A Simple Pharmaceutical Example to Illustrate the Method The diagnostic tree is a variant of such methods as “fault trees,” “fishbone diagrams,” and “root cause analysis”—approaches that will be familiar to people who have studied modern quality management (Juran and Godfrey 1999). • The method begins by asking, What is the performance problem targeted for improvement? What aspects of health status, citizen satisfaction, or financial protection need to be improved, either for specific groups or the population as a whole? • The next task is to identify the causes of that performance shortfall. • Then the causes of those causes are identified. • The step of seeking causes is repeated until the analysis has reached the point where causes have been identified with enough specificity that targeted policy responses can be developed. As figure 5.1 illustrates, multiple causes can be identified for each problem at each point in the analysis. Moreover, the diagram in figure 5.1 is simplified. It is entirely possible that some causes identified at one stage of the analysis are also causes of other factors identified at the same level of analysis. For example, it might be that lack of artemisinin-based combination therapies (ACTs) in the public sector is itself a cause of high private sector prices. Possibly one cause influences several subsequent effects. For example, ordering, logistical, and theft problems in the public sector might all have poor public sector management as a contributory cause. Nor is the diagram comFigure 5.1
Pharmaceutical Performance Diagnostic Tree Poor ordering Lack of ACTs in public clinics
Logistical difficulties Theft Lack of government resources
High levels of malaria in rural areas High prices for ACTs in private clinics
Lack of competition Lack of price regulation
Source: Authors’ representation. Note: ACT = artemisinin-based combination therapy.
Diagnosing Performance Problems and Developing a Policy Response
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