Special Evaluation/Report

The Team-Based Goals and Performance-Based Incentives (TBGI) intervention, which CARE conceptualized, developed, and implemented as part of the Ananya program in Bihar, leverages the power of incentives and lessons from motivational theory on teamwork and goal-setting to help improve maternal and child health. Under the intervention, CARE set targets for the percentage of eligible beneficiaries in a subcenter catchment area who should have adopted each of seven key health behaviors or goals (Box 1). All frontline health workers (FLWs) in a given subcenter, including the accredited social health activists (ASHAs), Anganwadi workers (AWWs), and the subcenters’ auxiliary nurse midwives (ANMs), received nonmonetary incentives (consisting of small household items) if their subcenters met five of seven goals in a given quarter. The intervention explicitly sought to encourage teamwork and cooperation among FLWs by providing these incentives for achievements by the subcenter as a whole rather than by individual FLWs, and by providing FLWs with information on the concept and importance of teamwork. It included additional elements to motivate the FLWs in each subcenter, such as a service pledge they recited together and a certificate of recognition for subcenters that met their targets in all quarters. Overall, the intervention was expected to lead to improvements in the incentivized outcomes and to broader changes in related, but nonincentivized, outcomes through increased FLW motivation and teamwork. [82 pages]
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Recent trends in the Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR), nutritional status, immunization and family planning, as highlighted in Figure 1, 2, 3 and 4, indicate that there are substantial gaps in achieving related MDG goals 4 and 5.

Despite recent gains and commitments from the Government of Bihar (GoB) 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 and availability of frontline and primary health center level services and staff, limited access to services by neglected and marginalized populations, lack of accurate data, lack of effective program management, weak training systems, absence of supervision in health facilities, poor functional integration of interventions, inadequate public health infrastructures, and an underdeveloped and unregulated private sector.

With support from the Bill and Melinda Gates Foundation, the Integrated Family Health Initiative (IFHI) program seeks to support the GoB to improve family health outcomes statewide as well as build their leadership and ownership towards these services. Ultimately this is to accelerate the progress toward MDG 4 to reduce child mortality and MDG 5 to improve maternal health. [12 pages] Read More...

The Information and Communication Technology (ICT) Continuum of Care Services (CCS) intervention was conceptualized and implemented by CARE as part of the Ananya program in Bihar.1 The intervention involves the provision of ICT-enabled mobile-phone-based tools for frontline workers (FLWs) that aim to increase the coverage and quality of services that FLWs provide, enhance their communication with beneficiaries, and facilitate supervision (Box 1 summarizes the features of the ICT-CCS tool). [123 pages] Read More...

The Family Health Initiative in Bihar, India (referred to in this report as the “Bihar Initiative”) is one of the foundation’s flagship programs. It represents a new approach to investing in global health, with the goal of yielding greater impacts on health outcomes and mortality, and accelerating progress toward Millennium Development Goals 4 and 5. In particular, the Bihar Initiative takes an integrated approach to improving reproductive, maternal, neonatal, and child health by leveraging and bundling services and delivery mechanisms from several of the foundation’s Global Health Strategies to improve uptake and coverage across the continuum of family health care. These strategies include Maternal, Neonatal, and Child Health; Family Planning; Nutrition; Vaccine Delivery; Tuberculosis; Enteric and Diarrheal Diseases; Pneumonia; and Neglected and Other Infectious Diseases. [60 pages] Read More...

In 2010, the Bill & Melinda Gates Foundation launched the Family Health Initiative in Bihar, India (now named “Ananya”, a Sanskrit word meaning “unique” or “unlike others”). The goals of the Ananya program (2010–2015) are to reduce maternal, newborn, and child mortality; malnutrition; fertility; and morbidity from infectious diseases by developing and implementing innovative and integrated health solutions that involve both the public and private sectors. More specifically, the program aims to expand the reach, coverage, and quality of (1) essential primary health and nutrition services for infants, children, and women of reproductive age; and (2) diagnostic and disease-control services for infectious diseases, including pneumonia, diarrhea, tuberculosis, and visceral leishmaniasis. [68 pages] Read More...

This report focuses on the findings from our process study of two early Ananya grants: (1) the Integrated Family Health Initiative (IFHI), led by CARE; and (2) Shaping Demand and Practices to Improve Family Health in Bihar (SDP), led by BBC Media Action. We focused on these two grants because their activities had begun earlier than other grants and had had time to take root. Next, we offer additional detail on the interventions, describe the data collection for the study, and summarize key findings. [120 pages] Read More...