The challenges of and solutions (strategies) for addressing sanitation uptake and sustainability issues in rural Karangasem, Bali, Indonesia

An effective sanitation system is vital for public health and the environment, as poor sanitation is a key contributor to a high burden of diarrhoea and hygiene related diseases and environmental pollution. Yet 2.4 billion people in developing countries are without access to sanitation facilities. Despite 15 years of international effort to halve the proportion of people without access to sanitation specified by the Millennium Development Goals (MDG) (2000-2015), little progress was made to enable the poor in rural areas and urban slums in the developing world to access effective sanitation. Moreover, the issues of sustainability relating to the usage and functioning of entire sanitation systems require more consideration to ensure safe management of human excreta. These concerns are reflected in the new sanitation target (Goal 6) of the Sustainable Development Goals urging countries to “ensure availability and sustainable management of water and sanitation for all” by 2030 (SDG) (UN, 2016). This new target poses many challenges to developing countries such as Indonesia. The challenges lie in the complex nature of sanitation issues from uptake to sustainability, which requires a multi-disciplinary solution. Evidence from many studies reveals the importance of considering multiple factors ranging from individual and behavioural, to cultural, socio-economic, institutional and technical aspects of sanitation systems. However, current approaches to address sanitation issues tend to be dominated by a single discipline perspective or are addressed from an individual level which only partially addresses the problem. There are a few studies in the sanitation sector suggesting comprehensive models, but they tend to be overly complicated and difficult for local professionals to apply to their practical situations. Comprehensively addressing sanitation issues is particularly important for rural areas in developing countries, which cannot afford costly infrastructure solutions. This is the case for Indonesia. In Indonesia, low sanitation coverage and the diverse cultural background of rural areas means that rural sanitation issues cannot be addressed by applying a uniform national program across the country. Unfortunately, there are few studies in Indonesia that provide a way for local professionals to comprehensively understand sanitation issues in different contexts. Studies of rural sanitation in Indonesia tend to focus more on increasing sanitation access or uptake from the perspectives of demand and engineering, rather than sustainability or maintenance issues and very few cover both. Most fail to examine the multiple inter-related determinants underpinning sanitation, and neglect culture and interrelated factors. This leads to many problems in delivering sanitation service in rural Indonesia. Thus, this study aims to examine comprehensively the challenges and solutions in addressing sanitation uptake and sustainability in rural Indonesia. It also aims to develop an integrative analytical framework to provide a better means to systematically identify and analyse the multiple determinants of sanitation so as to design corresponding strategies to suit the local context. This study adopted a mixed-method approach to examine in-depth the uptake and sustainability of sanitation through an extensive literature review and a field study combining both quantitative and qualitative methods. The data collection techniques include secondary data collection, key informant interviews with 36 relevant stakeholders and 34 community householders, a questionnaire survey of 202 householders, and physical observation of 63 sanitation facilities. The qualitative analysis involves domain, taxonomy and component analysis sequentially to identify themes, uncover relationships and find significance. The quantitative analysis includes descriptive, univariate and multivariate statistical analysis. The study began with a critical literature review to understand global challenges in addressing sanitation uptake and sustainability in developing countries in general and in rural Indonesia in particular. Drawing from the literature review, the study evolved to develop the Integrated Framework for Sanitation Service (IFSS) which was then applied in the subsequent field study in a rural setting of Bali Province, Indonesia to identify and analyse determinants of sanitation uptake and sustainability at the local level in order to suggest potential local actions. The IFSS is based on a combination of the ecological public health perspective on health determinants and the engineering perspective on sanitation life stages. The former drew from a WHO initiated approach to address multiple interconnected health determinants known as the Ottawa Charter health promotion action framework (OCHPF). The OCHPF provide an ecological framework for this study to identify, analyse and find solutions to address structural, environment, cultural, individual and service determinants of sanitation. While the latter, the engineering perspective provides a process framework to identify issues at the acceptance, construction, utilisation, maintenance and safe disposal stages. Applying the IFSS enables a systematic analysis of multi-faceted sanitation issues across the sanitation system life stages grounded in the realities of specific settings. The field study in rural Bali found six key issues of sanitation uptake and sustainability: 1) lack of demand for sanitation, 2) complex demands of local values concerning toilet construction, 3) inadequate quality of toilet construction, 4) non-continuous usage, 5) difficulties with maintenance of facilities and 6) lack of safe waste disposal service. The study then applied the IFSS to analyse the key issues identified and found that structural, cultural and service determinants were at least as influential in this setting as the environmental and individual determinants commonly identified by previous studies. The structural determinants include lack of policy and regulation for domestic wastewater management; unclear allocation of responsibility, lack of capacity and lack of collaboration of local government institutions; village social and organisational structures and economic status; and lack of sanitation curriculum in the education system. Cultural determinants include values related to purity and harmony, social support and traditional roles. The evidence also shows that cultural aspects influence structural, environmental, individual and service determinants. Service determinants include choice of promotion media, quality of delivery of sanitation programs and level of supply and maintenance service in rural areas. In order to address these interlinked determinants, the IFSS was again used to guide further development of action strategies. The recommended strategies include improving policies and guidelines to facilitate collaboration, working with cultural values and norms, and improving supply and maintenance services to meet local needs. The analytical tool “Integrated Framework for Sanitation Service” developed in this study is the first of its kind to combine health promotion and engineering perspectives in order to examine a complete sanitation system from uptake to sustainability. As demonstrated in this study, the IFSS can help local professionals and stakeholders to deal with complex sanitation issues in communities with increased clarity and understanding. More importantly, it can lead to the translation of scientific findings into usable concrete strategies to solve local problems. Thus, the IFSS should be useful not only to Bali province, but also to other parts of Indonesia and even other communities in developing countries sharing similar concerns about sanitation uptake and sustainability.

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