11Aug2022

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Policy Compendium

Evolving Roles of ICT in Nepal’s Education Sector

RUBIN Singh Maharjan

Abstract

Education is one of the most important aspects of human beings that drives human skills, art, and creativity. Without education, human values and ethics do not come along.  But since last March 2020, the physical classes have been completely closed due to the Covid-19 pandemic. As an alternative ICT (Information Communication Technology) came along creating an opportunity for online education that flourished around the world. An immediate shift from regular physical classes to online classes was a big jump for both teachers as well as students but there was no other alternative. Due to this the demand for internet users as well as mobile penetration has increased. The digital divide has been accruing since then as many students could not afford expensive mobile, television, and laptops of their own. From the government level, many policies related to ICT and different actions have been playing from the local level regarding ICT development. Technology has taken more control over our lives now as mobility is strictly prohibited. During this pandemic time, new policies related to ICT and different technological support have been taken to make sure that the flow of the teaching and learning process is not disturbed.

Introduction

Education has become one of the prime challenges for a developing nation like Nepal where poverty and bad governance are the crucial aspects that are keeping people away from education. Looking into the history of Nepal’s education system at the beginning from religious education in Temples, trusts, and monasteries literacy was started. Nepal did not have its education policy until 1939.  At the beginning of modern education itself, the Rana regime kept restrictions on education access in the education ordinance of 1939 manifested Rana policy made Nepalese people fall further behind in educating their citizens. In 1939 School Leaving Certificate (SLC) was recognized but still, the whole examination was conducted and controlled by Patna University in India which was slowly controlled by Nepal till 1947.  From 1951 to 1971 Liberal Policy of the government expanded access to education which brought a greater number of attendances in the education sector opening education for the general public. Focusing on School education in 1952 the Ministry of education was established. In 1954 National Education Planning Commission (NEC) was formed that reviewed the education situation and gave the suggestion to the government for the first time for financing in the education sector. This supporting information from the National Education Committee expanded access to education in 1961. The help of the United Nations’ technical cooperation for human resources and physical development for primary education by adopting the policy of partnership between government and the communities brought many changes in the education sector. The policy of School-based management was running during 1960.

In the area of education policy in Nepal, the congress government in 1959 adopted the policy to expand primary education by establishing one primary school in each election booth which supported more area coverage of schooling. By 1990 National Education System Plan (NESP) was formed but it lacked in addressing the nationalization of the education system. As soon as the Panchayat system prevailed NESP ended and in 1992 National Education Commission was appointed which gave a correction to the previous education policy. In 1998 a high-level education commission was formed and by 2008 the expansion of private education started booming around the country.

Nepal’s first education development plan was made in 1956 that focused on primary education and in 1971 National Education System Plan (NESP) was initiated that looked into school curriculum along with vocational education. From 1970 to 1990 the whole education system focused on giving equal access to education for both males and females and focusing on disadvantaged communities were the major target group. As it consisted of education for rural development (Seti Project) from1981 to 1991, primary education project from 1 983 to 1992, primary education development project from 1992 to 1998, basic and primary education project Part I and II from 1994 to 2004, and finally from 2004 to 2009 education for all program was started. So, we can see that expansion and maintaining access to education was the major focus area. Later in 1990, the Millennium Development Goals stated a global world target of education for all by 2015. (Consultants, 2009)

ICT (Information Communication Technology )

The term ICT is also used to refer to the convergence of audiovisual and telephone networks with computer networks through a single line system. There are expensive financial motivating forces to combine the phone arranger with the computer organize framework employing a single bound together framework of cabling, flag dissemination, and administration. Tools of communication like radio, TV, cell phones, computer and organized equipment, video conferencing, and remote learning. ICT implies the utilization of computer-based innovation and the Web to form data and communication administrations accessible to a wide range of users. (Tomar, 2021)

According to UNESCO, “Diverse set of technology tools and resources used to transmit, store, create, share or exchange information. These technological tools and resources include computers, the Internet (websites, blogs, and emails), live broadcasting technologies (radio, television, and webcasting), recording broadcasting technologies (podcasting, audio, and video players and storage devices), and telephony (fixed or mobile, satellite, Visio/video-conferencing, etc.) ” (UNESCO, n.d.)

General Objective:

To study the different provisions of ICT in the education of Nepal

Specific Objective:

1.      To find out the different policies made under ICT learning till now and its progress

2.      To find out about Government action during the covid-19 pandemic in the area of ICT development in the education sector

Methodology

The study followed a qualitative research design where means of secondary data from different research papers as well as newspaper articles had been taken to bring out different analyses from this research paper. The study area was specifically focused on Nepal as well as it has tried to compare with south Asian Countries and has brought different results from these authentic sources. Due to the Covid-19 pandemic situation, physically taking raw data was not possible so with the help of secondary data the following research took place. One of the metropolitan cities “Lalitpur” was taken for a detailed interview to get to know more about the grown reality of Nepal. 

ICT Policy Review

1st to 7th Plan of Nepal and its focused areas

From 1956 to 1990 the plans of Nepal in the area of education particularly focused on maintaining the quality of a school by funding a particular budget in the area of school staff, suppliers, services, and administration. With the increase in budget in a different year of planning. It also focused on power decentralization by giving authority to the district and preferred more local government schools. Provision of free education from 1 to 3 grade in all public schools. Also incorporated free education but did not play a good role. Another major objective was to increase access to school and this encouraged the private sector to open and operate the school and Early Childhood Education Development (ECED) centers. This also gave importance to female teachers to attract more female students to attend the school. Mainly poor and diligent students were focused on scholarship provision.

ICT and 15th Plan of Nepal

Curriculum-based on the development of human resources, infrastructure and technology, and life skills mainly digital learning materials will be developed to assist the teaching and learning process for English, Maths, Science, and technical subject. It also addresses ensuring life-long learning by connecting learned knowledge and skills with income-generating programs through informal education and alternative learning of electronic-library services at the local level.

In the area of the social sector in education, the 15th Plan mentions education and its technology-based learning where it says that the provision will be made for mobile programs on skills development and training to ensure the prescribed quality of technical and vocational education are focused. More technical stream education will be conducted in every community school. Innovative technology will be included in schools and university curricula as appropriate to utilize innovative technology.

ICT development In Education Policy of Nepal

Policy development from 1951 to 1990 there are some the areas where technical education and vocational training have been mentioned including non-formal education, distance education, and open learning as a starting phase for ICT development in the education policy of Nepal can be seen.

According to Master Plan 2013-17 in the part of Information and Communication Technology (ICT) in Education policy it says,

 ICT Policy 2010 states access to the Internet to all schools, national and international skilled human resources, promotion of Industry-Academia collaboration IT programmers focusing on students, teachers, and schools.

The School Sector Reform Plan (SSRP) states that ” ICT assisted teaching/learning will be implemented and expanded in all schools”. Alternative modes of schooling, distance learning by the Ministry of Education (MOE) is to develop learning support materials to enhance the quality of education through the use of ICT.

According to the three-year plan 2011-2013 of the government of Nepal policy related to ICT in Education: schools will be encouraged to use ICT in education to increase access to quality education in rural areas, the digital divide will be reduced and ICT will be integrated with all aspects of education.

Guiding Principles in developing a master plan,

1.      The first principle should be ICT for all students, meaning that the policy would act as an enabler to reduce the digital gap.

2.      The second principle should emphasize the role and function of ICT in education as a teaching and learning tool that would also encourage the utilization of all potential media and Technology.

3.      The third principle is to promote educational access and equity for all regardless of age, gender, ethnicity, disability, or location.

4.      The fourth principle is to emphasize the use of ICT to increase the efficiency and effectiveness of the management system in education. ICT will extensively be used to automatize and mechanize work processes such as the processing of official forms, timetable generation, management of information systems, lesson planning, financial management, and the maintenance of inventories.

According to this principle, there was action taken on the field on the part of skilled manpower development, and here are the key results and targets,

S. NTarget till 2017Achievement
1.218 Trainers Trained290 Trained till 2015
2.Teachers Trained for ICT20,000 teachers trained till 2017
3.Interactive Digital Content for students.All grades developed a total of 70 subject’s content till 2017

 Regarding different programs and activities, many committees are being formed like the functional National committee and coordination committee was formed in 2017.

·                       One E-government in the education sector was established in 2017.

So, looking at the master plan target and its achievement it shows really good progress till 2017. (MOE, 2013)

In-School sector Development Plan (2016/17 to 2022/23) by the ministry of education 2016 has shown the ensure equitable access to quality education for all that implies. Here ICT objective and improvement strategy and online course and material development and online self-learning method are mentioned that show more emphasis on remote learning strategy had been worked from the beginning itself.

The National Education system plan from 1971-76 by the ministry of education frames out a plan prepared/commanded by his majesty King Mahendra Bir Bikram Shah Dev. The provision of other educational materials like science and the vocational subject is better comprehended if films, firm-strips, and slides are used. Many other ways like education through radio and a basic requirement for school teachers training and teachers qualification are looked under. The education act 2028 (1971) also mentions opening school process, qualifications, mobile schools may be operated in remote mountain regions.

Digital Nepal framework 2019 is one of the latest events conducted in the area of Nepal’s ICT development programs. Open learning exchange (OLE) Nepal was established in 2007 which is one of the integrated technologies in classrooms. E-Paath includes more than 600 learning models for teachers. Her teacher’s training included 600 plus teachers trained in IT literacy. Technology infrastructure consisting of 5000 laptops in 100 schools was developed. Promoted digital inclusion and the smart classroom that was the focal agency of MOEST and supported agency by MOCIT (Ministry of Communication and information technology, MOF (Ministry of Finance), NDCL (Nepal Doorsanchar Company Limited). OLE Nepal in public schools focused, online learning platform in mostly rural and fewer facility people. Rent a laptop program, EMIS 2.0 (Education Management Information System) Mandatory for all public schools that integrate education management information system, as well as biometric attendance systems and CCTV comers including mobile learning centers in rural areas, are some of the ICT projects that had been in the planning phase.

ICT background of Nepal

ICT was never a priority before but providing equal opportunity for education for all was the main challenge. Due to not much implication of information communication technology used in Nepal, physical education was given more priority. Along with the changing scenario, the Covid-19 pandemic brought the necessity of online education where now technology is playing a huge role in the process of taking the quality of education forward. Due to this change, Nepal’s technological use has increased drastically. According to the 2019 Digital Nepal Framework, it shows that mobile penetration exceeded 100 percent whereas internet penetration reached 63 percent which shows great progress from 2012 which had only 62 percent and 21 percent respectively.  Here the government of Nepal also says that it is taking initiating steps to expand internet connectivity as part of its vision of a digital society that connects 90 percent of the population to broad services by 2020.   In the area of optical fiber cable coverage, 75 different locations in 45 districts are available (Telecome, 2021). Access to radio and digital television has reached 87 percent and 72 percent respectively according to the economic survey 2077-78 (Finace, 2020).

S. NParticularCoverage
1.                         Internet Penetration63%
2.                           Mobile Penetration100 + %
3.                           Optical Fiber Cable45 District
4.                           Radio Coverage87%
5.                           Television72%

Nepal in comparison with South Asian Countries in the area of ICT Development

Digital innovation in a developing country like Nepal has always been a huge challenge but every pandemic situation brings opportunity and this time it was digital innovation in education due to the Covid-19 pandemic.  Looking into the 2016 data of the ICT Development Index (IDI Index) it shows that the Maldives was first ranked in the Reginal IDI of south Asia in 2016, whereas Sri Lanka, Bhutan, India, Nepal, Bangladesh, Pakistan, and Afghanistan respectively ( Latif, et al., 2018). 2017 data from IDI shows the updated data where in the world ranking again the Maldives stand first with 85th ranked with 54.73 percentage among South Asian Countries where Nepal with 140th world rank with only 15 percent that has internet access. So, we can see the backwardness in the area of ICT (ICTdata, 2017).

Looking into internet penetration in mobile phones from 2014 to 2018 we can see the improvement of Bhutan with 33 percent, Bangladesh with 22 percent, Nepal with 33 percent, and Pakistan with 23 percent. On the other hand, we can see a huge increase in mobile internet perpetration in Nepal among other South Asian countries which shows good progress in the long run (GSMA, 2019) Overall, the increasing trend of Nepal in the area of ICT still lags in comparison to all the other countries of South Asia. But looking at the rate of increase in mobile as well as internet access it has given a good startup signal in the area of digital transformation in Nepal soon.

The covid-19 pandemic has become one of the worst crises hit around the world that not only affects human health but largely in the education sector. The immediate shift from physical education to online education was a hedge jump for a developing country like Nepal. As physical education was the prime process of teaching and learning. But with such a shift during the pandemic time, there was no other option. Depending upon ICT as a medium to connect with the students and having technological understanding was the main struggle for the teacher as well as for the students (Karki, 2020). To overcome this problem many strategies were used to connect the gap between the student and the teacher from the government side. The process of using radio, television, computer, and internet services was made for the schools that were facing problems to adjust new technology (Government, 2020). In Nepali university students who were involved in online education started having health-related problems and found online education not so effective were 55.6 percent of the teacher said that the classes were not so interactive whereas 41 percent of the students felt that the online classes were not effective (Dangal & Maharjan, 2021).  With a long lockdown physically teaching and learning activities were completely shut down and to reopen school the Ministry of Education, Science and Technology (MoEST) came up with a framework for reopening school based on the suggestions received from the province and local levels by reviewing the situation of Covid-19 pandemic at local and school levels (Ministry of Education, 2020). Going back to the lockdown again with the rise of the second wave giving more concern, especially for school-age children with no vaccine extended online classes. With this concern, the government started a process to obtain six million doses of Pfizer-BioNTech vaccine for under 12 children according to the Ministry of Health and Population (Republica, 2021). Along with the pandemic situation the students facing more problems in online education itself, with economic stress, parents not educated, internet access, fear of loss of the academic year as well as uncertainty in conducting physical classes and on top of that mental physical and social pressure on students (Dhungana, 2021). The digital divide in education started growing rise, especially for the students who are marginalized, students with disability, and low-income has detached from online education (Ojha, 2020). As the majority of the schools and students do not have access to a computer but government proposed online teaching which has created more gaps in education. To minimize such pressure on students during this pandemic Human Right Commission of Nepal had requested the Ministry of Education and private schools not to pressurize the students in the name of online education (Ghimire, 2020).

The shift from physical to online gave more pressure on parents, teachers, and educational institutions to continue the teaching and learning process. Parents balancing household work and jobs with their children’s online education gave more added role of guardians to educate their children. Due to this many parents lost their job squeezing the economic status that decrease to afford education.  This is just the situation in the urban area, but the guardian of the rural area is much more challenging.  In comparison to private schools, public schools are more technically backward and still need more support is needed to build technical knowledge. Looking into the data there is only 12 percent of public schools out of 30,000 have the information communication technology (ICT) delivery capability, with 30 percent having access to a computer and only 1 percent of public-school teachers can run online classes according to the Economic Survey of 2019-2020 (MOF, 2019-20). So, we can see from the data itself how the situation had been with the immediate shift from physical education to online. 

Interviewee Details

Name: Mahandra Bahadur Chettri

Post: Sichya Mahasakha Pramukh

Work Experience: High School Teacher for 3 years, After Lok sawa: worked in Education Monitoring Post (Sakha Adhikrit), worked in a different district like Baglung, Baitadi( Jila Sachiv), Kailali in (Upa Sachiv Post), Education Board (Upa Sachiv), District Education (Upa Sichaya Adhikari in Lalitpur Metropolitan City Office) and Now working in  Local Level Sichya Mahasakha Pramukh of Lalitpur.

Discussion and Recommendation

●     From Children’s development, pre-primary to class 12 school management responsibility is given to the local government. (Schools management: Teacher’s Salary, Appointment, Transfer, Holiday, estimation of the students) from School’s permission to primary to 11, 12-grade approval comes under our jurisdiction.

●     Education Procedure is made that has made education composition: Social Committee, Education committee (We discuss and make a decision mainly School education)

●      Before +2 different schools are different and now till +2 school. (Overall Management work is looked after us)

●     Support from LMC during this pandemic time: Computer lab establishment, ICT for long-term use has become more priority, ICT Knowledge more focused.

●     Last year a specific budget of Rs.12,000/- came from the Federal government along with internet services and the local government provided a subsidy to all the community schools and even this year at the rate of Rs 12,000/- subsidy was given to both school and +2 students. Before the subsidy was given to the only high school and from this year, they have provided it to all the basic schools. On top of the in addition for alternative online learning classes where for adhar bhut: Rs.15000/- and Mavi 25,000/- subsidy is given to all the community schools to implement the policy that they have made.

●     Result of the policy: Firstly, they have touched almost all the areas, access to education for all people especially for females, Dalit, differently able people, free textbooks

●     Due to the Covid-19 situation, some of the policies could not be that effective like the part of a monitoring mechanism for all the schools which was not at all possible.

●     Evaluation of these 14 policies: In a general aspect, all are a success but, in some parts, it is an only partial success like, Snack’s provision to school but the school did not open so this action also was not implemented, Sanitary pad distribution which also was not possible to give.

●     Firstly, needs were identified, Economic support from the Federal government and some from the Local government got little support. But in the area of alternative learning, they could not be addressed properly due to students having no access to online classes, and teachers having no skills in conducting online classes due to a lack of Budget. So, for this, they even gave some basic training to the teachers of public schools so that they can at least conduct classes from a mobile or any other device.

The local government not being able to work effectively in the area of ICT development with a lack of budget during the pandemic time. As a lesson learned we need more investment in ICT development and proper facilities for ICT-related training for both teachers as well as for the students is the most important priority for any kind of pandemic situation that may come in the future.

Most rural areas of Nepal are still deprived of proper technology as well as not aware of the importance of ICT policy. Sankhuwabha is one of them that still lacks trained teachers as well as skilled human resources as a major barrier to ICT in education policy. Not only this it has brought a big question on its proper monitoring and evaluation of schools regarding ICT development from the government working mechanism.  More awareness in the rural areas gives more concern according to Avinash Jha ( Jha,2021).

 Conclusion

The education sector needs immediate attention due to the Covid-19 pandemic and if we don’t bring changes in our teaching and learning process through online education the future of education quality will surely decrease leading to less enrollment rate of students. It’s been almost 2 years of a continuous shutdown of schools and as an alternative (ICT) Information Communication Technology played a huge role to fulfill this gap.  But challenges remain uncertain as all of a sudden change from physical to online has created many disparities. Lack of technical knowledge, lack of preparedness, and no proper online course design has made online courses more challenging for students. In the part of evaluating students through the examination process, we can see lots of confusion in deciding on how to take the examination for SEE, 11, and 12 classes. This has shown the dependency of the government on physical examination only and does not want to go for online examination as an alternative due to this pandemic situation. Using only one evaluation system for students is not at all good; it has to be improvised according to the situation.

Maximum use of technology due to this pandemic I would say has allowed us to do more things from technology. Not just studying from books but also studying from videos, online documents and different knowledge around the world can be our opportunity. But if we assume that if there were no Covid-19 pandemic then we would have never understood the importance of online classes. But now we can see the whole world is moving with online education with the help of ICT. This has boosted Nepal’s technological users’ knowledge and increased a greater number of mobile phones as well as internet penetration in Nepal. Even in comparison with South Asian countries, Nepal is slowly improving much better than other countries.

To look into a practical example of how local government bodies are working I took an interview with Mr. Mahadra Bahadur Chettri working as a Sichya Mahasakha Prakukh in Lalitpur Metropolitan City.  He has shared lots of information regarding ICT development in public schools and how they have been managing the current problem with different teaching-learning activities with the help of radio, small group teaching, documents, and giving monetary funds for internet access for all the public schools in Lalitpur. Looking at all the policies for this year and for the upcoming year they have planned different ICT-related development projects and more funding is allocated for ICT development in the education sector.  Local government bodies play a major role in the context of finding alternative education processes to education plays a major role.

In regards to different policies of Nepal related to ICT development in education, we can see lots of provisions since 1951. Distance learning and the use of technology training given to school staff were the basic approaches taken along with Master 2013-17 mentions different provisions of online education. But despite all those policies as well, planning while implementing during this pandemic time became a huge challenge for most of the school teachers as well as for the students. With the lessons learned and learning from our past now, we need proper planning regarding ICT for everyone and proper facilities are required for online oriented teaching-learning training for teachers with a proper evaluation system so that the flow of education is never disturbed even though there any short or pandemic situation.

Policy Recommendation

For a Quick-fix solution looking at the current situation supporting those students who are most vulnerable in the context of differently able or low economic status proper access to required reading materials should be provided. So that there is no case of digital divide seen in any area and for this, every school must keep the record of such students so that they can get immediate support so that the teaching and learning flow is not disturbed.

Secondly, preparing a separate syllabus during online classes as a backup so that the evaluation of the students can be determined accordingly and not in the same way as it used to in normal physical classes.

Establishing one technical team in each school that will be leading the teachers as well as students on online teaching and learning session. This will help in awareness regarding the importance of ICT development at the school level.

As we saw the mobile penetration rate of more than 100 percent we should also focus on mobile teaching and learning session packages as an alternative during the pandemic situation. This will help students as well as teachers’ continuity in the teaching and learning process. In some areas with no network as an alternative, required materials distribution should be managed by the local government itself.

As we saw in the pandemic the role of local government working efficiently so proper support and training related to ICT development is required so that if any such pandemic occurs local bodies are well prepared for anything. 

For a strategically long-term goal, the federal government itself should come into action for an ICT policies development for every school determining the requirements of internet services specification and proper budget allocation and distribution among all the local governments. Looking into the geographical area each Local government has its situation and requirements which are best for them. So, understanding the need and investing in specific ICT requirements would bring the best result.

References

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Policy Compendium

Need for Inclusion of Telemedicine in Private Health Insurance in Nepal

ANUSHRUTI Adhikari

LITERATURE REVIEW

Quality health care delivery system in a community is a vital factor for economic development. In the case of people from rural areas, when one has a condition that cannot be treated by a local primary care doctor and is referred to a specialist 3 to 4 hours away then those who can’t afford to take day off of work tend to put it off or don’t go to the specialist until their condition gets even worse which at time ends up being much more expensive to treat. People also tend to not make the follow-up visit again because of the transportation and financial issues. This is when telemedicine becomes an efficient alternative. It equalizes the quality of health care internationally so that everybody, regardless of where they live, can have a similar quality of healthcare (Klonoff, Joseph, Poropatich, et al, 2009).

Starting with reimbursable telemedicine services will help assure that administrative leadership, at the highest levels, is committed to the strategic and financial support of telemedicine implementation. Unlike just a few years ago, most healthcare executives are investing in telemedicine programs (Waller and Stotler, 2018 ).

Nationwide healthcare insurance plans and private insurers are reimbursing telemedicine as a part of health insurance programs, but their credibility against the physical consultation is still being reviewed. The fundamental question is how services delivered through telemedicine compare with those delivered through alternative means (Sisk and Sanders, 1998). The cost of telemedicine and lack of reimbursement for it are among the major barriers in the development of telemedicine (Kruse, Karem, Shifflet, et al 2016). Another impactful barrier to the implementation of telehealth solutions has been whether the amount allowed for payment is enough to create an economic incentive for doctors (especially given the current demands on doctors and their staff’s time), and for system integrators and device manufacturers to develop the technology (Hoffman, 2020).

National Insurance Program of the United States

Medicare is the federal health insurance program for people in the U.S. who are 65 or older, while Medicaid provides the same services for low-income families. Telehealth services of Medicare as a substitute for in-person visits include consultations, office visits, psychiatry services, and some physician fee schedule services. Since telehealth coverage can differ from one state to the other, many restrictions apply to this type of coverage. The implementation varies in terms of what service providers will be reimbursed for delivering, as well as how the parity between in-person and telehealth consultations is expected.

However, opponents of telehealth argue that telehealth services are not equivalent to in-person services and therefore should not receive parity to in-person services in reimbursements. According to them, telehealth should not be reimbursed the same amount as in-person care because of the costs and the savings associated with the two. Telehealth services are cost-effective and efficient, but opponents have argued that reimbursement for services should “mirror” those savings. Because of higher risks, possible lack of quality in care, and cost savings, many physicians believe that telemedicine should not be reimbursed on the same level as in-person care (Yang, 2016 ). Just as many innovative or beneficial ancillary services delivered in person are not reimbursed, those and more may not meet requirements for claims submission when delivered over distance (Waller and Stotler, 2018 ).

In the case of licensing requirements, the full professional medical license usually covers the ability to perform telemedicine visits with patients residing in a particular state (Shah, Amann, and Karlitz, 2020).

Telemedicine infrastructure costs are still largely either borne by the provider or paid for through grant funding. This threatens the long-term viability of telemedicine projects. Reimbursement of telemedicine transactions by private insurance is still somewhat rare and government reimbursement through Medicare and Medicaid is generally limited to services provided to under-served populations in real-time (Silverman 2003).

In early 2020, the COVID-19 pandemic threw a wrench into healthcare delivery models across the USA. Recognizing that without widespread availability of safe and accessible healthcare, the COVID-19 pandemic might also bring with it the second wave of morbidity and mortality from untreated acute and chronic conditions, CMS, commercial carriers, and state governments acted with unprecedented speed to dramatically expand telemedicine access and reimbursement (Bajowala, Milosch and Bansal, 2020). The Centers for Medicare and Medicaid Services and several state governors and medical boards reduced the burden on multistate licensing requirements for out-of-state providers and increased reimbursement and recognition for telemedicine services across insurance carriers (Shah, Amann, and Karlitz, 2020). Before COVID-19, insurance coverage for telemedicine was far from complete and included several restrictions even for the older population under Medicare (Dorsey and Topol, 2020). When the COVID-induced emergency expansion of telehealth expires, coverage and reimbursement rules will likely revert at least partially to these policies. Reimbursing for telemedicine visits at the same rate as in-person visits has been instrumental in encouraging increased telemedicine adoption among providers (Bajowala, Milosch, and Bansal, 2020). Regulations involve specifics on what types of providers, types of care, location of patient and provider (type of facility and geographical area), and nuances regarding facility billing. Some current procedural terminology (CPT) codes allow for telemedicine, but many do not (Waller and Stotler, 2018 ).

Telemedicine reimbursement policies have been slow to adapt to rapid advances in technology and increased demand for the service. Stringent geographic coverage and payment restrictions from both public and private health insurers have been barriers to telehealth adoption among healthcare providers (Bajowala, Milosch, and Bansal, 2020).

The Case for China

The characteristics of effective healthcare systems for developing nations like China are:

(1) equitable access to quality care;

(2) affordable health insurance; and

(3) financial sustainability.

Access to healthcare in China is very inequitable. For example, although 60% of China’s population lives in rural regions, only 20% of China’s health services resources are located in rural regions. Telemedicine, which improves access to care, would help to rectify this maldistribution of resources. Given that a telemedical business can be established with existing technology and minimal capital expenditures, China could likely improve its healthcare system by providing insurance coverage for telemedical services. Such insurance coverage would stimulate providers to enter the telemedical market, thereby improving access to care in rural China.

Telemedicine is likely to mean that far fewer healthcare institutions will be needed, and conceptually a handful of cities might be able to provide specialized healthcare services to the world. Moreover, because of the worldwide expansion of both health insurance and capital markets, the increased ability of patients to pay for medical services indicates that today’s telemedicine market should continue to expand in parallel with the global expansion of the insurance market (McLean, 2006).

The Case for Developing Countries

In developing countries, if a patient is taken care of using a telemedicine system, the delivered healthcare may not follow traditional techniques and as a result, the telemedicine consultation cannot be covered by insurance. European Health Telematics Association’s (EHTEL ) research shows that in most countries where healthcare is not state-funded there is no reimbursement process for telemedicine (Mahoney, 2003).

There is a paucity of dedicated, focused, and visionary telemedicine leaders in developing countries. Whatever telemedicine work we see in these developing countries is due to the individual efforts of these leaders and brand ambassadors of telemedicine. Lack of formal organizational structure to deliver telemedicine services is the biggest barrier for the development of telemedicine services in any country. Being a hybrid discipline, it needs collaboration with all possible stakeholders at each level of the healthcare delivery system.

Most telemedicine applications require a high speed and reliable Internet bandwidth to run smoothly. Tele-surgery, real-time teleophthalmology, real-time teleradiology, and emergency consultation are some examples of such applications. Unreliable and low wideband internet pose barriers to smooth delivery of telemedicine service (Bali, 2018).

It is a common fact that many provider physicians and clients cannot fix the technical problems arising from computer systems and ICT networks. So, for the proper and smooth functioning of the telemedicine system, we need to train manpower to establish stable and continuous communication during teleconsultation. Unfortunately, there is a serious lack of such trained persons in the system in most of the developing countries. The time gap between acquiring hardware and the development of customized software is so large that by the time software is ready, the hardware becomes obsolete. This mismatch between software and hardware also creates a bottleneck in the development of effective telemedicine solutions. Most telemedicine applications require a high speed and reliable Internet bandwidth to run smoothly.

Standardization of both hardware and software, as well as guidelines for practice, would help program managers to overcome interoperability, portability, and security issues. Several developing countries do not have a systemic telemedicine industry which means that their services are equivalent to that of an in-person consultation. Telehealth should be considered part of our tool kit for delivering healthcare and not a replacement for existing care, by transcending the conventional boundaries of traditional health services. Appropriate clinician reimbursement is key to telehealth uptake (Bursell, Zang, Keech, et al 2016).

On Technology

Availability of appropriate internet services and technological competence plays a key role on the patient side. Privacy concerns matter, even if we are temporarily allowed to use less secure lines (Shah, Amann, and Karlitz, 2020). Most doctors are not aware of the latest information technology and find difficulty using modern IT gadgets. There is a lack of telemedicine experts in the healthcare sector. There is a need to include a few chapters related to telemedicine in the medical education curriculum to sensitize and orient budding doctors to learn the technical part of this discipline. When a patient avails healthcare services through a telemedicine system, the insurance claim may not cover the cost of care as it is not delivered through the traditional healthcare system. Such discrimination seldom occurs in developing countries, where health insurance is still a rare commodity (Bali, 2018).

Several types of research on telemedicine support health policies that increase access, improve population health, and remove constraints to reach patients who live in developing countries and rural areas, and align both incentives and reimbursement to support the technology necessary to deliver these services. Telemedicine has the potential for growth and adoption (​​Kruse, Willians, Bohls, 2021).

INTRODUCTION TO TELEMEDICINE

What is Telemedicine?

Telemedicine is simply the use of technology to connect patients, doctors, types of research, or any other participant of a medical consultation at different locations. Telehealth, on the other hand, is used to encompass a broader application of technologies to distance education, health promotion, preventive services, consumer outreach, and other applications wherein electronic communications and information technologies are used to support healthcare services (Bali, 2018).

Traditional healthcare is far more expensive in terms of indirect costs. These costs outweigh the overall affordability of healthcare services whether they are public or private. Household health care expenditure constitutes a larger share (55.4%) of total health expenditure in Nepal. This high level of health expenditure implies that health care can place a significant financial burden on households and financial protection is one of the core components of universal health coverage. Individuals can drop below the poverty level when they pay for health care at the expense of meeting their basic needs (Poudel, 2019).

Due to the convenient, efficient, and progressive nature of the telemedicine solutions existing today, the idea of incorporating telemedicine as a possible replacement for physical consultation is becoming a viable policy option for many developing countries.

According to the Facts and Factors market research report, the Global Telemedicine Market size & share revenue is expected to grow from USD 40 Billion in 2019 to reach USD 150 Billion by 2026, at a 20% Compound Annual Growth Rate or CAGR growth during the forecast period of 2021-2026. Additionally, according to the Market Data Forecast, the telemedicine market of the Asia Pacific is estimated to grow from USD 10.33 billion in 2021 to USD 27.24 billion by 2026, with a CAGR of 21.40% over the next five years.

Benefits of Telemedicine

People living the furthest from a proper healthcare facility tend to compromise with their health if the total cost of seeking treatment is significant and catastrophic. As a result, medical problems which are visible or which have led the patient to a critical life-or-death situation get priority, while others are usually ignored until things get worse. One of the most common reasons for lack of motivation to visit the nearest (free) medical facility is the out-of-pocket expenditure on health, second only to geographical limits and distance. Educated communities or communities that have received awareness via local health workers are likely to give more attention to their health, but the gap between urban and rural communities in seeking healthcare stretches in a much more convoluted manner.

That being said, telemedicine solves the obvious problem of distance and limited time. In the case of public hospitals, Catastrophic Health Expenditure or CHE is usually caused by expenses other than low-priced medical fees such as expenses of travel, lodging, food, opportunity cost, etc. which telemedicine services do not require. For a patient to conveniently use telemedicine, there is a certain investment in technology during the very beginning – the burden of which can be taken over by the local municipality. In this case, the municipality arranges the telemedicine service on its premises. Otherwise, mobile-application-based telemedicine requires already-existing technology and some digital literacy.

Health workers and nurses too can communicate with their patients once both the parties are sufficiently trained to make use of the technology. They can also serve as mediators for patients who want to consult with doctors but may not do it independently. In the case of doctors, they can communicate with patients all over the country, while being ensured that their payment channels are secure and they will be automatically reimbursed per consultation.

Since the Coronavirus Pandemic has begun, telemedicine, for many patients, has become the only way to stay in touch with their doctors and actively seek consultations.

When Telemedicine Does Not Work

Urban concerns revolve more around privacy and quality.  There is no public policy related to telemedicine for the end-users, which can ensure privacy, confidentiality, and security of patient’s health information during teleconsultation.

In the case of rural communities, patients or health workers need to be welcoming of the technology without being biased. Internet speed and lack of digital literacy are some of the reasons why telemedicine won’t be accepted, let alone work.

Even if the country’s health initiatives do not rule out the importance of telemedicine, policies on the doctor’s end also need to be clear. Many practitioners fear malpractice-related legal issues, which prevents them from actively participating and developing telemedicine programs. Malpractice liability is an important barrier in the practice of telemedicine services.

Telemedicine set up can deploy varieties of information and communication technologies (ICTs) for transmitting information through texts, pictures, audio, and videos to a variety of healthcare providers. Cost depends on the type of ICT being used for the start-up. Setting an audio-visual ICT platform for teleconsultation needs huge investment. Budgetary constraints become a major barrier in the development of telemedicine networks in developing countries.

Reimbursement of telemedicine services has been reported as one of the important barriers in developed countries. When a patient avails healthcare services through a telemedicine system, an insurance claim may not cover the cost of care as it is not delivered through the traditional healthcare system. Such discrimination seldom occurs in developing countries, where health insurance is still rare (Bali, 2018).

PRACTICES IN TELEMEDICINE

International Practices of Telemedicine

Among the various countries currently drawing out their framework of how their telemedicine system should be, the telemedicine services are widely covered by the public health systems and if not, they are backed by private insurers. These countries are on their way to formulating specific laws that govern telemedicine following its unique nature in comparison to traditional consultation (DLA PIPER, 2020).

For this analysis, five countries with leading healthcare systems in the world that have identified telemedicine as an official means of healthcare consultation have been selected: Denmark, Austria, Australia, France, and Japan.

PROTOCOLS

While technically telemedicine is encouraged in Austria, medical guidelines stating that the doctor is personally and directly interacting with the patient could imply otherwise. In Denmark, innovators have adopted web and mobile applications that can assist patients to contact their local doctor, renew prescriptions and get reminders for medicines.

In Australia, telehealth medical practitioners are required to have an existing and continuous relationship with their patients. Therefore, ​​they can only provide telehealth services to patients who have seen the practitioner for a physical consultation in the last year or have seen another medical practitioner at the same practice for similar consultation during the same period.

Telehealth service in France is divided into telecare and telemedicine. In telecare, patients interact with pharmacists and medical auxiliaries while in telemedicine the patient has a typical consultation with the doctor.

LAWS AND REGULATIONS

There are no specific laws relating to telehealth but the practices are regulated by the Danish Healthcare Act. The Danish government has additionally issued guidelines that set a benchmark for telehealth projects. It also released “Strategy for Digital Health 2018-2022” focusing on digitization in the context of prevention, care, and treatment as well as development and research in the field of healthcare.

Telehealth in Japan are subjected to the Medical Practitioner’s Act which has been recently modified as was the need during the Covid-19 pandemic. The Act on the Protection of Personal Information (“APPI”) applies to the provision of telehealth in Japan, which assures that doctors and medical practitioners are seeking consent and explaining to patients why they need specific medical information.

In Austria in 2013, the Ministry of Health established a TeleHealth Commission, Tel Gesundheitsdienste-Commission, which continues to work on improving the scope of telehealth. But there is no official list as to which type of healthcare services are provided under telehealth. At this time there is no legal framework developed specifically for telehealth in Austria.

COVERAGE BY PUBLIC HEALTHCARE SYSTEM

Countries leading in healthcare systems such as Denmark and Australia provide telemedicine services under their public healthcare system. In Japan, only telehealth services of specific areas like pediatrics and life-style related diseases are covered by public health insurance. Additionally, medical institutions are allowed to decide if they want to adopt telehealth services. The rest are mostly covered by insurance companies. Telehealth services like videoconferencing with the doctor are included under France’s public healthcare system. Since January 1, 2018, the use of telemedicine is reimbursed in the same way as a face-to-face consultationinitiative% of the conventional social security rate, with the remaining 30% generally covered by the insured person’s private complementary health insurance. In Austria, medical advice via phone or video conference is reimbursed by the public health system.

RECONSIDERATIONS DUE TO COVID-19

The Covid-19 pandemic has accelerated the use of digital systems in both public and private healthcare facilities. Given Covid-19, the French social security system covered 100% of the cost of teleconsultations from March 18, 2020, until the end of 2020. In Australia, a health insurance package known as Telehealth Determination came into force under which the treatments and consultations delivered through telehealth but were not subsidized now become eligible for subsidy. In the case of Austria, remote health advice is reimbursed through the public system but in the light of the ongoing Covid-19 pandemic, several private insurers have begun including telemedicine services in their package.

Recent Telemedicine Practices in Nepal 

Recent government health strategies have been focused on strengthening Nepal’s telemedicine ecosystem.

In 2004, HealthNet Nepal conducted a pilot project for telemedicine in Nepal. It aimed to pilot the potentials of the store and forward methods in pathology, dermatology, and radiology. Om Hospital and Research Centre collaborated with Apollo Hospital in India in 2004 and started a telemedicine program. In 2010, the Ministry of Health started a rural telemedicine program in 25 district hospitals which was eventually expanded into further five districts. It provided services through the store and forward method,

video-conferencing, and hotline service “Hello Health”. In 2009, Nepal Wireless Networking Project was established by connecting a hospital in Pokhara with a health post in Nangi Village. Initiated by Dr. Mahabir Pun, he later went to facilitate municipalities like Kavre for telemedicine, along with experimenting with drones to carry medical items.

Recently an agreement was made to support Dhulikhel Hospital for Telemedicine and Health Informatics Program to serve remote and underserved communities through quality health care services, using technology and data-driven health care methods. Medic Mobile designs, builds, delivers, and supports open-source software for health workers and health systems including NGOs and INGOs in Nepal. WHO and UNICEF are supporting the piloting of the VaxTrac system that uses hand-held devices to record and track vaccinations.

Released in 2017, Nepal’s National E-Health Strategy aims to develop protocols and guidelines for implementing telemedicine services, develop user-friendly telemedicine consultation mechanisms and strengthen its services to link specialized medical experts at the central level with community health workers and volunteers.

Additionally, the 2019 Digital Nepal Framework policy includes digital health initiatives such as the National Digital Healthcare Program, Next-Generation Digital Healthcare Facilities, Electronic Health Records 2.0, Mobile Health Units, e-Maternal Care, Drones for delivery of emergency medical supplies, and Centralized Telemedicine Center.

Code of Conduct for Telemedicine Practitioners

Understanding these remote care developments, Nepal Medical Council released a Telemedicine Guideline for the registered medical practitioners in Nepal. According to this Code of Conduct, a Medical practitioner with a valid license of the Nepal Medical Council is entitled to provide telemedicine consultation to patients from any part of Nepal. Registered Medical Practitioners are expected to have been well trained in telemedicine before practicing telemedicine; Nepal Medical Council shall develop, or delegate a

A professional organization to develop, a defined short course on the practice of telemedicine, with the help of the experts working in the field of telemedicine in Nepal.

The guidelines have also set strict standards on bridging the gap felt in virtual consultations. However, it has specifically pointed out that Telemedicine should not be practiced as a substitute for conventional in-person care but should be practiced as a complimentary service where traditional in-person care is not

feasible is not accessible and is not affordable.

If the patient and/or accompanying relative is not able to understand the language, is not able to follow the guidance provided by the medical practitioner, he/she must be accompanied by the healthcare professional of the local area to interpret and guide the instructions provided by the medical practitioner.

While NMC has set its standards and the government has shown interest in strengthening this virtual healthcare package, there are relatively more efforts rolling out from the private institutions’ end. Even though their projects are following a short timeline, their impacts have become foundational and have guided us to brainstorm for Nepal’s next big telemedicine initiative.

Since the mentioned Code of Conduct advises patients to consider telemedicine as a complementary service and a necessity only when physical consultation is not possible, we cannot consider it as a true replacement for the health services that we currently have in hand.

HEALTHCARE SYSTEM IN NEPAL

Insurance Program in Nepal: Public and Private

The Social Health Security Program or SHSP acts as a Universal Health Coverage Program initiative affordable and accessible quality healthcare to all. It aims to promote pre-payment and risk pooling mechanisms to mobilize financial resources and subsidize health expenses for families identified as living in poverty, to eliminate their Catastrophic Health Expenditure or CHE. The government had announced this year that it had officially included all the provinces under this insurance program. The cost for this insurance is as cheap as USD 35 for a year for a family of up to 5 members, which individuals above 70 and those with severe and specified diseases will be provided with 100% subsidy.

Among the private insurers in Nepal, those providing medical insurance do not provide telemedicine products as of now. The number of checkups tied with the medical insurance in the policy does not specify if the checkups are supposed to be physical or virtual, but since telemedicine is still a new concept, it is understood that these checkups are physical.

The Burden of Healthcare during the Covid-19 Pandemic

Forecast of the first wave of Covid-19 in Nepal led to a nationwide lockdown in late March 2020. Ever since Nepal has been lifting and declaring lockdowns by reviewing the number of cases. 2020 left a lot of Nepalese confused and fearful, with fake news taking over the streets and people becoming more and more triggered by the day. As a result, while the first wave did not exactly challenge our healthcare channels, people suffering from non-Covid conditions did not visit hospitals out of fear, even when their health was worsening. Those who did go to the hospitals to receive treatments were sometimes ignored by hospital staff for the fear of catching Covid. Patients with long-term chronic conditions and even pregnant mothers faced untimely deaths due to this unsettling confusion and fear.

The second wave of Covid-19 which occurred around early May in 2021 did severely challenge our health system and left space for non-Covid patients to seek consultations or treatments. In both these Covid waves, we can see Nepal’s healthcare system being aggressively challenged. Patients with different degrees of health issues were scared of visiting hospitals. On the service end, while Covid doctors were working at full capacity, doctors of other healthcare problems had to take a break from their duties to make space for Covid patients. Even minor healthcare issues were not being addressed.

However, doctors and patients who had learned about recent healthtech innovations gave it a try. This year also saw an increase in the consumer base of leading digital wallet companies. We have yet to see if the habit of considering telemedicine as a substitute will be retained post-Covid. Considering the practices and responses in other countries, retention is likely to be low, since insured patients will favor hospital visits if telemedicine services are not being reimbursed and are not considered equivalent to a physical hospital. Therefore, while the crisis did favor innovations, post-crisis consumer behavioral patterns can bounce back to their original state.

CONSIDERING TELEMEDICINE UNDER PRIVATE INSURANCE

Inclusion of Telemedicine in Private Insurance

In the context of Nepal, telemedicine is technically not up to the benchmark to be able to replace a normal, regular visit to the doctor. If telemedicine is treated as a complementary service, that would have two extremely different impacts on the urban and rural communities. Urban communities who have covered by the health insurance would not bother investing in additional services while the uninsured would fear the risk of catastrophic health expenditure that may befall upon them and thus they would not be interested in accumulating any more fees. Rural communities will not consider complimentary services when even basic healthcare isn’t very easy to receive.

If the government considers establishing a proper telemedicine facility, that would require additional investments in technology, infrastructure, and training. Over the years, while the national health strategies have continuously highlighted the need for telemedicine, a specific model for it hasn’t come into action. As a result, rural healthcare is running on whatever means possible, but telemedicine approaches have never truly been a national, long-term priority. However, running a public telemedicine facility would remove the burden of cost from the rural communities’ shoulders.

Narrowing down the exact problems in the evolution of telemedicine, we are severely lacking investments in the overall industry. Over the past years, we have seen many telemedicine projects initiated by private bodies for a certain period. Hospitals, health facilities, and ICT experts have shown more enthusiasm in building telemedicine platforms and providing healthcare consultations through convenient platforms than the government. Therefore, it is likely that private institutions will eventually show interest in adopting long-term telemedicine technologies. When non-covid patients are avoiding hospitals, doctors and medical experts of all other kinds of health issues will have no choice but to remotely provide consultation in whatever way possible. This is where recent telemedicine technologies, whether mobile and website-based, have come in handy to bridge the gap.

This shows that no matter how much thought we give to the telemedicine industry, our demands for it do not shrink. Through whatever means possible, we rely on telemedicine. Be it in a rural community or a pandemic scenario, we need to reach our doctors anyhow. In specific times or places, it stops becoming a choice and starts to become a necessity.

Desired Outcome and Expansion of Healthcare

Reimbursable telemedicine services are cheaper and convenient to deliver. If insurers do include telemedicine in their overall medical insurance package, then depending upon the platform of the telemedicine, middlemen can be cut and teleconsultations can be provided directly by doctors on verified consultation platforms. For example, seeking teleconsultation through a mobile application allows the doctor to be paid as per their demand, without having to register as a patient, much like when we normally visit a hospital. Teleconsultation, therefore, becomes accessible and affordable, making it easier to be included in the already existing healthcare insurance plans.

Even though it is a complimentary service, when consumers are reimbursed for each teleconsultation by their private insurers, they will have more incentives to seek medical checkups if they weren’t seeking it before. This applies to lower-middle and middle-income families, who are digitally literate but cannot always afford to go to the doctor when they face any health problems. It allows them to ask several questions about health issues that they were previously ignoring. Doctors in teleconsultation can also assess patient’s reports and provide prescriptions while helping the patient to maintain digital records of the session. On the insurer’s end, the validity of the consultation and service can thus be regulated through these maintained digital records.

The surest way to make any mode of teleconsultation much cheaper is through ICT investment. The right investment in technology can make telemedicine services more compact, comprehensible, and convenient. This will also lead the insurers to educate their consumers about the digital possibilities of the telemedicine packages.

As for the low-income families, since they are covered by the national health insurance program already, the best way to include them in reimbursable telemedicine packages would be when the government decides to invest in “tried and tested” telemedicine technologies that have been verified or backed up by the private insurers. This way the government can pool the ICT resources at a national level, thus reducing the scale of investment in intangible resources and strengthening healthcare channels.

POLICY RECOMMENDATION

In light of the recent pandemic, we are more than aware of the fact that our healthcare system needs to be expanded and upgraded. Observing the current technical capabilities of healthcare innovations, we require solid medical insurance policies that allow the insured to access virtual healthcare consultations. Being insurance policies, Rastriya Beema Sansthan, the official regulator for the insurance companies of Nepal needs to direct their attention towards adding some telemedicine features to existing health policies.

Keeping in mind the identification of telemedicine in Nepal as a complementary service by the Nepal Medical Council, its service needs to be specified and therefore added to the existing policies and recognized as “ineligible as a replacement for a physical consultation”.  The nature of telemedicine also needs to be specified: is it operated via telephone, videoconferencing, or simply over the internet? How much would the insured have to pay to receive the consultation? Would they need simply a phone? Or would they need a smartphone, certified applications, and a good internet connection? Would the insurance also cover these costs? How will the insured be assisted in learning about the particular telemedicine operation?

To begin the demand for telemedicine services, insurance companies can provide a limited number of free telemedicine services in their existing policies with an additional fee for each additional teleconsultation.

Institutions that are running these telemedicine services, whether public or private need to be officially certified by the insurance companies as “eligible to provide reimbursable telemedicine services”. To ensure the smooth flow of certification, starting a telemedicine board is recommended.

Under the current telemedicine services, the clusters telemedicine providers have not been systematized properly. Therefore, even doctors or other consultants need to be included in a formal loop that can recognize them as official telemedicine providers and then provided them the required insurance policies accordingly eg. telemedicine malpractice insurance.

Finally, once the demand for privately insured telemedicine services rises, Rastriya Beema Sansthan can recommend similar policies to be added to the national insurance program which currently has nationwide coverage.

Upon making these policy changes, existing telemedicine services will have incentives to work upon their current services and improve them for insured users. The new policy will be financially reliable and they will be able to participate in a market that is far more competitive and excelling in terms of quality.