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” (6–8). 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 cost-effectively, 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.

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).

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 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).

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 should be provided to the staff and awareness-raising initiatives among the patients (21, 28). A study from India (40) also emphasized the lack of technical training among paramedics. Lack of technical illiteracy in digital health intervention was also identified as a hindering factor among Pakistani citizens in a study by Ittefaq, M., / Iqbal, A (42).

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.

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 people-centred digital health information that can address the practical, comprehensive needs of the people.