Ewars (Early Warning Alert and Response System) Sms (Short Message Service) - Based at Health Department of Purworejo Distric

Ewars (Early Warning Alert and Response System) Sms (Short Message Service) - Based at Health Department of Purworejo Distric Savitri Citra Budi 1, Nur Rokhman 2 1 Vocational College of Medical Records, Gadjah Mada University, Bulaksumur Yogyakarta 55281, Indonesia * E-mail of the corresponding author: vi3ku@yahoo.com 2 Vocational College of Medical Records, Gadjah Mada University, Bulaksumur Yogyakarta 55281, Indonesia * E-mail of the corresponding author: nurrokhman@ymail.com Abstract Background : Purworejo is one of Indonesian s disctrict which have topology conditions and it s consist of plateau and lowland. It s approximately 1.034,81752 km 2 in areas. With this kind of conditions, there is some difficulty for Local Government Clinic if they want to make some weekly disease report/ extraordinary incident/disaster (commonly mentioned as W2) to the Health Department. This W2 reports has a function for early detection for those extraordinary incident of disease so that it will makes faster to be handled. Local Government Clinic in district Purworejo have already used Early Warning Alert and Respons System (EWARS) application. This application used for making W2 report get easier than before. This research will observing EWARS SMS-based at Health Department of district Purworejo, Indonesia Purpose : 1. Discovering how EWARS SMS-based at Health Department of district Purworejo works. 2. Discovering influential factors from implementation of EWARS SMS-based at Health Department of district Purworejo. Research Metodology : This kind of research is descriptive qualitative which using case study for approximation method. Result : Realization of EWARS SMS-based at Health Department of district Purworejo using sources from Local Government Clinic s data reports. This W2 reports originated from out patient visit reports with new cases at Local Government Clinic, Local Government Clinic Ministrant, and village midwife. Tabulations of W2 reports using weekly form formats. The surveilans Local Government Clinic employee will sent this reports to EWARS in surveilans section of Health Department s manager. This W2 reports SMS-based has following formats weekly reports for...weeks; unit reporter name; code and 1 st amount cases; code and amount cases for; code and amount of unknown cases; and total Local Government Clinic s visits. Then, W2 reports will be sent by email to the Sub Directorate Surveilans Epidemiology of Indonesia s Health Department. Influencing factors for realization of EWARS SMSbased can be recognized as follows, there are the lackness of awareness from the employee about importance of W2 reports will delays W2 report to sent. There is not yet evaluation process to rate or valuated the successfullness of EWARS realization. Clear punishment and continously training is needed to increasing employees work-out concerned to realization of EWARS SMS-based. Keywords : EWARS, SMS, W2 reports, Local Government Clinic 43

1. Introduction According to Keputusan Menteri Kesehatan Republik Indonesia Nomor 1116/MENKES/SK/VIII/2003 about Guidelines of Health Epidemiology Surveilans Systems Implementation, W2 reports is an epidemic reports which are obligated to be reported for once each week by Local Government Clinic to the Health Department. This report has been exist in Indonesia. This reports used by Local Government Clinic or Distric s Health Department for Local Region Monitoring especially for infectious disease which potential for extraordinary incident. Early study have already done at Health Department and resulting an information that at Purworejo Distric, W2 reports have already using Early Warning Alert and Respons System (EWARS) application. On this system, W2 report of Local Government Clinic were sent by Short Messages Service (SMS). Considering the range of area and topology condition of Purworejo Distric is a kind of advantage with using this system to sent the reports on time. That things attracting the researcher to discover more about this EWARS implementation and the factors which influencing EWARS implementation at Health Department of Purworejo Distric. General purpose of this research is to discovering the delineation about EWARS implementation SMSbased at Health Department of Purworejo Distric. Particular purpose : 1) Discovering how EWARS SMS-based at Health Department of district Purworejo works.2) Discovering influential factors from implementation of EWARS SMS-based at Health Department of Purworejo distric. The advantages of this research for several part are as follow : health service infrastructure and health department, educational institution and researcher. Advantages for health service infrastructure and health department are as follow, one of them are this research can be used for suggestion and evaluation for Local Government Clinic, Pustu or Village Midwifer about EWARS implementation SMS-based. Advantage for educational institution are it can an additional references for comparing the theoritical with the reality happened. And the advantages for the researcher is with this research it can be widen the knowledge more about implementation of W2 reports. Epidemic Weekly Reports (W2) from Local Government Clinic and hospital is one of the importance component for early detection about the extraordinary incident of certain disease so that it obligated to sent once everyweek by Local Government Clinic or hospital to the Health Department. W2 reports loaded the summary of the victim and the deathness from the certain extraordinary potential disease and health problem of mother and children. W2 is the prime material to proceed routinely (once for everyweek) being information which can shows the indication of extraordinary disease incident. (Dinas Kesehatan Kota Yogyakarta, 2010). According to Buku Pedoman Sistem Kewaspadaan Dini dan respons, EWARS application is surveilance system which has advantages to show alert signals for incident increasement overboundary on certain Local Government Clinic work range or distric or maybe region. On this system, W2 reports of Local Government Clinic can be received by short or Short Messages Service (SMS). The purpose of EWARS are as follow : 1. Implementating early detection of extraordinary disease incident for infectious disease. 2. Stimulating on restraint the extraordinary disease incident for infectious disease. 3. Minimalize the illness/deathness which has relation to extraordinary disease incident. 4. Monitoring the tendency of infectious disease. 5. Assess the effect of restraint program which specific. According to Keputusan Menteri Kesehatan Republik Indonesia Nomor 1116/MENKES/SK/VIII/2003 about Pedoman Penyelenggaraan Sistem Surveilans Epidemiologi Kesehatan, epidemic reports at Local Government Clinic are including : a. W1 reports, which is epidemic reports which reported 1x 24 hour when the extraordinary disease incident or epidemic are happened b. W2 reports, which is epidemic reports which reported once everyweek by Local Government Clinic to the Health Department. This research is using descriptive research with qualitative approachment. Design of this research using case study. This research are done at Surveillance and imunization section of Health Department Purworejo Distric. Object of this research is EWARS implementation SMS-based at Health Department of Purworejo Distric. Subject of this research are 10 respondent, there are: EWARS manager of Healh Department, 1 Head P2PL section of Health Department, and 8 surveilance of Local Government Clinic s practitioner an Purworejo Distric. Data gathering methods is using interview, quesioner, and observation. Assignment of the eligibility of data using triangulation methods. The limitation of this research is the difficulity on getting quesioner result. Ditributing of quesionary to the 17 Local Government Clinic for 2 weeks, selama 2 minggu, at the reality, the researcher just found 44

response from 8 Local Government Clinic. So, the 8 result from that Local Government Clinic became the data of this research. 2. EWARS implementation SMS-based at Health Department of Purworejo Distric Regin EWARS SMS-based on Health Department of Purworejo Distric started to used since January 2012. This system made by bequest donation from World Bank for making some early cautionary system which recognized as EWARS. EWARS which was built by Health Department of Purworejo Distric utilizing communication media, Hand Phone (HP) for sending message which are as data source from Local Government Clinic and Pustu to the server which already prepared by the Health Department. As long as this way, EWARS used only for W2 reports of Local Government Clinic. Hospital in Purworejo still sent it directly with weekly format to the Health Department Purworejo Distric. That things happened because there s no EWARS software yet for hospital from central. To know more about EWARS implementation at di Health Department Purworejo Distric, below are the source of the data and its implementation, EWARS delivery system and EWARS advantages. 1) Data Source and Managing Data source for EWARS implementation at Health Department of Purworejo Distric are W2 Local Government Reports reports which coming from all units below them such as Local Government Clinic Helper and Village Midwife. Quesioner result about data source from EWARS report are W2 reports of Local Government Clinic which coming from Local Government Clinic Helper, Village Midwife, and Prime Local Government Clinic which coming from outpatient Local Government Clinic everyday. Visiting data of patient with new incident for one week at Local Clinic Government, Local Clinic Government Helper, and Village Midwife will be summarized and sent to the Health Department as W2 reports. New incident means as a new person who come to the health care facility for one week and having a new diagnosis. If it has been one week at the health care facility, (Local Clinic Government, Local Clinic Government Helper, and Village Midwife) there is no patient with new incident, so W2 reports will be sent and reported to the EWARS manager at Surveillance Division of Health Department eventhough it was only the total of the patient visiting data for one week. Weekly format which used for data source recapitulation containing format number serially, health care unit identity, reports period, 21 kind of infectious disease and syndrome and also code for each disease. Data which recapitulated for weekly format having a purpose as archieve for Local Clinic Government, Local Clinic Government Helper, and Village Midwife. After it was recapitulated, village midwife and nurses on the Local Government Clinic Helper were sent the data on weekly format to the surveillance practitioner of Local Government Clinic by SMS. SMS that sent by Local Government Clinic Helper s practitioner and Village Midwife every Saturday for each week. Then, from that SMS which received, Local Government Clinic s Surveilance made transcript on weekly formats. That format made for copies, one are the original for Local Government Clinic and the copy is for each Local Government Clinic Helper and Village Midwife who sent the reports. Below are observation result toward the facility which used for EWARS application SMS-based. Table 1. Facility Observation Result For EWARS Implementation SMS-based No Observing Aspect Available Absence 1 Weekly Formats Form (W2) 2 Recapitulation Book Reports W2 3 Computer for W2 recapitulation 4 HP for sending W2 reports Data source which used for EWARS implementation is W2 reports of Local Government Clinic. W2 reports of Local Government Clinic is an epidemic reports which reported every week. According to Keputusan Menteri Kesehatan Republik Indonesia Nomor 1479/MENKES/SK/X/2003 tentang Pedoman Penyelenggaraan Sistem Surveilans Epidemiologi Penyakit Menular dan Penyakit Tidak Menular Terpadu, surveilance atau epidemiology surveilance is analysis work out systemtically and continously toward some disease or health problem and conditions which influencing on increasement of infectious disease or health problem, so that it can be done by doing effective and efficient solution by collecting data, epidemiology information managing and distributing to the health care facility. Early Warning Alert and Respon System also as one of surveilance epidemiology system which are 45

collecting and managing data for each week about disease which showing increasement and spreading so that it can be performed an early tacling way to prevent the disease. Data source which used for EWARS implementation have already appropriate with keputusan Menteri Kesehatan Republik Indonesia Nomor 1116/MENKES/SK/VIII/2003 there is epidemic reports from visited data patient is for one week. 2) Report Sending By Surveilance of Local Government Clinic, W2 reports sent by SMS to one of EWARS manager s phone on Surveilance and Imunization Division of Health Department every Monday for each week. Based on observation result, at Surveilance Division of Health Department Purworejo Distric there available W2 reports recapitulation book. That book functionally for saving SMS transcript which already sent by Surveilance of Local Government Clinic, so that if one day that data is needed, that data is still available on recapitulation of W2 report book. Short Message Service which sent by Surveilance practitioner of Local Government Clinic to the EWARS Manager is SMS which consist of W2 reports with the format that already stated by the center. On the implementation, there still Local Government Clinic which too late for sending W2 reports to the Surveilance Division of Health Department. That overdue caused the completeness of reports will be decreased. The overdue of W2 report sending will be sent to the center by EWARS manager on Surveilance Division of Health Department. W2 report which already sent from surveilance practitioner of Local Government Clinic and already recapitulated then will be manage using EWARS software. Managerial process of W2 report Local Government Clinic are as follow : 1. All of Local Government Clinic Seluruh at Purworejo distric sending W2 reports by SMS to the EWARS manager s phone who available at Surveilance Division of Health Department. 2. EWARS Manager at Health Department receive that SMS then transcripting SMS data to the W2 recapitulation book. 3. Data transcript that available at recapitulation book then will be inputted to EWARS software. 4. Choose epidemiology reports week, choose health informer unit, then input the data which available at recapitulation book. 5. Contact the Local Government Clinic which not sent the weekly reports yet. 6. After all of the data are inputed to the EWARS software, then sent to the center by ewars.pusat@yahoo.com From data management until data input to the EWARS software will resulting Weekly Bulletin and Early Detection of Extraordinary Disease Incident. One of form about information technology development and telecommunication right now is cellular phone. Related to health sector, mobile phone technology look like fulfilling the society needs for fast and correct handling of health problem. Beside it can be used for direct communication, mobile phone also have another ability, there are it can can be used for sending short message by text. This application are known as SMS. Although data sending through this format have several disability such as the limitation of character which can be sent for one SMS and kind of font which can be used is being boundary, but sending message using this format is quietly famous because the cost of it relatively cheaper. On health sector, the usage of SMS facility on cellular phone have already applicated. SMS can be used as one of media for implementating the weekly reports fastly. According to Algoritma Diagnosis Penyakit dan Respons Serta Format Penyelidikan Epidemiologi, every Local Government Clinic units using SMS to reporting weekly data which appropriated with standard format of registry should following the same standard as follows : - Epidemiology Week to : - Informer Unit Name - The sum of disease cases which reporting on that week - The sum of patient visiting The example of reporting by SMS which are printed on Buku Algoritma Diagnosis Penyakit dan Respons Serta Format Penyelidikan Epidemiologi are : 46

2,Mranti,A10,B15,H3,T4,X110 Means Epidemiology Weeks 2, Informer Unit Name are Local Government Clinic Mranti, total of diarrhea cases = 10, total of malaria cases = 15, total of estimated DBD cases = 3, total of unknown disease cluster = 4, Total visit = 110 On the implementation, the practitioner who related to W2 report sending have already know about the format of SMS which are appropriate as the rules. But only the sending proceess was oftenly overdue. According to Panduan Pengguna Piranti Lunak (Software) Peringatan Dini Surveilans Penyakit Menular, Early Cautionary System and Respons is one kind of system which functionally to knowing the movement of one of infectious disease time to time with giving alert signal if the total of cases is exceed the boundary that already stated, so it will help Surveillans program manager to detecting indication of extraordinary disease incident encouraging fast respond to handling that problem. Surveilans unit of Health Department of Distric execute annualy potential diseae for extraordinary disease incident, directed to epidemiology transision, cases distribution, mortality and its relation with rik factors, programs development, environment changement, and utilizing the result of experience/research. The role of Health Department of Purworejo Distric on W2 reports management has been appropriate with Keputusan Menteri Kesehatan Republik Indonesia Nomor 1479/MENKES/SK/X/2003 about Pedoman Penyelenggaraan Sistem Surveilans Epidemiologi Penyakit Menular dan Tidak Menular Terpadu. 3) Output of W2 report Local Government Clinic Output of W2 reports will be served on weekly summary form (Weekly Bulletin) which uploaded every week by SIK of Health Department. On Weekly Bulletin consist of accuracy and completeness of the reports every week, morbidity proportion and disease incidency, development of case distribution, warning signal (alert) and respond and recommendation result. Weekly Bulletin as a feedback to the Local Government Clinic which showed on SIK. But from quesioner result, there were several Local Government Clinic which stated that there is no feedback yet from Health Department on Weekly Bulletin form. The lackness of Local Government Clinic knowledge about the feedback on Weekly Bulletin caused by there is no continuity meeting yet for EWARS implementation. Based on quesioner result, Local Government Clinic stated that EWARS training only held once on early 2012. Recapitulation result of W2 reports will be analyze directly for extraordinary disease incident or not. One case stated as extraordinary disease incident if that cases has reaching the limit of disease value which at EWARS. It also can bee seen from the increasement of case before or the case before is unavailable but suddenly come. With EWARS, will be known early about potential disease of extraordinary disease incident. Weekly bulletin made for every week and uploaded at SIK of Health Department Purworejo Distric. According to Pedoman Sistem Kewaspadaan Dini dan Respon, Surveilance Division of Distric and Regional will made a feedback with the summary of weekly reports including: a) Alert (cautionary signal) b) Relevant Epidemiology information c) Recommendation of suggested activity for controlling the caused factor of extraordinary disease incident. d) Result of weekly activity before to controlling extraordinary disease incident. Weekly bulletin which made by EWARS manager consist of naration with length of two pieces of page maximally. On the Weekly Bulletin also consist of output served on table form and graph, there are case distribution table based on kind of disease or the sympthom on SKD and respond and also the table about the total of cases and early cautionary signal at every Local Government Clinic. On the other side, graph which available, there are accuracy table, the completeness of SKD reports and respons also recapitulation graph of the highest cases every week. With this Weekly 47

Bulletin will easier the practitioner whom related to EWARS implementation to see the output which resulted from W2 reports with EWARS. 3. Factors which Influenced EWARS SMS-based on Health Departement Region on Purworejo Distric 1) Man Human resources as means are the practitioner who given the duty to sent W2 reports on EWARS implementation, they were Village Midwife, Nurse who work on Local Government Clinic Helper and Surveilance of Local Government. Based on questioner result about the obstacle of EWARS implementation, Local Government Clinic stated that the overdue of reports by Village Midwife and Local Government Clinic Helper caused W2 reports sending to the Health Department also overdue. Surveilance of Local Government Clinic must remind Village Midwife and Nurse to sent the reports. No awareness of the duty from Village Midwife, Nurse who work on Local Government Clinic Helper caused EWARS implementation are overdue. According to Hasibuan (2009), Human Resources are an integrated ability from contemplative capability and physical capability that available on each individual. Overdue of report sending by Village Midwife, Local Government Clinic Helper and Local Government Clinic is because the lack of duty awareness and the importance of W2 reports. The awareness and desire from the practitioner have a strong relation with motivation and self-dicipline from that practitioner. According to Sulaeman (2011), motivation is an effort to stimulate, encouragement or energy-generator of someone of a group of society so they want to work and collaborated optimally to resulting things that already planned to reaching purpoed that already stated. A good dicipline shows how much responsibility of someone with their duty that given to them. The lack of awareness and desire about the duty and responsibility from Village Midwife, Nurses who work on Local Government Clinic Helper and Surveillance Practitioner of Local Government Clinic caused W2 reports sending was oftenly overdue. Precutionary have already given to the surveillans practitioner of Local Government Clinic who oftenly overdue for sending W2 reports every week. But that precautionary only given by SMS. There s no oral precautionary or the written one for surveilance practitioner oflocal Government Clinic to sent W2 reports on time. 2) Money Based on questioner result about budget consideration for EWARS implementation, all of Local Government Clinic give statement that there is no budget consideration yet for EWARS implementation. To support the success of some implementating activity must be supported by enough budget to guarantee the ability of resources needed (Sianipar, 2003). W2 reports sending by Village Midwife, Local Government Clinic Helper and Local Government Clinic need budget on the implementation such as pulse. But until right now, budget for SMS sending by Surveilance practitioner of Local Government Clinic, Village Midwife, Local Government Clinic Helper still using their private budget. Means, there is no budget for health care facilities (Local Government Clinic, Village Midwife, Local Government Clinic Helper). The budget only given to Health Department Purworejo Distric by modem pulse and computer. 3) Methods Based on observation, EWARS implementation at Surveilance and Imunization Division of Health Department Purworejo Distric, there already available an Operating Standard Procedure such as Reporting Data Procedure in every implementer level, Data Validation, Monitoring, Evaluation, Limitation and Owner. According to Huffman (1994), procedure is a pathway for implementating particular tasks. According to Sabarguna (2005), service that implementated must have a particular rules orally or written, everyday operating rules, important to write for several needs: a) Clarity act, in order to practitioners training and practitioners founding programs. b) The clarity of duty and rights that the practitioner have to do at minimal. c) As one of the substance in order to value the health service d) Can be evaluated and develop continously. Health Department Purworejo Distric already have some procedure to EWARS implementation. But at the reality, evaluation procedure haven t done by Health Department Purworejo Distric after implementating EWARS. 4) Material (Data Source) W2 reports which sent by surveilance practitioner of Local Government Clinic to the EWARS manager 48

sometime not fulfill the completeness. That uncompleteness caused by the reports from Local Government Clinic Helper and Village Midwife to Local Government Clinic also overdue. Local Government Clinic only reporting data which available to decreasing the overdue reports on Surveilance Division of Health Department. But, the overdue data also must be reported to Surveilance Division of Health Department with frequent reports format. According to Sianipar and Entang (2003), on making particular material which needed from the outside such as materials, documents, folder or even fact and the data which available, on time, right qualifications which ready to manage must be an opportunities and if it was opposite, it can be some threats which delayed. For W2 sending to the center, data from Local Government Clinic, Village Midwife, Local Government Clinic Helper is very important. That data must be sent on time so thet completeness aspect can be fulfilled. But on the reality, Village Midwife, Local Government Clinic Helper s nurse is oftenly overdue to send the reports. So the completeness of W2 reports is decreased. If on Tuesday evening, the nurse and village midwife did not sent register data of patient with new cases, so the surveilance practitioner on Local Government Clinic only send the data which have available to decreasing the overdue on reports sending to the Health Department. Data which less complete will be resend to Health Department. Data which received on Health Department will be inputted to EWARS software in order to sent it to the center by email. Although, W2 reports data is less complete, but EWARS manager still sent that W2 reports by email to decreasing the overdue. 5) Equipment Equipment which used for EWARS system SMS-based di Health Department of Purworejo there are W2 report format, W2 recapitulation report, Handphone (HP) which used for sending W2 report, EWARS software, internet connecction, and permanent procedure of EWARS implementation from data source level until Health Department. Equipment does help the system work on. Alat. Based on Permenkes Republik Indonesia Nomor 512 tahun 2007 about Izin Praktik dan Pelaksanaan Praktik Kedokteran, Standard Operating Procedure is an instruction ware or steps which stated for solving some works which standard operational procedure give some right steps and the best one based on together-consensus to implementate every action and service function which made by health care facilities based on profession standard. Stated procedure on EWARS system SMS-based at Health Department of Purworejo Distric has available properly. Socialization and procedure also have been done. 4. Conclusion 1. EWARS Implementation on Health Department of Purworejo started from: a. Data Source and Managing Data source of W2 reports at Local Government Clinic on EWARS implementation have been appropriate with the rules, there are endemic reports which coming from patient visiting for one week with the new cases. W2 reports managing using weekly formats which proper on EWARS implementation. b. W2 Reports Sending Done by every health units using SMS which showed to EWARS manager at Surveillance Division of Health Department then it will be sent to the center by email. c. Output of W2 reports Served on Weekly Bulletin formed which available on SIK Health Department. 2. Faktors which influenced EWARS implementation at Surveillance and Imunization Division Health Department of Purworejo Distric a. Man, the lack of awareness for every practitioner in health care facilities about the importance of W2 reports. b. Money, There is no budget yet for Local Government Clinic, Village Midwife, Local Government Clinic Helper in order to EWARS implementation because the budget from the center only given for Health Department. c. Method, There is no evaluation yet to value the successness EWARS implementation at Health Department of Purworejo Distric. d. Material, The lackness of W2 completeness reports from Surveilance practitioner of Local Government Clinic. e. Equipment, which already good available. 5. Suggestion 49

1. Suggested that will be held continously training for all of practitioner which related to EWARS implementation so that they will understand more how the usage and implementation of EWARS better. 2. Suggested that monthly evaluation is needed to value the successness of EWARS implementation. 3. Certain cautionary should be given to diciplinate the surveilance practtitioner on Local Government Clinic, Village Midwife, Local Government Clinic Helper s nurse so that data sending to the Health Department will be on-time. References Azwar, Azrul. 1996. Pengantar Administrasi Kesehatan Edisi Ketiga. Binarupa Aksara : Jakarta Azwar, S. 2007. Metode Penelitian. Yogyakarta : Pustaka Pelajar. Depkes RI. 1997. Pedoaman Sistem Informasi Manejemen Puskesmas. Jakarta : Depkes RI. Depkes RI. 2008. Pedoman Sistem Kewaspadaan Dini dan Respons. Jakarta : Depkes RI. Depkes RI. 2008. Algoritma Diagnosis Penyakit dan Respons Serta Pedoman Penyelidikan Epidemiologi. Jakarta : Depkes RI Depkes RI. 2008. Panduan Pengguna Piranti Lunak (software) Peringatan Dini Surveilans Penyakit Menular. Jakarta : Depkes RI Dinas Kesehatan Kota Yogyakarta. 2010. Sistem Pelaporan Wabah/KLB th 2010. Diakses dari http://kesehatan.jogjakota.go.id/bulletin/index.php?option=com_content&view=article&id=72:bulletinepidemiologi-triwulan-ii-tahun-2010&catid=40:lapw2&itemid=59 tanggal 07 Januari 2012. Hasibuan, S. P. 2009. Manajemen Sumber Daya Manusia. Jakarta: Bumi Aksara. Sabarguna. 2005. Organisasi dan Manajemen Rumah Sakit, Cetakan Kedua. Yogyakarta: Konsorsium Rumah sakit Islam Jawa Tengah dan Yogyakarta. Sianipar dan Entang. 2003. Teknik-teknik Analisis Manajemen. Jakarta : Lembaga Administrasi Negara Republik Indonesia. Sulaeman, E.S. 2011. Manajemen Kesehatan Teori dan Praktik di Puskesmas. Yogyakarta : Gadjah Mada University Press. Wijono, D. 1997. Manajemen Kepemimpinan Dan Organisasi Kesehatan. Surabaya : Airlangga University Press. *** 50