Global Health Justice and Governance

Key Findings

Reversing the Enduring Impacts of the Global Gag Rule

This first cross-country analysis of the GGR’s impacts in the peer-reviewed literature documents how the GGR hinders Sexual and Reproductive Health programs and services in countries where abortion is highly and less restricted. Using examples from Kenya, Madagascar, and Nepal, our research shows that in addition to limiting non-governmental organization coordination and programs, the GGR damages public sector contraceptive and abortion service delivery and supply chains – the same services the US Agency for International Development prioritizes in these countries. The recission of the GGR is not in itself sufficient to reverse these harms. Permanent legislative repeal of the GGR by the US government, and increased funding commitments for SRH by the Kenyan, Malagasy and Nepali governments are needed to undo and prevent further damage.

Research Snapshots

Read key findings from our research, and implications for national sexual and reproductive health advocates, providers, and policymakers:

U.S. Global Gag Rule Undermines Access to Contraception in Madagascar (English)/ La règle du bâillon mondiale des États-Unis met en péril l'accès à la contraception à Madagascar (French)

U.S. Global Gag Rule Hinders Nepal's Health System at Multiple Levels

U.S. Global Gag Rule Fragments Kenya's Reproductive Health and HIV Services

Fact-Sheets and Advocacy Briefs

The Global Gag Rule disrupts HIV and Sexual and reproductive health integration in Kenya

Findings from two studies conducted by GHJG & APHRC and amfAR suggest that the expanded GGR disrupts HIV and sexual and reproductive health (SRH) integration in Kenya by reducing provision of SRH services by NGOs that certify the policy, and reducing provison of HIV services by those who have not. Read our brief here.  

the global gag rule is fracturing health care access in kenya

GHJG, APHRC, and PP Global developed factsheets that highlight top level findings and recommendations for advocates in Kenya and the U.S.

Long-term consequences of the ggr, post policy repeal

Research experts on the GGR are unanimous: Evidence shows that impacts of the GGR won’t simply end because the policy was repealed by President Biden. Many of the most damaging effects outlive the policy. Read more about these long-term consequences in our 2022 paper in BMJ, and the outcome document from our 2020 GGR Symposium here.

US House of Representatives Committee on Foreign Affairs Hearing: Unique Challenges Women Face in Global Health 

On February 5th, 2020, the House Foreign Affairs Committee held an open hearing on Global Women’s Health, the first in over a decade. Witnesses shared testimony which highlighted how the Trump Administration’s expanded GGR undoes decades of progress in improving women’s and girls’ life chances. GHJG submitted written testimony for the official record, which provides key findings from our research in Kenya, Nepal, and Madagascar. Watch the hearing, and read our testimony here.  

Repealing the Helms Amendment 

The Helms Amendment is a law which bars the use of U.S foreign assistance funding to pay for abortion as a method of family planning, even in countries where abortion is legal. Though it was signed into law in 1973, the Helms Amendment is frequently overinterpreted in much the same way the GGR is, undermining health providers’ ability to deliver available services, and women and girls' access to fundamental information about sexual and reproductive health.  

Given the similarities between the GGR and the Helms Amendment, and the organizations to which they apply, our GGR research uncovered the harmful effects of both policies, particularly in Nepal. We shared results related to the Helms Amendment with colleagues at Ipas, who included the data in advocacy resources about the harms of U.S foreign policies. Read the Nepal brief here.  

Special Publications

Exporting harm: Impact of the expanded Global Gag Rule on sexual and reproductive health and rights

Findings from Kenya, Madagascar, Nepal, and global interviews are published in a special issue of the journal Sexual and Reproductive Health Matters, along with commentaries from legal, advocacy, and service delivery experts in each of the three countries. The October 2020 launch of the special issue included presentations from the research teams in each country and GHJG. Recordings of the event are available in English and French.

Review highlights from each country paper below, and visit our publications page for access to each paper in full.

FINDINGS FROM KENYA

Kenya represents a context with a high HIV/AIDS burden (1.6 million people in Kenya are living with HIV/AIDS), and a high maternal mortality ratio--roughly 18% of maternal deaths attributed to unsafe abortion. This is likely connected to the complicated status of legal abortion in Kenya. The 2010 Constitution permits abortion when a woman’s health or life is in danger, and in cases of rape. However, abortion is still “illegal” under the penal code. This leads to confusion for providers and women around the country. Abortion is also highly controversial in Kenya.  While there is a robust community of activists and organizations advocating for sexual and reproductive health and rights, there is also strong opposition to safe abortion in the government as well as civil society. This makes implementing safe abortion very difficult.  

We found that the GGR adds to the confusion and conflict around abortion in Kenya and exacerbates an already difficult situation. 

LOSS OF NGO SUPPORT TO FACILITIES 

  • Organizations that did not sign the GGR reported having to downsize, cut staff, and reduce support to local facilities. In turn, these facilities receive fewer commodities, have to cut down on outreach activities, eliminate staff (ie: community health workers and providers) and/or reduce staff salaries and hours.  

  • Facility-level respondents reported that the Kenyan Ministry of Health is not equipped to meet demand for contraception and safe abortion commodities. Typically, the NGO sector fills this gap and provides commodities when the public sector isn’t able to. So, when the NGO sector is weakened by GGR it becomes even harder for women to access the services that they need. 

DISINTEGRATION OF HIV AND OTHER SRH SERVICES 

  • NGOs are reportedly forced to choose between continuing their reproductive health or HIV programming. Prior to this iteration of the GGR, USG global health funding priorities emphasized service integration, particularly for SRH and HIV care. Now, some NGOs are forced to dismantle trusted and successful integrated care models, creating inefficiencies. For example, patients have to travel to different providers and even different service delivery points in order to access care.   

DAMAGE TO COALITION SPACES AND COLLABORATION 

  • Organizations that signed GGR dropped out of coalitions and stopped attending meetings with organizations that did not sign. This disruption causes: unnecessary duplication of efforts and poor coordination, the undoing of government supported health strategies, a culture of fear and mistrust between groups, and siloed spaces within SRH advocacy, policy, and programs. 

  • Respondents simultaneously report an increase of SRHR opposition/anti-abortion voices. Though not necessarily a result of the GGR, a few respondents believe that government opposition to abortion, combined with the global gag rule, has emboldened the anti-abortion movement.

FINDINGS FROM NEPAL

Out of the three countries in this study, Nepal is the only of the three countries with an abortion law that is more liberal than the GGR, and a government that supports safe, free, legal, and accessible abortion services. Despite this supportive context for sexual and reproductive health and rights, we found that low policy awareness and a considerable chilling effect cut across levels of the Nepali health system and exacerbated impacts caused by routine implementation of the policy, undermining the ecology of SRH service delivery in Nepal as well as national sovereignty. 

UNDERMINED PROGRAM SUSTAINABILITY AND OBJECTIVES 

  • The GGR led to the early closeout of a major family planning program in Nepal, funded by USAID, that supported government health facilities in 22 of Nepal’s 77 districts. Specifically, the program trained providers on family planning methods, particularly long-acting reversible contraceptives (IUD and implant), implemented a quality improvement system, provided on-site coaching and monitoring of providers, and distributed clinic equipment and supplies. Because the program ended early: 

    • Program staff had limited time to transition activities and program management to the Nepal government, which undermined sustainability of the program components. 

    • Providers reported feeling under-trained/supported and lacking the confidence to provide the family planning methods that program that they had been trained on. 

    • Eight out of 24 health facilities failed to sustain service provision for long-acting reversible contraception following the program’s early closure. 

DISCONTINUATION OF ALLOWABLE SERVICE DELIVERY AND REFERRAL 

  • Facility managers and providers who work for NGOs that have signed the GGR reported that they stopped referring women for ANY SRH service (ie: contraception) to facilities where safe abortions are also performed. However, the GGR only restricted their ability to refer women to those facilities for abortion. 

  • There is also an exception to the GGR which allows NGOs to provide abortion referrals if pregnant clients tell their providers that they want to terminate their pregnancies and ask for an abortion referral. Our data suggest that this exception was not always followed. 

CHILLING EFFECT WITHIN THE GOVERNMENT SECTOR 

  • The GGR does not apply to US global health assistance money provided directly to governments. In other words, governments are not required to comply with the policy. However, our findings suggest that the GGR does influence government actors and spaces: 

    • NGOs that did not sign the GGR reported no longer being included in government-run processes or technical trainings, even on topics unrelated to abortion. 

    • Similarly, we learned that abortion-related information has been scrubbed from some Nepal government policies and guidelines. 

FINDINGS FROM MADAGASCAR

Madagascar has one of the world's strictest abortion laws, inherited from French colonial law. The penal code prohibits abortion without exception; it is punishable by imprisonment or a fine. The country also receives significantly less bilateral assistance than most countries in the region and is heavily reliant on the U.S government for family planning funding--88% of ODA for reproductive health comes from U.S. We found that the GGR has substantially reduced access to contraception for women and girls in Madagascar, disproving the assumption that the policy has little impact in countries with restrictive abortion laws. 

REDUCED CONTRACEPTIVE SERVICE DELIVERY POINTS 

  • One international organization that chose not to comply with the global gag rule was forced to close many of its health facilities and end outreach to rural hard-to-reach areas when it stopped receiving US global health assistance for family planning. This organization had previously been the largest NGO provider of family planning in the country and the only provider in some regions.  An estimated 40% of Malagasy women who use modern contraception received their services through this organization, which delivered 60% of all long-term contraceptives in the country. The funding loss resulted in:

  • The ending of a program that provided free contraceptives to 170,000 women and girls living in poverty.

  • Reduced staff stipends, trainings, supplies, and supervision for public and private providers.

INCREASED STOCKOUTS OF CONTRACEPTIVES AND CLIENT FEES

  • There have been many stockouts of family planning supplies in Madagascar since 2017. We found that facilities were experiencing long-term stockouts of contraceptives, especially oral contraceptives and injectables; and at times, certain contraceptives were not available anywhere in the country. These stock outs are caused by several factors, including the US defunding of UNFPA and the GGR.

  • Many clients reported multiple obstacles when attempting to procure contraceptive methods and services, with some traveling long distances and visiting multiple providers in the hopes of finding their preferred method, and others turning to the black market.

  • Increased cost of contraceptives was described as a barrier by providers and women. New prices were two to five times the original price--unaffordable for many. Some women described having to choose between using contraceptives and buying food for their families.