Luh “Sari” Putu Upadisari, a medical doctor, is improving the sexual and reproductive health of low-income women by ensuring they receive good quality health and educational services in the “public traditional market” in Indonesia.
The New Idea
Sari is creating venues for traditionally marginalized women market vendors and laborers to receive sexual and reproductive health services through her organization, the Rama Sesana Foundation. She has set up a health clinic in the public traditional market; a marketplace without fixed prices where people can buy their foodstuff and daily goods, to give women market vendors the opportunity to gain information and do routine checks for their sexual and reproductive health at affordable prices. By bringing such services closer to where this marginalized group spends most of its time, Sari has been able to reach thousands of women market vendors and laborers and improve their actions to promote optimal wellness, recovery, and rehabilitation. They are even able to take their spouses, male market workers, and other market visitors or shoppers to these health clinics, further extending the opportunity to increase knowledge, practice safe sex, and obtain available health care services.
By mobilizing underprivileged women and their spouses, middle-class women, targeted government interests, and medical doctor volunteers, Sari has been able to reduce peoples’ ignorance and made their needs visible, even to themselves, to improve women vendors and laborers’ reproductive health. She has persuaded the PD. Pasar Badung, Bali (the local government-owned company who manages the market, to set up a health clinic in the market). The clinic will be one of the public services provided by PD Pasar for market tenants and customers. Sari sees the clinic as an added value to the traditional market, where many disadvantaged women earn their living, in response to the rapid growth of the “modern market.”
With the potential to reach out to 12,650,000 vendors in 13,450 traditional markets throughout Indonesia, Sari plans to work with local governments through the Ministry for Women Empowerment and develop partnerships with traditional market management. Currently, Sari is also developing an informal community of medical doctors who together see the time has come to influence their peers to move the official focus from curing diseases to include disease prevention and the promotion of health.
The 2006 global statistics reports estimated 340 million curable (although often untreated) sexually transmitted infections (STIs) are transmitted annually throughout the world among people between the ages of 15 and 49. These viral infections cause genital warts and raise the risk of cervical cancer and the human immunodeficiency virus (HIV)/AIDS. In Indonesia, recent findings state that high levels of STIs and some with HIV-infection appear in married women, of whom 92 percent claim to have only one lifetime partner. This has suggested that the epidemic has penetrated a population previously considered “low risk.”
The information on HIV/AIDS and STIs is primarily targeted at high-risk groups and does not reach all segments of the population. Poor working women remain excluded from awareness of all of these issues. As a result of having no information, they are very vulnerable to being infected and suffer serious long-term life-threatening consequences. Women with the infection are more likely to be asymptomatic and thus remain untreated. Furthermore, the World Health Organization (WHO) affirmed that worldwide, 500,000 women are annually diagnosed with cervical cancer. Fifty percent of them die because they do not know that they have an advanced stage of cervical cancer, even though when detected early the infection can be cured.
Poor women tend to place a low priority on their health problems compared with the necessity to earn an income. They also tend to keep this problem to themselves, as they consider their relationship with their spouse very personal and private. In many cases, women’s health treatment is often influenced by their husband’s decision. There are very few counseling opportunities available in public health services. Furthermore, their services are focused more on curative than preventive treatment. Poor women have therefore less access to information than men and are less empowered to protect themselves.
The government has a low budget allocation for public health services. With local autonomy regulation, the government has even used health care services as a source of income by charging clients for public health services. The private sector is an alternative to the health care provision, especially in big cities. However, users are vulnerable to excessive treatment and expenses. Economically deprived women cannot afford these health services, and this problem is worsened due to the fact that there is virtually no social insurance scheme available for the poor.
Sari focuses on three main areas which she has identified as key to ensure the reproductive health of women. These are an improvement in knowledge, attitude/behavior, and the use of reproductive health services. Sari seized the opportunity within a traditional market to give more practical access to improve the underserved and low-income women’s reproductive health. Her pilot is in the traditional market of Badung, Bali where 3,000 to 5,000 women come daily as vendors and buyers.
One of Sari’s main strategies is therefore equipping poor women with reproductive health-related knowledge and information. Based on findings from a needs assessment survey she conducted in the market before she opened her clinic, less than 30 percent of women have knowledge of reproductive health and will seek help appropriately. She used the results of the research as an advocacy tool for the market management owned by a local government company called PD. Pasar, donors, and other related parties to mobilize support for the initiative. In 2004 Sari set up Rama Sesana Foundation, after having been granted a free space from the traditional market management for the health clinic and group discussion activities. Now, supported by seven staff members consisting of two medical doctor volunteers, administrative staff, counselors, laboratory staff, and field officers, Sari has been able to serve thousands of women in the Badung traditional market.
The changes that flow from the initiative count on the full participation of women market vendors and laborers in the education and outreach activities. Sari has made these women into peer educators for other women in the market. Together with the outreach officers, these 10 to15 peer educators spread the information to other women vendors and buyers. Through a one-on-one discussion at all hours, they have reached out to about 350 people per month. They share information around symptoms identification, early detection, and early treatment.
With the purpose to provide further in-depth information, especially around the issues of domestic abuse, Sari organizes monthly educational discussions. The discussion topics vary based on the women’s preference and are facilitated by staff or guest speakers. Along with these education activities, different information materials (over 500 per month) and condoms (over 250 per month) are distributed by outreach workers and at the clinic.
Privacy is integral to attaining the trust of all parties involved, and information is never available in the public system. To address this, Sari set up counseling services at the clinic. Key in the counseling is how comfortable women are to openly sharing their personal problems. Women are equipped with information on how to protect themselves from their and their partner’s high-risk behaviors.
The market is open 24 hours daily, and the clinic provides daytime services every day as well as a night service once a week. The number of clients has risen over time, indicating an increase in health-seeking behavior among women. Services provided by the clinic include counseling on reproductive health and anatomy, STDs and HIV/AIDS awareness, prevention of violence against women, drug abuse counseling, and so on. In addition, examination, screening and laboratory and medical treatment services are provided. Presently, there are about 50 women clients per month who get Pap smear tests conducted for cervical cancer, STDs and reproductive tract infections, and about 100 clients per month for partner referral. With a considerably high number of repeat clients, Sari has been successful in creating an institution that meets the needs of women.
The service cost associated with accessing health care has become one of the major barriers for low-income women. Sari has alternatively created a low-cost service, which is available to certain low-income women for free. The model is possible due to a cross-subsidy scheme Sari is applying. The model is not only among women in the market but also with women from other clinics outside the market. She has mobilized local resources and has partnered with the Darma Wanita (i.e. organization of civil servant wives) to ensure that the fund is immediately available for serious referral cases.
Sari is currently preparing to spread her model. She is in a discussion phase with different local governments in Bali and beyond Bali to pick up this idea. Sari has approached the Ministry for Women Empowerment to seek possibilities for a partnership together with PD. Pasar. She is also working to shift the paradigm in the medical profession to give more attention to health promotion and prevention, as opposed to curative care, which she believes is a need the overall system ought to address. Sari has identified a few people who are professional leaders in medicine who believe in this change and together they have set up a community. She also plans to actively participate in changing the teaching and orientation of doctors to include more attention to prevention. Sari’s work at the traditional market has already been used as a study case by the Medical Faculty of Udayana University in Bali.
Sari, the fifth of seven siblings was born in Bangli, Bali. Her father is a well-respected figure in the community and helps people with conflict resolution. He once worked as an outreach staffer at the Family Planning office, and young Sari often went along with her father visiting different villages.
As a student in junior high, Sari wanted to become a policewoman, but changed her field when she graduated from high school to become a doctor instead—due to her desire to help others. While her teenage friends were busy with their studies, Sari actively participated in her Banjar community activities, such as raising funds and promoting cooperative work among the youth. She was also involved in social activities during university at the Udayana Medical Faculty. During one of her visits to a village, Sari was extremely motivated by seeing a pregnant woman work. This experience moved her so much she decided to help working, underprivileged women be able to give birth to healthy children.
Sari worked at a private hospital right after she graduated in 1991 but then quit, as many of its practices and policies went against her ethics. As a medical doctor, she has more passion in public health for the poor. In 1992 she was posted at the sub-district health center for three-and a-half years, and joined different research projects on women’s health issues. In 1997 Sari volunteered at one of the local foundations where she had the opportunity to develop a STI program for sex workers and construction labors. Her field experience finally made her realize the need to find strategic ways to reach out to a much wider population. In 2004 Sari and colleagues founded her organization, Yayasan Rama Sesana, to achieve her mission of providing easy and affordable reproductive health care to all women despite their socioeconomic status.