LETTERS SUSTAINABILITY: THE CRITICAL PIECE IN A SUCCESSFUL INTERVENTION Acharya et al.’s recent article1 is commendable for its impact on saving lives of women and children in Uttar Pradesh, India. Having worked in both Uttar Pradesh and Bihar, India, during the same period (2008---2012), I had the opportunity to interact with several satisfied Sure Start beneficiaries and observe the commendable work done by this team. However, what is noticeably missing in this article is the mention of “sustainability” of one or more of the interventions. For example, authors describe the Mothers’ Groups (MGs) as an effective low-cost intervention that reportedly improved several targeted behaviors such as skilled workers for home delivery, washing hands before attending a delivery, feeding colostrum to newborn, and breastfeeding within an hour and exclusive breast feeding for the first week. Despite this significant influence of MGs on targeted behaviors, there was no mention of the future of these successful MGs— in the Discussion or “Conclusions” section— after the funding period. Did the local accredited social health activists take over managing these groups? Did the grantees

Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www. editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Mary E. Northridge, PhD, MPH, at [email protected].

attempt to institutionalize these groups by collaborating with local community leaders, Auxiliary Nurse Midwives at the primary health centers, anganwadi workers (existing frontline community health workers from the Integrated Child Development Services program), or other women’s groups within each community? The question is whether it was the author’s conscious decision not to mention the sustainability plans or there was no plan at all within the project framework to institutionalize a successful intervention for sustainability. It is disappointing either way, although the latter would be more serious because it results in waste of huge resources and years of hard work by the grantee and the community members who partnered in successfully implementing this project in their respective communities. Furthermore, absence of this information in the article leads a reader to conclude that the project overlooked the sustainability component of a very significant intervention that could save lives. Irrespective of whether the project is scaled-up or not, it is important that grantees attempt to sustain an effective low-cost intervention even after the funding period. Additionally, dissemination of the strategies adopted for sustainability, especially in a journal such as AJPH with a large and diverse audience, would have provided very critical information that could be replicated by other researchers and funders who work in communities with similar cultures. j Deepthi S. Varma, PhD, MSW, MPhil

About the Author Deepthi S. Varma is with the Department of Epidemiology, University of Florida, Gainesville. Correspondence should be send to Deepthi S. Varma, Research Assistant Scientist, Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, 2004 Mowry Road, PO Box 100231, University of Florida, Gainesville, FL 32610 (e-mail: dvarma@ufl.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted March 28, 2015. doi:10.2105/AJPH.2015.302702

July 2015, Vol 105, No. 7 | American Journal of Public Health

References 1. Acharya A, Lalwani T, Dutta R, et al. Evaluating a large-scale community-based intervention to improve pregnancy and newborn health among the rural poor in India. Am J Public Health. 2015;105(1):144---152.

ACHARYA ET AL. RESPOND The Sure Start Project was implemented at a large scale and involved pregnant women and subsequent perinatal period. No mothers who had received benefits from the Sure Start programs were affected by stoppage of funding in 2011. Policymakers were informed of the results of the Sure Start projects through various dissemination mechanisms: program report, individual contact, and formal presentations. The question of sustainability is important in the context of a project like Sure Start, and Verma raises some important points. Because of space limitations, a discussion on sustainability was not presented in our article. The present note addresses three issues: (1) continuation of the funding for the Mother’s Group and Accredited Social Health Activists (ASHA) worker’s activities as implemented in the Sure Start project, (2) whether Sure Start required efforts beyond those that can be continued without the project’s core support being active, and (3) whether sustainability can be ensured through efforts that would be carried out within the National Rural Health Mission (NRHM) as originated by the previous government in power in India. Experiments take up risky activities. Some of these projects are successful and yield important positive results. It is up to the government of a fairly large economy like that of India to choose any successful program over any other successful program or make additional money available for new programs. The possibility of governments not being forthcoming with funding in the future should not rule out attempts to discern which programs are able to help improve the lives of those who are poor. That the government of Uttar Pradesh or other states in India may or may not have funded

Letters | e1

LETTERS

Sure Start---type projects after the project had been evaluated should be considered independent of implementing the project and subsequently obtaining a thorough evaluation. That said, the Sure Start project was designed in a way to preserve its sustainability. It aggregated the efforts of 55 NGOs already working in the selected districts of Uttar Pradesh into a partnership architecture, overseen by four lead nongovernment organizations (NGOs) with the Program for Appropriate Technology in Health (PATH) as the technical transfer hub. The premise was that, by working within the NRHM structure to enhance the availability of ante- and postnatal care, the activities carried out could continue after the project’s end. Mothers’ group meetings would continue if ASHAs could be trained periodically and the NRHM-mandated village health sanitation committee would continue to support these activities. Managerial capacity of the village-level NGO workers would be enhanced through continuing inputs from lead NGOs who usually figure in many aspects of health care delivery in rural India when finances are made available. Sure Start made an effort to not create a parallel structure to NRHM. Additional staff were employed only for training purposes as trainers of field workers within the NGO structure already noted. The midmedia activities were employed through already established NGOs who knew the regions in which the project was implemented. The four lead NGOs or PATH were not distant partners who employed workers from outside or employed methods that cannot be implemented by the local partners. The evaluators of the project cannot answer the question of whether government workers would have incentives to carry out the activities that were performed by field-level workers and the trainers employed through the funding available through Sure Start. NRHM or any other schemes mandated in the near future would need to assess its capacity to work at the grassroots level. However, we do not believe that Sure Start had any elements that could not be implemented within the present administrative infrastructure if it sought to do so. j

Lysander Menezes, PhD Julie Knoll-Rajaratnam, PhD Tanya Lalwani, MPA Jenny Ruducha, DrPH Rahul Dutta, MSc Jeff Bernson, MPH, MPA

About the Authors Arnab Acharya is with the London School of Hygiene and Tropical Medicine, London, England. Leila Caleb Varkey is with the White Ribbon Alliance, New Delhi, India. Lysander Menezes is with the Program for Appropriate Technology in Health (PATH), New Delhi. Julie Knoll-Rajaratnam and Jeff Bernson are with PATH, Seattle, WA. Tanya Lalwani is with PATH, South San Francisco, CA. Jenny Ruducha is with the Center for Global Health and Development, Boston University, Boston, MA. Rahul Dutta is at the Clinton Health Access Initiative, New Delhi. Correspondence should be sent to Arnab Acharya, Global Health and Development, London School of Hygiene and Tropical Medicine, London, WC1 9SH, UK (e-mail: Arnab. [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted April 16, 2014. doi:10.2105/AJPH.2015.302725

Contributors All of the authors contributed to writing and stating their views for the reply to the letter to the editor.

Arnab Acharya, PhD, MPH Leila Caleb Varkey, DSc

e2 | Letters

American Journal of Public Health | July 2015, Vol 105, No. 7

Acharya et al. Respond.

Acharya et al. Respond. - PDF Download Free
428KB Sizes 0 Downloads 9 Views