interviews with poor households located within water service areas to identify connection status and explore reasons for nonconnection

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Classification of poor households as located within or outside a water service area

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Geotagging location of poor households

Analysis of reasons why poor households within water service areas are not connected to piped water services

RQ2: Why are poor households not connecting to piped water services?

Figure 2 Key steps in the research process

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3.2

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The study area included six communes across three provinces in Viet Nam’s Red River and Mekong

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River Deltas (Figure 3). Case study communes were selected based on preliminary data received

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from the Ministry of Agriculture and Rural Development’s Institute for Water Resource Economics

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and Management (IWEM), the National Centre for Rural Water Supply and Sanitation (NCERWASS)

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and relevant Provincial Centres for Rural Water Supply and Sanitation (pCERWASS). Preliminary data

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identified local poverty rates, water access figures, the number and types of water service providers

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Study area

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ACCEPTED MANUSCRIPT operating in each commune and any available information concerning efforts that had been made to

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reach poor households.

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156 Figure 3 Case study communes

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In selecting case study communes, we sought to include: a mix of communes in the north and the

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south to cover areas with different geographies and socio-economic characteristics; communes in

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which both private enterprises and other types of service providers were operating (to facilitate

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comparison); and a mix of sites where service providers had made particular efforts to include poor

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households, and sites where they had not. In two of the selected case study communes, the relevant

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private water providers had participated in a non-government organisation output-based aid (OBA)

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program, in which a subsidy was paid based on total household connections (across poor and non-

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poor households). OBA is a form of results-based financing used in contexts when customers are not

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able to pay the full cost of access to services, and where performance-based subsidies complement

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or replace user fees (Nguyen et al., 2014). This provided opportunity to explore the influence of this

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kind of program on poor household connection rates.

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3.3

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A team of field researchers comprising representatives from Central Institute for Natural Resources

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and Environmental Studies (Viet Nam National University) and the University of Technology Sydney

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undertook data collection with the assistance of local Provincial Centres for Rural Water Supply and

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Sanitation and Commune People’s Committees. All meetings and interviews were conducted in

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Vietnamese with English translation for the non-Vietnamese research team members. Qualitative

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and quantitative data was collected through interviews with 1,031 registered-poor householders as

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well as water service providers (n=17), local Commune People’s Committees (CPC) (n=6) and

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provincial authorities (n=3).

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All poor households registered on official commune poverty lists were visited (n= 1,031), and were

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the sample for the statistical analysis. The official Government of Viet Nam definition of poverty for

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rural areas was used, which at the time of research was based on an income threshold of
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400,000 (USD 17.50) /person/month.1

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In each case study commune, interviews with officials were conducted to understand the commune

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context and history, total commune population and lists of registered poor households. Water

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service providers were interviewed to clarify the history and operation of their water system

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(including any pro-poor mechanisms in place), define the boundaries of each water service area and

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determine the total number of connected households. Water service area boundaries were defined

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in discussion with water service providers, taking account of approximated pipe locations and the

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geographic accessibility of different locations with reference to e.g. waterways and roads.

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Interviews with poor households were conducted to determine if registered poor households were

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connected to a piped water source, reasons for non-connection and their primary drinking water

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sources. Global positioning system (GPS) coordinates were logged for each poor household visited.

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GPS coordinates were used to determine if visited households were located inside a water service

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Data collection and sampling

1 Decision No. 09/2011/QD-TTg of January 30, 2011, setting norms on poor households and households in danger of falling into poverty for the 2011-2015 period.

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ACCEPTED MANUSCRIPT area (WSA). Figure 3 presents an example commune, showing households visited as included or

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excluded from a WSA.

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Figure 4: Example commune (E) showing visited households (indicated by crosses), and defined WSA boundaries (private enterprise and state-owned enterprise)

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Data for non-poor households were calculated using information provided by commune officials and

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water service providers on: the total number of households in the commune; the number of

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households in each water service area; and the number of connected households in each water

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service area. Numbers of non-poor households were calculated as the difference between total

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household and poor household numbers based on detailed information about the location and

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connection status of each poor household.

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3.4

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3.4.1

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Two separate analysis processes, both using typical null hypothesis significance testing methods,

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were undertaken reflecting the two scales of interest: (i) commune level analysis testing the

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association between inclusion in a water service area and household poverty status; and (ii) water

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service area analysis testing the association between household poverty and connection status. For

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the second analysis, a stratified Chi-squared (χ2) test was used, as differences in the operations of

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the water service providers were expected to confound results when analysing aggregated data

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across the commune. For this reason, the Mantel-Haenszel procedure was used, which is a useful

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method for obtaining estimates of association, adjusted for the effect of confounding variables

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(Mantel and Haenszel, 1959; Mosteller, 1968; Gastwirth, 1984). This modification, along with a full

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explanation of the statistical analysis process, is described in detail in Appendix A.

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In addition to computed Chi-squared statistics, relative risks were calculated as an appropriate and

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intuitive measure of the degree of association between two dichotomous variables (Ospina et al.,

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2012). For the commune-wide analysis, these are a measure of magnitude of association which

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approximate how much more (or less) likely it is for non-poor households to be within a water

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service area. For the intra-WSA analysis, relative risks provide a measure of the size of association

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between poverty and connection status for each water service area. In communes where relative

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risk across water service areas were homogenous, a Mantel-Haenszel risk ratio was also computed,

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which is a weighted average of the varying water service providers' risk ratios indicating the size of

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the association between poverty status and connection status across water service providers (i.e. a

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common relative risk).

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3.4.2

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An embedded design approach involved parallel collation of qualitative and quantitative data.

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Qualitative data was collected during interviews with provincial and commune officials, water

Analytical approach

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Statistical analysis

Qualitative analysis

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ACCEPTED MANUSCRIPT service providers and householders. Semi-structured interview questions related to the history of

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water service provision, any mechanisms (from government or water service provider) for

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supporting poor households’ access, reasons why poor households were not connected to available

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piped water services, and differences in service delivery approaches across water service provider

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types. Open ended interview questions also created space for discussion of any additional issues

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related to water service delivery raised by interviewees.

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Qualitative data for each commune was collated and discussed by research team members during

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workshops in the field to identify patterns, emerging themes and any potential inconsistencies.

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Findings were then synthesized and considered with reference to the statistical analysis, which

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informed the development of case study reports for each commune. Qualitative findings relating to

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the experiences of water service providers and poor households were also contextualised with

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reference to separate but related research activities undertaken by the team which focused on

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regulatory arrangements for private water service provision, water operator functionality and

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customer satisfaction (described in Willetts et al., 2017).

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3.5

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Defining poverty status with reference to an income threshold likely underestimates the number of

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disadvantaged households, as those classified as ‘near poor’ would fit within the international

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standard of poverty (income of less than $US1 per day). Further, income-based approaches to

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defining poverty have been critiqued as simplistic and failing to capture the complexity of poverty

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with its multiple potential aspects of deprivation (as identified, for example, by the Multidimensional

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Poverty Index). However, in the absence of a viable alternative to inform identification of poor

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households in case study communes, the official definition was used as the best available measure.

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During an earlier qualitative phase of the research, an asset ownership review was conducted for

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households identified as poor on official lists. The correlation between official poverty status and the

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lived experiences of households was found to be sound (Grant et al. 2016).

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Limitations

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ACCEPTED MANUSCRIPT In addition to challenges defining poverty, it is important to note that the study focused on poverty

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rather than other aspects of potential disadvantage such as gender or disability, which also affect

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access to improved water supplies (Noga and Wolbring 2012; Leahy et al. 2017). It would be

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beneficial for future research to consider multiple dimensions of potential disadvantage to

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determine how they intersect to shape access to piped water.

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A further limitation relates to the quality of data collected, specifically in relation to the total

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number of households in each commune and the number of households connected to piped water

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services by service providers. While figures used were verified by a number of internal sources

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(commune officials, water service providers and district authorities), there remained a minor degree

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of uncertainty around the total number of connected households. Further, informal secondary

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connections such as from one household to a neighbouring family property were anecdotally quite

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common, but difficult to account for. The limitation in data quality was addressed through the

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selection of an analysis methodology appropriate for the available data. These analysis adjustments

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form a valuable contribution to further research of this nature, given that comprehensive and clear

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data is typically challenging to obtain in rural developing contexts. Nevertheless, it should be

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acknowledged that randomised sampling across all households in a commune would yield more

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accurate and in-depth analysis suitable for statistical modelling (i.e. regression), but would also be

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significantly more resource-intensive. Similarly, purposive sampling of communes limits the

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representativeness of the study across rural Viet Nam, though was necessary given logistical

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practicalities and the aim to include a mix of government, community and private piped systems.

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4

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This section presents and discusses six key findings from the analysis:

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Results and discussion

(i)

In two of six communes, water service area locations favoured non-poor households, with no significant difference found in the other four communes.

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(ii)

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In most cases, the probability of poor households being connected to piped water was lower than non-poor households.

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(iii)

Connection fees were the primary barrier to poor households accessing piped water.

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(iv)

No single type of service provider model (across government, community and private providers) was found to be more successful in reaching poor households.

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(v)

Where particular efforts were made to reach poor households, connection rates were more equitable.

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(vi)

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Sustainability of service delivery was revealed to be a concern, with implications for

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poor households’ access.

Finally, we reflect on implications from the research methods and findings for understanding how

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water access inequality plays out at local scales, pointing to both the value and challenges of local-

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level research and monitoring.

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4.1

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In two communes (A and E), the research found that the probability of non-poor households being

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located in a water service area were higher than for poor households, with risk ratios of 2.7 and 5.7

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(Table 4). In both communes, households outside of the water service areas tended to be in more

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challenging locations. For example in commune A (Figure 5) poor households outside the water

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service areas tended to be situated directly adjacent to the river and slightly away from other

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clusters of houses. In one instance, a poor household was in an informal location with their official

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address in a resettlement area across the commune. The piped network went past this informal area

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but did not serve it. In commune E, the area not located within water service areas was in the

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northern tip of the commune (Figure 4). Interviews with officials and water service providers

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identified constraints in extending piped networks to more challenging locations, including the need

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to recoup investment costs from user connection fees (discussed further below in section 4.3).

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In two of six communes, water service area locations favoured non-poor households

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ACCEPTED MANUSCRIPT Table 4 Results of analysis of poor and non-poor inclusion in water service area locations

Commune A Thanh Hai (Ha Nam) Commune B Hoa Hau (Ha Nam) Commune C Dong Phu (Thai Binh) Commune D Tan Phong (Tien Giang) Commune E Thien Trung (Tien Giang) Commune F Luong Hoa Lac (Tien Giang)

2

Number of households 3,671

χ

4,430

NS

Relative risk (95% CI) 2.7 (1.2-5.7) -

1,600

NS

-

3,310

0.41 (NS)

-

2,247

39.58****

2,862

NS

5.7 (3.1-10.3) -

6.69**

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NS (not significant) p>0.05; *p≤0.05; **p≤0.01; ***p≤0.001; ****p≤0.0001

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Commune (Province)

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Figure 5 Service area boundaries, poor household locations and connection status in Commune A

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In a third commune (D), the research found no significant difference in the location of poor and non-

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poor households with reference to water service areas. In the remaining three case study

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communes, this research question was not relevant as piped networks were available across the

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commune such that no areas were classified as being outside a water service area (defined as an

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area within which households had the option to connect).

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4.2

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The research found evidence that within water service areas, poor households had lower rates of

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connection to piped water services. Four of the six communes had at least one or more water

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service area in which the probability of poor households being connected to piped water were lower

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than non-poor households. This finding applied across seven of the ten water services areas in these

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four communes. Selected water services areas within these same communes showed different

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results, with either no significant difference between poor and non-poor connection rates (in two

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service areas) or in one commune, a situation where the poor had greater probability of being

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connected to piped water (discussed further below in section 4.4). Table 5 summarises findings

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across all communes and water services areas, presenting relative risks where these were relevant

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measures for comparing poor and non-poor connection rates.

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Table 5 Summary of findings on poor household water access within water service areas

Commune B Hoa Hau (Ha Nam)

Number of households

χ2

Relative risk (95% CI)

3,596

4.38*

1.3 (1.0-1.6)

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Commune A1 Thanh Hai (Ha Nam)

4,021

157.95****

2.4 (2.1-2.6)

409

98.736****

16.3 (9.3-28.4)

4% (n=68)

Water Service Area number (type of service provider) WSA1 (private enterprise) WSA2 (cooperative) WSA3 (household business) WSA1 (private enterprise) WSA2 (community managed) WSA1 (state owned enterprise) WSA2 (community managed) WSA1 (private enterprise, participated in OBA program) WSA2 (private enterprise) WSA3 (water user association)

900

0.013943 NS

-

700

3.8254 NS

-

315

3.78 NS

-

2,270

84.06****

2.4 (2.0-2.8)

719

-

WSA1 (private enterprise, participated in OBA program) WSA2 (state owned enterprise) WSA1 (water user association) WSA2 (private enterprise) WSA3 (private

1,187

NS (only one nonconnected household) 18.802****

1,014

33.557****

1.9 (1.6-2.2)

Rate of access to piped water 90%

Proportion of households that are poor 4% (n=142)

70%

5% (n=230)

40%

Commune D Tan Phong (Tien Giang)

78%

7% (n=219)

AC C

Commune C Dong Phu (Thai Binh)

EP

Commune (Province)

Commune E Thien Trung (Tien Giang)

Commune F Luong Hoa Lac (Tien Giang)

93%

Insufficient data

M AN U

SC

RI PT

Poor households had lower probability of connection to available piped water

8% (n=186)

6% (n=186)

2,862

0.6 (0.46-0.80)

Insufficient data, one of the five water service providers could not identify the number of connections within the

17

ACCEPTED MANUSCRIPT enterprise) WSA4 (cooperative) WSA5 (state owned enterprise) NS (not significant) p>0.05; *p≤0.05; **p≤0.01; ***p≤0.001; ****p≤0.0001 1 No significant difference between service areas so a common risk ratio for the whole commune was calculated

commune as the water service area crossed commune boundaries

In commune A, the probability of non-poor households being connected was found to be 1.3 times

322

higher than poor households. This applied across all three water service areas in the commune,

323

which included one managed by a large construction company (prompted to enter the water supply

324

market due to government subsidies for capital works), a household business and a cooperative.

325

None of the three service providers offered support to encourage poor households to connect. The

326

different ages and histories of the systems were reflected in different levels of service and customer

327

satisfaction, which may also have influenced poor households’ willingness to connect. The older

328

household business and cooperative systems suffered from intermittent service and low customer

329

demand (related to perceptions of low quality), while the newer private service charged higher

330

connection fees (on a cost-recovery basis) seen as prohibitive for poor households.

331

Of the two service providers operating in commune B, the private enterprise supplied 22 of the 24

332

hamlets with the community managed scheme serving the remaining two. In both water service

333

areas, the probability of non-poor households connecting was found to be higher than poor

334

households. Within the community managed water service area this can be explained by

335

affordability constraints and the absence of support mechanisms for poor household connection,

336

due to lack of service provider funds and a stated belief that all households should be offered the

337

same deal as non-poor households. Findings for the private water service area were surprising given

338

the reported (by the service provider) availability of two mechanisms to assist poor households to

339

connect: (i) households experiencing financial difficulty could pay their connection fee in

340

instalments; and (ii) poor households were exempt from the minimum contracted water use of

341

4m3/month. However, household interviews revealed that these support mechanisms were not well

342

known across the commune, potentially explaining the lower overall connection rates for poor

343

households.

AC C

EP

TE D

M AN U

SC

RI PT

321

18

ACCEPTED MANUSCRIPT In communes D and E, two of the water service areas (one in each commune) indicated higher rates

345

of connection for non-poor households. These included a private enterprise and a state-owned

346

enterprise. The private enterprise reported to have offered support for poor households in the form

347

of discounts and free advice, however as was the case in commune B these were not found to be

348

widely known by poor households. The state-owned enterprise offered free connection (in response

349

to a recent provincial policy decision), which should in principle have facilitated higher rates of poor

350

household connection, but interviews identified significant delays in the fulfilment of connection

351

requests. Of the remaining three service providers in these two communes, two (both in commune

352

D) had no significant difference in rates of connection between poor and non-poor households, and

353

one (a private enterprise service area in commune E) showed higher rates of connection for poor

354

households. These are explored further below (section 4.5).

355

Of the remaining two communes, in one (F) there was insufficient data available to compare service

356

areas and determine the relative rates of poor/non-poor connection, because one of the water

357

service areas crossed commune boundaries and the service provider was not able to identify

358

numbers of connections within the case study commune. Further, different interviewees gave

359

different reports on overall connection rates in the commune. In the other commune (C), the

360

research found no significant difference between rates of poor and non-poor connection, though it

361

is important to note factors that may have reduced demand for piped water across all (poor and

362

non-poor) households, as evidenced by the overall low rate of access across the commune (40%).

363

Specifically: the quality of piped water and service reliability across both service areas was reported

364

to be low by surveyed poor households; there was a strongly expressed preference to use rainwater

365

when available; and a previous international non-government organisation aid program had assisted

366

households to install protected wells. In light of these factors, it is likely that both poor and non-poor

367

households did not prioritise connecting to piped systems, particularly when connection fees were

368

perceived to be high (as discussed further below).

AC C

EP

TE D

M AN U

SC

RI PT

344

19

ACCEPTED MANUSCRIPT 369

4.3

370

Across all case study communes, and across government, community and private enterprise water

371

service areas, poor households reported their reason for not accessing piped water (when available)

372

as inability to afford the connection fee (Figure 5). This was a particularly clear finding in four

373

communes (A, B, C, D), with 68-100% of non-connected households citing unaffordability of the

374

connection fee as their primary reason for non-connection across all water service areas. This finding

375

was consistent with a previous phase of the research, which found connection fees to be reported as

376

the principal barrier to piped water access (Grant et al. 2016).

TE D

M AN U

SC

RI PT

Connection fees were unaffordable for poor households

EP

377

Figure 6 Reasons for non-connection reported by poor households in across government, community and private

379

enterprise water service areas

380

As well as connection fees being unaffordable, householder interviews revealed resentment towards

381

service providers related to the cost of connection fees, influenced by perceptions (and mis-

382

perceptions) about the costs involved in piped service delivery and its profitability. For example, one

383

householder questioned “how could they charge so much when they just pump water from the

384

river?” and another asserted “they are making a fortune and not helping us at all”.

385

In considering the barrier posed by connection fees, it is important to note that ‘connection fees’

386

may be broadly interpreted by households as comprising all costs associated with accessing the

AC C

378

20

ACCEPTED MANUSCRIPT piped system. For example, one householder in commune C reported that she had been connected

388

but had not been able to afford to build a mandatory storage tank (required to cope with

389

intermittent and variable water pressure) and so was cut off from the service. Allowing for

390

differences in interpretation of what constitutes connection fees, the range of fees across case study

391

communes was wide, from free connection (a recent development due to a provincial policy

392

directive in Tien Giang Province) to VND 4 million (USD 175) with a median fee of VND 600,000 (USD

393

26) (representing 150% of the monthly income threshold used to define poor households).

394

In two communes (E, F) unaffordability of the connection fee was also the most common reason for

395

non-connection, but the finding was less stark, as compared with other cited reasons. In commune

396

F, while acknowledging limitations relating to the reliability of data in this commune, 50% of non-

397

connected households cited unaffordability of connection fee as the primary barrier. This may be

398

due to the fact that poor households were offered free connection by private enterprises

399

participating in an output-based aid scheme, or on occasion through the charity of service providers

400

(as reported during service provider interviews). Other notable reasons were that connection was

401

not offered (33%), which contradicts information from the water service providers that these

402

households were within water service areas, and that the tariff was unaffordable (28%). In commune

403

E, 40% of non-connected households cited unaffordability of the connection fee as their reason for

404

not accessing the piped water service. ‘Other reasons’ were cited by almost 30% of non-connected

405

households. These included, for example, households that had applied for a connection but failed to

406

receive the service.

407

4.4

408

The research did not reveal strong differences between service provider types (across private,

409

government and community models) in terms of their success in reaching poor households. Points of

410

difference were, however, evident in different business models, namely connection fees and the

411

degree of payment flexibility offered to customers.

AC C

EP

TE D

M AN U

SC

RI PT

387

No particular service provider type was more successful at reaching poor households

21

ACCEPTED MANUSCRIPT Private enterprises included in the study tended to charge higher connection fees compared with

413

other types of service providers, a finding which was supported by a wider survey of water service

414

providers (Grant et al., 2016). In some cases, private enterprises reportedly sought to offset higher

415

connection fees by offering flexible payment options including discounts, exemptions and payment

416

by instalment. This was not similarly reported by government and community service providers.

417

However, it is important to note that discounts offered by private enterprises included in the

418

research may have been partly driven by their participation in a civil society output-based aid

419

program (discussed further below) and a consequent incentive to increase overall numbers of

420

connections, so further investigation would be required to determine the extent to which private

421

enterprises more generally offer flexible payment options. Further, differences between private

422

enterprises may be more important in driving pro-poor approaches than differences between

423

private and government or community models. Motivations and business management practices

424

differed substantially, with interviews revealing strong pro-social motives in some service providers,

425

while others were more focused on income generation.

426

Water user association and community-managed schemes tended not to provide targeted support

427

for poor households. Reasons included the fact that the selected schemes typically relied on shared

428

capital investment from participating households, and support for the poor would require cross-

429

subsidisation in the form of additional investment from other member households. Further, these

430

schemes required often-complex processes of collective decision-making, which may have served as

431

a barrier to the provision of support mechanisms for the poor, if consensus on their appropriateness

432

could not be reached. This was not a barrier for private enterprises, who could decide autonomously

433

to offer pro-poor support.

434

Overall, in the absence of civil society programs or government policies driving a focus on the poor,

435

water service providers did not offer targeted support. This indicates a need to be proactive in terms

436

of policies requiring service providers to focus on reaching poor households, such that existing gaps

AC C

EP

TE D

M AN U

SC

RI PT

412

22

ACCEPTED MANUSCRIPT between poor and non-poor access can be addressed in future water schemes. Given the clear

438

finding that connection fees were the primary barrier for poor households, strategies to either

439

subsidise these fees and/or facilitate flexible payment arrangements should be the focus of pro-poor

440

policy development.

441

4.5

442

The research identified one service area where the probability of poor households being connected

443

to piped water was 1.7 times higher than for non-poor households (risk ratio 0.6). This service area,

444

in commune E, was administered by a private enterprise operating since 1997. In addition to almost

445

20 years of operating experience, in recent years the enterprise had participated in an output-based

446

aid (OBA) program administered by the international non-government organisation East Meets West

447

Foundation.

448

East Meets West Foundation has applied an OBA approach in Viet Nam since 2007. In relevant case

449

study communes, the OBA approach was used to mobilise private finance by incentivising service

450

providers to increase household connections. Private enterprises pre-financed capital expenditure

451

and received partial reimbursement on verification of household connections (Nguyen et al., 2014).

452

The partial reimbursement was provided for all household connections regardless of poverty status,

453

though East Meets West actively encouraged a focus on poor households.

454

Given that this water service area represents a reversal of the dominant finding that the poor are

455

less likely to be connected to piped water services, efforts were made to understand whether

456

particular strategies were employed by this enterprise to target poor households and any other

457

potential reasons for higher poor household connection rates. No one reason was found to provide a

458

definitive explanation, and it is likely that a number of interrelated factors contributed to this

459

enterprise’s relative success in reaching the poor.

460

First, the enterprise had been operating in this location for almost 20 years and hence had both

461

extensive experience managing a water business and strong social ties within the community. This

AC C

EP

TE D

M AN U

SC

Support mechanisms facilitated equitable connection rates

RI PT

437

23

ACCEPTED MANUSCRIPT contributed to both a pro-poor outlook and sufficient security in business management to facilitate

463

the provision of support mechanisms to poor households. This financial security points to a

464

fundamental link between the viability of a business delivering a water service and managing related

465

assets, which depends on many factors including government-mandated connection fees and tariffs,

466

and the ability in financial terms to offer pro-poor support.

467

Second, the owner of the private enterprise was Buddhist and, motivated by his religious beliefs,

468

provided case-by-case support to poor households. This aligns with research identifying pro-social

469

motives as drivers of water entrepreneurship in Viet Nam and elsewhere, with religion identified as

470

one of a number of underlying factors along with empathy for the poor and related community roles

471

or positions (Willetts et al. 2016).

472

Third, the enterprise offered a reasonably low connection fee of VND 500,000 (USD 22), which is

473

likely related to participation in the OBA program through which a payment was made for each

474

connection achieved, allowing the enterprise to pass on savings in connection fees to customers.

475

This external support, while not mandating pro-poor behaviour, reduced the costs of connection for

476

all households and created conditions that enabled targeting and greater participation of poor

477

households.

478

It is also pertinent to consider the case of two water service areas in commune D where no

479

significant difference was found between rates of poor and non-poor access. These water service

480

areas represent situations where water service providers reached poor households at similar rates

481

to the general population, and in doing so did not contribute to further marginalisation of poor

482

households as is the case in areas where the poor had lower rates of access. One of these two

483

service areas was operated by a private enterprise that had also participated in the East Meets West

484

OBA program. This case was very recent, geographically contained (a small island), and only has 315

485

households in total. The service provider reached almost all households in the service area. The

486

other, a water user association system, was an older scheme with high overall rates of connection

AC C

EP

TE D

M AN U

SC

RI PT

462

24

ACCEPTED MANUSCRIPT 487

(across both poor and non-poor households) but concerns regarding sustainability. Low connection

488

fees and tariffs, while potentially creating favourable conditions for poor household connection,

489

were threatening the ongoing viability of the service with assets due for renewal and insufficient

490

funds for capital maintenance.

491

4.6

492

A final finding relates to issues that emerged during semi-structured interviews, and which have

493

relevance for decision-making by poor households around connection to piped services. In

494

particular, service providers and householders identified concerns relating to household use of

495

multiple water sources, water quality and water business viability.

496

Across non-connected poor households in all communes the research found a householder

497

preference for rainwater (Figure 7). Interviews with commune officials and service providers

498

suggested that connected households (poor and non-poor) also preferentially used rainwater (when

499

available) for drinking and cooking. Based on an end-use analysis of domestic water use in Viet Nam,

500

drinking and cooking could account for more than 20% of total water demand (Retamal et al. 2011).

TE D

50%

rt ru Ta nk e

wa t ce

ck

er

er nw at ai R

ed ttl Bo

rfa

0%

Su

10%

er fr o P m ip ne ed ig wa h b te ou r r Pr ot ec te d Pu d w e ug bl ic ll ta p/ st an dp ip e

20%

AC C

30%

Tu bo b e re w e h o ll, U le np ro te ct ed d U w e ug np ro ll te ct ed sp r in g

EP

40%

w at

Proportion of non−connected poor households

M AN U

SC

RI PT

Service sustainability was a concern, with implications for poor households’ access

501 502

Figure 7 Water sources used by non-connected poor households

25

ACCEPTED MANUSCRIPT Reasons for preferring rainwater included ‘better taste’ and perceived higher quality of rainwater

504

compared with piped water. In the north in particular, where the dominant source of piped water

505

was surface water, concerns about increasing levels of agricultural and industrial pollution were

506

expressed by both service providers and householders. Householders also described rainwater as

507

more consistent and reliable compared with piped services, which experienced interruptions and

508

were sometimes ‘muddy’ in appearance. The use of multiple sources of water has been noted in

509

other research in Viet Nam (Elliot et al. 2011) and is a subject of current sector discussion (Elliot et

510

al. 2017).

511

Related to the preference for rainwater, service providers reported reductions in demand

512

particularly during the rainy season. This meant demand for piped water was seasonal and that this

513

seasonal variability in demand may have implications for managing viable water businesses. Water

514

user association and other community-managed schemes in particular were struggling to remain

515

viable in the context of both low demand and low (government mandated) tariffs. Many schemes

516

included in the research had reached an age where capital maintenance or upgrading was required,

517

yet revenue was reported to be insufficient to meet this need. This reflects a common challenge

518

globally in sustainability of rural water supplies (Fonseca et al. 2011). In addition, these schemes

519

struggled to secure capital finance, particularly in a policy context, such as is the case in Viet Nam,

520

where the focus of support had shifted to increasing private sector involvement (Willetts et al.

521

2017).

522

Finally, some water service providers were focused on increasing customer demand for water as

523

their strategy to increase revenue and remain viable. In this context, determining and monitoring

524

sustainable extraction rates (particularly in areas drawing from groundwater) was a critical need,

525

and one that was not a focus at the time of this study.

AC C

EP

TE D

M AN U

SC

RI PT

503

26

ACCEPTED MANUSCRIPT 526

4.7

527

Reviewing the methods and findings of this study generated insights worth sharing to inform future

528

research as well as local government monitoring initiatives. First, the process of data collection was

529

challenging and resource intensive. The study required significant effort, cost and innovation in

530

methods in response to a lack of reliable information and data. Related to this, findings were

531

nuanced between and within communes, meaning translation into policy and investment

532

recommendations needs careful consideration. While the findings clearly show a gap in water

533

service for poor households across the communes investigated, this was not a universal picture and

534

it was challenging to interpret the complexity given sometimes contradictory information across

535

both qualitative and quantitative research components. The dynamics around water provision and

536

poverty are likely to be similarly complex in other locations, making both understanding the

537

situation and then developing strategies to reduce inequalities a substantial undertaking.

538

Nevertheless, the study generated valuable insights and sufficient clarity of findings to indicate that

539

targeted support is required to avoid systematic exclusion of poor households from water services.

540

Further, the study proved the value of a mixed-methods approach in addressing complex situations.

541

The statistical analysis provided evidence of inequalities in water access and indicated a need to

542

consider poverty dimensions of both the location of water services and individual household

543

connections when planning future investments. Qualitative findings ensured nuances and

544

influencing factors were brought to light, which are critical when translating research findings into

545

policy directions.

546

More generally, the research raises questions about how to manage local level monitoring to inform

547

local level decision making around inclusive water service delivery. Further work is needed to

548

consider: (i) what scale and type of data is essential to facilitate poor-inclusive service delivery; (ii)

549

who should be tasked with collecting and analysing it; and (iii) the roles of different actors in

550

translating data into decision making and regulation around water service planning and delivery.

AC C

EP

TE D

M AN U

SC

RI PT

Local level research and monitoring is both valuable and challenging

27

ACCEPTED MANUSCRIPT 551

These questions have implications for water service providers, commune authorities (Commune

552

People’s Committees) and provincial authorities (Provincial People’s Committees and Provincial

553

Centres for Rural Water Supply and Sanitation).

554

5

555

Reaching all with affordable, reliable and safe water is central to realise the human right to water

556

and fulfil the ambitions of the Sustainable Development Goals. Achieving universal access requires

557

improving our understanding of the local dynamics of water access in order to inform local

558

government activities in planning, regulating (and sometimes delivering) water services. This study

559

explored local experiences of piped water access for 1,031 poor households in rural Viet Nam.

560

Findings pointed to lower rates of piped water access for poor households across areas served by

561

government, private and community service providers, with connection fees the primary barrier.

562

Strategies for improving the affordability of connection fees should therefore be a focus for both

563

service providers and local governments in planning more inclusive water service delivery. The study

564

also found cases where financial assistance for private enterprises enabled more equitable

565

outcomes, suggesting opportunity to support and incentivise poor-inclusive service delivery across

566

service provider types. Finally, the research highlights both the value and complexity of rigorous

567

local-level water service monitoring. Further work is needed to strengthen local-level monitoring

568

such that governments can better understand and respond to inequalities in water service provision.

569

Acknowledgements

570

Funding: This work was supported by the Australian Department of Foreign Affairs through the

571

Australian Development Research Awards Scheme. The funding body was not involved in the

572

research or preparation of this article.

AC C

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Conclusion

28

ACCEPTED MANUSCRIPT The study described forms part of a larger research project investigating the role of private and

574

social enterprises in water and sanitation service delivery in a number of Southeast Asian countries.

575

Information and related research reports are available at www.enterpriseinwash.info.

576

The authors wish to acknowledge the contributions of researchers and enumerators from Viet Nam

577

National University and the Institute for Water Resources and Economics who supported data

578

collection. We also wish to acknowledge the invaluable contributions of research participants across

579

the six communes.

580

References

581

Batzella, E. and Ljung, P., 2014. The Role of Private Entrepreneurs in Enhancing Impact and Ensuring

582

Sustainability of Rural Water Supply in Vietnam, report on customer satisfaction survey and operator

583

survey undertaken as part of the Global Partnership for Output Based Aid-funded Rural Water

584

Supply Development Project, http://thrivenetworks.org/wp-

585

content/uploads/2017/03/KL_20140601_VN_Role_of_Private_Entrepreneurs_in_RWS_Batzella_Lju

586

ng.pdf, accessed 16 June 2018.

587

Elliott, M., MacDonald, M. C., Chan, T., Kearton, A., Shields, K. F., Bartram, J. K., & Hadwen, W. L.,

588

2017. Multiple Household Water Sources and Their Use in Remote Communities with Evidence From

589

Pacific Island Countries. Water Resources Research, 53(11), 9106–9117.

590

https://doi.org/10.1002/2017WR021047.

591

Elliot, M., Brown, J., Pham K. Nam, Vo Thi Hien, and Mark D. Sobsey. 2011. ‘Rainwater Harvesting

592

Practices and Attitudes in the Mekong Delta of Viet Nam’. Journal of Water, Sanitation and Hygiene

593

for Development 1 (3): 171. doi:10.2166/washdev.2011.024.

594

Fonseca, C., Franceys, R., Batchelor, C., McIntyre, P., Klutse, A., Komives, K., Moriarty, P., Naafs, A.,

595

Nyarko, K., Pezon, C., Potter, A., Reddy, R., & Snehalatha, M., 2011. Life-cycle costs approach:

AC C

EP

TE D

M AN U

SC

RI PT

573

29

ACCEPTED MANUSCRIPT Costing sustainable services. Briefing Note 1a. IRC International Water and Sanitation Centre.

597

https://www.ircwash.org/sites/default/files/briefing_note_1a_-_life-cycle_cost_approach.pdf

598

(accessed 7 March 2018).

599

Gastwirth, J. 1984. Statistical methods for analyzing claims of employment discrimination. Industrial

600

and Labor Relations Review, 38(1), 75-86. doi:10.2307/2523801.

601

General Statistics Office and UNICEF, 2015. Viet Nam Multiple Indicator Cluster Survey 2014, Final

602

Report. Ha Noi, Viet Nam.

603

Gero, A., Carrard, N., Murta, J., & Willetts, J., 2014. Private and social enterprise roles in water,

604

sanitation and hygiene for the poor: a systematic review, 4(3), 331–345.

605

https://doi.org/10.2166/washdev.2014.003

606

Government of Viet Nam, 2017. National Action Plan for the Implementation of the 2030

607

Sustainable Development Agenda. http://www.un.org.vn/en/publications/doc_download/543-the-

608

national-action-plan-for-the-implementation-of-the-2030-sustainable-development-agenda.html

609

accessed 18 June 2018.

610

Grant, M., Dominish, E., Carrard, N., Buy, L., Ha, H., Nghiem, T., 2016. Reducing or increasing

611

inequalities? The role of private water enterprises in rural Viet Nam, Development Bulletin, No 77.

612

31-36. Available at: https://crawford.anu.edu.au/rmap/devnet/devnet/db-77/db-77-ee-4.pdf.

613

Johnson, R. B., Onwuegbuzie, A. J., 2013. Mixed Methods Research: A Research Paradigm Whose

614

Time Has Come, Educational Researcher, 33(7), 14–26,

615

https://doi.org/10.3102/0013189X033007014.

616

Keatman T, Gosling L, Carrard N, Neumeyer H, Murta J, Roaf V & Adam A, 2017. Achieving universal

617

and equitable access to water, sanitation and hygiene (WASH) for all – practitioner perspectives and

AC C

EP

TE D

M AN U

SC

RI PT

596

30

ACCEPTED MANUSCRIPT perceptions, Proceedings of the 7th RWSN Forum “Water for All”, 29 Nov – 02 Dec 2016, Abidjan,

619

Côte d’Ivoire, Rural Water Supply Network, Skat Foundation, St. Gallen Switzerland p33-40.

620

Leahy, C., Winterford, K., Nghiem,T., Kelleher,J., Leong, L., & Willetts, J., 2017. Transforming gender

621

relations through water, sanitation, and hygiene programming and monitoring in Vietnam, Gender &

622

Development, 25:2, 283-301, DOI: 10.1080/13552074.2017.1331530.

623

Mantel, N. and Haenszel, M. 1959. Statistical aspects of the analysis of data from retrospective studies of

624

disease. Journal of the National Cancer Institute, 22, 719-748, https://doi.org/10.1093/jnci/22.4.719

625

Mosteller, F. 1968. Association and estimation in contingency tables. Journal of the American Statistical

626

Association, 62, 1-28, doi:10.2307/2283825

627

Noga, J., and Wolbring, G., 2012. The economic and social benefits and the barriers of providing

628

people with disabilities accessible clean water and sanitation. Sustainability. Vol. 4. pp.3023-3041.

629

doi:10.3390/su4113023.

630

Nguyen, M., Ljung, P., and Nguyen, H., 2014. ‘Output-Based Aid for delivering WASH services in

631

Vietnam: Ensuring Sustainability and Reaching the Poor’, paper presented at the 37th WEDC

632

International Conference, Hanoi, Vietnam.

633

Onwuegbuzie, A. J., Leech, N. L., 2017. On Becoming a Pragmatic Researcher  The Importance of

634

Combining Quantitative and Qualitative Research Methodologies, International Journal of Social

635

Research Methodology, 8(5), 375-387, https://doi.org/10.1080/13645570500402447.

636

Ospina, P. A., Nydam, D. V., Diciccio, T. J., 2012. Technical note: The risk ratio, an alternative to the

637

odds ratio for estimating the association between multiple risk factors and a dichotomous

638

outcome, Journal Of Dairy Science, 95(5), 2576–2584, https://doi-

639

org.ezproxy.lib.uts.edu.au/10.3168/jds.2011-4515.

AC C

EP

TE D

M AN U

SC

RI PT

618

31

ACCEPTED MANUSCRIPT Pati, A. B. K. and Neumeyer, H., 2018. ‘Making Rights Real in India: Using a tool on the rights to

641

water and sanitation with local government officials’, paper presented at the 41st WEDC

642

International Conference, Egerton University, Nakuru, Kenya.

643

Retamal, M., Nguyen Dinh Giang Nam, Willetts, J., Mitchell, C. and Carrard, N., 2011. Comparing

644

household water end-use data from Vietnam and Australia: Implications for water and wastewater

645

planning, Proceedings from Efficient '11 - 6th International Water Association Specialist Conference

646

on Efficient Use and Management of Water, International Water Association, London, UK, 1-12

647

Shields, K. F., Bain, R. E., Cronk, R., Wright, J. a., & Bartram, J., 2015. Association of Supply Type with

648

Fecal Contamination of Source Water and Household Stored Drinking Water in Developing

649

Countries: A Bivariate Meta-analysis. Environmental Health Perspectives, 123(12), 1222,

650

http://dx.doi.org.ezproxy.lib.uts.edu.au/10.1289/ehp.1409002.

651

UN Special Rapporteur on the human right to safe drinking water and sanitation (2014) Realising the

652

Human Rights to Water and Sanitation: A Handbook by the UN Special Rapporteur Catarina de

653

Albuquerque. Available from: www.righttowater.info/handbook/, accessed 5 July 2016.

654

United Nations (2015) Transforming our world: The 2030 agenda for sustainable development,

655

General Assembly resolution A/RES/70/1

656

https://sustainabledevelopment.un.org/content/documents/7891Transforming%20Our%20World.p

657

df, accessed 6 June 2016.

658

WHO/UNICEF (2017) Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and SDG

659

Baselines, https://www.who.int/mediacentre/news/releases/2017/launch-version-report-jmp-

660

water-sanitation-hygiene.pdf, verified 14 December 2018.

661

Willetts, J., Murta, J., Gero, A., 2016. Water and sanitation entrepreneurs in Indonesia, Viet Nam and

662

Timor-Leste: Traits, drivers and challenges, Enterprise in WASH – Working Paper 4, Institute for

AC C

EP

TE D

M AN U

SC

RI PT

640

32

ACCEPTED MANUSCRIPT Sustainable Futures, University of Technology Sydney, http://enterpriseinwash.info/wp-

664

content/uploads/2016/06/isf-uts_2016_working-paper-4-traits-drivers-and-barriers_cross-country-

665

review.pdf, accessed 16 June 2018.

666

Willetts, J., Grant., M., Carrard, N., Bui, L., Doan The, L., Pham Thi, D., and Dinh Van, D., (2017) Good

667

Water Governance for Inclusive Growth and Poverty Reduction. Paper presented at the 2017

668

OzWater Conference. Sydney, http://hdl.handle.net/10453/115352.

669

Wolf, J., Hunter, P. R., Freeman, M. C., Cumming, O., Clasen, T., Bartram, J., Higgins, J., Johnston, R.,

670

Medlicott, K., Boisson, S. and Prüss-Ustün, A., 2018. Impact of drinking water, sanitation and

671

handwashing with soap on childhood diarrhoeal disease: updated meta-analysis and meta-

672

regression, Tropical Medicine and International Health, 23(5), 508-525,

673

https://doi.org/10.1111/tmi.13051.

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M AN U

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Are piped water services reaching poor households? Empirical evidence from rural Viet Nam Highlights

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A survey of 1,031 poor households found inequalities in piped water services. Connection fees were the primary barrier to poor households accessing services. No single type of service provider was more successful in reaching the poor. Where it was provided, financial support enabled more equitable outcomes. Data gaps constrain monitoring of water poverty, requiring innovative responses.