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Almost half of the world's population is expected to experience water stress in their daily lives by 2050. The impacts of water scarcity on physical and psychosocial health are especially felt in arid regions of Ethiopia where semi-nomadic pastoralist populations are heavily reliant on groundwater for domestic and livestock needs. However, functional water supply infrastructure and reliable service delivery remain a challenge. A cross-sectional water security household survey of 469 heads of households and borehole runtime sensor data in Afar Region, Ethiopia, has three main findings. First, higher levels of household water insecurity experiences (HWISE) and water-related emotional distress (WRED) are positively correlated (0.57, plt;0.01) and are significantly associated with "limited" water service levels, the non-use of boreholes, and more vulnerable household demographics (female-headed households and lower household incomes). Lower HWISE scores are associated with increased borehole pump usage and reliability, with a cut-off point of 6 h of pump usage per day measured with electronic sensors. Adding additional water points to the dry lowlands of Afar have led to overcrowding and rangeland degradation in the past, highlighting a need to balance increased production for human consumption with livestock use. When it comes to climate resilience and adaptation, ensuring the reliability of what has already been constructed is a top priority for the regional government. Our findings suggest that increasing the reliability and daily usage of existing water supply systems over the short-sighted expansion of sources is worth the investment in services it will take to reach even the most far-flung communities.

Collaborative approaches are seen as a promising way to strengthen Water, Sanitation, and Hygiene (WASH) service delivery systems when challenges exceed the mandates and capabilities of any single entity. While collaborative approaches are well studied in high-income country contexts, current understanding of their application to international development contexts is limited. This paper uses fuzzy-set Qualitative Comparative Analysis to assess what conditions and pathways drove or impeded progress within eleven collaborative approaches for WASH service delivery in Eastern Africa. Evidence supported three main findings: (1) Government uptake of recommendations is necessary for progress but cannot be guaranteed solely by government participation in the collaboration, (2) different forms of problem identification are possible; problem scopes are often predefined to align with funders and partner government agendas, but flexible scopes that foster collective problem identification can reap benefits, and (3) hub convening power can be critical and convening power can be gained in different ways. Political dynamics, shifting priorities, and turnover undermine collaborative efforts, but collaborative approaches can still make progress in spite of turnover if funds are available for implementation of activities (i.e. in addition to funds for meetings and hub roles) and program implementers either facilitate collective problem identification or establish a hub with convening power. Yet even these tactics are vulnerable to instability, thus in highly unstable contexts, stakeholders and funders should be realistic from the outset about what they may be able to achieve. Building on existing theories of collaborative approaches, this work revealed that there is no single best design for collaborative approaches in WASH, rather, core elements worked together in different ways depending on the context.