The Implementation of Community Led Total Sanitation in Muntigunung, Tianyar Barat Village, Karangasem - Bali

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1 The Implementation of Community Led Total Sanitation in Muntigunung, Tianyar Barat Village, Karangasem - Bali Dwipayanti, N.M.U. 1,2, Suandi, I K. R. 2, Akbar, S. 3 & Zonni, H. 3 1 Environmental Health Unit, School of Public Health, Udayana University, Gedung PS IKM, Udayana University, Sudirman Campus, Jl. PB Sudirman, Denpasar Bali Indonesia 2 Future for Children Foundation, Dusun Muntigunung, Karangasem - Bali 3 Perkumpulan Mitra Samya, Mataram - NTB udwipayanti@gmail.com Abstract. Muntigunung is part of Tianyar Barat Village, Sub District Kubu, Karangasem Distric, Bali Province with 5,319 population and is organized into 35 community groups. Thirteen of the 35 groups are not reachable through road. Most of families are living under the poverty line with very poor sanitation condition. The approach that was selected to be used for the intervention program was Community Led Total Sanitation (CLTS). This approach focus on behavior change instead on the physical construction of sanitation facilities without any subsidy or hardware help given to the community and to identify natural leaders that may lead the change in the community. The program start with 3 pilot community groups that comprise of 100 families namely Cangkeng, Kulkul-1 and Kulkul-2 to see whether this approach was suitable and effective to overcome the problems in particular area. After six months, the first intervened group (Cangkeng) has achieved 50% (from 0%) of families with access to improved toilet while the rest still using unimproved toilet. The other two pilot groups also shown a good progress, where after 4 months implementation, there were 22 families has built their own toilet. From this pilot intervention program, it has successfully improved the capacity of the community to be able to lead and monitor their own change toward their vision. The role of local government and the community leader are very important to the successfulness of the program. Here the two components of CLTS, increasing demand and enabling environment has been addressed, while improving supply component is still need to be well addressed in the scale up stages of the program to cover the whole Muntigunung area. Keywords: behavior change, CLTS, hygiene, sanitation, non-subsidy 1

2 1 Introduction The Indonesian Government has committed to achieve Millennium Development Goals (MDGs) as the nation s commitment to improve the welfare of its population and the global community. The MDGs has been clearly outlined within the National Long-Term Development Plan (RPJPN ), the National Medium-Term Development Plan (RPJMN and ) and the Annual National Development Plans (RKP) [1]. Within the report of Indonesian achievement of MDGs 2010, the status of target achievements are categorized into three groups, namely a) targets that have been achieved, b) targets where significant progress has been demonstrated and are expected to be achieved by 2015 (on track), c) targets which are required a lot of effort to be achieved. Target 7c, that is to reduce the proportion of households without sustainable access to safe drinking water and basic sanitation by half by 2015 is one of the target where more effort is required to be achieved [1]. According to the report, in 2010 there were 47.73% of households that have access to improved drinking water and 51.19% of households have access to basic sanitation, and the target by 2015 are 68.87% and 62.41% respectively. Several studies in 2006 such as Indonesia Sanitation Sector Development Program (ISSDP) and Basic Human Services (BHS) have indicated that 47% of Indonesian population is still practicing open defecation and 47.5% of drinking water has E.coli content [2]. Those figures obviously have a contribution to a very high diarrhea incident rate in 2006 in all over Indonesia (423 cases per 1000 population of all ages)[2]. Based on this situation, some activities have been conducted in order to overcome the hygiene and sanitation problems in Indonesia. The trial of Community Led Total Sanitation (CLTS) has been carried out in 6 regencies in 2005 then followed by the enacting of total sanitation movement and hand washing campaign by the Ministry of Health and other related ministries. The replication of CLTS approach has successfully resulted 500 villages were declared as open defecation free (ODF) in Consequently, the National Strategy on Community Based Total Sanitation (Sanitasi Total BerbasisMasyarakat = STBM) that developed from the CLTS approach then was enacted in 2008 in order to accelerate the replication of this approach throughout Indonesia. Within the policy, total sanitation is defined as a condition where a community has stopped open defecation, practicing washing hand with soap, safe handling of drinking water and food, managing solid waste appropriately and managing household wastewater safely, which those conditions were further known as 5 pillars of STBM [2]. STBM has three main components in its application that are 1) increasing demand towards the sanitation facilities which promote 2

3 behavior change of the community, 2) improving supply system of the facilities within the community and 3) enabling environment to support and sustained the change within the community. In the implementation of STBM, the Ministry of Health is cooperating with Water and Sanitation Program (WSP) of the Word Bank which implement the similar program named Total Sanitation and Sanitation Marketing (TSSM) in capacity building of local health agency. East Java is one province that is successful in implementing this program. The investment ratio on sanitation facilities through this program is 9 : 1 between the community investment and local government investment [3]. This figure shows that the community movements could result such a very big impact in sanitation sectors. This is a remarkably different fact with previous approach in sanitation sectors that focus in giving subsidy for infrastructure with low impact on behavior change (many of facilities being un-used). The Ministry of Health has targeted to spread the program to other 10 (ten) provinces in Indonesia in year 2012 where Bali is one of those targeted province [4]. Moreover, the national target for this program is to have 20,000 STBM villages all over Indonesia by This is a very high target that was set to be able to achieve Indonesia MDGs, especially the target 7c. Dusun Muntigunung, (1,154 families representing a total population of 5,319 organized into 35 groups (kelompok)), is part of Desa Tianjar Barat, Sub District Kubu, Regency Karangasem in the north eastern part of Bali. The area covers 28 km² in altitudes between 200 and 800 meters above sea level. The terrain is rugged and many small canyons make it difficult to cross from one kelompok to the next. 13 of the 35 villages are not reachable through road. There are no rivers and no springs in this area. During the dry period between May and December people depend heavily on the rain water collected during the rainy season in family cubangs. Most of these cubangs are leaking, as the construction was done with low quality material, and roots of nearby trees are cracking the thin walls. At the same time, the cubangs are not covered so that an additional amount of water is being lost by evaporation, and the remaining water is being polluted. One can generally assume that the inhabitants of Muntigunung have a water reserve of around 3 to 4 weeks at their disposal, thereafter people have to collect water daily at the coast or in lake Batur and transport it back to their houses; those who can afford it buy it from tankers. The practice of hygiene behavior by Muntigunung community is very low as the environmental sanitation is also very poor. None of the families in the selected pilot kelompoks have safe sanitation facility. Open defecation is still a 3

4 common practice by the community. The behavior of open defecation that has become a custom since a very long time ago has made the community to lose the feeling of being ashamed and disgusting of their behavior. The knowledge of how germ could be transported from feces to food and human mouth (contamination route) has not become a common knowledge in the community at the present time. Based on the background situation and development strategies that have been planned, The Future for Children Foundation/VZK will support the behavior change within the community in the field of hygiene and sanitation in order to improve the health of the community. Learning from the experience of other organizations that implemented a sanitation program in another area, the triggering strategy to promote behavior change within the community has been proved to be very effective as of the present day. For that reason, The Future For Children Foundation /VZK will cooperate with School of Public Health Udayana University, Mitra Samya (MS) Foundation (Organization of Participation and Democracy study) and the Primary Health Care (Puskesmas)of Kubu II to implement the CLTS (Community Led Total Sanitation) method in Muntigunung village. 2 Methodology The CLTS method and approach that will be implemented are aimed to promote the behavior change in term of hygiene and sanitation and is part of the overall Indonesian government strategy to improve sanitation and hygiene all over in Indonesia. Learning from the experience of other organizations that implemented a sanitation program in another area, the triggering strategy to promote behavior change within the community has been proved to be very effective as of the present day. The Pilot program will be undertaken in two phases, priority 1 in the hamlet of Cangkeng (29 families), then followed (as soon thereafter as it is reasonably sound) by the hamlets of Kulkul1 (31 families) and Kulkul 2 (34 families) in Muntigunung village, Karangasem, Bali. The program is planned to be completed within 12 (twelve) months. The CLTS triggering and health promotion will be used as the strategy to increase the demand of latrine. The CLTS triggering will promote behavior change by sharing experience and support the latrine construction by the community utilizing potential local material and social capital. This triggering will focus to change the community behavior of defecating in open area into more hygiene behavior (in latrine) by systematic triggering and hands-off approach by the facilitators within where hardware subsidy is minimized. 4

5 There will be no promotion of specific latrine in the triggering process, but the demand of latrine will emerge through community initiative and solidarity to create their village environment becomes ODF. In this pilot program the triggering will also promote the washing hand with soap behavior in order to have more significant impact on community health especially maternal and children health. 3 Program Implementation Results The implementation of CLTS pilot program in three pilot kelompoks namely Cangkeng, Kulkul-1 and Kulkul-2 has been conducted from September 2011 up to July Some activities have been carried out that includes capacity building of puskesmas staff and motivators from community in September 2011, triggering at pilot kelompoks, monitoring and verification of behavior change in community as well as the final workshop on 12 July 2012 to present the result of the pilot program to the whole kelompoks in Muntigunung and to build Muntigunung commitment in order to support the implementation of the scale up program of CLTS. As the result of the pilot program, Cangkeng community has shown their behavior change toward more hygienic behavior. The community that previously defecates in open area, now has been changed into defecating in latrine. Community in Kulkul-1 and Kulkul-2 has also shown a similar progress, though still need more time to achieve open defecation free (ODF). The evidence of behavior change is shown from the construction of latrine and hand washing facilities in every household by the community with their own funding without any support from outside the community. The type of facilities that have been built by the community were also in high variety, start from a very simple one to a permanent type. The following graphs (Figure 1, 2 and 3) present latrine facilities progress in each pilot kelompok. The first month of each graph is the baseline condition of latrine ownership in each kelompok, then the triggering process was introduced soon after the baseline data has been collected. At present time, in Cangkeng, only one family who has not yet built latrine, in Kulkul-1 there are 9 families who have built their permanent latrines after the triggering process, while in Kulkul-2 there are 12 families who have built pit and permanent latrines as the result of the program. 5

6 Figure 1 Sanitation Facilities (Latrine) Progress in Cangkeng Figure 2 Sanitation Facilities (Latrine) Progress in Kulkul-1 Figure 4 and 5 show the progress of hand washing facilities ownership before promotion of hand washing with soap introduced to each kelompok (the left bar) and after the promotion (the right bar). The graph indicates that the community has started to make and use hand washing facilities, however there are still more than 50% families in Kulkul-1 and Kulkul-2 who have no hand washing facilities at this moment. It is therefore continues monitoring will be carried out by motivator and facilitator in order to promote hand washing practice. 6

7 Figure 3 Sanitation Facilities (Latrine) Progress in Kulkul-2 Figure 4 Hand Washing Facilities Progress in Cangkeng Figure 5 Hand Washing Facilities Progress in Kulkul-1(left) & Kulkul-2(right) 7

8 The pilot program has also developed a good networking and link to Indonesian national strategy for sanitation development called Sanitasi Total Berbasis Masyarakat (STBM) or Community Based Total Sanitation. The pilot program in Dusun Muntigunung and the motivation from the Bali Province Health Agency has also triggered the Karangasem government through Karangasem Health Agency to state that STBM program is become a compulsory program to be implemented in all 12 puskesmas (Primare Health Care) in all Karangasem. The CLTS pilot program in Muntigunung has become a CLTS learning centre for all puskesmas in Karangasem. The pilot program also has made the Puskesmas staff (Sanitarian), Desi Suarmini, who work closely with Future for Children Foundation in this program won the best price of community health workers of Bali Province. The workshop at Dusun Muntigunung which were attended by all representatives of all kelompoks in Muntigunung, has presented the result of the pilot program to the community and has gain whole community commitment to support and scale up the sanitation program throughout all kelompoks. In this workshop, there were 10 kelompoks of Muntigunung who has committed to be the next kelompoks to be intervened in the next period of scale up program. Those kelompoks are Tangkujuuk, Kresek, Tegalantang, Asahan, Baru, Pendem Kelod, Pendem Kaja, Antap, Batu Lempeh and Batu Gede. At the workshop, there also present the head of other dusun (located at the south part of Muntigunung), who also has stated his interest to implement the same program in his dusun. In the workshop, Muntigunung community also agreed to establish a Sanitation Committee to lead and organize the sanitation development in their dusun. The member of the committee consist of 35 head of kelompok from all Muntigunung, puskesmas staff, village midwife, community empowerment unit of Muntigunung, head of PKK (education for family welbeing = a women organization) and head of schools. The committee will work under the coordination of the Head of Dusun Muntigunung, the village development coordinator of Tianyar Barat, the head of Muntigunung traditional village (Bendesa Adat). The consultation and capacity building for this committee will be included in the scale up program of CLTS implementation in Muntigunung. 4 Discussion The first reason to implement sanitation and hygiene behavior intervention in Muntigunung is due to high morbidity rate among children in this area. As stated in many studies that intervention on water quality, sanitation facilities and hygiene behavior has been proved to have significant impact on reduction on diarrhea cases, though single focus and integrated intervention do not show significant difference in the level of impact [5]. It is expected that the success of this pilot program may have significant impact on children morbidity rate. 8

9 Based on the successfulness of the three of pilot kelompoks, it is therefore a strategy to replicate the similar program concerning sanitation development into other kelompoks Muntigunung is necessary. There are some lessons learnt from the pilot program to be used in improving the program in the scale up phase. Frankness and willingness to learn together shown by facilitator attitude has stimulated motivators and community to participate in the program. In the pilot program, woman motivators have shown a good interest and active participation though the number of woman motivators was less than man motivators, thus in the next scale up program, the number of women involved in the program will be increased. CLTS approach has been seen to give more opportunity towards gender empowerment [6]. There is a model developed to describe stages of decision in adopting sanitation change called preference, intention and choice [7]. In this CLTS pilot program, the community triggering was aimed to increase the demand of latrine where encouraging community to have preference in having sanitation facilities. This stage is called preference stage. In this stage some constraint factors that emerge were dissatisfaction with current practices and better understanding on health impact of sanitation facility. The feel of disgust on current condition, afraid of being sick, and ashamed are some of the triggering element to raise the dissatisfaction of the current practice. The following stage called intention was influence by competing priorities, difficulties to locate facility, available fund of the household. To reduce constraints of the intention stage was carried out community meeting to share thought and discuss any possibilities among the community member, thus they may support each other For the choice stage in this pilot program, constraints are limited information on available facility alternatives, limited skill in facility construction and cost of latrine. These constraints were minimized also through community discussion to solve their problem together. In CLTS approach, all stages of decision in adopting sanitation facility are mediated through community collective action. Thus any emerging constraints are tried to be addressed together by supporting each other. Within this process, the community has more chance to maintain their preference, to guide their intention and then support their choice of particular facility they choose to build and use. To ensure all these, meetings are directed by facilitator become crucial. It is also important to note that there are psychosocio-economic influences that need to be considered in triggering and promoting this behavior change such as culture/religion, women privacy values and other norm in the community [8]. There are some other constraint in implementing this pilot program that related to spcial factors. One of the obstacles include difficulties in gathering the community in a time to introduce triggering process and to do progress monitoring due to many religious activities happening within the community. 9

10 Other improvemnet required in the next scale-up program is in capacity of motivator to motivate the community, so they may optimise the effort to motivate change within their community. When the state of ODF acheived by a community, a good awareness on post-odf dynamic of CLTS is neccesary [6]. In this advance stages, the community is expected to continue the progress on sanitation ladder and adopting adequate facilities based on their local condition and material and skill availability. In this pilot program, it is also recognised that in order to spread the program across village and sub districs, full support and good institutional colaboration with goverment is crucial. From capacity building of puskesmas staff (sanitarian and other health workers) in term of CLTS facilitating will able to support the creating of enabling environment and to build trust of the community towards their government. The health agency may perform their function in guiding the community in implementing bottom-up sanitation development. To support the eanbling environment of community behavior change, the health sector should have a strong effort to advocate government and encouraging donor to allocate funding on water and sanitation as their success on prompting the importance of medicine [9]. Moreover, the sanitation sector which often put in shadow of water sector should be able to be seen separately with water sector and need specific concern as well as water sector [9]. Thus the health community becomes the key player who may bring all sector work together for water and sanitation [9]. 5 Conclusion The implementation of CLTS Pilot Program in Muntigunung has shown a good result in term of bahviour change towards stop open defecation though the state of ODF has not yet acheived. There are some lesson learnt from the pilot program in term of the constraints and problem solving that may improve and accelerate the program succes through out all community in Muntigunung. Those lessons learnt are related to social aspects such as cultural activities that may influence how to manage the program as well as technical aspects that may influence the intention and choice stages of adopting sanitation facility. All this aspect are expected to be well addressed in the next scale-up program in Muntigunung. 10

11 6 References [1] Alisjahbana AS. Report on the Achievement of the Millennium Development Goals Indonesia Jakarta: National Development Planning Agency (BAPPENAS), [2] National Strategy on Community Based Total Sanitation (STBM), 852/MENKES/SK/IX/2008 (2008). [3] WSP. Presentation Material at Planning Agency office of Bali Province in purpose for advocacy of STBM to Bali Government2012. [4] Nampira Z, Oral speech at the National Workshop on STBM, Bali, [5] Fewtrell L, Kaufmann RB, Kay D, Enanoria W, Haller L, Colford JM, Jr., Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis, The Lancet Infectious Diseases, 5(1):42-52, [6] Kar K, Why not Basics for All? Scopes and Challenges of Community-led Total Sanitation, IDS Bulletin, 43(2):93-6, [7] Jenkins MW, Scott B, Behavioral indicators of household decisionmaking and demand for sanitation and potential gains from social marketing in Ghana, Social Science & Medicine, 64(12): , [8] Avvannavar SM, Mani M, A conceptual model of people's approach to sanitation, Science of The Total Environment, 390(1):1-12, [9] Anonymous, Keeping sanitation in the international spotlight, The Lancet, 371(9618):1045-, Acknowledgement This project and paper were fully supported by Foundation of Future for Children in cooperation with Udayana University, Mitra Samya, Puskesmas Kubu II and Health Agency of Karangasem District, Bali Province. 11