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Fig. 4 | Globalization and Health

Fig. 4

From: Transforming Nepal’s primary health care delivery system in global health era: addressing historical and current implementation challenges

Fig. 4

Challenges and influencing factors in Nepal’s health care system. → (+) sign denotes a positive link, and → (−) sign denotes a negative link where a change in influencing factor is in the same direction as the influenced element. → ||indicates there is a delay where a change in influencing factor produces change in influenced element only after an interval of time. ‘RS’ denotes a reinforcing loop and ‘B’ denotes balancing loop. The figure shows the interaction of factors operating at the i) facility-level, ii) community health worker’s level (e.g. FCHVs) and iii) patients’ level in health system. Some of these factors (e.g. community involvement) operate at both the health facility and CHWs level. Development of causal loop diagrams were based on an iterative process of review incorporating author’s normative vision on health system. Thematic analysis and brainstorming with authors’ own reflexivity helped in constructing these causal loop diagrams (CLDs). More description about causal loop diagrams and its application in decision making is available in the reference [47,48,49]. For further information in CLDs, please follow the online resource from the John Hopkins University (https://www.coursera.org/learn/systems-thinking)

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