Closing the stroke care gap: a collaborative, self-sustainable telemedicine enabled model from rural Nepal

Stroke is a challenging global public health concern, disproportionately affecting people in rural communities. Stroke care is challenging in low and middle-income countries as it requires a coordinated multidisciplinary approach integrating pre-hospital recognition; acute stroke care, and long-term rehabilitation. Multiple barriers exist in LMICs: lack of community awareness; geographical and financial barriers; poor health systems; absence of standardized care pathways; and inadequate training among primary health care workers. Based on this background, this descriptive implementation-focused retrospective program evaluation describes the implementation and early impact of a collaborative, telemedicine supported multi-component health system intervention for stroke care in a rural government hospital in Nepal.

A non-government organization "Nepal Stroke Project (NSP)" partnered with Province Hospital Surkhet (PHS), a community-based tertiary center in remote western Nepal strengthening the stroke care capacity in the region via formation of a multidisciplinary stroke team, infrastructure development and capacity strengthening. NSP experts also provided telemedicine supported clinical guidance to the local stroke team through free digital platform such as WhatsApp. The program evaluation was guided by the RE-AIM framework and interpreted through a health systems strengthening perspective.

Baseline assessment identified major system-level barriers, including the absence of a dedicated stroke pathway, thrombolysis services, stroke-specific infrastructure, and specialist support. Following implementation, annual stroke admissions increased from 154 to 178 cases per year, and 10 healthcare personnel were trained. Intravenous thrombolysis, previously unavailable, was successfully administered to two patients, supported by telemedicine-guided decision-making and subsequent ICU transfer. Over the implementation period, 20 stroke patients received telemedicine consultations, routine stroke pathway activation was achieved for thrombolysis cases, and NIHSS documentation improved from absent at baseline to approximately 50% of cases. Service readiness was further strengthened through establishment of two dedicated stroke beds and provision of essential monitoring equipment.

The collaborative model has a potential for sustainable impact by strengthening long term capacity building, and enabling the local team to deliver comprehensive stroke care independently. This implementation model highlights the importance of maximizing existing resources through task-shifting, integrating stroke care within existing health systems, and fostering local ownership to ensure sustainability.