IssueBriefs UNICEF INDONESIA
OCTOBER 2012
Water, sanitation & hygiene Critical issues
P
oor sanitation and hygiene practices and unsafe water contribute to 88 per cent of deaths from diarrhoea amongst young children worldwide. In those who survive, frequent diarrhoea episodes contribute to malnutrition, which prevents the child from reaching his or her full potential. This, in turn, has serious implications for the quality of human capital and the future earning capability of a nation. In Indonesia, diarrhoea is still a major cause of death amongst children under the age of five. Riskesdas 2007 reports diarrhoea as the cause of 31 per cent of deaths between the ages of 1 month to a year, and 25 per cent of deaths between the ages of one to four years old. Compared to children from households using piped water, diarrhoea rates are higher by 34 per cent amongst young children from households using an open well for drinking water. Moreover, diarrhoea rates are higher by 66 per cent in young children from families practising open defecation in rivers or streams than those in households with a private toilet facility and septic tank. The important role of hygiene is often neglected. Diarrhoea-related deaths and illnesses are largely preventable. Even without improvements in water and sanitation systems, proper hand washing with soap can reduce the risk of diarrhoeal diseases by 42 to 47 per cent. The situation of the urban poor requires urgent attention. In urban slum areas, inadequate sanitation, poor hygiene practices, overcrowding and contaminated water converge to create unhealthy
unite for children
conditions. The associated diseases include dysentery, cholera and other diarrheal diseases, typhoid, hepatitis, typhus, leptospirosis, malaria, dengue, scabies, chronic respiratory diseases and intestinal parasitic infections. Moreover, poorer families who are less educated tend to have poor hygiene practices, which contribute to spreading disease and increasing the child mortality risk. A study of “mega-urban” Jakarta (called Jabotabek1), Bandung and Surabaya in 2000 showed that the poor living in Jakarta’s peri-urban areas are less educated than other Jakartans, having high school completion rates that are only one-fourth of those in the city centre. The same study calculated child mortality rates up to five times higher in Jabotabek’s poor peri-urban subdistricts than in Jakarta city centre.
Patterns and trends
I
n earlier decades, Indonesia made significant progress in increasing access to safe water supply and sanitation services. The water and sanitation targets of the seventh Millennium Development Goal (MDG) are to halve by 2015 the proportion of households without sustainable access to safe drinking water and basic sanitation. For Indonesia, this means achieving access rates of 68.9 and 62.4 per cent, respectively, for safe water and sanitation. Indonesia is currently not on track to achieve the 2015 MDG target in safe water. Calculations using 1
The urban area surrounding Jakarta; includes Bekasi; and Bogor and Depok in West Java Province; Tangerang and South Tangerang in Banten Province.
ISSUE BRIEFS
OCTOBER 2012
rief: Water, sanitation & hygiene
d unsafe from wide. In des e child n turn, man nation.
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Indonesia’s national MDG criteria for safe water and data from the 2010 census show that Indonesia needs Patterns and trends to reach an additional 56.8 million people with safe In earlier decades, madeifsignificant water supply by 2015.Indonesia Alternatively, the criteria progress in increasing access to safe water of the WHO-UNICEF Joint Monitoring Programme supply and sanitation services. The water and 2 were to be used, Indonesia (JMP) for safe water sanitation targets of the seventh Millennium would need to Goal reach(MDG) an additional 36.3by million people Development are to halve 2015 the of households without sustainable access byproportion 2015. Currently, even in the better-performing to safe drinking water basic sanitation. Foraround provinces (Central Javaand and DI Yogyakarta), Indonesia, this means achieving access rates of 68.9 one in three households lacks access to safe water and 62.4 per cent, respectively, for safe water and supply (Figure 1). sanitation.
glected. argely water and h soap y 42 to 47
urgent
ding and althy
ses, aria, s and er poor ding k. A abek 1), the poor educated mpletion city tality oor peri-
and Bogor and South
Quintile 4
D
Quintile 3
2010 Quintile 2
2007
Urban
Figure 2. Percentage of households with access to safe water, by rural/urban and wealth quintile, 2007 & 2010. Source: Riskesdas
Rural
2007 and 2010
Indonesia 0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Comparison with 2007 shows safe water access
Figure 1. Percentage of households with access to improved water sources, by province. Source: Riskesdas 2010. JMP criteria, bottled water not included.
0%
20%
40%
60%
80%
100%
Indonesia iswith currently on track to achieve thein Comparison 2007 not shows safe water access 2015 MDG target in safe water. Calculations using 2010 has declined by about seven per cent. This Indonesia’s national MDG criteria for safe water and reversal is largely to a decline inIndonesia urban areas (by data from the 2010due census show that 23 per cent of 2007 levels, Figure 2). Access towith safe needs to reach an additional 56.8 million people safe water supply bydecreased 2015. Alternatively, thecent criteria water in Jakarta has from 63 ifper in of the WHO-UNICEF Joint Monitoring Programme 2010 to 28 per cent in 2007, according to Riskesdas. 2 were to be used, Indonesia (JMP) for safe water Surprisingly, the two highest wealth quintiles have would need to reach an additional 36.3 million people also seen Currently, a decline even in safe access by 8 and 32 by 2015. in water the better-performing per cent respectively compared to 2007. Those who provinces (Central Java and DI Yogyakarta), around oneafford in three households lacks safe water can it buy packaged or access bottledtodrinking water: supply (Figure 1). households in Indonesia did so one-third the urban in 2010.
Since 1993, Indonesia has doubled the percentage of households having access to improved sanitation facilities, but it is still not on track to achieve the 2 JMP criteria do not specify the distance between the water 2015 MDG sanitation target. To achieve the national supply and excreta disposal site and are therefore less rigorous. MDG target in sanitation will require reaching an 1 additional 26 million people with improved sanitation 2
Quintile 5 (highest wealth)
Quintile 1 (lowest wealth)
DKI Jakarta Bangka Belitung Papua Central Kalimantan Riau Islands West Kalimantan Banten South Sumatra East Nusa Tenggara Aceh Jambi East Kalimantan North Sulawesi West Papua Riau South Kalimantan Maluku South Sulawesi West Sumatra Bali West Sulawesi North Sumatra West Java Central Sulawesi Bengkulu Lampung Southeast Sulawesi East Java West Nusa Tenggara North Maluku Gorontalo DI Yogyakarta Central Java
eptic
by 2015. Planning for the longer term requires dealing with even larger numbers: Riskesdas 2010 data show that overall, some 116 million people still lack adequate sanitation.
in 2010 has declined by about cent. Open defecation is a health andseven socialper issue that This reversal is largely due to a decline in urban needs urgent attention. Some 17 per cent of areas (by 23 per cent of 2007 levels, Figure 2). households in 2010 or about 41 million people still Access to safe water in Jakarta has decreased from defecate in the open.toThis includes one63 per cent in 2010 28 per cent in more 2007, than according third of the population in Gorontalo, Westwealth Sulawesi, to Riskesdas. Surprisingly, the two highest quintiles have also seenNusa a decline in safe water Central Sulawesi, West Tenggara and West access by 8 and 32 per cent respectively compared Kalimantan. The practice is even found in provinces to 2007. Those who can afford it buy packaged or with relatively sanitation bottled drinkinghigh water: one-thirdcoverage, the urbanand amongst the urban population and across wealth quintiles households in Indonesia did so in all 2010. (Figures 3 and 4).
East Nusa Teng Goron Central Kalima West Sula Pa West Nusa Teng West Pa West Sum Southeast Sula Central Sula West Kalima Lamp North Ma South Sum Ma South Kalima Ja A East INDONE West
Bangka Beli Beng South Sula Central North Sum Ba North Sula East Kalima
DI Yogyak Riau Isla DKI Jak
Since 1993, Indonesia has doubled the percentage of households having access to Sanitation coverage amongst different groups improved sanitation facilities, but it is still not on shows much stronger disparities than thattarget. for water track to achieve the 2015 MDG sanitation (Figure 4). The of target urbaninhouseholds To achieve the proportion national MDG sanitation will requireaccess reaching an additional 26 million people with having to improved sanitation facilities is improved sanitation by 2015. Planning for the longer nearly twice that of rural households. The proportion term requires dealing with even larger numbers: ofRiskesdas households served improved sanitation 2010 databy show that overall, some facilities 116 inmillion the highest is sanitation. 2.6 times that in the peoplewealth still lackquintile adequate
lowest wealth quintile. Geographic disparities are Open defecation is aof health social issue that also marked. The rate accessand to improved sanitation needs urgent attention. Some 17 per cent of in the best performing province (69.8 per cent, households in 2010 or about 41 million people still DKI Jakarta) is three higher than the defecate in the open. times This includes more that thanin oneworst performing province (22. 4 per cent, East Nusa third of the population in Gorontalo, West Sulawesi, Central Sulawesi, West Nusa Tenggara and West Tenggara). Kalimantan. The practice is even found in provinces with relatively high sanitation coverage, and amongst Faecal contamination of soil and water is common the urban population and across all wealth quintiles in(Figures urban areas, due to overcrowding, insanitary 3 and 4).
toilets and the release of raw sewage into the open
Sanitation coverage amongst different groups shows much stronger disparities than that for 2 JMP criteria do not specify the distance between the water water (Figure 4). The proportion of urban households supply and excretatodisposal sitesanitation and are therefore less having access improved facilities is rigorous nearly twice that of rural households. The proportion of households served by improved sanitation facilities in the highest wealth quintile is 2.6 times that in the lowest wealth quintile. Geographic disparities are also marked. The rate of access to improved sanitation in
Jakarta) is performing Tenggara)
Faecal co common insanitary into the o proportion or spring f within 10 m In Jakarta, (BPLHD) r by househ septic tank leak sewa
OCTOBER 2012
D 2010 2007
. Percentage of olds with to safe water, /urban and quintile, 2007 &
urce: Riskesdas 2010
% 100%
r access r cent. urban e 2). ased from according wealth water ompared aged or
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East Nusa Tenggara Gorontalo Central Kalimantan West Sulawesi Papua West Nusa Tenggara West Papua West Sumatra Southeast Sulawesi Central Sulawesi West Kalimantan Lampung North Maluku South Sumatra Maluku South Kalimantan Jambi Aceh East Java INDONESIA West Java Riau Bangka Belitung Bengkulu South Sulawesi Central Java North Sumatra Banten North Sulawesi East Kalimantan Bali DI Yogyakarta Riau Islands DKI Jakarta
Improved sanitation facilities
Shared/ unimproved sanitation facilities
Open defecation
Figure 3. Percentage of households using different means of excreta disposal, by province. Source: Riskesdas 2010, using JMP criteria for improved sanitation.
0%
20%
40%
60%
80%
groups hat for households ies is proportion on facilities at in the es are also nitation in t, DKI
Compared to the rich, the urban poor pay a larger proportion of their income for water that is of poorer quality. For example, Jakarta’s municipal piped system covers only a small proportion of its population, as service expansion cannot keep pace with the burgeoning population in urban areas. The rest of the population rely on a variety of sources, including shallow wells, water vendors and private networks connected to deep wells. Many of these alternative sources cost more per unit volume than piped water supply and are often used by the poor.
Barriers
M
ore investment is needed in the water and sanitation sector. The government investment in the sector is less than one per cent of GDP. The government is making efforts to address the issue. Following the initiation of PPSP (the National Sanitation Acceleration Programme) in 2010, the sanitation budget allocation by local governments increased in 2011 by 4 to 7 per cent.
100%
Different ministries and agencies involved in the water and sanitation sectors need stronger coordination. For example, contractors who build rural water systems are answerable to government agencies, rather than to the users of services. Responsibilities for maintenance are unclear and community management structures are weak. In recent years, the coordination has improved with the establishment of working groups called Pokja AMPL at national, provincial and district levels on drinking water and environmental sanitation.
s to ill not on n target. tation will eople with he longer bers: me 116 .
ssue that t of ople still han oneSulawesi, d West provinces d amongst quintiles
is a particular problem where consumers use suction pumps to obtain water from the city system.
Jakarta) is three times higher thanproportion that in the worst without treatment. A significant of all performing province (22.4 per cent, East Nusa urban households using a pump, well or spring for Tenggara).
their water supply have these sources within 10 Faecal soil and water is metres of contamination a septic tank oroftoilet discharge. In Jakarta, common in urban areas, due to overcrowding, the Jakarta Environmental Agency (BPLHD) reports insanitary toilets and the release of raw sewage that 41 per cent of dug wells used by households into the open without treatment. A significant areproportion less than of 10allmetres the septic Septic urban from households usingtank. a pump, well tanks are seldom out and leak sewage into or spring for theirpumped water supply have these sources 10 metres of and a septic tank or toilet thewithin surrounding soil groundwater. A discharge. 2007 World In Jakarta, the Jakarta Environmental Agency Bank report mentions that only 1.3 per cent of the (BPLHD) reports that 41 per cent of dug wells used population is connected a sewerage by households are less to than 10 metres system. from thePiped systems are prone to contamination due to leaks and septic tank. Septic tanks are seldom pumped out and leak sewage intocreated the surrounding soil andsupply. This negative pressure by intermittent groundwater. A 2007 World Bank report mentions
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Following decentralization, many district governments are constrained by a lack of sector expertise and institutional capacity. Remote districts find it difficult to recruit skilled personnel, who generally prefer to live and work in urban areas. Communities need to improve their hygiene awareness and practices. The hygiene situation is often poor in health centres and other public places, such as local markets and among street food vendors. A survey of six provinces, conducted by the University of Indonesia in 2005 for USAID, found that less than 15 per cent of mothers reported washing their hands with soap after defecation, 3
ISSUE BRIEFS
OCTOBER 2012
before preparing food, before feeding their child, before eating, or before cleaning the child’s bottom.
are being developed but progress is slow. Facilities, equipment and transport for solid waste management remain limited.
Field visits indicate the need to improve school hygiene, water and sanitation, but robust data are lacking in this respect. Data from the Ministry of Education and Culture indicate that 77 per cent of junior secondary schools are equipped with safe water supply from pipes or tube wells, meaning that over 10,000 junior secondary schools are without such facilities. Extrapolating the proportion to all of Indonesia’s 234,711 primary and secondary schools (2009) indicates the scale of action required. More than 50,000 schools are likely to need safe water supply.
Opportunities for action
Urban water utilities are poorly governed and generally small in coverage. Of the 402 local government-owned water utilities (PDAM), which serve mostly urban areas, only 31 had more than 50,000 connections in 2009. The smaller than optimal size leads to high operating costs. In 2010, the levels of unaccounted-for-water were between 38-40 per cent and only 30 PDAMs were able to recover full operating and maintenance costs. PDAMs divert a significant proportion of revenue – as much as an estimated 40 per cent – to the district government with little accountability, and have little or no funds left for operations and maintenance. Not surprisingly, urban water supply systems are generally in a state of neglect and deterioration. Some PDAMs have entered into Public-Public Partnerships, but the complexities of negotiations between the central, provincial and district governments have caused cancellations and delays. Urban sewerage and wastewater systems are generally under-developed and poorly managed. A World Bank study estimates that each year, households without proper sanitation facilities in Jakarta and across Indonesia release respectively 260,731 tons and 6.4 million tons of human faeces into water bodies without treatment. Arrangements for urban solid waste management are piecemeal and unregulated. The agency officially in charge of the sector contracts with small private entrepreneurs who collect and bring the waste from households to temporary storage facilities for onward transport by the agency. Neighbourhoods pay for these services through the local collectors. Landfills 4
T
he National Policy for Community-Based Water Supply and Environmental Sanitation provides an enabling framework. The policy makes good use of lessons learned in the water and sanitation sector in Indonesia and other countries. It follows sound principles of demand-responsive, community-based approaches, emphasizing the need for women’s involvement, and it focuses on the principles of sustainable operation, maintenance and cost-recovery. The National Programme of Community-Based Total Sanitation (STBM) and its five pillars form a useful framework. The five pillars are the elimination of open defecation, hand washing with soap, household water treatment, solid waste management and liquid waste management. The leadership of the Ministry of Health is crucial in scaling up STBM. Districts and provinces will need to accelerate efforts, keeping to national standards and guidelines. The poorest groups will need to have access to financing in order to initiate STBM. STBM needs social marketing approaches that mobilize large numbers of people and scale up the supply of and demand for improved sanitation facilities. Revitalizing school water and sanitation around health and social themes offers several opportunities. Students could become change agents in their communities for STBM and good health and hygiene practices, which should include point-of-use water treatment, appropriate water storage, diarrhoea reduction, and the prevention of dengue and malaria. Advocacy that makes the links with nutrition, early childhood development and education performance would be more powerful than messages on preventive health alone. Studies elsewhere suggest the persuasiveness of social reasons, such as the desire to feel and smell clean and follow social norms, and the use of soap as a desirable consumer product. Data systems need to be strengthened. The Government has expressed an interest in developing a National Schools STBM programme.
OCTOBER 2012 This will require better data collection and monitoring systems than currently exist for school water and sanitation. In addition, systems for water quality testing and reporting need to be strengthened and the data made public.
The involvement of both local government and private sector is essential for improving urban and peri-urban systems. • For urban areas, innovative technologies in sanitation and water provision need to be explored. Urban sanitation and sewerage systems present the greater challenge, since standard sanitation technologies may not work due to overcrowding, lack of space, and the proximity of water sources. In water supply, decentralized technologies and approaches, such as point-of-use water treatment, would be much more effective than centralized systems, due to the range of disparate sources and multiple providers. • Strengthening PDAMs’ governance and capacity will require the review of various roles, institutional processes and accountabilities, especially of PDAM heads. The central level should establish minimum standards of performance for PDAMs, with monitoring, enforcement and incentive mechanisms. • District agencies need convergent planning and targeting to make rural systems more sustainable. In their planning processes, the different district level agencies (public works, rural empowerment, district health office and the district planning office) should target the same communities, so that community mobilization and training takes place in the same communities where the infrastructure is built. This would optimize community participation in planning, construction and management of water supply and sanitation services. • Increasingly, the sustainability and continuity of water supply demand attention. One in ten households already suffers from irregular water supply, especially in the dry season. Optimizing water quality, quantity and sustainability will require water resource management involving a broad array of stakeholders. The government has initiated policy discussions on Water Safety Plans, which are aimed at ensuring the quality, quantity, continuity and affordability of water services.
ISSUE BRIEFS
Resources Adair, T. (2004): ‘Child Mortality in Indonesia’s Mega-Urban Regions: Measurement, Analysis of Differentials, and Policy Implications.’ 12th Biennial Conference of the Australian Population Association, 15-17 September 2004, Canberra. Bakker, K. and Kooy, M. (2010): ‘Citizens without a City: The Techno-Politics of Urban Water Governance’, Chapter 5 in Beyond Privatization: Governance failure and the world’s urban water crisis, K. Bakker. Ithaca: Cornell University Press. Bappenas (2010): Peta Jalan Percepatan Pencapaian Tujuan Pembangunan Milenium di Indonesia (Roadmap for Acceleration of MDG Achievement in Indonesia) Jakarta: Bappenas (National Development Planning Agency) Available from: http://www.bappenas.go.id/node/118/2814/peta-jalanpercepatan-pencapaian-tujuan-pembangunan-milenium-di-indonesia/ Black, R.E., Morris, S.S. and Bryce, J. (2003): ‘Where and why are 10 million children dying every year?’ Lancet 361: 2226-34. BPPSPAM (2010): Performance Evaluation of PDAMs in Indonesia. Jakarta: Ministry of Public Works, Badan Pendukung Pengembangan Sistem Penyedia Air Minum (Support Agency for the Development of Drinking Water Supply Systems) BPS-Statistics Indonesia and Macro International (2008): Indonesia Demographic and Health Survey (IDHS 2007). Calverton, Maryland, USA: Macro International and Jakarta: BPS. Crompton, D.W.T. and Savioli, L. (1993). ‘Intestinal parasitic infections and urbanization’ Bulletin of the World Health Organization, 71 (1): 1-7 Curtis, V. and Cairncross, S. (2003): ‘Effect of washing hands with soap on diarrhoea risk in the community: A systematic review.’ Lancet Infect Dis 2003; 3: 275-281 Fewtrell, L., Kaufmann, R.B., Kay, D., Enanoria, W., Haller, L. and Colford Jr, J.M. (2005): ‘Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: A systematic review and meta-analysis’ Lancet Infect Dis 2005; 5: 42–52 5
ISSUE BRIEFS
Jakarta Environmental Agency (BPLHD) (2012): Neraca Lingkungan Hidup Provinsi DKI Jakarta 2011. Jakarta: Badan Pengendalian Lingkungan Hidup Daerah (BPLHD) Ministry of Health (2008): Laporan Nasional: Riset Kesehatan Dasar (Riskesdas) 2007, Jakarta: Ministry of Health, National Institute of Health Research and Development. Ministry of Health (2011): Laporan Nasional: Riset Kesehatan Dasar (Riskesdas) 2010, Jakarta: Ministry of Health, National Institute of Health Research and Development. PERPAMSI (2010): Pemetaan Masalah PDAM di Indonesia (Mapping of PDAM Problem in Indonesia). Jakarta: Persatuan Perusahaan Air Minum Seluruh Indonesia (Indonesian Water Supply Association)
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University of Indonesia Center for Health Research (2006): Survei rumah tangga pelayanan kesehatan dasar di 30 kabupaten di 6 provinsi di Indonesia 2005. Final report. Jakarta: USAID - Indonesia Health Services Program Victora, C.G., Adair, L., Fall, C., Hallal, P.C., Martorell, R., Richter, L. and Sachdev, H.S. (2008): ‘Maternal and child undernutrition: consequences for adult health and human capital.’ Maternal and Child Undernutrition 2, Lancet 371: 340-357 World Bank (2008): Economic Impacts of Sanitation in Indonesia: A five-country study conducted in Cambodia, Indonesia, Lao PDR, the Philippines, and Vietnam under the Economics of Sanitation Initiative (ESI). Research Report August 2008. Jakarta: World Bank, Water and Sanitation Program.
Unger, A. and Riley, L.W. (2007) Slum health: From understanding to action. PLoS Med 4(10): e295. doi:10.1371/journal.pmed.0040295.
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This is one of a series of Issue Briefs developed by UNICEF Indonesia. For more information, contact
[email protected] or go to www.unicef.or.id
