seek timely care. This is because RMNCH-N care-seeking also depends on certain demand-side factors, and utilization patterns are largely context- and time-specific. This situation necessitates that the determinants of RMNCH-N utilization be identified and addressed to ensure prioritized investment decision-making.

In Bangladesh, the evidence-base is inconclusive on the demand- and supply-side determinants that should be addressed urgently for improving RMNCH-N utilization. While the prevailing evidence largely points to socio-economic, cultural and regional factors as the key drivers of RMNCH-N utilization,<sup>8</sup> little is known about the role of service delivery status and quality of care in RMNCH-N uptake. Similarly, the relative significance of supply-side determinants over the demand-side determinants is not clear. For instance, if quality of care is the key determinant of service uptake, improving quality versus sizably investing in addressing certain demand-side determinants (e.g., cultural barriers) would be an immediate priority. While most existing studies have used DHS data and demand-side determinants alone to examine the patterns of RMNCH-N utilization, assessments which combine both demand- and supply-side determinants of RMNCH-N utilization, are limited.

It is against this backdrop that the World Bank, in collaboration with the Ministry of Health and Family Welfare (MoHFW), carried out this technical assistance study to ascertain the most important determinants that need to be addressed, on a priority basis, to improve RMNCH-N outcomes further. A comparative assessment of the drivers of RMNCH-N performance across time periods (2014 and 2017 surveys) reflects the success, as well as gaps, in the government strategies and interventions for further policy navigation. Study findings would also be influential to RMNCH-N policy making in the post-COVID-19 context.

## **1.4 Aim**

The overall aim of this study was to inform strategic RMNCH-N investment decision-making, through a three-pronged approach that involved:

1. Identifying the top ten determinants that need to be addressed on a priority basis to improve RMNCH-N utilization, quality of care and outcomes nationally and for divisions (or states)

2. Comparing the relative importance of demand- and-supply-side determinants on key RMNCH-N indicators in the last decade (across two time points) in Bangladesh 3. Proposing key strategic steps for improving the RMNCH-N utilization and quality in the country.

This study used machine learning analysis as the selected data sources (given below) were high-dimensional and large.

# **2.Methodology**

## **2.1 Data sources**

Two sources of secondary data were used in this study: the Bangladesh Health facility Survey (BHFS) and the Demographic and Health Survey (DHS). Two rounds (2014 and 2017) of BHFS and DHS survey data were used. Data sources and timelines were selected considering the need for a comparative analysis across two time points using multiple rounds of household and facility surveys. Both DHS and BHFS cover similar timeframes, enabling such a comparison. Averages of BFHS indicators by district and location (urbanrural) were merged with the DHS data.

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