title: 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.
authors.affiliation: ICF International, Center for Design and Research in Sustainable Health and Human Development (CEDARS), Rockville, MD, USA; Maternal and Child Survival Program (MCSP), Washington, DC, USA. Electronic address: Eric.Sarriot@icfi.com.
authors.forename: Eric
authors.initials: E
authors.lastname: Sarriot
authors.affiliation: ICF International, Center for Design and Research in Sustainable Health and Human Development (CEDARS), Rockville, MD, USA; World Relief, International Programs, Baltimore, MD, USA; Maternal and Child Survival Program (MCSP), Washington, DC, USA.
authors.forename: Melanie
authors.initials: M
authors.lastname: Morrow
authors.affiliation: International Rescue Committee, Health Unit, International Programs Department, New York, NY, USA.
authors.forename: Anne
authors.initials: A
authors.lastname: Langston
authors.affiliation: Concern Worldwide Inc., Operations Department, New York, NY, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Weiss
authors.affiliation: International Rescue Committee, Health Unit, International Programs Department, New York, NY, USA.
authors.forename: Justine
authors.initials: J
authors.lastname: Landegger
authors.affiliation: Maternal Child Health Integrated Program (MCHIP), Washington, DC, USA.
authors.forename: Laban
authors.initials: L
authors.lastname: Tsuma
mesh_terms: D000328:Adult; D019090:Case Management / Q000458:organization & administration*; D002648:Child; D003153:Community Health Services / Q000458:organization & administration*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D003906:Developing Countries; D006301:Health Services Needs and Demand / Q000458:organization & administration; D006801:Humans; D011320:Primary Health Care / Q000458:organization & administration; D015397:Program Evaluation; D011785:Quality Assurance, Health Care / Q000458:organization & administration; D018570:Risk Assessment; D012432:Rwanda
keywords: Causal loop analysis; Community case management; Community health; Evaluation; Health systems; Rwanda; Sustainability; Systems thinking