4. Root cause analysis

Root cause analysis (RCA) is a systematic process for identifying “root causes” of problems or events. The root cause of a problem is the main cause or driver of that problem. An RCA is based on the idea that effective and efficient management requires preventing problems rather than solving them in an ad-hoc manner once they arise and acknowledges that sustainable solutions depend on improving underlying conditions.

Understanding the layers and determinants that contribute to priority challenges

The example from Kenya below shows the process of understanding the layers and determinants that contribute to priority challenges.


Consider the following:

  • What is known about the factors contributing to this problem?
  • What additional evidence is needed to better understand the root cause of this problem?
  • What can feasibly be addressed?

It is customary to refer to the root cause in the singular form, but several factors may in fact constitute the root causes of the problem. A factor is considered the root cause of a problem if removing it prevents the recurrence of the problem.

A causal factor is one that affects the outcome of an event, but it is not the root cause, i.e. the problem cannot be resolved by just removing this one issue. Although removing a causal factor can benefit an outcome, it does not prevent its recurrence with certainty.

Identifying root causes during the consultative workshop

Based on the values assigned to the identified problems and findings from the problem prioritization session and discussions, the root causes for each problem identified should be undertaken in sub-groups. Given the complexities of most of these problems and the many contributing factors (e.g. culture, health-system structure and processes, geographic context, etc.) these groups benefit from a rich mix of contributors from all relevant sectors and backgrounds (e.g. service providers both public and private, service users, policy- and decision-makers, community organisations, etc.)

Problems should have been identified on the basis of consolidated data, expert opinion, and personal experience (see Step 3: Problem Prioritisation) These sources can be reviewed again if necessary, noting any further gaps in evidence that are identified.


At this point it might be helpful to define some guiding questions around the prioritised problems to facilitate the group work. This is again best structured along the care continuum.

People not accessing the health system

People with TB 
seeking care but either not diagnosed or not notified

People notified as a TB case but not successfully treated

Group 1


Group 2

Pre-care seeking, including community engagement

Group 3

Diagnostic gap and integrated care

Group 4

Engaging all care providers

Group 5

Address notification loss and surveillance system gap

Group 6

Ensuring cure, including treatment support and social protection

Why is there low coverage of IPT (among people living with HIV or children)?

(explore separate root cause analysis for implementation of TPT for children and people living with HIV)

What are the problems related to infection control in primary health care, hospital and community?

(explore root cause based on identified problems)

Why do people with TB symptoms not access health system?

Why can’t we get people who have access to low level health facility system (L0: pharmacy, drug shop, traditional healer, etc. (facility without diagnostic capacity)) to the health system?

Why is there a low proportion of contact investigation?

Why is the increasing case notifications mainly in clinically diagnosed (clinical diagnosed has overtaken the bacteriologically confirmed)?

Why are we missing (fail to diagnose and notify) people who are already in the health system?

Why do not all facilities providing TB service provide standardized TB care?

Why are not all relevant health facilities are integrated into TB network services?

Why are not all cases reported? (high proportion of underreporting)

What are the barriers of data monitoring until treatment completion? (completeness and timeliness)

Why can electronic-case-based system not be implemented throughout all care providers in Indonesia?

Why is the success rate of DS-TB and DR-TB under the expected rate of 90%? (for DS-TB cure proportion decreasing, completed proportion increasing)

Why do TB patients and their household experience catastrophic cost?

People not accessing the health system

People with TB 
seeking care but either not diagnosed or not notified

People notified as a TB case but not successfully treated

Group 7

People with drug-resistant TB

-Why there is a low case detection of DR-TB? explore according to all phases/steps along the continuum of care)

-Why there is a low enrolment of diagnosed DR-TB patients?

-Why low success treatment of MDR and RR/TB?

Group 8

Children with TB

-Why there is a low case detection childhood TB? (explore according to all phases/steps along the continuum of care)

-Why there is a low case detection of TB among small children 0-4 years? (explore according to all phases/steps along the continuum of care)

Group 9

People living with HIV

-Why there is a low proportion of people know HIV status? (explore according to all phases/steps along the continuum of care)

-Why there is low coverage of ARV among TB/HIV patients? (explore according to all phases/steps along the continuum of care)

-(What are challenges in recording and reporting TB cases among people living with HIV)

Group 10

Key populations (congregate settings)

-Why case detection among people living in a congregate setting (pesantren, slum area, etc.) is not optimal? (explore according to all phases/steps along the continuum of care)

-Why case detection among people with high risk of developing TB (diabetes patients, smoker, malnourished children or adult, etc.) is not optimal? (explore according to all phases/steps along the continuum of care)

Consider the following in the discussions:

  • Identify potential causes of problems due to lack of multisector collaboration (across ministries, across programs, across institutions) for each relevant problem
  • Identify causes related to the existing system in social security system/ national health insurance)
  • Consider legal, gender, and human rights aspects in relevant topics or problems
  • Consider potential causes from the point of view of both national and subnational (provinces and districts), both urban vs rural, including remote areas.

In consultation with participants, sub-group chairs should select a tool or framework to use for identifying root causes. There are different tools available to determine the root causes of problems. The best-known methods are the Fishbone and 5 ‘Whys’ techniques. These are described below. The final step – irrespective of the technique used – is to group the results into thematic “intervention” areas.

Once root causes have been discussed and documented using the selected framework, rapporteurs for each sub-group can present the findings back to workshop participants. Findings from each sub-group should be collated by facilitators of the workshop, so that root causes common across focus areas can be highlighted in the feedback to participants at marked as a higher priority area to address (due to their impact on several problems).

The Fishbone Technique

This is a popular technique with a lot of free resources online and the preferred option chosen by most of the early adopter countries. We have included some of these in the resources section.

Step 1: The fishbone technique starts with defining a problem or issue (“Problem Statement”).

Step 2: The team will then construct the skeleton of a fishbone, and put the following categories on each of the six lines coming out of the “spine”: policy, people, equipment, methods, data, and finance. [Note: countries can decide to replace any of these with more locally appropriate themes, if required]

Step 3: The next step is to conduct a 5-minute brainstorm for each of the categories just listed. You can ask “How could this category have caused the problem to occur? These responses can then be added to the diagram.

Step 4: Discuss in the group and determine a few root causes to be further investigated (in more detail).


  • Alternatively to using pre-defined thematic categories, countries might initially decide to list all contributing factors/ assumed causes first and then group them into thematic areas in a subsequent step. This takes slightly longer but ensures that issues not neatly fitting the pre-defined thematic areas are not excluded by default.

The 5 ‘whys’ technique

This technique lets you ask “why did this happen?” five times. This is a way to get to the root cause of the problem for which an intervention can be designed so that the problem will not occur again.

Rate each cause by the likelihood that it led to this problem:

0 = Definitely not the cause, 1 = Not likely the cause, 2 = Could be the cause, 3 = Very likely the cause, 4 = Definitely the cause

Move forward with only the top-rated cause, and identify possible reasons for its occurrence (i.e., ask the second “why”). Follow the same process as above for the subsequent “whys” until you’ve reached the root cause of the problem.

  • The downside of this of this method is that it looks at underlying causes from a one-dimensional perspective which might make it complicated to map out interactions between different causes and factors.
  • Both techniques can be supplemented with the “Challenge Interview” approach, which is similar but does not ask “Why did this happen?”, but rather “Why does this matter to you?”.


Last Update: Wednesday, September 1, 2021  

Saturday, August 7, 2021 139 Maya Van Tol  4. Stakeholder Consultative Workshops
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