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

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.

The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014

“…However, as Tulenko et al point out, these developments have been heavily donor dependent, resulting in a fragmented environment where disease-specific responses dominate [8]. This raises important questions of sustainability and the need to integrate the plethora of new initiatives into coherent national programmes and local primary health care systems [35, 96]. …”

The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care

“…Hybrid trials to assess both program effectiveness and aspects of implementation and sustainability are becoming more common (28, 71). Systems science approaches, network analysis, time series analysis, survival analysis, and other nonlinear methods may also be useful for capturing the complexity of the continuation, discontinuation, and replacement of interventions within complex service settings (12,81,103,111). Experimental designs are not common in sustainability research, and they may be most useful for testing out which strategies are effective in increasing the sustainability of EBIs.…”

Alignment between nationally determined contributions and the sustainable development goals for West Africa

“…Causal loop analysis utilises diagrams to map the relationships between multiple variables and represent dynamical changes in systems (Rwashana et al, 2014). In constructing the causal loops, this study employed the Vensim PLE software (Ventana Systems Inc. (2009) Vensim, version 5.9) in a similar fashion described by Sarriot et al (2015). In the loop analysis "a positive (+) arrow from one variable to the next means that a change in the first causes a change in the second in the same direction, while a negative (−) arrow means that a change in the first variable causes a change in the second in the opposite direction" (Sarriot et al, 2015, p.149).…”