Background Paper on Water and Health for the COP workshop Bucharest, 2008


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The present Background Document has been prepared to provide the participants of the Workshop on Water and Health, (Bucharest, 14-16 May 2008) with a general analytical framework for water/environment and health sector links in Eastern Europe, Caucasus and Central Asia (EECCA) and with detailed information about the provisions of the UNECE/WHO-EURO Protocol on Water and Health to the Convention on the Protection and Use of Transboundary Watercourses and International Lakes. This Protocol is a legal treaty, designed to reduce water-related deaths and diseases. The Protocol entered into force in 2005 and by April 2008 has been ratified by 21 countries comprising both countries from the European Union (EU), South-Eastern Europe and EECCA. Ratifying the Protocol requires countries to translate a number of general provisions into national laws and regulations and create administrative and economic frameworks to secure its implementation.

The background document further presents preliminary country experience of target setting, monitoring and reporting according to the Protocol and the economic and financial considerations related to water and health in the context of the Protocol but also in the wider context like the Millennium Development Goals of increasing access to safe water and sanitation. The document aims at providing a broader understanding of water and health being closely linked, not only in the sense that water is necessary for any life, but also in a much broader economic, social and environmental context.

According to WHO, in the European region, lack of safe water and adequate sanitation is recognized as a major cause of child mortality and morbidity, especially in EECCA countries. Safe water and adequate sanitation in combination with improved hygiene have shown to be a cost-effective means to reduce health burdens. The first UNECE Assessment of Transboundary Rivers, Lakes and Groundwater in the UNECE region[1] clearly show that the contamination of drinking water sources in EECCA is significant. Actions to decrease water pollution from point sources (e.g. municipal and old industrial installations) are of primary importance. Outbreaks of diseases related to contaminated drinking water continue to occur in EECCA, but also in economically developed Western European countries. Available data analysed by the Organisation for Economic Co-operation and Development (OECD) from EECCA suggests, that the overall situation in the water and sanitation sector has deteriorated further, since it was originally assessed as critical in 2000.

Addressing the above problems and issues in a national and transboundary context is not a simple task. It requires strong policies and legislation, implementation and enforcement of regulations, well planned actions, well-capacitated institutions and availability of financial resources for infrastructure investments and management, and the engagement of stakeholders, not least the civil society. Addressing water and health not only requires actions in the water and environment sector, it also requires building better health systems, improving health surveys and building better systems of early warning to water users.

Water supply, sanitation, waste water treatment and water management involves health, water and environmental managers. These are working under different policies and legislation and under the responsibility of different institutions. Improving coordination and cooperation among health, water and environment practitioners and including other stakeholders, like civil society and private sector, have shown to be an effective way forward in gaining both health and environmental benefits. Climate change is also expected to impact water resources in EECCA countries, which again will impact the occurrence of water-related diseases. Adapting to climate change should therefore be integrated into national and local strategies and plans.

In the Ministerial Declaration of the sixth Ministerial Conference Environment For Europe in Belgrade 10-12 October 2007[2], the Ministers committed to strive together with citizens, civil society and the private sector to maintain or improve a healthy environment for present and future generations. The ministers further recommitted to the declarations of the World Summit for Sustainable Development to strive for a sustainable development.

This is the context in which this “Water and Health Workshop” has been organized. This background paper will focus on possible solutions and less on a description of the actual health situations and relations between health and water, although it is realized that the information on health, water and environment can be improved in EECCA. The aim is to promote the understanding of the public health consequences of the work carried out by those responsible for environment and water management, water supply and sanitation and, at the same time, promote an understanding of the basic principles of water and environment management, water supply and sanitation by those responsible for public health.

The background document will in particular focus on the Water and Health Protocol and how it could assist EECCA countries to address the water/environment/health related issues in their own country and in a transboundary context. Therefore benefits and challenges related to its implementation are presented as well as tools and good practices.

This workshop, organized in collaboration with the Eastern Europe, Caucasus and Central Asia (EECCA) component of the European Union Water Initiative (EUWI), is held under the auspices of the UNECE Water Convention and its Protocol on Water and Health within the framework of the Project Capacity for Water Cooperation (CWC) in Eastern Europe, Caucasus and Central Asia. The workshop will also be a UNDP annual Water Community of Practice (CoP) meeting.

The event is jointly organised by UNECE, UNDP, OSCE, WHO-EURO, and is also supported through the Environment and Security Initiative (ENVSEC). The European Commission supports the workshop organization as part of the EUWI - EECCA component. The Ministry of Environment and Sustainable Development of Romania hosts and co-organizes the workshop.

The Provisions of the Water and Health Protocol

The Protocol [3] addresses “water-related disease” and actions to prevent, control and reduce these. It defines water-related diseases as: any significant adverse effect on human health, such as death, disability or disorder, caused directly or indirectly by the condition, or changes in the quantity or quality, of any waters.

Water-related diseases comprise the following main types: a) diseases related to lack of access to safe drinking water, poor sanitation and insufficient hygiene or situations related to use of water likely to result in outbreaks or incidents of disease b) diseases related to exposure during recreational use of water like bathing c) diseases related to ingestion of food (plants or fish, shellfish) which has been exposed to contaminated water d) vector borne diseases associated with water, where water is the breeding site for disease vectors that play a key role in the spread of disease causing organisms e) non-communicable water associated health issues of which the effects of long terms exposure to inorganic chemicals that occur naturally in groundwater (like Arsenic) and exposure of chemicals from industrial and agriculture are most important.

The Protocol has provisions aiming to protect human health and wellbeing. This comprises adequate supplies of safe drinking water and adequate sanitation as well as a health system to survey the general health situation and situations which are likely to result in outbreaks or incidents of water-related diseases, like in cases of malfunction of the water distribution networks. Further provisions aim at an effective protection of water resources, used as resources for drinking water, food production and bathing. This implies that there should be an effective reduction and elimination of discharges and emissions of substances, which are judged to be hazardous to human health as well as to ecosystems. The Protocol requires Parties to take appropriate actions to develop legislation and policies as well as administrative and economic frameworks in which public, private and voluntary sectors can contribute to improving water management. What this means in practical terms will vary from country to country, depending on legislation on health and water management, the administrative set-up, including the status of implementation of integrated water resources management and basin management, established monitoring systems, financial structures and economic situation etc. The Protocol requires Parties to prevent, control and reduce water-related disease within a framework of integrated water management systems (IWRM) through basin management approaches.

Infrastructure development, new industrial installations etc, may impact the water and environment, and thus also health. The Protocol therefore includes provisions to assess these impacts and take actions to reduce these to an acceptable level. In taking measures to implement the Protocol, Parties should be guided by

The two core obligations of the Protocol, which are the practical means to put into practice the above principles and objectives are: Setting targets and target dates for water supply and sanitation, water management and health protection and establishing surveillance systems.

Although the Protocol is a legally binding instrument, it also leaves much flexibility for action to the Parties. With its wide scope, the implementation of the Protocol will be a challenge for EECCA countries. It seems on the basis of reports from Parties which are EU members [4], that the EU legislation makes it easier for these countries to implement the Protocol. However, many EU Member States do not have all elements of the Protocol in place either. To assist Parties in the Protocol’s implementation and provide further guidance on the different Protocol’s provisions, the Meeting of the Parties – the Protocol governing body – adopts a triennial programme of work and establishes specific bodies to carry out the different activities.

The current organizational setting, established at the first meeting of the Parties in January 2007 is as follows:

In this context, the preparation of guidelines undertaken by the Task Forces set up by the Meeting of the Parties of the Protocol will be most helpful, but also the thematically oriented meetings organised by the joint UNECE/WHO-EURO secretariat of the Protocol and capacity building workshops like the present CWC workshop. The Secretariats of the Protocol – UNECE and WHO Euro - both have web- pages which can assist countries which are already a Party or countries which are considering becoming a Party (see table 1) with substantial information and guidance. The web-pages are:

Good Practices in the UNECE region

To address the water-related diseases it is important to understand the complex nexus between water/health/environment issues. While water pollution – as addressed in the UNECE Convention on the Protection and use of Transboundary Watercourses and International Lakes and in e.g. the Water Framework Directive - is an environmental problem, it is also a health problem.

Humans are directly or indirectly exposed to water through many routes, part of which are illustrated in the diagram below, showing the freshwater cycle with a focus on water supplies connected to distribution networks.

Caption:Freshwater Cycle

The remainder of this chapter presents examples of initiatives/tools/guidance on good practices of addressing water/environment/health relations in the UNECE region. First an example of is presented with focus on ways to coordinate and cooperate among key sectors. Then follow good practices of addressing health issues in drinking water systems and in freshwater resources planning and management. This is followed by examples of health issues in relation to use of recreational waters and reuse of waste water. Finally an example of a integrated water and health strategy is presented.

Experiences in setting targets on water and health and in establishing surveillance systems

In order to achieve its objective, the Parties of the Protocol, within two years from becoming a Party, shall each establish and publish time-bound targets at national and/or local level. Targets shall cover drinking water supply and sanitation, health systems and water and environmental management issues.

The process of setting targets shall be carried out with a participatory approach, consulting all relevant national and local authorities, and other stakeholders, including the general public. Targets shall be periodically revised. A target can be many things and the Protocol leaves flexibility to adapt to country needs. Examples of targets are:

  • Development of a law, monitoring programme water management plan, introduction of a new approach
  • Institutional framework
  • Capacity building or a study
  • Social and economic issues
  • Quantifiable targets like % of population with access to safe water supply
  • National/local/pilot projects

When setting targets it is important that progress in fulfilling the targets can be monitored.

To read about country experiences in setting targets and establishing surveillance systems Click Here.

Economic and Financial Considerations related to water and health

International Support to Projects

The Protocol calls on Parties to improve the quality of their water supplies, their sanitation services and their management of water resources, and to address future health risks and ensure safe recreational water environments.

In order to meet these goals, article 14 in the Protocol calls for “International support for National Action” on preparation of water management plans, formulation of projects and execution of them, on establishment of surveillance systems, development of legislation, education, research and monitoring the activities. Implementation of article 14 was introduced at the first Meeting of the Parties in 2007, when the Parties decided to establish a mechanism for international support to EECCA and SEEE countries. The purpose of the mechanism is to promote the coordination of international aid to implement the Protocol and to enhance the capacity of recipient countries to access sources of finance by helping them formulate projects. This support mechanism called “Ad Hoc Project Facilitation Mechanism” comprises two elements: the Facilitator and the Ad Hoc Project Clearing House.

The objective of the Ad Hoc Project Clearing House is to identify priority activities of non-infrastructure intervention for countries in transition in the following areas:

To facilitate increased funding of water and health related projects the Ad Hoc Project Clearing House will assess the relevance of project proposals submitted through the Facilitator and make suggestions for matching donors’ assistance with proposals. The Ad Hoc Project Clearing House will further advocate funding of the proposals, but the actual financing of proposals will be on a voluntary basis.

As with any new initiative EECCA countries will need assistance to implement the Protocol. The “Ad Hoc Project Facilitation Mechanism” does not itself – at least not at present- have funding which can be spent on projects in EECCA countries. However, through the activities of the Facilitator it can assist EECCA countries in formulating good projects, which may be of interest for a donor or other institution which support project activities within the priority areas given above. EECCA countries on their side, can secure that the project has a high priority in the country and has a broad support from all relevant stakeholders. If the project can get national co-financing (in kind or in cash) this will often by e.g. donors be seen as an indication of national commitment to the project. With a well formulated project, strong national backing and engagement of relevant stakeholders, the “Ad Hoc Project Clearing house” can assist in advocating for funding though their networks. EECCA countries may also wish to present projects developed with assistance from the “Ad Hoc Project Facilitation Mechanism” to their development cooperation partners. Some donors have decentralised the decision power on development assistance to embassies and representations in EECCA countries.

Cost assessment of access to safe drinking water

Improving access to safe water and adequate sanitation is a core provision of the Protocol and the Protocol requires Parties to assess its costs and benefits. OECD EAP Task Force , based on data collection from about 400 utilities in EECCA, assessed that there is a need not only to invest in improved access but also in renovation of existing supplies in particular to decrease leakage, improve continuity of water supply and improve water quality at consumers. It is estimated by OECD EAP Task Force that there is a need to double the investment in EECCA in water supply to secure access to safe drinking water.

For more information about financing strategies in the WSS sector, Click Here.

Monitoring and Reporting Progress under the Protocol

The monitoring and reporting of progress is an essential element of the Protocol as it enables the Parties of the Protocol to review progress on the national implementation of the Protocol and to engage the public and other interested national stakeholders in the work done under the Protocol at national level. As the Protocol concerns the public health, the results of monitoring of water and effluent sampling shall be made available to the public. The monitoring will further be used as a basis for preparing a national assessment report which will aim at reviewing the targets, in order to assess if the targets are met in agreements with the target dates set.

Based on the monitoring and reporting at national level, the Parties of the Protocol will prepare a summary report showing the key aspects of progress in implementing the Protocol but not presenting actual monitoring data will be used to assess the compliance with the Protocol by a Compliance Committee. Policy decisions need to be informed by good data, which are transformed into relevant information for decision makers. With respect to the Protocol monitoring data and information will first be used to inform the process of target setting. This involves analyses of the present status of water-related diseases and how these can be prevented, reduced and controlled. When country specific targets are set the present monitoring system can be analysed to assess if it fulfils the monitoring needs and complemented where gaps are identified. The aim will be to establish an effective data collection system, which enables an assessment of the progress towards meeting the targets.

Indicators to monitor progress

The example from Hungary presented earlier, illustrates the role of indicators as the concrete measure to monitor the quality of drinking water supplied.

The targets and the dates for meeting the targets are set through national processes, but based on an ambition to seek harmonization and convergence between the targets. The indicators on the other hand are developed jointly and some of them will be alike for all Parties to the Protocol. Guideline material on indicators will be developed and adopted by the second Meeting of the Parties in 2010.

For information on the development of an indicator and data collect systems Click Here.

Legal Dimension of the Protocol on Water and Health: compliance, procedure and functions of the Compliance Commitee

As the Protocol on Water and Health is a legally binding instrument, provisions to ensure compliance with the Protocol have been seen as a necessity by the countries that negotiated it, in order to ensure maximum benefits from the Protocol in terms of safeguarding the right to healthy water for all UNECE citizens.

As described earlier, the Parties of the Protocol will prepare summary reports on their progress to meet targets and target dates set by each Party. The summary reports will be sent to the Secretariats of the Protocol (UNECE and WHO) and forwarded to the Compliance Committee for analysis as well as the Meeting of the Parties.cThe first Meeting of the Parties (Geneva 17-19 January 2007) adopted a Decision I/2 on review of compliance establishing a compliance review procedure of non-confrontational, non-judicial and consultative nature which includes the establishment of a Compliance Committee. The objective of the Compliance Committee is to secure compliance with the obligations under the Protocol, with a view to preventing disputes, by:

  1. Addressing cases of non-compliance by Parties; and
  2. Providing advice or assistance to Parties, where appropriate.

To read further about the Compliance Committee and legal dimensions of the Protocol Click Here.

Conclusions and recommendations for future actions

It is well justified to conclude that there are considerable benefits for EECCA countries in provision of access to safe water and adequate sanitation and in an effective protection of surface and groundwater resources. Combined with an effective system for detection, contingency planning and response to outbreaks and incidents of water-related diseases, EECCA countries can make considerable progress in preventing, reducing, and controlling water related diseases for the benefit of its populations..

At present four out of 12 EECCA countries: Azerbaijan, Moldova, Russia and Ukraine have ratified the Protocol on Water and Health and are now taking steps in implementing the Protocol. Although the situation in EECCA countries differs, there seems to be no reason to believe that the benefits are less in the 8 EECCA countries, which have not ratified the Protocol. Further a number of good practices are available in the European region on provision of safe drinking water, adequate sanitation, water management and systems for detection, contingency planning and response to outbreaks of water-related diseases which EECCA countries can use and adapt to their national conditions.

Experiences with implementation of the Protocol are gradually developing in the countries which have advanced most with the Protocol. Further guidance material on establishment of surveillance systems, target setting, monitoring and reporting is developed by the two relevant Task Forces established by the Meeting of the Parties.

It can further be concluded there will also be challenges for EECCA countries in the implementation of the Protocol. Developing the coordination and cooperation mechanisms and engaging all relevant stakeholders, providing the necessary data and information to set targets and to develop surveillance systems and early warnings and to monitor and report progress on meeting targets seem to be areas which will be most challenging. The inputs from participants from EECCA countries to the workshop will be able to detail this further, and to make the conclusion on challenges more specific.

Recommendations for the Future

On the basis of this analysis, the following future actions are recommended:

  1. To analyse the burden of disease of water-related diseases and the costs and benefits of improving access to safe water and sanitation and improved water management and health survey systems. This information will provide an input to the political decision process.
  2. To analyse the efficiency of existing national water, environment and water legislation and regional/international agreements and programmes to prevent, reduce and control water-related diseases. The good practices presented in the background document can be used as a benchmark for EECCA countries.
  3. The result of the analysis may be used as a basis for preparing a plan for improving efficiency of existing legislation and programmes and the basis for a decision to develop new legislation and to ratify the Protocol.
  4. Additional specific recommendation will be developed an included in the Final Report from the workshop Participants of the workshop are invited to contribute to this.
  5. EECCA countries which have already ratified the Protocol shall develop a national roadmap to set national targets and target dates, development of a surveillance system and establish the national institutional structures to implement, monitor and report the progress in the implementation of the Protocol.

The roadmap could be developed through

  • setting up an intergovernmental group to develop the roadmap;
  • undertaking an analysis of existing policies and plans;
  • assessing key problems and potential solutions in relation to prevention, reduction and controlling water-related diseases; * setting targets and target dates and plans for developing surveillance and early warning systems;
  • consult targets and target dates with the public and relevant stakeholders;
  • develop a plan for setting up monitoring and reporting system to follow progress.


  1. See
  3. UNECE and WHO, Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes. Full text available at
  4. National Reports on progress of Parties to implement the Protocol, reported to the First Meeting of the Parties, January 2007

See also

Background Paper on Water and Health for the COP workshop Bucharest, 2008/Good Practices in the UNECE region

Background Paper on Water and Health for the COP workshop Bucharest, 2008/Setting Targets on Water and Health and Establishing Surveillance Systems

Background Paper on Water and Health for the COP workshop Bucharest, 2008/Financing Strategies

Background Paper on Water and Health for the COP workshop Bucharest, 2008/Monitoring and Reporting Progress

Background Paper on Water and Health for the COP workshop Bucharest, 2008/Legal Dimensions

External Resources

WECF on Workshop for Water and Health


 Background document water and Health Final.doc


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