Causality analysis
Facilitators’ Workshop on District
Health Performance Improvement
Lilongwe, 25th – 27th March 2015
Diagnose
• Select interventions
• Define indicators
• Identify information sources and collect data
• Identify the bottlenecks
• Identify areas lagging behind
• Analyse the root causes of bottlenecks
Steps
Intervene
• Prioritize solutions with all stakeholders
• Define an implementation and monitoring plan
• Support implementation
Verify
• Monitor frequently using existing opportunities
Adjust
• Take corrective actions to ensure impact
Analyse the root causes of
bottlenecks and barriers
• The quality of the analysis depends on this
very step
• It is important to have around the table
people with the right knowledge and expertise
Who should be around the table?
The quality of the causality analysis is
a critical determinant of the quality
of the resulting plans and the impact
on health system performance
Once the bottleneck is identified, its causes need to
be assessed thoroughly
Determinants
from supply
100
90
80
70
60
50
40
30
20
10
0
Why?
Determinants
from demand
Determinants
from quality
1
Why?
2
commodities
human
resources
georgarphic
initial
access
utilization
continuous
utilization
effective
coverage /
quality
Aim
• To find the real cause which ignited the chain
of events leading to the under-performance:
– There is a cause-effect relationship to be explored
during the process of causality analysis
– Often do we stop at symptoms without getting to
the root cause (s) of the problem
An illustration of Benjamin Franklin on the
cause-effect relationship
• A kingdom was lost for a want of a
battle.
• A battle was lost for a want of an
army
• An army was lost for a want of a rider
• A rider was lost for a want of a horse
• A horse was lost for a want of a shoe
• A shoe was lost for a want of a nail
And all for the loss of a horseshoe nail.
Adapted from Benjamin Franklin’s poem
6e President of the USA, 1785 – 1788
A simple technique of 5 why
• A Japanese technique developed by Sakichi Toyoda and used
till today as the scientific basis to Toyota Automobile’s
approach .
• A question asking technique used to explore the cause-andeffect relationships underlying a particular problem.
• Allows a deep analysis, moving progressively from the effect
observed to the underlying cause
• Avoid the temptation of a quick and superficial analysis
limited to the common symptom, instead of the root causes
of observed problems
Explore root causes of key
bottlenecks
100%
80%
60%
40%
20%
0%
• Legislative/ Policy* Environment
• Budget & Expenditure
• Management/ Coordination
• Social Norms
?
?
?
?
?
?
?
?
We may find issues in the enabling
environment causing such bottlenecks
100%
80%
60%
40%
20%
0%
• Legislative/ Policy* Environment
X
• Budget & Expenditure
• Management/ Coordination
• Social Norms
X
X
Few useful rules
• Always cut your orange until the last piece before jumping
onto the apple
• Never stop the analysis to something which stills looks like a
symptom, and not a cause
• Always ensure that all possible causes have been looked into
as one problem might have more than one cause
• The number 5 is just a guide, not a law
Limitations
• More useful for supply and quality related bottlenecks and
less useful for determinants needing the beneficiaries’
perspectives (we use FGDs for that)
• Requires a multi-disciplinary team with the required expertise
in the various bottlenecks to be analyzed: Stakeholder
participation bring additional technical and financial resources
to the districts
• There is need for technical assistance initially to ensure good
quality of the analysis to improve the skills and build
confidence
Know what to look for when
facilitating a Causal Analysis
• Common causes of bottlenecks in the health
system (specific for each determinant)
• Main environmental factors (Social Norms,
Legislation/ Policy, Budget/ expenditure,
Management/ Coordination)
• Possible crisis/hazards (if relevant)