Pejabat Kesihatan Daerah Lubok Antu(Basic Information)

Background Of Lubok Antu Township:

       Lubok Antu Township “the sleepy cowboy town”,was established way back in the colonial era in the early 1800s. According to the elders, the first 2-3 shops were erected at a location adjacent to our present KK Lubok Antu which was later moved to the present location. The present old shop lots were erected approximately 20 meters from Batang Ai river bank. These are predominantly owned by typical China Men. Since then, these shops cater for the surrounding minor local Malay, Chinese communities and the majority of Iban communities residing along the Batang Ai River, as well as those residing along its major tributaries, such as Engkarie and Lemanak River.

       The geographical coordinate for Lubok Antu is lat;104.1780 long:111.836100, an area  predominantly dominated by Iban ethnic and as such Iban language is very much the lingua franca in the area. Majority of the Iban communities are practicing shifting rice cultivation, rubber tapping, oil palm planting and small scale enterprising on local produce such as the popular red Talipia and Tengadak fish as well as local agricultural produce.

         Since the resettlement programme in conjunction with the damming up of the Batang Ai River for first Sarawak’s  hydro-electric station in the 80s, it was not uncommon to see streams of visitors as well as the local communities comprising of various ethnics frequenting and packed the township for daily necessities or other activities. Lubok Antu Township is adjacent to the Sarawak-Kalimantan border that takes about 20 minutes drive to reach the Badau border post, as such this township is a common transit point for both illegal and legal Indonesians planning to go to other places in this country, as well as carrying out small scale enterprising for local agricultural produce and handicrafts with wide varieties of choice.

Location Of Present District Health Office:

    The geographical coordinate for District Health Office Lubok Antu is at Lat.1.041780 Longitude: 111.836100. To reach the District Health Office Lubok Antu one has to travel with land transport (land cruiser or private car) for 1.5 hours along a course of 82 km from Sri Aman town, through multiple “s” pattern “tidal wave” tar-sealed road that is gradually improved over years.

   We are responsible to our main administrative office that is Divisional Health Office Sri Aman, which is reachable through the above mentioned mean. The base Hospital that deals directly with all cases needing professional investigation and management, be it cases referred from outstation clinics under Lubok Antu district or klinik kesihatan Lubok Antu itself, is the present General Hospital Sri Aman, which is also of the same distance away.

Our Reception Counter

Health Screening

Counter Decor

Task Force

Background Of District Health Office Lubok Antu:

               With the increasing need for better and systematic health care system for the increasing population coinciding with logging boom and integrated planning for various socio-economic developments for Lubok Antu District, a District Health office was established sometime around the end of 90s to cater for the health of the general population. Various categories of staff were posted to Klinik Kesihatan Lubok Antu then, and this includes senior Assistant Medical officer to look after the eight rural health clinics in Lubok Antu district. A senior Health Inspector, few time-scale health inspectors and Public Health Assistants  were also posted here to form the task force for various disciplines of the public health section. These include Communicable disease control unit, Food safety, Occupational health and safety and Environmental health unit.

              For uncertain reason, the work force for the public health unit was dispersed in the year 2008, staffs from this unit were all stationed back in head office, Sri Aman. What left to date is the name of the existing District Health Office, with one Senior Assistant Medical Officer, one male attendant, one female attendant and a driver. The staffs that still remained were all merged into the integrated functioning machinery of rural curative service. 

Mode of Communication:

    The communication link between the District Health Office and local communities within the immediate areas, central administrative office, peripheral clinics and various government agencies is by land transport. Except Nanga Stamang, Nanga Delok and Nanga Patoh clinic, which are only accessible by powered long boat.

Lubok Antu District Health Office is easily contacted   through telephone or internet; however it is quite difficult to contact certain clinics that are not equipped with telephone/ internet/ USP in time of needs. Specifically, these clinics are:-

1.    KK Nanga Delok (no telecommunication system).

2.    KK Nanga Stamang (USP Break down).

 Table Indicating Mode Of Communication /Accessibility And Time Taken To Reach Each

                       Location/ clinic under Lubok Antu district:

no	Clinics	Accessible By	Telecommunication System	Time taken (From  Lubok Antu/ Sri  Aman)
1	KK. LUBOK ANTU	ROAD/ Land Transport	Telephone/ internet	1.5 hrs from Sri Aman
2	KK. ENGKILILI	ROAD/ Land Transport	Telephone/ internet	45 min from Sri Aman
3	KK. BATANG AI	ROAD/ Land Transport	Telephone/ internet	1.25hrs from Sri Aman
4	KK. MERINDUN	ROAD/ Land Transport	Telephone/ internet (USP)	1 hr from Sri Aman
5	KK.NANGA KESIT	ROAD/ Land Transport	Telephone/ internet	1 hr. From Sri Aman
6	KK. NANGA PATOH	RIVER/ Long Boat	Telephone/ internet (USP)	3-4hrs From KK. Lubok Antu
7	KK.NANGA STAMANG	RIVER/ Long Boat	Telephone/ internet (USP-not functioning)	1.5- 3 hrs from KK. Lubok Antu
8	KK.NANGA DELOK	RIVER/ Long Boat	No Telecommunication system	1hrs from hydro station

 

Community Profile:

I.    Local Dignitaries:

        Each longhouse in this area is looked after by a headman and an assistant. They are responsible to maintain optimal harmony of the population under their jurisdiction, by ensuring each individual abide to the standard native law and orders. Apart from this, there are few Penghulus in this area and these village chiefs are the most important liaison figures between any government agency and the local community.

JKKK/ local Health and Safety Committee

         Each longhouse has its own committee members to look after the implemented health project, especially the projects implemented by the BAKAS unit. As the in-charge of this primary health care unit, one ought to be pro-active to any problem encountered by the committee, and be ready to assist them reaching the best solution to any problem, or other wise to refer the matter to relevant authority.

iii: Traditional Healer: (Bomoh/ Manang):

     It is not uncommon to see a local resident resorting to traditional treatment for certain health problems in the Iban community anywhere in Sarawak. However, it is not an obvious practice in this area based on the following factors:

¨       That, 90% of the local population is quite aware of the effectiveness of modern medicine or treatment.

¨       95% of the Iban community are Christians.

 iV: Religious profile:

       92% of the total population are Christians, 6% are Buddhist/Taoist and the remaining 2% are Muslim. 95% of Iban community are Anglican Christians; however, a small number of them are still having mixed beliefs.

  v: Cultural Beliefs & Traditional Practices:

         The local Iban communities in this area are celebrating the annual Gawai Dayak as well as Christmas day. Common traditional ritual ceremonies, such as Gawai kelingkang, Gawai kenyalang and sandau ari, as well as  the common "miring ceremony", is the epitome of Iban tradition and is still widely practiced, but at certain places had been abandoned and replaced by Christian prayers in any occasion or ceremonial act.

COMMUNITY PARTICIPATION PROGRAMME:

a.    PENAL PENASIHAT KESIHATAN:

       This is a voluntary health advisory committee at rural setting, of which its members were selected by the Assistant Medical Officer in charge of each clinic. Each member is an important liaison figure between our health unit and the local community. They are responsible to assist us to identify and discuss certain needs in term of health promotion in an identified community. Official directive for state-wide uniform formation Penal Penasihat Kesihatan was launched in the mid 90s.

      According to the directive, selected penal penasihat would be given an official certificate and certain privileges in seeking medical treatment, and selection of member for each clinic should be carried out every two years, whereby we can either re-select the former member or get a fresh replacement. However, only the first batch of penal penasihat was issued certificates (two-year validity) to certify their involvement. Since then, there was no promising feedback for the subsequent new batches from the central management.  I have a personal opinion that this is the major factor for the descending initiative for new recruitment and redundancy in activation of this programme at various primary health care levels, be it at district, divisional or state level.

       Where possible, We can merge the effort of WKK and the Penal Penasihat Kesihatan at the local level, to assist us in the implementation of various health programmes such as implementation of healthy village, NCD screening programmes as well as various forms of health campaigns  scheduled to be conducted in a community level. This collaborative effort will certainly widen our coverage in early detection, prevention of non-communicable health condition in our health promotion programme.

  

b.    WAKIL KESIHATAN KAMPUNG/ VILLAGE HEALTH PROMOTER:

          The first Village Health Promoter recruitment and training program for Sri Aman Division was conducted for Klinik Kesihatan Meludam in the year 1983. Subsequent recruitment and training was planned to be conducted as an annual programme since 2003 in Sri Aman Division. The training sessions for the last few batches of new VHP/WKK were conducted in Klinik Kesihatan Batu Lintang,Sri Aman. Apart from new recruitment, refresher courses were also conducted accordingly. However due to limited allocation, only few batches were able to be trained since then. To date, there are a total of 70 trained Village Health promoters from 8 clinics under Lubok Antu district, only about 30% of the total numbers are considered active, based on the criteria that each individual did conduct various beneficial health promotion activities at the local level, and sent in the required reports at a frequency of at least once a year.

        We ought to treasure this voluntary Health body, as they are important liaison figures between the health department and the community. With proper coaching, they have the potential to assist us in various aspects in implementing an effective primary health care program. It is the responsibility of the Assistant Medical Officer in-charge, to see to the needs of all VHPs in his operational area, and should attempt to establish a good rapport with these workers in order to achieve optimal success in this program. I personally feel that, certain strategies have to be adhered to, in order to sustain the “pipe-line interest” of these Village Health Promoters in our area of practice.

Proposed Strategies To Sustain This Voluntary Health Programme:

• Sustain their activeness through regular visit and field coaching by clinic / travelling staffs.

• Assistant Medical Officer in-charge should be familiar with the name and general profile of each VHP/ WKK in his area.
• Assistant Medical Officer in-charge is responsible to ensure the rapport between VHPs/ WKK, JKKK and the village chiefs is well fostered towards developing a strong team.
• VHP/WKK is a ‘peoples’ project, therefore the real supervisor is the village JKKK, thus it is our responsibility to suggest to the JKKK how to identify problems and needs of the village, and how to improve the village working through committee blocks and units and related agencies or groups.

• To ensure that the basic drug supply and first aid requirements for WKK is adequate, which means we have to include the needs in our quarterly or supplementary indent.

• Ensure monthly return formats, leaflets/pamphlets for the WKK in our area is adequate at all time.

• Refresher courses should be conducted at regular intervals for all VHP/WKK, who still hold the interest to be voluntary Health care workers.

I: Table Indicating No. Of VHP/WKK Under The Care Of Each Clinic

No.	NAME OF KLINIK KESIHATAN	NO. OF VHP/WKK
1	KK. Engkilili	18
2	KK. Lubok Antu	13
3	KKNanga Patoh	11
4	KK. Nanga Kesit	7
5	KK. Merindun	7
6	KK. Batang Ai	5
7	KK. Nanga Stamang	5
8	KK. Nanga Delok	4
	District Total	70

Population Profile:

         Based on the latest information from the statistic department, Lubok Antu district has a total area of 2338 Km², with a total population of 25,100. There is a difference compare to our collective statistics, in which in our population survey, we would not include those staying outside a particular locality.   

        There are 3 major ethnics found in Lubok Antu District, namely; Iban, Chinese and Malays. The population in Lubok Antu District are predominantly dominated by Iban ethnic (92%), and Chinese accounts for about 6% of the total population, and the remaining are Malays (2%). Apart from Engkilili and Lubok Antu Township, majority of the population in the remote setting are Iban.

 

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PROFILE OF CLINICS UNDER PKD LUBOK ANTU :

          There are eight Rural Health Clinics / Klinik Kesihatan directly under the administrative monitoring and technical supervision of District Health Office Lubok Antu. Most clinic are easily accessible by land transport except 3 peripheral remote clinics; namely, Klinik Kesihatan Nanga Patoh in the upper region of Lemanak river, Klinik Kesihatan Nanga Stamang in the mid upper region of Engkarie river and Klinik Kesihatan Nanga Delok in mid region of Batang Ai river. Traceability of the exact locations of these clinics on Google map is guided by the following given geographical coordinates:-

 

   GEOGRAPHICAL COORDINATE OF EACH KLINIK KESIHATAN

NO.	Name of Health Facility	G.Coordinate
		Latitude	Longtitude
1.	Klinik Kesihatan Lubok Antu	1.041780	111.836100
2	Klinik Kesihatan Engkilili	1.184531	111.673602
3	Klinik Kesihatan Merindun	1.182890	111.742720
4	Klinik Kesihatan Batang Ai	1.127260	111.860960
5	Klinik Kesihatan Nanga Kesit	1.235190	111.784710
6	Klinik Kesihatan Nanga Stamang	1.311230	111.941360
7	Klinik Kesihatan Nanga Patoh	1.336120	111.831500
8	Klinik Kesihatan Nanga Delok	1.232230	112.021759

THE EIGHT KLINIK KESIHATAN IN LUBOK ANTU DISTRICT

SERVICES RENDERED BY EACH CLINIC:

              Service rendered by each of the eight clinic in Lubok Antu district is no different than the rest of the klinik kesihatan throught the state of Sarawak. We are now on the tract of integrated health care services based on the REAP concept, that function holistically in a package of four implementable services which include wellness, Illness, Support service and Emergency care (WISE). Apart from these routine services, one of the facilities in this district, that is Klinik Kesihatn Lubok Antu, is currently providing regular dental services to cope with the demand of the general population. This is achieved through provision of monthly visiting dental clinic based in Klinik Kesihatan Sri Aman.

              Based on our annual budget meeting (ABM), Klinik Kesihatan Lubok Antu is supposed to have 2 medical officers to boost the existing funtioning clinical  machinery, which is currently functioned by Assistant Medical Officers. The current nation-wide shortage of qualified Medical Officer could be the major factor hindering allocation of man power to this rural primary health care facility. However as a substitute, it had been planned by the Divisional authority to arrange for monthly visiting“Medical Officer’s clinic” in due course. With this planning, the local community will certainly get the benefits, in which there will be a substantial reduction in personal operating cost in the aspect of obtaining medical care.

1.    SCHOOL HEALTH SERVICE:

           The first round of School Health service is normally conducted at the beginning of a year through the division or district, whereas, the subsequent follow-up will be carried out at mid-year to complete  left-out  immunisation or health assessment. A school health team normally comprises of an Assistant Medical Officer, one or two community nurse(s) and or Staff nurses, an attendant and a driver. School Health Reports from the peripheral clinics are compiled by an appointed Assistant Medical Officer at district level, and these reports are to be submitted timely through e-reporting system.

                                 Name Of School Under Each Facility

No	Name Of Facility	Name Of School
1	Klinik Kesihatan Engkilili	SMK. ENGKILILI
		SK. BASI
		SK. EMPELAM
		SK. ENGKILILI NO.1
		SK. ENGKILILINO. 2
		SJK. CHUNG HUA,ENGKILILI
		SK. MERBONG
		SK. NANGA KUMPANG
		SK.  NANGA AUP
		SK. SEDARAT
2	Klinik Kesihatan Lubok Antu	SMK Lubok Antu
		SK. LUBOK ANTU
		SK. MELABAN
3	Klinik Kesihatan Batang Ai	SK. BATANG AI
		SK. SEKAROK
4	Klinik Kesihatan Merindun	SK. SEBANGKI
		SK. RIDAN
		SK. SAN SEMANJU
5	Klinik Kesihatan Nanga Kesit	SK. NANGA KESIT
		SK. NANGA MENYEBAT
6	Klinik Kesihatan Ng. Stamang	SK. ULU ENGKARI
		SK. NANGA TIBU
7	Klinik Kesihatan Nanga Patoh	SK. ULU LEMANAK
8	Klinik Kesihatan Nanga Delok	SK. NANGA DELOK

There are two secondary schools and 22 primary schools in Lubok Antu district. The total enrolment for respective classes covered is illustrated as per table below:-

Table: Enrolment Data For The Year 2011:

No.	Category Of school	Category of Class	Total Enrolment (Year: 2011)
1	Primary School  (22 schools)	Year 1	443
	Primary School	Year 6	483
		Total	926
2	Secondary School (2 schools)	Form 3	453
		Total	453

    

       Apart from giving immunisation to the eligible groups, visual acuity and general health assessment/ physical examination are compulsory procedures to be carried out during school health service, and any health discrepancy should be recorded and the final statistical report ( KSK201A) to be submitted timely according to schedule.

   VILLAGE HEALTH SERVICES:

      At present, there are 3 functioning village health teams in Lubok Antu district, namely; village health team from klinik kesihatan Lubok Antu, KK. Nanga Kesit and KK. Merindun. The regularity of operationalization of village health teams had been very much limited by the constraint in operating fund for the past one year.

      With effect from this year (2011) a more integrated approach is introduced in term of rendering village health services, whereby operating personnels have to concentrate more on health screening for early detection of both communicable and non-communicable diseases instead of putting more efforts on curative services.

      Klinik Kesihatan Lubok antu is currently covering 10 villages under jurisdiction of 3 adjacent clinics. 3 localities belonged to KK. Nanga Stamang, 3 belonged to KK. Nanga Delok and 4 localities belonged to KK. Batang Ai respectively. These will be ceded back to respective clinics with effect from the year 2012, except 4 localities under KK. Batang Ai.

Ceding back of localities to respective clinic, in particular those under KK. Nanga Stamang and Nanga Delok, is expected to reduce the operating cost and to foster better ties and understanding between  ralated clinics and the local communities in respective operational areas.

  

 TREND OF TUBERCULOSIS IN LUBOK ANTU DISTRICT:

        The increasing trend of tuberculosis in Lubok Antu District is a major national concern. Based on the following chart, there was a remarkable increase by 11 cases (39.3%) in the year 2004, and since then it was constantly increasing, except slight drop in the year 2008 and year 2010. By the first half of 2011, there are already 26 existing tuberculosis cases identified, and It is also clearly indicated that the incidence rate for the year 2011 is in an ascending manner. How many more newly infected and undetected cases each day is a puzzle.

  The detection rate through obtaining sputum specimens from suspected cases in the peripheral clinic setting is not very promising throughout our district or even division. I have a personal assumption that there are many other factors contributing to low detection rate in the primary health care setting apart from poor smears and late dispatch for laboratory examination. In future, research study should be suggested to be made possible to probe into factors such as attitude and competency of primary health care workers in relation to redundancy in early detection rate. This should be a major aspect to be looked into by a supervisor posted to this district.

THE TREND OF MALARIAL DISEASES IN LUBOK ANTU DISTRICT:

             Lubok Antu district had long been gazetted as malarious area, particularly the immediate localities in Lubok Antu itself. Lubok Antu is the transit point for all walks of life, such as foreigners of different ethnic from the neighbouring country (Indonesia) and loggers. The local communities are majority farmers, gardeners and plantation participants who are prone to constant exposure to mosquito bites, so these could be one of the factors account for acquisition and transmission of malarial disease in the district. Early detection and identification of malarial infections is done through passive case detection in all rural primary health care settings, whereby blood smears should be taken from all suspected fever cases, foreigners, border crossers loggers, plantation workers and those frequenting the jungle for foods, such as hunting and seasonal fruit collecting activities.

               I have personally observed that the positive detection rate at the Klinik Kesihatan level is very much lower than the hospital level. A very good example is the achievement in the year 2010 for Lubok Antu District, whereby only 3 out of 14 cases were detected by 8 clinics in the district, 11 cases were detected at hospital level. Based on random observational study through supervisory visits, the followings are most likely to be the contributing factors for low detection rate at the rural primary health care level:-

·         Not all symptomatic or those with different level of pyrexia were carefully examined and have their blood taken for examination.

·         Patients  who came with acute symptoms were referred to hospital without their blood smear taken first.

·         Most clinical staffs are not keen to perform blood taking procedures even though basically trained in this aspect.

·         Many were observed to have poor skill in smear preparation despite have attended several refresher courses. The possible reason for this  is low initiative in practice.

·         Majority of patient resort direct treatment at the base hospital.

       Strategies for Wider Coverage Of early Detection:

       For the past few years, the overall achievement in term of effort in blood slide collection for detection of malarial disease did not seem to be at satisfactory level. Few strategies have been put into use to increase the output:-

a.    Set up blood slide collection counter for trained attendants to assist in the work procedures.

b.    Compulsory for all Assistant Medical Officers to order BFMP for all relevant cases and to be recorded in the RHBKKK accordingly.

            A mini laboratory was recently set up at Klinik Kesihatan Lubok Antu manned by a Laboratory Assistant, who is at the mean time responsible to the Malaria Eradication Unit and responsible to examine all blood smears collected by 8 clinics under Lubok Antu district. This will ensure a satisfactory “turn-around time” for slide dispatch and examination throughout our district. A proposal and estimate for a full laboratory service has been forwarded to the ministry for consideration. This set up, as basic diagnostic aid in the clinical field will definitely ensure faster and more accurate diagnosis of clinical cases attended in the rural setting in future.The national target set for blood slide collection to detect malaria parasites is10% of the total monthly or annual new cases. A more specific approach towards early detection was introduced by the Malaria unit at the middle part of the year 2011, a quality assurance programme for malaria eradication which is to be closely adhered to by all Primary Health Care units. This programme emphasizes on the slide collection target intended for non-citizens, fever cases and “Turn-around time” of slide dispatch for laboratory examination as well as malarial drugs stock monitoring at the clinic level.

              With the implementation of this QAP in malaria eradication, any case detected is to be referred to the nearest hospital for admission and initiation of treatment. District supervisor should ensure that, all Assistant Medical Officer to comply closely to the standard procedures related to this programme. Achievement in blood slides collection from each clinic should be closely monitored in term of quality as well as quantity to achieve the set target.

LABORARTORY ASSISTANT AT WORK

INTERDEPARTMENTAL COLLABORATION.

        There are many other government agencies in Lubok Antu district, mainly situated iLubok Antu and Engkilili area. These agencies are such as;-

a.    The District Offices

b.    The education department.

c.    The Police, Immigration and Custom department.

d.    The Local Council.

e.    The Information Department.

f.     The Military Department.

g.    The National registration Department.

h.    The Agriculture Department.
          
             These agencies are undoubtedly having differences in term of administrative governance; however, there is a need to instil optimum spirit of interdepartmental collaboration, particularly in association with attempts to bring about community health development. A very good example in the ever organised interdepartmental collaborative effort in community Health Programme in our district was the “Gotong-Royong Perdana” organised jointly by the Local Council and our health unit in the year 2010. Apart from this, few health screening programmes were also organised under the invitation of local dignitaries (YBs), Women association and KEMAS in the year 2011. 

                                                          QUALITY IMPROVEMENT PROGRAMME:

            Most quality improvement programmes for implementation at various levels of the Health Care Facilities throughout the state of Sarawak were introduced in the early and mid 90s. Its popularity in our practise or in a particular Division or District, began to fade away since early part of the year 2000s, when turn- over rate of staffs at most facilities is total, in which those who had the experiences and competencies either had "been written-off" from the service or transferred elsewhere throughout the state. I should say, the tradition is totally extincted among the younger generation of today.  The most remarkable quality improvement programmes ever implemented in Sri Aman Division are such as:

a.    “The Damai Declaration Pledge” which carries the “Ten Commandments” as a guide towards quality improvement in all aspects of service output.(include readily available briefing note for every setting).

b.    The popular “5S” system which is an adaptable scientific approach in house-keeping suitable for any institution.

c.    Compulsory implementation of Quality Service Project, such as innovative project, QA project and simple research for individual district or clinic as an annual project.

         These were never been emphasised officially, particularly for the past 5 years. All these appear “Green” to the younger generation and would consider these are extra work and burden to them because no evidence of continuity of the process and couching after staff turn-over. I have the personal opinion that all these programmes should be re-activated if quality output in all aspect is to be sustained, particularly in the Rural Health Setting. We have implemented 2 quality improvement projects for our district in the year 2010 and 2011 respectively. Summary of these projects is as elucidated as follow:-

Project One (QA Project 2010-2011).

Title: Towards A More Cost Effective Repair of Generators In The Rural Health           Clinics.

Project Commenced: April, 2010.

 Selection Of Opportunities For Improvement:

·         Repair of generators for rural clinics required enormous amount of expenditure.

·         Difficulty in reaching the commercialised servicing centre due to geographical barriers and transportation difficulties.

·         .Doubtful quality output from commercialised service centre’s personnel.

                                                   Objectives:

This study aims;-

1.    To determine the magnitude of the problem.

2.    To identify common contributing factors associate with frequent breakdown of 

Generators belonged to remote clinics in Lubok Antu District.

3.    To introduce remedial actions to reduce the frequency of breakdown.

4.    To reduce the cost of repair.

Magnitude 0f Major Breakdown Due to Poor Maintenance:

	FACILITY/ YEAR	FREQUENCY OF BREAKDOWN
		2009	Reason for breakdown	Cost of repair (by commercialised centre)
1	KK. Nanga Delok	2 breakdown	Poor maintenance	RM: 5,320.00
2	KK. Nanga Stamang	2  breakdown	Poor maintenance	RM: 6,142.00
3	KK. Nanga Patoh	3  breakdown	Poor maintenance	RM: 8,210.00
TOTAL COST				RM:19,672
AVERAGE EXPENDITURE  INCURRED FOR EACH OVERHAUL				RM:2,810.30

                           Contributing Factors to Major Breakdown:

·         Staffs never border to know what should be done with the existing asset.

·         Staffs responsible to do daily commissioning of engines never read the printed instruction on the engine.

·         Previous supervisors had limited technical knowledge on mechanical asset.

·         No verbal guideline given by supplier while handing over of asset during initial process of commissioning.

Three major aspects of Maintenance Overlooked:

·         Cooling System- insufficient water/ stagnant water.

·         Lubricating system-wrong strength of M-oil used, oil Filter not regularly cleaned, some staffs not aware that the engine has oil filter.

      ·         Unaware head lubricant not filled at all (below air filter)

Major mechanical Problems Found:

·         Piston rings breakage.

·         Burned pistons and head gaskets.

·         Major scratches and burned down of engine’s block (Piston chamber).

·         Grand bar and connecting rod bearings detachment/ erosion.

            Key Measure of Improvement:

·         Reduction in the breakdown represents reduction in unnecessary additional cost of repair, which potentially compromises the quality of administrative function.

            (Reduction in frequent request for additional allocation)            

Remedial Measures:

·         Educating staffs on all aspects of basic maintenance, early identification of mechanical problem(s).

·         Department to purchase required spare parts.

·         Utilisation of existing skilled staff from PKD to handle repair,  and he is to carry out subsequent surveillance of mechanical functionality of all generators in the district.

 Effects of Change: 

•  Obvious reduction in the frequency of major breakdown.   

•      Reduction in the cost by RM: 2085.0 for each overhaul.

•      Reducing the gap of delayed repair and incidence of “staying in darkness” for rural staffs.

•      Staffs became more knowledgeable and responsible.

	FACILITY	Frequency Of Major Breakdown 2010	Problems Identified & nature of repair.	Cost of repair (by existing         skilled Staff)
1	KK. Nanga Stamang	1 breakdown (2nd break down brought forward from year 2009) (New Yanmar   Engine)	. Piston & Ring damage  Cone-rod & bearing  Block erosion, fuel & oil       .Filter, head gasket,    .water pump.  General Overhaul done	RM: 1130.00
2	KK. Nanga Delok	1 breakdown (2nd break down brought forward from year 2009) (Jiangdong )	. Piston & Ring damage . Piston & Ring damage . Fly wheel bearing &   Casing. .Water pump. Head  Gasket.  General Overhaul done	RM: 320.00
3	KK. Nanga Patoh	0	0	RM: 00
TOTAL				RM:1450.00
AVERAGE EXPENDITURE INCURRED FOR EACH OVERHAUL				RM:725.00

	FACILITY	Frequency Of Major Breakdown (2011 Jan-Nov)	Frequency Of Minor Breakdown (2011 Jan-Nov)	Problems Identified & nature of repair.	Cost of repair (by existing         skilled Staff)
1	KK. Nanga Stamang	0	0	0	RM: 00
2	KK. Nanga Delok	0	1	water pump damage	RM: 28.00
3	KK. Nanga Patoh	0	0	0	RM: 00
TOTAL					RM:28.00

Project Two (Innovative Project 2011).

Title: Towards Better and More Conducive Patient’s Reception (Counter Service).

Date of Commencement: August, 2011.

Facility Involved: Klinik Kesihatan Nanga Stamang.

Selection of Opportunities For Improvement:

·         No proper receptions counter for patient registration at Klinik kesihatan Nanga Stamang since the establishment of this facility, due to difficulty to bring in the bulky commercialised ready- made wooden counter. ( geographical barriers and transportation difficulties).

Existing Obvious Problems:

• Redundancy in the functioning for quality and productivity of service output at the patient’s reception point.

•           A small office table with space limitation is used as reception counter for the previous years.

•          Space limitation hinders smooth reception process and registration procedures which affect service output such as promptness and accurate recording during peak hours.

Remedial measures:

·         Planning for construction of concrete counter at minimal cost.

·         Allocation of fund for the project to be extracted from the monthly contribution from all existing staffs.( For buying commercialised materials such as cement and metal mesh)

·         Collective efforts to gather existing abundant natural resources as basic materials for counter construction. (Stone, gravels sand and wood/ranks).

Objectives:

Main Objective:

·         To create a conducive, users friendly environment for all categories of client resorting services from this clinic.

General Objectives:

·         To fulfil the goal of our department towards quality service improvement.

·         To instil the spirit of team work towards solving service problem in the rural setting.

·          Opening chances to related primary health care workers for acquiring practical experience through this pioneer project.

·         To instill spirit of “Self reliance” in solving work related problems without being too dependent on central management.

·         To create the ability to identify specific cost effective procedures in solving work related problems in the rural setting.

                                               Benefit of This Project:

a.    Cost Effective:

          The expenditure incurred for this innovation is approximately RM: 350.00, whereas supply and installation of a commercial wooden counter would cost not less than RM: 5,000.00, inclusive of transportation charges to rural clinic. In this project we were able to save up to RM: 4650.00.

b.    Durability:

      The basic materials for the construction of this counter are such as rocks with artistic surface textures and sands bonded together with cemented paste and gum. Thus, it is definitely much more durable than commercial wooden counter, which might be damaged in the course of transportation.

c.    Increased Conduciveness and Neatness :

     With larger work space, there would be no hindrance or limitation in mobility of staff carrying out work procedures. Basic requirement for registration and charges could be arranged neatly.

d.    Improved service Quality:

     Conducive, user’s friendly environment ensure smooth flow of work procedures, thus increase   the quality of service outputs and clients’ satisfaction.

e.    Time Saving And Increase Work productivity:

     Smooth work flow at the counter ensures timely completion of each service. With abundant of remaining free time thereafter, staffs can concentrate/ carry out other clinical services effectively, which compromises with work productivity.

f.     Replicability :

       This project is implementable in any rural setting where natural raw resources are abundant, and when transportation of bulky asset for official uses in a facility is not possible.

COLLECTIVE EFFORTS

FOUNDATION

NEW COUNTER

COUNTER DECOR

COLLECTIVE EFFORTS