J-Kesmas: Jurnal Fakultas Kesehatan Masyarakat (The Indonesian Journal of Public Healt.
Available at http://jurnal.
id/jkesmas p-ISSN: 2355-0643, e-ISSN: 2355-0988 Vol.
No.
April 2024
Open Access
RESEARCH ARTICLE
Correlation between Sanitation Facilities and Health Outcomes in Indonesia Lenindo, 2Vid Adrison West Sumatera Provincial Government.
Public Works Office Faculty of Economics and Business Universitas of Indonesia Corresponding author: Lenindo: lenindo@alumni.
Coauthor: V.
A: vadrison@yahoo.
Submitted: 21/11/2023 Revised: 14/01/2024 Accepted: 06/03/2024 Published online: 30/04/2024 doi: https://doi.
org/10.
35308/j-kesmas.
How to cite this article: Lenindo, & Adrison.
Correlation between Sanitation Facilities and Health Outcomes in Indonesia.
J-Kesmas: Jurnal Fakultas Kesehatan Masyarakat (The Indonesian Journal of Public Healt.
: 35-42
Abstract Poor sanitation is a significant contributor to health problems in developing countries.
The improper handling of household waste contaminates soil, surface water, and groundwater, posing health risks to communities through water consumption and exposure.
This study utilizes data from the National Socioeconomic Survey (Susena.
conducted by the Indonesian Central Bureau of Statistics (BPS) from 2016 to 2018 to examine the relationship between sanitation facilities and household health quality in Indonesia, analyzing a sample of 883,845 households.
Using ordinary least squares (OLS) regression, the findings indicate that households with adequate sanitation facilities generally experience better health outcomes.
This study underscores the importance of policy prioritization in establishing communal waste treatment facilities, such as wastewater treatment plants (WWTP.
, particularly in densely populated areas.
This approach aims to mitigate the adverse health impacts of domestic waste pollution on public health.
Keywords: Household Health.
Wastewater Treatment Plants.
Susenas.
Indonesia.
Urban.
Rural Introduction Poor sanitation conditions are among the leading causes of health issues in developing countries (Bartram, et al.
, 2005.
Bancalari & Martinez, 2.
report by UNICEF in 2023 indicates that diarrheal diseases cause approximately 480,000 deaths among children each year, while almost 60 per cent of them are attributable to unsafe drinking water and poor hygiene and sanitation.
Inadequate household waste management leads to contamination of soil, surface water, and groundwater, thereby impacting the health of surrounding communities through groundwater consumption and exposure (Palamuleni, 2002.
Murray & Drechsel.
The consumption of water contaminated with household waste can result in gastrointestinal diseases, while exposure to such pollution can cause skin infections and trachoma (White, et al.
, 2.
Compared with their peers, children exposed to household waste pollution in their environment experience more frequent diarrhea and lower growth rates (Checkley, et al.
, 2004.
Andres, et al.
, 2.
The health impacts of sanitation issues can be mitigated through equitable access to adequate sanitation facilities.
Adequate sanitation facilities constitute a system that separates human excreta and domestic waste from human contact (U.
Water.
In Indonesia, a sanitary toilet is considered to This article is licensed under CC BY- SA 4.
0 License effectively disrupt the chain of disease transmission (Ministry of Health Republic of Indonesia, 2.
A sanitary toilet consists of two parts that function as barriers between waste and human contact, namely, the upper structure and the substructure.
The upper structure primarily refers to the type of toilet used, with the pour-flush toilet (PFT) being the most effective in breaking the disease transmission chain.
PFTs have standing water in the toilet bowl, which serves as a barrier against odors and disease transmission within the toilet room (Central Statistics Agency, 2.
Apart from the upper structure, the substructure of the toilet also serves to separate domestic waste from human contact.
This separation occurs through the sedimentation of the solid waste and treatment of the wastewater before it can be discharged into water The operation of domestic waste treatment systems in Indonesia is regulated by the Ministry of Public Works and Housing Regulation No.
04 of 2017, where on-site wastewater treatment facilities at the household scale include individual septic tanks and/or communal wastewater treatment plants (WWTP.
Thus, adequate household sanitation facilities not only are limited to the use of pour-flush toilets but also need to be connected to waste treatment systems before discharge into water bodies.
Unfortunately, it is common to find toilets used without accompanying waste treatment facilities in Indonesia.
According to data from the National http://jurnal.
id/jkesmas/article/view/ Socioeconomic Survey (Susena.
by the Central Bureau of Statistics (BPS), approximately 12.
38% of households using PFTs were not connected to waste treatment units in 2018.
This figure is slightly higher than in 2016 when only 11.
26% of PFT users lacked septic tanks.
Meanwhile, the proportion of households with PFTs connected to WWTPs remained steady at around 65% from 2016 to 2018.
This stagnation may be attributed to the misconception that a safe toilet is a clean toilet, regardless of its potential to pollute the environment (CNN Indonesia, 2.
This indicates a societal tendency to prioritize the cleanliness of the visible parts of the toilet, neglecting the importance and function of its substructure.
Empirical evidence on the differential impact of household sanitary facilities on health outcomes can help raise public awareness, ultimately contributing to the increased availability of adequate sanitation Therefore, this study investigates the relationship between sanitation facility conditions and household health outcomes in Indonesia, emphasizing the presence and availability of waste treatment It compares health outcomes across households with varying sanitation setups: those without toilets, households with PFTs unconnected to WWTPs, and households with PFTs integrated into WWTPs.
The findings offer valuable insights into the role of waste treatment facilities and provide recommendations for enhancing sanitation policies in Indonesia.
Methods This research uses data from the National SocioEconomic Survey (Susena.
conducted by the Central Statistics Agency (BPS) for 2016, 2017 and 2018.
The unit of analysis consists of 883,845 households (RT.
obtained from combining data for these three years.
the household identification variable is not available, we cannot perform a panel data analysis.
As an alternative, we use pooled cross-sectional data to capture variations over time while controlling for timespecific effects.
This method enhances the robustness of the findings and provides a dynamic view of the impacts of sanitation facilities on household health.
The analysis was carried out using pooled ordinary least squares (POLS) to estimate the health production function.
The following are the empirical specifications used to investigate the relationship between sanitation facilities and neighborhood health ycAycuycycaycnyccycnycyc ycIycaycyceycnyc = yce.
cEyaycNycnyc , ycEyaycN ycycnycEa ycOycOycNycEycnyc , yaycuycuycycycuyco ycOycaycycnycaycaycoyceycycnyc The dependent variable.
AuMorbidity RateAy, reflects the ratio of household members experiencing health problems affecting daily activities in the past month.
The value ranges from 0 to 1, with values closer to 1 indicating poorer health quality.
Two categorical variables describe sanitation facilities: "PFT" for households with PFTs unequipped with waste processing facilities and "PFTs with WWTPs" for households with such facilities, such as septic tanks or wastewater treatment plants (Instalasi Pengolahan Air Limbah/IPAL).
The control variables include "Clean Water" .
if using suitable clean wate.
, "Vulnerable Age Rate" .
he ratio of vulnerable members under 5 and over 60 years ol.
, and the education level of the head of household .
ategorized into four levels, with those with a maximum of primary education as the referenc.
, "city" .
rban/rural statu.
, and "expend" .
onthly household expenditur.
Results Table 1.
Descriptive Statistics of the Continuous Variables Variable .
Morbidity Rate Household Expenditures in million Rupiah Vulnerable Age Rate Statistics .
Mean
Max
Min Mean
Max
Min Mean
Max
Min Total
0,157707
0,2655901
1,00
0,00
3,761226
3,474927
186,1922
0,1276238
0,1879817
0,2609898
This article is licensed under CC BY- SA 4.
0 License .
0,163988 0,267637 1,00 0,00 3,469497 3,238756 89,83256 0,140635 0,1850275
0,2616961
0,154545
0,263486
1,00
0,00
3,765105
3,459402
117,5338
0,1276238
0,1862565
0,2608934
0,154692
0,265563
1,00
0,00
4,045352
3,685693
186,1922
0,1342917
0,1926359
0,2603248
J-Kesmas: Jurnal Fakultas Kesehatan Masyarakat (The Indonesian Journal of Public Healt.
Available at http://jurnal.
id/jkesmas p-ISSN: 2355-0643, e-ISSN: 2355-0988 Vol.
No.
April 2024
Open Access
RESEARCH ARTICLE
Table 2.
Descriptive Statistics of Categorical Variables Variable Total
PFT
PFT with WWTP
Main Water Source Yes
12,2%
11,26%
12,95%
12,38%
87,8%
88,74%
87,05%
87,62%
Yes
64,85%
65,83%
63,52%
65,23%
35,15%
34,17%
36,48%
34,77%
73,38%
79,29%
69,36%
71,59%
26,62%
20,71%
39,64%
28,41%
57,15%
57,27%
57,05%
57,12%
42,85%
42,73%
42,95%
42,88%
55,99%
62,27%
53,32%
52,47%
12,30%
6,33%
15,3%
15,18%
23,37%
23,08%
23,35%
23,66%
8,34%
8,31%
8,03%
8,69%
Safe Rural Urban Household Head Last Education Risky Location Max.
Middle school/equi High school/equi University Table 3.
Household by Sanitation Type and Location Year
Total
Statistics Observation Total
Urban
Rural
Sanitation Type
Sanitation Type
Sanitation Type
No Toilet
PFT
PFT with WWTP
No Toilet
PFT
PFT with WWTP
No Toilet
PFT
PFT with WWTP
66,769
32,819
191,826
10,622
11,769
102,122
56,147
21,050
89,704
Observation 69,939 38,494 188,843 11,774 13,267 102,649 58,165 25,227 86,194 Observation 66,065 36,550 192,540 10,945 12,629 102,992 55,120 23,921 89,548 Observation 202,773 107,863 573,209 33,341 37,665 307,763 169,432 70,198 265,446 This article is licensed under CC BY- SA 4.
0 License http://jurnal.
id/jkesmas/article/view/ Table 4.
Household Morbidity Ratio Based on Sanitation Facilities and Location Sanitation Type
Year
Location No Toilet
PFT
Total PFT with WWTP Rural Urban Total Rural Urban Total Rural Urban Total Table 5.
Regression Results Variable Specification 1
Specification 2
Specification 3
Push-Flush Toilet
00503***
0123***
00552***
146***
0116***
00586***
00393***
139***
00553***
0150***
0265***
0398***
0103***
0108***
155***
00880***
00904***
158***
00375***
00324***
136***
00376***
0143***
0240***
0309***
00222***
00809*** .
00779***
162***
883,845
883,845
883,845
Push-Flush Toilet with Wastewater Treatment Plants Access to clean water Vulnerable Age Rate Urban Completed Junior High School Completed Senior High School Completed College/University Expenditure 2017 Year Dummy 2018 Year Dummy Constant Observations R-squared Standard errors in parentheses *** p<0.
01, ** p<0.
05, * p<0.
Discussion Descriptive Statistics The descriptive statistics are presented in Table 1 .
or continuous variable.
and Table 2 .
or categorical Table 1 shows a slight decrease in the overall morbidity rate from 16.
4% in 2016 to 15.
5% in 2018.
This improvement occurred even though the percentage of vulnerable individuals slightly increased from 18.
in 2016 to 19.
2% in 2018.
This article is licensed under CC BY- SA 4.
0 License In terms of adequate sanitation facilities (PFTs with WWTP.
, there was no significant improvement during the observation period.
The share of households connected with wastewater treatment facilities remained at approximately 65% in 2016 and 2018 (Table .
When we disaggregate observations by type of sanitation facility and location, there is a significant difference between rural and urban households.
depicted in Table 3, the share of households with adequate sanitation facilities in urban area was at least 80%, while households without toilets contributed http://jurnal.
id/jkesmas/article/view/ almost 10% of the total number of households during our observation period.
On the other hand, the share of rural households connected with wastewater treatment facilities ranges between 50% and 53%.
The fact that approximately 33% of rural households do not have toilets is concerning.
The absence of adequate sanitation facilities implies that household waste is directly disposed to the environment.
A house with PFTs that are not connected to WWTPs essentially practices open defecation, similar to a house without a toilet, as untreated waste is discharged directly to the The extent of open defecation poses a substantial risk to human health.
This is because open defecation introduces bacteria and toxins into the ecosystem and is harmful to human health.
Indeed, empirical studies provide strong evidence of this impact .
ee, for instance.
Blum, 1974.
Andres et al.
, 2017.
Bancalari and Martinez, 2017.
Bartram et al.
, 2005.
Daniels et al.
Duflo et al.
, 2015.
Wibowo and Tisdell, 1993.
Vlahov et al.
, 2007.
Esrey et al.
, 1.
To identify whether households with poor sanitation facilities tend to have a higher morbidity rate, we compared the morbidity rate with that of households with proper sanitation facilities.
The results are presented in Table 4.
As depicted in Table 4, households without toilets tend to have a greater morbidity rate than households with toilets.
Households connected with wastewater treatment facilities tend to have a lower morbidity rate.
This result holds for both rural and urban The morbidity rate for urban households without toilets is consistently greater than that for those in rural One possible explanation is that urban areas tend to have a higher population density.
Consequently, harmful bacteria and toxins can spread more easily in densely populated areas.
Empirical Results We estimate the morbidity rate sequentially to identify whether the result is sensitive to different Initially, we regressed the morbidity rate as a function of sanitation facilities, access to clean water, vulnerable age, location, and time effects.
The argument for excluding education level and monthly expenditure is because of a possible correlation between these two variables and the type of sanitation facility.
For instance, a household head with higher education may have better knowledge regarding the importance of adequate sanitation facilities for household membersAo Similarly, household income .
roxied by monthly expenditur.
is potentially correlated with the ability to have adequate sanitation facilities.
Specifically, households with higher incomes are more likely to have adequate sanitation facilities.
Including This article is licensed under CC BY- SA 4.
0 License these two variables will result in inaccurate conclusions regarding the impact of sanitation facilities on However, education and income may also directly affect morbidity.
For instance, education level may affect household preventive actions and directly affect household member health conditions.
Similarly, income may also affect householdsAo ability to afford preventive measures and thus affect morbidity.
To account for this possible direct effect, we include these variables The empirical results are presented in Table 5.
Except for PFT, the significance and sign of each parameter remain consistent across different Since specification 3 involves more variables that are found to be significant .
nd thus reduce the risk of omitted variable bia.
, we use the result from specification 3 as the basis for our analysis.
As shown in Table 5, the order of parameter magnitudes remains consistent across specifications.
For example, households with PFTs connected to wastewater treatment plants have lower morbidity rates than those without toilets.
The morbidity rates for households with PFTs not connected to wastewater treatment plants are not significantly different from those without toilets.
As previously mentioned, the lack of adequate sanitation facilities means household waste is directly disposed of in the environment, posing health Households with access to clean water tend to have a lower morbidity rate.
Although the parameter magnitude of clean water access in specifications 1 and 2 is less than the parameter for adequate sanitation .
PFT with WWTP), the parameter of both variables is close in specification 3.
The share of vulnerable household members is positively correlated with the morbidity rate.
A higher morbidity rate can also result from the impact of one person's illness on the health of others in the same household, regardless of whether the disease is If a nonvulnerable household member falls ill, there will be fewer people available to care for vulnerable members, thereby increasing their health Conversely, if a vulnerable member is the first to suffer from an illness, they will require care from an adult .
onvulnerable membe.
The time allocated for caregiving may reduce the rest of the caregiverAos time, increasing their own risk of illness.
The results in Table 5 suggest that urban households tend to have better health conditions than those living in rural areas, as indicated by the negative parameter for urban areas.
One possible explanation is that urban areas generally have more healthcare facilities, providing better access to healthcare for their residents http://jurnal.
id/jkesmas/article/view/ (Blum, 1.
The parameters for education indicate that households whose heads have not attained a junior high school education .
he reference grou.
tend to have higher morbidity rates.
Conversely, the higher the education level of the household head is, the lower the morbidity rate.
This is likely because higher education levels provide better knowledge, leading to more effective preventive and curative measures, thereby improving health conditions (Wibowo & Tisdell, 1.
The parameter for expenditure is negative and significant, indicating that wealthier households tend to have better health conditions.
As discussed earlier, income .
roxied by expenditur.
is positively correlated with a household's ability to afford preventive and curative measures.
Although income may also affect health outcomes through the availability of adequate sanitation, we do not investigate this channel.
The primary reason is that a two-stage estimation is needed:
the first stage involves nonlinear estimation .
uch as probit or logi.
, and the second stage involves linear Even if such an estimation were performed, it would not guarantee an accurate result for the indirect effect of income through adequate sanitation.
This is because income may vary over time, while the type of sanitation facility tends to remain constant once As an illustration, if a household with adequate sanitation experiences a decrease in income, the sanitation facilities will not be downgraded.
Therefore, despite not accounting for the indirect effect of income, we are confident that our results remain The parameters for the year dummies are both negative, indicating a general improvement in the health conditions of Indonesian households.
However, the parameters are very small, suggesting that the progress was slow from 2016 to 2018.
Conclusion This research underscores the critical importance of adequate sanitation facilities, particularly Pour-Flush Toilets (PFT.
with waste treatment, for communities in Indonesia.
Despite ongoing efforts, access to such facilities stagnated between 2016 and 2018, with urban areas generally faring better than rural areas.
Our empirical findings highlight the significant impact of various sanitation facilities on household health, demonstrating that PFTs with waste treatment are correlated with improved health outcomes.
The results of this study indicate the need for government intervention, especially in providing communal wastewater treatment plants (WWTP.
in densely populated low-income areas.
Several factors This article is licensed under CC BY- SA 4.
0 License support the recommendation for communal WWTPs.
First, there is the health impact.
Our empirical evidence shows that PFTs positively affect health only when waste treatment facilities are present.
The second factor is urban vulnerability.
While access to PFTs is high in urban areas .
pproximately 90%), many households lack adequate waste treatment facilities.
Given the greater vulnerability to sanitation issues in urban areas, communal WWTPs can mitigate pollution impacts.
The third factor is land efficiency.
Compared with individual septic tanks, communal WWTPs are more land-efficient.
They reduce environmental pollution and free up land previously used for waste disposal, decreasing exposure to pollution in serviced residential Acknowledgments We are grateful to the anonymous reviewers for their valuable input and comments.
Author Contribution and Competing Interest Lenindo and Vid Adrison both contributed to the research design, data collection, quantitative analysis, and writing.
Both authors have declared no competing interests in this research.
References