Nurfika Osman – Tackling waterborne diseases in Indonesia is a question of educating the 30 percent of the population still practicing open defecation, health experts say.

Eka Setiawan, a sanitation expert with Plan International Indonesia, a nongovernmental organization focusing on children's access to health care, sanitation and education, says residents who continue to defecate in rivers and streams must be made to realize the error of their ways.

"Accompany them around their neighborhoods and ask them to monitor the situation, then get them to participate in a sanitation discussion," he told the Jakarta Globe on Tuesday.

"Take them to the riverbanks where they practice open defecation and then to the riverbanks where they bathe or take water for drinking. When they realize that they're consuming their own feces and urine, they'll stop that behavior."

Poor hygiene was responsible for the contamination of 75 percent of the country's drinking water in 2008, according to the National Development Planning Agency (Bappenas). Health problems as a result of poor sanitation, including diarrhea, dengue fever, typhoid fever and cholera, cost the country Rp 57 billion ($6.6 million) a year, it said.

"People tend to underestimate the importance of sanitation and related diseases," Eka said. "In fact, if patients suffering from severe diarrhea are not given proper medical treatment within 48 hours, they can die."

He said the most vulnerable group was children under the age of five. Eighteen percent of the 161,000 deaths within this group in 2006 were caused by diarrhea, according to the World Health Organization.

The WHO also says there are at least 350 cases of typhoid fever per 100,000 people in Indonesia. A country is considered highly endemic for the disease at more than 100 cases per 100,000 people. In 2010, the WHO reported that the illness killed at least 50,000 Indonesians every year.

"Changing people's behavior by improving their awareness and knowledge is much more effective than spending money building them latrines when they don't understand the importance of sanitation," Eka said.

In East Nusa Tenggara's Pulau Ende district, officials are working with Unicef to declare the area Open Defecation Free.

Spurred by the high rate of diarrhea and other waterborne diseases, a community-led total sanitation, or CLTS, approach was launched in 2007, involving community and religious leaders, women and youths in the area.

"This declaration is a significant milestone because almost 30 percent of Indonesians, some 65 million people, still practice open defecation," Unicef representative Angela Kearney said, praising the initiative to eliminate open defecation by 2014.

In the past two years, the number of cases of diarrhea in Pulau Ende has fallen by 89 percent, according to district officials. Unicef says this speaks to the success of the ODF program, particularly in preventing child deaths.

"Globally, 5,000 children die every day from diarrhea because they don't have access to proper toilet facilities or fall victim to poor hygiene practices," Kearney said.

Over the last three years, communities in Pulau Ende have been made aware of the dangers of open defecation through the CLTS method.

The program marks a strategic shift from constructing toilets for individual households to community-led initiatives. Its proponents say the CLTS approach triggers the community's desire for change, directs them toward specific actions and encourages innovation and mutual support using local solutions and leading to greater sense of ownership and sustainability.

Programs supported through the initiatives also include hygiene promotion training for the community, construction of more than 1,500 rainwater tanks and the installation and repair of more than 170 wells.

Staff members and students at eight high schools have also received training on the importance of hygiene, and new school latrines have been built.

To support the program, the district administration has drafted a village regulation on water sanitation and hygiene that encourages community members to treat open defecation as a social taboo.