Good sanitation is important for public health, yet 2.4 billion people in developing countries do not have access to a proper toilet. Indonesia is one such country with a large population that has no access to a toilet and practises open defecation, particularly in rural areas [1]. Since 1990 Indonesia has increased sanitation access by 36% for its 2015 population, although the Millennium Development Goal has not yet been met [1]. Some of the progress comes from the implementation of the national sanitation program, Sanitasi Total Berbasis Masyarkat (STBM = Community Based Total Sanitation), started in 2006 and organised by the Ministry of Health. The program is based on the Community-led Total Sanitation (CLTS) approach to increase sanitation demand and combine it with a sanitation marketing approach to improve sanitation supply. However, the success of the STBM program varies widely across different villages, districts and provinces in the country, with an average success rate of 36%, and adoption sustainability is remain a challenge [2]. Here sustainability not only includes continuation of usage, but also proper functioning which ensures safe disposal of the human waste. With the new target of the Government of Indonesia for universal sanitation coverage by 2019 as well as the Sustainable Development Goals’ similar target by 2030, which means access for all regardless of setting, economic status or disability, the challenges are even greater [3]. There have been some debates about sanitation development approaches in the country, particularly in rural areas. The proponents of STBM argue that households actually have the knowledge and the funds to construct a sanitation facility in their household, and thus what they require is the motivation for demand and facilitation for access to supplies [4]. They argue that providing subsidies for toilet construction will only create a sense of dependency among the recipients [4]. However, there has been criticism that the approach does not consider the cultural, social and economic contexts of different communities in its implementation. The approach that blames poor people for their inability to practice safe sanitation by generating feeling of shame has exacerbated social stratification and also does not fit with the cultural norms in Indonesia [5, 6]. The emphasis on low cost toilets as the appropriate technology also has been criticised for not being sustainable since this option requires frequent repair and may not be hygienic [6]. In order to reduce the negative effects of interventions while also increasing the positive outcomes, there is a need for a comprehensive approach in addressing sanitation issues. The first reason is that Indonesia has a wide variety of cultural, social, economic and political contexts as well as geographical settings which lead to different combinations of factors affecting sanitation adoption and sustainability. This diversity requires a tailored intervention for each setting that considers cultural values, and the social and economic context for each of particular community. For this purpose, a comprehensive tool is necessary to guide local practitioners to assess not only individual factors but also socio-cultural and structural factors in order to apply the national program at the local community level. Secondly, the current report on sanitation development in Indonesia shows that sustainability of sanitation adoption, supply and maintenance in rural areas is still weak [3]. Sustaining safe sanitation practice requires a complete sanitation cycle from collection to disposal of waste, which is not only adopting a proper facility, but also maintaining its proper functions [7]. Thus, integrating the concern of the complete cycle of sanitation service into needs assessment and planning tools will not only address the demand and initial supply aspects, but also sustainability aspects. A third major issue in the sanitation sector is the lack of capacity of sanitation professionals in implementing sanitation development strategies [8]. The Government of Indonesia has started to integrate technical skills, such as facilitating CLTS triggering and developing sanitation market, into a formal curriculum for sanitation professionals [8]. However, these skills also need to be complemented with skills for integrating strategies and facilitating stakeholder collaboration. Generally, it has been acknowledged that sanitation issues are influenced by multifaceted and multi-level determinants [9]. These complex issues certainly require a comprehensive understanding of these inter-related factors, which will be better achieved with multi-sectoral collaboration in the assessment process [9]. To achieve this understanding, the local professional need a comprehensive framework to plot different dimensions of factors into a single matrix which will allow different stakeholders to collaborate in identifying more specific factors for their community, and also in designing and implementing integrated strategies. The output of such a framework will allow development of stronger arguments for advocacy to higher political levels in order to leverage sanitation in local development priorities. Thus, this study will recommend a comprehensive framework for sanitation development in Indonesia and will pilot the framework in a case study in rural Indonesia. The study will use a community needs assessment approach which looks at four different types of community needs, namely felt needs, expressed needs, normative needs and comparative needs, in a district in Bali as a case study area. Interviews and questionnaire surveys methods will be used to explore those needs and to un-pack the determinants. In conclusion, to improve sanitation up-take and sustainability in rural areas, Indonesia needs to provide their sanitation professionals with a comprehensive framework as a tool for assessing determinants and guiding action strategies. This framework should be able to: (1) Accommodate the analysis of social cultural, environmental and political aspects in the needs assessment process beside the individual aspects; (2) Integrate the sanitation service cycle to address sustainability and; (3) Assist sanitation professionals to facilitate stakeholder collaboration in the community. The study will not only recommend potential strategies for particular study areas, but also recommend a comprehensive framework for sanitation programs in developing countries.
