Sophia Eclarin

CPGH101
Reva Detar
Global Health Intervention Proposal: Indonesia’s Total Sanitation Program
I. Health Issue and Intervention
Many people around the world often lack basic sanitary facilities or clean water,
which forces them to practice open defecation, where they defecate in public spaces
like rivers and streets. Open defecation poses extreme risks for the community as
pathogens from fecal matter can get into food, which leads to diarrhea and dangerous
illnesses. In Indonesia, inadequate sanitation is a serious issue that impacts many; each
year, 50,000 deaths and 120 million illnesses are a result of inadequate sanitary
facilities. East Java is a large provincial area with several poor and rural communities
(Center for Global Development). Because of the widespread issue in the country,
government officials partnered with the World Bank Sanitation Program as well as the
Bill and Melinda Gates Foundation to test the Total Sanitation and Sanitation Marketing
Program as a scaled-up intervention.
The Total Sanitation and Sanitation Marketing Program, shortened as TSSM,
worked to motivate communities to use sanitation facilities instead of open defecation.
To accomplish their goals, they divided the program into three stages: community-led
total sanitation, marketing, and enabling environment (Center for Global Development).
Through community-led total sanitation, they demonstrated fecal contamination in
water to educate communities on the issue of open defecation to recognize its
consequences and encourage them to favor sanitation facilities. With marketing,
officials promoted using sanitary facilities by providing materials and catalogues
comparing different available sanitation solutions and low cost latrines. The
promotional material was created to increase the community desire for sanitary
facilities. The final stage was to create an enabling environment to advocate for
increases in sanitation funding and reward governments for their achievements to
motivate other areas to act similarly. TSSM attempted to incorporate the different social
determinants of health in order to create an effective intervention that benefits all
community members. Perhaps the biggest social determinant involved was the
socioeconomic status of people in the observed areas. Prior to the intervention, mostly
wealthier households could build sanitary facilities, leaving the poor with inadequate
sanitation. In efforts to alleviate this socioeconomic inequity, TSSM and government
officials provided funding for toilet and latrine construction to relieve some of the
financial burdens placed on families in provincial areas. The social environment of the
community is also a key social determinant of health that was addressed in the
intervention. Because many families did not understand that open defecation can result
in illnesses and diseases, they did not feel the need to own sanitary facilities. The lack of
 education on sanitation importance has left many people in Indonesia believing that
open defecation was simply the standard norm. The program worked to educate
community members on the severe risks of open defecation and the importance of
adequate sanitation. Overall, the Total Sanitation and Sanitation Program considered
some social determinants of health as well as the cultural context of Indonesia when
implementing their intervention.
II. Improving the Intervention
The implementation of TSSM in Indonesia had several successes. In 2011, East
Java had 2,200 communities that were verified as being open defecation free, and there
was a 30% drop in diarrhea prevalence (Center for Global Development). These
communities were 9% less likely to practice open defecation and 23% more likely to
build toilets (Center for Global Development). However, there were some limitations in
the intervention that prevented it from being completely effective. The largest
limitation for the intervention was the inability to prevent the inequity of sanitary
facility distribution. While they aimed to ensure all community members could have
access to sanitary facilities, the increased use of toilets still occurs mostly in wealthier
households because poor families could not afford improved sanitary facilities (Center
for Global Development). Because of the high demand for sanitation solutions, there
were resource constraints that resulted in extreme shortages to build the toilets and
latrines (Center for Global Development). Due to the shortages, local markets were
forced to raise prices for the few resources they had, making sanitation solutions
unaffordable for poor families. The final limitation was the ethical consideration not
taken into account when carrying out the intervention (Center for Global Development).
A large focus of the TSSM program was to encourage communities to implement
sanitation facilities by shaming people for practicing open defecation. However, many
critics considered this strategy to be extremely inconsiderate because it essentially
condemned the poor for living in poverty. From the extreme resource shortages and
socioeconomic inequities to some of the unethical strategies, the intervention has room
for many improvements to ensure it will become entirely successful. The TSSM program
had some positive outcomes, but was not a perfect intervention.
An intervention to help solve the sanitation issue would be to provide an
affordable sanitary facility to communities: low cost toilets with community septic tanks.
A study from the International Finance Corporation observed sanitation conditions in
the Philippines that developed the most affordable approaches to improve sanitary
facilities in provincial areas. Their research found that a low cost toilet with a communal
septic tank was most “preferred by 73% of households without toilets” (International
Finance Corporation). Furthermore, the sanitation solution is extremely affordable,
costing about $4 USD for both the toilet and tank (International Finance Corporation). If
a toilet is implemented in every household while the community shares a septic tank,
 families could enjoy privacy while still being able to have access to adequate sanitation.
TSSM officials and government leaders can partner with multinational corporations to
develop and manufacture the products needed for toilet construction to keep funds low
for the household (Montesano, 2016). If these sectors work together, many families and
communities can be able to have private toilets and communal septic tanks without
having to carry the burden of high costs.
Another component of the improved intervention would be to solely focus on
education communities on the importance of adequate sanitation instead of shaming
those who are forced to practice open defecation. By implementing sanitation
education programs, communities will be more willing to fund affordable sanitary
facilities (Project, 2018). By removing the tactic of shaming those who openly defecate,
the social taboo and stigma is also removed; the focus of the intervention will shift to
working on providing improved sanitary facilities without having to shame others to do
so.
III. Implementing and Evaluating a Sustainable Intervention
Before carrying out the improved intervention, researchers must go out into the
selected communities and collect data regarding the current sanitation conditions in
order to evaluate if better facilities need to be implemented. Furthermore, researchers
would need to survey the community members to gauge if they understand the
importance of sanitation conditions. Surveying community members allows the program
to determine how necessary it is for the education programs to be administered. By
directly working with the local government, the program workers can directly begin to
work towards developing the intervention to be specific to the community.
For the inputs of the solution, the program can bring in construction workers to
construct the household latrines and communal tanks. However, the program will need
to consult with government officials to provide funding for construction, Multinational
corporations can also partner with the program to manufacture the materials needed
for construction. Also, the program will be able to provide trained professionals with
educational workshops that will travel to different areas of the community to inform
them of the low-cost toilets and communal tanks and their benefits for the community’s
health. The educational workshops will also teach community members of the
correlation between serious diseases and open defecation in order to stress the
importance of adequate and proper sanitary facilities. After implementation of the
solution, the greatest outputs should be an immense reduction of diarrhea and disease
prevalence as well as toilet access in every household. Furthermore, the solution should
motivate surrounding communities to take similar action, resulting in a widespread
movement to provide adequate sanitary facilities. The solution should be able to inspire
other interventions in several other countries.
 Sustainability is a very integral component in a successful intervention to ensure
that the intervention lasts for generations to come. To ensure that the intervention is
sustainable, the septic tanks would be designed in a way to make them environmentally
friendly. Septic tanks break down waste with bacteria, filtering out the harmful
pathogens from the water, preventing it from leaving the tank and into fields of soil
(Environmental Protection Agency, 2017). Furthermore, they recycle the water for other
uses. Because the septic tanks use a natural process to filter out waste, they are not
causing any extreme damage which protects the ecosystems in the environment.
Eventually, the intervention could eventually scale up to all communities in the
country, as well as spread to other countries with similar sanitation issues. Other
interventions have been attempted in places in Asia and South America, but there have
been mixed results. However, with the dramatic increase in interests regarding
sanitation, it is likely that a similar solution can continue to be implemented worldwide.
There could be obstacles faced with this intervention. The biggest obstacle would likely
be acquiring funding and materials. The national government may not have enough
funds that can be allocated towards toilet construction, leaving the intervention with
little money to pay for the workers and the resources. Multinational corporations might
not want to manufacture materials for toilets if they do not receive an incentive or a
large profit from the final product. To overcome these obstacles, program leaders can
advocate strongly for increased sanitary facility funding by addressing its immense
benefits for the country; if the disease prevalence is lowered, people will be healthy
enough to seek jobs and work, boosting the economy. If the government funding is still
inadequate, the intervention program will work with nongovernmental organizations
such as the World Health Organization as well as non-profit organizations to ask for
donations to pay for toilet construction. With donations, government and program
funding, construction for toilets and septic tanks will be made possible. As for the
challenge regarding multinational corporations, the program could promote their
manufacturing efforts to solve the issue through advertisements, etc. If many
consumers see that the corporation is helping to solve a global issue, they will want to
invest in their company, boosting their sales. A final challenge could be that the septic
tanks could not be properly treated over time. If they are not cleaned regularly, there
could be a buildup of wastewater which causes an overflow of pathogens that the
bacteria might not be able to break down. Also, pathogens and bacteria might flow into
the neighboring water sources (Environmental Protection Agency, 2017). In order to
prevent this challenge, the program will bring in a specialized worker that will properly
manage the septic tank to ensure that it is functioning correctly without any buildup.
 References

Expanding Access to Improved Sanitation for the Poor. (n.d.). Retrieved from

https://www.ifc.org/wps/wcm/connect/topics_ext_content/ifc_external_corporate_site/

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the poor

How Your Septic System Can Impact Nearby Water Sources. (2017, November 06). Retrieved

from

https://www.epa.gov/septic/how-your-septic-system-can-impact-nearby-water-sources

Indonesia's Total Sanitation and Sanitation Marketing Program. (n.d.). Retrieved from

http://millionssaved.cgdev.org/case-studies/indonesias-total-sanitation-and-sanitation-m

arketing-program

Montesano, J., & LIXIL Group Corporation. (n.d.). Poor sanitation is one of the biggest causes of

child mortality. So what can we do about it? Retrieved from

https://www.weforum.org/agenda/2016/04/how-can-the-private-sector-play-a-bigger-ro

le-to-tackle-the-challenges-of-global-sanitation-and-hygiene/

Project, B. (2018, July 31). Education: Important for Improving Sanitation in Developing

Countries. Retrieved from

https://borgenproject.org/education-and-sanitation-in-developing-countries/