Diarrheal disease is the world’s second leading cause of death for children under five, claiming roughly 760,000 lives annually. Diarrhea depletes the body of essential water and salts, leading to severe dehydration and fluid loss, and can result in death. In addition, diarrhea is associated with malnutrition (since the body is unable to effectively absorb nutrients from food) which itself contributes to anemia, stunted growth, and poor immune response. Diarrhea is usually a symptom of an infection, typically from consuming food or water that has been contaminated with bacterial or parasitic organisms from human or animal fecal matter. An example of such an infection is typhoid fever which is transmitted from ingesting food or water contaminated with the feces of another infected person. In much of the developing world, access to hygienic toilets and hand-washing stations are not universal, nor is access to clean water or oral rehydration salts (an intervention used to replenish the loss of fluids), making certain populations particularly vulnerable to infection and disease.
In Indonesia more than 33,000 children die annually from diarrheal disease, with another 11,000 falling fatally ill to typhoid fever. Much of this disease burden is attributed to the lack of access to proper sanitation (e.g. flush-toilets or hygienic pit-latrines) of some 110 million Indonesians. Roughly 63 million of these individuals practice open defecation, a practice which significantly raises the risk of fecal contamination of food and water within the community. In Indonesia, a rural sanitation project, known as the Total Sanitation and Sanitation Marketing (TSSM) was launched to improve sanitation in rural communities of East Java by generating sanitation demand at scale and increasing the supply of sanitation products and services. This study seeks to identify whether the project improved sanitation practices in the community, and whether that led to the improved health of the population.
Taking advantage of the multi-phase rollout of the TSSM in East Java, researchers implemented a randomized control trial to evaluate the impacts of the program. They focused their evaluation in 8 rural districts and conducted baseline surveys of 2,087 households from 160 sub-villages within eight East Java districts. Using data from community health workers in each sub-village, researchers identified which households contained children who were under two years of age and randomly selected 13 households to survey. Data were collected on perceptions of poor sanitation and its consequences, access to improved sanitation, place of defecation, and child health outcomes (e.g. diarrhea prevalence, rate of parasitic infections, stunting and wasting indicators, and occurrence of anemia). Follow-up surveys were conducted 27 months later and roughly 91% of households in the baseline survey were questioned at endline.
Treatment and control assignment was conducted at the village level. Whereas control villages were not targeted by the program, treatment villages were visited by facilitators who conducted activities meant to stimulate demand for sanitation products and services. During these interactions, facilitators conducted a mapping where they asked villagers to describe their routes and areas where they practiced open defecation. This information helped researchers understand the intersection of fecal contamination routes. In addition, media campaigns were rolled out where billboards, radio, and print materials were distributed by village health workers advocating for improved sanitation practices. Lastly, to improve the availability of sanitation products and services, local masons were trained to build latrines and toilet facilities.
Results and Policy Implications
The baseline survey showed that the treatment and control villages were very comparable before the program was launched. The surveys conducted after the conclusion of the sanitation project showed that the treatment communities built more toilets, as compared to the control villages. Treatment villages also reported rates of child diarrhea that were 1.4 percentage points lower – a 30 percent reduction in overall incidence of diarrhea. The changes were most significant among households that did not have access to proper sanitation before the baseline survey, reporting a 5.8 percentage point reduction in open defecation after the program was implemented.
Researchers also gathered information about attitudes and barriers to improved sanitation. The vast majority of households in both treatment and control villages acknowledged the link between sanitation and child health and, conversely, the connection between open defecation and diarrheal disease in children. If a given household did not have access to proper sanitation, many villagers considered open defecation to be an acceptable practice. Finally, many villages expressed that the main barrier to improved sanitation facilities was the high cost of building and maintaining a latrine. In fact, most of the latrine construction occurred in the richer households in these poor communities.
The results of this research suggest that large-scale sanitation projects can have significant, positive effects in encouraging hygienic practices. The significant declines in the prevalence of diarrhea and parasitic infection amongst children indicate an overall improvement in child health. Due to the fact that open defecation is still practiced and is an attractive option for many households, encouraging better sanitation practices among the rural poor could have many benefits to the community.
2008 – 2011