Sure Start is a 5-year initiative working to reduce maternal and newborn deaths in India. It works in 7 districts in Uttar Pradesh and 7 cities in Maharashtra, with a combined population of 24.5 million. Sure Start collaborates with government and community partners to increase access to healthcare and raise awareness. Key strategies include training community health workers, establishing mothers' groups, improving referral systems, and using communication campaigns. Evaluation data shows increases in institutional deliveries, antenatal registration, and vaccination rates. Sure Start aligns with national health programs to help ensure sustainability.

1. FA C T S H E E T
www.path.org
Sure Start
Helping Mothers and Newborns Thrive
Each year, an estimated 78,000 In Maharashtra, Sure
women in India die from Start works with
pregnancy- and delivery- municipal corporations
related complications, in several urban
and a million babies die areas of seven cities
during the neonatal period.1 and has been invited
Sure Start—a five-year to contribute to
initiative based at PATH the Government of
and supported by the Bill & India’s forthcoming
Melinda Gates Foundation— National Urban Health Mission. To support Maharashtra’s
is working to reduce urban population, Sure Start is harnessing the value
these numbers by helping of innovative health financing models, volunteerism,
mothers and newborns convergence, and public-private partnerships. The project
survive and stay healthy. has already achieved tangible results at the community
level; examples include a documented increase in the
Because no one set of interventions will work everywhere, number of women giving birth in hospitals and an
Sure Start is based on the idea that maternal and neonatal increase in early registration of antenatal mothers.
health should be prioritised within primary health care
programmes and by communities themselves. The project
is reducing barriers to accessing lifesaving maternal and
newborn health (MNH) services by mobilising village-,
Empowering communities
block-, and district-level government, nongovernmental, Sure Start’s approach is based on extensive engagement
and community-based organisations. Working with 95 with rural and urban communities.
local partners—15 lead partners and their 80 consortia—
Sure Start is focusing on the states of Uttar Pradesh
and Maharashtra, working to improve MNH amongst Uttar Pradesh
a combined population of 24.5 million residents. • Sure Start has built
the capacity of
In Uttar Pradesh, Sure Start works in seven districts, 7,540 government-
collaborating with both the state government and the recognised
National Rural Health Mission. Across these districts, Accredited
Sure Start is activating Village Health and Sanitation Social Health
Committees (VHSCs), establishing mothers’ groups, and Activists (ASHAs)
working with community health workers. These efforts who work at
have produced concrete community actions in at least the village level, enabling them to share MNH
12,000 of Uttar Pradesh’s villages, improved access to knowledge within their communities.
needed funds for MNH, increased the number of health
providers delivering services, and promoted healthy • The project also establishes mothers’ groups to facilitate
practices that save the lives of mothers and their babies. meetings at the village level to help increase women’s
1
UNICEF. State of the World’s Children 2009: Maternal and Newborn Health. New York: UNICEF; 2008. Available online at: http://www.unicef.org/sowc09/.

2. awareness of MNH issues. Since January 2008, 68,000 • In Malegaon, client-satisfaction norms are being
group meetings have taken place with approximately developed by working with communities and
150,000 expectant mothers and their mothers-in-law. aiding their interaction with public-service
• In addition, Sure Start establishes and strengthens providers. This work is based on establishing a
VHSCs. These committees are democratic, community- shared platform for bringing about an overall
level forums charged with implementing government improvement in the quality of care.
health schemes and ensuring that better MNH services • In Nanded, Sure Start has allowed 200 families
are provided. Since September 2007, Sure Start has to take charge of their health by establishing
helped 30,000 committee meetings take place. a community-based health insurance scheme
that has a special provision for MNH.
Sure Start has worked with VHSCs in Uttar Pradesh to
ensure that 100 percent of committees have functional
plans for providing transport for expectant mothers Raising awareness
and that 94 percent have plans to improve the quality Sure Start employs a range of innovative communication
and reach of maternal and child health services. Sure techniques to ensure that the right messages about MNH
Start has also assisted VHSCs in accessing government reach communities effectively.
funding. As a result, some US$147,000 in discretionary
funds has been released to these committees.
Uttar Pradesh
Maharashtra • An extensive mass
media campaign
• In Nagpur, Sure Start is working to build the
entitled Pehla Ek
capacity of 35 community health groups, enabling
Ghanta (The First
them to effectively address MNH issues.
One Hour) has been
• In Navi Mumbai, the project is helping create 20 rolled out in all
community support groups that facilitate interaction districts where Sure
between communities and health service providers. Start operates. The
• In Solapur, effort includes setting up five hoardings (billboards) in
1,210 self-help each of the seven districts and outfitting 750 rickshaws
group members, with messages, in addition to organising quizzes and
208 college screening films with embedded MNH messaging.
volunteers, and • Messages on MNH have been disseminated in
216 community village melas (fairs) for maximum impact.
members are
• Innovative interpersonal communication tools—
now participating
including games, songs, and demonstrations—have been
in a volunteer
developed and rolled out in mothers’ group meetings.
programme to
work with the residents of informal settlements and help • Materials have been developed to facilitate home visits
raise awareness of MNH amongst antenatal mothers, for behaviour change. ASHAs have been trained in
their families, and other community members. their use and are now using them in their work.
• In Pune, Sure Start has helped form 30 committees • Communication materials to engage husbands of
of residents from informal settlements. These expectant or new mothers have been prepared and
Monitoring of MNH Status (MOMS) committees distributed, reaching more than 40,000 fathers in all.
are trained and charged with improving MNH in • A vast programme of wall writings has been undertaken
their neighbourhoods. Work at the community in most villages where Sure Start is active. These
level in Pune also aims at converging MNH with writings share information on different aspects of MNH.
HIV voluntary counselling and testing services.
• In greater Mumbai, the project is improving the Ensuring that expectant mothers are vaccinated against
quality of care available to communities by forming tetanus toxoid and take iron and folic acid tablets is
community action groups that facilitate the extension essential to maternal and newborn health. Sure Start’s
of better MNH services. Community resource efforts have helped 94 percent of all women in Uttar
centres have also been established to provide Pradesh receive the tetanus toxoid vaccine by their third
information about relevant government plans. trimester and 75 percent receive iron and folic
acid tablets.

3. Maharashtra Maharashtra
• As in Uttar Pradesh, Sure Start has developed • Collecting data. Sure Start also established an MIS
materials to facilitate home visits for behaviour change. in Maharashtra by incorporating rigorous design,
Community-level personnel have been trained in their pretesting, field testing, and partner feedback. The
use and are using them during their visits. system tracks approximately 22,000 pregnant women
• The project has received substantial coverage in the across seven cities, collecting data on MNH behaviours
press, in part because of its regular engagement with the and access to services through indicators such as the
media at the state and district levels. number of home visits conducted, the number of
antenatal mothers contacted for behaviour change
• Sure Start has produced information, education, and communication, percentage of antenatal mothers who
communication (IEC) materials that are being broadly have received tetanus toxoid vaccine, and the percentage
used. For example, all of the Navi Mumbai Municipal of deliveries taking place in institutions. The project
Corporation’s (NMMC’s) health posts and maternal has trained field staff, community health workers, and
and child health centres prominently display the supervisors to use the MIS, and the team monitors data
project’s materials. quality across the seven cities in Maharashtra where
• In Pune, street theatre, music performances, and Sure Start works.
other folk media are being used to increase awareness • Partnerships and trainings. Sure Start is collaboratively
of MNH. building the capacity of its partners across project areas.
The team regularly trains partners in all seven cities in
advocacy, financial management, and capacity-building.
Managing change Sure Start has facilitated three-day trainings for
Working in two states and collaborating with frontline government health workers in the seven cities,
95 partners requires Sure Start to use innovative effectively building their capacity to provide antenatal
management approaches. care. The project is also developing partnerships with
private practitioners for improved MNH services to the
community.
Uttar Pradesh
• Collecting data.
Sure Start established Improving financial models
a management In Maharashtra, Sure Start employs innovative models
information system of improved MNH financing for communities.
(MIS) after rigorous
design, pretesting, • Community-based health insurance. In Nanded,
field testing, and 200 families have enrolled in a community-based
partner feedback. The MIS allows Sure Start partners to health insurance plan by providing a premium of
collect data on several indicators for MNH behaviours Rs. 250 (US$5). Sure Start was able to keep this
and access to services. The project supports in-depth premium low by obtaining a subsidy from the
training of Sure Start personnel in use of the MIS, site local State Legislative Assembly. Through the plan,
visits to mothers’ groups and VHSCs to ensure data families receive maternal care (including antenatal
accuracy, and monitoring of ASHAs’ records. The MIS checkups), newborn care, hospitalisation for general
can be accessed by relevant government personnel and illness, and reimbursement of transportation
is designed to continue well after the project concludes. expenses. Six hospitals have enrolled in the plan.
• Partnerships and trainings. Sure Start works with • Emergency fund. In
partners with specialised knowledge of the project Nagpur, Sure Start has
areas. Throughout 2008, training, mentoring, and established 35 emergency
supervision activities enhanced partners’ capacity. The health funds (with a special
project has focused on strengthening institutional, provision for MNH care)
financial, and technical capabilities and planning for that allow the urban poor
increased sustainability of project activities. As a result, to access resources for
there has been remarkable growth in the institutional health needs. To date, 176
and programmatic capacities of all six lead partners. users have been briefed
on how and when to use
System improvements and enhanced credibility allowed these funds. The project
42 of the 55 consortium partners in Uttar Pradesh to has also initiated a prepaid
receive program funding from the government and card system that improves
the urban poor’s access to
private donors.
essential health services.

4. • Public-private in communities across the country. Sure Start has
partnerships. In Navi been well integrated with this programme from the
Mumbai, Sure Start beginning and works to support its objectives in
facilitated a partnership many ways: by providing support to ASHAs, helping
between the NMMC and establish and strengthen VHSCs, undertaking
local nongovernmental extensive IEC activities, and establishing an effective
organisations, community- MIS that ensures a two-way flow of information.
based organisations,
professional bodies,
institutions, and private Working with the National Urban
hospitals to provide Health Mission in Maharashtra
improved MNH services. In June 2008, the Government of India announced that
The NMMC collaborates it would launch the National Urban Health Mission to
with professional improve health in India’s urban areas. Since Sure Start is
associations of obstetricians, already working on this issue, the team has been invited
gynaecologists, paediatricians, dieticians, and yoga to participate extensively in planning the mission for
trainers. Decentralised antenatal care has since been Maharashtra. Like Sure Start, the mission will focus on
provided on a monthly basis through specialised strengthening public health delivery systems, improving
clinics at 20 urban health posts. The services address the capacities of local municipal bodies, and working to
complications during pregnancy and the postnatal collect accurate data
period for mothers and newborns. Since March and strengthen client-
2008, 213 newborns and 303 pregnant and postnatal provider linkages.
women have received care through this system. Sure Start is also
well integrated with
Institutional deliveries make the process of giving birth the government’s
much safer. In Navi Mumbai, the percentage of women Reproductive
delivering in hospitals has increased from 79 percent in and Child Health
2007 to 85 percent in 2008. Programme, Phase II.
Supporting government mechanisms
For more information
From the outset, Sure Start has aligned with
national-level government activities to ensure that To learn more about the Sure Start project or
its contributions to MNH will be sustainable. PATH’s MNH activities in India, please contact:
PATH
A-9 Qutab Institutional Area
Working with the National Rural New Delhi, India 110067
Health Mission in Uttar Pradesh Tel: 91-11-26530080-88
In 2005, the government announced the launch of the www.path.org
National Rural Health Mission, which aims to make
substantial improvements to the lives of villagers
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June 2009
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