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

Table 1 Implicit and explicit operationalization of systems thinking for Concern, Saidpur and Parbatipur

Principle in systems thinking^a	Concern’s management decision (implicit system approach)	Sustainability Framework (explicit method)
Consider boundaries of system, nested and overlapping systems	• Making the distinction between the national health system and local urban administrative systems, and focusing capacity building on the MHDs	• Local system and stakeholder mapping
		• Identification of interrelated roles between MOHFW and MHD
Construct reality through multiple perspectives	• Voices from all segments of society included in process	• Visioning and scenario planning
	• Participatory process	• Iterative, evidence based, and
		• participatory review of progress
		• Gender and equity awareness building through diversity in planning
Value and build on relationships	• Forum creation for relation between MHD – WHC – MOH	• Participatory assessment, bringing diverse stakeholders together
	• WHC as a hub for health promotion	• Mutual accountability through review of progress
	• Accountability of the municipal government to communities	• Mutual accountability through review of progress
Iterative learning	• Defining assessment criteria in HICAP and WHC	• Regular measurement of outcomes in multiple dimensions of assessment
Iterative learning	• Involvement of MHD and WHCs in Knowledge, Practice and Coverage Household Health Surveys including disaggregation by wealth quintiles to assess equity	• Cycle of visioning, defining measures, measuring, reviewing, adjusting

^aThere is not one set of recognized systems thinking principles, and this table is not exhaustive. Williams [12] emphasizes boundaries, perspectives, and relationships as central to systems thinking. Many authors emphasize learning, and specifically iterative learning, as an essential principle. Other authors also stress the value of collaboration across disciplines, sectors and organizations, transformational leadership, alternative scenario planning, using diversity of stakeholders to brainstorm and design, etc. [6, 7, 26].