title: 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: 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.
authors.affiliation: Director, ICF International Center for Design and Research in Sustainable Health and Human Development (CEDARS), 530 Gaither Road Suite 500, Rockville, MD 20850, USA. eric.sarriot@icfi.com.
authors.forename: Eric G
authors.initials: EG
authors.lastname: Sarriot
authors.forename: Michelle
authors.initials: M
authors.lastname: Kouletio
authors.forename: Dr Shamim
authors.initials: DS
authors.lastname: Jahan
authors.forename: Izaz
authors.initials: I
authors.lastname: Rasul
authors.forename: Akm
authors.initials: A
authors.lastname: Musha
mesh_terms: D001459:Bangladesh; D002648:Child; D002662:Child Health Services; D003695:Delivery of Health Care / Q000458:organization & administration; D005260:Female; D006078:Government Programs; D006801:Humans; D007231:Infant, Newborn; D008427:Maternal Health Services; D011057:Politics; D011247:Pregnancy; D015397:Program Evaluation; D012922:Social Change; D019037:Urban Health Services / Q000458:organization & administration; D014505:Urban Population