Innovation, Partnership, and Self-Reliance: Health Policy Lessons from India’s Bihar State

We’re excited that our team from Bihar (Cohort 1) will be at the CSIS Global Health Policy Center for a half-day conference examining the lessons learned from the Bihar Technical Support Program and its implications for U.S. foreign policy and assistance programs.

Wednesday, December 19, 2018 9:00 am – 1:30 pm
CSIS Headquarters

Click here to register for the online webcast 

Bihar State is the third largest in India with a population of 110 million, which would make it the 12th largest in the world if it was its own country.  Bihar has some of the highest rates of maternal, neonatal, and infant mortality in India, as well as malnutrition, stunting, and high fertility.  These issues are exacerbated by extreme poverty, early marriage, gender and social inequality, and low literacy rates.  The Bihar Technical Support Program, funded by the Bill & Melinda Gates Foundation and implemented by CARE, was founded to address these challenges with the goal of boosting capacity and self-reliance.  The program covers all 534 blocks in 38 districts of Bihar and involves at least 400 public sector hospitals and 200,000 frontline workers.

The Bihar Technical Support Program offers many lessons learned about innovative program design to meet a variety of critical health challenges in a large population, as well as for purposefully building capacity with the intent to transition support at a designated end date.  With self-reliance and country ownership on the Washington foreign policy community’s minds with USAID Administrator Mark Green’s strategic transitions agenda and proposals for significant reductions in U.S. foreign assistance spending, the Bihar program offers important lessons for broader health and development programs.

The conference runs from 9am – 1:30pm.  Conference Agenda:

Welcome Remarks
Sara M. Allinder
Executive Director and Senior Fellow
CSIS Global Health Policy Center

Introductory Remarks
Sushil Kumar Modi
Deputy Chief Minister, Government of Bihar

Panel I: Overview of the Bihar Technical Support Program and Achievements from the Partnership

Panelists:
Usha Kiran
India Country Lead, State Health and Community Systems
Bill & Melinda Gates Foundation

Mangal Pandey
Health Minister, Government of Bihar

Hemant Shah
Chief of Party
Bihar Technical Support Program

Moderator:
Heather Higginbottom
Chief Operating Officer
CARE

Panel II: The Role of Data and Innovation

Panelists:
Sanjay Kumar
Principal Health Secretary, Government of Bihar

Kenney Ng
Manager, Health Analytics Research Group
IBM

Macon Phillips
Chief Digital Officer
CARE

Moderator:
Sara M. Allinder
Executive Director and Senior Fellow
CSIS Global Health Policy Center

Panel III: Policy Implications of BTSP

Panelists:
Gary Darmstadt
Associate Dean for Maternal and Child Health
Stanford University School of Medicine

Kerry Pelzman
Deputy Assistant Administrator, Bureau for Global Health
USAID

Moderator:
J. Stephen Morrison
Senior Vice President and Director
CSIS Global Health Policy Center

This event is made possible through generous support from CARE.

Scaling checklists – do you have the right one?

Scaling checklists are a trendy tool…luckily, they’re also pretty useful! A number of organizations and programs have them, how do you find or develop right one for you? (Want to check out SxD’s? Click here)

In their blog series on scaling social impact, Apolitical calls out a few key elements you should always include:

  1. “Strive to understand the essential core of a program: not whether something works, but why it works, what conditions it requires, what can be trimmed and what cannot be compromised
  2. Imagine what it would look like at scale: to reach many more people, how big and complex would the organisation need to become; who would staff it, and who would pay for it
  3. Consider the minimum threshold of quality a program needs, and what level of control is necessary to ensure it”

Check out the full post here:

Scaling social impact – a checklist, and a warning

Why keep it simple in a complex world?

In order scale, your solution must be simple. But the world we live in is not simple, it’s complex. Development sector practitioners strive to design holistic interventions and models that address the real-world needs of program participants. How do we address this tension?

In their series on scaling social impact, Apolitical captured this fantastic analogy from Karen Levy, Director of Global Innovation at Evidence Action:

” There is a tendency in the development industry to try and approach problems from a holistic perspective. But when you talk that way, it becomes very hard to find an entry point. Yes, everything is connected; yes, everything is complicated — but if you let that be the framework through which you start, you won’t get anywhere.

That’s why the world is scattered with pilot projects. Lovely pilot projects that are trying to deal with holistic issues, but are never going to get beyond 50 schools or 50 villages. If you look at the things that have achieved massive scale, they are well-defined interventions — or at least started that way.

I always tell people: don’t try and paint the masterpiece — do one layer, and do it well, then do another on top of that. Just creating or strengthening a platform to deliver something simply but well gives you the opportunity to build other stuff on top of it.

Check out the rest of the interview here:

“The world is scattered with pilot projects trying to work holistically”

Key to scaling – Is your core obvious?

We’re big fans of Apolitical’s blog series on scaling social impact!  One of the hidden but crucial concepts the series surfaces is understanding what is core, or “fixed” and a non-negotiable element of your innovation:

“For one, it’s not always clear whether or how something is working. Impact evaluation is growing, but billions of dollars of policy expenditure remain inadequately unevaluated. And, even when impact is proven, it’s not always clear what exactly is responsible. Scaling up often requires paring down a program to its essentials — and for this you need to know what can and cannot be compromised.”

In Scale X Design, we emphasize learning and documenting “fixed” vs. “flexible” elements of your model. That’s the easy part. The tough part is testing, learning and iterating and managing this knowledge across loosely connected practitioners.

Read more here:

How to scale up social impact — the challenge of the 21st century

Innovation + Systems Strengthening in Bihar

Our Team-Based Goals and Incentives team from our Cohort 1 alums are part of a broader team dedicated to scaling innovation with the government of Bihar, India. In his annual letter, the Gates Foundation Director of the India Country Office highlight’s CARE’s work in Bihar, addressing the real-world challenges of making innovation effective in the midst of fragile and broken systems.  Way to go team!

The public health system in Bihar consists of hundreds of thousands of health workers, from doctors and auxiliary nurse midwives in primary health facilities to ASHA and Anganwadi workers who provide basic advice and care to women in communities. We began by helping the government test new techniques and technologies to improve the quality of these providers’ services in eight pilot districts. For example, to help frontline workers advise women about healthy practices like breastfeeding, we developed next-generation teaching aids based on digital technology. In facilities, we established a nurse-mentoring program that has, among other successes, doubled the number of nurses who wash their hands and wear gloves before and during procedures.

Though these interventions have led to successful outcomes, a careful review of the data revealed that by themselves they were unlikely to have enough impact on maternal, newborn, and child survival, which was the ultimate goal of the work. Therefore, the Government of Bihar, our foundation, and our grantee CARE India agreed to expand these investments in innovative methods and tools that solve specific problems to more districts and to augment them with investments in basic best practices that strengthen the underlying health system in general.

The partners are now working to bolster everything about Bihar’s health system, from budgeting and procurement to management practices and data collection. This two-pronged approach that layers technical solutions on top of a stronger health delivery platform promises to help Bihar meet its goals while generating lessons that will benefit other partners, especially other state governments interested in investing in the health and the human capital potential of their people.”

Read the full letter here

What’s in it for your scalers?

It’s great to see cohort 2 alumni,  #A-CARD, has just published a blog in FinDev gateway: https://findevgateway.org/blog/2018/dec/agriculture

In their lessons learned, the team cites how we had to learn the hard way about incentivizing our scalers – loan officers!

“The introduction of the A-Card has not been without its challenges. We have found that microfinance institutes (MFIs) sometimes experience a conflict of interest between offering A-Card and microfinance loans. Since MFIs earn only a 1 percent profit on A-Card and a 25 percent profit on standard loans, they have more incentive to push standard products on customers instead of offering the A-Card. To avoid this, the team is experimenting with individual local market actors like input retailers or Local Service Providers as a banking agent for this pilot.

Another lesson learned from the A-Card is that local bank staff didn’t have incentives to sell this product because it was not tied to their performance goals. We are currently working with banks to develop new incentive structures to overcome this.”

The motivations and “what’s in it for me?” perspective of our scalers – the people that we rely on to implement, promote and expand our innovation solution – are often the most overlooked!  A-CARD’s incredible impact on farmers won’t matter if loan officers don’t promote the solution.

Photo credit: Akram Ali, CARE Bangladesh