Report No: ICR00206 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-61270, IDA-D3610, IDA-63020, TF-A6941, TF-A4355) ON A CREDIT IN THE AMOUNT OF SDR361.2 MILLION (US$500 MILLION EQUIVALENT) AND A GRANT FROM THE GLOBAL FINANCING FACILITY IN SUPPORT OF EVERY WOMAN EVERY CHILD IN THE AMOUNT OF US$15 MILLION AND A GRANT IN THE AMOUNT OF SDR29.5 MILLION FROM THE IDA18 REGIONAL SUB‐WINDOW FOR REFUGEES AND HOST COMMUNITIES (US$41.67 MILLION EQUIVALENT) AND A CREDIT IN THE AMOUNT OF (SDR5.9) MILLION (US$8.33 MILLION EQUIVALENT) AND A GRANT FROM A MULTI-DONOR TRUST FUND FROM THE GOVERNMENT OF THE UNITED KINGDOM, THE GOVERNMENT OF SWEDEN AND THE GOVERNMENT OF THE NETHERLANDS IN THE AMOUNT OF US$131.16 MILLION EQUIVALENT TO THE PEOPLE'S REPUBLIC OF BANGLADESH FOR A HEALTH SECTOR SUPPORT PROJECT April 7, 2025 This ICR replaces the version published in the Board Operations System on March 26, 2025. The M&E Quality rating has been updated in the datasheet, page iii. Health, Nutrition & Population South Asia The World Bank Health Sector Support Project (P160846) ICR DOCUMENT CURRENCY EQUIVALENTS Exchange Rate Effective February 28, 2025 Currency Unit = Bangladesh Taka (BDT BDT 121.50 = US$1 US$ 1.31 = SDR 1 FISCAL YEAR July 1 - June 30 Regional Vice President: Martin Raiser Country Director: Gayle Martin Regional Director: Stefano Paternostro Practice Manager: Feng Zhao Task Team Leaders: Shiyong Wang, Bushra Binte Alam ICR Main Contributors: Pia Schneider, Kavita Phyllis Watsa The World Bank Health Sector Support Project (P160846) ICR DOCUMENT ABBREVIATIONS AND ACRONYMS AF Additional Financing AMS Asset Management System ANC Antenatal Care CC Community Clinics CEmONC Comprehensive Emergency Obstetric and Neonatal Care CMSD Central Medical Store Depot CPF Country Partnership Framework DGHS Directorate General of Health Services DH District Hospital DHIS District Health Information System DHS Demographic and Health Survey DLI Disbursement-Linked Indicator DLR Disbursement-Linked Result DP Development Partner e-GP Electronic Government Procurement EMF Environment Management Framework FA Financial Agreement FAP Fiduciary Action Plan FMAU Financial Management and Audit Unit FTPP Framework for Tribal People’s Plan FY Fiscal year GA Grant Agreement GAVI Global Alliance for Vaccines and Immunizations GBV Gender-Based Violence GDP Gross Domestic Product GFF Global Financing Facility GoB Government of Bangladesh GRS Grievance Redressal System HGSP Health and Gender Support Project for Cox’s Bazar district HNP Health, Nutrition and Population HNPSDP Health Nutrition and Population Sector Development Program HPNSP Health, Population and Nutrition Sector Program HSDP Health Sector Development Program HSSP Health Sector Support Project iBAS Integrated Budget and Accounting System IMED Implementation Monitoring and Evaluation Department IPF Investment Project Financing IRR Internal Rate of Return ISR Implementation Status Report IOI Intermediate Outcome Indicator MCH Maternal and Child Health MDG Millennium Development Goal The World Bank Health Sector Support Project (P160846) ICR DOCUMENT MDTF Multi-Donor Trust Fund M&E Monitoring and Evaluation MOHFW Ministry of Health and Family Welfare MOPA Ministry of Public Administration MTR Mid-Term Review NCD Non-Communicable Disease NCT National Competitive Tenders NGO Non-Governmental Organization NPV Net-Present Value OOP Out-of-Pocket PAD Project Appraisal Document PASA Programmatic Advisory Services and Analytics PEFA Public Expenditure and Financial Accountability PFM Public Financial Management PBC Performance-Based Condition PDO Project Development Objective PDOI Project Development Objective Indicator PPFP Postpartum Family Planning SDG Sustainable Development Goals SMF Social Management Framework SRH Sexual and Reproductive Health SWAp Sector-Wide Approach THE Total Health Expenditure ToC Theory of Change UN United Nations UNHCR United Nations High Commissioner for Refugees WHO World Health Organization The World Bank Health Sector Support Project (P160846) ICR DOCUMENT TABLE OF CONTENTS DATA SHEET ................................................................................................................................................. i I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES ....................................................................................1 II. OUTCOME ...................................................................................................................................................6 III. KEY FACTORS AFFECTING IMPLEMENTATION AND OUTCOME ................................................................. 13 IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME ............................ 14 V. LESSONS AND RECOMMENDATIONS .......................................................................................................... 16 ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS ........................................................................................ 18 ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION ....................................................... 51 ANNEX 3. PROJECT COST BY COMPONENT ......................................................................................................... 54 ANNEX 4. EFFICIENCY ANALYSIS ........................................................................................................................ 55 ANNEX 5. BORROWER, CO-FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS ................................. 57 ANNEX 6. SUPPORTING DOCUMENTS (IF ANY) ................................................................................................... 57 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT DATA SHEET @#&OPS~Doctype~OPS^dynamics@icrbasicdata#doctemplate BASIC DATA Product Information Operation ID Operation Name P160846 Health Sector Support Project Product Operation Short Name Investment Project Financing (IPF) HSSP Operation Status Approval Fiscal Year Closed 2018 Original EA Category Current EA Category Partial Assessment (B) (Restructuring Data Sheet - 03 Jul Partial Assessment (B) (Approval package - 28 Jul 2017) 2024) CLIENTS Borrower/Recipient Implementing Agency People's Republic of Bangladesh Ministry of Health and Family Welfare DEVELOPMENT OBJECTIVE Original Development Objective (Approved as part of Approval Package on 28-Jul-2017) The Project Development Objective (PDO) is to strengthen the health, nutrition and population (HNP) sector's core management systems and delivery of essential HNP services with a focus on selected geographical areas. Current Development Objective (Approved as part of Restructuring Package Seq No 1 on 13-Oct-2018) The Project Development Objective (PDO) is to strengthen the health, nutrition and population (HNP) sector's core management systems and delivery of essential HNP services with a focus on selected geographical areas. s s s s s @#&OPS~Doctype~OPS^dynamics@icrfinancing#doctemplate i The World Bank Health Sector Support Project (P160846) ICR DOCUMENT FINANCING Financing Source Original Amount (US$) Revised Amount (US$) Actual Disbursed (US$) World Bank Financing 550,000,000.00 517,708,648.56 539,245,428.46 IDA-61270 500,000,000.00 471,359,900.56 490,605,493.86 IDA-D3610 41,666,667.00 38,507,825.00 40,592,640.60 IDA-63020 8,333,333.00 7,840,923.00 8,047,294.00 World Bank Administered 146,160,719.00 145,890,719.00 146,160,719.00 Financing TF-A6941 131,160,719.00 131,160,719.00 130,890,719.00 TF-A4355 15,000,000.00 15,000,000.00 15,000,000.00 Non-World Bank Financing 770,000,000.00 0.00 0.00 Borrowing Agency 385,000,000.00 0.00 0.00 Borrowing Agency 385,000,000.00 0.00 0.00 Total 1,466,160,719.00 663,869,367.56 685,136,147.46 RESTRUCTURING AND/OR ADDITIONAL FINANCING Amount Disbursed Date(s) Type Key Revisions (US$M) • Development Objective 13-Oct-2018 Portal 65.10 • Results • Results 19-Apr-2020 Portal 210.46 • Other Changes 09-Apr-2021 Portal 361.52 • Results 23-Dec-2021 Portal 456.33 • Loan Closing Date Extension 18-Jan-2022 Portal 456.33 • Loan Closing Date Extension 11-Jul-2023 Portal 636.74 • Loan Closing Date Extension 25-Jun-2024 Portal 682.64 • Other Changes • Results 03-Jul-2024 Portal 682.64 • Loan Cancellations • Reallocations @#&OPS~Doctype~OPS^dynamics@icrkeydates#doctemplate KEY DATES Key Events Planned Date Actual Date ii The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Concept Review 25-Oct-2016 25-Oct-2016 Decision Review 02-May-2017 09-May-2017 Authorize Negotiations 12-Jun-2017 13-Jun-2017 Approval 28-Jul-2017 28-Jul-2017 Signing 28-Aug-2017 28-Aug-2017 Effectiveness 02-Nov-2017 02-Oct-2017 ICR/NCO 28-Mar-2025 -- Restructuring Sequence.01 Not Applicable 13-Oct-2018 Restructuring Sequence.02 Not Applicable 19-Apr-2020 Restructuring Sequence.03 Not Applicable 09-Apr-2021 Restructuring Sequence.04 Not Applicable 23-Dec-2021 Restructuring Sequence.05 Not Applicable 18-Jan-2022 Restructuring Sequence.06 Not Applicable 11-Jul-2023 Restructuring Sequence.07 Not Applicable 25-Jun-2024 Restructuring Sequence.08 Not Applicable 03-Jul-2024 ICR Sequence.01 (Interim) -- 23-Mar-2025 Automatically populated Operation Closing/Cancellation 30-Jun-2024 from Loans System @#&OPS~Doctype~OPS^dynamics@icrratings#doctemplate RATINGS SUMMARY Outcome Bank Performance M&E Quality Moderately Satisfactory Satisfactory Modest ISR RATINGS Actual Disbursements No. Date ISR Archived DO Rating IP Rating (US$M) 01 19-Sep-2017 Satisfactory Satisfactory 0.00 02 05-Apr-2018 Satisfactory Satisfactory 35.83 iii The World Bank Health Sector Support Project (P160846) ICR DOCUMENT 03 17-Oct-2018 Satisfactory Satisfactory 65.10 04 17-Apr-2019 Satisfactory Satisfactory 142.85 05 09-Jun-2019 Satisfactory Satisfactory 149.01 06 18-Oct-2019 Satisfactory Satisfactory 180.58 07 09-Jun-2020 Moderately Satisfactory Moderately Satisfactory 244.77 08 08-Feb-2021 Moderately Satisfactory Moderately Satisfactory 361.51 09 14-Oct-2021 Moderately Satisfactory Moderately Satisfactory 412.65 10 15-Apr-2022 Moderately Satisfactory Moderately Satisfactory 484.21 11 17-Jun-2022 Moderately Satisfactory Moderately Satisfactory 484.73 12 23-Dec-2022 Satisfactory Satisfactory 532.93 13 09-Aug-2023 Satisfactory Satisfactory 636.74 14 14-Feb-2024 Satisfactory Satisfactory 670.05 15 15-Jul-2024 Satisfactory Satisfactory 685.14 @#&OPS~Doctype~OPS^dynamics@icrsectortheme#doctemplate SECTORS AND THEMES Sectors Adaptation Mitigation Major Sector Sector % Co-benefits Co-benefits (%) (%) FY17 - Health 73 4 0 FY17 - Health FY17 - Public Administration - Health 27 0 0 Themes Major Theme Theme (Level 2) Theme (Level 3) % FY17 - Environment and Natural Resource FY17 - Climate change FY17 - Adaptation 3 Management FY17 - Human FY17 - Child Health 10 Development and FY17 - Health Systems and Policies Gender FY17 - Health Finance 21 iv The World Bank Health Sector Support Project (P160846) ICR DOCUMENT FY17 - Health System 20 Strengthening FY17 - Reproductive and 27 Maternal Health FY17 - Nutrition and Food Security FY17 - Nutrition 11 FY17 - Urban and Rural FY17 - Disaster Risk FY17 - Disaster Risk Management 50 Development Reduction v The World Bank Health Sector Support Project (P160846) ICR DOCUMENT ADM STAFF Role At Approval At ICR Practice Manager E. Gail Richardson Feng Zhao Regional Director -- Stefano Paternostro Global Director Timothy Grant Evans Juan Pablo Eusebio Uribe Restrepo Practice Group Vice President Mamta Murthi Country Director Qimiao Fan Gayle Martin Regional Vice President Annette Dixon Martin Raiser ADM Responsible Team Leader Patrick M. Mullen Shiyong Wang Co-Team Leader(s) Kari L. Hurt Bushra Binte Alam ICR Main Contributor Pia Schneider, Kavita Phyllis Watsa vi The World Bank Health Sector Support Project (P160846) ICR DOCUMENT I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES A. CONTEXT AT APPRAISAL 1. In 2017, when the Health Sector Support Project (HSSP, P160846) became effective, Bangladesh achieved substantial progress. Gross domestic product (GDP) growth had averaged 6.5 percent since 2010 and reached 7.1 percent in 2016, resulting in a per capita income of US$1,409 per year. Inflation had fallen to 5.9 percent in 2016. The fiscal deficit stood at 3.1 percent of GDP. The national poverty rate fell to 24.8 percent in 2015. Bangladesh was home to about 160 million people in 2016. The country is the eighth largest remittance-receiver globally. By 2014, child mortality dropped to 46 deaths/1,000 live births, and the maternal mortality ratio to 176 deaths/100,000 live births. By 2019, average life expectancy was 74.6 years, and the total fertility rate dropped to 2.3.1 2. Despite this progress, health financing remained inadequate. Low tax revenue collection at only 8 percent of GDP limited government spending. In 2016, the Government of Bangladesh (GoB) spent just five percent of its general expenditures on health (0.8 percent of GDP or US$6.20 per capita). High out-of-pocket (OOP) payments [63 percent of total health expenditures (THE)] had impoverishing effects on patients. The GoB’s health financing strategy 2012-2032 proposed a social health protection scheme for formal and informal workers, rewarded performance, results, and user fee retention, and strengthened national capacity and financial management. The World Bank recommended higher tobacco taxes, prioritized government health spending, and public financial management (PFM) in health. 3. Unequal health outcomes across socio-economic groups and regions required attention. Stunting fell to 36 percent in 2014; but remained high in the lowest socioeconomic quintile. Child marriage was common; half of women were married before age 18, and more effort was needed to reduce adolescent fertility (113 births per 1,000 women aged 15-19) and increase facility-based deliveries. The prevalence of infectious diseases mainly affecting the poor remained high. Non-communicable diseases (NCD) represented 14 of the top 20 causes of death, but primary care services to manage them were limited. Sylhet and Chattogram (formerly Chittagong) remained below the national average on key health utilization indicators, including for fully vaccinated children (nationwide: 84 percent in 2014, in Sylhet: 61 percent), and for facility-based deliveries (nationwide: 37 percent in 2014, Sylhet: 22.6 percent. The use of modern contraceptives in Sylhet and Chattogram also remained below the national average. 4. The Ministry of Health and Family Welfare (MOHFW) saw the Fourth Health, Population and Nutrition Sector Program (HPNSP, 2017-2024) as key to meeting the Sustainable Development Goals (SDGs). Its three components (Governance and Stewardship, Health, Nutrition and Population Systems Strengthening, and Provision of Quality HNP Services) emphasized institutional reforms and strengthened internal controls and fiduciary management systems. The National Population Policy (2012) aimed to eliminate gender discrimination, empower women, and remove barriers to family planning and maternal and child health (MCH) care. Since 1998, the World Bank has been part of a Sector-Wide Approach (SWAp) in health, adopting a series of multi-year strategies, programs, and budgets and supporting three investment financing operations in health. Under the Health Sector Development Program [HSDP (2011-2017), P118708, US$508 million with US$365 million pooled financing], an action plan was developed based on an Integrated Fiduciary Assessment to address key fiduciary risks. Project Development Objectives (PDOs) and Theory of Change (ToC) 5. The PDO, as stated in the Legal Agreement and Project Appraisal Document (PAD), was “to strengthen the health nutrition and population (HNP) sector’s core management systems and delivery of essential HNP services 1Demographic Health Survey 2022. And GBD 2019 Bangladesh Burden of Disease Collaborators (2023): The burden of diseases and risk factors in Bangladesh, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Global Health; 11: e1931-e1942 1 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT with a focus on selected geographical areas.” While the HSSP was to benefit the entire population, it targeted 50 million in Sylhet and Chattogram. Poverty rates were lowest in Chattogram (18 percent) and Sylhet (16 percent) in 2016, 2 but these regions reported worse outcomes in maternal and child health. Additional Financing (AF) and restructurings modified the results framework (Tables 4 and 5) but not the PDO. 6. ToC. The project had a clear results chain (Annex A, Table A1), with logical links between actions, outputs, outcomes, and PDO elements. The rationale for Bank support was based on three challenges: (a) foundational financing and system development priorities, including an underfunded health sector and health professional shortages; (b) the unfinished Millennium Development Goal (MDG) agenda in MCH, and (c) emerging challenges such as adolescent health and NCDs. Given Bangladesh’s record of achieving disbursement-linked indicators (DLIs) under the HSDP, the HSSP was first designed as a Program for Results (PforR) and revised to an Investment Project Financing (IPF) with DLIs during appraisal, using the SWAp framework to contribute financing to the HPNSP. Nine of 16 DLIs were linked to outputs or outcomes—good practice in IPF with DLI (now performance-based condition [PBC]) design. The design was informed by World Bank analytical work. The HSSP aimed to achieve its objective by strengthening governance and stewardship, the HNP system, and investing in quality of care with a focus on Sylhet and Chattogram divisions; and as of 2018, by developing HNP services for the one million displaced Rohingya population in Cox’s Bazar District in Chattogram, which had been hosted in the world’s largest refugee camp since August 2017, and supported by the United Nations High Commissioner for Refugees (UNHCR). Key Expected Outcomes, Outcome Indicators and Components 7. Five original PDO indicators (PDOIs) assessed the achievement of outcomes (Table 1). Two PDOIs on data capacity in community clinics (CC) and availability of accredited midwives assessed progress towards the PDO part one. Three PDOIs on normal deliveries, capacity to deliver Comprehensive Emergency Obstetric and Neonatal Care (CEmONC), and children benefiting from nutrition services, assessed PDO part two. Sixteen indicators were DLIs, including all original PDOIs. PDOI#1 supported gender-disaggregated data collection in CC, although the HSSP results framework did not include any gender-disaggregated indicators. The PAD detailed the DLI matrix, verification protocols, and the line of sight between the GoB program, DLIs, and the PDO. All HSSP DLI milestones emerged from joint World Bank, development partners (DPs), and GoB conversations. Civil society organizations and 21 agencies were consulted with task groups established by the government. The HSSP disbursed on-budget directly to the GoB treasury account on verified achievement of DLIs, aiming to finance GoB expenditures incurred under the HPNSP that were linked to PDO achievement. HSSP resources were “Reimbursable Project Aid” in the government budget system. Table 1: PDO Indicators (original) PDO parts PDOIs 1. Strengthening of 1. Increase in the number of CCs providing complete essential data on service delivery, including the HNP sector’s gender-disaggregated (DLI 8) core management 2. Increase in the number of Upazila Health Complexes with at least 2 accredited diploma midwives systems (DLI 7) 2. Strengthening of 3. Increase in the number of normal deliveries in public health facilities in Sylhet and Chittagong delivery of essential divisions (DLI 10) HNP services, with a 4. Increase in the number of District Hospitals (DH) with improved capacity to provide CEmONC focus on selected services in Sylhet and Chittagong divisions (DLI 11) geographical areas. 5. Increase in the percentage of registered children aged under 2 years receiving specified nutrition services in Sylhet and Chittagong divisions (DLI 14) 2 World Bank. 2019. Bangladesh Poverty Assessment. Facing old and new frontiers in poverty reduction. 2 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT 8. The three project components were aligned with the three components of the GoB’s Fourth Sector Program. They were designed to address key challenges as Bangladesh strove to attain the SDGs. • Component 1. Governance and Stewardship (Original allocation: US$81.0 million; revised US$97.9 million) aimed to improve governance and accountability systems through citizen engagement and grievance redressal (DLI 1). To lay the foundation for higher government health spending, it would support improved budget planning and allocation, an increase in budget and execution toward repair and maintenance to support basic service delivery by increasing delegation of budget authority to the service delivery level (DLI 2). • Component 2. HNP Systems Strengthening (Original allocation: US$170.5 million; revised US$160.06 million) prioritized system reform and development by strengthening MOFHW’s capacity to implement the internal audit function (DLI 3), expanding the Asset Management System (AMS) at the DH level (DLI 4); and reforming MOHFW's procurement and supply chain management processes (DLIs 5 and 6). It would support increased availability of qualified midwives (DLI 7), further development of the health management information system, and collection and analysis of gender‐disaggregated data on HNP service delivery (DLI 8). • Component 3. Provision of Quality HNP Services (Original allocation: US$248.5 million; revised US$241.86 million) supported essential services with a women‐friendly approach. Health inequalities would be reduced by targeting Sylhet and Chattogram. DLIs would incentivize better maternal care: increased utilization of health facilities for normal deliveries (DLI 10), improved capacity of DHs to provide emergency obstetric care services (DLI 11), improved readiness of public health facilities to provide family planning services (DLI 9); higher immunization coverage (DLI 12); improvements in government-delivered nutrition services, especially maternal nutrition interventions via antenatal care (ANC) services (DLI 13); and expanded infant and child nutrition interventions (DLI 14). It would support GoB strategies to address emerging challenges (adolescent health, nutrition) (DLI 15) and NCDs, focusing on hypertension and expanding coordinated urban health services (DLI 16). 9. The estimated IDA resource allocation for components 1-3 was US$500 million, approximately 45 percent of the total estimated project cost of US$1.1 billion to co-finance the HPNSP. The remaining resources would be provided by the GoB (US$385 million) and the Global Financing Facility (GFF) (US$15 million), with a financing gap of US$200 million. The GFF grant was based on the Bangladesh Investment Case 2016-20213 and it co-financed DLIs. The HSSP leveraged financing from Canada, the Netherlands, the Global Alliance for Vaccines and Immunizations (GAVI), Sweden, and the United Kingdom via a Multi-Donor Trust Fund (MDTF, TF0A6941-BD) amounting to US$131 million by closing. HSSP disbursed US$539.25 million of the total IDA (US$542.95 million) and US$145.89 million of the US$146.16 million in Trust Funds (GFF, MDTF), totaling US$685.14 million. Actual disbursement to Components 1-3 (US$608.5 million) 4 included US$462.6 million IDA, US$130.9 million MDTF, and US$15 million GFF. At closure, the World Bank did not approve a GoB request to reallocate an undisbursed SDR5.35 million (US$7.44 million) linked to the unachieved DLIs 6.2, 6.3, and 10.1. B. SIGNIFICANT CHANGES DURING IMPLEMENTATION 10. An AF of US$50 million (P167672, grant and credit) and restructuring (approved June 28, 2018, IDA-18 regional sub-window for refugees and host communities) addressed an emergency related to a Rohingya5 influx from Myanmar. A fourth component was added, with two PDOIs (Table 2) and three IOIs, but the PDO did not change. 3 While investment case evaluations are now more common, many of the earlier cases, like Bangladesh’s, have not been evaluated. 4 Difference between original allocation and actual disbursement for IDA is due to exchange rate fluctuations between XDR and US$. 5 In accordance with the CPF, this ICR uses the terminology “Rohingyas” and “displaced Rohingya population”. 3 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Table 2: New PDOIs added during restructuring PDO part Additional PDO indicators 2. Strengthening of delivery 6. Among the displaced Rohingya population in Cox's Bazar District, the number of children of essential HNP services, (ages 0‐11 months) who have received three doses of Pentavalent immunization, with a focus on selected disaggregated by gender (annual) geographical areas. 7. Among the displaced Rohingya population in Cox’s Bazar District, the number of births delivered in HNP facilities (annual) 11. Component 4: Develop HNP Services for the displaced Rohingya population in Cox’s Bazar District (Original allocation: US$50 million; actual: US$45.59 million6) was added in June 2018 (Annex A Table A1) to: (i) support GoB stewardship by enhancing planning, service management, coordination, monitoring, and disease surveillance capacities to respond to the crisis; (ii) enhance community and primary HNP services by financing essential HNP services provided by community health workers through 28 CCs, ensuring non-governmental organization (NGO)- provided services near the camps through about 200 service delivery points, and financing health service delivery for Rohingyas in union-level and NGO-managed facilities; and (iii) develop referral, inpatient HNP services for Rohingyas in two health complexes and the DH including communication, administration and medical record system. The AF financed MOHFW salaries/allowances, NGO operating costs under United Nations (UN) agency contracts, technical assistance, equipment, small infrastructure rehabilitation/maintenance, medicines and consumables. As Cox’s Bazar is in Chattogram (a target area), the HSSP supported HNP services for both local and Rohingya populations. HSSP funds were disbursed directly to UN agencies. The HSSP component 4 complemented the Health and Gender Support Project (HGSP) for Cox’s Bazar district (P171648) (2020-2024). Component 4 was not financed by MDTF/GFF. Other Changes 12. The project was restructured eight times; its closing date was extended by 18 months. The first restructuring responded to the Rohingya crisis. Procurement arrangements were modified to include provisions for agreements between the MOHFW and UN agencies that subcontracted NGOs to implement activities, and a new disbursement category was added for the AF. The original GFF TF focused on three DLIs: post-partum family planning (DLI 9), infant and child nutrition services (DLI 14), and school-based adolescent HNP programs (DLI 15). The second restructuring, with an amendment processed in October 2018, changed GFF co-financing to all DLIs under the first three components to be consistent with MDTF co-financers. The GFF continued to finance activities under the “Health financing strategy implementation” (P168010), which was a sub-task under the Bangladesh Health Financing and Fiduciary Programmatic ASA (P165906) that financed technical assistance and analytical work in support of the DLIs. The focus was on capacity building and knowledge exchange (health financing flagship course), and policy notes on PFM reforms, OOP payments and domestic resource mobilization. The restructuring of March 2021 addressed agreements from the Mid-Term Review (MTR). The details of these and other restructurings are in Table 3. 6Actual disbursement to Component 4 included US$7.63 million from IDA 6302 and US$37.96 million from IDA D361, totaling US$45.59 million based on the XDR/US$ exchange rate of January 22, 2025. 4 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Table 3: Summary of changes during the implementation of the HSSP Changes World Bank Objectives/Rationale Financing Agreement Approval (FA)/Grant Agreement (GA) Restructuring June 28, 2018 - Respond to an emergency in Cox’s Bazar District caused On Sept 20, 2018: Level 2 plus by an influx of Rohingya from Myanmar - FA for Grant No. D3610– AF (Board - Add component 4 to address health needs in Cox’s BD and Credit No. 63020– approved) Bazar and complement humanitarian assistance. BD - Add two new PDOIs and three new IOIs - Amendments to FA for - Modify procurement arrangements to include provision Credit No. 6127-BD and for agreements between MOHFW and UN agencies GFF Grant No. TF0A4355- - Add a new disbursement category for the AF. BD Restructuring October 13, - Reallocate GFF grants to the full set of disbursement On Oct 14, 2018: Level 2 2018 linked results (DLRs) of Fiscal Year (FY)17, FY18 and FY19 - Amendment to GA for as financed by the IDA credit, with retroactive financing GFF TF0A4355 of up to US$3 million to reimburse MOHFW’s eligible On Nov 5, 2018: expenditures incurred on/after January 1, 2017. - GA for MDTF TF0A6941 Restructuring April 19, 2020 - Modify unit prices of two DLRs (8.1 and 10.1) to enable On June 4, 2019: Level 2 disbursement for each unit of result achieved. - Amendment to GAs (GFF - Clarify disbursement limits for scalable results exceeding TF0A4355, MDTF annual targets. TF0A6941 - Revise baseline value of DLI 10 (PDO indicator). - Amendment to FA for Credit No. 6127-BD Restructuring March 11, - Modify twelve DLRs (including DLRs 10.1, 10.2, 12.2, 12.3 On March 15, 2021: Level 2 2021 modified to include Barisal division and address - Amendment to the FA for (post MTR) pandemic impact there on child immunization and Credit No. 6127-BD deliveries in public health facilities - Amendment to the GAs - Revise project results framework indicators. for TF0A4355 and - Modify/add allocated amounts to certain DLRs. TF0A6941 - Change references to Chittagong division to Chattogram. Restructuring December 23, - Extend closing dates of IDA credits and grant by one year Level 2 2021 from 12/31/2022 to 12/31/2023 - Extend GFF grant 21 months 12/31/2021 to 9/20/2023. Restructuring January 16, - Extend closing date of MDTF (TF0A6941) On December 26, 2021 Level 2 2022 - Amendment to GA for TF0A6941 Restructuring June 4, 2023 - Process no-cost extension of closing date by six months On July 4, 2023: Level 2 from December 31, 2023, to June 30, 2024, for IDA - Amendments to FA for proceeds (6127-BD, 6302-BD, D3610) and MDTF. GFF Credits 6127-BD, 6302-BD extension not needed. and Grant D361-BD - Revise DLR 4.2 target (30 to 14 DH) for IDA Cr. 6127-BD. - Amendment to the GAs for - Reallocate GFF proceeds between existing DLRs. TF0A4355 and TF0A6941 Restructuring June 27, 2024 - Cancel SDR 5,353,198.55 from IDA 6127-BD. On Jun 27, 2024 Level 2 - Reduce IDA allocation from disbursement category 1 by - Partial cancellation of SDR 5,353,198.55. credit proceeds from - Delete DLRs/PBCs 6.2 and 6.3 Credit No. 6127-BD - Delete IOI# 6 corresponding to DLR/PBC 6.3. Rationale for Changes and Implication for the Original ToC 13. The first restructuring and AF responded flexibly to the Rohingya crisis and supported the local population in Cox’s Bazar, enhancing the project’s contribution to the 2016-2020 Country Partnership Framework (CPF), Report 5 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT No. 103723‐BD. Supported by the United Nations High Commissioner for Refugees (UNHCR), Bangladesh would adhere to a framework for protecting refugees that was adequate to be eligible for the IDA-18 regional sub-window for refugees and host communities. The government of Canada expressed an intent to fund Bangladesh’s IDA repayment obligations related to the additional credit and financed one-sixth of the component, thereby helping to convert it into a grant. Cox’s Bazar’s population (about 2.6 million) had relatively poor HNP outcomes. The Rohingyas had urgent health needs related to infectious diseases; 24.3 percent of children were acutely malnourished, and 43.4 percent were stunted. Cox’s Bazar was not prepared for this emergency. About half the positions for physicians in public health facilities were unfilled, and staff were reassigned from other districts. The AF provided budget support to the GoB to its three-year plan for improved HNP services for the Rohingya in Cox’s Bazar. 14. The HSSP was affected by the COVID-19 pandemic which markedly slowed project implementation but also prompted a flexible response. Restructurings in December 2021 and January 2022 extended the closing date for IDA proceeds, the GFF, and the MDTF, respectively. This allowed enough time for DLRs to be achieved and project results to be verified. The March 2021 restructuring enabled a rapid response to the pandemic’s impact in Barisal division. II. OUTCOME A. RELEVANCE OF PDO 15. This ICR does not apply a split rating to evaluate the outcome of the HSSP as the project scope and the PDO did not change with the 2020 AF. There was a modest expansion of scope to cover selected indicators in Barisal division after the COVID-19 pandemic, in addition to Sylhet and Chattogram. 16. The PDO aligned well with the CPF priorities at project closure. The PDO remained highly relevant, as socioeconomic inclusion is one of three high-level outcomes in the CPF for FY23-FY27 (Report No: 181003-BD). The PDO, with its focus on HNP management and service delivery in Sylhet and Chattogram, remained relevant for the CPF objectives of improved effectiveness of public institutions to deliver services to citizens and business (objective 3), improved equitable access to quality services for human capital development (objective 4) and enhanced opportunities for women, poor and vulnerable groups (objective 5). The AF was aligned with CPF recommendations for the international sharing of refugee hosting costs and a medium-term approach to development interventions for the Rohingya and the host community, including better health services in Cox’s Bazar. The HSSP emphasized universal health coverage and reducing inequalities in Sylhet and Chattogram divisions and aligned well with the Bank's goal of ending extreme poverty by 2030. The HSSP did not explicitly align with the CPF’s climate-related priority. 17. The HSSP has been continuously aligned with GoB priorities. The HSSP was consistent with the country's Seventh Five Year Plan (2016-2020), which drew a link between health and growth. It used a SWAp to contribute to the GoB’s Fourth HPNSP (2017-2022), which was considered integral to the SDGs. The MoHFW is finalizing its 5th HPNSP (2024–2029) to accelerate progress toward achieving universal health coverage and the SDGs. The PDO focus on core management system is highly relevant to low levels of government health spending and high OOP payments being barriers to equitable access to care, weak stewardship, an unfinished MDG agenda and emerging health needs. 18. Considering the factors above, the PDO relevance rating is: High B. ACHIEVEMENT OF PDOs (EFFICACY) 19. The PDO contains two objectives, rated separately. The AF added a fourth component and modified the results framework, including two new PDOIs and three new IOIs. Cox’s Bazar in Chattogram was already a geographic focus area. Following the AF, the HSSP would support both the local and Rohingya populations. Seven indicator targets were revised upward in various restructurings. The operation is assessed based on the revised outcome targets. 6 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT 20. The ICR enriched the results framework by triangulating data from different sources. The Implementation Status Report (ISR) monitored results of indicators listed in the project results framework. These results were verified values reported by the Implementation Monitoring and Evaluation Department (IMED) of the Ministry of Planning. IMED verified results were used by the Bank for disbursement and project monitoring. Due to delayed reporting and verification by IMED, the final ISR reported on several indicators up to 2021/22 but verified results were not yet available for the final HSSP years (2023/24) to clarify whether results were sustained. The results framework did not compare Sylhet and Chattogram with the national average, or comparable divisions to assess any improvements for “lagging” regions. Although the HSSP supported gender-disaggregated data collection, there was no indicator to monitor results by gender. The ICR triangulated ISR results with government and survey data and used findings from the GoB’s endline evaluation (not independently verified)7 and the literature to assess trends until project closure. PDO 1: to strengthen the health nutrition and population (HNP) sector’s core management systems 21. Activities financed under Component 1 (citizen engagement and grievance redressal, budget planning and allocation) and Component 2 (financial management capacity at MOHFW to implement the internal audit function, expanding the AMS at DH level, reforming procurement/supply chain management processes, increased availability of qualified midwives, development of the health management information system) are outputs that were expected to lead to stronger core managements systems and contribute to PDO 1. The ToC for Component 1 plausibly linked outputs including improved citizen feedback systems to improved accountability and responsiveness of HNP services and better planning and budget allocation on repair and maintenance in health facilities, which was expected to lead to higher maintenance spending. Similarly, the ToC for Component 2 plausibly linked outcomes related to stronger HNP management systems to outputs including timely government spending, functioning medical equipment, improved availability of medicines, family planning commodities and medical supplies, skilled human resources, and health planning and policy informed by gender-disaggregated data. Indicators had a strong focus on setting up capacity but gave less attention to the outputs produced and how they contributed to core management systems. 22. Two PDOIs and six IOIs were DLIs and also monitored PDO achievement. Two IOI targets (for DLIs 2 and 4) were revised upwards, although the target for DLI 4 was revised downwards again to align with results for disbursement in 2022. Both DPOIs and two of six IOIs met their targets by project closure. Outcomes: • CCs providing complete essential data on service delivery, disaggregated by gender (DLI 8). From zero to 7,006 clinics with gender-disaggregated data in 2021, meeting the target of 7,000 (of a total of about 13,000 clinics nationwide). In 2012-2016, some CCs already reported service use disaggregated by gender; and more than half of CC services were provided to women,8 suggesting the HSSP’s baseline was likely not zero as it continued to support the MOHFW’s District Health Information System version 2 (DHIS2). The GoB endline evaluation reports 8,200 CCs in 2022, suggesting this activity is sustained. Data collection is an input indicator. The HSSP M&E framework did not track gender-disaggregated outputs and management decisions based on this data. • Upazila Health Complexes with at least two accredited diploma midwives (DLI 7): In 2022, 382 health complexes met this goal, exceeding the targeted 150 health complexes. The ISR reported no further results after the target was met in 2022. The GoB’s endline evaluation reported 692 complexes nationwide with two accredited diploma midwives in July 2024 (not independently verified). The HSSP did not assess how midwives improve access and outcomes. Another study found that professional midwives in government hospitals leads to improved availability 7 MOHFW. 2024. Endline Evaluation Report of 4th Health, Population and Nutrition Sector Program. GoB. 8 Riaz et al. 2020. Community clinics in Bangladesh: A unique example of public-private partnership. Heliyon. 7 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT and quality of maternity care.9 Between 2019 and 2023, midwives saved 218 neonatal lives and 28 maternal lives in Chattogram.10 Intermediate Results: Component 1: • Annual Grievance and Redress System (GRS) performance report from the previous calendar year is published (DLI 1): Three reports were published for 2020, 2021 and 2022, 11 after independent verification by IMED, and the project disbursed.12 The Directorate General of Health Services (DGHS) tracks grievances and complaints through its web-based portal.13 Since July 1, 2024, the portal has listed more than 5,100 individual complaints. The Annual GRS report for 2023 has not been published, partially meeting the target of annual publication. There is no information on how complaints have been addressed to improve management in health facilities and the system. • Repair and maintenance expenditures at Upazila level and below compared to FY16 (DLI 2): In FY21, the increase was 131 percent and 270 percent in FY22, meeting the original DLR 2.2 target of 100 percent increase and the revised IRI target of 270 percent. Based on these achievements (verified by IMED) the HSSP disbursed. The ISR reported no further results after 2022, and it is thus not clear whether this increase has been sustained until project closure. The MOHFWs Endline Evaluation reports the target was achieved by 100 percent in June 2024, and a cumulative increase of 179 percent in relevant expenditures from 2017-2024 (unverified results). In 2014–15, the MOHFW spent overall about 3 percent of recurrent expenditure on repair and maintenance. Since 2019- Figure 1: Repair & maintenance in % of total 2020, budget allocations to repair and maintenance for recurrent revised budget all health facilities have declined as a share of the Bangladesh Health Service Division recurrent revised budget (Figure 1).14 As the GoB has not published any information on budget allocations and 5.1% 4.5% 4.5% 4.1% actual expenditures on an Upazila level, this ICR cannot ascertain that the repair and maintenance expenditures 2019-20 2022-23 2023-24 2024-25 at the Upazila level have been protected within the overall MOHFW budget decline for repair and maintenance. Furthermore, although GoB agencies now receive the budget online (via the Integrated Budget and Accounting System iBAS++) the DGHS still experienced delays in fund release due to delayed fund release request letters, incomplete information on certified reconciled accounts and statements of expenditures, and non- compliance.15 Based on this information, the indicator is partially met at closure. While government spending on maintenance at the Upazila level is important, it is minuscule compared to other spending lines, such as wages and medicines. Thus, it is a relatively weak indicator to affect health system management. The HSSP did not monitor the impact of repair and maintenance spending on structural quality of service delivery in Upazila health facilities. Component 2: • MOHFW Financial Management and Audit Unit (FMAU) completes internal audit for the previous FY (DLI 3): Target is met in 2021 and 2022. The audit is yet to be completed for 2023. Based on the Public Expenditure and Financial Accountability (PEFA) (2023), the internal audit function is operational at the FMAU, and a few qualified 9 Anderson, R., et al. 2022. The impact of professional midwives and mentoring on the quality and availability of maternity care in government sub- district hospitals in Bangladesh: a mixed-methods observational study. BMC Pregnancy Childbirth 22, 827. 10 JHU (2024). Impact of skilled midwives on saving maternal and newborn lives in Bangladesh. 11 These reports were published on the GoB DGHS/MOHFW website. 12 The 2019 GRS report was verified in IMED’s 10th report, the 2020 GRS report in IMED’s 21st report, and the 2021 GRS report in IMED’s 25th report. 13 https://app.dghs.gov.bd/complaintbox/ 14 Health Services Division: Demand for Grants and Appropriations 2019 – 2025. 15 World Bank. 2019. PFM Bottlenecks Constraining Health Service Delivery at District Level and Below in Bangladesh. Knowledge Brief. 8 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT auditors have been recruited with support of the HSSP. The ICR rates this indicator as partially met. The project did not assess how recommendations from audit reports have been managed and addressed in health. • District‐level referral facilities in which AMS is implemented (DLI 4): 14 DHs in FY22, meeting the original target of 15 facilities, not the revised target of 30 facilities, meeting the final target of 14 revised down in 2023. The GoB published a nationwide list of 41 district hospitals implementing electronic AMS in 2024.16 The PEFA (2023) found physical asset management in health facilities is not fully tracked, and reporting on asset disposal is inadequate.17 The HSSP did not monitor the impact of AMS on the availability of assets in health facilities and management. • National Competitive Tenders (NCTs) using electronic Government Procurement (e‐GP) issued by MOHFW (DLI 5): 98 percent of NCTs in FY22 exceeding the targeted 75 percent. The e-GP system is mandatory, 18 and contributes to improved management systems. The HSSP did not monitor the impact of e-GP on the availability and management of commodities and medical supplies in health facilities and on reduced stockouts of medicines. • Ministry of Public Administration (MOPA) approves Central Medical Stores Depot (CMSD) restructuring proposal (DLI 6): The proposal was submitted, but has not been approved yet by MOPA, not meeting target of approval. 23. The project almost fully achieved its objectives related to stronger HNP core management systems under the original and revised targets. The final ISR reported indicator results up to 2021/22. The two PDOI results (gender- disaggregated data collection, midwives) were achieved and likely sustained until project closure in 2024. Two IRIs were achieved (AMS in DHs, NCTs e-GP), three were partially achieved (GRS report published, repair and maintenance expenditures, audits), and one IRI was not achieved (CMSD restructuring). The M&E framework focused on input factors and lacked output and outcome indicators to assess their impact on core management. This is consistent with an efficacy rating of Substantial (Annex Table 2). 24. Rating of PDO part 1: Substantial. PDO 2: to strengthen delivery of essential HNP services with a focus on selected geographical areas 25. The activities financed under Component 3 (improved readiness of health facilities to provide family‐planning services, increased utilization of maternal health services and normal deliveries, improved emergency obstetric care in DHs, enhanced immunization coverage, expanded maternal nutrition services and infant/child nutrition interventions, school-based adolescent HNP, and hypertension diagnoses and referral services in primary health care) all strengthen the delivery of essential HNP services. Additional Component 4 activities targeted Rohingyas in Cox’s Bazar by financing MOHFW salaries/allowances, operating costs of subcontracted NGOs, technical assistance, equipment, small infrastructure rehabilitation and maintenance, and medicines and consumables. 26. The ToC underpinning the second objective plausibly connected essential HNP service delivery with support to health facilities in Sylhet and Chattogram, including Cox’s Bazar district, with the most deprived population groups. Both components incentivized better quantity and quality of care in health facilities that serve the poor in these areas, plausibly contributing to the objective. The ToC for the AF was highly plausible to address the health needs of Rohingyas who face high rates of infectious and chronic diseases, malnutrition, mental health issues; live in crowded camp conditions and are exposed to natural disasters, landslides and heavy monsoon rains with negative health impacts.19 Sylhet and Chattogram were lagging areas that experienced tremendous change (Annex 1B).20 27. The results framework monitored the achievement of the second objective with five PDOIs and nine IOIs, which were also DLIs under component 3. Four PDOI targets (DLI 10 and 14, and both AF PDOI) and three IOI targets 16 http://hospitaldghs.gov.bd/wp-content/uploads/2024/06/MOHFW-Supply-Chain-Management-Portal.pdf 17 PEFA 2023. 18 https://www.cptu.gov.bd/media-communication/news-1446.html 19 Tsichlis, JT, et al. 2024. Prevalence of non-communicable disease among displaced Rohingya in southern Bangladesh: Int Health, 16,4; 409–415. 20 DHS 2022. 9 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT (DLI 12 and 13 and one AF IOI) were revised upwards, and one IOI target for the HNP core indicator on essential HNP services was revised downwards. Two of five PDOIs and seven of nine IOIs met their targets by project closure. Outcomes: Component 3: • Normal deliveries in public health facilities in Sylhet and Chattogram (DLI 10): from 106,673 in 2017 to 151,305 normal deliveries in FY21 and 175,262 in FY22, exceeding the original target of 146,000 and both revised target of 120,000 and 170,000 deliveries including in Barisal division, based on which the HSSP disbursed. Following March 2021 restructuring, this indicator was changed to include normal deliveries in Barisal division. The target was revised downwards in the ISR and upwards in the restructuring paper to 170,000 normal deliveries. Results for 2023 are not yet available; however, trend data and other agency results suggest the activity is sustained. • DHs with improved capacity to provide CEmONC services in Sylhet and Chattogram (DLI 11): 12 DHs in FY21 exceeded the target 10 DH and the project disbursed. In FY22, only 7 DH met the target. CEmONC is integral to Bangladesh’s National Strategy for Maternal Health 2019-2030.21 The HSSP did not monitor the impact of improved CEmONC on quality of care or service use. This indicator is partially achieved. • Registered children under age two receiving specified nutrition services in Sylhet and Chattogram (DLI 14): 77 percent in FY22 exceeded the original target of 35 percent and a revised target of 54 percent. Although the HSSP met the targets by FY22, child nutrition is still an issue in these regions. Based on the DHS 2022, the proportion of children fed a minimum acceptable diet is lowest in Sylhet (19 percent) and Chattogram (20 percent), below the national average of 29 percent. Furthermore, by 2022, stunting fell to 24 percent nationwide but remained highest in Sylhet (34 percent) and Chattogram (25 percent) (DHS 2022). Hence, the two regions are still lagging regions. Component 4 (AF): • Children (aged 0‐11 months) among the Rohingya in Cox's Bazar District who have received three doses of Pentavalent22 immunization, disaggregated by gender, annual: from 221 immunized children (2018) to 87,105 children cumulatively (42,646 boys; 44,4459 girls) immunized from April 2019 to December 2021 (33 months)—an average of 31,675 immunized children annually, meeting the original target (20,000 children annually) and partially meeting 90 percent of the revised annual target of 35,000. These results were likely sustained considering that WHO reported 96 percent of 420,000 children received the Pentavalent vaccine in Cox’s Bazar (November 2022),23 and GAVI reported a 98 percent Penta-3 vaccination rate nationwide.24 This PDO indicator is also a PDO indicator in the HGSP (2020-2024). • Births delivered in HNP facilities among the displaced Rohingya population in Cox’s Bazar District, annually: from 5,427 (2018) to 25,607 births cumulatively (April 2019 to December 2021, 33 months)—an annual average of 9,312 births meeting the original annual target of 10,000 births; but not the revised annual target of 20,000. The revised target exceeds the UNHCR-reported census data of 10,238 babies born to the Rohingya and registered in 2023,25 but is below the 30,000 births estimated by the MOH. The ICR rates this indicator as not met. The maternal death rate was 295 per 100,000 live births in Cox’s Bazar in 2023,26 higher than the national average of 196 per 100,000. Intermediate Results: Component 3: 21 GoB MOHFW. Bangladesh National Strategy for Maternal Health 2019-2030. 22 Pentavalent protects against diphtheria, tetanus, pertussis (whooping cough), hepatitis B, and Haemophilus influenzae type b (Hib). 23 WHO: Bangladesh: Protecting the most vulnerable – Pentavalent & Td vaccination campaign in Cox’s Bazar (7 June 2023) 24 GAVI Bangladesh immunization context: https://zdlh.gavi.org/country-profiles/bangladesh#immunization-context 25 UNHCR Annual Report 2023. 26 WHO. Cox’s Bazar Health Sector Bulletin. January 2024. 10 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT • Targeted public health facilities meeting readiness criteria for delivery of postpartum family planning services in Sylhet and Chattogram (DLI 9): 61.5 percent increase for FY22 substantially exceeding the target of 35 percent. • Districts reaching at least 85 percent coverage of measles-rubella vaccination among children aged 0-12 months in Sylhet and Chattogram (DLI 12): from 14 (2017) to 21 (FY22), exceeding the original target of 15 and the revised target of 18 districts. In the March 2021 restructuring, this indicator was changed to include Barisal division, and the target was revised. The GoB endline evaluation (4th HNP Strategy) shows 37 districts reaching 85 percent measles-rubella immunization rate in the three divisions in 2024. The WHO reports a 97 percent measles-rubella vaccination rate nationwide in 2023,27 suggesting sustained results. • Registered pregnant women receiving specified maternal nutrition services in Sylhet and Chattogram divisions, reported for the previous calendar year (CY) (DLI 13): from zero percent (2017) to 84 percent (FY22), exceeding the original target (25 percent) and the revised target (65 percent). This increase mainly happened between 2020 and 2022, considering that an impact evaluation found that from 2018 to 2020, the HSSP led to only a 2.7 percent increase among registered pregnant women receiving nutrition services.28 The UN contracts were extended in April 2022. Interventions also continued under the HGSP. The size of pregnant who were registered is unknown but could be only about one-third of the estimated number by the MOH (see above on births). • Districts where the school-based adolescent health program is implemented in Sylhet and Chattogram (DLI 15): Implemented in seven districts only in 2022, meeting the target of seven. Information for 2023 is not available. The DHS 2022 reports 24 percent of teenage girls have ever been pregnant nationwide, but rates were lowest in Sylhet (11 percent) and Chattogram (22 percent), continuing a historical trend. • Assessment completed of hypertension diagnosis and referral services at the primary level in at least two of 35 upazilas in Sylhet and of 100 upazilas in Chattogram (DLI 16). Target met in 2022. • People who have received essential HNP services, annual. 11.03 million cumulatively in 33 months (April 2019- December 2021), an annual average of 4.011 million, not meeting the original (5.78 million) or revised (5.3 million) annual targets. This indicator is partially achieved. Component 4 (AF): • HNP facilities providing an appropriate mix of family planning methods to the Rohingya in Cox's Bazar: from four facilities (2018) to 98 facilities (2022) exceeding the very low target of 15 facilities cumulative. The project did not track outputs of these facilities. In 2023, there were 138,000 first-time users of family planning methods.29 • Pregnant women and lactating mothers reached with social and behavior change interventions on infant and young child feeding among Rohingya in Cox’s Bazar: from 32,000 in 2018 to 288,656 women cumulatively for 33 months (4/2019-12/2021). Results for 2022 and 2023 are not monitored. The ICR computed an annualized average of 104,966 women, which far exceeded the original target of 67,000 women and partially met the revised target of 115,000 women. UNICEF reports 70,037 Rohingya pregnant and lactating women and caregivers of children 0- 23 months in Cox’s Bazar received counseling and messaging on nutrition, and 2,072 mothers in Bhasan Char.30 • Women and girls who have received women‐friendly services information on SRH health and rights/gender-based violence (GBV) among the Rohingya population Cox’s Bazar District: from 90,311 in 2018 to a cumulative number of 408,532 women and girls for 33 months (4/2019-12/2021). The ICR computed the annual average of 148,557 women and girls, exceeding the target of 138,000 women and girls. Results for 2022 and 2023 are not available. Services were provided by UNFPA in women-friendly spaces and continued under the HGSP (P171648). 27 WHO: Immunization Bangladesh. https://immunizationdata.who.int/dashboard/regions/south-east-asia-region/BGD 28 Raza W. and D Chaudhery. 2022. Impact of Health Sector Support Project on Essential Nutrition Services: Evidence from Bangladesh (2018-2020). HNP Discussion Paper. The World Bank. 29 Health Sector Cox’s Bazar: Health Sector Bulletin: January 2024. 30 UNICEF 2024. Humanitarian Situation Report No. 69. 11 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT 28. The HSSP partially achieved its objectives of improved essential HNP service delivery in Sylhet and Chattogram divisions. Two of five PDOI were fully met, one is substantially met (CEmONC in DH), one PDOI is partially met (Pentavalent), and one is not met (births in HNP facilities). Of the nine ICRIs, seven have fully met their targets, one is substantially met (social and behavior change), one is partially met (essential HNP services). MCH outcomes and stunting rates have improved nationwide and in the two divisions, although they are still lagging. DHS, WHO and GAVI data suggest high pentavalent immunization among children and facility-based deliveries in Cox’s Bazar district. In addition to WB support, the government received substantial support from the UNHCR, DPs and NGOs to provide care to about a million Rohingyas in Cox’s Bazar. This is consistent with an efficacy rating of Substantial (Annex Table 3). 29. The overall efficacy rating of the PDO is rated Substantial. Although the HSSP had a plausible results chain, it was not well reflected in the M&E framework which emphasized capacity built over outputs. The ISR did not report the most recent values for several indicators, and targets were relatively low. Of the seven PDOIs, four were achieved, one substantially achieved, one partially achieved, and one not achieved. Of the 15 ICRIs, nine were achieved, one substantially achieved, and four partially achieved. One ICRI was not achieved. Results from the GoB endline evaluation and the published literature suggest that health results are moving in the expected direction. Based on these findings and the triangulation process (Annex 1B), overall efficacy is rated Substantial (Annex Table 4). C. EFFICIENCY 30. The PAD’s efficiency analysis estimated the HSSP would lead to a net-present value (NPV) of US$2 billion over 20 years and 22 percent internal rate of return (IRR) using a 3 percent discount rate. This would be achieved by better health service delivery and health outcomes, prevented healthcare costs and income loss for households and prevented costs to the healthcare system. The cost-benefit analysis anticipated reduced OOP spending on medicines and higher labor productivity due to fewer days lost from illness. The updated economic analysis for the AF estimated a US$160 million NPV over ten years. 31. The HSSP disbursed US$685 million to the GoB treasury with a focus on efficiency gains through improved management and service delivery, yet the results framework did not include any indicators to track government health spending, its allocative efficiency of and its impact on project objectives. While the HSSP contributed to improved service delivery under the SWAp, the ICR efficiency analysis finds there is no evidence of higher government spending on health infrastructure and service delivery. Instead, the HSSP contributed to higher healthcare cost and income loss for patients, and did not affect labor productivity. The HSSP had a strong supply-side focus to build capacity and interventions to improve GoB spending were missing. The limited focus on the maintenance budget for Upazila health facilities did not affect allocative efficiency in the health system and patients’ OOP spending. DLIs and output indicators emphasized the capacity and availability of care, which is important, but gave less attention to outputs and outcomes produced with this capacity. Given the decades-long Bank and DP engagement under the SWAp and the large project amount, DLIs could have been designed more ambitiously to focus on outputs and outcomes in health and to increase the GoB health budget implementation. The detailed efficiency analysis is in Annex 4. 32. Considering all these factors, efficiency is rated as Modest. D. JUSTIFICATION OF OVERALL OUTCOME RATING 33. The overall outcome rating is Moderately Satisfactory. Relevance of the objectives is rated High. Efficacy is rated Substantial. Efficiency is rated Modest. The overall outcome rating is Moderately Satisfactory, indicative of moderate shortcomings in the HSSP’s achievement of the first and second objective and in project efficiency. 34. Rating: Moderately Satisfactory. E. OTHER OUTCOMES AND IMPACTS 12 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT 35. The focus on MCH care is expected to impact human capital and future health outcomes positively. In 2021, women reported a higher life expectancy of 74 years than men (71 years). The most common causes of mortality are NCDs with men being at higher risk, which can be monitored with diagnostic capacity for hypertension. 36. The project supported limited institutional strengthening. The emphasis was on the repair and maintenance budget, internal audits, and AMS. The project design did not include financing reforms to reduce high OOP expenses. 37. The HSSP mobilized US$15 million in private sector financing through co-financing from the GFF TF, which includes private sector financing from the Gates Foundation, and financed nutrition related TA and analytics. 38. The HSSP did not generate opportunities for the GoB to contract private sector expertise to strengthen care provision. Rather, it focused on the public sector and NGOs. Some analytical work was produced on the private sector. 39. Pharmaceutical spending management. Although over half of household OOP expenses are on medicines from private pharmacies, and the economic analysis expected household spending on medicines to decline, the HSSP design did not include measures to regulate and manage pharmaceutical spending by households and to improve the availability of free medicines in public health facilities. 40. Project interventions focused on improved service delivery in poor areas but not the impoverishing effect of health spending. The HSSP supported public health facilities that primarily serve the poor. Household survey analysis from 2016-2017 suggests that about 25 percent of the population incur catastrophic health expenditure, and 14 percent forgo care due to high fees. People with chronic illnesses are most affected.31 Future Bank support could focus on preventing high health spending for the population. III. KEY FACTORS AFFECTING IMPLEMENTATION AND OUTCOME A. KEY FACTORS DURING PREPARATION 41. During preparation, the HSSP design was informed by lessons from previous health projects. Stakeholders were appropriately engaged under the SWAp. After discussions with the government, the instrument was changed from a PforR to an IPF with DLIs. Recommendations from World Bank Integrity Vice Presidency reports informed the fiduciary action plan, which was maintained (though not required for an IPF). Once effective, the HSSP was ready to implement. B. KEY FACTORS DURING IMPLEMENTATION 42. Splitting of the MOHFW into two divisions. According to the GoB’s endline evaluation, the restructuring of the Ministry into two divisions affected the sector program. From the HSSP perspective, coordination issues may have led to inefficiencies in primary health care and family planning services, which are now under different directorates. 43. Lengthy time taken for results verification and/or reporting. The GoB’s capacity to verify results through the IMED was hampered by logistical issues in the pre- and post-COVID-19 period. After the pandemic, the production of the GoB’s annual report for the program results reporting was slow. The Bank recruited additional consultants to support the IMED. Capacity for verification that was painstakingly built under the HSSP may have again been eroded by staff changes following the political events of 2024. 44. The Bank produced a strong analytical program, including a Public Expenditure Tracking Survey based on 2019/20 data, and the HEU published a Public Expenditure Review for Health up to 2020. The Bank recruited 31Rahman et al. 2022. Forgone healthcare and financial burden due to OOP payments in Bangladesh. https://link.springer.com/content/pdf/10.1186/s13561-021-00348-6.pdf 13 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT consultants to support the Ministry with implementing recommendations to strengthen the implementation of the Fourth Sector Program. These analyses could be continued to inform the Fifth Sector Program. 45. Emergency needs of the Rohingya in Cox’s Bazar. The HSSP team responded to the challenge posed by the Rohingya influx, using the HSSP platform effectively and flexibly to bring in AF and work with UN agencies on implementation. This also imposed additional demands on the Ministry. Consolidated funding through HSSP and UN agencies to implementing NGOs facilitated their work. NGOs reported high staff turnover among staff working in the camps; hence, training more Rohingyas in community health, paramedics, nursing, midwifery, and data collection and M&E has been discussed to work with NGOs in the camps. 46. Impact of the COVID-19 pandemic. Bangladesh reported 2.05 million confirmed COVID-19 cases and 29,493 deaths as of April 2024. 32 Disrupted health services led to sharp declines in maternal health services, child immunizations, and family planning. There were also geographic disparities in the impact of the pandemic on health services; for example, Chattogram was among the worst affected divisions for ante-natal care and Barisal was among those worst affected for institutional deliveries. 33 The pandemic highlighted the need for better pandemic preparedness and response, procurement, logistical management (on top of existing supply chain vulnerabilities), infrastructure, and personnel in the health sector. Deteriorating food security had an impact on nutritional status. HSSP implementation was directly impacted by the pandemic, as was project supervision and verification of results. IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME A. QUALITY OF M&E 47. M&E design: The project ToC and results framework were aligned with the GoB’s Fourth HNP Sector Program. The indicators included in the results framework were also DLIs. The HSSP had 13 indicators on capacity, including three PDO indicators and 10 IOIs. It included only nine indicators on outputs, including four PDO indicators and five IOIs. Targets were set at a relatively low level, although the HSSP was building on the achievement of previous projects. The M&E framework did not compare indicators for Sylhet and Chattogram with the national average or comparable divisions to assess any improvements for “lagging” regions. There was no indicator to assess the impact of HSSP disbursement on GoB health expenditures related to HSSP activities and achievements. 48. M&E was mainly used to disburse the loan amount, and indicators were measured and verified until they met their targets for disbursement, mostly by FY22. The ISR reported data based on verification by IMED. There was a lag between data reporting by the Ministry of Health and IMED verification. The last ISR update is based on 2022 data verified at the end of 2023 and the ISR reported no further results on the sustainability of project achievements until closure. Nine indicator targets were revised during implementation—seven upwards, one downwards to meet the result, and one target (number of deliveries) was increased in the ISR but included lower and higher targets in the restructuring paper of March 2021. Although the M&E framework requested the reporting of annual values, cumulative numbers were reported for several indicators. Data collection and monitoring could have been strengthened, and M&E could have included indicators from the DHS2017/18 and DHS2022 that were implemented during the HSSP. The results framework did not reflect indicators used in the economic analysis (OOP payments, labor productivity or better health outcomes). Capacity constraints affected M&E implementation, including “bureaucracy 32 https://www.worldometers.info/coronavirus/country/bangladesh/ 33 Hossain AT, et al 2024. Impact of COVID-19 on the utilisation of maternal health services in Bangladesh: A division-level analysis. J Glob Health. 2024 Nov 22;14:05040. doi: 10.7189/jogh.14.05040. PMID: 39575613; PMCID: PMC11583111. 14 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT within the government, inadequate capacity and …staff changes” were noted as weaknesses in IMED in the ISR Seq. 11. Project results should have been monitored until closure and targets adjusted to assess the sustainability of DLIs. 49. Recognizing the significant challenges affecting verification during the pandemic, these shortcomings in the M&E system’s design, implementation and utilization are mainly due to the lack of data on whether results have been sustained after disbursement until project closure and the insufficient attention to outputs in the results chain, based on which the project M&E quality rating is Modest. B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE 50. Two safeguard policies were triggered: (i) Environmental Assessment OP/BP 4.01 and (ii) Indigenous Peoples OP/BP 4.10. The AF did not process any changes to these policies. 51. The HSSP was Environmental Assessment Category B. A moderate risk related to waste management in primary care facilities triggered Environmental Assessment OP/BP 4.01. An Environmental Management Framework (EMF) was developed and disclosed to mitigate potential negative impacts. The quality of policies and regulations on healthcare waste management was found adequate, but concerns were raised about GoB agencies’ capacity to implement environmental policies. No construction was planned under the HSSP. The EMF was expected to promote environmental health, but the HSSP design did not include environmental health services, and no documentation and progress reports were required to determine whether environmental protocols had been adequately followed during implementation in Sylhet and Chattogram, and in the HNP facilities in the Rohingya camps (AF). 52. Indigenous People. The project triggered the preparation of Indigenous Peoples Plan OP/BP 4.10 due to activities in Chattogram Hill Tracts and other areas. The MOHFW developed a Social Management Framework (SMF) and a Framework for Tribal People’s Plan (FTPP) to guide on gender, equity, voice, accountability, and tribal peoples. Both were reviewed by the Bank and publicly disclosed by the MOHFW in March 2017. The Indigenous people policy was triggered under the AF as host communities in Cox’s Bazar included ethnic communities with distinct characteristics of Indigenous peoples. The SMF and FTPP were updated to include new activities and identify mitigation for the displaced population, paying particular attention to GBV. The document was published in 2019.34 53. Fiduciary compliance. The HSSP continued to support the strengthening of the MOHFW’s fiduciary systems. This began under an AF of the HSDP. Under the HSSP, a Fiduciary Action Plan (FAP) laid out key actions to be achieved out to 2022, based on an Integrated Fiduciary Assessment done in 2015 and its action plan agreed to by the GoB, the World Bank, and health co-financing DPs. Early delays in achieving the FAP were monitored and resolved. In 2019, a critical step demonstrating progress was the preparation of the Interim Unaudited Financial Reports using the iBAS of the Ministry of Finance (ISR Seq 5). Given the known high fiduciary risk, it is significant that the FAP was supported throughout. There was no procurement under the HSSP except UN agencies agreements (component 4). 54. The HSSP included fiduciary-related DLRs to improve accountability and transparency by strengthening AMS and restructuring CMSD but were slow to progress. The MOPA-endorsed CMSD restructuring proposal was submitted to the Ministry of Finance but not approved. C. BANK PERFORMANCE 55. Quality at Entry. The original HSSP design reflected the GoB’s Fourth Sector Program priorities and the CPF and the HSSP was prepared under a collaborative SWAp. The design incorporated lessons from the previous health program and was informed by relevant analytical work. The project objectives were realistic, and the components aligned with the objectives; however, the targets were not ambitious enough for a project amount of US$685 million with DLIs that directly disburse to the treasury. The Bank was flexible and changed the lending instrument from PforR 34 https://ewsdata.rightsindevelopment.org/files/documents/79/WB-P171779_VSwI56D.pdf 15 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT to IPF with DLIs during the approval process, although an IPF with DLIs required fewer fiduciary controls than a PforR, which would have been important in a low-transparency context. The M&E design, implementation, and utilization were modest (see M&E section). The design could have included DLIs to be achieved annually with higher annual disbursement amounts towards the end of the project year. In the context of such low government health spending, more ambitious DLIs could have been included to incentivize higher government spending on health. 56. Quality at Entry Rating: Moderately Satisfactory. 57. Quality of supervision. The HSSP team published 15 ISRs diligently detailing DLR achievement and verification, progress on co-financing, and fiduciary and E&S aspects. Sector dialogue was conducted within the SWAp, not project mechanisms. The team’s ability to report on DLRs was hampered by delays, particularly in field-based verification, which caused a disbursement lag. The team conducted a Public Expenditure Tracking Survey for 2019/20 35 and excelled in managing co-financing and agreements to expedite implementation by UN agencies of component 4 in Cox’s Bazar. Despite supervision challenges in 2020-21, the MTR was completed with a six-month delay, and the project team was proactive in completing restructurings. There was only one change of ADM TTL. The project delivered PASA on key topics. Weaknesses in the M&E framework could have been more actively addressed, and results could have been tracked until project closure. Strengthening IMED’s capacity for verification was a challenge for the Bank team, compounded by COVID-19. Gains in capacity, supported even during the pandemic, may have been sustained in the normal course but 2024 was an extraordinary year with major changes impacting the GoB. 58. Candor of ratings. While fiduciary compliance was inadequate at the outset, steps were taken to expedite actions in the FAP. FM performance ratings reflected both delay and improvement. E&S compliance was monitored closely, and the risk rating was adjusted based on the context for implementation of component 4. Implementation progress and PDO ratings were downgraded as expected during the pandemic and later upgraded with robust justification. The M&E rating could have been downgraded somewhat earlier. 59. Quality of Supervision Rating: Satisfactory 60. Overall Bank performance is rated Satisfactory. Despite COVID-19-related challenges, the task team performed strongly on operational aspects, in the policy dialogue on health service delivery, and swiftly prepared a Rohingya emergency response. The team also made a strong effort to manage the co-financing efficiently and to produce relevant PASA. Shortcomings in the M&E framework could have been addressed better. D. RISK TO DEVELOPMENT OUTCOME 61. Massive ministry staff turnover, low government health expenditures, and high vacancy rates among health professionals. The political events of August 2024 (after project closure) resulted in massive staff turnover at the MOHFW. A lack of continuity and erosion of acquired capacity constitutes a risk to sustained outcomes that will need to be addressed in the future. Government health expenditures remained low and declined for maintenance and repairs in the health sector overall, which affects providers’ capacity to deliver care. Low government health spending also negatively affects patients who pay more out-of-pocket. There were high vacancy rates among health professionals in government health facilities. While more midwives were recruited, high vacancy rates continued, placing service delivery at risk, and highlighting the importance of higher government spending. V. LESSONS AND RECOMMENDATIONS • Optimize the use of DLIs and M&E until project closure. Future results-based operations could disburse annually and progressively increase targets to maintain focus on the reform and to monitor results until project closure. Verification should be based on timely data, including survey data. Issues in data should be addressed by 35 World Bank 2022. Public Expenditure Tracking Survey Bangladesh. 16 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT improving the quality and interoperability of government health datasets for accurate reporting. Partnering with local research institutes and universities can help build analytical capacity within the government. • Considering the changing DP environment, the SWAp approach needs to be revisited to ensure a collaborative approach that reduces transaction costs for the GoB and NGOs. The Bank may also want to reassess the optimal lending instrument in this changing context to support the government in its policy reforms and investments. • PDOs to strengthen core management systems should be measured based on outputs. This would include monitoring the availability and functionality of assets resulting from AMS capacity, and the use of data for policy reporting and decision-making due to better data systems. • The HSSP produced substantial analytical and advisory work on PFM and health financing and the MOHFW addressed some recommendations. These products can continue to be used in the health financing dialogue. • Given the very high OOP on health and low government health expenditures of 0.4 percent of GDP in 2021, health financing should be a top priority. With declining DP support for health, it is crucial to prioritize increased government health spending to reduce OOP expenses by implementing PFM reforms and elements of direct facility financing (PEFA 2023,36 recent PFM studies). GoB strategies also aim to establish a national social security system that covers sickness, maternity, and protection for formal sector industrial accidents. A decentralized approach to health financing reforms could be explored given the large population size. • Future Bank work could support implementing the Bangladesh Health Workforce Strategy 2023, focusing on streamlining recruitment and management of health professionals in health facilities.37 This will require policy and administrative reforms, increased government health spending, and investment in information technology. • Considering the high turnover of NGO-staff in the camps, NGOs could train and recruit Rohingya health workers, including community health workers, paramedics, nurses, midwives, data collectors, and analysts. A comprehensive approach to health in Cox’s Bazar will help address other determinants of ill health. • Pay closer attention to the impact of climate change on health. The analytical work on climate change and health is being used to inform efforts in climate-related disease surveillance, innovative vector control, and public health research under future Bank projects and TA. • Future Bank support could support government contracting with NGOs and the private sector, including for M&E, IT, laboratory services, cleaning, hospital kitchens, maintenance, and eventually for imaging services. This would necessitate efficient financing mechanisms for private providers and strengthening contract management capacity at the government. So far, only two PPPs have been operationalized in health.38 An IFC-supported dialysis PPP suspended service delivery due to delays in payments and arrears.39 36 PEFA 2021. Bangladesh Public Expenditure and Financial Accountability Assessment. April 2023. 37 GoB, MOHFW: Bangladesh Health Workforce Strategy 2023. 38 World Bank. 2024. Path to transform Bangladesh’s health system for better results. 39 IFC: Bangladesh Dialysis Centers (January 2016) and “Dialysis in in two key public hospitals face suspension (New Age, June 22, 2023). 17 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS Table A1: Results chain/theory of change Actions/Processes Outputs Outcomes PDO Elements Component 1. Governance and Stewardship Citizen feedback system is Citizen grievances receive responses (DLI Improved accountability & Strengthening of the HNP sector’s core improved 1) responsiveness of HNP services management systems Planning and budget Higher spending on repair & maintenance allocation at service delivery level (DLI2) Component 2. HNP Systems Strengthening Financial management Improved implementation of FM functions Financing of services is more efficient, (FM) system is (internal audit) (DLI 3) timely & accountable strengthened (DLI 3) AMS is implemented (DLI More efficient purchase, use and Assets (medical equipment) are 4) maintenance of assets available & functioning to support service delivery Procurement process More efficient, transparent, & timely Improved availability at improved using IT (DLI 5) procurement service delivery level of medicines, Institutional capacity is Improved procurement and supply family planning commodities and developed for other supplies procurement, supply management (DLI 6) Strengthening of the HNP sector’s core Training, recruitment Increased availability of midwives (DLI7) Skilled human resources are in place management systems and posting of qualified & providing quality midwives health care services Information systems Gender‐disaggregated data from CCs are Gender‐informed information is are strengthened, with collected and analyzed effectively used to inform planning gender disaggregated data and policy (DLI 8) Component 3. Provision of quality HNP services (Particularly in target Improved PPFP services, particularly in Increased utilization of family areas), resources, inputs & target areas (DLI 9) planning services actions are applied to improve: Page 18 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT PPFP services maternal health care Improved delivery of maternal health care Increased utilization of maternal service delivery services, particularly in target areas health care services, particularly in target areas (DLI 10) emergency Improved emergency obstetric care obstetric care services, particularly in target areas (DLI 11) immunization Improved immunization services across Increased coverage of measles services districts, particularly in target areas rubella immunization, particularly Strengthening of in target areas (DLI 12) delivery of essential HNP services, with a focus maternal, infant and child Maternal nutrition Increased utilization of maternal, on selected nutrition services services are expanded (DLI 13); Infant infant and child geographical areas and child nutrition services are expanded nutrition services and (DLI 14) household knowledge and behaviors improve Integrated and School‐based Increased utilization of sustainable strategy adolescent health and adolescent health, nutrition services for adolescent health nutrition services are & improved knowledge and within schools (DLI 15) delivered behaviors NCD (hypertension) NCD services are Increased utilization of NCD services are developed delivered services (DLI 16); Coordination on urban health services is improved (DLI 16) Component 4: Develop HNP Services for the displaced Rohingya population in Cox’s Bazar District (US$50 million) NOTE: This fourth component was added with AF in 2018, with no change in PDO Government capacity for Enhanced planning, coordination, Improved management capacity in Strengthening of the HNP sector’s core stewardship of the HNP monitoring, disease surveillance, service the HNP sector in Cox’s Bazar to management systems sector is developed in Cox’s management systems respond to health needs of displaced Bazar district Rohingya Community and primary Improved delivery of essential service Increased utilization of essential HNP Strengthening of HNP services enhanced for package (including key maternal, child, services among displaced Rohingya Page 19 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT displaced Rohingya in Cox’s neonatal services) at household/ delivery of essential HNP services, with a focus Bazar community and primary levels on selected Immunization services for children geographical areas among displayed Rohingya; Births delivered in HNP facilities among displaced Rohingya Inpatient and referral Enhanced capacity of DH and the Ukhia Increased utilization among services developed for and Teknaf Upazila Health Complexes to displaced Rohingya of emergency displaced Rohingya in Cox’s deliver inpatient and referral services obstetric and neonatal care, curative Bazar care, diagnostics at referral level Note: PDO indicators are shown in red. Page 20 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Annex Table A2: Achievement of PDO 1 Baseline Target Target ISR value at ICR value Difference Difference % met of target Indicator (BL) 2017 (PAD) revised completion BL to BL to ICR ISR (6/2024) target value PDO DLI8 Increase in the number of 0 7,000 7,006 7006 7000 7006 100% Community Clinics providing (FY22) complete essential data on service delivery, including gender- disaggregated PDO DLI7 Increase in the number of Upazila 0 150 382 382 150 382 255% Health Complexes with at least 2 (FY22) accredited diploma midwives IOI DLI 1 Annual GRS performance report for 0 1 3 years 3 of 4 years 1 0.75 75% previous CY is published (no=0 (2019, 2020, 2021) yes=1) IOI DLI2 Increase in percentage from FY16 0 100 270 131 179 270 179 66% baseline in repair and maintenance (ISR result (Endline eval. expenditure at the levels of Upazila for FY21) For FY22) and below IOI DLI3 MOHFW FMAU completes internal 0 1 2 years 2 of 3 years 1 0.67 66% audit for the previous fiscal year (2021, 2022) (no=1 yes=1) IOI DLI4 Increase in the number of district- 1 15 30 14 14 13 13 100% level referral facilities in which AMS then 14 (FY22) is implemented IOI DLI5 Increase in percentage of NCTs 0 75 98 98 75 98 131% using e-GP issued by MOHFW (FY22) IOI DLI6 MOPA approves CMSD restructuring 0 1 0 0 1 0 0% proposal (no=0 yes=1) Page 21 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Annex Table 3: Achievement of PDO 2 Baseline Target Target ISR value ICR value Difference Difference % of Indicator (BL) (PAD) revised BL to Target BL to ICR target 2017 ISR value met PDO DLI Increase in the number of normal deliveries in public 106,673 146,000 170,000 175,262 175,262 63,327 68,589 108% 10 health facilities in Sylhet and Chittagong divisions (FY21) PDO DLI Increase in the number of District Hospitals with - 10 DH 12 DH in 7 DH 10 7 70% 11 improved capacity to provide comprehensive FY21, emergency obstetric and neonatal care (CEmONC) 7 DH in services in Sylhet and Chittagong divisions FY22 PDO DLI Increase in the percentage of registered children aged - 35% 54% 77% (FY22) 77% 0.54 1 143% 14 under 2 years receiving specified nutrition services in Sylhet and Chittagong divisions AF PDOI Among the displaced Rohingya population in Cox's 221 20,000 35,000 87,105 31,675 34,779 31,454 90% Bazar District, the number of children (ages 0-11 (2018) (cumulative (annual months) who have received three doses of Pentavalent for 33 average) immunization, disaggregated by gender (annual) months) AF PDOI Among the displaced Rohingya population in Cox’s 5,427 10,000 20,000 25,607 9,312 14,573 3,885 27% Bazar District, the number of births delivered in HNP (2018) (cumulative (annual facilities (annual) 33 months) average) Component 3 DLI9 Targeted public health facilities meeting readiness 0 35% 61.5% 61.5% 0 1 176% criteria for delivery of postpartum family planning (PPFP) services in Sylhet and Chattogram divisions (DLI9): DLI12 Districts reaching at least 85% coverage of measles- 14 15 18 21 21 4 7 175% rubella vaccination among children aged 0-12 months in Sylhet and Chattogram divisions (DLI 12): DLI13 Registered pregnant women receiving specified 0 25% 65% 84% 84% 0.65 1 129% maternal nutrition services in Sylhet and Chattogram divisions, reported for the previous CY DLI15 Districts where the school-based adolescent health 0 7 7 (FY22) 7 7 7 100% program is implemented in Sylhet and Chattogram divisions DLI16 Assessment completed of hypertension diagnosis 0 2 2 2 2 2 100% and referral services at the primary level in at least 2 upazilas of 35 upazilas in Sylhet and of 100 upazilas in Chattogram Page 22 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT People who have received essential HNP services, 0 5,780,000 5,305,455 11.032 4,011,772 5,305,455 4,011,772 76% annual million (annual (cumulative average) 33 months) Component 4 added in 2018 HNP facilities providing an appropriate mix of family 4 15 98 36 11 32 288% planning methods to the Rohingya in Cox's Bazar (2018) District Pregnant women and lactating mothers reached with 32,000 67,000 115,000 288,656 104,966 83,000 72,966 88% social and behavior change interventions on infant (2018) (cumulative (annual and young child feeding among the Rohingya in Cox’s for 33 average) Bazar District months) Women and girls who have received women‐friendly 90,311 138,000 408,532 148,557 47,689 58,246 122% services information on sexual and reproductive (2018) (cumulative (annual health and rights/gender-based violence among the for 33 average) Rohingya population Cox’s Bazar District months) Annex Table 4: Efficacy Rating Summary Indicators PDO part 1 PDO part 2 weight PDOI IRI PDOI IRI Fully achieved/ surpassed (100%+) 2 2 2 7 1 Substantially achieved (80%-99%) 1 1 0.9 Partially Achieved (65%-79%) 3 1 1 0.72 Not Achieved (less than 64%) 1 1 0 Total number of indicators 2 6 5 9 % achieved 100% 69% 72% 96% High Modest Modest Substantial Efficacy rating Substantial Substantial Substantial Page 23 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT @#&OPS~Doctype~OPS^dynamics@icrresultframework#doctemplate A. RESULTS FRAMEWORK PDO Indicators by Outcomes Not Categorized Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year Increase in the number of Community Clinics providing Comments on achieving targets The reported number of 3,838 community clinics is for FY20 which was verified by IMED. The reported number complete essential data on service for FY21 is 6,009 CCs and for FY22 is 7006 CCs. The government's endline evaluation reports 8,200 in June 2024 delivery, including gender- (not verified). This indicator was achieved. disaggregated (DLI 8) (Number) PDO Outcome Increase in the number of Upazila Health Complexes with at least 2 Comments on achieving targets The final value of 692 was reported in the Government's endline report. This indicator was achieved. accredited diploma midwives (DLI 7) (Number) PDO Outcome Increase in the number of normal 175,262.00 Jun/2022 deliveries in public health facilities in Comments on achieving targets For this indicator, the verified result for the DLR from FY21 was 151,305. The most recent available data Sylhet and Chittagong divisions (DLI (175,262) was in the Government's endline report as the achievement in FY22. The endline target for this 10) (Number) PDO Outcome indicator was revised to 170,000 in a restructuring. This indicator is achieved (against the revised higher target). Increase in the number of District Hospitals with improved capacity to Comments on achieving targets While the DLR was met and verified (12 district hospitals for FY21), the endline result reported by the provide comprehensive emergency government was 7 in FY22. The result was therefore not sustained and this indicator was partially achieved. obstetric and neonatal care (CEmONC) services in Sylhet and Chittagong divisions (DLI 11) (Number) PDO Outcome 54.00 Jun/2024 Page 24 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Increase in the percentage of Comments on achieving targets This indicator is achieved. registered children aged under 2 years receiving specified nutrition services in Sylhet and Chittagong divisions (DLI 14) (Percentage) PDO Outcome Among the displaced Rohingya 35,000.00 Jun/2024 31,675.00 Dec/2021 population in Cox's Bazar District, the Comments on achieving targets For the period April 2019 to December 2021, the ISR reported a cumulative value of 87,105 children who number of children (ages 0-11 received 3 doses of pentavalent vaccination of whom 42,646 were boys and 44,459 were girls. As this was months) who have received three supposed to have been an annual value, the ICR computes an annual average of 31,675 (90% achieved), based doses of Pentavalent immunization, on the cumulative value over 33 months. WHO reported 96% of 420,000 children receiving the vaccine in Cox's disaggregated by gender (annual) Bazar in 2022, so this indicator is considered achieved. (Number) Among the displaced Rohingya 5,427.00 May/2018 population in Cox’s Bazar District, the Comments on achieving targets The ISR reported 25,607 for the period April 2019 to December 2021 as a cumulative number. However this was number of births delivered in HNP supposed to be an annual indicator. The ICR annualizes to 9312 over a 33 month period (27% achieved against facilities (annual) (Number) the revised target). This indicator was not achieved. Intermediate Indicators by Components Not Categorized Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year Annual GRS performance report for No Jun/2017 previous CY is published (DLI 1) Comments on achieving targets An annual GRS performance report has been published for 2020, 2021, and 2022. No report was published for (Yes/No) Component 2023. The report was published for three out of four years (75%). This indicator is partially achieved. Increase in percentage from FY16 0.00 Jun/2017 270.00 Jun/2024 baseline in repair and maintenance Comments on achieving targets 131% was the verified result for the DLR in FY21. In FY22 it was 179%, based on the Government's endline expenditure at the levels of Upazila report. This is a 66% level of achievement against the revised target. This indicator was partially achieved. and below (DLI 2) (Percentage) Component Yes Jun/2024 Page 25 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT MOHFW FMAU completes internal Comments on achieving targets The audit was done in FY21 and FY22. It was not done in FY23. It was done for two out of three years (67%). This audit for the previous fiscal year (DLI indicator was partially achieved 3) (Yes/No) Component Increase in the number of district- level referral facilities in which AMS is Comments on achieving targets The reported data for FY19, FY20, FY21 and FY22 are 8, 10, 12 and 14 district hospitals. These results were implemented (DLI 4) verified by IMED. The endline target was revised in 2023 through restructuring from 30 to 14 (not reflected in (Number) Component the ISR table). The hospital supply chain management portal reports 61 general and district hospitals in 2024 implementing AMS, of which 41 are district hospitals. This indicator is therefore considered achieved. Increase in percentage of NCTs using 75.00 Jun/2024 e-GP issued by MOHFW (DLI 5) Comments on achieving targets The reported data of 98% is for FY22 and has been verified by IMED. The use of this system is mandatory for (Percentage) Component procurement. This indicator is considered achieved. Increase in percentage of targeted public health facilities meeting Comments on achieving targets The value of 61.5% for FY22 has been verified by IMED. No data is available for later years in the government readiness criteria for delivery of PPFP endline report. The target was exceeded by almost double (176%) in FY22 in these lagging regions, hence this services in Sylhet and Chattogram indicator is considered achieved. divisions, reported for the previous CY (DLI 9) (Percentage) Component Increase in the number of districts 14.00 Jun/2017 21.00 Dec/2022 reaching at least 85% coverage of Comments on achieving targets The reported data of 21 districts for FY21-22 has been verified. This was achieved against a revised target of 18 measles-rubella vaccination among through restructuring in 2021 (not reflected here). The government endline report notes 37 districts reached children aged 0-12 months in Sylhet 85% measles-rubella vaccination rate in Sylhet, Chattogram and Barisal (Barisal was added through restructuring and Chattogram divisions (DLI 12) in March 2021). The WHO reported 97% coverage nationwide in 2023, suggesting sustained results. This (Number) Component indicator was achieved. Increase in the percentage of 65.00 Jun/2024 registered pregnant women receiving Comments on achieving targets The reported data of 84% for FY22 has been verified. UN contracts were closed in June 2022 and the specified maternal nutrition services interventions continued under the HGSP project. This indicator is achieved. in Sylhet and Chattogram divisions, reported for the previous CY (DLI 13) (Percentage) Component Number of districts where the school- 7.00 Jun/2024 based adolescent health program is Comments on achieving targets Implementation report of 7 districts has been verified by IMED for FY22, meeting the target. Information is not implemented in Sylhet and available on this program for 2023, so there is no data on sustained results up to the endline. DHS2022 reports Chattogram divisions (DLI 15) low rates of teenage pregnancy in Sylhet and Chattogram, relative to the national average. This indicator is (Number) therefore considered achieved. Page 26 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Assessment is completed of Yes Dec/2022 hypertension diagnosis and referral Comments on achieving targets This process took a few years and by 2022, assessment was completed in 2 Upazilas. The government's endline services at the primary level in at report notes that guidelines are being implemented and this is ready for scale-up. This indicator is achieved. least 2 Upazilas (DLI 16) (Yes/No) Component 0.00 Dec/2016 People who have received essential health, nutrition, and population Comments on achieving targets The indicator according to the PAD is annual. Data reported in the last ISR was *cumulative* achievement up to (HNP) services (Number) CY23. Reported data is 11,032,371 (CY2017, 2018, 2019, 2020, 2021, 2022 and 2023). Annualized over 7 years, the achievement is 1.58 million, which is 30% achieved against the revised target. This indicator is not achieved. People who have received essential health, nutrition, and Comments on achieving targets Annualized, this is 1.576 million per year, not meeting the revised target. population (HNP) services - Female (RMS requirement) (Number) Number of children immunized (Number) Comments on achieving targets See comment on parent indicator Number of women and 0.00 Dec/2016 children who have received Comments on achieving targets See comment on parent indicator basic nutrition services (Number) Number of deliveries attended by skilled health personnel Comments on achieving targets See comment on parent indicator (Number) The number of HNP facilities 4.00 May/2018 providing an appropriate mix of Comments on achieving targets This indicator has been achieved. The work continues under the HGSP. family planning methods to the displaced Rohingya population in Cox's Bazar District (cumulative) (Number) Among the displaced Rohingya population, the number of pregnant Comments on achieving targets The ISR incorrectly reports this indicator cumulatively. Annualized between April 2019 and December 2021 (the women and lactating mothers reported period noted in the ISR), the average for this annual indicator is 104,966 (88% achievement). This reached with social and behavior annualized number is reported in the ICR. This indicator is nearly achieved (achieves the original target and change interventions on infant and almost achieves the revised target). Page 27 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT young child feeding (annual) (Number) Among the displaced Rohingya population, the number of women Comments on achieving targets The ISR incorrectly reports this indicator cumulatively. Annualized between April 2019 and December 2021 (the and girls who have received through reported period noted in the ISR), the ICR reports the average for this annual indicator, i.e.. 148,557 (122% women-friendly services information achievement). This indicator is achieved. on sexual and reproductive health and rights/GBV (annual) (Number) Performance-based Conditions (PBC) Period Period Definition Period 1 FY2017 Period 2 FY2018 Period 3 FY2019 Period 4 FY2020 Period 5 FY2021 Period 6 FY2022 Baseline Period 1 Period 2 Period 3 Period 4 Period 5 Period 6 1:Citizen feedback system is strengthened (Text ) Achievement Level: Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 1.1:Assessment of current GRS is completed (Yes/No Achievement Level: ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount Page 28 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT ➢ 1.2:GRS guidelines are approved (Yes/No ) Achievement Level: Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 1.3:Annual GRS performance report for previous CY Achievement Level: is published (DLI 1) (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 2:Budget planning and allocation are improved Achievement Level: (Percentage ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 2.1:Operational plans (OPs) approved including Achievement Level: activities and budgets for achievement of DLIs (Number ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 2.2:Increase in percentage from FY16 baseline in Achievement Level: repair and maintenance expenditure at the levels of Upazila and below (DLI 2) (Percentage ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 3:Financial management system is strengthened (Text ) Achievement Level: Original/Revised Value Allocated Amount 0.00 Page 29 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Actual Value Actual Amount ➢ 3.1:MOHFW submits FMAU recruitment rules to Achievement Level: MOPA (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 3.2:MOPA endorses FMAU recruitment rules (Yes/No Achievement Level: ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 3.3:MOF concurs to FMAU recruitment rules (Yes/No Achievement Level: ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 3.4:MOPA approves FMAU recruitment rules (Yes/No Achievement Level: ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 3.5:At least 50% of required FMAU staff are recruited Achievement Level: (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 3.6:MOHFW FMAU completes internal audit for the Achievement Level: previous fiscal year (DLI 3) (Yes/No ) Page 30 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 4:Asset management is improved (Text ) Achievement Level: Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 4.1:Assessment and plan are approved for AMS Achievement Level: scale-up (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 4.2:Increase in the number of district-level referral Achievement Level: facilities in which AMS is implemented (DLI 4) (Number ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 5:Procurement process is improved using information Achievement Level: technology (Text ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 5.1:e-GP is initiated for procurement by MOHFW Achievement Level: (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount Page 31 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT ➢ 5.2:Increase in percentage of NCTs using e-GP issued Achievement Level: by MOHFW (DLI 5) (Percentage ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 6:Institutional capacity is developed for procurement Achievement Level: and supply management (Text ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 6.1:MOPA approves CMSD restructuring proposal Achievement Level: (DLI 6) (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 7:Availability of midwives for maternal care is Achievement Level: increased (Text ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 7.1:At least 2,500 midwife posts are created by Achievement Level: MOHFW and recruitment of midwives is underway (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 7.2:Increase in the number of Upazila Health Achievement Level: Complexes with at least 2 accredited diploma midwives (DLI 7) (Number ) Page 32 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 8:Information system is strengthened, including Achievement Level: gender-disaggregated data (Number (Thousand) ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 8.1:Increase in the number of Community Clinics Achievement Level: providing complete essential data on service delivery, including gender-disaggregated (DLI 8) (Number ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 9:Post-partum family planning services are improved Achievement Level: (Text ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 9.1:Facility readiness criteria and assessment Achievement Level: instrument for PPFP services are approved (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 9.2:Reporting and training guidelines for PPFP Achievement Level: services are approved (Yes/No ) Original/Revised Value Allocated Amount 0.00 Page 33 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Actual Value Actual Amount ➢ 9.3:Assessment and action plan are completed for Achievement Level: expansion of PPFP services in targeted health facilities in Sylhet and Chittagong divisions (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 9.4:Increase in percentage of targeted public health Achievement Level: facilities meeting readiness criteria for delivery of PPFP services in Sylhet and Chattogram divisions, reported for the previous CY (DLI 9) (Percentage ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 10:Utilization of maternal health care services is Achievement Level: increased (Text ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 10.1:Increase in the number of normal deliveries in Achievement Level: public health facilities in Sylhet and Chittagong divisions (DLI 10) (Number ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 10.2:Number of normal deliveries in public health Achievement Level: facilities in Sylhet, Chattogram and Barisal divisions, reported for the previous CY (Number ) Original/Revised Value Page 34 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Allocated Amount 0.00 Actual Value Actual Amount 11:Emergency obstetric care services are improved Achievement Level: (Text ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 11.1:Facility assessment instrument for CEmONC is Achievement Level: approved (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 11.2:Assessment and action plans are approved for Achievement Level: development of CEmONC services in targeted district hospitals in Sylhet and Chattogram divisions (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 11.3:Increase in the number of District Hospitals with Achievement Level: improved capacity to provide comprehensive emergency obstetric and neonatal care (CEmONC) services in Sylhet and Chittagong divisions (DLI 11) (Number ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 12:Immunization coverage and equity is enhanced Achievement Level: (Text ) Page 35 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 12.1:Immunization microplans for CY2017 are Achievement Level: approved for each district in Sylhet and Chattogram divisions (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 12.2:Increase in the number of districts reaching at Achievement Level: least 85% coverage of measles-rubella vaccination among children aged 0-12 months in Sylhet and Chattogram divisions (DLI 12) (Number ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 12.3:Number of districts reaching at least 85% Achievement Level: coverage of measles-rubella vaccination among children ages 0-12 months in Sylhet, Chattogram and Barisal divisions of Bangladesh,reported for the previous CY (Number ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 13:Maternal nutrition services are expanded (Text ) Achievement Level: Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 13.1:Technical standards for maternalnutrition Achievement Level: Page 36 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT services are approved (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 13.2:Reporting and quality assessment guidelines for Achievement Level: maternal nutrition services are approved (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 13.3:Assessment is completed of maternal nutrition Achievement Level: service quality in Sylhet and Chattogram divisions (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 13.4:Increase in the percentage of registered Achievement Level: pregnant women receiving specified maternal nutrition services in Sylhet and Chattogram divisions, reported for the previous CY (DLI 13) (Percentage ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 14:Infant and child nutrition services are expanded Achievement Level: (Text ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 14.1:Technical standards for infant and child Achievement Level: nutrition services are approved (Yes/No ) Page 37 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 14.2:Reporting and quality assessment guidelines for Achievement Level: infant and child nutrition services are approved (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 14.3:Assessment is completed of infant and child Achievement Level: nutrition service quality in Sylhet and Chattogram divisions (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 14.4:Increase in the percentage of registered Achievement Level: children aged under 2 years receiving specified nutrition services in Sylhet and Chittagong divisions (DLI 14) (Percentage ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount 15:School-based adolescent HNP program is developed Achievement Level: and implemented (Text ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 15.1:Revised teacher training manual is approved Achievement Level: (Yes/No ) Page 38 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 15.2:Assessment of current school-based services in Achievement Level: Sylhet and Chattogram divisions is jointly completed with the education sector (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 15.3:MOHFW completes training for the school- Achievement Level: based adolescent health program in at least 50 schools in targeted districts of Sylhet and Chattogram divisions (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 15.4:Budget for implementation of MOHFW's school Achievement Level: based adolescent HNP program is included in the relevant MOHFW operational plan (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 15.5:MOHFW implements the MOHFW's school- Achievement Level: based adolescent HNP program in targeted schools in at least 7 districts in Sylhet and Chattogram divisions (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount Page 39 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT 16:Emerging challenges are addressed (Text ) Achievement Level: Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 16.1:Urban Health Coordination Committee meets Achievement Level: and agrees on actions to improve coordination on urban health (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 16.2:Guidelines for screening, referral and treatment Achievement Level: of hypertension are approved (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 16.3:Plan and technical materials are approved for Achievement Level: implementation of hypertension diagnosis and referral services (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 16.4:Hypertension diagnosis and referral services are Achievement Level: implemented at the primary level in at least 2 upazilas (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount ➢ 16.5:Assessment is completed of hypertension Achievement Level: diagnosis and referral services at the primary level in Page 40 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT at least 2 Upazilas (DLI 16) (Yes/No ) Original/Revised Value Allocated Amount 0.00 Actual Value Actual Amount Actual disbursement to Components 1-3 (US$608.5 million) 40 included US$462.6 million IDA, US$130.9 million MDTF, and US$15 million GFF. Actual disbursement to Component 4: was US$45.59 million IDA.41 40Difference between original allocation and actual disbursement for IDA is due to exchange rate fluctuations between XDR and US$. 41Actual disbursement to Component 4 included US$7.63 million from IDA 6302 and US$37.96 million from IDA D361, totaling US$45.59 million based on the XDR/US$ exchange rate of January 22, 2025. Page 41 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT B. KEY OUTPUTS Page 42 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Component 1. Governance and Stewardship • Annual GRS performance report for previous CY is published (DLI 1) Intermediate Results Indicators • Increase in percentage from FY16 baseline in repair and maintenance expenditure at the levels of Upazila and below (DLI 2) • GRS report was published for 3 out of 4 possible years Key Outputs • Spending on repair and maintenance at the service delivery level is increased (linked to the achievement of the Component) from 0 in FY16 to 179 percent in FY22 Component 2. Health, Nutrition and Population Systems Strengthening • Increase in the number of Community Clinics providing complete essential data on service delivery, including gender-disaggregated (DLI8) PDO Indicators • Increase in the number of Upazila Health Complexes with at least 2 accredited diploma midwives (DLI7) • MOHFW FMAU completes internal audit for the previous FY (DLI 3) • Increase in the number of district-level referral facilities in which AMS is Intermediate Results Indicators implemented (DLI 4) • Increase in percentage of NCTs using e-GP issued by MOHFW (DLI 5) • Data collection increased, in 7,006 clinics, from zero at the start of the project, but no further indicators used gender-disaggregated data • The number of Upazila Health Complexes with at least two accredited midwives increased from 0 to 382. Key Outputs • Internal audits were conducted in two out of three years (audit capacity was (linked to the achievement of the Component) built under the project) • Asset management implemented in 14 facilities but information not available on how this might have affected the maintenance of assets • 98 percent of non competitive tenders use e-procurement • Component 3. Provision of Quality Health, Nutrition and Population Services Page 43 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT • Increase in the number of normal deliveries in public health facilities in Sylhet and Chittagong divisions (DLI 10) • Increase in the number of District Hospitals with improved capacity to provide PDO Indicators comprehensive emergency obstetric and neonatal care (CEmONC) services in Sylhet and Chittagong divisions (DLI 11) • Increase in the percentage of registered children aged under 2 years receiving specified nutrition services in Sylhet and Chittagong divisions (DLI 14) • Increase in percentage of targeted public health facilities meeting readiness criteria for delivery of PPFP services in Sylhet and Chattogram divisions, reported for the previous CY (DLI 9) • Increase in the number of districts reaching at least 85% coverage of measles- rubella vaccination among children aged 0-12 months in Sylhet and Chattogram divisions (DLI 12) • Increase in the percentage of registered pregnant women receiving specified Intermediate Result Indicators maternal nutrition services in Sylhet and Chattogram divisions, reported for the previous CY (DLI 13) • Number of districts where the school-based adolescent health program is implemented in Sylhet and Chattogram divisions (DLI 15) • Assessment is completed of hypertension diagnosis and referral services at the primary level in at least 2 Upazilas (DLI 16) • People who have received essential health, nutrition, and population (HNP) services Page 44 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT • PPFP services are improved, particularly in target areas • Number of normal deliveries in health facilities increased from 106,673 to over 175,000 in Sylhet, Chattogram, and Barisal divisions • Seven District Hospitals offer CemONC in the target divisions (below target) Key Outputs • Immunization services improved in 21 districts, particularly in target areas, (linked to the achievement of the Component) which reached at least 85% coverage of measles and rubella • 84% of registered women received maternal nutrition services in target areas • 77% of registered children under age 2 received nutrition services • School‐based adolescent health and nutrition services delivered in 7 districts • Two Upazilas completed hypertension diagnosis assessment. Component 4. Develop Health, Nutrition and Population Services for the displaced Rohingya population in Cox's Bazar District • Among the displaced Rohingya population in Cox's Bazar District, the number of children (ages 0-11 months) who have received three doses of Pentavalent PDO Indicators immunization, disaggregated by gender (annual) Among the displaced Rohingya population in Cox’s Bazar District, the number of births delivered in HNP facilities (annual) • The number of HNP facilities providing an appropriate mix of family planning methods to the displaced Rohingya population in Cox's Bazar District (cumulative) • Among the displaced Rohingya population, the number of pregnant women Intermediate Result Indicators and lactating mothers reached with social and behavior change interventions on infant and young child feeding (annual) • Among the displaced Rohingya population, the number of women and girls who have received through women-friendly services information on SRH and rights/GBV (annual) Page 45 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT • 31,675 Rohingya children received critical immunization services (Penta vaccine) in Cox’s Bazar • 9,312 deliveries took place in HNP facilities among Rohingya women in Cox’s Bazar • Modern contraception provided to Rohingya in 36 HNP facilities in Key Outputs Cox’s Bazar (linked to the achievement of the PDO Outcome) • Social and behavior change interventions on infant and child feeding reached 105,000 displaced pregant and lactating Rohingya women in Cox’s Bazar • More than 148,000 women and girls received women friendly services and information on SRH and rights among displaced Rohingya in Cox’s Bazar Page 46 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Annex 1 B: ICR Analysis: Results from additional analysis based on triangulation During the HSSP implementation, Bangladesh achieved remarkable improvements in MCH.42 • Total fertility decreased in Sylhet from 2.6 in 2017 to 2.3 in 2022. It remained unchanged at 2.5 in Chattogram. Teenage pregnancy rates decreased nationwide from 28 percent in 2018 to 24 percent in 2022. • Maternal mortality declined nationwide from 211 deaths in 2015 to 123 per 100,000 live births in 2022. 43 Cox’s Bazar reported a higher maternal mortality of 295/100,000 in 2023. • Under-5 mortality declined nationwide from 43 to 31 deaths per 1,000 live births, and infant mortality declined from 36 to 25 death per 1,000 births. • Child stunting declined significantly from 30.9 percent in 2018 to 23.6 percent in 2022 nationwide. During the same period, stunting fell from 32.8 to 24.9 percent in Chattogram, and from 42.7 to 33.9 percent in Sylhet. The project focus areas of Sylhet and Chattogram were lagging areas that experienced tremendous change. Migration and remittances are important income sources for local households. Between 2014 to 2018, the proportion of women with husbands who have migrated increased from 24 percent to 28 percent in Chattogram and from 12 percent to 20 percent in Sylhet.44 Both divisions report lower early marriage rates than the national average (Figure 2), and Sylhet has seen a marked decline in fertility since 2014 to the national average of 2.3 in 2022 (Figure 3). Figure 2: % of women married < age 18 Figure 3: Total fertility rate Sylhet Chattogram Sylhet Chattogram Bangladesh Bangladesh 80 4 2.9 60 3 2.6 59 58.9 54.1 50.1 2.3 40 44.8 2 25.4 20 23.2 1 0 0 2014 2017/18 2022 2014 2017/18 2022 Source: DHS 2014, 2017/18 and 2022. DLI 7: Upazila Health Complexes with at least two accredited diploma midwives (DLI 7): In 2022, 382 health complexes had at least two accredited diploma midwives, exceeding the target of 150 complexes. 42 DHS 2022. 43 WHO: https://data.who.int/indicators/i/C071DCB/AC597B1 44 DHS 2022. Page 47 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT In the absence of more recent data on midwives’ recruitment, the ICR focuses on the relevance and magnitude. The World Health Organization (WHO) reported a massive increase in trained nurses and midwives from 2017 to 2021 (Figure 4).45 Training is offered by 41 public and 71 private midwifery FIGURE 4: NURSES AND MIDWIVES institutes. The increase in nurses and midwives has not been IN BANGLADESH matched by increased government recruitment. In 2021, the GoB approved 2,996 public sector positions for midwives, but only Nursing Midwifery 1,145 midwives were recruited (Figure 5), leaving 62 percent of 26,737 46,47 13,583 positions vacant in 2021 (Figure 6). Chattogram and Sylhet 9,333 11,598 1,187 reported the highest vacancy rates for nurses and midwives 66,973 77,091 49,323 54,599 52,259 combined (42 percent in Chattogram and 53 percent in Sylhet). This means that only about 4 percent of all 26,737 midwives work 2017 2018 2019 2020 2021 in the public sector. Among them are the 754 working in Upazila health facilities in 2022, supported under the HSSP, which is a very small share equivalent to 2.8 percent of the 26,737 midwives. No data is available about the remaining 25,600 midwives not working in the public sector (Figure 5). They either work with NGOs, the private sector which saw a major increase in the share of deliveries ((Figure 7) or are out of the workforce. Figure 5: Nurses and midwives in Figure 6: Midwifery positions in public Bangladesh in 2021 sector, Bangladesh in 2021 not working in public sector 41,263 filled working in public sector 38% 25,592 35,828 vacant 62% 1,145 Midwives Nurses Source: WHO Southeast Asia; Nuruzzaman et al. 2022; Bangladesh Health Workforce Strategy 2021. 45 WHO Regional Health Observatory Southeast Asia: https://apps.who.int/gho/data/node.searo.HWFGRP_0040?lang=en 46 Nuruzzaman, M. et al. 2022. Informing investment in health workforce in Bangladesh: a health labour market analysis. Hum Resour Health 20, 73. 47 Bangladesh Health Workforce Strategy 2021. https://dgnm.gov.bd/sites/default/files/files/dgnm.portal.gov.bd/go_ultimate/ddeae4a2_47b3_48ae_b812_e9ce8539854f/2023-08-13-14-06- 3fd85cf63ab05484abdd4faa20afb023.pdf Page 48 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT DLI 10: Normal deliveries in public health facilities in Sylhet and Chattogram divisions . Based on the Bangladesh Health Facility Survey 2022, highest readiness scores to provide normal delivery services is reported in public facilities, NGO facilities, and in private health facilities. CCs are least ready for normal deliveries. Overall, facility-based deliveries increased from 2014 to 2022; although, the increase is greater in the private sector than in public Figure 7: % of live births in public and private facilities, 2014 - 48 facilities (Figure 7). About 21 percent of 2022 deliveries occurred in the public sector in DHS 2014 DHS 2017/18 DHS 2022 45.1 both divisions, above the national average of 36.7 31.5 28.3 29.9 18 percent in 2022, but considerably below 21 23.7 21.3 20 22.8 18.3 16.5 17.9 14.3 9.9 11.9 13 12.8 the private sector average of 45 percent nationwide. The DHS reports an increase in C-section rates to 45 percent in 2022, with Sylhet public Sylhet Chattogram Chattogram Bangladesh Bangladesh facility private public facility private public facility private more than 85 percent of all birth in private health facilities being C-sections.49 Inequalities remain high with 42 percent of women in the lowest quintile with facility- based deliveries in 2022 compared to 87 percent in the wealthiest quintile. DLI 9: Targeted public health facilities meeting readiness criteria for delivery of postpartum family planning (PPFP) services in Sylhet and Chattogram divisions: 61.5 percent increase for FY22 exceeding the target of 35 percent. In 2022, public health facilities and NGOs report a much higher average readiness score for family planning (5.4 in 2022) than private facilities (2.3).50 The HSSP did not collect any indicators to monitor family planning service use. Based on the DHS, the share of women using modern contraceptive methods remained 44 percent in Sylhet and increased to 49 percent in Chattogram but remained below the national average of 55 percent (Figure 8). Nationwide, the private sector was the main source for modern contraceptives users in 2022 (Figure 9). Figure 8: % of married women using modern Figure 9: % of users who get modern contraceptives contraceptives from private, public or NGO Sylhet Chattogram Bangladesh 70 Private 60 52 60 sector, 60 54.7 50 54 42 55 52 40 Public 49 facility, 37 50 47.2 30 44.8 20 45 40.9 44.3 10 4 40 0 NGO, 3 2014 2017/18 2022 2011 2017/18 2022 Source: DHS 2014, 2018, and 2022. 48 DHS 2014, 2017/18, and 2022. 49 Khan, MN. et al. 2023. Spatial distribution of caesarean deliveries and their determinants in Bangladesh: evidence from linked data of population and health facility survey. The Lancet Regional Health - Southeast Asia, 14. 50 BHFS 2022. GoB and USAID, August 2023. Page 49 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Page 50 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION A. TASK TEAM MEMBERS Name Role Shiyong Wang Team Leader Bushra Binte Alam Team Leader Hasib Ehsan Chowdhury Financial Management Specialist Md Kamruzzaman Procurement Specialist S. M. Zulkernine Environmental Specialist Kirti Nishan Chakma Social Specialist Elsa Suzanne Gilberte Le Groumellec Counsel Kari L. Hurt Team Member Rajagopala Raghavan Team Member Iffat Mahmud Team Member Md. Rafi Hossain Team Member Wameq Azfar Raza Team Member Deepika Nayar Chaudhery Team Member Atia Hossain Team Member Satish Kumar Shivakumar Team Member Phoebe M. Folger Team Member @#&OPS~Doctype~OPS^dynamics@icrannexstafftime#doctemplate B. STAFF TIME & COST Staff Time & Cost Stage of Project Cycle No. of Staff Weeks US$ (including travel and consultant costs) Page 51 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Preparation FY17 15.384 150,343.42 FY18 15.762 134,958.12 FY19 1.101 2,578.88 FY20 0.200 2,142.98 FY22 1.098 9,010.91 FY23 1.325 9,854.82 Total 34.87 308,889.13 Supervision/ICR FY18 55.521 460,416.90 FY19 149.848 1,330,459.90 FY20 121.093 1,161,539.26 FY21 76.997 681,869.51 FY22 137.725 1,117,808.65 FY23 110.669 811,324.07 FY24 114.753 1,005,362.27 FY25 34.229 255,737.67 Total 800.84 6,824,518.23 Page 52 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT Page 53 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT ANNEX 3. PROJECT COST BY COMPONENT 1. Amount at Approval (US$M) Anticipated Cofinancing Project from Other Total Project Cost Government Financing IDA Financing GFF Components Development Partners (Pooled with IDA) Component 1 175 62 81 9.5 32 Component 2 369.5 131 170.5 5.5 68 Component 3 555.5 192 248.5 100 Total 1,100 385 500 15 200 2. Amount at ICR (US$M) Project Government Financing IDA Financing GFF MDTF Components Component 1 n.a. Component 2 n.a. 473.03 15 130.9 Component 3 n.a. Component 4 n.a. 46.6 Total n.a. 519.63 15 130.9 Page 54 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT ANNEX 4. EFFICIENCY ANALYSIS 1. The efficiency analysis in the PAD estimated the HSSP would lead to a net-present value (NPV) of US$2 billion over 20 years and 22 percent internal rate of return (IRR) using a 3 percent discount rate. It estimates that this would be achieved by better health service delivery and health outcomes, prevented healthcare costs and income loss for households and prevented costs to the healthcare system. The project’s cost-benefit analysis anticipated reduced household OOP spending on medicines and higher labor productivity due to fewer days lost from illness. The economic analysis in the original PAD is not available to the ICR team. The updated economic analysis for the AF estimated that the US$50 million investment would generate a US$160 million NPV over ten years, resulting from disability-adjusted life years averted by providing a cost-effective MCH service package to the target population. The HSSP disbursed US$685 million (including US$539 million IDA and US$146 million TF) to the GoB treasury to co-finance a part of the Fourth Sector Program estimated to cost US$1.1 billion over five years. Trust funds from the GFF and the MDTF were used to co-finance analytical work and policy dialogue related to PETS, PFM, budget and expenditure analysis, and DRM. 2. There is no evidence to suggest that increased service delivery would prevent higher healthcare costs as suggested in the economic analysis. The HSSP disbursed to the treasury to support government efforts to strengthen health system capacity (component 1), and capacity in MCH care, family planning, and hypertension diagnosis and referrals (component 2). The government recruited more than 750 accredited midwives who work in Upazila health complexes, and the number of normal deliveries in public health facilities has increased; however, the project did not measure the budget implications of this additional hiring. The HSSP contributed to nutrition services for 77 percent of registered children and 84 percent of women in Sylhet and Chattogram, Penta-3 immunization for 87,105 children, and measles-rubella vaccinations for 85 percent of children in 21 districts. More than 11 million people received essential HNP services in public health facilities. In Cox’s Bazar, about 83 percent of the 10,200 babies born in 2023 were attended by skilled health staff and more than 408,500 women and girls received women-friendly information on reproductive health and GBV. In other settings, these interventions have proven to be cost-effective. The HSSP did not collect any data to examine their cost-effectiveness in Bangladesh. Increased service delivery leads to higher costs for all: households, the government and DPs who finance input factors to deliver care. Higher service use also leads to income loss for patients who pay transport costs to visit a health provider and user fees and opportunity costs due to time lost to get to the health facility, wait for the provider, travel to the pharmacy to purchase medicine, and travel home. Patients also lose income from a day of informal work. The M&E framework did not monitor health spending by government and households; hence, there is no evidence to suggest that the government increased health expenditures on health infrastructure and availability of care to improve service delivery and quality of care in health facilities. 3. Out-of-pocket payments have increased and are having an impoverishing effect. The economic analysis expected the HSSP to reduce household OOP spending on medicine. The project design did not include any interventions to reduce OOP spending on medicine or ensure the availability of medicines at zero cost to patients in health facilities. The monitoring and evaluation (M&E) framework did not monitor OOP spending. By 2021, government health expenditures remained low at 0.4 percent of GDP (Figure 10) and 16.9 percent of THE (Figure 11). Since 2019-2020, budget allocations to repair and maintenance for all health facilities have declined as a share of the recurrent revised budget. Out-of-pocket payments as a percentage of THE increased from 63 percent in 2012 to 68.5 percent in 202051 to 73 percent in 2021, the highest in the region (Figure 12). Out-of-pocket payments had an impoverishing effect for 8.61 million people in 2016. This number is likely to have increased by 2024, as more patients sought care in the private sector. Also, COVID- 19 contributed to a large number of hospitalized patients, who had to pay OOP to receive care. By design, the HSSP did 51Md Zahid Hasan, Sayem Ahmed, Gazi Golam Mehdi, et al. 2024. The effectiveness of a government-sponsored health protection scheme in reducing financial risks for the below-poverty-line population in Bangladesh, Health Policy and Planning, Volume 39, Issue 3, Pages 281–298. Page 55 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT not have a tangible impact on patients’ OOP spending, and government health expenditures did not increase. This was a missed opportunity for the Bank in a country with lowest government health expenditures. Fig. 10: Government and Total Health Fig. 11: Government and OOP in % of Expenditures in % of GDP, in 2021 THE, in 2021 12.0 10.0 100.0 10.0 80.0 7.2 9.0 14.3 27.5 43.6 8.0 18.8 5.2 5.4 5.6 60.0 49.8 51.3 70.3 73.0 6.0 4.1 3.6 3.3 3.7 3.9 40.0 70.4 71.6 4.0 2.4 2.2 2.2 1.9 1.8 57.4 59.4 46.5 2.0 0.4 1.1 1.1 20.0 34.3 33.2 18.8 16.9 0.0 0.0 Government health expenditure in % of GDP Out-of-pocket expenditure in % of THE Total health expenditure in % of GDP Government health expenditure in % of THE Source: WHO GHED: https://apps.who.int/gho/data/node.searo.GHEDGGHEDGDPSHA2011?lang=en 4. No evidence suggests that labor productivity improved due to better MCH. Better health status can increase the employment rate for women if there are formal sector jobs for women, transport, and childcare. In Chattogram and Sylhet, about 98 percent of women work in the informal sector, 52 including in low- or unpaid jobs and they face a significant gender wage gap.53 Informal sector jobs are characterized by low productivity, inadequate safety and health standards, and environmental hazards.54 Informal sector jobs often have a negative impact on women’s health as there are no occupational health standards for women to protect them. Labor productivity is considerably lower in the informal sector, which accounts for 88 percent of total employment nationwide and produces 43 percent of GDP, compared to the formal sector which employs about 12 percent of employment and contributes to 57 percent of GDP. 55 There is no evidence to suggest that improved health through the HSSP would lead to higher labor productivity and increased rates of return in a low-productivity informal labor market, as women earn significantly less than men. Women’s productivity will likely improve when transitioning from informal work to higher-wage employment in the formal sector.56 5. The NPV and IRR are lower than originally estimated. This is mainly due to the project design not supporting interventions that could have reduced OOP spending, and a higher discount rate. Bangladesh has sustained average growth rates of about 7 percent annually over the past decade, so a higher discount rate of about 10 percent over 20 years, instead of 3 percent, would have been more appropriate.57 The HSSP disbursed US$685 million over seven years. Increased health service use likely resulted in higher OOP payments for patients with some impoverishing effects. The 52 Bangladesh labor force survey 2022. file:///C:/Users/wb239466/Downloads/BGD_LFS_2022_Report.pdf 53 World Bank. 2021. Bangladesh Country Gender Assessment. 54 Sarker AR, et al. 2016. Effects of occupational illness on labor productivity: A socioeconomic aspect of informal sector workers in urban Bangladesh. J Occup Health.;58(2):209-15. 55 Khondker, B. 2019. Insights into the informal sector in Bangladesh. https://policyinsightsonline.com/2019/04/insights-into-the-informal-sector-in- bangladesh/ 56 Narayan, D. 2021. Training the Disadvantaged Youth and Labor Market Outcomes: Evidence from Bangladesh Journal of Development Economics Volume https://doi.org/https:/doi.org/10.1016/j.jdeveco.2020.102585149. 57 World Bank. 2016. Discounting costs and benefits in economic analysis of World Bank projects. Page 56 The World Bank Health Sector Support Project (P160846) ICR DOCUMENT HSSP cannot be expected to impact labor productivity for women who are predominantly active in unpaid or low-paid informal work. Rather, women working in the informal sector face a higher health risk. 6. Several aspects of the design and implementation could eventually contribute to technical efficiency. The design focused on tangible PFM reforms including building the audit function at the FMAU and setting up a complaint system that could eventually lead to efficiency gains in government health expenditures if audit recommendations and complaints are addressed. However, the HSSP did not monitor the output of this PFM capacity to show that it led to changes and contributed to stronger core management. The HSSP targeted the two lagging divisions with the highest health needs, Sylhet and Chattogram, and it focused on MCH care interventions that contribute to higher human capital among lower-income groups. The M&E framework did not monitor the reduction in the gap between the two lagging regions and the rest of the country during the project period. The design aligned with the GoB’s Fourth Sector Strategy and with DPs under the SWAp. Project implementation was efficiently managed with all project funds directly disbursing to the government budget. Trust funds from the GFF were used to co-finance analytical work on PFM and DRM and policy dialogue, although recommendations were not followed up by the government. An AF was processed to support the humanitarian response in Cox’s Bazar. The project was extended by 18 months from December 2022 to June 2024 as an AF was added. Seven indicator targets were revised upward at various stages of restructuring. While the project closed in June 2024, the ISR reported indicator results up to 2022. Targets were not revised once achieved and disbursed. 7. With a project amount of US$685 million mainly disbursing to the government budget, the design could have been more ambitious. The limited focus on the maintenance budget at the Upazila level, encompassing about 4 percent of government recurrent health expenditures, did not affect allocative efficiency and patients’ OOP spending. The HSSP had a strong supply-side focus and interventions to improve government spending were missing, leading to higher OOP spending with impoverishing effects for patients. DLIs and output indicators emphasized sector management and the capacity and availability of care, which is important. Given the decades-long Bank and DP engagement under the SWAp and the large project amount, the DLIs could have been designed more ambitiously to focus on outputs and outcomes in health and the government health budget implementation. ANNEX 5. BORROWER, CO-FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS “The relevant stakeholders have no comments on the report” as responded by the Planning Wing of the Ministry of Health and Family Welfare on March 5, 2025. ANNEX 6. SUPPORTING DOCUMENTS (IF ANY) Page 57