Ghana

Overview

The Global Gag Rule has abruptly interrupted key reproductive health programs in Ghana, forcing a major family planning organization to dramatically cut back essential rural outreach activities and clinic services. Leading reproductive health organizations have been unable to effectively engage in crucial partnerships and important HIV/AIDS activities have been stalled.

The Planned Parenthood Association of Ghana (PPAG), the oldest and largest family planning organization in Ghana, has been the main organization involved in community outreach in the country. Since the 1970s, PPAG has directed rural outreach programs with funding from the U.S. Agency for International Development (USAID); the most recent program was the Community-Based Services (CBS) project – the largest project directed by PPAG prior to the gag rule.

Funded entirely by USAID, the CBS project constituted 33 percent of PPAG’s total budget in 2001 and 2002. It focused on clinical as well as outreach services and included three clinics, 1,700 community-based distributors and 41 rural outreach nurses. The clinics provided a range of services such as contraceptives, sexually transmitted infection (STI) management, pregnancy testing, infertility management and voluntary testing and counselling (VCT) for HIV/AIDS. Community-based distributors and outreach nurses delivered vital family planning services – including contraceptives, long-term family planning methods and HIV/AIDS prevention education – to remote areas. At its height in 2002, the CBS project reached 697,000 clients – 33 percent men, 58 percent women and 15 percent youth.

The strength of PPAG's outreach activities made it not only an important service provider, but also an essential partner for other reproductive health organizations, such as the African Youth Alliance (AYA) and EngenderHealth. The AYA, specializing in adolescent sexual and reproductive health, delivers important information and services to youth aged 10-24 in its 20 project districts. EngenderHealth collaborates with key national training institutions, private provider associations, nongovernmental organizations (NGOs), and the Ghana Ministry of Health to strengthen the country's capacity in training and provision of high-quality reproductive health services, including long-term and permanent family planning methods, men's reproductive health, emergency obstetric care, post-abortion care, and STI management.

The Action for West Africa Region (AWARE) Reproductive Health and Child Survival project, led by EngenderHealth, is aimed at increasing the capacity of reproductive health organizations and building a strong network of reproductive health service providers throughout Western Africa. Both EngenderHealth and AYA view PPAG as an indispensable partner for developing and maintaining relationships in the rural communities, and for promoting family planning services in remote districts.

Family Planning Services Reduced

In September 2003, PPAG aligned with the International Planned Parenthood Federation (IPPF) and refused to abide by the gag rule restrictions. As a result, the organization lost US$200,000 in funding for the CBS project, leaving 1,700 trained community-based distributors without support and three clinics in peri-urban and rural communities facing closure. More than 1,327 communities have been affected by the gag rule.

The funding cut forced PPAG to dismiss 67 key staff members and reorganize 40 percent of its remaining staff, which has had a devastating effect on the structure and overall function of the organization. Fortunately, all three clinics, previously supported by USAID, have remained open. However, the nursing staff has been reduced by 44 percent, leaving only 23 nurses to conduct both clinic and outreach activities. The number of clients that receive services has been severely limited, and according to surveillance data collected by PPAG there has already been a 40 percent reduction in use of family planning for the half-year 2004 as compared to the half-year 2003. In addition, the communities that have lost PPAG distributors no longer receive necessary contraceptive supplies.

In an effort to continue outreach activities, PPAG has adopted a new social marketing strategy for the community-based distributors. The community volunteers buy contraceptives from PPAG at a reduced price, sell at an agreed higher price and keep the difference in price as an incentive. Approximately 1,000 of the original 1,700 volunteers have agreed to continue with the project. However, under the new strategy, volunteers do not receive the important educational training and supervision provided during the project, thus limiting the reproductive health impact of the program.

Key Partnerships Interrupted

Prior to the gag rule, PPAG outreach volunteers were active in most of the communities within the 20 chosen AYA project districts, making PPAG an obvious and integral partner for the project. The organization also had a very strong clinic network, ideal for incorporating the youth-friendly services promoted by AYA. Although PPAG continues to be a project partner, the major cutbacks in PPAG staff and the loss of its community-based distributors have limited its outreach capabilities, particularly in the most remote areas of Ghana. AYA was forced to reorganize the project and identify new potential partners, mostly Community-Based Organizations (CBOs), for the project.

Much like the partnership between AYA and PPAG, EngenderHealth relied on the outreach activities of PPAG to deliver high-quality, long-term reproductive health services to the rural areas. However, the gag rule terminated the partnership between EngenderHealth and PPAG, ending years of successful collaboration. EngenderHealth had trained many PPAG service providers before 2003 to deliver long-term contraceptive service methods. But when the partnership ended, training stopped and clients' access, specifically those in rural areas, to long-acting contraceptive methods was greatly reduced.

The gag rule has also meant that EngenderHealth is no longer able to partner with IPPF organizations such as PPAG for the region-wide AWARE project. This is a blow to both the AWARE project and to large family planning organizations like PPAG, because they are now unable to benefit from each other’s expertise at regional meetings and trainings.

The fear and uncertainty caused by the gag rule also interrupted a unique partnership between Ipas and the Ghana Social Marketing Foundation (GSMF). GSMF had been working with Ipas to distribute manual vacuum aspiration (MVA) kits to reproductive health service providers throughout Ghana. MVA kits are a safe and effective way to perform abortions and provide post-abortion care (PAC). However, in order to avoid any potential funding problems from the gag rule, GSMF terminated the partnership with Ipas in 2001. The "chilling effect" of the gag rule has clearly affected the ability of organizations to provide safe and effective services to women.

Post-Abortion Care Services Unavailable

Despite the fact that Ghanaian law allows abortion in cases that threaten a woman’s mental or physical health, unsafe abortion remains a problem. Many providers and women are not familiar with the law, and safe services are not widely available. According to data from the Korle-bu Teaching Hospital in Accra, approximately 30 percent of all maternal deaths are a result of unsafe abortion complications. Programs that incorporate both education and the provision of services are needed to reduce the number of women that die each year from abortion-related problems. The Ghana Ministry of Health and other stakeholders have initiated a campaign to address the issue of unsafe abortion and promote the implementation of abortion services to the extent of the law. However, the current environment of fear and silence perpetuated by the gag rule risks negatively affecting the message of this campaign.

HIV/AIDS Activities Limited

Prior to the gag rule, PPAG clinics and outreach activities included HIV/AIDS activities, such as prevention education and VCT services. However, given the massive reduction in the number of clients served through the clinics and outreach activities, the number of people receiving important HIV/AIDS information has decreased. While PPAG has been able to incorporate HIV/AIDS services for youth into its youth program, HIV/AIDS services for adults have been moved to the clinics and fail to reach the same number of clients as before. Funding obstacles perpetuated by the gag rule also limit the expansion of PPAG’s current HIV/AIDS activities.

In addition, PPAG and other similar organizations in countries in the USAID West Africa Regional Program (WARP), which strive to incorporate HIV/AIDS services with their core family planning and reproductive health services, are not able to receive technical assistance and support of USAID's regional health project, AWARE. Likewise, organizations involved in the AWARE project do not benefit from the family planning experience and best practices of PPAG. By preventing regional partnerships, the gag rule is crippling efforts to address reproductive health and HIV/AIDS in a coordinated and effective manner.

Conclusion

The gag rule in Ghana has limited family planning activities and disrupted many critical partnerships among leading reproductive health organizations. When the need for access to family planning, PAC and HIV/AIDS services is extremely high, the gag rule has limited the ability of organizations within the country and region to work together to promote effective and comprehensive reproductive health strategies. While organizations have developed innovative strategies for coping with the massive loss in funds and outreach support, these organizations are unable to move forward and expand programming in spite of the continuing increase in demand for services.