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

Abstract

BackgroundStarting 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.MethodsConcern 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).ResultsStrategic 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.ConclusionsSustainability 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.

Community Health Systems as Complex Adaptive Systems: Ontology and Praxis Lessons from an Urban Health Experience with Demonstrated Sustainability

“…Five years after the end of the project, Concern carried out a post-project evaluation with the two municipalities, based on the sustainability framework and indicators agreed upon by stakeholders in the design phase. Twelve indicators of maternal and child health improved tremendously 1 during the project (1999)(2000)(2001)(2002)(2003)(2004) (Sarriot 2014). Figure 2a and b show the comparative evolution of two illustrative indicators during and after the project against the national benchmarks of the Bangladesh Demographic and Health Survey (BDHS) urban estimates.…”

Self-Organization and Emergence in Global Health. Insights From Practice, Blind Spots and Possible Contributions From Complexity Science

“…For example, the Sustainability Framework [10] suggests a set of conditions, which if present at a certain level, will increase the odds of emergence of sustainability. These include: policies, specific capabilities, social capital, community capacity, macro-economic conditions, conflict, political stability, feasibility and acceptability of interventions.…”

“…Similar processes affect national to subnational negotiations. Interestingly, in the development field, the complexity matrix describes how specific problems fall on a continuum from simple to complex, and has been adapted to community health [10,37]. As complexity accrues and the world becomes pluralist or coercive, the definition of the goal to be pursued and the metrics of progress start relying on more constructivist and participatory methods for sense-making [10,21] to answer questions such as, can we sustain a level of collaboration required to maintain equitable health outcomes in communities?…”

“…It wasn't exactly a mistake, but it wasn't necessarily an intended strategy". An assessment five-year post-project [25] describes elements of self-organization among stakeholders of an urban health project in Bangladesh. While on the surface the architecture for urban community health was as-expected, different groups' self-interest led to a working equilibrium between all parties [26].…”

“…Progress towards the MDGs were achieved during a period of increase in gross domestic product (GDP) in developing countries, and an important part of the gains in child mortality are associated with GDP gains and social determinants of health rather than specific health interventions supported by global health strategies [5,7]. Secondly, most progress has been made in a context of increased development assistance [7,8], and this raises questions about the sustainability at scale of systems, of quality, and of health outcomes [9,10].…”