WATER AND SANITATION PROGRAM: TECHNICAL PAPER 72417 Economic Assessment of Sanitation Interventions in Indonesia A six-country study conducted in Cambodia, China, Indonesia, Lao PDR, the Philippines and Vietnam under the Economics of Sanitation Initiative (ESI) November 2011 The Water and Sanitation Program is a multi-donor partnership administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. THE WORLD BANK Water and Sanitation Program East Asia & the Pacific Regional Office Indonesia Stock Exchange Building Tower II, 13th Fl. Jl. Jend. Sudirman Kav. 52-53 Jakarta 12190 Indonesia Tel: (62-21) 5299 3003 Fax: (62 21) 5299 3004 Water and Sanitation Program (WSP) reports are published to communicate the results of WSP’s work to the development community. Some sources cited may be informal documents that are not readily available. 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Economic Assessment of Sanitation Interventions in Indonesia A six-country study conducted in Cambodia, China, Indonesia, Lao PDR, the Philippines and Vietnam under the Economics of Sanitation Initiative (ESI) Economic Assessment of Sanitation Interventions in Indonesia Executive Summary A. INTRODUCTION They need to come up with economic arguments to justify Statistics from the UN Joint Monitoring Programme show increased spending on sanitation. Therefore, comprehensive sanitation progress in Indonesia to be off-track – coverage and robust cost-benefit analyses that use reliable quantita- has to increase by more than 13 percentage points nation- tive and qualitative techniques are needed in order to maxi- ally from 2008 to 2015 to meet the sanitation target of the mize the possibility of securing adequate budget allocation. Millennium Development Goals, which the Government of Indonesia committed to in 2002. However, after being The Economics of Sanitation Initiative (ESI) Phase 2 a largely forgotten issue in the 15 years following the Asian presents a detailed cost-benefit analysis (CBA) of sanita- financial crisis of 1997-98, sanitation is now receiving in- tion interventions. It provides a comprehensive analysis at creasing attention from all levels of government in Indo- household level in three cities and two rural districts in In- nesia. Recently the Government of Indonesia has made donesia. With its quantitative and qualitative evidence, it considerable efforts to mobilize additional resources in or- strengthens arguments to mainstream sanitation in the na- der to finance the country’s needs for infrastructure proj- tional development agenda. The study results are expected ects. However, the annual budget allocation for sanitation to enhance political support for sanitation development. remains insubstantial at 0.03% of national government spending in recent years. Since 2010, a specific budget for B. STUDY AIMS AND METHODS sanitation has existed (as opposed to being subsumed into The purpose of the Economics of Sanitation Initiative (ESI) water supply). is to promote evidence-based decision making using im- proved methodologies and data sets, thus increasing the Since 2008, a cross-sectoral task team called the Sanitation effectiveness and sustainability of public and private sani- Technical Team (Tim Teknis Pembangunan Sanitasi – TTPS) tation spending. Better decision making techniques and has promoted the development of the national sanitation economic evidence themselves are also expected to stimu- sector. The Acceleration of Settlement Sanitation Develop- late additional spending on sanitation to meet and surpass ment Program (Percepatan Pembangunan Sanitasi Permuki- national coverage targets. The specific purpose of the ESI man – PPSP) has recently paved the way for the National Phase 2 study is to generate robust evidence on the costs Roadmap to Sanitation Development 2010-2014. For the and benefits of sanitation improvements in different pro- domestic wastewater subsector, the PPSP targets 330 cities grammatic and geographic contexts in Indonesia, leading and districts, with the aim of eradicating open defecation. to information about which are more efficient and sustain- This will be achieved by expanding existing sewerage net- able sanitation interventions and programs. Basic hygiene works in 16 cities to serve an additional five million people, aspects are also included, insofar as they affect health out- and constructing decentralized wastewater management comes. systems (known as SANIMAS) in all PPSP target cities and districts. The evidence is presented in simplified form and distilled into key recommendations to increase uptake by a range of Having such an ambitious sanitation development agenda, sanitation financiers and implementers, including different the TTPS and its partners need to cooperate with all rel- levels of government and sanitation sector partners, as well evant stakeholders for support, commitment and funding. as households and the private sector. www.wsp.org iii Economic Assessment of Sanitation Interventions in Indonesia | Executive Summary Standard outputs of CBA include benefit-cost ratios (BCR), and coverage of toilets in the selected field sites, and annual internal rate of return (IRR) and payback period the quality of local water bodies. The study enabled (PBP). Cost-effectiveness measures relevant to health im- assessment of the impact of specific local sanitation pacts are also provided to give information on the costs features on water quality. of achieving health improvements. On the cost side, de- 5. Market surveys were carried out in each field site. cision makers and stakeholders need to understand more For economic evaluation, local prices are required about the timing and size of costs (e.g. investment, opera- to value the impacts of improved sanitation and hy- tion, maintenance), as well as financial versus non-financial giene. Selected resource prices were recorded to re- costs, in order to make the appropriate investment decision flect local values. that increases intervention effectiveness and sustainability. 6. Health facility surveys were conducted in 2-3 health For data analysis and interpretation, financial costs were facilities serving each field site, covering at least one distinguished from non-financial costs, and costs were bro- community health center (PUSKESMAS) and one ken down by financier. In addition, intangible aspects of local public hospital. Variables collected include sanitation not quantified in monetary units are highlighted numbers of patients with different types of sanita- as being crucial to the optimal choice of sanitation inter- tion-related diseases, and the types and cost of treat- ventions. ment provided by the facilities. C. DATA SOURCES AND STUDY SITES D. MAIN ECONOMIC ANALYSIS RESULTS A range of surveys and data sources were used in five se- Economic analysis combines evidence on the cost and ben- lected field sites – see Table A – covering three urban and efits of sanitation improvements at household level. The two rural sites: benefit values come from the following components: 1. Household questionnaires were used in a total of • Improved health and thus avoiding costs due to 1500 households over the five sites (300 per site) di- sickness (disease treatment, transportation for hav- vided between households with improved and unim- ing treatment, productive time loss, and premature proved sanitation (Table A). mortality). 2. Focus group discussions were conducted to elicit be- • Time benefits from having a private toilet (less travel havior and preferences in relation to water, sanita- and no queuing time). tion and hygiene from different population groups, • Reduced water treatment and water access costs due with main distinctions by sanitation coverage (with to being able to use nearer water sources as they are versus without) and gender. no longer polluted due to poor sanitation. 3. Physical location surveys were carried out to identify important variables in relation to water, sanitation Benefit-cost figures vary depending on whether a system and hygiene in the general environment, land use, is operating at its ‘optimal’ or ‘actual’ capacity. The opti- water sources and environmental quality. mal cost/benefit of a system is the average cost/benefit per 4. Water quality measurement surveys were under- household when it operates at its designed capacity and is taken to identify the relationship between the type fully utilized by the household members, while the actual TABLE A: LIST OF SUB-DISTRICTS AND VILLAGES FOR ESI II SURVEY AREAS IN FIVE CITIES/DISTRICTS IN INDONESIA No City/District Sub-districts Villages 1 Banjarmasin City Central Banjarmasin Pekapuran Laut, Kelayan Luar 2 Malang City - Kedung Kandang - Mergosono, Tlogomas, Arjowinangun - Lowokwaru - Dinoyo 3 Payakumbuh North Payakumbuh Talawi, Kotopanjang, Payolinyam and Kubu Gadang villages 4 Lamongan District Turi Geger, Keben, Badurame, Turi 5 Tangerang District - Sepatan - Sarakan, Kayu Agung - Rajeg - Sukasari, Tanjakan iv Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Executive Summary cost/benefit reflects the similar costs at its observed rate of Masyarakat/Community-Based Sanitation) and the sewer- capacity utilization. The BCR is the main measurement of age systems at their actual capacities are less than 1, due efficiency reported in this study: an efficient sanitation in- largely to operating at 70% and 14% of their potential ca- vestment is defined as one that has a BCR value greater pacity, respectively. than 1. Figure A and Figure B show that the BCR values for almost all sanitation options at all study sites were greater These results above reflect open defecation as a starting than 1. The two exceptions are in the urban site of Banjar- point. However, some populations already have access to masin where the BCR of the SANIMAS (Sanitasi Berbasis some form of sanitation facility, and hence it is relevant to FIGURE A: BENEFIT-COST RATIOS OF DIFFERENT SANITATION OPTIONS IN THE TWO RURAL SITES shared toilet Lamongan District private wet pit private septic tank community facility Tangerang District private wet pit private septic tank optimal capacity 0 1 2 3 4 5 6 7 8 actual capacity bene�t - cost ratio FIGURE B: BENEFIT-COST RATIOS OF DIFFERENT SANITATION OPTIONS IN THE THREE URBAN SITES Banjarmasin community facility private sewerage shared toilet Malang private septic tank private communal sewerage Payakumbuh shared toilet private septic tank optimal capacity 0.0 0.5 1.0 1.5 2.0 2.5 3.0 actual capacity bene�t - cost ratio www.wsp.org v Economic Assessment of Sanitation Interventions in Indonesia | Executive Summary assess the ‘incremental’ economic performances of mov- any incurred costs for raising awareness and capacity among ing up the sanitation ladder. Such an analysis is applicable targeted beneficiaries prior to the facility construction, as for households that may consider upgrading their existing well as program management. For instance, Tangerang sanitation option to a better one. For example, households SANIMAS (a community-based sanitation system/CBS), still using shared toilets or community toilets may wish to was provided under an initiative of the central government, move up to private septic tank or private sewerage. Table WSP and NGOs. The NGOs (BORDA and its local NGO B and Table C show the economic performance of mov- partner, BEST) performed the awareness and capacity ing up some sanitation ladders in the rural study areas building of the communities. (Lamongan and Tangerang) and urban areas (Banjarmasin and Malang), respectively. Most steps up the ladder lead Figure D shows the urban sites. The community sanitation to a BCR of greater than 1 due to the incremental benefits option (SANIMAS) and the sewerage with treatment op- outweighing the incremental costs. However, in some cases tion are both from the site of Banjarmasin. In 2009, the in urban areas when moving to sewerage options, the costs SANIMAS systems were utilized by 70% of the intended outweigh the benefits, and hence the BCR falls below 1. beneficiaries, and the sewerage system was operating at 14% of its capacity, thus the actual average cost per house- E. DISAGGREGATED RESULTS hold for both sanitation options was much higher than the E1. COSTS optimal cost. Figure C and Figure D illustrate the main contributors of economic cost in rural and urban areas, respectively. Within E2. HEALTH BENEFITS the total economic costs, both in rural and urban areas, the Health care is the main contributor to costs averted in the capital costs are the main contributors and in some cases move from open defecation to improved sanitation, repre- there were almost no dedicated program costs. However, in senting between 60% and 70% of total health costs in both cases such as SANIMAS development in Tangerang district rural and urban sites (Figure E). The savings per household and other sanitation options applied in Payakumbuh (using are higher in rural areas due to higher baselines of disease, the Community-Led Total Sanitation (CLTS) approach) and savings decline significantly with subsequent moves up there were significant program costs. The program costs are the sanitation ladder. TABLE B: RURAL AREA EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARING DIFFERENT POINTS ON THE SANITATION LADDER Lamongan: Lamongan: Tangerang: Efficiency Scenario Moving from shared latrine to Moving from private wet latrine Moving from community measure private septic tank to private septic tank latrine to private septic tank Benefits per US$ Optimal 2.9 1.9 3.5 input Actual 2.4 1.6 2.7 Internal rate of Optimal 92% 36% 86% return (%) Actual 62% 21% 58% TABLE C: URBAN AREA EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARING DIFFERENT POINTS ON THE SANITATION LADDER Banjarmasin: Malang: Efficiency Moving from shared/community latrine to Scenario Moving from private wet measure Private septic tank Private toilet with sewerage latrine to communal sewerage Benefits per US$ Optimal 1.9 0.3 0.7 input Actual 1.2 0.2 0.6 Internal rate of Optimal 48% -7% 0% return (%) Actual 17% -8% -2% vi Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Executive Summary FIGURE C: BREAKDOWN OF ANNUAL ECONOMIC COSTS PER RURAL HOUSEHOLD (US$) community facility shared private dry pit private wet pit private septic tank 0 10 20 30 40 50 60 70 80 recurrent cost program costs capital costs FIGURE D: BREAKDOWN OF ANNUAL ECONOMIC COSTS PER URBAN HOUSEHOLD (US$) optimal community facility actual shared private dry pit private wet pit private septic tank private communal sewerage private optimal sewerage + treatment actual 0 50 100 150 200 250 300 350 capital costs program costs recurrent cost FIGURE E: HEALTH COSTS AVERTED OF IMPROVED SANITATION OPTIONS rural (open defecation (OD) to basic sanitation) urban (OD to sewerage) urban (basic sanitation to sewerage) 0 50 100 150 200 US$ saved per household premature mortality productivity health care www.wsp.org vii Economic Assessment of Sanitation Interventions in Indonesia | Executive Summary E3. WATER BENEFITS • Access time savings are obtained when a household Drinking water treatment costs are higher than the costs has private access to an improved toilet at their home. of obtaining the water in all study sites. In Banjarmasin, a • The value of time saved per year is equivalent to 30% city with many rivers, households spend much more on wa- of the average annual income for adults. For chil- ter treatment and for water access compared with the other dren, half of the value of adults is used, recognizing study sites. The economic cost of treating drinking water is that the OD practices of children affect the time use greater than the cost incurred in accessing water. of adults. • The household income is based on the national aver- Annual average costs saved per household are calculated age wage. based on the assumption that after 100% improved sanita- tion is achieved, a cheaper treatment method can be chosen. If a household has previously practiced open defecation and Table D depicts annual incurred costs of water treatment then changes to using a private toilet, they have the highest and annual average saved costs per household following potential saved time. Households in Tangerang and Malang 100% sanitation improvement. The cost savings are lower have the highest potential time saved compared with the than the total costs incurred because it is assumed that the other study sites. According to the Household Survey, the majority of households do not change their behavior due to average travel/waiting time for people in Tangerang and force of habit. Malang to reach and access defecation places (open land/ waterway, shared latrine and community latrine) are the E4. ACCESS TIME SAVINGS highest i.e. longer than 8 minutes per round trip. Mean- Time saving is one of the major benefit value drivers in the while, similar access time in the other sites is below 6 min- CBA calculation. The average annual value of potential time utes per round trip. Therefore, people in Tangerang and saved per household is shown in the Figure F. The time bene- Malang have the highest potential saved time if they all fit values are calculated under the following assumptions: have a private toilet (Figure F). TABLE D: WATER ACCESS AND HOUSEHOLD TREATMENT COSTS INCURRED AND AVERTED (US$) Annual average costs saved per household Annual average costs per household Variable following 100% sanitation coverage Water source access Water treatment Water source access Water treatment Lamongan 6 14 1 1 Tangerang 8 15 1 1 Banjarmasin 12 34 2 11 Malang 8 21 1 3 Payakumbuh 10 23 1 2 FIGURE F: AVERAGE POTENTIAL TIME SAVED PER YEAR PER HOUSEHOLD Lamongan Tangerang Banjarmasin Malang Payakumbuh young children (0-4 years) 0 100 200 300 400 500 600 700 800 children (5-14 years) average time saved per year per household (US$) adult viii Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Executive Summary E5. INTANGIBLE BENEFITS OF SANITATION Tourists and business visitors gave their opinions on what OPTIONS aspects of sanitation concerned them the most when visit- For households who currently have no toilet, they perceive ing Indonesia. Each respondent could choose a maximum that “proximity� and “cleanliness� are the most important of three factors. Figure I shows that food was the highest factors for getting a toilet, followed by “not having to share�, ranked factor, followed closely by drinking water (includ- “privacy�, “non-pollution� and “comfort� (see Figure G). ing bottled water) and unsanitary toilets. The availability of Due to technical challenges in converting these intangible public toilets was also a concern ranked by 10% of visitors. benefits into economic values, as well as distinguishing the Also of concern to business visitors especially was the han- value of each one separately (such as from a willingness-to- dling of currency notes. pay survey), these impacts were not monetized. E7. BUSINESS BENEFITS E6. TOURISM BENEFITS The business survey was conducted in Jakarta and Bandung Tourism is an important economic activity in Indonesia. and covered restaurants, hotels, a garment factory and food In 2008, it provided US$7.4 billion of revenue, the third processing industries. Most companies stated that among highest contributor of foreign exchange revenues, after oil other factors as indicated in Figure J, pleasant environ- and gas and palm oil. It also provides an important source ment for staff (which is represented by cleanliness, good of local government tax income, as well as jobs for 6.7 mil- air quality and good sanitation) is the most important fac- lion Indonesians. tor to consider in locating their business. Workers’ health and availability of good quality water are other sanitation- This study attempted to explore the impacts of general sani- related factors stated as being important by the interviewed tary conditions on tourists’ preferences to visit Indonesia businesses. and recommend Indonesia to their family and friends as a desirable holiday destination. Beside tourists on holiday, E8. PROGRAM PERFORMANCE business visitors were also included in the survey. Figure H The Program Approach Analysis (PAA) contrasts and com- shows respondents’ perceptions of general sanitary condi- pares the key indicators of impact for assessment of pro- tions of public places in cities, which generally are poorer gram effectiveness in relation to different impacts of im- than in private places, such as hotels, swimming pools, and proved sanitation. Table E shows selected indicators of restaurants. This shows that they perceived a considerable financing and program performance. The key indicator gap in sanitary conditions between different places in In- “% household members using their improved toilet regu- donesia. larly�, which was used to calculate health and access time FIGURE G: THE IMPORTANT FACTORS OF HAVING A TOILET (AVERAGE SCORE OF RESPONDENTS, RANKED FROM NOT IMPORTANT = 1 TO VERY IMPORTANT = 5) proximity clean not sharing privacy non-pollution comfort 0 1 2 3 4 5 www.wsp.org ix Economic Assessment of Sanitation Interventions in Indonesia | Executive Summary benefits under actual program conditions (for use in the are below 50% in Tangerang, Banjarmasin and Malang. For cost-benefit analysis), varied from 70% in Banjarmasin to the majority of sanitation options and sites, financing was 84% in both Payakumbuh and Malang. However, as shown provided by the household. Community toilets were largely in the lower part of Table E, other indicators of sanitation funded from non-household sources in Tangerang and Ban- practices show quite significant non-use of sanitation fa- jarmasin; while sewerage solutions were also largely funded cilities by children. Rates of handwashing at critical times from non-household sources in Malang and Banjarmasin. FIGURE H: GENERAL SANITARY EXPERIENCE (SCORE: 5 = VERY GOOD, 1 = VERY POOR) hotel swimming pool restaurant other cities capital city general sanitary condition open water 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 tourist business general sanitary experiences FIGURE I: SANITATION FACTORS CONCERNING VISITORS WHEN VISITING INDONESIA (UP TO 3 RESPONSES POSSIBLE PER RESPONDENT) food drinking water unsanitary toilet tap water public toilets currency notes swimming pool water 0% 5% 10% 15% 20% 25% tourist business x Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Executive Summary FIGURE J: IMPORTANCE OF ENVIRONMENTAL SANITATION CONDITIONS FOR LOCATING THE COMPANY (1 = UNIMPORTANT; 5 = IMPORTANT) availability of cheap and good land water quality directly available from nature (rivers, lakes, ground) workers' health pleasant environment for staff (clean, good air quality, good sanitation) 0 1 2 3 4 5 TABLE E: SELECTED INDICATORS OF FINANCING AND PROGRAM EFFECTIVENESS Rural sites Urban sites Variable Lamongan Tangerang Banjarmasin Malang Payakumbuh Years of program 7 1 Still ongoing 13 Still ongoing % household members using their 81% 82% 70% 84% 84% improved toilet regularly HOUSEHOLD CONTRIBUTION TO COST (FINANCIAL & NON-FINANCIAL) Community 100% 30% 11% na na Shared 100% 100% 100% 100% 82% Private dry pit 100% 100% 100% 100% 0% Private wet pit 100% 100% 100% 100% 71% Private septic tank 100% 100% 100% 100% 100% Private sewerage na na 9% na na Community sewerage na na na 37% na SANITATION PRACTICES AMONG HOUSEHOLDS: Using bush for defecation (sometimes or 16% 20% 2% 1% 17% often) Using bush for urination (sometimes or 23% 29% 2% 4% 26% often) Children using latrine 12% 13% 12% 57% 5% Children defecating in yard 39% 55% 29% 31% 36% Washed hands with soap yesterday 96% 21% 12% 50% 94% Washing hands after defecation 87% 4% 7% 32% 84% (sometimes or often) F. CONCLUSIONS 100% in many cases. At urban sites, all sanitation ladder The study results reveal that all sanitation interventions are options are economically feasible at their optimal utiliza- economically feasible at rural sites. The actual benefit-cost tion, with BCR values ranging from 1.1 for private toilet ratio or BCR values range from 2 (private septic tank in connected to the sewerage system in Banjarmasin to 4 for Lamongan district) to 6 (community and private pour- private wet pit in Malang city. In practice, below optimal flush toilets in Tangerang district). As payback periods are capacity utilization at project sites leads to reductions in short, the internal rates of return are very high, exceeding some BCR values to below 1. www.wsp.org xi Economic Assessment of Sanitation Interventions in Indonesia | Executive Summary The benefit value drivers in the quantitative analysis includes G. RECOMMENDATIONS the costs related to sickness, such as physician’s fee, medi- The development of sanitation in Indonesia has become a cines and transport to health facilities, as well as saving time national issue. The Government of Indonesia has placed from not traveling to a site of open defecation or queuing at the sanitation developments among the national priorities, public toilets. Marginal benefits have been valued related to declared in the 2nd National Sanitation Conference, De- averted pollution of local water sources and reduced travel cember 2009. The Sanitation Technical Team has initiated or treatment costs; however, the actual economic benefits a national “giant step� of sanitation development by means are likely to be significantly greater than those valued in this of organizing the Acceleration of Settlement Sanitation De- study. Among the valued benefits, the health benefits will velopment Program (PPSP) 2010-2014. One of the targets most likely lead to financial savings for households as well is for Indonesia to be free of open defecation by the end of as health care providers. Therefore, decreased risks to health 2014, or earlier. as a consequence of having better sanitation would lead to reduced household spending for health-seeking efforts, thus The ESI cost-benefit results can contribute to several of the safeguarding cash resources for other uses. six PPSP stages, which are (1) advocacy, (2) institutional preparation, (3) City Sanitation Strategy, (4) detailed tech- As well as the above quantitative BCR results, there are also nical proposals, (5) implementation, and (6) monitoring non-monetized benefits that should be considered to jus- and evaluation. tify any sanitation investment. People may consider paying a higher price to acquire intangible benefits such as com- Advocacy requires robust and convincing data and informa- fort, privacy, cleanliness and environmental improvements. tion to present the importance of sanitation improvement Women and the elderly are particularly likely to enjoy at household, community and national level. Decision these benefits. As well as individual and community-scale makers at central, provincial and local levels can each utilize benefits, an improved environment can also have positive the study results as evidence of the economic importance of knock-on effects on tourism and business, as well as gener- sanitation, thus leading to demand creation for sanitation. ating employment and value through a thriving sanitation supply market. The City Sanitation Strategy can use the CBA model to enrich its Environmental Health Risks Assessment (EHRA) The results point to the finding that, in order to have ef- study. The outcomes of such a study demonstrate not only ficient and economically feasible sanitation interventions – indicative health risks of particular areas, but also poten- particularly for a sewerage system and a community toilet tial quantitative benefits that might be acquired should the (SANIMAS) – the most important conditions are to in- sanitation condition in the areas be improved. crease the utilization of the facilities towards the optimal level (100%) and to increase the capacity utilization of the The detailed technical proposals – whose aim is to obtain treatment facility. The results of sensitivity analysis also commitments of contribution from stakeholders – can gain point to the uncertainty surrounding the benefits obtain- from field evidence on the costs and potential cost-benefits able from improved sanitation, and hence their economic of improved sanitation and hygiene programs, as well as in- feasibility. The choice of conservative input values in the formation on the actual performance of different programs. baseline assessment and the omission of several benefits from the quantitative analysis, suggest that the benefit-cost Monitoring and evaluation can learn from the frameworks ratios will be higher – possibly significantly higher – than used in this study, such as the CBA and PAA models, which those reported in the baseline assessment. are tools to periodically measure performance of sanitation xii Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Executive Summary programs during and after implementation. Sanitation fi- 2. Go beyond basic sanitation provision, where the nanciers and implementers will be able to assess to what population demands it and the funding is avail- extent the implemented sanitation programs have achieved able. In densely populated urban areas, only basic their goals and targets, and the division of the total benefits sanitation provision is no longer feasible due to the amongst the different beneficiaries and stakeholders. In the higher expectations of populations, space constraints long run such assessments are expected to increase program and risks of groundwater pollution. Decision mak- sustainability. ers should therefore be aware of the full range of conveyance and treatment options, and their related Three further overarching recommendations for decision costs and benefits, in order to avoid investing in ex- makers are proposed: pensive technologies that are difficult and costly to sustain. In municipalities where funding is sufficient 1. Intensify efforts to improve access for the entire to permit more sustained and quality services, these Indonesian population to improved basic sanita- will better capture the full environmental and health tion. Indonesia approved a sound community-based benefits and respond to the population’s wish for a sanitation strategy in 2008 that needs to be imple- clean, liveable environment. mented, and enough evidence is available to show that establishing a viable sanitation market – where 3. Promote evidence-based sanitation decision- demand by all income levels meets affordable and making. Variation in economic performance of san- good quality supply – is feasible. For policy makers itation options suggests that careful consideration of and local governments, this requires special atten- site conditions and local demand and preferences is tion to ensure demand is triggered, health benefits needed to select the most appropriate sanitation op- are captured, and coverage is sustained (i.e., avoid- tion and delivery approach. Decisions should take ing returning to open defecation). Sanitation provid- into account not only the measurable economic ers, from wholesalers to community-based masons, costs and benefits, but also other key factors for a need to improve on affordable, upgradable latrine decision, including intangible impacts and socio- structures and design to ensure widespread uptake. cultural issues that influence demand and behavior Information on sanitation options and models for change, availability of suppliers and private financ- households everywhere in Indonesia is another key ing, and actual household willingness and ability to element for rapidly accelerating and sustaining cov- pay for services. erage. www.wsp.org xiii Foreword The Economics of Sanitation Initiative (ESI) was first it an ‘attractive’ subject for media to promote as a worthy launched in 2007 as a response by the Water and Sanitation cause or politicians to stake their career on. Furthermore, Program (www.wsp.org) to major gaps in evidence among limited data exist on the tangible development benefits of Southeast Asian countries on the economic aspects of sani- sanitation for decision makers to justify making it a priority tation. The initiative provides evidence that supports sani- in government or private spending plans. tation advocacy, elevates the profile of sanitation, and acts as an effective tool to convince governments to take action. Based on this premise, the World Bank’s Water and Sanita- The ESI Phase 1 found that the economic costs of poor tion Program (WSP) is leading the Economics of Sanita- sanitation and hygiene amounted to over US$9.2 billion tion Initiative to compile existing evidence and to generate a year (2005 prices) in Cambodia, Indonesia, Lao PDR, new evidence on socio-economic aspects of sanitation. The the Philippines, and Vietnam. The ESI Phase 2 analyzes aim of ESI is to assist decision-makers at different levels to the costs and benefits of alternative sanitation interventions make informed choices on sanitation policies and resource and will enable stakeholders to make decisions on how to allocations. spend funds allocated to sanitation more efficiently. Due to the successful traction the study has gained in the East Asia In Indonesia, Phase 1 was completed in 2008, which es- and Pacific region, ESI has extended to Africa, South Asia timated the economic and social impacts of unimproved and Latin America and the Caribbean. sanitation on the population and economy of Indonesia, among other countries of Southeast Asia. The study showed In recognition of sanitation as a key aspect of human de- that the economic impacts of poor sanitation are US$6.3 velopment, target 10 of the Millennium Development billion per year for Indonesia, or US$28.6 per capita. This is Goals includes access to safe sanitation: “to reduce by half equivalent to 2.3% of annual GDP. These and other results between 1990 and 2015 the proportion of people without were disseminated widely to national policy makers, sector access to improved sanitation�. This reflects the fact that ac- partners, and decentralized government levels of Indonesia. cess to improved sanitation is a basic need: at home as well as when at the workplace or school, people appreciate and The current volume reports ESI Phase 2, which examines value a clean, safe, private and convenient place to urinate in greater depth the costs and benefits of specific sanita- and defecate. Good sanitation also contributes importantly tion interventions in a range of field settings in Indonesia. to achieving other development goals such as child mortal- The purpose is to provide information to decision makers ity reduction, school enrolment, nutritional status, gender on the impact of their decisions relating to sanitation – to equality, clean drinking water, environmental sustainability understand the costs and benefits of improved sanitation and improved quality of life of slum dwellers. in selected rural and urban locations, as well as to enable a better understanding of the overall national level impacts Despite its recognized importance, sanitation continues to of improving sanitation coverage in Indonesia, such as on lose ground to other development targets when it comes to tourism and businesses. On the cost side, decision makers priority setting by governments, households, private sector and stakeholders need to understand more about the timing and donors. This fact is hardly surprising given that sanita- and size of costs (e.g. investment, operation, maintenance), tion remains a largely taboo subject in society, neither is as well as financial versus non-financial costs, in order to xiv Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Foreword make the appropriate investment decision that increases in- tervention effectiveness and sustainability. On the benefit side, the monetary as well as non-monetary impacts need to be more fully understood in advocating for improved sanitation as well as making the optimal sanitation choice. For cost-benefit estimations, a sample of sites representing different contexts of Indonesia was selected to illustrate the range and sizes of sanitation cost and benefits and to assess efficiency of sanitation interventions. The research under this program is being conducted in four other countries: Cambodia, Lao PDR, Philippines and Vietnam, as well as covering Yunnan Province in the People’s Republic of China. While WSP has supported the development of this study, it is an ‘initiative’ in the broad- est sense, which includes the active contribution of many people and institutions (see Acknowledgment). www.wsp.org xv Abbreviations and Acronyms ADB Asian Development Bank ALOS Average Length of Stay (in hospital) ALRI Acute Lower Respiratory Infection AMPL Air Minum dan Penyehatan Lingkungan (Drinking Water and Environment Restoration) APBD Anggaran Pendapatan dan Belanja Daerah (Local budget) APBN Anggaran Pendapatan dan Belanja Negara (National budget) ASSDP/PPSP The Acceleration of Settlement Sanitation Development Program/ Percepatan Pembangunan Sanitasi Permukiman AusAID Australian Agency for International Development BAPPENAS The Indonesian National Development Planning Agency BCR Benefit-Cost Ratio BEST Bina Ekonomi Sosial Terpadu (Integrated Social Economy Development) BOD Biochemical Oxygen Demand BORDA Bremen Overseas Research and Development BPLHD Local Environmental Management Agency CBA Cost-Benefit Analysis CBS Community-Based Sanitation CBSS Community-Based Sewer System CER Cost-Effectiveness Ratio CLTS Community-Led Total Sanitation COD Chemical Oxygen Demand xvi Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Abbreviations and Acronyms CSS City Sanitation Strategy CWSHP Community Water, Sanitation and Health Project DALY Disability-Adjusted Life-Year DEP Detailed Engineering Program DEWATS Decentralized Wastewater Treatment System DHS Demographic and Health Survey DO Dissolved Oxygen EAP East Asia and the Pacific region E. coli Escherichia coli ESA External Support Agency ESI Economics of Sanitation Initiative FGD Focus Group Discussion FY Financial Year GDP Gross Domestic Product GNP Gross National Product GRP Gross Regional Product HCA Human Capital Approach HH Household HWWS HandWashing With Soap IBRD International Bank for Reconstruction and Development IDS Institute of Development Studies, University of Sussex, UK www.wsp.org xvii Economic Assessment of Sanitation Interventions in Indonesia | Abbreviations and Acronyms IEC Information, Education, and Communication IRR Internal Rate of Return ISSDP Indonesia Sanitation Sector Development Program JAMKESKO Jaminan Kesehatan Kota (Urban Health Insurance) JMP Joint Monitoring Programme, of WHO and UNICEF kg Kilograms KLH Kementerian Lingkungan Hidup (Ministry of Environment) KUDP Kalimantan Urban Development Project LIPI Lembaga Ilmu Pengetahuan Indonesia (The Indonesian Institute of Science) LP3ES Lembaga Penelitian, Pendidikan dan Penerangan Ekonomi (Institute for Social and Economic Research, Education, and Information) MCK Mandi Cuci Kakus (public toilet) MCK ++ MCK that is also designed to produce biogas MDG Millennium Development Goal mg/l Milligrams per liter MoH Ministry of Health MPW Ministry of Public Works NGO Non-Governmental Organization NPV Net Present Value NTB Nusa Tenggara Barat/West Nusa Tenggara (Province) NTT Nusa Tenggara Timur/East Nusa Tenggara (Province) OD Open Defecation xviii Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Abbreviations and Acronyms ODF Open Defecation Free O&M Operations and Maintenance P2KP Program Pengentasan Kemiskinan di Perkotaan (Urban Poverty Alleviation Program) PAA Program Approach Analysis Pamsimas Penyediaan Air Minum dan Sanitasi Berbasis Masyarakat (Community-based water supply and sanitation) PBP Payback Period PD PAL Perusahaan Daerah Pengelolaan Air Limbah (local wastewater management company) PDAM Perusahaan Daerah Air Minum (local government-owned drinking water enterprise) PHBS Perilaku Hidup Bersih Sehat (Health and Hygiene Behavior) PPLP Pengendalian Penyakit dan Penyehatan Lingkungan (Disease Control and Environmental Health) Puskesmas Pusat Kesehatan Masyarakat (Community Health Center) Puslitbang SDA/ Pusat Penelitian dan Pengembangan Sumber Daya Air PusAir (Center of Research and Development on Water Resources) RBC Rotating Biological Contactor SANIMAS Sanitasi Berbasis Masyarakat (Community-Based Sanitation) SANTT/TTPS Sanitation Technical Team/Tim Teknis Pembangunan Sanitasi SDG Sanitation Donor Group SPAL Sistem Penyaluran Air Limbah (collection network/sewerage system) STBM Sanitasi Total Berbasis Masyarakat (Community-Based Total Sanitation) www.wsp.org xix Economic Assessment of Sanitation Interventions in Indonesia | Abbreviations and Acronyms STP Sewage Treatment Plant SUSENAS Survei Sosial Ekonomi Nasional (national socio-economic survey) TSSM/SToPs Total Sanitation and Sanitation Marketing/Sanitasi Total dan Pemasaran Sanitasi UKS Unit Kesehatan Sekolah (School Health Unit) UNICEF United Nations Children’s Fund USAID United States Agency for International Development USDP Urban Sanitation Development Program VOSL Value of Statistical Life WASPOLA Water and Sanitation Policy Formulation and Action Planning WB World Bank WC Water Closet WHO World Health Organization WSLIC Water and Sanitation for Low Income Communities WSP Water and Sanitation Program WTP Water Treatment Plant WWTP Wastewater Treatment Plant xx Economic Assessment of Sanitation Interventions Glossary of Terms Benefit-cost ratio (BCR): The amount by which an intervention’s benefits exceed the same intervention’s costs. Technically: the ratio of the present value of the stream of benefits to the present value of the stream of costs. The higher the ratio, the more efficient the intervention. Cost per case averted: The discounted value of the costs for each case of a disease that is avoided resulting from an intervention. Cost per DALY averted: The discounted value of the costs for each DALY that is avoided resulting from an intervention. Cost per death averted: The discounted value of the costs for each death that is avoided resulting from an intervention. Cost-effectiveness ratio (CER): The ratio of the present value of the future costs to the present value of the future health benefits in non-monetary units (cases, deaths, disability-adjusted life-years). The lower the CER the more efficient the intervention. Diarrhea: The passage of three or more loose or liquid stools per day, or more frequently than is normal for the individual. It is usually a symptom of gastrointestinal infection, which can be caused by a variety of bacterial, viral and parasitic organisms. Infection is spread through contaminated food or drinking-water, or from person to person as a result of poor hygiene. Disability-Adjusted Life-Year (DALY): a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability. One DALY can be thought of as one lost year of “healthy� life (WHO 2010). Ecological sanitation (EcoSan)1: a new paradigm in sanitation that recognizes human excreta and water from households not as waste but as resources that can be recovered, treated where necessary and safely used again. It is based on the systematic implementation of reuse and recycling of nutrients and water as a hygienically safe, closed-loop and holistic alternative to conventional sanitation solutions (GTZ, 2009). The objectives are to offer economically and ecologically sustainable systems that aim to close the natural nutrient and water cycle. The approach is based on the systematic implementation of reuse and recycling of nutrients and water as a hygienically safe, closed-loop and holistic alternative that seeks to protect public health, prevent pollution and at the same time return valuable nutrients and humus to the soil. Externality: an externality is a consequence of an activity that is experienced by unrelated third parties. An externality can be either positive or negative. In the case of a sanitation intervention in a community practicing open defecation, a positive externality can result, whereby benefits extend beyond the households practicing improved sanitation, such as preventing surface and ground water pollution, reducing bad odors and improving outward (visual) appearances. An important positive externality in the case of sanitation is the reduced levels of disease, thus impacting labor force productivity. 1 http://www.ecosan.nl www.wsp.org xxi Economic Assessment of Sanitation Interventions in Indonesia | Glossary of Terms Helminthes: Parasitic worms that live and feed off living hosts, receiving nourishment and protection while disrupting their hosts’ nutrient absorption, causing weakness and disease. Hepatitis A: Acute infectious disease of the liver caused by the hepatitis A virus, which is commonly transmitted by the fecal-oral route via contaminated food or drinking water. Hepatitis E: A viral hepatitis (liver inflammation) caused by infection with a virus called hepatitis E virus (HEV). HEV is transmitted via the fecal-oral route. Improved sanitation: The use of the following facilities in the home compound: flush/pour-flush to piped sewer system/septic tank/pit latrine, ventilated improved pit (VIP) latrine, pit latrine with slab, or composting toilet (JMP, 2008). Income elasticity of demand: Measures the responsiveness of the demand for a good to a change in the income of the people demanding the good. It is calculated as the ratio of the percentage change in demand to the percentage change in income. For example, if, in response to a 10% increase in income, the demand for a good increased by 20%, the income elasticity of demand would be 20%/10% = 2. Intangible impact: An identifiable non-monetary consequence of an intervention that cannot be easily seen, touched or physically measured. It is a gain or loss that cannot be sufficiently quantified for purposes of accounting or financial reporting, but that contributes to changes in quality of life and project performance such as employee morale, work or life satisfaction, or quality of environment. Intangible benefits of improved sanitation include, for example, quality of life, comfort, security, dignity, personal and cultural preferences, among others. Internal rate of return: A measure used to compare the profitability of alternative uses of investment funds (or ‘projects’). It is the interest (or ‘discount’) rate at which the net present value (NPV) of costs (negative cash flows) of the investment equals the net present value of the benefits (positive cash flows) of the investment. In other words, the interest rate for which the BCR equals unity (1). Lifecycle costs: A costing analysis that takes into account not only the investment costs, but also operations and maintenance – hence giving a fuller picture of the commitment in future expenditures needed to keep a sanitation system running over its expected lifespan. Malaria: A mosquito-borne infectious disease caused by a eukaryotic protest of the genus Plasmodium. Malnutrition: The insufficient, excessive or imbalance of nutrient consumption. Net benefit: The monetary difference between present value of the future stream of benefits to the present value of the future stream of costs. xxii Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Glossary of Terms Net present value (NPV): The discounted value of the current and future stream of net benefits from a project. The NPV, a time series of cash flows, both incoming and outgoing, is the sum of the present values of the individual cash flows. In the case when all future cash flows are incoming (such as coupons and principal of a bond) and the only outflow of cash is the purchase price, the NPV is simply the present value of future cash flows minus the purchase price. Open defecation: The practice of disposing human feces in fields, forests, bushes, open bodies of water, beaches or other open spaces or disposed of with solid waste (JMP, 2008). Payback period (PBP): Represents the number of periods (e.g. years) that are necessary to recover the costs incurred until that time point (i.e. investment plus recurrent costs). For example, a $1000 investment which returned $500 per year would have a two-year payback period. Payback period intuitively measures how long something takes to “pay for itself.� Septic tank: Rectangular chamber, usually sited just below ground level, that receives and partially treats brown water from flush toilets, and can include other household wastewater. Unimproved sanitation: The use of the following facilities: flush/pour flush without isolation or treatment, pit latrine without slab/open pit, bucket, hanging toilet/hanging latrine, use of a public facility or sharing any improved facility, no facilities, bush or field (open defecation) (JMP, 2008). www.wsp.org xxiii Acknowledgments The study was led by the East Asia and Pacific (EAP) office of the World Bank’s Water and Sanitation Program (WSP), with the contribution of WSP teams and consultants in each of the participating countries. The study took three years to complete, and has undergone several major peer review processes. Guy Hutton (WSP Senior Water and Sanitation Economist and Task Team Leader) led the development of the concept and methodology for the ESI, the management and coordination of the country teams, the provision of regional tools and templates, and the report writing. Bjorn Larsen (WSP consultant) contributed to the development of generic data collection tools and the health methodology. Martin Albrecht (WSP) supported the research management and writing process. The study benefited from the continuous support of other WSP staff: Almud Weitz, Isabel Blackett, Yosa Yuliarsa, Irvan Tjondronegoro and support staff. The Indonesia research team, based at PT Mitra Lingkungan Dutaconsult (MLD) Indonesia, consisted of: Asep Winara (Team Leader), Oktarinda (Field Manager), Edi Purnomo (Statistician and Data Manager), Koderi Hadiwardoyo (Health Expert), Indon Merdykasari (Sanitation Engineer), Takdir Nurmadi (Senior Sociologist), Bert Bruinsma (Economics Advisor) and Dedek Gunawan (WSP consultant). The Team was supervised by Dadang Fadilah. Water quality monitoring was conducted by PT SUCOFINDO laboratories. Peer reviewers of the Indonesia report came from the Sanitation Technical Team (TTPS), academics, and the sanitation donor group. The TTPS is a national taskforce and cross-sectoral team responsible for promoting sanitation sector development in Indonesia. The leading agency of the team is the National Development Planning Agency (BAPPENAS) and the members are the Ministry of Health, the Ministry of Public Works, the Ministry of Home Affairs, the Ministry of Finance, the Ministry of Industry, and the Ministry of Environmental Affairs. The valuable inputs of the TTPS and its members at meetings held at study initiation and during write-up are greatly appreciated. Also, valuable peer review comments were received from Sophie Tremolet (Tremolet Consulting Ltd), Isabel Blackett (WSP Senior Sanitation Specialist), Irwan Sumadji (Lecturer, University of Indonesia) and Richard Pollard (ECA region, World Bank), for which the study team is extremely grateful. The ESI has been financed by the regional component of the Sustainable Sanitation in East Asia (SUSEA) program, which is funded by the Swedish International Development Agency (SIDA). The Asian Development Bank co-financed the consultant teams in Indonesia, Philippines and Vietnam. The study in Yunnan Province (China) was co-financed by ECO-Asia. WSP and the report authors are grateful to the funding agencies for their support. xxiv Economic Assessment of Sanitation Interventions Reference for citation: Economic assessment of sanitation interventions in Indonesia. Asep Winara, Guy Hutton, Oktarinda, Edi Purnomo, Koderi Hadiwardoyo, Indon Merdykasari, Takdir Nurmadi, Bert Bruinsma, Dedek Gunawan, Dadang Fadilah, Martin Albrecht. World Bank, Water and Sanitation Program. 2011. Other country reports: Economic assessment of sanitation interventions in Cambodia. Sam Sok Heng, Guy Hutton, Poch Kongchheng, Kov Phyrum. Water and Sanitation Program. World Bank. 2011. Economic assessment of sanitation interventions in Lao People’s Democratic Republic. U-Primo Rodriguez, Guy Hutton, Alan Boatman. World Bank, Water and Sanitation Program. 2012. Economic assessment of sanitation interventions in the Philippines. U-Primo Rodriguez, Guy Hutton, Nelissa Jamora, Dieldre Harder, Jeremy Ockelford and Edkarl Galing. World Bank, Water and Sanitation Program. 2011. Economic assessment of sanitation interventions in Vietnam. Nguyen Viet Anh, Guy Hutton, Hoang Thuy Lan, Phan Huyen Dan, Le Thu Hoa, Bui Thi Nhung. World Bank, Water and Sanitation Program. 2012. Economic assessment of sanitation interventions in Yunnan Province, People’s Republic of China. Liang Chuan, Guy Hutton, Yang Liqiong, Fang Jinming, Zhang Tiwei, Dong Lin, Zhang Pu, Luo Ronghuai. World Bank, Water and Sanitation Program. 2011. Regional synthesis report: Economic assessment of sanitation interventions in Southeast Asia. Guy Hutton, U-Primo Rodriguez, Asep Winara, Nguyen Viet Anh, Sam Sok Heng, Kov Phyrum, Liang Chuan, Isabel Blackett, Almud Weitz. World Bank, Water and Sanitation Program. 2012. Summary reports are available for each country, in both English and in the local languages. All country reports are accessible from http://www.wsp.org/pubs/index.asp www.wsp.org xxv Content Executive Summary ................................................................................................................................ iii A. Introduction.................................................................................................................................. iii B. Study Aims and Methods . ........................................................................................................... iii C. Data Sources and Study Sites ..................................................................................................... iv D. Main Economic Analysis .............................................................................................................. iv E. Disaggregated Results ................................................................................................................. vi F. Conclusions ................................................................................................................................. xi G. Recommendations . .....................................................................................................................xii Foreword . ............................................................................................................................................... xiv Abbreviations and Acronyms . ............................................................................................................... xvi Glossary of Terms . ................................................................................................................................. xxi Acknowledgments . ............................................................................................................................... xxiv Content .................................................................................................................................................. xxvi Selected Development Indicators ....................................................................................................... xxxvi I. Introduction....................................................................................................................................... 1 1.1 Background ................................................................................................................................. 1 1.2 Ongoing Sanitation Programs ...................................................................................................... 4 1.3 Report Outline ............................................................................................................................. 5 II. Study Aims . ...................................................................................................................................... 7 2.1 Overall Purpose ........................................................................................................................... 7 2.2 Study Aims .................................................................................................................................. 7 2.3 Specific Study Uses ..................................................................................................................... 7 2.4 Research Questions . ................................................................................................................... 8 III. Methods ........................................................................................................................................... 10 3.1 Technical Sanitation Interventions Evaluated ............................................................................... 10 3.2 Costs and Benefits Evaluated ..................................................................................................... 12 3.3 Field Studies ............................................................................................................................... 14 3.4 Program Approach Analysis ........................................................................................................ 25 3.5 National Studies . ........................................................................................................................ 26 IV. Local Benefits of Improved Sanitation and Hygiene ..................................................................... 30 4.1 Health ......................................................................................................................................... 30 4.2 Water . ........................................................................................................................................ 35 4.3 Access Time ............................................................................................................................... 44 4.4 Intangible .................................................................................................................................... 47 4.5 External Environment .................................................................................................................. 51 4.6 Summary of Local Impacts ......................................................................................................... 53 xxvi Economic Assessment of Sanitation Interventions V. National Benefits of Improved Sanitation and Hygiene . ............................................................... 57 5.1 Tourism . ..................................................................................................................................... 57 5.2 Business and Foreign Direct Investment . .................................................................................... 60 5.3 Sanitation Markets ...................................................................................................................... 62 5.4 Health ......................................................................................................................................... 63 5.5 Water . ........................................................................................................................................ 64 VI. Costs of Improved Sanitation and Hygiene ................................................................................... 65 6.1 Cost Summaries ......................................................................................................................... 65 6.2 Financing Sanitation and Hygiene ............................................................................................... 67 6.3 Sanitation Option by Wealth Quintile ........................................................................................... 69 6.4 Costs of Moving Up the Ladder .................................................................................................. 69 VII. Sanitation Program Design and Scaling Up . ................................................................................. 72 7.1 Program Approaches Applied in Field Sites . ............................................................................... 72 7.2 Comparison of Program Approaches and Performance............................................................... 77 7.3 Broader Analysis of the Program Approaches ............................................................................. 81 7.4 Analysis of Program Approaches ................................................................................................ 87 VIII. Efficiency of Improved Sanitation . ................................................................................................. 93 8.1 Efficiency of Sanitation Improvements Compared to No Facility .................................................. 93 8.2 Efficiency of Alternatives from Moving Up the Sanitation Ladder. ................................................. 102 8.3 Scaling Up Results for National Policy Making . .......................................................................... 106 8.4 Overall Cost-Benefit Assesment . ............................................................................................... 109 IX. Discussions . ................................................................................................................................... 110 9.1 Study Messages and Interpretation . .......................................................................................... 110 9.2 Utilization of Results In Decision Making . ................................................................................... 114 Bibliography .......................................................................................................................................... 121 Annex Tables ......................................................................................................................................... 123 www.wsp.org xxvii List of Tables Table 1. Sanitation coverage in Indonesia - 1990 versus latest year (2008)........................................ 2 Table 2. Classification of sanitation options evaluated in Indonesia . ................................................. 12 Table 3. Benefits of improved sanitation included in this study ......................................................... 13 Table 4. Background information on selected field sites ................................................................... 14 Table 5. Sanitation and hygiene coverage of ESI sample households . ............................................. 18 Table 6. Unit values for economic cost of time per day and loss of life (US$, 2008) .......................... 22 Table 7. List of sub-district and villages for ESI 2 survey areas in five cities/district in Indonesia ....... 23 Table 8. Sample sizes for tourist survey, by main origin of tourist ..................................................... 27 Table 9. Sample size for business survey, by main sectors of local and foreign firms ........................ 28 Table 10. Disease rates attributable to poor sanitation and hygiene, 2009.......................................... 30 Table 11. Proportion of population seeking health care for mild diarrheal disease, by age group ........ 31 Table 12. Average rate of inpatient admissions . ................................................................................. 31 Table 13. Unit costs associated with treatment of severe diarrheal disease (US$, 2009) .................... 31 Table 14. Average health care cost per person per year in field sites, by disease, age group and rural/urban location ..................................................................................................... 32 Table 15. Average productivity cost per person per year in field sites, by disease, age group and rural/urban location (US$)............................................................................................. 34 Table 16. Average mortality cost per person per year in field sites, by disease, age group and rural/urban location............................................................................................................. 34 Table 17. Perceived difference in diarrheal incidence since improved sanitation, in all field sites ......... 35 Table 18. Annual costs per household of poor sanitation and hygiene, and annual costs averted of improved sanitation (in US$, 2008) . ................................................................... 35 Table 19. Number of water samples taken in field sites, by water source ........................................... 36 Table 20. Water quality standards regulation....................................................................................... 37 Table 21. Water sample numbers and sample sites. ............................................................................ 38 Table 22. Water access and household treatment costs incurred and averted (US$) .......................... 43 Table 23. Water uses and impacts of polluted water........................................................................... 43 Table 24. Male and female perceptions about time saving ................................................................. 46 Table 25. Average time lost per household per day ............................................................................ 47 Table 26. Preferences related to toilet convenience from the focus discussion group.......................... 49 Table 27. Risk of hanging toilets . ....................................................................................................... 49 Table 28. Concerns of those practicing open defecation .................................................................... 53 Table 29. Summary of local impacts of sanitation improvement ......................................................... 56 Table 30. Background characteristics of respondents ........................................................................ 58 Table 31. Indonesia household sanitation profile - JMP March 2010 .................................................. 62 Table 32. Estimated number of annual cases and deaths attributed to poor sanitation and hygiene, 2006 .................................................................................................................... 63 Table 33. Summary of average cost per household in rural areas for different sanitation and hygiene options, using full (economic) cost (US$, 2009) ..................................................... 65 Table 34. Summary of average cost per household in urban areas for different sanitation and hygiene option, using full (economic) cost (US$, 2009) ....................................................... 66 xxviii Economic Assessment of Sanitation Interventions Incremental costs per household of moving up the sanitation ladder at rural sites Table 35. (US$, 2009) ........................................................................................................................ 70 Incremental costs per household of moving up the sanitation ladder at urban sites Table 36. (US$, 2009) ........................................................................................................................ 71 Table 37. Sanitation coverage information per field site ...................................................................... 72 Table 38. Number of private toilets built in Lamongan under WSLIC 2 ............................................... 73 Table 39. Total number of WSLIC 2 beneficiaries in Lamongan, 2008 ................................................ 73 Table 40. Composition of PD PAL subsidiaries ................................................................................... 74 Table 41. Reduction of wastewater parameters, and efficiency of the Banjarmasin wastewater treatment plant ................................................................................................................... 75 Ownership of private toilets before and after inception of the CLTS program in Table 42. Payakumbuh ...................................................................................................................... 77 Table 43. Selected indicators of overall program effectiveness ........................................................... 80 Table 44. Community contribution to the cost of CBSS development ................................................ 83 Table 45 Composition of the CBSS subscribers by monthly household disposable income .............. 84 Table 46 Community contribution to the cost of CBSS development ................................................ 86 Table 47 Rural area (Lamongan District) efficiency measures for main groupings of sanitation interventions, compared with “no toilet“ . ............................................................................ 95 Table 48 Rural area (Tangerang District) efficiency measures for main groupings of sanitation interventions, compared with “no toilet“ . ............................................................................ 96 Table 49 Urban area (Banjarmasin) efficiency measures for main groupings of sanitation interventions, compared with “no toilet“ . ............................................................................ 98 Table 50 Urban area (Malang) efficiency measures for main groupings of sanitation interventions, compared with “no toilet“ . ............................................................................ 99 Table 51 Urban area (Payakumbuh) efficiency measures for main groupings of sanitation interventions, compared with “no toilet“ . ............................................................................ 99 Table 52 Rural area (Lamongan District) efficiency measures for main groupings of sanitation interventions, comparing different points on the sanitation ladder ...................................... 103 Table 53 Rural area (Tangerang District) efficiency measures for main groupings of sanitation interventions, comparing different points on the sanitation ladder ...................................... 103 Table 54 Urban area (Banjarmasin) efficiency measures for main groupings of sanitation interventions, comparing different points on the sanitation ladder ...................................... 104 Table 55 Urban area (Malang) efficiency measures for main groupings of sanitation interventions, comparing different points on the sanitation ladder ...................................... 105 Table 56 Urban area (Payakumbuh) efficiency measures for main groupings of sanitation interventions, comparing different points on the sanitation ladder ...................................... 105 Table 57 Typical nationwide sanitation subgroups versus field site characteristics ............................ 107 Table 58 Sensitivity analysis results for Banjarmasin sewerage system . ........................................... 112 Table 59 Sensitivity analysis results for Banjarmasin community system . ......................................... 113 Table 60 Possible use of study results by TTPS team members and stakeholders ........................... 115 www.wsp.org xxix List of Figures Figure 1: The state budget (APBN) development in 1999 versus the last 4 years............................. 1 Figure 2: Sub-national sanitation coverage (SUSENAS 2007) ......................................................... 3 Figure 3: Variations in sanitation coverage by rural/urban................................................................. 4 Figure 4: Flow of data collected (inputs) and eventual cost-benefit assessments (outputs).............. 10 Figure 5: Representation of the sanitation technology “ladder�. ....................................................... 11 Figure 6: Location of study sites..................................................................................................... 19 Figure 7: Overview of methods for estimating field-level benefits of improved sanitation. ................. 20 Figure 8: Comparison of annual diarrhea case per person for under fives, between study sites. ...... 31 Figure 9: Average health care cost per person per year in field sites for diarrheal disease (mild and severe in US$). .................................................................................................. 32 Figure 10: Number of days away from productive activities, per disease with respect to person’s age.................................................................................................................... 33 Figure 11: Relative risk of fecal-oral diseases and helminthes of different risk exposure scenarios......................................................................................................................... 34 Figure 12: Health costs averted of improved sanitation options. ........................................................ 35 Figure 13: Turbidity and nitrate content readings. .............................................................................. 39 Figure 14: BOD and COD readings. .................................................................................................. 39 Figure 15: Extent of isolation of human excreta in field sites.............................................................. 39 Figure 16: Main household water access (%).................................................................................... 40 Figure 17: Water access costs, monthly average per household....................................................... 40 Figure 18: Characteristics of poor quality water cited by respondents. .............................................. 41 Figure 19: Households water treatment costs, by method and rural/urban location.......................... 42 Figure 20: Change in water treatment practices since improved latrines have been installed. ............ 43 Figure 21: Place of defecation of households without their own toilet. ............................................... 44 Figure 22: Time spent accessing toilet for those with no toilet, per trip. ............................................. 45 Figure 23: Defecation outside the household plot for children under five years.................................. 45 Figure 24: Preferences related to toilet proximity for those without toilet. ........................................... 45 Figure 25: How female respondents would spend an extra 30 minutes a day (%)............................. 46 Figure 26: Average time lost per year per household member (hours)............................................... 47 Figure 27: Average annual value of time savings (US$). ..................................................................... 47 Figure 28: Level of satisfaction with current toilet option, improved versus unimproved at all sites (1 = not satisfied, 5 = very satisfied)......................................................................... 50 Figure 29: A visual aid in the household interview............................................................................. 51 Figure 30: Major reasons for not having a private toilet..................................................................... 51 Figure 31: Household members that influence decisions about building or upgrading a private toilet..................................................................................................................... 51 Figure 32: Reasons to get a toilet for those currently without (1 = not important, 5 = very important)........................................................................................................... 52 Figure 33: Scoring of the quality of environmental sanitation by gender of respondent (score: 5 = clean, 1 = very dirty). .................................................................................................. 53 xxx Economic Assessment of Sanitation Interventions Figure 34: Unimproved sanitation practices by households that have toilets..................................... 54 Figure 35: Emptying of septic tanks and pits (%). .............................................................................. 54 Figure 36: Level of satisfaction with impact of current toilet option on the quality of the external environment (score: 5 = very satisfied, 1 = not satisfied). ..................................... 55 Figure 37: Perceptions of the external environmental (score: 5 = very good, 1 = very poor). .............. 55 Figure 38: Places visited by tourists (% respondents) and enjoyment of stay (score: 5 = very much, 1 = not at all)......................................................................................................... 58 Figure 39: General sanitary experience (score: 5 = very good, 1 = very poor). ................................... 59 Figure 40: Sanitary experience in relation to toilets and hand washing (score: 5 = very good, 1 = very poor)..................................................................................................................... 59 Figure 41: What factors were most concerning? (% citing, 3 responses per respondent).................. 59 Figure 42: Intention of visitors to return to indonesia......................................................................... 60 Figure 43: Reason for hesitancy to return......................................................................................... 60 Figure 44: Places visited by business visitor (% respondents) and enjoyment of stay........................ 61 Figure 45: Rating of environmental sanitation conditions in the location of the business survey interview (1 = best; 5 = worst).......................................................................................... 61 Figure 46: Importance of influencing factors for company location (1 = unimportant; 5 = important)........................................................................................................................ 62 Figure 47: Projection of Indonesia sanitation market size (US$ million).............................................. 63 Figure 48: Annual equivalent economic costs per rural household for major items (US$). .................. 66 Figure 49: Annual equivalent economic costs per urban household for major items (US$). ................ 67 Figure 50: Proportion of rural sanitation costs financed from different sources (%)............................ 68 Figure 51: Proportion of urban sanitation costs financed from different sources (%).......................... 68 Figure 52: Capital cost paid by households at rural sites ................................................................. 68 Figure 53: Capital cost paid by households at urban sites ............................................................... 69 Figure 54: Proportion of rural households selecting different sanitation options, by wealth quintile............................................................................................................................. 70 Figure 55: Proportion of urban households selecting different sanitation options, by asset quintile.... 70 Figure 56: Incremental costs per household of moving up the sanitation ladder (US$)...................... 71 Figure 57: Typical design of MCK++ in Tangerang district................................................................. 74 Figure 58: Schematic diagram of Banjarmasin sewerage system...................................................... 75 Figure 59: Proportion of households who said their participation in the program was voluntary. ........ 78 Figure 60: Proportion of households offered more than one sanitation option .................................. 78 Figure 61: Household contribution to total cost of toilet construction in rural sites. ............................ 79 Figure 62: Household contribution to total cost of toilet construction in urban sites.......................... 79 Figure 63: Frequency of supply of water for flushing, and of pit flooding and pit overflow.................. 79 Figure 64: Comparison of selected key indicators of program effectiveness . ................................... 81 Figure 65: SANIMAS fills the gap ..................................................................................................... 82 Figure 66: Example of the benefit value drivers’ contribution in Banjarmasin..................................... 94 Figure 67: Comparison of rural BCR values of different sanitation ladder and at different sites.......... 97 www.wsp.org xxxi Figure 68: Comparison of net present value of sanitation only and of sanitation + hygiene practices for toilet with septic tank at rural sites............................................................... 97 Figure 69: Cost per case averted ($) at rural sites............................................................................. 97 Figure 70: Comparison of urban BCR values of different sanitation ladder options and at .................................................................................................................. 100 different sites. Figure 71: Comparison of urban cost per case averted (US$).......................................................... 100 Figure 72: Economic performance of moving up the rural sanitation ladder. ..................................... 104 Figure 73: Economic performance of moving up the urban sanitation ladder benefit-cost ratios. ...... 106 xxxii Economic Assessment of Sanitation Interventions List of Annex Tables Table A 1. Sub-national sanitation coverage rates, latest year (2007) .............................................. 123 Table A 2. Selection of field sites for the economic study................................................................. 124 Table A 3. Assessment of advantages and limitations of different design options............................. 126 Table A 4. Aggregating equations for cost-benefit and cost-effectiveness analysis. .......................... 127 Table A 5. Methodology for benefit estimation (calculations, data sources, explanations)................. 128 Table A 6. Diseases linked to poor sanitation and hygiene, and primary transmission routes and vehicles.................................................................................................................... 131 Table A 7. Water quality measurement parameters.......................................................................... 132 Table A 8. Households sampled versus total households per village/community.............................. 132 Table A 9. Sample sizes of other surveys in study sites.................................................................... 133 Table A 10. Selection of programs for program approach analysis..................................................... 134 Table B 1. Rates per population for cases of disease....................................................................... 135 Table B 2. Rates per 1000 population for deaths............................................................................. 135 Table B 3. Rates per 1000 population for DALYs............................................................................. 135 Table B 4. Comparison of data sources for selected diseases......................................................... 136 Table B 5. Diarrheal incidence in the past year (or 2 weeks) in all field sites, by option. ..................... 137 Table B 6. Evidence on treatment seeking behavior for other diseases. ............................................ 138 Table B 7. Unit costs associated with treatment of severe diarrhea disease (US$, 2009).................. 140 Table B 8. Unit costs associated with treatment of ALRI (US$, 2009)............................................... 140 Table B 9. Unit costs associated with treatment of mild diarrhea disease (US$, 2009)..................... 140 Table C 1. Water quality measurement results. ................................................................................. 141 Table C 2. Pollution from poor sanitation and wastewater management (% of households).............. 142 Table C 3. Water access and costs. ................................................................................................. 142 Table C 4. Households citing poor water quality from their principal drinking water source. .............. 143 Table C 5. Household responses to polluted water – reasons for using water sources..................... 143 Table C 6. Treatment practices........................................................................................................ 144 Table C 7. Annual treatment costs (US$). ......................................................................................... 144 Table C 8. Water access and household treatment costs incurred and averted................................ 144 Table D 1. Place of defecation of households with no ‘own’ toilet.................................................... 145 Table D 2. Daily time spent accessing toilet for those with no toilet.................................................. 145 Table D 3. Practices related to young children................................................................................. 145 Table D 4. Preferences related to toilet convenience, from household questionnaire. ........................ 146 Table D 5. Opportunity cost of time – what respondents would spend an extra 30 mins a day doing (%)........................................................................................................................ 146 Table D 6. Average time savings per year, by household member (hours). ........................................ 147 Table D 7. Average annual value of time savings (US$). .................................................................... 147 www.wsp.org xxxiii Table E 1. Level of satisfaction with current toilet option, by option type (0% = not satisfied, 100% = very satisfied)..................................................................................................... 148 Table E 2. Important characteristics of a toilet for those currently without (0% = not important, 100% = very important). .................................................................................................. 148 Table F 1. Scoring of different types of living area (1 = clean, 2 = minor soiling, 3 = moderate soiling, 4 = major soiling, 5 = extreme soiling). ................................................................. 149 Table F 2. Proportion of households with and without toilet with unimproved sanitation practice..... 149 Table F 3. Implications of current toilet option for external environment (1 = not satisfied, 5 = very satisfied).................................................................................................................. 150 Table F 4. Perceptions of environmental sanitation state, by option type (1 = very bad, 5 = very good). ...................................................................................................................... 150 Table F 5. Ranking importance of environmental sanitation, by option type (1 = not important, 5 = very important).......................................................................................................... 151 Table G 1. Places visited (% respondents) and enjoyment of stay. .................................................... 152 Table G 2. General sanitary experience (score: 5 = very good, 1 = very poor). .................................. 152 Table G 3. Sanitary experience in relation to toilets and hand washing (score: 5 = very good, 1 = very poor).................................................................................................................... 153 Table G 4. What factors were most concerning? (% respondents citing the reason, maximum 3 responses per respondent).......................................................................................... 153 Table G 5. Health issues.................................................................................................................. 153 Table G 6. Intention to return to Indonesia. ....................................................................................... 153 Table G 7. Reasons not to return to Indonesia................................................................................. 153 Table H 1. Rating of environmental sanitation conditions in the location of the business survey .............................................................................. 154 interview (score: 1 = best; 5 = worst). Table H 2. Importance of environmental sanitation conditions for locating the company (score: 1 = unimportant; 5 = important)..................................................................................... 154 Table I 1. Lamongan average cost per household for different sanitation and hygiene options, using full (economic) cost (US$, 2009)............................................................... 155 Table I 2. Tangerang average cost per household for different sanitation and hygiene options, using full (economic) cost (US$, 2009)............................................................................ 156 Table I 3. Banjarmasin average cost per household for different sanitation and hygiene options, using full (economic) cost (US$, 2009)............................................................... 157 Table I 4. Malang average cost per household for different sanitation and hygiene options, using full (economic) cost (US$, 2009)............................................................................ 158 Table I 5. Payakumbuh average cost per household for different sanitation and hygiene options, using full (economic) cost (US$, 2009)............................................................... 159 xxxiv Economic Assessment of Sanitation Interventions Table I 6. Summary of average cost per household in rural areas for different sanitation and hygiene options, using full (economic) cost (US$, 2009).................................................. 160 Table I 7. Summary of average cost per household in urban areas for different sanitation and hygiene options, using full (economic) cost (US$, 2009).................................................. 161 Table J 1. Lamongan financial versus non-financial costs, in US$. ................................................... 162 Table J 2. Tangerang financial versus non-financial costs, in US$.................................................... 162 Table J 3. Banjarmasin financial versus non-financial costs, in US$................................................. 162 Table J 4. Malang financial versus non-financial costs, in US$......................................................... 163 Table J 5. Payakumbuh financial versus non-financial costs, in US$................................................ 163 Table K 1. Proportion of rural households selecting different sanitation options, by asset quintile..... 164 Table K 2. Proportion of urban households selecting different sanitation options, by asset quintile... 164 .................................. 165 Table L 1. Incremental costs of moving up the sanitation ladder (US$, 2009). Table M 1. Household choices and other interventions..................................................................... 166 Table M 2. Financing from household and project sources............................................................... 166 Table M 3. Appropriate technology................................................................................................... 166 Table M 4. Actual program performance in relation to key selected indicators for program effectiveness................................................................................................................... 167 Table M 5. Selected key indicators for program effectiveness........................................................... 168 Annex N. Steps of the field survey implementation......................................................................... 169 www.wsp.org xxxv Selected Development Indicators Variables Indonesia Population Total population (millions, 2008) 227.78 million Rural population (%) 51.7 % Urban population (%) 48.3 % Annual population growth (%) (2005-2010) 1.27 % Under 5 population (% of total) (2007) 10.8 % Under 5 mortality rate (deaths per 1,000) (2003-2007), 44.0 IDHS Female population (% of total) (2005) 49.7 % Population below poverty line (%) (2006) 17.75 % Economic Currency name Indonesian Rupiah (IDR) Year of cost data presented 2009 Currency exchange with US$ (2009 average) 10,387 GDP per capita (US$) (2009) US$ 2,349 GDP per capita in International $, adjusted for I$ 4,205 purchasing power Sanitation Improved total (%) (2008) 52 % Improved rural (%) (2008) 36 % Improved urban (%) (2008) 67 % Sewerage connection (national, 2008) (%) 2% Open defecation (%) (2008) 26% Sources: http://www.datastatistik-indonesia.com and World Bank Development Data I. Introduction 1.1 BACKGROUND Sanitation is receiving increasing attention from all levels ment and the substantial State budget deficits. The annual of government in Indonesia, after being a largely forgotten budget allocations for sanitation remains insubstantial at issue in the past 15 years following Asian financial crisis of 0.03% of national government spending in recent years2. 1997-98 with its serious deleterious effect on the State bud- Since 2010, a specific budget for sanitation exists (as op- get. Recently the Government of Indonesia has made con- posed to be subsumed into water supply). Figure 1 shows siderable efforts to mobilize additional resources in order the increasing State budget. to finance the country’s needs for infrastructure projects. However, investment in sanitation remains less politically At the national level, there exists a cross-sectoral task team and financially attractive than sectors such as energy and called Sanitation Technical Team (SanTT/TTPS), which transport, due to the tight monetary policy of the Govern- was established in 2008 to promote the development of the FIGURE 1: THE STATE BUDGET (APBN) DEVELOPMENT IN 1999 VERSUS THE LAST 4 YEARS3 1999 2007 2008 2009 2010 0 20 40 60 80 100 120 state expenditures US$ billion 2 Financial Working Note, Urban Sanitation Development Program (USDP), 2009 and 2010. 3 Ministry of Finance, Fiscal Policy Agency (Badan Kebijakan Fiskal), http://www.fiskal.depkeu.go.id www.wsp.org 1 Economic Assessment of Sanitation Interventions in Indonesia | Introduction national sanitation sector. The TTPS consists of all govern- The Indonesian Demographic and Health Survey (DHS) ment ministries involved in water and sanitation: National which was also utilized by the JMP to generate national Development Planning Agency (BAPPENAS), Ministry of coverage figures, has also presented different coverage fig- Public Works (MPW), Ministry of Health (MoH), Minis- ures. The survey, conducted in 2007, reported that 57% of try of Home Affairs (MoHA), Ministry of Finance (MoF), all households have a private toilet, 10% of the households Ministry of Environmental Affairs (MEA) and the Ministry use shared facilities, and the remaining 33% do not have of Industry (MoI). The team and its stakeholders, which a toilet. Hence, this amounts to a proportion of persons includes the Sanitation Donor Group (SDG), have already with access to basic of sanitation — in this case private and delivered many sanitation-related initiatives both at nation- shared toilets — to 67%, which is only a relatively small al as well as local levels. This is part of the government’s ef- difference from SUSENAS result. According to DHS, the forts to increase the access of improved sanitation facilities urban-rural differences of having a private toilet are quite according to the Millennium Development Goal (MDG) significant: 75% of urban households compared to only target for water supply and sanitation. 43% in rural areas enjoy the privilege of a private latrine. The JMP coverage figures of national sanitation coverage According to the MDG declaration, Indonesia has commit- for 1990 and 2008 are depicted in the Table 1. ted to achieve 65.5% coverage of access to improved sanita- tion by the year 2015. The WHO/UNICEF Joint Monitor- In line with cultural and economic diversity throughout ing Programme (JMP), which is responsible for monitoring the country, the sanitation coverage varied considerably be- the water and sanitation target, defines improved sanitation tween the 33 provinces that make up Indonesia. Figure 2 as access to own private toilet facility with excreta isolated shows sanitation coverage by province according to SUSE- with water seal or slab. In the report ‘Results of National NAS 2007. Household ownership of an improved latrine Basic Health Research’ (RISKESDA), the National So- varies from 25% to 80%, while in several provinces rates of cio-Economic Survey (SUSENAS) revealed in 2007 that open defecation remain above 40%. 58.9% households have their own toilets (73.2% in urban areas and 49.9% in rural areas) and 12.1% of households However, there has not been any clear indicator with re- use shared toilets (14.3% of urban areas and 10.7% in ru- gards to the reason behind variations among provinces. For ral areas). Therefore, from the SUSENAS survey, sanitation instance, the numbers and percentage of poor people in ur- access needs to increase by more than 7 percentage points ban area by province does not give any positive correlations nationally to achieve the MDG target. Using the JMP anal- with the coverage of “Private Toilet� and “No Toilet.� How- yses of 2010, which apply different criteria for what is an ever, Nusa Tenggara Barat Province with the highest per- improved latrine, access to improved sanitation stands at centage of poor people in the urban area (28.84%) has the 52% in 2008 (67% in urban areas and 36% in rural areas), highest “No Toilet� and the second lowest “Private Toilet� which is below the SUSENAS results, and more than 13% coverage. Figure 3 shows the variation of toilet ownership from the target. by households in urban and rural areas. TABLE 1: SANITATION COVERAGE IN INDONESIA – 1990 VERSUS LATEST YEAR (2008) Rural (%) Urban (%) Total (%) Coverage type 1990 2008 1990 2008 1990 2008 Improved 22 36 58 67 33 52 Unimproved 78 64 42 33 67 48 Shared 7 11 8 9 7 10 Unimproved facility 23 17 16 8 21 12 Open defecation 48 36 18 16 39 26 Source: WHO/UNICEF Joint Monitoring Programme for Water Supply & Sanitation, March 2010 2 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Introduction FIGURE 2: SUB-NATIONAL SANITATION COVERAGE (SUSENAS 2007) Riau Kepulauan Riau Kalimantan Timur DKI Jakarta Sumatera Utara Sumatera Selatan DI Yogyakarta Lampung Sulawesi Utara Jambi Jawa Barat Nusa Tenggara Timur Bangka Belitung Bengkulu Bali Kalimantan Selatan Jawa Tengah Sulawesi Selatan Kalimantan Barat Sulawesi Tenggara Jawa Timur Banten Nanggro Aceh Darussalam Kalimantan Tengah Sumatera Barat Papua Maluku Sulawesi Tengah Papua Barat Sulawesi Barat Maluku Utara Nusa Tenggara Barat Gorontalo 0 20 40 60 80 100 % sanitation coverage private toilet shared toilet community toilet no toilet www.wsp.org 3 Economic Assessment of Sanitation Interventions in Indonesia | Introduction FIGURE 3: VARIATIONS IN SANITATION COVERAGE BY RURAL/URBAN (SUSENAS 2007) 73% 14% urban 3% 9% 50% 11% rural 5% 35% 0 10 20 30 40 50 60 70 80 private toilet shared toilet community toilet no toilet 1.2 ONGOING SANITATION PROGRAMS 5% of total urban population, or 5 million people in In order to increase sanitation coverage and to improve eq- 16 cities, and constructing SANIMAS (Community uity in its distribution, the SanTT/TTPS encourages sani- Based Sanitation) facilities in each city. The priority tation development in urban and rural areas to become a is given to 330 selected cities/districts. national development priority. In line with this, an initia- • Implementing 3R (Reduce, Reuse and Recycle) tive ‘Acceleration of Settlement Sanitation Development practices to reduce waste by 20% and improving Program,’ also known as program Percepatan Pembangunan waste management service in 240 priority cities. Sanitasi Permukiman (ASSDP/PPSP), paved the way for the National Roadmap to Sanitation Development 2010- The prioritized locations of the ASSDP/PPSP Program are 2014 and set the sanitation development targets within the as follows: following period4: • Megapolitan, metropolitan, big and medium cities • ’Freedom from open and careless defecation’ in ur- • Provincial capitals ban and rural areas in accordance with the Sanitation • Cities of autonomous status Strategic Plans of each related department/agency at • Towns in the territories of districts/cities with vul- national level. nerable sanitation conditions • At-source reduction of waste generation and more environmentally-friendly waste management by ap- Having such an ambitious sanitation development agenda, plying sanitary landfill or controlled landfill systems the SanTT/TTPS and its partners need to cooperate with at the final disposal site5, and using safer technology. all relevant stakeholders such as government bodies, the na- • Reduction of flooding in a number of cities/urban tional and local parliaments, NGOs, and the private sec- areas. tor for joint support and commitment. They need to be able to obtain and utilize robust data and information on The roadmap reflects the Government’s commitment to the benefits of sanitation improvement for the public. By seriously put sanitation within the mainstream of national competing for budget allocations for operational spending development priorities. Currently, preparations are under- and infrastructure investment; the sanitation sector needs way for a Presidential Instruction (Inpres) that legally binds to come up with economic arguments to justify increased local governments to achieve targets. spending. Therefore, more comprehensive and robust cost- benefit analyses are needed, using reliable quantitative and These targets shall be achieved by means of: qualitative techniques, in order to enhance the possibilities • Increased service of off-site sewerage networks by of securing adequate budget allocation. 4 Roadmap to Sanitation Development 2010-2014, ISSDP Phase 2, 2009 5 Final disposal site or Tempat Pembuangan Akhir (TPA) has been changed to Final Processing Site according to Government Law on Solid Waste No. 18/2008. 4 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Introduction Results from ESI Phase 1, which described the economic • The specific study use: the expected contribution of losses that result from poor sanitation, have become an the study to various specific issues such as providing important reference for sanitation stakeholders including advocacy material, comparing efficiency of sanita- all levels of government in Indonesia. Extensively reported tion options to support optimal selection of sanita- by the media, the estimated economic losses of inadequate tion options, and proposing measures to maximize sanitation and hygiene – and the implied benefits of im- the benefits of sanitation programs. proving sanitation and hygiene – have successfully raised the profile of sanitation in government affairs. Chapter 3 presents the study methods that describe the whole flow of data collected (inputs) and eventual cost-ben- The Phase 2 of ESI presents the results of a detailed cost- efit assessments (outputs). It also covers the methodologies benefit analysis (CBA) of sanitation interventions. It pro- of technical sanitation interventions evaluation, costs and vides a more comprehensive analysis at household level benefits evaluation, field studies, program approach analy- than has ever been attempted in Indonesia, and with its sis, and national studies. The chapter describes field sites large amount of quantitative and qualitative evidence, it and how they were selected, the cost estimation methodol- strengthens arguments to prioritize sanitation in the na- ogy, benefit estimation methodology, data sources and data tional development agenda. As mentioned above, sanita- analysis. The national studies consist of tourist and business tion development in Indonesia falls mainly under local gov- surveys. ernments’ responsibility. The sanitation situation in many cities and districts, particularly the domestic wastewater Chapter 4 describes benefits of improved sanitation and sub-sector, are still below minimum service level standards hygiene at local level. Three main benefit value drivers at – especially in slums and densely populated areas. Nonethe- household level are analyzed i.e. health aspects, water as- less, there has not been any adequate attempt to position pects (sources and access) and access time to sanitation sanitation as one of the development program mainstreams facilities. In addition, there are also analysis of intangible of local stakeholders. In fact, sanitation is being neglected sanitation preferences and external environment issues. due to the perception that it lacks political leverage. Al- though the study results do not represent the country-wide Chapter 5 describes the national benefits of improved sani- sanitation situation, they give indicative values on the ben- tation and hygiene. It covers the effects of improved sani- efits of sanitation improvement as a whole. The study is tation and hygiene to tourism visits, business and foreign expected to enhance political support for sanitation devel- investment, sanitation markets, health indicators and water opment, particularly for the PPSP Program in Indonesia. quality. 1.3 REPORT OUTLINE Chapter 6 presents the costs of improved sanitation and The report is structured as follows: hygiene. It describes the cost summaries of specific sani- tation options at each study site, financing sanitation and Chapter 2 describes the study aims that cover the following hygiene, sanitation option by wealth quintile and costs of issues: moving up the ladder. • The overall study purpose: the expected contribu- tion of the study from a broader point of view such Chapter 7 analyzes the performance of different sanitation as promoting evidence-based decision making using programs. It covers more specific issues on the program improved methodologies and data sets, and the de- design – i.e. how the sanitation technologies are actually bate on approaches to sanitation financing and ways delivered. It selects and compares different key indicators of of scaling up sanitation improvements to meet na- program performance. tional targets. www.wsp.org 5 Economic Assessment of Sanitation Interventions in Indonesia | Introduction Chapter 8 presents the cost-benefit analysis of sanitation improvement and hygiene practices, covering both quanti- tative and qualitative impacts of improved sanitation. Chapter 9 discusses the study results and the main inter- pretations and messages. Chapter 10 presents recommendations to decision makers based on the study findings in Indonesia. Sanitation devel- opment has been moving up the agenda in Indonesia and in this regard the ESI Phase 2 results are expected to deliver valuable support for decision makers to allocate addition- al resources for the sanitation sector and help them select more efficient and sustainable sanitation services. 6 Economic Assessment of Sanitation Interventions II. Study Aims As mentioned in the previous chapter, sanitation has been The evidence is presented in simplified form and distilled attracting considerable attention from governments in In- into key recommendations to increase uptake by a range of donesia. The TTPS has secured a position for sanitation sanitation financiers and implementers, including various in the mainstream national development priorities, through levels of government and sanitation sector partners, as well the PPSP. However, despite being a key development prior- as households and the private sector. ity, the sanitation agenda has yet to win support from all its stakeholders. Standard outputs of cost-benefit analysis include benefit- cost ratios, internal rate of return, payback period, and net The Economics of Sanitation Initiative (ESI) Phase 2 study benefits (see Glossary). Cost-effectiveness measures relevant seizes on this momentum and has been designed to meet to health impacts will provide information on the costs of the TTPS requirements for robust evidence on the benefits achieving health improvements. In addition, intangible of sanitation improvement. Thus, it will help the sanitation aspects of sanitation not quantified in monetary units are development team to design matching interventions that highlighted as being crucial to the optimal choice of sanita- are economically viable. tion interventions. 2.1 OVERALL PURPOSE This study also contributes to the debate on approaches to The purpose of the Economics of Sanitation Initiative (ESI) sanitation financing and ways of scaling up sanitation im- is to promote evidence-based decision-making using im- provements to meet national targets. proved methodologies and data sets, thus increasing the effectiveness and sustainability of public and private sanita- 2.3 SPECIFIC STUDY USES tion spending. By providing hard evidence on the costs and benefits of im- proved sanitation, the study: Better decision-making techniques and economic evidence • Provides advocacy material for increased spending themselves are also expected to stimulate additional spend- on sanitation and generates the attention of sector ing on sanitation to meet and surpass national coverage tar- stakeholders to efficient implementation and scaling gets. up of improved sanitation. • Enables the inclusion of efficiency criteria in the 2.2 STUDY AIMS selection of sanitation options in government and The aim of this current study is to generate robust evidence donor strategic planning documents, and in specific on the costs and benefits of sanitation improvements in dif- sanitation projects and programs. ferent programmatic and geographic contexts in Indonesia, • Brings greater focus on appropriate technology leading to selection of the most efficient and sustainable through increased understanding of the marginal sanitation interventions and programs. Basic hygiene as- costs and benefits of moving up the ‘sanitation lad- pects are also included, insofar as they affect health out- der’ in different contexts. comes. • Provides the empirical basis for improved estimates of the total costs and benefits of meeting sanitation www.wsp.org 7 Economic Assessment of Sanitation Interventions in Indonesia | Study Aims targets (e.g. MDG targets), and contributes to na- vention and what the returns are. Several different efficiency tional strategic plans for meeting and surpassing the measures allow examination of the question from different MDG targets. angles, such as number of times by which benefits exceed • Contributes to the design of feasible financing op- costs, the annual equivalent returns, and the time to repay tions through identification of the beneficiaries as costs and start generating net benefits (see box). Also, as well as cost incidence of sanitation programs. sanitation and hygiene improvement also falls within the health domain, economic arguments can be made for in- 2.4 RESEARCH QUESTIONS vestment in sanitation and hygiene interventions with the In order to fulfill the overall purpose of the study, research health budget, if the health return per unit cost invested is questions were defined that have direct bearing on sanita- competitive compared with other uses of the same health tion policies and decisions. Separate questions were defined budget. for overall efficiency (i.e. costs versus benefits), and for costs and benefits6. As well as overall efficiency questions, it is useful from deci- sion-making, planning and advocacy perspectives to better The major concern in economic evaluation is to understand understand the nature and timing of costs and benefits, as economic and/or financial efficiency, in terms of return on well as how non-economic aspects affect the implementa- investment and recurrent expenditure. Hence the focus of tion of sanitation interventions, hence affecting their even- economic evaluation is on what it costs to deliver an inter- tual efficiency (see boxes below). Furthermore, given that BOX 1. RESEARCH QUESTIONS ON SANITATION EFFICIENCY i. Are the benefits greater than the costs of sanitation interventions? By what proportion do benefits exceed costs (benefit-cost ratio – BCR)? ii. What is the annual internal rate of return (IRR)? How does the IRR compare to national or international standards for investments of public and private funds? How does the IRR compare to other non- sanitation development interventions? iii. How long does it take for a household to recover its initial investment costs, at different levels of cost sharing (payback period – PBP)? iv. What is the net gain of each sanitation intervention (net present value – NPV)? What is the potential interest in sanitation as a business opportunity? v. What is the cost of achieving standard health gains such as averted death, cases and disability-adjusted life-year (DALY)? vi. How does economic performance vary across sanitation options, program approaches, locations, and countries? What factors explain performance? BOX 2. RESEARCH QUESTIONS ON SANITATION COSTS i. What is the range of costs for each technology option in different field settings? What factors determine cost levels (e.g. quality, duration of hardware and software services)? ii. What proportion of costs are capital, program and recurrent costs, for different interventions? What are necessary maintenance and repair interventions, and costs, to extend the life of hardware and increase sustainability? iii. What proportion of total (economic) cost is financial in nature? How are financial and economic costs financed in each field location? iv. What are the incremental costs of moving from one sanitation improvement to another - i.e. up the sanitation ladder – for specified populations to meet sanitation targets? 6 ‘Costs’ and ‘benefits’ refer simultaneously to financial and economic costs, unless otherwise specified. 8 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Study Aims several impacts of improved sanitation cannot easily be sanitation intervention may not be received due to factors quantified in monetary terms, this study attempts to give in the field that affect uptake of and compliance with the greater emphasis to these impacts in the overall cost-bene- intervention. These factors need to be better understood to fit assessment. The following boxes list a range of research advise future program design. Also, the ESI study touches questions considered by this study – note, however, that not on many financing issues, related to who is paying for the all questions could be addressed, or fully addressed in this interventions and who is benefiting from the interventions study (e.g. in the ‘Benefits’ box, questions iv through to viii (and thus who may be willing to pay). Given that scale-up are largely unanswered by this study). cannot be achieved with full subsidization of sanitation in- terventions by government or other sector partners, it will In addition, other research questions are crucial to appro- be key to better understand how public money and subsi- priate interpretation and use of information on sanitation dies can be used to leverage further investments from the costs and benefits. Most importantly, the full benefits of a private sector and from households themselves. BOX 3. RESEARCH QUESTIONS ON SANITATION BENEFITS i. What local evidence exists for the links between sanitation and the following impacts: health impact, water quality and water users, land use, time use, welfare, tourism, and the business environment (including foreign direct investment)? ii. What is the extent of the financial and economic benefits related to health expenditure, health-related productivity and premature mortality; household water uses; time savings; property value; and other welfare impacts? iii. What proportion of the benefits are pecuniary benefits (financial gains) and what proportion are non- pecuniary benefits? iv. What proportion of each benefit accrues to households that invest in sanitation and what proportion is external to the investor? v. What is the actual or likely willingness to pay of households and other agencies for improved sanitation? What is up-front versus annual recurrent willingness to pay? vi. How do benefits accrue or vary over time? vii. How is improved sanitation – and the related costs and benefits – tangibly linked with poverty reduction? What is the potential impact on national income and economic growth? viii. What is the overall household and community demand (expressed and latent demand) for improved sanitation? BOX 4. OTHER RESEARCH QUESTIONS i. How do program design and program implementation affect costs and benefits? In practice, (how) can sanitation programs be delivered more efficiently – i.e. reducing costs without reducing benefits? ii. How to leverage grants to incentivize investments in sanitation? iii. What factors determine program performance? What are the key factors of success and constraint, including contextual, institutional, financial, social and technical? iv. Which program approaches are best suited to which technical options? v. What is the acceptability of different sanitation options and program approaches? vi. What other issues determine intervention choice and program design in relation to local constraints: energy use, water use, polluting substance discharge, and option robustness/durability/maintenance requirements? vii. Based on research findings, what other key issues enter into sanitation option decisions? www.wsp.org 9 III. Methods The study methodology in Indonesia follows a standard accrue outside the sanitation improvement site are exclud- methodology developed at regional level reflecting estab- ed. Hence Output 3, overall cost-benefit assessment, takes lished cost-benefit techniques, which has been adapted to these into account. sanitation interventions and the Indonesia field study based on specific research needs and opportunities. As shown in 3.1 TECHNICAL SANITATION INTERVENTIONS Figure 4 the study consists of a field component that leads EVALUATED to quantitative cost-benefit estimates as well as in-depth The type of sanitation evaluated in this study is household study of qualitative aspects of sanitation. Two types of human excreta management. Interventions to improve field-level cost-benefit performance are presented: Output household human excreta management focus on both on- 1 reflects ideal performance assuming the intervention is site and off-site sanitation options. Indeed one of the key delivered, maintained and used appropriately, and Output aims of this study, where possible, is to compare the relative 2 reflects actual performance based on observed levels of efficiency of different sanitation technologies. Basic hygiene intervention effectiveness in the field sites. However, both aspects of sanitation are also included, insofar as they affect these analyses are partial, given that intangible benefits of health outcomes and intangible aspects. sanitation improvements as well as other benefits that may FIGURE 4: FLOW OF DATA COLLECTED (INPUTS) AND EVENTUAL COST-BENEFIT ASSESSMENTS (OUTPUTS) CHAPTER 4 Field-Level CHAPTER 8 Input 1: Monetary Bene�t Estimates Ideal Cost-Bene�t Output 1: Field Performance CHAPTER 8 Actual CHAPTER 6 Output 2: Cost-Bene�t CHAPTER 7 Field Performance Field-Level Field-Level Program Input 4: Input 2: Monetary Cost Approach Analysis Estimates CHAPTER 4 Intangible (Non-Monetized) CHAPTER 8 Input 3: Field-Level Costs and Bene�ts Overall Output 3: Cost-Bene�t CHAPTER 5 Assessment National-Level Input 5: Costs and Bene�ts 10 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Methods As well as human excreta management, interventions that physical/climatic environments such as soil type or water jointly address human waste and domestic wastewater man- scarcity). agement (especially in urban areas) are considered. While the study proposes conducting analyses of the costs To qualify as an economic evaluation study, cost-benefit and benefits of achieving the MDG targets and beyond, analysis compares at least two intervention options. It usu- sanitation options are not be restricted by ‘unimproved’ and ally includes comparison with the baseline of ‘do nothing’. ‘improved’ sanitation as defined by the WHO/UNICEF However, comparing two sanitation options will rarely be Joint Monitoring Programme (JMP). For example, some enough: ideally the analysis should compare all sanitation households will be interested in upgrading from one type options that are feasible for each setting – in terms of af- of improved sanitation to another type, such as from VIP to fordability, technical feasibility, and cultural acceptability – septic tank, or from septic tank to sewerage. Other house- so that a clear policy recommendation can be made based holds are faced with a decision whether to replace a facility on efficiency of a range of sanitation options, among other that has reached the end of its useful life. And under some factors. program approaches (e.g. Community-Led Total Sanitation or CLTS), households are encouraged to move up the lad- Technical sanitation options include all those interventions der, even if it does not imply a full move to JMP-defined that move households up the sanitation ladder and thus ‘improved’ sanitation, such as to the use of shared or unim- bring benefits. Figure 5 presents a generalized sanitation proved private latrines. ladder. The upward slope of the ladder reflects the assump- tion of greater benefits as you climb the ladder, but (gener- Using the ladder as a starting point, Table 2 shows differ- ally) with higher costs. The progression shown in Figure ent types of intervention (sub-categories) within the more 5 is not necessarily true in all settings and hence needs to broadly defined sanitation options. This classification pro- be adjusted to setting-specific features (e.g. rural or urban, vides an overview to allow a framework for interpretation of FIGURE 5: REPRESENTATION OF THE SANITATION TECHNOLOGY “LADDER� Costs per household Pour or mechanical flush with sewerage Pour or mechanical flush with septic tank Pour or mechanical flush latrine with pit Improved dry pit latrine with appropriate excreta management or reuse Improved public or shared latrine Unimproved pit latrine Water Quality Intangibles Public or unimproved shared latrine Health Status Open defecation Access Time (to land or water) Bene�ts per household www.wsp.org 11 Economic Assessment of Sanitation Interventions in Indonesia | Methods the specific options evaluated in the field settings (shown in 3.2 COSTS AND BENEFITS EVALUATED 3.2.2), given that option sub-categories may have different Sanitation costs are the denominator in the calculations to associated costs and benefits. estimate the cost-benefit and cost-effectiveness ratios, and thus crucial to the evaluation of sanitation option efficiency. The field studies revealed that the sanitation ladders typi- Summary cost measures include the total annual and life- cally found in the study sites can be described by a simpler cycle costs (see Glossary), cost per household and cost per set of options: capita. For financing and planning purposes, this study dis- 1) Open defecation aggregates costs for each sanitation option by capital, pro- 2) Shared/community/public latrine gram and recurrent costs; by financial and economic costs; 3) Community toilet with decentralized wastewater by financier; and by wealth quintile. The incremental costs treatment of moving up the sanitation ladder are assessed. 4) Private dry pit latrine 5) Private wet pit latrine To maximize the usefulness of economic analysis for diverse 6) Private toilet with septic tank audiences, benefits of improved sanitation and hygiene are 7) Private toilet with sewerage and off-site treatment divided into three categories. 1. Household direct benefits: these are incurred by the Open defecation is the lowest point on the sanitation lad- households that are making the sanitation improve- der, against which the relative benefits of the other sanita- ment. These actual or perceived benefits will drive tion options are measured. the decision by the household to invest in sanitation, TABLE 2: CLASSIFICATION OF SANITATION OPTIONS IN INDONESIA Categories Sub categories 0 Open defecation 0.1 In house - wrap and throw 0.2 On plot 0.3 On land outside plot 0.4 In house-excreta disposed to fish pond 0.5 In house-excreta disposed to canals/water body 1 Shared community/public latrine unimproved 1.1. No slabs 1.2 No superstructures 1.3 Inadequate sub structures 1.4 More than one of above 2 Private latrine, unimproved 2.1 No slabs 2.2 No superstructures 2.3 Inadequate sub structures 2.4 More than one of above 3 Community/public toilet, improved 3.1 Any of the technology option 5 - 6 4 Shared toilet, improved 4.1 Any of the technology option 5 - 6 5 Private dry latrine, improved 5.1 Simple dry pit latrine 5.2 Ventilated Improved Pit latrine 6 Private wet latrine, improved 6.1 Pour flush toilet - non water tight pit 6.2 Pour flush toilet - septic tank 6.3 Pour flush toilet - communal sewerage1 6.4 Pour flush toilet - centralized sewerage1 1 Can be simplified or normal sewerage 12 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Methods and will also guide the type of sanitation improve- in the country generally (e.g. investment climate). ment chosen. These benefits may include: health im- As well as improved management of human excreta, pacts related to household sanitation and hygiene, other contributors to environmental improvement local water resource impacts, access time, intangible such as solid waste management and wastewater impacts, house prices, and the value of human ex- treatment need to be considered. creta reuse. 2. Local level external benefits: these are potentially Therefore, the results of economic analysis in this study incurred by all households living in the environ- distinguish between impacts in the local community where ment where households improve their sanitation. the sanitation and hygiene improvements take place, and However, some of these benefits may not be sub- national level impacts. stantial until a critical mass of households has im- proved their sanitation. These benefits may include: Table 3, shows the impacts included in the current study, health impacts related to environmental exposure to distinguishing between those impacts that are expressed in pathogens (e.g. water sources, open defecation prac- monetary units and those that are expressed in non-mone- tices on land), aesthetics of environmental quality, tary units. and usability of local water sources for productive activities. Given the challenges in designing studies While the focus of this study is on household sanitation, to distinguish these benefits from household direct the importance of institutional sanitation also needs to be benefits (in 1.) this study groups local level external highlighted. For example, improved school sanitation af- benefits together with household direct benefits. fects decisions for children (especially girls) to start or stay 3. Wider scale external benefits: these result from im- in school until end of secondary level, and workplace sani- proved sanitation at the macro level. Benefits may tation affects decisions of the workforce (especially wom- include: water quality for productive uses, tourism, en) to take or continue work with a particular employer. local business impact, and foreign direct investment. These impacts are incremental over and above the first three They can be linked to coverage either in specific ar- above. However, these impacts are outside the scope of this eas or zones (e.g. tourist area or industrial zone), or present study. TABLE 3: BENEFITS OF IMPROVED SANITATION INCLUDED IN THIS STUDY Socio-economic impacts evaluated in Level Impact Monetary terms ($ values) Non-monetary terms (non-$) Health • Health care costs • Disease and mortality rates • Health-related productivity • Quality of life impacts • Premature death • Gender impacts Domestic water • Water sourcing • Link poor sanitation, water quality & water • Household treatment source and water treatment practices Local benefits • Use for income generating activities Other welfare • Time use • Convenience, comfort, privacy, status, security, gender Environmental • Land use changes quality • Aesthetics of household and community environment Tourism • Sanitation-tourism link: potential impact of poor sanitation on tourist numbers National Business • Sanitation-business link: potential impact of benefits poor sanitation on local business and FDI Sanitation markets • Potential national value of sanitation services www.wsp.org 13 Economic Assessment of Sanitation Interventions in Indonesia | Methods The next sections describe the study methods for the three to gather the views, preferences and conditions of house- major study components: the field level cost-benefit assess- holds that do not currently have improved private latrines. ment (3.3), the assessment of program effectiveness (3.4) and national level impacts (3.5). Section 3.6 summarizes The main criterion for site selection applied in this study the main cost-benefit presentations. is that there has been a sanitation project or program im- plemented in the past five years at a scale that allows the 3.3 FIELD STUDIES minimum sample size of 30 households to be collected per 3.3.1 FIELD SITE SELECTION AND DESCRIPTION sanitation option per site. Once this list of projects and pro- According to good economic analysis practice, the inter- grams was established, a further set of criteria was applied ventions evaluated should reflect the options available to to reduce the shortlist to five locations or projects (within households, communities and policy makers. Therefore, the the available budget). These criteria are (i) logistical feasi- selected field sites should offer a range of sanitation options bility of the research; (ii) potential for collaboration with typically available in Indonesia, and include both urban projects/programs; (iii) collectively representing Indonesia’s and rural sites. Five sites were selected in Indonesia, and in heterogeneity of geophysical, climatic, demographic and each site two sub-sites were selected: one in an area where socio-economic characteristics. Table A9 shows the long list many households have received sanitation improvement of projects, and how they performed in relation to these (intervention) and the other (the control) in an area where three criteria. The final five sites selected are presented be- few households have benefitted from sanitation projects. low. Table 4 shows the sanitation coverage in the selected The purpose of having a comparator, or control group, was field sites compared with national coverage. TABLE 4: BACKGROUND INFORMATION ON SELECTED FIELD SITES Variable Lamongan District Tangerang District Banjarmasin City Malang City Payakumbuh City Rural/urban Rural Rural Urban Urban Urban Households 338,534 (2007) 828,645 (2006) 154,527 (2006) 250,085 (2007) 24,725 (2007) (year of data) Population (year 1,439,886 (2008) 3,585,256 (2008) 602,725 (2006) 816,444 (2007) 104,969 (2007) of data) Av. household 4.25 4.32 3.90 3.26 4.24 size Covering Area i) 79 villages 3 villages 14 villages Sanitation % 45.9% 57.8% 44.1% 69.7% 49.2% improved ii) 26.3 % 24% 17.9% 26.3% 8.4% Hygiene % hand (East Java Province) (Banten Province) (South Kalimantan (East Java Province) (West Sumatera washing iii) Province) Province) PROJECT INFORMATION Start date Year 2001 Year 2008 Year 2000 Year 1986 Year 2007 Interventions WSLIC 2 SANIMAS Sewerage system/off Community-based CLTS site system sewer system (CBSS)/SANIMAS Target 33,286 HH 493 HH (2008) 25,364 HH (until 1,105 HH 9732 HH households 2010) (status Nov 2009) References: (1) District Health Office (Dinas Kesehatan) of each district, and The Sanitation White Book of Banjarmasin and Payakumbuh. (2) Community Based Sewer system in Malang, WSP, March 2000 (Field Note). (3) Laporan Nasional Riskesda 2007 (National Report of Basic Health Research, 2007) Notes: i) Villages received sanitation program interventions as mentioned ii) Statistics Bureau: sanitation improved is percentage of septic tank as the feces final disposal (Percik Magazine, March 2008) iii) Hygiene hand washing means the appropriate hand washing with soap before eating, before preparing food, after defecating, and after cleaning child/ babies feces, after touching animal. iv) Dinkes (Health Office), interview 14 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Methods Following is a brief description of the five districts and cities to clean, particularly during the dry season. Other respon- where the study sites were located. dents defecated in simple pit latrines. LAMONGAN DISTRICT The ESI 2 study of the WSLIC 2 intervention was con- Lamongan district is located in the northern part of the ducted in Turi subdistrict, which comprises four villages. province of East Java. The district borders with Java Sea A total of 300 households were interviewed for the survey. in the north and stretches to a mountainous volcanic area inland. This district has two seasons: the dry season lasts TANGERANG DISTRICT from May to October, and the rainy season from Novem- Tangerang is located about 30 km to the south of Jakarta. Lo- ber to April. Temperatures are tropical year round, reach- cated in Banten Province, to the west of Jakarta, Tangerang ing around 32oC in the dry season. The average rainfall is District borders the Java Sea to the north. Tangerang is dry around 2,670mm/year, falling mainly during the wet sea- from April to September, and wet from October to March. son. Passing through Lamongan district is Bengawan Solo, Temperatures range from 23oC to 33oC, and average an- one of Java’s largest rivers, which swells annually during nual rainfall is around 1,475 mm. Cisadane River passes rainy season. Its waters inundate rice fields and houses for through this district, and formerly served as the main water days or even weeks, causing the area to be prone to water- supply for agricultural irrigation. However, due to massive borne diseases. industrialization, Cisadane River is now a large wastewater disposal site for both domestic and industrial waste. Lamongan comprises 27 subdistricts, 476 rural villages and 12 urban wards. The 1,813 km2 area is home to 1,439,886 Tangerang District comprises 36 subdistricts, and 328 vil- people (2008)7. Lamongan is a busy hub town, on the lages. The 1,110 km2 district is home to 3,585,256 peo- northern main road and railway that connect Surabaya, the ple8 in 828,645 households, thus the population density main sea port of eastern Indonesia, with Jakarta, the capital is around 3,229 people/km2 (2008). More than 50% of city. In the southern part, agriculture is the main source of Tangerang population works in the industrial sector, and livelihood, with corn as the main crop, as well as vegetables only 3.2% work in the agricultural sector and services. and local fruits. In the northern part, fisheries are the main Tangerang District is a booming industrial area, but poor source of livelihood. housing provision resulting from poor urban settlement planning has led to the growth of slum areas, where sanita- Lamongan District Health Office (2008) noted that the tion is currently a major problem. number of households by type of latrine in the program lo- cation was as follows: simple pit latrine 305 HH, improved In both 2004 and 2007, Tangerang District experienced di- latrine 7,349 HH, pour flush latrine 5,956 HH, and on- arrheal disease outbreaks as a result of poor sanitation. Ac- site septic tank 12,516 HH. cording to Tangerang District Health Office (2008), around 70% of the district’s population – most living on the north Although Lamongan District was a WSLIC program site, coast in subdistricts such as Kresek, Kronjo, Pakuhaji and many people still use hanging toilets over rivers or ponds. Mauk – lacks proper toilet facilities. As at other sites where open defecation is practiced, people defecate in hanging toilets over ponds to feed their fish. In District health data also show that 7.6% of the population some areas, people still defecate in bamboo stands, in fields, uses no latrine facilities, 3.2% simple pit latrines, 4,2% and in rivers. Some people expressed a reluctance to have a wet swan-neck pit latrines, 10.4% latrines over fish ponds, private toilet at home because they were used to defecating 67.4% wet swan-neck latrines with septic tank, and 7.3% in the open. They believe that a toilet in the house makes other latrine facilities. Tangerang district does not have a the house smell unpleasant and requires too much water sewerage system. 7 www.lamongankab.go.id, Monday, 16 March 2009 8 District Health Office Tangerang, 2008 www.wsp.org 15 Economic Assessment of Sanitation Interventions in Indonesia | Methods Many industrial areas in Tangerang were developed with- The city is home to 602,725 people, in 154,527 house- out proper planning. Textile and garment factories, for ex- holds.9 The 72 km2 city comprises five subdistricts, where ample, were not established in planned industrial estates. 46.2% of the population trade for a living, 18.8% work in The district’s industrial areas lack adequate infrastructure, services industry, 10% in construction, 9.1% in industry, including proper sanitation systems. These labor intensive and the remaining 5.3% works in agriculture. industries attract many people from outside the area to settle nearby, which naturally leads to the creation of lo- In Banjarmasin, people who live around the riverbanks cal, small-scale economic enterprises. Most newcomers are (mainly poor communities) habitually use the rivers as low-income earners, and they rent simple rooms without “one-stop shops� for many of their daily activities, such as private toilets in densely populated areas. As the popula- bathing, washing and defecating, and even children’s play- tion grows, the waiting time to use public toilets increases, grounds. The larger rivers are also used for transportation. which triggers open defecation in these areas. Places used The people living in these areas are generally happy with for open defecation include empty plots of land around this situation, believing it to be the norm, and a practical houses, yards, rivers, fields, bushes, bamboo stands, and way of life. The drawbacks they did note included: even the streets. It is not surprising that in 2007 Tangerang • Having to go to the river as early as possible to be the experienced a diarrhea outbreak caused by Vibrio cholerae. first to arrive and get the best spot and cleaner water. • Accidents, such as falling into the river, which can The types of toilet used in these densely populated areas be fatal. include: • Community toilet facilities with pour-flush toilets Sanitation has not been communicated well within the and cemented walls. They have two or three toilets communities. Although subdistrict government workers and bathing rooms with one 2 x 3 x 2 m3 septic tank. have led occasional informal discussions to promote health The facilities were constructed by communities with and hygiene behavior, these events have not been sufficient support from an NGO, including a contribution to- to generate understanding of the importance of sanitation. wards the building materials. • Roofless hanging toilets over rivers and ponds. Users Some people whose houses are connected to the sewerage need to bring a bucket of water with them to cleanse system have had unpleasant experiences, such as: themselves after defecating. • Wastewater flowing back into the house because the • Private toilets with septic tank within a private plot. toilet is positioned lower than the wastewater treat- ment plant. The ESI 2 study of the SANIMAS intervention was car- • Residential areas being inundated with a mixture of ried out in Sarakan, Kayu Agung, Sukasari, and Tanjakan wastewater from the sewerage system and seawater villages in Sepatan and Rajeg subdistricts. A total of 300 whenever there is a tidal flood. households were interviewed for the survey. There is no indication as to whether these unpleasant expe- BANJARMASIN CITY riences have resulted in people’s reluctance to connect their Banjarmasin is the capital city of South Kalimantan Prov- toilets to the sewerage system. Some respondents men- ince. The climate here is tropical, with temperatures rang- tioned that there had been no campaign to build people’s ing from 25oC to 38oC and an average rainfall of 2,628 awareness about the benefits of connecting to the sewerage mm/year. The city is located on a swampy river delta with system. a very low average altitude of 0.16 m above sea level. Tidal flooding is common throughout the city. Banjarmasin is The Banjarmasin Sanitation Whitebook (2007) describes also known as ‘the city of a thousand rivers’ for the many access to sanitation facilities as follows: flush toilet to sewer- rivers that cross the city. age system, 1.9%; flush toilet to septic tank, 26.8%; flush 9 Sanitation Whitebook, Banjarmasin Municipal Government, 2007 16 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Methods toilet to pit latrine, 41.8%; flush toilet to ditch/river, 3.4%; • Many flies around the pit non-flush toilet to river, 8.2%; non-flush toilet to pit la- • Being ashamed when a guest needs to go to the toi- trine, 1.8%; and hanging toilet, 12.6%. let, because the latrine looks very dirty and is smelly The ESI 2 field survey was conducted in Central Banjarma- Some people use pour-flush toilet inside their houses. They sin subdistrict, in Pekapuran Laut and Kelayan Luar villag- are proud of owning their own toilets, which do not have es, where the sanitation intervention is a sewerage system. the unpleasant side-effects of the simple pit latrines. The A total of 300 households were interviewed for the survey. problem comes when there is lack of water during the dry season. MALANG CITY Malang is located in the highlands of East Java province, In 1985, a diarrhea epidemic occurred in the area that led 90 km to the south of Surabaya, the provincial capital. The to the death of several children from poor families. Prior to city has a mild climate with an average temperature of up to this outbreak, local children still defecated in open drains 24oC. Its beautiful scenery and cool weather make Malang right outside their houses. A local volunteer then took an a popular tourist destination in East Java. The hot season initiative to convince the community to adopt more hy- runs from May to August, and the rainy season from Sep- gienic defecation practices. He also initiated the construc- tember to March. Average rainfall is 1,833 mm per year tion of a communal sewerage system to encourage people to (2006). abandon their habit of defecating in open drains and rivers. Nearly two years later the system was in operation, but it Malang comprises five subdistricts (Blimbing, Klojen, Ke- took almost ten years for all members of the community to dungkandang, Sukun and Lowokwaru), 57 urban wards have their toilets connected to the system. and 10 rural villages. Covering an area of 110.6 km2, the city is home to 816,444 people (2007). The main liveli- The ESI 2 field survey was conducted in Kedung Kandang, hoods are small trading, industry, and services. The main Lowowaru, Mergosono, Tlogomas, Arjowinangun and Di- transport routes are the roads and railways that connect noyo subdistricts, where the sanitation intervention is com- Malang with other large cities in East Java. munal sewerage systems. A total of 300 households were interviewed for the survey. Some people living in the city still defecate in open areas such as yards, fields and rivers. On the riverbanks, some use PAYAKUMBUH CITY hanging toilets of cement construction. Like most medi- Payakumbuh city is located in West Sumatera Province. um-sized cities in the hilly areas of Java, Malang has fairly Batang Agam, Batang Lampasi, Batang Sinama rivers from deep river valleys dividing the urban area. Most of the older through the city from west to the east side. Covering an area parts of the city are built on ridge lines, while the newer of 80.3 km2, the city is located on a plain in the highlands parts, especially the low income areas, spread along the river of West Sumatra, at a height of 514 meters above sea level. valleys where land is more available. In general, the riverside Its moderate weather, with an average temperature of 26oC location makes disposal of human waste easier than on the and average rainfall of 2,000 – 2,500 mm/year, is ideal for ridges, but it also more prone to health risks and less envi- crop and vegetable farming. ronmentally friendly. Built in 1970, Payakumbuh comprises seven subdistricts, People here prefer to defecate in hanging toilets for much where 104,969 people (2007) live in 24,725 households. the same reasons as respondents from the other study sites. The population density is 1,305/km2. Most of the city’s inhabitants are small traders or small farmers. Others have simple pit latrines near their houses, which they perceive to be better than open defecation. However, Open defecation such as in yards, ponds and rivers is still they did report unpleasant experiences, such as: widely practiced in Payakumbuh. Some people use hanging • Bad smell during defecation toilets made from wood or bamboo over ponds around their www.wsp.org 17 Economic Assessment of Sanitation Interventions in Indonesia | Methods houses. They prefer to defecate in hanging toilets because: disaggregated, where possible, into hardware and software • it feeds their fishes costs. In Indonesia, physical or hardware development is • the toilet is in the open air so does not smell bad the responsibility of the Ministry of Public Works, while • they do not need to think about emptying septic software development (promotion, education, monitoring) tanks is the responsibility of the Ministry of Health. Some soft- ware costs, such as lobbying, meetings, transport costs, are The Payakumbuh City Sanitation Whitebook describes the not properly documented or recorded, so were not included domestic wastewater management situation as of the end in the cost estimates. Hence, the real program costs may be of 2006, as follows: connected to the sewerage system, 0%; greater than the figures presented. connected to a septic tank, 26%; hanging toilet above a fish pond, 40%; no facility, 34%. The latter two are categorized The annual equivalent costs of various sanitation options as open defecation. were calculated based on annualized investment cost (tak- ing into account the estimated length of life of hardware The ESI 2 field study in Payakumbuh took place in north and software components) and adding annual maintenance Payakumbuh, Talawi, Kotopanjang, Payolinyam, and Kubu and operational costs. For data analysis and interpretation, Gadang wards, where the sanitation intervention takes financial costs were distinguished from non-financial costs, a CLTS approach. A total of 300 households were inter- and costs were broken down by financier. Information from viewed for the survey.. documents of sanitation projects and providers as well as market prices was supplemented with interviews with key Table 5 presents an overview of the sanitation and hygiene resource people to ensure correctness of interpretation, and situations in the five study sites. to enable adjustment where necessary. 3.3.2 COST ESTIMATION METHODOLOGY 3.3.3 BENEFIT ESTIMATION METHODOLOGY This study estimates the comprehensive cost of various san- Economic evaluation of sanitation interventions should be itation options, including program management costs as based on sufficient evidence of impact, thus giving unbiased well as on-site and off-site hardware costs. Cost estimation estimates of economic efficiency. Hence the appropriate at- was based on information from three data sources (sanita- tribution of causality of impact is crucial, requiring a robust tion program or project documents, the provider or suppli- study design. Table A3 presents alternative study designs for er of sanitation services, and the ESI household question- conducting economic evaluation studies, starting at the top naire, described in 3.3.4). Data from these three sources with the most valid scientific approaches, down to the least were compiled, compared, and adjusted, and finally entered valid at the bottom. Given that the most valid scientific into standardized cost tabulation sheets. Capital costs are approach (a randomized time-series intervention study) TABLE 5: SANITATION AND HYGIENE COVERAGE OF ESI SAMPLE HOUSEHOLDS Lamongan Tangerang Banjarmasin Payakumbuh Option Malang City District District City City SANITATION Sewerage System - - 10% 51% (communal) - Septic tank 68% 37% 55% 14% 47% Wet private pit 5% 12% 4% 14% 3% Dry private pit 0.7% 12% 3% - 0.3% Open defecation (on land or water) 27% 42% 30% 20% 50% HYGIENE Hand washing with soap after defecation 45% 11% 6% 11% 23% (always) Source: ESI Household Survey 18 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Methods FIGURE 6: LOCATION OF STUDY SITES was not possible within the timeframe and resources of this Figure 7 shows an overview of the methods for estimating study, the most valid remaining option was to construct an the benefits of moving up the sanitation ladder. The actual economic model for assessment of cost-benefit of providing size of the benefit will depend on the specific sub-type of sanitation interventions and of moving from one sanitation sanitation intervention implemented and on the initial level coverage category to the next. A range of data was used in of sanitation. this model, reflecting both households with and without improved sanitation, to ensure that before and after inter- The specific methods for the sanitation benefits are de- vention scenarios were most appropriately captured. This scribed below. For a mathematical representation of the included capturing the current situation in each type of methodology, refer to the aggregating equations in Table household (e.g. health status and health seeking, water A4. practices, time use), as well as understanding attitudes to- wards poor and improved sanitation, and the factors driv- Health: For the purposes of cost-benefit and cost-effective- ing decisions. These data were supplemented with evidence ness analysis, three types of disease burden are evaluated: from other local, national and international surveys and numbers of cases (incidence or prevalence), numbers of data sets on variables that could not be scientifically cap- deaths, and disability-adjusted life-years (DALYs). Diseases tured in the field surveys (e.g. behavior and risk factors for included are all types of diarrheal disease, helminthes, hepa- health assessment). titis A and E, trachoma, scabies, malnutrition and diseases www.wsp.org 19 Economic Assessment of Sanitation Interventions in Indonesia | Methods related to malnutrition (malaria, acute lower respiratory in- nutrition are provided in the ESI Impact study re- fection, measles) (Table A 5). Health costs averted through port (Economic Impacts of Sanitation in Southeast improved sanitation are calculated by multiplying overall Asia11). health costs per household by the relative risk health re- • Health care costs are calculated by applying treat- duction from the improved sanitation and/or hygiene mea- ment seeking rates for different health care providers sures. Health costs are made up of disease treatment costs, to the disease rates, per population age group. The productivity losses and premature mortality losses. For cost- calculations also take into account hospital admis- effectiveness analysis, DALYs are calculated by combining sion rates for severe cases. Unit costs of services and the morbidity element (made up of disease rate, disability patient travel and sundry costs are applied based on weight and illness duration) and mortality element (mortal- treatment seeking. ity rate and life expectancy). Standard weights and disease • Health-related productivity costs are calculated by duration are sourced from the Global Burden of Disease applying time off work or school to the disease rates, study, and average life expectancy for Indonesia at birth per population age group. The economic cost of time male/female of 66/69 years is used (World Health Statistics lost due to illness reflects an opportunity cost of time 200810). or an actual financial loss for adults with paid work. The unit cost values are based on the average income • Rates of morbidity and mortality are sourced from rates per location. For adults a rate of 30% of the various data sets for three age groups (0-4 years, 5-14 average income is applied, reflecting a conservative years, 15+ years), and compared and adjusted to re- estimate of the value of time lost. For children 5-14 flect local variations in those rates (Hotez, 2003). years, sick time reflects lost time at school which has National disease and mortality rates were adjusted to an opportunity cost, valued at 15% of the average rates used for the field sites based on socio-economic income. For children under 5, the time of the child characteristics of the sampled populations. As not all carer is applied at 15% of the average income. Values fecal-oral diseases have a pathway from human ex- are provided in Table 6. creta, an attribution fraction of 0.88 is applied for • Premature death costs are calculated by multiply- these diseases. Skin diseases are attributed 0.5 due to ing the mortality rate by the unit value of a death. poor hygiene. Methods for the estimation of disease Although premature death imposes many costs on and mortality rates from indirect diseases via mal- societies, it is difficult to value them precisely. The FIGURE 7: OVERVIEW OF METHODS FOR ESTIMATING FIELD-LEVEL BENEFITS OF IMPROVED SANITATION BENEFIT POPULATION WITH POPULATION WITH BENEFIT CATEGORY UNIMPROVED SANITATION IMPROVED SANITATION ESTIMATED Data on health risk per person, Generic risk reduction, Averted health care costs, HEALTH by age category & socioeconomic using international literature reduced productivity loss, status reduced deaths Data on water source and Observed changes Reduced water sourcing WATER treatment practices in practices in populations and water treatment costs with improved sanitation Data on time to access toilet Observed reductions in time Opportunity cost of time ACCESS TIME per person per day to access toilet applied to time gains Attitudes and preferences Bene�ts cited of improved Strength of preferences for INTANGIBLES of householders to sanitation sanitation different sanitation aspects and willingness to pay Practices related Value gained, based on 10 REUSE World Health Organization 2006 at http://www.who.int to excreta reuse sales or own use 11 Economic Impacts of Sanitation in Southeast Asia, A four-country study conducted in Cambodia, Indonesia, the Philippines and Vietnam under the Economics of Sanitation Initiative (ESI), Water and Sanitation Program - East Asia and the Pacific (WSP-EAP) - World Bank East Asia and the Pacific Region, November 2007 20 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Methods method employed by this study – the human capi- • Accessing water from the source. Because households tal approach (HCA) – approximates economic loss pay more or walk further to access water from clean- by estimating the future discounted income stream er sources such as drilled wells, or they pay more for from a productive person, from the time of death piped water, it would in theory reduce these costs until the end of (what would have been) their pro- if sanitation improved. For example, traditionally ductive life. While this value may undervalue pre- people prefer the taste of water from shallow wells mature loss of life, as there is a value to human life to deeper wells, and hence would likely return to use beyond the productive worth of the workforce, the of shallow wells if they could guarantee cleaner, safer study faced limited alternative sources of value due water. Also, providers of piped water have to treat to lack of studies (e.g. value-of-a-statistical-life12). water less if it is less contaminated, thus saving costs. Values are provided in Table 11, including value of Hence, expected percentage cost reductions are ap- statistical life (VOSL) adjusted to Indonesia from plied to current costs of clean water access to esti- developed country studies. mate cost savings from improved sanitation. • Risk reductions of illness and death associated with • Household treatment of water. Traditionally many improved sanitation and hygiene interventions are households treat their water due to concerns about assessed from international literature, and are ap- safety and appearance. This is commonly true even plied and adjusted to reflect risk reduction in local for piped, treated water supplies. Boiling is the most settings based on baseline health risks and interven- popular method because it is perceived to guarantee tions applied. Figure 11 in Section 5.1.5 shows the water to be safe for drinking. However, boiling water risk reduction values used in this study. can require considerable cash outlays or it consumes their time for collecting fuel. Furthermore, boiling Water: While water has many uses at community level as water for drinking purposes is more costly to the well as for larger-scale productive purposes (e.g. industry), environment due to the use of wood, charcoal or the focus of the field study is use for domestic purposes, in electricity, with correspondingly higher CO2 emis- particular drinking water. The most specific link between sions than other treatment methods. If sanitation poor management of human excreta and water quality is is improved and the pathogens in the environment the safety aspect, which causes communities to take miti- reduced to low levels, then households would feel gating actions to avoid consuming unsafe water. These in- more ready to use a simple and less costly household clude reducing reliance on surface water and increasing use treatment method such as filtration or chlorination. of wells or treated piped water supply. It even involves the Hence, based on observations and expected future need to rely less on shallow dug wells, which are more eas- household treatment practices under situation of ily contaminated with pathogens, and to drill deeper wells. improved sanitation, the cost savings associated with As well as from sewage, water sources which communities alternative water treatment practices are calculated. traditionally relied on for their other domestic needs (such as cooking, washing, showering) are changed in favor of Access time: When households have their own private cleaner, but more expensive, water sources. Water quality latrine, many of them will save time every day, compared measurement is conducted as part of this study in represen- with the alternative of going to the bush or using a shared tative field sites, to enable detailed analysis of the impacts facility for their toilet needs. The time used for each sanita- of improved sanitation on local water quality (see Table tion option will vary from household to household, and A6). This study measures the actual or potential economic from person to person, as children, men, women, and the impacts of improving sanitation on two sets of mitigation elderly all have different sanitation preferences and prac- measures: tices. Therefore, this study calculates the time savings for 12 VOSL studies attempt to value what individuals are willing to pay to reduce the risk of death (e.g. safety measures) willing to accept for an increase in the risk of death. These values are extracted either from observations of actual market and individual behavior (‘hedonic pricing’) or from what individuals stated in relation to their preferences from interviews or written tests (‘contingent valuation’). Both these approaches estimate directly the willingness to pay of individuals, or society, for a reduction in the risk of death, and hence are more closely associated with actual welfare loss compared with the HCA. www.wsp.org 21 Economic Assessment of Sanitation Interventions in Indonesia | Methods TABLE 6: UNIT VALUES FOR ECONOMIC COST OF TIME PER DAY AND OF LOSS OF LIFE (US$, 2008) Daily value of time Value of life Technique 0-4 years 5-14 years 15+ years 15+ years 5-14 years 15+ years RURAL Human capital approach1 0.65 0.65 1.29 8,507 13,314 13,953 VOSL 2 49,351 49,351 49,351 URBAN Human capital approach1 0.65 0.65 1.29 8,507 13,314 13,953 VOSL2 49,351 49,351 49,351 1 2% real GDP or wage growth per year, discount rate = 8% 2 The VOSL of US$40 million is transferred to the study countries by adjusting downwards by the ratio of GDP per capita in each country to GDP per capita in the USA. The calculation is made using official exchange rates, assuming an income elasticity of 1.0. Direct exchange from higher to lower income countries implies an income elasticity assumption of 1.0, which may not be true in practice. different population groups of improving sanitation, based derstand and measure sanitation knowledge, practices and on observations of households both with and without im- preferences in terms of ranking scales. This enables a sepa- proved sanitation. The value of time is based on the same rate set of results to be provided alongside the monetary- values as health-related time savings (see above). based efficiency measures. Excreta reuse: Human excreta, if handled properly, can be External environment: Likewise, the impacts of poor a safe source of fertilizer, wastewater for irrigation or aqua- sanitation practices on the external environment are also culture, or biogas. However, improved human excreta reuse difficult to quantify in monetary terms. Hence, this study is not commonly practiced in Indonesia. As none of the attempts only to understand and measure practices and field sites include excreta reuse, this potential benefit is not preferences in relation to the broader environment, in terms valued in this study. of ranking scales. Given that human-related sanitation is only one of several factors in environmental quality, other Intangibles: Intangibles are major determinants of person- aspects – sources of water pollution, solid waste manage- al and community welfare such as comfort, privacy, con- ment, and animal waste – are also addressed to understand venience, safety, status and prestige. Due to the often very human excreta management within the overall picture of private nature of intangibles, it is difficult to elicit reliable environmental quality. responses from individuals, and some may vary consider- ably from one individual and social group to another. In- 3.3.4 DATA SOURCES tangibles are therefore difficult to quantify and summarize Given the range of costs and benefits estimated in this from a population perspective, and are even more difficult study, a range of data sources was defined, including both to value in monetary terms for cost-benefit analysis. Eco- up-to-date evidence from the field sites as well as evidence nomic tools do exist for quantitative assessment of intan- from other databases or studies. Given the limitations of the gible benefits such as the contingent valuation method and field study, some elements of benefits needed to be sourced willingness to pay surveys that are commonly used to value from other more reliable sources. Routine data systems such environmental goods. However, there are many challenges as the health information system are often poor quality and to the application of these methods in field settings which incomplete, while larger more reliable nationwide or local affect their reliability and validity, and ultimately appro- surveys may be out of date, or were not conducted in the priate interpretation of quantitative results. Furthermore, ESI field locations. willingness to pay often captures more than just the intan- gible variables being examined; it will also capture prefer- The contents of the field tools applied are introduced brief- ences that have been valued elsewhere (e.g. health and water ly below (the tools applied in Indonesia are available from benefits). This current study therefore attempts only to un- WSP). 22 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Methods Field tool 1: Household questionnaire mary health center officers, doctors, and local public hos- The household questionnaires consisted of two main parts: pital officers. The field study was conducted in 10-12 days the first was asked to household representatives (the senior in each city/district, from 12 January to 10 February 2009 male and/or female household member, based on availabil- for all sites. ity at time of interview), while the second was a shorter observational component covering mainly physical water, Before going ahead with the field survey, 1-2 subdistricts sanitation and hygiene features of the household. The in- were identified in each city/district to be the survey sites. terview part consisted of sections on: The site selection was based on the following criteria: 1) • Socio-economic and demographic information, and had sanitation intervention or sanitation development ini- household features tiatives more than 2 years ago, 2) the availability of house- • Current and past household sanitation options and holds with under-five children, 3) poor community, and practices, and mode of receipt 4) area with poor health condition. The poor community • Perceived benefits of sanitation, and preferences re- attribution is based on general national reference. For cities/ lated to external environment districts meeting these criteria, the field survey teams asked • Household water supply sources, treatment and stor- officers of local institutions, such as the district health of- age practices fice, ISSDP City Facilitators and local informal leaders, to • Health events and health treatment seeking select appropriate survey sites. The selected subdistricts and • Hygiene practices villages in each city/district are shown in Table 7. • Household solid waste practices Field tool 2: Focus group discussion The household questionnaire was applied to a total of 1,500 The purpose of the focus group discussion (FGD) was to households over the five sites, or roughly 300 per site, di- elicit behavior and preferences in relation to water, sanita- vided over households with improved and unimproved tion and hygiene from different population groups, with sanitation. Table 8 presents the sample sizes per sanitation main distinctions by sanitation coverage (with versus with- option and per field site. The figure of 300 respondents is out) and gender (male and female). The topics covered in greater than the minimum requirement for a statistically the FGDs followed a generic template of discussion topics, valid sample size according to the number of households but the depth of discussion was dictated by the readiness in each site. of the participants to discuss the topics. The added advan- tage of the FGD approach is that it allows discussion of Apart from household questionnaires, complementary field aspects of sanitation and hygiene that may not otherwise data sources were collected from direct interviews with pri- be revealed during face-to-face household interviews, and TABLE 7: LIST OF SUBDISTRICT AND VILLAGES FOR ESI 2 SURVEY AREAS IN FIVE CITIES/DISTRICTS IN INDONESIA Subdistricts Villages No City District Control area Intervention area 1 Control area 1 Payakumbuh City North Payakumbuh North Payakumbuh • Talawi • Payolinyam • Koto Panjang • Kubu Gadang 2 Banjarmasin City Central Banjarmasin Central Banjarmasin Pekapuran Laut Kelayan Luar 3 Malang City • Kedung Kandang • Kedung Kandang • Mergosono • Arjowinangun • Lowokwaru • Lowokwaru • Tlogomas • Dinoyo 4 Lamongan District Turi Turi • Geger • Badurame • Keben • Turi 5 Tangerang District Sepatan Rajeg • Sarakan • Sukasari • Kayu Agung • Tanjakan 1 During the study design phase, the idea of having an “Intervention Area� and “Control Area� was conceived. However, during the actual field study, it was found that no pure intervention areas nor pure control areas actually existed. Hence, the respondents were a mix of those who still practice open defection and those who have or use private toilets, shared toilets or community toilets. The detail steps of the field survey implementation are described in the Annex. www.wsp.org 23 Economic Assessment of Sanitation Interventions in Indonesia | Methods to either arrive at a consensus or otherwise to reflect the in Jakarta, and carried out in January 2010. The study en- diversity of opinions and preferences for sanitation and hy- abled assessment of the impact of specific local sanitation giene among the population. FGDs were led by a senior so- features on water quality. It also enabled a broader com- ciologist and notes taken by junior sociologists. Three FGD parison of water quality between study sites with different sessions were conducted at each site, each session lasting sanitation coverage levels. Water sources tested in each site roughly three hours. The groups constituted: included ground water (dug shallow wells, deeper drilled • A group of four senior female members of house- wells), standing water (ponds, lake, canal), and flowing wa- holds with improved sanitation facilities and four ter (river, wastewater channels). Table C 1 provides a list senior female members of households with unim- of water quality tests conducted, showing the type of test proved sanitation, and location per parameter, and the number and type of • A group of four senior male members of households water sources tested. For cost reasons, water testing was not with improved sanitation facilities and four senior done in all the sites (four of the five study sites). Parameters male members of households with unimproved sani- measured varied per water source, but generally included tation, BOD, COD, DO, nitrate, Chlorine, E Coli, pH, turbidity • A stakeholder group consisting of seven people, in- and conductivity. cluding local health department officers, local wom- en health cadres, and local NGO activists working Field tool 5: Market survey on sanitation. For economic evaluation, local prices are required to value the impacts of improved sanitation and hygiene. Selected Field tool 3: Physical location survey resource prices, and in some case resource quantities, were A survey of the physical environment was conducted in recorded from the most appropriate local source: labor pric- all field locations – given that there were several locations es (average wage, minimum wage) and employment rate, per site this gave three to five physical location surveys per water prices by source, water treatment filters, fuel prices, site. The main purpose was to identify important variables sanitation improvement costs, soap costs and pharmacy in relation to water, sanitation and hygiene in the general drug costs. One market survey was carried out per field site. environment, covering land use, water sources and envi- ronmental quality. This information was triangulated with Field tool 6: Health facility survey the household surveys and FGDs as well as the water qual- Given the importance of health impacts, a separate survey ity measurement survey, to enable appropriate conclusions was conducted in two to three health facilities serving each about the extent of poor sanitation and links to other im- field site. Variables collected include numbers of patients pact variables. This survey was conducted by the health ex- with different types of WSH-related disease, and the types pert of the ESI team. and cost of treatment provided by the facility. Data were supplemented by data collected or compiled at higher levels Field tool 4: Water quality measurement of the health system, such as district and city health offices. Given one of the major detrimental impacts of poor sanita- tion is the impact on surface as well as ground water qual- There were some constraints during secondary data collect- ity, special attention was paid in this study to identifying ing, such as: the relationship between the type and coverage of toilets in • Required data were not available, the selected field sites, and the quality of local water bod- • The format of available data/information did not ies. Given the time scale of this present study, it was not match the required format, possible to measure water quality variables before the proj- • Hospitals have strict procedures for releasing data. ect or program was implemented; neither was it possible To obtain data, the team needed to specify precisely to compare wet season and dry season measurements. The the data required and present an official letter of rec- water quality measurement survey was contracted to SU- ommendation from government. COFINDO, a state-owned engineering survey company 24 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Methods Other data sources: as well as collection of data from field Results are presented by field site and for each sanitation sites, to support the field level cost-benefit analysis, data improvement option compared with no sanitation option and information were collected from other sources, such as (i.e. open defecation). Also, selected steps up the sanitation reports, interviews with program implementers and project ladder are presented, such as from shared latrine to private data sets. The complete list of data sources is presented in latrine, from dry pit latrine to wet pit latrine, or from wet the Annex A 5. pit latrine to sewerage. The efficiency ratios are presented both under conditions of well-delivered sanitation pro- 3.3.5 DATA ANALYSIS grams which lead to well-functioning sustainable sanitation The types of costs and benefits included in the study are systems, as well as sanitation systems and practices under listed in section 3.2. This section describes how costs, ben- actual conditions, observed from the program approach efits and other relevant data are analyzed to arrive at overall analysis (section 3.4). Given that not all sanitation benefits estimates of cost-benefit. have been valued in monetary units, these benefits are de- scribed and presented in non-monetary units alongside the The field level cost-benefit analysis generates a set of effi- efficiency measures. Gender issues will be particularly cen- ciency measures from site-specific field studies, focusing on tral in the presentation of intangible benefits. actual implemented sanitation improvements, including household and community costs and benefits (see Chap- Further assessments are conducted to enable national inter- ter 8). The costs and benefits are estimated in economic pretation of efficiency results. This involves entering input terms for a 20-year period for each field site, using average values in the economic model corresponding to national values based on the field surveys and supplemented with averages for rural and urban areas, which is likely to give other data or assumptions. Five major efficiency measures different results from the specific field sites. are presented: 1. The benefit-cost ratio (BCR) is the present value of 3.4 PROGRAM APPROACH ANALYSIS the future benefits divided by the present value of The aim of the program approach analysis (PAA) is to show the future costs, for the 20-year period. Future costs the levels and determinants of performance of sanitation and benefits (i.e. beyond year 1) are discounted to programs. It evaluates the link between different program present value using a discount rate of 8% (sensitivity approaches and eventual efficiency and impact of the sani- analysis: low 3%, high 10%). tation options. It is also used as the basis for adjusting ideal 2. The cost-effectiveness ratio (CER) is the present intervention efficiency to estimate actual intervention ef- value of the future health benefits in non-monetary ficiency. The PAA also shows current practices in relation to units (cases, deaths, disability-adjusted life-years) di- sanitation program evaluation, and provides recommenda- vided by the present value of the future costs, for the tions for improved monitoring and evaluation of sanitation 20-year period. Future costs and health benefits (i.e. programs. beyond year 1) are discounted to present value using a discount rate (see above). The PAA is essentially a desk study, assessing sanitation 3. The internal rate of return (IRR) is the discount rate program documents, with additional information gained at which the present value equals zero – that is, the through interviews with sanitation program managers and costs equal the benefits – for the 20-year period. implementers. More in-depth studies and data were pos- 4. The payback period (PBP) is the time after which sible using the field sites for the cost-benefit analysis (see benefits have been paid back, assuming initial costs section 3.3). The PAA has six main steps: exceed benefits (due to capital cost) and over time 1. Listing of in-country sanitation programs and their benefits exceed costs, thus leading to a point that is characteristics, followed by a selection of sanitation break even. programs to include in the PAA (see Annex Table 5. The net present value (NPV) is the net discounted A7). Chapter 7.2 shows the selected programs and benefits minus the net discounted costs. their main characteristics. www.wsp.org 25 Economic Assessment of Sanitation Interventions in Indonesia | Methods 2. Assessment of specific types of program ‘approach’ to The PAA is constrained by lack of input data available from be compared. Program approaches that are chosen to programs evaluated, which limits the number of programs be included in this study are: that could be included in the study. The results of the analy- 1) WSLIC 2 (Water and Sanitation for Low In- sis are interpreted taking into account setting-specific con- come Communities 2) in Lamongan District, ditions, which are partially responsible for the performance 2) SANIMAS (Community-Based Sanitation) in results; hence findings are not definitive, but instead illus- Tangerang District, trative and instructive. 3) CBSS (Community-Based Sewer System) Malang City, 3.5 NATIONAL STUDIES 4) CLTS (Community-Led Total Sanitation) Paya- These studies have two main purposes: to assess the impacts kumbuh City, of improved sanitation outside the field study sites, for a 5) Sewerage system in Banjarmasin City. more comprehensive benefit assessment (tourism, business and sanitation markets); and to complement data collect- The first four programs above are community-driven ed at field level for better assessment of local level impacts projects. The field locations are considered represen- (health and water resources). tative for this study. The fifth site is an off-site sani- tation system. The sewerage system in the selected 3.5.1 TOURIST AND VISITOR SURVEY location, Banjarmasin, was initiated in 1998 under There is an unarguable link between sanitation and tour- a city government initiative. Formerly, the sewerage ism, however only very little evidence can be found. Poor systems were operated by the local water supply util- sanitation and hygiene affect tourists in two ways: ity, and in September 2006, their management was • Short-term welfare loss and expense. Tourists get taken over by PD PAL, a special local government- sick from diarrhea, intestinal worms, hepatitis, and owned enterprise for domestic wastewater manage- so on, which directly affect health care costs. Tour- ment. There were several particular reasons for se- ists are also exposed to poor sanitation, which means lecting this program: they do not enjoy their holiday to the full. • Its development commenced more than 10 • Reduced numbers of tourists. In the longer term, years ago, tourists will avoid tourist destinations that are • It has been funded by a variety of sources, deemed unsafe (from a health perspective) or un- • Actual uptake is currently only around 14% of pleasant, due to dirty water, malodorous environ- capacity, which is too low to reap economies of ment or lack of proper toilets, for example. Tourists scale. may stay away either because they themselves have 3. Evaluation of selected sanitation programs in terms had an unpleasant experience at a particular tourist of their program approaches and measurement of destination and choose not to come back; or they outputs and successes (e.g. unit costs, coverage, and have been advised not to visit a tourist destination uptake). For the assessment of actual efficiency, key due to, among other things, poor sanitation. indicators of program effectiveness are selected. 4. Analysis of factors that determine program perfor- This study attempts to explore these two impacts through a mance, focusing on economic variables. survey of non-resident foreign visitors and holidaymakers. 5. Evaluation of selected sanitation programs in terms Business visitors were also included to get their views from of their programming approach and measures of out- a business perspective. A total of 144 holiday tourists and put and success (e.g. unit costs, coverage, uptake). 110 business visitors were interviewed at Soekarno-Hatta For the assessment of actual efficiency, key indicators International Airport in Jakarta, as they were leaving Indo- of program effectiveness are selected. nesia. 6. Analysis of factors determining program perfor- mance, focusing on economic variables. 26 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Methods Table 8 shows the sample size by major category of nation- clean water or lose income from customers’ unwill- ality and type of visitor (holiday or business), disaggregated ingness to visit the location. It should be noted, that into first time and repeat visitors. the loss of customers assessed in one area does not necessarily mean an absolute loss for business sector, The survey at Soekarno-Hatta airport was conducted in as customers may choose to go elsewhere, such as English. Tourists were approached and the purpose of the other business located in other areas. questionnaire explained to them. If they agreed, they were • Poor sanitation may affect a foreign company’s de- given a questionnaire to fill out. Survey staff were on stand- cision to open a base in Indonesia, due to: (a) the by to answer any questions while the survey respondents health condition of local employees, based on actual were filling in the form. On average, the questionnaire took data or business perceptions of the health conditions 10 to 15 minutes to complete. Questions covered the fol- of the country’s workers; (b) perceived poor quality lowing topics: of water for business purposes and its related costs; • Length of trip, places stayed and hotel category, (c) general poor environmental condition, including • Level of enjoyment at different locations visited, and poor solid waste management and filthy and unhy- reasons, gienic conditions, which may affect the company’s • Sanitation conditions at places visited, and availabil- ability to do business in Indonesia; and (d) objec- ity of toilets, tions from foreign personnel about being based in • Water and sanitation-related sicknesses suffered, per- Indonesia due to, among other things, its poor sani- ceived sources, days of sickness, and type and cost of tary conditions. treatment sought, • Major sources of concern for spending holidays in To assess these hypothetical effects, ten businesses were sur- Indonesia, veyed through face-to-face interviews and, in some cases, • Intention to return to Indonesia, recommendation in-depth discussions. Table 9 shows the number of firms to friends, and reasons. by sector, and by ownership (local or foreign). These firms were selected based on the link between sanitation and their 3.5.2 BUSINESS SURVEY business, and the importance of the sector and the specific Besides affecting tourism, poor sanitation also has the po- firm to the economy of Indonesia. The surveyed foreign tential to affect businesses. Two types of impacts were as- firms were those that already have a presence in Indonesia sessed: local-level impacts on the day-to-day functioning of and hence a key category of firm – those that have decided businesses, and the broader impacts on business location against opening a base in Indonesia – were not part of the decisions: sample. However, the foreign firm, a garment producer, was • Businesses located in areas with poor sanitation may asked about the factors affecting their decision to be based pay higher costs e.g. having to pay more to access in Indonesia, as well as their experiences with the country. TABLE 8: SAMPLE SIZES FOR TOURIST SURVEY, BY MAIN ORIGIN OF TOURIST Holiday tourists Business visitors Holiday and Tourist First time Repeat First time Repeat business nationality Total Total visitors visitors visitors visitors total Europe 8 26 34 2 20 22 56 USA and Canada 6 7 13 1 4 5 18 Asia 15 39 54 10 54 64 118 Australia and 6 36 42 2 16 18 60 New Zealand Africa 0 1 1 0 1 1 2 Total 35 109 144 15 95 110 254 www.wsp.org 27 Economic Assessment of Sanitation Interventions in Indonesia | Methods TABLE 9: SAMPLE SIZE FOR BUSINESS SURVEY, BY MAIN SECTORS OF LOCAL AND FOREIGN FIRMS Details of sanitation inputs and costs are sourced princi- Main business Local pally from the field studies (household questionnaire, local Foreign firm Total market survey) where the specific toilet types and related or sector of firm business Hotel 2 0 2 input needs and costs have been assessed. Project and pro- Restaurant 4 0 4 gram costs have also been collected from the program ap- Garment 1 1 2 proach analysis (see 3.4). To estimate the overall potential producer market size of increasing sanitation coverage at national lev- Food producer 1 0 1 el, generic unit costs per sanitation option are applied to the (traditional likely options demanded by the population. Two scenarios medicine) were included: the market size of reaching the MDG target Convention hall 1 0 1 by 2015, and the market size of achieving and maintaining Total 9 1 10 100% coverage. The questionnaire covered the following topics: The calculation of national potential market size is based on • Ownership, sector, activities, employees and location the following assumption: of the firm. • The unit cost of the sanitation ladder is based on • Perceptions about the sanitation condition at com- provision costs of a private septic tank for urban ar- pany’s location. eas and costs of a simple pit latrine for rural areas. • Factors affecting the decision to be based in a par- • The cost components consist of costs for increasing ticular country or area, and plans to relocate. coverage of those currently without toilets and also • The production and sales costs related to various as- costs of replacement of existing sanitation facilities pects of poor sanitation, such as health, water, and according to their technical lifecycle assumptions. environment. • Potential costs and benefits of improved sanitation The TTPS, in the 2010 revised version of the Roadmap to to the business. Sanitation Development 2010-2014, has calculated generic unit costs and the total investment costs requirement to 3.5.3 NATIONAL SANITATION MARKETS achieve and maintain 100% coverage. The figure will then Sanitation markets include both input markets (the mar- automatically reflect the 100% coverage sanitation market ket value of expenditures to improve sanitation) and out- size. put markets (reuse of human excreta; animal excreta is also included as biogas is commonly produced using a mix of In Indonesia the reuse of sanitation ‘outputs’ (as fertilizer, human and animal excreta). soil conditioner, biogas) is very limited. It is useful to es- timate the potential economic benefits of these. Such an Assessment of sanitation input markets has three main aims: analysis will help support policy makers and the private sec- 1. To contribute to the estimation of intervention tor to assess whether reuse options could be economically costs, for inclusion in the cost-benefit analysis and and financially viable to stimulate investment in this area. cost-effectiveness analysis. However, due to insufficient data, this study did not calcu- 2. To examine how much interventions cost at field, late the potential economic value of this opportunity. project and at national level, and the main contribu- tors to cost, to assess in detail how to finance these 3.5.4 NATIONAL HEALTH STATISTICS costs. The field surveys provide data from the sampled households 3. To explore what the beneficial economic impacts and health facilities on disease incidence for selected dis- might be to the local and national economy, based eases related to poor sanitation. For some sites, other studies on the estimated size of the sanitation inputs market. conducted in the same locality provided alternative sourc- 28 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Methods es of disease incidence data. However, constraints in data on cities, such as the Sanitation Whitebooks of ISSDP par- robustness at field level requires supplementation of these ticipants, Sanitation Fast Track Assessment of the ISSDP, data with estimates of disease incidence and mortality rates and sanitation-related fact sheets provided by AMPL. from other sources, and adjustment to the health condi- tions of the specific field sites. Data were therefore sourced The links between poor sanitation, water quality and inland from national surveys (e.g. Demographic and Health Sur- fish production were assessed in the ESI sanitation ‘impact’ vey) and research studies, as well as internationally com- study. Where sewage is a significant contributor to degrad- piled statistics for Indonesia or the Southeast Asia region ed water resources – affecting biological oxygen demand as (World Health Organization; Disease Control Priorities well as toxicity (e.g. bacteria, parasites) – it was concluded, Project 2). The data from these different sources were com- based on limited scientific evidence, that fish reproduction, pared in terms of quality and applicability to the field sites, fish growth and fish survival is affected by poor sanitation. to finally select the most appropriate values for use in the cost-benefit analysis and the national health overview. 3.5.5 NATIONAL WATER STATISTICS National water quality data were collected and presented in the sanitation ‘impact’ study, covering mainly surface water of major lakes and rivers. Hence, this present study updates those data to provide a national level picture of the qual- ity of water resources, including ground water quality. The secondary data collection was mainly obtained from water and sanitation related documents at AMPL, a national level water and sanitation working group, and the Indonesia Sanitation Sector Development Program (ISSDP). Other sources are official websites of related government bodies such as provincial and city/district level environmental con- trol bodies. An increase of 1 mg/liter of BOD pollution will lead to an increase of about 25% in the national average of drinking water production costs.13 Poor or non-existent drainage systems in urban areas have received a high public profile due to regular flooding (e.g. Jakarta, where some parts of the city are regularly flooded during the rainy season, and occasionally there is severe flooding). Poor sanitation such as insufficient drainage or unimproved solid waste disposal (thus blocking drains) can lead to avoidable flooding in rainy season. Also, inappro- priate sanitation options in seasonally flooded rural areas can lead to avoidable surface water pollution and health hazards. Therefore, this study collected secondary evidence from government and donor assessments, university re- search, and media reports of flooding incidents, focusing 13 ISSDP Phase 1 Documentation, 2006. www.wsp.org 29 IV. Local Benefits of Improved Sanitation and Hygiene This chapter presents the following impacts of improved the estimates of health care and productivity costs (see later sanitation and hygiene at local level – covering household sections). Besides the significant burden on households in- and community impacts: dicated by the economic values in the cost-benefit analysis, • Health (section 4.1) diseases have a number of welfare effects on people, such • Water (section 4.2) as physical pain, mental suffering and inconvenience. The • Access time (section 4.3) focus group discussions did reveal, however, that diseases • Intangibles (section 4.4) caused by poor sanitation and hygiene are not perceived to • External environment (section 4.5) be too serious compared with other diseases, and medicines to treat these diseases are available at an affordable price. 4.1 HEALTH 4.1.1 DISEASE BURDEN OF POOR SANITATION According to available health data, young children are more AND HYGIENE susceptible to diarrheal diseases than older children (over In rural sites, it is estimated that there are 3.59 cases of five years of age) and adults. Figure 8 presents annual cases/ disease per person annually, 0.02 DALYs, and an annual person of mild diarrhea and severe diarrhea prevalence for risk of death of 0.38 per 1,000 people due to poor sanita- children under-five in the study sites. Mild and severe di- tion and hygiene (see Table 10). In urban areas, the rates arrhea will have a higher magnitude in rural sites, such as are 2.63 cases of disease per person annually, 0.011 DALYs, Lamongan and Tangerang, than in urban sites. and an annual risk of death of 0.44 per 1,000 people. The main burden comes from direct diseases i.e. diarrheal dis- 4.1.2 HEALTH CARE COSTS ease, respiratory infection (ALRI) and helminthes. Site-spe- Health care costs are estimated based on disease cases (Ta- cific rates used are presented in Table 10. ble 10), the proportion of illnesses treated by each provider (Table 11), inpatient admission rates and practices (Table To some extent, quality of life impacts associated with mor- 12) and the unit costs associated with each provider (Table bidity are reflected in the DALY calculations above, and in 13). TABLE 10: DISEASE RATES ATTRIBUTABLE TO POOR SANITATION AND HYGIENE, 2009 Rural sites Urban sites Disease Deaths/1000 Deaths/1000 Cases/person DALYs/person Cases/person DALYs/person people people Direct diseases Mild diarrhea 1.69 0.01 0.63 0.004 0.30 0.34 Severe diarrhea 1.06 0.01 0.48 0.003 Helminthes 0.37 - - 0.37 - 0.002 ALRI 0.48 0.08 0.00 0.42 0.09 0.003 Total 3.59 0.38 0.02 2.63 0.44 0.011 30 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene FIGURE 8: COMPARISON OF ANNUAL DIARRHEA CASE PER PERSON FOR UNDER-FIVES, BETWEEN STUDY SITES Lamongan Tangerang Banjarmasin Malang Payakumbuh 0 1 2 3 4 5 Diarrheal diseases mild Diarrheal diseases severe TABLE 11: PROPORTION OF POPULATION SEEKING HEALTH CARE FOR MILD DIARRHEAL DISEASE, BY AGE GROUP Rural Urban Age group Age group 0-4 Years 5-14 Years 15+ Years 0-4 Years 5-14 Years 15+ Years Public health facility 11% 8% 3% 21% 11% 10% Private formal health facility 24% 16% 6% 21% 13% 9% Pharmacy 0% 2% 0% 0% 1% 1% Private informal provider 3% 3% 1% 1% 0% 3% Self-treatment 1% 3% 12% 2% 2% 3% Others 0% 1% 1% 0% 0% 0% TABLE 12: AVERAGE RATE OF INPATIENT ADMISSION Rural Urban Disease Age group Age group 0-4 Years 5-14 Years 15+ Years 0-4 Years 5-14 Years 15+ Years Diarrheal disease 32% 8% 10% 12% 6% 11% Indirect: ALRI 10% 7% 6% 7% 5% 3% TABLE 13: UNIT COSTS ASSOCIATED WITH TREATMENT OF SEVERE DIARRHEAL DISEASE (US$, 2009) Outpatient cost (US$) Inpatient cost per day (US$) Health provider Health care Incidentals 1 ALOS (days) 2 Health care3 Incidentals1 Public/NGO Rural 9.63 1.85 0.39 33.41 0.48 Urban 9.63 1.94 0.42 33.41 0.48 Private formal Rural 19.25 1.85 0.39 45.92 0.48 Urban 19.25 1.94 0.42 45.92 0.48 Informal 4.81 Source: Ronnie Rivany. Indonesian – Diagnosis Related Group (INA-DRG ). Department of Health Policy and Analysis. SPHUI. 2008. 1 Incidentals: indirect costs borne by patients such as transport, food, and incidental expenses, per outpatient visit and per inpatient stay. 2 ALOS: average length of stay [days]. 3 Inpatient health care costs are presented per stay. www.wsp.org 31 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene Table 11 shows a summary of treatment-seeking rates for Unit costs for treatment of diarrheal disease are provided in mild diarrheal disease based on the household survey. The Table 13, by health care provider. The health care cost fig- evidence suggests that the majority of the population seeks ures are taken from a secondary data source (Rivany, 2008). care from public and private formal health facilities, with The inpatient room rates are for public hospital type B, higher rates of treatment seeking of public facilities in ur- with no available estimates distinguishing rural and urban ban areas. In rural sites, there are more people who prefer hospitals. Private formal care costs are more expensive than to be self-treated than in urban sites. The treatment-seeking public health provider and informal care costs. The health behavior also varies by age. People are more eager to bring care costs in public facilities are paid by the government as younger children (under five years of age) than older chil- part of health subsidy. dren to formal health facilities whenever they get diarrheal disease. Annex B shows treatment-seeking behavior for oth- Table 14 shows the annual costs per person (by age group) er diseases related to sanitation and hygiene. attributed to poor sanitation and hygiene in Indonesia, by disease. Costs in rural areas range from US$17 for adults to The average rate of inpatient admission (% of overall cases US$151 for young children. In urban areas, costs per per- admitted to hospital) for each disease is presented in Table son are lower, ranging from US$8 for adults to US$37 for 12, sourced from the household survey. The data suggest a young children. Significantly higher costs for young chil- significantly higher rate of admission for young children, dren in rural areas compared to urban areas is a combina- especially in rural areas. tion of higher numbers of cases per child, higher inpatient admission and outpatient visit rates. TABLE 14: AVERAGE HEALTH CARE COST PER PERSON PER YEAR IN FIELD SITES, BY DISEASE, AGE GROUP AND RURAL/ URBAN LOCATION Rural Urban Disease 0-4 Years 5-14 Years 15+ Years 0-4 Years 5-14 Years 15+ Years Diarrheal disease 142 35 15 27 11 5 ALRI 9 9 2 10 7 4 Total 151 44 17 37 18 8 FIGURE 9: AVERAGE HEALTH CARE COST PER PERSON PER YEAR IN FIELD SITES FOR DIARRHEAL DISEASE (MILD AND SEVERE IN US$) 0-4 years Rural 5-14 years 15+ years 0-4 years Urban 5-14 years 15+ years 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 Diarrheal diseases mild & severe ALRI 32 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene 4.1.3 PRODUCTIVITY COSTS Health-related productivity costs are calculated by multi- shows that the greatest productivity costs are incurred due plying time off of work or school to the disease rates, per to illness of children under five, in both urban and rural population age group. The economic cost of time lost due areas. This is because the disease prevalence for children un- to illness reflects an opportunity cost of time or an actual der five years is higher than for other age groups. The actual financial loss for adults with paid work. The unit costs for figures may be even greater as the children’s parents are also all locations are based on the national average wage. In or- involved in the care of their ill children, causing additional der to take into account variations in employment patterns, loss of productive time. a conservative value is given for adults – at a rate of 30% of the average income – reflecting a conservative estimate 4.1.4 MORTALITY COSTS of the value of time lost. For children 5-14 years, sick time For the mortality cost estimation, this study adopted data reflects lost time at school, which has an opportunity cost, from some international studies, which are compiled and valued at 15% of the average income. For children under 5, presented in the Table 16. The figures are estimated by the time of the child carer is applied at 15% of the average combining the annual risk of death per age group with the income. average value of life. Poor sanitation, through its important implications for child nutritional status, is associated with The household survey also revealed practices related to car- higher rates of diarrheal disease and acute lower respira- ers looking after the sick people. The average number of tory infection (ALRI), as well as increased mortality from a days to take care for the sick person in rural areas is 3.4 range of childhood diseases. However, there is no adequate days, at 13.7 hours/day, while the average number of days national data source that provides precise information on in urban areas is 4.3 days, at 13.3 hours per day. Table 15 the link between diarrheal disease and other diseases. FIGURE 10: NUMBER OF DAYS AWAY FROM PRODUCTIVE ACTIVITIES, PER DISEASE WITH RESPECT TO PERSON’S AGE 15+ years Rural 5-14 years 0-4 years 15+ years Urban 5-14 years 0-4 years 0 1 2 3 4 5 6 7 8 Days off productive activities Indirect: ALRI Indirect: Malaria Diarrheal diseases severe Diarrheal diseases mild www.wsp.org 33 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene 4.1.5 AVOIDED HEALTH COSTS narios (moving to treatment of sewage and wastewater) are Central to the arguments of improving sanitation and hy- relevant mainly for urban areas where sewerage systems are giene are the health improvements. Limited evidence ex- currently only available at urban areas. ists on the actual health impact of sanitation or hygiene programs on health outcomes in Indonesia and this study The answers given by household respondents to the ques- draws on international evidence. Figure 11 shows the dif- tion, “Have you noticed an observable change in the rate of ferent risk exposure scenarios being compared in this study, diarrheal disease in any household members since you re- and the reduced risk of fecal-oral disease and helminthes ceived the new latrine?�, are shown in the Table 17. At least infection associated with movements ‘up’ the sanitation lad- 80% of respondents in all categories answered that they do der. The left-hand scenarios (basic improved sanitation) are not feel any observable change in diarrheal disease rates in relevant mainly for rural areas, while the right-hand sce- any household member since they received a new latrine. A TABLE 15: AVERAGE PRODUCTIVITY COST PER PERSON PER YEAR IN FIELD SITES, BY DISEASE, AGE GROUP AND RURAL/ URBAN LOCATION (US$) Rural Urban Disease 0-4 Years 5-14 Years 15+ Years 0-4 Years 5-14 Years 15+ Years Diarrheal disease mild 11.73 6.22 6.80 2.69 1.91 3.07 Diarrheal disease severe 5.82 4.23 6.82 2.32 1.71 1.33 Malaria 0.00 0.00 0.00 0.02 0.02 0.03 ALRI 2.31 3.67 2.40 3.14 2.97 2.53 Total 19.86 14.11 16.02 8.17 6.60 6.96 TABLE 16: AVERAGE MORTALITY COST PER PERSON PER YEAR IN FIELD SITES, BY DISEASE, AGE GROUP AND RURAL/URBAN LOCATION Rural Urban Disease 0-4 Years 5-14 Years 15+ Years 0-4 Years 5-14 Years 15+ Years Diarrheal disease 11.49 0.50 0.52 11.49 0.50 0.52 Malaria 0.04 - - 0.04 - - ALRI 3.23 - - 3.23 - - Total 14.76 0.50 0.52 14.76 0.50 0.52 FIGURE 11: RELATIVE RISK OF FECAL-ORAL DISEASES AND HELMINTHES OF DIFFERENT RISK EXPOSURE SCENARIOS OD Basic SN Basic SN + HW Sewerage Sewerage + HW 0% 20% 40% 60% 80% 100% Fecal-oral Helminthes Relative Risks Key: OD – open defecation or unimproved sanitation; SN – sanitation; HW – hand washing, reflecting basic hygiene interventions 34 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene small proportion perceived that receiving new latrine leads in both rural and urban sites (Figure 12). The costs averted to “Probably less� or �A lot less� diarrheal disease. Note that in this table are utilized in the cost-benefit calculations in many of those answering from the septic tank and sewer- Chapter 8. Each study site has different costs averted values age categories were moving up from other improved sanita- according to their sanitation development situations. tion options, and hence the health effects are expected to be relatively fewer than for those previously practicing open 4.2 WATER defecation. These data are considered to be weaker than the Water is abundant in most parts of Indonesia. In 2004, international evidence presented in Figure 11, which are internal freshwater resources per capita were 15,500 m3, based on more rigorous scientific studies. which is significantly higher than other Asian countries such as India (1,185 m3) and China (2,183 m3). In terms of ma- Table 18 summarizes the total costs of poor sanitation and jor water resources, Indonesia has a large number of small hygiene in Indonesia, per household for the selected field and medium-sized rivers. A major characteristic of most In- sites, and total costs at national level. Health care is the donesian rivers is the high variability of runoff due to the main contributor to cost averted of improved sanitation, distinct separation between rainy and dry season. Most of representing between 60% and 70% of total health costs the rivers are located in the more humid western half of the TABLE 17: PERCEIVED DIFFERENCE IN DIARRHEAL INCIDENCE SINCE IMPROVED SANITATION, IN ALL FIELD SITES Answer to question “have you noticed an observable change in diarrheal disease Households in rates in any household members since you received the new latrine?� Sanitation coverage sample A lot less Probably less No Probably more Shared/public 36 0% 0% 97% 3% Dry pit 5 0% 20% 80% 0% Wet pit 71 7% 8% 83% 1% Septic tank 187 5% 11% 80% 4% Sewerage with treatment 121 2% 3% 95% 0% Note: Total responses for this question were 452 out of 1,500 respondents; the remaining respondents did not give any answer. TABLE 18: ANNUAL COSTS PER HOUSEHOLD OF POOR SANITATION AND HYGIENE, AND ANNUAL COSTS AVERTED OF IMPROVED SANITATION (IN US$, 2008) Costs (baseline risk) Costs averted Costs Rural (OD to Urban (OD to Urban (basic sanitation Rural Urban basic sanitation) sewerage) to sewerage) Health care 202 74 102 46 16 Productivity 80 33 30 20 7 Death 10 15 6 11 4 Total 292 123 138 76 27 FIGURE 12: HEALTH COSTS AVERTED OF IMPROVED SANITATION OPTIONS Rural (OD to basic sanitation) Urban (basic sanitation to sewerage) Urban (OD to sewerage) 0 30 60 90 120 150 Premature mortality Productivity Health care www.wsp.org 35 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene Indonesian archipelago, i.e. the islands of Sumatra, Java and indicators presented below suggest that significant pollution Kalimantan. Some of the rivers of major importance for is taking place in some parts of the country. Furthermore, human settlements include14 Cisadane (Banten, West Java), over-extraction of water from some rivers and other water Ciliwung (Jakarta), Citarum (West Java) (prior to construc- sources for irrigation purposes leads to reduced flow, thus tion of the Saguling Reservoir), Kali Brantas (East Java), greater pollution as well as depletion of the water resources. and Bengawan Solo (Central Java). The first four of these rivers run through highly densely populated areas, where 4.2.1 WATER RESOURCES human activities – both domestic and industrial – release Table 19 presents a summary of water sources in the two ru- large quantities of wastewater to Indonesia’s great rivers. ral and three urban field sites used to take water samples. In Kali Brantas, for example, receives about 150 tons/day of Tangerang District, although Cisadane river passes through wastewater, 60% originating from domestic wastewater the area, the local population do not identify the Cisadane and the remaining 40% from industries15. Citarum River as their source of water. However, Cisadane River is the in West Java, is also indicated to be highly polluted with do- source of water supply for the local water supply utility in mestic and industrial waste, with E. coli in the water reach- Tangerang City. Similarly, in Lamongan District, despite ing 50,000/100 ml16. the presence of a large river, local people tend to use ground water as their water source. Biochemical oxygen demand (BOD) is high due to intakes from agriculture, industry and domestic sources. The ESI The outskirts of Payakumbuh and Malang are upstream of Phase 1 study estimated that in 2005, domestic sources several rivers, which are also the water sources for the lo- contributed to 2.1 million tons of BOD per year to inland cal water supply utility in each area. The households in- water sources. The BOD came from an estimated 6.4 mil- terviewed in the ESI study sites generally identified their lion tons of feces and 64 million m3 of urine countrywide, sources of drinking and clean water, in declining order of plus at least 854 million m3 of gray water from urban areas. importance, as: 1) ground water, 2) spring water, and 3) As well as BOD, water resources are also contaminated by surface water. Ground water is extracted from dug wells and bacteriological and pharmaceutical elements. pump wells, while spring and surface water are treated, then transferred to and distributed by local water supply utilities. With small populations and abundant water resources, pol- The samples of water from Payakumbuh and Mergosono lutants would be diluted naturally. However, given the high showed low turbidity, although the samples were taken dur- density of population in many parts of Indonesia such as ing rainy season on January 2010 in rivers laden with waste- JABODETABEK17 area, Bandung, Surabaya and Medan, water and solid waste. the natural dilution process is not sufficient. Water quality TABLE 19: NUMBER OF WATER SAMPLES TAKEN IN FIELD SITES, BY WATER SOURCE No. Sample site Surface Dug well Borehole Piped water Total 1 Banjarmasin City 1 - - 5 6 2 Payakumbuh City 5 2 - 1 8 3 Malang City 5 1 2 9 17 4 Lamongan District 3 2 2 - 7 5 Tangerang District - 6 - - 6 TOTAL 14 11 4 15 44 14 Source: Status Lingkungan Hidup Indonesia, 2004, KLH; Puslitbang SDA 15 Badan Pengendalian Lingkungan Hidup Daerah/BPLHD (Environmental Control Agency) East Java, 2008 16 Pusat Penelitian dan Pengembangan Sumber Daya Air (Research Center for Water Resources), MPW, 2006 17 ‘Jabodetabek’ is an acronym for the conglomerate of the 5 cities of Jakarta, Bogor, Depok, Tangerang and Bekasi, which more and more grow together to one huge metropolitan area in the 20+ million inhabitants. 36 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene 4.2.2 WATER QUALITY AND ITS Ministry of Health Decree 907/Menkes/SK/VII/2002 on DETERMINANTS the Criteria for and Monitoring of Drinking Water Quality Ground water and surface water quality are affected by soil sets forth more specific criteria for drinking water quality condition and the practices of the surrounding communi- standards. Table 20 shows water quality standards estab- ties. Payakumbuh and Malang are located on upland plains. lished by these two statutes. Water quality is good in almost all rivers, as the fast flowing water allows for natural dilution. The water quality measurements in the ESI study were per- formed based on the type of water source and its designated In Banjarmasin, the quality of river water is poor. The color use, as follows: and turbidity of the water are not as good as in Payakum- • Piped water. The measured parameter is residual buh and Malang. Local people use rivers as disposal sites for chlorine, which protects users from water borne dis- solid waste and domestic wastewater, leading to occasional ease. Ministry of Health Decree 907/Menkes/SK/ outbreaks of diarrheal disease. It is common for people VII/ 2002 states that the adequate level of residual to use rivers as “one stop shops�, to dispose of waste, as chlorine from outlet reservoir to the farthest con- a source of water for bathing and washing, and children’s sumers is ≥ 0.2 mg/l (see Table 26). playgrounds. The larger rivers are used for transportation. • Surface water. The water quality measurement for Learning from larger cities like Jakarta, ‘clean river action’ surface water covers physical parameters (turbidity, has become a major issue for local governments and com- temperature, conductivity), chemical parameters munities. Floating solid waste in rivers and poor water qual- (nitrate, ammonia, COD, BOD, and DO), and bac- ity lead to higher treatment costs for water supply compa- teriology (E. coli). People use surface water mainly nies, and dirty and poor maintained rivers and lakes spoil for bathing and washing, and spring water for drink- the aesthetic view and affect aquatic life. ing (after boiling). Also, some local water supply utilities source raw water from springs. There are two regulations on water quality standards in In- • Groundwater. The water quality measurement pa- donesia. Government Regulation 82/2001 on Water Qual- rameters for ground water consist of E. coli, turbid- ity Management and Water Pollution Control classifies ity, conductivity, and ammonia. The samples were water by its designated use – for example, raw water that taken from both dug wells and boreholes. Water is designated to be processed for drinking water is Class samples from boreholes were tested only for conduc- 1 – and sets water quality standards for each class of water. tivity and ammonia content. TABLE 20: WATER QUALITY STANDARDS REGULATION Ministry of Health (MoH) Government Regulation Parameters Unit Decree No. 907/2002 No.82/2001 E Coli 0 250 in 250ml Biochemical Oxygen Demand (BOD) 2 mg/liter Chemical Oxygen Demand (COD) 1 mg/liter Turbidity 5 NTU Conductivity microS/cm Dissolved Oxygen (DO) 6 mg/liter Nitrate 50 10 mg/liter Ammonia 1.5 0.5 mg/liter Temperature ±3°C ±3°C °C pH 6,5 – 8,5 6-9 Chlorine (Cl) ≥0.2 0.03 mg/liter www.wsp.org 37 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene The water quality surveys were performed by PT Sucofindo organic materials that lead to water pollution. The higher Laboratories. The results show that some of the values are the BOD and COD concentrations, the greater the wa- above or below the thresholds for drinking water or raw ter pollution. The maximum threshold value is 2 mg/l for water that is designated to be processed for drinking water, BOD and 10 mg/l for COD (Government Regulation 82/ set by the water quality standards regulations. These figures 2001). Water samples from Bengawan Solo River, Dusun indicate pollution or inadequate levels of certain parameters Badurame Lake, and Anyar Lake in Lamongan District had in water bodies. For example, the piped water results show BOD and COD concentrations in excess of these thresh- that samples from Banjarmasin, Payakumbuh, and Malang olds. have inadequate levels of residual chlorine. People therefore need to treat this water for drinking using techniques such Dissolved oxygen (DO) is also a parameter indicating the as boiling, coagulant, filtration and/or disinfectant. presence of organic materials that lead to water pollution. The higher the DO value, the lower the water pollution, The results for E. coli existence could not be verified and and vice versa. The minimum threshold for DO is 6 mg/l. were therefore inconclusive. However, many surface water Water samples from Kelayan River in Banjarmasin and a sources reportedly showed visual contamination with hu- dug well in Mergosono, Malang had DO values below the man feces, which are likely to contain E. coli bacteria. minimum. Low levels of DO adversely affect aquatic life and may result in foul smelling water. Decree 907/Menkes/SK/VII/2002 sets the maximum ac- ceptable level of turbidity at 5 NTU. For this parameter, The acceptable water temperature range is ± 3oC from am- the water samples from almost all rivers and dug wells were bient temperature. All water sample temperatures were well above this threshold. For example, water from Kalayan within the acceptable water temperature range. River in Banjarmasin had a turbidity of 19 NTU, water from Batang Lampasi River in Payakumbuh had a turbidity The following figures provide a graphical presentation of of 11 NTU, water from a dug well at a site in Payakumbuh selected water quality readings. Water samples were taken had a turbidity of more than 200 NTU, and water from from piped water, surface water, dug wells and boreholes. Bengawan Solo River in Lamongan District, a turbidity of As shown in Table 21, a total of 44 samples were taken 916 NTU. Such high turbidity levels result from the large across the study sites. All the results portrayed in the fig- volumes of waste disposed of into these water bodies. ures correspond to the sample numbers shown in Table 26. Detailed results of the water quality measurements are Ammonium content in water comes from organic degrada- presented in the Annex, in Table F 6. tion or human excreta. The acceptable maximum ammoni- um content for drinking water is 1.5 mg/l. Almost all water TABLE 21: WATER SAMPLE NUMBERS AND SAMPLE SITES samples had an ammonium content below the threshold No. Sample site location Sample No. value, with the exception of water from a dug well in Paya- 1 Banjarmasin City 1-6 kumbuh, which had an ammonium content of 2 mg/l. 2 Payakumbuh City 7 - 14 3 Malang City 15 - 31 Biochemical processes in water bodies such as nitrification 4 Lamongan District 32 - 38 lower the pH level of the water. The ideal pH value is 7 5 Tangerang District 39 - 44 (neutral), and the acceptable range is between pH 6.5 and pH 8.5. The pH level of almost all the water samples was within the acceptable range, except for the water samples Figure 13 shows that water turbidity was generally below from Batang Lampasi River in Payakumbuh and spring wa- the maximum set by law, with the exception of the samples ter from Karangan River in Malang. from a dug well from Payakumbuh and of surface water in Lamongan, which had turbidity in excess of 200 NTU. All Biochemical oxygen demand (BOD) and chemical oxygen surface water samples contained high levels of nitrate. demand (COD) are parameters indicating the existence of 38 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene Figure 14 presents the COD and BOD readings. Again, defecate in hanging latrines over rivers. Hence, the rates of all surface water samples had BOD and COD readings in open defecation in these field sites is high. excess of the legal maximum. Despite these views, using rivers for latrines and dispos- Figure 15 shows the extent of isolation of sewage at the ing of household wastewater has unarguably led to serious field sites. Use of non-flush latrines (over rivers, ponds or surface water pollution. This not only damages the envi- ditches), hanging latrines, defecation in bushes, wrap and ronment, but also spoils the scenery. Cleaning up rivers is throw are categorized as open defecation. Many people in becoming a major concern to governments and communi- Payakumbuh, Lamongan and Tangerang still defecate in ties. In a metropolitan areas such as Jakarta, deterioration hanging latrines over rivers or ponds to feed their fish. In of water quality resulting from disposal of solid waste and Banjarmasin and Tangerang, people living on riverbanks domestic wastewater in rivers means that water supply utili- ties have to spend more on water treatment. FIGURE 13: TURBIDITY AND NITRATE CONTENT READINGS FIGURE 14: BOD AND COD READINGS 140 25 120 20 100 80 15 60 10 40 5 20 0 0 10 20 30 40 50 0 5 10 15 20 25 30 35 40 Turbidity (NTU) Nitrate (mg/liter) Turbidity maximum limit (MoH Decree-NTU) COD (mg/L) COD limit (Government Regulation) Nitrate maximum limit (Government Reg) BOD (mg/L) BOD limit (Government Regulation) FIGURE 15: EXTENT OF ISOLATION OF HUMAN EXCRETA IN FIELD SITES Lamongan Tangerang Banjarmasin Malang Payakumbuh 0% 20% 40% 60% 80% 100% Not isolated Not isolated Partial isolation Partial isolation Full isolation flush to water dry pit wet pit www.wsp.org 39 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene 4.2.3 HOUSEHOLD WATER ACCESS AND be higher than in rural areas. This may be because people TREATMENT COSTS living in urban areas purchase water from vendors or, where One of the major impacts of polluted water sources such access to wells is restricted, from well owners. People living as wells, springs, rivers and lakes is that it requires more in rural areas, however, have greater access to land to make intensive water treatment, which increases costs for human dug wells. Access to piped water in rural areas is almost zero activities. According to the national development planning because they are not covered by water supply utilities. agency, BAPPENAS, for every 1 mg/liter additional BOD concentration in a river from which water supply utilities Figure 18 presents a data summary of the responses by source water, average water treatment cost increases 25%.18 households to the question about the characteristics of poor As well as causing financial loss, pollution of rivers and lakes quality water, for three major water sources in rural and ur- also spoils the scenery and adversely affects aquatic life. ban areas. Respondents mentioned that non-piped protect- Accessing cleaner water from other, more distant sources ed water has the best quality for daily water consumption, increases the access costs to households and water supply especially in urban areas. Less than 10% of respondents us- utilities. Households that do not take precautionary mea- ing non-piped protected water in urban areas complained sures to treat their drinking water are exposed to higher risk about bad appearance, and less than 5% complained about of infectious disease or poisoning due to the chemical con- bad smell, bad taste, and solids content of their water. In tent of the polluted water. Figure 16 shows household water rural areas, the characteristics of non-piped protected wa- sources (primary sources of drinking water). Piped water ter appear to be adequate, except for solids content (tur- service coverage is currently only available in urban areas. bidity), with which almost 15% of the respondents were dissatisfied. Respondents in urban areas are generally not According to the household survey, average monthly cost satisfied with their water, mainly because of its poor appear- of accessing water costs per household ranges from US$0 ance; while for those in rural areas, the greatest concern was to US$1 for rural sites and US$0 to US$3.62 for urban about the solids content (22% of respondents). Piped water sites. Zero payment is for unprotected water sources, as us- in urban areas appears to provide no guarantee of better wa- ers can access the water free of charge (Figure 17). The aver- ter quality, as about 15% of respondents were not satisfied age monthly cost of accessing water in urban areas, even with the turbidity of their water. for non-piped water (protected and unprotected), tends to FIGURE 17: WATER ACCESS COSTS, MONTHLY AVERAGE FIGURE 16: MAIN HOUSEHOLD WATER ACCESS (%) PER HOUSEHOLD 80 4.0 Average monthly water source cost (US$) 70 3.5 Household main water access (%) 60 3.0 50 2.5 40 2.0 30 1.5 20 1.0 10 0.5 0 0.0 Rural sites Urban sites Rural sites Urban sites 18 ISSDP Advocacy Materials, Sanitation Development Technical Team (TTPS) of the National Development Planning Agency (BAPPENAS), 2007. 40 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene 4.2.4 HOUSEHOLD RESPONSE TO POLLUTED rural households use protected or unprotected wells as their WATER, AND RELATED COSTS main source of water. The ways in which households respond to polluted water sources vary from changing their water seller (if they pur- The results of the survey indicate that people in both urban chase water) to walking further to get free water, or treating and rural areas consider water quality, quantity and cost to their water. In urban areas, households tend to switch to be equally important. Water quality indicators consist of piped water – if available and affordable – harvest rainwater, better taste, less turbidity, clearer color and safer for health, purchase bottled water, and bring in water tankers. For dai- and the indicator of water quantity is continuous water ly consumption, about 40% of the respondents in urban ar- supply. In rural areas, people prefer to use protected water eas use piped water, while less than 1% of rural respondents sources than unprotected ones because the water is better enjoy this privilege. The vast majority (more than 90%) of quality and safer for health. FIGURE 18: CHARACTERISTICS OF POOR QUALITY WATER CITED BY RESPONDENTS Bad appearance Bad smell Piped water Bad taste Contains solids Any Bad appearance Non-piped protected Bad smell Bad taste Contains solids Any Bad appearance Bad smell Unprotected Bad taste Contains solids Any Rural 0 5 10 15 20 25 Percentage of respondents Urban www.wsp.org 41 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene As well as the various ways of coping with polluted water, about all aspects of their water sources, including water the respondents also practice water treatment. The house- quality, water supply continuity and availability, and time hold survey found various water treatment practices: more savings accessing the water. than 80% of the respondents said that boiling water is their most regular method treating water, although the propor- Figure 20 presents the respondents’ answers to the question: tion of respondents doing so is slightly higher in urban “Have you changed your water treatment practices since areas than in rural areas (Figure 19). Boiling water before improved latrines have been installed?�. In all almost sites, drinking is customary and people believe that raw water more than 80% of respondents stated that they had not is not potable. Therefore, households are used to boiling changed their water treatment practices. The only exception water (except bottled water) at home for drinking, even if was in Tangerang, where more than 60% of respondents their water is of good quality. had not changed their water treatment practices. The re- sponses are closely linked to the main method of treating A new market for drinking water is emerging in urban and water (boiling water). As noted above, except in the case rural areas. Small-scale enterprises process raw water into of ready-to-drink bottled water, households would not stop drinking water packaged in 19-liter bottles. The raw water boiling water at home regardless of whether they have bet- is sourced from water tankers supplied by the local water ter quality water. supply utility or from bore wells or dug wells. The water is treated using a serial filtering system and disinfected us- 4.2.5 HOUSEHOLD WATER COSTS AVERTED ing ultraviolet, ozone, or reverse osmosis, or a combination FROM IMPROVED SANITATION thereof. Consumers can bring their own gallon jars to the Table 22 shows the effect of sanitation improvement on the treatment plant to be refilled, or have the water delivered costs of accessing water sources and on the costs of water to the home. At around US$0.3 per gallon, this water is treatment. Household water treatment costs are higher than much cheaper than branded ready-to-drink bottled water water access costs in all study sites. In Banjarmasin, the city from large water producers, which costs US$1.1 per gallon. with many rivers, households spend significantly more on The government has set quality standards for the treatment treating and accessing water compared with the other study methods as well as quality of the treated water. Hence, these sites. two types of bottled water are commonly perceived to be of the same quality. Annual average costs averted per household are calculated based on the assumption that after total improved sanita- The way households source their water suggests that people tion, boiling water is not theoretically necessary anymore in urban areas are more concerned than rural households and a cheaper treatment method can be used instead. How- FIGURE 19: HOUSEHOLDS WATER TREATMENT, BY METHOD AND RURAL/URBAN LOCATION Boiling Settle to reduce suspended solids Filtering cloth Nothing Mechanical �ltering device Rural 0% 20% 40% 60% 80% 100% Urban 42 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene FIGURE 20: CHANGE IN WATER TREATMENT PRACTICES SINCE IMPROVED LATRINES HAVE BEEN INSTALLED Lamongan Tangerang Banjarmasin Malang Payakumbuh 0% 20% 40% 60% 80% 100% Have you changed your water treatment practices since improved latrines have been installed? Yes No No answer Do not know TABLE 22: WATER ACCESS AND HOUSEHOLD TREATMENT COSTS INCURRED AND AVERTED (US$) Annual average costs saved per household following Annual average costs per household Variable 100% sanitation coverage Water source access Water treatment Water source access Water treatment Lamongan 6 14 1 1 Tangerang 8 15 1 1 Banjarmasin 12 34 2 11 Malang 8 21 1 3 Payakumbuh 10 23 1 2 ever, given that very few households appear to be willing TABLE 23: WATER USES AND IMPACTS OF POLLUTED WATER to change their water treatment practices, a conservative estimate for change in household practices is made. Table Water use Impacts of polluted water 22 shows that the annual costs averted per household range Water treatment Increased production cost companies from US$2 to US$13 following total improved sanitation. Fish farming Additional pre-flow water treatment before entering fish ponds 4.2.6 WATER USE COSTS IN NON-DOMESTIC Factories Increased water treatment cost ACTIVITIES for operational purposes and for As well as for drinking, washing, bathing and cooking, wa- employees’ use ter is also crucial for other daily activities in households and Restaurants and Additional water treatment cost to hotels ensure water for cooking is clean communities. In rural areas, these include water for irriga- tion, for agriculture and livestock and fish farming, and in urban areas include water for offices, factories, and so on. cost is passed on to consumers, or covered by the local gov- Where sanitation is poor, water treatment companies have ernment budget. Table 23 presents the impacts of polluted to pay more to treat the water, although in most cases this water on water use. www.wsp.org 43 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene The impact of poor water quality on these productive ac- have to queue longer to access a toilet if they use shared tivities has an economic value. For example, a 1 mg/liter or community toilets, compared with those in rural areas. increase in BOD in a river that is a source of raw water In case of open defecation, people in rural areas generally for a water supply utility will increase in average national have more places for defecation available to them and find water production cost by 25%. The impacts on businesses it easier than urban dwellers to find “a private site� for def- are presented in the section on National Impacts in Chapter ecation. Urination is excluded from the calculation and it 5. Impacts on agriculture have not been examined because is assumed that defecation takes place once a day, hence the this was outside the scope of this study. access times are a minimum and the estimates of time sav- ings conservative. 4.3 ACCESS TIME 4.3.1 ACCESS TIME AND TIME SAVED Figure 23 shows the proportion young children under five Figure 21 presents the main places of defecation of house- defecating outside the household plot. The average number holds in rural and urban areas. Compared with urban dwell- of events is between 1 and 2 per day. In general, the pro- ers, a higher proportion of rural dwellers use a neighbor’s portion is more than 70%, except in Banjarmasin where it toilet. Conversely, a larger proportion of urban households is 65%. This figure indicates that the majority of children use their own plot than use a neighbor’s toilet. Patterns tend under five years old, whether or not the family has own to be similar for men, women and children. toilet, go outside the household plot to defecate. In Banjar- masin, the percentage of young children defecating outside Figure 22 shows that, compared with people in rural ar- the household plot is lower, and the number of defecation eas, people in urban areas who do not have a toilet need events per day is higher, compared with the other study more time to access a toilet or a place for defecation. The sites, because the many rivers flow through Banjarmasin higher population density of urban area means that people provide children with a place do defecate close to home. FIGURE 21: PLACE OF DEFECATION OF HOUSEHOLDS WITHOUT THEIR OWN TOILET Neighbor Women Own plot Outside plot Neighbor Men Own plot Outside plot Neighbor Children Own plot Outside plot 0 10 20 30 40 50 Rural Proportion of those with no own toilet using different places (%) Urban 44 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene 4.3.2 TIME SAVING AND UNIT VALUES OF TIME People who defecate in the open or use public toilets gener- Figure 24 summarizes the respondents’ level of satisfaction ally spend a long time queuing or finding a private place with the proximity of their place of defecation and how to defecate. Even people living near rivers that they use for important proximity is to them. In both rural and urban defecating prefer to get the best spot with the cleanest wa- areas, having a place to defecate within their own plot is ter, which means getting up and going to the river early in important. Those who do not have their own toilet are not the morning. Hence, this is time saved for households that satisfied with the proximity of, and the access time associ- have their own toilets. Table 24 presents the results of focus ated with, their current place of defecation. Time saving, group discussions, comparing male and female perceptions which is closely related to toilet proximity, has a value. of the convenience of and time savings from having a pri- vate toilet. FIGURE 22: TIME SPENT ACCESSING TOILET FOR THOSE WITH NO TOILET, PER TRIP Rural Women Urban Rural Men Urban Rural Children Urban 0 1 2 3 4 5 6 7 8 Time per trip and waiting (minutes) FIGURE 23: DEFECATION OUTSIDE THE HOUSEHOLD PLOT FOR CHILDREN UNDER FIVE YEARS Number of times per day 0 1 2 3 4 5 Lamongan Tangerang Banjarmasin Malang Payakumbuh 0 20 40 60 80 100 % Outside plot FIGURE 24: PREFERENCES RELATED TO TOILET PROXIMITY FOR THOSE WITHOUT A TOILET (%) Current proximity cited as satis�ed or very satis�ed Current toilet saves time Proximity is important 0 20 40 60 80 100 Rural Urban Proximity for those who have no toilets (%) www.wsp.org 45 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene TABLE 24: MALE AND FEMALE PERCEPTIONS ABOUT TIME 4.3.3 TOTAL VALUE OF TIME SAVED SAVING Time is saved when people use their own toilets as they do Male preferences Female preferences not have to look for safe places to defecate in the open nor • No need for queuing and • Spend less time than going spend time waiting or queuing to go to the toilet. Hence, save more time to public toilets or OD they spend less time going to the toilet. The value of time • Spend more time for more • Take better care of their saved is calculated in the cost-benefit analysis. productive activities under-five children and babies, as well as their cooking The ESI Phase 1 Study calculated on a national scale the • Children need toilet any time lost from using unimproved sanitation by having to time. They want to defecate make trips to defecate in the open or waiting to use shared without going too far latrines. The population – 10% using shared toilets and 15% practicing open defecation, equal to 25% of house- holds – was assumed to experience suboptimal access time. Figure 25 shows how female respondents would spend the For these households, open defecation was assumed to re- extra 30 minutes a day if they had a private toilet, selected quire 15 minutes per day extra to find a secluded spot for from ten activities listed in the questionnaire. Bathing and defecation, while for shared latrines the extra time queuing washing, which women prefer to do in privacy, are activities varied from 15 minutes in rural areas to 30 minutes in ur- that are closely linked to toilet ownership, while resting and ban areas. It was also assumed that access time in urban ar- cooking are activities that women would spend more time eas in Indonesia is relatively long because toilets are shared doing if they had their own toilet. This suggests that women with many people, and because it is common for people who do not have private toilets have less time to spend rest- to wash themselves while in the latrines, thus prolonging ing and cooking because they spend more time doing other queuing time. time-consuming activities, including going to the toilet. The FGDs revealed that the majority of men – especially The ESI Phase 2 Study also calculated time lost, on indi- those living in urban areas – would use the time saved to vidual basis as well as household basis, based on the house- do business. A similar pattern in the use of time saved was hold survey findings. Compared with those in the other indicated across rural and urban sites, with ‘bathing’ (per- field sites, households in Tangerang and Malang spent more sonal hygiene) and ‘resting’ ranked top of the list of activi- time going to places to defecate in the open or in toilets ties people would do if they had an extra 30 minutes a day. outside their plots. The average time spent making trips to FIGURE 25: HOW FEMALE RESPONDENTS WOULD SPEND AN EXTRA 30 MINUTES A DAY (%) Bathing Taking a rest Washing Cooking/Help cooking Shopping Business 0 20 40 60 80 100 Rural Urban 46 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene and/or waiting to defecate in these two sites was more than their own plot area) regularly. 8 minutes per round trip, compared with 6 minutes in the • A HH that uses communal toilets incurs some access other sites. Hence, the value of the potential time saving of time costs (US$X1) but still saves (US$X - US$X1) having private toilets is greatest in Tangerang and Malang. by not defecating in the open. • A HH that uses shared toilet incurs some access time Table 25 shows the average time lost per household per day costs (US$X2) lost but still saves (US$X - US$X2) at each field site. Similar to the results of ESI 1 study, these by not defecating in the open. figures constitute the average time lost per household mem- ber per year, as depicted in the Figure 26. A household that Figure 27 shows the average annual value of time savings shifts from open defecation to using a private toilet has the per household and household member, for households greatest potential time saving. without a private toilet that receive their own toilet. FIGURE 27: AVERAGE ANNUAL VALUE OF TIME SAVINGS TABLE 25: AVERAGE TIME LOST PER HOUSEHOLD PER DAY (US$) Average time lost per Study sites household per day (minutes) Lamongan Lamongan 33 Tangerang 115 Tangerang Banjarmasin 46 Banjarmasin Malang 77 Payakumbuh 40 Malang FIGURE 26: AVERAGE TIME LOST PER YEAR PER HOUSEHOLD MEMBER (HOURS) Payakumbuh Lamongan 0 20 40 60 80 100 Adult Children Children Tangerang 5-14 years old under �ve years old Banjarmasin 4.4 INTANGIBLES Malang In the absence of studies examining the intangible aspects of sanitation in Indonesia, the data presented here are en- Payakumbuh tirely from field work conducted as part of the ESI Phase 2 study. The data are from two main sources: a close-ended 0 100 200 300 400 500 600 700 800 household questionnaire, which was answered by the most Adult Children Children senior household member available for interview, and focus 5-14 years old under �ve years old group discussions (FGDs). At each of the five main sites, three FGDs were conducted with three groups of eight: Assuming that the value of time saved per year is equiva- one group of women, one group of men, and one group of lent to 30% of the average annual income of an adult and stakeholders (health office officials, NGOs, and community a child’s time is worth half that of an adult’s, the average or informal leaders). annual value of time saved per household member and per household is as shown in Figure 24. Calculation of the an- These two surveys collected perceptions, opinions, and nual value of time saved uses the economic loss (in US$) of preferences from a representative section of the communi- open defecation as the baseline. Such that: ties (see section 2.3 for methods and sampling approach). • A household (HH) can save a certain amount of Four sets of results are described here: (a) understanding of time – valued in monetary terms (US$X) – if the what sanitation is; (b) reason for current sanitation option; individuals in the HH use a private toilet (within (c) satisfaction with current sanitation option; and (d) for www.wsp.org 47 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene those without toilets, reasons to get a toilet, characteristics - Problems associated with defecating when it is rain- of a toilet, and willingness to pay for improved toilet. ing or at night - Dirty environment around the toilet area because In general, respondents have a good understanding of what the facilities are not kept clean sanitation is, although in some focus groups, their under- - Accidents in unstable toilets standing was limited. They perceive sanitation as something - When busy cooking, women worry if their young that has to do with toilets, wastewater disposal, solid waste, children leave the house to go to the toilet drainage, and environmental health. Their knowledge of sanitation ladders varies according to the sanitation ladder These are not issues for people who have their own toilet options that are available locally. For instance, respondents inside their house. in Payakumbuh and Lamongan were very familiar with dry pits, wet pits and septic tanks, but had little knowledge Respondents across the field sites held these general percep- about sewerage systems. Respondents in Banjarmasin are tions of their sanitation situation: very familiar with almost all the options on the sanitation • It is the norm, and there is no reason to change the ladder because a wide range of these options are available habits of generations. Hence, they have no awareness locally, including community toilets, shared toilets, private of what are good and bad sanitation practices. dry pit, private wet pit, private septic tank, and sewerage • Due to financial constraints, sanitation is not high systems. on their list of spending priorities. • They believe that diseases caused by poor sanitation, The FGDs revealed that land availability is an issue in urban such as diarrhea, are not serious and can be self treat- areas but less so in rural areas. People in urban areas per- ed with readily available over the counter medicines. ceived the provision of toilets in public places as important due to the lack of space available for private toilets on their The FGDs revealed that the opinions of men and women own plots. People in rural areas tend to perceive that provi- about having their own toilet differed in some respects, sion of toilet in public places as unimportant because land as shown in Table 26. Women are more concerned about for building toilets is readily available, and many house- safety, for themselves and for their children, while men are holds have their own toilets, albeit a simple dry or wet pit more concerned about practicality (proximity of the toilet). latrine. In rural areas, problems can arise when a household However, men and women did share the same opinions unknowingly digs a well close to a pit latrine currently or about access time and cleanliness. previously used by a neighbor. Hanging toilets on rivers or ponds are common in all the Most parents of schoolchildren entrust provision of school field sites. As well as being practical and comfortable, peo- toilets to the school principal, and they believe that the toi- ple defecate in these toilets to feed their fish in the ponds. let facilities in schools are satisfactory. Using a hanging toilet on a river means there is no need to flush as the feces are washed away by the river. Respondents Intangibles for households without their own toilets in- also said that because these toilets are in the open air, they clude: are able to breathe more easily and there are few or no un- - Feeling uncomfortable and insecure, and lack of pri- pleasant odors. vacy - Feeling ashamed being seen by others when defecat- However, the respondents did mention several drawbacks ing of using hanging toilets, including : - Dirty toilet bowls • The risk of accident, especially for children and el- - Long queuing times derly using the toilet at night or in the rainy season - Having to bring water with them to cleanse them- • Lack of privacy selves after defecating • The time taken to go from the house to the toilet. - Wet and muddy paths to the toilets Women are concerned about leaving their house- 48 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene hold chores, such as taking care of their children and Respondents were asked about their level of satisfaction in cooking, to go to the toilet terms of : • toilet position Table 27 summarizes the FGD findings on the risks and • toilet cleanliness (free from dirt, smell, and insects) problems associated with using hanging toilets at the field • toilet ownership (status) sites. • being able to offer a clean facility for visitors • health (avoiding diseases related to poor hygiene and Figure 28 shows the respondents’ level of satisfaction with sanitation) their current toilets. Compared with those using unim- • avoiding conflict proved sanitation, respondents with improved sanitation • convenience for children have a higher level of satisfaction for every aspect assessed. • convenience for elderly • night use of toilet For the household interviews, the respondents were asked • use of toilet when raining to score each aspect on a scale of 1 (not satisfied) to 5 (very • using toilet for bathing as well as defecating satisfied). Visual aids were used to help the respondents ex- • avoiding attacks by dangerous animals (snakes, etc.) press their opinion of their current toilet (see Figure 29). and insect bites TABLE 26: PREFERENCES RELATED TO TOILET CONVENIENCE FROM THE FOCUS GROUP DISCUSSIONS Preferences (rural and urban unless stated otherwise) Male preferences Female preferences • Land is available, but need to ensure adequate distance from • Safe to go any time, even at night and during rainy season neighbor’s pit latrine • Offers greater privacy • A source of pride • No need to negotiate wet, muddy paths to toilets • No need to bring water for cleansing after defecation (rural) • No risks of accidents • No need to queue for public toilets or arrive early to get the best • No need to worry about children if they want to defecate spot for open defecation (rural) • No flies • Clean and comfortable facility (rural) • No need to queue for public toilets or arrive early to get the best • Environment around toilets is not dirty (rural) spot for open defecation • Can keep the facilities clean and comfortable • Environment around toilets is not dirty (urban) TABLE 27: RISK OF HANGING TOILETS Variable Payakumbuh Banjarmasin Lamongan Malang Tangerang Current Hanging toilet on a Hanging toilet on a river Hanging toilet on a Pit latrine & hanging Hanging toilet on a river toilet pond large pond toilet on a river and open defecation Toilet Simple structure - Simple structure Simple structure Open defecation in yards, quality made from bamboo made from bamboo made from bamboo rivers, fields and public or wood or wood or wood places Reasons To feed the fish In the fresh air, and water In the fresh air, and Shared toilet beside Convenient to defecate for current available to cleanse after water available a river, drains straight into a plastic bag and toilet defecating to cleanse after into river dispose of anywhere defecating Risks of Risk of accident, Need to get there before Risk of accident Having full latrine Risk of accident toilet especially the elderly others & risk of accident hole and children (once led to a death) Problems Defecating when it is Competing with others for Defecating when it is Defecating when it is Long queues with toilet raining or at night space at the river raining or at night raining or at night Lack of privacy River used for bathing Lack of privacy Never think of Dirty and washing as well as emptying septic tank defecating Women have to leave Women have to leave their Women have to leave Women have to leave Women have to leave their their children and children and cooking their children and their children and children and cooking cooking cooking cooking www.wsp.org 49 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene FIGURE 28: LEVEL OF SATISFACTION WITH CURRENT TOILET OPTION, IMPROVED VERSUS UNIMPROVED AT ALL SITES (1 = NOT SATISFIED, 5 = VERY SATISFIED). Toilet position Cleanliness Status Visitors Health Conflict avoidance Convenience for children Convenience for elderly Night use of toilet Avoid rain Avoid dangerous animals Unimproved 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Improved Figure 29 is an example of the visual aids used during the reason for not having their own toilet was lack of space, household interviews to answer the question: “How satis- particularly for those living in densely populated areas. fied are you with your current sanitation option with regard to the following aspects?� Figure 31 shows which household members have the most influence in the decision whether or not to build or up- Figure 30 shows the main reasons from the focus group grade a private toilet. The respondents were senior female discussions that respondents who practice open defecation household members (wives). They had the most influence gave for not having a toilet. Across the field sites, 21% of in these decisions in only 7% of households, while in 63% all respondents had no toilet. Figure 30 shows that almost of households it was the senior male member (husband) 60% of respondents said they had no toilet because it was who made these decisions. Hence, it is the senior male too expensive. Due to financial constraints, sanitation is not household members who need to be convinced that that high on their list of spending priorities. The second main investment on sanitation is economically viable. 50 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene This information helps to answer practical questions about • 37% felt sometimes in danger and 14% often in how sanitation programs can be delivered more effectively danger, from going to defecate in the open – that is by increasing the value of benefits by raising the • 19% had heard about someone being attacked by awareness and participation of beneficiaries. It provides animals in the open defecation areas valuable input for program design and program implemen- • 72% expressed concern about the safety of their chil- tation. dren when they go to defecate in the open. Respondents who currently have no private toilet were These results indicate that safety is an issue when defecating asked about reasons they would build their own toilet if in the open. they were able to do so. Each aspect given a score ranging between 1 (not important) and 5 (very important). Intangi- 4.5 EXTERNAL ENVIRONMENT bles all scored 4 or more out of 5 ( Figure 32). The top three External environment refers to the area outside the toilet intangible benefits of having a private toilet were proximity, itself and not related to a toilet trip, and may include living cleanliness and not sharing. area, public areas, and private land, which can all be affected by open defecation practices and open conveyance of sew- Respondents who do not have their own toilets and practice age or flooding of unimproved toilets. The consequences of open defecation had the following concerns (see Table 28): water pollution have already been covered in section 4.2. FIGURE 29: A VISUAL AID IN THE HOUSEHOLD INTERVIEW 1 2 3 4 5 Not Satis�ed Less than Satis�ed Satis�ed Enough Satis�ed Very Satis�ed FIGURE 30: MAJOR REASONS FOR NOT HAVING A PRIVATE FIGURE 31: HOUSEHOLD MEMBERS THAT INFLUENCE TOILET DECISIONS ABOUT BUILDING OR UPGRADING A PRIVATE TOILET Cost is No space too high in or near 58% house Housewife 23% 7% Never been offered toilet Other facilities 13% 8% Other Not thought about it Parents 6% 6% 17% We do not Don’t want A pit toilet have a nearby to spend smells Husband water source time on too much 63% for a flush toilet cleaning 2% 2% 1% www.wsp.org 51 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene The sources of data are mainly the ESI surveys: physical lo- Figure 33 shows the scoring of the quality of environmental cation surveys, household interviews, and focus group dis- sanitation in private plots based on the household surveys. cussions. Given that poor solid waste management practice On average, almost all sites are moderately dirty, but urban and its impact on the external environment is also part of sites tend to be dirtier than rural sites. The detailed results poor sanitation, these have also been assessed to understand presented in Figure 33 show that Tangerang had the low- the contribution of each, and relative preferences regarding est score for cleanliness from solid waste, compared with their improvement. the other sites. Malang scored highest in all categories com- pared with the other sites, which is also consistent with the Physical location surveys were conducted in 5 study sites: qualitative environmental assessment. • Payakumbuh is located in a hilly area of West Suma- tra. Most of the residential areas of the city are not Even households that have improved toilets may continue densely populated. The city has a functioning public practicing poor sanitation behaviors. Figure 34 shows sani- cleaning service which is organized by the local mu- tation practices for households that have a toilet. While very nicipal government. Almost no piles of garbage were few household members practice open defecation, in some found along the tributaries. sites – notably Tangerang and Payakumbuh – people still • Tangerang District has an inadequate garbage collec- urinate in the open, dispose of feces in hanging toilets, and tion service, so garbage is piled up everywhere. The dispose of children’s stools in the environment. As revealed district has many public toilets. during the FGDs, some people in Payakumbuh prefer to • Lamongan District has well maintained residential defecate in hanging toilets in order to feed their fish (as well areas. Like most rural areas, population density is as preferring the open air and absence of bad smells). low. Housing is well maintained. • Malang city is in good physical condition. Garbage Figure 35 summarizes the responses of households that use is collected by the city cleaning service. Housing is septic tanks and pits to the question: Has your septic tank well maintained. or pit ever been emptied? The majority of the respondents – • Banjarmasin city is located in a low plain near the more than 90% in in Lamongan and Tangerang – said they estuary of Barito river. The external environment is had never emptied their septic tank or pit. In Malang and poor. Many households dispose of their solid waste Payakumbuh, between 30% and 40% of respondents stated into the rivers. that they did not know whether their septic tanks had ever FIGURE 32: REASONS TO GET A TOILET FOR THOSE CURRENTLY WITHOUT (1 = NOT IMPORTANT, 5 = VERY IMPORTANT) Proximity Clean Not sharing Privacy Non-pollution Comfort 0 1 2 3 4 5 52 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene been emptied, mainly because they had just recently moved that run through the city for washing, bathing and defecat- into the property. It is likely that septic tanks that have been ing. emptied are wet pit latrines, which are not waterproof and could potentially pollute the groundwater. Perceptions of the condition of the external environment are shown in the Figure 37. Again, respondents scored this Figure 36 shows how satisfied households are with their cur- aspect on a scale of 1 (not satisfied) to 5 (very satisfied). In rent toilet option with regard to its perceived impact on the general, they perceived the condition of the external envi- external environment. For all categories, the respondents ronment to be good. The FGDs revealed that open defeca- are, in general, fairly satisfied with their current option. In tion areas are perceived to be dirty. While urban sites score general, there is no significant difference in the levels of sat- slightly higher than rural sites, there was little difference isfaction for sewerage, septic tank and wet pit latrine. between the perceptions of households with improved sani- tation and those without, except regarding the presence of Compared with the other field sites, households in Ban- rodents and insects. jarmasin that practice open defecation were more satisfied with the perceived impact of their current toilet option on 4.6 SUMMARY OF LOCAL IMPACTS the environment. As discussed elsewhere in this report, Table 29 summarizes the local quantitative and qualitative these households see nothing wrong with using the rivers benefits of improved sanitation and hygiene. TABLE 28: CONCERNS OF THOSE PRACTICING OPEN DEFECATION Responses Concern No. responding Never Yes Have you felt in danger when going for OD? 348 50% 50% Are you worried about the safety of your children? 351 28% 72% Have you heard about someone being attacked by animals? 352 81% 19% FIGURE 33: SCORING OF THE QUALITY OF ENVIRONMENTAL SANITATION BY GENDER OF RESPONDENT ( SCORE: 5 = CLEAN, 1 = VERY DIRTY) 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 Human excreta Solid waste Human excreta Solid waste Women Men Malang Lamongan Payakumbuh Banjarmasin Tangerang www.wsp.org 53 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene FIGURE 34: UNIMPROVED SANITATION PRACTICES BY HOUSEHOLDS THAT HAVE TOILETS Open defecation Open urination Disposal of child stool in environment Disposal from hanging latrine 0% 10% 20% 30% 40% 50% 60% Proportion of HH with toilet with unimproved sanitation practice Lamongan Tangerang Banjarmasin Malang Payakumbuh FIGURE 35: EMPTYING OF SEPTIC TANKS AND PITS (%) Lamongan Tangerang Banjarmasin Malang Payakumbuh 0 20 40 60 80 100 Has the septic tank or pit ever been emptied while you have had it? (%) Yes No Do not know 54 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene FIGURE 36: LEVEL OF SATISFACTION WITH IMPACT OF CURRENT TOILET OPTION ON THE QUALITY OF THE EXTERNAL ENVIRONMENT (SCORE: 5 = VERY SATISFIED, 1 = NOT SATISFIED) Sewerage Septic tank Wet pit latrine Dry pit latrine OD 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Households’ satisfaction level Lamongan Tangerang Banjarmasin Malang Payakumbuh FIGURE 37: PERCEPTIONS OF THE EXTERNAL ENVIRONMENTAL (SCORE: 5 = VERY GOOD, 1 = VERY POOR) Rubbish Sewage Smoke Dirty Rodents Insects 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 External environment perceptions Rural improved Rural unimproved Urban improved Urban unimproved www.wsp.org 55 Economic Assessment of Sanitation Interventions in Indonesia | Local Benefits of Improved Sanitation and Hygiene TABLE 29: SUMMARY OF LOCAL IMPACTS OF SANITATION IMPROVEMENT Benefits of improved sanitation and hygiene Benefit Quantitative benefit Qualitative Benefit HEALTH Health burden/quality Rural sites: • Less pain and suffering of life • Disease per household: 18 cases • Reduced inconvenience of lost time • DALYs: 0.12 • Parents worry less and take less time off productive • Annual risk of death: 1.88 in 1,000 activities to care for sick children Urban sites: • Disease per household: 13 cases • DALYs: 0.06 • Annual risk of death: 2.19 in 1,000 Health care benefit per Rural sites: Households do not need to spend so much on health care person per year • 0-4 years: US$151.34 and health-seeking costs • 5-14 years: US$43.62 • 15 + years: US$16.65 Urban sites: • 0-4 years: US$36.70 • 5-14 years: US$18.50 • 15 + years: US$8.50 Productivity benefit per Rural sites: People are more productive when they are healthy and are person per year • 0-4 years: US$19.86 more willing to pay to be healthy • 5-14 years: US$14.11 • 15 + years: US$16.02 Urban sites: • 0-4 years: US$8.17 • 5-14 years: US$6.60 • 15 + years: US$6.96 Mortality benefit per Rural: US$19.86 People become more aware of the risks of sanitation when person per year (only Urban: US$8.17 they understand the links, and are more willing to pay to save under-five children) lives WATER Overall quality Better quality and more aesthetically pleasing environment Average costs saved per Rural: US$2 Better water quality: better taste, less turbidity, better color, household for domestic Urban: US$6 and safer; continuous water supply at affordable price uses Non-domestic uses Preventing an increase of BOD by 1 mg/liter in a source Reduced costs to obtain clean water for other productive of raw water for clean water company will avoid 25% activities such as livestock and fish farming, factories and increase in national average clean water production costs restaurants ACCESS TIME (annual value Rural: US$60 • Adults have more time for more productive activities of time savings) Urban: US$52 • Children can go to the toilet any time without having to go far and spending a lot of time INTANGIBLES • Respondents with improved sanitation have a higher • Private toilets eliminate queuing level of satisfaction (more than 70%) for every • Women take better care of their children and babies, as assessment aspect than those without unimproved well as their cooking sanitation (average 50%) • Safe to go any time, especially at night and during rainy • No need to be concerned about the safety of season their children when they go to defecate (72% of • Having more privacy and pride respondents) • No wet (slippery) and muddy path along the way to toilets • Reduced risk of accidents • No need to worry about children if they want to defecate • No flies • No need to go earlier to queue for the public toilets or get a good spot for open defecation • Can keep the facilities clean and comfortable • No dirty environment around toilets EXTERNAL ENVIRONMENT • Improved sanitation areas have higher scores of No dirty environment and unpleasant odors around living perception on environmental sanitation states than areas, public areas, and private land unimproved sanitation areas • Also have higher level of satisfaction with the external environment 56 Economic Assessment of Sanitation Interventions V. National Benefits of Improved Sanitation and Hygiene This chapter presents the potential impacts of improved ‘high-value’ tourists, i.e. those who are willing to pay more sanitation on: for their holiday. Currently foreign tourists spend on aver- • Tourism (section 5.1) age US$137 per day and stay for an average 8.6 days, giving • Businesses and foreign investment (section 5.2) average revenue per tourist visit of US$1,180. • Sanitation markets (section 5.3) • National health (section 5.4) The ESI Phase 2 study attempts to explore the impacts of • National water resources (section 5.5) the sanitary condition of the country generally, and tourism resorts specifically, on tourists’ preferences to visit Indonesia 5.1 TOURISM and recommend Indonesia to their family and friends when Tourism is an important economic activity in Indonesia and they return home. As well as tourists going on holiday, busi- provides a significant source of foreign exchange revenues. ness visitors were also included. A total of 144 holiday tour- In 2008, it provided US$7.4 billion of revenue, the third ists and 110 business visitors were interviewed in Soekar- highest contributor of foreign exchange revenues, after oil no-Hatta international airport at the departure gate before & gas and palm oil. It also provides an important source of leaving Indonesia. The survey was conducted in English local government tax income, as well as jobs for 6.7 million and was also available in Malay to include more Asian tour- Indonesians19. ists. It took 10 days to reach the target sample population of 250 visitors. Tourists were approached and explained the In 2008, Indonesia was visited by almost 6.5 million foreign purpose of the survey. If they agreed, they would be given a visitors, which was a significant increase from 4.8 million questionnaire form to fill out. On average, each respondent foreign visitors in 2006 and 5.5 million visitors in 2007. took about 10 to 15 minutes to complete the questionnaire. The tourist industry is expected to grow by 6.4% annually from 2008 to 201520. Table 30 shows the profile of the respondents of the busi- ness and tourism survey. The preference of tourists to choose Indonesia for their hol- iday destination is influenced by many factors. One set of On average, tourists rate their enjoyment at between 3.0 factors is related to the sanitary conditions of the country, and 3.5, out of a maximum score of 5.0, while visiting such as the quality of water resources, quality of outdoor places such as Jakarta, historical/temple sites, beaches, and environment (cleanliness and freedom from unpleasant natural or forest areas (Figure 38). Most of the respondents odors), food safety and hygiene, general availability of toi- who answered 1 or 2 (least enjoy) said that the historical lets offering comfort and privacy in hotels, restaurants, and site/temples and natural/forest areas that they visited were bus stations; and the related health risks of all the above. dirty and polluted. Experience shows that better sanitary conditions will attract 19 President’s speech at the opening of Visit Lombok Sumbawa 2012 and the International Ecotourism Business Forum, Mataram, West Nusa Tenggara, 6 July 2009 20 Statistical Report on Visitor Arrivals to Indonesia www.wsp.org 57 Economic Assessment of Sanitation Interventions in Indonesia | National Benefits of Improved Sanitation and Hygiene TABLE 30: BACKGROUND CHARACTERISTICS OF RESPONDENTS Australia and North Region of origin Asia Europe Africa Total New Zealand America Number of tourists interviewed 118 60 56 18 2 254 Gender (%) Male 79% 68% 54% 56% 50% 61% Female 21% 32% 46% 44% 50% 39% Average number of previous trips to 5 8 6 3 9 6 Indonesia Average length of stay of current trip 10 14 13 12 15 13 Purpose of visit (%) Tourist 46% 70% 61% 72% 50% 60% Business 54% 30% 39% 28% 50% 40% Hotel daily tariff in < 30 3% 10% 16% 6% 8% US$ 30-59 25% 10% 18% 44% 21% 60-89 34% 35% 27% 22% 32% 90-119 23% 22% 7% 22% 19% 120-149 12% 13% 16% 6% 13% 150 + 4% 10% 16% 0% 100% 9% FIGURE 38: PLACES VISITED BY TOURISTS (% RESPONDENTS) AND ENJOYMENT OF STAY (SCORE: 5 = VERY MUCH, 1 = NOT AT ALL) Enjoyment of stay score 0 1 2 3 4 5 Jakarta Historical/Temple Beaches Natural/Forest Within Indonesia 0 20 40 60 80 100 % of visitors to this place Figure 39 shows that on average, respondents perceived that In terms of toilet availability, fewer than 1% of respondents general sanitary conditions of public places, such as open said they could not find a toilet when needed. Figure 41 water and areas in the capital and other cities, to be poorer shows the sanitation issues of most concern to the respon- than those in private places, such as hotels, swimming pools, dents (3 responses per respondent). The top four concerns and restaurants. ‘High-value’ visitors who spend more than were with food, drinking water, unsanitary toilets and tap US$90 per night in a hotel said that the sanitary conditions water quality. are very good (average score is 4). This shows that in Indo- nesia sanitary conditions differ from place to place. Out of 254 respondents, there were 80 occurrences of gas- tro-intestinal illness, or 31% of respondents. More tour- Figure 40 show respondents’ perceptions of the quality of ists were sick (52 people or 36%) than business visitors toilets in airports, bus stations, and other places around the (28 people, or 26%). Out of different possible causes, both city, which were poorer than their perceptions of toilets in tourists and business visitors perceived food to be the num- private places, such as hotels and restaurants. ber one cause of gastro-intestinal illness. For tourists this 58 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | National Benefits of Improved Sanitation and Hygiene FIGURE 39: GENERAL SANITARY EXPERIENCE (SCORE: 5 = VERY GOOD, 1 = VERY POOR) open water general sanitary condition capital city other cities restaurant swimming pool hotel business tourist 0 1 2 3 4 5 FIGURE 40: SANITARY EXPERIENCE IN RELATION TO TOILETS AND HAND WASHING (SCORE: 5 = VERY GOOD, 1 = VERY POOR) city bus station airport restaurant hotel 0 1 2 3 4 5 business tourist quality of toilets in the place FIGURE 41: WHAT FACTORS WERE MOST CONCERNING? (% CITING, 3 RESPONSES PER RESPONDENT) swimming pool water currency notes public toilet tap water unsanitary toilet drinking water food 0% 5% 10% 15% 20% 25% business tourist tourism concerns www.wsp.org 59 Economic Assessment of Sanitation Interventions in Indonesia | National Benefits of Improved Sanitation and Hygiene was followed by drinking water and dirty environment, and When they were asked the reasons for their hesitance to for business visitors this was followed by water for washing return to Indonesia, almost 50% of visitors mentioned sani- and drinking water. Respondents stated that they suffered tation condition as the main factor, followed by safety and on average 3 days of symptoms and 2 days of being too un- cost (Figure 43). This is a strong indication to tourist agen- well to conduct normal activities. 35% of those sick went cies and government departments of the need to pay more to a medical clinic while 26% chose to buy medicines in a attention to improving sanitary conditions in Indonesia. shop/drug store. The remaining 39% did not seek medical care. On average, business visitors who got sick spent more 5.2 BUSINESS AND FOREIGN DIRECT on treatment (US$68) than tourists, who spent on average INVESTMENT US$25. The business survey was conducted in Jakarta and Band- ung. Jakarta was selected because it is the capital city and Most respondents said that they were willing to return to the location of many international and national companies; Indonesia (85%), while only 3% said they would not re- and Bandung because it is a major tourist destination with turn, and 13% were not sure about it. The majority of re- many international and national restaurants and hotels. spondents said they would advise friends to come (74%), Bandung is also a city with many textile factories: textiles while others said they would not advise friends to come and their related products are estimated to contribute ap- (9%), and 16% were not sure about it (Figure 42). proximately 10% to exports and are one of Indonesia’s top FIGURE 42: INTENTION OF VISITORS TO RETURN TO INDONESIA do not know to come? (%) advise friends maybe no yes do not know Indonesia? (%) maybe return to no yes 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% business tourist FIGURE 43: REASON FOR HESITANCY TO RETURN no need cost not safe sanitation 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% business tourist 60 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | National Benefits of Improved Sanitation and Hygiene ten non-oil and gas export commodities21. Also, the city ex- from excreta. Figure 45 shows the respondents’ concerns perienced a major garbage disposal problem a few years ago. about the environmental sanitation condition. They were most concerned about water pollution in rivers, followed As reported in Chapter 5.1, on average visitors rated their by the poor state of canals and rainwater drainage, poor enjoyment at around 3.0 (out of 5.0) while visiting various management of industrial solid waste, and lack of adequate places in Indonesia (Figure 44). toilets in public places. A separate survey conducted in a small selection of restau- A pleasant environment for staff – one that is clean with rants, hotels, garment factories and food processing com- good air quality and good sanitation – was a top priority panies in Jakarta and Bandung gathered opinions and pref- for companies that are considering locating their business, erences about environmental sanitation. The respondents especially for the food industry (food processing and res- were asked about the quality of river water, the state of ca- taurants). Figure 46 also shows that other important factors nals and rainwater drainage, management of sewage, man- influencing company location include workers’ health and agement of industrial wastewater, household coverage with quality of water available. As well as these factors, the de- private toilets, toilets in public places, household/office sol- velopment of the city’s infrastructure and supportive public id waste, management of industrial solid waste, air quality policies in their sector are important influencing factors. from vehicles, air quality from solid waste, and air quality FIGURE 44: PLACES VISITED BY BUSINESS VISITOR (% RESPONDENTS) AND ENJOYMENT OF STAY Enjoyment of stay score 0 1 2 3 4 5 Jakarta Historical/Temple Beaches Natural/Forest Within Indonesia 0 20 40 60 80 100 % of visitors to this place FIGURE 45: RATING OF ENVIRONMENTAL SANITATION CONDITIONS IN THE LOCATION OF THE BUSINESS SURVEY INTERVIEW (1 = BEST; 5 = WORST) air quality from vehicle air quality from excreta household coverage with private toilets household/of�ce solid waste management of industrial wastewater management of sewage air quality from solid waste toilets in public places management of industrial solid waste state of canals and rainwater drainage water quality in rivers 0 1 2 3 4 5 21 Ministry of Trade (http://www.depdag.go.id), 2009 www.wsp.org 61 Economic Assessment of Sanitation Interventions in Indonesia | National Benefits of Improved Sanitation and Hygiene FIGURE 46: IMPORTANCE OF INFLUENCING FACTORS FOR COMPANY LOCATION (1 = UNIMPORTANT; 5 = IMPORTANT) availability of cheap and good land water quality directly available from nature (rivers, lakes, ground) workers’ health pleasant air quality from staff (clean, good air quality, good sanitation) 0 1 2 3 4 5 TABLE 31: INDONESIA HOUSEHOLD SANITATION PROFILE – JMP MARCH 2010 Urban Rural Proportion Number of HH (Million) Proportion Number of HH (Million) Improved 67% 13 36% 9 Shared 9% 2 11% 3 Unimproved 8% 2 17% 4 Open Defecation 16% 3 36% 9 5.3 SANITATION MARKETS The Joint Monitoring Programme for water supply and The Government of Indonesia has set targets to make In- sanitation estimates the use of improved sanitation facilities donesia free from open defecation by 2014. It means that in Indonesia (the March 2010 update reports 2008 figures). households that still practice open defecation will have to A summary of coverage rates and populations benefitting use toilets, either private, shared or community toilets. The is shown in Table 36. These figures serve as the baseline to number of households practicing open defecation accounts calculate the total potential market size to achieve the PPSP for a major share of the overall sanitation market potential. target by the end of 2014 with additional costs of moving The calculation of the sanitation market size is based on the up from shared and unimproved toilets to private toilets following assumptions: with septic tank. • The market potential covers initial investment costs (sanitation material as well as related services such as According to the above assumptions and the sanitation pro- mason services) and annual maintenance costs. file (Table 31), the total potential sanitation market size is • The initial sanitation ladders consist of moving from 16.67 million new toilet units, which are worth US$17.3 open defecation or an unimproved or shared toilet, billion. This figure includes new toilet investment costs to an improved private toilet with septic tank. of US$16.8 billion and cumulative maintenance costs of • The unit price of a septic tank is adopted from the US$500 million from 2008 until 2014. Figure 47 shows “Sanitation System & Technology Option Refer- the market size projection, assuming equal coverage gains ence Book – TTPS, 2010�, which is US$1000 for in each year until 2014. For planning and budgeting pur- a private toilet with a technically standardized septic poses, it will be necessary to select sanitation technologies tank. and models that are affordable and demanded by the popu- • The annual maintenance cost is the average annual lations they serve – the actual unit costs may be lower than maintenance costs of private toilet found in study these values (especially in rural areas) or indeed higher, for sites (see Chapter 6). more advanced sewerage and treatment systems in large, densely-populated and higher-income urban centers. 62 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | National Benefits of Improved Sanitation and Hygiene FIGURE 47: PROJECTION OF INDONESIA SANITATION MARKET SIZE (US$ MILLION) 2014 2013 2012 2011 2010 2009 2008 investment costs 0 500 1,000 1,500 2,000 2,500 3,000 maintenance costs 5.4 HEALTH The ESI Phase 1 Study reported that poor sanitation and TABLE 32: ESTIMATED NUMBER OF ANNUAL CASES AND hygiene caused significant burden of disease in Indonesia DEATHS ATTRIBUTED TO POOR SANITATION AND HYGIENE, 20061 through illness and premature death. Table 32 shows the Disease Morbidity (cases) Mortality (deaths) estimated number of episodes and deaths attributed to poor DIRECT DISEASES sanitation for these selected diseases: diarrheal diseases, hel- minthes, scabies, trachoma, hepatitis A, hepatitis E, malnu- Diarrheal disease 89,417,461 22,880 trition and other diseases related to malnutrition. Helminthes 1,054,048 56 Scabies 28,659,082 583 Using the national DHS data as a data source, it is esti- Trachoma 174,079 - mated that 89 million cases of diarrhea were attributed to Hepatitis A 715,330 702 poor sanitation and hygiene,22 while 28 million cases of Hepatitis E 23,770 21 scabies were estimated to be attributed to poor hygiene Sub-total 120,043,770 24,242 practices. The national health information system report- INDIRECT DISEASES RELATED TO MALNUTRITION AMONG ed that 3 million malnourished children, a million cases CHILDREN UNDER FIVE YEARS of helminthes, and an additional 1 million cases of illness Malnutrition 3,073,220 na related to malnutrition, are attributed to poor sanitation ALRI 1,066,935 8,049 and hygiene. Other studies suggest significantly higher rates Malaria 87,818 1,887 of disease than those reported by government records. In Measles na 3,528 East Asia, helminthes are cited to have the prevalence rate Other na 11,282 of 36% (roundworm), 28% (whip worm) and 26% (hook worm), which would lead to more than fifty million cases. Protein energy na 1,144 malnutrition Three million malnourished children may also be a signifi- Sub-total 4,227,973 25,890 cant underestimate, in a country where 28% (5.4 million) Total 124,271,743 50,132 of the under-five children are estimated to be severely or moderately underweight. 1 Economic Impacts of Sanitation in Indonesia. A five-country study conducted in Cambodia, Indonesia, Lao PDR, the Philippines, and Vietnam under the Economics of Sanitation Initiative (ESI) Phase 1, The total number of deaths attributed to poor sanitation Research Report, WSP-EAP, World Bank Office Jakarta, August 2008. and hygiene exceeds 50,000, of which 24,000 are account- ed for by direct diseases (mainly diarrhea) and 26,000 by 22 Estimated using data from the National DHS 2007 which collected diarrheal incidence rates for the under five population (2.5 cases per child per year). www.wsp.org 63 Economic Assessment of Sanitation Interventions in Indonesia | National Benefits of Improved Sanitation and Hygiene indirect diseases related to malnutrition. These latter deaths treated human excreta into water bodies (rivers), producing include only under-five children and therefore underesti- around 4,400 tons phosphorous per year in these rivers. A mate the total deaths in all age groups. These data however 2006 study by West Java BPLHD revealed that domestic are already five years old, and require updating. Economic wastewater contributed up to 80% of the total surface wa- development and increasing coverage of basic services are ter pollution in West Java. Thus, the water in all rivers in expected to reduce the overall number; however, offsetting West Java that pass through urban areas like Bogor, Depok, this is the increasing population size and the remaining Bekasi, Bandung and Cirebon are not fit for use without challenges of slum populations. treatment26. The potential impact of increased local government engage- The most recent data from the Bekasi City BPLHD re- ment has been demonstrated by the government of Paya- vealed that almost all rivers in Bekasi are contaminated by kumbuh City, where sanitation has been mainstreamed in E. coli bacteria. E. coli concentrations in the city’s two larg- the city development program since 2006. In a speech at est rivers (Kali Malang and Kali Bekasi) are between 80,000 the City Sanitation Summit in 2008, the city’s mayor stated MPN/100 ml and 100,000 MPN/100 ml, which far ex- that the provision and improvement of household toilets, ceeds the maximum threshold of 1,000 MPN/100 ml. As via the CLTS approach, had resulted in a reduction in the a consequence, the local drinking water company has to city’s health subsidy budget from around US$290,000 per spend more on water treatment27. year to be less than US$100,000 per year within 2 years23. The situation is much the same in Jakarta and Surabaya. 5.5 WATER In 2002, the Environmental Technology Directorate of the Human excreta and wastewater directly disposed of into Agency for Technology Testing and Application (Badan water bodies, such as rivers and lakes, are major causes of Pengkajian dan Penerapan Teknologi/BPPT) reported that the serious pollution of surface water in Indonesia. For 70% of the wastewater disposed of in rivers in the Jakarta every 1 mg/liter additional BOD concentration in a river area was domestic wastewater, and average BOD was more from which water supply utilities source water, average than 90 mg/l. In Surabaya, research by local water supply water treatment cost increases 25%24. Research on surface utility Perum Jasa Tirta reported in 2004 that 87% of the water quality in Citarum River in West Java by the West wastewater disposed of in rivers in Surabaya was domestic Java Environmental Control Body (Badan Pengendalian wastewater, with the remainder coming from industry. The Lingkungan Hidup Daerah/BPLHD) in 2004 showed that large volume of organic material in domestic wastewater the high BOD in this river is due to intakes from domestic absorbs oxygen in the water and has caused the disappear- (44%-55%), industry (0%-42%), crop agriculture (10%- ance of many important river biota: there are now very few 36%) and livestock agriculture (3% -10%) sources25. wild fish in Surabaya’s rivers. With human populations – especially around rivers and These facts serve to remind all stakeholders of the urgency streams – growing over time, and in the absence of any and importance of improving sanitation. The environmen- serious efforts to control this pollution, the situation can tal damage caused by uncontrolled disposal of domestic only get worse. More than 19% of people dispose of un- wastewater into water bodies can no longer be ignored. 23 The Major of Payakumbuh City speech in the Opening Ceremony of Sanitation Summit, November 5th, 2008 24 Indonesia Sanitation Sector Development Program (ISSDP), 2007. 25 http://www.bplhdjabar.go.id/,09 October 2006 26 http://www.bplhdjabar.go.id/,09 October 2006 27 http://newspaper.pikiran-rakyat.com, May 12th, 2009 64 Economic Assessment of Sanitation Interventions VI. Costs of Improved Sanitation and Hygiene This chapter presents the cost results in different forms and costs in column 2 are distinct from sanitation costs, but it from different perspectives to aid understanding the nature can be added to sanitation costs to estimate the combined of costs: in section 6.1, a breakdown of investment, recur- costs of hygiene and sanitation interventions. Capital costs rent and program costs; in section 6.2, a breakdown by cat- refer to putting hardware in place, while program costs re- egory of financier (payer); in section 6.3, a breakdown of flect software (promotion and awareness raising campaign unit costs for different wealth quintiles; and in section 6.4, prior to the facility construction, education and monitor- a presentation of the marginal costs of moving up different ing). ‘rungs’ on the sanitation ladder. In rural areas, hardware investment cost ranges from US$53 6.1 COST SUMMARIES per household for dry pit latrine to US$557 per house- Table 33 and Table 34 show a summary of sanitation and hold for septic tank. The rural community toilet, which in hygiene costs in rural and urban study sites, respectively. Tangerang site is SANIMAS and serves around 100 house- Site-specific costs are provided in Annex I. The hygiene holds, costs US$ xx per household. The SANIMAS option TABLE 33: SUMMARY OF AVERAGE COST PER HOUSEHOLD IN RURAL AREAS FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, 2009) Cost Item Hygiene1 Community Shared Dry pit Wet pit Septic tank INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 2 151 130 53 70 557 2. Program 0.1 28 0.0 0.0 0.0 0.0 Sub-total 2 179 130 53 70 557 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 9.0 0.2 4.0 7.0 7.0 13.0 4. Maintenance 0.0 0.8 4.5 7.4 7.3 12.1 Sub-total 9.0 1.0 9.0 14.0 14.0 25.0 AVERAGE ANNUAL COST CALCULATIONS Duration2 3 20 10 5 5 20 Cost/household 10 19 28 27 32 82 Cost/capita 2 2 4 6 5 6 16 OF WHICH: % capital 9% 80% 69% 48% 55% 69% % program 0% 15% 0% 0% 0% 0% % recurrent 90% 5% 31% 52% 44% 31% Observations 4 208 23 98 41 54 224 1 Mainly soap purchase cost; Refers to length of life of hardware before full replacement ; Based on 5 persons per HH; Number of households 2 3 4 (respondents) www.wsp.org 65 Economic Assessment of Sanitation Interventions in Indonesia | Costs of Improved Sanitation and Hygiene is the only one with program costs measured, as it was de- costs are the dominant part of the overall costs. However, veloped under the government’s and NGO’s initiative, with in the absence of maintenance in the SANIMAS interven- US$28 investment cost per household spent, or around tion, there is a high risk that the facility will not last for 20 15% of total investment costs. years, or that people will continue to use it even when it is functional (due to poor hygienic conditions of the facil- Figure 48 illustrates the main components of annualized ity). Hence there needs to be am element of the SANIMAS costs in rural areas. When converted to annualized life cy- program that raises awareness on the importance of facility cle costs, taking into account the expected duration of the maintenance and institutes a mechanism for proper opera- investment, annual costs per household vary from US$19 tions and maintenance to take place. per year for SANIMAS to US$82 for septic tank. Capital TABLE 34: SUMMARY OF AVERAGE COST PER HOUSEHOLD IN URBAN AREAS FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, 2009) Community Septic Communal Sewerage + treatment3 Cost Item Hygiene1 Shared Wet pit Optimal Actual tank sewerage2 Optimal Actual INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 2 316 503 104 60 369 479 473 2,198 2. Program 0.1 0 0 13 13 13 0 0.6 3 Sub-total 2 316 503 117 73 382 479 474 2,201 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 9.0 4 6 3 8 7 13 13 36 4. Maintenance 0.0 3 5 8 13 23 32 39 54 Sub-total 9.0 7 11 11 21 30 45 52 90 AVERAGE ANNUAL COST CALCULATIONS Duration4 3 20 10 5 20 20 20 20 Cost/household 10 39 62 28 37 70 87 100 317 Cost/capita 2 8 12 6 7 14 17 20 63 OF WHICH: % capital 9% 83% 83% 55% 40% 53% 56% 48% 71% % program 0% 0% 0% 7% 8% 2% 0% 0% 0% % recurrent 91% 17% 17% 38% 53% 45% 44% 52% 29% Observations 5 29 92 116 318 137 46 46 1 Mainly soap purchase cost; 2 Malang city; 3 Banjarmasin city; 4 Refers to length of life (years) of hardware before full replacement; 5 Number of households (respondents) FIGURE 48: ANNUAL EQUIVALENT ECONOMIC COSTS PER RURAL HOUSEHOLD FOR MAJOR ITEMS (US$) private septic tank private wet pit private dry pit shared toilet community toilet 0 10 20 30 40 50 60 70 Recurrent cost Program costs Capital costs 66 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Costs of Improved Sanitation and Hygiene For urban sites, wet pit latrine is the lowest investment dents or participants in the focus group discussions in Ban- cost at US$73 per household. Shared latrine is higher at jarmasin mentioned that they were not well informed of US$117, with private septic tank at US$382. The private any initiatives on sanitation development. This led to lack sewerage and treatment system at Banjarmasin site and the of public willingness to connect their toilets with the sew- communal sewerage system in Malang site have the highest erage system, thus using less than 15% of the treatment investment cost at around US$480 per household. These plant’s capacity, even after more than 10 years of operation. results reflect the optimal capacity use of the sewerage sys- tems. However, when account is taken of the actual capac- 6.2 FINANCING SANITATION AND HYGIENE ity use of the sewerage and treatment system in Banjarma- The contribution of funds for sanitation initiatives depends sin site, the cost per household increased to over US$2,000 on which sanitation options are selected and who initiates per household. The community toilets in Banjarmasin in- the intervention. Figure 50 and Figure 51 show the propor- crease from US$316 to US$503 per household due to some tional contributions of different parties to total sanitation household members still going to rivers for defecation. costs at rural and urban sites, respectively. The figures show that community toilets (SANIMAS) and sewerage systems Figure 49 illustrates the main components of annualized receive major support from the government (central and/ costs in urban areas. Similar to the rural areas, the capi- or local government). In some cases of SANIMAS, NGOs tal costs are the most dominant part of the overall costs. contribute financially, also successfully creating community The difference between optimal and actual costs are shown demand or awareness. clearly for sewerage network and the community toilets. The contribution of program costs to the annualized costs For city sewerage systems, the government is responsible for is small compared to the capital costs and recurrent costs. the provision and financing of the entire sewerage networks, However, program implementers should be aware of the while households are only responsible for providing their fact that minimum or even zero budget allocation on pro- own toilets and connection from their house to the sew- gram costs for awareness raising and capacity building of erage network. As well as the connection fee, households the targeted beneficiaries may lead to less effective interven- also pay a monthly fee which contributes to operations and tion. Key stakeholders, especially beneficiaries, may not be maintenance. The other sanitation options are on-site sys- fully aware of the program, which can be a key determinant tems, whose financing usually fall under the responsibility of program success (see Chapter 7). For instance, respon- of households. FIGURE 49: ANNUAL EQUIVALENT ECONOMIC COSTS PER URBAN HOUSEHOLD FOR MAJOR ITEMS (US$) private sewerage actual + treatment optimal communal sewerage private septic tank private wet pit private dry pit shared toilet private sewerage actual + treatment optimal 0 50 100 150 200 250 300 350 Recurrent cost Program costs Capital costs www.wsp.org 67 Economic Assessment of Sanitation Interventions in Indonesia | Costs of Improved Sanitation and Hygiene FIGURE 50: PROPORTION OF RURAL SANITATION COSTS FINANCED FROM DIFFERENT SOURCES (%) private septic tank private wet pit private dry pit shared toilet community toilet hygiene 0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% government NGO/donor household FIGURE 51: PROPORTION OF URBAN SANITATION COSTS FINANCED FROM DIFFERENT SOURCES (%) private sewerage private communal sewerage private septic tank private wet pit shared toilet community toilet hygiene 0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% government NGO/donor household FIGURE 52: CAPITAL COST PAID BY HOUSEHOLDS AT RURAL SITES private septic tank private wet pit shared toilet community toilet rural capital costs 0 50 100 150 200 250 300 350 400 rural capital cost paid by household households’ �nancing contribution (US$) The local government of Payakumbuh city contributed Figure 52 and Figure 53 show the variation between sanita- through financing of program costs, as part of CLTS im- tion options of capital cost paid by households at rural sites plementation. The local government initiated campaigns and urban sites, respectively. The figures reflect that the fi- and community facilitation to raise the awareness of poor nancing sources for high initial capital of the sanitation op- households in Payakumbuh to move up their sanitation tions such as community toilets (SANIMAS) and sewerage ladder from open defection to the most affordable sanita- systems are mainly from the Government. Meanwhile, the tion options, which are private dry or wet pit. The latrines, ones with low initial capital like private on site toilets (dry however, were financed by households. pit, wet pit and septic tank) are mainly from households. 68 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Costs of Improved Sanitation and Hygiene FIGURE 53: CAPITAL COST PAID BY HOUSEHOLDS AT URBAN SITES private sewerage private communal sewerage private septic tank private wet pit shared toilet community toilet urban capital costs 0 500 1,000 1,500 2,000 2,500 urban capital cost paid by household households’ �nancing contribution (US$) The figures indicate that the decision to improve a sanita- 6.4 COSTS OF MOVING UP THE LADDER tion facility is influenced partly by the initial investment Costs of moving ‘up’ the sanitation ladder are presented in cost, and the recurrent costs. Households with lower cash Table 35 for rural sites and Table 36 for urban sites. Con- income tend to be more sensitive to the initial investment ceptually, community toilet projects such as SANIMAS are costs, and hence they tend to choose sanitation options that categorized as an improved public toilet, and its position in need a lower initial outlay of funds. Such an understanding term of sanitation ladder level is below private wet pit la- should obviously be considered by program implementers trine. However, the cost per household reached with SAN- in selecting technological options when they initiate a par- IMAS community toilets is higher than shared latrine or ticular sanitation intervention. private wet pit latrine. Therefore, moving ‘up’ the sanitation ladder from community toilets to private wet pit latrines 6.3 SANITATION OPTION BY WEALTH can lead to a theoretical cost saving. However, households QUINTILE using SANIMAS do so for justifiable reasons such as lack The wealth quintile analysis tabulates the proportion of of land availability or the attraction of not spending their households receiving each sanitation option by their own- own resources on a private toilet. For example, community ership of assets. Figure 54 shows that richer households are toilets for rural areas are in Tangerang district. The locations more likely to select septic tanks in rural areas, compared to where the present study was conducted are around indus- poorer households. Likewise, poorer households are much trial areas and are densely populated. For some households, more likely to access community or shared toilets compared it is difficult to provide enough space for family toilets and to rich (top quintile) households. they tend to use SANIMAS as provided by the government. In urban sites, there is an interesting finding that sewerage A similar situation takes place in the community toilets for connection is not linked to the wealth of a household, but urban areas in Banjarmasin. The city has 17 units of com- the financing mechanism. In Banjarmasin, all capital costs munity toilets (SANIMAS) at different sites, which serve including the connection fee are fully borne by the local around 1,200 households. Almost all construction costs government and the households only pay for construction were born by the government. The provision of SANIMAS of toilet room at home. Nevertheless, households’ willing- was partly intended to decrease the number of households ness to connect seems still relatively low. This is likely to be practicing open defecation at the rivers around the city. due to the absence of dedicated program costs to increase Almost all required investment costs were provided by the the population’s awareness of the system. government. Therefore, cheaper private toilet options such www.wsp.org 69 Economic Assessment of Sanitation Interventions in Indonesia | Costs of Improved Sanitation and Hygiene as pit latrine or septic tank would not necessarily lead the higher incremental costs to move up to septic tank than population to construct their own private toilets, as they from community and shared toilets. However, the ability would more likely be responsible for the financing. of a household to move up the ladder depends on the avail- ability of land within households’ own plot to develop a pri- Figure 56 shows the incremental costs of moving up the vate toilet including septic tank, and the financing incentive sanitation ladders from various initial sanitation ladders to and mechanism. For example, the costs of all household the top sanitation ladders at rural sites (septic tank) and connections to the sewerage systems are fully subsidized by at urban sites (urban sewerage systems). The incremental the local government and the households pay a monthly fee costs at rural sites show a linear trend according to the ini- (sewage treatment charge) and are responsible for building tial sanitation ladders. Wet pit, the cheapest option, needs toilets in their home. FIGURE 54: PROPORTION OF RURAL HOUSEHOLDS SELECTING DIFFERENT SANITATION OPTIONS, BY WEALTH QUINTILE private septic tank private pit latrine shared toilet community toilet 0 10% 20% 30% 40% 50% 60% wealthiest 20% upper non poor 20% non poor 20% poor 20% very poor 20% FIGURE 55: PROPORTION OF URBAN HOUSEHOLDS SELECTING DIFFERENT SANITATION OPTIONS, BY ASSET QUINTILE private sewerage + treatment private communal sewerage private septic tank private pit latrine shared toilet community toilet 0 5% 10% 15% 20% 25% 30% 35% 40% 45% wealthiest 20% upper non poor 20% non poor 20% poor 20% very poor 20% TABLE 35: INCREMENTAL COSTS PER HOUSEHOLD OF MOVING UP THE SANITATION LADDER AT RURAL SITES (US$, 2009) Target position on sanitation ladder Community Shared Dry pit Wet pit Septic tank Private wet pit - - - - 295 Initial Private dry pit - 70 - 25 319 sanitation ladder Shared 63 - -70 -45 249 Community - -65 -133 -108 186 70 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Costs of Improved Sanitation and Hygiene TABLE 36: INCREMENTAL COSTS PER HOUSEHOLD OF MOVING UP THE SANITATION LADDER AT URBAN SITES (US$, 2009) Target position on sanitation ladder Private Private septic Communal Community Shared Private wet pit sewerage + tank sewerage treatment* Communal 0 -3 sewerage Private septic - - - - 189 185 Initial tank sanitation Private wet pit 244 - - 219 407 404 ladder Private dry pit 263 58 19 237 426 423 Shared 205 - -39 180 368 365 Community - -205 -244 -25 163 160 * Assumed to operate at its optimal capacity FIGURE 56: INCREMENTAL COSTS PER HOUSEHOLD OF MOVING UP THE SANITATION LADDER (US$) private septic tank to urban sewerage wet pit to urban sewerage shared toilet to urban sewerage community to urban sewerage wet pit to septic tank shared toilet to septic tank community to septic tank 0 50 100 150 200 250 300 350 400 450 rural urban www.wsp.org 71 VII. Sanitation Program Design and Scaling Up This chapter evaluates selected sanitation programs in terms with other WSLIC 2 locations, Lamongan district has of their program approaches, their performance in relation the largest number of toilets financed by a revolving fund to outputs produced, their successes and their failures. scheme, which is at the core of the program. The program includes construction of household toilets, school toilets, 7.1 PROGRAM APPROACHES APPLIED IN and sewerage system (SPAL). FIELD SITES Table 37 shows the start and finish dates, number of house- As well as infrastructure and hardware development, the holds reached, and coverage of sanitation programs in the program also carries out prevention and treatment for envi- ESI field sites. ronmental-related diseases, including soil, water and stool tests, school deworming, community health counseling, 7.1.1 WSLIC 2 IN LAMONGAN DISTRICT and practical managerial and financial training, as well as The sanitation intervention in Lamongan District was Wa- training in water treatment and sanitation system operation ter and Sanitation for Low Income Communities (WSLIC and maintenance, and health community counseling. 1 and WSLIC 2), which included clean water, sanitation, training and community empowerment and hygiene com- A University of Indonesia study shows that the program ponents. WSLIC 1 ran from 1993 to 1999, and WSLIC 2 has increased the number of private toilet in some villages. started in 2000. The WSLIC 2 Program in Lamongan was Table 37 shows the overall coverage achieved by the project 72% financed by a World Bank loan, while the local gov- and Table 38 shows the number of toilets built per year ernment contributed 8% and the community 20% of the from the start of the program to the latest year of data. program cost (4% in cash and 16% in-kind). Compared TABLE 37: SANITATION COVERAGE INFORMATION PER FIELD SITE Households Project start Project end Site Rural/urban Interviewed Of which reached % Year Coverage (%) Year Coverage (%) in ESI survey by program* 1 Lamongan, 300 243 81 2001 - 2002 13 villages 2007 79 villages rural Revolving fund: Revolving fund: 547 HH 30,323 HH Self-Financing: CLTS: 2,040 HH 2346 HH Self-financing: 13,643 HH 2 Tangerang, 300 246 82 2007 - 2008 493 HH rural 3 Banjarmasin, 300 210 70 2000 (200 HH) Ongoing 904 HH urban (status Feb 2008) 4 Malang, 300 252 84 1986 100 HH 1999 737 HH urban 5 Payakumbuh, 300 252 84 2007 48% Ongoing 50.5% (4,871 HH) urban (4,661 HH) (status Nov 2009) 72 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up TABLE 38: NUMBER OF PRIVATE TOILETS BUILT IN SANIMAS, a community-based sanitation intervention, LAMONGAN UNDER WSLIC 2 engages the local community in the planning phase, tech- Year Units from revolving Units from self- nology options assessment and construction, and is oper- fund financing scheme financing ated and maintained by the community, with assistance 2001/2 574 2,346 from facilitators28. 2003 510 1,570 2004 371 1,011 The first SANIMAS in Tangerang was launched in 2008, 2005 466 180 in Pisangan Periuk, Sepatan District, where almost 80% of 2006 1,638 n.a. households had no private toilets. Financing of the con- n.a - data not available struction of the SANIMAS facility was shared by nation- al government (IDR100 million), regional government Although 73% of sanitation facilities were secured through (IDR200 million), Bremen Overseas Research and Devel- the revolving fund financing scheme, in reality the scheme opment Association (BORDA), BEST (IDR50 million), has been challenging to implement. Participants found it and the community (IDR2 million), for a total of IDR352 hard to pay the installments, as most of them are very poor. million (about US$35,000). The other SANIMAS facilities On the other hand, intensive health and hygiene behavior constructed in Tangerang district are in Sukadiri subdis- promotion has made the community more sanitation aware trict, which serves 326 households; Pagedangan subdistrict, and motivated them to build their own private toilets. Table which serves 62 households; and Sepatan subdistrict, which 39 shows the total number of beneficiaries of the sanitation serves 105 households.29 program as of 2008. In Tangerang, the technology option is MCK++30. This TABLE 39: TOTAL NUMBER OF WSLIC 2 BENEFICIARIES IN technology option uses the brown water flushed from the LAMONGAN, 2008 toilet to produce biogas. The septic tank is connected to No of beneficiaries No Subdistrict an airtight biogas digester plant, which is made from rein- Village (rural) HH Population forced concrete and installed underground beside the facil- 1 Turi 8 4,488 23,432 ity. Inside the digester, methane bacteria treat the wastewa- 2 Pucuk 3 2,162 9,547 ter and produce methane biogas. The local community uses 3 Brondong 1 1,204 3,248 the biogas for cooking. The gray water from bathing and 4 Ngimbang 1 765 3,188 washing passes through a sand filter before releasing into 5 Bluluk 2 1,673 6,643 the drainage system (see Figure 57). 6 Glagah 2 593 3,414 Total 17 10,885 49,472 These sanitation facilities have many advantages for the community. For a small fee (IDR1000), users can avoid Source: Lamongan District Health Office, 2008 long queues, have a safe and comfortable place to defecate, and continuous access to clean water for washing and bath- 7.1.2 COMMUNITY-BASED SANITATION ing. (SANIMAS) IN TANGERANG DISTRICT Several years ago, Tangerang experienced a diarrhea out- 7.1.3 BANJARMASIN SEWERAGE SYSTEM break that was attributed to poor sanitation. The Tangerang Banjarmasin is one of the few cities in Indonesia to have a District Health Office noted that around 70% of the local sewerage network and wastewater treatment plant. The first population – most on the north coast in districts such as sewerage system was built between 1998 and 2000 under Kresek, Kronjo, Pakuhaji, and Mauk – do not have proper the Integrated City Infrastructure Development Program toilet facilities. (Program Pembangunan Prasarana Kota Terpadu/P3KT) 28 Directorate of Diseases Control and Enviromental Health, Department of Public Works, WSES Workshop, November 2009 29 BEST (the facilitator NGO) Tangerang, 2008 30 MCK++ is a SANIMAS term used to describe a shared toilet facility, plus decentralized wastewater treatment system, plus biodigester. www.wsp.org 73 Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up FIGURE 57: TYPICAL DESIGN OF MCK++ IN TANGERANG DISTRICT1 1. Washing place 2. Digester 3. Tower reservoir 3 4. Expansion chamber 5. Balled reactor 6. Toilet 7. Outlet 6 7 1 4 8 2 5 1 Source: Kreatif Energi Indonesia of the Kalimantan Urban Development Project (KUDP). age of the sewerage system up to 75% of the city’s popu- Around 77% of the funds came from an IBRD loan, with lation. Non-domestic subscribers, including commerce, national government contributing 17% and local govern- industry and government, make up a large proportion ment 6% of the total. In 2006, Banjarmasin became a In- (41.5%) of the total (see Table 40). donesia Sanitation Development Program (ISSDP) Phase I TABLE 40: COMPOSITION OF PD PAL SUBSCRIBERS target location. Set up under this program, the cross-sectoral Average Banjarmasin City Sanitation Working Group (Kelompok HH Group % of monthly subscribers Kerja/Pokja Sanitasi Kota) planned a systematic integration payment (US$) of sanitation development. The working group carefully A1 12 % 1 mapped the existing sanitation situation in a City Sanita- A2 43% 1 tion White Book, and building on this baseline developed A3 3% 3 a city sanitation strategy (CSS) that detailed a five-year A4 0.5 % 17 strategic approach to develop the city’s sanitation system, Commercial, Industry, 41.5 % 17 including domestic wastewater, solid waste and drainage. Government/Institution, etc. Banjarmasin entered the monitoring and evaluation phase of ISSDP Phase I in 2009. Some sanitation projects in the Initially managed by a technical implementation unit of CSS – notably those aimed at expanding coverage of the the Banjarmasin city government water utility, the sewerage sewerage system – received funding commitment from the system is now managed by PD PAL, a new local govern- central government and donors. ment wastewater management enterprise. Wastewater en- tering the sewerage system undergoes primary treatment, Up until 2007, the sewerage system served only population and passes through a rotating biological contactor (RBC), of Lambung Mangkurat, or about 1% of the city’s popula- settling tank, and sand filter before being discharged into tion. In 2010, the sewerage system was extended to Kayu water bodies (Figure 58). Study findings indicate that re- Tangi and Pekapuran Raya. A second extension phase, duction of COD, BOD, suspended solids, and ammonia is scheduled to be fully operational by 2015, will bring cover- more than 90% efficient (see Table 41). 74 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up TABLE 41: REDUCTION OF WASTEWATER PARAMETERS, AND EFFICIENCY OF THE BANJARMASIN WASTEWATER TREATMENT PLANT1 Reduction figures Treatment efficiency No Parameter Influent Effluent (%) 1 COD (Chemical Oxygen Demand (500 – 700) mg/l (50 – 70) mg/l > 90 2 BOD (Biochemical Oxygen Demand) (250 – 300) mg/l (20 – 25) mg/l > 90 3 SS (Suspended Solid) (250 – 300) mg/l < 25 mg/l > 90 4 N¬3 – N (Ammonia) (15 – 20) mg/l <1 > 90 1 Source : City Sanitation Strategy - Banjarmasin , Pokja Sanitasi Kota Banjarmasin, March 2008 FIGURE 58: SCHEMATIC DIAGRAM OF BANJARMASIN SEWERAGE SYSTEM1 COMBINE SEWER DRAINAGE FLOAT & INSPECTION FLOATING CHAMBER (IC) MATTER PRIMARY ROTATING BIOLOGICAL TRAP CLARIFIER CONTRACTOR (RBC) MANHOLE DESINFECTION TANK MANHOLE SCREEN RAW SEWAGE PUMP STATION (RSPS) CARBON SAND FILTER FILTER PUMP FINAL CLARIFIER 1 Source : City Sanitation Strategy - Banjarmasin, Pokja Sanitasi Kota Banjarmasin, March 2008 www.wsp.org 75 Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up However, as of December 2010, only 4,277 households Financing for the initial program in Tlogomas was raised were connected to the system, or about 18% of its potential in full by the community, without additional support from of 24,000 households. PD PAL cites at least three reasons government or donors. For over a year, funds were collect- for this low coverage. First, people’s lack of awareness of the ed from the community to pay for the initial construction need for a wastewater treatment system in the city. Second, work, which took about two years to complete. Although the limited coverage of the main pipelines due to budget the first six households were connected to the CBSS in constraints, which means that coverage expansion priori- 1987, it took about ten years for all members of the com- tizes locations that are easiest to reach. Third, difficulties munity to get connected to the system. obtaining permission from communities to install under- ground in their areas. The CBSS consists of a network of collecting pipes, laid beneath footpaths or below existing drains, which connect In fact, PD PAL has been allocating less than 1% of the the sewage system to a network of houses. The treatment total sewerage system development budget to sanitation plant is located at the lowest point in the system, so the flow awareness campaigns, hence the reluctance of many house- depends entirely on gravity. Wastewater is filtered through holds to connect to the sewage system. The focus group an anaerobic suspended biomass tank, before being released discussions conducted in Banjarmasin as part of the ESI into the local watercourse. study corroborated this: respondents said they had received very little information about the health benefits of good The initial CBSS development raised community awareness sanitation and how these are linked to the sewerage system. and encouraged the villagers not to defecate in the open. Furthermore, respondents already connected to the sewage After collecting funds and planning technical aspects of system had a number of complaints, including having to the system, the community set about constructing the sys- deal with backwash of wastewater from the system during tem using local laborers and masons. The work began with floods. the construction of the treatment plant and progressively worked up the main collection network and connecting 7.1.4 COMMUNITY-BASED SEWER SYSTEM to households. Some houses did not have enough spaces (CBSS) – MALANG CITY for private toilets, thus communal or shared toilet facilities The Community-Based Sewer System (CBSS) in Malang were the logical solution in such densely populated area. City was pioneered by local volunteer Agus Gunarto in 1985. The proportion of funds raised by the community ranged from 10% in Samaan to 100% in Tlogomas. The funds were This initiative was triggered by a diarrhea outbreak in managed by a special committee set up by the community. Malang that resulted in many fatalities among children Users pay a monthly service charge for the operation and from poor families. Open defecation was the main cause of maintenance of the facility. One or two people, usually lo- this epidemic, as many households used rivers as their toilet cals, are hired to maintain the treatment plant. Funding of as well as for washing, bathing and cooking. major repairs and long term maintenance is handled on an ad-hoc basis and requires special collection of funds. The main sanitation intervention is a communal sewer- age system connected to private toilets. The first facility There are approximately 1,105 households in the five vil- was constructed in Tlogomas, on the outskirts of Malang lages covered by the CBSS. A study conducted by WSP in city. The system was then replicated in five nearby areas 2000 found that 404 households were connected to the with majority poor populations (Watugong, Mergosono, CBSS in Malang. Malang municipality was included in Bareng, Samaan, and Gadang), with support from NGOs, ISSDP Phase 2 in 2009 and is a target location for the Ur- multilateral donors and the city government. Most of the ban Sanitation Development Program (USDP) 2010-2014. communities in these areas are poor. 76 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up 7.1.5 COMMUNITY-LED TOTAL SANITATION commitment to building them. In the final stage of the trig- (CLTS) IN PAYAKUMBUH gering process, the community makes a written statement In Payakumbuh City, sanitation is a mainstream develop- on a large sheet of paper of its collective commitment to ment priority. In less than three years, sanitation programs stop open defecation and build sanitary toilets, which is dis- such as ISSDP, P2KP and Pamsimas have taken off and had played in a prominent position as a reminder to everyone. a positive impact on people’s health. These include three Arrangements are then made for the CLTS team to come programs – Clean and Healthy Lifestyle Campaign, Sanita- back to the village at a later date to check on its progress.32 tion for Schools, and Community-Led Total Sanitation – that aim to improve people’s sanitation awareness.31 As Table 42 below shows, ownership of private toilets has increased in all CLTS target locations since the inception of Launched in 2007, the CLTS program in Payakumbuh the program. aims to trigger the community to build household latrines. Sanitation options range from simple pit latrine to septic Local government has reported a decrease in the prevalence tank, but toilet construction is not subsidized. The pro- of diseases, including diarrhea, skin infections, intestinal gram covers 16 villages in West Payakumbuh, North Paya- infection, and pneumonia, since inception of the CLTS kumbuh, East Payakumbuh and Latina subdistricts. program in Payakumbuh, as indicated by the reduced cost of the municipal health insurance scheme over a two-year Led by the city health office, all local stakeholders are en- period. gaged in all aspects of the program, from planning through maintenance of the facilities. The triggering process begins 7.2 COMPARISON OF PROGRAM with briefing the community about the program. This is APPROACHES AND PERFORMANCE followed by a series of sanitation awareness raising activi- The ESI household survey revealed that, in general, house- ties, which include participatory mapping of the location, holds have the freedom to choose whether to participate calculation of the volume of feces produced by the com- in the sanitation initiatives. Figure 59 shows the extent of munity in a year and awareness of the consequences of not household choice and participation in decision making. The disposing of this properly, transect walks to open defecation sanitation programs encourage communities to voluntarily areas to interview villagers defecate in the open, and expla- own better sanitation facilities. However, in Lamongan the nation of food and drink become contaminated with fe- survey returned a different result: only one respondent re- cal matter. At focus group discussions, the villagers discuss ceived a latrine from a sanitation program, while the rest of why they defecate in the open, and are encouraged to feel the surveyed households said they had paid for construction ashamed of their behavior. They also discuss construction of the toilet themselves. of affordable sanitary toilets and the importance of having a TABLE 42: OWNERSHIP OF PRIVATE TOILETS BEFORE AND AFTER INCEPTION OF THE CLTS PROGRAM IN PAYAKUMBUH1 No. of Households with Private Toilets (pit latrine or septic tank) No Subdistrict After Triggering Before Triggering (2006) December 2009 December 2010 1 East Payakumbuh 1,187 3,738 4,349 2 South Payakumbuh 814 1,150 1,513 3 Latina 373 703 870 4 West Payakumbuh 454 5,297 6,045 5 North Payakumbuh 1,577 3,909 4,556 Total 4,405 14,797 17,378 1 Source : Payakumbuh Municipal Health Office, 2011 31 www.sanitasi.or.id 32 Source: Payakumbuh CLTS Implementation Report, 2008 www.wsp.org 77 Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up FIGURE 59: PROPORTION OF HOUSEHOLDS WHO SAID THEIR PARTICIPATION IN THE PROGRAM WAS VOLUNTARY Payakumbuh Malang Banjarmasin Tangerang Lamongan 0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% FIGURE 60: PROPORTION OF HOUSEHOLDS OFFERED MORE THAN ONE SANITATION OPTION Payakumbuh Malang Banjarmasin Tangerang Lamongan 0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% More than 70% of the respondents said that they were Respondents in Tangerang, Malang and Payakumbuh re- given more than one sanitation option, allowing them to ported having sufficient water for flushing, no pit flooding choose an option that was affordable to them and met their and no pit overflow. In Lamongan, about 10% of respon- preferences (Figure 60). Offering options is important be- dents said that they often or sometimes had pit flooding, cause it shows to the community that proper sanitation and 5% had experienced pit overflow. In Banjarmasin, need not be expensive. While communities in Tangerang 1.3% of respondent often had pit flooding and pit overflow and Malang were given a full range of options, in Payakum- (Figure 63). buh, the options were fewer. The most likely reason for this is that the CLTS program focuses not on subsidizing latrine Table 43 presents selected indicators of the overall effective- construction, but on triggering a change in behavior away ness of the five sanitation interventions, that serve as inputs from open defecation. The CLTS facilitators do not lecture to the cost-benefit analysis (see Chapter 8). or advise on sanitation habits, and do not provide external solutions, such as toilet designs. Rather, the aim is to trig- Key conclusions from these indicators of program effective- ger the community to make the decision to build their own ness are: toilets using simple technology, such as pit latrines. • The proportion of children using toilets is generally still low. The average financial contribution of households varied by • Handwashing with soap is not regularly practiced by site and sanitation option selected. On-site systems such as respondents in Banjarmasin and Tangerang. shared toilets, wet pit toilets, and septic tank toilets tend to • Although Banjarmasin has the lowest figure for open be funded by households (Figure 61 and Figure 62). The defecation, this is because use of hanging latrines was septic tank option is considerably more expensive than the not categorized as open defecation. shared option or private pit latrines. Figure 64 compares selected key indicators of program ef- fectiveness across the study locations. 78 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up FIGURE 61: HOUSEHOLD CONTRIBUTION TO TOTAL COST OF TOILET CONSTRUCTION IN RURAL SITES private septic tank private wet pit shared community rural capital costs 0 50 100 150 200 250 300 350 400 contribution by rural households households’ �nancing contribution (US$) FIGURE 62: HOUSEHOLD CONTRIBUTION TO TOTAL COST OF TOILET CONSTRUCTION IN URBAN SITES private sewerage private communal sewerage private septic tank private wet pit shared community urban capital costs 0 500 1,000 1,500 2,000 2,500 households’ �nancing contribution (US$) contribution by urban households FIGURE 63: FREQUENCY OF SUPPLY OF WATER FOR FLUSHING, AND OF PIT FLOODING AND PIT OVERFLOW Payakumbuh Malang Banjarmasin Tangerang Lamongan 0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% have suf�cient water for flushing no pit flooding no pit overflow www.wsp.org 79 Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up TABLE 43: SELECTED INDICATORS OF OVERALL PROGRAM EFFECTIVENESS Rural sites Urban sites Variable Lamongan Tangerang Banjarmasin Malang Payakumbuh Years of program 7 1 Still ongoing 13 Still ongoing % household members using their 81% 82% 70% 84% 84% improved toilet regularly HOUSEHOLD CONTRIBUTION TO COST (FINANCIAL & NON-FINANCIAL) Community 100% 30% 11% na na Shared 100% 100% 100% 100% 82% Private dry pit 100% 100% 100% 100% 0% Private wet pit 100% 100% 100% 100% 71% Private septic tank 100% 100% 100% 100% 100% Private sewerage na na 9% na na Community sewerage na na na 37% na SANITATION PRACTICES AMONG HOUSEHOLDS: Using bush or outdoor sites for 16% 20% 2% 1% 17% defecation (sometimes or often) Using bush or outdoor sites for 23% 29% 2% 4% 26% urination (sometimes or often) Children using latrine 12% 13% 12% 57% 5% Children defecating in yard 39% 55% 29% 31% 36% Washed hands with soap yesterday 96% 21% 12% 50% 94% Washing hands after defecation 87% 4% 7% 32% 84% (sometimes or often) WATER SOURCES AND SOAP FOR WASHING HANDS Using unprotected wells 21% 4% 31% 20% 16% Pit latrine/septic tank within 10m of 63% 71% 52% 67% 81% wells Signs of feces or waste around 8% 9% 19% 5% 9% toilets Signs of insects in toilets 6% 7% 27% 4% 15% Running water in or near toilets 68% 74% 38% 36% 37% Soap available for washing hands 25% 35% 14% 19% 25% 80 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up FIGURE 64: COMPARISON OF SELECTED KEY INDICATORS OF PROGRAM EFFECTIVENESS Payakumbuh Malang Banjarmasin Tangerang Lamongan 0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% hand washing with soap children using toilet no more open defecation 7.3 BROADER ANALYSIS OF THE PROGRAM Tenggara, East Java, West Java, Bangka Belitung, South Su- APPROACHES lawesi, and West Sulawesi). 7.3.1 WSLIC 2 (WATER AND SANITATION FOR Program Intervention. The sanitation component of LOW INCOME COMMUNITIES 2) WSLIC 2 program was SANIMAS. Although the initial re- Program Information. WSLIC 2 is a community-driven volving fund scheme for construction of household toilets development project in Indonesia under the Ministry of worked well in some areas and communities, their overall Health, and implemented by Ministry of Health, Minis- impact on low-income beneficiaries and sanitation cover- try of Home Affairs, Ministry of Public Works, and Min- age was limited. People’s willingness to repay the loan was istry of National Education. The project objective is to very low and led to discontinuity of the sanitation loans. In improve the level of health, productivity, and quality of practice, the loans were often treated as large hardware sub- life of low-income communities through behavior change, sidies, with little effort from the beneficiaries to pay them environment-based health services, clean water supply and back.33 safe sanitation. Regarded as an appropriate, accessible, sus- tainable, and effective participatory program, WSLIC 2 at- According to the latest WSLIC 2 progress report, the re- tempted to develop an integrated water supply, sanitation volving fund scheme provided 23,560 household loans in and hygiene improvement action plan in each sub-project 860 communities. This represented 27 loans for household community. The initial revolving fund system was later su- toilets in each community, which is equivalent to an 11% perseded by the CLTS approach. increase in sanitation coverage within the project commu- nities covered to date.34 Program Location. The program ran from 2000 to 2009, and covered 2,461 villages in 36 districts of eight provinces, Funding. According to a LP3ES report35, the sources of across Indonesia (South Sumatra, West Sumatra, West Nusa fund for WSLIC 2 were: IDA loan (72.5%), AusAID 33 Robinson, Andy, “Indonesia National Program for Community Water Supply and Sanitation Services, Improving Hygiene & Sanitation Behavior and Services�, World Bank, December 2005) 34 Kajian Cepat terhadap Program Pengentasan Kemiskinan Pemerintah RI, LP3ES, Oct 2007 35 Kajian Cepat terhadap Program Pengentasan Kemiskinan Pemerintah RI (Rapid Assessments of the GoI Poverty Alleviation Program), LP3ES, Oct 2007 www.wsp.org 81 Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up grant (6.1%), national and regional budgets (11.4%), and nities. It was implemented with the involvement of com- community contribution (9.9%). Each program location munity and other stakeholders such as local NGOs and received a budget allocation of between IDR195 million government through a process of empowerment. The ap- (US$18,773) and IDR280 million (US$26,957). The com- proach was an alternative option to fill the significant ‘gap’ munity is responsible for operation and maintenance of the between inappropriate sanitation such as open defecation facilities, for which users pay a monthly fee. and absorption pit, and the expensive conventional cen- tralized sewerage collection and treatment system. Besides Monitoring and evaluation. A rapid evaluation by LP3ES providing facilities and infrastructure, the program also (Institute for Social and Economic Research, Education, promoted health and hygiene behavior. In SANIMAS, and Information) in October 2007 in six villages found communities found their own informed demand and were that more than five years since the inception of WSLIC 2, given education about sanitation, hygiene, and diseases. the water supply and sanitation facilities constructed were The communities were encouraged to organize the op- working properly and still being used by the community. eration and maintenance of sanitation infrastructure, and The introduction of the CLTS approach in 2004-2005 sometimes according to requirements and abilities, sanita- had raised people’s awareness of health and hygiene behav- tion infrastructures were planned, designed and constructed ior, and some had built their own private toilets now that for and together with the community. The approaches were a reliable water supply was available. Diarrhea incidence highly demand responsive and relied on active participa- in project locations had also decreased as people stopped tion as well as contributions from target communities and defecating in the open and started handwashing with soap municipalities.36 Figure 65 shows how SANIMAS fills the regularly before eating and after defecating. gap in sanitation options. 7.3.2 SANIMAS Local governments act as facilitators, allocate local budget, Program Information. SANIMAS is a community-based and carry out monitoring and evaluation. The five princi- sanitation (CBS) option designed for poor urban commu- ples of SANIMAS are: demand-responsive approach/DRA, FIGURE 65: SANIMAS FILLS THE GAP1 convenience conventional centralized and high cost systems CBS - technical options common on-site sanitation systems costs 1 Source: BORDA 36 Directorate of Diseases Control and Enviromental Health, Department of Public Works, WSES Workshop, November 2009 82 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up participation (community involvement), technical options Monitoring and evaluation. In 2006, WASPOLA con- (of facility/infrastructure), self-selection process, and capac- ducted outcome monitoring in seven SANIMAS pilot ity-building. project locations and two control locations in Bali and East Java. The study revealed that in general the facilities SANIMAS was a component of the WASPOLA project, a were functioning well, that users were satisfied, and that development cooperation between the Indonesian Govern- proper and detailed financial records were being kept. The ment and the Australian Government coordinated by WSP. study also showed that more than 75% of people living near BORDA, a German NGO, working together with Indone- SANIMAS facilities had used these toilets for defecating. sian NGOs, was appointed to implement the SANIMAS However, there were some reports of facilities no longer be- project to assist the communities, local governments, and ing used after falling into disrepair because user fees had not local facilitators in designing, planning, and implementing been collected regularly to pay for their maintenance. Com- community-based sanitation (CBS) activities. To ensure the munity participation and women’s participation in particu- quality of project implementation, BORDA had assistance lar were found to be lacking, despite the aim of the program from several national NGOs. to give users a full voice in decision making. Program Location. In 2003, SANIMAS was piloted in A WSP study of Community-Based Sewer System (CBBS), seven districts/municipalities (Blitar, Pasuruan, Kediri, the SANIMAS program pioneered in Tlogomas, Malang, Mojokerto, Sidoarjo, Pamekasan, and Denpasar). In 2006, found that the most sustainable operating and maintenance SANIMAS was replicated in 345 locations in 157 munici- systems were in locations, such as Tlogomas and Mergo- palities in 27 provinces across Indonesia. As of 2010, SANI- sono, where external contribution was minimal. Despite MAS 1, SANIMAS 2, and SANIMAS 3 had been imple- more than half the population living below the poverty mented. line, people in Mergosono were willing to pay a significant part of the investment cost of the CBSS. Whether the sys- Program Intervention. A range of technology options is tem is totally or partially financed by the community, lower available under SANIMAS. MCK Plus is a public toilet income families contribute a higher percentage of their block, connected to a decentralized wastewater treatment monthly income than higher income groups. This is par- system, plus a biodigester (see chapter 7.1.2) This sanita- ticularly a clear example of how low-income households are tion option is suitable for densely populated areas with a willing to pay for something they consider to be necessary high proportion of rented accommodation and a shortage and appropriate (see Table 44 and Table 45). of land on which to build private toilets. The second and third options are shared septic tank connected to up to 20 Although all five systems have yet to meet effluent stan- households and shallow sewer connected to between 50 and dards, individually each has achieved a significant reduction 100 households. Both these options are suited to densely in environmental pollution. The pollution load originating populated areas where the beneficiaries have to have enough from the community had been halved, although the sys- land to build a private toilet on their own plot. tems do not meet national technical standards. TABLE 44: COMMUNITY CONTRIBUTION TO THE COST OF CBSS DEVELOPMENT Location Community contribution Government subsidy Other source (NGO, private sector) Tlogomas 100% - - Watugong 51.7% 5.8% 42.3% Mergosono 86.5% 13.5% - Bareng 47.6% 52.4% - Samaan 9.8% 90.2% - www.wsp.org 83 Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up TABLE 45: COMPOSITION OF THE CBSS SUBSCRIBERS BY MONTHLY HOUSEHOLD DISPOSABLE INCOME1 Household disposable income (US$) Location < 30 30 - 45 45 - 60 60 - 70 > 70 Tlogomas 0% 10% 20% 20% 50% Watugong 0% 36% 27% 18% 18% Mergosono 29% 29% 15% 21% 7% Bareng 25% 25% 0% 0% 50% Samaan 13% 0% 50% 38% 0% Average 13% 21% 23% 21% 21% 1 Source: Community-Based Sewer Systems in Malang, Indonesia, Sean Foley, Anton Soedjarwo, Richard Pollard, WSP, 2000. Building sustainable CBSS will require continuous finan- Monitoring and evaluation. A 2006 study by the Envi- cial, technical and management support from the govern- ronmental Services Program (ESP)38 assessed four main as- ment and donors, as well as increased community participa- pects (institutional, management, financial and technical) tion and awareness of hygiene behavior. of nine centralized wastewater systems. Of the nine, five (in Solo, Medan, Balikpapan, Bandung, and Cirebon) are 7.3.3 SEWERAGE OR CENTRALIZED SYSTEM managed by the local government water supply utility, and Program Information. Regarded as a high cost technol- two (in Jakarta, and recently in Banjarmasin) by a special ogy option compared with on-site sanitation systems, only local government-owned enterprise. The remaining two (in a few cities in Indonesia (Bandung, Banjarmasin, Balikpa- Tangerang and Yogyakarta) are under direct local govern- pan, Cirebon, Jakarta, Medan, Solo, Tangerang, and Yog- ment management. yakarta) have centralized sewage systems. In recent years, however the government has revised its policy framework The study found that only two of the nine wastewater man- for sustainable urban sanitation, in response to growing agement systems – in Bandung and Jakarta – have managed urbanization and increased pollution of water sources and to achieve full cost recovery, but even they could improve wastewater in larger cities. The new target is that by 2014, their financial performance. 5% of people living in 16 districts or cities will be served by city-scale sewerage systems.37 Wastewater in eight of the nine sewage systems is treated by aeration pond, aerated lagoon and activated sludge process, Funding. Initial construction was funded by grants or loans or a combination of these. The exception is the wastewater to local governments from donors such as the World Bank treatment plant in Balikpapan, which uses a rotating bio- and ADB. Operators have made additional investment in logical contactor. Evaluation of system performance found the systems, for installation of new connections, purchase that the average COD and BOD reduction is approxi- of equipment and other capital outlays. However, financing mately 50%. The highest COD reductions were recorded the cost of expanding the systems falls to local and national in Yogyakarta (89%) and Prapat (85%), and the highest governments as borrowing from financial institutions is al- BOD reductions in Banjarmasin (89%), Prapat (85%) and most impossible since most of the wastewater management Yogyakarta (88%). The lowest COD and BOD reductions systems (except those in Bandung and Jakarta) are still far were found in two wastewater treatment plants in Cirebon. from full cost recovery. 37 Directorate of Program Development presentation on Ministry of Public Works WSES policy, strategy, and programs, National conference on community based WSES , November 2009 38 The ESP is a five-year program which was developed by USAID/Indonesia in response to the Presidential Initiative of 2002 to improve sustainable management of water resources. This initiative supports activities in the following three key areas: (i) Access to clean water and sanitation services (ii) Improved watershed management (iii) Increasing the productivity of water 84 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up 7.3.4 COMMUNITY-LED TOTAL SANITATION Ministry of Home Affairs, and Ministry of General Affairs. (CLTS) Ad-hoc institutions at national and local level, and the na- Program Description. Community-Led Total Sanitation tional WSES working group are also involved. (CLTS) was launched in Indonesia in May 2005 through a series of pilot projects funded by the Water and Sanita- Location. The CLTS pilot project ran in six districts across tion Policy Formulation and Action Planning (WASPOLA) Indonesia: Sumbawa (West Nusa Tenggara), Lumajang project implemented by the Ministry of Health. (East Java), Muara Enim (South Sumatera), Bogor (West Java), Sambas (West Kalimantan), and Muaro Jambi (Jam- Recognizing that merely providing toilets does not guar- bi). The approach has since been replicated in various loca- antee their use, nor result in improved sanitation and hy- tions by both government and non-government agencies. giene, CLTS focuses on the behavioral change needed to ensure real and sustainable improvements – investing in Between 2008 and 2012, the government plans to trigger community mobilization instead of hardware, and shifting 10,000 villages using this approach. As of April 2009, 923 the focus from toilet construction for individual household villages had received CLTS triggering and 715 villages had to the development of open defecation free villages. By rais- been declared open defecation free. About 325,600 people ing awareness that as long as people continue to defecate in have gain access to improved sanitation facilities in 21 dis- open area (even a minority) everyone is at risk of disease, tricts.40 CLTS triggers the community’s desire for change, propels them into action and encourages innovation, mutual sup- Monitoring and evaluation. As part of the IDS research port, and appropriate local solutions, thus leading to greater project, ‘Going to Scale? The Potential of Community-Led ownership and sustainability. Total Sanitation, between 2006 and 2008, a study was made of nine villages in three districts that applied the CLTS ap- Following the success of the pilot, CLTS replaced WSLIC proach. The study found that the success of the CLTS ap- 2 (revolving fund scheme) in 2005. The approach subse- proach was influenced by both internal and external factors. quently proved successful in locations across Indonesia, Key internal factors were: sanitation being seen as a village and in 2007, the Government of Indonesia in cooperation priority, a sense of individual responsibility to contribute with the World Bank adopted the CLTS approach for the to public good, basic awareness of the benefits of using la- PAMSIMAS project, implemented in 115 districts across trines and handwashing with soap, being ashamed about Indonesia. The Asian Development Bank (ADB) has also defecating in the open, and women being able to influence adopted CLTS in the sanitation program Clean Water Sani- their spouses to build a latrine. External factors included tation and Health (CWSH) in 20 districts in Indonesia.39 strong support from and continuous triggering by commu- nity leaders, ongoing external support, availability of water Implementation and scaling up of CLTS in Indonesia has supply and resources for building latrines, including land, involved governmental and non-governmental institutions cash or in-kind materials, collective community commit- at various levels. The Ministry of Health, especially the ment to becoming open defecation free, and government Directorate General of Disease Control and Environmen- involvement. tal Health, is a key institution in CLTS implementation. Other central government bodies and ministries involved in Table 45 summarizes the four basic sanitation interventions CLTS include the National Development Planning Agency, and approaches discussed in this section. 39 Entry of the CLTS Approach in Indonesia, Edy/Udin, Percik Magazine Dec. 2008 40 Learning At Scale TSSM Project, Indonesia Country Update June 2009, Field Note, WSP www.wsp.org 85 Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up TABLE 46: COMMUNITY CONTRIBUTION TO THE COST OF CBSS DEVELOPMENT Change in Site Period of Provinces coverage Project/ Location, HH receiving Funding Project No covered/ Implementer Funder Annual Value over Data sources, reports used intervention urban/ intervention Mechanism (year to population project rural year) period 1 WSLIC 2: Rural South Sumatera, 2,409 villages −−Ministry of −−WB (loan) −−IDA credit : US$ 2000 - 2009 −−Rapid Evaluation Study of 1. SANIMAS West Sumatera, (2009) Health 72.5% 106,700,000.- poverty alleviation program - Private toilets West Nusa −−AusAID (total budget) WSLIC 2 and PAMSIMAS, - Public toilet Tenggara, East Target : 2000 −−Ministry of (grant) −−Grant LP3ES, October 2007 2. Institutional Java, West Java, villages / 37 Home Affairs (AusAID) −−Study of WSLIC 2 by Indonesia −−National 6.1% Sanitation Bangka Belitung, districts −−Ministry of and local University 2001 – 2006 (school South Sulawesi, Achievement : Public Works government −−National −−Indonesia National Program for toilets, village West Sulawesi 2,298 villages / and local Community Water Supply and office toilets, 37 districts − −Ministry of −−community government Sanitation Services, Improving community National contribution 11.4% Hygiene and Sanitation health center Education Behavior Services, Andy toilets, etc.) −−community Robinson, Dec 2005 3. Simplified 9.9% −−www.wslic2.go.id sewerage (SPAL) −−MoH presentation at WSES national workshop, Nov 2009 2 SANIMAS: Urban/ South Sumatera, 345 locations Ministry National −−National 2001 - 2004 −−Sanimas Outcome Monitoring −−MCK plus Rural West Sumatera, (2008) of Public government, government : (pilot project Study Final Report, Waspola, latrines West Nusa 21,000 low Works, local local material IDR - WB and April 2006 −−Shared septic Tenggara East income rural government government 100 million BORDA −−SANIMAS presentation at tank Java, West Java, communities APBD, −−Local Indonesia) the 2nd Philippine National −−Simplified Bangka Belitung, BORDA, government : 2005 to date Summit, July 2009 sewerage / South Sulawesi, community construction (Replication −−Pro-poor Water and shallow sewer West Sulawesi contribution IDR 200 of program Wastewater Management in million, on national Small Towns – Case Study, community scale with UN Economic and Social empowerment different Commission for Asia and the IDR 50 million funding Pacific, year ….. −−BORDA : schemes) −−www.pu.go.id community −−www.indonesia.go.id empowerment −−www.kimpraswil.go.id IDR 50 million −−Community Community-Based Sewer (in-kind & in- Systems in Malang, Indonesia, −−CBSS Malang City, cash) : 2-4% Sean Foley, Anton Soedjarwo, (Community subdistrict Richard Pollard, WSP (2000) Based Sewer Tlogomas, Community IDR System) / Watugong, contribution 1,991,506,462 SANIMAS Mergosono, ranged from (budget year Malang Bareng, 100% in 1999) Samaan Tlogomas to Construction 10% in Samaan of communal septic tank 3 Sewerage Urban West Java, - 2.33% PD PAL, local WB (IBRD Start of −−Comparative Study of system: South - 1.65% - water supply loan), national program Centralized Wastewater −−construction Kalimantan, coverage of utilities, local government (construction) Treatment Plants in Indonesia, of sewerage East city scale health offices and local in the first half ESP USAID, September 2006 system and Kalimantan, centralized government of the twentieth −−Banjarmasin Sanitation WWTP Jakarta, system century (built Whitebook, Program North Sumatera, by the Dutch). Development Technical Team, Central Java, End of program August 2007 Banten, is incalculable Yogyakarta since program coverage is still way below the expected level 4 CLTS: Urban/ West Sumatera, 138,733 −−Ministry World Bank No subsidy 2005 - −−Community Based Total Triggering to rural South Sumatera, households of Health for the basic Sanitation Strategy, Ministry of stop open Jambi, West (under WSLIC 2) (Directorate Government sanitation Health (2008) defecation Java, Banten, General of infrastructure. −−CLTS Payakumbuh reports East Java, West 10,000 villages Disease Funding is −−Payakumbuh Sanitation Kalimantan, (2008 – 2012) Control and needed for Whitebook, Payukumbuh West Nusa - Per April 2009: Environmental training and Sanitation Working Group and Tenggara, 932 villages Health) visits (for Municipal Government, 2007 have received −−National triggering, −−Institutional Dimensions CLTS triggering Planning mentoring, of Scaling Up of CLTS in and 715 villages Agency monitoring, Indonesia, Edy Priyono, 2008 declared ODF −−Ministry of etc.) −−CLTS, Learning from Home Affairs Community in Indonesia, Owin −−Ministry of Jamasy & Nina Shatifan, May General Affairs 2008 −−National WSES −−Community Led Total Working Group Sanitation (CLTS) in Indonesia, Bowo Leksono, Percik Magazine Dec. 2008 −−Learning At Scale TSSM Project, Indonesia Country Update June 2009, Field Note, WSP 86 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up 7.4 ANALYSIS OF PROGRAM APPROACHES bills. Hence, most rely on government subsidies to meet op- 7.4.1 PERFORMANCE OF PROGRAM erating and maintenance costs. System expansion is largely APPROACHES dependent on government support. Treatment plants are Overall, the sanitation programs that were analyzed in this generally idle due to insufficient flow, broken pumps or study have made an important contribution to sanitation both. improvement in Indonesia. Nevertheless, the program implementation has several shortcomings. WSLIC 2 suc- By focusing on triggering behavior change, CLTS has re- ceeded in improving water supply access, but the revolving sulted in reduced open defecation. In villages where every sanitation fund, which was the mainstay of WSLIC 2 sani- household uses its own toilet or a shared toilet with other tation program, did not fully succeed, and was unable to households, diarrhea incidence and outbreaks of vomit- reach the poorest communities. Other issues of the WSLIC ing have declined. Environmental benefits include ditches 2 program were: lack of awareness of low cost sanitation and water drainage free from human feces. People are more options, social gap between community leaders and poor concerned about safety and are aware that defecation in households, lack of clear hygiene improvement strategy and rivers may harm other people. Unlike WSLIC 2 program, community facilitators’ lack of knowledge and experience CLTS was successful in reaching the poorest households, of health and hygiene behavior. Therefore, only a part of but was relatively difficult and expensive to scale up and these participatory processes were translated into concrete hence likely to be less cost effective in reaching large and actions. diverse populations. To deliver a more efficient program, a solution needs to combine both ‘sanitation marketing’ and The SANIMAS program has built public toilets, shared sep- ‘total sanitation’ elements into the sanitation and hygiene tic tanks, and simplified sewerage systems that are still be- promotion component (TSSM/SToPs). Another downside ing used and work well. However, a few shortcomings were of the CLTS program is lack of effort from project facilita- noted, such as the lack of community access to information tors to encourage the community to resolve technical prob- and training, and participation of users in the SANIMAS lems, such as constructing toilets in dense settlements and development process. Under-specification of materials was swampy areas after a triggering process. Project facilitators also an issue. The CBSS program in Malang using the SAN- who have poor understanding of the behavior change con- IMAS approach is a good example of a community initia- cept tend to see a triggering process as a one-off event rather tive identifying and implementing sanitation solutions. than analyzing and responding to local contexts. With local CBSS was initiated, funded, organized, built, and operated project units focusing on meeting their water supply tar- by the community, and then replicated with support from gets, CLTS claimed to have served its purpose once some local governments, NGOs, external support agencies, and toilets had been built.41 Community members not engaging the private sector. The program achieved widespread aware- in the CLTS process was not due to lack of potential, but ness and broad improvements in personal hygiene practice rather because facilitators or informal leaders have not been among the communities. able to trigger villagers into action. Among the constrain- ing factors were poor leadership, divided community, de- Sewerage systems exist in less than ten cities in Indonesia, pendency on external assistance, resistance from influential and these networks are estimated to reach only 2.33% of the authority figures and lack of water supply. Yet, there was not total population (National Census, 2007), which is one of any clear operational strategy to shift from open defecation the lowest coverage levels in Asia. The systems cover a small to total sanitation. After a heavy-duty CLTS program, com- part of these cities, mainly city centers and commercial ar- munities were not willing to move on to improved hygiene eas. Performance of these sewerage systems varies from city behaviors that are equally important for health impact. to city. Only two (in Jakarta and Bandung) have achieved full cost recovery. Users are generally reluctant to pay ser- Despite the challenges left by various sanitation-related vice fees unless sewerage charges are collected through water programs, access to safe sanitation in intervention areas has 41 The CLTS Story in Indonesia, Empowering Communities, Transforming Institutions, Furthering Decentralization, Nilanjana Mukherjee & Nina Shatifan, October 2008). www.wsp.org 87 Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up increased in the past few years (increased use of pour flush project-driven or supply-driven approach, in which plan- latrine from 64% in 2004 to 69% in 2007). People have a ners and engineers assess people’s needs at a specific project growing awareness of hygienic and healthy behavior. Sup- site to determine the type of service provided, generally not port from the government in the areas of management, fi- taking into account the expressed needs and conditions of nance and technical issues, as well as community awareness the sanitation facilities users. and high level of community involvement has greatly con- tributed to the success of these sanitation-related programs. A sustainable sanitation program requires not only hard- ware, but also software intervention, including informa- Performance monitoring and evaluation is crucial to pro- tion, education and communication (IEC) campaigns. IEC gram sustainability and effectiveness. Government data media may take the form of educational and communica- on sanitation indicators need to be more accurate than at tion tools such as documentary film shows, radio shows, present. A study by EHRA found that in 2006, 69.3% of posters, banners, distribution of booklets leaflets, open-air the Indonesian population had access to ‘proper’ sanitation drama, or targeted folk music. The main focus of IEC ma- (e.g. toilet with a septic tank and or pit latrine). This figure terial development is creating local demand for sanitation. exceeds the MDG target for sanitation coverage, although the quality of the infrastructure was not considered.42 Of the four program approaches analyzed, CLTS had the strongest IEC component. Through mass, focused use of 7.4.2 INFORMATION, EDUCATION, AND IEC media, CLTS zeroes in on software rather than hard- COMMUNICATION (IEC): DEMAND-DRIVEN ware development. The triggering processes in CLTS pro- APPROACH VERSUS PROJECT-DRIVEN gram, such as fecal calculation, defecation mapping, con- APPROACH tamination flow, and focus group discussions are all part In response to historical experience of water supply and of the IEC campaign. A strong IEC component was also sanitation projects, after five years of preparation, in 2003 found in the sanitation marketing process, which was the Government of Indonesia introduced a national policy combined with CLTS to achieve total sanitation. The IEC on Development of Community-based Water Supply and campaigns included promoting options to masons, village Environmental Sanitation. Past experience indicated exist- contests and events, product demonstrations, and hygiene ing water supply and sanitation facilities were not func- promotion and support, through IEC media such as leaf- tioning properly mainly due to lack of active community lets, posters, videos, district radio, infomercials, local televi- involvement during the planning, construction, operation, sion programs, and village billboards. and maintenance processes. A limited range of sanitation options had led communities to select options that neither The SANIMAS and WSLIC 2 programs also made use of met their demands nor were compatible with local con- IEC media in the hygiene promotion campaigns, training ditions, including culture, managerial capacity, and geo- and focus group discussions, to encourage people to adopt graphic conditions. As a result of this low level of commu- health and hygiene behaviors and empower them to make nity involvement, the water supply and sanitation facilities community action plans for the proposed sanitation facility. were not properly maintained, which is the main cause of the poor sustainability and ineffective use of these facilities. Examples of programs with a strong demand-driven ap- As a result, these facilities and services had not provided proach are CLTS and CBSS in Malang, especially in Tlogo- long lasting benefits to users. Many studies found that pro- mas subdistrict. These two programs received no govern- grams that fully engaged the community and adopted a ment subsidies to build sanitation facilities. The cost of demand-driven approach have better sustainable infrastruc- construction was met by the community, as an impact of ture management, compared with programs that adopt a their awareness of the importance of having sanitary toilets. 42 EHRA study of six cities in Indonesia ( Surakarta, Denpasar, Banjarmasin, Blitar, Jambi, Payakumbuh) found that of the total number of household toilets with a septic tank on average only about 25% have been emptied since they were installed. Of those that have been emptied, only 17% had been emptied in the previous five years. 88 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up Other programs adopting a demand-driven approach are Technical acceptability relates to site conditions, space avail- SANIMAS and WSLIC 2. These programs were very de- ability, availability of local building materials and technical mand responsive and relied on active participation as well capacity. For example, septic tanks are not an appropriate as contribution from target communities and municipali- option for swampy areas such as the slum areas of Banjar- ties. The communities were given choices and assisted to masin. Better options would be a centralized sewage system select the most appropriate technology for their sanitation or shared septic tank. In hilly areas such as Bandung, devel- facilities. But unlike CLTS and CBSS Malang in Tlogomas opment of off-site systems would be technically problem- subdistrict, SANIMAS and WSLIC 2 received financial atic, and the investment, operation, and maintenance costs support from the government to build toilets. Compared would be very high. The logical choice of sanitation tech- with community-funded programs, sanitation programs nology would be septic tanks, or an off-site system divided in Indonesia that provide financial subsidies for toilet con- into clusters, each with its own wastewater treatment plant. struction do not leverage demand for sanitation in general as well, and are not as successful at engaging the private Economically acceptable means the capital costs of the fa- sector in creating market mechanisms that could offer a cility are within available budget, and the community can range of options for poor people, thereby leveraging health afford regular payments to cover operation and mainte- improvement.43 nance expenses, hence improving the sustainability of the sanitation facility. The CBSS in Tlogomas, Malang is a The WSLIC 2 revolving fund scheme had drawbacks too, good example of an economically acceptable technology. while the CBSS program in Malang (SANIMAS), which Here the community was willing to contribute to the capi- had the lowest level of financial subsidy, was more effective tal cost, and make regular payments to cover the OM costs, initiative than any of the programs that relied on financial amounting on average to less than 1% of their monthly subsidies. household expenditure. In addition, there is an explicit un- dertaking by the community that they will also be respon- The major drawbacks of the demand-driven, or commu- sible for any additional repair cost when required. Another nity-based approach are the often poor quality engineer- example is the construction of communal toilets in a dense- ing design due to lack of qualified technical advice, and the ly populated area in Jatiuwung, Tangerang district. Here as prolonged timeline for completion of the project. well as in-kind contributions, the community also made a 2–4% cash contribution to the construction of communal 7.4.3 CHOICE OF SANITATION TECHNOLOGY toilets, and are willing to pay a service fee that they find OPTIONS economically acceptable. The choice of sanitation technology options for a particu- lar sanitation program is influenced by social, technical, Environmentally acceptable means that water usage re- economic, and environmental acceptability. Social accept- flects water availability and the system takes into account ability is related to the culture or religious beliefs of a tar- the quality of groundwater and its surrounding ecosystem. get community. For instance, a study by WSP in East Java In a slum and densely populated area where there is little found that cleansing with water after defecating is common space between houses, building a private toilet with sep- practice in most communities. People who do not have tic tank is not environmentally acceptable as it could result their own toilets or who practice open defecation reported in contamination of groundwater. Here the better option that one of the benefits of defecating in rivers is the avail- is to build public toilets or a centralized wastewater treat- ability of water for cleansing after defecating. Thus, latrine ment plant on suitable plots, such as in Denpasar under the options need to consider water availability even if cleansing SANIMAS program. occurs in places other than latrines.44 43 Percik Magazine, December 2008 44 Opportunities to Improve Sanitation: Situation Assessment of Sanitation in Rural East Java, Indonesia. Jaime Frias. Water and Sanitation Program. 2008. www.wsp.org 89 Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up Sanitation options offered by unsubsidized programs such CLTS replication requires the involvement of various gov- as CLTS in low-income communities are very simple, in- ernment and non-government institutions, including the expensive constructions with a short life span. In East Java Ministry of Health, NGOs, community health centers, these are roofless superstructures with a wooden frame and village midwives, village authorities, volunteers and in- walls made from plastic, gunny sacks or bamboo mats. The formal leaders. Under the current decentralized system of slab is bamboo and clay-lined with a wooden lid, and the government, sanitation is a local government’s responsibil- pit is unlined.45 ity. Therefore, it is district government that decides which approach to adopt, although national government can en- Sanitation facilities with a longer life span, such as city-scale courage local governments to adopt a particular option and sewerage/centralized systems and septic tanks, are generally to scale up. more expensive. Although well-constructed and maintained septic tanks have a lifespan of 20 years or more, and about CLTS replication must be initiated by intensive sharing of 65% of urban households in Indonesia are connected to information within the government bureaucracy, to provide septic tanks, there is the threat of groundwater contamina- a clear picture of the basics of CLTS and how this approach tion in densely populated areas. can be used to improve health conditions, particularly envi- ronmental health. An important principle in CLTS scaling 7.4.4 PROGRAM REPLICATION up is ensuring that the system is able to run without any so- Generally, sanitation programs covered by this study are phisticated inputs (Narendranath 2007). Hence, the use of replicable under certain circumstances. It requires tremen- existing human resources and organizations is recommend- dous efforts and financial support, which committing par- ed, such as the community health center with sanitarians ties should be aware of. The CBSS program in Malang is and village midwives as frontline facilitators in the villages. a viable option for small towns in Indonesia. The system The biggest challenge is the availability of village midwives may not be replicable down to the last detail, but it can and and their willingness to live in the assigned village, because should be used as a model and adapted to fit local condi- only by staying for quite some time in a village can these tions. Currently, the CBSS program has been replicated in midwives become good facilitators.46 other subdistricts in Malang including Watugong, Mergo- sono, Samaan, Bareng, and Gadang. Further program Sewerage systems that require large investment are being replication would require support from local government expanded with support from multilateral and bilateral aid and other third parties, including NGOs, external support agencies. In order to deal with the massive public invest- agencies, and the private sector. ment, the modular system concept was proposed in the mid 1990s. This concept involves dividing urban areas by The replication of WSLIC 2 is WSLIC 3 or PAMSIMAS. population density and other physical factors, then de- However, unlike WSLIC 2, PAMSIMAS also serves urban veloping independent sanitation solutions for these areas. areas, and its replication is subsidized by national and lo- These modules can then be linked through trunk sewers as cal government, and the Ministry of Public Works acts as economies of scale develop. For the next five years, the gov- the executing agency of PAMSIMAS. The target is to reach ernment will focus more on optimizing the development of 5,000 villages or neighborhoods between 2007 and 2012, existing sewerage systems, by constructing additional net- and the target for additional replication by local govern- works and household connections.47 ment and communities is to reach about 1,000 villages or neighborhoods. 45 TSSM Project : Indonesia Country Update June 2009 (Learning at Scale) 46 Institutional Dimensions of Scaling Up of CLTS in Indonesia, Edy Priyono, 2008 47 Indonesia, Overview of Sanitation and Sewerage Experience and Policy Option, Sukarma & Pollard, 2001, www.indonesia.go.id. 90 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up 7.4.5 ISSUES THAT DETERMINE CHOICES OF Energy use. Sanitation facilities in low income areas should INTERVENTION AND PROGRAM DESIGN incorporate energy-saving technology to reduce operation Cost and efficiency. The cost-effectiveness of hygiene pro- costs. In Tlogomas, the CBBS is constructed in such a way motion or interventions such as handwashing campaigns that wastewater flows directly to a treatment plant located is closely related to the availability of water and sanitation at the lowest point of the system, and then discharged into a facilities. Most Indonesians use water for anal cleansing af- river or local water course. The flow of wastewater depends ter defecation, thus out-of-reach water is taken as a major entirely on gravity, hence using less energy than a pump barrier to use toilets, washing hands, and general hygiene. operated system. The hygiene interventions would be less cost-effective if water and sanitation facilities are either inadequate or not In Jatake village in Jatiuwung subdistrict, the SANIMAS available. public toilets produce biogas that the locals use for cooking and lighting, thereby reduced the need for regular energy. For toilet construction, the use of local materials, such as However, the proper operation and maintenance of the bio- bamboo, mud, or palm fronds, and familiar building tech- gas system is essential to its sustainability. niques will significantly reduce costs. Moreover, CLTS does not provide financial support for toilet construction or any Water use. Lack of water is a major constraint even when required external design. The important issue is for house- people are aware of the benefits of using toilets and are holds to make their own decision to stop open defecation ready to build them. People with limited access to clean and build the easiest and most affordable toilets as low-cost water tend to restrict the amount of water they use for facilities that can easily be improved and upgraded later. cooking and drinking. They would not want to waste water on flushing toilets or washing clothes. Even pour-flush op- Although community driven, WSLIC 2 did not really suc- tions, which require a minimum volume of water, would ceed in delivering access to improved sanitation among be difficult to maintain in areas with limited water supply. poor households. Lack of awareness about low-cost sanita- tion options is one of the most likely causes. Toilets con- In East Nusa Tenggara (NTT) where drought is an annual structed under government sanitation programs tend to occurrence, only 26.6% of the population uses goose neck promote solid walled and roofed toilet enclosures, with a water-sealed toilets; the rest defecate in the open, increas- pour-flush toilet pan and offset, and solid-lined pit with ing the prevalence of diarrhea. Pit latrines require less wa- some form of vent pipe. For poor communities this type ter than ‘regular’ toilets, but the waste often decomposes of toilet is not affordable without some form of subsidy. slowly and the smell is unbearable. The Indonesian Institute Low-cost toilet construction should be considered if more of Science is developing new technology to deal with sanita- effective sanitation programs for the poor is a goal. By us- tion problems in arid area. The Biotoilet is a dry toilet that ing local materials, familiar building techniques, and local uses sawdust to accelerate waste decomposition. Within five labor, the costs will be significantly reduced, and will be months, the waste is decomposed, forming compost. This more useful for the targeted community. technology has been piloted in three areas in Bandung (the LIPI Center of Applied Physics Research, Daarut Tauhid The SANIMAS example shows that facilities using more Islamic Boarding School, and Kiara Condong ward).48 Al- sophisticated technology are very costly, are used by only a though the pilot has been successful, the challenge lies in its few people, and fees will place a significant burden on poor social and cultural acceptability. families. SANIMAS design and construction must also take into account local conditions, including water availability, Polluting discharge. Improper discharge of wastewater local culture and characteristics, and the financial capacity leads to waterborne diseases such diarrhea. In urban slums, of the local community. households often discharge toilet waste directly into rivers 48 www.targetmdgs.org www.wsp.org 91 Economic Assessment of Sanitation Interventions in Indonesia | Sanitation Program Design and Scaling Up because they do not have the space to build a septic tank. tant than health and environmental benefits), such as ac- Kusuma Bangsa in Pemecutan Kaja ward, Denpasar has cessibility, increased property value, time savings, secured had a high incidence of diarrhea and other water-borne dis- proximity, privacy, and comfort (not feeling rushed). Water eases due to lack of proper sanitation facilities and frequent availability for anal cleansing is another consideration in floods, which have contaminated shallow wells and bored choice of sanitation option.50 wells. Before the SANIMAS program began, about 80% of the rented rooms and houses in which the majority of the In contrast, in Tlogomas, Malang, it was the unhealthy liv- local population live had small bathrooms and toilets with- ing conditions leading to the death of several people fol- out proper septic tanks. Wastewater from the toilets was lowing a diarrhea outbreak in 1985 that triggered people to discharged into a nearby stream. During the rainy season, stop defecating in the open and start using improved sanita- water from this waste and rubbish filled stream swamped tion. Hence, it can be concluded that increased awareness most houses in the area. The SANIMAS solution was to can trigger investment in sanitation for health and environ- construct a simple sewage system, which includes a waste- mental benefits. water treatment plant that treats around 60m3 of black and grey water per day. Inexpensive and easy to operate and Formative research on hygiene and health conducted by maintain, this DEWATS technology reduces the pollution Environmental Services Program (ESP) in September 2006 load by up to 90%49. in several urban, rural and peri-urban areas found that the perceived ideal toilet should have a goose neck water seal, Other issues. Sanitation choices do not necessary correlate with a bucket full of water beside the toilet and water dip- to wealth: many households living below the poverty line per within reach. The toilet should look clean and not smell, defecate in improved latrines and one-third of the richest have good drainage and be of a comfortable size. This ‘ideal’ (40% of the population) defecate in rivers (National Cen- toilet was found mostly in urban areas. In rural communi- sus, 2004). Studies in East Java found that other needs of- ties, the main factor preventing people from building toilets ten take priority over latrines. Preferences have little to do was lack of funds, although some of them were reported to with a family’s ability to pay and more with a household’s have high incomes. choice of expenditure. Underlying these preferences are poor awareness of potential benefits of latrines, poor aware- People are willing to invest in improved sanitation for sev- ness of latrine designs, models, and sanitation options, lack eral reasons, including: the desire to have facilities that they of understanding of health risks of defecating in rivers, and perceive as part of modern life, to safeguard their privacy, social acceptance of open defecation. However, people are enhance their self image and the assurance of being able to willing to pay for improved sanitation that offers practical defecate anytime, even when it is raining or at night when it and social benefits (which are perceived to be more impor- is uncomfortable and unsafe to defecate in the open. 49 DEWATS Treatment System Indonesia, BORDA 50 Opportunities to Improve Sanitation: Situation Assessment of Sanitation in Rural East Java, Indonesia. Jaime Frias. Water and Sanitation Program. 2008. 92 Economic Assessment of Sanitation Interventions VIII. Efficiency of Improved Sanitation This chapter synthesizes the information presented in The analysis starts from rural sites and then to urban site sit- Chapters 4 to 7 to present sanitation option efficiency un- uations. Cultural and environmental situation background der both ideal and actual program conditions. Alongside may influence economic value generation either among dif- the quantitative cost-benefit and cost-effectiveness ratios, ferent sites or between urban and rural situations. non-quantified impacts are also presented. The chapter consists of three sections: The benefit value drivers • Efficiency of sanitation interventions, compared As a prelude to the quantitative analysis, the following para- with no option (section 8.1). graphs describe the benefit value driver components. The • Efficiency of moving from improved sanitation op- benefit value drivers are: tions to other options ‘higher’ up the sanitation lad- • Being healthy and avoiding all related costs due to der (section 8.2). sickness such as disease treatment, transportation • Contextualization of the results in a national context costs for having treatment and unproductive time. and use of the results to scale up sanitation (section • Time benefits from having a private toilet (less travel 8.3). and no queuing time). • Overall cost-benefit assessment, taking into account • Reduced water treatment and water access costs due all the elements (section 8.4). to better environmental sanitation. 8.1 EFFICIENCY OF SANITATION AND Figure 66 shows an example set of benefit value drivers us- HYGIENE IMPROVEMENTS COMPARED ing the case of urban study sites in Banjarmasin. The full TO NO FACILITY benefit is represented as 100% which is obtained by choos- 8.1.1 QUANTITATIVE ANALYSIS ing sanitation options that have the full economic benefit, Economic analysis combines evidence on the cost and ben- such as private toilet with septic tank or sewerage and waste- efits of sanitation improvements already presented in ear- water treatment. The notion of the full economic benefit lier chapters, giving a number of alternative measurements means that it consists of all benefit value components i.e. of efficiency. As previously mentioned, each study site has “health benefit�, “time benefit� and “water treatment and atypical characteristics and therefore combining the results water access�. The other options on the sanitation ladders would be inappropriate; hence a separate presentation of are rewarded proportionally according to their total nomi- economic analysis is made for each site. However, the re- nal benefit value as a fraction of the full benefit value. For sults can be perceived as indicative figures of the economic example, private toilet connected to sewerage systems at its performance of sanitation improvement. optimal capacity can deliver total present value of benefits of US$1,166 (the full benefit, 100%) over a 20-year period, The following paragraphs will describe the ideas of where while private wet pit toilet can deliver total benefit US$391 the benefit values come from which covers all economic or 80% of the full benefit over the same period with an ad- costs incurred once a household with no toilet builds a toi- ditional reinvestment at Year 11, as it has 10 years expected let option with respect to its sanitation ladder alternative. life. www.wsp.org 93 Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation FIGURE 66: EXAMPLE OF THE BENEFIT VALUE DRIVERS’ CONTRIBUTION IN BANJARMASIN private sewerage private septic tank private wet pit shared toilet community toilet 0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% health water access & treatment time bene�t The figures also show that the main benefits come from be- The differentiations of benefit values between ‘optimal’ and ing healthy and avoiding spending due to sickness (paying ‘actual’ come from the following assumptions: for the doctor, medicines and transports to get to health • Benefit-cost figures vary depending on whether a facilities). The second largest benefit is the value of access system is operating at intended capacity (‘optimal’) time savings. Households receiving private toilets enjoy the or current capacity (‘actual’). greatest time savings as they do not need to travel or queue • Optimal cost figures come from engineering stan- for their toilet needs. For those who use shared or com- dards for particular sanitation ladders, while actual munity toilets, the time savings contribution is relatively cost figures come from field survey data. In some cas- smaller as they still need time to queue for their toilet needs. es the actual costs are less than the optimal costs due to under-specification of sanitation. For instance, The last benefit comes from water access and water treat- one can use substitute materials to get cheaper mate- ment. The estimated values reflect potential gain for house- rials option but sacrificing their quality and life time. holds in term of annual cost reduction for drinking water Such lower costs give more chance for poor house- treatment before and after improved sanitation. This value holds to afford private sanitation provision. Howev- is assumed, based on the fact that some households will er, the under specification sanitation leads to shorter decide not to boil their drinking water anymore and/or life time and needs more recurrent investment. choose a cheaper treatment method. Water source access Hence in terms of annual cost equivalent, it may not costs may also be reduced due to closer sources of water be cheaper to invest in below standard specifications. supply becoming cleaner and more usable for meeting do- • Ideal benefit figures are also related to program effec- mestic needs. tiveness. They are measured by sanitation utilization rates. A fully utilized sanitation option is in an ideal Benefit-cost analysis at rural sites situation where household members always use their Table 47 and Table 48 show BCR figures for rural sites at toilet every time they need it. While actual benefit Lamongan District and Tangerang District respectively. figures come from underutilized sanitation where They present results under both optimal and actual pro- household members, for any reasons, do not always gram conditions. The notion of optimal efficiency refers to use their toilet when they need it. In this case, the a condition of full achievement of all key performance indi- actual benefit values used to be less than the ideal cators of sanitation programs. Meanwhile, actual efficiency benefit values. refers to the existing achievement of sanitation programs which by definition are less than 100% of the optimal ef- The study results for Lamongan District reveal all perfor- ficiency. mance parameters are beyond their minimum feasible val- ues: 94 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation • Benefit-cost ratio: both its optimal and actual ben- The results for Tangerang district are similar to Lamongan. efit values of every ladder exceed its cost figures. The All benefit-cost figures show sanitation options to be eco- top sanitation ladder option in Lamongan District is nomically attractive, and for some cases the performance is private toilet with onsite septic tank. The BCR value higher than for Lamongan. reveals that for every US$1 input of investment costs generates US$3 under optimal program conditions Figure 67 shows how benefit figures of all sanitation lad- and US$2 under actual conditions. The BCR figures der options at rural sites cover their investment costs. As for other sanitation options are more favorable as the detailed in Figure 48 (Chapter 6), septic tanks are shown input of investment costs are much cheaper while to be the highest sanitation ladder option for rural sites in generated economic benefits (at household level) are terms of annualized cost, and hence have the least favor- almost similar. able benefit-cost ratios in both Lamongan and Tangerang • Internal rate of return: All sanitation options have districts. IRR of greater than 100%, which means that each year the investment value is more than repaid. Only The study also estimates the effect of basic hygiene inter- private septic tank under actual conditions has IRR ventions in addition to the sanitation intervention. The ba- below 100%, at 79%. sic hygiene practice is hand washing with soap (HWWS). • Payback period: For shared and private pit toilets In the rural areas, such an additional intervention delivers it takes less than 1 year for a household to recover additional values of health benefit. Adding hygiene practic- its initial investment costs. For private septic tank, es to sanitation interventions increases program efficiency the optimal payback period is 2 years and 3 months, and decreases the cost per DALY averted. It means the ad- while the actual is 2 years and 10 months ditional generated benefit values can cover required input • Net present value (NPV): All NPV values are posi- costs (costs for soaps and other related hygiene expenses). tive. It means the investments on any sanitation lad- It also implies that hygiene practice is an important factor der deliver positive net economic gains. to decrease health risks. Figure 68 shows the higher Net TABLE 47: RURAL AREA (LAMONGAN DISTRICT) EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED WITH “NO TOILET� Efficiency measure Scenario Shared toilet Private wet pit Private septic tank COST-BENEFIT MEASURES Optimal 6.7 6.1 3.3 Benefits per US$ input (US$) Actual 5.4 5.1 2.7 Optimal >100% >100% >100% Internal rate of return (%) Actual >100% >100% 79% Optimal 8 months 5 months 2 years 3 months Pay-back period Actual 10 months 6 months 2 years 10 months Optimal 1,498 1,757 2,081 Net present value (US$) Actual 1,174 1,394 1,379 COST-EFFECTIVENESS MEASURES Optimal 423 548 945 Cost per DALY averted (US$) Actual 522 485 1,378 Optimal 3 4 7 Cost per case averted (US$) Actual 4 5 10 Optimal 38,513 49,905 86,234 Cost per death averted (US$) Actual 47,489 61,535 125,819 The field sites: 1) Geger, 2) Keben, 3) Badurame and 4) Turi. www.wsp.org 95 Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation TABLE 48: RURAL AREA (TANGERANG DISTRICT) EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED WITH “NO TOILET� Efficiency measure Scenario Community toilet Shared toilet Private wet pit Private septic tank COST-BENEFIT MEASURES Optimal 3.0 4.7 7.8 4.3 Benefits per US$ input (US$) Actual 2.5 3.9 6.0 3.7 Optimal 44% >100% >100% 100% Internal rate of return (%) Actual 64% >100% >100% 79% Optimal 3 years 3 months 1 year 1 month 5 months 2 years Pay-back period Actual 4 years 1 year 4 months 5.5 months 2 years 3 months Optimal 908 1,266 2,064 2,371 Net present value (US$) Actual 662 945 1,525 1,769 COST-EFFECTIVENESS MEASURES Optimal 1,628 1,148 1,024 1,562 Cost per DALY averted (US$) Actual 1,988 1,401 1,034 1,725 Optimal 9 7 5 8 Cost per case averted (US$) Actual 10 8 7 9 Optimal 63,868 50,789 40,157 61,608 Cost per death averted (US$) Actual 77,983 62,013 49,031 68,061 The field sites: 1) Sarakan, 2) Kayu Agung, 3) Sukasari, and 4) Tanjakan Villages Present Values (NPVs) of benefit (optimal as well as actual) is the sewerage system in Banjarmasin whose in- as the result of adding hygiene practices to the sanitation vestment costs at optimal capacity are US$473 per interventions. household connection. Its BCR value is 1.1, which means if the systems operate at their optimal capac- The cost-effectiveness ratios indicate what a household has ity, they could deliver economically viable results. to pay to get “one additional unit of health benefit�. Figure However, in 2009 the system was operating at 14% 69 shows the cost per case averted at both rural sites. The capacity, thus giving significantly higher investment figures imply that in order to prevent a case of disease, a costs per household connection (US$2,201). Such household using a septic tank needs to pay more than a a high investment cost obviously makes it hard to household using any other sanitation ladder options. How- achieve economic viability. With its low capacity uti- ever, the figures omit other benefits such as time saving and lization, every US$1 input of investment generates intangible benefits. US$0.25 output of economic benefit. The BCR fig- ures for the other sanitation options are much higher Benefit-cost analysis at urban sites as the investment costs are much lower while gener- Table 49, Table 50 and Table 51 show that, for urban sites, ated economic benefits are similar. the optimal and actual performance of sanitation interven- • Internal rate of return: the IRRs for shared, private tions are similar to those in rural areas: all economic perfor- pit latrine and toilet with septic tank are favorable, at mance parameters are above their minimum economically rates of between 30% and well over 100%. For com- viable values. The results for Banjarmasin are described be- munity toilets the IRR is 15% at optimal function- low: ing, reduced to 5% at actual rates of capacity utiliza- • Benefit-cost ratio (BCR): the optimal economic tion. For off-site treatment, IRR is 12% at optimal benefits value of every sanitation option exceeds the functioning, reduced to a negative figure at actual costs. The most expensive sanitation ladder option rates of capacity utilization. 96 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation FIGURE 67: COMPARISON OF RURAL BCR VALUES OF DIFFERENT SANITATION LADDER AND AT DIFFERENT SITES private septic tank Tangerang District private wet pit community toilet private septic tank Lamongan District private wet pit shared toilet actual capacity 0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 optimal capacity bene�t - cost ratio FIGURE 68: COMPARISON OF NET PRESENT VALUE OF SANITATION ONLY AND OF SANITATION + HYGIENE PRACTICES FOR TOILET WITH SEPTIC TANK AT RURAL SITES sanitation + hygiene Tangerang District sanitation only sanitation + hygiene Lamongan District sanitation only 1,000 1,200 1,400 1,600 1,800 2,000 2,200 2,400 actual capacity bene�t - cost ratio optimal capacity FIGURE 69: COST PER CASE AVERTED ($) AT RURAL SITES private septic tank Tangerang District private wet pit community toilet private septic tank Lamongan District private wet pit shared toilet 0 2 4 6 8 10 12 actual capacity cost per case averted ($) optimal capacity www.wsp.org 97 Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation • Payback period: shared, private pit latrine and toilet go to rivers for their toilet related activity purposes with septic tank all have payback periods of less than (defecation, washing, bathing etc.). 3 years at optimal rate of toilet use by households, and less than 7 years for actual use. At optimal ca- Figure 70 shows benefit-cost ratio figures of selected sanita- pacity utilization, the maximum payback period is tion options at urban sites are greater than their investment around 8 years for off-site treatment, which is well costs (BCR>1). Refer to Figure 49 in chapter 6, private toi- below the expected length of life of 20 years. let connected to sewerage systems and community toilets, • Net present value (NPV): All NPV values at optimal which need higher annual equivalent investment costs per capacity are positive, which means that investment household than other sanitation ladder options. in toilets with any sanitation ladder options are eco- nomically viable.The differentiations of benefit val- The cost effectiveness figures for urban sites show almost ues between ‘optimal’ and ‘actual’ are based on the similar values for all sanitation ladder options. The urban same assumptions as the ones for rural analysis. In sites figures imply that in order to prevent a case of dis- case of Banjarmasin sewerage systems, the BCR fig- ease risk, at optimal capacity utilization, a household with ure at its actual capacity (by January 2010) is 0.2 private toilet connected to communal sewerage pays more (less than 1), Payback Period more than 20 years and than using any other sanitation ladder options. In the case NPV = -2,395. A similar case also happens to the of sewerage systems in Banjarmasin, its actual cost per case/ community toilets (SANIMAS) which operates at episode averted is extremely high compared to the other about 70% of their capacity and the BCR value is sanitation ladder options. 0.9. Some of the targeted beneficiaries sometime still TABLE 49: URBAN (BANJARMASIN) EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED WITH “NO TOILET� Community Private septic Private off-site Efficiency measure Scenario Shared toilet Private wet pit toilet tank treatment COST-BENEFIT MEASURES Benefits per US$ input Optimal 1.4 2.3 2.8 1.8 1.1 (US$) Actual 0.9 1.4 1.9 1.2 0.25 Optimal 15% 97% >100% 88% 12% Internal rate of return (%) Actual 5% 30% >100% 41% Negative Optimal 8 years 11 2 years 9 months 2 years 2 8 years 2 months months months Pay-back period Actual 16 years 10 4 years 1 year 3 months 7 years >20 years months Optimal 159 333 617 772 139 Net present value (US$) Actual -56 107 291 382 -2,395 COST-EFFECTIVENESS MEASURES Cost per DALY averted Optimal 1,502 993 1,299 978 (US$) Actual 2,142 1,416 1,198 1,395 Optimal 9 6 8 6 Cost per case averted (US$) Actual 13 9 11 8 Cost per death averted Optimal 47,948 31,696 41,462 31,419 (US$) Actual 68,399 45,215 59,146 44,820 The field sites: 1) Pekapuran Laut, 2) Kelayan Luar 98 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation TABLE 50: URBAN (MALANG) EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED WITH “NO TOILET� Private off-site Efficiency measure Scenario Shared toilet Private wet pit Private septic tank treatment COST-BENEFIT MEASURES Benefits per US$ input Optimal 2.8 4.3 2.5 2.3 (US$) Actual 2.3 3.6 2.1 1.9 Optimal >100% >100% 100% 55% Internal rate of return (%) Actual >100% >100% 65% 43% Optimal 1 year 8 months 7 months 2 years 3 years Pay-back period Actual 2 years 2 months 8 months 2 years 6 months 3 years 7 months Optimal 503 1,302 1,226 1,328 Net present value (US$) Actual 369 1,007 872 977 COST-EFFECTIVENESS MEASURES Cost per DALY averted Optimal 1,200 1,661 2,253 1,944 (US$) Actual 1,433 1,486 2,692 2,133 Optimal 9 12 16 38 Cost per case averted (US$) Actual 10 14 19 46 Cost per death averted Optimal 34,484 47,741 65,224 157,589 (US$) Actual 41,200 57,039 77,926 188,278 The field sites: 1) Kedung Kandang, 2) Lowowaru, 3) Mergosono, 4) Tlogomas, 5) Arjowinangun and 6) Dinoyo TABLE 51: URBAN (PAYAKUMBUH) EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED WITH “NO TOILET� Efficiency measure Scenario Shared toilet Private wet pit Private septic tank COST-BENEFIT MEASURES Benefits per US$ input Optimal 1.8 2.3 1.4 (US$) Actual 1.5 1.7 1.8 Optimal 50% >100% 16% Internal rate of return (%) Actual 68% >100% 30% Optimal 2 years 11 months 1 year 3 months 6 years 9 months Pay-back period Actual 3 years 8 months 1 year 11 months 6 years 6 months Optimal 273 530 336 Net present value (US$) Actual 144 266 243 COST-EFFECTIVENESS MEASURES Cost per DALY averted Optimal 1,674 1,995 2,714 (US$) Actual 1,988 1,649 2,435 Optimal 8 10 13 Cost per case averted (US$) Actual 10 12 12 Cost per death averted Optimal 38,847 46,293 63,518 (US$) Actual 46,137 54,980 56,990 The field sites: 1) Talawi, 2) Kotopanjang, 3) Payolinyam and 4) Kubu Gadang www.wsp.org 99 Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation Cost-effectiveness figures are mainly influenced by: nifcant awareness to the importance of possessing a private • Total investment costs of a household to develop a toilet. In addition, the local culture of West Sumatera with toilet. its cohesiveness and collectivist spirit also contributed to • Generated benefit in terms of avoided or reduced the way people built their toilets. Many households built health risks due to toilet ownership. Greater reduced their toilets with minimum input costs. They used sand and risks lead to lower cost per health gain achieved. (sometimes) cement received from their neighbors. They collectively purchased a molding tool so that they can make Figure 71 shows the comparison of cost per case/episode the toilet part by themselves from cement-sand mixtures. averted at urban sites. Community toilets, shared toilets The owners were involved in the construction processes to- and septic tank toilets deliver relatively low cost per case gether with masons. Such situations reduced cash capital averted compared to private toilet connected to communal spending significantly. However, the total capital costs for sewerage. In the case of Payakumbuh, as mentioned in the toilet investment per household may be greater than the previous chapter, the sanitation investment costs are very current figure as the value of time of the household devoted low. The CLTS approach in Payakumbuh has creates sig- to the toilet construction has not been included. FIGURE 70: COMPARISON OF URBAN BCR VALUES OF DIFFERENT SANITATION LADDER OPTIONS AND AT DIFFERENT SITES Payakumbuh private septic tank shared toilet private communal sewerage Malang private septic tank shared toilet Banjarmasin private sewerage community actual capacity 0.0 1.0 2.0 3.0 cost per case averted ($) optimal capacity FIGURE 71: COMPARISON OF URBAN COST PER CASE AVERTED (US$) Payakumbuh private septic tank shared toilet private communal sewerage Malang shared toilet Banjarmasin private sewerage community actual capacity 0 10 20 30 40 50 60 70 optimal capacity 100 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation The situation is very similar in Malang city, where people However, there are also factors that make people with im- built their communal sewerage systems collectively. People proved toilets continue to use toilet options defined as ‘un- contributed by direct involvement in the construction as improved’, such as hanging toilets on a river or on a fish well as providing some of the required materials. Although pond. For instance, some people in Payakumbuh prefer to not as low as in Payakumbuh, the capital costs for toilet defecate in hanging toilets on a pond to feed their fish, as investment per household were much reduced. In contrast, well as preferring the open air and absence of bad smell that the highly capital-intensive sewerage system in Banjarma- tends to accumulate in toilets that are not properly cleaned. sin, coupled with its low actual capacity utilization, leads to Another interesting finding from the Banjarmasin site is the very high cost per case averted of more than US$60, com- preference of households for open defecation in rivers in pared with other options and sites, where it is 20 years >20 years Net present value Optimal 324 255 (54) (US$) Actual 72 (102) (104) COST-EFFECTIVENESS MEASURES Cost per DALY Optimal 2,529 2,862 2,807 averted (US$) Actual 3,607 34,900 4,004 Cost per case averted Optimal 15 17 17 (US$) Actual 22 212 24 Cost per death Optimal 82,204 93,033 91,250 averted (US$) Actual 117,266 1,134,549 130,171 Note: Figures in parentheses are negative values Banjarmasin is a special case. Land scarcity is more of an is- For Malang City, moving up from shared latrine to com- sue here than at any of the other study sites. As mentioned munal sewerage would be economically unfavorable. Again, in the previous chapter, many poor households live along the total investment cost per household of private toilet riverbanks and use the rivers as their toilets as well as for connected to communal sewerage far outweighs the cost of washing, bathing and children playgrounds. Larger rivers shared latrines. The situation would probably be different if are also used for public transportation. The provision of im- land were as scarce as it is in Banjarmasin. proved toilets such as SANIMAS or shared toilets connect- ed to the sewerage system would certainly give these poor Figure 73 shows the summary of BCR values of moving households access to technically adequate and economically up sanitation ladders in the three urban study sites. A BCR viable sanitation. values of less than 1 indicates that the generated economic 104 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation TABLE 55: URBAN AREA (MALANG) EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARING DIFFERENT POINTS ON THE SANITATION LADDER Moving from shared latrine to: Moving from private wet pit latrine to: Efficiency measure Scenario Communal Private septic tank Private septic tank sewerage COST-BENEFIT MEASURES Benefits per US$ Optimal 3 0.8 0.7 input (US$) Actual 2 0.7 0.6 Internal rate of return Optimal 90% 3% 0% (%) Actual 62% 0% -2% Optimal 2 years 1 month 15 years 3 months >20 years Pay-back period Actual 2 years 7 months >20 years >20 years Net present value Optimal 855 (70) (179) (US$) Actual 625 (154) (263) COST-EFFECTIVENESS MEASURES Cost per DALY Optimal 3,373 3,642 4,521 averted (US$) Actual 4,030 4,351 5,401 Cost per case averted Optimal 24 26 32 (US$) Actual 29 31 38 Cost per death Optimal 98,870 106,744 132,514 averted (US$) Actual 118,124 127,532 158,321 Note: Figures in parentheses are negative values TABLE 56: URBAN AREA (PAYAKUMBUH) EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARING DIFFERENT POINTS ON THE SANITATION LADDER Moving from shared latrine to: Moving from private wet latrine to: Efficiency measure Scenario Private septic tank Private septic tank COST-BENEFIT MEASURES Optimal 1.5 0.6 Benefits per US$ input (US$) Actual 1.0 0.5 Optimal 20% -2% Internal rate of return (%) Actual 9% -9% Optimal 5 years 9 months >20 years Pay-back period Actual 9 years 11 months >20 years Optimal 198 (155) Net present value (US$) Actual 11 (217) COST-EFFECTIVENESS MEASURES Optimal 3,572 4,061 Cost per DALY averted (US$) Actual 4,242 4,823 Optimal 18 20 Cost per case averted (US$) Actual 21 24 Optimal 84,816 96,433 Cost per death averted (US$) Actual 100,732 114,529 Note: Figures in parentheses are negative values www.wsp.org 105 Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation benefit would be less than the incremental cost of moving 8.3 SCALING UP RESULTS FOR NATIONAL up the sanitation ladder. However, this does not mean that POLICY MAKING households should not move up the sanitation ladder, es- It has been pointed out in the previous section that the pecially given the challenges associated with building some study results do not represent nationwide sanitation situ- types of sanitation option, and the intangible benefits not ations. Such results should be perceived as indicative out- quantified in the benefit-cost calculations. The results in- comes for further exercises to promote evidence-based dicate how important it is that stakeholders, especially lo- decision-making in sanitation development. However, the cal governments, take measures to decrease the investment ultimate use of this study is not only the improvement of costs of sanitation options and promote more affordable sanitation decisions in the field sites of the study, but in as- ones. sessing national policies in the light of the field level results. How different are the selected sites in terms of the under- At the same time, greater attention needs to be given to rais- lying characteristics, and how replicable are the sanitation ing people’s awareness of the importance of having techni- interventions in the rest of the country? These issues are cally sound and comfortable toilets. The aim is to establish dealt with in turn. awareness among households to voluntarily engage and ac- tively participate in sanitation improvement programs. This In order to give a brief framework of thinking, Table 57 in turn will shift the financing burden, from government presents an assessment of some underlying characteristics bearing the whole cost to households contributing to the include economic, social, demographic, cultural, geophysi- cost of sanitation. cal with respect to the following aspects: FIGURE 73: ECONOMIC PERFORMANCE OF MOVING UP THE URBAN SANITATION LADDER BENEFIT-COST RATIOS private wet pit Payakumbuh shared toilet Payakumbuh private wet pit Malang initial sanitation ladder shared toilet Malang private wet pit Banjarmasin shared toilet Banjarmasin community toilet Banjarmasin 0.0 1.0 2.0 3.0 new sanitation ladder: private septic tank private communal sewerage private centralized sewerage + treatment 106 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation TABLE 57: TYPICAL NATIONWIDE SANITATION SUBGROUPS VERSUS FIELD SITE CHARACTERISTICS Population Sanitation Sites size Climate Social group Demographics Economy coverage represented Typical locations 1. Coastal Moderate to −− Temp: 22 – 26 Main occupation: −− Pop density: moderate −− Gross Regional Moderate - lowland high o C - Farming to high Product (GRP): (rural) −− Precipitation - Fisheries moderate low to moderate* 2. Coastal - High −− Temp : 22 – Main occupation: −− Pop density: high −− GRP: high High Lowland 26oC - industry (urban) −− Precipitation: - trading moderate 3. Upland - hilly Moderate to −− Temp : 22 – Main occupation: −− Pop density: moderate −− GRP: high High (urban) high 26oC - Trading to high −− -Precipitation: - industry high Field sites 1. Lamongan 1,439,886 −− Temperature: Ethnic: Javanese −− Pop Density: 794 people/ −− GRP : IDR 46% (rural) / (2008) 20 – 30oC Main occupation: km2 (2008) 5,336,440 per Coastal −− Precipitation: - Farming −− No. of HH : 338,534 HH capita/year lowland rural 2,670 mm/year - Fisheries −− Av. farm size: 4 persons/ −− Ability / willingness HH to pay for −− Av. children < 5: 1 sanitation option: person /HH 0 – 500,000 IDR 2. Tangerang 3,585,256 −− Temperature: Ethnic: −− Pop Density: 3,229 −− GRP : IDR 58% (rural) / (2008) 23 – 33oC Sundanese people/km2 (2008) 8,190,000 per coastal −− Precipitation: Main occupation: −− No. of HH: 828,645 HH capita/year lowland rural 1.475 mm/year -Industrial labor −− Av. farm size : 4 persons/ −− Ability / willingness HH to pay for −− Av. children < 5: 1 sanitation option: person /HH 0 – 500,000 IDR 3. Banjarmasin 602,725 −− Temperature: Ethnic: Banjar −− Pop Density: 8,371 −− GRP : IDR 44% (city) / (2006) 25 – 38oC Main occupation: people/km2 (2006) 8,043,860 per Coastal −− Precipitation: - small trading −− No. of HH: 154,527 HH capita/year lowland 2.682 mm/year - services (2006) −− Ability / willingness urban −− Flooding −− Av. Farm size : 4 to pay for occurred persons/HH sanitation option: during high −− Av. children < 5: 1 0 – 500,000 IDR tide person /HH 4. Malang (city) 816,444 −− Temperature: Ethnic: Javanese −− Pop Density: 7,418 −− GRP : IDR 70% / upland hilly (2007) 23 – 24oC - Madura people/km2 (2007) 25,161,600 per urban −− Precipitation: Main occupation: −− No. of HH: 250,085 HH capita/year 1.833 mm/year - small trading −− Av. Farm Size: 4 −− Ability / willingness - industry persons/HH to pay for - services −− Av. children <5: 1 person sanitation option: /HH 0 – 500,000 IDR 5. Payakumbuh 104,969 −− Temperature: Ethnic: Minang −− Pop Density: 1,305 −− GRP : IDR 49% (city) / (2007) 26oC Main occupation: people/km2 (2007) 12,900,000 per upland hilly −− Precipitation: - small trading −− Number of HH: 24,725 capita/year urban 2250 mm/year - small farmer HH −− Ability / willingness −− Humidity: −− Av. Farm size : 4 to pay for 45–50% persons/HH sanitation option: −− Av. children <5: 1 person 0 – 500,000 IDR /HH Notes: *) Definition by The Meteorology, Climatology and Geophysics Agency (BMKG) Indonesia: Low to moderate precipitation (rainfall): 20 - 50 mm per day, moderate to high precipitation 50-100 mm per day, above high precipitation: above 100 mm per day (http://id.wikipedia.org/wiki/) www.wsp.org 107 Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation • physical location – coastal, lowland/plain, upland, ership among households. This is expected to encourage all mountainous, etc, households to stop open defecation as soon as possible. • climatic features such as rainfall, water scarcity, and flooding, In recent years, the Government of Indonesia, in collabo- • social groups, ethnicity and related cultural factors ration with the World Bank’s WSP and the Netherlands affecting acceptance of sanitation options, Government, has delivered the Indonesia Sanitation Sector • demographics – family size, number of children un- Development Program (ISSDP). The program involved six der five, etc., cities in the first phase and eight cities in the second phase. • economic level of living, and ability or willingness to The program adopted a new approach for sanitation de- pay for sanitation options; and velopment which combined top down and bottom up ap- • sanitation coverage. proaches. The top down element is providing facilitation to city governments to develop comprehensive city scale sani- One of the criteria for selection of ESI study sites was to be tation strategies (CSS), and the bottom up element is en- representative of other parts of Indonesia in terms of geo- couraging local initiatives by involving all local stakeholders physical, climatic, demographic and socio-economic char- (local government bodies, local parliament, local communi- acteristics. The sanitation options applied in the field sites ties, local private sectors and local communication media) of this study are basically common to most national con- in assessing their own sanitation situation and developing a texts. For example, on-site septic tank and wet pit latrine five-year strategy to improve their city scale sanitation. The are the most common sanitation options in any district or approach also uses the existing sanitation condition as the city in Indonesia. Urban sewerage and communal sewer- baseline for further development. The ISSDP approach is age systems, meanwhile, are sanitation options that need considered successful and has been adopted as the approach further evaluation before they are promoted widely in In- for a nationwide program of sanitation development. A set donesia. of comprehensive methods has been developed that enables local governments to design and implement their sanita- A national sanitation program, particularly a scaling up tion development. Banjarmasin, Malang and Payakumbuh strategy, needs to take into account the appropriateness – three of the ESI Phase 2 field sites – are among the cities of sanitation option alternatives. In the past, massive top participating in the ISSDP. down delivery mechanisms have been used in programs of centralized government, with limited community par- In a previous chapter, it was reported that there is an imbal- ticipation, leading to low effectiveness and sustainability of ance in the distribution of responsibility in terms of sanita- the programs. Meanwhile, purely bottom up approaches tion financing. Households, many of which are poor, bear – waiting for households to make their own choices with most of the cost of almost all on site sanitation options. little outside intervention – are time consuming and have Offsite urban sewerage systems, meanwhile, are largely fi- limited effectiveness. Therefore, there should be a menu of nanced by governments. To establish more of a balance in technologies and delivery approaches from which selections the distribution of the responsibility for financing among can be made and implemented in the most appropriate way the stakeholders for all sanitation ladder options, requires for a particular field site. For example, for poor commu- adequate and appropriate campaigns to raise people’s sani- nities still practicing open defecation in Payakumbuh, the tation awareness and advocacy campaigns to get support CLTS approach has been proven the most effective at the from stakeholders. Well-planned and well-executed aware- initial stage of sanitation development. At a later stage, the ness and advocacy campaigns should address challenges in local government shifts the focus to delivering the so-called the sector such as financing and government stewardship “One Thousand Toilet Movement� to accelerate toilet own- capacity. 108 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Efficiency of Improved Sanitation 8.4 OVERALL COST-BENEFIT ASSESSMENT intervention: (1) from no sanitation option (open defeca- The ESI Phase 1 reported that in 2006 Indonesia lost an tion) or unimproved option (e.g. hanging toilet) to having estimated IDR56 trillion (US$6.3 billion) annually due to any type of improved toilet, whether communal, shared or poor sanitation and hygiene. This is equivalent to approxi- private; and (2) moving up the sanitation ladder from ba- mately 2.3% of gross domestic product (GDP). In other sic improved to more advanced improved toilets (Chapter words, the country would be able to benefit significantly if 8). Hence, program implementers are provided with robust sanitation and hygiene were improved. and detailed figures on which sanitation interventions may be economically viable in any given setting. Such quantita- The ESI Phase 2 Study extends the previous study results by tive information may also be used to support an advocacy generating robust evidence on the costs and benefits of sani- campaign to get support from stakeholders. tation improvements in different programmatic and geo- graphic contexts in Indonesia. The benefit analyses focus on Sanitation improvement options vary from basic level to household level at study sites as well as national level. The advanced level options. Each of them delivers specific eco- benefit of sanitation improvement at household level in- nomic benefits but each also entails a cost. Therefore, this volves three main potential benefit value drivers i.e. health study provides detailed information on sanitation invest- costs, time saving, and water access and treatment costs; all ment costs, which cover physical (capital) and nonphysical of which are presented quantitatively as well as qualitatively (program) costs, as well as operation and maintenance costs (Chapter 4). for each sanitation option. The figures are also presented on an annual basis in order to have fair and clear comparisons Benefit analysis at national level covers the knock-on effects among the available sanitation ladder options at each study of sanitation improvement on tourism, business and the site, given that different options have a different expected sanitation supply market, drawing on primary data as well life span (Chapter 6). Households of different socio-eco- as robust secondary data to make conclusions on the likely nomic levels – from poor to wealthy – can therefore choose economic impacts of sanitation improvements (Chapter which point on the sanitation ladder is appropriate for 5). Such an analysis enriches the comprehensiveness of the them, based on their preferences and ability to pay. study and provides an increased awareness that sanitation sector may have a broader effect on other economic sectors. In addition to the benefit analysis of sanitation improve- ment at household level and national level, the study pres- The main output of the ESI Phase 2 study is a set of CBA ents a program approach analysis (PPA), which informs results covering sanitation as well as hygiene improvement program implementers of the importance of implementing in selected rural and urban areas. It presents a thorough programs efficiently (Chapter 7). The PAA involved a struc- economic benefit analysis of sanitation improvement for all tured assessment of selected sanitation programs, present- available sanitation ladder options at the study sites. Quan- ing results on program effectiveness and the appropriate- tifiable benefits of having improved sanitation options were ness of a particular intervention approach with respect to monetized and evaluated using several economic perfor- specific geographical characteristics and cultural and socio- mance indicators. The analysis included two main types of economic contexts. www.wsp.org 109 IX. Discussion 9.1 STUDY MESSAGES AND INTERPRETATION 9.1.1 MAIN MESSAGES The study results at rural sites reveal that all sanitation inter- At all urban sites, moving up the sanitation ladder from ventions are economically feasible. The actual benefit-cost shared latrine to improved private septic tank is economi- ratio or BCR values range from 2.0 (private septic tank in cally feasible at both optimal and actual capacity utilization. Lamongan district) to 6.0 (community and private pour- Other improvement options for moving up the sanitation flush toilets in Tangerang district). As payback periods are ladder are not economically feasible, having a BCR of less short, the internal rates of return are very high, exceeding than 1. 100% in many cases. Therefore, all investments at any level on the sanitation ladder, both at optimal and actual utiliza- As well as the above quantitative benefits, there are also tion, are economically feasible at rural sites. non-monetized benefits that should be taken into account to justify any sanitation investment. People may consider At urban sites, all sanitation ladder options are economi- paying any price to acquire intangible benefits such as: cally feasible at their optimal utilization. The BCR values • The comfort of having a better environment as the range from 1.1 for private toilet connected to the sewerage result of possessing an improved private toilet. system in Banjarmasin to 4.0 for private wet pit in Malang • More privacy for doing other activities in a toilet city. Nevertheless, there are two sanitation ladder options room, especially for stay-at-home mothers, such as – SANIMAS and private toilet connected to the sewerage bathing, female hygiene, washing or cleaning home system in Banjarmasin – which are not economically fea- appliances. sible at their actual capacity utilization, both with BCR of • Economic gains from environmental improvements 0.2. Their actual levels of capacity utilization are 70% and such as not contaminating groundwater used for 14%, respectively. These figures are a reminder to program drinking water, or improved quality of the neighbor- implementers that sanitation interventions require careful hood (e.g. closed rather than open drains transport- planning and implementation. ing sewage). • Connecting to off-site systems such as communal or Given that some people already have some form of sani- urban sewerage systems due to limited space to build tation, the decision they face is whether to move further a septic tank. up the sanitation ladder. At rural sites, further investments • Larger scale economic benefits from having good in sanitation are economically justified, with the following sanitation, such as knock-on effects on tourism and BCR figures: business as well as the sanitation supply market. • Lamongan district: the lowest actual BCR is 2.0 with an annual rate of return of 21% for moving up from The benefit value drivers in the quantitative analysis include private wet latrine to improved private septic tank. the costs related to sickness, such as physician’s fee, medi- • Tangerang district: the lowest actual BCR is 1.2 with cines and transport to health facilities, as well as saving time an annual rate of return of 15% for moving up from from not traveling to site of open defecation or queuing at private wet latrine to improved private septic tank. public toilets. Marginal benefits have been valued related to 110 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Discussion averted pollution of local water sources and reduced travel 9.1.2 ROBUSTNESS OF RESULTS or treatment costs; however, the actual economic benefits To undertake the variety of economic calculations in the are likely to be significantly greater than those valued in this study, a range of assumptions had to be made as the basis study. Among the valued benefits, the health benefits will for the analysis. The main assumptions of the quantitative most likely lead to financial savings for households as well analysis are as follows: as health care providers. Therefore, decreased risks to health • The health risks posed by those who live in the study as a consequence of having better sanitation would lead to sites are assumed to be caused, among other things, reduced household spending on health-seeking efforts, thus by the level of sanitation. Open defecation practice safeguarding cash resources for other uses. is the most disease-prone option. Private toilet with septic tank and septage management, or toilets con- For sanitation financing purposes, benefits can be classified nected to sewerage systems with wastewater treat- into private and community benefits. Private benefits in- ment, have the lowest health risks. clude direct health benefits (averted transmission between • Time savings from having better sanitation will have members within the same household), access time savings economic benefits, whether the time savings are used and intangible benefits of an improved and closer toilet. for wage earning, for non-income productive ben- The community benefits include environmental benefits efit, or for leisure time. A conservative value of time that are enjoyed by the community as a result of the joint was used: 30% of the average wage for adults, and effort of households to improve their sanitation facility half of this value for children. as well as community-wide reductions of communicable • Having better sanitation will lead to improved envi- disease (often termed ‘health externalities’). Due to lack ronment quality, which will avert pollution of local of empirical evidence on the distinction between private water sources and reduce water treatment costs. and community health benefits, disaggregated results were not presented in this study. However, there are clear and The above assumptions may even be conservative under the established public health arguments for public investment following conditions: in sanitation to capture the health benefits, of which there 1. When averted costs from avoided disease cases are are many precedents in countries of the developed world. greater than their assumed values. Furthermore, investment in infrastructure is not enough: 2. Where there exists ample opportunities to earn ad- public funds also need to be utilized for raising community ditional income from the time saved and people are awareness and motivating households to take action. eager to spend their productive time in a productive manner. Linking the benefits above with gender and their distribu- 3. People’s behavior related to water treatment is heav- tional assessment also requires understanding the different ily influenced by water source quality. benefits for women, men, children and the elderly. In the previous chapter, it was mentioned that husbands are the On the other hand, the assumptions are considered to be decision makers when it comes to building and upgrading optimistic under the following conditions: a sanitation facility, especially for higher cost facilities or 1. Sanitation is not the only factor that affects people’s facilities that involve disruption such as housing improve- health risk. There may be other factors causing these ments. Therefore, husbands need to become one of the same diseases, such as the way parents take care of target groups for sensitization on the economic benefits of their under-five children, food safety and the hy- sanitation investment, to persuade them to invest. How- giene behavior of adults. ever, as housewives, children and the elderly tend to spend 2. Not everybody perceives that being higher up the more time at home than the husbands, they would be the sanitation ladder is preferable, nor does it leads to main beneficiaries of family toilet provision and would gain regular toilet utilization. In sites such as Payakum- greater intangible benefits. buh, some people who have private toilets still regu- www.wsp.org 111 Economic Assessment of Sanitation Interventions in Indonesia | Discussion larly defecate in hanging toilets on ponds. Therefore death, and the diarrheal disease rate. The selected case study there are some uncertainties in calculating benefits. for the sensitivity analysis was the Banjarmasin urban site, In order to explore the impact of breakdown in this presenting values for the sewerage system and the commu- assumption, the efficiency calculations are presented nity toilet options. Banjarmasin was selected as the BCR under different scenarios: optimal versus actual ca- of these sanitation options was the least favorable out of all pacity utilization. the sites – hence one can observe whether less pessimistic 3. In a country with relatively high unemployment assumptions would lead to a BCR of greater than unity. The like Indonesia, there are not many opportunities to assumptions used for the sensitivity analysis were as follows: profit from the saved time although people are eager • Value of time: increase to 100% of the average wage to spend the time productively. The opportunities for adults, and 50% for children. would be far fewer if people were reluctant to spend • Value of time: using GDP per capita instead of the the time saved productively. average wage. 4. People are not aware that having better sanitation • Value of premature death: substitute the alternative makes water treatment simpler and thus potentially value of statistical life (VOSL) for the human capi- reduces its cost. tal approach. This involved adjusting a VOSL from developed countries of US$2 million to Indonesia, In order to understand the sensitivity of the results to chang- based on the difference in income levels. es in these assumptions, a sensitivity analysis was conducted • Diarrheal disease rate: a rate of twice the baseline es- on three variables: the value of time, the value of premature timate is used. TABLE 58: SENSITIVITY ANALYSIS RESULTS FOR BANJARMASIN SEWERAGE SYSTEM Private toilet with off-site treatment at its actual capacity utilization Sensitivity analysis version Efficiency Scenario Baseline Increased Value of time Increased Increased All parameters measure analysis value value of time = GDP per value of baseline changed capita premature diarrheal death disease rate COST-BENEFIT MEASURES Benefits per Optimal 1.1 2.5 1.7 1.6 1.4 6 US$1 input (US$) Actual 0.2 0.6 0.4 0.4 0.30 1.3 Internal rate of Optimal 12% 70% 32% 28% 20% >100% return (%) Actual <0% <0% <0% <0% <0% 15% Pay-back period Optimal 8 years 2 2 years 5 4 years 1 4 years 6 5 years 11 11 months months months month months months Actual >20 years >20 years >20 years >20 years >20 years 7 years 1 month Net present value Optimal 139 227 751 647 380 4,910 ($) Actual (2,395) (89) (1,950) (2,024) (2,219) 1,081 COST-EFFECTIVENESS MEASURES Cost per DALY Optimal 2,548 2,548 2,548 2,548 2,211 2,211 averted (US$) Actual 10,818 10,818 10,818 10,818 9,389 9,389 Cost per case Optimal 15 15 15 15 11 11 averted (US$) Actual 66 66 66 66 47 47 Cost per death Optimal 81,874 81,874 81,874 81,874 81,874 81,874 averted (US$) Actual 347,621 347,621 347,621 347,621 347,621 347,621 112 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Discussion TABLE 59: SENSITIVITY ANALYSIS RESULTS FOR BANJARMASIN COMMUNITY TOILETS Community toilet with treatment Sensitivity analysis version Efficiency Optimistic Baseline Increased Value of time Increased Increased All parameters measure scenario analysis value value of time = GDP per value of baseline changed capita premature diarrheal death disease rate COST-BENEFIT MEASURES Benefits per Ideal 1.7 2 2 3 2 6 US$1 input (US$) Actual 1.1 1 2 2 1 4 Internal rate of Ideal 21% 32% 34% 38% 31% 173% return (%) Actual 9% 17% 17% 20% 0 73% Pay-back period Optimal 5 years 8 4 years 1 4 years 3 years 8 4 years 3 1 year 7 months month months months months Actual 4 years 1 3 years 5 3 years 3 2 years 11 3 years 6 1 year 3 month months months months months months Net present value Ideal 272 500 529 599 475 1,805 ($) Actual 24 184 205 253 166 1,101 COST-EFFECTIVENESS MEASURES Cost per DALY Ideal 1,502 1,502 1,502 1,502 1,302 1,302 averted (US$) Actual 2,142 2,142 2,142 2,142 1,858 1,858 Cost per case Ideal 9 9 9 9 7 7 averted (US$) Actual 13 13 13 13 9 9 Cost per death Ideal 47,948 47,948 47,948 47,948 47,948 47,948 averted (US$) Actual 68,399 68,399 68,399 68,399 68,399 68,399 Table 58 and Table 59 show the results for the sewerage ty surrounding the benefits obtainable from improved sani- system and the community toilets, respectively. According tation, and hence their economic feasibility. The choice of to the sensitivity analysis, the most influencing variable is conservative input values in the baseline assessment and the value of time by changing the average wage of adults to omission of several benefits from the quantitative analysis, 100% and of children to 50%. However, the change in any suggests that the benefit-cost ratios will be higher – possibly single parameter alone does not make the system economi- significantly higher – than those reported in the baseline cally feasible (i.e. BCR > 1) at the actual capacity utilization assessment. of centralized system of 14%. The system becomes econom- ically feasible only when all four parameters are changed at 9.1.3 GENERALIZABILITY OF RESULTS the same time. In the case of community toilets, changing It has been mentioned that the results of this study do not the average wage of adults to 100% and of children to 50% represent the country-wide sanitation situation. In terms of produces an economically feasible result. sanitation coverage, none of the five study sites, each with their own specific characteristics, would be representative The results point to the finding that, in order to have ef- of the general rural or urban sanitation situation in such a ficient and economically feasible sanitation interventions large country as Indonesia. There will be too many different – particularly for sewerage system and community toilets ‘typical’ settings, each with their own unique characteristics (SANIMAS) – the most important factors are increasing and each delivering different economic benefits as the result the utilization of the facilities towards the optimal level and of sanitation intervention. Therefore, the economic analysis increasing the capacity utilization of the treatment facility. results presented here for each site only truly represent the The adjustment of assumptions also point to the uncertain- sanitation intervention benefits at that particular site. www.wsp.org 113 Economic Assessment of Sanitation Interventions in Indonesia | Discussion However, areas with low improved sanitation coverage, For instance, when presenting BCR figures, the household with typical characteristics such as open defecation prac- should be a greater focus of advocacy efforts, as is the case tices and unprotected ground water sources, are expected with community-led approaches such as CLTS and sani- to have similar health status and water variables. Likewise, tation marketing approaches such as TSSM. The messages areas with a similar demographics, such as population den- on the economic return of investing in improved sanitation sity, age composition of family members and average wage, will help convince households to pay more for sanitation to will have similar benefits once their sanitation facilities are a level of effective demand that will lead to an investment improved. The fact that the major health benefits are attrib- decision. uted to the population aged five years and under, any set- tings with significantly lower fertility patterns (and hence At national and city/district level, the economic returns fewer young children per household) are likely to have low- together with information from the program approach er benefit-cost ratios. On the other hand, households with analysis, the costs of improved sanitation and their sources more adults will have greater access time savings. Larger of financing will support the policy aspects of sanitation households will generally have more favorable economic development, particularly for the PPSP, which is currently performance, as the costs are spread amongst more people. ongoing in Indonesia. For selection of interventions and appropriate technology through a better understanding of The same observation applies for the tourism and business costs (investment, recurrent, annual equivalent) and eco- surveys. A sample of 254 holidaymakers and business visi- nomic returns (annual, short-term, long-term), this study tors and ten companies interviewed cannot possibly repre- provides in-depth yet practical case studies. The models of sent the more than 6 million tourists visiting Indonesia each analysis have been developed in such way to cover the fol- year51 as well as the large numbers of companies located in lowing issues: Indonesia. There will be many different personal opinions • Enabling the inclusion of efficiency criteria in the about which are the most influential aspects of sanitation. selection of sanitation options when governments (at However, in general, the impact of poor sanitation on the central and local level) and/or donors prepare sanita- enjoyment of stay for tourists and the performance of em- tion strategic planning or specific sanitation projects ployee in a business will have similar results. Therefore, the and programs, results of this study can provide indicative figures for the • Bringing greater focus on appropriate technology benefits of sanitation improvement as a whole. through increased understanding of the marginal costs and benefits of moving up the sanitation lad- 9.2 UTILIZATION OF RESULTS IN DECISION der in different contexts. The policy makers may de- MAKING velop ‘stepping stone scenarios’ when they prepare 9.2.1 POTENTIAL USES OF RESULTS community-based sanitation program approaches, Although conducted in only five sites, this study provides which also consider the process of raising awareness hard evidence on the costs and benefits of improved sani- on better sanitation in the community. tation. These ‘indicative results’ provide strong advocacy materials to convince stakeholders to increase their spend- In order to accelerate progress and meet the government ing on sanitation, and to focus greater attention on more target as well as MDG target on sanitation coverage, the efficient program implementation and further scaling up PPSP has calculated that meeting both targets would re- of improved sanitation facilities. Traditionally advocacy quire a total spend of US$5,356 million within the next material is produced without specific targets and fed into five years. At the time of the launch of the program, the the public domain. The results of this study, on the other government committed to contributing about 30% of hand, provide more specific information for different target the total cost requirement and will seek to mobilize other groups and different sanitation stakeholders. sources of funding. This study also provides evidence-based 51 Ministry of Culture and Tourism, 2009. 114 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Discussion advocacy to convince all stakeholders that contributing to a national “giant step� of sanitation development through the total cost of the PPSP is economically feasible and will the Acceleration of Settlement Sanitation Development deliver valuable outcomes for the national economy. There- Program (PPSP) 2010-2014. One of the targets is for In- fore, it can be used to leverage grants to incentivize private donesia to be free of open defecation by the end of 2014, investments in sanitation. or earlier. In the sanitation program preparation phase, the cost- The first stage out of the six successive and comprehensive benefit model in this study can contribute to the design of PPSP stages52 is advocacy, which involves awareness-raising feasible financing options by identifying program beneficia- in order to create demand for sanitation among national, ries as well as cost incidence of the sanitation program. The provincial and city/district governments as well as among program planners can design ‘matching’ sanitation options end users (communities). Such advocacy requires robust and implementation approaches against the beneficiaries’ and convincing data and information to convince the cam- ability to pay and their level of awareness. In the end, it will paign targets of importance of sanitation improvement at contribute to optimize program effectiveness. household level. Therefore: 1. Decision makers at central, provincial and local lev- The sensitivity analysis reveals that the determinants of ef- els can each utilize the study results as evidence of ficiency are, on the benefit side, health variables, time sav- the economic importance of sanitation, thus leading ings and program performance. On the cost side, they are to demand creation for sanitation. low investment costs per household reached, low operation 2. The third stage of the PPSP – City Sanitation Strat- and maintenance costs, and efficient program delivery. It egy – can use the CBA model to enrich its Environ- is important that such information is well understood by mental Health Risks Assessment (EHRA) study. The program implementers. A good understanding of the de- outcomes of such a study demonstrate not only in- terminants of program efficiency will also help program dicative health risks of particular areas, but also po- implementers boost the benefits of sanitation programs. tential quantitative benefits that might be acquired should the sanitation condition in the areas be im- 9.2.2 TRANSLATING EVIDENCE TO ACTIONS proved. The Sanitation Technical Team (TTPS), which is respon- 3. During the fourth stage of the PPSP – compilation sible for formulating policies as well as planning and imple- of detailed technical proposals presenting sanitation menting national sanitation sector development, will be the programs or project profiles – the study results which party that will find the detailed study results most useful. can be utilized are the costs of improved sanitation Table 60 presents the TTPS team members as well as other and hygiene, the cost-benefit performance of sani- parties/ stakeholders whose areas of responsibility may lead tation investment, and the comparison of program them to use the results of the study. performance, with the aim of securing financing commitments from stakeholders. Each stakeholder 9.2.3 INTEGRATING ECONOMIC is offered the opportunity to take part in the pro- CONSIDERATIONS INTO DECISION MAKING posed sanitation programs, hence, there ought to be PROCESSES a balance of responsibilities and an optimal blend of The development of sanitation in Indonesia has become a contribution among them according to their posi- national issue. The Government of Indonesia has placed tion and capacity. Local governments can make use the sanitation developments among the national priorities, of the program approach analysis to help them de- declared at the 2nd National Sanitation Conference, De- cide which of the implemented approaches is most cember 2009. The Sanitation Technical Team has initiated appropriate to their local context. 52 The Organization and Management of the USDP Project, 2010: The six PPSP stages are (1) advocacy, (2) institutional preparation, (3) City Sanitation Strategy, (4) detailed technical proposals, (5) implementation, and (6) monitoring and evaluation. www.wsp.org 115 Economic Assessment of Sanitation Interventions in Indonesia | Discussion 4. The sixth stage of the PPSP – monitoring and evalu- programs have achieved their goals and targets, and ation – can learn from the frameworks used in this the division of the total benefits amongst the dif- study, such as the CBA and PAA models, which are ferent beneficiaries and stakeholders. Therefore, all tools to periodically measure performance of sani- contributing parties will have a fair assessment of tation programs during and after implementation. and possess a sense of ownership in the sanitation Sanitation financiers and implementers will be able programs. Hence, in the long run such assessments to assess to what extent the implemented sanitation are expected to increase program sustainability. TABLE 60: POSSIBLE USE OF STUDY RESULTS BY TTPS TEAM MEMBERS AND STAKEHOLDERS No. Party/Agency Use of Study Results Functional Activities 1 BAPPENAS • CBA results Coordinating all national level government agencies in • Program costs strategic planning and annual budgeting for sanitation sector. 2 Ministry of • CBA results • National level strategic planning, annual budgeting, Public Works • Program costs technology option development and selection. (MPW) • Design and implementation of appropriate sanitation options. 3 Ministry of • CEA results • Coordinating with BAPPENAS and MPW: conducting Health (MoH) • Program approach analysis health component of interventions at national level. • Intangible benefits • Program approach option development. • Design and implementation of appropriate sanitation approach. • Fostering program effectiveness to its optimal level. 4 Ministry of • Program approach analysis Facilitating all sanitation program implementation including Home Affair • Program costs capacity building at provincial and city/district level. (MoHA) 5 Ministry of • CBA results • National level annual budgeting for sanitation sector. Finance (MoF) • Program costs • Setting budget allocation for sanitation sector. • Potential impacts of improved sanitation on tourism, businesses, foreign investment, and sanitation markets 6 Decentralized • CBA results • Strategic planning, annual budgeting, program approach governments • Program costs selection at local level. • Program approach analysis • Implementation of appropriate technology option and • Intangible benefits sanitation approach. • Potential impacts of improved sanitation on • Achieving optimal program effectiveness. tourism, businesses, foreign investment, and • Sanitation supply assessment at local level. sanitation markets • Developing local potential to provide sanitation supply. 7 Sanitation • CBA results • Setting budget allocation to support sanitation Donor Group • Program costs development. and NGOs • Program approach analysis 8 Media • CBA & CEA results • Sensitization and advocacy to all stakeholders • Program approach analysis • Promoting and campaigning issues such as: • Potential impacts of improved sanitation on - sanitation is no longer private issue, but it is a public tourism, businesses, foreign investment, and shared issue, sanitation markets - there are knock on effects of improved sanitation • Intangible benefits on tourism, businesses and foreign investment, and sanitation markets 9 Households • CBA results • Messaging of cost-benefits through sanitation marketing to • Intangible benefits develop sanitation demand and improve willingness to pay for sanitation provision • Peer social marketing to increase awareness on gender sensitivity that women, children and elderly are the main beneficiary of family toilet provision 116 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Discussion One of the challenges in program cost assessment ISSDP facilitated 14 cities to develop their city sani- is the difficulty of matching the hardware costs of tation strategies (CSS). PPSP started in 2010 and an intervention with the software costs of the same will be facilitating 330 cities/districts to develop intervention, given that different sector ministries and implement their CSS during the next five years. manage different components of the same sanitation With such ambitious targets, and involving many programs. For example, it is difficult to match par- parties and various stakeholders with different levels ticular sanitation program costs in the Ministry of of awareness, building and maintaining a balanced Health (software component) with the correspond- awareness and understanding and involvement ing programs implemented by the Ministry of Pub- among the stakeholders will be a major challenge for lic Works (hardware component) as they were not the program. designed as integrated sanitation programs. Conse- 7. Communication tools should be developed which quently, it is difficult to calculate the total sanitation are easy to understand, are interesting and moti- intervention costs, covering all related software and vating and hence lead to accelerated awareness and hardware costs of the sanitation programs. Therefore commitments to support sanitation development. there is a need to synchronize and synergize all sani- The communication tools should include the mon- tation-related initiatives carried out separately by the etary value of sanitation benefits or CBA figures. It is various sector ministries. recommended that the TTPS facilitate local govern- 5. In order to have comprehensive cost figures for any ments (PPSP participants) to conduct these activities particular sanitation program, it is recommended in order to monetize the value of sanitation benefits. that all participating parties record and keep infor- 8. The CBA figures in this study can be used to trig- mation about related program costs and develop cal- ger initial awareness. The TTPS can then use the culations for overall program cost. For this purpose, CBA model to calculate sanitation cost-benefit per- the costs calculation model in this study can be ap- formance figures that can be used to develop the plied, with some adjustments according to program CSS in selected cities/districts. Simplified methods specific contexts. and tools are required in order to do this. Once the 6. Sanitation programs implemented by different min- selected cities/districts have calculated their sanita- istries should be coordinated to ensure effective tion cost-benefit figures, they can then help other funds disbursement and program implementation. participating cities/districts to do the same. In do- Inter-departmental cooperation in the WSLIC pro- ing so, there will be also a period of shared learning gram (Water and Sanitation for Low Income Com- among the sector ministries and local governments munities) and ISSDP are very good examples of this. to assess the economic benefits of sanitation de- WSLIC 3 (also known as PAMSIMAS), which was velopment. The PAA study showed that sanitation funded by the Ministry of Public Works, utilized program effectiveness is highly influenced by strong the CLTS approach developed by the Ministry of campaign, promotion and education for the com- Health. ISSDP, which implemented an institution- munity. For instance, FGD results in Banjarmasin al approach, fostered the creation of the TTPS in revealed that some community members did not 2007. The purpose of the TTPS is to synchronize understand the need for a sewerage system, which and coordinate sanitation developments throughout has deterred them from connecting to the sewerage their planning, implementation, monitoring and system. There may be other influencing factors for evaluation processes. Since then, any sanitation re- the households’ willingness to connect, however, lated initiatives from sector departments are incor- such as the government’s failure to allocate sufficient porated into an integrated sanitation development funds for program promotion, instead spending the program, which is now called PPSP. large portion of funds on construction of sanitation www.wsp.org 117 Economic Assessment of Sanitation Interventions in Indonesia | Discussion facilities. On the other hand, the CLTS program in departments, such as those responsible for tourism, indus- Payakumbuh allocated a large portion of funds on try and private sector development, to invest more in sani- community campaign and education as part of the tation. effort to put an end to open defecation, while the cost of sanitation facilities construction were borne 9.2.4 SUMMARY RECOMMENDATIONS by the community. The CLTS program has success- This study finds that all sanitation interventions have ben- fully reduced open defecation in the area. efits that exceed costs, when compared with “no sanitation 9. It is very important for governments to allocate facility.� The high net benefits from low-cost sanitation op- sufficient funds for software development to raise tions, such as pit latrines, suggest these technologies should people’s awareness of sanitation, and not just pro- be centerpiece to increasing access for rural households. vide funds for hardware development. Financing the However, in densely populated areas, pit latrines have lim- maintenance of the sanitation intervention should ited feasibility, and to improve quality of life in increasingly also be taken into account in order to ensure its sus- populous cities, decision makers need to take into account tainability. the economic benefits of improved conveyance and treat- 10. Program performance indicators revealed that hand- ment options. If funding is available, populations prefer washing with soap after defecation is not common options that transport waste off site. Appropriate treatment practice in local communities. As mentioned above, and/or isolation of waste is key to the future sustainable community campaigns and education initiatives are development of Indonesia. Based on the findings of this very important, especially those targeting health study, three key recommendations for decision makers are and hygiene behavior. Handwashing with soap as a proposed: component of health and hygiene behavior should 1. Intensify efforts to improve access for the entire always be part of a sanitation program. Paying more Indonesian population to improved basic sanita- attention to promoting handwashing with soap will tion. Indonesia approved a sound community-based enhance the effectiveness of sanitation programs and sanitation strategy in 2008 that needs to be imple- enable full capture of the health benefits. mented, and enough evidence is available to show that establishing a viable sanitation market – where Distribution of the responsibility for financing construc- demand by all income levels meets affordable and tion of sanitation facilities is often not balanced. In general, good quality supply – is feasible. For policy makers poor people using on-site systems bear the cost of their con- and local governments, this requires special atten- struction, while urban households with toilets connected to tion to ensure demand is triggered, health benefits a sewerage system rely on government to build their sanita- are captured, and coverage is sustained (i.e., avoid- tion facilities. Lack of awareness among urban communities ing a return to open defecation). Sanitation provid- of the importance of improved sanitation at household level ers, from wholesalers to community-based masons, is one of the reason behind the imbalance in the distribu- need to improve on affordable, upgradable latrine tion of financing responsibilities. An appropriate and easy- structures and design to ensure widespread uptake. to-understand awareness campaign program for stakehold- Information on sanitation options and models for ers, especially program beneficiaries, may help to redress the households everywhere in Indonesia is another key balance. element for rapidly accelerating and sustaining cov- erage. On the national level, the study also highlights the links 2. Go beyond basic sanitation provision, where the between sanitation and productive sectors that are key con- population demands it and the funding is avail- tributors to sustainable economic growth, such as tourism, able. In densely populated urban areas, only basic business and the sanitation supply market. These findings sanitation provision is no longer feasible due to the should be used to sensitize and convince other government higher expectations of populations, space constraints 118 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Discussion and risks of groundwater pollution. Decision mak- ers should therefore be aware of the full range of conveyance and treatment options, and their related costs and benefits, in order to avoid investing in ex- pensive technologies that are difficult and costly to sustain. In municipalities where funding is sufficient to permit more sustained and quality services, these will better capture the full environmental and health benefits and respond to the population’s wish for a clean, livable environment. 3. Promote evidence-based sanitation decision-mak- ing. Variations in economic performance of options suggest that careful consideration of site conditions and local demand and preferences is needed to select the most appropriate sanitation option and delivery approach. Decisions should take into account not only the measurable economic costs and benefits, but also other key factors for a decision, including intangible impacts and socio-cultural issues that in- fluence demand and behavior change, availability of suppliers and private financing, and actual house- hold willingness and ability to pay for services. www.wsp.org 119 Bibliography Buku Pedoman. SANIMAS. Directorate General of Human Jamasy, Owin and Shatifan, Nina. .CLTS – Learning from Settlement, Ministry of Public Works. 2006. Communities in Indonesia. May 2008. City Sanitation Strategy - Banjarmasin, Pokja Sanitasi Kota Kajian Cepat terhadap Program Pengentasan Kemiskinan Banjarmasin, March 2008. Pemerintah RI, LP3ES. October 2007. 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Total Sanitation and Sanita- The Enter of CLTS Approach to Indonesia, Edy/Udin, Percik tion Marketing Project: Indonesia Country Update June 2009. Magazine. December 2008. Field note. August 2009. TSSM Project: Indonesia Country Update. June 2009. Water and Sanitation Program. Urban Sanitation in Indone- sia: Planning for Progress. Field Note. April 2009. University of Indonesia. Study on WSLIC 2 from 2001 – 2006. 122 Economic Assessment of Sanitation Interventions Annex Tables ANNEX A. STUDY METHODS TABLE A 1. SUB-NATIONAL SANITATION COVERAGE RATES, LATEST YEAR (2007) No. Province Private Toilet Shared Toilet Community Toilet No Toilet 1 Riau 79.8 8.5 1.7 9.9 2 Kepulauan Riau 77.8 14.4 1.8 6.0 3 Kalimantan Timur 76.4 9.5 5.2 8.9 4 DKI Jakarta 72.6 20.1 6.7 0.7 5 Sumatra Utara 71.8 6.8 4.0 17.4 6 Sumatra Selatan 65.8 11.1 4.0 19.1 7 DI Yogyakarta 65.4 25.8 0.7 8.2 8 Sulawesi Utara 64.1 16.2 3.4 16.4 9 Lampung 64.1 11.1 1.8 23.0 10 Jambi 63.3 9.6 4.0 23.1 11 Jawa Barat 61.8 12.7 8.7 16.9 12 Nusa Tenggara Timur 60.8 12.1 1.6 25.5 13 Bangka Belitung 60.7 5.0 2.0 32.3 14 Bali 59.5 20.0 0.3 20.2 15 Bengkulu 59.5 9.9 2.4 28.2 16 Kalimantan Selatan 59.3 13.3 9.0 18.4 17 Jawa Tengah 58.7 12.4 3.5 25.4 18 Sulawesi Selatan 58.4 12.6 1.6 27.4 19 Kalimantan Barat 57.9 6.6 3.3 32.2 20 Sulawesi Tenggara 57.7 8.2 2.8 31.2 21 Jawa Timur 57.1 15.3 1.8 25.8 22 Banten 53.3 12.0 2.0 32.8 23 NAD 51.2 8.2 8.4 32.2 24 Kalimantan Tengah 51.1 14.5 8.4 26.1 25 Sumatera Barat 49.1 12.5 7.1 31.2 26 Papua 47.9 11.6 4.2 36.3 27 Maluku 46.5 7.1 7.6 38.9 28 Sulawesi Tengah 45.4 8.1 3.7 42.8 29 Papua Barat 43.3 16.1 13.1 27.5 30 Sulawesi Barat 42.0 7.0 3.1 47.9 31 Maluku Utara 36.8 18.5 7.7 36.9 32 Nusa Tenggara Barat 35.6 13.0 2.3 49.1 33 Gorontalo 31.0 19.2 7.5 42.2 Indonesia 58.9 12.1 4.2 24.8 Source : Susenas 2007 www.wsp.org 123 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE A 2. SELECTION OF FIELD SITES FOR THE ECONOMIC STUDY Program name Location(s) covered Implementing agents Selected field sites Reason for inclusion Lamongan District Sub-district : Turi Ministry of Health Kabupaten Lamongan has the largest number (East Java Province) / Villages : Turi, Badurame, of households coverage among other location WSLIC 2 Project Geger, Keben of WSLIC 2 project in Indonesia Tangerang District Sub-district : Sepatan Ministry of Public Works SANIMAS project has been implemented (Banten Province) / Villages : Sarakan, Kayu Agung in various areas in Indonesia. It is better if SANIMAS the chosen site is located not far away from Sub-district : Rajeg Jakarta to minimize the survey budget and Villages : Sukasari, Tanjakan manage / allocate the spare budget for other locations. Banjarmasin City Sub-district : Central Local Government • The sewerage system in Banjarmasin (South Kalimantan Banjarmasin is one of the few sewerage systems in Province) / Sewerage Villages : Pekapuran Laut, Indonesia that has a good performance and System Kelayan Luar management • Banjarmasin could be one of the 5 (five) sites locations for the ESI 2 study that is more or less represent typical sanitation conditions on Kalimantan Island. • Some data on the sanitation conditions in Banjarmasin are available already and access to related agencies or officials are easier, regarding the ongoing ISSDP project Malang City (East Sub-district: Kedung kandang, Local Government Malang City has a SANIMAS program Java Province) / Lowokwaru Ministry of Public Works that is initiated, funded, and managed by CBSS (Sanimas) Villages : Mergosono, the community, and proven successful. Tlogomas, Aryowinangun, The program has been replicated at other Dinoyo locations in the surrounding areas. Payakumbuh City Sub-district: North Ministry of Health Directorate • Availability of primary data as well (West Sumatera Payakumbuh General of Disease Control as secondary data regarding the Province) / CLTS Villages : Talawi, Kotopanjang, and Environmental Health pre-intervention conditions such as Panyolinyam, Kubu Gadang National Planning Agency environmental health survey report and the Ministry of Home Affairs CLTS Proceeding/ Report Ministry of General Affairs • Availability of commitment for a full support National Pokja AMPL from the local government (the Mayor (National Working Groups) and the Sanitation Working Group) which is indicated by a strong intention and providing required and available relevant data • There is a preliminary indication that having a more attention and commitment from the Local Government for sanitation improvement lead to a significant decrease of health subsidy budget during the last 3 consecutive years • A strong intention from BAPPENAS/ Sanitation Technical Team to include Payakumbuh in the ESI – 2 Study • Kodya Payakumbuh could be one of the 5 (five) site locations for the ESI 2 study that is more or less represent the sanitation condition at Sumatera Island. 124 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE A 2. SELECTION OF FIELD SITES FOR THE ECONOMIC STUDY (CONTINUED) Program name Location(s) covered Implementing agents Selected field sites Reason for inclusion WSLIC 2 : Although all of the location mentioned have a • Sumenep District (East large number of revolving fund, but the number Java Province) is still far below Kab. Lamongan. Another thing • Sampang District (East is the locations mentioned here are all located Java Province) in East Java province, the same as Kab. • Mojokerto District (East Lamongan Java Province) SANIMAS : Denpasar and Surakarta City located further • Denpasar City (Bali from Jakarta compared to Tangerang which Province) could influence the project budget • Surakarta City (Central Java Province) Sewerage System : The Surakarta Sewerage System doesn’t • Surakarta City (Central perform well enough compared to the one in Java Province) Banjarmasin. CLTS : • The study meant to represent the condition • Bogor District (West of Indonesia. Since location from Sumatera Java Province) Island hasn’t been represented, so Kab • Muara Enim District Bogor, Kab. Cirebon, and Kab. Ciamis (South Sumatera) (located at Java Island) should be excluded • Cirebon District (West • Kab. Muara Enim could be choosen as study Java) location for CLTS program but Payakumbuh • Ciamis District (West is much more prepared in availability of data, Java) support from local government, and is the chosen location of SanTT www.wsp.org 125 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE A 3. ASSESSMENT OF ADVANTAGES AND LIMITATIONS OF DIFFERENT DESIGN OPTIONS No. Design Advantages Limitations DESIGNS INVOLVING FIELD DATA COLLECTION 1 Economic study designed entirely for • Addresses the specific questions of • Expensive and long time period research purposes, including matching the research • May not capture health impact and randomization of comparison groups • Highly scientific design • Limited generalisability 2 Economic research attached to other • Captures health impact with degree of • Expensive and long time period research studies (e.g. randomized clinical precision • Few ongoing clinic trials trial) • Can conduct additional research on • Requires collaboration from start other impacts • Trials may not reflect real conditions • Add-on research cost is small • Limited comparison options • Statistical analysis possible 3 Economic research attached to pilot • Add-on research cost is small • Few pilot programs available study, with or without randomization • Options are policy relevant • Pilots often not designed with scientific • Matched case-control possible evaluation in mind (e.g. before vs. after • Can start research in mid-pilot surveys) • Pilot conditions not real life • Limited comparison options 4 Economic research attached to routine • Reflects real life conditions (e.g. uptake • No research infrastructure government or NGO/donor programs, and practices) • No scientific design without randomization • Research addresses key policy • Limited comparison options questions • Matched case-control possible DESIGNS INVOLVING SECONDARY DATA COLLECTION 5 Collection of data from a variety of local • Relatively low cost • Results imprecise and uncertain sources to conduct a modeling study • Short time frame feasible • Actual real-life implementation issues • Can compare several options and not addressed settings in research model • Can mix locally available and non-local data 6 Extraction of results from previous • Low cost • Limited relevance and results not economic studies • Results available rapidly trusted by policy makers • Gives overview from various • Published results themselves may not interventions and settings be precise 126 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE A 4. AGGREGATING EQUATIONS FOR COST-BENEFIT AND COST-EFFECTIVENESS ANALYSIS Cost-Benefit Analysis: 1) Benefit-cost ratios (BCR) o BCR (benefit cost ratio = PVB / PVC) where PVB = Present Value of Benefit and PVC = Present Value of Cost o It has to present an answer to the question: “Are the benefits greater than the costs 2) Net present value (NPV) o NPV is the sum of all terms of discounted cash inflow/outflow (present value or PV) PV = NCFt /(1+i)t where o t - the time of the cash flow o i - the discount rate (the rate of return that could be earned on an investment in the financial markets with similar risk.) o NCFt is the net cash flow (the amount of cash, inflow minus outflow) at time t. o It provides an answer to the question: “What the investment worth is in today’s money? “ 3) Internal rate of return (IRR): Given the (period, cash flow) pairs (n, Cn) where n is a positive integer, the total number of periods N, and the net present value NPV, the internal rate of return is given by r in: N Cn NPV = ∑ n=0 (1 + r) n =0 www.wsp.org 127 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE A 5. METHODOLOGY FOR BENEFIT ESTIMATION (CALCULATIONS, DATA SOURCES, EXPLANATIONS) Impacts included Variable Data sources Specific value/comment 1. HEALTH (All calculations are made using disaggregated data inputs on disease and age grouping: 0-4 years, 5-14 years, 15+ years) Diarrheal disease incidence (0-4 DHS years) Diarrheal disease incidence (over WHO stats 5 years) Helminthes prevalence Global review Hepatitis A and E incidence National health statistics Indirect diseases incidence WHO statistics 1.1 Health care savings (malaria, ALRI) Calculation: Malnutrition prevalence UNICEF/WHO statistics [Prevalence or incidence X Attribution to poor sanitation X Scabies and trachoma Incidence National health statistics ((% seeking outpatient care X visits per case X unit cost per Attribution of fecal-oral diseases WHO (Prüss et al. 2002) Value = 88% visit (medical and patient)) + to poor sanitation (Inpatient admission rate X days Attribution of helminthes to poor Global review Value = 100% per case X unit cost per day sanitation (medical and patient))] X Proportion of disease cases % disease cases seeking health DHS, SES, ESI household averted care survey, health statistics Outpatient visits per patient Inpatient admission rate Health facility statistics, ESI Inpatient days per admission household survey Health service unit costs Other patient costs (transport, ESI household survey food) % disease cases averted International literature review See Annex B for review 1.2 Health morbidity-related Days off productive activities ESI household survey productivity gains Basis of time value: GDP per National economic data Average product per capita Calculation: capita World Bank data (at sub-national level, where [Prevalence X Attribution to available) – 30% for adults, poor sanitation X Days off 15% for children productive activities X Value of time] X Proportion of disease cases averted Mortality rate (all diseases) WHO statistics (cross-checked with local stats) Basis of time value: GDP per National economic data Annual value of lost production capita World Bank data of working adults (human 1.3 Premature mortality savings capital approach) , from the time of death until the end of Calculation: (what would have been) their [Mortality rate X Attribution to productive life poor sanitation X Value of life] X Proportion of disease cases Discount rate for future earnings National governments Cost of capital estimate (8%) averted Long-term economic growth Assumption Value-of-statistical-life Developed country studies Adjusted to local purchasing power by multiplying by GDP per capita differential 128 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE A 5. METHODOLOGY FOR BENEFIT ESTIMATION (CALCULATIONS, DATA SOURCES, EXPLANATIONS) (CONTINUED) Impacts included Variable Data sources Specific value/comment 1.4 Disability-adjusted life- Duration of disability ESI household survey based on average length of years (DALY) averted each disease Disability weighting WHO burden of disease project Calculation: DALY = YLD+YLL Healthy life expectancy WHO statistics YLD: discounted disability based on weight and years Discount rate for future disease National governments Cost of capital estimate (8%) equivalent time burdens YLL: discounted future years Morbidity and mortality rates Various: see 1.1 and 1.3 (above) of healthy life lost 2. WATER (for household use) (weighted average costs were estimated for each water source and for each household water treatment method) Drinking water sources (%) in ESI household survey wet and dry seasons 2.1 Household water access Annual financial cost per ESI household survey; ESI savings household, per water source market survey Calculation: Annual non-financial cost per ESI household survey Annual costs X % costs household, per water source reduced, per water source Proportion of access cost ESI household survey; reduction under scenario of assumption 100% improved sanitation, per water source Proportion of households ESI household survey Validated by other national 2.2 Household water treating their water, by method statistics (DHS, SES) treatment savings Full annual cost per water ESI household survey; ESI treatment method market survey Calculation: (% households treating water Proportion of households ESI household survey; As well as stopping to treat, per method X annual cost) currently treating who stop assumption households may switch to X % households who stop treating under scenario of 100% an alternative – cheaper – treating improved sanitation treatment method if the cleaner water sources enable different water purification methods 3. ACCESS TIME SAVINGS (weighted average costs estimated for each age category and gender – young children, children and male and female adults) Household composition ESI household survey (demographics) Sanitation practice, by age ESI household survey group Calculation: Average round trip time to ESI household survey For households moving from % household members using access site of open defecation shared to private toilet, access OD X Time saved per trip due time to shared toilets is used to private toilet X average trips instead of OD per day X value of time Average number of round trips ESI household survey to defecation site per day Basis of time value: GDP per National economic data Average product per capita capita World Bank data (at sub-national level, where available) – 30% for adults, 15% for children www.wsp.org 129 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE A 5. METHODOLOGY FOR BENEFIT ESTIMATION (CALCULATIONS, DATA SOURCES, EXPLANATIONS) (CONTINUED) Impacts included Variable Data sources Specific value/comment 4. EXCRETA REUSE GAINS (reuse of excreta as fertilizer from either UDDT or double-vault pit latrine; and reuse of energy value from biogas digester) % households using reuse ESI household survey methods Calculation: % households using product (% households using product ESI household survey themselves themselves X value in own use) + (% households selling % households selling product ESI household survey product X selling price) to others Selling price ESI household & market survey Value in own use ESI market survey; assumption 130 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE A 6. DISEASES LINKED TO POOR SANITATION AND HYGIENE, AND PRIMARY TRANSMISSION ROUTES AND VEHICLES Disease Pathogen Primary transmission route Vehicle DIARRHEAL DISEASES (GASTROINTESTINAL TRACT INFECTIONS) Rotavirus diarrhea Virus Fecal-oral Water, person-to-person Typhoid/ paratyphoid Bacterium Fecal-oral and urine-oral Food, water + person-person Vibrio cholera Bacterium Fecal-oral Water, food Escherichia Coli Bacterium Fecal-oral Food, water + person-person Amebiasis (amebic dysentery) Protozoa 1 Fecal-oral Person-person, food, water, animal feces Giardiasis Protozoa 1 Fecal-oral Person-person, water (animals) Salmonellosis Bacterium Fecal-oral Food Shigellosis Bacterium Fecal-oral Person-person +food, water Campylobacter Enteritis Bacterium Fecal-oral Food, animal feces Helicobacter pylori Bacterium Fecal-oral Person-person + food, water Protozoa Other viruses 2 Virus Fecal-oral Person-person, food, water Malnutrition Caused by diarrheal disease and helminthes HELMINTHES (WORMS) Intestinal nematodes 3 Roundworm Fecal-oral Person-person + soil, raw fish Digenetic trematodes (e.g. Flukes (parasite) Fecal/urine-oral; fecal-skin Water and soil (snails) Schistosomiasis Japonicum) Cestodes Tapeworm Fecal-oral Person-person + raw fish EYE DISEASES Trachoma Bacterium Fecal-eye Person-person, via flies, fomites, coughing Adenoviruses (conjunctivitis) Protozoa 1 Fecal-eye Person-person SKIN DISEASES Ringworm (Tinea) Fungus Touch Person-person (Ectoparasite) Scabies Fungus Touch Person-person, sharing bed and clothing (Ectoparasite) OTHER DISEASES Hepatitis A Virus Fecal-oral Person-person, food (especially shellfish), water Hepatitis E Virus Fecal-oral Water Poliomyelitis Virus Fecal-oral, oral-oral Person-person Leptospirosis Bacterium Animal urine-oral Water and soil-swamps, rice fields, mud Sources: WHO http://www.who.int/water_sanitation_health/en/ and [75, 76] 1 There are several other protozoa-based causes of 2 Other viruses include: 3 Intestinal nematodes include: GIT, including • Adenovirus – respiratory and • Ascariasis (roundworm - soil) • Balantidium coli – dysentery, intestinal ulcers gastrointestinal infections • Trichuriasis trichiura (whipworm) • Cryptosporidium parvum - gastrointestinal • Astrovirus – gastrointestinal infections • Ancylostoma duodenale / Necator americanus infections • Calicivirus – gastrointestinal infections (hookworm) • Cyclospora cayetanensis - gastrointestinal • Norwalk viruses – gastrointestinal • Intestinal Capillariasis (raw freshwater fish in infections infections Philippines) • Dientamoeba fragilis – mild diarrhea • Reovirus – respiratory and gastrointestinal • Isospora belli / hominus – intestinal parasites, infections gastrointestinal infections www.wsp.org 131 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE A 7. WATER QUALITY MEASUREMENT PARAMETERS Parameter Test E-coli (cfu/100 ml) Coliscan Biological Oxygen Demand (BOD5) (mg/L) 5 day incubation Chemical Oxygen Demand (COD) (mg/L) 5 day incubation Dissolved Oxygen (DO) (mg/L) Hach DO Probe Nitrate (NO ) (mg/L) 3- Hach Photometer Ammonia (NH ) 4 Hach Photometer Conductivity (µS/cm) YSI Conductivity Meter Turbidity (NTU) TurbidiMeter pH pH Probe Water temperature ( C) o Hach ThermoProbe Residual chlorine (Cl) (in places provided with centralized chlorinated water supply) (mg/L) Field Kit TABLE A 8. HOUSEHOLDS SAMPLED VERSUS TOTAL HOUSEHOLDS PER VILLAGE/COMMUNITY Sewerage/STF Sampling of Septic Wet pit Dry pit Site With Without Shared Public OD Total households tank latrine latrine treatment treatment Sample 140 26 34 72 28 300 Lamongan Total 300 300 300 300 300 % sampled % 47% 9% 11% 24% % 9% % Sample 85 28 7 26 23 131 300 Tangerang Total 300 300 300 300 300 300 % sampled % % 28% 9% 2% 9% 8% 44% % Sample 46 165 1 19 33 16 20 300 Banjarmasin Total 300 300 300 300 300 300 300 % sampled 15% % 55% 0% 6% 11% 5% 7% % Sample 137 36 21 61 32 13 300 Malang Total 300 300 300 300 300 300 % sampled 46% % 12% 7% 20% 11% % 4% % Sample 117 3 11 27 15 127 300 Payakumbuh Total 300 300 300 300 300 300 % sampled % % 39% 1% 4% 9% 5% 42% % Sample 183 543 79 132 190 54 319 1500 Total Total 1500 1500 1500 1500 1500 1500 1500 % sampled 12% % 36% 5% 9% 13% 4% 21% % 132 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE A 9. SAMPLE SIZES OF OTHER SURVEYS IN STUDY SITES Focus Group Discussion Health facilities Physical Site Group Other Women1 Men2 location surveys Hospital Clinic groups3 Unimproved 4x3 4x3 • Local Public 7x3 Subdistrict Turi Hospital Lamongan Improved • Puskesmas Turi 4x3 4x3 Sub-total 24 persons 24 persons 21 • Polyclinic Sepatan • Subdistrict • Local Public Unimproved 4x3 4x3 Sarana Medika Sepatan Hospital • Dr. Ashari’s Clinic 7x3 • Subdistrict • Puskesmas Tangerang at Rajeg Rajeg Sepatan Improved • 6 physician 4x3 4x3 • Puskesmas Rajeg practices Sub-total 24 persons 24 persons 21 • Puskesmas • Subdistrict Gadang Hanyar Unimproved 4x3 4x3 Central • Puskesmas 7x3 Banjarmasin Banjarmasin Cempaka Improved 4x3 4x3 Sub-total 24 persons 24 persons 21 • Local Public • Subdistrict Hospital Saiful Kedung Anwar • 4 physician Unimproved 4x3 4x3 kandang • Puskesmas practices 7x3 • Subdistrict Malang Arjowinangun Lowokwaru • Puskesmas Dinoyo Improved 4x3 4x3 Sub-total 24 24 21 4x3 4x3 • 2 community health centres in North Payakumbuh Unimproved Subdistrict Subdistrict 7x3 North (Puskesmas Tarok Payakumbuh Payakumbuh and Puskesmas Lampasi) Improved 4x3 4x3 Sub-total 24 24 21 Unimproved 60 60 Total Improved 60 60 Total 120 120 105 1 4 x 3 means 4 persons x 3 sessions 2 idem 3 7 x 3 means 7 persons x 3 sessions 4 public health centre www.wsp.org 133 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE A 10. SELECTION OF PROGRAMS FOR PROGRAM APPROACH ANALYSIS Program name Location(s) covered Implementing agents Selected programs Reason for inclusion WSLIC 2 South Sumatera, West Sumatera, Ministry of Health • One Community Based Sanitation NTB, East Java, West Java, Babel, Program that used revolving fund South Sulawesi, West Sulawesi scheme • Program has finished and thus program data are more complete SANIMAS South Sumatera, West Sumatera, Ministry of Public One of Community Based Sanitation NTB, East Java, West Java, Babel, Works Program in Indonesia that has been South Sulawesi, West Sulawesi implemented in almost all provinces in Indonesia. Sewerage System Bandung (West Java),Banjarmasin Local water supply Represents city scale off- site sanitation (South Kalimantan), Balikpapan utilities/local health system (East Kalimantan), Jakarta authority/PD PAL (Jakarta), Medan (North Sumatera), Solo (Central Java), Tangerang (Banten), Yogyakarta (Yogyakarta) CBSS / Sanimas Malang Malang City : Local government/ • Example of program that is initiated, Ministry of Public funded, and managed by the Works community • The initiator, Pak Agus Gunarto has received a presidential award for his effort in creating a sanitation model/system in his village. He also encourages other communities in the near village to establish their own system. CLTS West Sumatera, South Sumatera, Ministry of Health A promising community based sanitation Jambi, West Java, Banten, East program, which is different from other Java, West Kalimantan, Nusa programs because no subsidy is given for Tenggara Barat, the physical development Non-selected programs Reason for exclusion Community Water Project is still on going (has just started). Services and Health The Project has been delayed because of (CWSH) regulation changes on loan mechanism and foreign loan from Department of Finance (KMK 35) Rural Water Supply and Focus more on clean water supply Sanitation in NTT Province (ProAir) 134 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX B. HEALTH IMPACT TABLE B 1. RATES PER POPULATION FOR CASES OF DISEASE Average Average Lamongan Tangerang Banjarmasin Malang Payakumbuh rural sites urban sites Direct diseases Mild diarrhea 8.43 3.16 10.81 6.05 3.37 2.66 3.45 Severe diarrhea 5.30 2.38 7.62 2.99 0.95 1.66 4.54 Helminthes 1.83 1.84 1.81 1.84 1.85 1.82 1.86 Scabies 3.70 7.57 3.52 Indirect diseases ALRI 2.41 2.09 1.65 3.17 4.18 1.81 0.27 Total 17.96 13.17 21.89 14.04 10.35 15.50 13.64 TABLE B 2. RATES PER 1000 POPULATION FOR DEATHS Average Average Lamongan Tangerang Banjarmasin Malang Payakumbuh rural sites urban sites Direct diseases Diarrhea 1.5 1.7 1.4 1.6 1.6 1.7 1.8 Helminthes 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 Indirect diseases Malnutrition 0.00 0.02 0.00 0.01 0.06 0.01 0.01 ALRI 0.38 0.42 0.36 0.40 0.42 0.38 0.48 Measles 0.17 0.19 0.16 0.18 0.18 0.17 0.21 Other indirect 0.01 0.05 0.01 0.01 0.12 0.01 0.01 Total 2.06 2.41 1.97 2.16 2.42 2.26 2.54 TABLE B 3. RATES PER 1000 POPULATION FOR DALYS Average Average Lamongan Tangerang Banjarmasin Malang Payakumbuh rural sites urban sites Direct diseases Mild diarrhea 0.06 0.02 0.09 0.03 0.02 0.02 0.00 Severe diarrhea 0.03 0.01 0.04 0.02 0.01 0.01 0.03 Helminthes 0.01 0.01 0.01 0.01 0.01 0.01 0.01 Scabies 0.00 0.00 0.00 0.00 - 0.01 0.00 Indirect diseases Malnutrition 0.000 0.000 0.000 0.000 0.001 0.000 0.000 ALRI 0.014 0.013 0.011 0.017 0.021 0.012 0.007 Measles 0.002 0.002 0.002 0.002 0.002 0.002 0.003 Other indirect 0.000 0.001 0.000 0.000 0.002 0.000 0.000 Total 0.12 0.06 0.16 0.08 0.07 0.07 0.05 www.wsp.org 135 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE B 4. COMPARISON OF DATA SOURCES FOR SELECTED DISEASES Data value Disease Age Data source Type of data Lamongan ESI Survey INA-DR +COT1 Unit cost of Inpatient Health Care/day • Public facility: 350 Under 5 • Private facility: 480 Local Public Hospital – Lamongan District Rate of inpatient admission 16.9% OTC Medicines 2 Pharmacy 10 ESI Survey Local Public Hospital – Lamongan District Rate of inpatient admission 10.3% Diarrhea Age 5-14 INA-DR +COT Unit cost of Inpatient Health Care/day • Public facility: 381 (mild) • Private facility: 511 OTC Medicines Pharmacy 10 ESI Survey INA-DR +COT Unit cost of Inpatient Health Care/day • Public facility: 381 Age 15+ • Private facility: 511 Local Public Hospital – Lamongan District Rate of inpatient admission 8.7% OTC Medicines Pharmacy 10 Under 5 ESI Survey INA-DR +COT1 Unit cost of Inpatient Health Care/day • Public facility: 349 • Private facility: 479 Local Public Hospital Lamongan District Rate of inpatient admission 2.27% Age 5-14 ESI Survey INA-DR +COT Unit cost of Inpatient Health Care/day • Public facility: 346 Diarrhea • Private facility: 476 (severe) Local Public Hospital Lamongan District Rate of inpatient admission 2.03% OTC Medicines Pharmacy 13 Age 15+ ESI Survey INA-DR +COT Unit cost of Inpatient Health Care/day • Public facility: 346 • Private facility: 476 Local Public Hospital Lamongan District Rate of inpatient admission 1.8% Under 5 Local Public Hospital Lamongan District Rate of inpatient admission 1.8% Scabies Age 5-14 Local Public Hospital Lamongan District Rate of inpatient admission 1.4% Age 15+ Local Public Hospital Lamongan District Rate of inpatient admission 0.7% Under 5 ESI Survey Malnutrition Age 5-14 ESI Survey Age 15+ ESI Survey Under 5 ESI Survey Malaria Age 5-14 ESI Survey Age 15+ ESI Survey ESI Survey Local Public Hospital Lamongan District Rate of inpatient admission 11.74% ALRI Under 5 INA-DR +COT Unit cost of Inpatient Health Care/day • Public facility: 277 • Private facility: 407 136 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE B 4. COMPARISON OF DATA SOURCES FOR SELECTED DISEASES (CONTINUED) Data value Disease Age Data source Type of data Lamongan OTC Medicines Pharmacy 27 ESI Survey Local Public Hospital Lamongan District Rate of inpatient admission 11.09% Age 5-14 • Public facility: 277 INA-DR +COT Unit cost of Inpatient Health Care/day • Private facility: 407 OTC Medicines Pharmacy 27 ESI Survey Local Public Hospital Lamongan District Rate of inpatient admission 8.22% Age 15+ • Public facility: 254 INA-DR +COT Unit cost of Inpatient Health Care/day • Private facility: 384 OTC Medicines Pharmacy 25 Under 5 ESI Survey Hepatitis A,E Age 5-14 ESI Survey Age 15+ ESI Survey Remarks: 1 INA –DRG - COT = Indonesia - Diagnosis Related Group – Cost of Treatment 2 OTC Medicines = Over the Counter Medicines TABLE B 5. DIARRHEAL INCIDENCE IN THE PAST YEAR (OR 2 WEEKS) IN ALL FIELD SITES, BY OPTION Age group Significant difference Sanitation coverage Households in sample Total <5 5-14 15+ with OD Open defecation 1570 20.9 23.2 20.2 20.8 0.072 Shared/public 304 4.5 3.4 4.0 4.0 0.362 Dry pit 784 11.5 11.2 9.8 10.4 0.083 Wet pit 517 6.9 6.6 6.9 6.9 0.940 Septic tank 2984 39.8 39.4 39.6 39.8 0.980 Sewerage 720 9.8 8.6 9.7 9.6 0.500 www.wsp.org 137 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE B 6. EVIDENCE ON TREATMENT SEEKING BEHAVIOR FOR OTHER DISEASES Data source by % seeking treatment from other disease. rural/ Observations Public Private Private Self- Total Pharmacy provider urban and year provider formal clinic informal care treatment DIARRHEA DISEASE MILD ESI Survey 0-4 years old Rural 11% 24.1% 2.7% 0% 0.6% 0.0% 38% 2009 ESI Survey 4-15 years old Rural 8% 16% 3% 2% 3% 0.7% 32% 2009 ESI Survey 15+ years Rural 3% 6% 1% 0% 12% 1.0% 23% 2009 DIARRHEA DISEASE SEVERE ESI Survey 0-4 years old Rural 31.9% 9% 0% 0% 0.0% 40.7% 2009 ESI Survey 4-15 years old Rural 15.5% 17.3% 3.0% 0% 1.7% 37.5% 2009 ESI Survey 15+ years Rural 5.9% 22.3% 5% 0% 4.9% 37.7% 2009 INDIRECT : ALRI ESI Survey 0-4 years old Rural 19.2% 16.0% 0.0% 0% 0.0% 35.2% 2009 ESI Survey 4-15 years old Rural 12.3% 5.9% 0% 0% 0% 18.2% Year of data ESI Survey 15+ years Rural 9.8% 8.4% 4.1% 0% 4.9% 27.2% 2009 138 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE B 6. EVIDENCE ON TREATMENT SEEKING BEHAVIOR FOR OTHER DISEASES (CONTINUED) Data source by % seeking treatment from other disease. rural/ Observations Public Private Private Self- Total Pharmacy provider urban and year provider formal clinic informal care treatment DIARRHEA DISEASE MILD ESI Survey 0-4 years old Urban 21.2% 21.4% 0.7% 0% 2.5% 45.7% 2009 ESI Survey 4-15 years old Urban 11.2% 13.4% 0% 1% 3% 29.1% Year of data ESI Survey 15+ years Urban 10.1% 8.5% 2.7% 1% 3.4% 25.6% 2009 DIARRHEA DISEASE SEVERE ESI Survey 0-4 years old Urban 20.4% 15.2% 0.2% 0% 0.0% 35.8% 2009 ESI Survey 4-15 years old Urban 9.2% 13.7% 2% 0% 0% 24.5% Year of data ESI Survey 15+ years Urban 12.5% 12.8% 4.6% 0% 1.7% 31.7% 2009 INDIRECT : ALRI ESI Survey 0-4 years old Urban 27.6% 9.7% 3.5% 0% 13.3% 54.2% 2009 ESI Survey 4-15 years old Urban 13.8% 8.5% 0% 0% 4% 26.4% Year of data ESI Survey 15+ years Urban 11.4% 8.2% 5.7% 0.0% 6.7% 32.0% 2009 www.wsp.org 139 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE B 7. UNIT COSTS ASSOCIATED WITH TREATMENT OF SEVERE DIARRHEA DISEASE (USD 2009) Outpatient cost (US$) Inpatient cost (US$) Health provider Health care Incidentals 1 ALOS 2 Health care3 Incidentals1 Public/NGO Rural (ref) 9.63 1.85 0.39 33.41 0.48 Urban (ref) 9.63 1.94 0.42 33.41 0.48 Private formal Rural (ref) 19.25 1.85 0.39 45.92 0.48 Urban (ref) 19.25 1.94 0.42 45.92 0.48 Informal Rural (ref) 4.81 - - - - Urban (ref) 4.81 - - - - 1 Incidentals: non-health patient costs such as transport, food, and incidental expenses, per outpatient visit and per inpatient stay. 2 ALOS: average length of stay. 3 Inpatient health care costs are presented per stay TABLE B 8. UNIT COSTS ASSOCIATED WITH TREATMENT OF ALRI (US$, 2009) Outpatient cost (US$) Inpatient cost (US$) Health provider Health care Incidentals1 ALOS2 Health care3 Incidentals1 Public/NGO Rural (ref) 6.42 1.96 0.29 25.93 0.70 Urban (ref) 6.42 1.80 0.35 25.93 0.70 Private formal Rural (ref) 19.25 1.96 0.29 38.45 0.70 Urban (ref) 19.25 1.80 0.35 38.45 0.70 Informal Rural (ref) 0.0 - - - - Urban (ref) 0.0 - - - - 1 Incidentals: non-health patient costs such as transport, food, and incidental expenses, per outpatient visit and per inpatient stay. 2 ALOS: average length of stay. 3 Inpatient health care costs are presented per stay TABLE B 9. UNIT COSTS ASSOCIATED WITH TREATMENT OF MILD DIARRHEA DISEASE (US$, 2009) Outpatient cost (US$) Inpatient cost (US$) Health provider Health care Incidentals 1 ALOS 2 Health care3 Incidentals1 Public/NGO Rural (ref) 6.42 1.96 0.26 35.69 0.64 Urban (ref) 6.42 1.80 0.33 35.69 0.64 Private formal Rural (ref) 14.44 2.31 0.26 48.20 0.64 Urban (ref) 14.44 1.80 0.33 48.20 0.64 Informal Rural (ref) 2.89 - - - - Urban (ref) 2.89 - - - - 1 Incidentals: non-health patient costs such as transport, food, and incidental expenses, per outpatient visit and per inpatient stay. 2 ALOS: average length of stay. 3 Inpatient health care costs are presented per stay 140 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX C. WATER QUALITY IMPACT TABLE C 1. WATER QUALITY MEASUREMENT RESULTS Sample Turbidity Nitrate (mg/ Ammonia Ammonia Max. pH Sample Location Source No. (NTU) liter) (as NH3) Limit (Gov.Reg.) 1 0.5 Banjarmasin Piped Water 2 0.5 Piped Water 3 0.5 Piped Water 4 18.9 7.9 0.92 0.5 6.69 Surface 5 0.5 Piped Water 6 0.5 Piped Water 7 0 0.44 0.23 0.5 6.85 Payakumbuh Surface 8 0 0.77 0.23 0.5 6.16 Surface 9 0 0.32 0.25 0.5 7.76 Surface 10 0 0.33 34 0.5 7.11 Surface 11 11.2 2.3 0.12 0.5 5.22 Surface 12 0.5 Piped Water 13 0.5 Dug well 14 0.5 Dug well 15 0.5 Malang City Piped Water 16 0.5 Piped Water 17 0.5 Piped Water 18 0.017 0.5 Borehole 19 0.09 0.5 Borehole 20 0 60.9 0.06 0.5 7 Surface 21 0 17.7 0.05 0.5 6.16 Surface 22 0 0.11 0.5 Dug well 23 0.5 Piped Water 24 0.5 Piped Water 25 0 28.7 0.11 0.5 6.98 Surface 26 0.5 Piped Water 27 0.5 Piped Water 28 0.5 Piped Water 29 0.5 Piped Water 30 0 29.8 0.09 0.5 5.29 Surface 31 0 19.4 0.09 0.5 6.65 Surface 32 >200 0.2 0.5 7.61 Surface (urban) 33 0 0.27 0.5 Dug well 34 6 0.15 0.5 7.44 Surface (urban) 35 0.1 0.5 Borehole 36 0.85 0.5 Borehole 37 0 1.1 0.5 Dug well 38 11 0.18 0.5 7.32 Surface (urban) 39 0 0.24 0.5 Tangerang Dug well 40 0 <0.02 0.5 Dug well www.wsp.org 141 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE C 1. WATER QUALITY MEASUREMENT RESULTS (CONTINUED) Sample Ammonia (as Ammonia Max. Turbidity (NTU) Nitrate (mg/liter) pH Sample Location Source No. NH3) Limit (Gov.Reg.) 40 0 <0.02 0.5 Dug well 41 0 0.1 0.5 Dug well 42 1 0.06 0.5 Dug well 43 0 0.24 0.5 Dug well 44 6 0.21 0.5 Dug well TABLE C 2. POLLUTION FROM POOR SANITATION AND WASTEWATER MANAGEMENT (% OF HOUSEHOLDS) Human excreta management (%) Household wastewater (%) Field site Not isolated Partial isolation Full Drain to Drain to water to wastewater OD Flush to water Dry pit Wet pit isolation ground sources treatment facilities Lamongan 25.00% 1.80% 0.70% 5.10% 68% 87.00% 9.33% 1.33% Tangerang 39.16% 2.50% 11.80% 11.50% 37% 84.33% 7.00% 0.67% Banjarmasin 18.90% 8.40% 2.90% 3.90% 65% 83.33% 12.67% 1.33% Malang 2.40% 17.60% 0 14.60% 65% 40.00% 10.33% 44.00% Payakumbuh 42.30% 7.80% 0.30% 2.60% 47% 71.67% 1.33% 18.00% Average rural 32.08% 2.15% 6.25% 8.30% 52.55% 85.67% 8.17% 1.00% Average urban 21.20% 11.27% 1.07% 7.03% 59.10% 65.00% 8.11% 21.11% Source: ESI 2 Field Surveys TABLE C 3. WATER ACCESS AND COSTS Non-piped protected source Piped water (treated) Non-piped unprotected source (including untreated piped) Field site Location Average Average Average % access % access % access monthly cost monthly cost monthly cost Lamongan Improved 0.00 1.64 23.01 2.38 0.00 0.00 Unimproved 0.00 0.00 9.73 1.73 0.00 0.00 OD 0.00 0.00 6.19 1.93 6.25 0.00 Tangerang Improved 1.56 3.85 10.62 0.00 15.63 0.00 Unimproved 0.00 0.00 0.88 0.00 12.50 0.00 OD 0.00 0.00 34.51 0.00 43.75 0.00 Banjarmasin Improved 37.50 4.81 2.65 6.74 0.00 0.00 Unimproved 25.00 4.81 0.00 10.40 0.00 0.00 OD 21.88 1.30 0.00 12.80 0.00 0.00 Malang Improved 1.56 4.38 4.42 1.44 0.00 0.00 Unimproved 0.00 4.81 0.00 0.00 0.00 0.00 OD 0.00 0.00 0.88 1.16 0.00 0.00 Payakumbuh Improved 4.69 1.93 1.77 0.00 0.00 0.00 Unimproved 1.56 0.96 0.00 0.00 0.00 0.00 OD 6.25 8 5.31 0 21.88 0.00 Average rural 0.26 0.91 14.16 1.01 13.02 0.00 Average urban 10.94 3.45 1.67 3.62 2.43 0.00 142 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE C 4. HOUSEHOLDS CITING POOR WATER QUALITY FROM THEIR PRINCIPAL DRINKING WATER SOURCE Non-piped protected source (including Piped water (treated) Non-piped unprotected source untreated piped) Field Bad Bad Bad site Bad Contain Bad Bad Contain Bad Contain appear- Bad smell Any appear- appear- Bad Any N taste solids N smell taste solids Any (%) N smell solids ance1 (%) (%) ance1 ance1 taste (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Ban- jarma- 159 91.67 60.87 95.83 85.86 75.00 3 0.00 0.00 0.00 2.88 0.00 162 0.00 0.00 0.00 0.00 0.0 sin Ma- 22 8.33 30.43 2.08 12.12 25.00 15 29.41 14.29 0.00 7.69 25.00 0 0.00 0.00 0.00 0.00 0.0 lang Paya- kum- 5 0.00 8.70 2.08 2.02 0.00 19 23.53 28.57 23.08 8.65 25.00 23 66.67 75.00 50.00 20.83 0.0 buh La- mo- 0 0.00 0.00 0.00 0.00 0.00 21 0.00 14.29 23.08 14.42 50.00 2 0.00 0.00 0.00 4.17 0.0 ngan Ta- nge- 0 0.00 0.00 0.00 0.00 0.00 87 47.06 42.86 53.85 66.35 0.00 43 33.33 25.00 50.00 75.00 0.0 rang Ave- rage 0.00 0.00 0.00 0.00 0.00 23.53 28.57 38.46 40.38 25.00 16.67 12.50 25.00 39.58 0.0 rural Ave- rage 33.33 33.33 33.33 33.33 33.33 17.65 14.29 7.69 6.41 16.67 22.22 25.00 16.67 6.94 0.0 urban TABLE C 5. HOUSEHOLD RESPONSES TO POLLUTED WATER – REASONS FOR USING WATER SOURCES Non-piped protected source Non-piped unprotected Piped water (treated) (including untreated piped) source Field site Location Quality Quantity Cost Quality Quantity Cost Quality Quantity Cost (%) (%) (%) (%) (%) (%) (%) (%) (%) Lamongan Improved 0.00 0.00 0.00 4.44 5.82 4.67 0.00 0.00 0.00 Unimproved 0.62 0.65 0.63 15.00 21.82 19.57 1.02 0.00 0.00 OD 0.00 0.00 0.00 1.48 2.18 3.23 2.04 2.17 2.02 Tangerang Improved 0.00 0.00 0.00 1.48 1.45 1.44 5.10 4.35 4.04 Unimproved 0.21 0.22 0.21 13.89 10.18 11.49 17.35 15.22 19.19 OD 0.00 0.00 0.00 15.19 14.36 14.36 32.65 33.70 31.31 Banjarmasin Improved 13.07 13.17 13.63 0.19 0.18 0.18 0.00 0.00 0.00 Unimproved 34.85 35.85 35.85 2.41 2.36 2.33 0.00 0.00 0.00 OD 3.73 3.46 3.77 0.19 0.18 0.18 0.00 0.00 0.00 Malang Improved 0.41 0.43 0.63 1.30 0.55 0.90 0.00 0.00 0.00 Unimproved 18.26 16.20 16.14 20.93 18.18 18.85 2.04 2.17 4.04 OD 0.00 0.00 0.00 0.93 0.55 0.90 0.00 0.00 0.00 Payakumbuh Improved 3.53 3.67 3.56 1.67 1.64 1.62 1.02 1.09 1.01 Unimproved 17.84 18.57 18.03 9.44 9.27 9.16 6.12 6.52 6.06 OD 7.47 7.78 7.55 11.48 11.27 11.13 32.65 34.78 32.32 Average rural 0.14 0.14 0.14 8.58 9.30 9.13 9.69 9.24 9.43 Average urban 11.02 11.02 11.02 5.39 4.91 5.03 4.65 4.95 4.83 www.wsp.org 143 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE C 6. TREATMENT PRACTICES Field site Boiling Chlorine Filtering device Filtering cloth Settle-removal solid Use mineral water Nothing Lamongan 86.8 0 0.7 0.3 13.7 9.7 7.7 Tangerang 90.7 0.7 3 10 63.7 10.7 2 Banjarmasin 88 0 0.7 0 22.3 5 6.4 Malang 91.7 0 1 0 3 10.7 0.3 Payakumbuh 91.7 0 0 2.7 0.3 9 1.2 Average rural 88.8 0.4 1.9 5.2 38.7 10.2 4.9 Average urban 90.5 0.0 0.6 0.9 8.5 8.2 2.6 TABLE C 7. ANNUAL TREATMENT COSTS (US$) Field site Boil Filter Chemical (Chlorine) Solar Homemade device Stand and settle Other Lamongan 27 0 0 0 5 3 3 Tangerang 32 2 0 0 2 3 2 Banjarmasin 79 0 0 0 0 7 5 Malang 39 0 0 0 1 1 1 Payakumbuh 40 0 0 0 4 4 3 TABLE C 8. WATER ACCESS AND HOUSEHOLD TREATMENT COSTS INCURRED AND AVERTED Annual average costs per household Annual average costs saved per household following Variable 100% sanitation coverage Water source access Water treatment Water source access Water treatment Lamongan 5.68 14.98 0.95 0.83 Tangerang 7.70 14.72 0.73 0.83 Banjarmasin 11.55 33.93 1.97 10.84 Malang 8.28 20.92 1.10 3.16 Payakumbuh 10.49 23.02 1.36 2.04 Average rural 6.69 14.85 0.84 0.83 Average urban 10.11 25.95 1.48 5.35 144 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX D. ACCESS TIME TABLE D 1. PLACE OF DEFECATION OF HOUSEHOLDS WITH NO ‘OWN’ TOILET Women Men Children E1.3 + OD with answer N Neighbor Own plot Outside plot N Neighbor Own Outside N Neighbor Own Outside on outside plot (4.5) (3) (1.2) (4.5) plot plot plot plot Lamongan 214 14.7 23.7 1.6 214 14.9 23.8 1.6 216 16.3 25.3 1.6 Tangerang 150 36.8 13.6 1.6 147 36.2 13.4 1.6 115 32.6 10.7 3.2 Banjarmasin 127 42.1 23.2 29.0 228 3.2 22.8 54.8 220 3.5 23.2 53.2 Malang 253 3.2 22.9 54.8 254 42.6 23.4 29.0 254 46.5 24.7 29.0 Payakumbuh 150 3.2 16.6 12.9 150 3.2 16.6 12.9 136 1.2 16.0 12.9 Average rural 171 18.2 18.0 5.4 170 18.1 17.9 5.4 156 16.7 17.4 5.9 Average urban 190 22.6 23.1 41.9 241 22.9 23.1 41.9 237 25.0 24.0 41.1 TABLE D 2. DAILY TIME SPENT ACCESSING TOILET FOR THOSE WITH NO TOILET Women Men Children Time per trip No. of times Time per trip No. of times Time per trip No. of times and waiting per day and waiting per day and waiting per day Lamongan 2.5 1.0 2.6 1.0 2.23 1.0 Tangerang 5.1 1.4 4.2 1.4 4.34 1.3 Banjarmasin 10.3 2.5 12.4 2.3 11.96 2.3 Malang 5.0 1.0 5.0 1.0 5.00 1.0 Payakumbuh 6.0 1.6 6.0 1.6 6.44 1.6 Average rural 5 1 4 1 4 1 Average urban 8 2 9 2 8 2 TABLE D 3. PRACTICES RELATED TO YOUNG CHILDREN Parents accompanying young Of which: children % outside plot No. of times per day Lamongan 101 88.9 1.7 Tangerang 105 81.8 1.5 Banjarmasin 156 67.5 2.0 Malang 285 90.0 1.0 Payakumbuh 143 76.7 1.0 Average rural 116 85.4 1.6 Average urban 221 78.1 1.3 www.wsp.org 145 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE D 4. PREFERENCES RELATED TO TOILET CONVENIENCE, FROM HOUSEHOLD QUESTIONNAIRE Perceived benefits of sanitation (B6.1): proximity Those without toilet: reasons to get a toilet cited as satisfied or very satisfied Site Those with toilet Those without toilet Saves time (B7.16) Proximity is an important characteristic (B7.17) Lamongan 3.3 1.4 1.2 3.7 Tangerang 3.7 2.7 0.0 37.0 Banjarmasin 3.6 2.9 0.0 5.9 Malang 3.9 2.6 1.9 37.9 Payakumbuh 3.7 2.7 1.6 15.4 Average rural 3.5 2.1 0.6 20.4 Average urban 3.7 2.7 1.2 19.7 TABLE D 5. OPPORTUNITY COST OF TIME – WHAT RESPONDENTS WOULD SPEND AN EXTRA 30 MINS A DAY DOING (%) Use time as Opportunity cost Lamongan Tangerang Banjarmasin Malang Payakumbuh Bathing 88% 92% 81% 94% 86% Taking a rest 75% 80% 85% 86% 79% Washing 72% 13% 48% 31% 39% Cooking/Help cooking 72% 21% 51% 28% 36% Shopping 32% 22% 39% 43% 6% Business 18% 4% 10% 12% 4% Average Rural Average Urban Bathing 90% 87% Taking a rest 78% 83% Washing 42% 39% Cooking/Help cooking 47% 38% Shopping 27% 29% Business 11% 9% 146 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE D 6. AVERAGE TIME SAVINGS PER YEAR, BY HOUSEHOLD MEMBER (HOURS) Site Young Children (0-4 years old) Children (5-14 years old) Adult Total Lamongan 33.9 42.7 41.0 117.6 Tangerang 142.0 138.3 140.0 420.3 Banjarmasin 59.3 54.2 54.5 168.1 Malang 80.6 96.3 97.3 274.1 Payakumbuh 37.2 57.4 50.8 145.3 Average rural 87.9 90.5 90.5 269.0 Average urban 59.0 69.3 67.5 195.8 TABLE D 7. AVERAGE ANNUAL VALUE OF TIME SAVINGS (US$) Site Young Children (0-4 years old) Children (5-14 years old) Adult Lamongan 27.0 23.3 234.0 Tangerang 125.3 98.7 729.2 Banjarmasin 54.8 41.0 274.9 Malang 77.8 52.6 523.0 Payakumbuh 39.0 48.2 234.5 Average rural 76.1 61.0 481.6 Average urban 57.2 47.2 344.1 www.wsp.org 147 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX E. INTANGIBLE USER PREFERENCES FOR SANITATION TABLE E 1. LEVEL OF SATISFACTION WITH CURRENT TOILET OPTION, BY OPTION TYPE (0% = NOT SATISFIED, 100% = VERY SATISFIED) Those with improved sanitation Those with unimproved sanitation Characteristic Sewer/septic Wet pit Dry pit Compost Average Unimproved pit Shared No Average tank latrine latrine toilet or bucket toilet toilet Toilet position 70% 54% Cleanliness 69% 53% Status 73% 58% Visitors 72% 55% Maintaining 70% 54% Health 72% 53% Conflict avoidance 74% 60% Convenience for children 72% 52% Convenience for elderly 74% 54% Night use of toilet 74% 53% Avoid rain 73% 52% Showering 71% 57% Dangerous animals 74% 53% Source: Household survey TABLE E 2. IMPORTANT CHARACTERISTICS OF A TOILET FOR THOSE CURRENTLY WITHOUT (0% = NOT IMPORTANT, 100% = VERY IMPORTANT) Characteristic Average score Comfortable toilet position 80% Cleanliness and freedom from unpleasant odours and insects 83% Having a toilet not needing to share with other households 82% Having privacy when at the toilet 82% Proximity of toilet to house 83% Pour-flush compared to dry pit latrine 83% Having a toilet disposal system that does not require emptying (piped sewer vs septic tank) 76% Having a toilet disposal system that does not pollute yours, neighbors’, or your community’s environment 81% 148 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX F. EXTERNAL ENVIRONMENT TABLE F 1. SCORING OF DIFFERENT TYPES OF LIVING AREA (1 = CLEAN, 2 = MINOR SOILING, 3 = MODERATE SOILING, 4 = MAJOR SOILING, 5 = EXTREME SOILING) Private plots Community living areas (market. roadside. etc) Other land (e.g. on edge of villages) Site Human excreta Solid waste Human excreta Solid waste Human excreta Solid waste Lamongan 2.9 2.2 2.8 2.7 2.2 2.9 Tangerang 3.1 1.9 2.3 2.0 2.1 2.2 Banjarmasin 3.4 2.3 2.6 2.6 2.0 2.9 Malang 3.6 2.6 3.4 3.0 2.9 3.5 Payakumbuh 3.0 2.2 2.7 2.5 2.4 2.9 Av. Rural 3.0 2.1 2.5 2.4 2.1 2.6 Av. urban 3.3 2.4 2.9 2.7 2.4 3.1 Source: private plots: ESI household observation instrument; community: physical location survey TABLE F 2. PROPORTION OF HOUSEHOLDS WITH AND WITHOUT TOILET WITH UNIMPROVED SANITATION PRACTICE Households with toilet Households with no toilet Other land (e.g. on edge of villages) Site Open defecation Open urination Disposal Disposal from Disposal child stool See children (sometimes, often) (sometimes, often) child stool in hanging latrine in in environment1 defecating in yard2 environment1 environment 1 Lamongan 2% 1% 2% 10% 1% 1% Tangerang 5% 30% 11% 37% 1% 1% Banjarmasin 0% 7% 0% 7% 0% 1% Malang 0% 1% 0% 2% 0% 0% Payakumbuh 0% 30% 5% 50% 0% 1% Av. Rural 4% 15% 7% 24% 1% 1% Av. urban 0% 13% 2% 20% 0% 1% 1 Answering ‘put in drain or ditch’, ‘thrown in garbage’, ‘buried in ground’ and ‘left in open’) 2 Answering ‘sometimes’ or ‘often’ www.wsp.org 149 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE F 3. IMPLICATION OF CURRENT TOILET OPTION FOR EXTERNAL ENVIRONMENT (1 = NOT SATISFIED, 5 = VERY SATISFIED) Improved sanitation Unimproved Characteristic Sewerage Septic tank Wet pit latrine Dry pit latrine OD POLLUTION OF YOUR OR NEIGHBORS’ ENVIRONMENT Lamongan na 69% 64% 40% 28% Tangerang na 74% 79% na 40% Banjarmasin 75% 72% 56% 60% 58% Malang 73% 75% 73% na 49% Payakumbuh na 71% 44% na 40% Av. Rural na 71% 71% 40% 34% Av. urban 74% 73% 58% 60% 49% SMELL AROUND HOUSE Lamongan na 69% 63% 38% 29% Tangerang na 74% 79% na 46% Banjarmasin 75% 72% 58% 68% 61% Malang 67% 71% 78% na 62% Payakumbuh na 73% 58% na 50% Av. Rural na 72% 71% 38% 37% Av. urban 71% 72% 65% 68% 58% remark: 0% - 100% range of not satisfied to very satisfied Source: Household survey TABLE F 4. PERCEPTIONS OF ENVIRONMENTAL SANITATION STATE, BY OPTION TYPE (1 = VERY BAD, 5 = VERY GOOD) Perception of environmental sanitation state Interv/ Site Rubbish Sewage Standing Smoke Smell Dirt outside Direct inside Rodents Insects control water Lamongan improved 54% 56% 56% 59% 43% 60% 60% 54% 56% unimproved 54% 55% 56% 57% 47% 59% 58% 57% 59% Tangerang improved 43% 52% 45% 46% 43% 46% 53% 34% 35% unimproved 37% 40% 39% 43% 40% 41% 52% 34% 34% Banjarmasin improved 52% 52% 52% 59% 39% 52% 53% 44% 49% unimproved 52% 52% 53% 59% 38% 50% 52% 44% 46% Malang improved 52% 68% 66% 69% 57% 61% 62% 52% 51% unimproved 23% 65% 67% 71% 55% 62% 64% 50% 48% Payakumbuh improved 53% 55% 58% 57% 48% 57% 60% 55% 53% unimproved 50% 51% 54% 57% 47% 57% 60% 54% 54% Av. Rural improved 49% 54% 50% 52% 43% 53% 57% 44% 45% Av. Rural unimproved 46% 48% 47% 50% 44% 50% 55% 45% 46% Av. Urban improved 52% 58% 58% 62% 48% 57% 58% 50% 51% Av. Urban unimproved 42% 56% 58% 62% 47% 57% 59% 49% 49% remark: 0% - 100% range of not satisfied to very satisfied 150 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE F 5. RANKING IMPORTANCE OF ENVIRONMENTAL SANITATION, BY OPTION TYPE (1 = NOT IMPORTANT, 5 = VERY IMPORTANT) Interv Perceived importance of environmental sanitation management Site /control Rubbish Sewage Water Smoke Smell Dirt outside Direct inside Rodents Insects Lamongan improved 70% 70% 66% 63% 67% 63% 62% 67% 66% unimproved 78% 77% 69% 64% 70% 65% 65% 69% 67% Tangerang improved 84% 81% 80% 78% 81% 77% 77% 88% 86% unimproved 79% 81% 79% 77% 78% 79% 79% 84% 85% Banjarmasin improved 83% 81% 79% 78% 80% 79% 79% 82% 79% unimproved 80% 79% 78% 77% 79% 78% 79% 80% 79% Malang improved 83% 77% 75% 72% 78% 78% 79% 85% 85% unimproved 84% 82% 79% 78% 81% 82% 87% 86% 87% Payakumbuh improved 69% 68% 59% 58% 66% 58% 60% 65% 64% unimproved 71% 71% 62% 59% 69% 58% 57% 58% 64% Av. Rural improved 77% 75% 73% 71% 74% 70% 70% 78% 76% Av. Rural unimproved 78% 79% 74% 70% 74% 72% 72% 76% 76% Av. Urban improved 78% 75% 71% 69% 75% 71% 72% 77% 76% Av. Urban unimproved 79% 78% 73% 71% 76% 72% 74% 75% 77% remark: range 0% - 100% describes the range of very bad condition to very good condition www.wsp.org 151 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX G. TOURISM TABLE G 1. PLACES VISITED (% RESPONDENTS) AND ENJOYMENT OF STAY Place 1 (Jakarta) Place 2 (historical/ Place 3 (beaches) Place 4 (natural or Place 5 (within temple sites) forest) Indonesia) No of Hotel visi- no of % Score* no of % Score* no of % Score* no of % Score* no of % Score* tariff tors visitors visitors visitors visitors visitors to this to this to this to this to this place place place place place TOURIST 1-29 18 18 13.3% 3.06 13 14.0% 3.08 13 17.8% 3.31 15 18.5% 3.47 17 14.5% 3.18 30-59 37 34 25.2% 3.21 28 30.1% 3.21 20 27.4% 2.85 24 29.6% 3.50 32 27.4% 3.22 60-89 43 40 29.6% 3.33 26 28.0% 3.62 17 23.3% 3.00 17 21.0% 3.82 29 24.8% 3.35 90-119 25 24 17.8% 3.63 16 17.2% 3.31 11 15.1% 2.64 15 18.5% 3.20 21 17.9% 3.05 120-149 11 11 8.1% 3.36 6 6.5% 3.17 6 8.2% 3.17 6 7.4% 3.83 10 8.5% 3.20 150+ 10 8 5.9% 3.50 4 4.3% 2.75 6 8.2% 2.67 4 4.9% 2.75 8 6.8% 2.38 TOTAL 144 135 100% 93 100% 73 100% 81 100% 117 100% BUSINESS 1-29 1 1 0.9% 4.00 0 0.0% 0.00 0 0.0% 0.00 0 0.0% 0.00 1 1.5% 3.00 30-59 19 16 14.5% 3.56 9 23.7% 3.44 6 18.8% 3.50 8 25.8% 4.13 13 20.0% 3.54 60-89 34 29 26.4% 3.79 12 31.6% 2.33 12 37.5% 2.58 13 41.9% 3.08 26 40.0% 3.42 90-119 23 20 18.2% 3.40 6 15.8% 2.83 6 18.8% 1.50 2 6.5% 2.50 9 13.8% 2.56 120-149 21 19 17.3% 3.53 7 18.4% 2.14 4 12.5% 2.00 4 12.9% 2.00 9 13.8% 2.44 150+ 12 10 9.1% 3.80 4 10.5% 3.25 4 12.5% 4.25 4 12.9% 3.75 7 10.8% 3.43 TOTAL 110 95 86% 38 100% 32 100% 31 100% 65 100% Source: ESI Tourism Survey. Key: * Visitors surveyed were asked to rank from a maximum score of 5 (“very much�) to a minimum of 1 (“not at all�). TABLE G 2. GENERAL SANITARY EXPERIENCE (SCORE: 5 = VERY GOOD, 1 = VERY POOR) Category Hotel tariff No of General Hotel Swimming Open water Restaurant Capital city Other cities visitors sanitary pool condition Tourist <30 18 1.83 2.94 3.44 2.72 3.11 2.55 2.57 30-59 37 2.49 3.49 3.50 2.46 3.19 2.71 2.59 60-89 43 2.24 3.68 3.74 2.21 3.56 2.44 3.16 90-119 25 2.71 3.96 3.90 2.42 3.76 2.96 3.08 120-149 11 2.18 3.80 3.25 2.29 3.60 2.90 2.83 150+ 10 1.80 3.20 3.22 1.71 3.50 2.00 2.20 Business <30 1 3.00 3.00 2.00 - 3.00 0.00 0.00 30-59 19 3.00 3.74 3.67 2.78 3.58 3.27 3.00 60-89 34 2.68 3.94 3.50 2.20 3.67 2.88 3.31 90-119 23 2.61 3.96 3.56 2.29 3.68 2.77 2.50 120-149 21 2.33 4.00 4.07 1.75 4.00 2.65 2.80 150+ 12 2.25 4.27 3.82 2.60 3.67 2.80 3.67 Source: ESI Tourism Survey. 152 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE G 3. SANITARY EXPERIENCE IN RELATION TO TOILETS AND HAND WASHING (SCORE: 5 = VERY GOOD, 1 = VERY POOR) Category Quality of toilets in the place Toilet availability Water and soap for hand washing (5 = always) Hotel Restaurant Airport Bus station City % could not find impact on stay Restaurant Bus station City when needed (5 = significant) Tourist 3.52 3.13 2.90 1.93 1.97 0.70 2.82 3.27 1.90 2.33 Business 3.53 3.25 3.10 2.14 1.94 0.48 3.00 3.33 2.12 2.18 Source: ESI Tourism Survey. TABLE G 4. WHAT FACTORS WERE MOST CONCERNING? (% RESPONDENTS CITING THE REASON, MAXIMUM 3 RESPONSES PER RESPONDENT) Unsanitary Category Drinking water Tap water Swimming pool water Food Currency notes Shaking hand Public toilets toilet Tourist 19 17 2 23 3 1 19 11 Business 19 18 1 19 12 2 17 10 Source: ESI Tourism Survey. TABLE G 5. HEALTH ISSUES Category Average no of days of Average no of days of No Medical Care Outpatient Inpatient Shop Av. Cost (USD) symptoms incapacitation (%) (%) (%) (%) Tourist 3.08 1.91 64.88 26.93 0.0 27.80 24.75 Business 3.21 2.00 47.50 42.50 0.0 25.00 67.50 TABLE G 6. INTENTION TO RETURN TO INDONESIA Return to Indonesia? (%) Advise friends to come? (%) Category Yes No Maybe Do not know Yes No Maybe Do not know Tourist 76.38% 2.85% 16.60% 4.17% 71.75% 10.95% 14.18% 3.13% Business 93.30% 2.27% 4.43% 0.00% 76.47% 6.22% 18.54% 3.46% TABLE G 7. REASONS NOT TO RETURN TO INDONESIA Category Sanitation Not safe Cost No need Tourist 44.83% 33.63% 17.97% 16.25% Business 47.00% 35.63% 23.33% 17.50% www.wsp.org 153 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX H. BUSINESS TABLE H 1. RATING OF ENVIRONMENTAL SANITATION CONDITIONS IN THE LOCATION OF THE BUSINESS SURVEY INTERVIEW (SCORE: 1 = BEST; 5 = WORST) Variable Restaurants Hotels Garment factories Food processing Water quality in rivers 3.5 4.0 2.0 NA State of canals and rainwater drainage 2.5 2.0 3.0 NA Management of sewage 2.3 2.0 2.0 NA Management of industrial wastewater 2.3 2.0 2.0 2.0 Household coverage with private toilets 2.0 2.0 2.0 2.0 Toilets in public places 2.2 2.0 3.0 3.0 Household/office solid waste 1.8 2.0 2.0 4.0 Management of industrial solid waste 2.0 3.0 2.0 4.0 Air quality from vehicles 2.0 - 3.0 3.0 Air quality from solid waste 2.0 1.0 3.0 4.0 Air quality from excreta 1.8 2.0 2.0 3.0 Source: ESI Business Survey. TABLE H 2. IMPORTANCE OF ENVIRONMENTAL SANITATION CONDITIONS FOR LOCATING THE COMPANY (SCORE: 1 = UNIMPORTANT; 5 = IMPORTANT) Variable Restaurants Hotels Garment factories Food processing Workers' health 4.8 4.5 5 5 Water quality directly available from nature (rivers, lakes, ground) 4.8 4.5 5 5 Pleasant environment for your staff (clean, good air quality, 5 4.5 5 5 proper sewerage and sanitation) Availability of cheap and good land 4.4 4.5 5 5 Source: ESI Business Survey. 154 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX I. COST TABLES TABLE I 1. LAMONGAN AVERAGE COST PER HOUSEHOLD FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, 2009) DISCOUNT RATE 8% Cost Item Hygiene1 Shared Dry pit Wet pit Septic tank INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 2 99 43 56 564 Average Annual 0.9 15 11 14 57 2. Program na 0.1 0.0 0.0 0.2 Average Annual na 0.0 0.0 0.0 0.0 SUB-TOTAL 2 99 43 56 564 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 7 4 7 7 13 4. Maintenance 0 7 13 13 21 5. Program - - - - - SUB-TOTAL 7 11 20 20 34 AVERAGE ANNUAL COST CALCULATIONS Duration2 3 10 5 5 8 Cost/household 10 26 30 33 91 Cost/capita 3 2 5 6 7 18 OF WHICH: % capital 9% 57% 35% 42% 63% % program 23% 0% 0% 0% 0% % recurrent 68% 43% 65% 58% 37% Observations 4 72 34 26 140 1 Mainly annual soap cost 2 Refers to length of life of hardware before full replacement 3 Based on 5 persons per HH 4 Number of households (respondents) www.wsp.org 155 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE I 2. TANGERANG AVERAGE COST PER HOUSEHOLD FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, 2009) DISCOUNT RATE 8% Cost Item Hygiene1 Community Shared Dry pit Wet pit Septic tank INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 2 151 160 62 85 550 Average Annual 1 15 24 16 21 56 2. Program - 28 0.2 0.2 0.2 0.1 Average Annual - 3 0 0 0 0 SUB-TOTAL 2 179 161 62 85 550 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 11 0 4 7 7 13 4. Maintenance 0 0.8 2.0 1.9 1.9 3.3 5. Program - - - - - - SUB-TOTAL 11 0 4 7 7 13 AVERAGE ANNUAL COST CALCULATIONS Duration2 3 20 10 5 5 20 Cost/household 12 18 28 22 28 69 Cost/capita3 2 4 6 4 6 14 OF WHICH: % capital 8% 84% 85% 69% 76% 81% % program 0% 16% 0% 0% 0% 0% % recurrent 92% 1% 15% 30% 24% 19% Observations4 23 26 7 28 85 1 Mainly annual soap cost 2 Refers to length of life of hardware before full replacement 3 Based on 5 persons per HH 4 Number of households (respondents) 156 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE I 3. BANJARMASIN AVERAGE COST PER HOUSEHOLD FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, 2009) Cost Item Hygiene1 Community Shared Dry pit Wet pit Septic tank Sewerage INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 2 316 88 45 48 221 473 Average Annual 1 32 13 11 12 22 48 2. Program 0 0 0.2 0.2 0.2 0.4 0.4 Average Annual - - 0 0 0 0 0 SUB-TOTAL 2 316 89 45 48 221 473 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 8 4 2 na 7 7 13 4. Maintenance - 3 5 10 na 13 39 5. Program - - - - - - - SUB-TOTAL 8 7 7 10 7 20 52 AVERAGE ANNUAL COST CALCULATIONS Duration2 3 20 10 5 5 20 20 Cost/household 9 39 20 21 19 43 100 Cost/capita3 2 8 4 4 4 9 20 OF WHICH: % capital 10% 83% 65% 54% 63% 52% 48% % program 0% 0% 0% 0% 0% 0% 0% % recurrent 90% 17% 35% 46% 37% 48% 52% Observations4 16 33 19 1 165 46 1 Mainly annual soap cost 2 Refers to length of life of hardware before full replacement 3 Based on 5 persons per HH 4 Number of households (respondents) www.wsp.org 157 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE I 4. MALANG AVERAGE COST PER HOUSEHOLD FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, 2009) Cost Item Hygiene1 Shared Dry pit Wet pit Septic tank Sewerage INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 2 106 56 71 319 479 Average Annual 1 11 8 18 80 49 2. Program - - - - - - Average Annual - - - - - - SUB-TOTAL 2 106 56 71 319 479 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 12 7 7 7 7 7 4. Maintenance - na 10 13 27 32 5. Program - - - - - - SUB-TOTAL 12 7 17 20 34 39 AVERAGE ANNUAL COST CALCULATIONS Duration2 3 10 5 5 20 20 Cost/household 12 18 25 38 114 87 Cost/capita3 2 4 5 8 23 17 OF WHICH: % capital 7% 61% 33% 46% 70% 56% % program 0% 0% 0% 0% 0% 0% % recurrent 93% 39% 67% 54% 30% 44% Observations4 32 61 21 36 137 1 Mainly annual soap cost 2 Refers to length of life of hardware before full replacement 3 Based on 5 persons per HH 4 Number of households (respondents) 158 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE I 5. PAYAKUMBUH AVERAGE COST PER HOUSEHOLD FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, 2009) Cost Item Hygiene1 Shared Dry pit Wet pit Septic tank INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 2 118 22 61 567 Average Annual 1 18 6 15 58 2. Program - 26 25.6 25.6 0.1 Average Annual 0.0 3.8 3.9 3.10 3.11 SUB-TOTAL 2 143.7 47.7 86.8 354.4 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 7 4 na 7 11 4. Maintenance - 6 na 11 16 5. Program - - - - - SUB-TOTAL 7 9 - 18 26 AVERAGE ANNUAL COST CALCULATIONS Duration2 3 10 5 5 20 Cost/household 8 31 12 40 87 Cost/capita3 2 6 2 8 17 OF WHICH: % capital 12% 57% 46% 38% 67% % program 0% 12% 54% 16% 3% % recurrent 88% 30% 0% 46% 30% Observations4 27 11 3 117 1 Mainly annual soap cost 2 Refers to length of life of hardware before full replacement 3 Based on 5 persons per HH 4 Number of households (respondents) www.wsp.org 159 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE I 6. SUMMARY OF AVERAGE COST PER HOUSEHOLD IN RURAL AREAS FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, 2009) Cost Item Hygiene1 Community Shared Dry pit Wet pit Septic tank INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 2 151 130 53 70 557 2. Program - 28 0.1 0.2 0.2 0.2 SUB-TOTAL 2 179 130 53 70 557 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 9 0 4 7 7 9 4. Maintenance - 0.8 4.5 7.4 7.3 - 5. Program na na na na na na SUB-TOTAL 9 1 9 14 14 9 AVERAGE ANNUAL COST CALCULATIONS Duration2 3 20 10 5 5 20 Cost/household 10 19 28 27 32 82 Cost/capita 3 2 4 6 5 6 16 OF WHICH: % capital 9% 80% 69% 48% 55% 69% % program 0% 15% 0% 0% 0% 0% % recurrent 90% 5% 31% 52% 44% 31% Observations 4 208 23 98 41 54 224 1 Mainly annual soap cost 2 Refers to length of life of hardware before full replacement 3 Based on 5 persons per HH 4 Number of households (respondents) 160 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE I 7. SUMMARY OF AVERAGE COST PER HOUSEHOLD IN URBAN AREAS FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, 2009) Community Urban sewerage + Private Urban Urban septic Urban Communal treatment Cost Item Hygiene1a Shared dry pit wet pit tank sewerage1b Optimal Actual Optimal Actual INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 2 316 503 104 41 60 369 479 473 2,198 2. Program - - - 13 13 13 13.0 - 0.4 3.0 SUB-TOTAL 2 316 503 117 54 73 382 479 473 2,201 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 9 4 6 3 7 8 7 13 13 36 4. Maintenance - 3 5 8 10 13 23 32 39 54 5. Program na na na na na na na na na na SUB-TOTAL 9 7 11 11 17 21 30 45 52 90 AVERAGE ANNUAL COST CALCULATIONS Duration2 3 20 20 10 5 5 20 20 20 20 Cost/household 10 39 62 28 31 37 70 87 100 317 Cost/capita 2 8 12 6 6 7 14 17 20 63 OF WHICH: % Capital 9% 83% 83% 55% 34% 40% 53% 56% 48% 71% %Program 0% 0% 0% 7% 11% 8% 2% 0% 0% 0% % Recurrent 91% 17% 17% 38% 55% 53% 45% 44% 52% 29% Observations 3 29 92 92 116 318 137 46 46 46 1a Mainly annual soap cost 1b Malang city 1c Banjarmasin city 2 Refers to length of life (years) of hardware before full replacement 3 Number of households (respondents) www.wsp.org 161 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX J. FINANCIAL COSTS TABLE J 1. LAMONGAN FINANCIAL VERSUS NON-FINANCIAL COSTS, IN US$ Septic tank Cost category Hygiene Shared Dry pit Wet pit Optimal Actual Financial - 80 30 41 550 241 Investment Non-financial 2 19 13 14 14 57 Sub-total 2 99 43 56 564 298 Financial 7 11 20 19 34 34 Recurrent Non-financial - - - - - - Sub-total 7 11 20 19 34 34 Financial 23 19 20 23 77 63 Annual equivalent Non-financial 10 7 10 10 14 23 Sub-total 33 26 30 33 91 86 TABLE J 2. TANGERANG FINANCIAL VERSUS NON-FINANCIAL COSTS, IN US$ Septic tank Cost category Hygiene Community Shared Dry pit Wet pit Dry pit Wet pit Financial 0 179 161 43 44 550 481 Investment Non-financial 2 0 - 20 41 - - Sub-total 2 179 161 62 85 550 481 Financial 11 1 6 9 9 16 16 Recurrent Non-financial - 0 - - - - - Sub-total 11 1 6 9 9 16 16 Financial 0 19 26 13 13 59 52 Annual equivalent Non-financial 12 0 4 12 17 13 13 Sub-total 12 19 30 24 30 72 65 TABLE J 3. BANJARMASIN FINANCIAL VERSUS NON-FINANCIAL COSTS, IN US$ Community Septic Sewerage Cost category Hygiene Shared Dry pit Wet pit Optimal Actual tank Optimal Actual Financial 0 287 474 65 22 24 195 415 2,141 Investment Non-financial 2 28 28 23 23 23 26 58 58 Sub-total 2 316 503 88 45 48 221 473 2,198 Financial 8 7 11 12 10 20 34 52 93 Recurrent Non-financial - 0 - - - - - - Sub-total 8 7 11 12 10 20 34 52 93 Financial 8 36 59 22 16 27 34 72 136 Annual equivalent Non-financial 1 3 3 3 6 6 - 3 6 Sub-total 9 39 62 25 21 32 34 75 141 162 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE J 4. MALANG FINANCIAL VERSUS NON-FINANCIAL COSTS, IN US$ Cost category Hygiene Shared Dry pit Wet pit Septic tank Communal sewerage Financial - 94 35 38 281 420 Investment Non-financial 2 13 22 32 38 59 Sub-total 2 106 56 71 319 479 Financial 12 12 17 20 34 39 Recurrent Non-financial - - - - - - Sub-total 12 12 17 20 34 39 Financial - 24 19 23 56 74 Annual equivalent Non-financial 12 4 12 15 11 13 Sub-total 12 28 31 38 67 87 TABLE J 5. PAYAKUMBUH FINANCIAL VERSUS NON-FINANCIAL COSTS, IN US$ Unimproved Septic tank Cost category Hygiene Shared Dry pit Wet pit private latrine Ideal Actual Financial 0 241 138 36 76 550 337 Investment Non-financial 2 - 6 12 11 17 17 Sub-total 2 241 144 48 87 567 354 Financial 7 7 9 11 18 26 26 Recurrent Non-financial - - - - - - - Sub-total 7 7 9 11 18 26 26 Financial 0 25 26 20 30 72 50 Annual equivalent Non-financial 8 7 4 3 10 12 12 Sub-total 8 31 31 23 40 84 62 www.wsp.org 163 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX K. SANITATION OPTIONS BY ASSET QUINTILE TABLE K 1. PROPORTION OF RURAL HOUSEHOLDS SELECTING DIFFERENT SANITATION OPTIONS, BY ASSET QUINTILE Asset quintile Community toilets Shared Dry pit Wet pit Septic tank Very poor 20% 6% 2% 2% 0% 5% Poor 20% 5% 7% 3% 3% 9% Non poor 20% 1% 1% 2% 3% 13% Upper non poor 20% 1% 2% 0% 3% 14% Wealthiest 20% 1% 1% 2% 2% 10% TABLE K 2. PROPORTION OF URBAN HOUSEHOLDS SELECTING DIFFERENT SANITATION OPTIONS, BY ASSET QUINTILE Community Shared Dry pit Wet pit Septic tank Communal Sewerage with toilets sewerage treatment Very poor 20% 2% 4% 3% 0% 4% 1% 2% Poor 20% 2% 2% 3% 1% 5% 4% 1% Non poor 20% 1% 2% 2% 1% 9% 5% 1% Upper non poor 20% 0% 2% 2% 0% 11% 5% 1% Wealthiest 20% 0% 1% 2% 1% 14% 4% 1% 164 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX L. INCREMENTAL COSTS OF MOVING UP THE SANITATION LADDER TABLE L 1. INCREMENTAL COSTS OF MOVING UP THE SANITATION LADDER (US$, 2009) Community Shared toilet Private dry Private wet Private septic Communal Private Cost item toilet pit pit tank sewerage sewerage Lamongan Shared toilet -56 -44 465 Private dry pit - - 13 521 Private wet pit - - - 508 Tangerang Community toilet -19 -117 -94 371 Shared toilet - -98 -76 390 Private dry pit - - 23 488 Private wet pit - - - 465 Banjarmasin Community toilet -227 -271 -268 -95 158 Shared toilet -44 -41 133 385 Private dry pit - 3 176 428 Private wet pit - - 173 425 Private septic tank 252 Malang Shared toilet -50 -36 212 373 Private dry pit 14 262 423 Private wet pit 248 408 Private septic tank 160 Communal sewerage - Payakumbuh Shared toilet -96 -57 210 Private dry pit - - - 39 306 Private wet pit 267 Private septic tank www.wsp.org 165 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX M. PROGRAM APPROACH ANALYSIS TABLE M 1. HOUSEHOLD CHOICES AND OTHER INTERVENTIONS Site Rural/ Number of Was household given a Was household given a Hygiene awareness Water intervention urban households choice to participate? (%) choice of options (%) (%) offered (%) interviewed Yes, No, not Yes, choice No, choice Yes No Yes No voluntary voluntary available not available 1 Rural 300 - - - - - - - - 2 Rural 300 100 - 96.4 3.6 85.7 14.3 64.3 35.7 3 Urban 300 93.8 6.3 87.5 12.5 66.7 33.7 12.5 87.5 4 Urban 300 98.6 1.4 94.6 5.4 60.5 39.5 10.9 89.1 5 Urban 300 100 - 71.4 28.6 100 - 71.4 28.6 … … TABLE M 2. FINANCING FROM HOUSEHOLD AND PROJECT SOURCES Site Rural/ Number of households Household pays for facility Non cash household contribution urban interviewed Project value input Yes No No Labor Materials 1 Rural 300 100 - - - - 2 Rural 300 30.4 69.6 44.4 52.8 2.8 3 Urban 300 24.2 75.8 95.6 2.2 2.2 4 Urban 300 74.8 25.2 97.2 2.8 - 5 Urban 300 - 100 85.7 14.3 - … … TABLE M 3. APPROPRIATE TECHNOLOGY Site Rural/ Number of households % households with % households with pit % households with pit urban interviewed insufficient water for flushing flooding overflow Sometimes Often Sometimes Often Sometimes Often 1 Rural 300 0 0 3.7 6.3 3 2 2 Rural 300 0 0.3 0 0 0 0 3 Urban 300 0.3 0 0 1.3 0 1.3 4 Urban 300 0.3 0.3 0 0 0 0 5 Urban 300 0 0 0 0 0 0 … … 166 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE M 4. ACTUAL PROGRAM PERFORMANCE IN RELATION TO KEY SELECTED INDICATORS FOR PROGRAM EFFECTIVENESS Impact Indicator Lamongan Tangerang Banjarmasin Malang Payakumbuh Health (sanitation % household members using improved 81% 82% 70% 84% 84% intervention) toilet regularly Health (hygiene % households (always) washing hands 45% 11% 6% 11% 23% intervention) after defecation % latrines with signs of feces around toilet 7.67% 8.67% 18.73% 5% 9.33% Rural: % of tubewells and dug wells Water source 100% 100% - - - tested which have zero E Coli Urban: main water source - tested - - 100% 100% 100% samples which have zero E Coli % households using non-boiling Water treatment 85% 70% 23% 70% 57% household water treatment methods % household members using own toilet instead of off-plot options 87% 74% 72% 82% 59% Men 89% 64% 73% 83% 60% Access time Women 88% 76% 72% 81% 56% Children 5-14 89% 72% 73% 82% 58% Children 0-4 Own use: % households applying human Re-use excreta in own land or using human - - - - - excreta for biogas Sales: % households selling human - - - - - excreta or biogas Average score (as % of maximum score of Intangibles 3% 3% 9% 9% 4.7% 5) of satisfaction questions Average score (as % of maximum score External of 5) of external environment questions 4% 4% 8% 8% 4.8% environment relating to sewage www.wsp.org 167 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables TABLE M 5. SELECTED KEY INDICATORS FOR PROGRAM EFFECTIVENESS Impact Indicator area Actual proposed indicator FOR QUANTITATIVE CBA • Proportion of household members using improved Health (sanitation intervention) • Extent of use of improved toilet toilet instead of previous unimproved option • Decreased incidence of disease(s) caused by poor Health (hygiene intervention) • Rate of patient admission to health care facilities. sanitation. • Proportion of households, who answered ‘yes’ to • Extent of hand washing with soap after defecation, washing hands after defecation, or • Proportion of improved latrines in which there Health (hygiene intervention) • Hygienic state of improved toilet. are signs of feces around toilet (observational questionnaire). • Rural area: % of tube wells and dug wells tested • Water quality is adequate from nearest low-cost to contain zero E. coli, Water source source (rural area) and from piped supply (urban • Urban area (areas with piped water): % tested area). samples in which chlorine is at adequate level. • Households feel safe to use cheaper and simpler • Proportion of households using non-boiling Water treatment household treatment methods household water treatment methods • Proportion of household members using own • Extent of use of own toilet compared to off-plot Access time toilet instead of off-plot options (can split by men, sanitation facilities or OD women, children 5-14, children <5) • Own use: proportion of households applying human excreta in own land or using human • Extent of actual reuse of human excreta out of all excreta for biogas Reuse households with reuse options • Sales: proportion of households selling human excreta or biogas FOR QUALITATIVE ANALYSIS • Degree of satisfaction with key aspects of toilet • Average score (as % of maximum score of 5) of all Intangibles facility relevant satisfaction questions • Average score (as % of maximum score of 5) of • Degree of continued soiling of external External environment two external environment questions relating to environment with human excreta sewage (visibility and smell questions) 168 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables ANNEX N: STEPS OF THE FIELD SURVEY IMPLEMENTATION Briefing for field coordinators Field coordinators were recruited in Jakarta. Before leaving for the field, they were briefed and received training on their responsibilities in the field study. They were also involved in a pilot test of the household questionnaire and observational component, and the health facility study. Each coordinator was responsible for all data collection processes in the field where she/he was assigned, including FGD implementation and all required arrangements with local stakeholders to get their support and inputs. In each site, the Field Coordinator was assisted by one local counterpart. The local counterpart assisted the Field Coordinator to recruit interviewers/enumerators, obtain survey permit from the local authorities, help with enumerators training, and support all data collection processes. The criteria of enumerator recruitment were: −− Experienced with activities related to local communities and local government, −− Good verbal communication skills, −− Understand sanitation issues, −− Fully committed to get the data collection done. There were 8 interviewers in each survey site. Most of them were graduated from public health faculty or health workers/cadres. Most interviewers were women. Training for interviewers The selected candidates for interviewers/enumerators in each site were given an intensive 3 day training on conducting the field survey. The training was facilitated by the ESI Team from PT. MLD who was also assisted by each field coordinator and local counterparts. The training aimed at giving the interviewers/ enumerators an adequate level of comprehension to conduct the HH survey. There were classroom sessions as well as field testing in a village near the training location. The interview tests were evaluated in the classroom to assess whether the questionnaires were practical enough. Field preparation and household interviews The field preparation encompassed determining a base camp, preparing interviewers training, and contacting all related parties to ensure successful survey, such as getting research permit at village level. The samples or respondents were gathered from the field sites by creating a list of targeted households, with special focus on families with children under-five. The process involved field personnel, such as enumerators and local health cadres and involved the following steps: −− Visiting the selected villages to identify and record the number and names of under-five children in those villages, −− Visiting local midwifery clinics or midwife practitioners to get additional data of families with under-five children, −− Once the respondent candidates list was completed, the field personnel selected them randomly to be interviewed. www.wsp.org 169 Economic Assessment of Sanitation Interventions in Indonesia | Annex Tables The household survey team collected data by visiting the respondents’ houses. With household questionnaires in hand, the enumerators interviewed the housewives for 40-60 minutes, including a direct observation of their toilet facilities. The household survey did not encounter significant problems, except for revisiting the house when the selected respondents were not at home because they were working. To ensure the quality of data collection in the field, the interviewers and the field coordinator conducted data reconciliation every end of the day after the interviews. There were three stages to verify the questionnaire responses: 1. The first stage: peer review among interviewers. The result of an interviewer was verified by another interviewer until all questionnaire responses of that day were all cross-checked. The purpose of this stage was to make sure that all questions in the questionnaires were properly filled out, 2. The second stage: the field coordinator thoroughly reviewed all questionnaire responses. The purpose of this stage was to ensure no mistakes in filling in of the questionnaire, 3. The third stage: the field coordinator randomly revisited some respondents to verify that the respondents were really interviewed by the interviewers. These verification stages were conducted during the field surveys to ensure prompt actions were taken following identification of problems related to the questionnaires. For instance, should there be a questionnaire that has not been properly filled out, the field coordinator would ask the interviewer to visit the respondent of that particular questionnaire again and would make sure that all questions are answered. If the interviewer failed to meet a certain respondent until the second visit, then the respondent would be replaced with the following person in the respondent list. Employing such verification method in this study resulted in zero non-response or error response rate and credible confidential data to be processed. At the same time, there were parallel data collection activities in each site survey (see below). 170 Economic Assessment of Sanitation Interventions