‘Protecting Life in Global Health Assistance’? Towards a framework for assessing the health systems impact of the expanded Global Gag Rule

Schaaf, Marta; Maistrellis, Emily; Thomas, Hana; Cooper, Bergen

doi:10.1136/bmjgh-2019-001786

Cited by 16 publications

(22 citation statements)

References 15 publications

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“…Our findings revealed the causal pathway of GGR's impact in Madagascar (Figure 1), similar to that hypothesised and detected elsewhere. [28][29][30][31][32] Reduced funding to NGOs who do not certify the GGR resulted in the closure of and reduced support to contraceptive service delivery points, leading to stockouts and increased costs for clients. This ultimately resulted in women discontinuing contraceptive use and experiencing unintended pregnancies.…”

Section: Resultsmentioning

confidence: 99%

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Slowing progress: the US Global Gag Rule undermines access to contraception in Madagascar

Ravaoarisoa¹,

Razafimahatratra²,

Rakotondratsara³

et al. 2020

Sexual and Reproductive Health Matters

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Madagascar's health system is highly dependent on donor funding, especially from the United States (US), and relies on a few nongovernmental organisations (NGOs) to provide contraceptive services in remote areas of the country. The Trump administration reinstated and expanded the Global Gag Rule (GGR) in 2017; this policy requires non-US NGOs receiving US global health funding to certify that neither they nor their sub-grantees will provide, counsel or refer for abortion as a method of family planning. Evidence of the impact of the GGR in a country with restrictive abortion laws, like Madagascar-which has no explicit exception to save the woman's life, is limited. Researchers conducted semistructured interviews with 259 representatives of the Ministry of Health and NGOs, public and private health providers, community health workers and contraceptive clients in Antananarivo and eight districts between May 2019 and March 2020. Interviews highlighted the impact of the GGR on NGOs that did not certify the policy and lost their US funding. This reduction in funding led to fewer contraceptive service delivery points, including mobile outreach services, a critical component of care in rural areas. Public and private health providers reported increased contraceptive stockouts and fees charged to clients. Although the GGR is ostensibly about abortion, it has reduced access to contraception for the Malagasy population. This is one of few studies to directly document the impact on women who themselves described their increased difficulties obtaining contraception ultimately resulting in discontinuation of contraceptive use, unintended pregnancies and unsafe abortions.

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Section: Resultsmentioning

confidence: 99%

“…NGO representatives, health providers, and clients. Guides were developed based on the hypothesised impact of the GGR, informed in part by research on previous iterations of the policy [28]. …”

mentioning

confidence: 99%

Slowing progress: the US Global Gag Rule undermines access to contraception in Madagascar

Ravaoarisoa¹,

Razafimahatratra²,

Rakotondratsara³

et al. 2020

Sexual and Reproductive Health Matters

Self Cite

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“…Other donors have made efforts to provide replacement funding to fill the gap left by GGR. 37 However, the amounts provided are insufficient to alleviate the GGR-induced financial blow to many NGOs in Kenya, given that the US is Kenya’s largest bilateral health donor. 22 Kenya had 71 active US global health awards that were subject to the expanded GGR between May 2017 and September 2018.…”

Section: Discussionmentioning

confidence: 99%

Foreign assistance or attack? Impact of the expanded Global Gag Rule on sexual and reproductive health and rights in Kenya

Ushie

Juma

Kimemia

et al. 2020

Sexual and Reproductive Health Matters

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In 2017, the Trump Administration reinstated and expanded the Global Gag Rule (GGR). This policy requires non-governmental organisations (NGOs) not based in the US to certify that they will not provide, counsel, refer, or advocate for abortion as a method of family planning in order to receive most categories of US global health assistance. Robust empirical evidence demonstrating the policy's impacts is acutely lacking. This paper describes the effects of the expanded GGR policy in Kenya eighteen months after its reinstatement. We conducted semi-structured interviews with purposively selected representatives of US-and non-US-based NGOs, as well as managers and health providers at public and private health facilities, between September 2018 and March 2019. Organisations reported critical funding loss as they were forced to choose between US government-funded projects and projects supporting safe abortion. This resulted in the fragmentation of sexual and reproductive health and HIV services, and closure of some service delivery programmes. At public and private health facilities, participants reported staffing shortages and increased stock-outs of family planning and safe abortion commodities. The expanded GGR's effects transcended abortion care by also disrupting collaboration and health promotion activities, strengthening opposition to sexual and reproductive health and rights in some segments of Kenyan civil society and government. Our findings indicate that the GGR exposes and exacerbates the weaknesses and vulnerabilities of the Kenyan health system, and illuminates the need for action to mitigate these harms.

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“…First, NGOs receiving U.S. assistance are now prohibited from using their finances to fund other organizations that provide abortion-related services (Open Society Foundations 2019). Secondly, the restriction now casts a wider net, applying to NGOs receiving any kind of global health assistance funding rather than NGOs receiving specifically family planning assistance funding (Giorgio et al 2020;Schaff et al 2019; The White House 2017). Together, these two changes further restrict available funding for reproductive and sexual healthcare.…”

Section: Global Gag Rule Expansion: Trump Administrationmentioning

confidence: 99%

Permanently Repealing the Global Gag Rule Will Internationally Advance Reproductive and Sexual Health

Varma

2021

JSPG

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The Global Gag Rule bans foreign nongovernmental organizations (NGOs) that receive U.S. global health assistance funding from providing abortion services and referrals, advocating for abortion rights, or funding other organizations that provide abortion-related services. The rule presents a double bind: if NGOs elect to continue providing abortion-related care, they must forgo U.S. funding, requiring them to roll back services across the board. This reduces access to contraceptives, family planning resources, and maternal and child healthcare. The alternate option is to shut down abortion-related care to retain U.S. funding. Thus, the rule is ineffective in its purpose as it creates barriers to comprehensive sexual and reproductive healthcare, leading to increases in unintended pregnancies, abortions, and newborn and maternal death rates. In addition, restricted funding has negative implications for HIV/AIDS and reproductive cancer screening and treatment. The rule is currently implemented and repealed by each incoming president using executive orders. The United States Congress should pass the Global Health, Empowerment, and Rights Act and repeal the Helms Amendment. This will permanently revoke the Global Gag Rule and reduce unintended pregnancies, abortions, and child and maternal mortality rates across the world.

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‘Protecting Life in Global Health Assistance’? Towards a framework for assessing the health systems impact of the expanded Global Gag Rule

Cited by 16 publications

References 15 publications

Slowing progress: the US Global Gag Rule undermines access to contraception in Madagascar

Slowing progress: the US Global Gag Rule undermines access to contraception in Madagascar

Foreign assistance or attack? Impact of the expanded Global Gag Rule on sexual and reproductive health and rights in Kenya

Permanently Repealing the Global Gag Rule Will Internationally Advance Reproductive and Sexual Health

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