Sector Wide Approach to Strengthening Health ( SWASTH )

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


"To undertake development interventions in state like Bihar, it’s best to partner with the government"

Prakash Kumar, Team Leader, Bihar Technical Assistance Support Team (BTAST), a health sector reform programme in Bihar supported by DFID-UK, says that the Sector Wide Approach to Strengthening Health (SWASTH) programme has come a long way since it was conceptualised in 2008 and all major indicators of health, social welfare & public health department have improved in the state. Excerpts from the interview:

OneWorld: The SWASTH programme is embedded in the government system. How has been the experience of working closely with the government?

Mr Kumar: SWASTH was conceptualised in 2008 to support Bihar government to have a coordinated approach on improving the state of health, nutrition, water and sanitation in the state. The actual implementation of the programme started in 2010.

It was a first of its kind experiment where everything -- the annual plan, log frame indicators, the targets, and the results -- had to be worked together with the state counterparts.

It was not easy in the beginning and also the government counterparts had no prior experience of working with development partners in such a project. Initially, the government counterparts wanted to know about the value addition to the ongoing programmes.

So, after initial hiccups, the government started strengthening the main objective of the programme instead of creating something new or work in a parallel way. This made things easier.

OneWorld: How has the SWASTH programme helped enhance health, nutrition, or WASH in Bihar?

Mr Kumar: Yes, there have been many substantial changes from 2010 to 2016. The major indicators of health, social welfare & public health department have improved.
One example is that of having more Additional Primary Health Centres (APHCs) at the block level so that the burden on PHCs could be reduced. Today, about 430 APHCs are residing in the state, with one PHC at the block level and catering to a population of 1,50,000-2,00,000. Now, the State Health Society has got APHCs operational. We have supported these health facilities from the beginning by doing the gap analysis.

OneWorld: How did you address the challenge of human resource management for such large infrastructure?

Mr Kumar: Earlier, the state did not have its own database for human resources working in the health sector. This programme has successfully created a complete Human Resource Information System (HRIS) for the state.  The database prepared by the BTAST has been fully handed over to the state and the state is now regularly updating the database. Now, the decision makers have the numbers of staff working here along with their domains. It has made decision making easier.

We also helped the state in addressing the shortage of nursing faculty with the help of virtual classrooms.

Another big contribution to the state has been continuous capacity building in the last six years. The capacity building is not only on the clinical and diagnostic side but also on the system strengthening like accounting and auditing.

We also supported creation of skills labs where in-house training is provided to the nursing staff. Two such nursing labs are operational. One is in Muzaffarpur medical college and the other is in Bhagalpur medical college.

After the success of these two skills labs, the state decided to have two more skills labs. One at Bhagalpur and other at Gaya, and now four skills labs are fully operational in the state.

OneWorld: How did you address the infrastructural gaps?

Mr Kumar: We are supporting six medical colleges because there are a lot of infrastructural gaps in them. We are supporting medical colleges with financial assistance of Rs 170 crore to fill those gaps, so that they can get recognition from Medical Council of India.

When we started supporting the Government of Bihar in 2010, the total number of seats available for MBBS was 275, but with our regular support and advocacy the number has increased to 550, raising demand for better infrastructure.

BTAST and DFID supported the state government in its plan to set up two medical colleges.  One of them, Nalanda Medical College is now fully operational with financial assistance of Rs 150 crore.

On the social welfare front, some of the notable interventions are the conditional cash transfers. This is being implemented in Gaya with support of the Government of Bihar wherein the pregnant women and children are the beneficiary of the programme.

OneWorld: What have been the achievements on the nutrition front?
Mr Kumar:
We are supporting the Bihar Government on nutrition initiatives because the state has a large number of children who are severely malnourished.  We are also supporting the Community-Based Management of Acute Malnutrition (CMAM) initiative in Purnea district. We have already identified 5,500 children and their treatment will start from next month.

This is the largest treatment of the malnourished in the world, and after the success of this pilot, the state government will scale up with its own resources.

Besides, we are engaged in capacity building of the social welfare staff. We have planned regular orientation and refresher courses for all the frontline functionaries including Anganwadi Sevikas, Child Development Project Officers (CDPOs), Lady Supervisors, District Programme Officers (DPOs), and also the state government staff.

OneWorld: What kind of work has been done in the area of water and sanitation?

Mr Kumar: We have successfully advocated to the state government the benefits of adopting community participation as one of the major strategies before going in for toilet constructions. This has also helped in community sensitization and also in sensitization of various stakeholders on similar lines to support the state government for piloting such initiatives in Bihar.

Another major support that we have provided to the Public Health Engineering Department has been for the ranking of water testing and also geo-tagging of the sources. Now, the state has got data of all the sources with water quality to prepare the mitigation plan for safe water supply to the community.

One of the very important objectives of this programme was also to create an enabling environment so that other bilateral agencies or funding agencies come and support the Government of Bihar on this development agenda.

This was also one of the major objectives of the programme because the government counterparts did not have any prior experience of having any interaction with funding agencies. This programme also created a sensitization and capacity building environment.

OneWorld: What have been the lessons?

Mr Kumar: SWASTH is a very good programme. This is the way forward, if other bilateral or donor agencies want to come to Bihar. They have to plan development interventions in complete partnership with the Government of Bihar. Working in parallel is not going to help and be sustainable. So, that’s the learning from this programme. Working with the system or government takes some time in the beginning, but once it is embedded in the system it’s going to sustain itself and cover a larger number of groups in the future.
The other key learning is that the economics of scale-up are very important. Having a small pilot without going through the economics of the scale up is not going to help a state like Bihar because it has a huge population. So, when other agencies or bilateral agencies coming to work in Bihar, they have to be very careful about economics while doing any pilot. We did exactly that.

The third learning has been for the state government, which has understood the advantage of working with all the stakeholders. Now Bihar is the first state where Bihar Vikas Mission (BVM) has been established. BVM will be the nodal agency for all development work in the state. I can see that in the next 2-3 years BVM will be playing a larger role in supporting all departments to take up the development agenda to achieve the targets. I can also see very clearly that SWASTH has a role for these three departments.

So, we are very happy that we are exiting this programme when there is a body like BVM to be the nodal agency for all development work in the state. So, this is the way forward and the last thing which I want to mention is that any bilateral agencies if they want to come and work in Bihar, then they should first start consultation with BVM, which will give them a very good beginning and understanding of the work and sustainability to their programmes, too.