Human excrement is home to a cornucopia of pathogens, including those that cause polio and cholera; when people ingest fecal matter, these microbes find new hosts. Modern sanitation systems prevent these harmful pathogens from entering the water and the food supply.^source Open defecation offers no such safeguards; as a result, feces spread diarrheal and other diseases to surrounding communities, particularly poor ones that lack piped water and draw drinking water from contaminated rivers and wells. Researchers have estimated that inadequate sanitation is to blame for one-fifth of the global diarrhea burden, accounting for 280,000 deaths and 18.6 million DALYs lost each year.^source

The lack of private sanitation facilities leads to additional dangers for women and girls. To avoid defecating in public, many wait until night to seek relief.^source Darkness offers some privacy, but it also cloaks potential threats: unwanted attention, harassment, and even the specter of rape or violence.^source

In Indonesia—a huge and highly diverse archipelago of over 200 million people—the scope of the sanitation crisis was daunting. As of 2005, an estimated 27 percent of Indonesians, including 37 percent in rural areas, practiced open defecation.^source The cost was unacceptable. Each year, 50,000 deaths and 120 million illnesses were attributed to poor sanitation practices and inadequate sanitation facilities, causing an estimated US$6.3 billion in annual economic loss.^source Due to limited resources and a failure to convince poor rural households that open defecation posed real health risks, past initiatives to improve sanitation had fallen flat.^source

Water and sanitation projects in Indonesia during the 20th century had focused on the construction of and financing for communal private sanitary facilities. But these efforts often failed to prompt the level of behavior change needed to generate health gains.^source Efforts to construct hygienic latrines were particularly criticized for exacerbating social inequities: the poorest were left behind as wealthier households benefited from government subsidies for toilet construction.^source Indonesian government officials and the international policy community wrestled with “deep frustration over the continued lack of progress in the sanitation sector.”^source It was clear the challenge required a different approach.

In late 2003, Indonesia field staff from the World Bank’s Water and Sanitation Program (WSP) found one potential solution: Community-Led Total Sanitation (CLTS), a new approach that focused on self-motivated, community-level behavior change. On a trip to Bangladeshi villages, the group visited communities that had been declared “open defecation-free,” or ODF. Success was attributed to the CLTS approach.^source CLTS worked by first increasing demand for good sanitation. The programs were designed to "trigger" feelings of shame in people who practiced open defecation, leading them to seek improved sanitation. It attempted to mobilize entire villages by drawing on their collective identity and social connections to change social norms.

WSP eyewitnesses eagerly shared their findings with Indonesian government officials, and invited a CLTS researcher to present the approach to high-level Indonesian stakeholders. Three months later, WSP flew a group of Indonesian officials to Bangladesh to show them the CLTS in action.^source Upon their return, the officials pushed for adoption of the new approach.

By the first half of 2005, donor-supported field trials of CLTS had begun in 17 Indonesian communities; others joined soon thereafter. The program showed early success: several participating communities quickly achieved ODF status. In 2006, impressed by the initiative’s rapid achievements, minister of health Ibu Siti Fadilah elevated CLTS as a pillar of the country’s sanitation policy.^source

Some within the government and donor organizations questioned whether these successes would translate at scale. In 2007, they were slated to find out: the Indonesian government partnered with WSP and the Bill & Melinda Gates Foundation to test a scaled Total Sanitation and Sanitation Marketing (TSSM) program based on the CLTS and complementary social marketing techniques. They planned to test TSSM in India, Indonesia, and Tanzania.^source In Indonesia, the coalition zeroed in on East Java, a diverse and largely poor and rural province of nearly 37 million people, where CLTS pilot programs had been successful.^source

To kick off the scaled-up initiative, TSSM teams embarked on “road shows” across East Java to introduce the new approach to local authorities. From 2007 to 2010, district and subdistrict level implementers rolled out TSSM in three stages across 29 districts. The targeted communities were typically those with a high prevalence of open defecation and diarrhea that were not benefitting from other sanitation programs. 

The TSSM program consisted of three core components designed to simultaneously address demand- and supply-side impediments to sanitation improvements: (1) CLTS; (2) sanitation marketing; and (3) development of an enabling environment. In addition, a routine monitoring system recorded sanitation access in each community and noted whether it had achieved ODF status.^source

CLTS focused on “triggering” sessions, designed to motivate communities to abandon open defecation in favor of sanitation facilities. During each session, a trained facilitator met with community leaders and residents. They typically started with a mapping exercise, showing where community members lived, drew water, and defecated. The facilitator then led community members on a walk through the hamlet, identifying human waste and attempting to trigger feelings of shame and disgust by modeling fecal contamination of drinking water. For example, a facilitator might first dip a hair in feces, and then dip that same hair in a glass of drinking water.^source When asked to drink the contaminated water, community members would of course refuse. In such ways, they were led to recognize the everyday consequences of open defecation.

The facilitator would educate communities on the health risks of open defecation, creating a sense of urgency to fix the problem. The facilitator would not prescribe a particular sanitation solution or strategy, but instead leave the community to independently mobilize and plan next steps. ^source

The marketing component addressed consumers’ attitudes towards sanitation. First, the TSSM commissioned market research on the barriers to sanitation uptake. The researchers found that individuals often misunderstood the connection between open defecation and disease, and consequently saw latrines as an unnecessary and unaffordable expense.

The TSSM then took steps to boost demand for and supply of affordable sanitation solutions. For example, it printed and distributed promotional materials to dissuade open defecation and catalogues comparing different sanitation options. It also trained local masons to construct low-cost latrines.^source

The TSSM included dedicated activities to create an enabling environment for sanitation expansion. This included advocacy and policy outreach to national and local government representatives to secure support, increase funding, create favorable regulations, and incentivize achievements.^source

The program enlisted one of Indonesia's leading newspapers, Jawa Pos, to help drive local government accountability. Already, Jawa Pos monitored the achievements of local governments, offering “autonomy awards” to recognize high performance. TSSM convinced the paper to include measures of sanitation progress among its award indicators to help motivate district-level stakeholders to act.^source

By 2011, the TSSM program had “triggered” 6,250 communities in East Java, of which 2,200 were verified as open defecation free. In total, 1.4 million Javanese enjoyed newfound access to improved sanitation facilities, constructed and fully financed by households themselves.^source

To facilitate a rigorous impact evaluation, the World Bank randomized implementation of the TSSM at the village level during the second phase of rollout. The results of the assessment were modest but impressive: communities selected for “triggering” were 23 percent more likely to build a toilet and 9 percent less likely to practice open defecation, compared to villages not targeted for the intervention. These behavioral changes translated to a 30 percent drop in the prevalence of diarrhea among people living in the target communities.^source Millions Saved researchers found the program averted 220 deaths over four years; those life years gained, combined with the diarrhea morbidity averted, translate to more than 18,500 DALYs averted.

Despite its notable health impact, the program did not increase equity in sanitation access. The bulk of construction and increased use of toilets occurred among better-off families; the poorest households remained unable to afford improved sanitation, and thus saw no significant improvements in toilet ownership. Still, poor families benefitted from community-wide sanitation advances. For example, poor children experienced large decreases in the prevalence of diarrhea and lower-respiratory infections. This possibly reflected decreases in fecal contamination of food and water due to new toilets elsewhere in the community.^source

TSSM program costs totaled about US$14 million, including the private cost to households of toilet and latrine construction. In total, each additional latrine required a US$65 investment. Of that sum,  government spending totaled about US$5 per additional latrine, mostly on training and triggering; the WSP spent US$14 per additional latrine for program management; and private households spent US$46 per latrine to cover the costs of construction.^source District governments contributed in small amounts from their own budgets. Their contributions varied, but averaged IDR118 million (US$13,100) annually between 2007 and 2010.^source

Were the TSSM investments in sanitation worth it? The UN Development Programme estimates that each dollar invested in water and sanitation yields US$8 in return.^source For the East Java program, Millions Saved researchers estimated that the program cost US$749 per DALY averted, decreasing to US$213 per DALY after excluding the costs to households.^source This is much lower than Indonesia's GDP per capita (US$2,947), deeming the program very cost-effective according to WHO recommendations.

However, despite the program's cost-effectiveness, Indonesian government funding for sanitation remains insufficient to meet international goals. To reach the Millennium Development Goal target—halving those without access to basic sanitation—the Indonesian government would have needed to spend US$600 million each year. Yet in the 30 years prior to 2007, government and donor funds for sanitation together totaled just US$27 million annually. Overall public expenditure on sanitation was only 0.04 percent of total public spending in 2009.^source

Despite impressive CLTS results elsewhere, Indonesia faced a number of initial hurdles that had to be overcome to achieve impact. East Java had limited experience with at-scale sanitation programs and hence limited capacity to implement the new initiative. The country’s decentralization in 2001 had resulted in fragmentation of authority and complex lines of accountability, presenting a major challenge to any large-scale program. And given the TSSM program offered no subsidies or material benefits, it was a hard sell for district and village officials.^source

Still, devolved control over the program led to uneven implementation and mixed results. Some local authorities immediately stepped up to the plate with resources and support for triggering sessions; others trailed behind. Areas abutting lakes, rivers, and beaches were among the biggest laggards; the longstanding practice of water defecation proved difficult to dismantle.^source  To incentivize the achievement of ODF in these areas, program leaders and district governments stepped in with a number of initiatives, including a partnership with Jawa Pos, cash rewards, and "clustering" intervention sites to increase motivation for collective change.^source

As the program progressed, it became clear that supply-side interventions had not kept pace with the increased demand for sanitation. After nearly two years, the program’s marketing component was up-and-running, but local markets still suffered from a shortage of low-cost sanitation solutions. And even where lower-cost options were available, costs could still exceed what the poorest households could afford. Some communities overcame this roadblock by pooling funds for a shared latrine or offering within-hamlet subsidies to poor families. ^source However, the inability of many poor families to fund latrine construction remains an important barrier to sanitation expansion and a source of further inequity.

Motivated by the success of TSSM in East Java, similar programs are now underway in rural communities nationwide.^source Yet Indonesian officials worry that the value of increased demand for sanitation is of limited value for the most deprive people, who may demand improved sanitation but cannot afford latrines.^source This concern is validated by evaluation results showing that interventions had little to no impact on latrine construction among the poorest families.^source Finding a solution to this challenge is no easy task; some have suggested the government expand construction subsidies, but research has shown subsidies may impede attainment of ODF by eroding the intrinsic desire for change.^source As in Indonesia, countries everywhere must consider how to overcome the resource constraints impeding sanitation uptake by the poorest.

Others express concerns about some of the program’s tactics, such as its focus on shaming people who practice open defecation. Critics have suggested that a program built on this premise cannot be considered fully community-led and participatory. They have also noted some of the TSSM’s promotional messages cross the fine line between persuasive communication and divisive propaganda that blames the poor for their poverty.^source  The results of these messages can be devastating: those too poor or reluctant to use latrines may experience public shaming or fines.^source These serious ethical quandaries must be carefully considered when scaling-up similar interventions in other contexts.

Global interest in sanitation has exploded, with CLTS at the forefront of the movement. In 2013, United Nations deputy secretary-general Jan Eliasson launched a high-profile campaign to end open defecation by 2025.^source Dozens of countries in Asia, Africa, and Latin America have introduced CLTS initiatives, albeit with mixed results. And the Bill & Melinda Gates Foundation has challenged the world to “reinvent the toilet,” funding 16 innovative projects that transform human waste into energy or fertilizer.^source Will the Indonesian experience inform a global sanitation revolution? Only time will tell—but it’s clear the world is finally mobilizing to move the ‘call of nature’ indoors.^source