Posted by: davidjolson | 04/27/2011

Improving infant survival by engaging private sector in India’s most impoverished state

This guest blog was written by Priya Anant, who leads the India hub of the Center for Health Market Innovations at ACCESS Health International. ACCESS works in Bihar under a grant from the Norwegian government.

BIHAR, India — If you told me five years back I would be working in Bihar on a sophisticated government contracting program to improve child survival, I would have been incredulous. For many years simply driving through the state was unsafe. The restoration of law and order has been a huge change in Bihar over the last few years, and has emboldened many development agencies to come to launch new initiatives, including the one that took me here recently for a two-week visit.

Auxiliary nurse midwives sit attentively at a block meeting in Bihar.

Traveling in Jehanabad and Nalanda districts, I understood songwriter Gulshan Bawra’s inspiration when he wrote the beautiful lyrics Mere desh ki dharti sonaa ugale, ugale hire moti….mere desh ki dharti (the earth of my country produces gold, silver and diamonds). Endless fields of golden grain sway gently in the summer breeze contrasting with the state’s still significant problems. Bihar grapples with widespread landlessness — government estimates 10% overall, but sample surveys have shown pockets that have over 50% landless, and a huge burden of maternal and infant deaths. Abundantly endowed with natural resources, Bihar has one of the poorest health indicators in the country.

Many may be surprised to learn that a large percentage of poor in Bihar seek care from the private sector. 70% of the doctors are in the private sector and the remaining 30% have a right to be there too, beyond office hours, if they choose to. Unfortunately the private sector is largely unregulated and subject to market forces. With little government oversight, the rate, nature and quality of services is often determined by whether the services are available from other sources and how they are priced and provided.

Yet, as I learned, there is obvious commitment to change the status quo: The newly invigorated state government has an ambitious agenda to redeem the state. “Primary education and health have to be provided by the government,” a senior administrator told me.

There is also frantic building activity across the state. The State Health Society, Bihar (SHSB) is one of the swankiest state offices that I have been to. In our interviews about child health programs, senior heads of departments shared their concern about the shortcoming of existing staff — quality, productivity, and insufficient numbers.

Indeed, of the 80,000 odd Accredited Social Health Activist (ASHA) workers across the state, 40% are yet to be trained on the first four of seven modules. Government is responding by stepping up the pace by expanding the trainer institutions. Last year, the state actually could not absorb its funds, and returned Rs. 696 out of the 1,274 Crores (USD 1.39-2.55 billion) unspent to India’s central health ministry, along with an interest of Rs.17 Crores (USD 3.4 million). I am skeptical that more money would translate into improved health care availability and attendant improvement in indicators.

I was in Bihar on a project for the state government to engage private sector providers with the goal of improving infant survival, the third phase of ACCESS Health International’s engagement with our partner, the Norway India Partnership Initiative (NIPI). State- and district-level research on the state of the existing private sector highlighted the need and opportunity to engage the private sector.

The third phase of our engagement with NIPI is to help the government strengthen the infant care services through the public system as well as create pilots engaging private sector for infant care provision. Our scope of work is to help structure, design the purchase and work with the government to implement and fine tune the design so it can be scaled across the state. We work in Bihar and Orissa as part of this two-year project (the experience will be documented on the Center for Health Market Innovations, like other government contracting initiatives in India).

Aside from NIPI, many development partners are working to shore up the state’s health:

  • UK’s Department for International Development provides technical assistance to the state for public-private partnerships and health sector reform.
  • UNFPA focuses on improving access to good quality family planning services.
  • The latest entrant, the Bill & Melinda Gates Foundation, has provided two large implementation-focused grants, a consortium led by CARE and a grant for World Health Partners to expand from neighboring Uttar Pradesh to Bihar.

What is common among most partners is the agenda of working with the government to strengthen health systems. A stewardship role to be played by the government would help these agencies to align missions, work together and with each other in a meaningful manner. The informal channels of communication currently used would then be formalised.

Bihar currently has an infant mortality rate of 52/1,000 live births, against the national average of 50, and aims to reach below 30 by 2012. 53,000 infants were lost last year according to the state’s data. We are now out on a fact finding mission in Bihar to collect facts, figures and human stories to corroborate the need to make infant care services available to the poorest, no matter where it comes from, public or private. The goal is to help influence decisions to do what is most required to ensure that infants are not lost due to notional boundaries and fixed ideologies around provision roles.


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