Urban Water Insecurity and Public Health in Kathmandu Valley, Nepal: A Systematic Review of Contamination Sources, Health Risks, and Governance Gaps

Urban water insecurity is an increasingly critical challenge in rapidly urbanizing regions of the Global South, driven by population growth, environmental degradation, infrastructure limitations, and institutional constraints. Kathmandu Valley, Nepal, exemplifies these interconnected pressures. This study presents a systematic review of 45 peer-reviewed and selected grey literature sources published between 2000 and 2025, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they examined drinking water contamination, public health risks, household coping practices, wastewater-related exposure, or governance dynamics in Kathmandu Valley, Nepal. Findings were synthesized using a narrative thematic approach. The review identifies widespread contamination across municipal supply systems, groundwater, tanker water, traditional water sources, and household-stored water. Microbial contamination, particularly total coliforms, fecal coliforms, and Escherichia coli, emerged as the most consistently reported and immediate public health concern. Chemical and physicochemical contaminants, including ammonia, iron, arsenic, nitrate, and turbidity, were also widely reported, especially in shallow and deep groundwater systems. Seasonal dynamics further influenced exposure risks, with increased microbial contamination during monsoon periods and greater dependence on alternative and less regulated water sources during dry seasons. The findings further indicate that unsafe water exposure is associated with a substantial burden of waterborne diseases and emerging risks such as antimicrobial resistance. Although household water treatment practices reduced contamination in some cases, risks often persisted due to recontamination during storage and handling. These burdens disproportionately affected marginalized and peri-urban populations with limited access to safe and reliable water infrastructure. The review also highlights persistent governance challenges, including institutional fragmentation, weak regulatory enforcement, inadequate infrastructure investment, and growing dependence on informal water supply systems. Together, these conditions contribute to a hybrid urban water system in which formal and informal sources coexist without consistent quality control. Overall, the evidence demonstrates that water insecurity in Kathmandu Valley is a systemic condition shaped by the interaction of environmental contamination, unequal exposure, household coping limitations, and fragmented governance. By integrating environmental, public health, and governance evidence, this review advances understanding of urban water insecurity in rapidly urbanizing contexts and highlights the need for integrated, equity-oriented, and governance-informed interventions. These findings have broader relevance for cities across the Global South experiencing similar environmental and infrastructural pressures.