Nepal’s 2015 constitution guarantees the right to health, yet challenges persist in delivering quality health services, particularly in the face of increasing urban complexities. Non-communicable diseases (NCDs) now account for 66% of all deaths in Nepal1, highlighting an urgent need to strengthen the health system to provide quality services to respond to this rise, particularly for the urban poor and vulnerable populations. However, issues such as poor coordination across the government tiers (federal, province and local); unclear roles at provincial and district levels in relation to health; and, limited municipal capacity, hinder the overall capacity for developing evidence-driven policies, plans, and budgets that can address the rising NCDs. The presence of multiple health service providers, including an unregulated private sector, adds further complexity. With the context of limited data, resource constraints and capacity gaps, functional partnerships between municipalities and private health providers are more important than ever. As well as the ongoing efforts to strengthen public health facilities, it is essential to enhance the coordination between municipal health systems and the wide range of private healthcare providers in order to deliver quality NCD prevention and care services, particularly for the urban poor. The Problem Pokhara Metropolitan City (PMC) is facing challenges in delivering quality basic health services, whilst experiencing a rise in NCDs. The number of cases of hypertension (29,848) and diabetes (25,943) are particularly prevalent and concerning for residents of informal settlements and among the urban poor. In this context, Pokhara Metropolitan City (PMC) and HERD International jointly initiated a study to examine how to strengthen urban health systems, as part of the CHORUS research programme. What We Did Three key factors stood out as influential in establishing a strategic partnership with PMC:

1. HERDi’s longstanding history of collaboration and proven track record in working to strengthen health systems in Nepal
2. 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
3. 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, which has played a crucial role in strengthening trust and nurturing a mature research partnership

To initiate the joint project, consultative meetings were held with key officials in PMC in which key issues and challenges within the urban health system were explored. Together, we visited local health facilities and consulted with health workers at public facilities, private providers and non-government organizations, and conducted a comprehensive stakeholder analysis.  Through multiple rounds of discussions and evidence review, we jointly identified PMC’s priority areas for strengthening urban health systems, which included:

1. Strengthening data systems,
2. Generating new evidence in multiple areas including health needs of the urban poor,
3. Understanding the presence of private health providers and their role in healthcare delivery, particularly in relation to NCD management,
4. Identifying areas for improvement in PMC’s health systems.

Following extensive consultation with stakeholders, PMC endorsed the research plan and took on collaborative ownership of the CHORUS project through the PMC’s multi-sectoral Project Advisory Committee. The study is divided into three main phases: (i) An extensive needs assessment to identifying the readiness of the urban health system to provide NCD services, and the health seeking behavior of urban residents, especially from poor communities, (ii) the co-creation of a model to improve service quality of the health service providers and (iii) an evaluation of the intervention model, looking at reach, effectiveness, adoption and maintenance. The needs assessment involved multiple data collection methods including the mapping of 660 health service providers and extensive qualitative interviews and focus group discussions with system level stakeholders, community members, community health volunteers and health system actors. Key findings included:

• Private health facilities were identified as the major services providers. Private pharmacies were the largest within this group (352 of the 601).
• The public health facilities under the PMC had a low service readiness score, particularly for diabetes and hypertension.
• Pharmacies were found to offer health services beyond dispensing medicines, despite their low readiness and authority to deliver such services.
• The prominent role of private providers, especially pharmacies, as the the primary point of contact for NCD services, was mainly attributed to factors like proximity, trust, and extended service hours.

The needs assessment found that urban residents heavily utilised these private providers. These findings generated diverse opinion amongst stakeholders, who were at first hesitant to consider a formal linkage with private providers for the provision of NCD services. The CHORUS team held extensive discussions, drawing on locally generated evidence and synthesised secondary evidence. Over time, a consensus was achieved, and the joint study commenced with a focus on engaging private healthcare providers in prevention and care of NDCs, by developing service linkage with private pharmacies and addressing the needs of the urban poor. Pathway to Impact Through the various stages of co-creation, the stakeholders used the evidence on the utilisation of private sector for NCD services and their role and readiness to develop a model to engage 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. Pharmacies expressed their interest in developing a service linkage but suggested a partnership-oriented model over regulatory measure. They suggested a simplified recording and reporting system to facilitate information linkages. Additionally, they advocated for the strengthening of public facilities for NCD care before the development of referral linkage. Importantly, as a motivation, they expected capacity development interventions in delivering NCD care services and acknowledgement of their work by the PMC. Following rounds of discussions and co-creation workshops with stakeholders, a mutually agreed partnership model between the PMC and private pharmacies has been developed. 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. Lessons and Recommendations

• Harnessing local data and advancing local ownership: in-depth analysis and use of existing data generated through municipal routine information system, supported by tailored dissemination to relevant stakeholders and optimal use of stakeholder platforms, contributed significantly to enhance stakeholders’ understanding, ownership and accountability in strengthening urban health systems.
• Strategic evidence generation, optimising application: generating new evidence in priority areas for stakeholders, and using effective and innovative dissemination methods played a crucial role in addressing evidence gaps and understanding issues, which led to an evidence-informed decision-making culture among stakeholders.
• Embedded practices, strengthening trust and relationships: the embedded research approach, combined with longstanding collaboration between researchers and PMC officials, proved invaluable in building trust and relationships, leading to ownership and institutionalisation of the study design, implementations, and uptake.
• The power of sustained dialogue, driving impact: continuous engagement and communication between health system actors and private healthcare providers has been crucial for facilitating the public-private partnership for NCD care. This helped build the confidence of the private sector in their role within the municipality led urban health systems, leading to impact.
• Adaptive strategies, bridging gaps in organisation: potential challenges arising from frequent leadership change at the municipal level can be mitigated by engaging all actors in the municipal system from the outset, establishing relationships, trust and maintaining continuous communication at the organisational level.