WHO:Clean water - a basic human right

This text is taken from the WHO report "Health and Environment in Europe: Progress Assessment", 2010, ISBN 978 92 890 4198 0. [2]

Regional priority goal I: We aim to prevent and significantly reduce the morbidity and mortality arising from gastrointestinal disorders and other health effects, by ensuring that adequate measures are taken to improve access to safe and affordable water and sanitation for all children

Key messages

• Population access to improved water sources, sanitation and wastewater treatment has increased over the past two decades in most Member States. Progress in many countries in the east of the Region is, however slow, giving rise to important health inequalities.
• Water-related diseases remain a burden for people throughout the Region, including in the most economically developed countries. To reduce these diseases, a change is required from the present system of controlling drinking-water solely at the tap towards quality management along the production and distribution continuum from capture to tap. Thus there needs to be a shift in policy approach from penalties to active support.
• Gaps remain in our understanding of the distribution and causes of water-related diseases. Harmonized surveillance systems for waterborne diseases and outbreaks are needed throughout the Region, as are systems for monitoring health risks related to bathing water. It is particularly important to maintain a core of expertise to advise on and conduct outbreak investigation; testing, implementing and revising procedures in cooperation with other actors; and updating regulations

and policy.

• Legislation adopted in the framework of the EU acquis communautaire is an important policy driver throughout the Region. The United Nations Economic Commission for Europe (UNECE)/ WHO Protocol on Water and Health offers the Region-wide legal framework for the reduction of water-related diseases, integrated water resource management, a sustainable water supply compliant with WHO’s Guidelines for drinking-water quality and adequate sanitation for all.
• Climate change is adding to the challenge of providing sustainable water and sanitation services. Urgent action is required to assess systematically the climate change resilience of water supply and sanitation utilities, and to include the effects of climate change in water safety plans.

Public health importance

Water-related diseases are persistent but decreasing

Safe drinking- and bathing water are vital for health. Illnesses arise from exposure to water contaminated by pathogenic viruses, bacteria or protozoa or by chemical substances which may enter water sources naturally or through human activity.

In the Region, diarrhoea arising from poor water quality, sanitation and hygiene is estimated to cause 33 000 deaths and 1 182 000 disability-adjusted life years (DALYs) every year, with over 90% of both occurring in low- and middle-income countries. These deaths are largely preventable: the risk of water-related disease decreases where standards of water, sanitation and personal hygiene are high.

When action is taken to prevent water-related diseases, lives are saved. Mortality from diarrhoeal disease in children aged 0–4 years has fallen in the Region since the mid-1990s, with particularly dramatic reductions in the newly independent states. Figure shows the standardized death rates (SDR)4 for diarrhoeal disease in this age group in EU and newly independent states. It is both necessary and feasible to make further reductions by improving water and sanitation.

Standardized death rates from diarrhoea in children 0–4 years in the EU and newly independent states

The pattern of outbreaks5 of waterborne disease across nations can give considerable insights into the quality of drinking- and bathing water. Between 2000 and 2007, 350 outbreaks of waterborne disease related to drinking-water were recorded in the country surveillance systems and reported by 14 Member States, resulting in over 47 000 episodes of illness (5). Owing to wide variations in countries’ systems, their lack of sensitivity and underreporting, the differences between countries are more likely to reflect the efficiency of surveillance rather than the water-related public health situation. Even though only 14 countries submitted the key public health indicator and the limitations in the current health surveillance practices, this information show that outbreaks are not restricted to developing countries. Infants and young children are at disproportionately high risk of waterborne diseases, yet no country was able to submit child-specific information.

Region-wide, harmonized and effective surveillance systems for waterborne diseases and outbreaks thereof would greatly enhance understanding of the causal agents and the ability to prevent and eliminate the health risks. This requires urgent action related to public health.

Water-related health determinants: geographical and time patterns

Access to improved water supply: disparities within and between countries

Sustainable access to safe drinking-water lies at the core of public health. It indicates the extent to which essential needs are met, and is defined by the United Nations as a fundamental human right.

Reported outbreaks of diseases arising from drinking-water in selected European countries, 2000–2007

The United Nations Millennium Development Goals aim to halve, by 2015, the proportion of people without sustainable access to an “improved” drinking-water supply and basic sanitation. In Europe, there is an east-west gradient for access to an improved supply of safe drinking-water, defined as permanent access to an adequate amount of safe drinking-water preferably within, or at least near to, the household. In western Europe (EurG-A), virtually the whole population has had access to a public water supply since the 1990s. In the east of the Region (EurG-D), access remains low (although improving), ranging from 58% to 80%. Rural populations have less access to an improved water supply, and this disparity also increases towards the east of the Region. In more extreme cases, there are four to five rural dwellers without improved drinking-water for every one person lacking an improved supply in urban centres.

Access to improved water supplies across the Region has generally improved. Between 1990 and 2006, people in central and eastern Europe in particular experienced a marked improvement in water supplies, particularly in rural areas (8). There was however, some deterioration in access to a water supply in Bosnia and Herzegovina, Kazakhstan, Serbia and Montenegro, Slovakia, Tajikistan and Uzbekistan.

Percentage of the population with house connections to improved water sources in urban and rural areas, WHO European Region, 2006 or latest available year

Percentage change in population with house connections to improved water sources between 1990 and 2006 in the WHO European Region

Wastewater collection, treatment and sanitation: pronounced country differences

Access to safe drinking-water does not eliminate water-related diseases. Hand-to-mouth transmission of diseases present in faeces will occur if hygienic practices are poor. Moreover, industrial and agricultural processes also contaminate water sources in various ways that require the water to receive significant treatment if it is subsequently used for human consumption. Especially in coastal areas, the discharge of untreated sewage may result in the contamination of the bathing waters and present a major human risk. Taken together, these points emphasize that sanitation and wastewater treatment are essential for public health.

Approximately three quarters of the European population live in urban environments, where the collection and treatment of urban wastewater is especially important. The proportion of the population connected to wastewater treatment facilities grew steadily in most countries between 1995 and 2005, with a connection average of approximately 69% in 2005. Nevertheless, many eastern European countries still require substantial investment to reach the 80% or higher coverage typical of most western countries.

There is a conspicuous disparity between urban and rural areas in the percentage of the population living in homes connected to improved sanitation facilities. In almost all European countries, at least 60% of the urban population is connected, whereas in rural areas, mainly in the eastern part of the Region, this is often around 20% or lower. The situation is improving in some countries: Albania, Belarus, Hungary, Lithuania and Turkey all reported considerable progress in coverage in rural areas between 1995 and 2004. More needs to be done: it is estimated that providing access to a regulated water supply and full sanitation coverage, with partial treatment for sewage for the entire population of children in countries with low mortality in both children and adults, would save about 3700 lives and 140 000 DALYs annually. In the northern Mediterranean countries, and in particular in the coastal areas where the population doubles in summer, 24% of the coastal cities with populations of more than 2000 inhabitants have no access to wastewater treatment plants, affecting 2.7 million of the permanent population.

Good sanitary practices are also necessary. Even when the infrastructure has been improved, an estimated 30% of the water-related environmental burden of disease may remain unless hygiene is also improved. Better hygiene need not be complex or expensive: Promoting hand-washing with soap has been shown to be the single most cost-effective health intervention.

Safe bathing water: faltering progress

The safety of bathing water is tightly linked to sanitation and wastewater treatment: allowing contaminants to enter fresh water or the sea increases exposure by bathers and causes disease outbreaks. Children are at higher risk than adults, because they play for longer periods in recreational waters, are more likely to swallow water and may lack immunity to endemic diseases.

The global burden of disease attributable to gastroenteric infections arising from unsafe recreational water was recently estimated at 66 000 DALYs. Data on the public health impact of contaminated bathing water in the European Region are scarce: only nine countries have monitoring systems that record outbreaks from bathing water. Data from these countries indicate that outbreaks from bathing water are rare, causing a total of 4 to14 outbreaks annually between them. The low disease burden from recreational water may be related to the known improvements in EU bathing water quality, as well as to the significant limitations of routine country surveillance. Furthermore, it is still difficult to attribute illnesses to exposure in recreational water owing to the large number of other transmission routes of the pathogens.

Changes between 1995 and 2005 (or latest available year) in the population connected to wastewater treatment facilities in selected European countries

Quality of coastal and fresh water bathing sites in the EU, 1990-2008

The overall quality of bathing waters in the EU has markedly improved since 1990. Compliance with mandatory values (minimum quality requirements) increased between 1990 and 2008 from 80% to 96% in coastal waters and from 52% to 92% in fresh waters. From 2007 to 2008, compliance increased for coastal waters by 1.1% and fresh waters by 3.3%. The water quality of EU coastal zones improved considerably from 1990 to 2004 and has remained high. Specifically, 95% or more of coastal bathing areas have complied with mandatory requirements since 1999 and over 85% have complied with more stringent guide values. The results of the 2006 survey on the quality of bathing waters in the Mediterranean have shown that six European Mediterranean countries complied fully with national legislation and five countries had a compliance rate of 95–99%; in three countries only 30–46% of the monitored beaches were in compliance.

Fresh water zones have been less likely to meet standards and showed a negative trend for a period after 2003, following years of improvement. Compliance with mandatory values fell from 92% in the 2003 season to 86% in 2005, before rising to 89% for 2006–2007 and 92% in 2008. This can be largely explained by the increased number of bathing areas that were insufficiently sampled. Compliance with fresh water guide values also showed a negative trend after 2003 (68%), falling to 62% in 2007 before rising to 73% in 2008.

Mandatory compliance for coastal zones tends to be higher, on average, than for fresh water ones. All but two countries monitored reported over 80% mandatory compliance for coastal waters. Slovenia is one of those two countries but its compliance with the more stringent guide values is higher than several other countries. Compliance of coastal bathing areas with mandatory water quality values is better on average on the North Sea, Atlantic and Mediterranean coasts than in the rest of the EU.

Bathing water quality for coastal zones in countries of the EU

Recent compliance with mandatory values has been highest in the fresh water catchments of the Atlantic, North Sea, Baltic and Black Sea. It is notable that some countries with poor coastal waters compliance, such as Bulgaria and Estonia, reported relatively satisfactory fresh water compliance.

Mandatory standards focus on key parameters of faecal contamination. Illness may, however, be caused by other pathogens than those covered by mandatory requirements. High levels of compliance with the standards do not necessarily mean that there are no factors that could affect public health. An expansion of monitoring schemes to the full range of parameters of WHO’s Guidelines on safe recreational water environments would minimize the number of sites that are insufficiently sampled and thereby reduce uncertainties about bathing water safety.

Emerging issues

Climate change is expected to alter the epidemiology of water-related disease in a number of ways, for example through changes to rainfall and flooding. Floods can have catastrophic consequences for basic water and sanitation infrastructure, distributing sewage, with its associated health risks, across entire neighbourhoods and communities. Physical damage and the loss of utility can take years to repair or recover, while the loss of heritage and items of historical importance (whether to nations or individuals), with its psychological importance and sense of well-being, can be unrecoverable. Where long-term rainfall is increasing, groundwater levels may rise and thus decrease the efficiency of the natural purification processes and increase the risks of infectious disease and exposure to toxic chemicals. Despite uncertainties in predicting the consequences of climate change, in most regions enough knowledge and technology is already available for policies to be initiated that will maximize the resilience of the water sector, taking into account the potential resilience of different water and sanitation technologies. Necessary responses to climate change present a general opportunity for substantial improvements to health and development.

Potential resilience of different water and sanitatio technologies

	Water technoligies	Sanitation technologies
Category 1: Potentially resilient to all expected climate changes	Utility piped water Tube wells	Pit latrines Low-flush sptic system
Category 2: Potentially resilient to most expected climate chages	Protected springs Small piped system	High-volume septic system Convetional and modified sewerage systems
Category 3: Potentially resilient to only a restricted number of expected climate changes	Dug wells Rainwater harvesting	-
Technologies categorized as "not improved"	Unprotected dug wells/sprigs Carts with tanks/drums Surface waters Bottled water	Latrines without a slab/platform Hanging latrines

Co-benefits of providing improved drinking-water, sanitation and wastewater treatment

The provision of access to improved drinking-water, sanitation and wastewater treatment is closely aligned with other global health and non-health objectives, and will help achieve the health objectives of the fourth and seventh millennium development goals as well as, more indirectly, other goals.

A cost-benefit analysis undertaken by WHO in 2004 (21) found that reaching the seventh millennium development goal’s target for water and sanitation would bring substantial economic gains: it was estimated that the return on investment would be 3–34 to 1, depending on the region. Moreover, maintaining clean water sources for human health also helps to maintain the environmental integrity of aquatic ecosystems, which contributes to this goal as well as other international conventions that aim to protect biological diversity.

Taken together, the multiple benefits of improved water supplies and sanitation demonstrate the need for intersectoral public policies integrating health in the context of sustainable development.

Water, sanitation and health: policy analysis

People in Europe are aware of, and concerned about, the importance of good water quality. When questioned in a major survey across the EU about the environmental issues that worried them most, almost half answered water pollution, second only to climate change. The importance of water quality is also reflected in the many different measures taken in Europe since the 19th century to supply people with safe water and good sanitation. It is no accident that a classic, and still insightful, example of a public health measure concerns water quality: the closing of the Broad Street pump in London in 1854 where Dr John Snow made the connection between a cholera outbreak and contaminated water.

The policy survey covered the following four topics under regional priority goal I: drinking-water quality, sanitation, sewage and bathing water quality (both coastal/fresh water and swimming pools). Thirtyseven Member States responded, although not necessarily to all the topics. Here the focus is on policies for drinking- and bathing water quality, with an analysis of the policy profiles along six key aspects of the integration of public governance and health policy (so-called “healthy public policy”). Policy profiles are presented as radar plots in clockwise order of the six aspects. These are:

• policy development
• implementation and enforcement mechanisms
• mechanisms of policy accountability for health
• involvement of health sector in the policy cycle
• equity considerations
• approaches to information provided to the public.

The policy profiles for drinking- and bathing water quality show a similar pattern, with very low equity considerations reported by all country groupings.

Profiles of policies on drinking- and bathing water quality, by country grouping

Public governance

Objectives, scope and type of policy measures

The high scores for policy development in all the country groupings indicate the importance of water quality for many decades in the Member States. A closer look at national policy measures shows that the objectives most frequently reported were those of compliance with quality standards, regulations and international commitments both at EU and Region-wide level (e.g. the Protocol on Water and Health). The highest rates (80–100%) were in EurG-A and EurG-B countries. Less frequently reported (60–80%) were policy objectives related to management of the drinking-water supply and to reducing risks to health. This is troubling, as the Guidelines on drinking-water quality and the Protocol on Water and Health have both highlighted the value of focusing on preventive management approaches along the continuum from water resources to consumer. It is also of concern that the building of infrastructure was reported as a policy measure objective less often (around 70% of countries), if the east-west disparities in access to improved water sources are to be reduced.

Around two thirds of the countries reported the existence of legislation (as opposed to action plans, programmes, guidelines, etc.) concerning drinking- or bathing water quality. This is consistent with earlier assessments of European policies on water quality. There are more policies, white papers, actions plans, etc. for drinking-water than for bathing water.

Types of policy instrument for drinking- and bathing water quality

Some countries reported that the quality of drinking- and bathing water was covered by more than one legal instrument: for example, Finland and Lithuania referred to more than five acts in their answers to the survey. Some laws dated back to the 1960s and 1970s (for example, in Germany) but three quarters of the laws were not enacted until the 21st century.

Impact of international policy processes on national standards

The situation regarding a number of legal acts on the quality of drinking- and bathing water already in place in many Member States (partly unique for regional priority goal I compared with the other goals) reflects the development of policy in the Region. More importantly, it reflects advances in regulatory approaches as a result of evolving scientific evidence and knowledge.

EU directives are compulsory for most of the countries within the EurG-A and EurG-B groupings. They also drive the policy and legal agenda of the accession countries in the EurG-C grouping and, interestingly, in other countries outside the EU (e.g. Belarus, Kyrgyzstan, Russian Federation) that have reported following EU legislation on drinking-water quality. The European Commission has amended and published the new bathing water Directive 2006/7/EC following the advance in scientific evidence reviewed in the WHO Guidelines for safe recreational water environments. In its 2004 Guidelines for drinking-water quality, WHO introduced the concepts of risk assessment and risk management at every stage in the production and distribution of drinking-water. Currently, the Commission is amending the Drinking-water Directive to incorporate the newest health standards and EU water policy and legislation. These developments show how international health norms can drive national policy and regulations.

There are, however, shortcomings in the enforcement of and compliance with the policies; EurG-C countries report them as partly under-provided for drinking-water quality, and EurG-D countries the same for bathing water quality. Measures to deal with non-compliance differ among the country groupings. Penalties for infringements are the highest in EurG-D countries for violations of both drinking- and bathing water quality; EurG-A countries also tend to rely more on this measure than EurG-B and EurG-C countries. Action plans and remedial measures to minimize the risk of non-compliance for the quality of both drinking- and bathing water are commonest in EurG-A and EurG-B countries. The action programmes reported by EurG-C countries as a common measure to eliminate non-compliance of bathing water quality most likely reflects the importance of local tourism.

The greater number of action programmes and remedial measures to ensure the quality of drinkingwater and safe water for recreation in European countries demonstrates the growing importance of those policy instruments during the last decade. WHO’s work in setting health-relevant international guidelines for water quality has been an important driver for this movement. As already mentioned, the continuing revision of the EU drinking-water directive in accordance with the Guidelines for drinking-water quality will introduce a novel integrated approach to water safety applicable to all systems, from large complex piped systems to community-managed sources. Action programmes to prevent, reduce or eliminate the causes of pollution of bathing water are most often put in place by the EU countries.

Healthy public policy

EurG-C and EurG-D countries score highly on policy accountability for health and the involvement of the health sector, in particular as regards drinking-water quality, and report a high degree of health policy integration. This is a consequence of the water and sanitation problems encountered in these countries which give rise to traditional infectious diseases (Shigellosis, Hepatitis A, etc.) and require the active intervention of the health sector (28). Nevertheless, the most effective way of providing safe drinkingwater is to eliminate the risk of infection at source. These measures usually lie outside the health sector and their successful implementation requires a strong intersectoral approach.

Policy evaluation and health accountability

The two commonest evaluation methods in almost all groupings are simple information gathering and water quality monitoring networks. The most infrequent measure is the surveillance of diseases and outbreaks related to drinking-water. This information is typically included in the monitoring of general infectious diseases, which limits its usefulness for the specific purpose of control and improvement of public health. In contrast to all the others, the EurG-D countries reported to a great extent the existence of surveillance systems for waterborne diseases and their use in relevant policy-making. Unfortunately, no newly independent state provided information on water-related disease outbreaks. The same is true of mandatory periodic evaluation and follow-up on health consequences, where EurG-D countries have a high score. A Regional Office review of the availability and quality of data required for following the health-related millennium development goals in the newly independent states has revealed considerable limitations in the water and sanitation-related indicators when assessed against international definitions of best practice.

Measures to ensure compliance with policies for drinking- and bathing water quality, by country grouping

Periodic reviews of policy obligations and targets are also infrequent in all countries. Parties to the Protocol on Water and Health are, however, obliged to set targets, monitor progress towards these targets and report on such progress to the Meeting of Parties. Guidelines on target-setting, indicators and reporting have been developed and pilot programmes are under way.

Health sector involvement in intersectoral policy action

Coordinated, integrated measures that cut across departmental boundaries and responsibilities are critically important for water and health promotion and protection. All groupings, with the exception of EurG-A, score highly on involvement of the health sector throughout the policy cycle relating to both drinking- and bathing water quality. EurG-A countries reported the lowest degree of health sector involvement, in particular with the monitoring and evaluation of drinking-water policy implementation, while EurG-D countries had the highest scores across the entire policy cycle, including control and enforcement of policy. This may reflect differences in sector responsibilities as well as differences in the status of public health related to water questions.

This indicator-based assessment revealed both a considerable east-west divide in populations’ access to improved water sources and persisting urban-rural disparities. To rely on the health sector alone to solve problems regarding water quality and the building of the underlying infrastructure may not be realistic because the responsibility for measures needed to act or to ensure compliance lies elsewhere. For example, the figure below illustrates that the rural populations in most of the EurG-A countries have good access to improved drinking-water sources, while at the same time there is relatively low involvement of the health sector. Policy development and enforcement of water legislation should be the responsibility of those sectors with the means to change a situation, such as the authorities responsible for the environment or social planning.

Population access to improved water sources (rural) and health sector involvement in drinkingwater quality policy-making, by country grouping

Responsibility for preventive policy and infrastructural measures, and enforcing the compliance of various actors, lies with the environment or social planning sectors and – beyond them – with those responsible for setting priorities for the national agenda and investment. A subsidiary but crucial point is the need for integrated, cross-departmental intersectoral action. Within this proactive policy framework, the role of the health sector, together with the necessary resources and expertise for it to discharge its responsibilities successfully, becomes even more important. The perspective and experience of the health professions must be included whenever intersectoral policies on water and sanitation are developed, and subsequently they must be able to track and influence the implementation of those policies. This includes the setting of water quality standards and safety plans which adapt WHO guidelines to country-specific circumstances and monitoring of the health gains from their implementation. The health sector also has to build or maintain expertise in evaluating the underlying causes of outbreaks, and be able to implement harmonized methods of surveillance and reporting of waterborne diseases. Finally, health professionals, both generalists and specialists, are in the best position to influence personal hygiene behaviour, thus raising awareness of the determinants of water-related health and generating demands for solutions.

Equity considerations

All country groupings reported limited consideration of vulnerable or underprivileged population groups, including children and rural populations, in water and sanitation policies, perhaps because water and sanitation are seen as universal goods as opposed to targeted measures. Countries with advanced infrastructures may aim to secure equal universal access to water and sanitation. Given the considerable differences in urban and rural access to improved water sources, and the health risks associated with small water supplies and local wells or boreholes in rural areas, it may still be important to combine the universal approach with targeted action programmes. For example, the EurG-C countries have a relatively low score regarding specific action aimed at the population at risk in areas where the quality of drinking-water is poor (Fig. 11). This issue can easily slip “out of sight, out of mind” so (as has been pointed out many times) it is essential to maintain accurate monitoring of population coverage by water and sanitation services. Such statistics help to prevent this issue slipping off the policy agenda.

Children’s health, and ensuring their safe water environment, is relatively low on the policy agenda: only half of the countries in the EurG-C grouping reported consideration of children in water quality policy, even fewer in the other countries. Action dedicated to education in personal hygiene and promoting hygienic behaviour in schools and kindergartens was reported by the EurG-B, EurG-C and EurG-D groupings and, to a much less extent (20%), in EurG-A countries.

Transparency and communication

Providing people with information on water quality in a readily accessible and understandable format allows them to make informed decisions regarding their health, lifestyle choices and risk avoidance, among other factors. It can mobilize public opinion and inform polluters and governments of the scale of a problem and what the public expect them to do about it.

Even though it is clearly stated in the Directives on bathing water (2006/7/EC, article 12) and on drinking-water quality (98/83/EC, article 13) that up-to-date information on water quality must be available for consumers, the EurG-A countries score poorly in particular as regards drinkingwater quality. It may not be easy to extract easily understandable yet accurate information from the vast amount of data on compliance with drinking-water parameters and standards, despite intensive monitoring. Nevertheless, it must be done. Similar challenges are routinely encountered and surmounted by professional communicators in other fields.

The EU bathing water directive from 2006 provides clear guidelines on how to inform the public about water quality. The directive lays down that member states must present four quality categories for bathing waters – poor, sufficient, good and excellent. According to the European Environment Agency (EEA), Cyprus, Denmark, Estonia, Hungary, Latvia, Lithuania, Slovakia, Spain and Sweden started to monitor bathing waters according to the more stringent new European legislation during the 2008 bathing season, while Luxembourg started in the 2007 bathing season. The EEA has created an interactive observatory bringing together data on bathing water quality with feedback and observations by millions of ordinary people. Another important initiative, which has been driving the development of bathing water quality, is the Blue flag programme, established and run by the Foundation for Environmental Education. The award of a Blue Flag beach is based on compliance with criteria covering different aspects of water quality and environmental management.

Even though the collection of information now seems to be relatively well taken care of, it is essential to establish how easy it is for the public, bathers and tourists to get access to that information and to use it to make informed choices.

Overall progress

Comparing health outcomes related to water and sanitation either between countries or over time is difficult, not least because of differences in surveillance and reporting. This is a key message of this chapter: the need to expand and standardize surveillance systems. The same is true for monitoring the quality of bathing water sites.

The data that are generally available indicate positive trends over the past 10 to 20 years. Between 1995 and 2005, diarrhoeal disease decreased in children aged 0–4 years in all European sub-regions. The proportion of the population connected to an improved water supply increased in most countries between 1995 and 2005, especially in rural areas. This trend needs to continue to close the often large gap between urban and rural areas. The proportion of the population connected to wastewater treatment facilities also increased in most countries over the same period but exhibited a similar urban-rural disparity.

Over the past five to six years, the quality of coastal bathing sites has remained high but fresh water areas have reported some decline in quality. Two future challenges are to increase the percentage of areas conforming to guide values and to reduce the number of sites that are insufficiently sampled.

This improving situation probably reflects the continuous improvement in the health relevance of international standards on the quality of drinking- and bathing water. Nevertheless, more now needs to be done. In particular, there is a need for concerted intersectoral action to ensure that those responsible for the design and implementation of new regulations (such as the authorities responsible for the environment or social planning) consult, and draw upon the skills and knowledge of, the health sector. The health sector should build and maintain expertise to be both leader and catalyst of such cross- sectoral action to improve public health.

Further development of the UNECE/WHO Protocol on Water and Health, in particular the mechanisms for compliance, monitoring and reporting and guidelines for their application in the Member States, will lead to it becoming the Region-wide legal framework for water and health.

See also

• Health and Environment in Europe: Progress Assessment
• WHO:Be mobile, active - and safe!
• WHO:Clean air for health
• WHO:Eliminating environmental health hazards
• WHO:Implementing the CEHAP for Europe:the role of intersectoral collaboration

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