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.
Highlights
Starting in 1999, Concern Worldwide Inc. (Concern) worked with two Bangladeshi municipal health departments to support delivery of maternal and child health preventive services
In 2000, CORE partnered with a US Agency for International Development (USAID) project implemented by Macro International in a study called the ‘Sustainability Initiative,’ in order to improve the conceptualization and implementation of more sustainable strategies in community health [14,15]
The method is described elsewhere as a participatory process involving the six steps described in Figure 2, bringing together situation assessment, planning, evaluation, and strengthening relationships between the actors, based on consistent reference to data and learning steps [23]. We describe how these steps were adapted by Concern and which elements of planning and evaluation were integrated in the model: 1) Defining the local system, and the common long-term vision In February 2003, Concern and its partners defined the system of local actors expected to carry out the task of health promotion at the municipality level during a 6-day workshop using stakeholder mapping, and developing a common vision through participatory group activities [14]
Summary
Starting in 1999, Concern Worldwide Inc. (Concern) worked with two Bangladeshi municipal health departments to support delivery of maternal and child health preventive services. Overlapping with the field of global health and global development, the world of evaluation is itself trying to better approach non-linear realities, complexity, and systems thinking [11]. In 2000, CORE partnered with a US Agency for International Development (USAID) project implemented by Macro International in a study called the ‘Sustainability Initiative,’ in order to improve the conceptualization and implementation of more sustainable strategies in community health [14,15]. By 2002, this collaboration had produced a tool (the Sustainability Framework) for sustainability planning and evaluation Concern needed an evaluation and learning tool able to guide the implementation of project strategies (by the municipalities themselves) toward greater odds of sustainability. The interest in learning, bridged the local Bangladeshi and the global context when USAID provided additional funds to Concern to carry out a post-project evaluation 3 and 5 years after the end of the project (2007 and 2009)
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