86368 from EVIDENCE to POLICY Learning what works, from the Human Development Network February, 2014 Can Demand for Toilets be Encouraged? Evidence from Indonesia Proper sanitation reduces the spread of illnesses such and habit of behavior all play a role in slowing the end as diarrhea and typhoid, which can be transmitted of open defecation. through fecal matter. In countries where people prac- The World Bank is committed to helping countries tice open defecation develop the necessary infrastructure and practices to re- in rivers, fields and duce disease and enable families to raise healthy children. forests, these illnesses In Indonesia, the Water and Sanitation Program, an in- are harder to stop. Fe- ternational partnership supported by the World Bank, cal matter is tracked worked with the government to develop new approaches into homes and into to discourage open defecation and increase the number of food, causing life- toilets in poor, rural areas. An impact evaluation of a pro- threatening disease, gram to foster demand for toilets by raising awareness— WATER particularly among instead of building sanitation facilities and hoping people infants and children would use them—did show a boost in toilet construction under the age of five. and a drop in diarrheal illness. The changes, however, Development prac- were mainly seen in non-poor households, indicating titioners and policy- that in some cases, subsidies might be worth considering makers seeking to improve sanitation and reduce open when working with households that might need a little defecation are still searching for the most effective pro- extra assistance to make the shift from open defecation grams. Financial constraints, inadequate water systems to indoor toilets. Context Close to half of Indonesia’s 247 million people don’t communities, especially to children and babies. There’s have access to proper sanitation—such as a flush toi- an economic cost as well. Economists have estimated let or pit latrine—and some 63 million practice open that Indonesia loses about $6.3 billion annually be- defecation. This poses a serious health hazard in their cause of poor health, lost productivity, clean water re- placement, and other costs related to sanitation. In Indonesia, sanitation practices are so poor that roughly 11 The Water and Sanitation Program, a multi-donor percent of children suffer from diarrhea in any two-week period, trust fund administered by the World Bank, supported and more than 33,000 die each year from the disease. Another 11,000 children die annually from typhoid. governments in India, Indonesia and Tanzania in im- World Bank report: plementing programs at scale. In Indonesia, the Total https://www.wsp.org/sites/wsp.org/files/publications/WSP-Indonesia-Sanitation- Impact-Evaluation-Field-Note.pdf Sanitation and Sanitation Marketing program sought to reduce open defecation by building demand for san- itation facilities through campaigns about the dangers cilitators provided people with information about the of tracking feces into food and other risks. Concur- benefits of using toilets and the health problems associ- rently, the program sought to encourage the supply of ated with not using them; social marketing campaigns materials needed to build toilets. sought to identify what people wanted and then to en- The program, implemented in rural communities courage the private sector to make these available; and of East Java in concert with the national government a program aimed to develop and support government and local administrations, had three components: Fa- sanitation policies. Evaluation The program was scaled-up in three phases in East Java’s in this phase of the roll-out, and 10 villages were ran- 29 rural districts, starting in 2007. The evaluation was domly assigned to be in the treatment group, meaning implemented during Phase Two, by which point start- they were supposed to receive the program. In total, up issues had been dealt with. Eight of the 11 districts 160 villages were assigned to the evaluation. A baseline in the Phase Two roll-out, which began in 2008, were household survey was conducted in these communities included in the evaluation. Within each district, 10 in 2008, including a health-nutrition component for WATER villages were randomly assigned to the control group, children under the age of five. Follow-up data was col- meaning they weren’t supposed to receive the program lected 24 months later. Findings The program caused a decline in open 22 percent of people in villages where the program was defecation—especially among households close implemented and who had access to a toilet reported to a river and among people who had access to defecating in the open, compared with 26 percent in toilet facilities but usually didn’t use them. the control group. The percentage of households that reported that at least The program had a significant impact on one member defecated in the open dropped by 4.4 per- construction of toilets. centage points, with bigger declines in villages closer to the river. Overall, 53 percent of households in the con- Sixteen percent of households in villages where the pro- trol group and 48.8 percent of households in villages gram was implemented built toilets, compared with 13 where the program was implemented reported that at percent in the control villages. But generally, change least one member defecated in the open, with men and wasn’t seen among households at the bottom of the in- children doing it more often than women. Much of the come scale, indicating that boosting demand might not decline was driven by households that already had ac- be enough to change behavior when funds aren’t avail- cess to sanitation facilities. At the two-year survey mark, able for those without the money to build. *This policy note is based on “Impact evaluation of a large scale rural sanitation project in Indonesia,” by Lisa Cameron, Manisha Shah and Susan Olivia, #6360, World Bank. http://elibrary.worldbank.org/doi/book/10.1596/1813-9450-6360 Reported rates of childhood diarrhea had heard of the program’s specific sanitation activities, declined in villages where the program was such as a public meeting. implemented and the children had less blood Concurrently, villagers were receiving messages or mucus in their stools, which can indicate a about good sanitation practices through a variety of lower rate of parasites. sources, not all of them related to the program. Televi- sion and village health staff were most frequently cited Diarrhea in children under 5, based on reports by care- as a source of information, both when it came to this givers, dropped by 1.4 percentage points. On average, specific program and information in general about sani- 2.4 percent of children in areas where the project was tation and health. implemented had diarrhea in the week prior to the sur- vey, compared to 3.8 percent in the control group, a statistically significant difference. Because people who practice open defecation sometimes believe it’s cleaner, especially if they defecate in a river, the program included a “walk of shame” to show households how fecal matter travels from the outdoors into food and drinking water. Trained representatives went to each village to discuss sanitation and the role it plays in health. The meetings were held in public spaces and open to everyone. The meetings included a presentation in which villagers were asked to mark on the ground where they lived, where they defecated and what routes they took back and forth. People would become horrified as they realized that they were usually crisscrossing feces-contaminated areas. Facilitators used this to discuss how the villages could work to reach Open Defecation Free status (which comes with public recognition from local authorities) by constructing and using sanitation facilities. Two years into the program, 11 percent of villages had been desig- An overwhelming majority agreed that having nated open defecation free. a toilet improved health, but people continued to tolerate open defecation. But program implementation didn’t always reach everyone in the village. People might not More than 90 percent of respondents polled after the have been around the day the facilitator came program ended agreed that having a toilet benefitted the to talk, or they may have simply not known community and protected against diarrhea. But nearly about it in advance. a third still believed it was okay for people to defecate outside if they didn’t own a toilet and only 72 percent Two years after the program was launched, 25 percent of thought that diarrhea was a consequence of others def- households in villages in the treatment group said they ecating in the open. The main obstacle to constructing toilets in hold in the sample. (The actual cost is $50 to $90 for a households appears to be cost. slab latrine, which generally refers to a pit covered with a concrete slab with a hole for defecation.) A majority On average, people estimated that the cost of a latrine of households in both treatment and control villages re- would be $135, which corresponds to roughly one-third ported that costs of building a toilet in their home had of the annual per capita income for the average house- risen in the last 12 months. Conclusion While the program showed some progress in chang- communities near rivers might further improve sani- ing attitudes toward open defecation and increasing tation and decrease incidents of diarrhea in children knowledge about the health risks involved in the prac- under five. The evaluation also found that wealthier tice, people in many areas of Indonesia continue to households tended to build more toilets in the home. defecate outside, particularly in rivers. Many house- When designing such programs, policy makers may holds reported believing that defecating in rivers was want to consider giving credits or subsidies to poor better than in a pit latrine. Thus, focusing programs on households to increase impact. WATER The Human Development Network, part of the World Bank Group, supports and disseminates research evaluating the impact of development projects to help alleviate poverty. The goal is to collect and build empirical evidence that can help governments and development organizations design and implement the most appropriate and effective policies for better educational, health and job opportunities for people in developing countries. For more information about who we are and what we do, go to: http://www.worldbank.org/sief. The Evidence to Policy note series is produced by SIEF with generous support from the British government’s Department for International Development. THE WORLD BANK, HUMAN DEVELOPMENT NETWORK 1818 H STREET, NW WASHINGTON, DC 20433 Produced by Office of the Chief Economist, Human Development Network, Communications/Aliza Marcus