Systems Thinking – a Diagnostic
Journey
Catherine Connor
Abt Associates Inc.
DLI Workshop on HSS
August 24, 2011
Abt Associates Inc.
In collaboration with:
I Aga Khan Foundation I Bitrán y Asociados
I BRAC University I Broad Branch Associates
I Deloitte Consulting, LLP I Forum One Communications
I RTI International I Training Resources Group
I Tulane University’s School of Public Health
What we will do in this session
Practice “systems thinking” by applying a technique to
diagnose causes of poor health system performance
 Diagnostic journey or root cause analysis
 Use data
 Look for causes that you can do something about
 Anticipate effects of proposed interventions
Why do we need to think differently?
Health systems are
Governance
Medicines &
Technology
context-specific
Information
People
non-linear
Human
Resources
dynamic
Financing
Service
Delivery
How do we do ‘systems thinking’?
Take a diagnostic journey to
understand the
causes of the problems we
observe
• Multiple, inter-dependent causes with
multiple effects
• Work backwards and sideways
• Use data. Suspend judgment.
• Look for causes that can be affected by
policy or programs
Where do we begin?
We begin with a common performance outcome – high child mortality
due to preventable, treatable disease
A poor rural family is desperate
because their 3 year old son Elias has
severe diarrhea.
• What obstacles will they face?
• Why? What are the causes of these obstacles?
Why did Elias get diarrhea?
Why did Elias get diarrhea
Poor
hygiene
Unsafe
water
source
Why?
Why did Elias get diarrhea?
No
CHWs
Poor
hygiene
Unsafe
water
source
Data on literacy rates
and grade completion
Lack
basic
education
Poverty
Centralized
government not
accountability
to rural areas
Why not treat Elias at home?
Why not treat Elias at home?
Don’t know
home care
Why?
Don’t
have ORT
Why not treat Elias at home?
Don’t know
home care
No
community
health
workers
Sector strategy or
district health plan
Why?
Don’t have
ORT
Why not treat Elias at home?
No CHWs
Don’t know
home care
Don’t
have
ORT
No
training
available
Centralized
government
not
accountable
to rural
areas
What obstacles does the family face
to get care at a health facility?
What obstacles does the family face
to get care at a health facility?
Facility
without
supplies
No $ for
transport
to nearest
facility
Data on stock outs
Why?
Data on use rates
Why obstacles does the family face
to get care at a health facility?
Facility
without
supplies
No $ for
transport
to nearest
facility
Poor
purchasing
Leakage
Insufficient
Few
rural
quantity of
facilities
services
No roads
Data on procurement
and supply chain
Data on # and location
of facilities
Why?
What obstacles does the family face
to get care at a health facility?
Group Exercise
Low
Demand
Limited
Supply
• Form groups of 4-5
• Half of the groups will
analyze the causes of
Low Demand
• other half Limited
Supply
Systems Thinking
Small group exercise - instructions
 Groups of 4-5
 Half analyze the causes of Low Demand; other half
Limited Supply
For next 30 minutes, please:
1. Brainstorm causes and write on yellow post-it notes
and map causal web on flip chart
2. What data are available to identify/prioritize causes?
See hand out of data sources and write on green postit notes next to the suspected cause
Systems Thinking
Small group exercise – Sharing
What are the causes of causes of Low Demand?
Limited Supply?
2. What data are available to identify primary causes?
1.
3.
Extra: Which causes/problems are more amenable
to policy and programmatic solutions? Circle with
marker.
Systems thinking leads to better
system interventions
‘A systems
perspective can minimize the mess;
many of today’s problems are because of
yesterday’s solutions”
Dr. Irene Akua Agyepong, Ghana Health Service 2009
Thank you
Reports related to this presentation
are available at www.HealthSystems2020.org
Abt Associates Inc.
In collaboration with:
I Aga Khan Foundation I Bitrán y Asociados
I BRAC University I Broad Branch Associates
I Deloitte Consulting, LLP I Forum One Communications
I RTI International I Training Resources Group
I Tulane University’s School of Public Health