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


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Forms and Structures of Institutional Arrangements

To address water/environment and health sector issues, a solid institutional structure with broad representation from the most important sectors related to water/environment and health is fundamental.

The Hungarian experiences show that coordination and cooperation between different sectors is very important in order to fulfil the vision of an integrated approach to improve prevention, control and reduction of water related diseases. It is also important to have representation of Ministries of Finance/Economy, as the Protocol implementation may imply additional investments. As implementation - in particular related to access to water and sanitation – will also take place at local level, the participation of local government representatives is crucial.

A major effort however is still needed to get "Environmental Health” issues higher on the national agenda, not only in EECCA but also in many other regions of the world. The traditional focus on "cure” rather than "prevention” in the health sector should be challenged. The Protocol with its holistic approach and focus on water-related diseases can be seen as a step in the right direction.

Water Safety Planning - Managing drinking-water quality from catchment to consumer

Effective catchment management can decrease the contamination of the source water used for drinking water purposes. Management instruments for IWRM can, if water-related health and water quality issues are addressed, assist in making drinking water safer for consumers, in particular in cases where the capacity to treat source water for drinking water supply is low or non-existing.

Understanding the reasons for variation in source water quality is important as it will influence the requirements for treatment, treatment efficiency and the resulting health risks associated with the water to be supplied to consumers. Whether water is drawn from surface or underground sources, it is important to understand the characteristics of the local catchment or aquifer. The extent to which potentially polluting activities in the catchment can be reduced may, however, be limited by the pressures for increased development in the catchment. However, introducing good practice in reducing or eliminating microbial and chemical pollution through reductions of pollution at the source (cleaner technologies) or through waste water treatment is often possible without substantially restricting activities in the catchment.

Water Safety Planning

Water Safety Planning is a risk management tool - which is highly relevant for the Protocol and which can be made part of its implementation. Water Safety Plans can assist water suppliers and water managers in securing that safe water is provided to the consumers. Water Safety Plans should, by preference be developed for individual drinking-water systems. A Water Safety Plan has three key components:

  • System assessment to determine whether the drinking-water supply chain (up to the point of consumption) as a whole can deliver water of a sufficient quality (meeting health-based targets). This also includes the assessment of design of new systems.
  • Identifying control measures in a drinking water system that will collectively control identified risks and ensure that the water has a sufficient quality.
  • Management plans for the water supply system (from catchment to tap) describing actions to be taken during normal operation or incident condition and documenting plans and programmes.

Resource protection and source protection are the first steps in the protection of drinking water quality. Where catchment management is beyond the jurisdiction of the drinking water supplies - which is often the case - the identification of hazards, planning and implementation of control measures will require coordination with other agencies. These may include planning authorities, catchment boards, environmental and water resource regulators and land owners like agriculture and industry, whose activities have an impact on water quality.

Assessing the hazards in water abstracted for drinking water

Hazards and hazardous events that can have an impact on catchments and that should be taken into consideration as part of a hazard assessment include:

  • rapid variation in raw water quality for drinking water
  • sewage and septic system discharges
  • chemical use in catchment areas (e.g. use of fertilizers and agricultural pesticides)
  • major spills, both accidental and deliberate
  • human access through e.g recreational activities
  • wildlife and livestock
  • land use (e.g. animal husbandry, agriculture, forestry, industrial area, waste disposal, mining) and change in land use
  • inadequate buffer zones and vegetation, soil erosion and failure of sediment traps
  • stormwater flows and discharges
  • waste disposal or mining sites/contaminated sites/hazardous wastes
  • geology (naturally occurring chemicals)
  • unconfined and shallow aquifers (including groundwater under direct influence of surface water)
  • stratification
  • algae and cyanobacterial blooms
  • climatic and seasonal variations (e.g. heavy rainfalls, droughts) and natural disasters

Prioritizing Hazards for Control

Once potential hazards and their sources have been identified, the risks associated with each hazard and hazardous event should be compared so that priorities for risk management can be established and documented. Although there are numerous contaminants that can compromise drinking water quality, not every hazard will require the same degree of attention. The risk associated with each hazard or hazardous event may be described by identifying the likelihood of occurrence (e.g. certain, possible or rare) and evaluating the consequences if the hazard occurred (e.g. insignificant, major, catastrophic). The aim is to distinguish between important and less important hazards and hazardous events. The likelihood of occurrence can be based on the result of the assessment as mentioned above. The consequence of the hazard can be based on information of the microbial, chemical and radiological contaminants. The WHO Guidelines for Drinking Water is a source of information which can be used for that purpose.

Control Measures

Effective resource and source protection includes the following elements:

  1. developing and implementing a catchment management plan, which includes control measures to protect surface water and groundwater sources.
  2. ensuring that planning regulations include the protection of water resources (land use planning and watershed/river basin management) from potentially polluting activities and that these are enforced
  3. promoting awareness in the community of the impact of human activity on water quality.

Examples of control measures for effective protection of source water and catchments include:

  1. control of wastewater discharges
  2. control of human activities within catchment boundaries
  3. land use planning procedures, use of planning and environmental regulations to regulate potential water-polluting developments
  4. specific protective requirements (e.g. containment) for chemical industry or refuelling stations
  5. run-off interception
  6. regular inspection of catchment areas.
  7. Retention of water in reservoirs can reduce the number of faecal microorganisms through settling and inactivation.

Control measures for groundwater sources should include protecting the aquifer and the local area around the well.

Water Safety Plans

Added values identified [1]

Water Safety Plans in Schools


As the example from Tulln shows, users consider Water Safety Plans to have considerable added values. As the example of WECF shows, the concept also has a wide applicability.

Guidance material from WHO comprises guidance to establish Water Safety Plans, not only for large or medium scale water supplies, but also for local small scale supplies, and is thus relevant both for urban and rural water supply. Preparing a Water Safety Plan could be one of the national targets under the Protocol.

Health Impact Assessment

Health Impact Assessment (HIA)[3] aims to identify how development includes unintended changes in health determinants and resulting changes in health outcomes. HIA provides a basis to pro-actively address any risks associated with health hazards. HIA also addresses health improvement opportunities in development. Health hazards, risks and opportunities also may be addressed explicitly in environmental assessment.

Development planning is typically conducted outside the health sector and is concerned with social and economic development, for example energy, agriculture, industry and transport. With a considerably larger proportion of resources at their disposal, and with a responsibility for action that may change environmental and social health determinants significantly, these other sectors outstrip the health sector in the potential to affect, protect and promote population health.

Development planning without adequate consideration of human health may pass hidden “costs” on to affected communities, in the form of an increased burden of disease and reduced well-being. From an equity point of view, it is often marginalized and disadvantaged groups who experience most of these adverse health effects. From an institutional point of view, it is the health sector that must cope with development-induced health problems and to which the costs are incurred of dealing with an increased disease burden.

HIA provides a systematic process through which health hazards, risks and opportunities can be identified and addressed upstream in the development planning process, to avoid the transfer of these hidden costs and to promote multi-sectoral responsibility for health and well-being. The production of public health management plans with safeguards, mitigating measures and health promotional activities in an integral part of HIA.

Water/environment/health addressed in IWRM planning processes

At WSSD in Johannesburg in 2002 it was decided that all countries should develop IWRM Plans by 2005. The IWRM plans aims at initiating a reform process in which countries start implement the IWRM principles[4]. The IWRM plans are aimed at understanding and prioritising key water resources issues, including those related to health, and developing plans for improved water management.

An example is the IWRM 2005 Programme for Central Asia [5] undertaken with support from UNEP and implemented in close collaboration with GWP and the heads of national water management bodies. The objective was to promote and build capacity on IWRM planning in the five Central Asian countries through a regional process involving all five countries and to assist in developing IWRM plans in Tajikistan, Kyrgyzstan and Uzbekistan.

The development of the IWRM Roadmaps also engaged representatives of health authorities at national and local level. The analysis of national water resources issues addressed not only water quantity but also the deteriorating quality of surface and groundwater, lack of access to safe water and prevention of emergency situations. The consultation process of the IWRM Roadmap led to a prioritisation of actions. This comprised recommendations on improving water quality monitoring systems, decrease of water body contamination, establishment of waste water treatment systems. Such actions were prioritised as medium to long term actions, while establishment of basin irrigation systems, water efficiency, basin organisations and water user associations were considered as short term priorities.

Water and Health addressed in a Transboundary Context

Parties to the Protocol bordering the same transboundary shall cooperate and assist each other to prevent, control and reduce transboundary effects of water related diseases. An example of the development of management goals, including health goals is the management of the Bug River as illustrated below:

As the examples from Central Asia, Caucasus and Bug River show health ministries are engaged as a stakeholder in IWRM activities and health issues are taken into account both in the analysis of problems and issues as well as in the prioritisation of goals and actions. In EECCA it seems that arguments based on the reduction of water-related diseases, are often more convincing to decision makers than arguments based on environmental quality. There exist however a number of challenges in EECCA in relati on to IWRM and health. First of all there is a relative high focus on quantitative aspects of water and water use in water resources management rather than qualitative aspects, and the water and health link is often seen narrowly as securing the necessary amount of water for water supply. Also except for [Glossary/Flood|floods]], risk assessment is generally not an integral part of IWRM. And “health people” are not in “the driving seat” in IWRM, which are most often driven by prominent water users - to secure the important supply of water for economic development. It is thus still a major challenge to get water-related health into IWRM plans – a challenge which however can be better faced if more countries become Parties and implement the Protocol.

Water Framework Directive and other relevant EU legislation - illustrating links between water, environment and health

The involvement of the European Union in water legislation and management started in 1975 with formulation of common standards later to be followed by directives, predominantly on water quality. The formulation of the Water Framework Directive started in 1995 with an open consultation of relevant stakeholders. The Directive was finally adopted in 2000 and is a major innovation uniting all Member States in a commitment to jointly manage all their freshwater resources on a basin scale.

Main principles of the Water Framework Directive are:

  1. Integrated water policy;
  2. River basin approach;
  3. Principles of precaution and preventive action,
  4. Principle of remedial measures at the source of the threats to the environment;
  5. Polluter-pays principle and the principle of the recovery of costs linked to water
  6. Decision making at the lowest possible level,
  7. Combined approach setting emissions limit values and environmental quality standards.
  8. Involvement of the public as a condition for success.

Following the Directive all Member States have to achieve good status for water bodies before 2015, unless an exemption has been granted. Their status will be evaluated and the European Commission will be able to prosecute the failing Member States. The Water Framework Directive is linked to other directives on issues like drinking water and bathing water and on setting environmental quality standards on substances that are hazardous to health and environment.

The Directive further sets out a precise timetable for its implementation and has established monitoring systems for all water bodies within the European Union. For EU Members a large proportion of the targets for the Protocol on Water and Health and the target dates for their implementation will derive from EU Directives. For instance the Bathing Water Directive sets a target on assignment of bathing profiles with description of pollution risks and proposals for measures for improvement in the quality. Both non-members and applicant countries might find guidelines and targets from EU directives relevant for implementation of the Protocol. A robust commitment to public participation in water management is also shared by the Water Framework Directive and the Protocol on Water and Health. The WFD however, has good ecological quality as its primary objective and not water-related diseases as the Protocol does.

Safe recreational use of coastal and estuarine waters

A new Bathing Water Directive has become law in the EU Member States from March 2008 and will take effect from 2015. This will set even stricter water quality standards. The following example show the initiatives taken in UK to tackle problems related to bathing water[6].

Safe use of wastewater in agriculture and aquaculture

Wastewater, excreta and grey water are increasingly used for the irrigation of agricultural crops and in Glossary/Aquaculture\aquaculture. In many countries, they have come to be important water resources. In addition, they provide an important mode of nutrient recycling. As good-quality freshwater becomes increasingly scarce due to population growth, urbanization and climate change, the use of wastewater in agriculture will increase proportionally. At least 10% of the world’s population is thought to consume foods produced by irrigation with wastewater. Principal driving forces, other than scarcity, for the increased use of wastewater are:

  • population increase and related increased demand for food and fibre and deriving increase demand for irrigational water;
  • a growing recognition of the resource value of wastewater and the nutrients it contains;

The use of wastewater and excreta in aquaculture is geographically more confined: it is of importance in Bangladesh, China, India, Indonesia and Vietnam. The extent to which it is practiced in EECCA countries is not known. Aquaculture includes the production of fish and aquatic vegetables for direct consumption, as well as the production of fish seed (fingerlings) or of fish or aquatic plants that serve as feed for livestock or other fish. New concepts of sanitation (e.g. eco-sanitation with separation of urine and faeces) also open new avenues for the use of excreta and greywater in agriculture. Recycling and re-use practices imply a number of health hazards linked to disease-causing organisms: viruses, bacteria and parasites.

Links between work under the Protocol and the EU Water Initiative Policy Dialogues

National Policy Dialogues (NDPs) have been developed as the main operational instrument to implement the work program of the EUWI-EECCA Component. The overall objectives of NPDs are to initiate country-specific activities regarding Water Supply and Sanitation and Integrated Water Resources Management to improve regulatory and administrative frameworks, help setting country priorities, and identify projects and develop capacity in the EECCA region. This includes a dialogue, which among others involves public authorities and representatives of the civil society (see box below).

The examples show that a partnership model, like the one under the EUWI, can promote not only the overall objective of the EUWI, but at the same time also objectives of the Water Convention, its Protocol on Water and Health, the Environmental Strategy for EECCA etc. An example of a holistic approach to environment, water and health management is the Danish Environment and Health Strategy. Although Denmark has not ratified the Protocol, the health strategy implementation shows the importance Denmark is putting to a healthy environment.

In 2003 the Danish Government adopted an Environment and Health Strategy and a Ten-point Plan for its implementation. The aim was to limit negative environmental impacts and thereby prevent adverse effects on public health. With the strategy the Government wished to establish an overview of the effects of environmental factors on health and to set forth goals and initiatives for the coming years. Among other things the strategy is intended to create a common framework for enhanced cooperation between the authorities dealing with environment and health. The strategy sets human health in focus and identifies environmental factors, that affect the Danish Population in their everyday lives, for example via the air, the water and the diet. The strategy realises that in many areas there is sound knowledge on how environmental factors affect health but are areas, in which there is not sufficient knowledge to take targeted action.

The strategy is based on four fundamental principles:

  1. Everyone must be ensured a high level of protection;
  2. the precautionary principle must be applied;
  3. the adverse effects of environmental factors on health must be prevented;
  4. information and involvement must be ensured so that everyone can take responsibility for a healthy life.

The Ten-point plan has two specific water goals: “groundwater and drinking water must be protected” and “beaches and lakes designated as bathing areas and swimming pools must have good, hygienic quality”, and other goals which indirectly address water: “Food must be safe and free from pollution”; “Research into the significance of environmental factors on health is to be enhanced” and “Cooperation between authorities must be strengthened”. The actions in relation to groundwater includes regulations of the use of pesticides, fertilizers and the application of manure to agricultural land, a continuation of remediation of waste deposits and landfills, designation of areas with special drinking water interests including mapping and survey of pollutants. Protection of bathing water comprise investments in waste water treatment at point sources and open land and research on new health risk factors like endocrine disruptors. The strategy continues to be a vehicle for an improved understanding of links between health, environment and water and has put health back into the agenda of environmental protection in Denmark.


  1. Source: WHO Europe; Support to the Development of a Framework for the Implementation of Water Safety Plans in the European Union. Draft, 2007
  2. WECF, Flyer on “Water Safety Plans in Pictures” 1803/2008
  3. Health Impact Assessment, IAIA, Special Publication Series no 5, September 2006
  4. GWP TEC 10, IWRM Plans, Why, What and How, 2004.
  5. UNEP Collaborating Centre on Water and Environment and Global Water Partnership,

See also

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

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

Protocol on Water and Health

Convention on the Protection and Use of Transboundary Watercourses and International Lakes

Managing Water and Health issues in Mali

External Resources

WECF on Workshop for Water and Health


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