AS we drive out of the old city of Lucknow in a north-westerly direction, and try and get onto the highway to Hardoi, it is not always easy to appreciate the history and former majesty of the buildings and bylanes that surround one. Little remains of Avadh’s old grandeur. What the British didn’t destroy after 1857 has been buried under independent India’s crowds and teeming numbers, dirt and grime, traffic pollution and cluttered markets.

It is equally difficult to tell where Lucknow district actually ends and Hardoi, the neighbouring district, begins. If there is a sign, it is easy to miss; the rush and crush and the very visible poverty of Uttar Pradesh has enveloped one long earlier. Only a short distance from the state capital, we have driven into the heart of North India’s – or all India’s – development problem, the locus of so many of its most embarrassing social indices.

A little over an hour down the highway, we turn into a narrow road. A few minutes later, it virtually disappears, yielding to a dirt track. A small settlement is visible and the car stops. Walking through fields, avoiding cows as well as robust deposits of dung, we make it to our destination: the hamlet of Harpalpur Patti.

The setting is unprepossessing and decidedly ordinary. The man we are about to meet, as I soon discover, is not. Desh Raj Dwivedi, a tall, oak-tree of a man, is pradhan (chief) of the village, technically the head of a gram panchayat (village committee) that governs five vicinal hamlets and a combined population of 3,460. He’s also a quiet, understated achiever, having changed the village administration’s attitude towards public health.

When we meet him, Dwivedi is chairing a meeting of the Village Health and Sanitation Committee (VHSC), an institution designed under the National Rural Health Mission (NRHM) to give local communities a say, a stake and a leadership role in building health and sanitation capacities in their village. Theory has not always translated to practice but, under Dwivedi’s leadership, Harpalpur Patti is an exception. In the previous year, a Department of Health assessment gave the VHSC a score of 70 per cent. ‘But we are not satisfied,’ says Dwivedi, ‘immunization and institutional delivery remain our shortcomings.’

The resolve surprises us. Cow belt politics, even local cow belt politics, is supposed to be all about caste coalitions and individual machismo. Since when did elected representatives begin to locate their appeal in maternal and newborn health (MNH) attainments?

For Dwivedi, MNH is not politics. It’s something much closer home. Three years ago, his daughter-in-law died of eclampsia, a pregnancy-related complication that can lead to a fatal seizure. The tragedy shook Dwivedi. Rather than a grandchild, the family was left with a funeral. What didn’t help was when doctors told him it could have been prevented. If the signs of pre-eclampsia – the predecessor condition – had been read and detected, if his daughter-in-law’s pregnancy-induced hypertension, high blood pressure, nausea and swollen feet had been reported to a medical facility, she may still have been alive.

 

In the winter of 2008, Dwivedi’s son’s wife – he had remarried his late wife’s sister – got pregnant. This time, the family looked out for the signs of pre-eclampsia, as well as other potential problems. Rather than a delivery at home, Dwivedi insisted the baby be born in a hospital. A medical institution would have the facilities, equipment and support staff to take care of emergencies – and potentially save a life.

Much more had happened in the intervening years. The realization that pregnancy did not just automatically graduate into childbirth and did require human intervention, support and nurturing, as well as the protective gaze of medical science, had changed Dwivedi. He had convened a VHSC meeting and asked members to warn village faith healers and exorcists – the ‘jhar phook’ practitioners – to stay away from pregnant women, young infants and their families and instead leave them to the devices of modern medicine and MNH best practices. He had exercised his authority to ensure the auxiliary nurse midwife (ANM) assigned to Harpalpur Patti paid regular visits and checked on and counselled expectant mothers.

Nearest to his heart, however, has been making transport arrangements for pregnant women in times of exigency. The phone numbers of three car owners in the village and the vicinity, as well as what they charge, are displayed prominently. When a pregnant woman develops labour pains or begins to bleed – indicating complications – her family can summon a car and rush her to a hospital in Hardoi town or in Lucknow.

One of the cars and mobile numbers on the list is that of the pradhan himself. Not only does Dwivedi provide his car for those who need it, he doesn’t charge. It’s his way of atoning for the needless death of his daughter-in-law, a fate he is determined no other pregnant woman in the village will suffer. ‘That is why my car is available if anybody needs it,’ he says. ‘Only if somebody is using it and it is not there, is a rented car called in. This is how I remember my daughter-in-law. In return, I get more blessings than any rupees can earn me.’

 

That family tragedy three years was the trigger. Yet, as Dwivedi acknowledges, what really helped him put his anguish and restiveness into constructive action was the arrival of Sure Start in Harpalpur Patti. Sure Start is an MNH programme being implemented in seven rural districts of Uttar Pradesh and seven towns of Maharashtra by the health agency PATH. It is actually rolled out using a vast network of 95 partners, small NGOs and social sector organizations that are well entrenched in local communities.

Supported by the Bill and Melinda Gates Foundation, Sure Start promotes no new technology and calls for no new vaccines, no sophisticated development of new drugs. It does something much more basic: urge communities to claim their entitlements. The organizations essential premise is this: the government and its public health system, under the NRHM for example, can build hospitals, clinics and medical facilities, make available free medicines and vaccines, employ and deploy community-level health workers. It cannot, however, ensure that this matrix will be used.

 

Supply does not inevitably induce demand. The community has to be made aware of its entitlements and taught to claim them. Behaviour change and education have to leave their impact on expectant women, young mothers and their families. Sure Start and its partners play this catalyst role.

The pradhan of Harpalpur Patti may be an embodiment of Sure Start’s achievements, but he is not alone. In the seven districts of Uttar Pradesh where the organization works, 94 per cent of all expectant women have received the tetanus toxoid vaccine by their third trimester; 75 per cent have been given iron and folic acid tablets; every single VHSC now has emergency transportation provisions to take pregnant women to institutions for delivery; and home deliveries have reduced from 76 per cent in 2005 to 43 per cent in 2009.

The results are impressive but how have they been achieved? Sure Start’s methods are disarmingly simple. They focus on two local institutions – the Mothers’ Group, a collective of pregnant women, young mothers and mothers-in-law (who are key decision-makers on MNH matters), and the VHSC.

Convened and activated by Sure Start, the Mothers’ Group meetings bring mothers and women whose families are immediately affected by MNH issues on a common platform with the accredited social health activist or ASHA and the anganwadi worker (AWW), the community-level worker responsible for newborn health and nutrition.

As one Sure Start volunteer-worker put it: ‘There are three components to our message – antenatal, delivery-related and postnatal.’ The desirability of institutional delivery is written into its communication strategy. Yet, there is a recognition that not all families will opt for institutional care. Sure Start strives to ensure the safety and well-being of the mother and the newborn in both circumstances.

 

Sure Start provides no clinical services, has no hard infrastructure. It only pushes behaviour change – a big gap in NRHM – and educates the community on its rights and responsibilities, and on services it can avail from the ASHAs, ANMs and at government facilities.

The Mothers’ Group meeting we attended at Budhwara village in Barabanki district, east of Lucknow, offered an interesting mix. Of the 15 women attending, two were ASHAs, three were AWWs, four were pregnant, one was the mother-in-law of a woman who was pregnant but was busy at home preparing food for family members about to break their Ramzan roza (fast), three were mothers of infants, and two hoped to start a family in the coming months.

Indeed, the Sure Start meetings have become hand-holding sessions from, literally, pre-conception to infancy. Vidyavati, a resident of Budhwara and mother of Sandhya, now six months old, has been coming for over a year. As she put it, ‘I like these meetings because I find I can share my thoughts and anxieties and ask basic questions. I also learn a lot.’

 

What has she learnt? Sure Start uses flip charts, illustrated posters and small models (such as dolls) to demonstrate the correct manner of wrapping a baby and keeping it warm. It instils the importance of exclusive breastfeeding, of abiding with a rigorous immunization schedule and of taking care of the mother’s nutrition (iron and folic acid tablets) during the pregnancy.

At the Mothers’ Group meetings, Sure Start also introduces mothers to the need to make plans for financial emergencies and begin saving money for, say, a complicated delivery.

When the baby arrives, traditional practices in the village include giving it a cold water bath – which is severely damaging for the newborn, who has just been pulled out of the warm cocoon of the maternal womb – and feeding it goat’s milk. The yellow colostrum, the juice that in a sense anticipates breast milk and is crucial nutrition, is rejected as dirty and thrown away.

At the Mothers’ Groups meetings, these practices are explained as dangerous and potentially life-threatening and the need to keep the infant warm and to feed it the mother’s milk is emphasized. Innovative mechanisms – such as a derivation of the Snakes and Ladders board game that points to the possibly calamitous consequences of ignoring MNH protocol – are resorted to.

One popular Sure Start tool is a ‘Letter from an unborn child to the father.’ The mother carries this home from the Mothers’ Group and the text is a request from the child to its father, asking that its mother be looked after, specific needs for her be addressed, and the father take care of the child appropriately in the first days after birth.

The Mothers’ Groups meetings are not just counselling sessions on basic MNH but are also confidence building efforts in societies where women have traditionally been sidestepped and where the anxieties and concerns of motherhood are most acutely felt. At the Mothers’ Group meeting in Harpalpur Patti – attended by eight pregnant women, some of them coming for their 15th such monthly meeting, indicating a long, pre-pregnancy association – at least one expectant mother asked: ‘I am so thin and weak; will my milk be enough for my baby?’

It is not an uncommon question. Every mother worries she is not doing enough for her children. In a rural setting, with the mother sharing decision-making with her husband, in-laws and a host of other family and community stakeholders, it is easy to persuade a young mother that her milk is not adequate and that her newborn needs extra doses of goat’s milk, honey and other food. One of the goals of Sure Start is to educate the mother to know better and give her the inner strength to say: ‘No, my milk is enough for my baby.’

 

Describing the difference between commitment and involvement, the tennis player Martina Navratilova once famously said, ‘It’s like ham and eggs. The chicken is involved; the pig is committed.’ The association of males and females with MNH has been somewhat analogous. Traditionally, this has been a female domain: the woman is committed; the man is only somewhat vaguely involved.

The VHSC is the device Sure Start/the NRHM has sought to use to change that. The VHSC is a male dominated body, with key elected officials of the village panchayati raj institutions as ex-officio members. It brings together female health workers and male political decision-makers. The VHSC also has a small corpus that it is free to use for the benefit of the community and to further its health and sanitation goals. Sure Start attempts to guide the VHSC and have this money spent in building sustainable capacities that can serve the MNH cause.

 

In Budhwara (Barabanki), Sure Start urged pradhan and VHSC chairman Jabir Ali to get the committee to fund the building of a sub-health centre (SHC), a small health facility that has one bed and a doctor visiting periodically. ‘Now our plan is to have two beds and regular doctors,’ says Ali. ‘We would eventually like institutional deliveries in our own village, at this centre.’ He also complains the SHC has no electricity and wants the state government to rectify this, but that’s another story!

The VHSC has other tasks. It monitors the performance of the ASHA and ANMs – the health workers who are meant to regularly visit pregnant women and provide them folic acid and iron supplements and the tetanus shot, among other entitlements – mobilize emergency vehicle services (which is a very ‘male thing’ in a Uttar Pradesh village). In Harpalpur Patti, the VHSC warned and expelled faith healers who often presented themselves as alternatives to medical doctors and did more harm in reinforcing traditional quackery.

Dwivedi and his VHSC have also introduced a documentation culture. Each time a pregnant woman, having reached term or encountering premature labour, is taken to a hospital or institution for delivery, under the NRHM guidelines, her ASHA is required to go along and brief the doctor on her medical history. This is the theory, in practice the ASHA is not always around.

Encouraged by its Sure Start interlocutors, the Harpalpur Patti VHSC has designed referral pads. These will be filled regularly by the ASHA and, when the expectant mother sets off for the hospital, signed by the village pradhan. This attested document will then become the official record handing over on behalf of the VHSC, the community and the woman’s family to the obstetrician.

 

Moving from Sure Start in rural Uttar Pradesh to Sure Start in urban Maharashtra entails not just a new geography and landscape but a very different set of MNH challenges. Maharashtra is one of India’s most urbanized states and, therefore, also home to one of the largest populations of the urban poor in any one province.

Unlike the uniformity of the Hindi heartland, each of the seven towns in Maharashtra where Sure Start is present in, has a peculiar set of problems. The demographic mix, the conditions in the individual city, the proximity or otherwise to a big maternity hospital – all of these make a difference. As such, Sure Start Maharashtra is both one project and seven models. Each of the seven cities is experimenting with an innovation and it is hoped that between them the seven innovations will provide templates to address MNH issues in the gamut of urban centres in India.

Examples would be illustrative. The model in Nanded is built around community-based health insurance. The model in Malegaon stresses quality of care through a public-private partnership and has drawn unique lessons from experiences in Muslim clusters, working within a community framework that has its own sensitivities. The model in Solapur – Sure Start works with 25 per cent of the city’s 850,000 people, in 70 of its 256 slums – is underpinned by the principle of volunteerism. Sure Start works here with a local health NGO, which runs a hospital in a rural location 40 km from the city and has a number of outreach centres.

 

A once prosperous textiles town, Solapur’s story is emblematic of many others in Maharashtra. When the mills fell silent, employment collapsed and the local economy began to sink. What was left behind was a cosmopolitan community – located at the crossroads of the Deccan, Solapur had attracted economic migrants from southern India; answering to questions in Marathi, Telugu and Kannada is among Sure Start’s mandates. However, social conditions have regressed sharply. Solapur has today become, in the words of one local official, a ‘rural city’.

For Sure Start, Solapur also meant specific needs that had to be addressed. About half the working women in the slums Sure Start and its partners function in are beedi workers. Not surprisingly, incidence of low birth weight babies is high as nicotine gets absorbed in the mother’s breath, skin and sweat and harms the foetus. ‘Between 20 and 28 per cent of babies born in our slums,’ says a Sure Start associate, ‘have low birth weight. And nicotine is a very likely cause.’

Sure Start’s agent of change in Solapur is the volunteer. There are 200 volunteers, each of them responsible for a population of 1,000. Some of them are community members and slum dwellers. A vast number are kishoris – young women, largely college students – who are future paramedics, antenatal care-givers or social workers, and are interning with Sure Start.

The consortium that oversees the Sure Start programme in Solapur includes a representative from the Department of Social Work (DSW) at the city’s Walchand College. Students from this college and the DSWs in three other city colleges have been incorporated into the Sure Start family, and given charge of slum clusters close to their places of residence.

 

For the college students, participation in Sure Start wins them credits under the Union Ministry of Youth Affairs’ National Service Scheme (NSS). Enriched by the Sure Start experience, one of the Solapur colleges has even approached the University Grants Commission for funding to organize a 10-day camp on urban MNH.

On their part, PATH and Sure Start pay the four colleges Rs 500 per volunteer per month. The money is used by the colleges to buy cycles for the kishoris and laboratory and educational equipment for their institutions and students. It is a classic win-win situation that, local health authorities suggest, could be adopted by the upcoming National Urban Health Mission and incentivize community involvement in health interventions.

Community volunteers, some of them illiterate women, are the foot-soldiers of Sure Start. They are trained by 20 facilitators, Sure Start’s core team in Solapur. The training is both practical and oral, uses flash cards, visuals and is kept jargon free. The idea is the MNH message should be as accessible to the unlettered woman as the educated one.

We went to a meeting of community volunteers in Qurban Hussain Nagar, a largely Muslim neighbourhood. Shahnaz Mahal Sheikh, a mainstay of Sure Start in this slum cluster, was an early convert but acknowledges it was initially difficult to convince others in her community. ‘Forty women have delivered here in the past two years,’ she says, ‘but about two of every three have done so at home.’ There was no hostility to institutional delivery, she shrugs, just ‘poverty and ignorance’.

Given this, the first task of volunteers is to go house to house, requesting pregnant women and their families to register the mother-to-be with the AWW and then go to the local hospital or urban health centre for free investigations and supplements. They are also invited for Mothers’ Groups meetings and introduced to danger signs – headaches, swollen feet, high blood pressure (feeling giddy), bleeding. Sometimes providing key information is a key draw. Simply telling the woman and her family that she is entitled to Rs 600 as an incentive if she goes to the hospital for a cost-free delivery comes as a surprise, and works wonders.

 

In the early days, Sure Start faced obstacles. ‘Most difficult to reach out to were the Muslim women,’ says one official, ‘as conservative families would not let women volunteers speak to them, much less allow them to go to Mothers’ Group meetings.’ So how did Sure Start volunteers cope? Shahnaz Shaikh explains: ‘We kept going back to those families, over and over again. By the third visit, they allowed us in. Then they found we wanted nothing but only offered well-meaning advice…’ It is a measure of progress that, today, of the 200 volunteers in Solapur, 30 are Muslim. This is crucial social capital.

In the absence of an informed family support system, Sure Start has incubated self-help groups (SHGs). The SHG is the natural evolution of the Mothers’ Group. The Hanuman Nagar SHG – 11 members, three of them also Sure Start volunteers – is a case in point. Its members save Rs 50 each a month and have created a revolving fund.

In other parts of the country, an SHG has a vocational motive, giving loans to members from the revolving fund to help them set up small businesses or tide over family crises. In Solapur, the SHG provides a loan when a member has a baby. It also serves one other purpose. As Bhagyashree Boble, a member of the Hanuman Nagar SHG explains, ‘Sometimes the family members of pregnant women, even if otherwise cooperative, just don’t understand what to do. At these times, SHG members stand in and take the mother to hospital for delivery.’

 

Thanks to Sure Start’s single-minded message to pregnant women that they must register themselves with the ANM to avail their entitlements, the workload of ANMs in Solapur’s slum areas has actually gone up. In some slums, ANMs use Sure Start volunteers and community volunteers as support staff, and have adopted Sure Start’s pregnancy register and documentation design.

If that is the good news, there are grim tidings as well. The neighbourhood of Bohurupee Nagar, residence of the Bohurupee, traditionally nomadic folk artistes, is still a dark zone in that home deliveries remain the norm here. In another local community, branding newborns with a hot iron and using water and even tea as top feed within hours of birth is practised. There are also instances of mothers being given local alcohol to ease labour pains!

As becomes clear, Sure Start’s mission is on course, but still incomplete. The diversity of India’s MNH challenges, whether in Uttar Pradesh or Maharashtra or elsewhere, will take more than one organization and one programme, more than just the government or just civil society. This is a collective enterprise; it is India’s obligation to its future.