Introduction:
Nepal has made significant progress in the field of information technology (IT) since the establishment of the first Technical Training Institute in 1963 under Tribhuvan University. However, there have been several challenges and opportunities in the development of the digital health sector in Nepal. T
Historical Development of IT Sector in Nepal:
The government of Nepal introduced the use of information technology based on a computer system for conducting the 1971 census using IBM 1401, a second-generation mainframe computer. However, it was used more as a calculator, and it took almost 19.7 months to process the census reports of 11.5 million population. In 1974, the Centre of Data Processing (Yantirk Saralikara Kendra) was established to continue the use of technology in data processing for the government purpose. Despite the lack of an encouraging political and policy-level environment private sectors express its courage to import microcomputers (Apple, Vector, Sirus, etc.) for individual and private business purposes in the 1980s. After the democratic people's movement in 1990, many computer training institutes and FM radios were established in Kathmandu and other major cities of Nepal. The Computer Association of Nepal (CAN) was formed in 1992 to serve as an umbrella organization for IT organizations, business organizations, software and hardware vendors, importers, internet service providers, etc. Internet service with limited email facility in Nepal started in 1995 by Mercantile Communications Pvt. Ltd. Academic courses related to IT and computer engineering were initiated in the late 1990s. To regulate telecommunication and other ICT activities, the Telecommunication Authority (NTA) was formed based on the Telecommunication Act 1997. The National Information Technology Centre (NITC) was established in 2001 to develop and promote the information technology sector in the Government of Nepal. However, as of 2000, only 0.2% of the total population had access to the internet. The first IT Policy was formulated in 2000 with a vision of positioning Nepal on the global IT map within the next five years, which adopted a 15-point strategic framework. Since then, this policy has been reviewed twice. In 2003, the High-Level Commission for Information Technology (HLCIT) was formed as the apex body under the chair of the Prime Minister to provide crucial policy and strategic direction to Nepali IT sector. However, this commission was dismissed in 2011, after initiating several projects such as the establishment of IT parks, developing e-governance master plans, and installing tele-centres and wireless networks in rural communities. After the dismissal of the apex body, the Department of Information Technology (DoIT) was established under the Ministry of Information Communication and Technology. In 2019, DoIT announced the Digital Nepal Framework, covering eight different sectors, including digital foundation, agriculture, health, education, energy, tourism, finance, and urban infrastructure. Digital health is one of the eight major areas of the Digital Nepal Framework. However, with the department-level bureaucratic profile, DoIT faced difficulties in coordinating and bringing all the stakeholders onto one platform. As a result, the government realized the need for political commitment and leadership to have a leapfrog jump in the digital economy. In 2022, the government established the e-Governance Commission under the chairmanship of the Prime Minister. The other members of the commission are the Minister of MoIC, Chief Secretary, MoIC Secretary, and member-secretary
Digital Health In Nepal
Digital health is one of the priority areas of the Nepal government and is included in the Digital Nepal Framework (DNF 2019). The Ministry of Health and Population (MoHP) has formulated e-Health strategies and an e-Health roadmap for the digitization of health sectors data and application.
Policy:
The National Health Sector Strategy (NHSS) has mentioned electronic health and associated applications, but unfortunately, the government has not been able to clearly allocate a budget for digital health initiatives. The latest IHIMS roadmap is focused on digital health components such as artificial intelligence (AI) and data science. The Public Health Act 2078 and Statistical Act 2079 have slightly touched on basic data governance with limited discussion on electronics policies. These policy documents, such as the eHealth strategy and the Digital Nepal Framework, are outdated and need to be updated to align with new policies and demands.
Access and Infrastructure:
Nepal has made efforts to improve last-mile connection and access to underserved communities through the National Broadband Policy 2071 and the allocation of RTDF budget by the Nepal Telecom Authority (NTA) has increased access to technology and the internet in rural areas of Nepal. However, the country could not demonstrate a clear alignment between its national digital strategy and the core components of Universal Health Coverage (UHC), such as financial protection, access to quality health services, and equitable distribution of health resources. Private sectors have invested in both technology and the health sector, which has been helpful.
Standards:
Nepal Statistical Act 2079, Privacy Act 2018, and the Public Health Act address the protection of personal data, but there is a lack of clarity and emphasis on cybersecurity in the context of digital health. Further improvements and the drafting and implementation of a dedicated digital law may be necessary to strengthen data security and protect sensitive health information. In case of cross-border data security, it hasn't been considered yet in Nepal, despite a significant percentage of the population living abroad and many Nepalese citizens seeking healthcare services in other countries such as India and Thiland. It is essential for Nepal to prioritize developing and implementing robust data security and sharing policies and frameworks to address this gap and ensure the safe exchange and storage of health-related data across borders.
Training and workforce:
There is a gap in digital health training for certain groups of healthcare professionals, especially for community health workers, nurses, allied health professionals, and health managers/administrators. The digital health-related skilled specialized training for these groups can ensure that they can effectively use digital technologies to deliver quality healthcare delivery and patient outcomes. Graduates in digital health are not yet being produced from local universities, which could indicate that there is still a gap in the training of digital health workers in Nepal. To address this, it may be necessary to further strengthen the digital health training curriculum in universities and colleges to ensure that graduates have the necessary skills and knowledge to effectively use digital technologies in healthcare delivery. It is also important to note that digital health training should not be limited to academic programs but should also be provided as in-service training for healthcare professionals already in the workforce.
National Digital Health Architecture:
It is important to establish a national digital health architecture and/or health information exchange (HIE) in order to enable the interoperability and standardization of digital health systems and applications across different healthcare providers and settings. By establishing a national digital health architecture, Nepal can ensure that digital health systems and applications are designed, developed, and implemented in a coordinated and standardized way, with a focus on ensuring that different systems and applications can communicate and exchange information with each other. With the funding support from GIZ
Digital Health and Application:
Nepal has achieved remarkable success in implementing digital health solutions over the past decade, despite challenging circumstances. This has been possible due to the collaborative efforts of the government and external development partners (EDPs). This report highlights some of the successful digital health initiatives in Nepal.
Routine Reporting System DHIS2:
The government, in collaboration with EDPs, has rolled out the routine reporting system DHIS2 to over 7,500 health facilities in Nepal. This has enabled online reporting from these facilities, allowing for more efficient and accurate data collection and analysis.
eLMIS Health Logistics Recording System:
The eLMIS health logistics recording system has been adopted by more than 2,700 health facilities in Nepal. This system helps in the efficient management of health logistics, including procurement, storage, and distribution of medicines and medical supplies.
Electronic Medical Records (EMRs):
Provincial and federal hospitals in Nepal have implemented EMRs with a focus on billing, pharmacy, and patient registration. Several medical recording software systems, such as Midas, Dolphin, Cogent, Nepal HER, Mediflow and Decode, are available in the market to facilitate the adoption of EMRs. However, most of these systems are not interoperable with each other. Nonetheless, most of these software systems send data to DHIS2 using DHIS2 open API. Some of the software system such as Nepal HER is interoperable with Nepal health insurance system.
Amakomaya Maternal Health tracking system:
The non-profit initiative Amakomaya Apps has been a successful mHealth application in Nepal since its inception in 2011. It has contributed innovatively to maternal and child health tracking purposes and provided technical support to the Ministry of Health and Population/Department of Health Services for upgrading DHIS2 and implementing other digital health applications. During the COVID-19 pandemic, Amakomaya provided strong technical support to the Ministry of Health and Population on COVID-19 case tracking, COVID-19 vaccine management, and COVID-19 vaccine certification. With funding support from EDPs, Amakomaya has continuously launched online consultations for pregnant mothers since 2020. To date, more than 11,000 mothers have registered in the system and availed of online consultation services.
Nepal's success in implementing digital health solutions is commendable, especially in challenging circumstances. These initiatives have helped in the efficient management of healthcare services, improved data collection and analysis, and enhanced maternal and child health tracking. Continued support and investment from the government and EDPs are crucial to sustaining these digital health initiatives in Nepal.
Major EDPs supporting in Digital Health initiative in Nepal
1) UNDP (For digitization and policy formation)
2) GIZ (Recording, reporting and standardization)
3) Save the Children/Global Fund (Infrastructure and eLMIS)
4) USAID ((Infrastructure, eLMIS and many more)
5) WHO (Technical support)
6) UNICEF (Application development, HR and tech support)
7) Word Bank and Asian Development Bank (Big size project support)