Using the Safe Water Optimization Tool to Improve Water Quality in Humanitarian Settings: Reflections on Our Work in Somaliland

We’ve previously written about learnings from our HIF WASH Evidence Challenge study in Uganda. That work looked at the role that the SWOT can have in assuring water safety in refugee and IDP camps supplied by surface water sources delivered by piped networks and water trucks.

Another component of our study looked at how the SWOT could be used to assure water safety in institutions and medical facilities. For this work, we partnered with Médecins Sans Frontières (MSF) in Somaliland to implement and evaluate how the SWOT could be used to ensure water safety at the Las Anod General Hospital.

While an uptick in conflict and insecurity at the site prevented us from completing all our study objectives, in this blog we share some of the insights we gained from our work there.

Introduction: What was our goal in the Somaliland study?

Providing clean water in medical facilities is critical for drinking, hygiene, patient care, medical procedures, and preventing nosocomial infections (infections acquired in a healthcare setting). Our goal was to evaluate how well the Safe Water Optimization Tool (SWOT) works for ensuring water safety in a medical facility setting by deploying the SWOT at the Las Anod General Hospital in Sool, Somaliland.

Background on the Las Anod General Hospital and MSF’s role there.

Las Anod General Hospital (LAGH), located in the capital city of the disputed Sool region in southeastern Somaliland, is a Level 5 hospital with a 73-bed capacity. MSF began operations in LAGH in May 2019, providing technical and financial assistance for the hospital's emergency room, operating theatre, and sexual and reproductive healthcare services, among other supports.

Securing a safe and reliable water supply for the hospital has been a persistent challenge. The hospital has its own borehole, which was constructed in 2019, as well as a reverse osmosis (RO) treatment system. However, the RO system stopped functioning in 2020 due to lack of maintenance and spare parts. Since then, MSF has been supporting the hospital to purchase RO-treated groundwater from a local supplier for drinking, medical, and infection prevention and control (IPC) purposes.   

The estimated potable water demand of the hospital is around 26 m3 per month. Water deliveries are made every few days. Water is delivered via truck by the private supplier, who is required to chlorinate water before delivery to the hospital’s underground tank. On arrival, the water is tested for FRC, pH, and turbidity by the MSF team, and additional HTH chlorine is added when the FRC is below 0.2 mg/L.

Chlorinated water is then pumped into an elevated tank connected to a piped distribution system serving six potable water tapstands located in the staff and patient areas (a separate piped network provides non-potable water for other domestic purposes. MSF has instituted regular water quality monitoring at various points in the water supply chain at the hospital.

How was the SWOT used in the hospital?

The SWOT was deployed at the Las Anod General Hospital as part of normal WASH operations and used routine water quality monitoring data. Data collection was handled by the MSF Water and Sanitation (WatSan) Technician using KoBoToolbox with a SWOT survey template. 

Using the SWOT in a hospital setting required making some adaptations to the tool, as it has previously been used in refugee and IDP camp settings. Specifically, water deliveries are made every few days to the hospital, so chlorinated water must be stored after chlorination in the overhead tank for much longer than it would typically be stored in a camp setting. The SWOT was therefore modified to allow for much longer durations of protection than would normally be the case in a camp setting (up to multiple days).  

At the same time, the distance from the water tanks to the taps was much shorter at the hospital compared to the considerable distances that people sometimes have to transport water in the camp setting. While in a camp people would typically collect water in large containers for the whole family to use over the course of a day, in the hospital people usually filled small personal water bottles which they would drink from over a short time period (typically 1 to 3 hours at most).

For this reason, we considered the drinking water taps in the hospital wards to be the point-of-consumption, and this was where we wanted to ensure water safety. Our goal therefore was to ensure adequate chlorination in the elevated tank to persist so that water at the taps in the hospital wards was adequately protected over several days.

Water quality measurements including free residual chlorine (FRC), turbidity, pH, water temperature, and electrical conductivity were collected from trucks as they delivered water to the hospital (point-of-delivery), at the hospital’s elevated storage tank (point-of-distribution), and at six taps (points-of-consumption) around the hospital grounds where staff and visitors filled their water bottles. Data collection was conducted between September and December 2022, though there were interruptions to data collection due to intensifying conflict in the region.

Before the SWOT recommendation was provided, baseline data showed that the median FRC at the tank was 0.40 mg/L, and 64% of tap samples had an FRC meeting the water safety threshold of at least 0.2 mg/L. Baseline data was uploaded to the SWOT, which generated a site-specific FRC target recommendation of 0.8 mg/L FRC to be maintained at the elevated tank to ensure sufficient FRC at taps for up to 24 hours.  

The FRC target was implemented by the WatSan team, but was soon decreased to 0.6 mg/L FRC in response to taste and odour complaints received from water-users in the days following the initial change. This modified target was seen to better balance the competing concerns of having sufficient FRC to ensure water safety and not so much as to drive taste and odour driven rejection of treated water.  

After the SWOT FRC target recommendation was issued to the MSF team, they were able to increase the FRC at the tank up to a median of 0.49 mg/L, however only two of the ten water tank samples showed the SWOT target of 0.6 mg/L had been reached. Despite this, water safety at the taps increased, all samples taken within 24 hours of chlorination had an FRC of at least 0.2 mg/L. This reduced slightly to 93% for samples taken over 24 hours from chlorination (up to 150 hours).

What did we learn?

The study offered valuable insights into how the SWOT can help improve water safety in medical facilities such as the Las Anod General Hospital. With water quality monitoring data from tanks and taps at the hospital, the SWOT was able to generate a site-specific and evidence-based water chlorination target that could optimize water safety at taps around the hospital.

After the SWOT’s FRC target recommendation was implemented in the hospital’s water system by the MSF WatSan Team, there was a considerable improvement in the proportion of hospital taps with sufficient FRC (i.e., 0.2 mg/L) to protect water against pathogenic recontamination after one or more days of storage—going from 59.9% at baseline to 93.3% at endline following SWOT implementation.

The study also, once again, highlighted the importance of taste and odour as a critical factor to balance when setting a water chlorination target, as adjustments were made to the FRC target recommendation in response to water-user preferences. Acceptance of chlorine taste and odour in drinking water is highly personal and can vary greatly across populations. We recommend understanding local chlorine taste and odour acceptability thresholds as part of a chlorination programme, and always providing channels for water users to feedback their concerns. We are developing tools to help water system operators rapidly determine population-specific chlorine taste and odour acceptability thresholds to be part of the SWOT toolkit. 

Overall, this case study in Somaliland demonstrated the effectiveness of the SWOT as a tool for enhancing water safety in healthcare settings in resource-constrained and crisis-affected settings.

Next steps...

For our next steps, we will apply lessons learned from the Las Anod Hospital to similar environments and continue to refine and enhance the SWOT for the medical facility water system and other humanitarian water supply use cases. We also hope to expand the use of the SWOT beyond humanitarian response settings to be used by local health authorities in healthcare facilities in non-emergency settings. 

Unfortunately, the conflict affecting the Sool region of Somaliland has escalated rapidly, to such a point that MSF had to withdraw from the Las Anod Hospital in July 2023. We hope that the situation improves, and the MSF team can return to provide medical care to patients in need at Las Anod and in the surrounding regions. The SWOT team is ready to support MSF and any medical humanitarian actors with deploying the SWOT to ensure water safety for patients, caregivers, and staff in medical facilities.