Health System Strengthening through the UNDP-Global Fund Partnership

LESSONS FROM EVALUATIONS: HEALTH SYSTEM STRENGTHENING THROUGH THE UNDP-GLOBAL FUND PARTNERSHIP Co-authors: Yosef Abraha, Rim Benhima, Tae Young Kim and Ian Grubb UNDP has partnered with the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) since it was established in 2002 to implement grants to tackle HIV, tuberculosis (TB), and malaria. This longstanding partnership has also evolved to help countries prevent, prepare for, and respond to new pandemics like COVID-19 and future health threats. The UNDP partnership with This paper identifies seven the Global Fund focuses on three interlinked areas: lessons from UNDP work to 1) supporting the effective implementation of Global Fund grants in countries facing complex emergencies, sanctions or other challenging operating environments, and significant capacity constraints; 2) strengthening the capacity of national partners to manage Global Fund grants and build resilient and sustainable health systems; and 3) leveraging UNDP policy expertise and strategic partnerships to promote effective governance, human rights, gender equality and other measures to increase equitable access to health services.

strengthen national health systems through the Global Fund. It is a rapid evaluation synthesis, drawn from material issued by UNDP between 2013 and 2023, and external evaluative evidence.

Through this partnership, UNDP has implemented Global Fund grants in 51 countries in a single country principal recipient (PR) role, and in another 28 countries under regional/multi-country grants. UNDP manages an average of 712 percent of total Global Fund resources annually. UNDP engages national and local counterparts, the ‘sub-recipients’ and other United Nations agencies in implementing Global Fund grants. Since its inception, the UNDP-Global Fund partnership has supported the delivery of essential health services for HIV, tuberculosis and malaria prevention, diagnosis and treatment, reaching millions and contributing to progress on Sustainable Development Goal (SDG) 3 – Good Health and Wellbeing for All.

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Lesson 1

Capacity-strengthening is a long-term process that requires sustained effort over time.

UNDP was most successful when it used systematic approaches to assess and develop capacity. This involved providing end-to-end support tailored to the specific country context and the needs of its partners.

Capacity-strengthening is a significant component of the UNDP-Global Fund partnership. UNDP supported national programmes, designated and potential national PRs and sub-grantees to strengthen their capacity to implement Global Fund grants. The partnership is also critical to the success and sustainability of national HIV, TB and malaria programmes in many countries. Evaluative evidence shows that UNDP strengthened national capacities to improve the performance of health systems and ensure the sustainability of health programmes in many countries (Sao Tome Principe, Turkmenistan, Indonesia, Zambia, Mali, Nigeria, Togo, Iran, Belize, Liberia, Djibouti, South Sudan and Tajikistan, Belize, Kyrgyzstan and Afghanistan, 1 among others). In these countries, capacities were strengthened, including for programme management, sub-recipient management, financial management, fiduciary controls and oversight, procurement and supply chain management, and monitoring and evaluation.

UNDP also supported the capacity-strengthening of civil society organizations (CSOs) and key population groups. The strong partnerships with, and empowerment of, CSOs and key population groups were considered important factors for implementing and sustaining national HIV, tuberculosis and malaria programmes. 2 For example, in Cuba and Zimbabwe, UNDP prioritized activities to strengthen the capacity of CSOs to adequately deliver services and to advocate for sustainable disease responses. 3 In Angola, UNDP strengthened the capacity of local networks and community groups to help reach more pregnant women living with HIV, with the overall goal of ensuring that all babies are born free of HIV. 4 UNDP established a systematic approach to capacity-development based on an end-to-end support model tailored to the country context and partner needs, while leveraging its global experience. 5 Its framework for capacity-development started with a participatory multi-stakeholder process to establish priorities and conduct a comprehensive capacity assessment that informs the development of the capacity-development plan. This approach was a key success factor for achieving strengthened capacities for health systems.

In Zambia, UNDP developed a clear process for a capacity-strengthening plan, reprogramming the Global Fund grant to support capacity-building activities and supporting the Zambian Ministry of Health to reassume the PR role. 6 The twoyear capacity-development plan was firmly grounded in strengthening national institutions and systems, rather than creating parallel systems. The plan included the development of an automated financial management system, which was supported by developing and operationalizing a financial manual and standard operating procedures, rolled out with supporting hardware at the national level. The plan UNDP developed helped the country to successfully strengthen national entities and hand over its PR role to the Government in 2016. 7 In Zimbabwe, UNDP facilitated the preparation and implementation of a comprehensive capacity-development plan in 2015. 8 The capacity-development plan included procurement and supply chain management, public financial management, and risk management for health, including internal audit and HMIS, emphasizing human resource development across each. 9 UNDP capacity-building support enabled the Ministry of Health to assume the PR role from the Global Fund in 2015.26 Governments that successfully took on the PR role continue to ask for UNDP assistance (Sao Tome Principe, Zimbabwe, Togo, Kyrgyzstan, Tajikistan and El Salvador 10). This is because capacity-building is a long-term process, that requires sustained effort over time. Therefore, UNDP usually continues to provide technical assistance even after exiting the PR role. In providing such a continuum of support, UNDP often combines multiple support modalities, building on its experience as a PR. This support, as well as UNDP flexibility in support mechanisms, are critical to ensuring a continuum of services and a gradual transition away from donor-funded health programmes.

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Lesson 2

Fostering national ownership facilitated the timely transfer of principal recipient roles to national entities. UNDP was most successful in promoting national ownership when pursuing a tailored and phased approach to the transitions of grants, and leveraging existing tools and frameworks to help governments establish plans with concrete milestones and timelines.

When UNDP acted as an interim PR, it worked with national partners and the Global Fund to improve grant management, implementation, and oversight while strengthening national systems and institutions to assume the PR role over time. Both UNDP and the Global Fund ensured that their work was in line with national health priorities and considered country ownership as critical to the success of their support.

UNDP supported country ownership by providing implementation support to deliver essential services for the prevention, diagnosis and treatment of HIV, tuberculosis and malaria tailored to the national health strategies, plans, capacities and contexts (Iraq, Zambia and Afghanistan 11). Some of the implementation support provided by UNDP included facilitating technical reviews, policy dialogues and consensus-building among national stakeholders for the prevention, diagnosis and treatment of HIV, tuberculosis and malaria. UNDP also bolstered country ownership by engaging additional national and local sub-recipients to implement grant activities and strengthen their institutional and financial management (Iran, Zambia, Uzbekistan, Afghanistan, Indonesia and Angola 12).

For example, the Programme Management Units for Global Fund grants from UNDP and the Ministry of Health in Zambia progressively combined their operations and began working as a single team. This strengthened national ownership of Global Fund-supported programmes and laid the foundation for the eventual transition of the PR role back to the Ministry of Health in 2016. 13 UNDP has also designed a range of tools, guidance, and templates to support transition processes for Global Fund grants, which were tested in several countries and could adapt to the country context. This included a comprehensive framework and tools for developing a programme transition plan or strategy. 14 Successful transitions of the PR role from UNDP to one or more national entities (Zimbabwe, Zambia, Belize and El Salvador 15) depended on factors such as: a transparent and participatory process, clear vision and leadership that managed the transition plan and processed effectively; change management that strengthened systems to meet the Global Fund and national requirements; implementation structures and arrangements with clear roles and responsibilities; measurable and concrete timelines and milestones; and effective monitoring of progress.

The transition of the PR role from UNDP to national entities was not a one-size-fits-all approach but a context-specific and tailored process that considered each country’s specific needs and opportunities. 16 For example, where the national entity had previously been a PR and a large, well-performing sub-recipient, the risks were lower and the milestones were more likely to be achieved (Zambia 17).

A phased approach over a more extended period was more appropriate in fragile countries impacted by conflict or natural disasters and/or challenging operating environments (El Salvador and Belarus 18). UNDP also played a co-PR role in countries with an identified need to strengthen systems and build capacity, where short-term technical assistance is insufficient to achieve the desired health outcomes. In El Salvador, between 2007 and 2013, the Government and UNDP became co-PRs of Global Fund HIV and TB grants. An effective division of labour between the El Salvador Government and UNDP as co-PRs enabled the Ministry of Health to focus on expanding treatment and care, while UNDP leveraged its expertise in procurement, prevention, human rights and key populations. 19 In 2013, UNDP exited as PR for all grants, transferring this role to the Ministry of Health and Plan El Salvador, but continued to provide capacity-development support to the new PRs for procurement and supply chain management. From January 2015, for the first time, El Salvador began to independently manage and implement all Global Fund resources allocated to the country. This experience shows that, with sustained investments in infrastructure, process and people, a country emerging from prolonged conflict can successfully rebuild national institutions, foster multisectoral engagement and implement innovative approaches to health.

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In some cases, transitions of the PR role to national entities encountered delays (Panama and Djibouti 20). For example, in Djibouti, the transition of PR role from UNDP to the national entity was initiated in 2019, but was still not completed as circumstances led to changes in the agreed plan. The COVID-19 pandemic, which disrupted the regular operation of the health sector, was also a contributing factor to the delay in transition. 21

Lesson 3

Inclusive health governance helped health systems meet the needs of those most likely to be left behind. Most progress in this area was made when Global Fund Country Coordination Mechanisms were empowered to foster stakeholder collaboration and participatory decision-making during the design and implementation of programmes.

Inclusive health governance was essential to ensure that all people’s health needs and rights were met and respected, especially those most likely to be left behind, historically marginalized, or excluded. 22 The UNDP-Global Fund partnership worked to build and strengthen inclusive health governance, primarily through the Global Fund Country Coordination Mechanisms (CCMs). 23 CCMs are national committees that bring together stakeholders and representatives from different sectors to coordinate and oversee the development of grant proposals and implementation of Global Fund grants in their countries. 24 Evaluative evidence demonstrates that UNDP significantly enhanced the participation and representation of key populations, 25 civil society, and communities in CCMs over the past two decades (South Sudan, Zambia, El Salvador, Ukraine and Indonesia 26).

UNDP supported CCMs in various ways, such as: providing technical assistance (Sao Tome and Principe, South Sudan, El Salvador, Iran, Ukraine and Chad 27); supporting CCMs to ensure the meaningful participation and representation of key populations (Angola, Belize, Afghanistan, South Sudan, Kyrgyzstan and Sao Tome and Principe 28); promoting the integration of social inclusion principles and approaches into CCM decision-making and grant implementation processes (Indonesia and Sao Tome and Principe 29); and strengthening the linkages and coordination between CCMs and other relevant national and local governance structures (Indonesia, Kyrgyzstan and Tajikistan 30). In doing so, UNDP helped countries to strengthen health governance and coordination mechanisms so as to perform their roles effectively and inclusively. 31 The UNDP and Global Fund partnership was grounded in leaving no one behind and reaching the furthest behind first.

Evaluative evidence from several countries (Iran, Uzbekistan, Afghanistan, Mozambique, Zambia, Kyrgyzstan, Belize and Cuba, 32 among others) shows that UNDP was effective in enabling health and other services to reach vulnerable populations at risk of HIV, TB and malaria, including people with disabilities, prisoners and mobile and refugee populations. In Sao Tome & Principe, for example, disparities and inequalities at all levels were tackled through the participation of vulnerable groups in the CCM and by increasing their access to social protection and essential social services. 33 Similarly, UNDP supported the national health system to better deploy to reach remote and high-riskbehaviour populations (Gabon and Iran 34). In Iran, outreach activities enabled coverage expansion to at-risk populations through mobile health centres. 35 Through a Global Fund multi-country grant, UNDP also worked with UNHCR to effectively reach mobile and refugee populations in Afghanistan, Iran and Pakistan with TB prevention and treatment services. 36 A 2016 thematic evaluation found that only limited efforts had been made to reach persons with disabilities in UNDP activities related to health, including work related to HIV and projects funded by the Global Fund. 37 To address this gap, UNDP took several actions, such as: developing and implementing a series of policy statements and services in support of disability-inclusive development at global, regional and country levels; providing technical assistance and capacitystrengthening on including disability issues for national partners and CCMs; supporting the institutional capacity of countries to collect and analyse reliable and disaggregated data on people with disabilities; and supporting the engagement and participation of CSOs and communities of people with disabilities in health programmes and decisionmaking processes. These actions helped to enhance the performance, adaptability and stability of national institutions and actors, and promote the governance principles of participation, inclusion and non-discrimination.

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Lesson 4

Anti-corruption, transparency and accountability measures were important enablers of health system strengthening, particularly when country systems were fragile. Few successful entry points for UNDP were captured in evaluations. However, other literature pointed to the implementation of risk-based frameworks for corruption prevention, fiduciary control and internal audit systems in national institutions, and promoting social accountability, including using digital technology, as promising avenues.

Accountability measures were key enablers of health system strengthening. Through partnerships with a broad range of global, regional and national stakeholders, including the Global Fund, 38 UNDP provided policy and programme support on anti-corruption, transparency, and accountability across sectors in more than 80 countries annually, working with a broad range of partners. 39 The Global Network for Anti-corruption, Transparency and Accountability in Health stands out as a global initiative and network where UNDP global anti-corruption and health teams work in partnership with the Global Fund, NORAD, World Health Organization (WHO) and World Bank to tackle corruption in the health sector.

Where financial irregularities were reported at the level of UNDP and/or government, grant managers were unable to take advantage of flexible arrangements under the Global Fund’s challenging operating environments (COE) provisions – with severe operational consequences for UNDP and its partners, as seen in Sudan, for example. 40 Since the 2017 UNDP Strategic Plan Evaluation, and building on its governance expertise and health system strengthening portfolio, UNDP is acknowledged to be well positioned to advance integrated work in health, development and good governance. 41 For over a decade now, UNDP has harnessed these experiences to develop and support countries to apply methods and good practices to map corruption risks and develop strategies to address them, and to sustain partnerships to tackle corruption in the health sector. However, these experiences were not well documented and assessed in evaluation reports, and more needs to be done to enable organizational learning in this area. Promising avenues to strengthen accountability in the health sector that were documented elsewhere include: supporting the implementation of risk-based frameworks for corruption prevention; strengthening fiduciary control and internal audit systems in national institutions; and promoting social accountability (for citizens and/or CSOs to participate directly or indirectly in exacting accountability), including using digital technology. 42 Tunisia was the first country where UNDP piloted the Conceptual Framework for Corruption Risk Assessment at Sectoral Level. 43 The framework supported the health sector in identifying and mitigating the risk of corruption at multiple levels of health service delivery and enhancing the transparency and efficiency of services in several public hospitals. Critically, implementing the corruption risk assessment supported multi-stakeholder participation, bringing together health sector personnel with members of the anti-corruption body to inform risk mapping and the development of comprehensive strategies and measures to improve transparency and accountability. The lessons and progress in advancing risk-based corruption prevention in Tunisia, particularly in the health sector, served to inform parallel efforts across the region. 44 In Zimbabwe, UNDP in partnership with the Global Fund, supported the Ministry of Health and Childcare to strengthen its internal audit function. 45 Key milestones included the development of a revised internal audit charter, an internal audit operating policy, and a memorandum of understanding between internal audit and management. A risk management policy, strategy and audit programme were also launched, which provided a framework for the sectorwide approach to risk. UNDP also supported the Ministry of Health and Childcare in improving the utility of the public financial management system for managing donor funding and ensuring linkages with the internal audit function.

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UNDP supported the use of digital technology to enhance the availability and transparency of data for decision-making, including through public procurement systems and logistics management information systems for health. In Ukraine, for example, UNDP supported the development of the national e-procurement platform Prozorro, which was launched to allow government bodies to conduct procurement deals electronically and transparently and give citizens open access to the contracts. 46 Prozorro was a tool to identify corruption risks, as citizens could submit feedback and report violations across the procurement cycle. While putting UNDP in charge of the procurement function was a meaningful way to promote accountability in line with the best international standards, sustainability remained a concern.

Interruptions in public procurement processes threatened the continued treatment of the most vulnerable patients and increased the risk of corrupt practice. 47 Although anti-corruption was a cross-cutting strategic priority for UNDP, accountability and transparency in public administration has not been adequately prioritized. 48 There is a scarcity of evaluative evidence on anti-corruption, transparency and accountability initiatives as enablers of health system strengthening. However, the available evidence suggests that the availability of funding was a key factor affecting the success of anti-corruption initiatives. 49

Lesson 5

Where UNDP operated in crisis and post-crisis countries with early recovery mandates, a flexible approach that balanced fiduciary controls with programmatic results worked best to strengthen health systems and programmes.

In settings where protracted conflicts severely damaged national capacities to implement and sustain disease programmes, UNDP country offices were able to fill critical gaps, restore technical capacities 50 and boost community health workers’ ability to deliver health services by building capacity and deploying skills to hard-to-reach areas. 51 UNDP work in partnership with the Global Fund included supporting governments to implement large-scale health programmes in challenging operating environments, making health and community systems more resilient, and helping countries to strengthen laws and policies so that healthcare reached the people who needed it most and no one was left behind. 52 UNDP also supported health system resilience by integrating broader development dimensions of health, including enabling environments and attention to health determinants. 53 Over the years of its partnership with the Global Fund, UNDP has become a leader in implementing health programmes in the most challenging crisis contexts and conflict-affected countries. UNDP managed Global Fund grants in Iraq, Mali, Syria, South Sudan, Afghanistan and other countries in crisis. 54 In such settings, UNDP connected the Global Fund grant with its early recovery mandate in crisis and post-crisis countries. This helped to ensure that Global Fund investments in health systems aligned with early recovery efforts and contributed to building resilient health systems in crisisaffected countries. In Iraq and Syria, for example, where UNDP served as interim PR before transitioning out of this role in 2016, it was able to reach TB patients in areas controlled by the Islamic State of Iraq and al-Sham (ISIS) and other contested areas. UNDP also supported governments in Ebola-affected countries to adjust their Global Fund programmes to combat the outbreaks. 55 UNDP operated effectively in these challenging operating environments through a flexible and risk-tolerant approach that balanced fiduciary controls with programmatic results. 56 The Global Fund COE policy provided a systematic approach to address outcomes in particularly difficult programmatic settings. 57 Where UNDP supported implementing health programmes and Global Fund grants in challenging operating environments, it used diverse strategies to maximize resilience, depending on the setting. Approaches deployed included using mobile payment systems and 6

electronic tracking of patients to ensure the continuity of treatment and essential services, and supply chain management responsive to the impact of conflict. 58 In South Sudan, where UNDP is PR for the Global Fund grant, the COE policy facilitated the involvement of CSOs and key and vulnerable populations through single-quote partner selection, a simplified reporting format with longer reporting times, and harmonization of per diem rates to avoid attrition. Sub-sub-recipients working with key and vulnerable populations played a crucial role in negotiating the release of patients/ beneficiaries from prisons, where they were held for being men who have sex with men or sex workers. With their grassroots knowledge and networks, these organizations provided unique services beyond the scope of most humanitarian/development partners. 59 In South-West Asia, UNDP managed the Global Fund regional programme to address the needs of migrant, refugee and displaced persons. UNDP effectively supported the provision of TB interventions among millions of Afghan refugees, returnees and mobile populations in Afghanistan, Iran and Pakistan. In addition to supporting service delivery, the programme developed a cross-border TB platform and strategy and regional guidelines for cross-border TB prevention and care in South-West Asia. 60 UNDP was well positioned to support programming in the context of health emergencies. It had experience implementing above-allocation funding, reprogramming existing funds, and mobilizing complementary resources in close coordination with the Global Fund and other United Nations agencies. For example, in 2021, Haiti was hit by a 7.2 magnitude earthquake and Tropical Depression Grace, limiting access to early treatment for malaria and leading to an increase in malaria transmission. The Global Fund approved a UNDP Haiti request for nearly $1 million in emergency funding, which enabled malaria services to reach 500,000 affected people throughout southern regions, including displaced and hard-to-reach communities. 61

Lesson 6

A strong health system requires effective procurement and supply chain management. UNDP efforts to leverage its global procurement architecture and expertise to support health procurement efforts proved particularly effective in crisis-affected countries and during the COVID-19 pandemic.

A strong health system requires effective procurement and supply chain management (PSM) to ensure the timely and adequate delivery of medicines and other health commodities. UNDP expertise, built through more than 15 years of implementing PSM support services, played a key role in helping countries receiving Global Fund financing to manage healthcare supply chains and identify systemic challenges that require improvement (Kyrgyzstan, Indonesia, Afghanistan, South Sudan and Zambia62).

UNDP also played a crucial role in supporting countries facing crises and operational challenges to ensure the continuity of PSM systems. This was especially relevant in regions where procurement processes were impacted by international sanctions imposed on governments (Iran, Iraq and Cuba 63). UNDP also leveraged existing tools, processes and frameworks for PSM strengthening to support Global Fund grant implementation, such as human resources and innovation (digitization).

UNDP invested in human resources through scaling-up on-the-job and formal training sessions, including through professional certification programmes for health workers in PSM-related areas, such as accreditation from the internationally recognized Chartered Institute of Purchasing and Supply and supply chain leadership programmes with partner organizations 64 – an area yet to be evaluated.

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UNDP contributed to the implementation of innovative technology for health (see the Reflections paper on digital technologies such as electronic data interchange and e-procurement systems), which was central to supporting resilient and sustainable systems for health. UNDP was involved in piloting and implementing several innovations in the supply chain. These included upstream innovation for sustainable procurement, such as engaging manufacturers through longterm agreements, optimizing medicine packaging to reduce waste and freight costs, and supporting mobile phonebased or other electronic logistic management information systems to allow the tracking of inventory and the monitoring of cold chain temperature for vaccines at the most peripheral storage level.

UNDP supported implementing digital health initiatives focusing on COVID-19 vaccine delivery, medical supply chains, HIV, TB, maternal and child health, and communicable and non-communicable disease service delivery. In Burundi, Chad, Djibouti and Guinea-Bissau, the UNDP-Global Fund partnership, in collaboration with governments, effectively rolled out mobile technology to digitize HIV, TB and malaria data to map, track, prevent and treat health outbreaks in real-time. The national TB programme in Moldova, in partnership with UNDP, scaled up a mobile application that allowed TB patients to video themselves taking medicines at a time of the day and location convenient for them. 65 UNDP also leveraged its global procurement architecture and expertise to support health procurement efforts within national COVID-19 response plans financed through the Global Fund COVID-19 Response Mechanism. 66 In Belize, through the Global Fund, UNDP allocated $526,000 to support several critical interventions, including procuring three GeneXpert Machines and test kits to facilitate molecular testing and decentralizing COVID-19 testing services. 67 The machines also supported the decentralization of TB and HIV viral load testing.

While presenting unprecedented challenges, the COVID-19 pandemic accelerated the digitization of health services. 68 As countries faced the urgent need to minimize physical contact, telehealth solutions and digital platforms for healthcare consultations were widely deployed.

Lesson 7

Strong partnerships facilitate health system strengthening. UNDP was most successful in implementing Global Fund grants and building resilient and sustainable systems for health when leveraging its strong presence at country, regional and global levels, as well as its longstanding partnerships with major global health partners.

Strong partnerships were the cornerstone of UNDP work to strengthen systems for health. In supporting countries in their PR role or any other development service implementation support, UNDP works closely with other United Nations entities, development organizations, CSOs, private sector, academia and key populations.

Leveraging the strong presence of UNDP at country, regional and global levels, as well as longstanding partnerships with major global health partners, helped countries to develop resilient and sustainable systems for health. This was particularly clear in the case of the partnership with the Global Fund, where strategic and corporate-level linkages have been cultivated and maintained over the last two decades.

In implementing Global Fund grants, UNDP has worked with different United Nations entities such as WHO, UNICEF, UNAIDS, UNFPA, and WFP (Mali, Burundi, Kyrgyzstan, Sao Tome and Principe, Zimbabwe 69 among others). For example, in Sao Tome and Principe, with funding from the Global Fund, UNDP collaborated with WHO to contribute to the implementation of the District Health Information System 2, to reinforce the country’s health information system. 70 In Zimbabwe, in coordination with UNICEF, the main partner for the national vaccine programme, UNDP carried out extensive procurement to augment the cold chain infrastructure. 71 In the Arab States, UNDP collaborated with the Global Fund and WHO to support the roll-out of the corruption risk methodology across other regions, building on the good practices that have emerged from the region. 72 8

In its response to the COVID-19 pandemic, UNDP and its country offices worked under the leadership of United Nations Resident Coordinators and in close collaboration with specialized United Nations agencies, United Nations Regional Economic Commissions, and international financial institutions to assess the socioeconomic impacts of the pandemic on economies and communities. As the technical lead for the socioeconomic response, UNDP has engaged in countrylevel health system support, such as purchasing medical supplies and materials, providing support to digital learning platforms for education, and supporting recovery. 73 The Reflections series synthesizes lessons from past evaluations to support organizational learning about what works and what doesn't in different development contexts. The aim of the series is to provide relevant, useful, and accessible lessons to UNDP country offices as well as to the wider community of development practitioners. It is a rapid evaluation synthesis from material issued by UNDP between 2013 and 2023, as well as from external evaluative evidence. The sources consist of country-level and thematic evaluations conducted by the UNDP Independent Evaluation Office (IEO), quality-assured decentralized evaluations commissioned by UNDP country offices and key evaluative studies published in academic journals and in grey literature repositories on the topic of Health System Strengthening through the UNDP-Global Fund Partnership. This paper draws on 66 evaluations and studies. Development of this paper leveraged a combination of AI-led searches in the UNDP AIDA (Artificial Intelligence for Development Analytics) tool and human-led analysis. This reflection paper is based only on publicly available evaluative evidence and studies conducted in the last ten years. It might not reflect the recent developments of the partnership not captured in evaluations.

References 1

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UNDP IEO (2015), ‘Assessment of Development Results: Iraq’, https://erc.undp.org/evaluation/documents/download/8707 UNDP Zambia (2015), ‘Strengthening National Capacity to Fight AIDS, TB and Malaria: A case study report on the partnership between UNDP and the Ministry of Health in Zambia’.

UNDP IEO (2020c), ‘Independent Country Programme Evaluation: Islamic Republic of Afghanistan’.

APMG HEALTH (2020), ‘Focused Country Evaluations: Iran HIV Evaluation’, https://erc.undp.org/evaluation/evaluations/detail/13203, UNDP Zambia (2015), ‘Strengthening National Capacity to Fight AIDS, TB and Malaria: A case study report on the partnership between UNDP and the Ministry of Health in Zambia’, UNDP Uzbekistan (2013), ‘Independent Mid-term Review of Implementation of the First Phase of the Global Fund’s Project (HIV Component) in Uzbekistan’, https://erc.undp.org/evaluation/evaluations/detail/6681 UNDP IEO (2020c), ‘Independent Country Programme Evaluation: Islamic Republic of Afghanistan’, UNDP Indonesia (2013), ‘Management and Technical Assistant Facility to Strengthen the Implementation of Global Fund Grants in Indonesia’, UNDP (2023b) ‘UNDP Capacity Development Toolkit’.

UNDP Zambia (2015), ‘Strengthening National Capacity to Fight AIDS, TB and Malaria: A case study report on the partnership between UNDP and the Ministry of Health in Zambia’.

UNDP (2023b) ‘UNDP Capacity Development Toolkit’.

UNDP Zimbabwe (2020b), ‘UNDP and Global Fund support to strengthen financial and risk management for the delivery of health services in Zimbabwe’, UNDP Zambia (2015), ‘Strengthening National Capacity to Fight AIDS, TB and Malaria: A case study report on the partnership between UNDP and the Ministry of Health in Zambia’, UNDP Belize (2023), ‘UNDP and the Global Fund in Belize: A case study’, UNDP El Salvador (2017), ‘Strengthening National Capacity to Fight AIDS and Tuberculosis: A case study of UNDP’s support to the implementation Global Fund grants in El Salvador’.

UNDP (2023b) ‘UNDP Capacity Development Toolkit’.

UNDP Zambia (2015), ‘Strengthening National Capacity to Fight AIDS, TB and Malaria: A case study report on the partnership between UNDP and the Ministry of Health in Zambia’.

UNDP El Salvador (2017), ‘Strengthening National Capacity to Fight AIDS and Tuberculosis: A case study of UNDP’s support to the implementation Global Fund grants in El Salvador’, UNDP Belarus, ‘Capacity development and transition plan: Belarus’, https://undpcapacitydevelopmentforhealth.org/wp-content/uploads/2023/06/capacity-development-and-transition-plan-belarus09-07-2015.pdf UNDP El Salvador (2017), ‘Strengthening National Capacity to Fight AIDS and Tuberculosis: A case study of UNDP’s support to the implementation Global Fund grants in El Salvador’.

UNDP IEO (2020d), ‘Independent Country Programme Evaluation: Panama’, https://erc.undp.org/evaluation/evaluations/detail/12284, UNDP IEO (2023a), ‘Independent Country Programme Evaluation: Djibouti’, In Press.

UNDP IEO (2023a), UNDP IEO (2023a), ‘Independent Country Programme Evaluation: Djibouti’.

UNDP Zimbabwe (2020a), ‘UNDP and Global Fund support to strengthen the national health management information system: UNDP case study’, UNDP Evaluation Office (2013), Evaluation of the Regional Programme for Latin America and the Caribbean, 20082013’, https://erc.undp.org/evaluation/documents/download/6819 UNDP (2021a), ‘Unified Budget Results and Accountability Framework 2016-2021’, https://open.unaids.org/sites/default/files/documents/UNDP_Organizational report_2020.pdf UNDP (2015), ‘UNDP Global Fund partnership (2014-2015): Annual Report’, https://www.undp.org/publications/undp-global-fund-partnership-annual-report-2014-2015 The Global Fund (2020), ‘Country Coordinating Mechanism Evolution : Enhancing Partnership and Sustainability of Health Governance’,

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https://www.theglobalfund.org/media/10028/ccm_evolutionenhancingpartnershipsustainabilityofhealthgovernance _guide_en.pdf UNDP Sao Tome and Principe (2022), ‘Evaluation of the UNDP Country Programme Document ( CPD ) for São Tomé and Príncipe – 2017-2022’.

UNDP IEO (2022), ‘Independent Country Evaluation: South Sudan’, https://erc.undp.org/evaluation/evaluations/detail/12787 UNDP Zambia (2015), ‘Strengthening National Capacity to Fight AIDS, TB and Malaria: A case study report on the partnership between UNDP and the Ministry of Health in Zambia’, UNDP El Salvador (2017), ‘Strengthening National Capacity to Fight AIDS and Tuberculosis: A case study of UNDP’s support to the implementation Global Fund grants in El Salvador’, UNDP Ukraine (2020), ‘Evaluation of Procurement Support Services to the Ministry of Health of Ukraine’, https://erc.undp.org/evaluation/evaluations/detail/9458, UNDP Indonesia (2013), ‘Management and Technical Assistant Facility to Strengthen the Implementation of Global Fund Grants in Indonesia’.

UNDP IEO (2016a), Independent Country Evaluation: Sao Tome and Principe’, https://erc.undp.org/evaluation/documents/download/10266, UNDP South Sudan (2016), ‘Global Fund Grant for Strengthening Health Systems in South Sudan: Round 9 GFATM / UNDP’, UNDP El Salvador (2017), ‘Strengthening National Capacity to Fight AIDS and Tuberculosis: A case study of UNDP’s support to the implementation Global Fund grants in El Salvador’ UNDP Iran (2022), ‘Country Programme (2017-2021) Evaluation - UNDP Iran’, UNDP Ukraine (2020), ‘Evaluation of Procurement Support Services to the Ministry of Health of Ukraine’, UNDP IEO (2021b), ‘Independent Country Programme Evaluation: Chad’, https://erc.undp.org/evaluation/evaluations/detail/12786 UNDP Angola (2022), ‘Report of the Final Evaluation UNDP Angola Country Programme (2020-2022)’, UNDAF (2017), ‘Belize UNDAF 2013-2016 Evaluation’, UNDP Belize (2023), ‘UNDP and the Global Fund in Belize: A case study’, UNDP IEO (2020c), ‘Independent Country Programme Evaluation: Islamic Republic of Afghanistan’, UNDP IEO (2022), ‘Independent Country Evaluation: South Sudan’, UNDP Kyrgzistan (2022), ‘Decentralized Country Programme Evaluation of the UNDP Country Programme for the Kyrgyz Republic 2018-2022’, https://erc.undp.org/evaluation/evaluations/detail/9860 UNDP IEO (2016a), Independent Country Evaluation: Sao Tome and Principe’ UNDP IEO (2020e), ‘Independent Country Programme Evaluation: Indonesia’, https://erc.undp.org/evaluation/evaluations/detail/12275, UNDP IEO (2016a), Independent Country Evaluation: Sao Tome and Principe’.

UNDP IEO (2020e), ‘Independent Country Programme Evaluation: Indonesia’, UNDP IEO (2017a), ‘Assessment of Development Results: The Kyrgyz Republic’, UNDP Tajikistan (2013), ‘Outcome Evaluation for UNDP Tajikistan HIV / AIDS, TB and Malaria Control Program 2010 – 2013 Final Report’.

UNDP Kazakhstan (2015), Outcome Evaluation on Social Inclusion and Quality of Life Improvement’, https://erc.undp.org/evaluation/evaluations/detail/4708, University of Southern California (2021), ‘Global Project for the Evaluation of the Global Commission on HIV and the Law’, https://erc.undp.org/evaluation/documents/detail/18635 APMG HEALTH (2020), ‘Focused Country Evaluations: Iran HIV Evaluation’, UNDP Uzbekistan (2013), ‘Independent Mid-term Review of Implementation of the First Phase of the Global Fund’s Project (HIV Component) in Uzbekistan’, UNDP IEO (2020c), ‘Independent Country Programme Evaluation: Islamic Republic of Afghanistan’, UNDP Mozambique (2014), ‘Final Evaluation of National Strategic HIV and AIDS Response plan’, https://erc.undp.org/evaluation/documents/download/8524

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UNDP IEO (2021a), ‘Independent Country Programme Evaluation: Zambia’,

UNDP Kyrgzistan (2022), ‘Decentralized Country Programme Evaluation of the UNDP Country Programme for the Kyrgyz Republic 2018-2022’, 33 34

35 36 37

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41

42 43

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45

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47 48 49

50 51 52

UNDP Belize (2023), ‘UNDP and the Global Fund in Belize: A case study’, UNDP IEO (2019), ‘Independent Country Programme Evaluation: Cuba’.

UNDP IEO (2016a), Independent Country Evaluation: Sao Tome and Principe’.

UNDP IEO (2016b), ‘Independent Evaluation Office. Assessment of Development Results: Gabon’, https://erc.undp.org/evaluation/evaluations/detail/8293, UNDP Iran (2022), ‘Country Programme (2017-2021) Evaluation - UNDP Iran’, UNDP Iran (2022), ‘Country Programme (2017-2021) Evaluation - UNDP Iran’.

(2023a), ‘UNDP Health Systems Solutions to Accelerate Sustainable Health Outcomes’.

UNDP IEO (2016c), ‘Evaluation of Disability Inclusive Development at UNDP’, https://erc.undp.org/evaluation/evaluations/detail/7079 UNDP (2023d), ‘Anti-corruption, transparency and accountability in the health sector’, https://undpcapacitydevelopmentforhealth.org/category/health-system-components/anti-corruption-for-health/overview-anticorruption-for-health/ UNDP (2023d), ‘Anti-corruption, transparency and accountability in the health sector’, UNDP (2021b), ‘End of Project Evaluation of Anti-Corruption for Peaceful and Inclusive Societies (ACPIS) Global Project’, https://erc.undp.org/evaluation/evaluations/detail/9821, UNDP IEO (2016d), ‘Evaluation of UNDP contribution to anti-corruption and addressing drivers of corruption’, https://erc.undp.org/evaluation/evaluations/detail/7081 The Global Fund (2020), ‘Global Fund Prospective Country Evaluation: 2020 Synthesis Report’, https://archive.theglobalfund.org/media/11086/archive_terg-2020-pce-synthesis_report_en.pdf UNDP (2021b), ‘End of Project Evaluation of Anti-Corruption for Peaceful and Inclusive Societies (ACPIS) Global Project’ UNDP IEO (2017b), ‘Evaluation of the UNDP strategic plan and global and regional programmes’, https://erc.undp.org/evaluation/evaluations/detail/7850 UNDP (2023d), ‘Anti-corruption, transparency and accountability in the health sector’) UNDP Tunisia (2021), ‘A risk-based approach to tackle corruption in the health sector Lessons from Tunisia: UNDP case study’, https://www.undp.org/sites/g/files/zskgke326/files/migration/arabstates/UNDP-Tunisia-2021-Casestudy-Risk-based-Anti-corruption-for-Health-in-Tunisia.pdf UNDP (2018), ‘Conceptual Framework for Corruption Risk Assessment at Sectoral Level’, https://undpcapacitydevelopmentforhealth.org/wp-content/uploads/2021/05/CRA-at-Sectoral-Level_2018.pdf UNDP Tunisia (2021), ‘A risk-based approach to tackle corruption in the health sector Lessons from Tunisia: UNDP case study’ UNDP Zimbabwe (2020b), ‘UNDP and Global Fund support to strengthen financial and risk management for the delivery of health services in Zimbabwe’.

Mackey TK, Cuomo RE (2020), ‘An interdisciplinary review of digital technologies to facilitate anti-corruption, transparency and accountability in medicines procurement anti-corruption, transparency and accountability in medicines procurement. Glob Health Action. 2020;13(1)’, https://doi.org/10.1080/16549716.2019.1695241 UNDP IEO (2016a), Independent Country Evaluation: Sao Tome and Principe’.

UNDP IEO (2016d), ‘Evaluation of UNDP contribution to anti-corruption and addressing drivers of corruption’.

UNDP (2021b), ‘End of Project Evaluation of Anti-Corruption for Peaceful and Inclusive Societies (ACPIS) Global Project’, Gorodensky A, Bowra A, Saeed G, Kohler J (2022), ‘Anti-corruption in global health systems: Using key informant interviews to explore anti-corruption, accountability and transparency in international health organisations. BMJ Open’, https://bmjopen.bmj.com/content/bmjopen/12/12/e064137.full.pdf UNDP IEO (2015), ‘Assessment of Development Results: Iraq’.

UNDP IEO (2020c), ‘Independent Country Programme Evaluation: Islamic Republic of Afghanistan’.

UNDP (2021a), ‘Unified Budget Results and Accountability Framework 2016-2021’.

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54 55 56

57

58 59

60 61 62

63

64 65 66

67 68

69

UNDP (2023e), ‘Global Fund partnership and Health systems’, https://www.undp.org/geneva/global-fund-partnershipand-health-systems UNDP (2020), ‘Global Fund Partnership & COVID-19’, https://www.undp.org/sites/g/files/zskgke326/files/migration/ir/15705b91c24e04dc0a97c3fdbe45cf8cadc20cd3edf7 5961ae73d761bbb72277.pdf UNDP (2023b) ‘UNDP Capacity Development Toolkit’.

Ibid.

The Global Fund (2022), ‘Technical Evaluation Reference Group (TERG): Thematic Evaluation of the Global Fund’s Performance in Challenging Operating Environments’, https://www.theglobalfund.org/media/12656/terg_challenging-operating-environments-thematicevaluation_report_en.pdf The Global Fund (2014), ‘TERG Position Paper: Thematic Review of the Global Fund in “Fragile States” 2014’, https://archive.theglobalfund.org/media/3006/archive_terg-evaluation-2013-2014-thematic-review-fragilestates_positionpaper_en.pdf The Global Fund (2017), ‘Global Fund Grant Management in High Risk Environments’, https://www.theglobalfund.org/media/4284/oig_gf-oig-17-002_report_en.pdf?u=636488964760000000 The Global Fund (2022), ‘Technical Evaluation Reference Group (TERG): Thematic Evaluation of the Global Fund’s Performance in Challenging Operating Environments’.

UNDP (2023c) The Global Fund (2022), ‘Technical Evaluation Reference Group (TERG): Thematic Evaluation of the Global Fund’s Performance in Challenging Operating Environments’.

Ibid.

UNDP (2023a), ‘UNDP Health Systems Solutions to Accelerate Sustainable Health Outcomes’.

UNDP IEO (2017a), ‘Assessment of Development Results: The Kyrgyz Republic’, UNDP Indonesia (2013), ‘Management and Technical Assistant Facility to Strengthen the Implementation of Global Fund Grants in Indonesia’, UNDP IEO (2020e), ‘Independent Country Programme Evaluation: Indonesia’, UNDP South Sudan (2016), ‘Global Fund Grant for Strengthening Health Systems in South Sudan: Round 9 GFATM / UNDP’, UNDP IEO (2021a), ‘Independent Country Programme Evaluation: Zambia’, APMG HEALTH (2020), ‘Focused Country Evaluations: Iran HIV Evaluation’, UNDP IEO (2015), ‘Assessment of Development Results: Iraq’, UNDP IEO (2019), ‘Independent Country Programme Evaluation: Cuba’.

UNDP (2023b) ‘UNDP Capacity Development Toolkit’ Ibid.

MOPAN (2022), ‘MOPAN Assessment of the Global Fund’, https://www.mopanonline.org/assessments/globalfund2021/MOPAN_2022_GlobalFund_PartI_FinalWeb.pdf UNDP Belize (2023), ‘UNDP and the Global Fund in Belize: A case study’.

Ayala-öström B (2023), ‘Accelerating access to and delivery of new health technologies for tuberculosis, malaria and neglected tropical diseases: Supporting countries to achieve universal health coverage’, https://erc.undp.org/evaluation/documents/download/22101 UNDP IEO (2020b), ‘Independent Country Programme Evaluation: Mali’, UNDP IEO (2023b), ‘Independent Country Programme Evaluation: Burundi’, https://erc.undp.org/evaluation/documents/download/22476 UNDP Kyrgzistan (2022), ‘Decentralized Country Programme Evaluation of the UNDP Country Programme for the Kyrgyz Republic 2018-2022’, UNDP Sao Tome and Principe (2022), ‘Evaluation of the UNDP Country Programme Document ( CPD ) for São Tomé and Príncipe – 2017-2022’.

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UNDP Zimbabwe (2020c), ‘The impact of UNDP-managed Global Fund investments in procurement and supply chain systems in Zimbabwe.

UNDP Sao Tome and Principe (2022), ‘Evaluation of the UNDP Country Programme Document ( CPD ) for São Tomé and Príncipe – 2017-2022’.

UNDP Zimbabwe (2020c), ‘The impact of UNDP-managed Global Fund investments in procurement and supply chain systems in Zimbabwe, UNDP Tunisia (2021), ‘A risk-based approach to tackle corruption in the health sector Lessons from Tunisia: UNDP case study’.

UNDP IEO (2020f), ‘Evaluation of UNDP support to conflict-affected countries’, https://erc.undp.org/evaluation/documents/download/18359

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