ABSTRACT

This article aimed to highlight the relevance of surveillance of water quality for human consumption in the context of access to safe drinking-water. To fulfill it plentifully, adequate information and communication to society is essential. Thus, public access to the qualitative component is a fundamental element to health assurance and so is the establishment of water quality surveillance regulation for human consumption in the world and in Brazil. Since the 1980's, water quality surveillance actions have been fundamental to guarantee the right to have access to water in Brazil. However, although communication actions of surveillance results are planned in the policy scope of surveillance, in order to empower users, there are some setbacks in information production and its communication that ends up compromising access, seen mainly in the perspective of availability and quality of drinking-water.

KEYWORDS:
Water quality; Drinking water; Surveillance

Introduction

Access to sanitation is considered an imperative condition to human dignity and survival, as much as the adequate provision of water regarding quantity and quality. It is stated that the involvement of individuals in economic and social activities depends, primarily, on quality of life, which is made viable from the access to sanitation, housing, health and education¹1 Paganini WS, Galvão Junior AC. Aspectos conceituais da regulação dos serviços de água e esgoto no Brasil. Eng. Sanit. Ambient. 2009; 14(1):79-88.^,22 Razzolini MTP, Günther WMR. Impactos na saúde das deficiências de acesso a água. Saúde soc. 2008; 17(1):21-32.. Besides facilitating the access or increasing the coverage of water supply systems, it is fundamental to ensure that the water provided meets the quality requirements for the intended uses.

In Brazil, the Consolidation Ordinance No. 05/2017 of the Ministry of Health³3 Brasil. Portaria de Consolidação nº 5, de 28 de setembro de 2017. Consolidação das normas sobre as ações e os serviços de Saúde do Sistema Único de Saúde. Diário Oficial da União. 5 Set 2017., in its Annex XX, regulates the 'control and surveillance of water quality for human consumption and its potability standard'. Among other objectives, it establishes that treatment procedures undertaken on supply systems meet the purposes, with the creation of the National Program of Surveillance of Water Quality for Human Consumption, known as Vigiagua, in which are included the actions of quality control and surveillance as fundamental elements to ensure the access to quality water.

Among the surveillance attributions, stands out the permanent and continuous diffusion of information on the quality of water for consumption and associated health risks; this is regulated by Federal Decree No. 5.440/2005, which 'instructs on the instruments for the diffusion of information to consumers on the quality of water for human consumption'³3 Brasil. Portaria de Consolidação nº 5, de 28 de setembro de 2017. Consolidação das normas sobre as ações e os serviços de Saúde do Sistema Único de Saúde. Diário Oficial da União. 5 Set 2017.

4 Bevilacqua PD, Carmo RF, Melo CM, et al. Vigilância da qualidade da água para consumo humano no âmbito municipal: contornos, desafios e possibilidades. Saúde soc. 2014; 23(2):467-83.

5 Brasil. Decreto nº 5.440, de 04 de maio de 2005. Estabelece definições e procedimentos sobre o controle de qualidade da água de sistemas de abastecimento e institui mecanismos e instrumentos para divulgação de informação ao consumidor sobre a qualidade da água para consumo humano. Diário Oficial da União. 4 Maio 2005.^-66 Brasil. Portaria nº 2.914 de 12 de dezembro de 2011. Ministério da Saúde. Dispõe sobre os procedimentos de controle e de vigilância da qualidade da água para consumo humano e seu padrão de potabilidade. Ministério da Saúde. Diário Oficial da União. 12 Dez 2011.. The systematization and diffusion of data on the quality of the water to consumers is one of the levels of action of surveillance procedures; according to the Pan-American Health Organization (Paho) it has a higher complexity degree and depends on the success of the other stages, such as the monitoring⁷7 Brasil. Manual de procedimentos em vigilância em saúde ambiental relacionada à qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde; 2006.. In the context of information, difficulties range from data generation and its conversion into information, to its availability to society⁴4 Bevilacqua PD, Carmo RF, Melo CM, et al. Vigilância da qualidade da água para consumo humano no âmbito municipal: contornos, desafios e possibilidades. Saúde soc. 2014; 23(2):467-83.^,88 Brasil. Vigilância e controle da qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde ; 2006.^,99 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004.. This paper presents the outcomes of a review research that aimed to point out the relevance of the surveillance of water quality for human consumption in the context of the access to drinking-water, highlighting the normalization and informational perspective as fundamental elements for its achievement.

Methodology

This study has an exploratory and descriptive character. The bibliographical and documental review was carried out to identify normative instruments and strategies for water quality surveillance, namely in the Brazilian context. The review and, thus, the discussion focus on the access, normalization of water quality surveillance, and information production, aiming at providing effective communication of outcomes to society.

Water, health and the regulation for human consumption

The relationship between water and health has been recognized since long: in Ancient Greece, Hypocrites, in his work 'Water, air and places', outlined the first systematic effort to present a cause-and-effect relationship between the physical environment and disease¹⁰10 Giatti LL. Fundamentos das relações entre saúde e ambiente. In: Giatti LL, organizador. Fundamentos de saúde ambiental. Manaus: UFAM; 2009.

11 Heller L. Saneamento e Saúde. Brasília, DF: OPAS; 1997.

12 Libânio M. Fundamentos de qualidade e tratamento de água. 3. ed. Campinas: Átomo; 2010.^-1313 Rezende SC, Heller L. O saneamento no Brasil: políticas e interfaces. 2. ed. rev. e ampliada. Belo Horizonte: Universidade Federal de Minas Gerais; 2008. (Coleção Ingenium).. Although the relationship between health and water quality has been established since ancient times, the confirmation only occurred in the 19th century with the observations of the English physician John Snow in 1855. His studies verified the association between the water consumed by the population of Broad Street neighborhood, in London, and the incidence of cholera. Drawing on his studies, there were important advances in the understanding of the relationship between contaminated water and diseases: since then the quality of water became an issue of interest to public health⁹9 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004.^,1414 Rosen G. Uma história da saúde pública. São Paulo: Hucitec; Unesp; 1994..

In recent decades, many epidemiological studies indicate the increase in life expectancy, reduction in child mortality rate, among other health benefits, due to the improvement of water supply services. In Brazil, Heller¹¹11 Heller L. Saneamento e Saúde. Brasília, DF: OPAS; 1997. produced one of the first systematic works on the relationship between sanitation and health, in a review of 256 epidemiological studies relating water-borne diseases and sanitation. The World Health Organization (WHO) estimates that low-quality water and the precarious sanitation and hygiene conditions cause the death of 200 persons per hour. Also according to WHO's statistics, 80% of diseases in developing countries are disseminated by water; be it directly, as diarrhea, or indirectly, as malaria, dengue, yellow fever, and others related to vectors that depend on water for their proliferation¹⁵15 Camello TCF, Garcia VS, Araújo SB, et al. Gestão e vigilância em saúde ambiental. Rio de Janeiro: Thex; 2009.^,1616 Neves-Silva P, Heller L. O direito humano à água e ao esgotamento sanitário como instrumento para promoção da saúde de populações vulneráveis. Ciênc. Saúde Colet. 2016; 21(6):1861-1870.. Thus, WHO estimates that investments in water and sewage could have an impact in approximately 9.1% of the global disease burden, i.e., on the premature mortality burden and years of life lost due to diseases¹⁵15 Camello TCF, Garcia VS, Araújo SB, et al. Gestão e vigilância em saúde ambiental. Rio de Janeiro: Thex; 2009.^,1717 Giatti LL. Precariedades em saneamento básico, doenças de veiculação hídrica e demais moléstias associadas. In: Giatti LL, organizador. Fundamentos de saúde ambiental. Manaus: UFAM ; 2009. p. 24-58.^,1818 Oliveira AF, Leite IC, Valente JG. Global burden of diarrheal disease attributable to the water supply and sanitation system in the State of Minas Gerais, Brazil: 2005. Ciênc. Saúde Colet. 2015; 20(4):1027-36..

Evidences produced from various studies along the years indicate that the close relationship between water supply and health is uncontestable. Water treatment process is a necessary condition to comply with the quality established by norms, and therefore improve the control of diseases⁷7 Brasil. Manual de procedimentos em vigilância em saúde ambiental relacionada à qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde; 2006.. However, it is noteworthy that the implementation and operation of treatment systems, when isolated, though relevant, are not capable of ensuring the quality of water distributed to the population. It is fundamental to establish combined actions of control and surveillance, structural measures, and conceptual, regulatory and institutional frameworks, such as potability norms that indicate safety and quality requirements for the supplied water¹¹11 Heller L. Saneamento e Saúde. Brasília, DF: OPAS; 1997..

The notion of potability is understood as a universal concept. However, the norms and standards vary among countries due to environmental aspects, such as the quality of the water that is cached, and social, cultural, economic, and technological aspects, which all together may reflect on the feasibility of norms application¹⁹19 Pinto VG. Análise comparativa de legislações relativas à qualidade da água para consumo humano na América do Sul [dissertação]. Belo Horizonte: Universidade Federal de Minas Gerais ; 2006.. Each country should establish its own viable potability standards to be applied, monitored, controlled and surveilled, considering its particularities, epidemiological aspects, toxicological essays, and water quality assessment.

In the United States of America, the discussion on potability standards began in 1914 (figure 1), when the United States Public Health Service first referred to bacteriological contamination. However, the North American federal norm established a microbiological standard only for the water produced by a supply system that would be transported in ships and trains to other States⁹9 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004.^,1212 Libânio M. Fundamentos de qualidade e tratamento de água. 3. ed. Campinas: Átomo; 2010.^,1919 Pinto VG. Análise comparativa de legislações relativas à qualidade da água para consumo humano na América do Sul [dissertação]. Belo Horizonte: Universidade Federal de Minas Gerais ; 2006.. In 1925, that norm went through its first process of revision in which recommendations were added about the protection of water sources and the effects of pollution on them. It was suggested, as a norm, that the water for consumption should be odorless, tasteless, and colorless, and should not contain soluble mineral substances. In the following years several other revisions were made; to be highlighted is the 1942 revision, in which were included sample spots for collection and bacteriological analysis in the distribution system, and limits for lead, copper, zinc and iron¹²12 Libânio M. Fundamentos de qualidade e tratamento de água. 3. ed. Campinas: Átomo; 2010.^,1919 Pinto VG. Análise comparativa de legislações relativas à qualidade da água para consumo humano na América do Sul [dissertação]. Belo Horizonte: Universidade Federal de Minas Gerais ; 2006..

In 1974, the North American Congress passed the Safe Drinking Water Act - SDWA; it corresponds to the potability norm of the Brazilian Ministry of Health. The SDWA established maximum and minimum values for a series of organic and inorganic compounds in drinking-water; and as laboratory techniques were improved, new maximum values were established - the legislation indicates revisions every six years. Currently, SDWA is administered by the United States Environmental Protection Agency (Usepa), which has adopted two categories of potability standards: the National Primary Drinking Water Regulation (NPDWR), comprising standards referring to contaminants presenting risks to health, with a mandatory character, and to these parameters are added the establishment of techniques and treatment applicable to achieve the established values; and the National Secondary Drinking Water Regulation (NSDWR), which is not a mandatory normative standard, but rather guidelines about substances that can produce aesthetic and organoleptic impacts, and may or not be adopted as a recommendation by the States⁹9 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004.^,1919 Pinto VG. Análise comparativa de legislações relativas à qualidade da água para consumo humano na América do Sul [dissertação]. Belo Horizonte: Universidade Federal de Minas Gerais ; 2006.^,2020 United States Environmental Protection Agency. Understanding the Safe Drinking Water Act. [internet]. 2004 [acesso em 2019 abr 23]. Disponível em: https://www.epa.gov/sites/production/files/2015-04/documents/epa816f04030.pdf.
https://www.epa.gov/sites/production/fil... .

In the 1950s, WHO launched the first guidelines for the standardization of drinking-water quality. In 1956 the 'Standards of Drinking-Water Quality and Methods of Examination Applicable to European Countries' was published; it underwent the first revision in 1959. The work was the first WHO's initiative on the elaboration of guidelines regarding water potability and its aim was to standardize the diffusion of analytical data¹⁹19 Pinto VG. Análise comparativa de legislações relativas à qualidade da água para consumo humano na América do Sul [dissertação]. Belo Horizonte: Universidade Federal de Minas Gerais ; 2006..

After the launch of the European standards, WHO published in 1958 the first edition of the 'International Standards for Drinking-Water', aimed at the other countries. The document established minimum quality standards for domestic supply, besides determining the adequate analysis methods. The strategy adopted by WHO was to stimulate other countries to improve the quality of supplied water. However, a distance was observed between the standards adopted as 'European' and the so-called 'international standards': the international standards established minimum standards that were feasible of being achieved, including by developing countries; whereas the European standards, due to the economic and technological apparatus, presented more rigorous standards. After three editions of the 'International Standards for Drinking-Water', in 1983 the international standards were substituted by the 'Guidelines for Drinking Water Quality' (GDWQ), which unified the recommendations for the quality of water for human consumption with no distinction between countries due to their economic and technological apparatus¹⁹19 Pinto VG. Análise comparativa de legislações relativas à qualidade da água para consumo humano na América do Sul [dissertação]. Belo Horizonte: Universidade Federal de Minas Gerais ; 2006..

In 1993, ten years later, the second edition was published; in 2004 the third edition; and in 2011, the fourth and last edition was published, reedited in 2017. Besides establishing guidelines for microbiological, chemical, radioactive and organoleptic standards, it also established goals for health protection of populations, prioritizing aspects related to water quality management in view of climate changes and shortage situation²¹21 World Health Organization, organizador. Guidelines for drinking-water quality. 4. ed. Geneva: WHO; 2011.^,2222 World Health Organization. Guias para lacalidad del agua de consumo humano: cuarta edición que incorpora la primera adenda. Geneva: WHO ; 2017..

The normalization of water quality for human consumption in Brazil

In Brazil, the existing potability norms basically follow the standards recommended by WHO as presented in the 'Guidelines for Drinking Water Quality'. The Federal Decree No. 7.9367, of March 9, 1977, attributed the competence to the Ministry of Health to produce norms and standards of water potability for human consumption. The first potability norm was established that same year by Ordinance No. 56²³23 Brasil. Ministério da Saúde. Portaria nº 36, de 19 de janeiro de 1990. Altera a portaria de nº 56/1977. Diário Oficial da União. 20 Jan 1990. of the Ministry of Health, defining the maximum limits for several physical, chemical and biological characteristics inherent to consumption water. Until then, the quality of water in Brazil was guided by the recommendations of the United States Public Health Service, together with WHO's guidelines⁵5 Brasil. Decreto nº 5.440, de 04 de maio de 2005. Estabelece definições e procedimentos sobre o controle de qualidade da água de sistemas de abastecimento e institui mecanismos e instrumentos para divulgação de informação ao consumidor sobre a qualidade da água para consumo humano. Diário Oficial da União. 4 Maio 2005.^,99 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004.^,1212 Libânio M. Fundamentos de qualidade e tratamento de água. 3. ed. Campinas: Átomo; 2010.. Although Ordinance No. 56 determined that those responsible for water supply systems should comply with the norms, not all states in the country accomplished the effective control to verify the compliance with the normalized standards. In order to stimulate the health state secretariats to accomplish surveillance actions, in 1986 the Ministry of Health created the National Program of Surveillance of Water Quality for Human Consumption⁹9 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004.^,2424 Fernandes Neto ML. Norma Brasileira de Potabilidade de Água: Análise dos parâmetros agrotóxicos numa abordagem de avaliação de risco [internet]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2010. p. 169. [acesso em 2016 dez 10]. Disponível em: http://www.arca.fiocruz.br/handle/icict/2581.
http://www.arca.fiocruz.br/handle/icict/... .

In January 1990, the Ministry of Health published the Ordinance No. 36, increasing the number of parameters and restricting some of the limits. Due to these restrictions, the implementation of this norm was postponed until 1992, following demands of public agencies involved in the administration of water supply systems in the country¹²12 Libânio M. Fundamentos de qualidade e tratamento de água. 3. ed. Campinas: Átomo; 2010.^,2323 Brasil. Ministério da Saúde. Portaria nº 36, de 19 de janeiro de 1990. Altera a portaria de nº 56/1977. Diário Oficial da União. 20 Jan 1990.. The Ordinance No. 36/1990 innovates by dividing the potability standards in three categories: one refers to physical, organoleptic and chemical categories; one refers to bacteriological categories; and one to radioactive categories⁷7 Brasil. Manual de procedimentos em vigilância em saúde ambiental relacionada à qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde; 2006.. Oliveira Junior and collaborators²⁵25 Oliveira A, Magalhães TB, Mata RN, et al. Sistema de Informação de Vigilância da Qualidade da Água para Consumo Humano (Sisagua): características, evolução e aplicabilidade*. Epidemiol. Serv. Saúde [internet]. 2019 [acesso em 2019 abr 30]; 28(1):e2018117. Disponível em: http://www.scielo.br/pdf/ress/v28n1/2237-9622-ress-28-01-e2018117.pdf.
http://www.scielo.br/pdf/ress/v28n1/2237... add that the ordinance was a landmark for the establishment of an important tool in the context of information: it launched the bases for the conception of the first version of the Information System of Surveillance of Water Quality for Human Consumption, known as Sisagua. It became available only in the year 2000, when, after the deadline for the revision established in the norm, the Ordinance No. 1.469 was published, and it was implemented in January 2003. In the same year there was a structural change: the Health Surveillance Secretariat (SVS) was created with the attributes of the former National Health Foundation (Funasa); the previous ordinance was revoked by the Ordinance No. 518, of March 2004¹²12 Libânio M. Fundamentos de qualidade e tratamento de água. 3. ed. Campinas: Átomo; 2010.^,2424 Fernandes Neto ML. Norma Brasileira de Potabilidade de Água: Análise dos parâmetros agrotóxicos numa abordagem de avaliação de risco [internet]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2010. p. 169. [acesso em 2016 dez 10]. Disponível em: http://www.arca.fiocruz.br/handle/icict/2581.
http://www.arca.fiocruz.br/handle/icict/... .

The Ordinance No. 518/2004 categorizes microbiological parameters according to the treatment phase. This ordinance considers the following standards: microbiological standard, including the turbidity standard for water post-filtering and post-disinfection; standard for chemical substances that represent health risk; radioactivity standard; and standard of acceptance for human consumption⁷7 Brasil. Manual de procedimentos em vigilância em saúde ambiental relacionada à qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde; 2006.. For chemical substances posing health risks, the ordinance categorized them as inorganics, organics, pesticides, disinfectants, and secondary disinfectant products. It is worthy of note that the pesticides were not characterized as organic substances, but rather as a specific typology of substances due to their persistence in the environmental matrices and their relevance in the context of public health at that time.

The following edition was established by Ordinance No. 2.914/2011. This was the fifth ordinance since 1977; it was the most democratic and participative, having had the involvement of several segments that participated in the control and surveillance of the quality of water for human consumption²⁶26 Ribeiro MCM. Nova portaria de potabilidade de água: busca de consenso para viabilizar a melhoria da qualidade da água potável distribuída no Brasil. Rev. DAE. 2012; (189):1-76.. It adjusted the maximum and minimum values for various substances based on the approach of quantitative evaluation of chemical risk. The more rigorous microbiological standard followed the methodology of quantitative evaluation of microbiological risk, which guided the definition of turbidity standard of filtered water, as indicator of protozoan removal, and the parameters for disinfection control, indicators of inactivation of bacteria, viruses and protozoans²⁶26 Ribeiro MCM. Nova portaria de potabilidade de água: busca de consenso para viabilizar a melhoria da qualidade da água potável distribuída no Brasil. Rev. DAE. 2012; (189):1-76.. The number of chemical substances that represent health risk, the organoleptic standard and the characteristics of the water were between 74 and 87. Also, the more rigorous control of turbidity standard as part of the microbiological standard, from 1 uT to 0,5 uT, should be stressed. The ordinance explains the procedure for the control of organoleptic standards, which are to be measured in terms of the maximum intensity of perception through standardized techniques of sensorial evaluation. The microbiological standard maintains the mandatory analysis of E. coli, considered as gold standard for fecal contamination. A requirement was included for the periodical analysis of Giardia cysts and Cryptosporidium oocysts in water sources with high occurrence of E. coli⁶6 Brasil. Portaria nº 2.914 de 12 de dezembro de 2011. Ministério da Saúde. Dispõe sobre os procedimentos de controle e de vigilância da qualidade da água para consumo humano e seu padrão de potabilidade. Ministério da Saúde. Diário Oficial da União. 12 Dez 2011.^,2626 Ribeiro MCM. Nova portaria de potabilidade de água: busca de consenso para viabilizar a melhoria da qualidade da água potável distribuída no Brasil. Rev. DAE. 2012; (189):1-76..

Recently, the Ministry of Health published the Consolidation Ordinance No. 5, of September 28, 2017; in its article 8640, subsection CXXXIII, it revoked the Ordinance No. 2.914/11³3 Brasil. Portaria de Consolidação nº 5, de 28 de setembro de 2017. Consolidação das normas sobre as ações e os serviços de Saúde do Sistema Único de Saúde. Diário Oficial da União. 5 Set 2017.. The contents referring to the National Program of Surveillance of Water Quality for Human Consumption became part of Annex XX of the new ordinance. The ordinance consolidated the norms of actions and all health services provided by the Brazilian Unified Health System (SUS). From the legal perspective, in theory the consolidation did not materialize changes in the range of the consolidated instruments or in their normative force; it only integrates norms in one sole legal statute.

Chart 1 presents aspects of changes in the ordinances along the years. It is observed that from the first ordinance to the current one, new definitions have been incorporated and the number of parameters to be monitored has increased significantly due to the improvement of technological support. Moreover, it is noticed that the notion of surveillance of water quality is strengthened in the latest ordinance; however, when considering the relevance of actions performed and the magnitude of their impact, the performance along the years is still poor and weakened by the structural arrangements of those who carry them out − the municipalities.

Surveillance of water quality for human consumption

During the 1980s and 1990s, the Brazilian sanitary reform enabled health surveillance actions to include into their scope the socio-environmental determinants of health problems. Freitas and Freitas⁹9 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004. highlight in this process the creation of the Unified Health System (SUS) in 1990 and the National Plan of Health and Environment in Sustainable Development designed in 1995 as a Brazilian contribution to the Pan-American Conference on Health and Environment in Sustainable Human Development (Copasad), held in 1992. Through these plans, environmental health surveillance gained links with the attributions of SUS. Environmental surveillance is a continuous and systematic process of data follow-up; more recently is has been defined by the National Health Council (CNS), in its Resolution No. 588/2018, as a set of actions and activities that enable the knowledge and identification of environmental determinants and conditionals that interfere in human health, with the purpose of improving, recommending and adopting measures of health promotion and prevention, and monitoring risk factors related with diseases or health worsening⁷7 Brasil. Manual de procedimentos em vigilância em saúde ambiental relacionada à qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde; 2006.^,1515 Camello TCF, Garcia VS, Araújo SB, et al. Gestão e vigilância em saúde ambiental. Rio de Janeiro: Thex; 2009.^,2828 Brasil. Resolução MS/CNS nº 588, de 12 de julho de 2018. Fica instituída a Política Nacional de Vigilância em Saúde (PNVS), aprovada por meio desta resolução. Diário Oficial da União. 13 Ago 2018..

In 2005, the Normative Instruction No. 01/2005 of the Ministry of Health established the competences of the various spheres of environmental health surveillance in the country. This norm provided the regulations of the National Subsystem of Environmental Health Surveillance (SINVSA) with the attributions of coordination, evaluation, planning, follow-up, inspection, and control of surveillance actions related with diseases and health worsening regarding water for human consumption, soil and air contamination, natural disasters, environmental contaminants and chemical substances, accidents with dangerous products, physical factors effects and healthy conditions in the work environment⁵5 Brasil. Decreto nº 5.440, de 04 de maio de 2005. Estabelece definições e procedimentos sobre o controle de qualidade da água de sistemas de abastecimento e institui mecanismos e instrumentos para divulgação de informação ao consumidor sobre a qualidade da água para consumo humano. Diário Oficial da União. 4 Maio 2005.^,1515 Camello TCF, Garcia VS, Araújo SB, et al. Gestão e vigilância em saúde ambiental. Rio de Janeiro: Thex; 2009..

Surveillance of water quality for human consumption emerged in 1986 when the Ministry of Health created the National Program of Surveillance of Water Quality for Human Consumption, known as Vigiagua. At that time, surveillance did not have the current scope: it was restricted to normative and laboratorial control. However, it was after the edition of Ordinance No. 1.469/00 that Vigiagua was implemented by the General Coordination of Environmental Health Surveillance (CGVAM)⁴4 Bevilacqua PD, Carmo RF, Melo CM, et al. Vigilância da qualidade da água para consumo humano no âmbito municipal: contornos, desafios e possibilidades. Saúde soc. 2014; 23(2):467-83.^,99 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004.^,1515 Camello TCF, Garcia VS, Araújo SB, et al. Gestão e vigilância em saúde ambiental. Rio de Janeiro: Thex; 2009.^,2727 Brasil. Portaria nº 1469, de 29 de dezembro de 2000. Estabelece os procedimentos e responsabilidades relativos ao controle e vigilância da qualidade da água para consumo humano e seu padrão de potabilidade, e dá outras providências. 2000. Diário Oficial da União. 30 Dez 2000.. Environmental health surveillance related with water quality for human consumption comprises a set of actions systematically and continuously performed by public health authorities with the following objectives: to ensure that water consumed by the population complies with the standards and norms established by legislation; and to assess the risks to human health represented by water for consumption⁸8 Brasil. Vigilância e controle da qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde ; 2006..

Control and surveillance actions are contemplated in the scope of Vigiagua. These two types of actions are differentiated by competence attribution: surveillance is under the responsibility of the health sector; the control of water quality for human consumption is under the competence of those responsible for the operation of water supply systems. Both types of actions configurate fundamental instruments to ensure the protection of consumers' health⁶6 Brasil. Portaria nº 2.914 de 12 de dezembro de 2011. Ministério da Saúde. Dispõe sobre os procedimentos de controle e de vigilância da qualidade da água para consumo humano e seu padrão de potabilidade. Ministério da Saúde. Diário Oficial da União. 12 Dez 2011.^,88 Brasil. Vigilância e controle da qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde ; 2006..

Water quality surveillance includes inspection, monitoring and informational actions; it needs operational indicators, water physicochemical and microbiological indicators, and epidemiological, sanitary and environmental indicators⁷7 Brasil. Manual de procedimentos em vigilância em saúde ambiental relacionada à qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde; 2006.. One of the challenges is to ensure an integrated assessment, which is understood as a joint interpretation of data on the quality of the water for human consumption along the supply and the consumption stages, comprising the parts of a dynamic totality⁴4 Bevilacqua PD, Carmo RF, Melo CM, et al. Vigilância da qualidade da água para consumo humano no âmbito municipal: contornos, desafios e possibilidades. Saúde soc. 2014; 23(2):467-83.^,99 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004..

Seeking to standardize the actions on water quality surveillance, the Health Surveillance Secretariat adopted an operational model distributed in strategic and basic actions. The basic actions are organized in three groups: information actions, executive actions, and risk management actions (figure 2). Information actions are related to feeding Sisagua, data analysis and evaluation, social communication and mobilization, and availability of information to consumers. These actions are directly related with the executive monitoring actions⁷7 Brasil. Manual de procedimentos em vigilância em saúde ambiental relacionada à qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde; 2006.^,88 Brasil. Vigilância e controle da qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde ; 2006..

Sisagua has been fed with data from the monitoring of microbiological, chemical and physicochemical parameters, collected by the water quality control and the surveillance. The surveillance module refers to data from the monitoring of water quality carried out by the health secretariats of municipalities²⁵25 Oliveira A, Magalhães TB, Mata RN, et al. Sistema de Informação de Vigilância da Qualidade da Água para Consumo Humano (Sisagua): características, evolução e aplicabilidade*. Epidemiol. Serv. Saúde [internet]. 2019 [acesso em 2019 abr 30]; 28(1):e2018117. Disponível em: http://www.scielo.br/pdf/ress/v28n1/2237-9622-ress-28-01-e2018117.pdf.
http://www.scielo.br/pdf/ress/v28n1/2237... . The system aims to support surveillance actions, providing information on the supply and quality of water for human consumption, originating in all forms of supply. The continuous insertion of data into Sisagua is, thus, a fundamental condition for the achievement of the specific objectives of Vigiagua, such as the systematic follow-up of monitoring, information to the population about the quality of the water and health risks, health risks management, education promotion, social mobilization and communication, and supply of subsidies for the definition of strategies for actions by the agents involved in the process of ensuring the quality of water⁷7 Brasil. Manual de procedimentos em vigilância em saúde ambiental relacionada à qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde; 2006.^,99 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004.^,2525 Oliveira A, Magalhães TB, Mata RN, et al. Sistema de Informação de Vigilância da Qualidade da Água para Consumo Humano (Sisagua): características, evolução e aplicabilidade*. Epidemiol. Serv. Saúde [internet]. 2019 [acesso em 2019 abr 30]; 28(1):e2018117. Disponível em: http://www.scielo.br/pdf/ress/v28n1/2237-9622-ress-28-01-e2018117.pdf.
http://www.scielo.br/pdf/ress/v28n1/2237... ^,2929 Brasil. Ministério da Saúde. Programa nacional de vigilância em saúde ambiental relacionada à qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde ; 2005. (Série C-Projetos, programas e relatórios)..

When assessing the challenges of Sisagua and surveillance actions, Freitas and Freitas⁹9 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004. highlight the production of data, and the analysis and dissemination of information as stages that are precariously carried out. The authors point out that the fragility in data collection, analysis and feeding the data bases generates problems regarding the availability of information for all levels. The non-availability of information, in their perception,

goes against one of the attributions of the federal level, which is the dissemination of information aiming at increasing the population's sanitary awareness and its participation in the activities of surveillance and control of worsening aspects⁹9 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004.⁽¹⁰⁰⁾.

The dissemination of information to consumers, as established by Decree No. 5.440/2005, should be carried out in a clear and easily understandable manner5 and this requires a careful evaluation of the adequacy of what is being made available to the public. Annex XX of the Consolidation Ordinance No. 5/2017³3 Brasil. Portaria de Consolidação nº 5, de 28 de setembro de 2017. Consolidação das normas sobre as ações e os serviços de Saúde do Sistema Único de Saúde. Diário Oficial da União. 5 Set 2017., in accordance with Decree No. 5.440/2005, highlights that the agent responsible for the water supply should systematize the information about the water quality in a way that is understandable to consumers and it should be available for immediate access; it also defines that the States should ensure the information to the population in conformity with Decree No. 5.440/2005.

In the process of making information available, aspects that should be observed are language, contents, means of communication, and especially a reflection should be made on the effectiveness of the communication³3 Brasil. Portaria de Consolidação nº 5, de 28 de setembro de 2017. Consolidação das normas sobre as ações e os serviços de Saúde do Sistema Único de Saúde. Diário Oficial da União. 5 Set 2017.

4 Bevilacqua PD, Carmo RF, Melo CM, et al. Vigilância da qualidade da água para consumo humano no âmbito municipal: contornos, desafios e possibilidades. Saúde soc. 2014; 23(2):467-83.^-55 Brasil. Decreto nº 5.440, de 04 de maio de 2005. Estabelece definições e procedimentos sobre o controle de qualidade da água de sistemas de abastecimento e institui mecanismos e instrumentos para divulgação de informação ao consumidor sobre a qualidade da água para consumo humano. Diário Oficial da União. 4 Maio 2005.. Almeida³⁰30 Almeida RAS. Índice de qualidade de águas subterrâneas destinadas ao uso na produção de água potável (IQAS) [dissertação]. Salvador: Universidade Federal da Bahia; 2007. p. 184. provides a criticism to the ordinance on potability, which defines the standards but does not enable a classification of water in a scale of quality, and this requires further explanations to the non-expert public. In this perspective, another challenge that can be pointed is that of participative management. In the conception of Freitas and Freitas⁹9 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004., the understanding of participation by managers and technicians who work in surveillance and control has been to merely inform the population and the health and environment councils about the quality of water,

in a passive and asymmetric way, by means of monthly reports that register a certain past qualitative state, which is insufficient for disease prevention⁹9 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004.¹⁰⁰¹.

Surveillance, Information and Empowerment

Promoting health implies promoting quality of life, focusing on healthy and sustainable environments. In order to achieve this, it is necessary to have access to water of good quality and sanitation³¹31 Toledo RF, Pelicioni MCF. O papel da educação para a promoção da saúde. In: Giatti LL, organizador. Fundamentos de Saúde Ambiental. Manaus: UFAM; 2009.. It is worth noting that access to water is considered a fundamental right of human beings. The discussion in this regard dates to 1977, when the United Nations stated that everyone, regardless of their economic and social situation, was entitled to have access to drinking water in enough quantity and quality to meet basic needs. In 1979, the 'Convention on the Elimination of All Forms of Discrimination against Women' recognized that women had to be given access to water. Ten years later, in 1989, the 'Convention on the Rights of the Child' established free access to water for children, as this would be a fundamental premise for their development. More recently, in the 2000s, the right to water was mentioned in the 'General Comment' on health as a fundamental right to promote human health. Despite these milestones, access to water was only internationally recognized as a human right by the United Nations General Assembly in 2010, with Resolution A/RES/64/292 on the Human Right to Water and Sanitation¹⁶16 Neves-Silva P, Heller L. O direito humano à água e ao esgotamento sanitário como instrumento para promoção da saúde de populações vulneráveis. Ciênc. Saúde Colet. 2016; 21(6):1861-1870.^,3232 Ribeiro WC. Geografia política da água. São Paulo: Annablume; 2008. (Coleção Cidadania e meio ambiente).^,3333 Augusto LGS, Gurgel IGD, Câmara Neto HF, et al. O contexto global e nacional frente aos desafios do acesso adequado à água para consumo humano. Ciênc. Saúde Colet. 2012; 17:1511-1522..

Access to drinking water is a complex process due to the various factors involved, and requirements such as availability, quality/safety, consumer acceptability of its characteristics, and physical and financial accessibility, should be considered, in addition to the general principles of human rights²2 Razzolini MTP, Günther WMR. Impactos na saúde das deficiências de acesso a água. Saúde soc. 2008; 17(1):21-32.^,1616 Neves-Silva P, Heller L. O direito humano à água e ao esgotamento sanitário como instrumento para promoção da saúde de populações vulneráveis. Ciênc. Saúde Colet. 2016; 21(6):1861-1870.^,3434 Brasil. Plano Nacional de Saneamento Básico - PLANSAB. Brasília, DF: Ministério das Cidades; 2013.. Therefore, it involves the quantitative and qualitative perspective. The simple access to the supply system or the percentage of coverage does not truly reflect the universalization of the service, nor the quality of the service, and should therefore also consider the socioeconomic and cultural elements of the communities and the quality of the services provided²2 Razzolini MTP, Günther WMR. Impactos na saúde das deficiências de acesso a água. Saúde soc. 2008; 17(1):21-32.^,3434 Brasil. Plano Nacional de Saneamento Básico - PLANSAB. Brasília, DF: Ministério das Cidades; 2013..

The precarious situation of access may pose a risk to the increased incidence of water-related diseases. As it is a complex issue, it needs to be seen from the perspective of health promotion. In the health promotion process, communities play a relevant role, since, as defined by the first International Conference on Health Promotion, held in Ottawa in 1986, health promotion is a process of training the community to improve their quality of life, by allowing for the control of health determinants, which includes greater engagement and social participation³⁵35 Buss PM. Promoção da saúde e qualidade de vida. Ciênc. Saúde Colet. 2000; 5(1):163-177.. Reaffirming the importance of the role of communities in health promotion, the sixth International Conference on Health Promotion, held in 2005 in Bangkok, Thailand, emphasized the importance of training human resources for health promotion, advocating that the promotion of health is also the focus of the community and civil society initiatives³¹31 Toledo RF, Pelicioni MCF. O papel da educação para a promoção da saúde. In: Giatti LL, organizador. Fundamentos de Saúde Ambiental. Manaus: UFAM; 2009..

In Brazil, the Unified Health System (SUS) is organized following some basic guidelines, including community participation. The monitoring of water quality in Brazil is based on the principles and guidelines of SUS, which includes the doctrinal ones, namely integrality, equality and equity; the organizational ones, which deal with decentralization, regionalization, hierarchization; and the executive ones, which determine the use of epidemiology, integration of health, environment and sanitation actions, organization of services in order to avoid duplication of means to serve the same purposes, dissemination of information and community participation. In addition to the principle of essentiality, it is important to understand that access to water in enough quantity and adequate quality is fundamental to human life⁴4 Bevilacqua PD, Carmo RF, Melo CM, et al. Vigilância da qualidade da água para consumo humano no âmbito municipal: contornos, desafios e possibilidades. Saúde soc. 2014; 23(2):467-83..

Data collection, regular data analysis and their regular dissemination stand out as key components within surveillance actions for drinking water quality. This tripod subsidizes control, education and social communications actions⁸8 Brasil. Vigilância e controle da qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde ; 2006.. The availability of information about the quality of the water provided to the population should be made clear, giving them autonomy to face their problems. This autonomy is what Toledo and Pelicioni³¹31 Toledo RF, Pelicioni MCF. O papel da educação para a promoção da saúde. In: Giatti LL, organizador. Fundamentos de Saúde Ambiental. Manaus: UFAM; 2009. call empowerment, which is a process of the individual's growth as a social subject, for her personal, interpersonal or political power development. According to the authors, in health promotion, empowerment enables individuals to extend control over their lives through community participation.

As an extension of health promotion, in the 1990s, the Primary Care in Environmental Health (Apsa) was created, According to the Paho, it is a preventive and participatory environmental action strategy at the local level that allows for the definition of their responsibilities and duties in relation to the protection, conservation and restoration of the environment and health at the individual and community levels¹⁵15 Camello TCF, Garcia VS, Araújo SB, et al. Gestão e vigilância em saúde ambiental. Rio de Janeiro: Thex; 2009.. In all contexts, be it health promotion, Apsa or water quality surveillance, community development requires full and continuous access to information - a fundamental condition for the empowerment process³¹31 Toledo RF, Pelicioni MCF. O papel da educação para a promoção da saúde. In: Giatti LL, organizador. Fundamentos de Saúde Ambiental. Manaus: UFAM; 2009..

In the process of monitoring the quality of water for human consumption, Freitas and Freitas⁹9 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004. point out as obstacles to the participation of society and social control the limitation in information production. There is a clear difficulty in converting data into information. In addition, they are unavailable in many diverse spheres and even to the population. The availability of information to the society aided by health actions is provided for in the Federal Law No. 8.080/90 (the law that created SUS) and in Annex XX of the Consolidation Ordinance No. 5/2017, in which it is clear that those responsible for control and surveillance keep the population informed about water quality. In addition, the Brazilian Consumer Protection and Defense Code establishes as a basic right adequate and clear information on products and services. Non-availability also contradicts the Union's role in promoting health awareness and the participation of the population³3 Brasil. Portaria de Consolidação nº 5, de 28 de setembro de 2017. Consolidação das normas sobre as ações e os serviços de Saúde do Sistema Único de Saúde. Diário Oficial da União. 5 Set 2017.^,77 Brasil. Manual de procedimentos em vigilância em saúde ambiental relacionada à qualidade da água para consumo humano. Brasília, DF: Ministério da Saúde; 2006.^,99 Freitas MB, Freitas CM. A vigilância da qualidade da água para consumo humano: desafios e perspectivas para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2005; 10(4):993-1004..

The way communication about water quality has often been established is reductionist, and not directed to users, who are often lay, which excludes the decision-making process from the community. Information is a fundamental element in the process of analysis of access to water. Its absence or service fragility eventually compromises access to water, hindering social participation, and the establishment of actions for promotion and prevention in environmental health.

The data contained in Sisagua are in the public domain and may be requested at any time. In addition, the data entered in the latest version of the system, Sisagua 4, are available at the Brazilian Open Data Portal. Due to its nature and purpose, the database supports water quality surveillance actions, as well as provides indicators of environmental health and characterization of water supply in Brazil²⁵25 Oliveira A, Magalhães TB, Mata RN, et al. Sistema de Informação de Vigilância da Qualidade da Água para Consumo Humano (Sisagua): características, evolução e aplicabilidade*. Epidemiol. Serv. Saúde [internet]. 2019 [acesso em 2019 abr 30]; 28(1):e2018117. Disponível em: http://www.scielo.br/pdf/ress/v28n1/2237-9622-ress-28-01-e2018117.pdf.
http://www.scielo.br/pdf/ress/v28n1/2237... . However, it should be noted that Sisagua data are used by management and research institutions. Despite the progress made to make the surveillance process public and transparent, the published data need special treatment and there is no effective communication to the users.

Final remarks

Access to drinking water, which is already consolidated as a fundamental right of human beings, must be guaranteed in terms of quantitative and qualitative availability. Regarding quality, treatment is not the only way to guarantee access to water. Strategies such as surveillance, directed to the regulated standards of potability, are fundamental to meet this component. Normatively, the surveillance process is already consolidated in the Brazilian context; however, in the practical field, there are many challenges. Among the various actions inherent in the scope of water quality surveillance, those regarding information, especially in the field of communication and social mobilization, are often regarded as secondary, due to weaknesses that are beyond communication actions. These are weaknesses in executive actions, such as monitoring. Such gaps compromise access in its qualitative component and prevent full compliance with the purposes of water quality surveillance. In addition, such gaps may also hinder, to some extent, research aimed at monitoring Diseases Related to Poor Environmental Sanitation (DRSAI) and at establishing causal relations with surveillance data. Although there has recently been an effort to make this data widely and openly available to society, it is still necessary to improve work on how it is made intelligible to society. Transparency in data production and information play a fundamental role in effective social mobilization in the pursuit and defense of access to water. In short, every process needs to be strengthened: it is necessary to invest in surveillance structures, laboratory equipment and human capital, so that basic surveillance actions can be more effective.

Acknowledgements

I would like to thank the Coordination of Superior Level Staff Improvement (Capes), the National Council for Scientific and Technological Development (CNPq), the Department of Health and Environmental Sanitation of the Sergio Arouca National School of Public Health/Fundação Oswaldo Cruz (Ensp/Fiocruz) and the Federal Institute of Piauí (IFPI).

References

Publication Dates

History