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Indonesia National Program for Community Water Supply and Sanitation Services


5.1 Scale of activities

The WHO-UNICEF Joint Monitoring Programme47 (JMP) reports that only 38% of the rural population in Indonesia have ‘access to improved sanitation coverage’48, and suggests that rural coverage has not increased since 1985 (see Annex 5). 

Table 1 Scale of rural sanitation challenge in Indonesia

Population Access to sanitation Access to water supply
Improved Unserved Improved Unserved
Rural 118 million
45 million
73 million
81 million
36 million
Urban 100 million
70 million
30 million
89 million
11 million
Total 218 million 115 million
103 million
170 million
47 million

Source: JMP (2004); WDR (2005)

Given a total population of 218 million, this suggests that about 73 million rural inhabitants are currently without access to adequate sanitation services. In contrast, rural access to water supply is 69%, with 36 million rural inhabitants unserved, i.e. half as few as the population without access to sanitation (see Table 1). Based on the JMP figures, achieving the Millennium Development Goals49 (MDGs) will involve providing access to improved sanitation services to 36 million rural inhabitants over the next ten years.

Scale of rural sanitation challenge in Indonesia

47 A global initiative by the WHO & UNICEF to report on the status of water supply and sanitation services and support country efforts to monitor the sector
48 The JMP defines improved sanitation as: ventilated improved pit latrines, simple pit latrines, pour-flush latrines, or connections to septic or sewer systems. Note: this definition excludes bucket latrines, open pit latrines and public or shared latrines. 
49 Halving the number of people without access to sanitation by 2015

The rural population without access to sanitation is double that without access to water supply, but sector finance remains heavily skewed towards investment in water supply. Local governments in Indonesia appear to regard sanitation as the business of individuals, NGOs, the private sector or the national government. In this respect, sectoral allocations of the consolidated block grant provided for local government infrastructure (DAU) are revealing. Typically, water supply and housing dominate local spending, consuming 80% and 15% of the DAU funds respectively, leaving only 5% for investments in sanitation50
Local governments are often reluctant to expend their limited funds on non-hardware components, as there is more political mileage in tangible construction activities. Therefore, high-level advocacy is required to ensure that government departments and local governments give sufficient priority and budget allocations to the software and capacity building activities needed for sanitation and hygiene improvement. 
5.2 Program sustainability and effective use

Many different approaches to sanitation and hygiene improvement have been tried in Indonesia. More recently, community participation and ‘informed choice’ have been introduced to increase the involvement of communities in the planning and design of development activities. These new approaches aim to improve demand-responsiveness and thus produce more sustainable water and sanitation systems. 

However, despite large investments in the rural water supply and sanitation sub-sector, the proportion of the rural population with access to improved sanitation has been static for the last twenty years. The bulk of the investment has been on water supply systems, and very few of the expenditures on sanitation and hygiene promotion appear to have resulted in either sustainable infrastructure or long-term behavior change.
There is substantial anecdotal evidence of abandoned and unused toilets from previous sanitation projects; revolving sanitation funds that never revolved because nobody repaid the loans; toilet manufacturing projects that did not sell any toilets; and non-poor households that received a new toilet every few years from different sanitation projects.  
Whilst most sanitation and hygiene programs include detailed and well thought-out implementation plans, few of these plans seem to translate into effective activities. In combined water supply and sanitation programs, water supply development generally consumes the majority of program time and resources. Given the limited time and resources remaining, sanitation promotion then becomes a simple toilet building exercise, with hygiene promotion tacked on to interventions as something of an afterthought. 

Abandoned ESWS toilet (1996) in foreground
and new toilet built using WSLIC-2 loan (2004)
in background: Desa Luk, Sumbawa

5.3 Performance monitoring

Another key problem is that few sanitation and hygiene improvement programs have any measure of success other than increases in sanitation coverage. Given the central objective of health improvement, the success of sanitation and hygiene interventions should be measured not by the number of toilets and handwashing facilities constructed, but by reductions in diarrhea prevalence, reductions in open defecation, and improvements in health and hygiene behavior. Programs need to assess whether sanitation and hygiene facilities are being effectively used; whether they are sustainable; and whether interventions are reaching the target population. 
The development of locally appropriate indicators to monitor public health and program performance is essential, but is a difficult task. Counting toilets is far easier than measuring gradual changes in hygiene behavior and diarrhea prevalence across a large and varied population. In Indonesia, most data on community health are derived from national household surveys, from clinical records of primary health centers (Puskesmas) and local hospitals, or from monthly reports made by community midwives (Bidan Desa). 
The two latter data sources are problematic. Despite their high disease burden, poor households living in rural areas often bypass government health services by buying medicines from local shops and obtaining treatment from traditional healers or private doctors. As a result, the clinical data from primary health centers do not usually represent a full picture of morbidity among poor, rural households. Community midwives are supposed to collect information on diarrhea prevalence and morbidity, which is reported to the Puskesmas (Primary Health Centre) on a monthly basis. The quality of this data depends on the experience and commitment of the midwife, as well as their relationship with the community and the Puskesmas, thus varies greatly from place to place.
Improving the sustainability and effective use of the infrastructure and behavior change resulting from sanitation and hygiene interventions will require considerable strengthening of community and health facility monitoring, as well as a radical change in the way that these programs measure their performance and effectiveness. Sections 7.4.2 and 7.4.3 contain some initial proposals for the monitoring of program performance and impact, but this area requires close collaboration between the program preparation team and the Ministry of Health in order to define practical and reliable monitoring indicators.

50 The World Bank (2004) Indonesia: averting an infrastructure crisis – a framework for policy and action


The NPCWSSS ‘improving sanitation and hygiene behavior and services’ component needs to be different from previous Indonesian water supply and sanitation interventions in two important ways: firstly, for the sanitation and hygiene component to have any national impact on rural access to improved sanitation, or on hygiene behavior and public health, it must operate at a far larger scale than existing interventions; and, secondly, it must adopt a more programmatic approach in order to provide the long-term institutional support and monitoring required for effective sanitation and hygiene improvement.
The new program needs to meet the twin challenges of making sanitation and hygiene improvement more effective, equitable and sustainable, while also adapting interventions for implementation at large-scale across the diverse contexts found in Indonesia.
There is increasing global support for sanitation and hygiene marketing as a possible solution to the large-scale and cost-effective provision of sanitation and hygiene services. The argument is that most progress in increasing access to sanitation has been achieved by private suppliers supplying individual households, and that marketing has been more successful than anything else in promoting the adoption of sanitary toilets and making sustainable changes to people’s hygiene behavior. However, there are concerns about the ability of the marketing approach to reach the poorest households. In contrast, intensive, participatory approaches like Community-Led Total Sanitation (CLTS) are good at reaching the poorest households, but are relatively difficult and expensive to scale up, and hence likely to be less cost-effective in reaching large, diverse populations.   
6.1 Combined marketing and total sanitation approach

One solution is to combine both ‘sanitation marketing’ and ‘total sanitation’ elements into the sanitation and hygiene promotion component. The early promise of CLTS in Indonesia suggests that this approach, when adapted and used within a carefully structured and targeted program, will provide an effective way of reaching the poorest households in remote, rural communities. The rest of the population can be served by a large-scale marketing program designed to develop appropriate products and services; build local sanitation businesses and supply chains; and promote sanitation and hygiene improvements. 
The proposed program strategy will use provincial sanitation awareness and hygiene promotion campaigns, modeled on the campaigns planned by the Indonesia Sanitation Sector Development Program (ISSDP), and targeted at the market segments identified by the initial consumer research in each province. Beneath these provincial campaigns, there will be a two-pronged strategy: the marketing component will work outwards from the rural centers and main roads, building supply chains and local capacity; meanwhile the ‘total sanitation’ component will start in the most remote, unserved, rural communities and work inwards towards the expanding supply chains. In the long-term, it is hoped that the reach and effectiveness of market supply will enable the ‘total sanitation’ component to be phased out completely. 

6.2 Phased approach in the total sanitation program

The need for cost-effectiveness requires that the total sanitation program is both simple and structured. An incremental and sequenced approach will be adopted in each community, starting with simple and low-cost interventions, and only progressing to further, more complex interventions when the community reaches its initial performanc targets. The intention is to make the sanitation and hygiene interventions more demand-responsive, with further interventions only triggered when the community demonstrates interest and commitment to the improvement of its sanitation and hygiene behavior and services, and make the interventions simpler to understand, implement and monitor.  
It has been suggested51 that many people in Indonesia are already aware of key hygiene issues like the need to wash hands before eating and after defecation; to boil and safely store drinking water; and to improve personal hygiene by regular bathing. The problem that this awareness is rarely reflected in hygiene behavior because of common househol constraints (inadequate water supply close to the home; no toilet; high cost of services) and the lack of any motivation or incentive for change. Therefore, the challenge is not in passing on negative hygiene messages (“don’t do this or that”), but in triggering positiv and sustained behavioral change in the most cost-effective manner.  
Therefore, it is proposed that community-level sanitation and hygiene interventions should follow a simple three-stage process, as follows:
Stage 1 Campaign to stop open defecation (including safe disposal of child feces)
Stage 2 Campaign to improve handwashing
Stage 3 Campaign to improve other hygiene behavior and services (key behaviors and services identified by the community using PHAST methodology)
The Stage 2 handwashing campaign will not be triggered until the community achieves the Stage 1 goal of completely stopping open defecation. Similarly, the Stage 3 hygiene improvement campaign will not be triggered until the community achieves the Stage 2 goal of ensuring that everyone washes their hands with soap after coming into contact with feces, i.e. after defecation and anal cleansing, or after cleaning feces from a child.
This structured approach is intended to focus program and community attention on the two key actions that isolate fecal material and prevent it from reaching the local environment52:
•  safe disposal of adult and child feces, and 
•  handwashing with soap after defecation. 
Once a community has shown its commitment to changing these two critical hygiene behaviors, then the program will invest time and effort in the application of a more detailed methodology, e.g. PHAST, to determine the specific hygiene behaviors and health problems that the community would like to improve.

51 Hetler (1999) Water Supply and Sanitation for Low Income Communities Project: Community hygiene education assessment
52 The World Bank (2005) The handwashing handbook: A guide for developing a hygiene promotion program to increase handwashing with soap

Stage 1 trigger: Community application and selection
Stage 2 trigger: 100% access to sanitation + 0% open defecation
Stage 3 trigger: 100% handwashing with soap (after contact with feces)
The trigger settings in this three-stage process are critical. If set too high, the triggers will prevent communities from progressing to the next stage of the process, thus restricting the number of communities that are involved in handwashing and hygiene improvement campaigns. A lower trigger setting for stage one, such as after 50% reduction in open defecation, would ensure that more communities reach the second stage, but is more difficult to assess and, more importantly, would remove the drive to achieve a complete stop to open defecation and 100% access to private sanitation facilities. 
As discussed earlier (Section 3.1), research suggests that handwashing with soap is the single most effective public health intervention. Therefore, it could be argued that, by starting with the campaign to stop open defecation, the total sanitation program will save fewer lives and deprive some poor communities (those that do not manage to achieve the Stage 1 goal of stopping open defecation) of the basic hygiene education needed for full and beneficial health impacts. However, it should not be forgotten that the sanitation and hygiene marketing program will involve detailed and targeted hygiene promotion campaigns that use a number of different channels to deliver locally appropriate hygiene improvement messages on a number of relevant topics, which will undoubtedly include handwashing, and which should eventually reach every community in Indonesia. 
In the total sanitation program, open defecation was selected as the primary behavior requiring change, ahead of handwashing, because this behavior change entails the provision and usage of sanitary toilets, and economic research suggests that hygiene promotion interventions, e.g. handwashing campaigns, are twice as cost-effective in communities where water supply and sanitation facilities already exist53. Based on the CLTS pilot projects, key stakeholders in Indonesia confirm the value of focusing program and community attention on achieving ‘total sanitation’, and also suggest that the empowerment and enthusiasm associated with reaching ‘open defecation free’ status then primes communities for rapid change and improvement on other fronts.
In summary, the total sanitation program will focus on safe excreta management and handwashing first, only moving on to examine other environmental sanitation and hygiene issues (e.g. solid waste management, drainage, food hygiene, water storage, vector control) once these primary behavior changes have been successfully achieved.
6.3 Sanitation markets

The market for sanitation products and services is rarely well developed in rural parts of Indonesia. Ceramic toilet pans are available in most towns, but there are few low-cost sanitation products, such as plastic toilet pans, and few local masons with experience of building anything other than urban-style pour-flush toilets. 

53  Varley et al (1998)

In order to encourage the development of sustainable sanitation markets, and meet demand generated by the ‘total sanitation’ and ‘sanitation marketing’ programs, it is important to work with local manufacturers and service providers to develop appropriate sanitation products and services, and build local sanitation businesses and supply chains. 
However, given the failure of previous efforts to create sanitation marts and train masons to build standard toilets, it is recommended that the design of each provincial ‘sanitation supply chain and business development program’ be based on a thorough and realistic analysis of local conditions, business needs and customer demands.
6.4 Institutional support mechanisms

Behavior change takes time to set in. Rural households can revert to their old habits very quickly if new toilets become blocked, broken or smelly, and if nobody is on hand to provide timely advice and encouragement when other problems or challenges arise. 
Regular monitoring is essential for the success of decentralized implementation, and provides important feedback on the sustainability of sanitation products and services. In addition, regular follow-up by outsiders encourages households and community groups to continue with new roles and hygiene practices, and makes it more likely that toilets will remain clean and in use when latrine pits fill up and renovations are required. 
The focus of the ‘total sanitation program’ is on triggering behavior change, which inevitably results in a rolling program that moves on once the sub-project is complete in a particular village. The behavior change process takes some time and may empower the community involved to tackle other development challenges, but still requires regular monitoring and support for the development of long-term and sustainable sanitation and hygiene improvements. Therefore, it is recommended that the total sanitation and sanitation marketing programs be supplemented by the establishment of institutional support mechanisms, such as local sanitation and hygiene units, embedded in local government. 
While the institutional model for the implementation of the NPCWSSS remains to be finalized, it is clear that significant re-skilling is required in order that line ministries, and local government units of the Ministry of Health and Ministry of Home Affairs, are equipped to drive a program of behavior change and health improvement. The proposed local sanitation and hygiene units may prove effective in leading this re-skilling and institutional change process.
The Ministry of Health employs more than 50,000 community midwives (Bidan Desa) in Indonesia, as well as a sanitarian in each health centre (Puskesmas). Wherever possible, given their other duties and commitments, these sanitarians and midwives should be involved in the program. In particular, midwives should be involved in the community handwashing and hygiene campaigns, as life-changing events like the birth of a baby are critical opportunities for changing the habits and hygiene behavior of mothers (and others that care for young children)54
54 The World Bank (2005) The handwashing handbook: A guide for developing a hygiene promotion program to increase handwashing with soap
6.5 Baseline sanitation data

It is vitally important that new baseline sanitation data is collected, and that broad consensus is reached on the use of these revised access figures for planning and monitoring purposes. The sanitation and hygiene improvement component detailed below contains proposals for conducting a national baseline survey of sanitation facilities, and it is hoped that this process will lead to the creation of a national database on community-based water supply and sanitation services.
6.6 Program finance

The proposed sanitation and hygiene improvement component includes significant investments in software and capacity building activities, with very little funding recommended for direct construction or subsidy of sanitation and hygiene facilities. 
Given GoI’s apparent reluctance to invest in non-hardware activities, this may create problems in the financing of the program. There is likely to be some grant funding available to the NPCWSSS, either from AusAID or some of the other donors working in the sector, which allows the possibility that non-repayable funding could be used to part-finance the software and capacity building expenditures. However, in light of the need for stronger support and priority to the sanitation sub-sector, and the central role that software activities and capacity building play in sanitation and hygiene improvements, it is recommended that the GOI re-appraises its financial policies for community-based infrastructure programs.
The proposed sanitation and hygiene marketing campaigns need to cover a far larger and more diverse audience than the proposed total sanitation program. Given the significant unknowns in pricing national and provincial campaigns managed by the public sector, it is possible that the marketing costs have been under-estimated. Therefore, wherever finance is inadequate, or there is a need to deepen, expand or extend the program, it is hoped that the marketing campaigns and business development programs will be able to attract sufficient investment from private industry, e.g. soap companies interested in supporting handwashing campaigns; pharmaceutical companies interested in supporting health improvement campaigns; and manufacturers interested in expanding their markets.

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