Policy change to improve access to safe abortion care in federal Nepal

In Nepal's constitution, safe abortion care is recognized as an essential component of a comprehensive approach to fulfill individuals' sexual and reproductive health and rights. In the current context of transition to a three‐level governance (federal, provincial, and local), there are opportunities to accelerate decentralization and devolution of decision‐making power, increase access to and coverage of safe abortion services, and improve health outcomes. This article documents the processes and results of the policy change undertaken by the Ministry of Health and Population in collaboration with development partners to decentralize the approval process of safe abortion sites and providers with the objective to increase access to and coverage of safe abortion services. With the decentralization of certification, the approval process for safe abortion service sites and providers has become simpler, less time consuming, and less expensive by reducing cost of traveling to Kathmandu or approaching authorities at the federal level. This has resulted in expanding safe abortion services across the country including remote areas with marginalized populations. Evidence‐based advocacy enabled policy change for decentralization of the approval process. Collaboration among stakeholders has been vital for implementing the policy change, including issuing directives from the federal to provincial levels and capacity strengthening of provincial level officials in understanding the requirements for approval of sites and providers.

if the mental/physical health or the life of the pregnant woman is at risk, if there is a probability of fetal deformity or incompatibility with life, or if the individual has HIV or other incurable disease. 1 In Nepal, abortion services can be provided only at approved facilities (public, nongovernmental organization [NGO], and private sector healthcare facilities) and by authorized providers who have fulfilled the prescribed standards and competencies and cleared the due diligence process.
Government-registered medical abortion medicines (combination regimen) are available at retail pharmacies only on prescription by accredited safe abortion providers.The Right to Safe Motherhood and Reproductive Health Regulation (2020) 2 stipulate safe abortion service methods and criteria for service providers to provide them.In Nepal, trained auxiliary nurse midwives are authorized to provide abortion services within 10 weeks of gestation using medical abortion.Abortion using manual vacuum aspiration within 10 weeks of gestation can be provided by trained staff nurse/ midwife or doctors.Abortions up to 12 weeks of gestation by surgical evacuation or manual vacuum aspiration can only be provided by trained doctors including MBBS doctors.Beyond 12 weeks and up to 28 weeks of gestation, abortion can only be performed by trained postgraduate doctors including obstetrician/gynecologists or MDGP doctors. 3ring the COVID-19 pandemic, interim guidance for reproductive, maternal, newborn and child health services was implemented, which made a provision for mobilizing trained health service providers from NGOs and the private sector to provide home-based medical abortion services. 4fore the policy change in 2021, approval of facilities and providers was centralized within the Family Welfare Division as the only authorized body to approve who and where safe abortion services could be provided. 5though abortion has been legal in Nepal since 2002, there is limited awareness about the legality of abortion, the location of safe abortion facilities, and the conditions under which a woman can terminate an unintended pregnancy.The Nepal Demographic Health Survey 2016 reported that only four in 10 women (41%) were aware that abortion is legal in Nepal. 6Of 492 women who had an abortion in the 5 years preceding the survey, 71% accessed abortion from a doctor, nurse, or auxiliary nurse midwife, 19% received services from a pharmacist or medical shop, while 5% received services from a health assistant or other health workers.Only half of the respondents (51%) reported that they had received abortion services from an authorized abortion facility, while 27% had their abortions at home. 6pal revised its Constitution in 2015 and became a federal democratic republic, thereby starting a process of complete restructuring of the country's political system and devolution of power and resources.The three-tier governance has one federal government, seven provincial, and 753 local governments comprising of 460 rural municipalities, 276 urban municipalities, 11 sub-metropolitan cities, and 6 metropolitan cities. 7 All provinces and local bodies have their own legislature and elected governing body.The spirit of federalization is reflected in the Public Health Service Act 2018, which authorizes the federal, provincial, and local levels to issue licenses to provide health services.It also classified safe abortion services under basic free health services. 8The Act does not specify the process of decentralization of approval of safe abortion sites or providers.
During this transition phase to a new administrative structure and legal scenario, program managers and service providers were not clear on how to integrate safe abortion services within existing reproductive health service delivery.Providers were hesitant in taking on the roles of safe abortion providers. 9,10At provincial and local level, there was lack of clarity on roles and responsibilities as well as the capacity to undertake the approval process for safe abortion sites and providers.As a result, approval of safe abortion sites and providers was irregular and many service sites and providers were not able to get accreditation despite meeting all the criteria for provision of abortion services at different gestational ages.
Within the federalized context, there was a need for policy change to decentralize the process of approval of safe abortion sites and providers from federal to provincial and local levels, and to build the capacities of program managers to undertake this task with the objective of increasing access to safe abortion services.This article presents the steps undertaken to facilitate the policy change, the results achieved, and the challenges faced.

| S TR ATEG IE S TO FACILITATE P OLI C Y CHANG E TO DECENTR ALIZE THE APPROVAL PRO CE SS FOR SAFE ABORTI ON S ITE S AND PROVIDER S
The following interventions aimed to facilitate the decentralized approval process for safe abortion sites and providers: (1) evidencebased advocacy for policy change; and (2) technical support and capacity strengthening of provincial and local health authorities to conduct facility readiness assessments.

| Evidence-based advocacy for policy change to decentralize the approval process for safe abortion facilities and providers
In Both the documents clarified the roles and responsibilities of each level of government (federal, provincial, and local) in decentralizing authorization of safe abortion facilities and providers (Figure 2).A detailed checklist guided the authorities on the approval process and ensured that quality of care did not suffer in the new certification format.The designated authorities at the three levels of government for the approval of safe abortion facilities and providers are also described in these documents (Table 1).
A series of workshops was conducted by the Family Welfare Division to sensitize program managers, service providers, and relevant ministry focal points working in maternal and reproductive The decentralized approval process for health facilities as safe abortion service sites since 2021.
health units at provincial level.These provincial-level focal points further sensitized the local-level focal points.These one-day in-person orientation workshops focused on familiarizing the participants with the requirements to authorize safe abortion service sites and providers, the assessment process for facility readiness in accordance with the evaluation checklist, and qualification and training requirements of providers as per the Safe Abortion Service Program Management Guidelines (2021). 3cognizing the need to provide ongoing support, provinciallevel WHO consultants were recruited in 2020 and deployed in all seven provinces.Their role was to provide direct support to the provincial directorate in health system strengthening for sexual and reproductive health, facilitate and assist in the process of implementing the new policy of decentralization, and act as a liaison between different ministerial departments and development partners.

| ACHIE VEMENTS: DECENTR ALIZED PRO CE SS FOR APPROVING SAFE ABORTI ON S ITE S AND PROVIDER S
The Steering Committee and Technical Working Committees at federal and provincial levels provided strategic direction as well as support and guidance in the local context.They provided a platform to F I G U R E 2 Timeline showing the decentralized process of approving safe abortion facilities and providers in Nepal.

Serial number
Government level Designated authority for approval discuss sexual and reproductive health-related issues with partners and stakeholders and made concerted efforts for health system strengthening and improving access to quality safe abortion services.The decentralized process for approving health facilities to offer medical or/and surgical safe abortion services starts with a site assessment by the authorized entity using a health facility assessment checklist, which annexed in safe abortion service guidelines. 3For accreditation of service providers, as per those guidelines, the applicants were required to submit certificates of educational qualifi-

| CHALLENG E S
COVID-19 has been the biggest challenge for implementing the proposed policy change as the government had overarching priorities to respond to the pandemic.The health system was overburdened and the focus of policy makers was on ensuring continuation of essential health services to the population.
Nepal is still in a transition phase of federalization and is undergoing a period of adjustment of resources and responsibilities between the three layers of government-federal, provincial, and local.
Moreover, as the country moves to a federal system of governance, there have been changes in the leadership at the federal level and transfers at provincial level.Limited health system capacity at the provincial and local levels to undertake newly assigned roles and responsibilities has delayed the process of decentralization of approval of sites and providers and reporting.

| CON CLUS ION
There is a positive policy and legal environment in Nepal and policy makers have a united vision to build a stronger heath system.This would be possible through collaborative efforts at different levels with multiple stakeholders.Evidence-based advocacy is a must for any policy-level reforms.Evidence on the current situation of safe abortion services presented to the relevant ministries paved the way for an agreement on decentralization of the approval process.
The continuous engagement of the government and development August 2019, a federal level Steering Committee and a Technical Working Committee were established under the chairpersonship of the Health Secretary and the Director of the Family Welfare Division, respectively.The aim of these committees was to strengthen coordination and planning, and to advocate and facilitate for the proposed policy change.These committees comprised representatives of various ministries, WHO, UNFPA, Population Services International, Ipas Nepal, Marie Stopes International, Family Planning Association of Nepal, Nepal Society of Obstetricians and Gynecologists, and academia.In September 2019, the Family Welfare Division of the Department of Health Services, Ministry of Health and Population developed a policy brief in close collaboration with WHO and stakeholders.The policy brief outlined the steps envisaged to decentralize the approval process, strengthen provincial and local level capacity, and shift the responsibilities of training and approval of safe abortion sites and providers in alignment with the federal system and the Right to Safe Motherhood and Reproductive Health Act (2018). 1 A provincial-level stakeholder mapping and situation analysis of safe abortion services was conducted in 2020-21.A comprehensive assessment was done based on qualitative and quantitative data collected from all seven provinces.Findings suggested gaps in abortion service delivery due to inadequate or nonfunctional listed safe abortion service sites.Twenty-eight percent of government abortion sites were found to be nonfunctional at the time of the assessment.During health system restructuring, service providers, including trained safe abortion providers, were transferred to different places in different roles leaving the approved sites nonfunctional.Program managers and service providers had limited knowledge about the new Right to Safe Motherhood and Reproductive Health Act (2018) 1 and their roles in the newly federalized context.The need to update service providers and program managers at all levels emerged as a priority for ensuring continuation of safe abortion services.These findings were used for advocacy to decentralize the procedures for approving safe abortion sites and service providers.At first, findings were shared with the Steering Committee and Technical Working Committee at the federal level, emphasizing the urgent need to empower provincial and local level authorities to facilitate approval of sites and providers.The mandate agreed by the Steering Committee and the Technical Working Committee was to implement the new rules and regulations to decentralize the approval process for sites and providers to provincial and local levels.Hence, a need was expressed to establish Technical Working Committees in all seven provinces to provide support and guidance in the local context for this process of decentralization.In March 2021, the Family Welfare Division issued a directive to the Provincial Health Directors to create a mechanism to strengthen and monitor sexual and reproductive health services.Between March and May 2021, provincial-level Technical Working Committees under the chairpersonship of the Director of the Provincial Health Directorate were formed with representation from the local government, private providers, NGOs, and the Nepal Society of Obstetricians and Gynecologists working at provincial and local levels.Major events that paved the way for decentralizing the approval process for abortion facilities and providers are summarized in Figure 1.2.2 | Technical support and capacity strengthening of provincial and local health authorities to conduct facility readiness assessments Although the Right to Safe Motherhood and Reproductive Health Act was passed in 2018, the regulations to govern the Act were not formulated until 2020.The Technical Working Committee at the federal level drafted the Right to Safe Motherhood and Reproductive Health Regulation 2 and updated the Safe Abortion Service Program Management Guidelines, 3 which were endorsed by the Government in 2020 and 2021, respectively.A series of consultations with a range of stakeholders including key government officials, development partners, and NGOs at national, provincial, and local level provided technical inputs in formulation of these regulations and guidelines.

Formulation
of the Right to Safe Motherhood and Reproductive Health Regulation (2020) 2 and the Safe Abortion Service Program Management Guidelines (2021) 3 specified the steps toward decentralization of approval of sites and providers.The authority to approve provincial and local level sites and service providers has been delegated to their respective provincial and local-level governments.At provincial level, different provinces have different designated authorities including the Ministry of Health and Population or the Provincial Health Directorate, as applicable in their respective settings.At the local level the approval assessment is the responsibility of the Health Division/Department.The Family Welfare Division continues to be the authorized body responsible for assessing federal-level sites and service providers along with the approval of all safe abortion services at 13-28 weeks of gestational age.All seven provinces now have the authority to approve safe abortion service sites and providers.
cation and abortion training along with affiliation to a health facility in line with the criteria for provision of abortion services at different gestational ages.If the facility and the service provider fulfill the criteria, a certificate is issued.With the exception of government facilities, NGOs and private clinics must pay a fee of NPR 5000 (about US$ 39) and providers a fee of NPR 1000 (about US$ 8) for the certification.Every 5 years the approval process must be repeated.Between 2018 and 2019, and until the Right to Safe Motherhood and Reproductive Health Regulation (2020) 2 came into force, no sites or providers had been listed at the provincial or local level.With decentralization of the approval process for safe abortion sites and providers this process has become simpler, less time consuming, and less expensive by reducing the cost of traveling to or approaching the Family Welfare Division at the federal level.At the provincial and local level, capacity strengthening workshops for program managers and providers have increased their competencies to undertake new tasks and responsibilities in the federalized context.Policy makers and program managers at all levels of government are sensitized to the Right to Safe Motherhood and Reproductive Health Act (2018), Right to Safe Motherhood and Reproductive Health Regulation (2020), and Safe Abortion Service Program Management Guidelines (2021). 1,2,3There is a sense of ownership at provincial and local level after transitioning of responsibilities.Many provinces have prioritized safe abortion services and budgeted necessary funds for training, supervision, and monitoring of safe abortion services and stigma-reduction activities to improve access to safe abortion services.Due to the policy change, 136 new sites and 300 new service providers were approved at the provincial and local level between 2021 and 2022.The online routine health management information system collects, records, analyzes, and evaluates abortion-related data and provides reports to facilitate decision-making.In the recently revised reporting system, indicators for the number and age of pregnant women seeking safe abortion services, gestational age, method of abortion service received, and use of postabortion contraceptive are reported.Similarly, monitoring of safe abortion sites and service providers is done through the newly developed web-based tracking system .
partners, from inception to implementation of the policy change, has been critical.Major support has come from different ministries and departments who made certification of sites and providers at provincial and local levels official through its inclusion in the Right to Safe Motherhood and Reproductive Health Regulation (2020) and the Safe Abortion Service Program Management Guidelines (2021). 2,3Capacity building and accountability are essential for decentralization of the health system.Different ministries have supported the capacity strengthening of provincial-level officers in understanding the assessment checklist for approval of facilities and abortion providers by allocating resources for training.Development partners supported the policy change process by conducting capacity strengthening workshops and supportive supervision for trained personnel.The decentralized process for approving health facilities and providers offering safe abortion services has resulted in expansion of safe abortion services across the country, including in remote areas with marginalized populations.E TH I C S A PPROVA L Ethics approval was not applicable as this article describes the processes and results of policy change undertaken by the Ministry of Health and Population in collaboration with development partners to decentralize the approval process for safe abortion sites and providers and was not conducted as research activities.