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PUJASERA (PERGUNAKAN JAMBAN SEHAT RAKYAT AMAN /Utilizing Healthy Latrines and People will be Safe)
Public Health Center Tampo (Puskesmas Tampo)

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Unhealthy environmental conditions increase the risk of disease. In accordance with Sustainable Development Goals (SDGs) number 3 points 6, in 2012 an estimated 889,000 people died caused by infectious diseases especially by feces contamination on water and soil, compounded with hand washing facilities were inadequate and poor sanitation services. This is also reflected in Banyuwangi, East Java, Indonesia. Notwithstanding all the gift of nature, it is a disconcerting fact that Banyuwangi has a poor environmental health. Of all 217 villages, there were only 27 villages having healthy latrines. Most of inhabitants still defecated in the open air or outside of designated latrines which inevitably triggers many potential diseases. Such situation also applies in Public Health Center (Puskesmas) Tampo working area as one of 45 Puskesmas’s located in Banyuwangi. Across the vast area of 27,185 km2 inhabited by 25,997 citizens, Banyuwangi is passed by a huge river with many fragmented creeks nearby the villages. For decades, thousand villagers have been utilizing river by conducting their activities in the river bank which is under the management of Local Department of Public Works for Irrigation. All this time, they litter, defecate, laundry, and take a bath in the river. As a result, river stream is highly polluted by both organic waste of feces and inorganic waste resulted from the habit of river waste disposal. Since the major livelihood of the people comes from farming, countless number of families settles communally amid the farmland to get close to their workplace. Such condition highly facilitates the practice of open defecation in the river or in the farmland. The 2013 data pinpoints the fact that of all 8,045 families in the working area of Puskesmas Tampo, there were only 1,034 families equipped with healthy latrines in their houses. Hence, it is possible to say that none of the 4 villages in the working area of Puskesmas Tampo has Open Defecation Free (ODF) status. Consequently, such condition is entailed by the rocketing rate of illnesses ranging from diarrhea 28.2%, thypoid 8.7%, skin diseases 12%, DHF 0.25%, and influenza 10.3 % of the entire inhabitants. In fact, it is noted that diarrhea has been entailed by starvation and two deaths. The practice of open defecation is attributed to some factors. First, cultural tradition adhered by people from generation to generation. Second, low income which hinders people to build their own healthy latrines. Third, low education leading to rudimentary understanding on the significance of healthy latrines. Those foregoing three factors perfectly portray the complexity of the problem. Such disconcerting condition is even made worse by the absence of sanitarians working in Puskesmas Tampo to promote and bring village people to light about healthy life style with environmental health awareness. It is noteworthy that this entire time environmental health program is simply managed incidentally by medical practitioners without expertise in sanitation. Moreover, there is no viable clinic sanitation facility in Puskesmas Tampo despite the substantial significance of facility to be referred by patient suffering from environmental health problem.

B. Strategic Approach

 2. What was the solution?
(1) Community empowerment by training people to become cadre of PUJASERA (Pergunakan Jamban Sehat Rakyat Aman / Utilizing Healthy Latrines and People will be Safe), healthy latrines community, and Open Defecate Free (ODF) Task Force as the forefront of the program implementation. (2) Cooperating with PNPM Mandiri (Program Nasional Pemberdayaan Masyarakat Mandiri / Independent Community Empowerment National Program) for Rural Areas to provide the people with soft loan and bridge them with the local hardware stores to ease the provision of healthy latrines material. (3) Forming latrines lottery club or “Arisan Jamban” to ease the burden of the club members to build their own healthy latrines.
 3. How did the initiative solve the problem and improve people’s lives?
The program was initiated when Head of Public Health Service (Puskesmas) Tampo with several staffs conducted mapping and in-depth study to come through with the solution of environmental problem in their working area dealing with the common open defecation practice among the society. As a result, they came up with an innovative program referred to as “Pergunakan Jamban Sehat Rakyat Aman” (Utilizing Healthy Latrines and People will be Safe) or known as “PUJASERA” in the end of 2014. As a pioneer of program, head of Puskesmas Tampo held cross sector workshop by inviting some related stakeholders such as those from Sub-district Leader Forum (Forpimka), Head of Technical Implementation Unit of Education Office (UPTD Pendidikan), Local Department of Public Works for Irrigation, The local village Heads, local and religious figures, Management of PNPM Mandiri for Rural Areas, owner of local material stores, and the whole employees of Puskesmas Tampo. The innovation takes the form of social empowerment to target the villagers with no healthy latrines. To promote this program massively, the head of Puskesmas Tampo took two strategic measurements. First, by working hand in hand with Jawa Pos Radar Banyuwangi print media and with Bintang Tenggara FM Radio as an electronic media partner. Second, performed by putting up some banners in strategic public spots and by distributing leaflets directly to the society. Afterwards, the head of Puskesmas Tampo made a team of PUJASERA Cadre trained to become the forefront of healthy latrines program implementation consisting of primary and secondary school students, Bhakti Husada Scouts, local figures, religious figures, and youths. To sustain the quality of PUJASERA Cadre, the head of Puskesmas Tampo held some periodical training. To bring the targeted society in close contact with PUJASERA program, the head of Puskesmas Tampo applied the following strategies: First, inviting the entire stakeholders to promote ODF program through a parade or “arak-arakan” carrying some banners and posters about ODF all around the village and all along the river bank. Second, applied by triggering some Muslim Forums and other existing groups in the society in the evening. Third, establishing 12 healthy latrines lottery clubs in each village scheduled to assemble once a month. The members of the lottery club consisted of the whole villagers with no healthy latrines. In terms of financing the provision of healthy latrines, the head of Puskesmas Tampo established a partnership with PNPM Mandiri for Rural Areas which provided the people with soft loans and cooperated with the local building store owners who provided them with building materials for healthy latrines. Meanwhile, to come through with the problem of void sanitarian workers, the head of Puskesmas Tampo put the nurses to the best uses as sanitarian workers by firstly assigning them to join some trainings held by Department of Health. To optimize the counseling and service for sanitation in the Puskesmas, the head of Puskesmas Tampo provided the society with Sanitation Clinic opening every day to receive some referred cases from Public Polyclinics and Maternal and Child Health related to environmental health problems. Having run for two years, it is proven that PUJASERA program brings some obvious fruitful achievements and advantages in reality, especially for the most susceptible groups expanding from the underprivileged, the less educated, women, children, the elderly, and adolescents. These achievements can be seen from the significant escalating rate of healthy latrines ownership from 1,034 to 7,391 of all the 8,045 households in the working area of Puskesmas Tampo. The level of sickness owing to poor sanitation also diminishes from 35% to 15% of the entire villagers.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Apparently there are 3 considerable things which uniquely distinguish PUJASERA program from others: First, ODF campaign which takes the form of a parade or “arak-arakan”. To bring the program closer to people, the whole stakeholders paraded together all along the village road and river bank by holding up some banners and posters. The banner and poster are a calling out for utilizing healthy latrines. Second, distinguishing factor is the optimization of social role as the forefront of the program. To handle popping up problems dealing with healthy latrines, the program initiator made the best use of the society by training some people to be the cadre of PUJASERA, establishing Healthy Latrines Community, and ODF Task Force. Third, attempt to highly value local wisdoms “Gotong Royong” or working together. To fund the provision of healthy latrines, the program initiator established some healthy latrines lottery clubs involving the entire villagers who did not have healthy latrines and cooperated with PNPM Mandiri for Rural Areas which provided the villagers with soft loan. To facilitate the building of healthy latrines, the program initiator also worked hand in hand with the owner of local hardware stores to get the latrines material easily.
 5. Who implemented the initiative and what is the size of the population affected by this initiative?
PUJASERA program was implemented by entire staff of Puskesmas Tampo as a program coordinator in each working area, PUJASERA Cadre, and Healthy latrines Community. As forefront, cadres had been acknowledged with sound knowledge on how to trigger, to inform healthy latrines definition, healthy latrines criteria, how to build healthy latrines, and open defecation effect towards environmental health. This knowledge is derived from sustainable trainings held by Puskesmas Tampo. PUJASERA Cadres play a significant role expanding from the ODF campaign through parade all around the villages and river bank and by triggering Muslim studies forum and other groups in the society in the evening. While conducting the trigger, PUJASERA Cadre also list some households with no healthy latrines, plan the time schedule for making healthy latrines, and provide them with soft loan derived from the cooperation with PNPM Mandiri for Rural Areas as well as inform them with the ease of material provision from the local hardware stores. The Healthy Latrines Community led by the village head is assigned to establish 12 healthy latrines lottery clubs in every village each of which consists of 30 households with no possession of healthy latrines. The program has obviously benefitted the most susceptible groups expanding from the underprivileged, the less educated, women, children, the elderly, and adolescents. These achievements can be seen from the significant escalating rate of healthy latrines ownership from 1,034 to 7,391 of all the 8,045 households in the working area of Puskesmas Tampo. To put it in details, every household at least consists of 3 people which can be concluded that the total number of villagers to get the benefit from the program is around 19,071 people. In addition, it also diminishes the level of sickness owing to poor sanitation from 35% to 15% of the entire villagers.
 6. How was the strategy implemented and what resources were mobilized?
Legally, PUJASERA program was established based on the Decree of the head of Puskesmas Tampo No. 440/40/429.114.29/2014 issued on April 8th 2014. To clarify the workflow of the program, the program initiator and staffs compiled a Standard Operational Procedure (SOP). The SOP enables the workflow of the program in accordance to the scheduled timeline. Considering the void of sanitarians in Puskesmas Tampo, the Puskesmas sent its nurses to join some sanitation trainings held by Local Department of Health of Banyuwangi Regency to turn them into a professional sanitarian with prowess ability in managing environmental health problems excellently. The Puskesmas also opened up a sanitation clinic operating daily to receive some referred patients related to environmental health problems. Furthermore, to socialize to the society, the Puskesmas cooperated with Jawa Pos Radar Banyuwangi Newspaper and Bintang Tenggara FM Radio as media partner. In addition to the foregoing promotion, socialization is also carried out by placing some banners in some public spots and distributing leaflets directly to the society. ODF campaign was also conducted by a parade on every Friday at 6.00 AM simultaneously headed by the village heads by marching along the street village and river bank. To make sure that the program is well implemented, the program initiator held some training for the Cadre of PUJASERA in Puskesmas Tampo. The training material is about how to trigger, to inform healthy latrines definition, healthy latrines criteria, how to build healthy latrines, and open defecation effect towards environmental health. The training bears a significant role to acknowledge the cadre with related knowledge in order to prepare these human resources to become the forefront of the program. To instill the villagers with healthy life style in the early childhood, Puskesmas Tampo worked hand in hand with UPTD Pendidikan to recruit and train the cadre of PUJASERA from primary and secondary school. 26 students were selected from each school to be trained as the cadre of PUJASERA. It is these cadres who work to influence their friends to live a healthy and hygienic life style. Meanwhile, to ease the provision of healthy latrines, Puskesmas provided the society with some financial techniques including by establishing healthy latrines lottery clubs divided into 12 groups, each of which consisting of 30 household members. Each meeting requires the members to deposit the amount of IDR 40,000 which will be mounting to 1,200,000 when calculated together. Afterwards, the process of building the healthy latrines is carried out together. Lack of fund is still the most classical difficulty in Indonesia which hinders the attempt to develop further. To overcome such problem, Puskesmas Tampo invited PNPM Mandiri for Rural Areas to provide the villagers with some soft loan amounting to IDR 1,200,000 per latrines. The soft loan is directly provided to the local material store which is bound in cooperation to provide the villagers with healthy latrines materials. Once completed, it will be reported to the management of PNPM Mandiri for Rural Areas to be visited before the loan is being provided. The financial resources of the program always increase year to year. To monitor and evaluate the program implementation according to schedule, the village head formed ODF Task Force consisting of 12 people from the local and religious figures. This Task Force is committed to monitor all the agenda of the program aiming primarily to shift the shared tradition of open defecation and leave it behind and lead them to a more healthy and hygienic life style.
 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The followings are stakeholders involved in PUJASERA program: (1) Head of Local Department of Health as the person in charge at the regency level had been instructing each Puskesmas to manage ODF village as a follow up of “Gemari Gunakan Latrines/ GGJ” (Be Fond of Using Latrines) program in Banyuwangi Regency since 2013; (2) The head of Puskesmas Tampo as acted as initiator, catalyst, and facilitator of a breakthrough PUJASERA program; (3) Puskesmas Tampo staffs acted as the prime mover and supervisor for the implementation of the breakthrough program; (4) the head of UPTD Education acted as partner of the establishment of PUJASERA Cadre in both primary and secondary school who also facilitated counseling at school; (5) the sub-district head of Cluring acted as the regional head with a direct social responsibility by making an agreement of the possession of healthy latrines both through individual and communal agreement; (6) village head as the regional stakeholder at village level had a direct responsibility on the success and sustainability of the program by establishing ODF Task Force; (7) Local Department of Public Works for Irrigation acted as the department in charge of the sustainable environmental cleanliness of the river, especially carried out by demolishing open defecation places all along the river bank; (8) Jawa Pos Radar Banyuwangi and Bintang Tenggara FM Radio acted as media partner to publish the breakthrough PUJASERA program; (9) PNPM Mandiri for Rural Areas acted as a partner who provided the people with soft loan and supervision team; (10) Owner of local hardware store acted as a partner who provided the people with healthy latrines materials; and (11) Local social and religious figures were engaged as PUJASERA Cadre acting as the forefront for triggering, making, and informing healthy latrines in the working area of Puskesmas Tampo.
 8. What were the most successful outputs and why was the initiative effective?
The followings are 5 tangible outputs pinpointing the success of PUJASERA program: (1) Realization of 3 ODF villages from 4 villages in the working area of Puskesmas Tampo (consist from Kaliploso, Plampangrejo, and Tampo Villages); (2) the escalating rate of healthy latrines possession. This especially prevails for the most susceptible group since they can make their dream and urge for having a healthy latrines come true owing to the PUJASERA implementation. The rate of healthy latrines possession significantly escalated from 1,034 to 7,381 of the total 8,045 households. In other words, in the course of year 2014 to 2016, there had been 6357 healthy latrines built for every household; (3) Illnesses rate owing to poor sanitation can be suppressed from 35% to 15% of the total inhabitants. To put it into details, the rate comes from the plummeting percentage of diarrhea from 28.2% to 12 %, typoid from 8.7% to 3.8%, DHF from 0.25% to 0.10%, and influenza from 10.3% to 8.5%; and (4) The creation of a healthy environment, clean rivers free from feces contamination on water and soil, in accordance with the purpose of SDGs number 3 points 6 and synergy with ODF campaign activities; (5) The establishment of Sanitation Clinic in Puskesmas Tampo through Decree No. 440.01/40/429.114.29/2014 concerning the commencement of service of sanitation clinic every day to receive patient referrals related to environmental health good of BP, KIA, or nutrition division. The activities carried out in them are appropriate counseling to patients with diseases due to the impact of poor sanitation.
 9. What were the main obstacles encountered and how were they overcome?
There are some constraints which hinder PUJASERA program implementation, among which are: (1) Time constraint. It is impossible to do the triggering during daytime considering the fact that it involves many program implementers from many instances and local figures who happen to have other agendas during the day. In addition, the most people have to work to farmland during the day, thus only allowing the program to be implemented out of working hours (in the evening); (2) Human resource constraints. The void of sanitation workers has forced Puskesmas Tampo to optimize its nurses. To come through with the solution, the Puskesmas sent its nurses to Local Department of Health to join some training on environmental health; (3) Cultural constraints. It is an uphill task to persuade people to abandon their habits of open defecation despite the fact that they already possess designated latrines. Hence, the most necessary strategy to apply is by luring them to leave the past culture behind through the provision of real effects of open defecation; (4) Financial constraints. Poverty has set people to think that innovation should come from an aid. To overcome such mindset, the program initiator cooperated with PNPM Mandiri for Rural Areas to provide them with soft loan and latrines lottery club with communal assistance in the making process of the latrines; (5) Psychological constraints. Previously, there were some doubts about the success of the program from the stakeholders involved. Hence, several measurements were taken to assure the people to bring about the program into reality; (6) Facilities and Infrastructure Constraints. Prior to the establishment of sanitation clinic, the range of environmental health sanitation visit in Puskesmas Tampo was very limited. Thus, the program initiator established sanitation clinic to receive some referred patients suffering from environmental health problems.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The primary achievement resulted from the program initiative includes: (1) Cultural aspect. In terms of cultural aspect, there has been a cultural shift in regards to the practice of open defecation to designated healthy latrines. The shift only takes place because people have gained the positive impact of PUJASERA breakthrough program through all of its strategies and implementation; (2) Health Aspect. There has been a significant rise in terms of public health as seen from the declining level of sickness due to unhealthy environment proven by the whole patient visit. To put it into details, the surge in public health includes the plummeting rate of diarrhea from 28.2% to 14%, thypoid from 8.7% to 3.8%, DHF from 0.25% to 0.10%, influeza from 10.3% to 8.5%; (3) Financial aspect. The unfortunate people now can have their own healthy latrines easily without being entangled with a complicated process; (4) Facilities and Infrastructure aspect. The health service can now be better provided owing to the existence of sanitation clinic in Puskesmas Tampo. This leads to surging rate of sanitation clinic visit from 1.30% to 3.88%, thus exceeding the 2% target set by the government, (5) Social aspect. The social group directly affected by the innovation is the poor, youths, women, and elderly. The innovation inevitably raises their social status to a better rank. Poor sanitation owing to poverty is now no longer prevails. As a result, people from the susceptible group, especially women can leave the indignity of defecating in the open. Such is applies for the youths who do not need to be ashamed of friends or colleague’s visit for having good sanitation. Moreover, the elderly may avoid the risk of danger from the practice of open defecation such as drowning, slipping, and being attacked by wild animals; (6) Human resources aspect. The achievement in terms of human resources lies in the coordination and synchronized activities of all stakeholders involved in the program, especially the involvement of key public figures; (7) Environmental/ ecological aspect. It is proven that the program can bring about healthier and cleaner environment, especially for the side of the river bank. The absence of human feces considerably lessens river pollution. The effect of public service in the program can best be measured from: (1) Ease of access to build healthy latrines. People were no longer hindered with financial problem to build healthy latrines since they are provided with the soft loan and healthy latrines lottery club, derived from partnership with PNPM Mandiri for Rural Areas as the loan provider and cooperation with the local hardware stores aiding the procurement of healthy latrines; (2) Peaking level of healthy latrines ownership. The rate of healthy latrines substantially rocketed from 1,034 to 7,391 of the total 8,045 households. In other words, between 2014 and there had been 350 healthy latrines built; (3) Plummeting level of sickness. The level of sickness owing to poor sanitation can be suppressed from 35% to15% of the total citizens.
 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Integrity in a certain program will only be met when it is implemented consistently by those who have great commitment. Efforts to make PUJASERA as program integrity is by way of a grant from PNPM Mandiri for rural area soft loans provided directly to the store building that has been designated as a provider of materials for healthy latrines. In the process are led by PUJASERA cadre and healthy latrines community with mutual cooperation with villagers. In order to loan can be utilized in a responsible or accountable, PNPM Mandiri for rural area management always do visitation and monitoring of the healthy latrines development. Reporting is always monitored by PUJASERA cadre, healthy latrines community, and ODF task force. Healthy latrine construction funds from PNPM Mandiri for rural area amount IDR 420,000,000 used for build 350 latrines, from generous amount IDR 15,000,000 to build 12 latrines, from healthy latrines lottery amount IDR 333,600,000 to build 278 latrines, while from the non-governmental funds collected amount IDR 120,480,000 to be built 100 latrines. From several sources of funding above, reporting can be done in an accountable because Puskesmas Tampo build networks with various stakeholders who have the authority as a sub-district forum leader, UPTD Pendidikan, the Local Department of Public Works for Irrigation, village heads, community and religious leaders, PNPM Mandiri for rural area, and as well as the local material store owners. From efforts to build the network the financial problems can be resolved, greatly facilitate, and ease the public. In this case any stakeholder who has authority is monitoring each other in terms of the use of funds and reporting is done transparently through cross-sector workshops. So the budget corruption potential can be reduced to 0%. After the funding issue is resolved, the next problem is the publication in order to community is not just a knowing, but also wants to play an active role. Puskesmas Tampo do some breakthroughs such as through ODF campaigns which cooperate with Jawa Pos Radar Banyuwangi Newspaper and Bintang Tenggara FM radio, as well as through social media like YouTube with link https://youtu.be/UsSSQxZpujY address, and continue to do campaign to the community. Consistency in realizing the ideal mission and never give up attitude when facing various constraints indicates that this program have an integrity.
 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Principally, PUJASERA program was not specifically initiated for the sake of women alone. However, its achievement clearly reaches women on the whole in that they no longer had to suffer the indignity of defecating in the river. If prior to the program they were forced to defecate in the open, now they can defecate in a private place. In addition, now women no longer have to venture out before dawn or after dark, leaving them vulnerable to potential hazards such as slipping, drowning, being attacked by wild animals or harassment from the opposite sex. In other words, seen through a gender perspective, one can say that the program is a hundred percent in favor of women's interests. Furthermore, the program is also able to target the most susceptible groups such as the underprivileged, the youth, women and the elderly. One of the primary reasons why people defecate in the river is the inability to access their own healthy latrines owing to poverty. Such problem can be cured through a soft loan from PNPM Mandiri for Rural Areas and ease of healthy latrines materials provision from local hardware store in cooperation with the program.

Contact Information

Institution Name:   Public Health Center Tampo (Puskesmas Tampo)
Institution Type:   Local Government  
Contact Person:   TATIEK SETYANINGSING
Title:   Mrs  
Telephone/ Fax:   081249713027
Institution's / Project's Website:  
E-mail:   tatieksetya@gmail.com  
Address:   JL. PURWOHARJO NO. 130 BANYUWANGI JAWA TIMUR / EAST JAVA
Postal Code:   68482
City:   BANYUWANGI
State/Province:   JAWA TIMUR/ EAST JAVA
Country:  

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