India: Meghalaya Health Systems Strengthening Project (MHSSP) Implementation Support mission October 21-25, 2024 Technical Note 1. The World Bank (WB) team1 conducted the Implementation Support Mission of the MHSSP Project from October 21-25, 2024. The content of this Technical Note was discussed at the mission wrap-up meeting. 2. Overall implementation progress and progress toward achievement of the PDO have both been rated at moderately satisfactory. It has met year three targets2 for four out of five PDO indicators, except for the District hospital National Quality Assurance Standards (NQAS) certification. Progress on 13 intermediate indicators shows good improvement, with eight indicators related to management capacity, service delivery, and health insurance coverage either achieved or surpassed. The indicator for fund utilization in targeted facilities is on track and can be achieved soon with better supervision and support. However, four indicators related to timely payments to IPA units, stock-out of essential drugs, and clinical vignettes participation and score improvement are delayed, with some yet to start reporting progress. 3. As of today, the project has disbursed US$ 13.91 million, 35% of the total USD 40 million allocation, reflecting expenditures up to June 30, 2024. The claim for the quarter ending September 2024, reporting expenditures of approximately INR 16.01 crores (US$ 1.92 million), is being processed. This disbursement aligns with projections. Of the 38 agreed actions from the last mission, 28 are fully completed, eight are partially completed, and two are not completed. Component 1: Improving accountability, management and strengthening governance: 4. Significant progress has been made in the last six months under this component, with implementation expanding across the state. Currently, 122 Internal Performance Agreement (IPA) entities are actively participating, including five state-level entities and 17 secondary care health facilities such as district hospitals, Meghalaya Institute of Mental Health & Neurosciences (MIMHANS), TB hospitals, and maternal hospitals, 11 district level administrative entities and 89 lower-level health facilities such as Primary Health Centre’s (PHCs) and Community Health Centre’s (CHCs). Three rounds of quarterly assessments have been completed, providing valuable insights to guide IPA entities toward achieving project results. Although disbursement and expenditure under the IPA have improved over the last three quarters, the overall disbursement at the mid-term of the project stands at about 35 percent, with 55 percent of that being spent (accounting for 17 percent of expenditure against allocation). 5. To enhance expenditure under the IPA, the project team could consider providing substitutes for the block medical officer and block development officer to ensure timely approvals in their absence. Additionally, case-by-case waivers could be implemented for health facilities to procure drugs using IPA grants. Entities should be encouraged to view the IPA as a complementary resource rather than standalone funds, focusing on high-value activities outlined in their improvement plans and linking 1 Amith Bathula Nagaraj (Sr. Health Specialist and Task Team Leader), Ananta Krishna Karur (Financial Management Specialist), Sangeeta Patel (Procurement Specialist), Charu Jain (Environment Specialist), Lakshmi Sripada (Operations and Technical), Arun Jaggi (Consultant), Dr. Lincoln Choudhury (Consultant), Ranjan B Verma (Consultant, Social development), Rakesh Kumar (Consultant), Philp Kumar (consultant), Shubam Gupta (consultant) and Jyoti Sriram (Sr. Program Assistant). 2 Adjusted target as per duration of implementation till Sep 2024 (semi-annual). these activities to quality improvements that address gaps in achieving NQAS standards. Furthermore, all designated First Referral Units (FRUs) should be included under the IPA to bolster the state’s efforts to improve maternal and child health outcomes. Lastly, the IPA operations manual to be revised along with detailed budget for discussion and subsequently table for approval of PSC and Bank. 6. Coordination between the project team and the quality assurance team from the Directorate of Health Services has improved. Joint meetings have identified areas where the IPA grant can provide additional support. The Directorate of Health Services (DHS) quality assurance (QA) team has agreed to consider ex-ante results equivalent to state-level assessments and has requested the project to conduct a full NQAS assessment of PHCs and multi department assessment (minimum six departments as per NQAS certification criteria) of CHC, SDH, District level health facilities to be undertaken from the current IPA cycle onwards. It was also agreed that district hospitals scoring 70 or higher in more than six departments should be prepared for partial accreditation, with similar provisions for CHCs. 7. The implementation of Clinical Vignettes has started slowly, significantly affecting current progress. Currently, about 40 percent of staff in IPA facilities have participated in these Vignettes. The current system does not allow for measuring knowledge improvement before and after the course. Therefore, for the purpose of the IPA score, the third-party agency (TPA) will assess knowledge improvement among sample attendees, while for the results framework, the average scores of participants (regardless of case) will be compared between the baseline and subsequent rounds. This activity requires close monitoring to address the delayed start. 8. Third-Party Verification and Quality Assessment: The project has completed three rounds of ex-post assessments, revealing score variations exceeding 10 percent at over half of the sites compared to ex- ante assessments. This discrepancy raises concerns about the quality of training on the new IPA manual and the assessment methods used. As a result, funds are being released based solely on ex- ante scores, contrary to the IPA grant manual's terms. To address these inconsistencies, the Project Management Unit (PMU) will hold a joint meeting with assessors and IPA entities to clarify contentious points and establish a common understanding of indicators and methodologies for future assessments. The PMU should consolidate the IPA cycle-wise ex-ante and share the comparison report with the Bank within one month of completing each IPA cycle. 9. Additionally, there is a need to increase the number of ex-post assessment teams to reduce the assessment duration from one month to two weeks. The next ex-post assessment will coincide with the mid-term assessment. Tools, methods, and timelines for this assessment have been shared with the PMU, and the details have been finalized, aiming to complete the mid-term assessment report by 15 January 2025; bi-weekly short joint review meetings can be done to avoid any delay. Component 2: Strengthening systems to improve the quality of health services: 10. Infrastructure Development: Out of 149 health facilities under thirteen contracts worth INR 73.90 Cr, work at 110 facilities is complete, with financial progress at 73 percent of the contract value. The remaining facilities are on track for completion as scheduled. Nursing schools at Nongpoh, Nongstoin, and Williamnagar are proposed for repairs and renovation. Conditional assessment of the existing infrastructure is expected to be completed by November 2024, with procurement for the nursing schools starting by January 2025. Significant investments from both project and State funds are being made in infrastructure development. The project team will develop a manual for preventive maintenance of buildings, with potential support from the Bank. 11. Significant progress made on Human Resources for Health (HRH) in the state: Significant progress has been made in HRH in the state. The draft report of the functional review of health directorates and institutions has received stakeholder inputs, and the revised version will be submitted by 20 November 2024. The creation of the Public Health Management Cadre (PHMC), Specialist Cadre, and transfer posting policies have cabinet approval and await final state approval. The e-HRMIS (Manav Sampada) is progressing well and will be adopted by early 2025. The team will focus on HRH forecasting, wage bill, fiscal analysis, and finalizing the HRH strategy and management framework. The project is also documenting HRH topics for discussion papers and policy briefs. 12. The Capacity Building contracting is completing its second year. Over the last year, nearly 55 percent of doctors and 30 percent of nurses have been trained. In 2025, the focus will be on completing the remaining training, initiating training for the nurse tutor cadre, and activating skill lab training in the Ramaiah simulation lab in Bangalore. A midline assessment of the capacity building implementation design and curriculum will be completed by 15 January 2025. 13. Progress in pre-service education in nursing has been slow. All nursing infrastructure is undergoing soil testing, and revised bill of quantities (BoQs) will be submitted by 30 December 2024. The state team and the nursing cell in the Directorate of Health Services have sought World Bank support to strengthen the quality of nursing education. Key priority areas will be identified by December 2024, and support will be designed accordingly. 14. Innovations: The state has led several initiatives under service delivery redesign (SDR), including the establishment of transit homes, training of doctors in CEmONC, LSAS and ultrasound, uptake of the Mother App, and regular community engagement through Village Health Committees (VHCs). These interventions have streamlined the state's priority to activate the first referral units (FRUs) in a phased manner. During this mission, the task team has initiated preparations for the process evaluation of SDR with in-principal agreement from the state. Component 3: Increasing coverage and utilization of health service: 15. Community Interventions - Early Childhood Development (ECD) Intervention: Out of 10 deliverables, five are completed, one is in progress, and four are pending. With the contract closing in February 2025, close monitoring is essential to ensure timely completion and avoid last-minute extensions. 16. Social Behavior Change Communication (SBCC): In July 2024, PMU engaged the Society for Action in Community Health (SACH) to develop a comprehensive SBCC strategy, including monitoring and evaluation framework for all SBCC and capacity building activities. The focus is on providing top-up communication support while collaborating with other departments. PMU has also initiated the development of relevant information education and communication materials for display at various health facilities. The draft designs by The Other Studio need PMU ratification. Lastly, the PMU shall also identify the well performing health facilities such as Sohra CHC and develop the case study that captures the determinant of success and share with other practitioners; also develop communication material using the learnings from maternal death audit to have impactful communication; and turn them into interactive training material especially for case escalation that can be incorporated into clinical vignettes. 17. Project Management and Coordination: Bi-weekly review meetings with component leads from the PMU and the Bank team, along with monthly reviews by the project director, have significantly enhanced progress and quality. Improved coordination between the PMU and the Directorate is evident in IPA activities and joint planning for NQAS. The only outstanding issue is communicating with the Department of Economic Affairs (DEA) about savings from foreign exchange rate fluctuations and potential cancellation plans. This communication should align with the agreement with the State Finance Department, justifying the use of savings in line with the PDO or State priorities. 18. Cross-Learning and Study Tours: The project includes provisions for cross-learning and study tours. The PMU has requested the Bank team to facilitate a study tour to developed countries, focusing on social insurance and health service delivery, particularly in the Latin American region. The Bank team has contacted task team members and government counterparts and will expedite arrangements for the study tour. 19. Procurement Performance [Rating: Moderately Satisfactory]: The STEP status report shows that out of 83 Bank-cleared activities, 50 are signed and under implementation, 11 are completed, and 22 are either cancelled or terminated. The Project Team was encouraged to update the Procurement Plan for the next 18 months. 20. Contract Amendments: As mentioned during the last ISM, all contract amendments must occur before the contract's expiration. The Bank cannot approve extensions made after the contract's duration, even if only for additional time. The Bank also recommended closely monitoring underperforming contracts, especially in civil works, and making decisions regarding partial cancellation or penalties according to contract terms. 21. Financial Management Performance [Rating: Satisfactory]: For FY24-25, State Finance Department has sanctioned INR 113.80 crores, with INR 30 crore already drawn and the rest of the amount is committed. Complying with FM requirements, the project maintains up-to-date financial records and timely submits IUFR. There have been no delays in fund releases, and the FY23-24 audit report was submitted before the due date. Consequently, the FM rating has been upgraded to “satisfactory.� 22. Environmental and Social (E&S) Management [Rating: Moderately Satisfactory]: No significant environmental management concerns have been reported. The mission emphasized the need for detailed quantitative information in progress reports. The PMU and contractors are staffed with environmental experts ensuring compliance. Environmental screening of around 80 deep burial pits and ETPs is underway. The Department collaborates with the State Pollution Control Board and Meghalayan Medicinal Drugs & Services Limited (MMDSL) to build state capacity in Biomedical Waste Management (BMWM). The state will establish BMWM Cells/ committees at state and district levels, involve IPA entities to augment efforts, and use IPA grants to address gaps, including assessing the efficiency of existing treatment facilities. 23. The progress in the project's social management is rated satisfactory due to consistent performance against the commitment plan- establishment of a Grievance Redress Mechanism GRM); establishment of mandatory Internal Complaint Committees (ICC); regular sensitization of junior engineers (JEs) and contractors; continuous consultation with key stakeholders; development of gender sensitization training modules on gender based violence (GBV); monitoring of labor management procedures at construction sites. Additionally, the Bank team will work with PMU to develop the success story of “Gender: under the project that emphasizes on service utilization and leadership role of women in the State. 24. The Bank and PMU have scheduled the next mission for January 2025, which will serve as a mid-term review of the project. Preparations for the MTR have been agreed upon. 25. Next steps and agreed actions are in the table below. – Table 1: Summary of Agreed Actions S. No. Actions Responsible Due Date Component 1: Improving accountability, management and strengthening governance IPA Grants at State and District Level 1. IPA monthly meeting with Bank task team from November 2024 PMU Nov 15 2024 onwards. 2. Documentation of the good practices in IPA (Meghalaya) PMU Dec 15 2024 3. Next release of payments to be made as per the IPA manual PMU Feb 28 2025 including application of penalty 4. Complete the mid-term assessment with full NQAS PMU 15 Jan 2025 5. Work on new IPA grant manual and submit the draft for bank PMU 15 Feb 2025 review Clinical vignettes 6. 6Share clinical vignette scores and the scoring system details with PMU 15 Nov 2024 Bank 7. 7Share the final; list of clinical vignettes and monthly roll out plans PMU 15 Dec2024 including non-IPA facilities 8. 8 End of every Share the clinical vignette score analytics on every quarter PMU quarterly assessment Component 2: Strengthening systems to improve the quality of health services Human Resources for Health (HRH) 9. 9Revised report on functional review of the directorates PMU & IQVIA Nov 20 2024 10. 1HRH Dissemination of all the key findings (Desk review, PMU Dec 15 2024 0Enumeration, functional review) with Dist Medical Health Officers 11. Sharing of Draft HRH strategy and management framework IQVIA Mar 10 2025 Capacity Building 12. Simulation lab exposure visit plan and curriculum PMU & Nov 20 2024 RICHPI 13. Capacity Building midline assessment and key findings RICHPI Jan 15 2025 Pre-service education (Nursing) 14. State level discussions on Nursing reform agenda PMA & PMU Nov 10 2024 15. RFP and BoQs for Nursing institutes PMA & PMU Dec 30 2024 Infrastructure development 16. Complete structural assessment of nursing schools at Nongpoh, PMU 30 Nov 2024 Nongstoin and Williamnagar Component 3: Increasing coverage and utilization of health service SBCC 17. Stakeholders meeting with SACH team to identify the need for PMU, SACH Nov 30 2024 appropriate (top-up) communication materials 18. PMU, The Development of communication materials for display at health Other Dec 15 2024 facilities. Studio 19. Finalization of communication strategy including detailed capacity PMU, SACH Jan 30 2025 building plan 20. Identify district, block and village level functionaries and build their PMU, SACH Feb 20 2025 capacity to roll out the training plan 21. PMU, SACH, Development of communication materials for all relevant health The Mar 30 2025 programs as per the SBCC strategy document. Other Studio Table 1: Summary of Agreed Actions S. No. Actions Responsible Due Date 22. PMU and Rolling out the phase wise interventions in select 3 districts April 30 2025 SACH 23. Develop monitoring formats for trainings and communication SACH and April 30 2025 materials PMU Service Delivery Redesign (SDR) 24. Re-starting weekly meetings with the State PMU Oct 30 2024 25. Developing protocol of the process evaluation of SDR WBTT Nov 15 2024 26. Initiating process evaluation for SDR WBTT Dec 15 2024 Financial Management 27. FY24-25 Budget funds - Funds withdrawal PMU Ongoing 28. Internal audit report till June 30, 2024 PMU Oct 31 2024 29. FY24-25 Budget funds - Funds withdrawal PMU Ongoing Environmental and Social Standards 30. Finalize Waste Characterization Study WBTT Nov 30 2024 31. Nov 30 2024 Study on gender differences in utilization of health services in the (Finalize design) public sector in Meghalaya. PMU Jan 15 2025 (First draft) 32. Review of existing Civil Works (awarded, ongoing, completed) in PMU Finalize checklist by terms of inclusion – accessibility, gender friendly etc. to suggest Nov 30 2024 opportunities for retrofitting and upscaling Jan 20 2025 (Complete review)