WATER AND SANITATION PROGRAM: LEARNING NOTE Scaling Up Rural Sanitation Key findings Building Rural • Indonesia faces a shortage Sanitation Capacity of sanitation professionals exceeding 12,000 to reach its ambitious target of universal sanitation Nationwide in Indonesia access by 2019 and this cannot be met by fragmented business-as-usual training. August 2016 • The Ministry of Health (MoH) institutionalizes capacity building nationwide through three streams: i) in-service accredited training tied with staff performance credit, ii) pre-service training through health schools’ curriculum, and iii) distance training through e-learning. • The first 18-month institutionalization process has shown promising results: By December 2015, almost 500 people have been awarded credit points; 497 people accessed the e-learning with 92% completion rate for mandatory module; and more than 2,000 students already completed the class. • Critical success factors are: effective coordination mechanisms led by MoH; optimal use of existing organization and staff incentive structures; and complimentary web-technologies in addition to classroom and field- INTRODUCTION based training to achieve cost Lagging behind many of its middle-in- Building on this recent success, in efficiency and reach a wider audience. come peers in terms of access to 2014, the Minister of Health declared • Continuous promotion, innovation sanitation, in particular in rural areas, STBM as the national program in order and facilitation through systematic Indonesia has recently experienced an to reach the government’s new target support and robust monitoring and acceleration from 36% in 2008 to 47% of universal access to improved san- evaluation will help achieve increased uptake of the new courses led by in 20151 as a result of the Government itation by 2019.2 The STBM program MoH. of Indonesia’s sanitation program called consists of five pillars3; under its Open Sanitasi Total Berbasis Masyarakat Defecation Free pillar, the program en- (STBM) that was initiated in 2008. visages: 1 JMP (2015) Progress on Sanitation and Drinking Water – Update 2015. 2 This was done through Ministerial Decree 3/2014. The universal access target for sanitation by 2019 has been formally endorsed in the government’s third five-year medium-term development plan (RPJMN) 2015-19. 3 STBM pillars: 1) open-defecation free, 2) hand washing with soap, 3) household water supply and food management, 4) household solid waste management, and 5) household wastewater management. 2 Building Rural Sanitation Capacity Nationwide in Indonesia Scaling Up Rural Sanitation i) Creating demand through community empowerment and through various training approaches by technical units within behavior change; MoH, at different levels of local government, and by develop- ii) Increasing supply of affordable and aspirational sanitation ment partners and NGOs through their projects. Thus, MoH facilities by the private sector, and was faced with the problem on how to shift from fragmenta- iii) Enhancing the enabling environment for implementation tion to a nationwide program that builds capacity of sanitation at-scale. professionals in a way that allows for rapid scaling up while guaranteeing quality control. Since 2007, the World Bank Group’s Water and Sanitation Program (WSP) has provided technical assistance to the Gov- ACTION ernment of Indonesia to help develop and shape the imple- In 2011, the Directorate of Environmental Health of MoH mentation of its national rural sanitation program. With sup- asked WSP to help conduct an evaluation of existing training port from development partners, and primarily through the initiatives and provide suggestions on how a high-quality and World Bank-funded National Rural Water Supply and Sanita- sustainable training program could be established. Following tion Project (PAMSIMAS), the government has now embed- an evaluation of existing training initiatives in 2012 by WSP, in ded STBM in the national roll-out of PAMSIMAS covering 220 2013 MOH asked WSP to provide a technical assistance to districts and cities in 32 out of Indonesia’s 34 provinces. create and deliver an at-scale training program for sanitation. A joint team of representatives from several units within MoH PROBLEM STATEMENT and WSP collaborated closely over two years and developed Nationwide implementation to reach universal access by a nationwide capacity building program that essentially con- 2019 implies that capacity at local level in highly-decentral- sists of three streams: ized Indonesia will need to be drastically increased in a short time span. From 2006 to 2013 MoH reported an increase • Pre-service training, aimed at students of health schools. in sanitarians, i.e. government health officers responsible This stream has integrated STBM as a mandatory subject for sanitation4, from 8,200 to 10,500, or around 4% a year.5 at all 24 public and 4 private environmental health schools However, in 2014, 30% of the 9,599 community health cen- so as to meet the future need of human resources. ters in the 34 provinces of Indonesia still did not have any san- itarians employed. Government estimated that an additional • In-service training, aimed at existing government and proj- 12,000 sanitation professionals are needed to empower com- ect staff through a modular program of accredited training. munity members and provide technical expertise to reach the While improving the capacity of staff to carry out their im- Millennium Development Goal target of 68% for sanitation.6 mediate tasks, performance credits are gained as an incen- With the new universal access target, the demand for trained tive for staff to advance their careers. sanitation professionals will further increase significantly. This means more than doubling the existing cadre of sanitarians, • Web-based e-learning courses, available for both audienc- with all of them requiring up-to-date knowledge and skills to es as well as for any other interested stakeholders to sup- implement the STBM program. plement and/or complement face-to-face training and thus bridge the connectivity gap across the archipelago. While efforts to increase the quality and quantity of sanita- tion personnel took place in the past, effective quality control, This Learning Note describes the transformative process and incentives and the required scale were lacking. Most capac- key lessons learned while developing a nationwide sanitation ity building and staff development activities were carried out capacity building program in Indonesia. 4 A sanitarian is a government officer responsible for sanitation, who can be posted at community health centers, hospitals, health offices, or schools in both urban and rural areas. Their primary domain is at community health centers. 5 http://www.bankdata.depkes.go.id/ 6 http://www.depkes.go.id/article/print/20143250004/peran-jumlah-dan-mutu-tenaga-kesehatan-dukung-percepatan-mdgs-dan-implementasi-jkn.html www.wsp.org Scaling Up Rural Sanitation Building Rural Sanitation Capacity Nationwide in Indonesia 3 Figure 1. Diagram of the Institutionalization of Capacity Building for Rural Sanitation Human Resources STBM Human Resources Pre Service In Service Health Polytechnic Students Civil Servant and Professionals Integration of STBM into Curriculum Standardization and Accreditation • Subject credits • Certificate • Early involvement in local government programs • Credits STBM E-Learning: health polytechnic students, civil servants and professionals, and wider public interested in STBM • Certificate of participation KEY LESSONS to successful completion of accredited training. Hosting of the Selecting the institutional home for a national capacity program in PPSDM also facilitated optimal use of the different building program requires strategic consideration on streams, and better coordination and alignment between dif- mandate, resources and opportunities to leverage ex- ferent department’s work plans and targets. isting systems. Linking STBM training with accredited certificates and Rather than project-based cascading training, a training pro- performance credits creates demand for such training gram institutionalized within the existing government health but requires diligent preparation to meet quality stan- and education systems was deemed to be more sustainable dards. For over a decade, MoH has operated an incentive and scalable in a country of the size and level of decentraliza- program, rewarding staff with performance credit points for tion as Indonesia. completing accredited trainings.7 Staff members are required to continue their education through course work to increase The MoH Agency for the Development and Empowerment job performance and get promotions, which come with higher of Human Resources in Health (PPSDM) was selected as financial bonuses. To capitalize on such incentives that con- the institutional home for the national STBM capacity build- tribute to staff demand for training, the MoH-WSP task team ing program because of its official mandate and experience, chose to closely follow the steps of the government accredi- and well-developed mechanisms for capacity building, and tation process outlined below. its resources and organizational structure, with presence at Box 1. Government Accreditation Process all levels of government, i.e. from national to provincial level. 1. preparing training needs assessment Positioning PPSDM as the host of the STBM capacity building 2. developing training goals program accelerated the mainstreaming of human resources 3. designing the program: training tools (modules, multi- development for sanitation in MoH. Based on the existing ac- media), implementation plan, availability of trainers creditation systems of PPSDM, the STBM in-service training 4. implementing the pilot training could adopt a structured and standardized format, ensuring 5. evaluating and adjusting the training government accreditation and performance credits attached 6 MoH Decree No. 725/2003 standard on the Guideline for Health Training Arrangement. www.wsp.org 4 Building Rural Sanitation Capacity Nationwide in Indonesia Scaling Up Rural Sanitation This labor-intensive process, which took place over more Many entities are organizing STBM training, including govern- than a year, resulted in five accredited curricula and modules ment offices, development partners, NGOs, and contracted by March 2014: firms. While all training organizers in principle agreed to use the accredited curriculum and modules of the STBM train- 1. training for STBM facilitators ing, the newly established accreditation process included 2. training of trainers for STBM facilitators several quality control steps that posed initial challenges for 3. training for STBM entrepreneurs training organizers (see box 2). Planned training timelines and 4. training of trainers for STBM entrepreneurs budgets did not always match the diligent preparation pro- 5. STBM training for lecturers of environmental health schools cess required for accreditation, resulting in certificates and performance credits not being issued for all participants even By November 2015, almost 1,000 people participated in the though the accredited modules were followed in the training. above training programs. Of the initial round, however, only around 50% of participants were awarded accredited certif- With better preparation, it is expected that all organizers icates, including the staff performance credits. This was due would be able to conduct accredited training in the future. to initial difficulties of training organizers in meeting the ac- The above experience also resulted in the development of creditation standards, especially 4 and 5, as highlighted in an abbreviated version of the accredited training to accom- box 2. modate budgets and training duration. This version com- bines e-learning with shorter training (e.g. reducing the train- Box 2. Example of requirements for accredited training of STBM facilitators ing hours from 47 to 30 hours for STBM facilitators). 1. Forty-seven training hours during day time (or upon Working with professional environmental health asso- completion of 30 hours e-learning) ciations and health school fora was instrumental inte- 2. Certified or competent trainers proven by verified cur- grating STBM into existing curricula to allow rapid na- riculum vitae and completion of a master trainer tional scale-up of pre-service training. 3. A set of evaluation forms to be used in the training 4. A minimum standard for the venue and training docu- In order to ensure enough qualified sanitation staff in the fu- mentation to be printed ture, the STBM concept was integrated into the curriculum of 5. Dedicated staff for training administration existing government environmental health schools. While the existing curricula already included environmental health top- ics and lecturers were familiar with such content, the biggest challenge was to convince lecturers about the different imple- mentation approach of STBM. As STBM follows a commu- nity empowerment method including a no-subsidy principle, it was deemed necessary to integrate significant amounts of field work in the curriculum, a departure from more theoretical ways the subject was taught previously. In May 2013, the Directorate of Environmental Health and PPSDM invited lecturers, members of the Communication Forum of Environmental Health Schools (Forkom JKL), and members of the Environmental Health Experts Association in Indonesia (HAKLI) for an exposure visit to see the implemen- Government staff are taking STBM e-learning in Bima, West Nusa Tenggara tation of STBM. This provided them an opportunity to directly (Photo: Inong/WSP) observe and communicate with community members on the www.wsp.org Scaling Up Rural Sanitation Building Rural Sanitation Capacity Nationwide in Indonesia 5 process and impact of the STBM process. As a result, lectur- The in-service training stream—in line with other such train- ers, Forkom JKL, and HAKLI members all agreed to integrate ing—includes mandatory field work by the students. How- STBM into three mandatory subjects of the health schools, ever, the key difference is that the STBM in-service training namely: i) health promotion, ii) basic environmental health, emphasizes different and practical skill sets, such as facili- and iii) community empowerment. tation of community empowerment or Community-Led Total Sanitation. This fieldwork changed students’ mindset about In addition to that, the MoH-WSP task team also participated the need for behavior change and community processes to in developing the accredited curriculum for lecturers. All lec- address open defecation. turers are now required to pass this STBM accredited train- ing for lecturers before delivering the content in their schools. The partnership between STBM implementers and health While individual schools were put in charge of developing their schools proved to have other unanticipated benefits. The syllabus, teaching plan and organizing the financing for teach- schools’ support for the STBM program has injected new en- ing and field work, Forkom JKL and HAKLI agreed to support thusiasm at local district health offices to implement STBM. the quality assurance of the teaching process. Simultaneously, it has created interest and encouraged health schools to conduct research on rural sanitation issues, both Teaching started in nine schools in January 2014. Shortly af- from a demand and supply side perspective. The develop- terwards, Forkom JKL expressed its ambition for rapid na- ment of the in-service training stream benefited greatly from tional scale-up during the Annual Meeting of Environmental the participation of local government implementers, universi- Health Experts, convened by HAKLI in April 2014 in Makas- ties, and professional associations, which enhanced the qual- sar, South Sulawesi. Training for lecturers from all 24 public ity of the STBM training materials. environmental health schools and 4 private schools was con- ducted in the following months. By September 2014, all 28 E-learning can be a cost-effective supportive pillar for schools had already delivered STBM courses to more than in-service and pre-service training, as well as an effi- 1,500 students. cient way to reach a wider audience with a high quality training program. In-service training can deliver positive spin-offs such as increased attention to STBM and better coordination The Indonesian population of around 250 million people is between health schools and local government imple- spread out over more than 17,000 islands. Internet coverage menters. is increasing rapidly, estimated to be around 50% in 2015. Given the limitations in training budget, availability of trainers, and quality control issues, MoH decided to create a web-en- abled distance learning course to complement the pre-ser- vice and in-service training streams. The curriculum and modules for STBM e-learning were devel- oped from the accredited face-to-face curriculum and mod- ules. The contents of the e-learning emphasize the concep- tual and theoretical aspect of the STBM program, developing essential knowledge as a foundation. Practical skills are still to be delivered in the form of face-to-face classroom training combined with field-work (e.g. on facilitation, triggering, en- trepreneurship, and monitoring). The e-learning consists of 4 Triggering by students from Makassar health schools in Patampanua, modules, available in Bahasa Indonesia and English: Pinrang district, South Sulawesi (Photo: Poltekkes Makassar) www.wsp.org 6 Building Rural Sanitation Capacity Nationwide in Indonesia Scaling Up Rural Sanitation 1) basic concept of STBM, The e-learning has also been utilized by the nationwide PAM- 2) STBM facilitators, SIMAS project for provincial coordinators and district facilita- 3) STBM entrepreneurs, and tors to update their knowledge on STBM. They also effectively 4) STBM monitoring and evaluation use the e-learning as a handy and interactive tool to introduce STBM as a national program. Besides providing an opportunity for anyone interested to learn about STBM, e-learning also allows for cost-effective By November 2015, more than 600 people have participated and shorter face-to-face training once e-learning is success- in the e-learning courses. The participants have a variety of fully completed. For example, the ‘classical’ STBM facilitators professional backgrounds beyond health officers and sanitar- training was 6-7 days (47 hours), but upon e-learning com- ians, such as consultants, project staff, teachers, lecturers, pletion, the face-to-face training can be reduced to 3-4 days students, NGO staff, and citizens/volunteers working on em- (30 hours). powerment activities in their communities. While self-printable certificates of participation are available As expected, e-learning has not been without its challeng- upon successful completion of the e-learning, an accredited es, mostly teething problems that come with the use of new certificate with performance credits is only awarded to those technology.8 Also, since e-learning is open to everyone, its staff who pass the combined e-learning and the face-to-face completion rate has been modest, standing at 45% by March training sessions. 2015. To accelerate the completion rate, since June 2015 the MoH has requested STBM-related project staff and local E-learning can be accessed at http://elearning.stbm-indone- health officers to complete the e-learning before participat- sia.org and was officially launched by the Minister of Health ing in any national and regional technical events—leading to on 3 September 2014 at the STBM National Coordination a jump in completion rate to 92% for mandatory module by Meeting in Jakarta. The e-learning marketing strategy has so November 2015. far successfully relied on promotion by government high level officials in various forums as well as STBM partners. RECOMMENDATIONS GOING FORWARD Through technical assistance, the MoH has successfully cre- ated the foundations of a nationwide institutionalized capacity building program. Going forward, more effort and learning is needed to ensure wide-scale adoption of the different streams and to sustain the accreditation of the program over time. Initial thoughts on how to address the challenges for consol- idating the national capacity building program are as follows: • The division of labor and organizational responsibilities for the STBM capacity building program need to be further delineated among the different units within MoH, i.e. the lead technical units such as the Directorate of Environmen- Health Minister Nafsiah Mboy points to a monitor featuring updated national tal Health and the STBM secretariat to monitor and facili- STBM data as National Development Planning Minister Armida Alisjahbana tate nationwide implementation and PPSDM unit to ensure (left) and WBG-WSP Task Team Leader (right) look on following the intro- duction of STBM E-Learning in Jakarta. quality implementation and incentive mechanism. 7 There were several technical issues experienced by users, such as delay in auto-response during the registration, insufficient server capacity, and weak internet capacity at the side of the end users. www.wsp.org Scaling Up Rural Sanitation Building Rural Sanitation Capacity Nationwide in Indonesia 7 • To ensure higher levels of accreditation, it is necessary to • In order to sustain accreditation, the technical units of the better disseminate information and provide support for Ministry of Health and PPSDM will need to jointly carry out training organizers on the procedures for accreditation. regular post-training evaluation. This is required to ensure This may be done through developing a dedicated help- that training content and approach remains relevant and desk within the existing STBM secretariat. up-to-date. • The proposed help-desk may also support better coordina- • While looking ahead at the universal sanitation target, the tion, monitoring and evaluation of training plans developed STBM national program needs to further investigate what by STBM partners, and keeping formal records of accred- modifications are needed to suit denser urban environ- ited STBM trainers. Such systematic support and monitor- ments and/or other challenging conditions.8 As a result, the ing is especially relevant now that projects like PAMSIMAS modules developed for the three different streams will need are used for nationwide implementation of STBM. The fa- to be adjusted over time to include new insights and ap- cilitation of accredited capacity building will be required at proaches. all levels, including village, district, province, and central. 8 Three recent laws have been supportive to scale up the STBM sanitation program, including Law No.6/2014 and Law No. 23/2014. These state the responsibility and management of water and sanitation is at district government level. Law No. 36/2014 on health workers requires all health workers to participate in a capacity building program annually, which is to be conducted by the accredited institution, which is indeed PPSDM. www.wsp.org 8 Building Rural Sanitation Capacity Nationwide in Indonesia Scaling Up Rural Sanitation Acknowledgment RELATED READING This Learning Note was prepared by JMP (2014) Progress on Sanitation and http://www.wsp.org/sites/wsp.org/ Rahmi Kasri, Deviariandy Setiawan, Drinking Water – Update 2014 files/publications/WSP_BuildingCapac- Nyoman Oka, Emily Rand and Susanna Smets. Valuable contributions are ity_TSSM.pdf acknowledged from Almud Weitz. Qipra Galang Kualita (2012). Final Re- Editing support was provided by Yosa port of the Sanitation Training and h t t p : / / w w w. w s p . o r g / s i t e s / w s p . Yuliarsa. Capacity Study. http://www.scribd. org/files/publications/WSP-Poli- com/doc/133763915/Final-Re- port-Sanitation-Training-and-Capaci- cy-and-Sector-Reform-to-Acceler- ate-Access-to-Improved-Rural-Sanita- About the program ty-Study#scribd tion.pdf Today, 2.5 billion people live without access to improved sanitation. Of https://www.openknowledge.world- http://www.wsp.org/sites/wsp.org/ these, 71% live in rural communities. To address this challenge, WSP is bank.org/handle/10986/11698 files/publications/WSP-Indonesia-En- working with governments and local abling-Environment-Endline.pdf private sector to build capacity and https://wsp.org/sites/wsp.org/files/ strengthen performance monitoring, publications/WSP-Indonesia-Sanita- http://www.wsp.org/toolkit/indonesia policy, financing, and other components tion-Impact-Evaluation-Field-Note.pdf needed to develop and institutionalize large scale, sustainable rural sanitation programs. With a focus on building a rigorous evidence base to support replication, WSP combines Community- Led Total Sanitation, behavior change communication, and sanitation marketing to generate sanitation demand and strengthen the supply of sanitation products and services, leading to improved health for people in rural areas. For more information, please visit www.wsp.org/scalingupsanitation. Contact Us Email: wspeap@worldbank.org Website: www.worldbank.org/water www.wsp.org. The Water and Sanitation Program is a multi-donor partnership, part of the World Bank Group's Water Global Practice, supporting poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. WSP’s donors include Australia, Austria, Denmark, Finland, France, the Bill & Melinda Gates Foundation, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank. 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. © 2016 International Bank for Reconstruction and Development/The World Bank