Public Health System Survey in Bihar 2018-2019

Budget and implementation constraints required us to select a sample of districts rather than covering all 38 districts of Bihar. At the same time, we needed a large sample to be representative of the diversity within the state, and allow us to capture some variation across district-level institutional characteristics. These constraints led us to determine 16 as the number of districts in which to undertake the survey. The purposive selection of which 16 study districts, from among the 38 of Bihar, was made using the following criteria:

• represent the 9 administrative divisions of Bihar: Patna, Tirhut, Darbhanga, Kosi, Purnia, Saran, Bhagalpur, Munger, Magadh
• represent both border and interior districts
• select "old" and "new" districts (those which were created after 1991) because district age might matter in interesting ways for their capacity to deliver (to be discussed further)
• select districts which might vary in historical institutions that shape norms.

We first explored an established literature in India which finds that there are persistent effects on current service delivery of the long-gone historical institution of the Zamindari system of land revenue (Pandey, 2010; Banerjee and Iyer, 2005). However, since all of the districts of Bihar are classified as belonging to the Zamindari system, we could not use this established measure of historical institutions in selecting the study districts. We then turned to a newer literature which examines the early construction of railway lines in the late 1800s in the United States and India as a potential source of institutional variation (Donaldson, 2018; Donaldson and Hornbeck, 2016; Atack, Haines and Margo, various). The 16 districts in our study include those through which passed the first railway lines in Bihar, and those that received railway lines a decade or so later.

Within each of the 16 districts, 4 blocks were selected using a random number generator,after stratifying by proximity to the main railway line. Within each block, 4 Gram Panchayats (GPs) were selected using a random number generator. However, in one block each in the districts of Lakhisarai and Buxar, 3 GPs instead of 4 were selected because the sampling protocol required a sufficient number of replacement respondents to be available, and these districts only had 3 GPs fulfilling the replacement requirement (more details in section on Respondents below). This yields a sample of respondents drawn from 16 districts, 64 blocks from within those districts, and 254 Gram Panchayats (GPs) from within those blocks.

Citizen Survey: The citizen survey was aimed at respondents from 16 households residing in each GP area. The survey firm was provided with a list of respondents (with replacements) drawn randomly from the electoral rolls available of all voting-age adults in Bihar's population. The target sample size is thus 4064 citizens (16 each from 254 GPs). Within the category of citizens, the survey additionally targeted office-bearing members of women's Self Help Groups (SHG) under a rural livelihoods program in Bihar known as Jeevika. However, we had no lists available with names of SHG leaders of the village-level organziations across GPs. In the absence of these lists, we relied on the survey firm to ensure that enumerator teams would identify SHG leaders during their field-work. The data from SHG leaders that has been provided to us is thus subject to a greater than usual caveat: the risk of whether the enumerator teams accuratelyidentified and obtained interviews with the targeted SHG respondents. The instructions provided to the survey teams was to ask the GP Mukhiya and other GPlevel respondents (such as the ANM, ASHA and AWW) about the GP-level federated organzation of all the SHGs across the GP's communities to identify its President,Secretary and Treasurer. That is, 3 SHG leaders were targeted for each GP, for a total sample of 762 (3 each from 254 GPs) SHG leaders.

Politician Survey: Lists were provided to the survey teams of all incumbent Mukhiyas to be interveiwed, and a random selection (with replacement) of 3 Ward members and 3 candidates from among those who contested the previous GP elections of 2016. The targeted sample size of GP politicians is thus 1778 (7 each from 254 GPs)

Bureaucrats: The survey firm was responsible for identifying and interviewing the respondents holding these positions. The final data submitted by the survey firm contains 293 respondents in supervisory or management positions, including: 13 Civil Surgeons,11 Chief Medical Officers (including 4 who were in Acting capacity), 23 Superintendents (including 13 in Deputy or Acting capacity), 9 District Programme Officers- NHM, 4 District RCH and Immunization In-charge, 7 District Community Mobilizers, 58 MOICs, 58 Acting Facility Incharge, 43 Block Program Managers-NHM, 29 Block RCH Programme officers, and 35 Block Community Mobilizers.

Public Providers of Health Services: The survey team was provided a list (with replacements) of 3 AWW workers to interveiw per GP, for a targeted sample of 762 AWW respondents. The survey team was provided with a list of randomly selected candidates for the categories of respondents for all the PHCs and higher-level health facilities (such as District Hospitals) across the 64 blocks of the study area.