Challenges and opportunities for implementing digital health interventions in Nepal: A rapid review

Background In recent times, digital technologies in health care have been well recognized in Nepal. It is crucial to understand what is works well and areas that need improvements in the digital health ecosystem. This rapid review was carried out to provide an overview of Nepal's challenges and opportunities for implementing digital health interventions. Methods This study is reported according to PRISMA guidelines and used telehealth, telemedicine, e-health, mobile health, digital health, implementation, opportunities, challenges and Nepal as key search terms to identify primary studies published between 1 January 2010 and 30 December 2021 in four databases, namely PubMed, Google Scholar, Scopus, and CINAHL. Initially, identified studies were screened against predetermined selection criteria, and data were extracted, and the findings were narratively synthesized. Result The review identified various challenges, opportunities, and benefits of implementing digital health initiatives in Nepal. The most expressed challenge was inadequate technical facilities (lack of electricity and internet) and rugged geographical distribution, which makes transportation difficult in hilly and mountain areas. Shortage of skilled workforce and supportive policies were also notable challenges documented. Meanwhile, major opportunities identified were education and training of the students and health practitioners and increasing awareness among the general population. Conclusion This review identified various factors associated with the successful implementation of digital health initiatives in Nepal. Our findings may guide the formulation of digital health policy and interventions to improve mass health outcomes using digital health services.


Introduction
In the 21st century, digital health can connect healthcare systems and deliver health services to promote health outcomes for people of all ages (1). The field of knowledge and practice are essentially associated with the development and use of digital technologies to improve health (2). The World Health Organization defined telemedicine as "the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities" (3). Similarly, Jacob et al. (2020) defined mobile health (mHealth) as the medicinal practice conducted through any portable gadget like a cell phone or patient monitoring device. Digital health encompasses a comprehensive approach to providing health care services to the patients in different forms like synchronous and asynchronous or through remote monitoring and mobile health (4). The advantage of deploying telehealth is enhancing the ease of access to health services (1). Most developed countries have effectively used digital health, and many developing countries follow the pattern of adopting digital health (5) In Nepal, a lower-middle-income country situated between China and India, 83% of the population lives in rural areas. One-fourth of the population is classified as "under the poverty line" (6)(7)(8). Recent data from 2021 shows that 92.54% of the Nepalese population takes 15 min with motorized travel mode and 94.63% take 60 min of walking distance to have to access health care facilities in Nepal (9), health infrastructure is poorly developed, and the country has a low health human index (10). In rural areas, establishing well-equipped health care centers with specialized health services is an ongoing challenge for the government (10). A poor economy is an important but not the sole barrier to healthcare access in Nepal. Nepal's rugged terrain, especially in the mountains, makes transportation, and installation difficult; consequently, access to visiting health facilities is limited (7). With multiple challenges surrounding effective health care delivery, the government's plan to make universal health coverage is not fully illustrated. Therefore, digital health is considered one of the promising resources to make health care accessible costeffectively, especially in tough-to-reach areas (5,10).
In the context of rural Nepal, telehealth offers great opportunities such as remote consultation of medical practitioners (otherwise practicing in urban areas) (11,12), remote delivery of specialized services, distance education and training of local health care providers, and collaboration of local health workers with other national and international experts. Such distance learning and collaboration can bring positive changes among the health care providers regarding their skills and the services they provide (4). Additionally, using information and communication technology (ICT), digital health may help to improve health literacy and bring positive change in people's health behaviours (13). Digital health also connects patients electronically with the health care providers so that personalized medical plans can be developed to deliver better health care for improved health outcomes (14) In Nepal, the Telecommunication Act and National Telecommunication Policy were established in the late 1990s. The digital health system was introduced as HealthNet in 1995 (11,15) by a non-governmental organization (NGO) to provide affordable internet services for people to access health care facilities. After that, in 2002 the "Nepal wireless project" and "hello-health" were established to provide ICT access and digital health services in remote settings of Nepal. Similarly, the National Health Education, Information and Communication Centre (NHEICC) started using cell phones to educate people on sexual and reproductive health. Additionally, there are many digital health information systems including HIV Surveillance, eTB register, mental health counselling in Nepal, being supported by World Health Organization (WHO), United Nations International Children's Educational Fund (UNICEF), and Save the Children (6,16).
Though the internet service is accessible to less than 35% of the overall population in Nepal, the subscription of smartphones has increased from 0.043 per 100 people in the year 2000 to 139 per 100 people in 2020 (15). In a nutshell, various small-scale digital health programs are operational in Nepal but are often vertical in approach (6). Although digital health is not a silver bullet when offered as a stand-alone solution, deploying digital health intervention has successfully addressed public health issues in LMICs and can potentially do so in Nepal (17). There is an ongoing body of work in Nepal that has unearthed opportunities and challenges in rural digital health ranging from community health care centers to specialists in tertiary hospitals (18). All of them are based on specific health issues and carried out as pilot projects in specific regions of Nepal. For example, collaborative care for psychiatric patients in a rural setting (19), capacity building and text messaging intervention in the Dhanusha district (20), and dengue prevention through mobile SMS (21).
While the importance of digital health has been well acknowledged, it is imperative to understand the barriers and enablers for implementing digital health in Nepal that may guide the development and implementation of digital health intervention in Nepal. Therefore, this narrative review aims to provide a synopsis of Nepal's challenges and opportunities for implementing digital health initiatives.

Methods
This review method was developed by following the guidelines and criteria set in Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) (22). The rapid review protocol was registered in PROSPERO (CRD42020199056).

Search strategy
An electronic search was conducted between 1 January 2010 and 30 December 2021 through PUBMED, Scopus, CINAHL, and Google Scholar using the keywords: Telehealth, Telemedicine, e-health, digital health, challenges, implementation, and Nepal. These keywords were searched in Medline using the Boolean operators "AND" and "OR" (a detailed search strategy is provided in Box 1.
Inclusion criteria: I. Primary studies focusing digital health in any setting in Nepal. II. Primary studies regardless of study design (e.g., qualitative, quantitative, observational, pilot study, case study, and Randomised controlled trial (RCT)) were included in the study.
Exclusion criteria: I. Studies on public health issues that did not consider digital health approach II. Conference abstracts, commentaries, reviews, and letter to editor III. Studies published in a language other than English.

Study selection
Initial records retrieved from each of the four databases were imported into Mendeley, where duplicates were removed. On the title and abstract screening, studies were excluded based on the selection criteria. Two authors (RP and DB) did the abstract screening, whereas title screening was done by all three authors (RP, DB, and MKC). After those studies were subjected to fulltext screening to determine their eligibility for inclusion, which was done independently and later discussed for confirmation in a group. Any reviewer discrepancies were resolved by conducting a group meeting and further discussing them with the supervisor (UNY).
The PRISMA (22) diagram illustrates the screening process for the study selection ( Figure 1).

Data extraction
Data from the selected articles for final inclusion was divided among three reviewers (RP, DB, and MKC). The extracted data include the region, year, and authors of the publication. It also consists of the study design, service offered, the digital device/ technology used, the challenges faced, and the opportunities to deliver health services through digital devices /technologies. A data extraction sheet was developed ( Table 1), and data were extracted from the information based on the selected 19 articles, and the results were discussed with the study team members.

Data synthesis
Data synthesis was done for both quantitative and qualitative data that highlighted the challenges and opportunities related to digital health interventions in Nepal. Both primary and secondary studies, including digital health interventions, were included in this review. Content analysis (23) was performed for descriptive evaluation of the selected articles, based on which specified outcomes were identified and arranged into two themes: challenges in implementation digital health, and future opportunities in digital health implementation.

Results
The final literature search was conducted on 30 December 2021, which yielded 35,789 results through four different databases (CINAHL 28,046, Google Scholar 3650, Scopus 3884, and PubMed 209). After removing duplicates and screening the titles and abstracts of the articles using BOX 1 List of search items Challenges: "Challenges" OR "Problems" OR "Difficulties" OR "Chance" OR "Possibilities" OR "Potential" OR "Scope" OR "Issues" OR "Concerns" OR "Obstacles" OR "Barriers." Digital health: "Digital health" OR "Telehealth" OR "Mobile health" OR "mHealth" OR "Telemedicine" OR "eHealth" OR "telehealth" OR "Remote medicine" OR "Teletherapy" OR Distance medicine." Nepal "Nepal" OR "Rural Nepal" OR "Urban Nepal" OR "Developing country." exclusion criteria, only 28 papers were selected for full-text screening. Of these 28 studies, 9 studies were excluded because of the following reasons: four mentioned the benefits of using ICT in Nepal, five were excluded for only focusing on the efficacy/ use of mobile phones and internet in Nepal. A total of 19 articles that met the eligibility criteria were included for data extraction. The characteristics and findings summary of all the selected 19 papers are mentioned in the Table 2, highlighting various challenges and future scope/ opportunities in implementing digital health services in Nepal.
As only a few studies reported, the enablers for implementing digital health are merged with the benefits and opportunities. The first enabler was that the stakeholders of rural areas were likely to adopt digital health services if supplied with good technical equipment (13, 24) and motivations (organizational and governmental support for digital health (programs) (24,25). Second was the sustainable relationship between patients, paramedics and consultants which will further help sustain the digital health programs (19,24,26,27). In this context, challenges are defined as the problems or barriers faced by stakeholders (health care providers and patients) during the implementation of digital health programs in Nepal. Different challenges faced by stakeholders are categorized into six sub-themes: technical challenges, geographical challenges, policy challenges, lack of skilled workforce, funding challenges, and other challenges. All those themes and sub-themes were developed by analyzing various themes illustrated in Figure 2.

Technical challenges
Technical challenges are defined as technical issues faced during the implementation of telemedicine in Nepal. Technical challenges include network problems, frequent power cuts/ lack of electricity, blurred image, poor sound quality/cut-off the sound during video consultations due to slow internet connection, and interrupted service due to poor network quality. These technical issues were mentioned in 14 papers (10,13,19,21,(24)(25)(26)(28)(29)(30)(31)(32)(33)(34), of which network connection problems (13, 21, 24, 31) and frequent power cuts (29,31) were the major technical challenges for implementing digital health successfully.

Geographical challenge
Five studies (10,13,24,27,32) mentioned rugged geography as one of the challenges faced in implementing digital health services in Nepal. The geographical factors identified by the authors were uneven geographical distribution like hilly and mountainous regions, which have made transportation difficult due to the lack of roadways in these areas. Also, the rough terrain has made the installation of mobile towers and other computer devices difficult and facing maintenance difficulties (21).

Lack of supportive policies
Lack of supportive policies was mentioned in four studies (10,13,24,25) which were political instability, frequent transfer of trained doctors/ health workers, and lack of government support like lack of motivation by the government to their staff in terms of compensation and bonus salaries (24) have become a reason to end the telemedicine program.

Skilled workforce challenges
Five studies (10,13,24,25,28) mentioned the lack of skilled workforces, such as the lack of IT specialists, who could provide technical training to health workers about video consultations, and the lack of technical knowledge among health workers. Piya (24) also mentioned the lack of basic internet use and video consultations among health professionals. Furthermore, there was insufficiently trained staff at the local health care centers who could encourage the public towards digital health. Thus, the lack of specialists for teleconsultation has discouraged the program and interrupted the whole digital health project.

Funding challenges
Funding challenges in terms of buying costly equipment, high installation charges, and training staff were identified by four studies (10,24,26,33). Digital health programs in Nepal depend on funding and volunteers; when funding stops, the whole project gets disturbed and terminated (24). Similarly, installing new and advanced technologies is expensive in a resource constrained country (26). Moreover, Basu et al. 2015 (32) mentioned the lack of IT specialists in Nepal, and it was financially challenging to recruit the experts from overseas.

Other challenges
Four studies mentioned that adaptation challenges and misdiagnosis are categorized as other challenges (13, 19, 24, 33). Adaption challenges make it difficult to train senior doctors who believe in face-to-face consultation rather than video consultations, and it was also challenge to convince patients about the benefits of digital health. Furthermore, one of the papers mentioned a case of misdiagnosis, which occurred through the conveyance of wrong messages due to an interrupted phone connection (13).

Opportunities
For digital health services, opportunities are defined as the service or facility provided by digital health to the public to deliver medical services regardless of distance and time  Opportunities are also categorized into four forms education, training and awareness; cost-effective treatment; equity and increased health access and future use (Figure 3).
In the context of digital health, opportunities are not just limited to using technology remotely to deliver health care services but also simultaneously adaptation by staff to the new working practices. Firstly, the professionals (health care providers) need to trust the digital system, reassure the patients of the privacy and confidentiality of collected health information, and ensure affordability for individuals and health care organizations (13).
Additionally, telehealth interventions' experiences and outcomes depend on the design details and factors like health literacy, digital literacy, and the quality of integration with clinical care pathways. To realize the long-term benefits of -Participants feel a significant reduction in perceived pain due to various musculoskeletal conditions. -There is no significant difference between TPT and face-to-face physiotherapy.
-Telephone-based tele-therapy seemed a feasible option for pain management where high technology is beyond reach and has a literacy rate. -It could be a choice to deliver home-based rehabilitation to enhance the older population's wellness. -People get supportive and affordable care services.
-Got the opportunity to observe and experience the dynamic changes in the knowledge, attitude, and practice of all the stakeholders. -Led to a completely different understanding of the difficulties between telemedicine interventions.

Meyers et al., 2017
Type -Due to inadequate management and planning, the program failed to achieve its goal and collapsed.
-Provide information for future mHealth interventions in similar contexts. -Information was only obtained and shared among DFY (Doctors for You) after a disaster. -The problem is in the transportation of medical personnel and supplies. -Electricity and save drinking water problems during that time.
-Real-time analysis of such online data helps to decision makers in forming resources and mapping strategies dynamically. -Provide medical aid and other needs to needy people during disaster crises.
-Provide a lesson that government should always be on standby to help in critical disasters.

Education, training, and awareness
Digital health is a platform for all health stakeholders that provides an opportunity for health education, training, and awareness. Opportunities were mentioned in 10 studies- (13, 19, 21, 24-26, 32, 33, 35, 36) through different forms such as telesurgery and teleconsultation by medical students. It was mentioned that doctors learned about IT skills during health care delivery (13, 26), and patients also got the opportunity to learn about the use of technical devices (24).

Cost-effective Treatment
Cost-effective treatment was mentioned by four studies (10,27,29,35). Cost-effective treatment in terms of reduced traveling costs with no excess consultation fee was mentioned in these articles. Patients from rural areas had to visit hospitals in the city for specialist consultations, which was reduced when they started getting digital consultations in their locality. As mentioned in a case study (37), untreated patients with face-to-face consultation were found to be adequately treated through mobile tele dermatology. Thus, patients were found satisfied and attracted to the quality of service they obtained through digital consultation, where they did not have to pay an extra for the specialist service.

Equity and Increased health access service
As mentioned in 12 studies (10, 13, 19, 21, 24, 26, 31-34, 36, 38), patients from rural areas were found to be more focused on their health issues and were interested in using digital health services. Similarly, another study by Sikhar Swar et al. (19) showed improvement in patients' mental health status in far western regions. Digital health services delivered for diabetic care, childcare, and maternal health care in rural areas showed similar outcomes compared with urban health care facilities. Thus, telehealth service was more affordable and accessible to the public, and assistance was provided by the health professionals as required, which encouraged patients to use this service (38).

Future use
Future use of digital health was mentioned in four studies (10,21,34,38) in different forms, like the opportunity to review digital health care policy and implementation on a large scale. Lots of successful pilot projects by Morrison et al. (31); Hong et al. (29), and case studies by Shrestha et al. (37) and Basu et al. (32), among few, have been conducted in various parts of the country yielding major positive outcomes with some drawbacks also. From all those outcomes, the government, including other Challenges for implementing digital health interventions in Nepal.
Parajuli et al. 10.3389/fdgth.2022.861019 Frontiers in Digital Health stakeholders, can use the results for implementing those projects in revised form on a large scale. Doctors, nurses, and even patients need to be trained regarding digital health use and its translation into their workplace without any technical hassle (39).

Discussion
This review explores the challenges of implementing digital health programs in Nepal before Covid 19 and future opportunities. The most recognized barriers were technical barriers such as network overload, frequent power cuts, lack of electricity, and internet problems (13,19,24,29,31,34). Similarly, the lack of sufficient technology and infrastructure crisis (inadequate telephone network, Wi-Fi connectivity, and mobile phone penetration) for running digital health has also become a huge barrier to its implementation in Nepal (10,21,25). A study conducted in Bangladesh by Hoque et al. (39) found similar technical issues like lack of ICT infrastructures (lack of electricity and network problems), and a study done in India (40) mentioned the lack of broadband for quality of video consultation. Less than 85% of the houses in Nepal have access to electricity, which are facing rolling blackouts commonly known as load shedding for several hours and multiple times a day. Industrial production is also dependent on this limited power supply. Remote Nepal is mainly affected and has compelled the citizens to use alternate sources like small solar power systems or diesel for power supply (41). Some papers also found a lack of IT skills among doctors, nurses, and other health care workers. Younger doctors and interns are willing to learn about the new technology, but for senior doctors, it is hard to convince them to be tech-friendly (24). A similar pattern was also found in a study done by Hoque, M. R., Maximum, M. F. A., & Bao, Y. (39) among the older administrative staff who were found to be a bit resistant to adapting to new technology.
Apart from technical issues, a skilled workforce plays an important role in the smooth functioning of digital technology, but many lagging factors were found. On one side, there was a lack of operational skills among health care staff (10,13,25), and on another side, the literacy gap among people in the rural-terai region was found (20). Thus, training Opportunities for implementing digital health interventions in Nepal. Additionally, funding plays a vital role in supporting digital health services and, in the context of Nepal, is a major motivational factor for its sustainability. The WHO also has mentioned the lack of funding as a major factor for lagging digital health services in developing countries (43). Though the government has planned to expand the digital health facilities, a separate budget in this sector is not allocated, and does not fall into a top priority list. Thus, reimbursement can also be used as a motivational factor to support the volunteers/digital health in the long run. Studies from Bangladesh (39,44) also found similar funding-related problems, including access to digital tools that affect the adaptation of digital health.
The new information and technology era may lead to new hope and more services for the public in Nepal, where geographically varied places and their landscape become barriers to health care delivery. Due to a lack of infrastructure and other facilities, people lag in accessing health services and have died from curable and preventable diseases. So, digital health and modern medical technology offer treatment, cure, and awareness in addressing health needs without traveling out of hometowns. Developing countries like Nepal, India, and Bangladesh and even developed countries like Australia have shown the cost-effective benefits of digital health in aged care centres and disability centres in remote areas (45).
Digital health interventions conducted in remote villages of Nepal have shown equal consultations and treatment benefits as received by urban patients (38). Hence, digital health empowering community hospitals and tertiary centers has shown fruitful application (25), thus extending to larger areas. Medical students were found learning through tele-education. The intern doctors of Kathmandu model hospital were virtually experiencing the surgery conducted in Korea through telesurgery. They were eager to learn about the techniques (13). In addition, mid-level health workers and volunteers also had telephone for video consultations to care for the patients (20,31).
Furthermore, most of the digital health interventions we have included in our review were conducted in small areas or specific locations, with a positive outcome. This has the potential to expand digital health services in a broader context by empowering community health care centres through relaying information to and fro with the tertiary hospitals. For instance, a study carried out by Mercado et al., (30) at Tilganga Institute of Ophthalmology (TIO) in Kathmandu, and rural eye hospital in Dhangadi, and a rural cataract camp in Hetauda showed the potential of digital health further to expand their impact in other areas (30).
Digital health literacy is the most among doctors, and patients play an essential role while implementing digital health. Few papers (13, 21, 24) have mentioned the importance of digital literacy among the stakeholders. The confidentiality of patients' information is also a significant concern. Morrison et al. noted that confidentiality might not be considered an essential factor for telephone-related consultations (31). Pradhan et al. mentioned that Nepal has no specific data protection law (46). Additionally, the negligence in patients' data protection systems while conducting digital health programs was mentioned by Rai (13).
A quantitative study shows equal access to diabetes care in rural and urban areas. Teleophthalmology also has reduced the travel cost (29,38). Patients were eager about digital health (34) and were found equally satisfied whet her they were treated face to face or through tele ophthalmic means (29). Additionally, the majority of the patients' were comfortable with telephone consultation (34). Phone-based SMS was also used as a health promotion tool for dengue control and increased awareness about nutrition (21).
Nepal's government should take heed to developing a national digital health strategy that may guide the effective implementation of digital health interventions in Nepal. Evidence has highlighted the importance of digital health education among health care providers (34). Moreover, a center for digital capacities and knowledge should be established to train, coach, and facilitate the human resource to digitalize the health system (46), which motivates them to uptake new technology without hesitation (34). It may allow the government to deliver services in a people-centered approach improving digital health literacy and the quality and safety of health services, thereby helping the country to achieve universal health coverage.

Strength and Limitations of the study
Like other studies, this paper does have strengths and limitations. The strengths include: (i) findings based on the review of peer-reviewed journal articles, and (ii) findings might guide the policy and practice for digital interventions in Nepal. This study had some key limitations. First, the literature search was done in selected databases using key search terms which might not have captured all the published evidence. Secondly, the study only reviewed articles published within a particular time framework and did not include grey literature; therefore, findings should be interpreted carefully. Thirdly, the search was limited to English, meaning this study did not consider articles published in Nepali.

Conclusion
The study identified various challenges and opportunities that can guide the development and successful implementation of digital health interventions in Nepal. Moreover, decision-makers should involve wider stakeholders including information technology experts and the developmental partners in building the capacity of public health facilities, and workforces to effectively tailor and deliver digital health interventions in Nepal. While digital transformations have great potential to benefit population health, they may exacerbate social inequalities. Therefore, future research should focus on social and cultural determinants of digital health literacy at the professional level (those who develop, deploy, recommend, and prescribe digital health services) and community level (those who use digital health services). This may guide the development of peoplecentred digital health information that can address the practical, comprehensive needs of the people.

Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding author/s.

Author contributions
RP, DB, and MKC conceptualize and design the study under the supervision of UNY. RP, DB, and MKC analyzed and prepared the first draft. UNY revised paper for its intellectual content and provided significant inputs to improve the quality of the work. UNY, SKM and SS provided significant inputs, edited, and approved the final version to be submitted. All authors contributed to the article and approved the submitted version.