Sector Wide Approach to Strengthening Health ( SWASTH )

Bihar Technical Assistance Support Team (BTAST)
Government of Bihar initiative supported by Department for International Development, UK


Quality improvement efforts in public health facilities of Bihar

This case study has been developed to showcase the outcomes of technical assistance provided to various health facilities identified by the state government to make quality improvements, and help them reach Family Friendly Hospital Initiative (FFHI) and National Quality Assurance Standards certification levels. The case study draws from internal documents and conversations with internal stakeholders. Information from the ground was gathered through a field trip to four health facilities including Pandaul and Rahika in Madhubani district, and Dumraon and Shahpur in Bhojpur district. This included some in-depth personal interviews and group discussions with external stakeholders. These facilities were selected as examples of facilities to get a mix of both ‘high’ performing and ‘low’ performing facilities. The health facilities of different standards and certifications were selected in order to draw a comparison and see how certification mechanisms contribute to improving the health systems.

Responding to the need for bolstering the state’s public health apparatus, the Government of Bihar (GoB) has made a commitment to improving the quality of services being provided at its healthfacilities. So, Bihar is implementing Quality Management System (QMS), which encourages health facilities to assess user requirements for services, define the processes that can help in achieving the desired level of services, and keep the processes under check for consistency. The state government intends to institutionalise quality improvement in the system by ensuring quality certification under the Family Friendly Hospital Initiative (FFHI), and subsequently under the National Quality Assurance Standards (NQAS).
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) has been providing technical assistance to selected health facilities identified by the state government to improve the quality of services. The study compares the functioning of health facilities that are deemed to be providing services in compliance of NQAS and FFHI standards, as compared to facilities that are yet to improve, to determine any differences in care, patient satisfaction, and service uptake. Field observations and information gathering shows that the efforts were seen in the improved quality of care, patient satisfaction, and service uptake at primary health centre (PHC),Pandaul and sub-divisional hospital (SDH), Dumraon. These two facilities were seen to be providing better services. By comparison, high quality of services are still wanting in PHC, Rahika and referral hospital (RH), Shahpur, which are still making efforts to reach such standards.

This documentation also highlights the inputs BTAST provided in creating an enabling environment for quality improvement and supporting health facilities in adhering to the checklists required for NQAS and FFHI certification. BTAST lent its support through regular monitoring visits, handholding, and regular advocacy with officials. On the ground, the BTAST Quality Assurance Consultants helped PHC, Pandaul identify gaps and provided suggestions based on which appropriate corrective actions could be taken. Rogi Kalyan Samiti (RKS) too was seen to be playing a crucial role in strengthening the facilities by generating resources at the local level.

Sustaining the acquired quality standards is a key concern. Information from the Sub Divisional Hospital at Dumraon, which had earlier reached FFHI gold standard level, shows how poor quality can seep into a hospital system after a period of time and adversely affect service delivery and footfall of visitors 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 some of the key gaps that can derail the quality improvement process. Anysustainable solution for ensuring continued delivery of quality care will need to not only address these long-standing issues, but also adequately respond to the critical need for regular monitoring and corrective action and securing the buy-in and motivation of healthcare staff.

This case study was written by Ashok Kumar at OneWorld Foundation India and reviewed by BTAST.