There was rich discussion on this important topic in 3ie’s Delhi Seminar on 8 Feb 2013, where Dr. Arnab Acharya, Professor and Vice-Dean, Jindal School of Government and Public Policy, Sonipat, India, presented key findings from an impact evaluation of the Sure Start programme in Uttar Pradesh, India, implemented from 2006-2010.

What can we learn from Sure Start?

The Bill & Melinda Gates Foundation-funded Sure Start project aimed to increase community awareness of and positive behaviours towards pregnancy and neonatal care in India. Now complete, it is a ‘learning project’ that could generate valuable lessons for incorporation into similar efforts across other areas, including the Government of India’s National Rural Health Mission. Sure Start was implemented in three states including Uttar Pradesh, where it was implemented in the villages of seven districts. A small randomised control trial has shown the innovations in the programme to be effective in several parts of South Asia.

The Sure Start project was implemented at two levels of intensity. Level 1 (L1) was only through media campaigns for generating awareness. Level 2 (L2) was a more intensive programme implemented in 40% of the villages involved in the project and included media campaigns, mentoring ASHAs (community frontline health workers) who promoted safe pregnancy and newborn baby care to women during Mother’s Group meetings and home visits. Mother’s Groups were informal groups of pregnant women and mothers-in-law, facilitated by Sure Start, to spread maternal and newborn health awareness using fun methods like games, music, and dance.

Key lessons

The evaluation was conducted through two rounds of surveys of 12,000 women; one conducted before the project started in 2007, and the second once the project had finished in 2010. The survey looked at both villages involved in the project intensively (L2) and villages where Sure Start had only implemented the media campaign (L1). The two sets of villages were then compared between each other and over time to see which innovations had made a difference to health outcomes, and whether the mother’s groups were effective pathways to change for women in the community. Sure Start found that:

1. Significantly more women accessed prenatal care and less women experienced pregnancy complications with attendance in Mother’s Groups in L2 areas as compared to women in L1 areas, who were only exposed to media messages.
2. As the newborn death rate was already much lower than expected in 2007, the subsequent mortality rates in 2010 did not show a significant decline in the L2 areas where Sure Start worked more intensively when compared to the L1 areas, which only received the media campaign.
3. Women belonging to vulnerable caste groups benefited more from attendance in Mother’s Groups, as compared to similar women exposed only to media messages.

Concluding the presentation, Dr. Acharya reiterated that the results do show a trend towards better health in L2 (where a more intensive health programme was implemented alongside the media campaign) as compared to L1 areas (where only the mass media campaign was implemented).

What we still need to know

1. More data would be needed to see if Sure Start’s innovations reduced neonatal deaths. This was largely attributed to the number of villages surveyed not being large enough. However, it is also important to consider the methodological difficulty in planning the evaluation of such a large and complex programme as Sure Start.
2. The socio-economic context of the villages in the project may have influenced the results. Participation in Mother’s Groups could be analysed in much detail, including the relationship between the socio-economic profile of the women and the extent to which they participated in the project activities. Dr. Acharya and a representative from PATH informed the group that such analysis was ongoing.
3. The innovations created demand but what about the supply of health services? While the Sure Start programme encouraged women to visit facilities, there was no concurrent effort to improve the capacity of health centres to deal with the increased numbers of women approaching them for maternal and newborn ailments or complications.

Influencing future large scale maternal and newborn health projects

Sure Start indeed represents a unique programme with many lessons that can benefit scale-up strategies for community level interventions to improve healthy behaviors. Finding ways to get more women to participate in Mother’s Group meetings could be an important policy implication for more traditional environments, such as Uttar Pradesh, where young married women do not usually interact with each other.

Sure Start’s lessons on the beneficial effects of Mother’s Groups on improving behaviors for better health of mothers and newborns should be shared with the wider public health community