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EVALUATION ON LARVA OBSERVER EMPOWERMENT IN ERADICATING DENGUE HEMORRHAGIC FEVER IN BANTUL DISTRICT
Summary As Partial Fulfillment of MPH Degree Health Policy and Management Program Graduate School of Public Health

Proposed by:

HADI PRANOTO
NIM: 08/278331/PKU/10434

To GRADUATE PROGRAM FAKULTY OF MEDECINE GADJAH MADA UNIVERSITY YOGYAKARTA 2011

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EVALUASI PEMBERDAYAAN JURU PEMANTAU JENTIK DALAM PEMBERANTASAN DEMAM BERDARAH DENGUE DI KABUPATEN BANTUL EVALUATION ON LARVA OBSERVER EMPOWERMENT IN ERADICATING DENGUE HEMORRHAGIC FEVER IN BANTUL DISTRICT
Hadi Pranoto1, Mubasysyir Hasanbasri2, Retna Siwi Padmawati3 ABSTRACT Background: Dengue Hemorrhagic Fever (DHF) has become a problem in Bantul district and led to an extraordinary event. The government of Bantul had done frequent health education to people, been mobilizing them to implement breeding place eradication (PSN), fogging, and carried out activity of free villages from 4 basic health problems, including DHF. Innovative measures taken by Bantul District government in prevention of DHF is empowering larva observer in family groups level (Jumantik RT) with the main task of periodically observing larva breeding sites, eradicating them, and reporting its results to the higher level such as Jumantik Desa. Jumantik Desa in their tasks were monitoring activity performance of Jumantik RT, reporting the result of larva breeding sites eradication to the higher authority, and evaluating its implementation. Objective: This study aimed at evaluating the empowerment of Jumantik RT and Jumantik Desa in eradicating DHF in Bantul District. Method: A qualitative research with rapid assessment procedure (RAP) was used for this research. The number of subjects were 99.consisted those who were working in the field up to the decision makers. Data were collected by focus group discussion, in-depth interviews, observation and documents study. The study was located in six endemic DHF subdistricts. Results: Jumantik empowerment in eradicating DHF in Bantul District was begun by health cader recruitment to be Jumantik RT and Jumantik Desa. Recruitment was done by direct appointment of Dukuh based on the recommendation of Head of RT, PPKBD and Public Health Center. The teamwork of Jumantik was Head of RT, Head of the Ten Home Group, Dukuh, Team of DHF from sub-district and district of Bantul. The training process for Jumantik Desa was carried out by the Health Center of Bantul Districts and for Jumantik RT by local village. The Jumantiks were equipped by the periodic larva eradication, flashlight, and leaflet of DHF and abate powder. Reward for them were budgeted from Bantul District in the form of monthly honorary. Jumantik empowerment had been successfully improving the absence of larva rate (ABJ). Conclusion: The community participation in the implementation of breeding place eradication (PSN) encouraged by Larva Observers empowerment has increased the absence of larva rate (ABJ) Keywords: evaluation, empowerment, Jumantik, dengue hemorrhagic fever. ---------------------------------------------1. Bantul Distric Health Office, Daerah Istimewa Yogyakarta Province 2. Graduate Program of Health Service Management and Policy, Gadjah Mada University. 3. Graduate Program of Health Service Management and Policy, Gadjah Mada University.

INTRODUCTION Dengue Hemorrhagic Fever (DHF) has been recognized as life threatening and anxiousness inducing in Indonesian society. The disease generally affects children particularly in heavily populated cities. In the process, the disease nonetheless affects adults. Dengue Hemorrhagic Fever (DHF) is an infection cause by dengue virus, transmitted from an individual to another by the bites of Aedes. Aegypti as well as Aedes albopictus. The dengue vector is identified almost in every area in Indonesia, except in the areas with an altitude of more than 1.000 meters above the sea level.1 Prevention of DHF depends much on vector control, namely Aedes aegypti and Aedes albopictus. The most effective way of preventing DHF is Breeding Place Eradication (PSN) as well as cleaning, closing, and burying groundwater pools. Breeding Place Eradication (PSN) efforts must be conducted in a simultaneous and sustainable way by all of the society members.2 Failure in eradicating DHF was not resulted from funding scarcity, ineffective poverty alleviation efforts, poor health services, but rather from lack of community empowerment and lack of common will to participate in eradicating DHF.3 Local Government of Bantul District had been taking some innovative measures to eradicate DHF. These include Empowerment of Larva Observers (Jumantik). This innovative effort was taken because the society in Bantul District was regarded has lacking the awareness to practice clean and healthy life; Breeding Place Eradication (PSN) efforts were insufficient. Instead, the society needed constant monitoring and control in implementing Breeding Place Eradication (PSN). The study aims at describing the role of Larva Observers (Jumantik) in Periodic Larva Observations and community empowerment in Breeding Place Eradication (PSN) of DHF.

METHOD A qualitative research was conducted. Qualitative data were used to present the findings in the forms of narratives, descriptions, written documents and non-written documents (pictures, photos).4 Qualitative research is commonly used to in social and behavioral sciences or those domains pertaining to human roles and behavior.5 The study used Rapid Assessment Procedures (RAP) design. The design was useful to collect focused information in a timely and reliable way. In-depth interview was used to collect data on the roles of Larva Observers (Jumantik) since the techniques allow the researchers to collect much information from the informants.6 The study was conducted in Bantul District, Special Province of Yogyakarta. Informants of the study were selected from 6 sub-districts endemic of DHF. They were Sewon, Sedayu, Kasihan, Banguntapan, Piyungan, and Bantul. In-depth interviews and focused group discussion to collect the data were conducted in two months, from March to April 2011. Subjects of the study were individuals involved in Jumantik empowerment in the 6 selected subdistricts endemic of DHF in Bantul District: Head of District Health Office, Head of Health Problems Eradication Division, Head of Surveillance Section, Head of Subdistrict, Head of Health Center, P2 DHF Programmers in the Health Center, and Village Chiefs.

RESULTS AND DISCUSSION 1. Recruitment Process of Larva Observer Cadres Most of the cadres of larva observers at neighborhood (RT) level were directly appointed by RT chief, PKK chief at dusun level, and PKKBD. Larva observers at village level (Village Jumantik) were appointed by village chiefs based on the recommendation of the health center. Roles and responsibilities of formal and non-formal figures in the

recruitment process of larva observer at dusun level, RT level, and village level was varied with subdistricts endemics of DHF. Diversity also applied in selecting cadres that fulfill certain criteria, such as willingness and ability to do societal tasks, activeness in communal activities at dusun level, family support, and willingness to do more for people in need. Roles and responsibilities of formal and non-formal figures are presented in the following Table 1. Table 1. Process of Larva Observer Recruitment in 6 Subdistricts Endemic of DHF in Bantul Regency in 2007 Subdistrict
Sedayu

Coordinator
PKK dusun RT Chief Dukuh Health Center Village Chief

Roles
Recommending names Registering cadre names Deciding cadre names Suggesting cadre names Selecting Jumantik Cadres at Village level Suggesting names Determining the names suggested by RT chief Suggesting names Determining names of Jumantik Cadres at village level

Conditions
Cadres, active Time availability Willingness to work for society Voluntary, intention. Self-awareness

Kasihan

RT Chief Dukuh Health center Village chief

Sewon

PPKBD PLKB RT chief Dukuh Health center Lurah Dukuh Health Center Lurah

Bantul

Providing data on names Providing information on active cadres Registering cadres at RT level Selecting cadres to be Jumantik Suggesting candidates of Jumantik Deciding Jumantik at Village Level Directing appointing cadres Recommending names of cadre Deciding Village Jumantik Suggesting cadre names Deciding cadres Suggesting names Deciding Village Jumantik Selecting and appointing cadres Suggesting cadre names Deciding Village Jumantik

Time Availability Patience

Banguntapan

Piyungan

PPKBD Dukuh Health Center Lurah bu dukuh Health Center Village Chief

Familiarity with work area Local residents Time availability, capability Willingness Time availability Sociability Willingness Tenure as a cadre

Recruitment process of Larva Observer cadres at RT and Village levels involved formal and non-formal figures regarded as reliable and knowledgeable. To be selected, the cadres should be familiar with the area, and as a result, they did not need extra energy to understand local language and culture; the cadres were recognized by the community members. This allowed RT and Village Jumantik more space to get access from a house to another. The process of recruitment and those in charge of recruiting community health staffs were consistent to the notion7 that every country has its own standard criteria in selecting community health staffs. However, the selection process were mostly conducted by local elites, political leaders, and health care providers using certain criteria, such as married women (since they were more unlikely to go out of the community), 20-35 years old, local residents, socially acceptable individuals, literacy, active participation in societal activities, and willingness to work for the society. 2. Teamwork in Assisting Larva Observers Regents decree No. 02/2009 was issued to establish and enforce the roles of Larva Observers at RT and Village levels. The composition of the team is depicted in the following chart.
DHF Responsive Team at Regency Level DHF Responsive Team at Subdistrict Level Jumantik at Village Level RT Chief, Dukuh, PKK, PPKBD, Sub PPKBD Jumantik at RT Level Society Officers of Dasa wisma, Fatherhood group

Figure 1. Teamwork of Larva Observers

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Roles of Team
Larva Observers (Jumantik) at RT Level

Description
Periodic Larva Observation (PJB) Recording & Reporting of PJB Findings Implementation of Breeding Place Eradication (PSN) at RT Level

Best practice
Conducting PJB once a week Mobilizing PSN from home to another, along with PJB Recording and reporting the findings of PJB

Problems
Rain, delayed PJB Refusal from some residents against PJB Difficulty in controlling homes with no inhabitant.

Larva observers (Jumantik) at Village Level

Recapitulating of PJB data on Jumantik at RT Level Calculating absence of larva rate (ABJ) at dusun and village levels Evaluating PJB and ABJ Monitoring and evaluating performance of Jumantik at RT Level

Collecting and inventorying the findings of PJB by Jumantik at RT Level Calculating ABJ at dusun and village level, analyzing ABJ Evaluating PBJ, ABJ, and Jumantik Performance at RT level, along with community health officers

Work area and the number of dusuns were different from a village to another Delay in reporting by Jumantik at RT level

Village

Monitoring of PSN at community level Monitoring of PJB by Jumantik Mobilizing dusun for PSN Monitoring PSN implementation at community level every two weeks Mobilizing LS at village level to monitor PJB at community level Evaluating Jumantik empowerment at subdistrict level Providing technical assistance to DHF Responsive Team at Subdistrict Level & Jumantik at Village level Evaluating technical aspects of Jumantik activities at model villages, at monthly interval Assessing Jumantik Performance at Village & RT level Facilitating PJB format for Jumantik

Monitoring PSN & PBJ at dusun level, along with DHF Responsive Team at Subdistrict and Regency Level Scheduling PSN monitoring at village and dusun level Monitoring PSN by the community at dusun level Evaluating Jumantik empowerment at subdistrict level Scheduling Gertak PSN Monitoring at subdistrict level Monitoring of Gertak PSN by the community at model dusun, along with DHF Responsive Team at Subdistrict Level Providing PJB format for Jumantik

Dependence upon active participation of Village health care staffs Limitation of team personnel to monitor PNS at community level in a simultaneous way

DHF Responsive Team at Subdistrict Level

DHF Responsive Team at Regency Level

Figure 1 and Table 1 reveal that Larva Observer teamwork had an explicit job description. The teamwork was also facilitated by the government institutions at subdistrict and district level. The supports came not only from health sectors, rather, they came in cross-sector format that involved Work Units within the local government. Dengue Hemorrhage Fever Responsive Team at Subdistrict and District levels served as driving forces for Larva Observer at RT and Village levels. The strategy was used to solve various problems, particularly lack of community awareness for PSN. The strategy was used to find out the availability of Jumantik officers who were ready for PJB and PSN.8 There were three principal strategies to achieve an effective teamwork. Firstly, individuals with knowledge, skills, and appropriate attitude might choose team-based works. Secondly, the team could modify the tasks, job structure and framework. Thirdly, individual competence of the team members could develop through training.

3. Training and Aids to Facilitate Tasks Training at district level aimed at providing skills and capabilities for Village Jumantik in conducting their principal tasks as coordinators of Jumantik RT at village level. At the beginning of the training sessions, the participants were provided with the policies of Local Government of Bantul in eradicating DHF, namely, empowerment of Larva Observers (Jumantik). The training sessions took two days, with training materials involving technical and administrative aspects. Aids available for larva observers (Jumantik) included the Format of PJB for dusun level to be used by Larva Observers at RT Level, Recapitulation Form for Village Larva Observers, Flashlight, Abate, DHF Leaflet for the family members. Technically, the training materials are presented in the following table.

Table 3. Training of Village and RT Larva Observers

Targets Village Larva Observers (Jumantik) Coordinat or District Health Office Method Lecture Discussion Materials Local government policy on DHF eradication DHF Vector Growth pattern of Aedes as well as control and eradication Management ofDHF Periodic Larva Control Recording and Reporting DHF Vector Growth pattern of Aedes as well as control and eradication Management of DHF Periodic Larva Control Recording and Reporting Facilitator Head of District Health Office Head of PMK Division Head of Surveillance Section District Health Office Officials

RT Larva Observers (Jumantik)

Village

Lecture Discussion

Health Center and Village

Training for Village Larva Observers were of importance since a Larva Observer (Jumantik) at village level served dual functions in the family and in the society. In the family where she served as a wife and as a mother, a woman must be prudent in allocating time for her family. In the society, most of Larva Observer serves as social workers that receive much trust from the other community members to be health care cadres, PPKBD, Dasa Wisma staff, PKK staff, and other societal activities. With such abundant tasks, training became a means for enhancing skills and building self-confidence in conducting their principal tasks.9 Training provide opportunities for the community health staff to learn much about skills, to educate themselves, and to interact with professional staffs from higher level, and to get many other advantages that were otherwise unavailable in other places. The training was focused not only to provide preventive and curative health services for the society, but also to teach the larva observers on the right way to communicate with the community members.

4. Reward System Reward for Larva Observers (Jumantik) at Bantul District was allocated in Local Budget Amendment of 2007 and Local Budget of 2008 and 2009 through District Health Office. The reward came in the form of honorarium payment for Village and RT Larva Observers. The size of the payments was based upon local financial conditions as stipulated in the Regents Decree. Honorarium for Village and RT Larva Observers were calculated every month and paid during the Evaluation Meeting of RT Larva Observers in subdistrict level and Evaluation of Village Larva Observers at District level. Honorarium for RT Larva Observers were Rp. 40.000,before taxation (5%), Rp 250.000,- for Village Larva Observers before taxation (5%) for the period of October-December 2007. The rate of honorarium was flat, regardless the size of work area, number of homes to visit, and workload of the Larva Observers (Jumantik). Since there was budget cut for Larva Observer empowerment at Bantul District, honorarium for RT Larva Observers were reduced to Rp 200.000,before taxation (5%) and Rp 150.000 before taxation (5%) for Village Larva Observers in 2008. In 2009, the larva observers receive the honorarium only for 6 months (January June, 2009). It was expected that RT and Village Jumantik in 3 years (20072009) that the society could understand its needs in eradicating DHF and could work autonomously in DHF eradication. Because of funding scarcity as a whole, PMK Division should give priority to programs that really need funds. DHF is actually one of he priorities, but PSN could not be conducted by the family and without sufficient funds. (WWCR MDL-3) Honorarium for the Larva Observers was disproportionate to the workload and responsibilities. As a response, Local Government of Bantul provided rewards for RT and Village Larva Observers (Jumantik) in a simultaneous way. As a result, the society could work autonomously in community empowerment for hemorrhagic fever eradication. With a single funding source (Local Budget), the local

government had very limited capability to maintain the DHF eradication program. Even more problematic was increasing the amount of honorarium paid to the Larva Observers (Jumantik). To maintain the sustainability of the program and to increase the amounts of honorarium received by the Larva Observers (Jumantik), additional funds from private sectors were an indispensable aid. Reward should not have been in the form of money. It might come in other forms, such as training as well as certificate of appreciation for what the larva observers had done for the society.10 When the amount of honorarium was not adequate as an incentive for the health care staffs, other forms of incentive might be networks built by the health care staff, opportunity for self-development, training and peer supports.

5. Coverage of Larva Absence Rate (ABJ) Encouraging community participation for PSN in eradicating hemorrhagic fever constituted an extensive process and required patience and diligence in providing motivation and knowledge for individuals, groups, society members, and even for government officials in a sustainable way. Simultaneous and constant PSN resulted in increased ABJ.

Output of Jumantik empowerment was increase in Larva Absence Rate (ABJ), which suggested that more home were free of Aedes and reflected the success of the community in conducting PSN in a simultaneous and constant way.

Larva Absence Rate (ABJ) data in 6 subdistricts endemic of DHF since the onset of Jumantik empowerment program are presented in the following table.

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Table 4. Larva Absence Rate (ABJ) in 6 subdistricts endemic of DHF, Bantul District, 2007-2010
NO SUBDISTRICT 1 2 3 4 5 6 Sedayu Kasihan Sewon Bantul Banguntapan Piyungan ABJ ABJ 2008 2009 89,5 93,75 77 87,95 85 87,79 77 94,31 85,67 89,13 86 81,61 83,36 89,09

2007 81,5 80,5 76 75,5 84,5 65 77,17

2010 77,95 84 75,7 81,48 82,17 78,52 79,97

Source: PMK Division

Larva Observer empowerment successfully increased ABJ in 6 subdistricts endemic of DHF in 2007-2009, since teamwork functioned well, so did the advocates provided by the Local Government of Bantul through Bapak Ibu Asuh in subdistrict level. The trend of ABJ in the subdistricts endemic of DHF from 20072009 increased, particularly in the subdistricts of Sedayu, Sewon, Bantul, and Banguntapan. However, increase in ABJ was still below the target indicator of DHF program, namely 95%11; and in 2010, there was a declining trend in the endemic subdistricts. Decrease of ABJ in the 6 subdistricts during the year of 2010 was attributable to the following causes: a. Frequency of PJB implementation by Larva Observers (Jumantik) at RT level was not once a week. This influenced community preparedness for PSN. There was a declining trend in the attitudes and morale of the society members to implement PSN since no body reminded them and no body monitored them. A study11 found that attitude referred to ones predisposition to behave. The better (more positive) the respondents attitude was, the higher their participation in preventing and eradicating DHF would be. b. Control over PSN by Dengue Hemorrhagic Fever Responsive Team at subdistrict and district level was considered loose; this

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influenced the preparedness and capability of local residents to conduct PSN. c. Dismissal of reward system for Larva Observers at RT and Village levels since July 2009 because of funding limitation and unavailability of reward in another form for Larva Observers resulted in the fact that implementation and monitoring of PSN by the community and PJB by Larva Observers at RT level were deployed to respective subdistrict.

CONCLUSIONS AND SUGGESTIONS Larva observers (Jumantik) empowerment in eradicating DHF in Bantul District increased ABJ. In conducting their roles as Larva Observers at RT and Village levels, the larva observers were facilitated by the local government by means of teamwork that were established and structured through a Regents Decree. In the lowest levels (RT and dusun), the team of RT Larva Observers consisted of RT chief, PPKBD, Dukuh, and fatherhood group staffs. Jumantik empowerment constituted an innovation from the Local Government of Bantul in eradicating DHF by allocating funds for honorarium of the Larva Observers through the Local Budget. For the sustainability of Larva Observer empowerment, Local Government of Bantul needs to build a partnership with private sectors that actively participate in DHF eradication.

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