Request for Application #2019-020

Digital Financial Services on Health Outcomes and Health Systems

NepalEHR for universal health coverage: Scalability of an integrated solution for financial protection in a newly decentralized health system

Executive summary: 

Possible is an innovative healthcare delivery organization in Nepal that partners directly with local governments to identify challenges to integrated primary healthcare systems, design and implement solutions to address gaps, and evaluate and iterate on solutions for quality and efficiency in the country’s new municipal health system environment. Over the last five years, Possible has developed NepalEHR ( as a leading public sector, home-to-facility health information system. Together with Digital Square’s support, we have integrated this electronic health record (EHR)—built on the OpenMRS platform—with OpenIMIS. The goal of this project is to adapt, test, and evaluate the potential for NepalEHR to increase financial protection at scale in a newly decentralized health system. Given our more than a decade-long experience in implementing and testing innovative digital and service delivery solutions in Nepal, we are well positioned to leverage this opportunity for broader health systems strengthening and impact.

Consortium Team: 

Possible’s inter-disciplinary team focuses on real-world evaluation and implementation research that utilizes qualitative and quantitative data to produce meaningful insights about how and why programs work, don’t work, and are potentially scalable within the constraints of government resources and systems. Below we describe the key personnel involved in the evaluation:

Sabitri Sapkota, MPH, PHD is Director of Implementation Research and Site-PI, and brings over twenty years of experience in healthcare systems research and evaluation. She oversees the evaluation of the NepalEHR platform and is responsible for coordination with government and other stakeholders to map our advocacy efforts to national needs for designing integrated digital systems.

Aradhana Thapa, MPH is Director of Healthcare Design, and leads strategy and design of the organization’s municipal healthcare delivery product, including Possible’s networks of CHWs.

Sarita Sharma, MPH is Monitoring & Evaluation Manager, and oversees the design, integrity, and execution of Possible’s approach to monitoring and evaluation, including high quality data feedback loops for continuous programmatic improvement and research alike.

Rekha Khatri, MSW is Qualitative Research Analyst, and oversees the application of rigorous qualitative methods in understanding understanding the context and mechanisms of impact surrounding our work.

As a systems strengthening organization, Possible operates in a rich ecosystem of partners and stakeholders, including partnering directly with the municipal, state, and national governments. Possible has also partnered with the German Development Cooperation (GIZ) to roll out NepalEHR in a district hospital in Nuwakot, and to iterate on and evaluate the NepalEHR <> IMIS integration module. Our team is also in regular contact with the broader OpenMRS community, the Bahmni coalition, and AeHIN for updates and learning from other countries. We recognize the inherent value in collaborating with others to tackle pressing healthcare systems design issues, and are keenly aware of the need to collaborate broadly with other organizations and stakeholder within and outside of Nepal on this project.

Application Status: 
Not Approved


We note that the proposed research is focused on project implementation, whereas the intended purpose of this research it to provide a landscaping of existing solutions and country case studies of implementations which are at a state to demonstrate results and respond to the research inquiry. We recommend realigning the focus of the application accordingly.

Apologies for the slow reply here! and thank you for this important point. While we do not assess the landscape of all interventions and services currenlty available in Nepal, our approach is to hopefully shed light on policies and dynamics already taking place throughout the country, as they relate to one specific approach to tackle DFS for improved financial protection and overall health systems strenghtening & responsiveness:

1) Enrollment experience in the nation-wide health insurance scheme that is being rolled out in all districts throughout Nepal following the National Insurance Act passed recently. While we will focus in on a specific case study in catchment areas where we work, we suspect the lessons learned here are wholly applicable to other municipalities throughout Nepal seeking to increase enrollment in insurance to reduce OOP expenditures and medical debt, and understand the drivers and barriers to enrollment;

2) OpenMRS <> IMIS integration - There has been a national push for digitizing healthcare delivery systems in LMICs, particulalry in Nepal. With the support of Digital Square, and in collaboration with the Government of Nepal, we have successfully integrated an OpenMRS platform with OpenIMIS - we believe the first known integration globally - and have begun to already process claims through this system. We are currently at a stage to begin evaluating the effectiveness of this integration on the ability to track, monitor, and act upon claims processes as central to ensuring DFS is responsive to the needs of healthcare systems workers/managers. We hope this will help answers about how to make claims processing seamless for facilities, how to ensure compliance for reimbursement, provide opportunity for improved claim success rates (e.g., reducing duplicates and false records) at the source, and help guide the national insurance board on burden of disease and concomitant costs;

3) Assess technical refinements and HR needs. There are still unanswered questions about the pragmatics of implementing a nation-wide policy already underway. The insights we hope to generate will be widely applicable to other municipalities;

4) Produce actionable data. We hope to be able to estimate with greater geospatial and temporal resolution household medical debt, catastrophic healthcare expenditure, and thresholds of impoverishment; and visualize these data to examine and monitor trends in participation, reimbursement, and financial protection over time.

How will findings benefit the entire sector, rather than only this consortium? How will you genericize findings beyong Nepal context? 

Thank you, this is a great question! We hope that our work will be applicable to those working broadly in the global health space in a number of specialized areas, including (1) financial protection and UHC, (2) human resources for health, (3) innovative digital platforms and technical integrations, (4) data visualizations, and (5) measuring the patient experience of interacting with novel DFS solutions.

The OpenMRS <>  OpenIMIS integration we've implemented in Nepal is the first of its kind, and we hope to generate relevant lessons learned in integrating the two platforms. This inlcudes monitoring the impact of such an open-source integration to help understand and improve the effectiveness of claims processing; clearly understand and define the human and technical resources needed to efficiently utilize the integration, as well as visualize and act upon the data it provides in as near-to-real-time as possible; and elucidate the qualitative dimensions that drive or inhibit people from enrolling in newly legislated insurance schemes. As LMICs globally move towards mixed modalities of strategic purchasing of healthcare services, such as insurance, the lessons learned and evidence generated from our approach will hopefully be widely applicable both within Nepal, and globally in other similar settings.