WATER AND SANITATION PROGRAM: FIELD NOTE October 2013 85200 Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia 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. Acknowledgments This Field Note was prepared by Rebekah Pinto, with valuable inputs provided by Deviariandy Setiawan, Ari Kamasan and Claire Chase. The author also gratefully acknowledges review comments provided by Almud Weitz, WSP Principal Regional Team Leader, and Eduardo Perez, WSP Senior Sanitation Specialist. 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. The findings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its affiliated organizations, or to members of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank Group concerning the legal status of any territory or the endorsement or acceptance of such boundaries. The material in this publication is copyrighted. Requests for permission to reproduce portions of it should be sent to wsp@worldbank.org. WSP encourages the dissemination of its work and will normally grant permission promptly. For more information, please visit www.wsp.org. © 2013 International Bank for Reconstruction and Development/The World Bank The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org Contents Overview .................................................................................................................................................. 1 Background .............................................................................................................................................. 2 Departing from Business As Usual: “Light“ Technical Assistance for Sanitation Service at Scale ............... 4 Objectives and Targets .............................................................................................................................. 4 Results and Learning ................................................................................................................................ 7 Measuring Results and Impact ................................................................................................................. 14 Program Effects on Child Health Outcomes .............................................................................................. 14 Lessons Learned from Scaling Up Rural Sanitation in Indonesia .............................................................. 15 References .............................................................................................................................................. 17 www.wsp.org D www.wsp.org Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia However, in 2005 the Government of Indonesia embarked on a new approach to improving rural sanitation known as Community-Led Total Sanitation (or CLTS) piloted origi- nally in Bangladesh. Instead of focusing on toilet construc- tion, the CLTS approach recognized that sustainable de- mand for improved sanitation came only when households and communities were part of the process of identifying and addressing the problem. In order to demonstrate the success of this new approach, a small pilot began in 2005 as part of two larger scale water and sanitation programs funded by the World Bank and Asian Development Bank. The success of this small pilot led to its initial expansion to additional villages and eventually in 2007 to the creation of the Scaling Up Rural Sanitation Program (initially known OVERVIEW as the Total Sanitation and Sanitation Marketing Project or Inadequate access to sanitation remains a persistent issue, af- TSSM). TSSM, which was a demonstration of a community- fecting the lives of millions of children and families especially led approach at scale2, started in the East Java province of In- in poor and rural communities throughout the world. In donesia as a result of collaboration between the Government Indonesia, efforts to expand coverage have barely affected the of Indonesia, Bill & Melinda Gates Foundation and the Wa- lives of poorest populations where rampant diarrheal disease ter and Sanitation Program (WSP) of the World Bank. continues to affect the health and well-being of the next gen- eration of children. These efforts were further complicated The TSSM approach combines three innovative approach- by policies that provided sanitation hardware subsidies lim- es: (i) CLTS to generate demand; (ii) sanitation marketing ited to populations identified under specific programs, rather to reinforce demand generation and increase supply of sani- than strategies aimed at promoting large-scale sustained be- tation goods and services; and (iii) strategies to strengthen havior change such as awareness building and hygiene educa- the country’s enabling environment so that improvements tion. As a result, Indonesia has the second highest number could grow and ultimately be sustained. By December of open defecators worldwide at 59 million, according to the 2011, 2,200 communities in 29 districts have been official- 2013 update published by the WHO/UNICEF Joint Moni- ly declared and verified as Open Defecation Free (ODF), toring Programme (JMP)1, and lags substantially behind its and over 1.4 million people have gained access to improved peers in the region in terms of access to sanitation. sanitation as a result of exposure to the program.3 1 Progress on Drinking Water and Sanitation: 2013 Update. Joint Monitoring Programme, WHO/UNICEF. 2 East Java has a total population of 37 million (70 percent rural). 3 WSP Project Monitoring Data. 2011. These figures have continued to grow beyond the December 2011 closing date of TSSM but December 2011 is used for consistency throughout the document. www.wsp.org 1 FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia TSSM signified a strategic policy shift for sanitation on the part of the Government of Indonesia. What began as an at-scale, provincial program has become the backbone of Indonesia’s national rural sanitation program today. A new National Strategy for Community-Based Total Sanitation (Sanitasi Total Berbasis Masyarakat, or STBM) was adopted in 2008 and builds further upon TSSM’s three-pronged ap- proach for improving the health of poor households and communities. Under the umbrella of STBM, and building on lessons learned in East Java, 32 out of 33 provinces in Indonesia5 are now beginning to assume full responsibility for financing and implementation of the new strategy, pro- gressively internalizing the new approaches and applying these to their entire province, with technical assistance pro- vided by WSP to the STBM secretariat and 5 provinces as well as through the World Bank-funded Third Water Sup- ply and Sanitation for Low Income Communities (Pamsi- mas) project.6 This Field Note presents the achievements, learning and reflections that resulted from implementing a large-scale sanitation program in East Java, Indonesia and provides recommendations for future initiatives aimed at increasing access to improved sanitation globally. As part of efforts to gather evidence on the health and wel- BACKGROUND fare impacts of this approach, TSSM utilized a rigorous im- Over the past decade the Indonesian economy has experi- pact evaluation to measure the effects of the intervention enced positive economic growth, witnessed impressive reduc- on individual and collective sanitation behaviors, as well as tions in poverty, and has made continued progress toward the program’s impact on the health and welfare of children many of its Millennium Development Goal targets for 2015. under the age of five. Of 160 randomly selected commu- However, these improvements partially mask the persistent nities including 2,100 households, treatment communi- problem of inadequate access to sanitation still facing mil- ties witnessed a 29 percent increase in toilet construction lions of Indonesians, especially those that are from poor, rural (albeit not among the poorest quintile of the households households. Indonesia is currently not on track to meet the surveyed) and a 30 percent decrease in diarrhea prevalence 2015 sanitation Millennium Development Goal: of Indone- reported by care-givers of children under the age of five.4 sia’s 240 million residents, just over half (56 percent) belong This randomized controlled trial evaluation also found that to households with access to any kind of sanitation. In rural the program had impacts on other child health indicators areas the problem is magnified—just 39 percent of individu- ranging from reducing parasitic diseases to improvements als have access to sanitation and another 40 percent of rural in height and weight among households with no sanitation residents still regularly engage in the practice of open defeca- at baseline. tion, using fields, beaches and most often rivers. 4 Cameron, Shah and Olivia. Impact Evaluation of a Large-Scale Rural Sanitation Project in Indonesia. World Bank Impact Evaluation Series No. 83. February 2013. 5 The exception is DKI Jakarta which is classified as 100 percent urban. 6 Additional funding for Pamsimas to be implemented over the period 2013-2016 has been approved in May 2013 and will cover 32 provinces. As agreed with the Government, the STBM implementation approach has been revised towards a district-wide approach that allows STBM implementation not only in selected Pamsimas sites but across all villages in a district. 2 www.wsp.org FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia Motivated by mounting challenges in the rural sanitation sector, the Government of Indonesia launched STBM in 2008 in an effort to improve sector effectiveness and reach the sanitation MDG. The new STBM strategy focuses on sustaining behavior change for sanitation and hygiene, cre- ating demand at scale through community participation and empowerment and improving market supply as a re- sponse to generated demand. To complement these efforts the Ministry of Health and the East Java Provincial Gov- ernment, with support from WSP, implemented the TSSM project from 2007-20109 as an at-scale demonstration of implementing STBM at the local level. When implementation started in East Java, a host of chal- lenges had to be overcome to ensure effectiveness: • Clarity on Roles & Responsibilities: Indonesia is Inadequate sanitation disproportionately affects poor com- highly decentralized and although policies are designed munities, as well as contributes to diarrheal disease, one of at the national level, local district governments are fully the leading causes of death in children under five. Wide- responsible for planning, funding and implementing spread open defecation leads to feces being tracked through their development agendas, including those related to villages and into people’s houses, where it is ingested. Re- rural sanitation. Decentralization has also meant that a peated bouts of diarrhea as a result of poor sanitation and widening pool of stakeholders and administrative bod- hygiene practices have been linked to long-term growth de- ies are charged with improvements to rural sanitation. ficiencies (stunting) in children under two, which in turn At the beginning of TSSM, confusion and fragmenta- leads to impaired long-term cognitive development and tion over responsibilities and procedures often delayed schooling attainment, as well as adult morbidity and lower implementation of a sustained sanitation program. incomes. Currently 36 percent of Indonesian children un- • Lack of Demand & Awareness: Among participating der 5 are moderately or severely stunted, making it among districts an important gap existed between knowledge the 14 countries along with India and Nigeria that share about transmission of diseases from open defecation when the greatest percentage of the global burden of stunted chil- feces did not visibly contaminate the immediate environ- dren. ment. Despite relatively high levels of knowledge among the population about sanitation, few seemed to under- Poor sanitation also places a high economic burden on stand the health hazards of openly defecating in rivers or countries, particularly in Indonesia. According to a WSP far from where people lived. Information and education study, the economic costs of poor sanitation are estimated campaigns focusing primarily on top-down messages to be as high as Rp56 trillion (US$6.3 billion), equivalent around health hazards did not seem to reach the broad to 2.3 percent of the country’s GDP in 2006.7 This same population in order to instigate lasting behavior change. study estimated that poor sanitation and hygiene prac- • Hardware vs. Behavior Change Approach: Prior to tices also contributed to 120 million disease incidents and TSSM, the government maintained a subsidy-based 50,000 premature deaths annually.8 approach to providing sanitation hardware to house- 7 Napitupulu and Hutton, 2008. 8 ibid, 2008. 9 The project was subsequently extended to December 2011. 10 Mukherjee et. al. 2012. www.wsp.org 3 FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia holds under various programs. This did not foster last- and fiscal allocations at the central and local levels support ing change – Indonesia’s rural sanitation coverage rates the scaling up and sustainability of interventions. barely changed over the past decades - because it ig- nored why communities continued to defecate in the The success of the demand generation approach lies in open. It also under-utilized the power of collective ac- combining distinct elements aimed at getting communities tion and responsibility for improving sanitation facilities to both stop open defecation, as well as build and utilize for all community members. Expectations that subsidies improved latrines, community-led total sanitation (CLTS) would eventually become available for all hampered col- and behavior change communications (BCC). CLTS uses lective action and created social divisions.10 For the new community-based sanitation ‘triggering’ events, awareness approach to be successful, districts had to be convinced building and careful verification to successfully catalyze one-by-one that having two competing approaches community commitment and demand for becoming 100 would not work and that a broad-based policy shift in percent Open-Defecation Free (ODF). line with STBM was required. • Limited Availability of Low-Cost Latrine Options: This is complemented by formative research-based BCC The challenge of increasing demand for improved sanita- strategies and a market research-based supply improve- tion options was compounded by the fact that local mar- ment program. The objective of the supply improvement kets did not offer latrines catering to those with lower program is to build on CLTS efforts by increasing individ- purchasing power. Many households used personal sav- ual consumer demand for and market supply of improved ings to fund what was perceived as highly-priced latrine sanitation solutions that are both affordable and preferred construction. Local masons had limited experience on by consumers of all classes and income levels. Over time, how to package together a variety of low-cost latrine so- growth of improved supply is sustained through continued, lutions for households that would enable consumers to quality entrepreneur training, monitoring and regulation of invest in affordable and upgradable sanitation solutions. the market. This is complemented with targeted advocacy Such supply needed to be built up quickly if the newly to local governments and capacity building for local gov- created demand was to lead to substantial latrine uptake. ernment agencies. DEPARTING FROM BUSINESS AS USUAL: OBJECTIVES & TARGETS “LIGHT” TECHNICAL ASSISTANCE FOR The project’s overall goal in East Java was to design and SANITATION SERVICES AT SCALE implement an innovative, sustainable program to reduce The TSSM approach departs from typical modes of deliver- open defecation and increase access to hygienic sanitation ing sanitation services by recognizing that sanitation is a in all 29 rural districts throughout East Java. The hypoth- multi-sectoral issue that has long-term impacts on health, esis behind the approach (or ‘theory of action’) was that education and the economy and next, that improvements ‘light’, time-bound11 technical assistance could be extended in sanitation infrastructure alone will not solve the myriad across the whole province provided that local governments of sanitation problems. Demand for new and improved la- would be in the driver seat and implement – and largely trines, as well as improvements in hygiene behaviors, come fund – interventions through existing government systems, only when there is a change in community-level percep- while households would be able to fund their own toilet tions about the impacts of the lack of sanitation. investments provided the market catered to their demand for affordable and desirable products. TSSM utilizes a theory of change developed globally by WSP that connects strengthened sanitation supply with de- The following section summarizes the results against these mand creation and behavior change, rooted in an enabling objectives, as well as lessons learned over the course of the environment whereby policy, institutional arrangements TSSM project in East Java. 11 Each district received technical assistance for a period of only 8-9 months. 4 www.wsp.org FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia TABLE 1. RESULTS SUMMARY AND KEY ACHIEVEMENT Objectives and Targets 2007 Baseline 2009 Target 2011 Achievement Objective 1: Increase Collective Demand and Behavior Change Among Communities and Households through CLTS and BCC Campaign Number of communities “triggered” 0 2,700 6,250 (231%) Number of communities declared and verified open defecation free 0 870 2,200 (252%) Population gaining access to improved sanitation fully financed by households 0 1.4 million 1.4 million Objective 2: Strengthening the Supply of Affordable Latrines and Services for Households12 Business model of one-stop-shop sanitation developed and promoted to 60 entrepreneurs from 28 n/a n/a local entrepreneurs districts trained Objective 3: Strengthening the Enabling Environment Policy, Strategy and Direction Strategic Planning STBM Approval No Yes Yes District Strategies Implemented 0 14 (48%) 28 (96%)13 Political Support National Sanitation Budget Allocation US$1.3 million US$2.2 million US$800 million14 Policy Alignment: Total Sanitation UNICEF Indonesia No Yes Yes Plan Indonesia No Yes Yes Ministry of Public Works No Yes Partial Program Methodology Total Sanitation at Scale Number and percentage of districts using total sanitation approach 54 districts (15%) 150 districts (43%) 252 districts (72%) UNICEF Indonesia No Yes Yes Plan Indonesia No Yes Yes Sanitation Marketing at Scale Number and percentage of districts using sanitation marketing approach 0 - 28 districts15 UNICEF Indonesia No Yes Yes Plan Indonesia No Yes Yes Implementation Capacity Knowledge Management Exposure visits (people per year) 0 200 16016 Best practice seminars 0 4 4 WSP field notes 0 1 117 Active Sanitarians East Java: filled positions 620/826 (75%) 750/833 (90%) 632/833 (76%) East Java: active entrepreneurs 0 29 618 12 Project activities related to supply strengthening were introduced following a consumer market survey showing limited knowledge and accessibility presented challenges to adoption of improved household sanitation options. For this reason 2009 targets were not originally included in the program’s design. 13 Thirteen districts have completed their strategic sanitation plans for 4-5 years with official endorsement by the Head of District or the head of the local health department, and 15 districts have incorporated the rural sanitation strategic plans into existing multi-year district strategic plans for water and sanitation (Renstra AMPL) or Health (Renstra Kesehatan). 14 The majority of this amount has been earmarked for urban sanitation infrastructure. 15 One district in East Java has not adopted the main elements of the TSSM methodology. 16 Fourteen internal district-to-district and nine international/external (from Cambodia, Laos, East Timor, the Philippines, Vietnam, India, Pakistan, WSLIC-2, and the Asian Development Bank-supported Community Water Services and Health Project) exposure visits over the last two years. 17 WSP 2009. 18 These data were obtained from an assessment that took place in July 2010. At the completion of the project in December 2011, the number of active sanitation entrepreneurs in East Java reached 30. www.wsp.org 5 FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia TABLE 1. RESULTS SUMMARY AND KEY ACHIEVEMENT (CONT’D) Objectives and Targets 2007 Baseline 2009 Target 2011 Achievement Availability of Goods and Services Technology Options Promoted by local producers 5 10 6 Found in poor households 2 4 3 Rural Service Providers Number of trained masons 0 +25% +3% Number of sanitation businesses 0 +44% 6 User Satisfaction Owners of improved latrines Unknown 75% 85%19 Owners of unimproved latrines Unknown - 57% Users of shared latrines Unknown - 34% Financing Sanitation Finance Annual sanitation budget US$169,000 US$750,000 US$372,00020 (East Java) Sanitation Incentives National sanitation award No Yes No East Java sanitation award No Yes Yes East Java ODF incentive 0 US$67,000 US$22,000 Cost-Effective Implementation Effectiveness (East Java) Nr. triggered communities 0 2,700 6,250 (231%) Verified ODF communities 0 870 2,200 (252%) ODF success rate - - 35% Cost-Effectiveness Program cost per ODF community US$6,400 US$4,000 US$1,060 Program cost per latrine in use US$9 US$5 US$4.26 Leverage ratio (household: program) 2:1 4:1 5.3:1 Monitoring & Evaluation Monitoring systems National outcome monitoring No Yes Yes21 Finance for national monitoring US$0 - US$110,00022 Harmonization with JMP indicators No Yes No Sanitation evaluations WSP-financed (East Java) 0 2 2 Government-financed (national) 0 2 0 19 User satisfaction data from Nielsen (2008) that demonstrated satisfaction is far higher among owners of improved latrines, and thus satisfaction should increase as improved sanitation coverage rises. 20 Total budget allocations by the provincial government and 29 district governments peaked at US$603,000 in 2009, then declined to US$372,000 in the 2010 election year. 21 The national sms and web-based monitoring ssystem was launched in October 2011, during national coordination meeting for STBM (Rakornas). 22 Puskesmas budget for all sanitation software activities (100 puskesmas in 2010; 8,000 puskesmas in 2011 is equal to US$8.9 million in budget allocations). 6 www.wsp.org FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia expressing their desire to participate, with priority given to those willing to co-finance implementation; (ii) no subsi- dies would be provided for household toilet construction in accordance with STBM; (iii) no monetary incentives would be given to communities verified as ODF. At the sub-village level, triggering events typically begin with a ‘walk of shame’ where villages are asked to provide a tour of where defecation occurs. Following this, facilitators help individuals analyze how fecal contamination spreads from exposed excreta to their living environments, food and drinking water supply. Finally, a social mapping exercise leads community members through the process of identify- ing where they live, where they defecate and the routes they take there and back. The realization of how closely these RESULTS AND LEARNING activities take place, often leads to collective action to be Objective 1: Increasing Collective Demand and Be- free from the hazard by becoming ODF. In order to achieve havior Change Among Communities and Households this following triggering, communities must come together Through CLTS and BCC Campaign and forge their own action plan, with only limited support from project staff. Communities that are verified ODF by One of the key challenges to expanding sanitation interven- government agencies receive recognition from local and tions in Indonesia is motivating households to recognize provincial government leadership. Sub-villages who have and appreciate the importance of defecating in hygienic la- received CLTS are also vital in triggering other sub-villages trines for their families and their community. In East Java to become ODF.23 96 percent of households that do not have access to sani- tation report defecating in rivers. Open defecation, espe- In East Java the CLTS approach resulted in tangible im- cially in rivers, is still culturally acceptable and frequently provements to household-level sanitation behavior change. considered more convenient than using sanitation facilities. The fraction of households reporting that at least one mem- To combat this perception the CLTS approach aims to ‘trig- ber engages in open defecation is systematically lower in ger’ the desire for a community environment that is ODF. communities that participated in the project (‘treatment’ At the district level, the TSSM intervention began with a communities). Households reporting that a member con- series of roadshows aimed at generating stakeholder buy- tinues to practice open defecation is 4.4 percentage points in through presentations that demonstrated the economic lower in treatment villages. Among communities on rivers, and social impacts of poor sanitation. These roadshows also open defecation by any household member is 6 percent- provided a forum for establishing the program’s ‘rules of age points lower in treatment communities than in control engagement’, namely that (i) formal letters of interest had communities participating in the TSSM impact evalua- to be received from district, subdistrict and village leaders tion.24 23 Typically 5-10 subvillages comprise a single village. 24 Draft. TSSM Impact Evaluation. 2012. www.wsp.org 7 FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia sustained. One pathway that has proved successful for ensuring sustained repeat behavior change messaging to communities is working in collaboration with health pro- motion units (Promkes) at the Ministry of Health. Work- ing through Promkes provided an institutional “home” for promoting messages around rural sanitation, with forma- tive research aiding in the development of tools that dis- trict governments can use to develop their own sanitation improvement campaigns. Objective 2: Strengthening the Supply of Affordable La- trines and Services for Households While CLTS has proved effective for triggering a commu- nity desire and effort to be free from open defecation, it Lessons Learned alone is not sufficient for driving the adoption of improved TSSM monitoring data show rapid progress in more than latrines. For a community to be able to sustain ODF status, 5,000 triggered communities in East Java, with demand ac- increased household demand must be met with a range of celerating from district governments.25 About 83 percent of options that would allow individuals to progressively up- these communities were ‘triggered’ with local government grade facilities over a sustained period of time. Supply-side funding, indicating a high – and growing – degree of local challenges centered around how to popularize what con- government ownership of the approach. One of the keys stitutes an ideal safe, healthy, hygienic sanitation facility to success was an approach that required early buy-in from among consumers and suppliers, as well as how to motivate districts, subdistrict and village leadership, as well as their the market (including manufacturers, suppliers, vendors explicit interest and commitment to engaging with proj- and masons) to deliver a range of sanitation options priced ect facilitators. Over time TSSM shifted to explore alter- for different segments of consumers. native strategies for sustaining buy-in from districts such as competitions between areas, award ceremonies, and re- In order to meet these challenges WSP developed a stra- purposing project outcomes to lobby for additional budget tegic sanitation behavior change framework to help guide allocation. the analysis of determinants of sanitation behavior change based on extensive market research collected in East Java. However, triggering alone was not enough to guarantee Formative research using SaniFOAM (Sanitation Frame- successful progression to ODF, which was achieved by work of Opportunity, Ability and Motivation) revealed a over 2,200 communities by December 2011. Repeat mes- number of clear factors constraining adoption of latrines: saging and targeted monitoring and follow-up through household visits were key to ensuring consistent support • Flush latrines were perceived as prohibitively expensive to households. Repeat messaging, which mainly occurred by households through existing congregational and communal gather- • Disease was seen as a result of poverty and/or destiny ings, was especially important for reinforcing the themes and not related to sanitation behaviors of the original triggering event. For communities that take • Sanitation was perceived as a waste of clean water espe- several months to become ODF, periodic re-checks may cially in water scarce areas, whereas open defecation is be a valuable tool for ensuring that ODF status has been clean, convenient and free 25 Inception Report for the Five Year At-Scale Sanitation and Hygiene Implementation Program in Indonesia. WSP, World Bank Group. 2011. 8 www.wsp.org FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia • Although sanitation materials and services appeared market research to understand consumer preferences and plentiful, suppliers presented relatively expensive op- the supply capacity of local markets, followed by devel- tions when asked about the cost of a hygienic latrine oping pro-poor marketing strategies in response, should facility have preceded implementation of CLTS and BCC inter- • The supply market chain for sanitation was fragmented ventions to generate demand while helping local capacity and lacked clear standards to identify safe, hygienic la- to grow. trines, thus perpetuating the assumption among consum- ers that safe latrines were unaffordable In addition to implementation delays, this component required a substantial revision in its approach based on It was from this new framework for action that the following emerging lessons from the first half of the year. Training features were added to TSSM in an effort to enhance supply of masons proved to be ineffective as participants, who and bolster community demand for low-cost latrine options: were chosen by the district to ensure district ownership in this component, were not appropriate candidates for a) Promotion of definitions of ‘improved’ and ‘unim- training and in some cases had limited interaction with proved’ sanitation as part of all program implemen- communities that needed upgraded facilities the most. tation tools and resources in a way that makes it easy Initially, this resulted in an imbalance between communi- to understand the difference between the two at the ties in which demand was ignited through CLTS and local community level markets’ ability to provide a range of low-cost options for b) Creation of an Informed Choice Catalogue (ICC) consumers. Adjustments to the approach included intro- of safe sanitation options that: (i) illustrates all pos- ducing increasingly rigorous selection criteria for training sible combinations from lowest to highest cost; and recipients; shifting the pool of trainees from masons ‘one (ii) promotes the idea that safe, hygienic latrines are level up’ to sanitation entrepreneurs; and ensuring that affordable and good for all there was a better match between those trained and the c) Development of mason training/accreditation pro- communities being targeted as part of TSSM. The result gram designed to equip every district with masons was a marked increase in the number of toilets sold and capable of facilitating informed consumer choice- built in treatment communities since TSSM’s inception, making from the ICC, as well as promote and deliver almost 30 percent higher in treatment versus control com- safe improved sanitation options (“WC-ku Sehat”) munities (representing a 31 percent increase in the rate of d) Promotion of “WC-ku Sehat” thumbs-up sign brand- toilet construction over baseline).26 ing for facilities that meet ‘improved sanitation’ criteria e) Launch of a vendor orientation program to promote “WC-ku Sehat” option and link consumers with trained masons Lessons Learned Strengthening the supply of affordable latrine proved to be substantially more difficult than increasing demand. Progress in improving local supply capacity was initially delayed due to difficulties in identifying and recruiting a marketing expert for TSSM, a position henceforth not seen in the sanitation sector. The sanitation-marketing component thus started with an 18-month delay. Ideally, 26 Ibid. Draft. TSSM Impact Evaluation. 2012. www.wsp.org 9 FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia But traditional individual training models alone are not entrepreneurs, was a valuable tool for encouraging house- enough to motivate sanitation market transformation. Part- holds to upgrade existing latrines and building awareness nerships with community organizations proved effective, as about low-cost options for progressive upgrades of latrine was done with ‘one-stop-shop’ sanitation centers in East facilities. Actors at the provincial and district level that Java. These centers provide conventional mason services were exposed to the catalogue found it a useful tool, al- with information centers, promotional creativity, technical though many at the village level, for which cost is perceived support provision, as well as sanitation construction materi- as the main impediment to latrine adoption, reported less als. Currently there are approximately 85 one-stop centers exposure to the ICC. Evidence from the TSSM Impact in operation in East Java that have sold over 15,000 sani- Evaluation demonstrates the need for continued awareness tation packages, generating more than US$1.3 million in building about low-cost latrine options, especially at the revenue.27 household level. On average households surveyed estimated that it would cost approximately Rp1.2 million to build a Delays in project implementation of this objective also had latrine (US$135), roughly equal to the average household’s an effect on the distribution of the informed choice cata- per capita, per month income. In reality, TSSM estimates logue (ICC) to various stakeholders. This catalogue, which the actual cost to install a latrine with a slab to be in the was used widely in training of sanitarians, masons and range of US$50 to US$90.28 BOX 1. LEARNING FROM SUCCESS: LATRINE SAVINGS CLUBS IN JOMBANG DISTRICT The sanitation business in Jombang district is growing thanks to the efforts of a local sanitarian named Subianadi. As part of his job responsibilities Subianadi is responsible for environmental programming in each of the areas sub-villages, including the construction of healthy latrines. To accelerate community demand for construction of healthy latrines, Subianadi initially proposed the idea of a latrine savings club or arisan where club members could pay Rp1,000 (approximately US$0.09) a day towards a new latrine, an idea that was readily accepted by villagers who felt it was easy to set aside Rp1,000 a day without too much trouble. Volunteers were set to collect contribu- tions from club members every day and the idea was officially endorsed by the subdistrict leader. Using this savings club scheme, Subianadi and his team have been able to help construct 23 household latrines per month, per village, with outstanding orders for 111 latrines. Under this scheme, each member of the savings club eventually receives a savings pot of Rp600,000 (approximately US$54), which can be used towards the con- struction of a new latrine. The models’ success has meant that word has continued to spread—with the club now being developed in several subdistricts beyond Subiandi’s subdistrict of Sumobito. Subiandi said when the idea of the savings club scheme was introduced, villagers initially doubted that Rp600,000 was sufficient funding to build a healthy latrine. He often uses BCC materials to address these concerns, and demonstrates that there are a range of healthy latrines at various prices. The savings club scheme also does away with the need for hardware subsidies and loans from financial institutions because the turnover of funds is rapid enough for Subianadi to purchase materials and pay the masons. Subianadi also believes that sanitarians are instrumental to the successful construction of healthy latrines as they are considered credible experts in the eyes of the community. However, more needs to be done to socialize the importance of this work among sanitarians who still feel that it is occasionally “unfamiliar and bothersome” work that places additional burdens such as travel on their everyday work. 27 WSP Project Monitoring Data. August 2012. 28 Water and Sanitation Program, 2012. 10 www.wsp.org FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia Each of these community-led innovations provides indica- tions that support the idea that poor households are will- ing to invest in the mid-priced pour-flush latrine options if some form of credit to enable payment by installments is made available to them. In the future, support to Indonesia’s sanitation entrepre- neurs is poised to expand. Entrepreneurs have come togeth- er to form the Asosiasi Pengelola and Pemberdayaan Sanitasi Indonesia (APPSANI, or Indonesia Sanitation Developer and Empowerment Association) in early 2012. Through APPSANI entrepreneurs will be able to collectively advo- cate for standardization of pricing, standards, recruitment of new entrepreneurs and a training curriculum. These ef- However, cost alone does not paint the full picture of why forts are also being reinforced by the Ministry of Health, poor households decided not to adopt improved latrines. which has begun to require local governments interested in Households that cited ‘lack of money’ as a reason for not expanding STBM to provide cofinancing for local sanita- owning a latrine also reported owning assets such as tele- tion entrepreneur training. visions, motorbikes, bicycles, livestock, cell phones, paddy fields and permanent housing with brickwork, masonry and Objective 3: Strengthening the Enabling Environment tiled roofs.29 The issue is not only of cost, but also of house- hold prioritization and awareness about the continued dan- In order to seriously address the sanitation crisis in Indo- gers of open defecation. The one advantage of assets, such nesia, national and local governments need to take a strong as a television or motorbike, is that they can be bought on lead in ensuring accountability and sustainability of sani- credit and paid off over several months. Affordable financ- tation interventions in the short, medium and long-term ing options such as installment credit or deferred payments in order to ensure that project outcomes, no matter how would provide affordable pathways for poor households successful, survive once external funding ceases. For this looking to upgrade latrines, especially when coupled with reason, an enabling environment is central to the scaling up targeted promotion about the range of products available and sustainability of project outcomes. For the purposes of on the market. TSSM an enabling environment was defined as one where the policy, institutional and financial environment pro- In East Java the cost barrier was also addressed through a motes mutually self-sustaining growth of, demand for number of innovative financing mechanisms that empow- and supply of improved sanitation. Success in achieving ered villages to leverage group resources to help poor house- this objective is focused on eight dimensions: holds gain access to latrines. In some cases, entrepreneurs engaged with local microfinance institutions to provide  Policy, Strategy and Direction households with available credit. Another mechanism was  Institutional Arrangements the use of group savings (arisans) commonly used in Java  Program Methodology to enable poor households to raise funds for large expenses,  Implementation Capacity such as sanitation revolving funds. In some cases, arisan  Availability of Products and Tools groups even entered into agreements with local sanitation  Financing material retailers to get supplies on credit, build facilities  Cost-Effective Implementation and pay back the total amount in six monthly installments.  Monitoring & Evaluation 29 Ibid, Mukherjee et. al. 2012. www.wsp.org 11 FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia BOX 2. STRENGTHENING THE ENABLING ENVIRONMENT As part of WSP’s commitment to supporting sustainable change at scale in Indonesia, the program has continued to provide high quality technical support well beyond the life of the project. Since 2010, Ministry of Health’s STBM Secretariat, with support from WSP, has continued to scale up its efforts to strengthen the enabling environment through sanitation policy development, adoption of behavior change and sanitation marketing strategies, creation of improved systems for monitoring and evaluation and greater sub-national investment in rural sanitation im- provements. WSP also provides capacity building support to the Department for Human Resource Development within Ministry of Health, where together they are making strides in improving: • Standardization and accreditation of sanitation entrepreneurs • Provision of performance-based provider incentives for civil servants • Collaboration with provincial training institutes (Health Polytechnics) to integrate STBM training material into for- mal curriculum WSP is also co-managing the health component of the Pamsimas project in 32 provinces through provision of technical, monitoring and training assistance at provincial, regional and national levels. Lessons Learned Policy, Strategy and Direction support for STBM (using As part of creating sustainable Institutional Arrangements, the TSSM approach) is continuing to grow in Indonesia the TSSM approach has been successful in developing own- and is already significant among key ministries such as the ership and encouraging greater allocation of local govern- Ministry of Health and the Ministry of Planning (BAPPE- ment funds towards rural sanitation. For every Rp1 million NAS). For the Ministry of Health, STBM is an essential the project was successful in leveraging an additional Rp2-37 part of the 2009-2014 Strategic Plan, targeting implemen- million, depending on the district, between January 2008 tation in 20,000 villages and as a program priority for su- and December 2010. Decentralization of decision-making pervision under the National Medium-Term Development has also been critical for assuring local governments’ involve- Plan by the Presidential Unit for Development, Monitoring ment in taking responsibility for decisions around whether to and Control, all of which are aimed at making Indonesia adopt particular approaches, utilize project tools or partici- ODF by 2014. Through the project, WSP also provided pate in capacity building activities. intensive technical assistance to districts about how to pre- pare detailed district sanitation plans for scale-up to ensure Increases in the Availability of Products, Tools and Ser- sustained funding for rural sanitation. These plans pro- vices have led to improved latrine designs and technology vide a roadmap for how sanitarians, village midwives and options that have now expanded beyond East Java into four health cadres can work collaboratively in order to imple- additional provinces, both through TSSM training courses ment STBM strategies in their community. This effort has and knowledge sharing at stakeholder events. One of the born ample fruit as several districts have already completed most popular models of provision remains the one-stop their strategic plans and/or incorporated these plans into shop where customers can organize latrine construction in their existing multi-year district strategic plans for water one easy visit, allowing them to choose from a range of low- and sanitation. NGOs have also signaled their support of cost latrine options that can be delivered and installed in a CLTS, with variations having been adopted by UNICEF timely manner. One-stop shops, run by sanitation entre- and Plan Indonesia as central components of their sanita- preneurs, have now expanded to four new provinces where tion programs. local governments are increasingly providing resources to 12 www.wsp.org FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia support the training and coordination needed to match in improved sanitation. Under this project, total govern- increased community demand for improved latrines with ment costs were US$2.73 per beneficiary. The study found entrepreneurs ready to serve them. that households with no exposure to the program invested approximately US$5.82 while households that did partici- District governments have also begun to select communica- pate spent an additional US$2.94 on improving sanitation tion materials from a menu of design templates and repli- over and above control households, representing a 47 per- cate them over local media channels using their own funds. cent increase in spending. Thus, every US$1 spent by the Progress in getting districts to fully utilize these resources government returned increased household investment of is beginning to climb, although future research into les- US$1.08. Increases were also reported for poor households sons learned about why some district governments decide who were also willing to make substantial investments in to use or not use BCC materials could potentially provide improved sanitation, spending US$1.55 per capita more pathways for improving and sustaining utilization. Going than their counterparts who were in control communities.30 forward, opportunities also exist to expand distribution and Moreover, the treatment induced greater investments from awareness building around the ICC, as well as create formal the private sector on the supply side, and from the com- systems at all levels of government (district, province and munity in terms of volunteer time, totaling an additional national) to collect and share innovative designs and techni- US$2.86 per beneficiary. Once this is accounted for, ev- cal options. ery US$1 spent by the government leveraged an additional US$2.13 in total new investments from households, com- One result of the TSSM project in East Java has been a munities and the private sector. This demonstrates that rela- growing awareness of the importance of Cost-effective Imple- tively small amounts of government spending can trigger mentation rather than simple measurement of latrine and significant non-government investments, emphasizing the latrine subsidies. A recent costing study on the TSSM pro- importance of collecting information on these investments gram in East Java demonstrates the potential of the TSSM when estimating cost-effectiveness of implementation. program to leverage noteworthy investments by households 30 Chase, Briceno, Naafs, 2013. www.wsp.org 13 FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia • Documentation and dissemination of lessons, which provided stakeholders at the central and local level with publications, study tours and opportuni- ties to engage in learning events in order to review progress and capture lessons learned before further expansion of activities. One of the biggest challenges faced over the course of the TSSM project was availability of reliable, timely data on rural sanitation access and hygiene behaviors. Currently in Indo- nesia there exists no functional monitoring system for rural sanitation, other than the annual Susenas socio-economic household survey, which provides only representative data on MEASURING RESULTS & IMPACTS use of household sanitation facilities. Likewise, at the local Monitoring and evaluation of progress towards each of the level, there is no reliable monitoring of sanitation outcomes project’s objectives and targets was considered a major com- such as latrine usage, hand washing with soap, safe disposal ponent of the program from its earliest stages. Multiple col- of infant excreta or open defecation rates. Thus, TSSM fo- lection pathways, as well as continuous monitoring of data cused heavily on improving the quality and reliability of rural accuracy and efficiency, allowed WSP to measure success sanitation data by developing a community-based monitor- frequently, as well as highlight areas where course correc- ing system that feeds access and behavior data regularly into tions were necessary during implementation. The monitor- local, provincial and ultimately national databases. Currently, ing and evaluation component of TSSM included the fol- an improved version of the system, developed as part of the lowing elements: original program design, is being managed by the STBM Secretariat in order to provide resources for local-level facili- • Project implementation monitoring and improve- ties to collect and analyze project-monitoring data. This new ment regularly monitored progress of individual, web and SMS-based system will eventually provide an inter- planned activities. This process was an ongoing dy- active platform for program trouble-shooting and up-to-date namic process that allowed the project to use data information for policy decision-making. and information in real time to make adjustments as needed to project implementation. PROGRAM EFFECTS ON CHILD HEALTH • Monitoring and evaluation of expected outcomes OUTCOMES and results that monitored increases in access to Of the four most important causes of under-5 mortality hygienic sanitation, number of open-defecation free in Indonesia two - diarrhea and typhoid - are preventable communities and hygiene behavior changes. fecal-borne illnesses directly linked to inadequate water • Impact Evaluation that measured the project inter- supply, sanitation and hygiene issues.31 In Indonesia alone, vention’s health, behavioral, welfare and economic about 11 percent of children suffer from diarrhea in any impacts. 2-week period and it has been estimated that an excess of • Enabling Environment Assessment that examined 33,000 children die each year in Indonesia from diarrhea national and local government policies for accelerat- and 11,000 from typhoid.32 Children under five in Indone- ing rates of increased access to sanitation, especially sia continue to bear the brunt of inadequate rural sanitation among the poorest communities. through increased instances of morbidity through early life. 31 MOH, 2002. 32 Curtis, 2004. 14 www.wsp.org FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia Diarrheal diseases are one of the most significant causes of way, the project was successful in generating local govern- malnutrition and nutrient malabsorption, which can lead ment’s early interest and creating a strong foundation for to impaired physical growth (stunting), reduced resistance sustained partnership over the course of the project’s imple- to infection, long-term gastrointestinal disorders and even mentation. The project also managed to adjust implemen- long-term cognitive deficiencies.33 tation approaches based on a continuing flow of lessons coming in through a variety of formal and informal reviews Among TSSM’s achievements was a notable reduction in and reflections that helped define which of the approaches diarrhea prevalence (7-day and 2-day recall) among com- was working well (for example, pairing government coun- munities receiving the intervention. Specifically, being terparts with CLTS specialists to learn from them during in treatment communities was associated with diarrhea triggering and verification) and which needed adjustment prevalence being lowered by approximately 1.3 percent- (such as revising supply side strengthening from a focus on age points from a 4.6 percent base. These decreases were masons to entrepreneurs). driven largely by non-poor households that did not have adequate sanitation facilities at the beginning of the proj- Enhancing local government capacities to fully imple- ect. Among the other effects on child health, instance of ment STBM requires continued, long-term commitment. parasitic infection in treatment communities was lower, as Despite growing steadily over the past few years, local gov- was the instance of refusal to eat and instance of blood or ernments are still working under their capacity to imple- mucous in stool.34 ment and sustain resourcing for large-scale rural sanitation programs. This includes greater supervision of CLTS facili- LESSONS LEARNED FROM SCALING UP tators, greater support for sanitarians and engagement of RURAL SANITATION IN INDONESIA private sector suppliers. Going forward, it will be necessary Four years of TSSM implementation have not only provided to continue to develop the capacity of local governments to a wealth of lessons but also a pathway forward for scaling up adopt total sanitation and sanitation marketing strategies rural sanitation throughout Indonesia. With an established including strategic plans, standardized tools, training mate- legal framework, widespread political support and demon- rials and budget allocations. Institutionalizing knowledge strated effects at a large scale, the STBM framework has the sharing, especially through peer-to-peer exchanges, has potential to substantially increase the number of rural Indo- been especially helpful in improving capacity and sustain- nesians with access to and use of an improved toilet. ing local governments’ engagement in building the sector. A project approach that adjusts for country context was Quality formative research is central to effective pro- key for ensuring client ownership. The decentralized na- gram design. Over the course of the project, carefully ture of Indonesia’s regulatory environment made work- planned, early formative research was critical in both ing closely with district leadership an essential element in understanding the underlying factors motivating indi- ensuring project ownership and sustainability. Early road vidual sanitation behavior change and potential gaps in shows provided an opportunity to socialize a wide array of the sanitation supply chain. Through this research district stakeholders from health, education, finance and develop- governments have been able to more effectively use local ment to the importance of scaling-up rural sanitation in- media to deliver targeted messages to the community as a terventions through a behavior change-focused approach. pathway for increasing demand for improved sanitation Following socialization, districts were required to submit solutions. In turn, suppliers have been able to offer a bet- letters of intent guaranteeing their commitment to staffing ter array of product options that are tailored to meet con- and providing future resourcing for rural sanitation. In this sumer preferences. 33 Murray, Lopez (1997); Guerrant et al (1999); Baqui et al (1993); Schneider et al (1978); Humphrey (2009). 34 Instance of parasitic infection intensity for Ascaris and Trichuris, estimated as egg worms per milligram, was not statistically significant over the whole sample. www.wsp.org 15 FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia Champions from a variety of stakeholders can facilitate lies. Results from the program’s impact evaluation indicate greater program reach and sustainability. Identifying and that non-poor households were more likely to build a toilet acknowledging champions can be the catalyst to accelerate as a result of exposure to the program rather than poorer government’s buy-in to the program. In Indonesia, an early households. According to government data, a number of understanding of various actors’ motives prior to imple- treatment and control villages have become open defe- mentation allowed WSP flexibility in being able to package cation-free after the endline survey was finalized, which the project’s potential benefits from a variety of stakehold- would suggest that all households including the poorest er’s perspectives. The process of identifying or monitoring have by now been able to build some kind of toilet for individual(s) or institution as champions should be embed- the community to be verified as open defecation-free. ded into the project intervention design from the earliest However, further in-depth research is necessary to confirm stages of planning. It is important to ensure that emerging these results and more importantly, to fully understand champions — be they government employees, volunteers, willingness to pay, availability of affordable products, and engaged mothers, etc. — are embedded in the program to financing strategies and options (e.g., provision of cred- ensure maximum program reach. it for households and/or entrepreneurs, collective saving schemes for households, or ‘smart’ subsidies well targeted For the poorest, cost is still the biggest challenge to adopt- at these families) to speed up equitable access to improved ing improved sanitation. The cost of toilet construction sanitation and to ensure that the poorest households are still presents a challenge in particular to the poorest fami- not left behind. 16 www.wsp.org FIELD NOTE: Results, Impacts, and Learning from Improving Sanitation at Scale in East Java, Indonesia REFERENCES Amin, S., Rangarajan, A., Borkum, E. 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Water and Sanitation Program. The World Bank. 2012. 18 www.wsp.org THE WORLD BANK