Water and sanitation

Bringing the water system back to life in Tigray

In November 2022, after signing a peace agreement, Doctors Without Borders (MSF) teams were able to re-enter Tigray and restart medical humanitarian activities. Our first priority was rehabilitating health facilities' water systems and establishing waste management systems. We also worked hard to bring safe water to people's homes, protecting them from waterborne diseases like cholera.

When the last of the four existing hand-pumps in the village of May Kwait were destroyed during the end of the war, people had no other choice but to walk 1.5 km to fetch water from the river. Everybody fell ill with diarrhea.
Gabriella Bianchi/MSF

“I’m the water man,” says Weldekiros Assefa, an engineer and water and sanitation expert for Doctors Without Borders (MSF) in Ethiopia. “I have the best job at MSF.”

Assefa is checking water hand pumps in May Kwait, a small village in northwestern Tigray, a region in Ethiopia, where 600 hand pumps are working again after being repaired with the help of MSF. The repaired pumps restore access to clean water in a place where – not long ago – water was scarce to non-existent during two years of civil war.

MSF Ethiopia, Tigray Water & Sanitation Employees
Weldekiros Assefa is an engineer and MSF’s water and sanitation expert. Together with Murra Omleca, a member of the water committee and a representative of the rural water authority, he is checking the repair of four hand-pumps in May Kwait, a small village an hour’s drive from Shire where, thanks to MSF’s donation of spare parts, people are able to drink clean water out of the wells again.
Gabriella Bianchi/MSF

“When the fighting got really bad here and people fled into the forest for a week,” Assefa explains. “When they returned, the electricity had been cut off and the water hand pumps that many rely on for water had been dismantled and filled with stones.” They were the last working pumps in the area.

The people of May Kwait had no choice but to walk 1.5 km to fetch water from the river. Many became ill with diarrhoea. Whatever water people had was mainly used for cooking and drinking, but not for washing – increasing the risk of skin diseases and other illnesses that spread rapidly without access to hygiene.

Muley is the accountant for the water committee in May Kwait a village west of Shire. Before the war, the money collected from the community would be used to buy spare parts for hand pumps repairs. However the war disrupted this arrangement.
Gabriella Bianchi/MSF

MSF returns to Tigray

When MSF teams were able to return to Tigray in November 2022, the region was emerging from a devastating two-year civil war. The war caused significant damage to infrastructure, whether due to lack of maintenance, intentional destruction, or fighting. Health facilities were hardly functioning.

Among MSF’s first priorities was rehabilitating health facilities’ water systems and re-establishing a functioning waste management system. In Shire’s Suhul hospital, for instance, the team managed to get safe water flowing again and built latrines, showers, and areas for washing. They also installed incinerators to ensure safe disposal of sharp, soft, and organic medical waste such as needles, syringes, soiled dressings and body parts. Most crucially, the team cleared a mountain of rubbish containing hazardous medical waste close to the facility.

Since December 2022 MSF has been trucking clean water from Sheraro treatment plant to 6 IDP camps. At the height of the emergency intervention, MSF trucks delivered 1.4 million litres every day.
Gabriella Bianchi/MSF

Another critical goal was to bring safe water into people’s homes as a bulwark against the spread of waterborne diseases, including acute watery diarrhoea, skin and eye diseases, and those caused by parasites. The biggest fear was that the lack of access to clean water might trigger a cholera outbreak.

Between December 2022 and March 2023, several assessments were done in northwest and central Tigray and showed that only 34% of water hand pumps were still functioning among the 2000 surveyed across 14 districts. It was critical to repair the unusable pumps before the rainy season, when water sources can become contaminated from open-air defecation, increasing the risk of cholera outbreaks.

Hedat is the mother of Hyab, a one-month-old baby. She has come to MSF supported health post in Adi Asser to get her child vaccinated.
Gabriella Bianchi/MSF

When water hand pumps aren’t functioning, people use water from lakes and rivers, which is often unsafe. “At one stage, towards the end of March, almost one in four ambulatory patients we were seeing in Tigray were suffering from preventable waterborne diseases,” says Samreen Hussain, MSF medical coordinator in Ethiopia.

At the end of April, several cases of acute watery diarrhoea were recorded in Derso, a small village south of Sheraro, after a ten-year-old boy died on his way to a rural health facility. “The conditions in the village were very poor,” says Daniel Shmondi, an MSF water and sanitation supervisor who was among the team assessing the situation in the area. “There were no wells and people were using water from the river for all purposes. Open air defecation was common practice near homes.”


In response, the team distributed water purification tablets to 120 households and checked whether other villagers had become sick. They found that two siblings of the boy who died had severe diarrhoea, and they were then admitted to an isolation centre that MSF helped set up in Sheraro to prepare for a possible cholera outbreak. This also triggered a response at Suhul Hospital, the referral facility for the region, which is a two-hour drive away.

The hospital rehabilitated its cholera treatment centre and trained staff to strengthen their ability to respond during outbreaks. Early in the morning, Adisalem loads his camel with the spare parts he will need to repair a hand pump in Ademeyti, a village at the border with Eritrea. “In this area most people have not returned yet,” he says. “Many are still living in camps or with hosts in the community.”

Persisting insecurity has also slowed down recovery from the war. Water infrastructure in Tigray underwent costly repairs several times, only to be looted or intentionally destroyed again.

MSF, Ethiopia, Tigray water & sanitation, Adisalen, water pump repair man
Adisalen, a water pump repair man and member of the water committee of his village, is loading a camel who will transport spare parts donated by MSF to Ademeyti, a village north of Shiraro where security is still a concern.
Gabriella Bianchi/MSF

Aid organisations have been hesitant to carry out new big interventions. Pumps for the water treatment plant that provides safe water to the city of Sheraro took six months to be replaced. During that time, the city survived thanks to deliveries made by trucks or donkeys. In addition, MSF provided up to 1.4 million litres of safe water for six displacement camps daily.

Where water utility technicians are unavailable, MSF technicians perform the rehabilitation directly while training new staff hired by the water administration. The objective is to act as a catalyst in re-activating the pre-existing public hand pump repair system.

As recovery continues, more resources and efforts will still be required to increase the availability of safe water and improve overall sanitation and hygiene conditions in parts of Tigray.