Background Persons with disabilities can have physical, mental, intellectual, or sensory impairments which can hinder their social participation. Despite Sustainable Development Goals call for “universal access to sexual and reproductive health (SRH)”, women with disabilities (WwDs) continue to experience barriers to access SRH services in Nepal. This study evaluated factors affecting the utilization of SRH services among WwDs in Ilam district, Nepal. Methods A mixed-method study with 384 WwDs of reproductive age was conducted in Ilam district, eastern Nepal. Quantitative data were collected using a structured questionnaire. Relationships between utilization of SRH services and associated factors were explored using multivariate logistic regression analysis. Qualitative data were collected from focus groups with female community health volunteers and interviews with WwDs, health workers and local political leaders. They were audio-recorded, translated and transcribed into English and were thematically analyzed. Results Among 384 respondents (31% physical; 7% vision,16% hearing, 7% voice&speech,12% mental/psychosocial, 9% intellectual, 18% multiple disabilities), only 15% of them had ever utilized any SRH services. No requirement (57%) and unaware of SRH services (24%) were the major reasons for not utilizing SRH services. A majority (81%) of them reported that the nearest health facility was not disability-inclusive (73%), specifically referring to the inaccessible road (48%). Multivariate analysis showed that being married (AOR = 121.7, 95% CI: 12.206–1214.338), having perceived need for SRH services (AOR = 5.5; 95% CI: 1.419–21.357) and perceived susceptibility to SRH related disease/condition (AOR = 6.0; 95% CI:1.978–18.370) were positively associated with the utilization of SRH services. Qualitative findings revealed that illiteracy, poor socioeconomic status, and lack of information hindered the utilization of SRH services. WwDs faced socioeconomic (lack of empowerment, lack of family support), structural (distant health facility, inaccessible-infrastructure), and attitudinal (stigmatization, bad behaviour of health care providers, perception that SRH is needed only for married) barriers to access SRH services. Conclusions Utilization of SRH services among WwDs was very low in Ilam district, Nepal. The findings of this study warrant a need to promote awareness-raising programs to WwDs and their family members, sensitization programs to health service providers, and ensure the provision of disability-inclusive SRH services in all health facilities.

In 2001, we conducted a survey of 1500 randomly sampled households in Kathmandu to determine the costs people were incurring to cope with Kathmandu's poor quality, unreliable piped water supply system. From 2001 until 2014, there was little additional public investment in the municipal water supply system. In the summer of 2014, we attempted to reinterview all 1500 households in our 2001 sample to determine how they had managed to deal with the growing water shortage and the deteriorating condition of the piped water infrastructure in Kathmandu and to compare their coping costs in 2014 with those we first estimated in 2001. Average household coping costs more than doubled in real terms over the period from 2001 to 2014, from US$5 to US$12 per month (measured in 2014 prices). The composition of household coping costs changed from 2001 to 2014, as households responded to the deteriorating condition of the piped water infrastructure by drilling more private wells, purchasing water from both tanker truck and bottled water vendors, and installing more storage tanks. These investments and expenditures resulted in a decline in the time households spend collecting water from outside the home. Our analysis suggests that the significant increase in coping costs between 2001 and 2014 may provide an opportunity for the municipal water utility to substantially increase water tariffs if the quantity and quality of piped services can be improved. However, the capital investments made by some households in private wells, pumping and treatment systems, and storage tanks in response to the delay in infrastructure investment may lock them into current patterns of water use, at least in the short run, and thus make it difficult to predict how they would respond to tariff increases for improved piped water services.

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South Asia is a hotspot for populations and economies adversely impacted by poor water security. This is evident in the case of Nepal where it has been estimated that 20% of households have no access to a domestic water source and two-thirds of the urban households live with inadequate water supply. Therefore, many depend on private solutions, such as private wells and purchasing water from informal water markets, to meet household water needs. Within this context, this paper examines whether private water vendors provide equitable access to both poor and wealthy households, whether they practice discriminatory pricing and whether poor households face a greater financial burden in meeting their household water needs. The analysis uses primary data collected from a 1,500-household survey conducted in 2014 and uses regression analyses to derive the results. The results reveal patterns of inequity in the private water market, but seemingly not purely due to an inherent bias against poorer households. Regardless, the market does not serve the poor adequately and given the lack of alternatives that poor households have, it points to an urgent need for the government to step in to counterbalance the deficiencies of the market.

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