In the last few years, Bihar has shown improvement on some important family health indicators, driven by cumulative eorts of the national and the state government to strengthen the state public health system’s quality. The latest data released by the fourth National Family Health Survey (NFHS-4), 2015–2016, shows that the share of women availing institutional births and receiving pre- and postnatal care has gone up substantially in the state. The fertility rate in Bihar has also come down from 4 children per woman in NHFS-3 to 3.4 in NHFS-4. However, Bihar still finds itself encumbered by daunting public health challenges on multiple fronts. The state continues to struggle on the nutritional status of children, with a huge share of underweight and stunted children. Further, over two-thirds of the children are anaemic.

Commitment to Improved Quality

• The State Health Society, Bihar (SHSB) has been leading on second generation reform initiatives in the state in alignment with the Government of India (GoI) priorities and policies. In the past, focus was mostly on tertiary services.
• However, in recent years, there has been a shift towards improving quality of care in relation to maternal and newborn child health and primary health. This commitment towards provision of quality health services to women and children is in line with the Government of India’s reproductive, maternal, newborn, child, and adolescent health (RMNCH+A) strategy.
• Improved service quality is a crucial focus area for GoB. The state has been working with Sector Wide Approach to Strengthening Health (SWASTH) -a programme supported by the Department of International Development (DFID-UK) – to build quality at various health institutions by identifying and addressing gaps.
• The state government intends to institutionalise continuous quality improvements through a quality certication mechanism.
• This was previously done through the Family Friendly Hospital Initiative (FFHI) till 2014, and subsequently under the National Quality Assurance Standards (NQAS).
• In fact, Bihar is a pioneer in quality assurance, becoming the rst state in the country to start the quality assurance process through the FFHI standards initiative in 2011-12. NQAS was launched in 2013 at the national level, and GoB started implementing the NQAS initiative in November 2014.

QUALITY ASSURANCE AND THE ROLE OF BTAST

• The advent of the second generation reforms has seen signicant investment in public sector health systems and infrastructure, especially in relation to quality improvement. In 2011-12, the SHSB adopted FFHI, which is a check list- based quality assurance certication programme.
• FFHI, which was developed to suit conditions in the state, provided the framework to carry out improvements in health facilities, mainly primary health centres and district and referral hospitals.
• To guide implementation of FFHI, the GoB asked its development partners to provide technical support to hospital administrators and service providers.
• The Bihar Technical Assistance and Support Team (BTAST), a consortium formed by Care UK, Care India, Options Consultancy Services and IPE Global, and supported by the Department for International Development (DFID-UK) has been providing technical assistance to selected health facilities identied by the state government to improve the quality of services.
• BTAST was allocated a bulk of the districts – 25 out of 38 districts.

However, in March 2014, GoI rolled out protocols and guidelines for NQAS with the intention of standardising quality assurance in the public sector health system in the country. As part of the quality assurance process, quality assurance committees or quality teams have been instituted at state level, district level, and at each facility level. The process entails a two-pronged approach:

1. strengthening of systems and processes and
2. ensuring IPHS standards.

This approach is integrated into the public health system’s natural functioning, in conformity with the quality assurance cells at state, district, and regional level. State government
departments were encouraged to include NQAS related quality assurance activities in annual Programme Implementation Plans (PIPs). The Government of Bihar has been an early adopter of NQAS, having stepped up its quality assurance objectives from FFHI to NQAS certication for which SHSB developed a quality assurance road map with support from BTAST.

Bihar initiated some innovations in the NQAS implementation process to meet local needs, while keeping the overall process in line with central government guidelines. For example, while the central guidelines do not have any provision for regional quality assurance committees, the state BTAST Intervention Districts Non-Intervention Districts health department has constituted regional quality assurance committees in nine regions following approval from the central government. The main rationale behind the constitution of regional committees is the ease of monitoring through regional channels. This provision, it is hoped, would enable the process to be better managed and the regional stakeholders to be more responsible. BTAST has been helping SHSB at the eld
level as well as at the strategic level.

It has been helping with building quality assurance teams at dierent levels, handholding quality assurance committee members at the facility level in understanding their roles and responsibilities in the quality assurance process, as ell as creating a roadmap for NQAS and FFHI compliance. The Quality Assurance Roadmap, for 2014-16, has three focus areas: strengthening quality assurance mechanisms and structures across levels; upgrading facilities to full quality related criteria as per the NQAS framework and certication;
and training and capacity building of service providers. Whereas most states are strengthening facilities on their own, Bihar has employed Quality Consultants through BTAST at the facility and district level. BTAST’s technical experts supported SHSB at the state level. Some of the specic components of work have included:

• Developing concept notes, road maps and work plans; drafting ToR, protocols and guidelines for quality improvement; carrying out assessments and studies on quality related issues; providing trainers for thematic workshops; supporting recruitment for quality assurance units; and, creating a pool of experts on quality assurance.
• Addressing gaps in service provision that had been identied through assessments and verications by supporting facility managers and district level managers to strengthen the infrastructure in labour rooms at various facilities (designated as ‘Delivery points’)
• Helping selected facilities to improve the quality of care as per NQAS standards.
• Assisting service providers in the use of supportive supervision checklists and client survey checklists; and mentored district offcials in monitoring and supportive supervision processes.
• Strengthening DQACs and RQACs to ensure regular meetings and members full their responsibilities
• Supporting district authorities in the preparation of District Health Action Plans and allocation of resources Supporting facility managers to systematically collect and analyse Key Performance Indicators (KPI) related data and develop quarterly KPI dashboards
• Providing technical assistance to three government medical college hospitals on implementation of NQAS in their MCH units

Apart from the crucial issue of sustainability, other barriers to quality of care became apparent. Manpower shortage, especially of nursing staff and specialists; lack of training; persistent infrastructural issues; and shortage of emergency medicines and instruments and labour room essentials are the key gaps in some of the facilities. Along with addressing these longstanding issues, any sustainable solution for ensuring continued delivery of quality care must also address the critical need for regular monitoring and corrective action and securing the buy-in and motivation of healthcare staff.