In 2014, the C-section rate in Brazil was 57%, the highest in the world. In the country's private health system, 84% of children were delivered by C-section. The system was designed to prefer C-sections. After educating doctors and patients, the upstream solution caused a 40% increase in natural ...

Organisations have a tendency for downstream thinking. To succeed, leaders should change the focus to upstream thinking.

• Identify problems early
• Target leverage points in complex systems
• Find reliable methods to measure success
• Consider new ways...

Banning plastic bags in San Diego caused serious unintended consequences.

The deadly 2017 hepatitis A outbreak in San Diego is attributed to the lack of plastic bags. Homeless people used the bags to dispose of their own waste. But when the bags became hard to come by, the ...

• Problem blindness. "This problem is inevitable." You can't fix a problem you can't see.
• A lack of ownership. "It's not my problem to fix." People resist acting on a problem because they may feel it is not their place. When no one ow...

Downstream actions are reactions to problems. These efforts are fast and tangible.

Upstream actions attempt to prevent those problems from happening in the first place by systematically reducing the harm caused by those problems. These efforts are slower an...

• Expedia: 58% of customers who booked travel on Expedia placed a call afterwards for a copy of their itinerary. No one was responsible for ensuring that customers didn't need to call for support. It was identified as an upstream problem. Once changes were in place, the need f...

• “Rising tides” test. What else might explain the short-term success other than our efforts?
• Misalignment test. How can we find misalignment as early as possible? What alternative measures could provide potential replacements?
• Lazy bur...