Executive Summary

NGO rural and youth outreach programs cut back
One of the most cost-effective and successful innovations in family planning has been provision of information and services to hard-to-reach populations through networks of trained community workers, a strategy known as community-based distribution (CBD). CBD workers provide a range of services in often-forgotten rural communities and urban slums. In countries like Ethiopia, where mountain communities are two days away from the nearest highway, a CBD worker may be the only accessible healthcare provider. Rural CBD programs in Ethiopia and Zambia are now suffering from a lack of USAID contraceptive supplies and a reduced capacity to train and support community workers in the network. And in Kenya, where USAID had contributed constant support to the nation’s CBD efforts, FPAK was forced to cut the number of CBD workers by 50 percent and has had difficulty getting adequate supplies of contraceptives to the remaining staff.

CBD programs with a built-in youth component have also suffered. The Family Guidance Association of Ethiopia and Marie Stopes International Ethiopia have both had to reduce trainings of youth peer educators. This is detrimental in a country where early marriage is common (in some rural parts of Ethiopia, the average age of marriage for girls is 13), and more than half of all pregnant teenagers have abortions. Continuous efforts to educate youth about reproductive health and family planning are essential.

Weakening HIV/AIDS Prevention

Family planning groups forced to reduce screening and treatment for sexually transmitted infections (STIs), including HIV/AIDS
At a time when the U.S. government is expressing its strong commitment to address HIV/AIDS globally, the Global Gag Rule is undermining its ability to follow through on this commitment. The gag rule prevents the U.S. from working with the most effective NGO partners serving two populations at greatest risk of infection — women and youth. Although the policy applies only to family planning funds, it is significantly impacting the HIV/AIDS prevention efforts of reproductive health providers.

Due to the Global Gag Rule, Marie Stopes International Kenya (MSI Kenya) was forced to close a clinic located in Kisumu, in a province where HIV prevalence is the highest in the country. In Kenya, women comprise 60 percent of HIV cases. The Kisumu clinic provided health services to approximately 400 women each month and also supported a cadre of community healthcare workers. When MSI Kenya’s Mathare Valley clinic closed, services for STI screening and treatment and HIV testing and counseling, along with other basic family planning and reproductive healthcare, ended for a community of 300,000 people — with no other clinic nearby.

Ghana has also been hard hit. The Planned Parenthood Association of Ghana not only had to cut family planning services due to loss of USAID funding, but nearly 700,000 clients lost access to HIV prevention services such as voluntary counseling and testing (VCT) and prevention education.

In rural Ethiopia, the Global Gag Rule has undermined essential HIV/AIDS services. The loss of U.S. funds to the Family Guidance Association of Ethiopia (FGAE) has reduced the capacity of its clinics and CBD programs to provide VCT services in Nazareth, a rural community south-east of Addis Ababa. The other VCT provider in Nazareth targets truck drivers and sex workers, leaving FGAE as the primary VCT provider for the rest of the population.

Supplies of USAID contraceptives cut
In 2000, donors supplied less than one-eighth of the condoms needed to fight the spread of HIV/AIDS in developing countries. By 2002, the Global Gag Rule had resulted in the loss of USAID-donated contraceptives including condoms (purchased with family planning funds), to NGOs in 29 countries. From Burundi to Uganda, Nicaragua to Western Samoa, each of these countries is struggling to combat HIV/AIDS and other sexually transmitted infections. Reducing access to condoms through NGOs that have a strong presence at the community level is a dangerous gamble with people’s lives.

Youth sexual and reproductive health prevention activities halted
The loss of U.S. family planning funding has also interfered with efforts to deliver HIV/AIDS prevention information to youth. In Cameroon, the Cameroon National Association for Family Welfare closed a youth center where young people were taught how to be responsible parents, protect against STIs and prevent HIV/AIDS. On the Caribbean island of St. Lucia, the Planned Parenthood Association eliminated plans to train 218 youth peer educators for a program that would have reached 12,000 school-aged children with reproductive health information, including critically needed education on preventing HIV/AIDS.

Integrated programs for family health hampered
For Kenya, the Global Gag Rule has interfered with a major integrated health program. In early 2001, USAID launched the AMKENI Project, a five-year, $16 million program with an integrated approach to women’s health, child survival and HIV/AIDS prevention. Public health specialists and HIV/AIDS experts have endorsed integrating HIV/AIDS prevention with family planning programs as a key strategy, particularly in countries such as Kenya and elsewhere in Africa where the disease has spread into the general population. But almost simultaneous with the AMKENI launch, in an office an ocean away, the decision was made to reinstate the Global Gag Rule. When FPAK and MSI Kenya rejected the policy, AMKENI lost access to FPAK and MSI Kenya’s large networks of 35 clinics and experienced community health workers able to reach tens of thousands of Kenyan women. The Global Gag Rule clearly curtailed the potential reach of USAID-funded family planning initiatives in Kenya.

The Bottom Line

Contradicting core American values
Two central tenets of U.S. foreign assistance are (1) to administer taxpayer funds efficiently, with maximum benefits to the recipients of U.S. aid and (2) to promote and support American democratic values abroad. The Global Gag Rule violates both of these principles.

First, as described in the cases above, it creates impediments to the delivery of family planning. Further, it abrogates the moral and ethical obligations of doctors and nurses to provide patients with comprehensive reproductive health information, counseling and referral — services that are legally permitted in their own countries and that would be legal if these providers were in the United States providing the same care to American women.

Second, the Global Gag Rule restricts organizations from freely expressing their views and advocating for policies they regard as essential to saving women’s lives and health. And it is perceived by foreign organizations as interference by the U.S. government with domestic decision-making and legal activities in their countries.

“I think the Americans are running away from their responsibility,” commented the director of one prominent Kenyan NGO. “How do Americans talk about equality of women and run away from reproductive health? The gag rule has let Kenya down. The gag rule has made women suffer. The gag rule has made more women die, because they can’t access safe family planning.”

The loss suffered by NGOs that do not agree to the restrictions imposed by the Global Gag Rule is incalculable. The consequent cutbacks in services and supplies effectively tie the hands of service providers; and, by doing so, compromise the health and well-being of millions of women, men and children. The policy erodes trust between health practitioners and their clients, reduces access to HIV/AIDS-prevention measures, and, perhaps most poignantly, renders untold numbers of couples vulnerable to unplanned and unwanted pregnancies, which result in more — not fewer — abortions. Until overseas recipients of U.S. assistance are free to inform and provide those in their care with every option for optimum health, the conditions that prolong poverty, illness, conflict and misery will persist.

The effects of the Global Gag Rule prove that healthcare policy that puts ideology before sound public health practices has a tremendous impact on service delivery. With so many lives at stake, the United States cannot afford to alienate, disparage, or leave out any provider or group of providers that is able to deliver cost-effective and comprehensive reproductive health services. The evidence gathered here strongly demonstrates why the Global Gag Rule should be repealed.