Page 35 - AW MayJune 19

SPECIAL FEATURE

common in the urban sanitation space. The universal access to water and sanitation. Geographic targeting
access targets will be met primarily through on-site can be used to reach areas where undernutrition
sanitation systems with fecal sludge management (72.5 and underlying deprivations are high. In these areas,
percent); smaller shares are planned for centralized interventions should be colocated to achieve service
and decentralized sewerage (12.5 percent) and basic improvements across multiple sectors that impact
sanitation (15 percent). Low consumer demand for stunting. PAMSIMAS can serve as the main platform
fecal waste management services is a reflection of for multisectoral convergence between WASH and
both the lack of integrated services and the lack of other programs addressing nutrition outcomes in
knowledge about safe management and disposal young children, with oversight of implementation
practices. Part of the solution will require generating coordinated through the National Development
the necessary demand and changing the behavior of Planning Agency (Bappenas).
individuals, communities, and providers. But behavior • Crowd in resources until communities achieve
change cannot happen in a vacuum—it also requires near universal coverage of sanitation. There is now
a coherent policy framework, clarity on institutional compelling evidence, both within Indonesia and
arrangements, and adequate enforcement of LG globally, that sanitation levels of a community are
ordinances for design, construction, and desludging more important than those of any one household. The
(World Bank and Australian Aid 2013). Coordination evidence shows that health and nutritional benefits
between MoH and MoPWH will be needed for effective mainly accrue after a minimum threshold level of
implementation of STBM in urban areas, along with the coverage is surpassed, and that full benefits may only
Ministry of Environment and Forestry (MoEF) to enforce be achieved as sanitation becomes universal. This
new regulations on effluent standards. evidence supports existing sector practices, which aim
• Elevate the profile of sanitation in political and fiscal for open-defecation free (ODF) areas, and suggests
discussions, as well as in intrahousehold decision- that resources should be spent on bringing as many
making. This change could require a shift in the communities as possible to universal or near-universal
narrative around urban sanitation to emphasize not levels of coverage in order to realize the health
only elements of modernity and competitiveness, but benefits of sanitation.
also the lifelong effects on intellectual and economic • Adapt water and sanitation interventions to be more
potential of early life stunting, caused in part by poor “child-centric.” The five pillars of STBM ([1] stop open
sanitation. AKKOPSI (Regency/City Alliance for Better defecation; [2] hand washing with soap; [3] household
Sanitation) could lead advocacy efforts with mayors safe water treatment and storage, and safe food
and district heads. handling; [4] safe disposal and management of
solid waste; and [5] safe disposal and management
Fact 5 of wastewater) are comprehensive across WASH
An estimated 9 million children (37 percent) under five in services, but may still miss some of the dominant fecal
Indonesia are stunted. Children in rural areas are more contamination pathways that affect small children. An
likely to be stunted than children in urban areas, but a emerging approach known as “baby WASH” or “child-
centered WASH” focuses on interrupting exposure
child from the lowest income quintile is just as likely to pathways that are most strongly associated with
be stunted whether he or she lives in an urban area (48 subsequent diarrheal disease. The MoH should adapt
percent likelihood) or a rural area (49 percent). Owning existing STBM behavior-change communication
a toilet and having access to clean drinking water materials and LG capacity building to incorporate
supply, as well as living in a community where most of baby WASH, while implementation of the approach
one’s neighbors own a toilet, are important drivers of should be aligned with the current nutrition-sensitive
child growth and cognitive development in Indonesia. pilot of PAMSIMAS.
Access to WASH is just one key driver of nutrition, with food • Target slum areas and informal settlements with
security, care, and access to health care being additional multisectoral action. Conditions of poverty,
factors. The nutritional impact of WASH investments can overcrowding, and poor quality services interact
be enhanced through multisectoral convergence to to magnify the risks of poor water and sanitation
ensure that children have simultaneous access to all in densely populated urban slums. The speed and
drivers of nutrition. scale of urbanization in Indonesia contributes to
the urgency with which these challenges must be
Recommended Action addressed. Multisectoral approaches have largely
Champion multisectoral approaches to reduce child focused on rural areas, but the challenge in urban
stunting slums and informal settlements is complex, as an
• Capitalize on synergies of multisectoral approaches. effective response involves a multitude of actors and
Progress toward reducing stunting in Indonesia can be is complicated by institutional constraints and tenure
enhanced by coordinated multisectoral interventions insecurity. Additional work is needed to understand
that address effectively the four key underlying the contamination pathways unique to these settings,
and how to effectively engage different actors under
determinants of nutritional status— food security, the National Slum Upgrading Program (KOTAKU).
access to health care, child care practices, and

Asian Water MAY/JUNE 2019 33