Global Health

Indonesia is the world’s fourth most populated country. The population of the country is mainly urban based, thus having a population disparity. Poor Sanitation is one of the major problems, which is faced by the people in both the urban in the rural area. Due to the excessive population in the urban areas, there are more issues in the urban areas rather than the rural ones. Poor sanitation system is one of the key reasons for the poor overall health of the country, which is also affecting the economic growth of the country. After 1945, the sanitation system was not one of the main issues, which appeared to the government, but after 1970s, the government noticed that the sanitary systems are having an adverse effect on the health systems, which in turn is affecting the economic growth of the country. The sanitation system is a huge system and does not stay enclosed until the topic of accessing proper toilets by the people. Sanitation involves wastewater management, sewage management, keeping the drinking water clean and accessing proper toilets in every household. Every department has different issues and every issue is equally important as it affects the entire cycle. The poor sanitation issues are having an adverse impact on the health of the people as diarrhoea seems to be a common disease among them. in Indonesia, 88% of the diarrhoea cases were caused due to the poor sanitation and lack of clean drinking water. Diarrhoea is one of the major health issues in the country as it has caused 31% of postnatal mortality and 25% of child mortality. The study points out the various loopholes in the sanitary systems of Indonesia and provides several interventions to face the situations. A complete report regarding the impact of the interventions have also been presented in the study along with the cost benefits for the government. Using the cost benefit analysis the government can think of ways to improve the sanitation system at much lower costs and even think about saving some money in the long run.  It is the duty of the Indonesian government to fulfil the needs of this basic right for its people and take an active stand in improving the health conditions of its people.

Indonesia is the world’s fourth most populated country with a population of around 245 million people.  Most of the population lives in the urban part of the country, as the population is divided as 71% in the urban areas and 44% in the rural areas. The average growth rate of the urban population in Indonesia is 3.3% per year.  In 2011, when the sanitation data from the fourth wave of Indonesia Family Life Survey was studied, only 59% of the total population had adequate access to sanitation (Borja-Vega, 2014). Due to poor sanitation systems, people are facing several health problems like diarrhoea, dysentery and so on. The people are also facing issues regarding the accessibility to clean drinking water, which is putting them into greater health risks.

Background

The sanitation sector in Indonesia was considered a private and household sector responsibility, which means that there was neither any intervention from the public institutions nor there were any financial contributions from them. During 1945, after independence the government’s focus shifted to building the economic condition of the country rather than the basic rights of the people such as sanitation. Around the 1970s, the scenario started to change and the government started to understand the impact of poor health on the economic growth of the nation (Rosyadi et al., 2017). There was more financial contribution in the health sectors although there was limited contribution in the sanitation programs. Another important fact about the Indonesian sanitation system is that by sanitation they only mean disposing off the solid waste and cover it and the drainage system denote the wastewater management.

The government has shown considerable interest in developing the sanitation systems in the recent years, otherwise the government was never much interested in the sanitation sectors. Between 1970 and 2000, the average budget per person was IDR200 for sanitation (Engel & Susilo, 2014). Only four cities had centralized sewage systems before 1980, which was built during the Dutch colonial era. By 2012, the number went up to twelve cities having a centralised sanitation system. The centralised sanitation system does not cover the entire town and has remained mostly underused. for an instance, In Indonesia, Jakarta is the most populated city having a population of around 10 million people, but the city’s sanitation system covers only 2% of the city’s inhabitants.

About 14% of the population prefers open defecation. Over the years the people have been getting access to improved sanitation facilities and by 2010, 73% people started using various toilets such as public toilets or even private washrooms (Fitria, Susanna & Eryando, 2018). The manually flushed toilets are quite common in Indonesia. The growth rate in people accessing to sanitation systems is much less than its other Asian neighbouring countries.

                                           

                                                         Figure: History of Sanitation Development in Indonesia

In 2007, according to the World Bank’s Water and Sanitation Program, Indonesia has lost their IDR 56 trillion in GDP for its poor sanitation systems. The toll that the government misses its GDP per annum is IDR275, 000 in the urban areas for poor sanitation. Although the Indonesian government has understood, their flaws and they have started taking action against it to maintain proper sanitation and hygiene.

Economic background

Recently, there are laws regarding the proper disposal of fiscal matter for the local governing body, such as Law 32/ 2004 on the regional government institutions. The local governing bodies have been given several regulations and separate frameworks have been made for them to follow while disposing excreta matter. Following particular processes has eased the ways to implement the laws in this matter, for the government.

The government of Indonesia plays an active part in helping the situation for the sake of its people. There are several suggestive ways, in which the government can work with the people to create sanitary systems; this will also improve the overall health of the people. All three aspects such as sanitation, wastewater management and clean drinking water are interrelated and have huge effects on the health of the people.

According to the latest WHO-UNICEF report, about 18% of the total households in Indonesia are depended on surface water for drinking water. Another 11% can use piped water, although the quality available is much low for drinking water. Besides the poor quality, there are other problems too regarding the accessibility such as interrupted supply, poor water flow; the piped water is sometimes too unsafe to drink because it may contain faecal coliform (Mozar & Sijbesma, 2010). To overcome this situation, the people often boil their water before consuming it. Although according to the latest surveys, it has been found that the water is not boiled up to the mark and the water still remains too contaminated to be consumed. To resolve these issues, there are techniques, which can be applied for, further treatment of the drinking water such as bleaching, chlorination, using filters or treating the water through solar disinfection. All these techniques can be applied to produce quality drinking water and decrease the risk of getting diarrhoea.

Wastewater management is another issue, which is involved in the sanitation process. In Indonesia, the main technique used to manage waste water is by using septic tanks. About 65% of the total population is relied on this method to manage their waste water. The Indonesian government has set some quality standards for the septic tanks, but they are hardly enforced by the people (Patunru, 2015). Due to this negligence, most of the septic tanks often encounter the groundwater and some of them have leaks, which happen to leak the wastewater, and later it seeps into the ground. In the rural regions, people often have their septic tanks closely built by their wells that are also a contamination risk. The government does not have any rules and regulations regarding the management and the disposal of the septic tank wastages in Indonesia. In this context, the first intervention, which is required, is setting up various rules and regulations regarding the disposal of the septic tank wastes. Next comes, setting up a proper government body to oversee these issues and maintain the regulations. The government should create a department and hire people who will be responsible for cleaning up the septic tanks of a particular area; they should also oversee the proper maintenance of the septic tanks in a given area. 

Legal Background

                                   

                                                     Figure: Wastewater and Septage Flow in Urban Indonesia

The central government should come forward and set up public budgets framework for sanitation issue. The government should also engage various private and the public bodies in raising adequate funds to bring in the latest technology to manage the sanitation systems. Efficient technicians and managers should be hired for operating the latest technology (Pribadi, 2017). The framework should cover all the departments related to the issue of sanitation.

To manage the sanitation of every household, a proper survey should be conducted to determine the number of houses accessing a proper toilet system. The households having no toilets should be instructed officially by the government to build toilets at home. The government should also provide subsidies to the people who are not able to build toilets at their homes. The government will also have to invest in building public toilets in various areas. The government should have stringent laws for the people regarding maintenance of proper hygiene in various restaurants and at homes.

Spreading awareness is also an important part of the intervention process. Advertisements, posters and several campaigns should be organised by the government to spread awareness regarding proper sanitation and maintenance of proper hygiene. The campaign volunteers should visit from door to door and make the residents understand the importance of proper sanitation and its impact on their health.

The sewage system of the city also plays an important role in the wastewater management of the people. Currently, centralized sewage system is limited to only twelve cities in Indonesia. These twelve cities have access to advanced sewage treatment plants with facilities like Upflow Anaerobic Sludge Blanket (UASB) systems, rotating biological contact systems and so on. Although the systems remain underused and slowly the systems have, started bearing huge fixed costs (Chong et al., 2016). The underused systems could have been used to their optimum capacity to decrease the poor sewage systems thus contributing to the better sanitary systems. The untreated excreta seep into the groundwater contaminating the entire network.

The government should set up a review team and deeply examine the sanitation planning systems of the state. The review team should try to implement new innovative methods and ideas to reform the old system and make it more efficient. New technologies should be implemented in the sanitation systems and at the treatment plants.

The intervention

 Improvement of the sanitary systems in Indonesia can resolve many problems of the people. The first thing, which will improve, is the health conditions of the people. Due to the practice of poor sanitation methods in Indonesia, several excreta transmitted diseases such as Diarrhoea, cholera, typhoid, polio; often afflict the people and so on. in the urban areas people are often seen to live within a community, which means that people in the same community more or less live in the same living conditions (Komarulzaman et al., 2017). Thus, when a person in a community is exposed to these diseases, the health of the entire community is at risk. Whereas, on the other hand, the people can be saved from this health risk by implementing proper sanitary techniques and manage proper hygiene in their living places.

Drinking pure water is also an integral part to avoid such diseases. People in Indonesia are depended either on the surface water or on the piped water for drinking water. Thus, there is a high chance that there is faecal matter in the drinking water. To overcome this situation, people boil their water and drink it, but still there is enough possibility that the faecal germs would remain in the water. When the government helps the people to maintain proper sanitation and they also look into the matter that the wastewater from the septic tanks do not come in contact with the groundwater, they try to make drinking water much safer for the people. Poor health conditions of the people means that the government will have to spend more money in the health systems rather than other systems which actually requires some reformation. Thus, this is affecting the entire economic standing of a nation. From the perspective of the people, when a person falls ill, most of the income of a household is invested in curing that person. Thus, it can be seen that the average income of the household goes down and so does the living conditions of the people belonging to that household. Diseases form a barrier in the growth of the nation. Children are supposed to be the future of the nation, but in Indonesia around 25% of the newborn babies die due to diarrhoea (White, 2011). This is a very sad fact, that the only reason behind the high mortatility rate of Indonesians is their poor sanitation methods.

Reforming the entire sanitation system will bring about a major change in the living conditions of the people. With the increase in various departments overseeing this issue, there is a possibility that there will be more jobs for the people. Proper sanitation will also help the government in maintaining clean roads and places, thus spending much less on the cleaning and maintaining processes. With the implementation of the latest technologies, the government can also think of ways to recycle and reuse the sewage in many other productive ways (Kohlitz et al., 2018). The government will also be to think of many innovative ways to save the environment by recycling the sewage or even thinking of better ways to dispose off the garbage without harming the environment.

Sanitation problem is considered to be one of the major problems in Indonesia. The issues that are impacting on to increase the sanitation problem in Indonesia are ineffectiveness of the urban population of Indonesia to hold a well treated septage, poor waste water drainage system, a large investment has been made for a long term plan, undeveloped financial framework for sanitation and poor utilization of sanitary system.  It causes a great time and effort loss which results in low productivity and poor water quality. Moreover, it is adversely impactful on the tourism economy. The nation has failed to refer the effective sanitation and ramification in the area of $38 billion. A recent study has disclosed the fact that poor situation for the sanitation costs additional $9.2 billion each year Indonesia which is around 2% of the overall GDP of Indonesia. As per the report of World Health Organization (WHO) the latrine sanitation cost in Indonesia is over$26 every year and the cost of septic tank is $160. Hence, it is also notable that annual latrine sanitation cost per person is $3.92 and septic tank is $12.39 which is considered to be a big amount as per a low GDP nation like Indonesia (Venkataramanan et al., 2018). In the rural Indonesia, cost per improved latrine is $45 and cost pre pour flush latrine is $65. In the suburban area the cost jumps up to $160 and $175 respectively. A normal simple pit latrine generally costs $11 to 54 based on its quality. On the other hand, a septic tank may cost up to $799 per tank. Thus, the annual per capita sanitation cost in Indonesia may range from $24 to $260.

The annual per capita waste water cost may range from $24 to $260. This is significant that the overall sanitation cost reaches around $9 billion to $30 billion per year.However, if the sanitation cost is compared to the developed country USA spends $142 billion per capita for sanitation excluding the program, planning and supervision cost. However, it is differentiation of the annual GDP that differentiates the sanitation cost between Indonesia and other developed country. The cost benefit analysis can be helpful here to determine the cost of the sanitation across the communities. It is also an helpful techniques to measure and assume the future cost of sanitation. Thus, Indonesia may be advised to develop a fund achieving program. It is estimated that this may beneficial for them to save around $38 billion every year and 92% of the overall target for sanitation. The benefit cost ratio supports the fund achieving program to accomplish the sanitation target. Additionally, the disease control priority projects must be implemented for the development of the cost benefit ratio for Indonesia. This project is helpful in saving around $3.35 per DALY loss averted. Moreover, the project is also helpful in providing an additional $11.15 loss averted(Hutton, Haller & Bartram, 2008). The averted loss signify the effective, measurement of cost saving. Thus, the more cost is saved, the more it reduces the sanitation cost. The ultimate target of this cost benefit analysis is to describe the existing costs and assuming costs in order to reduce the overhead cost. Hence, it is also noted that disease control priority project can assumed to perform effectively in order to achieve the development goal. The target must be on increasing sanitation quality without increasing cost(“The Economic Returns of Sanitation Interventions in Indonesia”, 2015).

The latest trend has made it clear that the sanitation investment has been increased by the Indonesian government for past eight years. The sanitation investment for Indonesia in 2004 was $0.2/cap which has changed into $5.0/cap in 2012.He3nce, the investment trend on sanitation has signified Indonesia’s newly adopted cost benefit framework to develop sanitation without impacting on budget.

Conclusion

Sanitation is an important issue in Indonesia, which the government has been ignoring for quite a while. Although in the recent years, the government has been actively trying to reform the sanitation system of the country to improve the overall heath of the population. Maintaining proper hygiene is very important for people for avoiding diseases like diarrhoea, which is a major health risk in Indonesia. To maintain proper hygiene people should have access to proper toilets, the sewage systems of the cities should be able to dispose and treat the sludge properly, the wastewater should be managed properly so that it would not seep into the groundwater contaminating the drinking water and so on. All these systems form the complete sanitation cycle. In the study, the government has been suggested several interventions to improve the sanitation systems of Indonesia. The government will have to improve the sewage and the drainage system of the cities, funding should be brought in for improving the sanitation systems, the old systems that are underused should be put to use. The government should try and make toilets accessible to the people in many ways such as, the government should spread more awareness regarding the importance of sanitation; the government can help the people to build toilets in their homes by providing subsidies.  The government should try to improve the central plumbing systems so that it may become easier to construct and use toilets in every household without being bothered about the disposal of the faecal matters. It is very important that improving the sanitation system will in turn improve the health of the entire population.  The mortality rates of the Indonesian population are expected to go down with proper sanitary systems. Indonesian government has lost a portion of its annual GDP due to their poor sanitation. Effective working on this issue will help the government to mitigate many of their economical issues.

References

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Chong, Y., Abeysuriya, K., Hidayat, L., Sulistio, H., & Willetts, J. R. (2016). Strengthening local governance arrangements for sanitation: case studies of small cities in Indonesia. Aquatic Procedia.

Engel, S., & Susilo, A. (2014). Shaming and Sanitation in Indonesia: A Return to Colonial Public Health Practices?. Development And Change, 45(1), 157-178. doi: 10.1111/dech.12075

Fitria, L., Susanna, D., & Eryando, T. (2018). Personal Hygiene and Sanitation in Cafeterias at University X in Depok, Indonesia. Kne Life Sciences, 4(1), 93. doi: 10.18502/kls.v4i1.1370

Kohlitz, J. P., Rostiani, R., Indarti, N., Murta, J., & Willetts, J. (2018). Sludge removal enterprises in Indonesia: factors affecting entrepreneurial success. Journal of Water Sanitation and Hygiene for Development, 8(2), 246-256. 

Komarulzaman, A., Smits, J., & de Jong, E. (2017). Clean water, sanitation and diarrhoea in Indonesia: Effects of household and community factors. Global public health, 12(9), 1141-1155.

Mozar, R., & Sijbesma, C. (2010). Gender- and Poor-inclusive Community-managed Sanitation and Hygiene in Urban Indonesia. Water Practice And Technology, 5(4). doi: 10.2166/wpt.2010.103

Patunru, A. (2015). Access to Safe Drinking Water and Sanitation in Indonesia. Asia & The Pacific Policy Studies, 2(2), 234-244. doi: 10.1002/app5.81

Pribadi, K. T. (2017). The health care system in Indonesia. In Health Care Systems in Developing Countries in Asia (pp. 131-148). Routledge.

Rosyadi, M. K., Pujianti, N., Setyaningrum, R., Rahman, F., & Saputra, M. (2017). Evaluation of Waste Water Treatment Toward Physical, Chemical, and Biological Parameters in WWTP Basirih Banjarmasin, Indonesia. Indian Journal of Public Health Research & Development, 8(4).

Venkataramanan, V., Crocker, J., Karon, A., & Bartram, J. (2018). Community-led total sanitation: a mixed-methods systematic review of evidence and its quality. Environmental health perspectives, 126(2), 026001.

White, W. (2011). Confronting culture to overcome sector failure: sanitation in Indonesia. Journal Of Water, Sanitation And Hygiene For Development, 1(4), 269-278. doi: 10.2166/washdev.2011.028

Hutton, G., Haller, L., & Bartram, J. (2008). Global Cost-benefit Analysis of Water Supply and Sanitation Intervention. Retrieved from https://www.researchgate.net/publication/5963649_Global_Cost-benefit_Analysis_of_Water_Supply_and_Sanitation_Intervention

The Economic Returns of Sanitation Interventions in Indonesia. (2015). Retrieved from https://sanitationdrive2015.org/wp-content/uploads/2013/07/wsp-indonesia-economic-returns.pdf