KLINIK SANITASI Onny setiani Definition of Health WHO 1948 • A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity Determinant of Health • The range of personal, social, economic, and environmental factors that influence health status determinants of health. Determinants of Health : • What makes people healthy or unhealthy? • How can we create a society in which everyone has a chance to healthy life? • How can we create a society in which everyone has a chance to live a long WHO definition of Environmental Health Environmental health comprises those aspects of human health, including quality of life, that are determined by physical, biological, social, and psychosocial factors in the environment. It also refers to the theory and practice of assessing, correcting, controlling, and preventing those factors in the environment that can potentially affect adversely the health of present and future generations Contributors to the Environment B iological: microorganisms present in soil, water air, insects, parasite. Chemical : heavy metals from industry and settlement , Air pollutants, toxic wastes, pesticides Physical − Temperature, Humidity, Noise, electromagnetic field, ionizing and non-ionizing radiation Socio/economic − Access to safe and sufficient health care IMPACT OF HUMAN ACTIVITY ON HEALTH Community Activity Agriculture Industry, MINING ENVIRONMENT WATER, INDOOR, AMBIENT AIR, SOIL, Health of Community Health of Worker PUSKESMAS • Pusat Kesehatan Masyarakat yang selanjutnya disebut Puskesmas adalah fasilitas pelayanan kesehatan yang menyelenggarakan upaya kesehatan masyakarat dan upaya kesehatan perseorangan tingkat pertama, dengan lebih mengutamakan upaya promotif dan preventif tanpa mengabaikan upaya kuratif dan rehabilitatif, untuk mencapai derajat kesehatan masyarakat yang setinggitingginya di wilayah kerjanya. Pelayanan Kesehatan Lingkungan dan KLINIK SANITASI • Pelayanan Kesehatan Lingkungan adalah kegiatan atau serangkaian kegiatan yang ditujukan untuk mewujudkan kualitas lingkungan yang sehat baik dari aspek fisik, kimia, biologi, maupun sosial guna mencegah penyakit dan/atau gangguan kesehatan yang diakibatkan oleh faktor risiko lingkungan. • Klinik sanitasi merupakan program promosi kesehatan inovatif untuk menanggulangi penyakit berbasis lingkungan. Kegiatan klinik sanitasi seperti konseling, survey kesling dan kunjungan rumah dan intervensi kesehatan. Faktor Risiko Lingkungan • Faktor Risiko Lingkungan adalah hal, keadaan, atau peristiwa yang berkaitan dengan kualitas media lingkungan yang mempengaruhi atau berkontribusi terhadap terjadinya penyakit dan/atau gangguan kesehatan. PENYELENGGARAAN • Pasal 2 (1) Setiap Puskesmas wajib menyelenggarakan Pelayanan Kesehatan Lingkungan. • Pasal 2 (2) Pelayanan Kesehatan Lingkungan sebagaimana dimaksud pada ayat (1) merupakan bagian dari pelayanan kesehatan paripurna yang diberikan kepada Pasien. • Pasal 3 Kegiatan Pelayanan Kesehatan Lingkungan dilakukan dalam bentuk: • a. Konseling; • b. Inspeksi Kesehatan Lingkungan; dan/atau • c. Intervensi Kesehatan Lingkungan. Pasal 5 : Pelayanan Konseling di Puskesmas harus dilaksanakan setiap hari kerja. Pasal 6 (1) Konseling : Inspeksi kesehatan Lingkungan Pasal 6 (2) Inspeksi Kesehatan Lingkungan sebagaimana dimaksud pada ayat (1) dilakukan dengan cara: • a. pengamatan fisik media lingkungan; • b. pengukuran media lingkungan di tempat; • c. uji laboratorium; dan/atau • d. analisis risiko kesehatan lingkungan. • Psal 7 (1) Intervensi Kesehatan Lingkungan yang dapat dilaksanakan secara mandiri atau bekerjasama dengan pemangku kepentingan dan pihak terkait lainnya • Pasal 7 (2) Intervensi Kesehatan Lingkungan sebagaimana dimaksud pada ayat (1) dapat berupa: • a. komunikasi, informasi, dan edukasi, serta penggerakan/pemberdayaan masyarakat; • b. perbaikan dan pembangunan sarana; • c. pengembangan teknologi tepat guna; dan/atau • d. rekayasa lingkungan Untuk terselenggaranya kegiatan Pelayanan Kesehatan Lingkungan di Puskesmas harus didukung dengan ketersediaan: • a. sumber daya manusia; • b. sarana dan prasarana yang diperlukan; dan • c. pendanaan yang memadai. (2) Sumber daya manusia sebagaimana dimaksud pada ayat (1) huruf a paling sedikit 1 (satu) orang Tenaga Kesehatan Lingkungan yang memiliki izin sesuai dengan ketentuan peraturan perundangundangan. (3) Sarana dan prasarana sebagaimana dimaksud pada ayat (1) huruf b paling sedikit meliputi: a. ruang untuk Konseling yang terintegrasi dengan layanan Konseling lain; b. laboratorium kesehatan lingkungan yang terintegrasi dengan laboratorium yang ada Puskesmas; c. peralatan yang dibutuhkan dalam Intervensi Kesehatan Lingkungan; dan d. media komunikasi, informasi, dan edukasi Pasal 13 • (3) Pemantauan dan evaluasi Pelayanan Kesehatan Lingkungan di Puskesmas sebagaimana dimaksud pada ayat (2) mencakup Pelayanan Kesehatan Lingkungan Puskesmas dan pelaksanaan pengawasan kualitas media lingkungan dalam rangka program kesehatan. • (4) Hasil pemantauan dan evaluasi sebagaimana dimaksud pada ayat (3) dibahas dalam pertemuan integrasi lintas program Puskesmas secara berkala • Pasal 14 Hasil pemantauan dan evaluasi digunakan untuk mengukur kinerja Pelayanan Kesehatan Lingkungan di Puskesmas yang sekaligus menjadi indikator dalam penilaian akreditasi Puskesmas. BAB V PENCATATAN DAN PELAPORAN • Pasal 15 (1) Setiap Pasien yang diberikan Pelayanan Kesehatan Lingkungan di Puskesmas wajib dicatat dalam lembar status Kesehatan Lingkungan Pasien dengan menggunakan contoh sebagaimana terlampir. • (2) Lembar status Kesehatan Lingkungan Pasien sebagaimana dimaksud pada ayat (1) merupakan resume/kesimpulan hasil Konseling, hasil Inspeksi Kesehatan Lingkungan yang dilakukan terhadap Pasien, dan Intervensi Kesehatan Lingkungan yang dilakukan. • Pasal 16 (1) Puskesmas wajib menyampaikan laporan kegiatan Pelayanan Kesehatan Lingkungan secara berkala kepada Kepala Dinas Kesehatan Kabupaten/Kota. • (2) Laporan kegiatan Pelayanan Kesehatan Lingkungan sebagaimana dimaksud pada ayat (1) merupakan bahan pertimbangan untuk menetapkan kebijakan kesehatan lingkungan dalam skala kabupaten/kota. • Pasal 17 Dalam hal Pasien yang diberikan Pelayanan Kesehatan Lingkungan adalah anggota masyarakat yang bertempat tinggal di luar wilayah Puskesmas, maka Kepala Puskesmas wajib melaporkan kepada Kepala Dinas Kesehatan Kabupaten/Kota setempat untuk ditindaklanjuti. • Pasal 18 Pencatatan dan pelaporan kegiatan Pelayanan Kesehatan Lingkungan di Puskesmas terintegrasi BAB VI KETENTUAN PERALIHAN • Pasal 19 Pada saat Peraturan Menteri ini mulai berlaku, Puskesmas yang belum memiliki sumber daya dalam penyelenggaraan Pelayanan Kesehatan Lingkungan harus menyesuaikan dengan ketentuan Peraturan Menteri ini dalam jangka waktu paling lama 3 (tiga) tahun sejak Peraturan Menteri ini mulai berlaku • BAB VII KETENTUAN PENUTUP Pasal 20 Peraturan Menteri ini mulai berlaku KLINIK SANITASI PUSKESMAS • Klinik sanitasi adalah Ruang Pelayanan Informasi tentang upaya pencegahan dan penanggulangan penyakit berbasis lingkungan. • Disebut Penyakit berbasis lingkungan, karena sumber penyakitnya berasal dari lingkungan yang buruk (air, udara, tanah yang tercemar), yaitu Penyakit Diare, Kecacingan, ISPA, Malaria, DBD, TB, Paru, Kulit/Gatal-Gatal, Keracunan Makanan/minuman/Pestisida dan keluhan akibat lingkungan yang buruk/akibat kerja • Klinik Sanitasi Berada di Puskesmas dan menjadi bagian yang tidak terpisahkan dari program pelayanan Puskesmas dengan yang bertugas : Petugas sanitarian Puskesmas / Petugas Penyuluh Puskesmas Tujuan Klinik sanitasi : • Dapat mengetahui penyebab sakitnya • Mampu melakukan pencegahan terhadap berbagai penyakit akibat lingkungan Terhadap Petugas • 1. Dapat Mengetahui secara tepat Gaya Hidup Pasien dan Kondisi Lingkungan Pasien • 2. Dapat memberikan saran yang tepat kepada pasien sesuai dengan masalah yang dihadapinya • 3. Dapat Menyusun Rencana Intervensi Perbaikan Lingkungan Barriers to accessing health services include: • Lack of availability • Lack of insurance • High cost Individual Behavior • Individual behavior also plays a role in health outcomes. For example, if an individual quits smoking, his or her risk of developing heart disease is greatly reduced. • Many public health and health care interventions focus on changing individual behaviors such as substance abuse, diet, and physical activity. Positive changes in individual behavior can reduce the rates of chronic disease in this country. • Examples of individual behavior determinants of health include: • Diet • Physical activity • Alcohol, • cigarette, • drug use • Hand washing • Biology and Genetics • Some biological and genetic factors affect specific populations more than others. For example, older adults are biologically prone to being in poorer health than adolescents due to the physical and cognitive effects of aging. Biological determinants of health include: • Age • Sex • Inherited conditions, such as sickle-cell anemia, hemophilia • Carrying the BRCA1 or BRCA2 gene increases risk for breast and ovarian cancer • Family history of disease Take Home Examination:/ Case study Report: • 1 . Identification determinant of Health of community living in Agriculture Area. • 2. Describe factors associated with the health of mother and child health in Agriculture area. • 3. Explain personal, social, economic, and environmental factors that influence health status of farmers and mothers and child health in agriculture area. CONCEPS OF HEALTH AND FACTORS RELATED TO HUMAN HEALTH BEHAVIOUR FACTORS INDIVIDUAL CHARACTERI STICS HUMAN HEALTH HEALTH SERVICES/FACILITIE S ENVIRONMENTA L FACTORS Escherichia coli (CDC) CDC melaporkan bahwa bakteri E coli yang ditemukan mewabah di sejumlah negara bagian itu merupakan jenis baru, seperti diberitakan CNN, Rabu (11/11/2020). Strain wabah E coli yang dilaporkan di 6 negara bagian tsb terindentifikasi pada sampel selada romaine yang dikemas Tanimaura & Antle romaine. Ascariasis E coli (food safety Internat Council) One important type of E. coli produces enterotoxins called Shiga toxins and causes diarrhoea that is often bloody. Patients can develop blood clotting conditions and kidney failure that may result in death. Although these severe infections are not common, in the last few years there have been several food poisoning outbreaks caused by these and other types E. coli . Young children, older adults and immune-comprised people have an increased risk of more severe infections and death. A wide variety of foods have been implicated in outbreaks caused by Shiga toxin producing E. coli around the world, including unpasteurised apple and orange juices, sprouted seeds, fruits and vegetables, raw milk and raw milk cheeses, raw flour, and meat and meat products, especially undercooked food. Untreated and unprotected water supplies can also be a source of the bacterium. YERSINIA ENTEROCOLITICA (Wikipedia) • Yersinia enterocolitica adalah spesies bakteri gram-negatif, tidak menghasilkan spora, fakultatif anaeobik, yang termasuk ke dalam golongan Enterobacteriacea. Pada suhu 20-25 °C, bakteri ini dapat bergerak, n • Pada suhu 37 °C tidak terjadi pergerakan. Yersinia enterocolitica infection (Yersiniosis/Yersinia) is a food-borne illness primarily caused by the bacteria Yersinia enterocolitica. These bacteria are frequently isolated in soil, water, animals, and a variety of foods. Pigs are assumed to be the main carrier of Yersinia enterocolitica. CURRENT ISSUE: MOTHERS and CHILD HEALTH KESEHATAN IBU KESEHATAN ANAK KESEHATAN KELUARGA 49.. Foto dokumen lapangan (onny) Environmental Health Exposure • Acute environmental catastrophes (high-level exposures): Minamata disease (1953–1961) − Methyl mercury poisoning, Chernobyl (1986) − Nuclear reactor accident • Chronic (low-level) exposures : Pesticide poisoning on farmers in Beran , Kenigoro, Magelang 2007. • Indirect effects of global environmental changes Health Effects 1. Adverse Effect (keadaan/kondisi berbahaya yang tidak sesuai harapan/tujuan /undesired harmful effect ). vs. beneficial (menguntungkan) 2. Acute vs delayed onset 3. Clinical vs. subclinical manifestations 4. chronic (irreversible) vs Transient (reversible)/lasting only for a short time; impermanent. Example of Manifestation Effect on Blood Profile: Anemia, Increase of White Blood Cells, Leukemia, Leucocytosis, Red Blood Cell lysis and Red Blood Cell count decrease, Change of MCV (Mean Corpuscular Volume) , MCH (Mean Corpuscular Haemoglobin, MCHC on Red Blood Cells, Polycitemia ,etc. Lung disease : Pulmonary Fibrosis, Pulmonary function Disorders, Pneumoconiosis. Reproductive effects: Abortus spontaneous, Low Birth Weight (BBLR). Teratogenic effects Neurologic effects Immunosuppression and hypersensitivity Cancer Low Birth Weight: (BBLR= Bayi Berat lahir Rendah) • Low birthweight is a term used to describe babies who are born weighing less than 2,500 grams • Over half of multiple birth babies have low birthweight compared with only about 6 percent of single birth babies. RECENT Public Health Paradigm • The public health paradigm change from the challenge of improving drinking water safety, environmental sanitation, housing condition to the discovery of vaccine and antibiotics during the 19th and 20th centuries, and emerging and re-emerging infectious diseases and the increasing burden of chronic diseases in the 21st century. WHO • For Indonesia?? Still need the challenge of improving drinking water safety, environmental sanitation, housing condition, healthy foods, good and appropriate health services • Recent PH paradigm: assess the risks of such challenges to the environment and population, effective communication to develop strategies to deal with environmental health chellenge. Vulnerable groups • • • • • • Children Disabled Reproductive age (women) Elderly Low socioeconomic status Living in polluted area, over populated area • Living in agriculture areas where pesticides are widely used. • Living in unappropriate managed Industrial Risk Assessment and Risk Management RISK ASSESSMENT 1. Define the problem 2. Measure its magnitude 3. Understand key determinants RISK MANAGEMENT: 4. Develop intervention/ prevention strategies 5. Set policy/priorities 6. Implement and evaluate Social Factors • Social determinants of health reflect the social factors and physical conditions of the environment in which people are born, live, learn, play, work, and age. Also known as social and physical determinants of health, they impact a wide range of health, functioning, and quality-oflife outcomes. Examples of social determinants include: • Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods • Social norms and attitudes, such as discrimination • Exposure to crime, violence, and social disorder, such as the presence of trash • Social support and social interactions • Exposure to mass media and emerging technologies, such as the Internet or cell phones • Socioeconomic conditions, such as concentrated poverty • Quality schools • Transportation options • Public safety • Residential segregation Physical Determinants • Natural environment, such as plants, weather, or climate change • Built environment, such as buildings or transportation • Worksites, schools, and recreational settings • Housing, homes, and neighborhoods • Exposure to toxic substances and other physical hazards • Physical barriers, especially for people with disabilities • Aesthetic elements, such as good lighting, trees, or benches * Poor health outcomes are often made worse by the interaction between individuals and their social and physical environment. • Health Services • Both access to health services and the quality of health services can impact health. Healthy People 2020 directly addresses access to health services as a topic area and incorporates quality of health services throughout a number of topic areas. • Lack of access, or limited access, to health services greatly impacts an individual’s health status. For example, when individuals do not have health insurance, they are less likely to participate in preventive care and are more likely to delay medical treatment.3 STUNTING • Stunting is the impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation. Children are defined as stunted if their height-for-age is more than two standard deviations below the WHO Child Growth Standards median. • Stunting in early life -- particularly in the first 1000 days from conception until the age of two - impaired growth has adverse functional consequences on the child. Some of those consequences include poor cognition and educational performance, low adult wages, lost productivity and, when accompanied by excessive weight gain later in childhood, an increased risk of nutrition-related chronic diseases in adult life. • Linear growth in early childhood is a strong marker of healthy growth given its association with morbidity and mortality risk, noncommunicable diseases in later life, and learning capacity and productivity. cognitive, language and sensory-motor capacities WHO How are they defined? • Underweight: weight for age < –2 standard deviations (SD) of the WHO Child Growth Standards median • Stunting: height for age < –2 SD of the WHO Child Growth Standards median • Wasting: weight for height < –2 SD of the WHO Child Growth Standards median • Overweight: weight for height > +2 SD of the WHO Child Growth Standards median Diarrhoeal disease atau PENYAKIT DIARE • Diarrhoeal disease is the second leading cause of death in children under five years old. It is both preventable and treatable. • Each year diarrhoea kills around 525 000 children under five. • A significant proportion of diarrhoeal disease can be prevented through safe drinking-water and adequate sanitation and hygiene. • Globally, there are nearly 1.7 billion cases of childhood diarrhoeal disease every year. • Diarrhoea is a leading cause of malnutrition in children under five years old. • Severe dehydration and fluid loss were the main causes of diarrhoea deaths Cause and type : • Diarrhoea is usually a symptom of an infection in the intestinal tract, which can be caused by a variety of bacterial, viral and parasitic organisms and toxic contamination in drinking water/food. • Infection is spread through contaminated food or drinking-water, or from person-to-person as a result of poor hygiene. • There are three clinical types of diarrhoea: • acute watery diarrhoea – lasts several hours or days, and includes cholera; • acute bloody diarrhoea – also called dysentery; and • persistent diarrhoea – lasts 14 days or longer. Dehydration • The most severe threat posed by diarrhoea is dehydration. During a diarrhoeal episode, water and electrolytes (sodium, chloride, potassium and bicarbonate) are lost through liquid stools, vomit, sweat, urine and breathing. Dehydration occurs when these losses are not replaced. • The degree of dehydration is rated on a scale of three. • Severe dehydration (at least two of the following signs): – lethargy/unconsciousness – sunken eyes – unable to drink or drink poorly – skin pinch goes back very slowly ( ≥2 seconds ) Some dehydration (two or more of the following signs): •restlessness, irritability •sunken eyes •drinks eagerly, thirsty •No dehydration (not enough signs to classify as some or severe dehydration). Infection: Diarrhoea is a symptom of infections caused by a host of bacterial, viral and parasitic organisms, most of which are spread by faecescontaminated water. Infection is more common when there is a shortage of adequate sanitation and hygiene and safe water for drinking, cooking and cleaning. Rotavirus and Escherichia coli, are the two most common etiological agents of moderate-to-severe diarrhoea in low-income countries. Other pathogens such as cryptosporidium and shigella species may also be important. Location-specific etiologic patterns also need to be considered. • Prevention and treatment • • • • • • • • Key measures to prevent diarrhoea include: access to safe drinking-water; use of improved sanitation; hand washing with soap; exclusive breastfeeding for the first six months of life; good personal and food hygiene; health education about how infections spread; and rotavirus vaccination (in epidemic or pandemic case) Key measures to treat diarrhoea include the following: • Rehydration: with oral rehydration salts (ORS) solution. ORS is a mixture of clean water, salt and sugar. It costs a few cents per treatment. ORS is absorbed in the small intestine and replaces the water and electrolytes lost in the faeces. • Zinc supplements: zinc supplements reduce the duration of a diarrhoea episode by 25% and are associated with a 30% reduction in stool volume. • Rehydration: with intravenous fluids in case of severe dehydration or shock. • Nutrient-rich foods: the vicious circle of malnutrition and diarrhoea can be broken by continuing to give nutrient-rich foods – including breast milk – during an episode, and by giving a nutritious diet – including exclusive breastfeeding for the first six months of life. • Consulting a health professional , for management of persistent diarrhoea , blood in stool or if there are signs of dehydration. Underweight: • As weight is easy to measure, this is the indicator for which most data have been collected in the past. Evidence has shown that the mortality risk of children who are even mildly underweight is increased, and severely underweight children are at even greater risk. Stunting: • Children who suffer from growth retardation as a result of poor diets or recurrent infections tend to be at greater risk for illness and death. Stunting is the result of long-term nutritional deprivation and often results in delayed mental development, poor school performance and reduced intellectual capacity. This in turn affects economic productivity at national level. Women of short stature are at greater risk for obstetric complications because of a smaller pelvis. Small women are at greater risk of delivering an infant with low birth weight, contributing to the intergenerational cycle of malnutrition, as infants of low birth weight or retarded intrauterine growth tend be smaller as adults. Wasting: • Wasting in children is a symptom of acute undernutrition, usually as a consequence of insufficient food intake or a high incidence of infectious diseases, especially diarrhoea. Wasting in turn impairs the functioning of the immune system and can lead to increased severity and duration of and susceptibility to infectious diseases and an increased risk for death. Overweight: Childhood obesity is associated with a higher probability of obesity in adulthood, which can lead to a variety of disabilities and diseases, such as diabetes and cardiovascular diseases. The risks for most noncommunicable diseases resulting from obesity : • cardiovascular diseases, mainly heart disease and stroke; • diabetes; • musculoskeletal disorders, especially osteoarthritis; and • cancers of the endometrium, breast and colon. • The indicators are defined as the proportion of children aged 6–59 months who received one or two high doses of vitamin A supplements within 1 year. Current international recommendations call for high-dose vitamin A supplementation every 4–6 months for all children between the ages of 6 and 59 months living in affected areas. The recommended doses are 100 000 IU for 6–12-month-old children and 200 000 IU • Programmes to control vitamin A deficiency enhance children’s chances of survival, reduce the severity of childhood illnesses, ease the strain on health systems and hospitals and contribute to the wellbeing of children, their families and communities. • The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. • The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of efforts to improve child survival, a two-thirds reduction in mortality of children under 5 by the year 2015. • Supplementation with vitamin A reduces child mortality, measuring the proportion of children who have received vitamin A within the past 6 months can be used to monitor coverage with interventions for achieving the child survival-related Millennium Development Goals. • Supplementation with vitamin A is a safe, cost-effective, efficient means for eliminating its deficiency and improving child survival. Vit A 100 IU?? 200 IU?? • Vitamin A is a fat-soluble vitamin, as also are vitamins D, E and K. It is therefore necessary to have some fat in the diet for these vitamins to be adequately absorbed. • One of the most important consequences of vitamin A deficiency is dryness of the eyes eventually leading to blindness. It remains one of the main causes of blindness in the world. Night blindness is also an eye complication of early vitamin A deficiency. kandungan vitamin lain dari wortel, antara lain: - Beta caroten •Biotin vitamin B ini sangat berperan penting dalam metabolisme lemak dan protein. •Vitamin K= phylloquinone.: untuk pembekuan darah dan dapat menjaga kesehatan tulang. •Vitamin B6 mengubah makanan menjadi energi. •Kalium •alfa-karoten, lutein, polyacetylenes dan antosianin. • All women should have access to skilled care during pregnancy and at delivery to ensure the detection and management of complications. • Every woman, rich or poor, has a 15% risk for complications around the time of delivery, but almost no maternal deaths occur in developed regions. • The lack of progress in reducing maternal mortality in many countries often reflects the low value placed on the lives of women and their limited role in setting public priorities. • The lives of many women in developing countries could be saved by reproductive health interventions that people in rich countries take for granted, such as the presence of skilled health personnel at delivery. • The current WHO recommendation is universal supplementation with 60 mg of iron and 400 μg of folic acid daily during pregnancy, as soon as possible after the beginning of gestation and no later than the third month and continuing for the rest of pregnancy. Whereas there is no internationally accepted indicator for these concerns, the indicator could be defined as the percentage of mothers who Improved drinking-water sources • Improved drinking-water sources are defined in terms of the types of technology and levels of services that are likely to provide safe water. • Improved water sources include household connections, public standpipes, boreholes, protected dug wells, protected springs and rainwater collection. • Unimproved water sources are unprotected wells, unprotected springs, vendor-provided water, bottled water (unless water for other uses is available from an improved source) and tanker truck-provided water. • ‘Reasonable access’ is broadly defined as the availability of at least 20 litres per person per day from a source within 1 kilometre of the user's dwelling. Improved sanitation facilities • Improved sanitation facilities are defined in terms of the types of technology and levels of services that are likely to be sanitary. Improved sanitation includes connection to a public sewers, connection to septic systems, pour-flush latrines, simple pit latrines and ventilated improved pit latrines. Service or bucket latrines (from which excreta are removed manually), public latrines and open latrines are not considered to be improved sanitation. CONTOH KASUS : STUNTING • Topik: MODEL PELAYANAN KESEHATAN PRIMER TERPADU DENGAN KLINIK SANITASI PLUS UNTUK PENCEGAHAN STUNTING PADA BALITA • DASAR PER UU : PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 13 TAHUN 2015 TENTANG PENYELENGGARAAN PELAYANAN KESEHATAN LINGKUNGAN DI PUSKESMAS *Ditetapkan di Jakarta pada tanggal 26 Februari
