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YAYASAN RAMA SESANA: Reproductive Health
Clinic at Badung Market
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YKIP, in association with the Annika Linden Foundation, is funding a further 3 years (2006-2008) of the "Improving Reproductive Health and Empowerment of Market Women in Bali through Information and Health Services" project of the Yayasan Rama Sesana. This health clinic is housed on the 4th floor of the Pasar Badung, Bali's largest traditional market. All of the services are either low-cost or free and are available to over 4,000 women market workers, in addition to customers/visitors, reaching an estimated 6000 people per year.
 The Yayasan Rama Sesana (YRS) clinic at the traditional market (Pasar Badung) in Denpasar was officially opened by I Gusti Ayu Bintang Dharmawati, head of the Center of the Consolidated Services for Women's Empowerment for Bali on August 25, 2004, after several months of services. in August of 2004, but has been operational since January 2004. Concentrating on the population around them, vendors, their partners, and customers, YRS has been able to amass a large client base which can easily be reached.
The initiative of dr. Luh Putu Upadisari with start-up support of BIWA, and with majority funding from YKIP/Bali and the Annika Linden Foundation, in additional to small grants and private donations for certain components. The YRS Clinic has served thousands of women and their partners since it opened. The clinic provides free and low-cost pap smears, contraception, pregnancy tests and prenatal care, and tests for STDs and HIV/AIDS and general medical check-ups, as well as monthly educational discussions on health topics, and outreach to the general public.
There are an estimated 3000 people with HIV/AIDS in Bali alone (as of June 2006). Women are particularly at risk for STDs due to documented sexual high-risk behavior of men (use of sex workers, etc), and suffer more severe consequences (impaired fertility and health) due to biological vulnerability and the lack of early symptoms of many STDs in women. Other health problems affecting women, such as breast and cervical cancer, reproductive tract infections, domestic violence and maternal death are also common in Bali.
Women tend to put low priority on their health problems thus failing to allocate time and money for seeking health care. They also tend to have less access to information than men and to be less empowered to act to protect themselves. In the context of the severe economic downturn on Bali since the October 2002 and 2005 bombs, money in household budgets for health spending is more limited than ever and health concerns even more likely to be ignored.
Women who work in the marketplace bring in a daily income of anywhere from Rp 5,000 (US .35 cents for the porters) to a profit of Rp 30,000 (US $3.50) per day for the meat sellers. These and other higher income vendors are able to pay for their medications in full (or nearly), thus subsidizing the medicines for the porters and other lower income women.
 Given the above background, this project has been designed as one set of intervention activities to meet the needs of vulnerable women in the general population in Bali. The overall project goals are as follows:
- To improve community knowledge and awareness in Bali of accurate and important information about reproductive health (including STDs and HIV/AIDS, cancer, safe motherhood, domestic violence, etc).
- Empowerment of women market vendors (pedagang), who play an important role in the family/community in information dissemination, to extend this role to include accurate and important information about reproductive health (including STDs and HIV/AIDS).
- To improve community reproductive health in Bali, including prevention of wider spread of STDs (including HIV/AIDS), by providing quality and affordable services, beginning especially with women market vendors, and their women clients.
A. CLINICAL ACTIVITIES
YRS promotes reproductive health, encouraging all female clients to undergo a pelvic exam to allow screening for cervical cancer, STDs, and other reproductive infections.
Pap smears are provided to about 50 clients per month and overall about 2.5% have received results suspicious for cervical cancer (they are referred for - and receive financial assistance if needed - for follow-up tests and treatments).
The most common STDs that have been found at this clinic are:
- Gonorrhea (about 6% of those tested)
- Trichomoniasis (about 4% of those tested)
- More than 50% also have indications of other unspecified cervical infection
The most common infections found are non-sexually transmissible:
- Candidiasis (about a third of clients tested)
- Bacterial vaginosis (about a third of clients tested)
Family Planning services are available here. A consultation session includes in-depth counseling on the full range of methods (including demonstration of condom use). The methods provided from the clinic are injection, pill, IUD and condoms. Check-up for implants is available, but not insertion/removal (patients are referred to other facilities). Rapid testing for pregnancy is also available here.
Other reproductive health related services provided at the YRS clinic include breast examination (with clients taught the SADARI method of breast self-exam for early signs of cancer) and prenatal care (including planning for a safe delivery). Counseling, referral and support services cover issues relating to HIV/AIDS, drug abuse, unintended pregnancy, and violence against women and children.
Aside from Reproductive Health services, many clients are also treated for respiratory infections, gastro-intestinal infections, skin and joint diseases, cardiovascular disorders, ENT, anemia, and fatigue. Referrals are made for other treatments as required.
Since January 2005, the clinic has opened one night a week to serve those who work in the evenings. The clinic is normally housed on the fourth floor of the market and is closed at night. However, a new program began in 2005 whereby the clinic moves down to a small beauty salon on the ground floor of the market on Friday evenings. This location also assures the safety of the women as they don't have to go up four floors to an isolated area. The clinic is open from 7 - 11 p.m. on Fridays.
 Since November 2005, YRS has started a Tetanus Neonatorun immunization program as well.
In an exciting initiative, YRS is in process of setting up a new clinic location to attract higher-paying clients, as a fund-raising initiative to subsidize low-income clients at the market location. This new branch is located at Jalan Tukad Buaji 37A in Panjer, Denpasar, and will soon also be open for business offering quality services for the general public (August 2006).
B. EDUCATIONAL ACTIVITIES
 Aside from medical check-ups, YRS also emphasizes education (for patients and the broader community) to increase knowledge on health issues, with a view to positively influencing their attitudes and encouraging safer behavior. This is done through various forms of communication, information and education.
YRS holds monthly discussions open to the market community on general and reproductive health topics of interest. These are usually attended by between 30-50 people. Every two months YRS invites a resource person from outside the foundation as a guest speaker. The last speaker of 2005 was from the Department of Animal Husbandry and he spoke on bird flu. In 2006, topics have included "Various contraceptive methods and their side effects"; "Dengue Fever and how to prevent it" and HIV/AIDS and Reproductive Health".
In addition, small spontaneous discussions are held with groups of patients in the YRS waiting room by YRS counselors. Also, clients who come to the clinic are given information/brochures and offered the opportunity to meet with counselors.
Furthermore, YRS has an outreach program which involves staff working in shifts around the clock to cover all areas of the market vicinity, approaching people face-to-face to talk about health, to distribute informational brochures and condoms, and to refer them to the clinic.
 To support and extend this outreach work, YRS has a pool of 10-15 active peer educators, motivated individuals from the market community, who help distribute information on YRS's services and programs, and condoms. Each month YRS holds support/training meetings for these peer educators.
To obtain a free supply of condoms and pamphlets for distribution, YRS works in conjunction with DKT, Dance4Life, the Health Department and Yayasan Kerti Praja. Condoms are distributed free of charge.
The Educational and Pap smear components of YRS's activities are supported by the World Population Foundation of the Netherlands, and various other smaller donors as well as private donations.
C. CLIENT VISITS
Over the course of the twelve months of 2005, there have been 5,017 client visits (including new and repeat clients), with an average of 21 per day. Most of the clinic's clients are unable to pay fully for the services and the medications. YRS asks that a small fee, such as Rp 10,000 - 15,000 (under $2 US) be paid for medications.
The number of new patients in 2005 is 1,266 and repeat patients 3,751 for a total of 5,017 patients using the clinic in 2005.
In the first quarter of 2006, 1,576 patients (an average of 23/day) visited the clinic; 1,259 of these were repeat patients. Of these patients, 151 got pap smears and 246 had STD lab tests done. The other patients came in for consultations on contraceptive services and general health issues.
While most of these patients are served during regular day hours, starting in January 2005, regular weekly night services were held (50 sessions), serving a total of 821 patient visits (average of 16.4 patients per night session); 17.8% of those visits included Pap smear services.
YRS recruits and supports a pool of about 10-15 vendors or market workers to participate in a peer educator program (average of 12 women per month); they assist with outreach work and attend monthly support/training meetings. An outreach program is also in place where YRS staff go into the market and speak with women about their health concerns. The total number of women outreached this first quarter of 2006 is 401.
422 informational brochures were distributed in the first quarter of 2006 to target groups ; 224 to those patients who have come to the clinic. 747 condoms were given out free in the first quarter.
For further information and photographs, please go to www.yrsbali.org
THE YRS TEAM
 Founder/director: dr. Luh Putu Upadisari. Dr. Sari is a general practicing medical doctor with 3 years of experience working as a doctor and research assistant for a foundation and clinic serving mainly sex workers (Yayasan Kerti Praja), plus an additional 3 years experience as a project manager for the Indonesia HIV/AIDS and STD Prevention and Care Project (AusAID) during which time she supervised a prevalence study in Bali, Kupang and Ujung Pandang, and supported work to upgrade capacities for RTI/STD management at local service delivery points in Bali. She has also worked at various hospitals, clinics and community health centers, and has run an active private practice from her home.
Distinguished co-founders who act as advisors for the foundation:
- D.P. Wijaya, MA, a long-time staffer of the training center at the National Family Planning Coordinating Board (BKKBN), Bali Province, with extensive experience in counseling training for field staff of BKKBN through-out Bali, with a Master degree from an Australian university, and specialized in demography and family planning technical management.
- Tari Adnyani, former district Director of BKKBN (Buleleng and Badung districts) and former Executive Secretary of the Indonesian Planned Parenthood Association (PKBI), Bali branch, and past/current AusAID research-fellow in Adult Reproductive Health.
 Volunteer/Consultant: Jane H. Patten, MPH. Ms. Patten has been involved with the project from the start (January 2003), assisting dr. Sari in designing and implementing all aspects of the project so far (fundraising, preliminary assessment, baseline survey, clinic construction and staff training, report writing, donor communications and networking). Ms. Patten has a Masters degree in Public Health from the University of California at Berkeley (1996) and has since worked for many projects and organizations on issues, services and studies relating to women's reproductive health
In addition to Dr. Sari herself, the current YRS clinic team include Dr. Surti, nurses/counselors/outreach workers Kadek and Ayu, lab analyst Gung Joni, administrative and finance officer Desak, reception/data entry assistant Iluh, and courier/office assistant Darma (the only male!). Everybody joins in with outreach work and dissemination of materials.
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