A decade ago, we formed a partnership with the Government of Bihar to improve health outcomes in the areas of maternal and child health, nutrition, family planning, immunization, and infectious disease elimination. We have since expanded our focus to include strengthening health systems, boosting agricultural production, and promoting women’s economic empowerment, in step with the Government of Bihar’s development goals.
A community health worker uses her mobile phone to update information on a woman and her newborn during a home visit in Samda village, Bihar.

At a glance

  • Bihar, India’s most densely populated state, has experienced rapid economic growth in recent years. But it remains one of the poorest states in the country, with acute development challenges that affect its 127 million people, 85 percent of whom live in rural areas.
  • Improving health outcomes is a key focus of our work in Bihar—to support the state’s efforts to improve maternal, newborn, and child health and nutrition; expand coverage of immunization and family planning services; combat neglected tropical diseases, and strengthen the public health system.
  • Bihar is also a key area of focus for our agricultural development efforts in India, which include helping to increase agricultural productivity for smallholder farmers; smallholder farmer household income; equitable consumption of a safe, affordable, nutritious diet year-round; and women’s empowerment in agriculture.
  • We work with JEEViKA, a Bihar government platform, to support self-help groups and key state agencies in implementing interventions that integrate health and nutrition and promote women’s economic empowerment.


The foundation’s partnership with the Government of Bihar began in 2010, through the signing of a Memorandum of Cooperation (MoC) to support the state’s goals in the areas of maternal, newborn, and child health; childhood nutrition; family planning; immunization; and infectious disease control. The work began with pilot testing innovations in community-based interventions led by community health workers and facility-based primary care interventions, tools, and processes in eight of the 38 districts in Bihar.

A 2014 agreement with the Government of Bihar and India's Ministry of Health and Family Welfare called for scaling up these innovations statewide, with an added emphasis on improving health systems (including in human resources, supply chains, data systems, and contracting), expanding public-private partnerships, and improving financial planning and service delivery. The MoC with the state government has been renewed until 2021, with an expanded scope that includes programs in agriculture, financial inclusion, and women’s economic empowerment.

Our support for the state government is built on a model of providing technical assistance to government programs at the field level and state level through partner organizations that have the appropriate expertise. We also test innovations and generate evidence to strengthen the scale and capacity of health and nutrition systems, in partnership with the state government, other global development agencies, domestic philanthropic organizations, local institutions, and domestic and international research partners.

Our work with partner organizations and the Government of Bihar have contributed to notable improvements on numerous fronts:

  • Bihar’s neonatal mortality rate, infant mortality rate, stillbirth rate, and maternal mortality ratio have fallen significantly over the last four to five years.

  • From 2015 to 2019, Bihar saw a 5.5 percentage point decrease in stunting and a 6 percentage point increase in modern contraceptive prevalence. These are among the highest rates of change among states in India.

  • Between 2016 and 2019, maternal and child health program coverage improved, leading to gains in prenatal care (especially in the first trimester, with an increase in coverage from 35 percent to 53 percent), postnatal care (from 42 percent to 57 percent), and institutional delivery (from 64 percent to 76 percent).

  • Aided by an initiative implemented across all public facilities in Bihar to track weak, very-low-birthweight, and premature newborns, neonatal mortality in this cohort decreased significantly over the last four years.

  • From 2005 to 2015, the number of fully immunized children (age 12 to 23 months) in Bihar increased from about 30 percent to around 80 percent.

  • Visceral leishmaniasis (kala azar) cases fell from about 25,000 before 2010 to about 1,300 cases in 2020, with Bihar inching closer to eliminating the disease.

  • Facility-level quality of care has improved significantly through simulation-aided onsite mentoring of nurses and doctors in combination with other quality improvement interventions and frequent clinical reviews by facility teams (e.g., for all cases of complications or a random sample of regular deliveries) in public facilities.

  • Essential drugs and commodities are now available at about 70 percent of Bihar’s public health facilities, and the state’s neonatal mortality rate, infant mortality rate, stillbirth rate, and maternal mortality ratio have fallen significantly.

  • The practice of exclusive breastfeeding of infants under 5 months of age has increased, as has the timely initiation of breastfeeding for babies born in public health facilities and at home.

  • Although Bihar has historically been one of the highest-burden states for tuberculosis (TB), TB case notification quadrupled between 2013 and 2016, due to the Public-Private Interface Agency (PPIA) pilot project in Bihar’s capital city, Patna. The PPIA model has since been scaled up in Bihar and nationally.
A child receives polio drops in Roti Mushahari village, Bihar.
A child receives polio drops in Roti Mushahari village, Bihar.
  • The government’s rural livelihoods program, JEEViKA, mobilized about 1 million women’s self-help groups to deliver key health and nutrition messages to their communities, specifically to address harder-to-move indicators such as minimum dietary diversity (for childhood nutrition) and contraceptive prevalence among young couples.

  • Through improved use of technology, such as the new NGO-DARPAN system that connects non-governmental organizations and the Indian government, program administrators have access to weekly data on the availability of health services (which facilitates operational problem solving) and quarterly reviews of key health indicators at the district level.

  • Several innovations that were tested and piloted in Bihar have been incorporated in other Indian states or have been scaled up nationally. Examples include a digital health app for community health workers, incremental learning approaches for community health workers, and mobilization of self-help groups to disseminate health and nutrition information.

Beyond health, we provide support to the Bihar government in realizing its goals of improved food security and economic development.

  • We support the Bihar government in realizing its goals for food security and economic development. We provide the government with support for monitoring, decision support, and investment tracking systems, particularly those centered on nutrition implementation, integrating agriculture and livestock data across dashboards, and facilitating the transition toward an e-governance system. We also focus on improving information availability to end beneficiaries and share evidence-based implementation plans for execution of inclusive agricultural transformation (IAT) reforms and policies.

  • We support the Partnerships for Women’s Empowerment and Rights (POWER) project, which was initiated in 2013 in three states, including Bihar. It aims to improve quality of life in rural communities by improving sanitation facilities, expanding access to safe drinking water, and serving other livelihood needs—all under the leadership of women.

  • We also support the Sakshamaa program, which seeks to bridge the gender gap by garnering data and evidence through a network of researchers, and provides technical support to Government of Bihar. This program has led to improved collection, quality and frequency of data including the launch of a Bihar Gender Dashboard and Report Card which the government has leveraged to identify target domains including child marriage and girls’ education, barriers to women’s economic empowerment such as mobility, safety, and labor market access, and districts that require more intensive resources and programming to address multiple gender gaps.

  • Going forward, we plan to partner more closely with the Government of Bihar and the Government of India to sustainably build local institutional capacity that the Government of Bihar can access and use while continuing the momentum of progress toward achieving India's targets under the Sustainable Development Goals for 2030 and beyond.

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