WASHINGTON — A lack of communication and conflicting information about the implementation of the Mexico City policy, also known as the “global gag rule,” persists even as the funding restrictions have led to shrinking programs, shuttered clinics, and disrupted advocacy efforts, according to a new report from the Center for Health and Gender Equity, or CHANGE.
Under the expanded version of the “global gag rule” introduced by United States President Donald Trump soon after his inauguration in January 2017, foreign NGOs that receive any U.S. global health assistance are prohibited from performing or promoting “abortion as a method of family planning.” That includes offering legal advice or counselling related to abortion.
“Abortions, you cannot stop them, once a woman decides she doesn’t want a pregnancy she finds ways of dealing with the issue, so the gag rule is really not helping in any way.”— Edinah Masiyiwa, executive director of the Women’s Action Group
Organizations that do not agree to comply with the policy have often seen funding cut off swiftly. For those who do chose to comply, there are a host of other challenges.
“This gag rule is prescribing chaos in our countries,” said Edinah Masiyiwa, the executive director of the Women’s Action Group in Zimbabwe. “I want to reiterate — abortions, you cannot stop them, once a woman decides she doesn’t want a pregnancy she finds ways of dealing with the issue, so the gag rule is really not helping in any way.”
The CHANGE report released Tuesday at an event in Washington, D.C., is titled “Prescribing Chaos in Global Health,” and outlines a history of impacts of the “global gag rule” and some of the adverse effects seen since Trump reinstated the policy — including for some countries a clash between local law and the gag rule, and in some cases, a lack of ability to work with the best partners.
The paper is the latest in a string of reports from different organizations tracking the policy’s impacts. The U.S. government is also conducting reviews, the first of which, a six-month review, was released in February.
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And while there have been efforts to fill the gaps left by a lack of U.S. funding in these areas, several people said it was insufficient, unsustainable, and often came with strings attached.
One of the challenges is that much of that funding is targeted at sexual and reproductive health and rights, but isn’t addressing other areas where the gag rule has had impacts, such as HIV/AIDS, malaria, tuberculosis, and sanitation, Santos Simione, the executive director of Mozambican Association for Family Development, AMODEFA, said at the event.
Challenges in communication
AMODEFA had been implementing several U.S.-funded programs, but after the Mexico City policy was put in place, they received conflicting messages by different staff of the same prime contractor they were working with, according to Simione.
He got a call from one program manager asking if they would sign on to the policy, and when he said no, he was told he had to stop their work on an LGBTI program. A week later, another manager from the same organization asked him to sign an agreement for a new program for orphaned children; and that manager didn’t know anything about the “global gag rule,” Simione said, noting that even the contractor was confused about what programs could and couldn’t go forward.
The report also highlights that countries such as Mozambique and Zimbabwe received no direct information from the U.S Agency for International Development on the new policy and its impact on their funding and services. This included organizations that were direct recipients of U.S. government funding. Media, their networks, and fellow NGOs were more likely to be the source of information on the policy, including the effects it could have on their operations.
For many organizations, the confusion that existed and still exists about the policy means that they have taken an overly cautious approach. According to CHANGE, confusion surrounding the rule has led organizations “to over-interpret” the policy for fear of being found noncompliant.
According to a study respondent in Mexico City, “organizations are very nervous about Mexico City, especially when they are signing up to it. And so the tendency is for them to err on the side of caution and to over-interpret it, rather than to interpret it to the letter and/or be a bit brave in interpreting it.”
The “global gag rule” has further impacted the ability for NGOs to enter into new partnerships, or maintain existing ones, fearing that one may make the other noncompliant under the new policy.
Some organizations told CHANGE they had walked away from opportunities “they would have otherwise pursued because of uncertainty around applicability of the policy.” This included WaterAid America, which turned down opportunities in three sub-Saharan African countries.
Communication about the policy has been particularly opaque for local organizations and subcontractors who may not have known about the policy and may receive conflicting information — while U.S.-based organizations have the ability to ask USAID for policy guidance, Jamie Vernaelde, senior research and policy analyst at PAI, told Devex.
Due in part to a lack of knowledge around the rule, there has been what Bergen Cooper, the director of policy research at CHANGE, called a “chilling effect” — leading to programs being modified or eliminated unnecessarily out of fear they might not comply. For example, CHANGE found that organizations were curtailing counselings on teen pregnancy, she said.
“It has nothing to do with the policy. It is like a horrible game of telephone with people changing activities they didn’t need to change,” she said.
CHANGE did note that some organizations have been able to challenge the applicability of the “global gag rule” to their operations — and succeeded in maintaining funding.
“Pushing back on whether or not the funds are actually subject to the gag rule, we’ve seen a couple of successes in challenging the application of the rule and in a couple of cases have gotten the [U.S. government representative] to agree that the grant wasn’t subject to the rule,” one interviewee told CHANGE.
Impacts at clinic level
The most vulnerable in developing countries — including women and girls, sex workers, LGBT populations, and people living with disability — are bearing the brunt of the changes, according to the report.
As sexual and reproductive health services have become directly linked to women’s health services as well as services to identify, prevent, and treat HIV and other sexually transmitted infections, the “global gag rule” has seen knock-on effects to other services.
By March 2017, one NGO interviewed had stopped pregnancy consultations for adolescents and removed materials on abortion. Other NGOs were no longer administering emergency contraception or postabortion care following the introduction of the policy.
Before the gag rule, about two-thirds of AMODEFA’s funding came from different U.S. sources — so it has already seen a dramatic negative impact on its work, the people it serves, and its partnerships. The organization had been running 20 youth clinics supported by the U.S. government; half have been forced to close, limiting access to sexual and reproductive health education and care.
In one clinic AMODEFA runs in Mozambique’s Gaza province, which has the highest HIV prevalence rate in the country at 24.4 percent, the impacts were immediate and dramatic when they lost funding for their program at the end of September 2017. The clinic went from serving 6,799 women with consultation services, precounseling, and counseling to reduce risk from July-September, to just 833 from October-December, and the number of people tested for HIV dropped from 5,981 to 671 in that same time period.
Family planning services, supporting both men and women, declined rapidly, as well as STI and gynecological services. Male condom consultation dropped from 94,217 to just 11,198 between quarters. And by December, there were zero patients for gynecology consultations, counselling for cancer prevention or menstrual regulation services.
In another example highlighted in the report, a DREAMS program, which is the U.S. President's Emergency Plan for AIDS Relief’s effort to reach adolescent girls to prevent HIV, was abandoned in Zimbabwe, when the local implementing partner didn’t agree to the Mexico City policy, leaving a group of girls who had come to rely on the program that was providing education and a savings group on their own.
“There are many problems affecting the country and the gag rule is just … coming to increase the problems the country is facing,” Simione said.
Beyond effects that might be more obvious, such as HIV and AIDS prevention and treatment work, it is also having impacts on water, sanitation, and hygiene programs, as well as nutrition programs, CHANGE’s Cooper said at the event.
The children born from unintended pregnancies are likely to have worse nutritional status including measures of weight and height, she said.
Advocacy and policy
The implementation of the “global gag rule” is also impacting local advocacy efforts around sexual and reproductive health issues, sometimes clashing with government-level policy, and is raising questions about country ownership.
In Zimbabwe, both women’s and men’s organizations had built a movement to push for a liberalization of the Termination of Pregnancy Act, but the gag rule has moved those efforts three steps back, said Masiyiwa, of the Women’s Action Group.
The country’s ministry of health’s dependence on donor funds, particularly from the U.S., also makes policy change to liberalize abortion unlikely, she said, adding that the rule has “really affected advocacy work.”
“Aid should not be practiced in a way to oppress the country that receives the money with disregard to autonomy.”— Helena Chiquele, gender program officer at Oxfam
Beyond hindering advocacy efforts, negative impacts are emerging for women who are legally allowed to terminate a pregnancy as is permitted in cases of rape, incest, or if the mother’s health is in jeopardy — and fewer rape cases are being reported, Masiyiwa said.
“We are a developing country looking forward to having integrated programing look at all areas that impact women sexual and reproductive health and rights, linkages to HIV/AIDS and gender-based violence,” she said. “So, all that work is also affected because we are no longer effective in programming.”
In Mozambique, after a bitter 10-year debate and discussion, legislation passed legalizing abortion in 2004, but the Mexico City policy is allowing retractors to push against the law once again, Helena Chiquele, a gender program officer at Oxfam in Mozambique, said.
The U.S. comes in “from far away with a disregard for our priorities,” Chiquele said. “Aid should not be practiced in a way to oppress the country that receives the money with disregard to autonomy.”
While some organizations were trying to prove that the gag rule was unconstitutional, the reliance of the country’s health system on U.S. funding stopped them because it seemed clear they would not get government support, said Chiquele.
It’s also divided organizations and disrupted partnerships, several of the panelists at the report launch event said. Organizations have had to make tough decisions — sign on to the policy and keep their funds but potentially compromise some of their values and principles, or don’t, and bear the consequences of shutting down programs.
For those who decide to accept the terms of the “global gag rule,” particularly those who relied on U.S. funding for nearly all of their budget, it can also be a challenging and frustrating process, PAI’s Vernaelde told Devex.
For many of those organizations, they can no longer partner with organizations that might be best suited due to their trust with the communities, their experience, and their ability to reach the vulnerable. In research she did in Ethiopia about the gag rule’s impacts, she found that organizations were “angry they were put in that position.”
In part due to the difficulties of finding local partners who are compliant with the rule in some places, more grants may go instead to U.S. NGOs. During the Obama administration, there was a big push toward country ownership and the integration of health services, with an emphasis on building local capacity and having in-country organizations lead those efforts. Now, because they can’t partner with local NGOs who are subject to the rule and will not agree to it, more U.S. NGOs will get grants instead of the local NGOs that have networks and contracts, Vernaelde predicted.
Further negative impacts are likely on their way toward the end of 2018, when a host of contracts signed before the rule was in place are set to expire. Whether or not donors continue to step up, there are questions about them being able to make up for the funding and programming deficits; about pulling those funds from other areas, such as humanitarian assistance; and whether the money will be flexible enough for organizations to use effectively, Vernaelde added.