Kathmandu reflects a rich cultural heritage blended with modern lifestyle. The cosmopolitan city has a multi-linguist and multi-cultured society where people from across all Nepal’s regions and ethnicity groups reside.
Kathmandu Metropolitan City is fast growing, with uncontrolled urban development and a rapidly growing population with a high population density. In recent years the city has experienced devastating natural disasters in the form of an earthquake and a flood. The continued unplanned urban expansion has seen marginalisation of the urban poor. The escalating land and building prices put housing beyond the reach of many, resulting in increasing numbers of people living in the slum and informal squatter settlements.
Parasites are prevalent amongst those using untreated water and those who are illiterate; HIV infection rates in street children in Kathmandu is nearly 20-fold higher than the general population; TB cases are significantly higher. Hypertension rates are higher amongst those living in slum areas. A study conducted in the Sinamangal squatter area of Kathmandu found high levels of cardiovascular disease risk factors including smoking, high alcohol consumption, poor diet, and a lack of physical exercise.
Pollution caused by the rapid increase in population and the industrial environment represent additional hazards to the health of the urban poor, as does the discharge of large volumes of untreated domestic sewage and industrial effluent into the river systems and chemical and biological pollution of shallow ground water through septic tanks and industrial waste.
The resilience of the urban poor is strong. Social organisation within the informal settlements and local initiatives and self-help schemes help to reduce vulnerability. However, there is a lack of public investment in slums and squatter areas, and the health challenges are multifaceted, and local government policies are not keeping pace with the changing health needs of the urban poor.
The new state architecture of Nepal, as defined by the 2015 constitution, has 3 tiers of government (federal, provincial and local), for which new legislation, institutions and administrative procedures are being formalised. In the new structure, health is one of the most decentralised sectors, with local government holding responsibility for primary health care functions and urban health governance, whilst federal government is responsible for overall policy.
The national government has introduced a seven step process for local governments to implement the annual budgeting and planning that includes health-related plans. This process also includes village level selection of the plans which are prioritized by wards and are finally endorsed by village/municipal assembly.
Whilst the new structure is still in its nascent stage, clarity of functions between the tiers is still being defined, and as the urban health system is new to the local government bodies there is a need and opportunity look at how to strengthen capacity, and cross sector collaboration to ensure the health needs of the urban poor can be addressed.
Pokhara Metropolitan City (PMC), a provincial capital of Gandaki province, is geographically the largest metropolitan city of Nepal occupying an area of 464.24 sq km. Pokhara is the market centre of the province and was upgraded from a municipality to a Metropolitan City in 2017. PMC is going through an unprecedented population growth due to the migration from the peripheral districts and is among the five metropolitan cities with the highest population (2020 census). According to the metropolitan city records, there are 9,752 households living in 212 squatter settlement in the metropolitan city.
There are 19 health posts, 2 primary health centres, 1 urban health promotion center, 18 urban health centre and 1 primary hospital under the Pokhara Metropolitan City. Diabetes and cardiovascular diseases are among the major non-communicable disease. According to PMC’s strategic planning documents, maternal mortality rate is 239 out of 100,000 live births, and child mortality is 27 of 100,000 live births. A lack of health workers and a limited availability of services are key challenges faced by the local health system to address the basic health of the city dwellers. Poor urban residents are more vulnerable to health hazards as they live under poor living conditions. For example, 10% of people living in PMC do not have a latrine. Poverty levels in PMC mean many people cannot afford the quality health care services in private hospitals, yet out of pocket costs are high as public health facilities are facing challenges to provide specialist and symptomatic care to the people.