PBH Case study 20

Overview of Indonesia’s Total Sanitation and Sanitation Marketing Program (TSSM)

• Health Goal: Reduce childhood deaths by halting the spread of diarrheal diseases through feces-contaminated water and food sources.

• Strategy: Educate rural communities about the dangers of open defecation.

  • Increase demand for hygienic sanitation.

  • Boost supply and availability of affordable hygienic products and services.

• Health Impact:

  • Diarrhea prevalence decreased by 30%.

  • Achieved verification of 2,200 communities as "open defecation free" (ODF).

  • Saved approximately 220 lives and prevented nearly 19,000 disability-adjusted life years (DALYs) lost from diarrhea between 2007-2011.

• Factors for Success:

  • Designed interventions leveraging Indonesia’s decentralized political system.

  • Capitalized on community motivation towards health.

  • Integrated demand-side and supply-side components.

• Financing:

  • Total cost of US$14 million over four years, including household expenses.

  • Cost-effectiveness ratio: US$749 per DALY averted (reduced to US$213 per DALY when excluding household costs).

• Scale:

  • Impacted 6,250 communities across 29 rural districts, serving approximately 9.2 million individuals.

  • Increased latrine access for 1.4 million people.

The Issue of Open Defecation

• Over one billion individuals lack basic sanitary facilities, forcing poor populations to defecate in public spaces, leading to health risks from pathogens in fecal matter.

• In 2005, 27% of Indonesians (37% in rural areas) engaged in open defecation, with approximately 60 million people affected.

• Health Risks:

  • Contributes to diseases like polio, cholera, typhoid, schistosomiasis, and cryptosporidiosis.

  • Modern sanitation systems prevent pathogens from contaminating water and food sources, while open defecation does not.

• Impact Statistics:

  • Open defecation accounts for about 20% of the global diarrhea burden.

  • 280,000 deaths and 18.6 million DALYs attributed annually to inadequate sanitation.

Historical Context of Sanitation in Indonesia

• Sanitation projects have been part of Indonesia's development efforts since the 1920s under colonial rule.

• Previous governmental initiatives met with limited success due to lack of awareness among poor rural households about health risks associated with open defecation.

• Previous Programs:

  • Primarily focused on construction of free or subsidized toilets.

  • Failures linked to failure in behavior change and addressing non-material drivers (beliefs and preferences about sanitation).

Implementation of TSSM

• Adopted Community-Led Total Sanitation (CLTS) approach after successful trials in Bangladesh; aimed for community-level initiative and self-motivation to change behavior.

• Initial trials showed promise, leading to a scale-up supported by partnerships (World Bank and Bill & Melinda Gates Foundation).

• Details of the Approach:

  • Focus on community engagement; no prescriptive solutions from facilitators.

  • Efforts nourished demand by educating communities about sanitation's health impacts and fostering community pride.

• By mid-2005, the initiative spread to multiple communities with remarkable outcomes, laying the foundation for national policies centered around TSSM.

Key Components of TSSM

1. Community-Led Total Sanitation (CLTS): Facilitated community-triggering sessions to motivate abandonment of open defecation.

2. Sanitation Marketing: Addressed misconceptions about sanitation-related health risks and costs.

• Market research revealed community misunderstandings about latrine affordability.

• Included training for local masons and distribution of promotional materials on sanitation benefits.

3. Enabling Environment: Engaged in policy advocacy and local government accountability to facilitate sanitation expansion.

• Collaborated with Jawa Pos—local media for fostering awareness and accountability in sanitation improvement initiatives.

Outcomes

• Achievements included verification of 2,200 communities as ODF and substantial reductions (30%) in diahrrea prevalence.

• Communities engaged showed significantly higher rates of toilet construction and lower open defecation practices compared to control villages.

• Economic Impact:

  • Total program investment approximated US$14 million, with favorable cost-effectiveness findings.

  • Lower costs encouraged private investment in sanitation by households.

Observed Challenges

• Equity Issues: Many poorer families did not benefit equally from TSSM achievements despite overall improvements in community sanitation.

• Behavior Change: Required a structured, participatory approach to engage communities effectively.

• Sustainable Solutions: Adequate supply-side solutions needed to meet increased demand for sanitation structures.

Global Implications

• Indonesia’s TSSM serves as a model for global sanitation programs—the focus must remain on accessible sanitation for vulnerable populations.

• Growing recognition worldwide of the urgency in addressing sanitation needs as part of public health initiatives—with renewed focus on eliminating open defecation globally.

Inadequate water quality and poor sanitation significantly contribute to health issues in Indonesian communities by facilitating the spread of waterborne diseases. In the case study, over one billion people worldwide lack basic sanitary facilities, forcing marginalized populations to defecate in public spaces. This practice leads to contamination of drinking water with pathogens present in fecal matter, which in turn increases the risk of diseases such as polio, cholera, typhoid, schistosomiasis, and cryptosporidiosis. In Indonesia, specifically, in 2005, 27% of the population engaged in open defecation, resulting in severe health risks and contributing to an estimated global burden of 280,000 deaths annually due to inadequate sanitation. The lack of modern sanitation systems means that pathogens continue to thrive and contaminate water and food sources, thereby fueling the cycle of disease and poor health outcomes.