Elsevier

Social Science & Medicine

Volume 131, April 2015, Pages 147-155
Social Science & Medicine

A causal loop analysis of the sustainability of integrated community case management in Rwanda

https://doi.org/10.1016/j.socscimed.2015.03.014Get rights and content
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Highlights

  • We examine systems factors of sustainability of integrated Community Case Management in Rwanda.

  • A sustainability assessment and causal loop analysis reveals three long-term risk scenarios.

  • Financial, political, and technical threats are found in balancing and reinforcing causal loops.

  • Consequences of choices and non-choices are delayed and hard to predict in complex health systems.

  • Threats at multiple levels of the system need to be mitigated to protect benefits achieved to date.

Abstract

Expansion of community health services in Rwanda has come with the national scale up of integrated Community Case Management (iCCM) of malaria, pneumonia and diarrhea. We used a sustainability assessment framework as part of a large-scale project evaluation to identify factors affecting iCCM sustainability (2011). We then (2012) used causal-loop analysis to identify systems determinants of iCCM sustainability from a national systems perspective. This allows us to develop three high-probability future scenarios putting the achievements of community health at risk, and to recommend mitigating strategies. Our causal loop diagram highlights both balancing and reinforcing loops of cause and effect in the national iCCM system. Financial, political and technical scenarios carry high probability for threatening the sustainability through: (1) reduction in performance-based financing resources, (2) political shocks and erosion of political commitment for community health, and (3) insufficient progress in resolving district health systems--“building blocks”--performance gaps. In a complex health system, the consequences of choices may be delayed and hard to predict precisely. Causal loop analysis and scenario mapping make explicit complex cause-and-effects relationships and high probability risks, which need to be anticipated and mitigated.

Keywords

Sustainability
Causal loop analysis
Community case management
Evaluation
Health systems
Rwanda
Systems thinking
Community health

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