Bihar Technical Support Program

Bihar Technical Support Program

Publication info


Project Name: Bihar Technical Support Program (BTSP)

Funder: Bill & Melinda Gates Foundation

Partner: Government of Bihar

Program start date: 2011 (ongoing)

Location: India

Objective: To support the Health and Social Welfare Departments of the Government of Bihar, India, to reduce rates of maternal, newborn, and child mortality and malnutrition, and to improve immunization rates and reproductive health services (including family planning).



Bihar is the third largest state in India, with a population of over 110 million. Despite recent gains, Bihar has some of the country's highest rates of maternal, neonatal, and infant mortality, as well as a high prevalence of malnutrition, stunted growth, and high fertility rates. Extreme poverty, gender and social inequality, low literacy rates, and early marriage further compound BIhar's poor health outcomes.

Despite progress and commitments from the Government of Bihar and active leadership of key stakeholders to improve health infrastructure and outcomes, deep-rooted problems limit the government's ability to affect lasting change. Persistent barriers include poor quality services, lack of availability and skills of frontline health workers (FLWs) and facility staff, limited accessibility of services by neglected and marginalized populations, lack of accurate data, and inadequate public health infrastructure.


What is CARE doing?

To address the health challenges in Bihar, CARE India launched the Bihar Technical Support Program (BTSP) in 2011 with funding from the Bill & Melinda Gates Foundation. CARE is supporting the Government of Bihar to strengthen and improve reproductive, maternal, newborn, child, adolescent, and nutrition outcomes, including across the continuum of care for family health services and beyond.

CARE's work in Bihar began in eight high-risk districts, focusing on the facility level, particularly quality of care, and the community level, through frontline health workers and outreach. As a result of successful implementation of key interventions at these levels and much learning, CARE began providing state-wide technical support to the government in 2013 to scale up outreach and facility-centered interventions to all 38 districts in the state. Through this partnership, CARE has contributed to significant improvements in the health system. For example, in 2005, public health facilities had a client load of 39 people per facility per month. In 2018, that figure is about 10,000 people per facility per month. Today, CARE and the government continue to invest in sustaining improvements made through scale-up as well as addressing systematic issues by transforming institutions, organizational structure, regulations, and governance.


Key innovations and interventions

Within the package of evidence-based interventions, CARE also developed and piloted innovative solutions that address the various issues which impede access to high quality services in Bihar. The innovations were developed for the Bihar context, but many have already been scaled nationally. These innovations have engaged over 40,000 FLWs in approximately 2,300 health sub-centers (each health sub-center generally covers a population of 5,000).

Mobile health for continuum of care services:
Mobile phones and related technologies aid FLWs to register pregnant women, mothers, and newborns and track their services through the stages of pregnancy, delivery, and postnatal care. Real-time data provide FLWs with decision-making tools, such as counseling protocols, to provide timely and quality health services.

Tracking and management of very low birth weight babies:
A digital scale improves the accuracy of identifying very low birth weight babies. FLWs provide immediate and systematic post-natal care and follow-up with families, to improve neonatal health outcomes.

Incremental learning approach:
Different cadres of FLWs across government programs work together as teams to improve planning and delivery of services and enhance FLW skills and coordination.

Team-based goals and incentives:
Teamwork and motivation of FLWs is strengthened through the setting of collective targets and recognition of successful teams on a quarterly basis with a small non-financial reward.

Quality improvement at health facilities:
A self-driven quality improvement process empowers all facility staff, from the doctor to the sweepers, to identify gaps in infrastructure and capacity, assess readiness to provide care, and develop action plans that improve facility conditions, build a sense of pride and ownership among staff, and creates a welcome and respectful atmosphere for clients.

Mobile nurse mentoring program:
Following assessment of labor room nurse skills through direct observation of deliveries, mobile nurse mentoring teams tailor on-the-job training using skills labs, simulations, and ongoing mentoring.


Notable accomplishments

Since 2011, CARE and the Government of Bihar have made great strides in testing and implementing innovations to improve health outcomes and strengthen the health system. Some key successes from this partnership include:

- More than 16,700 babies saved as a result of collective actions, including the tracking and management of very low birth weight babies.

- One year after introducing mobile technology to aid FLWs in registering and tracking patients, managing care, and counseling pregnant women and mothers with newborns, 88 percent of mothers were visited at least twice at home by a FLW during their last trimester of pregnancy, compared to only 37 percent at baseline. Contraceptive use also increased by 10 percent. This innovation is being scaled to eight other states in India, beginning with the training of 100,000 FLWs.

- Implementation of the nurse mentoring program at 17 under-performing emergency obstetric and newborn care facilities resulted in more comprehensive identification of high-risk pregnancies, better management of complications, and decline in unsafe labor room practices. The program is being scaled statewide in Bihar.

BTSP has also contributed to state-level impact in the areas of maternal and infant mortality. Bihar's maternal mortality ratio is now 165 per 100,000 live births (2018) compared to 312 per 100,000 live births in 2005. The infant mortality rate has also significantly decreased from 61 per 1,000 live births in 2005 to 38 per 1,000 live births in 2018. Success has also been achieved in institutional delivery increasing to 76% and immunization coverage reaching 81%.


What's next?

The program aims to continue improving health outcomes in Bihar and is focused on providing managerial and leadership support to the Government of Bihar to implement these activities and the innovations described. It will also draw a sharper focus on interventions to strengthen health systems, services at facilities, and community-based interventions. CARE is additionally focused on elevating and diffusing the learnings from BTSP through Learning Exchange for Adaptation and Diffusion (LEAD). LEAD is supporting sharing, adaptation, and scale-up of key innovations and creating a platform to connect people with ideas. Driven from CARE's work in Bihar, the LEAD approach will initially bring together interested CARE offices in South Asia to participate in a regional network and share knowledge on key innovations in program design and scale.

For more information and videos from CARE's work in Bihar, visit



Project brief

Innovation briefs:

  1. Building Skills, Saving Lives: The Incremental Learning Approach
  2. Working Better Together: Team-Based Goals and Incentives
  3. Making Magic in Health Facilities: Facility Quality Improvement
  4. A Model for Mentorship: Mobile Nurse Mentoring
  5. The Littlest Lives: Weak Newborn Tracking