IMPROVING QUALITY OF SERVICE ONE ROOF (ONE STOP SERVICE) FOR GROUP STIGMA
Ubud II Public Health Unit

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Gianyar Regency is one of many tourism destinations in Bali. Tourism activities surely impact the region both positively and negatively. One of the negative influence of the state being of the regency as tourism destination is the increase of free sex activities as well as the drugs abuse, resulting in the transmission of HIV / AIDS. HIV / AIDS is a social disease that has a huge impact both on individuals and families, especially in rural areas with strong kinship and religiosity. Patients will hide the status to both the family and the surrounding community, even worse many do not concern about their status though they have experienced such risky behaviors. Various efforts have been conducted by governments, communities and NGOs including socialization, seminars, as well as discussion to increase the public awareness of the disease yet several rejections to the patients still exist, in the forms of stigmatization and discrimination. The existence of Clinical Voluntary Counseling and Testing (VCT) in three health centers have not been able to lift the enthusiasm of the people especially those at risk to find out their well-being state related to the disease. The average visit to the institution is only 6 people annually (from 2009 – 2011). More suffer were experienced by the positively-diagnosed patients. Not only they were weak due to the deficient of their immune system but also they were burdened by the psychological issues because of the stigmatization and discrimination from their surroundings, whereas they desperately needed the restless support to get through the medication or treatment. Even more, many people were so ignorant when they knew one of the patients passed away. The whole initial HIV/AIDS treatment or medication (from drug testing until the beginning of medical treatment) could take up to 7-14 days, passed through lengthy administrative procedures, as well as spent lots of time and money. The whole series of tests in the process (pre-test counseling, blood test, post-test counseling, treatment preparation investigations like complete blood count, renal function, liver function, CD4, x-rays and medication counseling) the patients had to undergo, the separated locations of the tests, and the reluctance of many insurance companies to cover such claim on the disease truly cause a huge burden to the patients. . Such circumstances should be immediately terminated by the realization of a service for those who are marginalized / stigmatized into free, simple, and prompt one-stop-service. It is expected that the patient will feel safe and comfortable to undergo such examinations and treatment.

B. Strategic Approach

 2. What was the solution?
Head of Public Health Taskforce Unit of Ubud II conducted a comprehensive evaluation for the condition by holding an across-sectors meeting in December 2012. The meeting involved the NGOs and other related parties including Officials from Local Office of Public Health, HIV/AIDS Countermeasures Commission(ACC/KPA), Heads of Districts, District Police Chief, District Military Commander, Head of Villages, Indigenous Leaders, and Dua Hati Foundation. The meeting formulated the followings: 1. Most injected-drug users converted to oral-based drugs resulting in the decreased number of HIV/AIDS transmission through unsterilized syringes; 2. Due to the high rate of HIV/AIDS transmission through sexual activities in 2011, it was crucial to apply visible solution to mitigate the rate of HIV/AIDS transmission through Sexually-Transmitted Infections (STI); 3. The HIV/AIDS high risk people and the patients of STI were reluctant to having a medical examinations due to the identity secrecy issues, the high cost, and the lengthy procedures); 4. Patients with HIV/AIDS were reluctant to being referred to the new hospital due to psychological reasons including social stigmatization and discrimination. Other reasons were about the cost, the distance, and the lengthy procedure. The meeting members then arranged the action plans to overcome such issues, encouraging the HIV/AIDS high-risk people and patients to the VCT Clinics to have their tests and to gain more access to Anti-Retroviral (ARV) treatment. The agreed actions plan were as followings: 1. Providing screening and treatment service for at-risk groups including Satellite Methadone for injected-drug users, clinic for STI patients, and tests for all pregnant women. 2. Providing clinics to treat people with HIV / AIDS as well as completing all laboratory facilities. 3. Integrating the two activities in one health center location in Public Health Center of Ubud II, setting up a budget for all forms of financing, and preparing a companion for those who have problems either at the stage of examination or treatment.

 3. How did the initiative solve the problem and improve people’s lives?
The initiative is creative and innovative due to the following reasons: 1. It provides services that can broaden the coverage of people wanting to know their status related to the use of methadone, provide treatment for patients with STI, and STI and HIV testing for all pregnant women; 2. It provides a simple, concise, and free service for people with HIV/AIDS concern to obtain examination and treatment; 3. It unites all those services at one place at Public Health Center of Ubud II for straightforward and comfortable tests and treatment; 4. It provides companionship to facilitate patients having difficulty accessing the services because of stigma or due to their poor physical condition; 5. It provides a special line to the clinic so that patients will not mingle with the public health clinic visits.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The initiative to improve the quality of one stop service for socially stigmatized groups was carried out according to the following strategies: a. Problems Identification • Most injected-drug users converted to oral-based drugs resulting in the decreased number of HIV/AIDS transmission through unsterilized syringes; • Due to the high rate of HIV/AIDS transmission through sexual activities in 2011, it was crucial to apply visible solution to mitigate the rate of HIV/AIDS transmission through Sexually-Transmitted Infections (STI); • The HIV/AIDS high risk people and the patients of STI were reluctant to having a medical examinations due to the identity secrecy issues, the high cost, and the lengthy procedures); • Patients with HIV/AIDS were reluctant to being referred to the new hospital due to psychological reasons including social stigmatization and discrimination. Other reasons were about the cost, the distance, and the lengthy procedure. The problems sparked the idea of HIV/AIDS cases detection by conducting the screening at Methadone Clinic, STI Clinic and by providing such simple, prompt, and free service for people living with HIV/AIDS. b. Coordination Handling groups of people who require a high privacy needs to involve the people winning the trust of the group. After having a warm welcome from the Local Office of Public Health, the coordination continued to strive the support (in the forms of human resources, infrastructure and facilities, and fund) from NGOs, private parties, and social foundations. c. Resources Preparation Once there was an agreement between the government and the private parties, preparation activities we then conducted, taking forms of human resources provision and training, facilities and infrastructures building, and diagnosis and treatments. Some of the facilities, such as computers, laboratory facilities including CD4 testing tool, and office furniture (including drugs closet) were financed by foundations. Human resources provision (one doctor, one analyst, and three counsellors) was handled by the Bali Peduli Foundation. d. Cooperation Agreement The contract was between the Gianyar Regent and Bali Peduli Foundation. With the completion of all resources and infrastructures, as well as the facilities, the one-stop-service clinic for socially stigmatized and discriminated group was officially opened for public in July 2013. e. Service Socialization As a new public service, the institution needs to widely disseminate the information about its existence. Socialization activities were done in several ways: • Publishing brochures about HIV/AIDS, Methadone and IMS, direct meetings with the citizens, youth group, the members of Family Welfare Education Program; • Providing online information on website of www.balipeduli.org giving information about Anggrek Clinic – Public Health Center of Ubud II.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The parties associated with this service are:  Methadone and VCT Clinic a. Provincial and Local Office of Public Health as service regulators; b. HCPI as funders; c. Provincial and Local AIDS Commission as partners and funders; d. Local and National Narcotics Agency as partners and funders; e. Sanglah Public Hospital as the custodian of Methadone clinic; f. Dua Hati Foundation as partner and field outreach  STI and Counselling and Support Treatment (CST) Clinic a. Provincial and Local Office of Public Health as service regulators; b. Provincial and Local AIDS Commission as partners and funders; c. Sanjiwani Public Hospital of Gianyar Regency as the custodian of CST Clinic; d. Bali Peduli Foundation as partners and funders; e. Rotary Club Foundation as partners and funders  Government authorities and village Leaders, as well as community leaders.
 6. How was the strategy implemented and what resources were mobilized?
The initial phase of the establishment of the Methadone clinic in 2008 was fully funded by HCPI covering the clinic infrastructure, personnel training and clinic’s operational activities. In 2009 and 2010, the clinic’s operational activities were funded by Local HIV/AIDS Countermeasure Commission (ACC/KPA), Local Narcotics Agency, and Local Budget of Gianyar Regency. In 2011 and 2012, the clinic’s operational activities were funded by Provincial and Local Budget. In 2013, methadone clinic’s maintenance and VCT operational activities were funded by ACC/KPA and Local Budget while the STI Clinic and CST Clinic were funded by the Bali Peduli Foundation, Rotary Club Foundation, and local budget. Other support in the form of liquid methadone drug was handled by Sanglah Public Hospital. The drugs and medication for STI and ARV were supported by central government authorities via Local Office of Public Health and Sanjiwani Public Hospital of Gianyar Regency. The personnel involved in the service are: a. 7 civil servants and 2 private employees (two doctors, one pharmacist assistant, two nurses, one laboratory attendant, and two security guards) on methadone and VCT clinics. All the power received special training before serving. b. 2 government doctors and nurses and 5 private employees (one doctor, one analyst, one administration officer, and two counsellors) for STI and CST clinics.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Concrete outputs of the service are: a. VCT Clinic Services The increase number of visits to VCT Clinic from the average of 0.5 people monthly in 2009 to 79 people monthly in 2014. There has been an increase in the number of people having a thorough HIV/AIDS examination from 0.2 people monthly in 2009 to 3.5 people monthly in 2014. b. STI Clinic Services Average visit in 2013 was as many as 40.5 people monthly. The number increased to 107.3 people monthly in 2014. c. HIV / AIDS Treatment (CST) Since its opening, the clinic has been handling 64 patients (one under-aged was referred to custodian hospital, one people was referred to 2nd Degree Treatment, three people died, and four people were dropped out from the treatment). The dropped-out patient were then encouraged to continue their medication.

 8. What were the most successful outputs and why was the initiative effective?
Monitoring and evaluation were conducted comprehensively and sequentially by Bali Peduli Foundation and Public Health Center of Ubud II. The three-monthly evaluation is also conducted involving components of the service (Technical Taskforce Unit of Public Health Center of Ubud II, Local Office of Public Health of Gianyar Regency, Local and Provincial ACC, Bali Peduli Foundation, and Dua Hati Foundation), assessing the results, the constraints, as well as the solution. Annual evaluation is done by involving all components of the service (Technical Taskforce Unit of Public Health Center of Ubud II, Local Office of Public Health of Gianyar Regency, Local and Provincial ACC, National Narcotics Agency, Chief of District Police, Heads of Districts, Village Leaders, Indigenous Leaders, Bali Peduli Foundation, and Dua Hati Foundation), assessing the same matters along with the recommended inputs for future references. The annual meeting is also a means of introduction and program information dissemination to new leaders inside the government authorities, particularly the Districts Office and District Police Department with frequent replacement of the leaderships.

 9. What were the main obstacles encountered and how were they overcome?
1. Funding The allocation of funds from the government is still limited in the field of promotion and prevention have not touched the curative phase. No insurance companies are willing to take the disease as their point of protection. Proposal were submitted to government institutions and agencies and the response were quite positive, particularly from Local and National Narcotics Agency. The biggest funding is from Bali Peduli Foundation supported by the Rotary Club. 2. Manpower/Human Resources The innovation needs qualified, trained, and experienced personnel. Some of the human resources are coming from government institutions while others are from private institutions and the two foundation supporting the innovation. 3. The Legal Matters To legalize the service, some legal documents have been signed and documented:  The cooperation agreement between the Gianyar Regent and Bali Peduli Foundation;  The cooperation agreement between Technical Taskforce Unit of Public Health Center of Ubud II and HIV/AIDS Countermeasure Commission (ACC/KPA);  The cooperation agreement between Technical Taskforce Unit of Public Health Center of Ubud II and HCPI;  The Inauguration of the clinics 4. Public Participation  Inviting government agencies, private and public figures at the time of service opening and inauguration;  Conducting a direct meeting with community, social groups, or at- risk social groups through discussions and seminars;  Spreading certain brochures to government institutions, private parties, and high-risk social group;  Disseminating the information through the online media on www.balipeduli.org.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
a. Life Expectancy  The decrease of injected-drug dependence Oral-based liquid methadone controlled consumption and home-treatment of the methadone reduce the risk of the patients’ being overdosed as well as minimize the spending on the cost;  The improved medication for HIV/AIDS patients; ARV treatment improves the improvement of physical recovery of the patients. The recovery time can be as low as two months. b. Life Quality  The decrease of injected-drug dependence The easiness of taking once-a-day liquid methadone lessens the addiction to the syringe-based drugs;  The well-being state of HIV/AIDS patients The short period of recovery surely improves the patints’ productivity to achieve more in their life without any worries about the disease they are living with. c. Awareness HIV/AIDS is feared by society; stigma and discrimination are even worse due to lack of knowledge about the transmission of the disease. Lack of willingness from the at-risk social groups to concern about their well-being state was also the reason why the situation in the past was so worrying. The service allows the at-risk people to increase their awareness of the disease. The statement is proved by the increase of the number of visits to the clinics. The more awareness people have of the disease, the better chance people will soon eliminate any kinds of stigmatizing and discriminating the at-risk and high-risk social groups.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
A program’s sustainability in the future is strongly influenced by the commitment from all parties or components to the issues, not only the objects of the program, but also the parties holding and implementing the program. The objective of this initiative is in line with the 6th indicators in the process of realizing the Millennium Development Goals. The eradication of the infectious disease is a very crucial objectives having to be comprehended by all health personnel in a country. The financing of the initiative is in the state of being sustained in continuous support by the government authorities. The manpower or human resources are also in the middle of continuous training, ensuring the smooth transfer of knowledge to other health personnel in the future. Some public health centers are also conducting intensive training on implementing such initiative and disseminating information about the sustainability of the program. The replication will be implemented in stages, with future improved development. There will be more trainings for doctors, paramedics, as well as health analysts to gain more knowledge in dealing with and eradicating the sexually transmitted disease and the intensive cares needed to overcome and treat the existing cases.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Common experiences of the learning process obtained in the implementation of the service are as follows: a. Innovation enhances the service quality for socially stigmatized and discriminated social groups. Such innovation was started in Gianyar Regency and has been sustained and developed ever since. b. The presence of fresh funds, adequate infrastructure, skilled personnel are absolutely necessary to make the service friendly and affordable. The presence of donors is indeed necessary for the government and the insurance companies are reluctant to covering such matters. c. Cross-sector and NGO involvement to the success and continuity of service is surely required. d. The involvement of NGOs and patients privacy/confidentiality enclosure are key to successful continuity of the program. Recommendations to the front for this service as follows: a. Treatment of HIV / AIDS has evolved in most hospitals, but the model of service required will not ever be the same for every place. A complete and comprehensive services would be very appropriate in the countryside are where the role of public’s stigma is still very strong. b. In setting up the service for people living with HIV/AIDS who are in need of life-long treatment with high drug adherence, simplicity, immediacy and generosity of services become very important consideration. c. Stigma and discrimination against the people with HIV/AIDS is still high; normative socialization did not get the intended results; counseling is an excellent way to increase the depth of knowledge about HIV/AIDS. It is expected that all health facilities will be equipped with VCT clinics managed by well-trained health personnel to accelerate the intended achievement of the service.

Contact Information

Institution Name:   Ubud II Public Health Unit
Institution Type:   Government Agency  
Contact Person:   Ngurah Adnyana
Title:   Head of Unit Public Health Ubud II  
Telephone/ Fax:   +62361 970112 (+6281338232829)/+62361 970112
Institution's / Project's Website:  
E-mail:   ngurah_adnyana66@yahoo.com  
Address:   Kutuh Banjar, village of Sayan, Ubud sub district, Gianyar, Bali
Postal Code:   80571
City:   Gianyar
State/Province:   Bali
Country:  

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