At the core of the balanced scorecard: Understanding cause-and-effect relationships in health and social care.

Healthcare organizations increasingly use performance management systems to ensure flexibility, service quality, and cost efficiency. In this context, the balanced scorecard (BSC) represents one of the most popular performance management tools for achieving these objectives. A crucial element that makes it widely employed is that it allows measures and perspectives to be linked through clearly defined cause-and-effect relationships. Nevertheless, despite its centrality in implementing BSC, a discussion regarding the effective interpretation of cause-and-effect relationships has sparked. In particular, the previous literature emphasizes the dichotomy between non-statistical causality, i.e., based on logical or finality relationships, and causality tested statistically. This study aims to investigate the nature of causal relationships between indicators and perspectives of BSC through a systematic literature review of studies conducted in the health and social care contexts. Findings reveal that both perspectives of causality can be identified; however, numerous directions for future research are possible for both. Overall, there is a need for more attention to theoretical perspectives supporting causal analysis. Furthermore, although the development of quantitative methodologies to support empirical analyses is remarkable, there is room for further improvement. Finally, the research focuses mainly on the organizational level, overlooking the role of BSC causality at other levels.