Public Health Notes: August 2020

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.

References

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Robertson, L. J. (2019). The impact of urbanization on mental health service provision: a Brazil, Russia, India, China, South Africa and Africa focus. Curr Opin Psychiatry, 32(3), 224-231. doi: 10.1097/YCO.0000000000000495

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