Despite significant reduction in under-five mortality in Indonesia over the past 20 years, neonatal mortality rate remains stagnant[1]; Indonesia still accounts for the 8th largest number of neonatal deaths in the world [2]. According to the Ministry of Health (MoH) national health survey[3], sepsis accounted for 12% and 21% of mortality of 0 - 6 days and 7 – 28 days age groups, respectively. Simple interventions such as handwashing and clean birth practices, in both homes and healthcare facilities (HCF), could significantly reduce the risks of neonatal mortality[4]. Promoting good hygiene including hand washing with soap also leads to fewer cases of diarrhoea and pneumonia among children under five[5].

In addition, Indonesia has over one-third of children under five years old affected by stunting, and 12% by wasting, while 18% and 5% of children are severely stunted and wasted, repectively[3]. Provision of adequate water, sanitation and hygiene (WASH) services is essential for delivering health and nutritional support services in communities including HCF.

Despite these urgent needs for adequate WASH services in HCF, achieving universal access in HCF remains a big challenge in Indonesia, where over 30 million people still practice open defecation[6].


Evidence generation

Given limited attention to WASH in HCF in Indonesia, National Institute of Health Research Development (NIHRD), MoH, Indonesia with support from UNICEF has jointly initiated data analysis of existing national data sets [7,8] as part of WASH in HCF advocacy. The key findings highlight poor WASH conditions with large geographical disparity. Presence of a handwashing station with soap was not observed in two thirds of immunization rooms, and one third of delivery rooms in primary health centers (Puskesmas). Over one third of village maternity clinics (Polindes) did not have access to sanitation facilities.

In 2016, UNICEF examined the WASH situation in local health centres across three provinces (Puskesmas, n=34). Major findings include (1) lack of routine water quality testing (29%), (2) lack of handwashing station with soap and water available within 5m of all toilets (85%), and (3) lack of regular hand hygiene promotion training for all healthcare staffs (67%). In terms of community perceptions of WASH in HCF, a recent UNICEF survey in eastern Indonesia (n=3,243) showed that one third of respondents did not agree that their closest Auxiliary Pusksmas (Pustu) had adequate WASH services for patients. These community views will affect their health-care seeking behaviour.  


WASH in HCF situational analysis

Currently the Environmental Health Unit and NIHRD, MoH with UNICEF support, have been leading a series of discussions on WASH in HCF (focusing on primary health centers, Puskesmas) with key stakeholders of MoH in order to

(1) review WASH in HCF-related policies and minimum standards, and clarify roles and responsibilities across directorates;

(2) map out existing national monitoring systems and identify a WASH in HCF monitoring entry point; and

(3) explore opportunities to strengthen health facility accreditation mechanisms for incentivising managers of HCF to improve their WASH facilities and infection prevention protocols. 


Expected key outcomes of focus group discussions include (by the end of 2017):

  • WASH in HCF advocacy document(s) with concrete and actionable recommendations (e.g. clear roles/responsibilities, and strategies to improve existing national monitoring systems and data sharing mechanisms) developed and shared with higher-level government officials for cross-directorial actions
  •  A core WASH in HCF technical working group within MoH established for continued discussions and tracking of improvements in WASH in HCF for regular reporting towards the SDGs.      


[1] Indonesia Demographic Health Survey (1992-2012)

[2] Lawn JE, Blencowe H, Oza S, You D, Lee AC, et al. (2014) Every Newborn: progress, priorities, and potential beyond survival. Lancet 384: 189-205.

[3] Riskesdas, National Health Survey, Ministry of Health, Government of Indonesia (2007)

[4] Blencowe H, Cousens S, Mullany LC, Lee AC, Kerber K, et al. (2011) Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect. BMC Public Health 11 Suppl 3: S11.

[5] World Health Organization, & UNICEF. (2013). Ending preventable child deaths from pneumonia and diarrhoea by 2025: The integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD).

[6] Joint Monitoring Programme, WHO/UNICEF (2017) Progress on sanitation and drinking water.

[7] Rifaskes, National Health Facility Survey, Ministry of Health, Government of Indonesia (2011).

[8] Podes, National Village Potential Survey, BPS (National Bureau of Statistic), Government of Indonesia (2011)