Urbanization in Global and National Context
Urban areas
have drastically being populated and transforming population health, especially
for the urban poor. More than half of the total world population dwells in
urban areas and expected to increase to 66% by 2050 (UN, 2014). Nepal has 26.5 million populations with a
growth rate of 1.35 per annum. Population density of Nepal is estimated at 181
per sq.kms. Kathmandu district has the highest density (4408 people per square
kilometer) and Manang (3 people per square kilometer) has the least (Central Bureau of Statistics &
GoN, 2012). One in three urban
dwellers – 828 million people – lives in a slum, producing slum cities within
cities, whereas, more than 90% of slums are found in developing countries (UN, 2015). 18.2% of the total
population has been residing in urban areas, and 54.3% of urban population
living in slums in Nepal was reported in 2014, according to World Bank
collection of development indicators, compiled from officially recognized
sources (WorldBank, 2014). Poverty is set to become
an increasingly urban phenomenon. Rapid and often unplanned urban growth is
associated with unfulfilled population demands that outstrip service capacity.
Existing Research and Key Findings
World
Health Organization (WHO) identifies a range of general determinants of urban
health: physical, social, cultural and environmental. Urbanization has been
considered as one of the determinants of health (Phillips, 1993). Urban poor are exposed to
a double risk of both infection and chronic degenerative ailments (Elsey et al., 2019; Phillips, 1993). Vector
borne diseases are a growing threat to the urban life, with increase in cardiovascular
diseases, cancers, chronic respiratory diseases and diabetes attributed to urban
living on risky behaviors such as tobacco and alcohol use, poor diet and
limited physical activity (Elsey et al., 2019). Strong
links have been established between socio-environmental factors and common
mental disorders. Increased violence and mental illness have become a common
feature of unplanned urbanization (Robertson, 2019).
To the
wider extent, water and sanitation were identified as key urban health
challenges, with urban poor households and slum settlements both affected by
poor quality and reliability of water provision and high numbers of households
sharing toilets. (Elsey et al., 2019).
Effective
Community Health Planning and Services programme are seen implemented in rural
areas. But such programmes has faced multiple challenges in its adaptation to
the urban environment communities (Adams, Islam, & Ahmed, 2015; Elsey et al., 2019). Instead
vulnerable urban population must rely on tertiary care or unregulated private
providers; for example, in Bangladesh, 80% of health providers near urban slums
were found to be private; the majority of whom were pharmacists or traditional doctors,
only 37% with formal medical qualification (Elsey et al., 2019). Almost
exclusive systematic exclusion of vulnerable populations’ from the health
service is evident that attributes to logistical and financial inaccessibility
of health facilities to residents of informal settlements and slums, as well as
impaired care-seeking related to poor health literacy (Robertson, 2019).
Despite
posing several key challenges due to urbanization, local governments have been
overlooked in funding and are under-resourced financially to respond to the
wider determinants of health (Elsey et al., 2016; Mirzoev et al., 2019).Thus,
there is a necessity of conceptualization of the urban health system.
Policy landscape
In Nepal, National
Urban Development Strategy (NUDS) has been prepared in line with National Urban
Policy (NUP), 2007, the Sustainable Development Goals (SDGs) and the New Urban
Agenda, to address the critical issues and challenges of urbanization through
strategies including establishment of adequate urban amenities and improving
environmental health conditions (GoN/MoUD, 2017). Nepal’s new decentralized
federal system emphasizes bottom-up planning (Dulal, 2009; Elsey et al., 2019). With the
new federal structures, municipalities have increased decision making and
budgetary powers to deliver healthcare to their populations, but coverage,
quality and level of service provided remains a challenge. Dulal, 2009 argues
that formulation of appropriate policy and management of health development
systems in Nepal should be led by involving its native health experts. Agreeing
to the fact that there is a substantial private sector, mostly dominant in
urban areas and influences from the international organizations are visible
mostly at the Federal level, e.g. through negotiations between the government
and donors (Mirzoev et al., 2019).
Research Gaps and Approaches to Address Urban Poor
There exist
disparities in health among the urban dwellers; urban poor being more deprived,
holding less priority position in the urban health planning than the local
elites. Elsey et al., 2016 highlights four methodological challenges which could
lead to under-representation of the urban poorest and skew urban estimates in household
surveys: Census data excluding illegal settlements and the homeless; inconsistent
definitions of urban and rural; household questionnaires overlooking multiple
household dwellings; multiple occupancy in a household that arouse challenge
for survey enumerators.
Elsey et
al., 2019 illustrates the concepts of multisectoral approach, engaging urban
poor residents, recognition of the plurality of health service providers and role
of data and information within the urban health system. In the conference
paper, the authors advocates about WHO’s Urban Health Equity Assessment
Response Tool (HEART) which provide information to inform a response to
inequities within urban areas (Elsey et al., 2016). Moreover,
in a pilot study, HERD and its collaborators, including the Ministry of Health
and Population in Nepal, adapted gridded population data rather than census
data for sampling and OpenStreetMap household listing whilst planning an urban
health survey in order to overcome the urban disparities (Elsey et al., 2016). The
participatory version of Urban HEART performed by Urban Health Resource Centre (UHRC)
in piloted sites of India is another approach that has been discussed in the
paper. This approach justifies the involvement of the local level of community
representatives such as slum community group members, teams of local women’s
group members to identify the response or action in parallel with the
assessment for improving the representation of the urban poor in
cross-sectional surveys. (Elsey et al., 2016). The
authors are confident that this practical approach ensures to strengthen
self-reliance and resilience among vulnerable segments of city populations. However,
the effectiveness of the approaches discussed in the paper has not been
detailed.
Conclusion
Urbanization
has been considered as one of the determinants of health. With the drastic
increment of urban population, poverty is set to become an increasingly urban
phenomenon additionally burdened with communicable as well as chronic diseases
attributed to several urban lives living on risky behaviors and lifestyle.
While urban poor population is deprived of adequate facilities and health
services, they are often less prioritized in urban planning. This demands the necessity
of conceptualization of the urban health development and planning system which
should be led by native health experts. There are several methodological
challenges in the urban planning about inclusion of illegal settlements, the
homeless, multiple household dwellings, and multiple occupancy in a household,
which need to be addressed through innovative approaches as discussed in the
conference paper. Further new concepts and strategies for urban development and
planning system should be explored and implemented practically through
participatory approach, and evaluation studies of such approaches should be
mandatory.
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