Advancing the application of systems thinking in health: sustainability evaluation as learning and sense-making in a complex urban health system in Northern Bangladesh

Health Research Policy and Systems

AKM Musha¹  Izaz Rasul²  Dr Shamim Jahan³  Michelle Kouletio⁵  Eric G Sarriot⁴ 

[1] Country Director, Concern Worldwide, House 15 SW(D), Road 7, Gulshan 1, Dhaka, Bangladesh;Director of Health Programs, Concern Worldwide, House 15 SW(D), Road 7, Gulshan 1, Dhaka, Bangladesh;Country Director, University of Chicago Research, House 4 Road 2B, Sector 4, Uttara, Dhaka 123, Bangladesh;Director, ICF International Center for Design and Research in Sustainable Health and Human Development (CEDARS), 530 Gaither Road Suite 500, Rockville, MD 20850, USA;Health Consultant, US Embassy, 01 BP 2012 Cotonou, Republic of Benin

关键词: Urban health;    Systems thinking;    Sustainability;    Prevention;    Participatory;    Learning;    Health systems;    Evaluation;    Equity;    Complex adaptive systems;   

Others  :  1177330
DOI  :  10.1186/1478-4505-12-45

 received in 2014-01-06, accepted in 2014-07-08,  发布年份 2014

【 摘 要 】

Background

Starting in 1999, Concern Worldwide Inc. (Concern) worked with two Bangladeshi municipal health departments to support delivery of maternal and child health preventive services. A mid-term evaluation identified sustainability challenges. Concern relied on systems thinking implicitly to re-prioritize sustainability, but stakeholders also required a method, an explicit set of processes, to guide their decisions and choices during and after the project.

Methods

Concern chose the Sustainability Framework method to generate creative thinking from stakeholders, create a common vision, and monitor progress. The Framework is based on participatory and iterative steps: defining (mapping) the local system and articulating a long-term vision, describing scenarios for achieving the vision, defining the elements of the model, and selecting corresponding indicators, setting and executing an assessment plan,, and repeated stakeholder engagement in analysis and decisions . Formal assessments took place up to 5 years post-project (2009).

Results

Strategic choices for the project were guided by articulating a collective vision for sustainable health, mapping the system of actors required to effect and sustain change, and defining different components of analysis. Municipal authorities oriented health teams toward equity-oriented service delivery efforts, strengthening of the functionality of Ward Health Committees, resource leveraging between municipalities and the Ministry of Health, and mitigation of contextual risks. Regular reference to a vision (and set of metrics (population health, organizational and community capacity) mitigated political factors. Key structures and processes were maintained following elections and political changes. Post-project achievements included the maintenance or improvement 5 years post-project (2009) in 9 of the 11 health indicator gains realized during the project (1999–2004). Some elements of performance and capacity weakened, but reductions in the equity gap achieved during the project were largely maintained post-project.

Conclusions

Sustainability is dynamic and results from local systems processes, which can be strengthened through both implicit and explicit systems thinking steps applied with constancy of purpose.

【 授权许可】

   
2014 Sarriot et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

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