IMPLEMENTATION OF SANITATION CLINIC PROGRAM IN EAST LOMBOK REGENCY, PROVINCE OF WEST NUSA TENGGARA, INDONESIA

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1 IMPLEMENTATION OF SANITATION CLINIC PROGRAM IN EAST LOMBOK REGENCY, PROVINCE OF WEST NUSA TENGGARA, INDONESIA Dr. Eko Budi Santoso, MT Institut Pemerintahan Dalam Negeri or Institute of Home Affair Administration, Baiq Maya Rosita Institut Pemerintahan Dalam Negeri, Abstract Public health can be influenced by environmental factors, behavior, health care, and heredity. The first three factors are easier to be found the solution rather than heredity. One of the efforts to improve the quality of the first three factors in East Lombok district has been implemented is the sanitation clinic program. Sanitation clinic program for the first time held in Indonesia by East Lombok Regency in 1995 which then have been followed by several other regencies in the province, then Province of East Java, South Sulawesi, South Sumatera, and South Kalimantan as well as other provinces in Indonesia. Although as a pioneer of sanitation clinic program, but the indicators of environmental health in East Lombok has not been good enough. This research seeks to explore and describe the implementation of sanitation clinic program in East Lombok regency, especially in the district of Terara which is one of the most densely populated districts in East Lombok regency, and the constraints encountered in its implementation. The method used is qualitative explorative and descriptive research, with research locus in the District of Terara in East Lombok Regency. Data were collected by interview, observation and documentation. It is concluded that the implementation of Sanitation Clinic Program (SCP) in Terara district, one of district in East Lombok regency, has not been implemented quite well and there are still many constraints encountered in its implementation. Some of the constraints include the budget for sanitation clinic program that is still limited and inadequate number of officers who are experts in the field of sanitation. It is recomended to conduct training and supervision of District Health Center (DHC) personnel in charge to SCP, so that the sanitation clinic program through the integrated efforts of environmental sanitation and the eradication of disease based on environment, can run well. And added enough budget to implement the program in accordance with the number of existing cases. Keywords: Program Implementation, Sanitation Clinic, East Lombok Regency, Province of West Nusa Tenggara A. INTRODUCTION Health is a basic right for every individual and all citizens the right to obtain the same degree of health. Many factors affect the health (both of the individual and public health). Cited from Hendrik L. Blum (1974 ) in Soekidjo Notoatmojo, the factors are environmental, behavioral, health care, and heredity. Optimum Status of health can be achieved when these four factors together have been in optimum conditions. When the one of the factors disturbed or not optimal condition, the health status will be shifted under optimum condition, too. Based on the Regulation of Minister of Health Number 13 of 2015 concerning the Implementation of Environmental Health Services in District Health Center (DHC), on Article 2 which reads "Each DHC are obliged to implement Environmental Health Services, which is part of the comprehensive health care provided to patients ". According to the 1

2 regulation, so every DHC to carry out the public health service to the community in the district. East Lombok Regency is one of the most densely populated district in the province of West Nusa Tenggara with the rate of population increase by 0.6% per year, and the total population of East Lombok district in 2014 amounted to 1,130,205 persons. This regency is the widest territory and highest population among 10 regencies in West Nusa Tenggara province. (CBS, 2014). There has been an increase in the construction of family latrine (water closet) and water supply each year in urban areas of the regency, but still not prevalenly distributed. It influences the level of public environmental health still in low level, especially in rural areas. Regard to the time of starting the sanitation clinic program in 1995 that have more 20 years, and the evironment health level still in low lwvel, so it show that the result of the Sanitation Clinic Program (SHP) is not in good result. Although East Lombok is a pioneer of service activities sanitation clinic, but 85 of 192 total health workers in all health centers located in East Lombok regencies, in the field of sanitarian and public health, which is generally dominated by the nursing profession. This proves that there is still a low number of personnel who are experts in the field of sanitation and public health. SCP is the development of program introduced by the DHC of Wanasaba in East Lombok regency of West Nusa Tenggara province in year of Furthermore, this program was followed by several DHCs in any DHCs in any onther provinces, formerly in East Java, South East Sulawesi, South Kalimantan, South Sumatra and South Kalimantan. Until 2004, the SCP program has spread throughout the provinces in Indonesia, has reached 23.4 % of all DHC in Indonesia (1,527 of 6521 DHCs in Indonesia (Aini, 2004 at the Department of Health, 2001). Terara sub-district is one of the subdistrict located in East Lombok regency, that consists of 10 villages with level of public health is still in low level. Although this district as the second district which has done the SCP after Wanasaba District, but still have many people with any diseases. Thera are many villages in low condition of sanitation because of the facilities and infrastructure to reach the village is still poor. B. METHODS This research is part of social research (Silalahi, 2006), that was be done with qualitative approach with inductive approach (Creswell, 2013). The specific method are descrpitive and explorative method. According to social research methode, Ulber Silalahi in the book Social Research Methods (2006 : 11) says that the social research methods in a broad sense is a way and a systematic procedure and was organized to investigate a particular social problem with the intent to obtain information to be used as a solution to the problem. Cresswell (2013: 4) explain about qualitative research, as cited below: " Qualitative research is methods to explore and understand the meaning that the individual or group of people sejumah ascribed social or humanitarian issues. This qualitative research process involves important efforts, such as asking questions and procedures, collect specific data and participants, analyze the data inductively from the themes that were particular to general themes, and interpret the meaning of data. The final report on this study has a flexible structure or framework. Anyone involved in this research form must implement a stylish perspective inductive research, focusing on the individual meanings, and found the meaning of the complexity problem ". This research collects data, facts, and other evident in the subjects studied (social phenomenon) and analyze them to get deep understanding of the object of research to 2

3 find out what was going on. And then describe them to the report to have solution needed, and make inductive meaning to make wider solution to the similar condition of social phenomenon and problems. Data collection techniques used are three techniques, namely : 1. Interview to the Chief of Medical Officer of East Lombok Regency, head of Disease Control and Environmental Health Development, 3 officer of the DHCs of Terara District that held responsibility in Community Sanitation, and 10 persons of Terara District who get the service of the Terara DHC 2. Observation by performing the direct observation of procedure and implementation of medical services in Terara DHC, especially in dicipline of the officer of DHC in SCP services, facility and infrastructures, and in location of the SCP services. 3. Documentation, that is done by collecting the documentation related the implementation of SCP in Terara District, the activities carried out by officers of sanitation clinic services. Operationalization of the concept studied uses the concept of Hendrik L. Blum (that public health can be affected by environmental factors, behavior, health care, and heredity) and normative aspect regulated by the Ministry of Health of 2001 which says that Service of sanitation clinic is a tools to address public health problems through integrated efforts of environmental health and disease eradication with elucidation, counseling and technical assistance from the attendant of DHCs. Clinical sanitation services not as a standalone unit, but as part of the DHC, working closely with other programs of related sectors in the working area of DHCs. Table 1 Operationalization of Focus of Concept Studied Focus of Concept studied Implementation of Sanitation Clinic Program Category integrated efforts of environmental health trough elucidation, counseling and technical assistace Diseases Control through elucidation, counseling and technical assistance Sub Category 1. Improvement of evironmental sanitation 2. Improvement of clean water quality 3. Improvement of family toilet 4. Improvement of environment cleanness 1. Improvement of healtful habit 2. Control of infectious diseases 3. improvement of disease eradication activities C. RESULTS AND DISCUSSION C1. Integrated Efforts Of Environmental Health Integrated efforts of environmental health is the effort made by clinic sanitation staff in order to improve public health. This effort is done through elucidation, counseling and technical assistace of: 1) implrovement of environmental sanitation; 2) improvement of clean water quality; and 3) improvement of family toilet/latrines. The complete result and discussion about each of sub category, are described below. From the discussion below, it can be shown that on the sub category improvement of environment sanitation, implementation of SCP has not been run well. On the sub category of improvement of quality of clean water, also can be shown that implementation of SCP has not been conducted well. And neither the result on the sub category of improvement of family 3

4 latrines/toilet. So it can be made sub conclusion that on the category of integrated effort on environtment health, implementation of SCP in Terara District has not been conducted well by staff or officer of SPC with few constraints. C1.1 Improvement of Environment Sanitation From the research conducted, the improvement of environment sanitation in Terara District has not run well because of funding constraint. The local government of East Lombok Regency via District Head of Terara has not able to provide well the improvement of environment sanitation in Terara District. The limited funds owned by the region to implement environmental sanitation have an impact on society of Terara District that is unfulfilled on public sanitation. That is one of the causes of the low quality of sanitation in Terara District which should be able to be a role model for other district of East Lombok Regency, because Terara is the second district that run the Sanitation Clinic Program in East Lombok Regency, after the former of Wanasaba District. This limitation also cause the weak of technical assistace which can be tranfer to the society of Terara, especially in material and devices form related to the raising of environment sanitation quality. The second cause is the limitation of human resources who have high expertise to conduct elucidation and counseling about environment sanitation to the community of Terara District. It is caused by the proffesional background of the staff of Sanitation Clinic Program are all from nurse education. They have little knowledge in environment sanitation and development of environment sanitation. The effects of the limitations in Terara District are: 1) Still easy to find person who waste human garbage to the river; 2) easy to find environtment with unpleasent smells, espesialy in high density settelement; 3) easy to find garbage or trash scattered in any settlement; 4) poor in providing garbage box or garbage dump in neigborhood. C1.2 Improvement of Clean Water Quality Water quality is important for everyday purposes, both for consumption and for other purposes. Some health problems often found in Indonesia are related to the water quality consumed by community in any purposes, ie for drinking, bathing, cooking and washing. In accordance with the drinking water quality targets for people in East Lombok regency is include 85 % people. This target was set by the Office of Health of East Lombok Regency for But it has not reached yet. So the spread of the disease due to the quality of water consumed by the people is still low, especially for people who are in the area Nearby river. Improvement effort to raise the quality of clean water for people can be said that the last result is in low level. It is caused by limitation in fund to conduct elucidation, counseling, and technical assistance to raise awareness of the people to use clean water, to facilitate the people in providing the clean water for their families. It is easy to found people use water from river directly to fulfill many daily uses, such as bathing, washing, and coocking. These indicate that the impact of the program, still in low level impact in dayly of people life. C1.3 Improvement of Family toilet/latrines As according to Hendrik L Blum (1974) in Soekidjo Notoatmojo (2007), there are four factors that can affect people's health, include environment, behavior, health care and heredity. These four factors are a major source of health problems, but the three factors are the esier factor to be improved by human. One of the efforts can be improved is improving the familiy latrine. The ideal conditions is at least one family one latrine. The target of the Local Office of Health of East Lombok Regency on 2015 was 100% households with latrines. But in reality the target has not been reached yet. There are 4

5 still many people who use latrine in places that should not be used as latrines, such as river. It hapens because many household does not have latrine for their family. Many people want to be provided their need of latrine for their family by local government. It shows the failure (unsuccessfull result) of the effort in improvement the family latrine. The effort done by SCP staff of DHC (in elucidation and counseling) can not change the awareness of people to provide their latrine as their need to get better health. And the technical assistance done, also can not provide mostly they need. The failure can be affected by the limitation of the SCP fund to conduct the elucidation, counseling, and technical assistance, and also the weak of SCP staff in conducting the elucidation and counseling. C2. Disease Eradication Eradication of the disease is one of the two main strategies in the implementation of the SCP, in addition to the integrated efforts of environmental health, to be able to address the public health problems. This is as stated in white book of Clinic Sanitation (2011) which reads "Clinic sanitation is a tools for the community to address address public health problems through integrated efforts of environmental health and disease control with elucidation, counseling and technical assistance from the attendant of DHCs. In this research, the eradication of the disease as one of two categories as the focus of this study. There are three sub categories in this category (Disease control), namely: 1) Improvement of clean and healtful habit; 2) control of infectious diseases; and 3) improvement of disease eradication activities. All of the efforts at the three sub categories are conducted by elucidation, counseling, dan technical assistance. Implementation of the three sub categories can be stated that they are not run properly in accordance with the purpose of the sanitation clinic. It hapens because some of the obstacles are faced, both from officials as well as from the patients or clients. So the spread of the disease based on the environment in the district Terara still high and the need for special treatment or action in order to reduce the amount of spread of disease in the community. Since the SCP conducted to the community, it should be able to reduce the number of patients who indicated disease based on the environment. From the data and analisis below, can be shown that implementation of SCP in Terara District has been able to change clean and healthful habits of people. On the other hand, the conditions of sub category of control of infectious diseases, shows that implementation of SCP has reach the low level of success. Sub category of improvement of disease eradication activities, also shows the low level of achievement. So it can be conclude that on the category of disease eradication, implementation of SPC has not been conducted quite well or in low achievement. It can be shown that 232 of 320 patients (72,5 %) at the DHC Terara during the month of January 2016, are the patients with diseases based on environment. The number of patients suffering from disease based on the environment shows that the increase of disease eradication has not been able to overcome the problem of infectious disease based on environment. Real counseling data got through the documentation technique, shows that there are 53 of 736 (4.8%) patients, have been implemented the advise stated by the staff or officer of SCP. It means that the success rate of implementation of SCP in Terara District is still considerably lower than 70%, the target to be achieved. C2.1 Improvement of Clean and Healtful Habits Clean living habits of society into something that should be improved, especially in people who are prone to 5

6 disease environments based environments such as rural and slum areas. Increase habits of cleanliness this is a task that must be carried out by the clinic sanitation. SHP implementation in District Terara through elucidation, counseling and technical assistance of disease control, is expected to be able to the control of many diseases related to the environment. It is expected to improve public health. It accordance with Law No. 36 Year 2009 on Health on Article 162 paragraph 1, which says "environmental health held to realize the quality of a healthy environment". Clean and Healtful habits for people in the District Terara, show the increasing condition, with evident such as positive response from the community through small things in daily life. Some of the daily better little things chaged, are the habit of washing their hands before eating, using of clean eating tools, and the consumption of healthy food menu. This indicates that the SHP officers/staff had success in running the elucidation and counseling about the importance of clean and healthy living habits. The strategy done are doing the elucidation and counseling to the schools both at primary and secondary school in Terara District. C2.2 Control of infectious Diseases Control of infectious disease is one of three sub categories that compose the category of disease eradication. The infectious disease meant here is the disease that easy to infect from one to others, that the infection or disease transmission strongly influenced by environment conditions. Some of the infectious diseases based on environment conditions, include Acute Respiratory Infections (ARI), pulmonary tuberculosis, diarrhea, malaria, Dengue Hemorrhagic Fever (DHF), food poisoning, intestinal worms, as well as health problems caused by chemical poisoning and pesticides. Implementation of SCP is expected to overcome the problems in society of Terara Diastrict that has a number of patients suffering from disease based on the environment, in high quantities. There was 232 of 320 patients (72,5 %) at the DHC Terara during the month of January 2016, are the patients with diseases based on environment). The large number of patients with diseases environmentally based, shows an indication that the implementation of the SCP has not been able to overcome the problem of infectious disease based on environment. C2.3 Improvement of Disease Eradication Activities Terara eradication of the disease in Terara district generally has started to increase (according to informants from SCP staff), although for certain diseases is still high. The high number of disease patients is also found in some parts of Terara District, because of limited funds and the number of sanitation clinic staff / officer to reach them. But the action taken sanitation clinic officers in addressing diseases, particularly environmentally based disease problems, according to the community opinion, there has been no improvement. So that there is a difference of views between opinion of informan from SCP program actors and communities that receive their program. From the counseling data documented, it was got the fact that there are only 53 of 736 (4.8%) patients who carry out the advice given by the SCP staff after the counseling session. Compared to the target to be achieved (70%), it can be said that the achievement of implementation of SCP in Terara district is still very low. D. CONCLUSION AND RECOMMENDATION D.1. Conclusion The conclusion of this study is the implementation of clinical Sanitation Clinic Program (SCP) in Terara District through integrated efforts of environmental health and efforts to eradicate the disease with 6

7 elucidation, counseling and technical assistance still has not done well. And neither the achievement targets of SCP (has not been reached well). There are still many constraints encountered in SCP implementation. Some of the constraints include the budget for sanitation clinic program that is still limited and inadequate number of officers who are experts in the field of sanitation. Awareness of the people that just want to be provided their need by government, also contribute to the unsuccessfull result of the SCP in Terara District. Related to the concept of Blum (1974 in Notoatmojo, 2007), the result of this research shows that the District Terara can not work optimally in the fourth of health factors, namely environmental factors, behavior, health care, and heredity. So the effect of these is the low level of health indicator of Terara District. If the problems in these factors can be overcome, then the achievement of the District Terara will be able to compete with of another District in East Lombok, such as Montong Betok District that has already been Pilot district for sanitation clinic, and District Wanasaba that have already been able to overcome the problem of environment based diseases on their society. And the concept of Blum, is still proved quite well at this case of this research. D.2. Recomendation According to the conclusion, it is recomended some action, such as below: 1. Add the budget to conduct the SCP, adjusted to the number of cases in each part area of Terara District 2. Give training to the staff or officer in charge to the SCP, to increase the capacity 3. Add the medical profesional and public health officer at DHC, especially to conduct the SCP 4. Make Closed Supervision System to the staff in charge 5. Make good relationship to the informal leader in order esier to transfer awareness of value and clean and healthfull habit. E. REFRENCES John Creswell. (2013). Research Design. Yogyakarta: Library Learning. Notoatmodjo, Soekidjo. (2007). The Public Health Sciences and Arts. Jakarta: PT. Rineka Reserved. Silalahi, Uber. (2010). Social Research Methods. Bandung: PT. Refika Aditama. Entjang, Beautiful. (1991). Public Health Sciences. Bandung: PT. Citra Aditya Bakti..(2011) The White Book of Clinic Sanitation. East Lombok: Office of Health of East Lombok Regency..(2014). East Lombok Regency in Number Year East Lombok: Statistic Center Agency of East Lombok Regency.(2015). Minister regulation of Heath number 13, year of 2015 about Implementation of Environmental Health Services at the Distric Healt Center (DHC) (Penyelenggaraan Pelayanan Kesehatan Lingkungan di Puskesmas), Jakarta: Ministry of Health of Indonesia.(2013). Minister Regulation of Health number 1202/MENKES/SK/VIII/2003, year 2013 about The Guidance of Counseling for Sanitation Clinic staff. Jakarta: Ministry of Health of Indonesia. 7