Implementation of Environmental Health Services (Sanitation Clinic) in Public Health Centers Indonesia

The Indonesian government has implemented clinical sanitation to improve a healthier environment and reduce mortality from environmental-based diseases. This effort is carried out to reduce the incidence of environmental-based diseases such as diarrhea and Acute Respiratory Infections (ARI). However, in 2017 the number of ARI sufferers in one of the provinces in Indonesia reached 45.38%, while diarrhea reached 28.3%. The diarrhea mortality rate increased to 4.76% in 2018, while the prevalence of ARI reached 9.1%. Therefore, this article aims to examine the performance of the sanitation clinic program at the Indonesian Health Center. The review method used is the narrative. Total percentage of 78.33% for the category of public health centers that have carried out the stages of sanitation clinics starting from the counselling stage to the intervention stage following established regulations. This percentage is still low because it has not received a 100% score. The implementation of the program has not been supported by adequate counselling media. In addition, the Public Health Center does not yet have a counselling room, and there is still a shortage of operational funds. Monitoring and evaluation need to be carried out to improve the service performance of the sanitation clinic program.


Introduction
revealed that environmental health is one of the factors that can affect health. The quality of an environment has to be maintained because environmental health also plays a role in achieving optimal health status. An environmentally-based disease is related to or has a close relationship with one or more environmental components in a space where a community group works or lives for a certain period (Fahmi, 2014). Three dominant factors cause the emergence of environmental-based diseases. The three factors include clean water facilities, excreta disposal, and waste. Then these factors will interact together with lousy human behaviour and create worse environmental sanitation (Selomo et al., 2018). Indonesia is a country with a population of 271,349,889 people. Environmentally based diseases are still a problem today. Diarrhoea and ARI are environmental-based diseases always included in the top 10 diseases in almost all Public health centres in Indonesia (Purnama, 2016). In 2018 there was a spike in cases of diarrheal disease and caused ten extraordinary outbreaks, occurring in 8 provinces and eight districts or cities spread throughout Indonesia. Diarrhoea is a disease characterized by changes in the concentration of stools to become more liquid with or without mucus or blood. Diarrhoea can also increase the frequency of bowel movements more than three times a day (Ariani, 2016).
Based on table 1. the mortality rate of diarrheal diseases due to extraordinary outbreaks continued to increase until in 2018 it increased relatively high to 4.76% from 2017, which was 1.97% (Kementerian Kesehatan Republik Indonesia, 2018). Meanwhile, in 2019 environmental-based diseases became the leading cause of death in children aged 29 days -11 months, causing 746 deaths in diarrheal conditions and 979 deaths in pneumonia. It also occurred in children under five aged 12-59 months; diarrhoea was the most common cause of death, followed by other diseases, including pneumonia, fever, malaria, diphtheria, measles (Kementerian Kesehatan Republik Indonesia, 2019). To improve the quality of a healthier environment and reduce the mortality rate of environmental-based diseases and overcome environmental health problems, the Government has attempted to implement promotive, preventive, and curative environmental health services that are carried out in an integrated manner. This activity is known as a sanitation clinic and is carried out at the Public Health Center. Public health centres are the front line in providing health services for the community because they are pretty effective in helping the community provide first aid with standard health services (Sanah, 2017). There are four functions of the Public Health Center in realizing health development. One of its functions is related to the sanitation clinic program, namely maintaining and improving health services that are equitable, quality, and affordable and maintaining and improving the health of individuals, groups, communities, and their environment (Alamsyah and Muliawati, 2013). Sanitation Clinic activities focus on residents with high risk or (high-risk group). The implementation of the sanitation clinic consists of several environmental inspection activities, counselling, and environmental health interventions that must be supported by the availability of adequate resources, infrastructure, and funding.
The sanitation clinic service at the Public Health Center is carried out in two ways, indoors and outdoors. Activities in the room are carried out in the counselling room located inside the public health centre. This activity is called counselling. The patient consults on environmental problems that are being experienced. As for services outside the room, the officer will visit the patient's location to observe and check on the condition of buildings and facilities' quality at the patient's residence, commonly called environmental health inspections. Based on the Environmental Health Inspection results, the officer will carry out appropriate interventions to resolve the environmental health problems experienced by the patient (Kementerian Kesehatan Republik Indonesia, 2015).
Even though the Public Health Center has implemented a sanitation clinic, it is still found that the coverage of the implementation of the sanitation clinic is low and has not reached the target at the Public Health Center. Based on previous research, the results obtained from one of the Public Health Centers in Indonesia, the scope of achieving the implementation of sanitation clinics has not reached the target, especially in counselling and environmental inspection activities. The performance of counselling got a score of 11.70%, while the target to be achieved was 29.70%. Meanwhile, the results of environmental inspections were only 43.38%, still quite far from the target to be completed, which was 100% (Susanti et al., 2019). It is directly proportional to discovering environmental-based diseases with cases that tend to increase.
There have been many studies or articles discussing the sanitation clinic program at Public health centres in an area. Still, there have been no studies examining further and comparing the implementation of sanitation clinics in several public health centres in several regions in Indonesia. Therefore, this study will discuss further and compare the performance of sanitation clinics in several Public health centres in several areas in Indonesia. This study can be a reference or recommendation for the government and environmental health service workers to improve services or performance in sanitation clinic programs at Public health centres.

Methods
This research was conducted through a literature study of various articles. Based on 32 relevant articles, 13 are the main articles discussed further in this paper. The articles that have been obtained will then be collected, tabulated, compared, then summarized, and concluded. Search articles using several keywords, including sanitation clinics, counselling, environmental health inspections, environmental health interventions, and environmental health services at Public Health Center. Articles were obtained from 70% of accredited journal sites (Sinta, DOAJ, Garuda, Google Scholar, Indonesian Publication Index. Indonesia One Search). The selection of articles is carried out by considering several criteria, including selected articles relevant to the research topic. The research location is in the territory of Indonesia, full-text journals. It can be accessed as a whole, and the selected articles are articles with a publication date of no more than the last ten years.

3.
Result and Discussion   shows the results of the implementation of sanitation clinics at several public health centers in Indonesia, which will be discussed in this article with a total percentage of 78.33% for the category of Public health centers that have carried out the stages of sanitation clinics starting from the counselling stage to the intervention stage following established regulations by the government, the percentage also shows the criteria for human resources, facilities, infrastructure, and appropriate funding. This percentage is still low and does not meet the requirements because it has not received a 100% score. While Table 2. shows the Public Health Centers in Indonesia, which are located in several regions with different criteria fulfilment in the operation of sanitation clinics. The best satisfaction is in the Public Health Centers in Kabupaten Indragiri Hilir; all criteria have been met except for human resources. Meanwhile, at the Public Health Center in Tegal, only the human resources and funding criteria have been met. The fulfilment results of other Public Health Centers criteria are listed in the table below. The explanation of each standard is discussed further in the following subchapter. Table 2. Fulfillment of sanitation clinic criteria in several regions in Indonesia Regional Stages/Criteria

Facilities and Infrastructure
Funding Description A : Appropriate NA : Not Appropriate

Counseling
Environmental Health Services, commonly known as sanitation clinics, must be carried out by every Public Health Center in Indonesia. Sanitation clinic activities are divided into several stages. The first stage begins with counselling. It is defined as communication and interaction between environmental health workers and a patient or client; counselling is carried out in the hope of finding environmental health problems suffered by patients. The initial counselling step is to find environmental risk factors associated with and suspected to be the cause of environmental health problems. Integrated control is implemented with care and treatment if it is found. Counselling is carried out in the counselling room or health promotion room every day. To be better understood by patients, the implementation of counselling can use the help of tools for pilots and printed or electronic information media. After the counselling, the environmental health officer will make the results and conclusions written in the environmental health sheet. If further action is required by observing the tendency to develop a disease, the environmental health worker will plan for the next stage by making an Environmental Health Inspection appointment (Kementerian Kesehatan Republik Indonesia, 2015).
The Public health centre that runs the sanitation clinic program has carried out the counselling stage. However, it is still not optimal in its implementation, and there are still discrepancies with applicable regulations. At the Public Health Center in the Ciracas area, counselling activities are carried out by interviewing patients and officers asking about their problems and the environmental conditions around the patient's residence. Then after getting the risk factors or causes, the officer will give simple suggestions, which can be applied easily by the patient. Counselling at the Ciracas Public Health Center follows applicable regulations. Counselling is carried out every working day from 09.00 to 11.00 PM. However, the implementation of counselling is still considered less than optimal due to the lack of patients visiting. The lack of patients visiting can be proven by environmental-based disease cases (Queena and Dewanti, 2021). The accumulated number of patients who came to the Public Health Center in the Bukittingi area to conduct counselling from 2010 to 2012 still did not meet the target (Jamarin et al., 2016). That is due to a lack of awareness from the surrounding community and a lack of socialization from Public Health Center officers.
One of the Public health centres in the Tegal area has also carried out counselling. However, the counselling at the Public health centre is not following the Minister of Health Regulation of the Republic of Indonesia No. 13 of 2015. The time for counselling at the Public Health Center should be carried out every day, while at the Public Health Center, it was only once a week. The lack of facilities and infrastructure in the form of a particular counselling room is why counselling can only be carried out once a week (Agustin and Siyam, 2020). This incident also occurred in six public health centres in the Denpasar City area, which did not provide counselling services every day, only two or once a week. That is unfortunate because the counselling stage is an essential part of environmental-based diseases experienced by patients that can be found early. It is necessary to carry out counselling every working day to overcome environmental-based disorders experienced by patients that patients who wish to consult do not have to wait longer, and environmental health problems can be quickly resolved (Irmayanti and Yulianti, 2020).

Environmental Health Inspection
Environmental health inspection is the second stage after the implementation of counselling. The outline of this stage, including direct observations and inspections of environmental media, is carried out. These observations are based on applicable and quality standards. The goal is to create and improve the quality of a healthier environment. Environmental Health Inspections are carried out by Environmental Health Workers with qualifications including sanitarians, microbiologists, and entomologists. For the time of implementation, unlike counselling activities, Environmental Health Inspection activities can be carried out outside the working hours of the Public Health Center and carried out no later than 24 hours after the implementation of the counselling. Officers are also required to carry an Environmental Health Inspection guide which contains a chart and a list of questions for each disease. A follow-up plan follows the results of the Environmental Health Inspection in the form of an Environmental Health Intervention. Environmental Health Inspections can be carried out in various ways, including physical observation of environmental media, laboratory tests, environmental media measurements, and environmental health risk analysis (Kementerian Kesehatan Republik Indonesia, 2015).
The initial step of the inspection stage is to conclude from the results of the counselling activity. Then if it is deemed necessary to take further action, the Environmental Health worker will make an appointment for a home visit with the patient and his family. Officers prepare and bring necessary equipment and tools, including measuring instruments for environmental quality parameters, Environmental Health Inspection, environmental health status forms, and outreach media, either printed or electronic. Then the next step is to observe the environmental media and community behaviour. After completion, the officer will provide follow-up advice to the patient. Follow-up can be in the form of implementing an immediate Environmental Health Intervention. Suggested interventions should consider the level of cost, level of difficulty, and effectiveness (Kementerian Kesehatan Republik Indonesia, 2015).
Environmental health inspections are carried out when the counselling results require follow-up and an agreement between the patient and the environmental health officer. Based on the number of patients who received environmental health interventions in the form of home visits by environmental health workers at the Lumajang District Public Health Center and Banjar District Public Health Center, it was pretty high, namely 98 and 114 people visited (Sugiharto and Oktami, 2018). In contrast, environmental health intervention activities at the Ciracas Public Health Center continue to decline. It is the impact of the pandemic period where many local people are still afraid to receive home visits (Queena and Dewanti, 2021). The Public Health Center in the Bukittinggi area also experienced environmental health inspection activities that had not yet reached the target and were still below expectations. Lack of human resources and excessive workload are the leading causes. Environmental health inspections at one of the Public Health Centers in the Tegal area are carried out in public places. In carrying out environmental health inspections, environmental health officers cannot reach all public places in their working areas and only focus on Islamic boarding schools and some schools. As a result, the number of public places is not proportional to the number of sanitarian officers that causes the officers to experience an excessive workload. The lack of several officers also impacts the number of environmental health inspections that can be carried out. If, ideally, they are carried out every six months, Public Health Center officers can only carry them out once a year (Agustin and Siyam, 2020).

Environmental Health Intervention
Environmental Health Interventions can be defined as control activities to achieve a healthier environmental quality. Environmental health interventions are carried out by considering chemical, biological, physical, and social aspects. For the implementation method, environmental health interventions are usually carried out independently. However, suppose a case with a more significant and broader potential risk is found outside their working area. In that case, the environmental health worker will submit to the Head of the District or City Health Office to implement an integrated environmental health intervention. Integrated implementation is defined as an implementation that requires coordination and assistance from other sectors or across sectors, either with local governments or with the private sector. Environmental health interventions are not much different from environmental health inspections in their implementation, which can be carried out outside the working hours of the Public Health Center following an agreement with the relevant parties. Communication, information, and education media are needed to support environmental health interventions (Kementerian Kesehatan Republik Indonesia, 2015).
Environmental Health Intervention activities consist of several types, including communication, information, and education, such as installing and or socializing environmental health promotion media. The second is by carrying out repairs and construction of facilities such as providing handwashing facilities with bamboo material and making septic tanks. The third is the development of appropriate technology, such as making compost from organic waste and processing household wastewater for fish farming. The last is doing environmental engineering, for example, by planting antimosquito and anti-rat plants for vector control and rearing tin head fish or guppies as mosquito larvae eaters (Kementerian Kesehatan Republik Indonesia, 2015).
One of the Public Health Centers in the Ciracas area, after going through the counselling phase and receiving home visits, only some patients received intervention in the form of improving sanitation facilities; the rest only received intervention in the form of counselling. However, outreach activities are only carried out twice a week due to limited health personnel. The development efforts have resulted in behavioural changes in clients visiting the sanitation clinic. Where 9 of 18 patients already have adequate basic sanitation facilities, with the construction of wells and latrines, patients are no longer open defecation [11]. These results are outstanding because they can prevent littering that can pollute the environment, especially water and soil sources. Faecal contamination can cause cholera, dysentery, diarrhoea, schistosomiasis, typhoid, worm-borne diseases, and other vector-borne diseases (Azizah et al., 2019).
Meanwhile, at one Public Health Center in the Tegal area, the sanitarian staff only intervened when a health problem such as diarrhoea and dengue fever occurred. Implementation of interventions for other health problems has not been carried out. However, its performance has been integrated with other programs and sectors. At the Public Health Center in Kuantan Singing Regency, environmental health interventions were carried out to socialize about healthy latrines and healthy water to the community. However, the problem was that public awareness was still lacking by not attending and not participating in the socialization. Then, the people who have attended and participated in the socialization are also not entirely willing to change their lifestyle into a cleaner and healthier lifestyle by making changes to their living environment (Windari, 2014). Environmental health interventions have been implemented at the Public Health Center in Lumajang and Banjar districts. However, not all patients are willing to implement health interventions suggested by environmental health workers. The economic limitations of the patients are the cause, making it difficult to finance the fulfilment of basic sanitation needs, such as the availability of clean water facilities. These healthy latrines meet health requirements (Sugiharto and Oktami, 2018).

Resources
To implement better sanitation clinic services and the achievement of targets for implementing sanitation clinics, Public Health Center must be supported by the availability of adequate resources. These resources include human resources, facilities, infrastructure, and proper funding. The first one starts with human resources, with the requirement that it consists of at least one Environmental Health Worker who has a permit following the provisions of the legislation. Secondly, Public Health Center must be equipped with supporting facilities or commonly referred to as facilities and infrastructure, which consist of (room for counselling or health promotion room following the provisions of the legislation, environmental health laboratory, and Public Health Center must provide the equipment needed in implementing Environmental Health Interventions includes communication, information, and education media). Finally, the Public Health Center must plan and provide adequate and adequate funding to run the sanitation clinic program. Funding usually comes from the government or local government budget (Kementerian Kesehatan Republik Indonesia, 2015).

Human Resources
In the Bukittinggi area, Public Health Center has seven sanitation clinic officers with educational qualifications that comply with applicable regulations. All officers have a Diploma in Environmental Health and a Bachelor's Degree in Public Health. However, not all sanitarians have received training; only 2 of 7 officers have attended sanitation clinic training (Jamarin et al., 2016). Similar to the Public Health Center in the Bukittinggi area, the Public Health Center in the Tegal area has environmental health officers who have followed the Minister of Health of the Republic of Indonesia No. 13 of 2015, with a minimum education of a Diploma and has a permit following applicable regulations. However, the officers' knowledge, skills, and workability are still lacking because the officers have never attended training related to sanitation clinics (Agustin and Siyam, 2020). A similar incident also occurred in one of the Public Health Centers located in Indragiri Hilir Regency; the sanitation clinic staff had not received more in-depth understanding and training related to the sanitation clinic program and many Environmental Health officers who are fresh graduates with less experience (Zaman, 2021).
Eleven Public Health Center in Denpasar City, sanitation clinic officers have carried out their duties and obligations well. Each officer has understood the scope, function, and responsibilities of the sanitation clinic services at the Public Health Center. Officers also understand how to counsel patients and conclude problems related to the patient's illness. Moreover, the officer can provide follow-up advice according to the issues faced by the patient [14]. At the Public Health Center in Kuantan Singing Regency, the sanitation clinic officers have carried out their duties exceptionally well, but not optimally. The reason is that there is no balance between the existing program and the number of available staff. As a result, counselling and program monitoring for the community are ineffective (Windari, 2014). It also happened to the Public Health Center in the Ciracas area, where there was only one officer responsible for the sanitation clinic program.
As a result, officers' workload becomes more and more excessive because officers also have other responsibilities outside the sanitation clinic program (Queena and Dewanti, 2021). The limited number of sanitation clinic staff is also experienced by health centres in Lumajang and Banjar districts; these limitations cause treatment that is not optimal for environmental-based patients. Only some patients can get sanitation clinic services (Sugiharto and Oktami, 2018). Human resources, or environmental health officers, are a core element in an organization. Human resources are an essential key to improving the service performance of a health organization and achieving the service target that has been determined [19]. The role of human resources should be to follow the vision, mission, goals of an organization. Therefore adjustments must be made to the increasingly competitive organizational development and an increasingly developing environment (Yuniarsih and Suwatno, 2009).

Facilities and Infrastructure
Facilities and infrastructure are essential to support the ongoing sanitation clinic program. At the Ciracas Public Health Center, officers are equipped with measuring tools for duty. However, some of the devices were damaged and could no longer be used due to maintenance. Due to limited funds, damaged tools cannot be repaired (Queena and Dewanti, 2021). It also happened at the Kuantan Singing Public Health Center; it was found that the supporting facilities for the smooth implementation of the sanitation clinic program were still inadequate, such as the unavailability of computers to support administrative activities in the sanitation clinic program (Windari, 2014). While at the Denpasar City Public Health Center, it can be seen that there is room for counselling at 11 Public health centres, but there are 54.5% of 11 Public health centres have available water quality measuring devices and facilities in the form of communication media, information, and education (Irmayanti and Yulianti, 2020).
Meanwhile, at Tegal's Public Health Centres, the facilities and infrastructure have not been equipped in communication, information, and education media (Agustin and Siyam, 2020). Only one of the 7 Public Health Center has a particular room for a sanitation clinic in Bukittingi. Then, there is one Public Health Center that does not have media for counselling in the form of posters. Posters are one of the essential educational media to have; signs combine visuals with colour and imply messages, intending to capture attention and instil meaningful ideas in memory. A study conducted by Jamilah proved a difference in students' knowledge before and after being given health counselling interventions with poster media for seven days (Jumilah et al., 2017).
The government made a guidebook to achieve environmental health services and run a better sanitation clinic program as a reference for program implementation, and 7 Public Health Centers in Bukittingi already have the guidebook (Jumilah et al., 2017). It also applies to the Ciracas health centre, which consistently implements the program by following and referring to the Standard Operating Procedure (SOP) in the form of Guidelines for the Implementation of the Environmental Health Program at the Public Health Center [11]. Meanwhile, at the Public Health Center in Indragiri Hilir Regency, there is no comprehensive guide to implementing a sanitation clinic [18]. Standard Operational Procedure or SOP is an essential component that serves as a reference in carrying out a job; it contains work procedures and work systems in a work unit (Tjipto, 2006). Improving the quality of sanitation can be done by rehabilitating damaged sanitation facilities and increasing access to development in areas with poor sanitation (Lopez, 2020).

Funding
Adequate funding is very influential and is one of the essential factors for the sanitation clinic program to be carried out regularly and run optimally. A total of 11 Public Health Center in Denpasar City have adequate funding with funds from the Regional Revenue and Expenditure Budget and Health Operational Assistance (Irmayanti and Yulianti, 2020). It also happened to the Public Health Center in Tegal and followed the Minister of Health of the Republic of Indonesia No. 13 the Year 2015 [13]. At the Public Health Center located in Bukittingi, of the seven Public Health Centers, there are only three that allocate a particular budget and have adequate funding [12].
Meanwhile, at the Ciracas Public Health Center, operational funds for the sanitation clinic program are not yet available. This limited funding is the cause of the inadequate services provided at the sanitation clinic and the existing infrastructure [11]. In direct comparison with the Public Health Center in Bukittinggi, it is known that the Public Health Center in Kuantan Singing Regency cannot carry out activities such as conducting counselling because of insufficient funds. As a result, the existing programs cannot be carried out routinely and effectively (Windari, 2014). Funds are an equally important component of human resources and infrastructure. Limited funds will significantly affect the running of a program, the goals and targets of a program will not be achieved, and the program will not run optimally (Hariandja and Marihot, 2002).
When implementing a program, the factors that can influence its success are human resources' ability, strength, and creativity. Another factor, namely efforts to maintain or monitor actions, must also be made. This effort aims to improve performance, prevent damage to facilities and infrastructure, and extend service life. This monitoring can reduce repair costs and determine the cost-effective maintenance of facilities and infrastructure (Qomar, 2007). In addition to efforts to maintain, control or evaluate efforts, control has a function to ensure the level of effectiveness and efficiency needed to achieve the goals of an organization. Power, in this case, is intended to see whether the activities have been running by the predetermined plan (Masram and Mu'ah, 2015). It is necessary to monitor and evaluate the sanitation clinic program at each public health centre so that the objectives and success rate of the program can be increased. By comparing the implementation of sanitation clinics in public health centres in several regions, it was found that there were still many shortcomings in its performance; the implementation of clinical sanitation was not optimal, which was the cause of the high incidence of environmental-based sanitation.

Conclusions
The sanitation clinic program at the Indonesian Public Health Center has been running. However, there are still discrepancies with applicable regulations in its implementation until the results obtained are less than optimal. Total percentage of 78.33% for the category of Public health centres that have carried out the stages of sanitation clinics starting from the counselling stage to the intervention stage following established regulations by the government. The percentage also shows the human resources and facilities, infrastructure, and appropriate funding criteria. This percentage is still low and does not meet the requirements because it has not received a 100% score. At the counselling stage, discrepancies were still found at the time of implementation, which was only carried out 1 to 2 times in 1 week. Not all patients received home visits at the environmental health inspection stage due to limited environmental health workers.
Furthermore, not all patients received improved sanitation facilities; limited funds were the primary cause. Meanwhile, in the aspect of resources, discrepancies are still found. In human resources, training is needed to improve environmental health workers' knowledge, skills, and work abilities. It is also necessary to increase the number of environmental health workers at each Public Health Center so that officers can focus more on implementing and monitoring the sanitation clinic program so that the program can run effectively. The facilities and infrastructure owned are also not adequate; there are still Public Health Center that does not have counselling rooms and counselling media (communication, information, education), both printed and electronic. There are still Public Health Centers with limited and insufficient funds for funding. That is the cause of the sanitation clinic services that do not reach all patients, and the existing facilities are inadequate. Hence it is necessary to carry out routine and integrated monitoring and evaluation to improve the performance of the sanitation clinic program service.