Approximately 25% of domestic vegetable production in Pakistan depends on wastewater. IWMI’s work (MTP Project 10 2006-2008; Output Target 1) extensively documented livelihood and health implications associated with wastewater agriculture by engaging project partners’ staff to collect data after methodology design and training by IWMI, and discussed them at many forums. More recent work has focused on mitigation of negative impacts, translating the findings into interventions, particularly in relation to health issues (see Annex 1).
Using feedback collected by the BMZ project, here we describe how IWMI’s work has impacted the grass-root health institutional level by addressing health risks associated with wastewater irrigation and implementing a risk mitigation strategy to contain selected infections. To this end, an IWMI-recommended holistic approach [encompassing diagnostic tests (stool surveys, water quality tests etc.), health assessments (surveys), awareness raising on health risks associated with wastewater-based livelihoods, and educational outreach programs on sanitation and hygiene behavior] was adopted and institutionalized with support from key partners in Faisalabad, Pakistan – the National Program for Primary Health Care and Family Planning (NPFP & PHC). They conducted the field program, with diagnostic support provided by the Institute of Public Health and PunjabMedicalCollege.
IWMI’s research data were used to pilot a de-worming campaign-introduced as mass-scale anti-helminthic treatments through NPFP & PHC to reduce worm burdens in the communities-which was coupled with health education on wastewater irrigation based livelihoods. This institutionalization, which involved the direct engagement of Lady Health Supervisors (LHSs) and Lady Health Workers ( LHWs), was seen as a sustainable, positive outcome of IWMI’s research. The LHWs constitute the grass-root level arm of the NPFP & PHC that provides primary health care services at the community level. This group of health staff are women, >18 years old, from the community.
Further, based on IWMI’s work, a package of interventions, from training events to treatment was developed and implemented by NPFP & PHC. In keeping with the holistic approach, complementary studies were carried out to assess groundwater quality (drinking water) and sanitation infrastructure with the support of the Water and Sanitation Agency (WASA) whereby the community and regulatory stakeholders were brought together to discuss and address sustainable health risk mitigation options through inter-sectoral and cross-scale dialogue.
In summary, IWMI’s research formed the basis for an inter-sectoral dialogue on the negative impacts of wastewater use for crop production; pilot level institutionalization of interventions and enhancement of knowledge and skills of the LHSs and LHWs within the community to address the negative health impacts of wastewater use; and the development of strategies for a long term surveillance program for infection containment within communities in other parts of the country. The NPFP & PHC highlights the importance of our strategic and targeted research outputs, has recognized the key role of LHWs in promoting safe use of wastewater and good hygiene practices within the community, and is willing to extend its application countrywide (Annexes 2 & 3).
Population pressure and increasing water competition in a changing climate require us to take stock of the availability and use of water across scales. Water availability not only influences farmers’ commercial prospects but also irrigation-related enterprises and agri-businesses. Greater water scarcity could jeopardize irrigation and agricultural markets while excessive water use can lead to declining ecosystems, water quality and soil health. IWMI advises development partners and the public and private sectors on all aspects of water resource availability and use through a variety of advanced modeling and remote-sensing products and tools, including 
The ability of farmers to engage in or expand irrigation depends on the prevailing socioeconomic, ecological and political contexts, which are often complex, non-linear and changeable. Overcoming systemic barriers to farmer-led irrigation development while taking advantage of existing opportunities 
A lack of affordable credit, particularly for women and resource-poor farmers, is one of the main barriers to expanding farmer-led irrigation in low- and middle-income countries. But 
Scaling farmer-led irrigation requires strengthening human capacity and knowledge exchange among all actors and stakeholders involved. IWMI takes an action research approach, working with national and international research institutions, governments, extension agents and public and private organizations to co-develop the scaling ecosystem and strengthen capacity to drive scaling networks and collective action. We support the