Sure Start, an initiative by PATH works to promote maternal and new born health through community action in India. Get to know Sure Start better…take a look.

1. Sure Start Improved Maternal and Newborn Health through Community Action and Strengthened institutional Capacity.

2. Sure Start: At a Glance Sure Start, a project funded by the BMGF and implemented by PATH works with about 25 million individuals and hopes to improve MNH in UP and Maharashtra by Supporting relevant government health programmes Empowering communities to bring about an improvement in MNH Raising awareness on MNH using innovative communication techniques Employing unique financial models to improve demand for and supply of MNH services Ensuring a smooth flow of vital information and involving a consortium of partners in program implementation Creating client provider linkages Along with successes there were numerous challenges (to be discussed later)

3. Objective 1: Sure Start: Objectives To significantly increase individual household and community actions that directly and indirectly improve maternal and newborn health

4. Objective 2: To enhance systems and institutional capabilities for sustained improved maternal newborn care and health Sure Start: Objectives

5. Empowering Communities Sure Start’s approach is based on extensive engagement with rural and urban communities Training ASHAs Strengthening VHSCs Fostering mothers’ groups Empowering communities to reach out to service providers, program planners and policy makers Establishing MOMs committees Setting up community support groups, community action groups and volunteer groups Enabling communities to to monitor the quality and acceptability of health service Facilitating community-health provider dialogue

6. Empowering Communities: Examples of Progress ASHAs: 7,540 have been trained VHSCs: Strengthened 2,811 committees and 34,000 meetings have taken place at which MNH plans were made and reviewed Mothers’ groups: 80,000 meetings with 12,00,000 women MOMs committees: 30 committees established Volunteers:1,634 volunteers recruited Community groups: 35 groups groups in Nagpur and 20 in Navi Mumbai

8. Raising Awareness: Examples of Progress Five billboards and 750 rickshaws in each district carry MNH messaging Innovative letters from the unborn child have been distributed to 40,000 fathers-to-be 89% villages have emergency transport plans displayed in at least two prominent places Increased demand for IFA tablets in Solapur Increased demand for JSY payments Rise in early registrations

9. Raising Awareness: Early Indicators of Success 80% of all women in their 3rd trimester chose to receive the TT2 injections while 79% received IFA tablets, partly as a result of Sure Start efforts to raise awareness in UP Partly due to innovative IPC material developed by Sure Start there has been a steady increase in attendance at mothers’ groups meetings from 5.8% in baseline to 47% in June '09 Percentage of women attending antenatal check ups in Navi Mumbai:

10. Managing Change Working in two states and collaborating with 95 partners requires Sure Start to use innovative management approaches The Management Information System Building the capacity of partners

11. MIS The Management Information System in UP SO DHS/CMO RKS/MO in charge VHSC/Pradhan/ANM ASHAs Informationin Informationout Number of home visits for behaviour change communication Percentage of institutional deliveries Percentage of ANCs reached for institutional deliveries Number of pregnant women/mother-in-laws attending MG meetings attending Number of VHSCs Outcome of pregnancies for mothers and newborns Number of women practicing recommended behaviour Information related to supplies, quality of services, availability of staff, vacancies, referrals addressed, etc. All stakeholders are being taught to interpret and use the MIS data relevant to their level

12. Working with partners: Examples of progress UP Institutional, financial, technical and human resource management capabilities have been built Example of Impact: 42 out of 55 consortium partners received programme funding from the Government and private donors due to improvements in their systems and enhanced credibility PANI is replicating the Sure Start model in 4 districts through funding from CAIRN Energy India

13. Working with partners: Examples of progress Maharashtra Regular training of partners in advocacy, financial management and improvement in capacity building 3 day trainings for frontline Government health workers to effectively build their capacities for the provision of antenatal care Partnerships and collaboration with private practitioners for improved MNH services to the community (subsidised care, adoption of protocols and improvement in QoC) CM of Maharashtra commends Sure Start in a joint advocacy event and highlighted the government’s commitment to improve MNH in the state

14. Innovative Financial Models In Maharashtra, Sure Start employs innovative models of improved MNH financing for communities Public-Private Partnership in Navi Mumbai: collaboration between the NMMC and professional bodies of obstetricians, gynaecologists, paediatricians, dieticians and yoga trainers hospitals to provide improved MNH services

15. Innovative Financial Models Community-based health insurance in NANDED: 200 families have enrolled in a community-based health insurance plan Emergency fund in NAGPUR: 35 emergency health funds have been established that allow the urban poor to access resources for MNH and other health needs

16. From inception, Sure Start in UP has been designed to work with and build upon the NRHM NRHM:2012 SS, UP: 2010 ü Provision for an incentive-basedheath volunteer over1000 population (ASHA) Strengthening approx 7540 ASHAsusing NRHM guidelines ü Facilitating district, block andvillage-level planning and review.Strengthening VHSCs-30,000 meetings have taken place since September 2007 Decentralised planning andestablishment of Village Health &Sanitation Committees (VHSCs) ü Strengthening local capacitiesand partnerships with NGOsand private providers Increased emphasis onpublic private partnership ü Systematic evidence based advocacy and communication activities for community reach and demand for quality of services Sporadic IEC activities ü Demonstrating a system for two-way flow of information through MIS reporting and feedback mechanisms Two-way information flow of data

17. Similarly, in Maharashtra Sure Start is fully integrated with the soon-to-be-launched NUHM NUHM SS, Maharashtra ü Public health delivery system– focusing on inadequacies,strategies to strengthen Inadequacies in the public healthsystem identified through situationanalysis in the seven cities ü Weak management capacitiesof local municipal bodies Building capacities ofthe municipal corporations ü Data being generatedthrough the MIS No data available ü Testing a model on convergenceof maternal and newborn healthand HIV/AIDS Convergence ü Strengthening client provider linkages with diverse group of providers and community level workers Multiplicity of service provider

18. Challenges Community behaviors and strong beliefs around MNH practices Limited skills available in the field: intense capacity building High staff turnover: increasing as project reaches maturity Ensuring quality referral services Empowerment can lead to clashes Fostering a positive advocacy approach among NGO partners i.e. bridging the public–private divide Frequent transfers of key officials Slow roll out of the government health programme Maintaining motivation of the Sure Start partners and sustaining their interest

19. How we will measure success Evidence of community action, individual knowledge and behaviour change will be collected Gauging a change in community attitudes to MNH. Analyzing community activation through VHSCs and Community Groups. Collecting data on MNH becoming a health priority Estimating the degree of awareness of safe birth practices , recognition of danger signs, etc. Examining indirect indicators of change such as early registrations, use of IFA tablets, TT immunizations, institutional deliveries and ANC checkups, PNC check ups

20. How we will measure success/2 Evidence of concrete steps to improve MNH will be collected Looking at number of villages with emergency transportation plans Examining the number of villages with easily accessible emergency information Estimating the number of home visits and mothers’ groups that are sustainable

21. How we will measure success/3 Trends in NMR Some academics are questioning the reliability of short-term fluctuations in NMR Baseline data suggested lower-than-expected NMR Shifts in mortality may not be strong but indicators relating to attitude/behaviour change are also measures of success