Annual Review - Summary Sheet
This Summary Sheet captures the headlines on programme performance, agreed actions and learning over the
course of the review period. It should be attached to all subsequent reviews to build a complete picture of actions
and learning throughout the life of the programme.
Title: Sector Wide Approach to Strengthen Health (SWASTH) in Bihar
Review Date: July 28 – August 01, 2014
Programme Value: £145 million
Project Code: 114506
Start Date: June 2010
End Date: March 31, 2016
Summary of Programme Performance
Year
Programme Score
Risk Rating
2013-14
2012-13
2011-12
2010-11
A
A
A+
A
equivalent
Medium
Medium
Medium
Medium
Summary of progress, lessons learnt and headline actions
The UK is providing up to £145 million (£100m financial aid, and £45m technical assistance) over six
years (2010-2016), to Government of Bihar’s Departments of Health, Social Welfare and Public Health
Engineering, to help improve health, nutrition, water and sanitation outcomes through the Sector Wide
Approach to Strengthening Health (SWASTH) programme. DFID has contracted the Bihar Technical
Assistance and Support Team (BTAST), a consortium formed by Care UK, Options, and IPE Global, to
provide technical assistance.
Overall, the programme is achieving results in one of India’s poorest states. Maternal, neonatal and child
mortality are falling. There is significant political commitment to inclusive growth and human
development. DFID funded technical assistance (TA) is helping to leverage financial aid through support
to capacity building and scaling up new interventions. DFID TA is supporting the state government in its
sustainability strategy for post 2015. TA supported the state’s new strategic roadmap 2014-16 for
improvement of quality in health facilities, and 90% of the targeted facilities are compliant with basic
quality standards. TA is also enabling improvements in nursing and midwifery training, with over 1200
new graduates from 29 colleges expected by end 2015, new skills labs and competency based curricula.
DFID has funded an innovative virtual classroom (VC) model, leading to improvements of between 50 to
90% in five key competencies for safe delivery. The model has also been recommended by central
government for adoption by other states.
The new Nutrition Monitoring Unit in the Social Welfare Department is providing technical and
management support for the government’s new nutrition campaign, and government will fund the Unit’s
staff post 2015. TA has also improved the hitherto weak capacity of the central department for water and
sanitation, and posts are now funded by government to build district capacity. A number of water quality,
piped water and storage schemes have been successfully piloted, but now need to be implemented by
government with TA support. With DFID support, Bihar is the first state to undertake state wide blanket
testing of water quality. TA is also supporting innovative community based approaches for community
led sanitation are generating good results with over 300 open defecation free villages.
The rural livelihoods agency, JEEViKA, is supported by DFID TA to roll out at scale the participatory
learning platform, Gram Varta Plus, which is making very good progress. This platform will ensure
sustained behaviour change for health, nutrition and WASH through the large existing network of
government sponsored women’s self-help groups. It has reached 30,000 groups this year and an
exploratory study has showed positive results for sample behaviours. An impact evaluation has been
commissioned.
1
DFID funded TA is improving the efficiency and effectiveness of government spending, including
financial aid, according to DFID’s independent VfM study, and thereby contributing to results.
Government allocations and disbursements to health have risen by 17.5% from 2012/13. Utilisation of
central government schemes stands at over 60% across all three departments. Increased absorption is
in part due to BTAST inputs with the departments to build capacity and accelerate implementation.
DFID TA is providing support to government departments to implement recommendations of the
Fiduciary Risk Assessment 2013, including strengthening procurement capacity. The Government of
Bihar has set up a new corporation - Bihar Medical Services and Infrastructure Corporation Limited
(BMSICL) to procure and supply medicines, equipment and infrastructure. There have been recent
allegations concerning value for money in procurement. The government immediately responded with an
independent investigation, and DFID has offered to support a review and recommendations against
international standards. Bihar is also introducing measures to address corruption through for example
setting up a Special Vigilance Unit to pursue allegations against high-level civil servants.
Lessons
1 It is critical to start sustainability planning early, especially with regard to sanctioning new government
posts and planning for the institutionalization and scale up of proven new interventions, and to have an
agreed transition and sustainability strategy to ensure preparation for ending financial aid by 2015.
Developing and sustaining strong partnerships with other development partners is essential.
2 Quality improvement in health facilities is making progress. However, certification has been hampered
by weak capacity and lack of government prioritisation this year at state level. Processes and staffing
capacity for quality assurance need to be advocated for and institutionalised at district, regional and state
levels to ensure sustainability.
3 It is important to ensure and promote use of data, knowledge sharing, dissemination and cross
learning, especially for innovative approaches, such as community mobilisation through women’s selfhelp groups, preventing violence against women and demand side mobilisation for sanitation, both within
the state and nationally.
Key actions
1 DFID will support government in an independent review and recommendations for strengthening the
new procurement corporation. DFID TA should provide support for procurement and supply chain
management, including compliance with international procurement standards, and an action plan for
district level supply chain strengthening. (Action: DFID and DFID TA with government, by November
2014)
2 Gender and scheduled caste/scheduled tribe status continue to affect negatively people’s demand,
utilisation and experience of services, especially for women and girls. A stocktake across SWASTH
interventions and greater disaggregation of data is needed, together with developing strategies to
address the barriers in the most disadvantaged areas in focus districts (Action: DFID TA by end 2014).
3 A cross departmental strategy is needed for strengthening integrated frontline services for health,
nutrition and WASH, including governance, accountability, human resources, and commodities. This
should include agreement on required quality standards by the departments, and a capacity building plan
for frontline staff to ensure required skills and knowledge for quality service delivery at community level
(Action: DFID TA to support government departments by end 2014).
4 Government capacity for human resources leadership and management should be built and sustained
post 2015 through the State Health Society cell. Full use needs to be made of the new human resources
management database to inform human resources policy and strategy for recruitment, retention and
management (Action: Dept of Health/State Health Society with DFID TA by March 2015)
5 Institutional partnerships should be developed in response to state needs, with UK organisations such
as the Royal College of GPs, for medical training and education, including possible distance learning
(Action: Patna Medical College, State Health Society with DFID TA by December 2014)
2
6 The monitoring, evaluation and learning strategy should include a communications and advocacy
component. The methodology for the evaluation of the Gram Varta initiative should be comparable with
those of similar approaches funded by other development partners. (Action: DFID TA by October 2014)
7 DFID will undertake a portfolio review of WASH interventions across its three focus states, and ensure
that the planned WASH evaluation is comparable with those of other states and contributes to wider
evidence base and learning on WASH in India and more widely (Action: DFID by December 2014)
A. Introduction and Context (1 page)
DevTracker Link to Business Case:
NA
DevTracker Link to Log frame:
http://devtracker.dfid.gov.uk/projects/GB-1-114506/
Summary of Programme
What support is the UK providing?
The UK will provide up to £145 million (£100m Financial Aid, and £45m Technical Assistance) over six years
(2010-2016), to Government of Bihar Departments of Health (DoH), Social Welfare (SWD) and Public Health
Engineering (PHED), to help improve health, nutrition and water and sanitation outcomes through the Sector Wide
Approach to Strengthening Health (SWASTH). DFID has contracted the Bihar Technical Assistance and Support
Team (BTAST), a consortium formed by Care UK, Options, and IPE Global, to provide technical assistance to the
SWASTH programme implementing departments. Additionally, DFID has also contracted Population Council for
testing interventions to prevent violence against women (VAW), and KRAN consulting to provide software for drugs
procurement and inventory management. DFID also has accountable grant agreements with Jhpiego to support
Government of Bihar to strengthen pre-service nursing education and with Intrahealth to strengthen the human
resources for health department.
What are the expected results?
Output: DFID grants will support five outputs under the SWASTH programme:




Increased scale and functionality of nutrition, health and water and sanitation services
Community level processes established to manage, demand and monitor services
Systems strengthened for improving efficiency and effectiveness
Capacity to work with non-government actors enhanced

Quality and use of monitoring and evaluation systems improved
Outcome: The achievements of the above outputs are expected to “increase use of quality, essential nutrition,
health and water and sanitation services especially by poorest people and excluded groups”. This outcome will be
achieved as demonstrated by improvements in antenatal coverage, institutional delivery, child immunisation, child
feeding practices, and access to safe drinking water and sanitation (see progress Table in Section B)
SWASTH is on track with its major contribution to DFID India nutrition (15.43%), health (24.09% - safe births) and
WASH (65.7%) results for the 2010-2015 Development Results Framework.
Impact: SWASTH programme is expected “to improve the nutrition and health status of people in Bihar,
particularly the poorest and excluded”. The programme will contribute to reductions in maternal and child deaths, in
under weight children under five and anaemia in women, and increased use of modern contraception (see progress
Table in section B)
What is the context in which UK support is provided?
Despite impressive economic growth and reduction in poverty in recent years, Bihar continues to be poorest among
all the major states in India, with around one third of its population still below the poverty line 1. The state’s per
capita social sector budget allocation is currently £30 (2013-14)2. This includes budget allocation of £3 for
1
2
About 35 million people live below poverty line. See press note on poverty estimates 2011-12, Planning Commission, GoI
Estimated based on data in Economic Survey 2013-14 and using average exchange rate during 2013, 1GBP= 96.85 INR.
3
healthcare services 3, which is much less than per capita budget required viz. £35 (or US$ 60) to reach health
MDGs and to ensure universal health coverage by 20154.
In recent years, Bihar has recorded some progress towards achieving health MDGs. Significant reductions
continue in maternal, neonatal, infant and child deaths5. The state’s Infant Mortality Rate (IMR) and Neo-Natal
Mortality Rate (NNMR) currently stand at 43 per 1,000 live births and 28 per live births respectively, which are
close to national average. Over the last six years, the maternal mortality ratio has fallen by around 30% (312
deaths per 100,000 live births, in 2006 to 219, in 2012), and under five deaths by over 32% (84.5 deaths per 1000
live births to 57). However, the current level is far above the national average of 178. The state’s Total Fertility Rate
(TFR) continues to be high at 3.5 children per woman, and modern contraceptive use just 41%.
High prevalence of child malnutrition persists. Although there is no recent data, progress on nutrition status for
women and children is likely to be limited. It is estimated that about 5 million children in the state suffer from
chronic malnutrition. According to the most recent data, 40% of children are underweight6.
Access to piped water supply is very low in Bihar, at less than 3% 7. The majority of the population rely on tube
wells or bore wells for drinking water. There is ground water depletion and/or water contamination in most districts.
Access to toilets is estimated at less than 20%, and use even lower, with over 90% of the population practising
open defecation8.
Over the past five years, the state has increased political commitment to inclusive growth and poverty reduction,
and to human development and gender equity as a key driver. It has developed a strategic and ambitious road map
to improve human development indicators through action across all sectors: the Manav Vikas Mission, which
includes nutrition, health, clean water and sanitation, livelihoods and food security, education, empowerment and
gender and social equity needs of every household. Although elections are due in 2015, which might hinder
progress in the short term, the overall policy direction of government is likely to be sustained irrespective of the
winning party or coalition.
B: PERFORMANCE AND CONCLUSIONS (1-2 pages)
Annual Outcome Assessment
Progress is mixed with regard to outcome indicators. In line with the government goal, the target for deliveries in
facilities by 2015/16 has been increased from 45%, to 65%. Performance has also improved significantly, with the
state meeting the 55% target for 2013/14. DFID’s TA has contributed through strengthening service availability,
human resources, essential supplies and infrastructure, and systems for quality improvement. Significant
challenges remain, and TA to ensure sustainability for these critical system functions will continue to 2016. With
respect to front line services (eg Village Health, Nutrition and Sanitation Days), the main state focus has been on
immunisation, reflected in good progress on the immunisation indicator, and in Bihar’s critical contribution to India’s
achievement of polio free status in March 2014. Slower statewide progress on other outcome indicators (ANC,
infant and young child feeding) can be broadly linked to two factors: limited capacity for integrated front line service
delivery for reproductive and child health (ie beyond immunisation), and demand side barriers. Health related
behaviour is strongly influenced by deep rooted social and norms, and by discrimination due to gender and
scheduled caste/tribe status.
DFID TA and FA have been supporting government to build capacity and develop and demonstrate innovative
strategies for enhancing both service delivery and community mobilisation. During the remaining two years of
SWASTH, the TA strategy will support scale up of these strategies, including human resource capacity building,
community mobilisation and empowering women’s self-help groups for social and behaviour change. DFID, with
DFID TA are considering the exit and sustainability strategy with government to 2015 and beyond, which will also
be informed by the TA transition strategy. Emerging priorities include UK technical partnerships for health training,
further institutionalisation of improved systems and capacity, and focused TA for community mobilisation, WASH
and nutrition.
3
4
State Budget 2014-15
WHO (2010): Health systems financing - the path to universal coverage
5
SRS 2007 and 2012
6 Hungama 2011/12
7 Census 2011
8 Census 2011
4
Outcome: indicators and progress to 2013/14
Baseline
Outcome Indicators
Milestone
(2013-14)
% of women who have
received ante natal care
(ANC)9
Deliveries taking place in all
health facilities (%)
Children aged 12-23 months
fully immunized (%)
Children breast-fed within
one hour of birth (%)
17
7.8
(AHS
12/13)
19.9 (NFHS
05/06)
55
55.4 (AHS
12/13)
32.8 (NFHS
05/06)
68
69.9 (AHS
12/13)
16 (NFHS
05/06)
45
37
(AHS
(12/13)
4.6 (DLHS
07/08)
Children (6 to 23 months)
given complementary
feeding (breast milk and
semi-solids)
23.1 (NFHS
05/06)
Number of people with
sustainable access to clean
drinking water sources
46.4
m
(NBA/GOI)
Number of people with
sustainable access to an
improved sanitation facility
Target
2015-16
Progress
16.8
m
(NBA/GOI)
40
NA
54.4 m
56.8
(NBA)
m
30.0 m
26.6
(NBA)
m
Comments
Milestone
substantially
not met.
19
65
Milestone
met
expectation
72
Milestone
met
expectation
60
Milestone
substantially
not met.
50
Data will be
available
66.8
Milestone
met
expectation
40
Milestone
moderately
did not meet
expectation
Impact: indicators and progress to 2013/14
Impact indicators
Base line
Milestone
2013-14
Progress
Maternal Mortality Ratio
261(SRS
2006)
237
219 (SRS
2012)
64 (m 67;
f 73)
70
(AHS
2012/13)
58
Improvement
since
baseline but milestone
is not met
Under 5
(U5MR)
Mortality
%
95 (NFHS
2005-06)
Target
2015-16
200
Comments
Exceeded expectation
Contraceptive Prevalence
Rate % (CPR)
34.1(DLHS3 and AHS)
2007
40
41.2 (AHS
41
2012/13)
Moderately exceeded
expectation.
Under-weight children %
(0-5 years)
55.9 (NFHS
2005-6)
45
N/A
Data n/a
9
37
This indicator is based on full ANC. India tracks progress on three ANC visits, as do DFID’s other state programmes. From 2014/15, SWASTH
will align with this, and baseline and targets will be changed accordingly.
5
Pregnant women age 1549 with anaemia %
60 (NFHS
2005-06)
54
N/A
50
Data n/a
Aggregate Output Score and Description: Overall Output Score: A
Output
Impact weight
Score
Output 1: scale and functionality of services
30%
B
Output 2: community processes
25%
A+
Output 3: systems efficiency and effectiveness
20%
A
Output 4: non-government partnerships
10%
B
Output 5: monitoring and evaluation
15%
B
Output 1 (scale and functionality of services): the availability and use of health, nutrition, and WASH services in
the state have improved significantly as per examples below:

The number of outpatients visiting the government hospitals has increased, from 63 million in 2011-12 to
79 million in 2013-14 recording an increase by 12% per year, while the inpatient numbers increased from
3.9 million in 2011-12 to 4.4 million in 2013-14 representing an average growth rate of 6.2% per year.
 There has been significant increase in institutional deliveries, from 1.43 million in 2011-12 to 2.97 million in
2013-14.
 Complete immunization of children aged 12-23 months currently stands at 70% as compared to 64.5% in
2010-11.
 Nearly 90% of the 91,000 sanctioned Anganwadi Centres are functioning as per government norms and
nutrition services now reach around 4.36 million children in the state, an increase from 4 million in 2012/13.
 Number of people with sustainable access to clean drinking water sources increased from 58% in 2008-09
to 62% by March 201410.
 Number of people with sustainable access to an improved sanitation facility increased from 14% in 2008-09
to an estimated 29% by July 201411.
This year DFID funded TA has supported the state’s new strategic roadmap 2014-16 for improvement of quality in
health facilities, and is working with over 150 facilities in 25 districts, including district hospitals. This progress, and
the DFID funded contribution, have been praised by quality leads in both GoB and GoI MoHFW/NHM. However,
although over 100 facilities have received district certification, capacity constraints at state level have prevented full
certification. Following major delays in taking forward the strategy to improve nutrition and child development
services, through developing over 1700 nodal anganwadi centres, momentum is now increasing, with recruitment
underway and phase 1 centres selected for upgradation. DFID funded TA has improved the hitherto weak capacity
of the PHED. A number of water quality, piped water and storage schemes have been prepared or successfully
piloted, but urgently need to be implemented. With DFID support, Bihar is the first state to undertake state wide
blanket testing of water quality.
Output 2 (community processes to manage, demand and monitor services): DFID TA is supporting Bihar’s
rural livelihood mission (JEEViKA) to roll out Gram Varta Plus, a participatory learning and action platform for the
women’s self-help groups. It has taken off in 30,000 groups already and a small exploratory study showed positive
results for sample behaviours. An impact evaluation has been commissioned. Innovative community based
approaches for community led sanitation are generating good results with over 300 open defecation free villages.
DFID TA is working with district governments to ensure that direct provision of the subsidy for ‘pukka’ toilets is
expedited, so that communities do not slip back and lose their open defecation free status.
Output 3 (systems strengthened for improving efficiency and effectiveness): DFID funded TA is improving
efficiency and effectiveness, according to DFID’s independent VfM study, and thereby contributing to results12.
Human resource capacity is critical to improving efficiency and effectiveness. DFID funded TA is supporting
government to improve nursing and midwifery training, with over 1200 new graduates from 29 colleges expected by
end 2015, new skills labs and competency based curricula. An innovative virtual classroom (VC) model is
improving the quality of pre service nurse training in 17 colleges. The first phase has been successful, with
improvements in a sample of 80 students of between 50 to 90% in five key competencies for safe delivery. The VC
model will be scaled up to all 29 nursing colleges, alongside the skills labs already supported by DFID’s TA. The
model has also been recommended by MoHFW/NHM for adoption by other states. DFID TA has also supported a
10 Source: www.ddws.nic.in
11 Estimate calculated based on PHED Annual Report 2013/14 and 2011 Census
12 Assessing Value for Money in Health Portfolio across States in India – Bihar State Report, e-Pact Consortium, May 2014
6
strategic approach to ICDS planning and implementation, and the state’s new nutrition campaign, through the
Nutrition Monitoring Unit, and institutional strengthening of midlevel and district anganwadi training centres.
However, further efforts are needed to ensure convergence on quality improvement and capacity building for
frontline services, the VHSND platform. GOB allocations to health have risen by 17.5% from 2012/13. Utilisation of
central government schemes stands at over 60% across all three departments. Increased absorption is in part due
to DFID TA inputs with the departments to build capacity and accelerate implementation.
Output 4 (Capacity to work with non government actors): The Clinical Establishments Act finally became law in
November 2013. However, state and district capacity to implement the Act and promote provider registration is
weak, and professional and public concern persist. The process is under judicial review, which is preventing DFID
TA from supporting next steps. DFID TA has assisted government in making progress in 14 contracting PPPs,
including for dialysis, imaging and cardiology units. However, progress in developing investment PPPs, where
public and private sectors share the risk, is still needed, for example for new nursing schools and medical colleges.
Output 5 (M&E systems): Progress on implementing three randomised control studies is satisfactory
(interventions to prevent VAW, double salt fortification and cash transfers for health and nutrition outcomes).
However, there have been data quality concerns and serious delays with completing the concurrent monitoring
Round 1 and commissioning Round 2, which need to be resolved urgently by end 2014.
Lessons It is critical to start sustainability planning early, especially with regard to sanctioning new government
posts and planning for the institutionalization and scale up of proven new interventions, and to have an agreed
transition and sustainability strategy to ensure preparation for ending financial aid by 2015. Developing and
sustaining strong complementary partnerships with other development partners is essential.
Human resources for health remain a major challenge, in terms of quality, quantity, and distribution, with staff
vacancies in most rural facilities. The new human resources database supported by DFID is a critical tool for
workforce planning. However, potential for change is limited unless overarching constraints such as salary
structure of doctors are addressed by the government.
It is important to ensure and promote use of data, knowledge sharing, dissemination and cross learning, especially
for innovative approaches, such as Gram Varta, preventing violence against women and demand side mobilisation
for sanitation, both within the state and nationally. The emerging experience of the help lines and centres could be
valuable to the Ministry Women and Child Development initiative for one stop crisis centres, but require more
support and a documentation strategy.
Innovations such as Nodal AWCs that require government systems for implementation (recruitment of additional
workers, upgradation etc), take time to embed. DFID TA played a vital role in streamlining and accelerating the
process, but frequent changes in leadership at the departmental level delayed the decision making. It is important
to build evidence on the effectiveness of the strategy early in the process.
Actions
Output 1 DFID will support government in an independent review and recommendations for strengthening the new
procurement corporation. DFID TA should provide support for procurement and supply chain management,
including compliance with international procurement standards, and an action plan for district level supply chain
strengthening. Urgent action is needed to address facility stock outs in RMNCH+A districts. (Action: DFID and
DFID TA with government and the corporation, by November 2014)
Support to Dept Social Welfare should fully align with Bal Kuposhan Mukt and will need to adapt to the strategy’s
campaign mode. This should include a review of ICDS capacity building trainings and their effectiveness, and
support to develop training MIS and quality assurance mechanism (Action: DFID TA by December 2014).
Output 2 Gender and scheduled caste/scheduled tribe status continue to affect negatively people’s demand,
utilisation and experience of services, especially for women and girls. A stocktake across SWASTH interventions
and greater disaggregation of data is needed, together with developing strategies to address the barriers in the
most disadvantaged areas in focus districts (Action: DFID TA by end 2014).
Output 3 A cross departmental strategy is needed for strengthening integrated frontline services for health, nutrition
and WASH, including governance, accountability, human resources, and commodities. This should include
agreement on required quality standards by the departments, and a capacity building plan for frontline staff to
ensure required skills and knowledge for quality service delivery at community level (Action: DFID TA to support
government departments to do this).
7
Institutional partnerships should be developed in response to state needs, with UK organisations such as the Royal
College of GPs, for medical training and education, including possible distance learning (Action: Patna Medical
College, State Health Society with DFID TA by December 2014)
Output 4 An information campaign should be conducted to improve understanding of the Clinical Establishments
Act and its potential benefits among providers and the public (Action: State health Society with DFID TA, by end
December 2014)
Output 5 The monitoring, evaluation and learning strategy should include a communications and advocacy
component. The methodology for the evaluation of the Gram Varta initiative should be comparable with those of
similar approaches funded by other development partners. Co-ordination is needed among funding and technical
partners to enable the government lead agency play its role in ensuring that the overall state demand side
behaviour change strategy is coherent and maximises VfM. (Action: DFID TA by end October 2014)
DFID will undertake a portfolio review of WASH interventions across its three focus states, and ensure that the
planned WASH evaluation is comparable with those of other states and contributes to learning on WASH in India
and more widely (Action: DFID by December 2014
Has the log frame been updated since the last review? Yes. Following the last annual review the logical
framework of the SWASTH programme was revised, to take into account more recent baseline data and reflect
more rapid progress on some indicators.
C: DETAILED OUTPUT SCORING (1 page per output)
Output Title
Increased scale and functionality of nutrition, health and water and sanitation
1
Output number per LF
Output Score
B
Risk:
Medium
Impact weighting (%):
Risk revised since last AR?
No
Impact weighting % revised No
since last AR?
8
30
Indicator(s)
Milestones (2013-14)
Progress
Score
1.1
Number
of
Nodal
Anganwadi Centres fully
functional. (NWC upgraded,
Uddeepika recruited, trained
and
conducting
cluster
meetings)
1,200 /1731
1731 nodal AWC notified; 52
Uddeepika recruited and inducted.
Cluster meetings yet to be started
B
4 million
4.36 million
A+
40%
89%13
13 state, 30 regional, 66 district
A+
1.2 Number of
reached
with
services
children
nutrition
1.3 % of 122 facilities made
FFHI compliant (ie district,
regional or state level
certification)
1.4 % of facilities in 10 HPD
with stock out of RMNCH+A
drugs
79%14
(based on survey sample)
60%
1.5 Additional habitation with
access to clean drinking
water through:
 Arsenic/Fluoride
treatment units
surface water
and/or
 Number of rehabilitated
bore wells
 New water storage
1
Source: HMIS data
2
C
A+
750
7933
30,000
41,378 (including 21,188 new hand
pumps)4
400
3305
Source: MPR, March 2014, ICDS, DoSW
3,4,5
Source: Annual Report 2013-14, PHED
Key Points
The Government of Bihar with DFID’s support is implementing ‘Uddeepan’ 15 an innovative strategy to improve
performance of Anganwadi Centres (AWCs), with stronger focus on services for under 2s under the Integrated
Child Development Service (ICDS). The concept and budget was approved by the Bihar Cabinet in 2012, and
1,731 Uddeepan Kendra (Phase 1) in 9 focus districts were notified. However due to delays in approval for the
Uddeepika (additional worker) position, the nodal AWC could not be made functional this year. Of the total 1,731
Uddeepikas, only 52 are on board and are currently undergoing trainings. The remaining 1680 positions will be on
board by September 2014. The Government has initiated the process for identification of Nodal Anganwadi Centres
in another 10 Phase II districts.
DFID’s support to ICDS strengthening has contributed to an increase in the estimated number of children
reached with nutrition services to 4.36 million, compared to 4 million in 2012/1316. The government’s Manav Vikas
(Human Development) Mission and the new nutrition campaign, Bal-Kuposhan Mukta (malnutrition free child), are
emphasising universal coverage. The number of newly enrolled children out of total births has increased from 44%
to 83%, although actual coverage is estimated at 31% of the total births.
The coverage of essential frontline interventions, in addition to immunisation, is improving slowly17. The
Village Health Sanitation Nutrition Days (VHSND) are a key platform for delivering front line health, nutrition and
WASH services and behaviour change interventions. Data for 534 blocks for VHSND over three quarters has been
collected, analysed and disseminated at state, divisional and district levels. The same tool has also been shared
with Bill & Melinda Gates Foundation for uniform monitoring of VHSND in the state. Monthly review is being
undertaken in two divisions. Of the total 991,077 planned VHSND sessions (July 2013- June 2014) 961,881
VHSND sessions (97%) were held. Of the total 202,769 planned sessions 194,896 (96%) were conducted in the 9
13 Source FFHI / SHSB MIS June 2014
14 Source SRU
15 Uddeepan is a Hindi word that means ‘encouragement and stimulation’. Uddeepan Kendra, or the Nodal Aganwadi Centre, is an AWC at the Gram Panchayat level that will act as resource
centre / hub for clusters of 8-10 AWCs in a particular catchment area and will provide mentoring support to these centres through an additional worker, Udeepika.
16 ICDS MIS MPR. Note that Annual Review 2012/13 reported 7.1 million, instead of 4 million, children reached. This is the births enrolment figure (which has risen to 11 million this year)
rather than actual coverage.
17 SWASTH MIS 2013-14
9
priority districts18. However, service quality is often poor, with stockouts in essential commodities and weak
provider capacity (see output 3).
Quality improvement in health facilities is a major focus of DFID’S technical assistance. The State Health
Society (SHS), Bihar, prepared a roadmap in 2013/14 to roll out quality improvement processes and standards in
all health facilities as per national policy for upgradation and certification, and in line with RMNCH+A requirements.
The roadmap is informed by the lessons demonstrated through implementation of DFID supported Family Friendly
Health Initiative (FFHI) in 2012/13 as well as a realistic appreciation of the extent of effort needed to improve
service quality in Bihar’s public sector health system. A new system, National Quality Assurance Standards
19(NQAS) and the National Accreditation Board for Hospitals (NABH) 20 has been introduced, which builds on the
FFHI approach and standards. A total of 150 facilities in 25 districts have been assigned to DFID TA team for
accreditation, of which 90 should be certified by 201621.
DFID’s TA has supported the State Health Society to:
 complete gap analysis, initiate Standard Operating Procedures, and capacity building, and facilitate
formation of QA committee in all 36 District Hospitals for NQAS and two facilities (Sub Divisional Hospital,
Danapur and District Hospital Buxar) for NABH.
 roll out FFHI QI process in the 122 facilities in 25 districts (of a total of 238). Of these over 100 have
achieved district level certification. However, state level certification has been given for only 13 facilities,
due to delays and capacity constraints.
 strengthen the quality assurance system, building capacity of 25 District and 9 Regional Quality Assurance
Committees (DQAC and RQAC) and facility level quality assurance committees.
The National Health Mission (NHM) lead at the Ministry of Health and Family Welfare, Government of India
commented: ‘I am really impressed by this [quality scores of 17 district hospitals]: Bihar is moving!’, and the State
Health Society Government of Bihar lead appreciates the continued and significant contribution from DFID’s
technical assistance.
DFID is an important partner in the implementation of RMNCH+A, in Bihar working closely with Bill &Melinda
Gates Foundation (BMGF), the lead development partner for Bihar. Through DFID’s technical assistance 2
technical specialists (urban health and maternal health) have been nominated to the State Resource Unit. DFID is
directly responsible for RMNCH+A roll out in 3 high priority districts - Jamui, Katihar and Kishanganj. Through the
DFID’s technical assistance under RMNCH+A 141 Maternal and Child Health centres in Level-1 facilities
operationalized as 24x7 delivery points against a target of 150 facilities. Gap analysis for 514 additional Primary
Health Centres (APHC) have been undertaken, of which 213 have been operationalized as delivery points with 193
functioning as 24x7 facilities.
DFID’s technical assistance is supporting Government of Bihar to strengthen six medical colleges. For
example, the equipment audits were undertaken based on Medical Council of India (MCI) guidelines. Patna MCH is
being supported with quality improvement of services through public private partnerships. A potential partnership
with the Royal College GPs, UK is also be being explored for medical education and training.
Procurement and supply chain management remain weak in Bihar. Stocks of drugs and consumables in health
facilities, both from central and state supply, continue to be inadequate. Through DFID’s technical assistance a
rapid assessment of availability of key drugs and status of supply chain using the RMNCH+A tracer drugs was
undertaken. Among those surveyed in 12 districts, 79% (38/48) were stock-out facilities. DFID’s technical
assistance is supporting the district officials to improve inventory management at facility and district levels. The
State Resource Unit is with support from DFID developing a training manual, which will be soon rolled out across
the state.
The Government of Bihar has set up a new procurement corporation - Bihar Medical Services and Infrastructure
Corporation Limited (BMSICL), with the aim to improve governance and value for money (VfM). The results have
been mixed. Although DFID’s independent VfM study found some improvements in procurement practices and
18 ICDS MPR; cross validated through District Project Officer monitoring visit reports
19 The roadmap designates 1 District Hospital, 1 SDH/Referral Hospital and 1 PHC in each district to implement either FFHI or NAQS standards with the objective of achieving accreditation.
Whilst District Hospitals and non-DH First Referral Units will apply for NQAS accreditation, the PHCs that have already initiated the FFHI programme will acquire certification by the end of FY
2016. In addition, Mother and Child Health (MCH) units of 6 Medical Colleges will apply for NQAS related accreditation.
20The FFHI system generates a certification which will be awarded every 3 years to facilities that meet standards focusing in particular on Maternal and New born Health services. The new
NQAS system is similar but applies to the whole facility. The National Accreditation Board for Hospitals (NABH) has designed an exhaustive healthcare standard for hospitals and healthcare
providers. This standard consists of stringent 600 plus objective elements for the hospital to achieve in order to get the NABH accreditation. These standards are divided between patient
centered standards and organization centred standards
21 BTAST strategy for TA: quality improvement in health facilities, 2014-2016
10
prices paid, there have also been media and state audit reports of problems, which government is investigating.
DFID’s technical assistance will support the government to transparently monitor performance of procurement
reforms against international good practice standards, as well as strengthening implementation.
DFID’s technical assistance is supporting the Public Health and Engineering Department (PHED)
Government of Bihar to develop the project plan and leverage World Bank funding for new piped water supply
schemes. So far ten Detailed Project Reports (DPR) have been prepared with support from BTAST for the 24x7
mini water supply schemes for benchmark Panchayats (5 DPRs each in phase 1 & phase 2). DFID’s financial aid
will support the implementation of these schemes.
The Department is leading on developing Water Security Plans (WSPs) in four water stressed blocks of two
districts to ensure safe drinking water over next 30 years, using both surface and ground water. A project for
restoring traditional water storage tanks (ooranies) has been implemented with DFID’s technical assistance. The
findings of the pilot indicate that the tanks can provide a safe source of water, with a steep fall in fluoride levels, as
well as a higher water table all year, and less time for women in fetching water. Government is considering scalingup in contaminated areas.
DFID’s financial aid and technical assistance has been instrumental in supporting Government of Bihar to
demonstrate innovations.
 100 model school water and sanitation (WATSAN) complexes are in process of construction
across 10 districts. These complexes are designed with 24 hour running water supply and have
separate facilities for boys & girls. However, of the 32 completed complexes, only 7 have been handed
over to the schools.
 100 solar powered mini piped water supply schemes (single village schemes) in Mahadalit
habitations in Gaya to address water scarcity and water quality issues in the sparse remote
settlements.
 Undertaking blanket testing of all public water sources to ascertain quality and location of its
sources. Following DFID’s technical assistance testing in 22 water quality affected districts, the
Government is now financing blanket testing in remaining 16 districts to cover the entire state. This is a
major achievement: Bihar is the first state to carry out the blanket testing and GIS mapping of
public water supply source of entire state.
 Smart Water System, in a block in Naland. This is a mobile-web based tool for ‘smart’ monitoring of
drinking water supply to alert maintenance teams to hand pump problems and reduce delays. It is
being integrated into Interactive Voice Responsive System of PHED.
 Mobile Water Quality Testing laboratories provided through FA were extensively used to monitor the
drinking water quality in the areas affected by outbreaks of acute encephalitis/ Japanese encephalitis
Syndrome (AE/JES) disease, as part of the government’s emergency response and mitigation plan.
Summary of responses to issues raised in previous annual reviews






It was recommended that DFID TA use the prescription audit to develop and implement a strategy
including advocacy to ensure rational use of antibiotics as a part of quality improvement and wider efforts
to optimise value for money (including health outcomes) and reduce anti-microbial resistance. This work
needs to be accelerated.
Procurement of fridges for facility delivery rooms (oxytocin storage) was recommended. Rs 1 Crore was
budgeted under FA for procurement of fridge for all delivery points across the state. DFID TA’s district team
is advocating at facility level to procure fridges from the patient welfare committee funds.
It was recommended that quality standards for integrated VHSND services are defined and agreed with all
relevant departments. Skills building of front line workers, including anganwadi workers on growth
monitoring, is included in Bal KuposhanMukta Bihar. (see output 3)
Action on the recommendation for updating habitation data based on Census 2011 and Rural Development
Department data for assessing gaps in water supply service has been completed. Terms of reference were
shared with the Government. Based on the terms of reference the department has updated the data
internally.
Integrating the Water Quality Monitoring and Surveillance (WQMS) framework with on-going water quality
monitoring activities and aligning the same with blanket testing of water sources has been done. GIS
mapping has been tagged with water quality parameter under blanket testing for WQMS across the state.
Scaling-up of piped water supply schemes in model ODF villages is underway. Four detailed project
reports have been prepared and submitted to the department, and two tenders are out.
Recommendations
11
















Quality improvement strategy should include a timetable for expediting plans for facility up gradation
(including 25 district hospitals), which may also utilise financial aid allocations for the department (Action:
SHS/DoHFW and DFID TA by December 2014).
Embed Quality of Care (QoC) into on-going monitoring, through:
- Including the new quality KPIs in the dashboard monitoring system of the state. These could include
indicators that reflect QoC across the system (coverage, facility readiness, utilisation, service content)
(Action: DoHFW and DFID TA by November 2014).
- Use of quality indicators at the district level, especially for the District Quality Assurance Committee
(DQAC), to measure the “readiness” of facilities for certification. (Action: DoHFW and DFID TA
November 2014.
- Further institutionalising quality improvement processes at state level and formalise a process to
ensure continued compliance of facilities certified (Action: DoHFW and DFID TA by March 2015).
Develop a strategy/work plan for overarching areas (quality improvement, HR, procurement and supply
chain management), clearly linked to government policy and strategy (Action: DFID TA by November
2014).
Carry out mapping of home deliveries, assess demand side barriers and develop a strategy to make births
at home safer while at the same time promoting and enabling quality institutional delivery, working with
local communities (Action: DFID TA with SHS and other development partners by January 2015).
Undertake a follow up study on Out of Pocket expenses including inpatient diet (Action: DFID TA by
January 2015).
Undertake assessment of ambulance services and demonstrate effective functioning in few districts
(Action: DFID TA by March 2015).
Design roadmap for Universal Health Coverage in the selected district, with emphasis on service
organisation and referral pathways, primary care and prevention (Action: SHS with DFID TA by January
2015).
Undertake a) independent assessment of Bihar Medical Services and Infrastructure Corporation Limited
(BMSICL) functioning (DFID by November 2014) and b) offer DFID TA now for:
- queuing system (CCTV, signage , communication related issues)( by September 2014
- facilitate logistics and administrative support for the admission process in 4 medical and 1 dental college
for next academic year (by November 2014)
- undertake an assessment of infrastructure and financial requirements for setting up 6 Warehouses in
state and supporting the implementation through DFID’s financial aid (by August 201)
Hands-on training of all Uddeepikas to be completed and at least 80% NAWC functional in 9 priority
districts , with second phase approvals/work for the remaining 29 districts to be initiated (Action: SWD with
DFID TA support by July 2015)
Monitoring mechanisms to be in place and integrated with SWASTH MIS as well as Government of Bihar
MIS (Action: SWD with DFID TA by June 2015)
The impact assessment of NAWC should be planned as a priority, with the baseline established; including
cost per beneficiary / or cost per NAWC (Action: DFID TA by March 2015)
Implementation of the piped water supply schemes needs to be accelerated including in Gaya, Nawada,
Jehanabad and Adhaura. (Action: PHED with support from DFID TA by January 2015 )
A plan is needed for setting up 76 sub-divisional laboratories in the state for water quality (Action: PHED
and DFID TA by end 2014)
Community ownership should be developed for all water supply schemes, and community education and
mobilisation should be part of all contracted agency TORs. (Action: DFID TA by October 2015)
The remaining school watsan complexes should be handed over in a phased manner, starting from
November 2014. Maintenance needs to be outsourced to an agency (Action PHED with DFID TA by
December 2014).
Develop 10 more Ooranies as a successful model for safe water storage (Action: PHED by mid 2015).
Output Title
Community level processes established to manage, demand and monitor
services
2
Output number per LF
Output Score
A+
Risk:
Medium
Impact weighting (%):
Risk revised since last AR?
No
Impact weighting % revised No
since last AR?
12
25
Indicator(s)
Milestones (2013-14)
Progress
Score
20,000
30,028 mobilised during the year1
A++
7 districts
A+
31722
A+
2.1 Cumulative number of Gram
Varta SHGs mobilized for health,
nutrition, water and sanitation
2.2 Number of districts with
comprehensive program for
preventing Violence Against Women
(VAW): protection officers trained;
Helplines functional according to
guidelines; Community interventions
for preventing VAW
4 districts
2.3 Number of Open Defecation Free
(ODF) Panchayats (Nirmal)
2.4 Percentage in 9 priority districts
as per state guidelines and budget
spent of a) of functioning Rogi Kalyan
Samiti
300
30%
b) of functioning VHSNCs
1
Source: MIS of WDC, Jeevika, and Mahila Samakhya
Source: B-TAST
Over 50% (facility sample from 20
districts23)
30%
2,3
45% (sample from 9 districts)
Source: WDC & Mahila Samakhya
4
A+
A
Source: B-TAST
5,6
Key Points
DFID TA for community mobilisation for improving household and community health, nutrition and WASH
practices: the extensive network of women’s self help groups (supported by Bihar’s rural livelihood mission JEEViKA, Women Development Corporation (WDC) and Mahila Samakhya) is providing the institutional framework
for scaling up a Participatory Learning and Action (PLA) approach to social change called Gram Varta. Rapid scale
up is proving feasible, and progress is faster than expected. Gram Varta will cover over 50,000 SHG groups with a
membership of over 600,000 women reaching around 3 million people. Milestones have been made more
ambitious, and the approach is underway in 30,000 groups. Field visit observation confirmed a high level of
participation by members, and an increase in their awareness and reported collective actions.



Over 3,551 community level women have been trained as resource persons, facilitators and supervisors –
a capacity which will remain within the community.
A project steering committee at the state level including JEEViKA (CEO), and Social Welfare Department
(secretary) under the chairmanship of the Principal Secretary, Health has been established. The committee
will ensure interdepartmental convergence for effective supply side response to the demand generated
through Gram Varta, as well as support scale up.
An integrated MIS for all the three (JEEViKA, Mahila Samakhya and WDC) agencies has been developed
to ensure effective programme monitoring.
BTAST has assisted government with community wide behaviour change interventions:



designing and implementing the integrated state-wide media campaign with key messages for behaviour
change, Dus ka Dum, which has been launched in six districts. The campaign addresses 10 issues
including girl child education and delaying child marriage, complete immunisation early and exclusive
breast feeding, treatment of diarrhoea with zinc and ORS, and vitamin A Supplementation.
state level training of trainers was completed and training for front line workers planned in August 2014, in
order to roll out the inter personal communication (IPC) intervention developed by BBC Media Action Trust,
the Mobile Kunji tools to reach 20,787 front line workers.
worked with Population Foundation India (PFI) to launch the edutainment serial, “Main Kuchh Bhi Kar Sakti
Hoon” (MKBKS), with the public service channel, Doodoshan Bihar in June 2014, the first state to do so.
There is increased demand from government for DFID TA for Kala-azar elimination by end 2015: DFID TA
continues to support the government’s road map with other partners, including the centrally DFID funded
programme, with a focus on community participation. The concept of community voucher scheme has been
22 Nirmal Bharat Abhiyaan
23 Annual Report of performance of RKS in Bihar (B-TAST)
13
developed and approved by Department of Health, to increase access to timely and quality treatment and
medication.
Similarly, there is high level demand for TA support to public health emergency preparedness and response for
prevention, treatment and control of Japanese Encephalitis/Acute Encephalitis Syndrome (JE/AES) epidemic.
BTAST is supporting the Department of Health for: a) awareness campaigns on the symptoms and prevention of
JE/AES among communities and frontline workers through folk and mid media in two highly endemic districts
(Muzaffarpur and Champaran East), b) immunisation of over 13387640 (96%) children under the JE mass
campaign and c) a study to identify the cause of AES in Muzaffarpur and support to modify treatment protocol
including administration of 10% dextrose that is reducing child deaths.
Prevention of Violence Against Women (VAW): The Indian National Family Health Survey data (2006-7) showed
significant correlation between domestic violence against women with malnutrition and poor uptake of primary
health care services by women and children. In Bihar, DFID is implementing a comprehensive package of
initiatives to prevent Violence against Women (VAW) through SWASTH. The core partner for the VAW component
is the Women Development Corporation (WDC), Social Welfare Department, Government of Bihar. The package of
interventions has three components: state wide institution strengthening such as help lines, short stay homes,
community courts (Narri Adalat); community mobilization and awareness; and building the evidence base on VAW.
Significant progress includes help lines strengthened across the state by improving management information
systems, establishing standard operating procedures, developing guidelines for funds flow, providing a 24x7
number to VAW programme officers. The figure below indicates the increase in the case load of the help lines, and
number of cases resolved (although there is wide variation across districts). Community mobilisation to address
domestic violence has been expanded from 2 pilot districts to 7 districts. An RCT is underway (see M&E section)
Figure: Violence against women: number of registered cases and resolutions, Bihar helplines (WCD MIS)
3000
2010-2011 Registered
2000
2010-2011 Solved
1000
2013-2014 Registered
Supaul
Sheohar
Madhub…
Banka
Purnea
Patna
Jehanabad
Jamui
Gaya
Kisanganj
Araria
Madhep…
2013-2014 Solved
0
Community mobilisation for improving access and use of clean water, sanitation and hygiene: DFID TA is
working with government to promote demand side behaviour change, through Community Led Sanitation
approaches (modified CLTS), to complement the government supply side subsidy schemes. There are four
different models: direct CLS (where a resource agency is providing mobilisation inputs); promoting CLS through the
self help group network; integrating CLS into the Gram Varta process; and providing hand-holding support to PHED
officials at block and district levels.
 52 Gram Panchayats have achieved Nirmal Bharat status, and are open defecation free (ODF)
 Technical assistance provided to JEEVIKA, Mahila Samakhya and Women Development Corporation for
integration of CLS with Gram Varta Plus by including five WATSAN meeting cycles.
 Community Led Sanitation training and handholding support has been extended to 6 new districts, to
create a resource pool of more than 750 trained resource persons in 12 districts
 State level strategy for hygiene and sanitation promotion in consultation with other development partners.
However, the DFID team also observed that some ODF villages are slipping back largely because of slow (or no in
some cases) construction of toilets, because incentive funds are not being advanced for pukka toilet construction to
replace the temporary kacha toilets.
Summary of responses to issues raised in previous annual reviews (where relevant)


DFID TA was recommended to developed and share with all the three departments an overall behaviour
change strategy for SWASTH programme, with targets set for high focus districts. This has been done
although it has not been approved.
It was recommended that staff, systems, and mechanism to roll out Gram Varta in 9 priority districts should
be agreed and operationalized with Jeevika, Mahila Samakhya and WDC; the Project Steering Committee
established under the chairmanship of the Principal Secretary, DoH; and an integrated MIS of all three
agencies developed. This has been done.
14





The recommendation to scale-up VAW interventions through multi-sector engagement in seven districts
through education, police and judiciary interventions has been done.
The recommended framework for mass media campaign to promote BCC for WASH has been prepared
and shared with the department, and WASH messages are integrated with Dus ka Dum, and launched in 6
districts.
It was recommended that the government’s annual action plan for Nirmal Bharat Abhiyan should be
updated/revised as against the current number of households, with the revised targets for 12th and 13th
Five-Year plans. The Department has now submitted annual action plan to Government of India.
As recommended, progress has been made with the department to introduce a mechanism for advancing
incentive fund for toilet construction to community (both SHG and non-SHG members) to improve
sustainability. Direct Cash Transfer (DCT) has been initiated in the state, and an amount of Rs.3.55 Crores
has already been transferred directly to the beneficiary account. The amount of fund transferred to
Panchayati Raj Institutions, as at August 2014, is Rs.109.46 Crores.
DFID TA was advised to undertake a gender and equity stock take of the SWASTH programme against
key indicators. Progress has been slow and the study will be only completed by December 2014.
Recommendations










It has been agreed that DFID TA will include a limited number of interventions to strengthen state capacity
to respond to public health preparedness and response to disease outbreaks (JE/AES) and contribute to
new kala-azar elimination goals, working closely with DFID’s global programme and to support the state’s
elimination roadmap (Action: DFID TA to agree workplan by end November 2014).
Oversight of Gram Varta roll out by WDC, Jeevika, and Mahila Samakhya needs to be strengthened: a)
through ensuring regular meetings of the Gram Varta Project Steering Committee (first meeting by
October 2014); b) regular submission of Gram Varta reports that include: the status of implementation; an
action plan that focuses on saturation, convergence and sustainability, and a strategy for the non-SHG
areas from September 2014; and c) ensure the renewal of MoU between Jeevika and WDC, due in
September 2014. (Action: DFID TA)
Baseline data using round 1 concurrent monitoring data for Gram Varta across the 9 priority districts is to
be collated and analysed by October 2014. (Action: BTAST)
A scale up strategy, including key learnings, for the package of interventions on Violence Against Women
should be developed by the Women Development Corporation and other departments (DFID TA, WDC)
Develop a policy note to establish linkages between Violence Against Women and health and nutrition
outcomes. There is a need to assess and analyse the data of the blocks where VAW are taking place to
explore any impact on health and nutrition indicators, as compared to non intervention blocks. (DFID TA)
Review Women Development Corporation restructuring; develop the strategy for effective utilisation and
sustainability plan for the Gender Resource Centre by October 2014, including potential links with A.N
Sinha Institute. (Action: DFID TA)
Undertake gender and equity analysis of SWASTH programme (eg coverage and use of key interventions
in disadvantaged blocks) by December 2014, including key indicators which should then be shared on
regular basis. (Action: BTAST)
Strengthen the Community Led Sanitation (CLS) programme by: a) a strategy to ensure that slip back in
ODF declared villages is addressed through multipronged approaches, including subsidy transfer, and
handholding support for continuous monitoring and strengthening of Nigrani Committees (Watch
Committees); b) linking community mobilisers (Swachhta Doots) and resource persons to optimise use of
the latter; and c) plan the pre work required in the new blocks, including a focus on avoiding any slippages
once the agencies move out of the villages – which means that DFID TA needs to ensure that incentives
are in place for the community post triggering ODF (Action: DFID TA with PHED).
The Hand Pump Training Centres (call centres for repairing of hand pumps) need to be scaled up and 2-3
districts need to be completely saturated. The department also needs to give official recognition to these
centres. DFID TA needs to: a) facilitate the process with the department to ensure that the HPCT are
recognised officially; and b) work with self-help groups to ensure that more HPCTs are set up in at least 3
more districts and the each district is completely saturated. The districts and SHGs need to be identified by
end August. Districts will be saturated by December 2015 (Action: DFID TA with PHED).
The system interactive voice response system for the PHED Central Grievances Redressal Cell should be
set up and implementation started (Action: DFID TA with PHED, October 2014).
Output Title
Systems strengthened for improving efficiency and effectiveness
3
Output number per LF
Risk:
Output Score
High
Impact weighting (%):
15
A
20
Risk revised since last AR?
Indicator(s)
No
Impact weighting % revised No
since last AR?
Milestones (2013-14)
Progress
3.1 % of vacancies amongst
sanctioned frontline staff
a) ANM
15
221
b) AWW
<5
42
c) ICDS Supervisor
50
103
d) PHED Engineers – JE
50
504
e) Nurses
50
565
f) Anaesthetists
50
100 (under NHM)
g) Lab technicians
35
13
h) Contractual NRHM
35
346
i) Contractual PHED (NBA)
50
247
3.2 % posts funded by TA/FA
sanctioned by government
16
Score
B
16
A
3.3 Number of AWW having
adequate knowledge of growth
monitoring in SWASTH 9
priority districts
18,742
18, 30419
A
3.4 Up gradation of ANM and
GNM schools with virtual class
rooms
17
17
A
Rs. 2,300 crores
Rs. 3,665 crores (RE)14
A+
3.5
State
allocation
health
budget
3.6 % Utilisation of funds of
central schemes
A
55%
73%15
60%
62%16
c) Nirmal Bharat Abhiyan
55%
66%17
3.7 Number of FRA benchmarks
assessed as substantial or high
risk for DHFW/DSW/PHED
8/8/6
a) NRHM
b) National Rural
Water Programme
Drinking
8/8/618
B
1,5,6
8 Source: B-TAST
9,10,11 Source: MIS,
Source: HRIS 2,3 Source: MPR, April 2014, ICDS, DSW 4,7,12 Source: PHED
13
NMU, ICDS, DSW
Dept. has decided not to up-grade any existing nursing college and set up only new schools in medical
college and hospitals 14 Budget Document 2014-15 15 Source: Bihar SHS 16 Source: GoI website 17 Source: GoI website
18 Revised ratings are based on recent FRA (2013) which included district level assessment.
Key Points
DFID TA is providing support to key components of HR policy, strategy and management, which is contributing to
improving capacity and reducing vacancies in some key posts. The Department has set up a task force chaired by
the joint secretary. An early achievement is the approval of the administrative cadre for medical colleges, by the
government. The Human Resource and Information System (HRIS) cell has been constituted and is functional,
although it still lacks senior HR expertise. The HRIS is fully operational and the Department is using updated data
for decision making and rational deployment of human resource (hiring, transfer and promotion of staff). Data for
48495 staffs including 19304 contractual staffs and 27883 regular staffs has been uploaded.
16
DFID TA is ensuring that key TA/FA funded posts are sanctioned by government, to ensure continued
capacity. This year 16 posts at district level were sanctioned, to improve utilisation of government funds for water
and sanitation schemes.
Number of TA/FA posts sanctioned by government
FA/TA total (in position)
Sanctioned by gov by 13/14
Target for 14/15
Target for 15/16
Total to be sanctioned
Balance positions that will
not be taken up by the
Government
Health
Central
15
Nil
8
4
12
Health
District
34
Nil
8
9
17
SWD
Central
15
Nil
3
3
6
SWD
District
Nil
Nil
Nil
Nil
PHED
Central
6
Nil
3
3
6
PHED
District
18
16
Nil
Nil
16
Total
3
17
9
Nil
Nil
2
31
88
16
22
19
57 (65%)
By 2015/16, 57 posts will be sanctioned. The remaining 31 positions will not continue. These include the quality
improvement staff for health (whose functions will be carried out by district officials), and SWD central staff (where
positions are already sanctioned)
DFID TA helped the state develop a new online patient registration and follow up system, Sanjeevani, which
has been rolled out in 36 District Hospitals and 534 Primary health centres. Over 14 million patients had been
registered by July 2014.
DFID TA has supported improving training for nurses, with respect both to training quality, and numbers
graduating, with over 1200 new ANMs and GNMs expected to graduate by 2015. Bihar has an estimated shortfall
in ANMs of 5335 (22%, down from 28% in 2013) and GNMs of 5012 (54%) as well as facing challenges in
delivering high quality training in rural areas. DFID is financing improvements in training capacity in all 28 colleges
across the state. Two skills labs for pre and in service nursing education have been established in Muzaffarpur and
Bhagalpur Medical Colleges. Training has been completed with more than 950 participants (both in service and pre
service nurses).
DFID funded the introduction of an innovative virtual classroom model for improving the quality of pre service
nurse training in two instructor locations, (the College of Nursing Patna and the College of Nursing Kolkata) and 17
colleges. Using CISCO technology to enable virtual online teaching, the first phase has been successful, with
improvements in a sample of 80 students of between 50 to 90% in five key competencies for safe delivery.
DFID TA has introduced clinical mentoring to improve quality of maternal and child health care in FFHI facilities,
through a 3 day mentoring programme. This was conducted in 56 facilities of 14 districts. However, initial analysis
of the data shows limited improvement of key skills. Further work will be done on the inservice training strategy with
government and other partners.
DFID TA is strengthening the monitoring of coverage and quality of VHSND, the monthly platform at AWCs for
integrated front line service delivery by the three workers (ANM, ASHA and AWW) is an important component of
SWASTH. While quarterly monitoring reveals steady improvement in essential services, they are still skewed
towards routine immunisation, and comprehensiveness and quality remain a concern. As yet there is no cross
departmental agreement on quality standards or a joined up approach to capacity building for front line workers.
DFID TA is also helping to improve the management and technical capacity for the SWD and ICDS. Finance
Department has approved 211 Nutrition Monitoring Unit positions. The Unit has supported developing the nutrition
policy and strategy and rolling out the new Bal Kuposhan Mukta Bihar campaign, including FA utilisation.
Based on the comprehensive gap analysis/needs assessment undertaken of 62 Anganwadi Training Centres
(AWTC) and 2 Mid Level Training Centre (MLTC) institutes, the Department now has a plan to strengthen the
institutional capacity of the state anganwadi centre training institutes. It includes a training MIS and a process for
the assessment of effectiveness of the various trainings, to be implemented before end 2014.
The Social Welfare Department with DFID TA support has made progress on training of key cadres under the ICDS
programme:

A total of 50,836 frontline workers (18,304 AWWs, 15,371 AWHs, and 17,161 ASHAs) trained on
first 1000 days of life
17

Training of state level trainers in mobile kunji, an interactive learning tool developed by BBC Media
action, was completed
State Cabinet has approved the Integrated Performance Management System (IPMS) for ICDS and
recommended to pilot and evaluate the system in four districts before scaling up. IPMS will be the primary
mechanism to monitor, review and improve progress in implementing ICDS. The Technical Advisory Group (TAG)
submitted its concept note to the department, including a broad design of the system and a road map for
implementation.The IPMS will build on experiences from other projects and first be piloted in 4 districts
(Madhubani, Supaul, Arrariah and Kishanganj). The terms of reference were approved by the department and the
tender process for the pilot has commenced.
Financing and fiduciary risk management: The state health budget allocation has increased by 17.53% over the
previous year driven by the systematic approach to strengthening infrastructure as well as staffing supported by
BTAST. There has also been good progress by the government in utilisation of budgets under the flagship
schemes.
2013-14
Scheme
Allocation
Utilisation
NRHM (health)
1559.21
1152.27 (73%)24
NRDWP (water)
920.00
570.51 (62%)25
NBA (sanitation)
295.38
156.19 (66%)26
There has been limited progress towards improving financial management practices and following up on the
recommendations of the FRA study 2013. DFID TA continues to follow up with the three departments of
Government of Bihar regarding compliance. Many of the recommendations involve policy decisions by government
which are time consuming. Examples of progress on some FRA recommendations are tabled below.
FRA
recommendation
Progress 2013/14
Accounting, book
keeping practices
and financial
management
Computerised accounting system using Tally software has been rolled out by the health
department across the state facilities, however much support is required for effective usage
and maintaining of accounts using the software. For PHED, selection of agency for accounting
support, introduction of computerised accounting and training to accounts personnel is in
process.
DFID TA has contracted out bank reconciliation of accounts at district and subdistrict level
facilities to chartered accountant firms.
Training programmes with focus on accounting and book keeping have been conducted
although the progress on this has been varied across the three departments.
Strengthening
planning and
budgeting
process
Adoption of MTEF and integrating it in the budget making process is on but limited capacity
and genuine interest from the lower level officials are a big hindrance. Attempts are being
made to influence the deaprtments to introduce comprehensive outcome based budgeting in
health department.
DFID has supported state health society to set up a budget cell which has been accepted and
agreed by health department.
Budget and audit cell established in PHED. Three employees are in place, selection of two
more to be done shortly.
Strengthening
internal controls
and audit
practices
DFID TA has provided technical support to the health department to set up concurrent audit.
Strengthening
procurement and
The drug procurement through BMSICL has been operationalised.
The e- procurement system in the PHED system has been strengthened.
The public expenditure review has been completed and based on the recommendations of the
study, government has initiated several actions, including: involvement of BMSICL to speed up
construction of facilities; recruitment of accountants at APHC level; increased number of
Nutrition Rehabilitation Centres (NRCs); and a review of diagnostics charges to reduce ‘out of
pocket expenses’ by patients.
24 Source: BSHS
25 Source: GoI Website
26 Source: GoI Website
18
organisational
structure for
ensuring value for
money
DFID TA is planning support to both review and further strengthen the procurement agency.
Summary of responses to issues raised in previous annual reviews



It was recommended to update the capacity building matrix to reflect the current status of training across
the departments, and establish system to track trainings and assess knowledge and skills of participants by
Nov 2013. This has not been actioned. This should be taken forward in Year 5.
Monitoring/follow-up of trainees who participated in skill lab training was recommended. This is done, but
there is no formal system for providing post training support to trainees of skills lab on a regular basis.
Review of complication case loads of ANMs in L1 facilities was recommended but has not been done, and
should be addressed in Year 5.
Recommendations

An action plan is needed for strategic use of the new HRIS database, including using HRIS data for district
level planning and appropriate resource deployment based on location, facilities, infrastructure & service
demand to ensure proper/effective service delivery. The HR cell should be staffed with at least one HR
expert (Action SHS with DFID TA, by December 2014)
 The health human resources strategy should include: appropriate staffing for the new Nursing Directorate;
strengthening State Institute for Health and Family Welfare, pre and in-service training plan for key cadres;
collaboration with UK partners; and strengthening ANM capacity in VHSND (as part of an integrated
approach with other departments) (Action Department of Health, and SHS with DFID TA, by December
2014)
 Specific TA/FA inputs towards improving VHSND service quality to be agreed and steps take to implement
by September 2014, and quality standards and process to be defined and agreed with ICDS and Dept
Health. This should include strengthening of trainings for ANMs and AWW, use of monitoring data, quality
standards development, supportive supervision and a district task force. (Action: DFID TA with government
departments by October 2014)
 Skills building of anganwadi workers on growth monitoring (weighing, plotting, counselling and referrals)
should be prioritized as one of the key inputs to the VHSND in 9 priority districts. (Action: SWD with DFID
TA by June 2015)
 Undertake assessment and analysis of best practices across India on incentivising deployment and
recruitment of Human Resource for health. This needs to be presented to the Secretary cum ED, State
Health Society by October 2014. (Action: DFID TA)
 Finalise the detailed action plan for strengthening the training institutes and developing a training
effectiveness plan (including use of rapid assessments and a training MIS for health and nutrition cadres).
(Action DFID TA with SWD by November 2014)
 Regular follow up is needed with the departments for ensuring the FA spent. DFID TA district level teams
need to ensure that the infrastructure plans from their districts are being approved and to provide support
to the district administration for the APHCs up gradation. Field visit showed that many capital expenditure
plan of APHCs and PHCs are pending at state for approval for more than a year (DFID TA ongoing).
 BTAST needs to regularly follow up with the department for ensuring the FA spent. BTAST district level
teams need to ensure that the infrastructure plans from their districts are being approved. BTAST team
need to provide support to the district administration for the APHCs up gradation. Field visit showed that
many capital expenditure plan of APHCs and PHCs are pending at state for approval for more than a year.
 There is a need for all three departments to ensure strengthening of their internal audit cells, for the MTEF
process to be integrated in the budget cycle, filling up of vacancies and capacity building of staff,
mandatory reconciliation of bank and cash, streamlining and transparency in procurement system, and
effective
implementation
of
Tally
software
for
accounting
purposes.
19
Output Title
Capacity to work with non-government actors enhanced
4
Output number per LF
Output Score
B
Risk:
Medium
Impact weighting (%):
Risk revised since last AR?
No
Impact weighting % revised No
since last AR?
Milestones
(2013-14)
Indicator(s)
4.1 Proportion of private sector providers
registered under the Clinical
Establishments Act 2013
15%
4.2 Number and scale of Public Private
Partnership arrangements in health,
nutrition and sanitation functional (includes
Demand Side Financing/Results Based
Financing initiatives)
15
10
Progress
Progress is not possible
because the process is under
judicial review
Score
n/a
DHFW: 14 PPPs in different
stages
B
Key Points
The Clinical Establishments Act was passed in Nov 2013, but its implementation is still to take off. There has been
limited publicity and encouragement for service providers to be registered, along with weak capacity at district level
to effectively implement the Act. DFID TA plans to support the department in creating awareness about the act and
support the state to have full infrastructure at district level for empanelment of facilities. However the process is
under judicial review and the plan can only be initiated after the Honourable Court’s decision.
DFID TA has supported significant progress on designing and implementing PPP contracts for health. Fourteen
expressions of interest are published, of which 5 full proposals have been requested and 1 contract is signed. The
PPP agreement (for dialysis centres in 8 MCH and 16 DHs) has been completed. Two further PPP agreements will
be rolled out by October 2014, for imaging centres (in 33 DHs and 7 MCH) and cardiology centres (in one SDH and
one DH).
Summary of responses to issues raised in previous annual reviews


DFID TA has not been able to undertake the recommended review of current public private partnerships in
the health sector, due to lack of approval from state health society. However, this needs to be revisited with
the new executive director of the society.
As recommended, DFID TA has developed a capacity building plan and helped revamp the PPP cell in the
state health society, and empanelment of agencies to provide transaction advice is underway
Recommendations


Develop a strategic business plan and model for PPP including a risk sharing investment model, guidance
on setting up an appropriate regulatory framework, and including the proposed risk sharing partnership
model for nursing schools and medical college hospitals.(Action: DFID TA, by December 2014)
Develop an information campaign to increase awareness of the benefits of the Act among professionals
and the public (Action: DFID TA and SHS).
20
Output Title
Quality and use of monitoring and evaluation systems
5
Output number per LF
Output Score
B
15
Risk:
Medium
Impact weighting (%):
Risk revised since last AR?
No
Impact weighting % revised No
since last AR?
Indicator(s)
Milestones
Progress
Score
C
5.1 Availability of valid and
reliable data for planning and
delivery
First phase of concurrent
monitoring survey
completed
Survey completed in only 50% of the
blocks (338)
5.2 Annual Report on budget,
expenditure, plan and
performance of nutrition, health
and water & sanitation
published in appropriate formats
(eg factsheets) by government
for public transparency at
different levels.
Annual Report published;
discussed
with
CSOs
(within 3 months of the
publication)
Annual reports of various depts. for
the year 2013-14 published and
available in public domain, but
consultation with CSOs has not taken
place.
At
least
1
scientific
research study designed
and initiated and scale up
plan
for
effective
intervention prepared and
approved.
3 Randomised Control Trials (RCTs)
ongoing - all on track
5.3 Scientific studies and
evaluations conducted with
recommendations generated for
scale up.
B
A+
Key Points
The first round of concurrent monitoring for health and nutrition service provision, utilisation and outcomes data
in Bihar could not be completed owing to data quality issues and protracted dialogue among partners with the
contracted agency to resolve the issue. BTAST aims to complete the first round as a priority by end 2014 latest.
Simultaneously the process for Round 2 data collection will be initiated.
Three scientific studies and evaluations include:
The Bihar Child Support Programme (BCSP) conditional cash transfer pilot (2013-2016) to assess impact on
nutrition outcomes for children: The baseline has been established and the pre-pilot phase in Sahora Gram
Panchayat, Gaya has been completed. The main pilot informed by the lessons of the pre-pilot phase now needs to
be initiated.
Evaluating the Impact of Supplying Double Fortified Salt (DFS) using the Public Distribution System in
Bihar March 2012-Juy 2015 - J-PAL in partnership with the State Health Society (SHS), Government of Bihar and
Tata Salt.
- Price Experiment Phase: Two price experiments (Agiaon and Behea) were conducted prior to the main
evaluation phase to test the effect of price, information campaign, and store type on DFS purchases
and to identify a pricing level and information campaign to be used for the second phase, District-wide
randomized evaluation of DFS.
- Main Evaluation Phase: Baseline involving 40,000 individuals in 6000 households in 400 villages
spread across the 14 blocks of Bhojpur district was established in March 2012. This was followed by
an intervention phase, where the PDS and Kirana stores (local grocery shops) in 200 villages are
continually stocked with DFS. Three additional small evaluations have been built into the main
evaluation to understand the factors affecting DFS take-up in real life settings better. These are
underway. The endline (same in scope as baseline), has now been initiated and will be completed by
June 2015.
Violence against Women (VAW) 2012-2016 has been initiated with the objective to identify and test effective
interventions to mitigate risk and promote protective factors and scale up successful approaches in Bihar. Overall
research design has been agreed; formative study completed, published and disseminated. 6 papers written and
presented in several national and international conferences; op-eds in leading dailies. Rigorous independent
impact evaluation is being undertaken of four most promising interventions that mitigate risk and help promote
prevention of violence against women. The implementation of the evidence building component is progressing well.
21
Over the reporting period a number of activities has been undertaken which includes baseline data collection;
implementation of three of the four arms. Monthly project reviews are undertaken by the key technical advisory
group (Population Council and CEDPA India) to ensure quality of implementation.
Progress on five studies is on track:
- Changing adolescent attitudes and practices through sports and life skills education, with Nehru Yuva
Kendras (NYKs) 2 arm RCT; baseline completed; intervention rolled out.
- Women’s empowerment through SHGs; with WDC; (3arm RCT); baseline underway; modules
designed.
- Changing notions of masculinity and modifying lifestyle factors through Panchayati Raj Institutions
(Quasi–experimental); modules prepared; Institutional Review Board approval awaited.
- Screening, identifying and referring women at risk of violence. (Quasi experimental); Institutional
Review Board approval pending).
- Assessment of services for women in distress-helplines and short stay homes. With WDC; Study
designed changed to have repeated surveys; protocol approved by IRB; assessment to begin in Jan
2014.
Summary of responses to issues raised in previous annual reviews



As recommended, score cards for the 9 priority districts have been developed but they need to be further
refined as communication tools.
Cash Transfer (CT) baseline to be completed; implementation to be initiated in full scale by Dec 2013. The
baseline is completed but implementation is yet to be initiated at full scale.
The recommendation for assessment of sustained sanitation behaviour in terms of usage of toilets,
localised solid & liquid waste management, hand washing and school & Anganwadi sanitation is yet to be
initiated.
Recommendations




Concurrent monitoring Round 1 phase 2 should be completed by November 2014 and Round 2 by October
2015. A robust quality assurance mechanism should be established to ensure data quality is not
compromised and that analysis is of high quality. Data analysis and dissemination to GoB should be
completed by December 2015 (Action: DFID TA)
Expedite the procurement of contractor by government using FA to implement Integrated Performance
Management System (IPMS). The agency needs to draw on lessons/best practices from the existing work
of other development partners in the state as well as ensure that the IPM software is aligned with the new
ICDS MIS and the web based MIS being planned under World Bank supported ISSNIP programme in
Bihar (Action: SWD with support from DFID TA)
Implementation of Conditional Cash Transfer pilot to be initiated in full scale by September 2014; and a
clear evaluation workplan needs to be shared with DFID by August 2014. (Action DFID TA in consultation
with SWD and OPM)
A process evaluation of CLTS piloted in four districts should be commissioned, including comparison of
direct CLTS vs. SHG model. The study design should be comparable with those for the WASH
programmes in MP and Orissa. (Action: DFID TA by November 2014)
D: VALUE FOR MONEY & FINANCIAL PERFORMANCE (1-2 pages)
Performance of key cost drivers
The main cost drivers of FA are: payments for salaries/honorarium (e.g. salaries of support unit staff; honorarium of
additional worker at nodal AWCs; salaries of nursing skill lab); purchase of equipment; civil constructions; upgradation of facilities; training; monitoring and supervision; mobility costs; etc. While cost drivers mostly remained
the same, FA utilisation has to date been slow (see below).
The TA cost drivers are driven by DFID TA staff costs, short term consultancy, community intervention, monitoring
and evaluation, research/study/survey, training and capacity building. These cost drivers performed well and
achieved economy in procurement during the review period (discussed in the next section).
Performance against VfM metrics
The VfM performance has been assessed based on UK Treasury’s ‘3 Es’, namely economy (procurement of right
quality inputs at right price), efficiency (quality and quantity of outputs produced by inputs), and effectiveness
(outcome/impact). In addition, VfM analysis has taken into account equity aspect of the programme (fair distribution
of programme benefits).
22
Economy
Procurement of TA and payment system: DFID has contracted BTAST (consortium of three firms) through
international competitive bidding process and the negotiated process for contract extension. The payment to
BTAST is linked to ‘output based deliverables’ to ensure better value for money. During the review period there are
instances that payment has been delayed or stopped for non-delivery or for poor quality of delivery.
Savings in sub-contracting by DFID TA, BTAST: During the review period (2013-14), actual value of subcontracting was $0.62 million with an average fee rate of $165 per day (8.5% higher over the previous year rate of
£152 in line with average inflation rate). This rate is two-thirds of the DFID’s approved consultancy fee of £250 per
day. Sixty per cent of the sub-contract procurement had been through competitive (direct and limited) tendering
process. BTAST achieved 14% savings in sub-contracting through negotiations.
Economy in use of FA funds: GoB adheres to GOI guidelines or cost-estimates (especially relating to
construction and equipment) wherever available. Examples below show how the unit cost achieved was lower than
GoI benchmark.
 Costs of training at skills lab: The state has set up two nursing skills lab, one in Bhagalpur and another in
Muzaffarpur districts, and both became operational during 2013-14. The skills labs are equipped to provide
high quality, competency based training to medical and nursing staffs for RMNCH+A services. During 201314, each lab conducted a series of 3-day training programmes, and on average a total of 777 participants
attended those programmes. The training cost (capital and recurring expenditure) was Rs. 4,220 or £44 27 per
trainee compared to normative training cost based on GoI budget guidelines 28 of Rs. 5,390 or £56 per trainee.
Thus, unit cost of training at skills lab in Bihar is 22% lower than the normative cost and represents good value
for money. The training quality was found to be satisfactory – post-training assessment scores were 53% to
74% higher compared to pre-training assessment scores.
 Costs of providing fluoride free drinking water: During the review period, BTAST initiated development of a
drinking water pond, called Oorani, in Tetariya village in Gaya district to provide fluoride free water to about
100 households (624 beneficiaries) in the village. The village committee carried out the construction works
under the supervision and technical support of DHAN foundation. The cost of the project was only Rs.11 lakhs
(£11,000) and financed out of TA funds. Amortising the capital cost over 15 years, unit cost works out to be as
low as Rs 217 or £2 per beneficiary. The village committee will bear annual O&M costs.
 Mini piped-water supply scheme: Under FA support implementation of 100 schemes of mini piped-water
supply in Mahadalit (most backward) habitations covering an estimated population of 100,000s is underway.
The per capita cost is estimated to be Rs. 2,350 or £24, which includes O&M costs for five years. The cost is
reasonable, and economical compared to other piped-water supply, since it runs on solar power for
uninterrupted supply of electricity and lasts longer due to minimum maintenance of machinery.
Efficiency
Utilisation of government and FA funds (2010-2014): The disbursement and utilisation of the central funding for
health, nutrition and PHED are now all over 60%, as described under Output 3.
Utilisation of FA funds has been slow. The three departments together absorbed 42% of the FA budget, mainly due
to slow off take of activities and delays in procurement by SWD and PHED. However, DFID expects significant
acceleration of spend for example on the IPMS and nodal anganwadi centres.
Service delivery: It is difficult to capture the efficiency gains across all the interventions due to lack of data and
activity based costing. There are examples of efficiency gains that the TA support or the programme has managed
to achieve and influence.



The drugs budget has increased from Rs258 crores in 2013-14 to Rs 321 crores in 2014-15, and per capita
drug budget from Rs. 21 to Rs. 26. This has ensured greater availability of drugs and reduced out of pocket
expenditures on drugs.
Support to quality improvement, communications and investment in APHCS has resulted in increase in
inpatients from 32.8 Lakhs in 2012-13 to 35.7 Lakhs in 2013-14; and outpatients from 751 Lakhs in 201213 to 792 Lakhs in 2013-14. Increase in OPD and increase in bed occupancy ratio (98.37% in 2013-14 )
indicates more effective utilisation of resources.
The trends in other health outputs/ indicators, such as increases in institutional delivery from 14.3 lakhs in
2012/13 to 16.3 lakhs in 2013/14 without significant increase in available infrastructure point to potential
efficiencies, although there is a continued need to monitor and improve quality.
27 Currency conversion is done using average exchange rate during 2013 viz. 1GBP= 96.85 INR.
28 MHFW, GoI (Jan 2013): Skills Lab Operational Guidelines, 13-14
23


Support to upgradation of APHCs is expected to bring down patient numbers in higher level facilities and
thereby improve efficiency. Moreover, from beneficiary point of view this should contribute to substantial
savings in terms of time and transportation charges.
The pilot initative (Oorani storage ponds), has a per capita cost £2 compared to per capita cost of alternate
approaches of fluoride treatment of at least £5.
Effectiveness and cost effectiveness
It is difficult to assess impact and effectiveness because the programme is one of several large overlapping
interventions, with similar objectives, and some areas lack annual data and information. However, the recent DFID
contracted study to assess the VfM of the health portfolio in India suggested that if FA and TA are fully utilised and
the programme achieve the targets regarding IMR, U5MR, and underweight children (0-5 year), then cost per
DALY gained through the programme would be $116 29. This is much lower than WHO’s suggested threshold for
very cost-effective interventions, namely the state’s per capita nominal GDP that stood at about £300 in 2012-13.
The study has also mentioned that several interventions such as setting up of BMSCIL, community mobilisation,
strengthening health facilities, and skill labs for nursing training have potential to be highly cost effective for
achieving health outcomes if properly being scaled up or implemented. The effectiveness of the nutrition and PHED
interventions are difficult to assess because many of the DFID supported key interventions are in process of
scaling up and it is premature to assess the outcomes.
Equity
Improving equity with respect to gender and disadvantaged groups is part of SWASTH’s overarching aim. All
programme interventions (e.g. FFHI, community based mobilisation, setting up of nodal AWCs, Oorani, help lines
to reduce VAW) are focused on priority districts and the beneficiaries are mainly poor and marginalised people. At
present, disaggregated data for equity analysis against programme milestones are not available. BTAST is in the
process of undertaking a comprehensive gender and equity analysis to evaluate and establish equity-value for
money of the programme.
How does VfM performance compare to the original VfM proposition in the business case?
Overall, SWASTH has performed reasonably well in terms of all the VfM measures assessed in the original project
memorandum.
Does the project continue to represent value for money? Yes. The recent VFM study conducted by ITAD
suggested that the interventions supported through the programme represent or has potential to achieve better
value for money in terms of economy, efficiency and effectiveness.
Quality of financial management
Accounting and auditing: The programme adheres to all financial accounting and reporting requirements. An
audit discharge has been done for the period 2010-11 and 2011-12 based on the expenditure statements
presented to the Bihar assembly for these years. The audit for 2012-13 will be done by December 2014. All the
three implementing departments carried out audit of accounts related to FA for the year 2012-13, with no
qualification, and the reports were shared with DFID. Comments and observations from the audit reports presented
have been taken up for specific actions by each of the departments. Audit for the year 2013-14 is likely to
commence in August/September 2014 in the three departments and the reports are expected by October
2014. The ‘procurement audit’ of all the three departments will be carried out post completion of financial audit.
E: RISK (½ page)
Overall risk rating: Medium
Overview of programme risk
Key risk factors
Fiduciary risk
substantial
continues
to
be
Staff turnover - Risk of short tenure of
29
Mitigation plan
Risk rating
During the review period, FRA was re-assessed
and the risks of all the three departments rated
‘substantial’. Refer to table below on actions
planned against the FRA recommendations
High
The change in senior officials did lead to slow
High
e-Pact Consortium (May 2014): Assessing Value for Money in Health Portfolio across States in India – Bihar State Report
24
Key risk factors
senior officials in the implementing
departments continues
Mitigation plan
down of pace of some of the activities. The TA
team is working with government to institutionalise
system improvements, in human resource
management and procurement for example, to
reduce vulnerability to individual staff changes.


Political - Reforms in the health,
nutrition, and water and sanitation
sectors do not continue to be high on
political agenda.

Implementing capacity - Service
delivery may be affected by staff
shortages in government departments
TA will continue to work with government to create
and fill vacant positions, and implement human
resource management strategies to improve
recruitment and retention
 Department of Health has filled up some
vacancies and made appointments of doctors
and nurses although more staff is required.
Similarly, SWD has filled up the vacant posts of
lady supervisor to a large extent and the
recruitment process is continuing. The vacancy
level of PHED-junior engineer posts has also
declined significantly.
 Despite a shortage of staff, service deliveries
by the concerned departments have improved
significantly.

Staff obstruction to reform

Lack of data and exclusion of
disadvantaged
areas/groups
and
gender discrimination
The Chief Minister of the state himself visits
and takes stock of implementation of various
programmes at the grass root level.
The forthcoming Bihar State elections and the
Code of Conduct may slow down decisionmaking in 2015. The TA team will ensure that
decisions requiring government sign off will be
taken prior to the Code of Conduct being put
into place.
With respect to election outcomes, it is likely
that the successful party/coalition will continue
to prioritise these reforms.


Risk rating
Low
Medium
The
implementing
departments
have
undertaken several initiatives for transparency
in procurement, strengthening of financial
management, and for improving monitoring
and control systems.
So far there has not been any resistance from
the departmental staffs.
Low
BTAST is working in the poorest districts, and
prioritising the disadvantaged blocks.
BTAST will improve its ability to tracking the
progress in the underserved areas and groups
through the concurrent monitoring surveys.
Medium
Outstanding actions from risk assessment
The recommendations of the recently conducted FRA are summarised below:
Jointly for all the three departments:

Holding one-day Advocacy Workshop to educate officers of GoB departments, including officers of
Finance, Planning, Health, SWD, PHED, etc., on multiyear budgeting, preparation of realistic budgets to
avoid major deviations
(BTAST to organise the workshop – date to be decided in consultation with the concerned depts.)
For Health Department:

Conducting a three-day training of all accounts and audit personnel posted at district and state HQ
(BTAST to organise the workshop in September 2014)
For SWD Department:

Conducting training of DPOs/ CDPOs on financial matters
25

(Training is on-going)
Conducting training of field level Accounts personnel on various accounting issues
(ToR for contracting agency under preparation)
For PHED:

Introduction of computerized accounting system using Tally software in 42 divisional units
(Process initiated)
F: COMMERCIAL CONSIDERATIONS (½ page)
Delivery against planned timeframe
Overall programme momentum is growing. Many initiatives and activities have picked up pace this year, including
Gram Varta, the comprehensive approach to preventing, and quality improvement in health facilities. Some
initiatives that were delayed (due to slow government approvals) have only now been initiated, such as notification
of nodal anganwadi centres and IPMS. Therefore it is essential that the TA team keeps up the pace and ensures
that these activities are finished in time, before the end of the programme. There are certain evaluations where
endline data will be available later in 2016/17. These activities will be funded directly by DFID and not through the
SWASTH subcontract pool.
Performance of partnership(s)
DFID has very good partnership with the three departments implementing SWASTH: Health, Social Welfare and
Public Health and Engineering. DFID is part of each project steering committee meeting scheduled under the
chairmanship of the Development Commissioner. DFID is well respected and valued for its support.
DFID has contracted the technical assistance and management support to the Bihar Technical Assistance Support
Team (BTAST) consortium led by Care UK, with partners Options and IPE. The TA contract was initially let for a
period of 5 years up to 15 June 2014 including one year to design the project, with a provision for extension.
Recently the contract has been extended for a period of 21.5 months through a negotiated process, approved by
the Minister of State.
DFID also has good co-ordination with the other development partners present in Bihar, essential for building
sustainability and efficiency. Significant effort has been invested to co-ordinate and harmonise with Bill and Melinda
Gates Foundation’s operations in Bihar, which are also delegated to Care. This is leading to improved knowledge
sharing, use of data and learning from each other’s experience, avoiding duplication and agreeing division of
labour. DFID also ensures alignment of BTAST with the DFID’s other state projects, such as SPUR (urban reform
project, working in close collaboration with the Urban Development Department) and Governance and
Administration reforms project.
Asset monitoring and control The asset registers maintained online by office are updated on a six monthly
basis and an annual asset check is conducted of the assets maintained by BTAST. The asset register was last
updated in July 2014.
G: CONDITIONALITY (½ page)
Update on partnership principles
DFID India support to GoB is based on a shared commitment to the four principles for all development partnerships
(to support poverty reduction and the MDGs, human rights and international obligations, public financial
management, good governance and transparency, and domestic accountability). The principles are included in the
MOU signed with the GoI for all programmes. An updated assessment of Bihar’s alignment with the principles was
undertaken for this review (see Annex 1). The principles for poverty reduction and the MDGs are reflected in the
Manas Vikas Mission framework. DFID is working with government to improve PFM, governance and transparency
and domestic accountability, and this is operationalized through logframe output indicators. According to the
Project Memorandum, the state government is required to ensure that SWASTH funds are provided as additional to
(i) state share of national government schemes; (ii) expenditure required by the XII and XIII Finance Commission
and Supreme Court judgements; and (iii) the state plan contribution. These conditions are fully met. The Project
Memorandum also specifies that DFID funds will be itemized under budget heads following standard GoI and state
government rules and procedures. The state government has complied with this condition.
26
H: MONITORING & EVALUATION (½ page)
Evidence and evaluation
A detailed status of scientific evaluations and studies has been provided under Output 5. There are three specific
areas where new evidence has been published, and which further reinforce SWASTH programme strategies:
 Dangour et al (Cochrane Library, Aug 2013). A systematic review of water, sanitation and hygiene (WASH)
interventions found a small positive association with improved nutritional outcomes in children. However,
the authors noted a limited evidence base, and the short duration of randomised trials from which data is
available.
 Adair et al (Lancet 2013; 382: 525–34): Reviewed data for 8362 participants in prospective birth cohorts
from 5 countries (including India), and concluded that interventions in countries of low and middle income
to increase birth weight and linear growth during the first 2 years of life are likely to result in substantial
gains in height and schooling, and give some protection from adult chronic disease risk factors, with few
adverse trade-offs.
 Coffey et al (SQUAT Research Brief no 1, June 2014) report on a survey of sanitation preferences among
3,200 rural households (over 22,000 people), in five states including Bihar. Government latrines are
particularly unlikely to be used. Most people who own a government-constructed latrine defecate in the
open. In over 40% households with a toilet, at least one family member (usually male), prefers and
continues to defecate in the open.
With respect to Gram Varta, there is already significant data generated by Ekjut and others to justify adopting this
PLA approach in rural India30. DFID will further demonstrate that Gram Varta process is a cost effective strategy for
changing attitudes and behaviours, and improving health, nutrition and WASH outcomes. An independent impact
evaluation by 3ie has been planned for 2014-2016.
The exploratory study was completed in 2014 of Gram Varta (SWASTH’s community based approach for
‘participatory learning and action’ (PLA) through a cycle of 20 community meetings) in Maner block of Patna.
Findings demonstrate potential of PLA in bringing about behaviour changes and practices related to health,
nutrition, hygiene and sanitation. Results show:
 50% increase in breast feeding after one hour of birth (30% to 80%)
 38% increase in complimentary feeding after 6 months (43% to 81% )
 10% increase in consumption of IFA tables by women (12% to 22% )
 15% increase in households with toilets and its usage (24% to 39%)
 13% increase in household using boiled and filtered water for drinking (16% to 29%)
Case studies also show an increase in women’s self-efficacy and agency.
Monitoring Activities throughout Review Period (2013 -14):
 Progress reports and payment based deliverables of various consultancy contracts are reviewed monthly by
the DFID technical team.
 Mid-Year Review was held in March 2014
 DFID contracted a third party monitoring agency to validate project deliverables on sample basis.
 DFID UK National Audit Office (NAO) reviewed the programmatic, financial and management systems and a
field visit to Bihar and were satisfied with the internal control systems 31. The project had a Contract
Performance Review in April 2014.
Annual Review Process
The joint Annual Review was undertaken during 28 July to 1 August 2014. The review included field visits and state
level presentations and discussions. The field visits were conducted in 2 districts Jehanabad and Gaya. The
participants included DFID team, officials from DHFW, DSW, PHED and representatives from the Government of
India. Technical agencies such as UNICEF, UNFPA, BMGF, JHPIEGO, IntraHealth International also participated
in the review. The Annual Review Report is informed by independent sources of survey data like SRS, AHS, HMIS,
Prost et al (2013):A systematic review and meta-analysis of women’s groups practising participatory learning and
action (PLA) to improve maternal and newborn health in low resource settings, Lancet; 381: 1736–46). This analysis of seven
trials demonstrated that exposure to women’s groups was linked to a 37% reduction in maternal mortality and a 23% reduction
in neonatal mortality. The authors propose PLA as a scalable and cost-effective strategy for improving maternal and newborn
health given adequate population coverage and group attendance by pregnant women.
30
31
DFID India Country Office Report, National Audit Office January 2014
27
and HRIS. Detailed progress documentation on BTAST outputs, presentations by the Government of Bihar, and
findings of various surveys and reports were reviewed to support the conclusions.
Recommendations
•
Finalize SWASTH Monitoring Learning and Evaluation (MLE) strategy and an action plan (DFID TA by end
•
•
•
of August 2014)
A fully functional MLE Unit (DFID TA by August/September 2014)
A fully developed and functional SWASTH Management Information System (MIS) (DFID TA by
September/October 2014)
SWASTH concurrent monitoring (DFID TA)
- Round 1 phase 2 to be completed by October 2014.
- Round 2 all phases including the TOR, tendering and data collection to be completed/finalized by Nov
2014
See Annex 2 for examples of beneficiary feedback.
28