Designing for Impact and Institutionalization: Applying Systems Thinking to Sustainable Postpartum Family Planning Approaches for First-Time Mothers in Bangladesh

Public health practitioners often design interventions prioritizing potential impact over sustainability. To assess the potential for impact and institutionalization, we applied systems thinking to postpartum family planning approaches for first-time mothers in Bangladesh. Key Messages Donor-funded multilevel approaches to address barriers for young first-time mothers in using modern postpartum family planning methods have largely focused on integrated service delivery—an approach that has proven challenging to institu-tionalize within government health systems. To achieve lasting impact, an approach must be both effective (able to produce the desired impact) and able to be institutionalized. Yet, considerations for whether and how approaches can be institutionalized within existing health systems are often underrepresented in program design. To increase the use of postpartum family planning by first-time mothers in Bangladesh, we adapted the Viable System Model to the context of the Bangladeshi health system and developed a tool and process for assessing the potential for institutionalization alongside potential for impact during a program design process. ABSTRACT Integrated service delivery approaches have shown promise to increase use of services including postpartum family planning (PPFP) by young, first-time mothers (FTMs) but have proven challenging to scale and institutionalize. Integration adds complexity, requiring careful assessment of effects on a range of key system functions from demand creation and service delivery to oversight and governance. Through an innovative design process, we selected approaches to increase FTMs’ PPFP use through existing health systems. We generated programmatic options and then sought to select approaches based on (1) potential impact on FTMs’ PPFP uptake and (2) potential to institutionalize in the health system. The latter represented an innovation in addressing management systems’ drivers of scalability and sustainability; to accomplish it, we developed a participatory design process to assess the potential of an approach to be institutionalized in a specific context. We adapted a management systems theory, the Viable System Model (VSM), which presents 5 essential organizational functions and the relations required between them to improve the viability (performance and institutionalization) of organizational systems. Drawing from the VSM, we developed a process for reviewing the effects of proposed approaches on provider workload, client flow, infrastructure, revisions to guidelines and job descriptions, coordination and management, and information systems. The VSM provided a structure to identify potential displacement of capacity in the health system and mitigate often neglected organizational challenges that compromise institutionalization. The process informed the elimination of approaches with potential for impact but that had deal-breakers to institutionalization, such as increased workload or shifted job descriptions, in the Bangladeshi context. For the selected approaches, consideration of systems elements fostered discussion of expected risks to institutionalization, highlighting needed mitigation efforts and monitoring during implementation.