O

ne of the Millennium Development Goals (MDG) committed to by the international community in 2000 was halving the proportion of people lacking sustainable access to safe drinking water and basic sanitation by 2015.

While drinking water coverage surpassed the MDG drinking water coverage target by 1 percent in 2012, 2.5 billion people still lacked improved sanitation facilities.  

An estimated 784 million people still used public or shared sanitation facilities while the other 732 million used sanitation facilities that did not meet hygiene standards, according to the UN. Further, globally, 1 billion people practiced open defecation. Thus, the world remains far off-track and is unlikely to achieve the MDG sanitation target.

 Indonesia is unfortunately one of the 69 countries that contributes to this conundrum. In 2012, only 50-75 percent of its population had access to improved sanitation facilities.

About 54 million people, mostly in rural areas, still practiced open defecation, making Indonesia second out of the 10 countries responsible for 82 percent of the 1 billion people who defecate in the open. Given the health threats associated with substandard sanitation, serious efforts to prevent and overcome sanitation issues and open defecation is urgently needed.

As the world commemorates World Toilet Day on Nov. 19, which this year highlights the themes of equality and dignity, public health professionals and stakeholders must be reminded of the impacts of unimproved sanitation and open defecation and actions to be taken up by government.

Acute gastrointestinal infections, mostly caused by viruses and bacteria, such as diarrheal and typhoid fever diseases, are the most common health effects.

Over two decades, these two diseases have ranked among the top-25 causes of premature death In Indonesia. As every year 2 million children worldwide under 5 years-of-age die due to diarrhea, this disease ranks as the fourth-worst cause of premature death in Indonesia.

With respect to open defecation, women are the most affected. Many women, particularly in rural areas whose households have no improved sanitation facilities, must defecate in shared sanitation facilities, if available, or in spaces like rivers or bushes. Defecating in open spaces gives women no privacy, safety or dignity. They even become vulnerable to violence.

The situation requires determined action. First there needs to be stronger political will and commitment to speed up the improvement of sanitation.

The second step is developing collaboration between high-level stakeholders by identifying potential partners and establishing coalitions on the local, national and internationally levels, while strengthening existing collaborations.

The third step is designing process of change. To do this, the government and its coalitions need to collect relevant and updated information and evidence-based data, including related public health problems and violence against women.

The government can then closely evaluate existing sanitation programs and design or modify them to be cost-effective and country-specific. The fourth step is evaluating and improving existing policies or developing new ones. These should include ensuring the protection of women who need access to sanitation facilities and overcoming sanitation inequalities in rural and urban areas.  

The World Health Organization and UNICEF noted in their 2014 progress report that Indonesia was one of 35 countries to have increased rural sanitation coverage, but that it had failed to ensure equality.

The government needs to multiply available resources and improve sanitation equally and proportionally in urban and rural areas. The government should not only involve, but also work to build the capacity of health personnel for promoting health issues in society.  

To succeed in all this, the government must work closely with communities and households.

Lastly is sanitation financing. A number of countries with high diarrhea-related infant mortality rate spent less than 0.5 percent of GDP on water and sanitation. Therefore, allocating adequate funds to the national health budget is necessary.

In conclusion, there are still many more people that cannot lack access to quality sanitation.

Unimproved sanitation facilities do not only negatively impact public health, they also compromise women'€™s dignity and safety. The government needs to make a strong commitment to deal with the country'€™s sanitation issues. The national government also needs to establish and strengthen linkages and coalitions, design change processes, develop policies, multiply the availability of resources and design effective financing.

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The writer is a researcher at Women Research Institute, and an alumnus of health management and policy at Georgia State University'€™s school of public health in Atlanta, Georgia, US.