# **1. INTRODUCTION**

Of the four most important causes of mortality for children under five years old in Indonesia, two (diarrhea and typhoid) are fecal-borne illnesses directly linked to inadequate water supply, sanitation, and hygiene issues (Ministry of Health, 2002). In Indonesia, about 11 percent of children have diarrhea in any two-week period and it has been estimated that more than 33,000 children die each year from diarrhea and 11,000 from typhoid (Curtis, 2004). Inadequate sanitation is associated not only with adverse health effects, but also with significant economic losses. A recent estimate of the economic losses in Indonesia from inadequate sanitation and poor hygiene practices puts them at more than 2.4 percent of the country’s gross domestic product (GDP), or approximately US$6.3 billion (Napitupulu and Hutton, 2008).<sup>2</sup> Despite wide recognition of the consequent health burdens, a large fraction of the world’s population still lacks access to basic sanitation. For instance, it is estimated that 110 million people in Indonesia lack access to proper sanitation (WHO/UNICEF, 2012). Of these, 63 million practice open defecation (WHO/UNICEF, 2012). Open defecation is of fundamental importance to development because of the health hazard it poses to anyone living nearby. If some members of a community continue to defecate in the open, the whole community is at greater risk of diarrheal diseases than people living in communities where open defecation is not practiced. Preventable diseases that result from lack of sanitation and poor hygiene behavior cause a tremendous disease burden among the poor. The greatest disease burden falls on infants and children under five years old (Murray and Lopez, 1997). By reducing normal food consumption and nutrient adsorption, diarrheal diseases are also a significant cause of malnutrition, leading to impaired physical growth and cognitive development (Guerrant et al., 1999), reduced resistance to infection (Baqui et al., 1993), and, potentially, long-term gastrointestinal disorders (Schneider et al., 1978). Improvements in sanitation thus can help reduce the transmission of pathogens that cause diarrhea by preventing human fecal matter from contaminating environments.

In January 2007, the Water and Sanitation Program (WSP) launched the Scaling Up Rural Sanitation program<sup>3</sup> to address the precarious sanitation conditions of large rural populations in the developing world. With technical support from WSP, local and national governments are implementing the program in three countries: Indonesia, India, and Tanzania.

The Scaling Up Rural Sanitation program focuses on learning how to combine the approaches of Community-Led Total Sanitation (CLTS), behavior change communications, and social marketing of sanitation to generate sanitation demand and strengthen the supply of sanitation products and services at scale, leading to improved health for people in rural areas. The project

> 2 A recent four-county study estimate found that the annual economic impact of poor sanitation is approximately US$1.4 billion (1.5 percent of GDP) in the Philippines, US$780 million (1.3 percent of GDP) in Vietnam, and US$450 million (7.2 percent of GDP) in Cambodia (WSP, 2008).

> 3 For more information on the Scaling Up Rural Sanitation program, see www.wsp.org/scalingupsanitation.

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