Maharjan, U., Baral, S., Giri, S., Khimbanjar, S., Khanal, S., Rumble, C.

Background
The census of 2011 identified that 17% of Nepals population live in
urban areas. While Nepal may be less urbanised than its neighbours,
it is also the most rapidly urbanising country in South Asia with 6.7%
growth in urban compared to 2.3% growth in rural areas (Muzzini
2013). To understand how well these expanding urban communities
can access health services , across six municipalities of Nepal:
HERD have been providing essential health care through the
Manohara Community Health Centre (MCHC) to an urban slum
community in Kathmandu since 2008. To understand the feasibility
of providing EHCS quantitative clinic data was analysed.

Methods
Rapid Assessment of Municipalities:
HERD in conjunction with Primary Health Care Revitalisation Division
(MoHP) visited six municipalities to conduct a rapid assessment of
urban health facilities. Team members from HERD and PHCRD
visited:
Birgunj
Bharatpur
Biratanagar
Bhadrapur
Sidharthanagar
Butwal
Meetings were conducted with district health officials, including the
focal person for urban health in the municipality. Data was collected
on the umber of urban health centres, their management, level of
coordination between district health offices and the municipalities,
challenges faced by the UHCs and suggestions for improvement.
Manohara Community Health Centre (MCHC):
The data from the MCHC for a period 2008 to 2014 was collected
and analysed. Services analysed included TB, Immunisation, Safe
Motherhood and Family Planning

Objectives
To
understand
current
service provision of Essential
Health Care Services (EHCS)
to the urban poor
To analyse service delivery in
one clinic for the urban poor
in Kathmandu

Key Findings from

Municipality Assessment
Lack of clarity on
roles of DPHO,
Municipalities and
UHC

No guidelines for UHC

operation

Results from Manohara clinic

The Manohara slum population is currently an estimated 4,500
population. The clinic sees an average of 10,000 patients per year.

No supervision and
monitoring

ANC Visits: The Challenge of Providing 4 ANC Sessions

Family planning Clients by Ethnicity

2008-2014

45

Weak coordination
between DPHO
and Municipalities

40

No formal coordination
structures or forums

35
Dalit

30

Disadvantaged Janajati

Lack of staff with

appropriate skill
mix to deliver
services

Disadvantaged non dalit terai

25

Not all have Health

assistants;

Some without Auxiliary

Nurse Midwives
leading to poor ANC
provision

20

1st ANC

Religious Minorities

4th ANC

Relatively advantaged Janajatis

Upper caste groups

15

Others
Total

10

Human resource
limitations

Poor remuneration and

untimely budget
release disrupting
salary disbursements.

UH volunteer not
recognized as national
volunteer (FCHVs)

Confusion whether
recruitment is
responsibilty of District
Public Health Office or
Municipality.

5
Manohara Urban
Clinic

0
2009

2010

2011

2012

2013

Totally Immunised Children by Outreach and

Manohara Clinic

Total Number of Registered TB Cases

Limited ownership
for urban health
by Municipalities

Many municipalities
havent allocated
resources (financial
and HR) for UH

30

250

25

200

20

Lack of
Infrastructure

150

Many UHCs didnt their

own building; lack of
separate rooms for
ANC, FP

15
100
10
50

Lack of
equipment,
registers, drugs

Poor service and lack of

monitoring

0
2008

2009

2010

2011

2012

2013

2014

2008

2009

2010
Outreach clinic

Municipal UHCs Staff working at UHCs

Population
Birgunj
139,068
4
HA (3); ANM (4); AHW (4);
Helper (4)
Bharatpur
143,836
4
HA ( 2); ANM (3); CMA (1);
AHW (2); Helper (4)
Biratanagar
197,711
5
AHW (14); ANM (9)
Bhadrapur
18, 607
2
HA (2); 1 (ANM)
Sidharthanagar 65, 629
2
HA (4); ANM (4); AHW (4)

2011

2012

2013

2014

Manohara Clinic

Municipality

Butwal

118,462

HA (4); ANM (4); AHW (4)

Conclusions
This work has highlighted challenges to the provision of EHCS to
the urban poor. There is a need for improvements in
infrastructure and for greater coordination with clear lines of
responsibility established. A health centre like Manohara
Community Health Centre are important to provide EHCS to the
urban poor. A national Urban Health Policy and guidance are
essential to delivering EHCS to the urban poor with services
targeted to marginalised communities.
Health Research and
Social Development Forum (HERD)
PO Box 24133, Kathmandu, Nepal
Tel: 4 23 80 45, 4 10 20 72
Fax: 4 10 20 16 www.herd.org.np