systems tools for c h s a g c l diagrams

SYSTEMS TOOLS FOR

COMPLEX HEALTH

SYSTEMS:

A GUIDE TO CREATING

CAUSAL LOOP DIAGRAMS

SESSION FOUR

CAUSAL LOOP

DIAGRAMS

• Identify the causal loop diagram (CLD) seed

structure

• Build causal loop diagram

• Identify polarity of variable relationships

• Identify feedback loops

• Identify leverage points

Session outline

Session Four 3

• Identify the causal loop diagram (CLD)

seed structure

• Build a causal loop diagram




Session outline

Session Four 4

Session Four 5

As you identify your seed structure – think back to

boundary issues:

• What is the question or issue that is driving the creation of

the causal loop diagram?

• What are the boundaries of your system?

• Think about the level at which you want to intervene?

Determine the CLD seed

structure

From your interrelationship digraph

– Identify your output or outcome of interest

variable

– Identify an intervention/driving variable at your

reference level

Determine the CLD seed

structure

Session Four 6

mothers attendingANC, hospital

deliveries and PNC

level of awarenessof MHC and NHC

health ofmothers death risk of

neonate

safe deliveriesand PNC

socio-economicstatus

resource adequacy(staffing, drugs,

logistics andsupplies)

neonatalsurvival

healtheducation by

healthworkers

perceptions andbelief in myths

mothers' birthpreparedness

care ofnewborn

Surface seed model using

drivers and outcomes

Session Four 7

Surface seed model using main

drivers and outcomes

Session Four 8

mothers attending ANC,hospital deliveries and

PNC


death risk ofneonate


Session outline


structure





Session Four 9

• Determine the “seed structure”:

– Identify your output or outcome of interest variable

– Identify a intervention variable at your reference level

• Explore the linkages between these variables

and identify intervening variables that explain

the situation

Building your own System

Map

Session Four 10


deliveries and PNC


health ofmothers death risk of

neonate


socio-economicstatus



neonatalsurvival

healtheducation by

healthworkers

perceptions andbelief in myths

mothers' birthpreparedness

care ofnewborn

Identify intermediate variables

using IRD as a guide

Session Four 11


deliveries and PNC


death riskof neonate

safedeliveriesand PNC

neonatal survival

healtheducation by

health workers

mothers' birth

preparedness

Insert intermediate variables

using IRD as a guide

Session Four 12

• Determine the “seed structure”:

– Identify your output or outcome of interest variable

– Identify your key intervention variable

• Explore the linkages between these variables and identify intervening variables that explain the situation

• Explore linkages amongst the other key variables in your system, looking for feedback loops


Map

Session Four 13


deliveries and PNC


death riskof neonate safe

deliveriesand PNC

socio-economic

status

resource adequacy

(staffing, drugs,

logistics and

supplies)

neonatal survival

healtheducation by

health workers

perceptions

and belief in

myths

mothers' birth

preparedness

care of

newborn

Build CLD – drawing on

relationships identified in IRD

Session Four 14


deliveries and PNC


health of mothers


deliveriesand PNC

socio-economic

status

resource adequacy

(staffing, drugs,

logistics and

supplies)

neonatal survival

healtheducation by

health workers

perceptions

and belief in

myths

mothers' birth

preparedness

care of

newborn



15

• Determine the “seed structure”: – Identify your output or outcome of interest variable

– Identify your key intervention variable

• Explore the linkages between these variables and identify intervening variables that explain the situation

• Explore linkages amongst the other key variables in your system, looking for feedback loops

• Identify additional variables to be added to the system to better explain the relationship between two variables


Map

Session Four 16


deliveries and PNC


health of mothers


deliveriesand PNC

socio-economic

status

resource adequacy

(staffing, drugs,

logistics and

supplies)

neonatal survival

healtheducation by

health workers

perceptions

and belief in

myths

mothers' birth

preparedness

care of

newborn

???

???



17


deliveries and PNC


health of mothers


deliveriesand PNC

socio-economic

status

resource adequacy

(staffing, drugs,

logistics and

supplies)

neonatal survival

healtheducation by

health workers

perceptions

and belief in

myths

mothers' birth

preparedness

care of

newborn

trust in thehealthcare

service

Mothers'frustration (longwaiting times,stock outs)

Identify and add additional variables

to deepen understanding of the

relationships

18

Indicate delays

Session Four 19

Session outline


structure





Session Four 20

• Pick a starting variable in your CLD

• Assess whether arrows between two variables

indicate change in the same or opposite direction

• For each “pair” of variables decide what would

happen if variable A changed: would it result in a

change in the same direction (+) or opposite

direction (-) in variable B?

• Label each arrow to indicate the direction of effect.

If change is in the same direction use a “+” sign, and if

the change is in opposite directions use a “-“ sign

Identifying the polarity of

variable relationships

Session Four 21

mothersattending ANC,

hospitaldeliveries and

PNC





service

Mothers'frustration (long

waiting times,stock outs)

Determine the polarity of the links

Determine the polarity of the

links

Session Four 22



PNC





service



+


links

Session Four 23



PNC





service



-

-

-

+


links

Session Four 24



PNC





service



- -

-

+ +

+

+


links

Session Four 25

mothers attending ANC,

hospital deliveries and PNC

level of awareness of

MHC and NHC

health of mothers

death risk of

neonatesafe deliveries and

PNC

socio-economic

status

resource adequacy

(staffing, drugs,

logistics and

supplies)

neonatal survival

healtheducation by

health workers

perceptions

and belief in

myths

mothers' birth

preparedness

care of

newborn


service



links

26




MHC and NHC

health of mothers

death risk of


PNC

socio-economic

status

resource adequacy

(staffing, drugs,

logistics and

supplies)

neonatal survival

healtheducation by

health workers

perceptions

and belief in

myths

+

+

+

+

-

mothers' birth

preparedness

+

+

--

--

+

care of

newborn

+

- +

-

-

-

+

+


service

+

+


-

-

-

+

+

+

+

+


links

27

Session outline


structure





Session Four 28

• A reinforcing loop is one in which an action

produces a result which influences more of the same

action thus resulting in growth or decline at an ever-

increasing rate

• Where feedback increases the impact of a change, we

call this a Reinforcing Loop.

• Positive reinforcing loops produce virtuous cycles

• Negative reinforcing loops produce vicious cycles.

Reinforcing loops

Session Four 29

Employee

Performance

Supervisor’s

Supportive

Behavior

Unsupportive

Behavior

Structure

+

+

Perf.

Level

Time

Behavior Over Time

Supportive

Behavior

Employee

Performance

Supervisor’s

Supportive

Behavior

Reinforcing loops

Session Four 30

• Balancing processes generate the forces of resistance, which eventually limit growth, maintain stability, and achieve equilibrium

• Balancing loops reduces the impact of a change and are goal seeking

• Shortcut to determining a balancing loop: Count the number of minus signs (-) in the loop: an odd number of minus signs = balancing loop

Balancing Loops

Session Four 31

Structure

Desired Utilization

Time

Behavior Over Time

100

100 - -

100 ++

Actual Utilization

Balancing Loops

Session Four 32

utilization ofprimary care

services

staff motivation

workload

quality of care at

primary level

staffproductivity

respectful

care

_ +

+ +

+

+ +




MHC and NHC

health of mothers

death risk of


PNC

socio-economic

status

resource adequacy

(staffing, drugs,

logistics and

supplies)

neonatal survival

healtheducation by

health workers

perceptions

and belief in

myths

+

+

+

+

-

mothers' birth

preparedness

+

+

--

--

+

care of

newborn

+

- +

-

-

-

+

+


service

+

+


-

-

-

+

+

+

+

+

Identify the feedback loops

33


34



PNC





service



- -

-

+ +

+

+


35



PNC




+

-


service

+

+



--

+

Reinforcing

Loop



PNC




+

-


service

+

+



--

+


36

Balancing

Loop


37



PNC




+

-


service

+

+



--

+

Balancing

Loop


38

Balancing

Loop



PNC




+

-


service

+

+



--

+

R

B

B

Balancing

Loop

Reinforcing

Loop




MHC and NHC

health of mothers

death risk of


PNC

socio-economic

status

resource adequacy

(staffing, drugs,

logistics and

supplies)

neonatal survival

healtheducation by

health workers

perceptions

and belief in

myths

+

+

+

+

-

mothers' birth

preparedness

+

+

--

--

+

care of

newborn

+

- +

-

-

-

+

+


service

+

+


-

-

-

+

+

+

+

+

R

B

Feedback loops

39

Session outline


structure





Session Four 40

A leverage point is a place in the system’s structure:

– where micro changes can result in macro results.

– when an intervention can be applied

A low leverage point—small level of intervention or change

force results in a small change in the behavior of the system.

Often used to address intermediate causes of a problem

A high leverage point—small level of intervention/change

force, causes a large change in the system’s behavior. Used

to resolve root causes.

Leverage Points

Session Four 41

Points of leverage: physical and

informational

42

TYPE LEVER AIM

Physical

• Change physical amount

of elements and stocks

• Change structure of

physical systems e.g.;

staffing structures

• Focus on changing inputs

• Focus on more proximal drivers

Note: Low leverage potential

Informational

• Change rate of system

responses

• Manage relationships and

timing between feedback

loops

• Create new loops to

connect different system

elements

• Reduce system delays

• Examine stabilizing/ resisting influence

of balancing feedback loops

• Reinforce virtuous feedback loops

• Explore and alter who has access to

what information

Points of leverage: social and conscious

43

TYPE LEVER AIM

Social

• Alter rules of the system

(such as incentives,

punishments, constraints)

to support desired goals

• Alter goals of the system

- what a system seeks to

achieve

• Understand and change what the rules are

and who has power over them

• Nurture innovation, flexibility, variation

and collaboration

Note: High leverage potential

Conscious

• Shift mindset or paradigm

out of which the system

arises

• View whole system functioning and

dynamics

• Expose anomalies and failures in old

paradigm and challenge assumptions

• Work with active change agents

Note: Highest leverage potential

Leverage Points and intervention

strategies

System Dynamic Strategic Intervention

System is stagnant or stalled Look for constraints

Vicious cycles Identify “brakes”

Examine intervention points to

return process to virtuous

cycle

Reinforce virtuous feedback cycles

Find the strongest feedback structure operating then review the

implications and generic leverage points.

Examine each link and consider the consequence of

strengthening it or weakening it.

44

Session Four 45

Examine CLD for potential policy resistance following strategy

implementation

Develop “what if” alternatives to mitigate policy resistance by:

• Adding a new link or loop – can the system start doing

something differently or new?

• Breaking or weakening a link between two variables – can

the system stop doing something or do less of something.

• Strengthening a link and hence a loop – can the system do

more of something that was working.

• Alter delays.

• Switching an + to a - (or vice versa) on the link from one

variable to another – by getting the system to behave in a

different way.

Overcoming policy resistance




MHC and NHC

health of mothers

death risk of


PNC

socio-economic

status

resource adequacy

(staffing, drugs,

logistics and

supplies)

neonatal survival

healtheducation by

health workers

perceptions

and belief in

myths

+

+

+

+

-

mothers' birth

preparedness

+

+

--

--

+

care of

newborn

+

- +

-

-

-

+

+


service

+

+


-

-

-

+

+

+

+

+

R

B

Examine the systems map

46

• Feedback loops • Dynamic changes • Leverage points • Policy resistance

Identify the following: • Underlying issue for which this CLD has been developed

• Reference level informing the CLD

• Source of information used to construct the CLD?

• How people’s mental models and assumptions were made explicit

• Key variables of interest/key outcomes in this CLD?

• Main drivers – proximal and distal of outcomes of interest and how they interact

• Major feedback loops in this CLD interacting to give rise to the system behaviour?

• Thinking about intervening in the system

• What is your scope of influence and how does this impact the level of leverage possible?

• What are the range of strategic interventions possible and how would these impact the

system if successfully implemented.

• What are possible points of policy resistance and how might those be mitigated given

the specific system dynamics

• Finally – consider the boundaries of the system – how were these determined?

Whose voices are included in the system and who is left out? What additional

elements should be included?

Exploring causal loop

diagrams

Session Four 47

• Explain root problems, their drivers and feedback

mechanisms

• Identify potential leverage points for interventions

• Explore appropriate intermediate and outcome

measures

• Model the potential impact of system interventions

• Identify potential policy resistance

• Formulate appropriate research questions

• Make explicit our theory of change

How do we use Systems

Thinking Tools?

Session Four 48

• Meadows D. Leverage Points: Places to Intervene in a System. Donella Meadows

Institute. 1999. http://www.donellameadows.org/archives/leverage-points-

places-to-intervene-in-a-system/

References

Session Four 49

http://www.donellameadows.org/archives/leverage-points-places-to-intervene-in-a-system/
















This work was coordinated by the Alliance for Health Policy and Systems Research,

the World Health Organization, with the aid of a grant from the

International Development Research Centre, Ottawa, Canada.

Thank you

Presentation developed by Helen de Pinho MBBCh, MBA, FCPH

assisted by Anna M. Larsen BS, MPH

Averting Maternal Death and Disability Program (AMDD)

Heilbrunn Department of Population and Family Health

Mailman School of Public Health

Columbia University

February 2015

systems tools for c h s a g c l diagrams

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