Strengthening Urban Health System in Pokhara Metropolitan City: CHORUS-I 

Background

The growing numbers of urban poor around the world face several health challenges including the double burden of diseases, exposure to environmental and human-made hazards and limited access to quality and affordable health care. In the context of the urban poor being overlooked in data, programmes and policies, this study aims to strengthen the urban system in Nepal. This study is part of the community-led Responsive and Effective Urban Health System – CHORUS implemented by the International Research Project Consortium (RPC) in Bangladesh, Ghana, Nepal and Nigeria. The Study in Nepal generates useful evidence to inform national and sub-national policies and program to address the quality healthcare needs of urban populations. This study’s objective is to strengthen the health system that improves urban poor access to primary health care. Our study focusses on four key themes which we call CHORUS Pillar. These include: 

1. Linking the plurality of health care providers. 

2. Building multi sectoral collaboration to address wider determinants of health. 

3. Strengthening systems to prevent and respond to the double burden of non-communicable (NCDs) and communicable diseases (CDs). 

4. Identifying, Reaching and engaging the urban poor. 

CHORUS Projects in Nepal 

We have two major studies on health system strengthening being implemented in Pokhara Metropolitan City in Kaski, Gandaki Provinces and Budhanikantha Municipality in Kathmandu, Bagmati Province Nepal.  

1. Project One: Understanding the approaches to strengthen the service delivery of non-communicable disease programmes for urban poor at the primary health care setting in Pokhara 

2. Project Two: Co-Designing Urban Health Data Hub: A Comprehensive Initiative in the Budhanilkantha Municipality of Kathmandu, Nepal 

In CHORUS, we also have four other projects under the Innovation Fund scheme led by early/mid-career researchers. These projects include: 

1. Pathways to effective coverage for mental health services among urban adolescents 

2. Ethnographic Study of Intersecting Inequities of Urban Poor in Kathmandu, Nepal 

3. Assessing Urban Poverty and Deprivation in Nepal 

4. Media’s role in informing urban health policy: A cross country study of Bangladesh and Nepal 

CHORUS Project 1: Strengthening Urban Health System 

Urban Health System Strengthening Study aims to understanding the approaches to strengthen the service delivery of non-communicable disease programmes for urban poor at the primary health care setting in Pokhara Metropolitan City of Gandaki Province in Nepal.  

Focus of the project 

This is the participatory action research employing mixed method implemented in Pokhara Metropolitan City, Gandaki Province of Nepal. project aims to understand the approaches to strengthen local (municipal/urban) health system that engages with private health providers in delivering quality health services with focus on NCD prevention and care, to urban poor and marginalized. The study has two phases: i) Need assessment and co-creation phase, through which evidence are generated to develop an intervention regarding the engagement of local health system actors and private sectors in delivering NCDs, focusing on the urban poor community; and ii) Implementation and evaluation phase that records baseline indicators, implements the intervention package, and evaluates the intervention packages based on the defined indicators at the baseline. The need assessment phase has been completed and the intervention designed has been completed. Based on the evidence of need assessment, we are piloting a model to link pharmacy and primary hospital run by Pokhara metropolitan city to address NCDs, particularly diabetes and hypertension.  

Need Assessment  

Three key factors stood out influential in establishing a strategic partnership with Pokhara Metropolitan city. Firstly, HERD International’s long-standing history of collaboration and proven track record in enhancing urban health systems provided a strong foundation for the partnership. Secondly, the need to advance health service readiness within PMC-managed health facilities emphasised the critical importance of high-quality evidence for informed planning aimed at improving access to and utilisation of quality health services. Thirdly, PMC’s appreciation for the embedded technical support provided by HERD International over several years – an approach characterised by collaborative working, knowledge exchange, and facilitating evidence-informed decision making- played a crucial role in strengthening trust and nurturing a mature research partnership. Following extensive consultations with key stakeholders, PMC Following extensive consultations with stakeholders, PMC endorsed the research plan and taken collaborative ownership of the study through the PMC’s Project Advisory Committee – a multisectoral committee within PMC. Consequently, the study commenced with a focus on engaging private healthcare providers in prevention and care of NDCs, particularly by developing service linkage with private pharmacies and addressing the needs of the urban poor.  

Quantitative analysis involving mapping of 660 health service providers using GPS coordinates, with 601 private health facilities identified as the major service providers with pharmacies (352) being the largest. The assessment found that public health facilities under the PMC, including Health Post, Urban Health Centre, Urban Health Promotion Centre and Primary Health Care Centre, had mean service readiness score below the threshold of 70, particularly for diabetes (56) and hypertension (46). The pharmacies were found to offer health services beyond dispensing medicines, despite their low readiness and delegated authority to deliver such services. Qualitative method included key informant interviews (KIIs) with the system level actors (PMC Health Division, Provincial Health Directorate, Health Facility In-charge). Additionally, Focus Group Discussions (FGDs) were conducted with the Female Community Health Volunteers (FCHVs) and community members, and In-Depth Interviews (IDIs) were held with the individuals living with NCDs. Findings highlighted the prominent role of private providers, especially pharmacies, as the primary point of contact for NCDs services, mainly attributed to factors like proximity, trust, and extended service hours.  

Co-creating interventions  

The dissemination of locally generated evidence targeted to stakeholders at different levels: system, institution and community. System-level stakeholders included elected leaders of PMC and its officials, health facility operation and management committee members, and provincial health authorities. The stakeholders acknowledged the poor readiness of NCD services leading to poor quality of care. As highlighted by the evidence, a focal point of discussion was private pharmacies, them being the first point of contact for urban populations including the urban poor. There were diverse opinions among the stakeholders whether the PMC should consider developing service linkage with pharmacies in NCD preventions and care. Multiple discussions with stakeholders on engaging private sector in NCD prevention and care also supported by evidence synthesis from secondary analysis of national survey data, which also highlighted the pharmacies as a major service provider for different health care including NCDs, child health and family planning. Use of locally generated evidence and evidence synthesis from secondary analysis helped establish consensus among stakeholders on the importance of engaging private health providers especially pharmacies. We utilised monthly and annual review meetings of PMC to share these evidences.  

Development of service linkage  

Linked to the evidence, stakeholders agreed to develop a model – engaging private pharmacies in NCD prevention and care, particularly for the urban poor. The intervention included a service linkage between PMC health facilities and private pharmacies, capacity development of pharmacies in screening, counseling, and referral services for NCD. The co-creation process also emphasised the linkage between pharmacies and public health facilities for information management and referral services for diagnosis and management of NCDs. The service linkage aims to strengthen the capacity of pharmacies in NCD screening, providing tailored health information to patient, recording and reporting of cases, and referring cases to public facilities for further management. Additionally, PMC will continue to focus its investment in strengthening public health facilities and provide supportive supervision, coaching and mentoring services to frontline health workers alongside information management including periodic review.  

Establishing service linkage model

Pharmacies in the project implementation sites have been enrolled in the study. Following training on customized PEN protocol, these pharmacies will perform active screening of their clients, maintain recording register refer needy patients to the referral hospital. Their service will be reported to the government HMIS. 

This intervention aims to deliver desirable outcomes, especially concerning NCD care among the urban poor. Learning from this study is expected to help PMC and other local government to upscale similar initiatives. 

COVID-19 and Cities: A Nepal Study, 2020

The study “COVID and Cities” was conceptualized in the initial phase of CHORUS project implementation when the entire world was grappling with COVID-19 Pandemic. This study aimed to understand the response to COVID-19 in Nepal from January to August 2020 through review of mass media content and relevant policies published during the period. We identified three different news media as data source for the study based on their coverage, diversity of language, and access whereas 71 policy documents related to COVID-19 were identified for the study. This study assessed measures taken by government of Nepal to prevent and control COVID-19 and its impact on health and livelihood of the urban poor. The study reported here draws on data from a review of mass media coverage and review of policies on COVID-19 published from 1 January 2020 to 31 August 2020. Please find our policy brief, study report and journal article to know the findings of the study.

Partners

This programme is a collaboration among the University of Leeds, University of York, HERD  International Nepal, ARK Foundation Bangladesh, University of Ghana, University of Nigeria, BRAC University and London School of Hygiene and Tropical Medicine

More Details

www.chorusurbanhealth.org

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