Meghalaya Health Systems Strengthening Project Mid- term Review Mission January 16 – 23, 2025 Aide Memoire I. INTRODUCTION 1. A World Bank team1 conducted a hybrid mission from January 16 to 23, 2025, for the mid-term review (MTR) of the Meghalaya Health Systems Strengthening Project (P173589) in India. The objectives of the mission were to assess: (i) the progress made towards achieving the project development objective (PDO); (ii) the efficiency and effectiveness of project implementation, resource utilization, and management practices; (iii) fiduciary and safeguards management under the project; and (iv) to draw recommendations for improving project implementation, addressing identified challenges, and identifying potential areas for restructuring. 2. The team extends its gratitude to the Government of Meghalaya (GoM), Directorate officials, State Project Management Unit (SPMU) staff, medical officers, health facility staff, and other stakeholders for their support during the mission, including the field visit to Re-Bhoi and East Khasi Hills Districts. Key observations and discussions from the mission were shared with the project team, and the mission's decisions were reviewed during the wrap-up meeting on January 22, 2025, with Mr. Sampath Kumar, Principal Secretary Health and Family Welfare, GoM, and Mr. Ram Kumar, Commissioner Health and Family Welfare, GoM. II. PROJECT DATA AND RATINGS Table 1: Key Project Data and Ratings Project Data Original Project Amount US$40 million Total Disbursement US$18.189 million (45.47percent) Project effectiveness November 26, 2021 Closing Date March 31, 2027 Project Ratings: Previous Current Progress towards achievement of Project Development Objectives MS MS (PDO) Overall Implementation Progress (IP) MS S Component 1: Improving accountability, management and MS MS strengthening governance; US$18 million; Disbursed US$6.272 million Component 2: Strengthening systems to improve the quality of S S health services US$16.90 million; Disbursed US$11.694 million Component 3: Increasing coverage and utilization of health services MS S US$5 million; Disbursed US$0.222 million 1 Mr. Amith Nagaraj (Sr. Operations Officer and Task Team Leader), Mr. Paul Procee (Operations manager, India), Ms. Aparnaa Somanathan (Practice Manager, HNP,SAR), Ms. Lakshmi Sripada (Operations and Technical), Ms. Sangeeta Patel (Procurement Specialist), Mr. Ananta Krishna Karur (Financial Management Specialist), Rajesh Jha (Consultant – Technical), Dr. Lincoln Choudhury (Consultant – Technical), Mr. Philip ((Consultant – Technical), Mr. Rakesh Aggarwal ((Consultant – Technical), Ms. Charu Jain (Environment Specialist), Ms. Swati Dogra ( Social Development Specialist), Mr. Ranjan B Verma (Consultant, Social Development), and Ms. Jyoti Sriram (Senior Team Assistant). 1 III. IMPLEMENTATION PROGRESS AND KEY FINDINGS 3. Overall progress: The project development objective (PDO) is to improve management capacity, quality and utilization of health services in Meghalaya. Based on the findings of this review, the PDO and the Project Results Indicators remain relevant and are unchanged. There are five PDO level indicators. The project has achieved year three targets2 for four out of five PDO indicators, except for the district hospital National Quality Assurance Standards (NQAS) certification. Progress on 13 intermediate indicators have shown significant improvement, with eight indicators related to management capacity, service delivery, and health insurance coverage either achieved or surpassed. The indicator for fund utilization in targeted facilities is on track and can be achieved soon with better supervision and support. However, four indicators related to timely payments to internal performance agreement (IPA) units, stock-out of essential drugs, and clinical vignettes participation and score improvement are delayed. Year-wise progress on the Results Framework (RF) is detailed in Annex 1. 4. While the overall disbursement under the project is on track according to projections, the disbursement among components varies. As of February 11, 2025, US$18.189 million has been disbursed out of a total loan value of US$40 million, which is 45.47 percent. The project has reported the expenditure incurred until December 31, 2024. In the light of above progress, the PDO continues to be moderately satisfactory (MS) and implementation progress rating upgraded to satisfactory (S). 5. Component 1 Improving accountability, management and strengthening governance: Over the past three years, the Meghalaya Health Systems Strengthening Project has made significant strides, expanding implementation statewide. The project has successfully signed 122 Internal Performance Agreements (IPAs) with all planned institutions to enhance quality and management capacity. However, the rollout of Clinical Vignettes has been slow, impacting progress. Currently, about 78 percent of staff in IPA facilities have participated, but the system lacks a mechanism to measure knowledge improvement pre- and post-course. Third-Party Verification and Quality Assessment have also faced delays. Three rounds of ex-post assessments revealed significant score variations compared to ex-ante assessments, raising concerns about training quality and assessment methods. Consequently, funds are released based on ex-ante scores, however, the post ex-ante are not being used for imposing penalty that is contrary to the IPA grant manual. The Project Management Unit (PMU) has been conducting joint meetings with assessors and IPA entities to address inconsistencies and establish a common understanding. 6. Improvement in quality of care: The mid-term analysis of 46 health facilities revealed significant achievements. The average IPA score increased by 34 percent in Primary Health Centres (PHCs) and 36 percent in Community Health Centres (CHCs), surpassing the target of a 15 percent. Similarly, the NQAS scores in various quality metrics across IPA facilities compared to non-IPA facilities confirm that IPAs positively impact on service quality. Among the facilities, 17 PHCs and 2 CHCs are above the NQAS eligibility threshold, indicating potential for certification. However, two District Hospitals (DHs) and one Sub-District Hospital (SDH) showed declines in NQAS scores. Despite some declines, one DH is eligible for NQAS certification based on the overall assessment. Refer to Annex 2 for more details. 2 Adjusted target as per duration of implementation till Sep 2024 (semi-annual). 7. The IPA fund disbursement has significantly contributed to enhancing health expenditure. The mid- term analysis of the Meghalaya Health Systems Strengthening Project shows significant achievements. With a total allocation of INR 1,269,000,000 (US$ 18.00 million) for IPA, the cumulative disbursement reached INR 519,139,073 (US$ 6.27 million), accounting for 35.34 percent disbursement. Mid-term expenditure stands at INR 334,981,107.74 (US$ 4.049 million), representing 64.55 percent of the disbursed amount. Although progress is below the planned disbursement, the expenditure has effectively improved health service quality and patient experience. The IPA grant has notably enhanced the management capacity of health facilities, fostering autonomy and efficient resource utilization. 8. Improved coverage and utilization of health services. A comparative analysis of outpatient (OPD), inpatient (IPD), and delivery numbers was conducted for 46 institutions, using health management information system (HMIS) data from 2021-22 and 2024-25. The results demonstrated significant improvements: OPD and IPD numbers increased in 41 and 32 facilities respectively, and the number of deliveries increased in 34 facilities. This validates the project contribution in improving the utilization of health services. Refer to annex 2 for more details on increase in service utilization among health facilities. 9. Revision of IPA manual during implementation to shift the focus from “Quality of care� to Quality of implementing national programs�. From the project design phase to implementation, the State recognized the need to shift the IPA focus towards enhancing the quality of national program implementation. Consequently, tools, indicators, and the grant release framework were revised to align with result achievements, driven by the State's reliance on national grants. Revised indicators still attribute 70 percent to improving service quality and utilization, but the weightage on NQAS was reduced to 15 percent. This led to marginal progress in achieving PDO targets related to NQAS certification at district hospitals. However, the proposed modification aims to integrate IPA into regular health financing, facilitating a shift from input-based to results-based financing. 10. Simplification of third party / ex-post assessment and application of penalty in low-capacity setting. During the project design phase, the assessment cycle by internal and third parties was planned to occur once per quarter. Recognizing the efforts required for assessment and verification of results, the project team decided to move from a quarterly cycle to a four-month cycle. This change provided more time for supportive supervision and implementation handholding. Given the low capacity and experience in implementing results-based financing for the first time, a temporary moratorium on the penalty clause was applied until the assessment process could be streamlined. The MTR recommends moving away from the penalty clause and conduct the assessments once in 6 months to improve operational efficiency. 11. Key actions and recommendations: (i) apply for NQAS certification for facilities reached the qualifying score; (ii) close monitoring of IPAs especially for timely release and utilization of funds; (iii) further simplification of verification and grant release for sustainability with inhouse resources; and (iv) initiate the process of sustainability of component 1 by linking it with release of government resources through the IPA approach. Once the above actions are completed, especially the timely release of grants and timely verification, the component ratings will be revised. 12. Component 2 Strengthening systems to improve the quality of health services: The planned activities under this component have made significant progress in last three years that includes, renovating 115 healthcare facilities, enhancing human resource for health (HRH) reforms and implementing key policies. Capacity building efforts in training health staff using evidence-based approach, improving service delivery and infrastructure, thus contributing substantially to the project's objectives of enhancing service quality and utilization of health services. 13. Health infrastructure improvement has brought efficiency and complementarity in the state systems. The contracting and implementation of the first two lots of infrastructure work provided significant insights into managing renovation and repair projects at health facilities. A detailed assessment was conducted to identify actual needs, ensure complementarity with available resources, and coordinate efforts with central and state funding, resulting in high efficiency in civil works for balance of works implemented. This was further enhanced by establishing a dedicated health engineering wing, to monitor the works. To ensure sustainability, a preventive maintenance manual for health infrastructure is being developed, which will be a pioneering effort in India. As a result of systematic planning, the project ensured the immediate use of infrastructure for service delivery, and significantly contributed to health facilities meeting NQAS standards. 14. This investment has modernized healthcare infrastructure, improved patient experience, enhanced water supply and sanitation, and ensured safe disposal of pollutants (through decentralized solutions including construction of sharp-pits, deep burial pits, and Effluent Treatment Plant (ETPs). Capacity building efforts for engineering staff have strengthened state capacity in monitoring health infrastructure projects. 15. Consolidation of civil works and functionality along with long term preventive maintenance is critical for success of the project investment and sustainability. As part of the project, institutional reforms were introduced to manage civil works in public health. Under the project, the State is proposing to (i) develop Preventive Maintenance Manual which will provide technical guidelines and (ii) institutionalize maintenance activities which will be implemented in alignment with predefined budgetary framework. The State can also further develop synergies between Public Works Department (PWD) and the maintenance wing, institutionalise “Data Driven decision making�, develop asset registry and decentralised reporting mechanism and explore financing options including, public-private partnerships (PPPs) in the maintenance of health facilities. 16. Need based HRH reforms to address the changing health needs: The State health department has made significant strides in HRH reforms under the Meghalaya Health Systems Strengthening Project. An HR enumeration revealed irrational workforce deployment and gaps, leading to the establishment of the Meghalaya Medical Services Recruitment Board, which filled 400 doctor and 200 nurse positions in 60 days. Key policy reforms, including specialist and public health management cadres (PHMC) and rural transfer policies, are nearing approval. A dedicated HRH Technical Working Group monitors policy creation and implementation. A functional review of the directorates is underway to align with PHMC. The project's contributions align with federal project India's Enhanced Health Service Delivery Program (EHSDP) focusing on HRH reforms, supporting a shift from input-based to results-based financing. 17. Scientific training needs assessment and institutional development for sustainable decentralized training. The project support for a training needs assessment, followed by the revival of State training institutions and decentralized training programs in a more sustainable manner, set a benchmark and organized the workflow for training and capacity building of health workforce. This not only structured the techno-managerial training but also the skills programs for both existing staff and new recruits. The systematic approach to training streamlined the identification of training needs and avoided duplication with national program trainings and saved resources. As a result, health staff received training without being away from their services for extended periods. The induction of newly recruited staff significantly improved their skills and contributed to higher staff satisfaction levels. Over half of the mandated trainings have been completed, covering 309 Medical Officers, 588 Staff Nurses, and 36 District Nursing Instructors. The project also supported the Regional Health and Family Welfare Training Centre in areas like training M&E, curriculum development, and workflow management. 18. Nursing reforms and improving pre-service education for nursing: Progress in pre-service nursing education has been slow. To address this, all nursing infrastructure has been assessed to develop bills of quantities (BoQs) for improving training facilities. The State team and the nursing cell in the Directorate of Health Services have sought World Bank support to enhance the quality of nursing education. Technical insights from the project have yielded collateral benefits, that enabled the state to implement innovative interventions aimed at improving the employability of nurses in the international market, thereby contributing to labor force participation. Approximately 200 nurses have been trained to meet international market requirements in the care economy. Furthermore, the State has developed a long-term nursing reform roadmap, which has attracted the interest of private donors and foundations. This has resulted in additional resources being made available to the State for nursing improvements. 19. Health innovations: The State has implemented several initiatives under service delivery redesign (SDR) to enhance healthcare delivery. Key interventions include establishing transit homes, training doctors in CEmONC, Life Saving Anesthesia Skills (LSAS), and ultrasound, promoting the Mother App, and engaging communities through Village Health Committees (VHCs). These efforts have prioritized the phased activation of first referral units (FRUs) and the adoption of solar energy in health facilities via PPPs. 20. SDR process evaluation to assess the implementation and inform course correction: The key health innovation implemented by the State are at different maturity level owing to the different intervention timeline. A process evaluation is planned to systematically assess the progress of key SDR interventions, measure heterogeneity and inform future strategies and sustainability. The World Bank team had a stakeholder consultation with GoM stakeholders and PMU team members to align on the process evaluation scope, design, and timeline. The next steps would include completion of field data collection and analytics in next 6 months followed by stakeholder consultations. 21. A notable innovation is the launch of the Drone Delivery Hub and Network, with a Drone Station at Jengjal Sub-divisional Hospital in West Garo Hills. This initiative supports logistics for rural health facilities within a 50 km radius, providing routine and emergency deliveries of medical commodities. The 'Reverse Logistics' feature enhances efficiency by transporting samples and reports back to the Drone Station. Currently, five to eight flights operate daily, serving 25 health facilities. The project aims to refine the manual indenting system and evaluate service outcomes for cost-benefit analysis and the entire initiative has been mainstreamed within health department for sustainability. 22. Key actions and recommendations: (i) development and implementation of SOP for preventive maintenance of health infrastructure; (ii) completion of remaining infrastructure works in next 18 months; (iii) dissemination of HRH reform work to all the health department leadership and take forward the other reform agenda within the project period; and (iv) expedite civil works contracting under nursing. 23. Component 3 Increasing coverage and utilization of health services: This component focuses on health insurance and activities for social behavior change communication that augment utilization of services. In the last three years of implementation, the project has made significant progress under this component. The majority of the technical assistance (TA) activities that were planned for health insurance were completed during the first year of implementation, and the recommendations from the assessment were embedded into the program design. Given the longstanding health insurance program in the State, the resources for additional activities were met from the State budget, while to maintain the rigor, the implementation agency of Megha Health Insurance Scheme (MHIS) was included under IPA. The development of a communication strategy had initiation hiccups in terms of finding the suitable agency that understand the sensitivity of tribal populations, but meanwhile, the PMU have strengthened their inhouse teams to develop some creative communication programs targeting on health needs like teenage pregnancy and women health. 24. Technical assistance in health Insurance guiding the improvised internal capacity for operations and revision of health benefit package to improve utilization: A comprehensive review of the MHIS and the Health Benefits Package (HBP) revealed strong systems with areas for operational improvement. The State Health Agency decided to address these gaps in-house, leveraging the existing strong team. The MHIS enhanced its human resource capacity by recruiting dedicated staff for each district hospital and three state-level managers. The HBP review led to a new benefits package, rationalizing procedures based on claims data, illness incidence, and feedback. The revised HBP, rolled out in 2022, increased service uptake by 25 percent. 25. Effective Communication Strategies for Addressing Teenage Pregnancy and Maternal Mortality: The PMU team achieved significant progress in developing communication products for Teenage Pregnancy and Maternal Mortality issues. They launched the "ADOLESCENT Unfiltered" PODCAST, an innovative digital/social media platform that gained substantial traction among youth, with multiple episodes released on YouTube, Facebook, and Instagram. The podcast's performance metrics were impressive, reaching 292,442 accounts on Instagram with 25,914 content interactions, and achieving 813.4K views, 3.2M impressions, and 28.3K hours of watch time on YouTube. Additionally, the PMU developed posters to address the urgent need for Maternal Mortality awareness. However, further rollout plans for additional podcast episodes, as well as appropriate training, engagement plans for key stakeholders, and the development of other communication materials, are still pending. 26. Key actions and recommendations: (i) close monitoring on the process of developing communication strategy to be more selective and aligned with state priorities; and (ii) demonstrate implementation of communication strategy for select areas during life of project. 27. Project Management and Coordination: The project has significantly benefited from the stable leadership under the project. The majority of the technical positions under the project were filled during the early stage of project initialization and maintained. Cross support and sharing of resources between PMU, National Health Mission (NHM) and Directorate have improved the project coordination that not only improved the skills and competency of the project team but is also promising in terms of the sustainability of quality implementation. The project has appointed a project management agency that is envisaged to provide technical support and expertise not available in the State. About 30-40 percent of the positions have been vacant for long which is mainly due to not meeting the requirements of the positions. This is an appropriate time to re-imagine the need for such technical support under the project and beyond and amend the contract with the agency to plan the available resources. 28. Environmental and Social Management: Significant progress on environmental and social (E&S) management has been achieved since the project's inception. The project has complied well with Environmental and Social Commitment Plan (ESCP) requirements, with consistent monitoring and gradually improving reporting quality. After initial challenges, the project successfully engaged and retained E&S staff at all levels, including PMU, Project Management Agency (PMA), Junior Engineers (JEs) at the district level, and contractors. Regular E&S management training was provided at all levels. The Waste Characterization Study, which informs the Bio-Medical Waste Management (BMWM) Plan, is being finalized. 29. Since implementation of civil work-related E&S management compliance has been good, it provides an opportunity to integrate the learnings and process steps into standard bidding documents of the overall health department works to mainstream them. 30. Environment Management [Rating: Satisfactory]. ESS 1, 2, 3, 4, 7, and 10 were applicable during project preparation and have been well complied with. Civil works investments have adhered to Environmental and Social Management Framework (ESMF) requirements, with no incidents reported from any site. Required clearances, including those from the Forest Department for tree cutting, were obtained promptly. Only two trees were cut, and the contractor will undertake compensatory planting of 40 trees. Regular stakeholder consultations were conducted at various stages of individual work cycles. Mercury-free equipment adoption was facilitated through Meghalaya Medicinal Drugs & Services Limited (MMDSL). A third-party midline assessment found that resource conservation practices were adopted in both IPA and non-IPA HCFs, with 8.6 percent of IPA PHCs having arrangements with waste recyclers, which was not observed in non-IPA HCFs. 31. Bio-Medical Waste Management (BMWM): The Meghalaya State Health Department recognizes the challenges of BMWM and is working collaboratively with the State Pollution Control Board (SPCB) and Meghalaya Medicinal Drugs & Services Limited (MMDSL) to build capacity in BMWM. A Waste Characterization Study, currently under finalization, was conducted to understand the quantity and types of medical waste generated in government healthcare facilities (HCFs). This study will inform the development of a comprehensive BMWM Plan. The State has outlined a plan that includes capacity- building programs, development of a demonstrative BMW management model, creation of a comprehensive BMWM plan for solid waste, a pilot project in West and Southwest Garo Hills districts, and identification of zones for Central BMW Treatment Facilities (CBMWTF) with cost analyses. To support these activities, a dedicated BMWM Cell will be established. 32. The State is implementing these initiatives using its own resources and is seeking further support from the Bank. Decentralized solutions, such as sharp pits and deep burial pits, have been implemented in 92 IPA HCFs where waste transportation was limited. Environmental screening of deep burial pits and ETPs is underway with SPCB support, with reassessed groundwater table levels expected to reduce the number of pits at risk of non-compliance. Capacity building on BMWM has improved in both IPA and non-IPA HCFs, with training manuals and staff training exceeding 80% in most facilities. The State is actively working to ensure all staff receive BMWM training. For more details refer to annex 5. 33. Social Management [Rating: Satisfactory]: The progress in the project’s social management is rated satisfactory given the consistent performance against the commitment plan including stakeholder consultation, labor management, setting up procedures at the construction sites, gender sensitization, and gender-based violence (GBV) training to staff and JEs. The draft Terms of Reference (ToR) developed for the gender success storyline regarding the project activities requires refining and covering intervention areas such as non-communicable diseases (NCDs), maternal and child health, mental health, and overall gender empowerment. The midline assessment suggests a majority of PHCs and CHCs maintain grievance registers and 89 percent of the grievances are redressed. The establishment and implementation of an online Grievance Redress Mechanism (GRM) has been over two years now and the offtake of grievances has been very low to negligible, and hence, there is a need to undertake a diagnostic assessment in identifying the limitations and planning appropriate measures to improve upon. 34. Procurement [Rating: Satisfactory]: The progress on the procurement is rated satisfactory as all procurements are implemented well within the project period. As per STEP system, of the 62 activities cleared by the World Bank, 20 are completed, 38 activities have been signed, 2 terminated 1 under implementation and 1 pending implementation. The status of the signed contracts was shared by the State project team. The activity under implementation is for civil works consisting of 3 lots, with a combined value of US$ 7 million which is at the bidding phase. It was brought to the notice of the project team that the minimum bid period of 30 days must be provided for the Request for Bid (RFB) contract. There is one goods contract under Pending Implementation stage which may get extended or dropped in future depending on the need. Based on the information provided, it is observed that the project is fully committed, and no new procurements are anticipated in the future except for 1 or 2 minor small value contracts like audit consultancy. 35. Financial Management (FM) [Rating: Satisfactory]: In compliance with FM requirements, the project maintains required financial records up-to-date and submitted required financial reports and Interim Unaudited Financial Report (IUFR) on time. The necessary operational financial data are maintained in accordance with agreed FM arrangements. Since the last mission, there have not been any changes, Therefore, the rating has been retained as Satisfactory. For FY24-25, Finance Department has sanctioned an amount of INR 113.80 crores, of which INR 30 crore has been drawn. As of January 1, 2025, the project had an opening balance of INR 0.82 crore. The available funds are not sufficient to meet the expenditure till March 31, 2025. Therefore, it is advised to follow up with FD for release of balance funds. The project has prepared and submitted a budget estimate of Rs. 100.74 crore for FY25-26. IV. KEY LEARNINGS AND RECOMMENDATIONS FROM MTR 36. The project is being implemented as a "sector-wide" initiative, engaging with the state on all major health sector aspects. It is crucial to capture and articulate the overall impact on the health sector in the state for future engagements and project designs. An economic analysis of the project's benefits, both direct and indirect, to the health sector should be conducted. These benefits should be captured and reflected in the project evaluation and Implementation Completion and Results Report (ICR). Additionally, it is important to demonstrate and build the storyline of small projects with high impact using a sector-wide approach. 37. Sustainability and integration of results-based financing through IPA beyond the project. The current IPA administration involves a significant government role and fiduciary systems, with the State government committed to continuing financing and shifting the health sector to results-based financing. It is essential to assess if the results warrant the continuation of this strategy and further strengthen the state's commitment to sustaining it. To ensure sustainability and ease, the IPA should be modified and integrated into regular health financing. A phased road map and strategy should be developed for adopting IPA-based financing in administrative units and health facilities. Policy decisions should be supported with evidence comparing quality and performance in IPA and non-IPA facilities. Additionally, a detailed governance and institutional assessment should be conducted for the IPA rollout and grant release, and government funds should be quantified with equity calculations applied to achieve results. 38. Developing knowledge products: At the MTR stage, it is recommended that the project focuses on developing various knowledge products. These products can include comprehensive case studies, policy briefs, and technical reports that capture the lessons learned, best practices, and innovative approaches implemented during the project. Some of potential areas could be implementation of IPA, HRH reforms, civil works etc. These knowledge products will not only enhance the project's impact but also serve as valuable resources for future projects and stakeholders in the health sector. 39. The areas for restructuring. In light of learnings from the implementation, changes in government priorities and changing needs of the State, the following are the suggested areas for restructuring: a. Calibrating the definition and scope of PDO and intermediate indicators to help streamline with government systems to sustain beyond project. The project can consider expanding the PDO indicator on NQAS to include lower-level facilities and revise the end-of-project targets. The project can also incorporate other government-initiated quality accreditation programs (PMJAY-QA certification, Muskan, Kayakalp, etc.) into the indicator definition. b. Revise unit of measurement under clinical vignettes which currently lacks a system to measure pre and post-test knowledge. The current system has all the clinical cases in form of interactive training for different cadre, but it does not allow measuring knowledge improvement before and after the course. The MTR suggests we continue with the weighted score for clinical vignettes i.e. 10 percent and restructure the indicator in results framework to capture different measurement to understanding their implementation. c. Re-appropriation of funds in Component 3 to nursing activities in Component 2 within the input-based financing category. d. As per the recent directive of Department of Economic Affairs, the savings on account of exchange rate between US$ and INR needs to be cancelled, unless until the revised cabinet note is furnished to draw complete credit. The Government may request for cancellation of US$ 2.5 million that is under savings on account of the exchange rate. V. NEXT STEPS AND AGREED ACTIONS Table 1: Summary of Agreed Actions S. No. Actions Responsible Due Date Component 1: Improving accountability, management and strengthening governance IPA Grants at State and District Level 1. Expedite the process for NQAS certification in the health facilities reported PMU March 30, 2025 qualifying score as per internal assessment 2. In light of agreed revision of verification cycle, ensure timely verification and PMU April 1, 2025 release of grants to IPA entities. 3. Share the revised IPA manual to reflect the revised / simplified verification and PMU March 31, 2025 grant release cycle, and secure Bank and PSC approval. 4. Develop the sustainability plan for IPA PMU August 31, 2025 5. Enhance rollout of Clinical Vignettes to all the target groups PMU April 1, 2025 Component 2: Strengthening systems to improve the quality of health services Human Resources for Health (HRH) 6. Approve functional review of the directorates report PMU Feb 28 2025 7. Stakeholder consultations using key findings from HRH Desk review, PMU March 31 2025 Enumeration, functional review 8. ShareDraft HRH forecasting and fiscal analysis IQVIA May 15 2025 9. Share Draft HRH strategy and management framework IQVIA June 15 2025 Table 1: Summary of Agreed Actions S. No. Actions Responsible Due Date Capacity Building 10. Capacity Building midline assessment and key findings RICHPI Feb 28 2025 Pre-service education (Nursing) 11. State level discussions on Nursing reform agenda PMU/PMA Feb 28 2025 Infrastructure development 12. Completion of evaluation and Award of contract for the Nursing Tender. PMU March 2025 13. Complete package 7.a and 7.b; and 1.5, 4. aa, and 4.bb PMU Dec 25 2025 Component 3: Increasing coverage and utilization of health service SBCC 14. Stakeholders meeting with SACH team to identify the need for appropriate PMU/SACH Nov 30 2024 (top-up) communication materials 15. Development of communication materials for display at health facilities. PMU Dec 15 2024 16. Finalization of communication strategy including detailed capacity building plan PMU/SACH Feb 28 2025 17. Identify district, block and village level functionaries and build their capacity to PMU/SACH March 10 2025 roll out the training plan 18. Development of communication materials as per the SBCC strategy document. PMU/SACH Mar 30 2025 19. Rolling out the phase wise interventions in select 3 districts PMU/SACH April 30 2025 20. Develop monitoring formats for trainings and communication materials PMU/SACH April 30 2025 Service Delivery Redesign (SDR) 21. IRB approval for process evaluation of SDR PMU/ Bank March 1, 2025 22. Commence data collection and KII for process evaluation PMU/ Bank March 1, 2025 23. Consultation with stakeholders on preliminary process evaluation results PMU/ Bank June 30, 2025 Financial Management 24. Fund withdrawal by the PMU from FD PMU In progress 25. Internal audit report for the period Sep-23 to Sep 2024 (6 monthly) PMU January 31, 2025 26. Disbursement projection for FY25-26 and till project closing quarter wise/year PMU Feb 28, 2005 wise 27. Realistic disbursement projection with annual action plan till project closing PMU Feb 28, 2025 28. 20 percent state contribution details PMU Feb 28, 2025 29. Reconciled IPA statement with total release, UC submitted and balance in IPA PMU March 10, 2025 account unit wise Environmental and Social Standards 30. ToR for the gender success storyline PMU March 15, 2025 31. Diagnostic Assessment of online GRM system to address issues of offtake PMU May 15, 2025 32. Establish Bio-medical waste management cell at the state level with members PMU April 25, 2025 from DoHFW, PMU, PCB and Urban etc 33. Environmental screening of deep burial pits and ETPs completed and share the findings report and recommended actions with Bank. PMU May 30, 2025 34. Continue E&S monitoring of ongoing civil works PMU December 2025 35. Ensure E&S management part of civil contracts of nursing schools PMU February 2025 Project management 36. Send the request for project restructuring as per the agreed changes to DEA PMU April 15, 2025 Annexure 1: Results Framework Mar-23 Mar-24 Mar-25 Mar-26 Mar-27 Indicator Name Description Baseline Yr 1 Yr 2 Yr 3 Yr 4 End Target PDO Indicators To improve Management capacity, quality, and utilization of health services in Meghalaya. 1. The percentage point increase in average Target 0 5 10 15 15 20 performance score in targeted administrative units as per internal performance agreement Achievement 0 28.47 31.44 from baseline. (Percentage) 2. Cumulative number of districts hospitals which Target 0 2 3 5 7 9 are NQAS certified. (Number) Achievement 0 0 0 3. The percentage point increase in average quality Target 0 5 10 15 15 20 index score for CHCs and PHC from baseline. 0 27.25 74.38 (Percentage) Achievement 4. Increase in number of patients utilizing 1,650,932.00 1,650,932.00 1,700,000.00 1,730,000.00 1,750,000.00 1,800,000.00 Target government health services OPD in targeted facilities. (Number) Achievement 1,650,932.00 1,817,210.00 1,403,441.00 5. Percentage of claims settled within agreed Target 50 55 60 70 80 90 turnaround time. (Percentage) Achievement 96.1 64.6 64.60 Intermediate Results Indicators by Components - Improving accountability, management and strengthening governance. 1. Percentage of internal performance agreements Target 0 80 90 90 100 100 reviewed as per the operational manual. Achievement 0 99.19 99.19 (Percentage) 2. Percentage of targeted facilities and Baseline 0 administrative units that receive performance Target 80 90 95 100 100 payment, as per operations manual. (Percentage) Achievement 0 0 0 3. Percentage point increase in average patient Baseline 0 satisfaction score in targeted health facilities. Target 5 15 20 20 25 (Percentage) Achievement 0 40.7 72.5 4. People who have received essential health, Target 26,040.00 26,500.00 53,500.00 81,000.00 109,000.00 137,500.00 nutrition, and population (HNP) services (CRI, Achievement 40,819.00 57,296.00 111,109.00 Number) Mar-23 Mar-24 Mar-25 Mar-26 Mar-27 Indicator Name Description Baseline Yr 1 Yr 2 Yr 3 Yr 4 End Target 5. Number of deliveries attended by skilled health Target 26,040.00 26,500.00 53,500.00 81,000.00 109,000.00 137,500.00 personnel (CRI, Number) Achievement 40,819.00 57,296.00 111,109.00 6. Percentage point decrease of targeted health Baseline 0 facilities reported stock-out of essential drugs. Target 0 20 20 15 10 10 (Percentage) Achievement 0 0 0 Strengthening systems to improve the quality of health services. 7. The percentage point increase in score among those who participated in clinical vignettes. Target 0 5 10 15 20 25 (Percentage) Achievement 0 0 0 8. Percentage of medical doctors and nurses from Baseline 0 targeted facilities participated in clinical Target 20 50 80 90 90 vignettes. (Percentage) Achievement 0 0 40 9. Average score for bio medical waste Baseline 0 management in targeted health facilities at Target 10 15 20 25 30 district, PHC and CHC level. (Percentage) Achievement 0 0 73 10. Percentage of targeted facilities where Baseline 0 quality scoring was done by higher level in last Target 80 80 85 90 95 quarter. (Percentage) Achievement 0 100 100 Increasing coverage and utilization of health services. 11. Increase in percentage coverage of Baseline 56 households under health insurance scheme. Target 60 65 70 75 80 (Percentage) Achievement 69.31 77 88 12. Increase in number of women patients Baseline 84,055.00 utilizing government health services IPD in Target 84055 92460 101707 111877 123064 targeted facilities. (Number) Achievement 78145 98914 81,116 13. Percentage of local fund utilization Baseline 0 (including performance grants and Insurance Target 20 40 60 80 80 reimbursements) in targeted hospitals. (Percentage) Achievement 0 30 56.19 Annex 2: India - Meghalaya Health Systems Strengthening Project (MHSSP) : Mid- term Review Mission - January 16 to 23, 2025 1. Overview of the Midline Assessment The Meghalaya Health Systems Strengthening Project (MHSSP) aims to strengthen the overall public health system and improve access to quality healthcare for the people of Meghalaya. The Project Development Objective of MHSSP is to improve management capacity, quality and utilization of health services in Meghalaya. The project has completed over three years, and it was essential at this stage to conduct a midline assessment. The Third-Party Verification (TPV) Agency (Sutra) for the project was engaged for conducting the midline assessment and the scope of work involved data collection, analysing data and preparing a technical report. The midline assessment comprised of three key components which are as follows: • Assessment of facilities using Internal Performance Agreement (IPA) assessment tools • Assessment of facilities using National Quality Assurance Standards (NQAS) assessment tools (all Departments) • Assessment of facilities with respect to additional indicators related to Environmental and Social Standards (ESS) and Service Delivery Redesign (SDR) 2. Methodology The Terms of Reference for the assessment stated that 50% of IPA entities and 10 non-IPA entities would need to be covered. The selection of IPA facilities was undertaken keeping in mind the set of facilities that were covered as part of the last round of counter-verification (round four). Those entities which were not covered in the last round were covered as part of the midline assessment. An exception was made in case of the three Directorates, MHIS and MMDSL. Apart from the IPA entities, ten non-IPA entities were covered as part of the assessment. This was only in case of PHCs and CHCs as all other entities are covered under the project and therefore could not have non-IPA comparators. Non-IPA facilities were selected using Propensity Score Matching (PSM) which is a statistical technique used in observational studies to estimate causal effects of a treatment by creating counterfactual scenarios. Treatment assignment is often influenced by confounding factors, making it challenging to estimate impact. PSM addresses this by matching treated and untreated units that have similar probabilities of receiving treatment, as estimated by a propensity score. Variables used for sample selection were population covered, number of pregnant women registered in Mother App, number of institutional deliveries and number of pregnant women who received at least one ANC. The data collection tools that were used for the assessment were standardised NQAS toolkits as provided by the PMU, IPA tools as provided by the PMU and an online tool for additional ESS and SDR indicators. Pre-testing of tools was undertaken at a sample facility located in East Khasi Hills district and the final tools were approved by the PMU. Five teams were organised for data collection. Each team included an NQAS Assessor, an IPA Assessor, an Assessor for ESS and SDR aspects and a field researcher. The teams were provided an orientation by the PMU prior to commencement of field work. Field work was undertaken between 19th November 2024 and 21st December 2024. IPA assessment was undertaken in 76 sample health facilities and administrative units. ESS and SDR assessment were undertaken in 65 health facilities. NQAS assessment was undertaken in 51 out of 65 health facilities by Sutra. NQAS assessment in the remaining 14 health facilities was undertaken by the state and results were provided to the Sutra team for analysis. Along with this the PMU also provided baseline NQAS results to Sutra for undertaking a comparison with the midline status. It may be noted that Sutra had not conducted the baseline NQAS assessment. Data was compiled, transformed and analysed using statistical methods for measuring central tendency like mean. 3. Summary Findings The following section summarises key findings from the midline assessment. 3.1. NQAS- Summary Findings • 12.1%-point increase in overall NQAS score of PHCs between baseline and midline • 28.2%-point increase in overall NQAS score of CHCs between baseline and midline • 22.0%-point increase in overall NQAS score of Hospitals between baseline and midline 3.2. IPA- Summary Findings • IPA PHCs performed better than non-IPA PHCs across all indicators • IPA CHCs performed better than non-IPA PHCs across all indicators 3.3. ESS+SDR- Summary Findings • All sample IPA PHCs and 66.7% of IPA CHCs were maintaining Grievance Registers compared to none of the non-IPA PHCs and 20% of non IPA CHCs • 88.5 % of selected IPA PHCs and 87.5% of IPA CHCs had redressed grievances compared to none of the non-IPA PHCs. However all non IPA CHCs were addressing grievances • 77 % IPA PHCs and 83 % IPA CHCs had BMW training manuals compared to all non-IPA PHCs and 80 % non IPA CHCs • 8.6 % IPA PHCs and 16.7 % IPA CHCs had arrangements with recyclers, which was not found in non IPA PHCs and CHCs Annexure 3: FM Inputs Disbursements: As of February 11, 2025, US$18.189 million has been disbursed out of a total loan value of US$40 million, i.e., 45.47%. The project has reported the expenditure incurred until December 31, 2024 Cate Percentag gory Category Description Allocated Disbursed Undisbursed e Goods, works, non-consulting services, consulting services, Incremental Operating Costs and Training and Workshops for the Project – Component 2 & 3 of the 1 Project 21,900,000.00 11,710,336.40 10,189,663.60 29.28 Performance Incentive Grants - 2 Component 1 18,000,000.00 6,379,552.65 11,620,447.35 15.95% 3 Emergency Expenditures - - - 0.00% 4 Front-end fee 100,000.00 100,000.00 - 0.25% 5 Int Rate Cap or Int Rate Coll Prem - - - Totals 40,000,000.00 18,189,889.05 21,810,110.95 45.47 Budget Provision: For FY24-25, FD has sanctioned an amount of INR 113.80 crores, of which the project has so far drawn INR 30 crores till December 31, 2024. As of January 01, 2025, the project had an opening balance of INR 0.82 crore. The available funds are not sufficient to meet the expenditure till March 31, 2025. Therefore, it is advised to follow up with FD for release of balance funds. The project has prepared and submitted a budget estimate of Rs. 100.74 crore for FY25-26. Disbursement projection and action plan: To make sure the project is carried out properly, PMU must work with all the district offices and IPA units to assess the exact fund utilization and prepare annual action plan till project closing, based on the working, restructuring of the project may be required to assess the additional fund requirements and improve disbursements. PMU also advised to avoid preparing overstated estimates/projection or yearly action plans and ensure the preparation of an accurate annual action plan before submitting a budget proposal to FD for the upcoming year. The PMU must also prepare a plan of action for utilizing the remaining loan balance of US$24.19 million by the project closing date of March 31, 2027. Exchange difference: Based on the current status of the project, the price of awarded and pipeline contracts amounts to Rs.175.47 crores, while the total IPA amount stands at Rs.126.90 crores. The total project cost amounts to Rs. 302.36 crores. Accordingly, the project has committed an excess of Rs. 20.36 crores over the Rs. 282 crores approved project cost. As per the exchange savings working, the project is gaining an amount of US$2.58 million, which will be sufficient to cover the excess committed amount of Rs. 20.36 crore. Financial Management Unit (FMU): A Chief Financial Officer (CFO) from the Meghalaya State Finance & Accounts Services currently leads the Financial Management unit, supervising the project's financial management arrangements. Under the PMU, one finance consultant and two accountants support the CFO. Apart from regular accounting, existing IPA team should also focus on IPA related activities and monitoring of IPA funds. Capacity building: During the mission discussion, it is observed that divisions and IPA units need extensive training on project FM arrangements, IPA operations, and bookkeeping. Therefore, the mission has recommended strengthening and providing training, especially in accounting and finance, immediately. If needed, the project may engage a CA firm to train, build capacity, and monitor mechanisms for IPA-related transactions. Accounting, reporting, and payments: The project's accounting is done on the Tally system, with a separate ledger account set up to track project-related costs and expenses. DHFW PMU in Shillong centrally manages all payments. Audit Report: The project has submitted the FY23-24 audit report and the same has been accepted by the bank. Rating: Since the last mission, there have not been any changes, the project maintains required financial records up-to-date and submitted required financial reports and IUFR on time. The necessary operational financial data are maintained in accordance with agreed FM arrangements. Therefore, the rating has been upgraded to a satisfactory level. Annexure 4: Social Behavior Change Communication related activities, key achievements, on-going challenges, and solutions to improve overall implementation A. The following activities have been undertaken by Meghalaya Health Systems Strengthening Project. 1. The project has recently engaged ‘SACH and Firstborn Collective’ for developing of SBCC strategy document to support the project in developing communication strategy and the required IEC tools. The agency has submitted the inception report, and it is yet to submit the draft SBCC strategy document and the relevant communication materials by January 2025. 2. Communication products developed for 2 topics of ‘Teenage Pregnancy and Maternal Mortality issues’ by PMU team. The innovative digital / social media communication platform for addressing the Teenage Pregnancy “ADOLESCENT Unfiltered� PODCAST has gained traction with youth and project is successful in launching many episodes of the PODCAST on various social media channels of YouTube, Facebook and Instagram, which are regular with the youth. Further roll out plan for the additional episodes of PODCAST need to be streamlined. Moreover, the PMU also developed posters to immediately address the urgent need for Maternal Mortality. Appropriate trainings and engagement plan for all key stakeholders and development of other communication materials is pending. Adolescents Unfiltered performance- (i) Instagram: 2,92,442 accounts reached, 25,914 content interactions, including 22,931 likes, 11,578 comments, 1,239 saves, and 3,706 shares (ii) YouTube: Views: 813.4K, Impressions: 3.2 M & Watch Time: 28.3 K hrs 3. As part of meaningful engagement of youth and teenagers in the drive against Teenage Pregnancy, the PMU has undertaken the following innovative initiatives: i. Profiled target audiences for tailored communication ii. Hosted an Online Slogan Writing Competition iii. Launched Adolescents Unfiltered Podcast for empowering informed decisions iv. Produced thematic Khasi and Garo songs on teenage pregnancy prevention v. Developed short films in drama/comedy genres with social media influencers vi. Partnered with YouTube channels for discussions involving public figures and leaders 4. IEC Material Revamp at various health facilities across the state: The PMU has engaged another communication agency “The Other Design Studio� from Bangalore to undertake the following activities: i. Redesigned the existing posters, hoardings, flyers, and brochures for health workers and communities on important public health issues such as anaemia and Tuberculosis etc. ii. The agency also developed various templates for revamping the IEC materials displayed in health facilities from PHC to District Hospitals. The templates need to be approved and necessary approvals to be given to ensure that the agency can complete the redesigning of IEC materials. iii. The agency has also developed the guidelines for Placement and design of IEC materials. With optimal use of print colours and design elements, etc. PMU is planning to share these guidelines post their approval. 5. Social Media influencers collaborations The PMU has identified, engaged and oriented the Social Media Influencers with considerable following especially among the Teenagers and Youth of Meghalaya. This strategy will help promote the male participation in maternal health, enhancing institutional delivery and also speak on sensitive public health issues such Cancer, tuberculosis, and Meghalaya Insurance etc. The PMU has also designed and developed Social Media Campaigns on malaria, NCDs, diarrhoea, deworming. In addition, the SBCC team has created awareness materials - animation films and posters on: POSH ACT and Grievance Redressal Mechanisms (GRM) 6. Authored and published articles in local newspapers covering key topics such as RBSK, CM-SMS, ASHA Pay, PM-ABHIM, and other health initiatives. B. Challenges The MHSSP Communication team needs to work closely with the new agency in getting them up to speed on many issues, conduct / facilitate discussions with key stakeholders from government, health facilities, and community institutions at village level. Any delays in design, development, approvals and implementation will adversely affect the timelines of the project. Given the large numbers of villages to be covered and the various ethnic groups, the communication products need to be sensitive towards the needs of the various groups/ communities. C. Steps to improve overall implementation • Develop comprehensive implementation plan for SBCC roll out. (It is to be noted that there are various topics to be covered with different community groups). • Follow up meetings with newly recruited communication agency to ensure that they meet the timelines for all deliverables. • Develop additional PODCAST episodes for “ADOLESCENT Unfiltered� • The PMU needs to supply all the printed materials to all the health facilities and share the guidelines for displaying the new IEC materials. • Organize fortnightly online review meetings with representatives from PMU, NHM, Communication agency, implementing health facilities and WBTT. These meetings to be documented and regular follow-up to be done with required information dissemination to all partners involved. • Bi-annual stakeholders’ meetings with all relevant heads of the departments, PMU, NHM, Communication agency, health facility representatives and WBTT, where PMU will share the progress, challenges and support required to meet the deadlines as per the implementation plan. • Recruitment of additional support at PMU specifically for SBCC to roll out the implementation plan and better coordination with all stakeholders concerned. • Identify relevant district officials to support and undertake frequent field visits to cover all districts and provide supportive supervision. • Faster approvals from PMU and NHM as required for approving the designs of the communication materials. Annexure 5 - Bio-Medical Waste Management (BMWM) The Department of Health and Family Welfare is working collaboratively with State Pollution Control Board (SPCB) and Meghalaya Medicinal Drugs & Services Limited (MMDSL), through its own resources, to build capacity of the state on BMWM in a phased manner. A pilot has been initiated in West and South-West Garo Hills to collect information on amount of BMW generated from government HCFs, develop logistics plan to collect waste, provide OHS training to staff, etc. A. Common Bio Medical Waste Treatment Facility (CBMWTF): 1. The State is pursuing the plan of having CBMWTFs across the state with practical logistics from source of generation to treatment and final disposal. 2. The team is working on ways to commission TURA CBMWTF. It is a challenge because statutory clearances, including environmental clearance, were not taken for construction of this facility constructed under Smart City by Urban Development Department. A consultant has been engaged by Urban Department to undertake EIA. 3. Pilot is underway in West and South-West Garo Hills to study the logistics of collection, disinfection, OHS. B. Equipment procurement 1. Currently, only 10 kg bags are available to HCFs. The government wants to introduce smaller standardized sizes since amount of waste generated at many HCFs is less than 5kgs. 2. The BMWM team has requested for potential of Bank financing procurement of autoclaves, shredders and automatic weighing machines, with training on these equipment’s, in West and South-West Garo Hills to help with the outcome of the pilot. Having these equipment’s at individual HCF level will help reduce OHS risks as well as load on logistics and CBMWTF. C. Institutional Management and Capacity Building Both Project and Bank team agree that there is need for constituting a BMWM Cell within DoHFW as well as on significance of DoHFW taking ownership on reporting, collection and data management on BMW generated by HCFs. 1. Formation of BMWM Cell: With growing emphasis on BMWM by GoM as well as NGT, there is need for a dedicated team of experts to manage the agenda of BMWM within DoHFW. Therefore, Government wants to constitute BMWM Cell in DoHFW and will be custodian of BMWM agenda. 2. Centralized digital system for recording of BMW generated from government HCFs: • As per current practice, only annual reporting by HCFs is shared with SPCB. No information is ever reported to DoHFW even though it is their responsibility to manage BMW. Since, the State is laying emphasis on BMWM, it is important that the amount of waste generated by HCFs is maintained by DoHFW. This will help them with their resource planning. • SPCB and MMDSL have collaborated and taken the initiative to collect real time reporting of BMW generated from government HCFs, starting with the pilot districts. The team has developed KoBo Toolbox application to capture information real time and is being tested. So far, the data was being collected manually and transcribed digitally. • Going forward, bar coding will be used for West and South-West Garo Hills while migrating to KoBo Toolbox. Capacity Building: • The BMWM Team has started 5-day residential training through NEHU on OHS risks and management related to BMWM. • The initiative is being dove tailed with the pilot, starting with West and South-West Garo Hills. • Resource people cut across SPCB, private CBMWTFs Operators, private hospitals, DHS, MMDSL. • Two batch of 30 professionals each have received training. The subsequent batches will also be trained for NQAS certification and non-IPA components, covering 24 HCFs. • Currently, only government HCFs being covered. Plan is to expand to government blood banks, vet clinics, etc. Not sure about private entities. Funding is solely from government budget. Interventions through the Project need to be identified. D. Other Potential Areas of Intervention: 1. Conditional assessment of existing infrastructure including CBMWTF in Shillong and incinerators at various government HCFs. This will help in understanding the investment required to make the existing infrastructure function efficiently, scope of transferring the ownership to DoHFW in case of CBMWTF, and other institutional, O&M, and budgetary modalities. 2. Assessment of HCFs where BMW storage is not existent or needs refurbishment. 3. Detailed study on quantity of liquid medical waste being generated in the State and its characteristics. Currently, no government HCF meets BMWM Rules 2016 and thereof requirements on this aspect due to lack of information. Also, there is lack of sewer network in the State and the effluent from HCFs is being discharged into the environment (natural drains) after pre-treatment 4. Policy reform on collection of expired and unused medicines and their disposal. 5. Mercury based waste: Currently being collected and disposed by a firm in Kolkata. More details to be collected and potential gaps, if any, need to be explored. 6. Radioactive waste: Though management of radioactive waste does not fall under the purview of SPCB and is rather governed by AERB Guidelines with responsibility resting with DoHFW, SPCB admitted there is a lot needs to be done. The details need to be researched and fleshed out. This can be policy level intervention.