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Learning to strengthen health system in Bihar

Cindy Carlson

This learning grant supports the Bill and Melinda Gates Foundation (BMGF), Government of Bihar and implementing partners to develop new strategies and approaches for strengthening the public health system to make progress towards the Sustainable Development Goals.

To do this, working in partnership with the Public Health Foundation of India and Johns Hopkins University, we apply the latest conceptual thinking on health systems to diagnose constraints to performance at individual, organisational and institutional levels and identify policy and programmatic strategies to overcome them.

This is anchored around the interdependencies of system ‘hardware’ (physical inputs), ‘tangible software’ (the capacities and formal processes within the system) and ‘intangible software’ (the informal institutions – values, norms, incentives and relationships), embedded within a broader public sector governance framework and socio-political context.

We have developed pioneering ethnographic research methods and novel conceptual frameworks and are exploring path-breaking interventions to create an enabling environment and develop a culture of performance, including through coaching and mentoring managers to adopt transformational leadership styles, developing transferable skills, and promoting trust and teamwork.


The global community working on health systems is increasingly understanding that the performance of health systems depends on both having sufficient hardware (drugs, infrastructure, HR, finance etc.), but also the behaviours of people within the system – whether providers, managers or administrators. People’s behaviour is shaped not only by individual factors, but also by the culture of the organisation that they work in and the broader institutional environment – both its formal and informal aspects. Hardware and software aspects interact – for example, a lack of resources can demotivate providers – and often amplify one another to create an environment which is not conducive to performance.

The interdependency of hardware and software factors mean that improving the performance of a system is very challenging. Our research supports the latest conceptual thinking in complexity science, that isolated, targeted interventions have marginal impact and that hardware and software problems need to be addressed in an integrated manner. However, the evidence base on what it takes to ‘rewire’ intangible software in particular remains nascent, and recognises high context specificity. Through our work, we have been trying to explore appropriate intervention strategies for the context of Bihar.

Our approach

Our initial focus was to gain a greater understanding of the problem diagnostic. In particular, we have used ethnographic research methods to understand the people within the system, and the drivers of different types of behaviours that would need to change if system performance was to improve. This builds upon the Means, Motives and Opportunity (MMO) framework developed by OPM that is used to diagnose the constraints to individual performance, and has been published in BMJ Global Health. For example, embedded ethnographic researchers for long periods of time in primary health centres and community health centres, to understand how the organisational and institutional environment affects individual MMO, and to better identify the unwritten scripts that determine behaviour.

We have also undertaken complementary work to understand the genesis of these institutional constraints – including a detailed context assessment that goes beyond a traditional political economy analysis, and situates health system performance within a broader socio-political legacy.

Based on this diagnostic work, we are identifying interventions and approaches that may help to improve systems performance. For example, we have explored the potential role of coaching and mentoring district and block-level managers to develop their transformational leadership. Currently, however, managers tend to adopt punitive, transactional management styles that demotivate and are counterproductive.


We are supporting BMGF and their partners to leverage the insights from this learning grant in their design of future phases of support to the health system of Bihar.

See also: How performance targets can ingrain a culture of ‘performing out’: An ethnography of two Indian primary healthcare facilities