Health Systems Strengthening Evaluation

Laura Gagliardone
Beth Ann Plowman
UNICEF Evaluation Office
Publication Year:
  • SDG 1 - No Poverty
  • SDG 2 - Zero Hunger
  • SDG 3 - Good Health and Well-Being
  • SDG 10 - Reduced Inequalities

Learning on health systems strengthening through evaluation


Why is health systems strengthening important for UNICEF?

“UNICEF has identified an important role for itself: ensuring that national systems are strong and resilient and able to provide sustained, quality services to those who need them, particularly children”

UNICEF Ethiopia / Zerihun Sewunet

Strong systems are key to UNICEF’s ability to achieve its strategic goals and respond to global imperatives such as the Sustainable Development Goals, including the target on universal health coverage. In 2016, UNICEF published ‘The UNICEF Health Systems Strengthening Approach’, an internal operational framework to help the organization decide how it can most effectively support health systems strengthening (HSS) in different contexts. For UNICEF, the HSS approach connects community, sub-national and national levels, and emphasizes the importance of community engagement and sub-national management capacity to the overall performance of national health systems.



Who is the evaluation for?

The primary users of this evaluation are UNICEF internal decision-makers interested in learning the evaluation findings and the recommendations for better future programming.

How did UNICEF evaluate this?

 UNICEF Ethiopia / Mulugeta Ayene

In 2017, UNICEF Evaluation Office commissioned a formative evaluation of HSS programming to generate evidence and learning on what is needed for successful implementation. The main objectives of the evaluation were to: 1) assess the relevance, efficiency, effectiveness, equity focus and sustainability of UNICEF’s HSS approach; 2) assess and document HSS programming at the implementation level; and 3) based on the evidence gathered, produce clear conclusions and recommendations for policy and management decisions to further transform HSS within UNICEF.

Evaluation data collection and analysis took place over two years, in 2017 and 2018. Data collection encompassed 6 detailed and 11 summarized country studies; 4 multi-country thematic case studies, key informant interviews, document review and an on-line survey. The evaluation was based on a theory of change for UNICEF’s HSS work. Evaluation questions were conceptualized around 2 high-level inquiries: 1) To what extent is UNICEF implementing relevant and effective HSS interventions? 2) What strategies and factors have enabled or hindered progress?


What did we learn?

UNICEF Ethiopia Country Office

The evaluation concluded that making the shift to HSS is complex and difficult to achieve. In many contexts, funding streams, government demands and UNICEF’s lead position as an implementing partner, including in emergency responses, can pull the organization into a supportive, rather than strengthening approach. UNICEF was also found to have a comparative advantage for HSS in specific areas, including in strengthening sub-national governance in the era of decentralization, and improving data for decision-making.




What are our recommendations?

The evaluation team has identified priority recommendations that will help UNICEF accelerate and strengthen its transition towards HSS:

  • Clarify the vision for UNICEF’s role in HSS and develop a cross-organization strategy to deliver on this vision. This will provide clear direction to UNICEF staff and partners on what UNICEF intends when it talks about transitioning to HSS
  • Ensure that UNICEF staff have the skills and knowledge to incorporate systems thinking into their day-to-day work
  • Support country offices to strengthen their focus on HSS
  • Develop and implement a clear strategy for monitoring and evaluating UNICEF’s HSS work
  • Ensure that UNICEF is learning from its HSS work to support the continuous improvement of planning and contribute to an evidence base as a global public good
  • Advocate across UNICEF for an organization-wide change management process to increase the organization’s engagement on HSS and ensure that systems are in place to strengthen the effectiveness of HSS
  • Develop partnerships with external stakeholders to maximize UNICEF’s comparative advantage in this area of work.

The Health Systems Strengthening Evaluation can be accessed here.



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