Submission ID 131803
| Issue/Objective | Nepal's 2015 federal restructuring reclassified the officially designated urban population from 17% to 66%, driven largely by political and administrative considerations rather than functional settlement characteristics. This created three settlement categories: areas that remained rural (R→R, rural before and after), areas reclassified as urban (R→U, rural before and urban now), and longstanding urban areas (U→U). Many newly designated urban municipalities continue to exhibit rural features, raising concerns about whether national rural/urban classifications adequately reflect on-the-ground conditions. This study examined whether more granular settlement classifications provide additional insight into health service access and utilization beyond Nepal's official binary categories, and whether reliance on that binary masks meaningful variation in service access and need. |
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| Methodology/Approach | Using Nepal Demographic and Health Surveys (NDHS) from 2011, 2016, and 2022, descriptive cluster-level analyses applied three complementary classification frameworks: rural-urban transition categories (R→R, R→U, U→U); an agrarian index constructed from NDHS variables on agricultural occupation, land, and livestock ownership; and the Degree of Urbanization (DEGURBA), a functional settlement classification based on population size, density, and built-up structure. A Monte Carlo point-in-polygon procedure accounted for GPS displacement of cluster coordinates in assigning clusters to rural-urban transition categories and DEGURBA classifications. |
| Results | R→R areas showed poorest performance across most indicators; U→U areas performed best. R→U areas showed substantial internal heterogeneity, on some indicators resembling R→R and on others falling intermediate. Agrarian-index stratification of R→U areas revealed three distinct sub-groups: high-agrarian clusters resembled rural conditions while low-agrarian clusters approached urban performance. Aggregating R→U and U→U as an urban category obscured meaningful gaps in service access and conditions. DEGURBA produced a consistent three-tier gradient with narrower internal variation. |
| Discussion/Conclusion | Nepal's binary rural/urban classification is analytically limited in a post-restructuring context. Populations in R→U areas, now counted as urban, risk losing eligibility for rural-targeted programs while remaining functionally rural in service access and outcomes. Nepal's National Statistics Office piloted DEGURBA at ward level in 2024, creating an immediate opportunity to integrate settlement-sensitive classifications into HMIS/DHIS2 reporting and conditional grant formulas. Without such integration, municipalities may employ service models misaligned with actual population needs. Reclaiming health equity requires seeing where populations actually are, not where administrative labels place them. |
| Presenters and Affiliations | Sushanti Chapagain Bucktowar University of Alberta Sushanti Chapagain Bucktowar University of Alberta Stephen Hodgins University of Alberta Sandeep Agrawal University of Alberta |
