1. 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 Systems Thinking – a Diagnostic Journey Catherine Connor Abt Associates Inc. DLI Workshop on HSS August 24, 2011

2. 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 What we will do in this session

3. Why do we need to think differently? People Governance Information Financing Service Delivery Human Resources Medicines & Technology Health systems are dynamic non-linear context-specific

4. 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

5. Where do we begin? A poor rural family is desperate because their 3 year old son Elias has severe diarrhea. We begin with a common performance outcome – high child mortality due to preventable, treatable disease What obstacles will they face? Why? What are the causes of these obstacles?

6. Why did Elias get diarrhea?

7. Why did Elias get diarrhea Unsafe water source Poor hygiene Why?

8. Why did Elias get diarrhea? Unsafe water source Poor hygiene Lack basic education Poverty Centralized government not accountability to rural areas No CHWs Data on literacy rates and grade completion

9. Why not treat Elias at home?

10. Don’t have ORT Don’t know home care Why?

11. Why not treat Elias at home? Don’t have ORT Don’t know home care No community health workers Why? Sector strategy or district health plan

12. Why not treat Elias at home? Don’t have ORT Don’t know home care No CHWs No training available Centralized government not accountable to rural areas

13. What obstacles does the family face to get care at a health facility?

14. No $ for transport to nearest facility Facility without supplies What obstacles does the family face to get care at a health facility? Why? Data on stock outs Data on use rates

15. Why obstacles does the family face to get care at a health facility? No $ for transport to nearest facility Insufficient quantity of services Facility without supplies Few rural facilities Poor purchasing Leakage No roads Why? Data on # and location of facilities Data on procurement and supply chain

16. Limited Supply Low Demand What obstacles does the family face to get care at a health facility? Group Exercise Form groups of 4-5 Half of the groups will analyze the causes of Low Demand other half Limited Supply

17. 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 post- it notes next to the suspected cause

18. 1. What are the causes of causes of Low Demand ? Limited Supply? 2. What data are available to identify primary causes? 3. Extra: Which causes/problems are more amenable to policy and programmatic solutions? Circle with marker. Systems Thinking Small group exercise – Sharing

19. 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 Cost recovery Vertical trainings in hotels Decentralization Free care Job descriptions

20. 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 Thank you Reports related to this presentation are available at www.HealthSystems2020.org