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PAI Testimony for U.S. House Hearing on Global Women’s Health

Policy Briefs

U.S. House Hearing on Global Women’s Health

February 5, 2020

Chairman Engel, Ranking Member McCaul and Members of the Committee:

PAI advocates for policies that put women in charge of their sexual and reproductive health. We work with policymakers in Washington, D.C., and a vast network of partners in the Global South to remove roadblocks between women and the services and supplies they need. For over 50 years, we’ve helped women succeed by upholding their basic rights.

PAI appreciates the committee dedicating time to consider the unique challenges women face in global health. We know that a woman’s ability to be an agent of change for her family and community is eroded and undermined when her health needs, including her sexual and reproductive health needs, are not being met.

Since assuming office, the Trump administration has focused their global health policy agenda on undermining women’s health. As detailed in our testimony, this has proven detrimental to America’s foreign policy objectives, to health programs in the 60+ countries around the world who benefit from U.S. global health assistance and to women’s health.

On January 23, 2017, in one of his first actions as president, Donald Trump reinstated and significantly expanded the application of the Mexico City Policy, officially renamed “Protecting Life in Global Health Assistance,” and widely known by its critics as the Global Gag Rule⁠. This policy risks women’s health and lives by forcing foreign nongovernmental organizations (NGOs) to choose between receiving U.S. global health assistance and providing comprehensive sexual and reproductive health care. In order to comply with the Global Gag Rule, providers must agree not to provide information, referrals or services for abortion or to advocate for the liberalization of abortion laws in their country with their own, non-U.S. funds.

PAI has documented the impacts of the Global Gag Rule on family planning since its inception in 1984 under President Reagan. Now, we are documenting the impact of the policy on all U.S. global health assistance, as well as the impact on funding from non-U.S. bilateral donors, private foundations and multilateral organizations as a result of the policy being expanded twice under this administration.

The Trump administration’s Global Gag Rule goes further than previous iterations of the policy, extending its restrictions to all global health assistance provided through the U.S. Agency for International Development (USAID), the Department of State and the Department of Health and Human Services in more than 60 low- and middle-income countries. Now, in addition to all foreign NGOs providing family planning and reproductive health care, those providing services related to HIV/AIDS, maternal and newborn health, malaria, tuberculosis, other infectious diseases, nutrition or any other global health program are required to comply with the policy in order to continue to receive U.S global health assistance.

The Global Gag Rule reaches beyond longstanding limitations on using U.S. government funds for safe abortion care, even though unsafe abortion is a leading cause of maternal morbidity and mortality in the Global South. The Helms Amendment has restricted the use of U.S. foreign assistance funds for “abortion as a method of family planning” since 1973. The Global Gag Rule restricts what an organization can do with its private, non-U.S. government funds. Since its initial expansion under the Trump administration, an interpretation of the language implementing the policy was released in March 2019. This interpretation effectively prohibits a foreign subrecipient from using its non-U.S. government assistance to support any kind of health or development work of a foreign partner that receives no U.S. government global health assistance, if that partner separately engages in abortion-related work with its own funding—essentially blacklisting those organizations. Under this interpretation, in order to remain in compliance with the Global Gag Rule, a foreign NGO would have to track funding they flow-down to a subgrantee from a bilateral donor or a private foundation, for example related to girls education, and ensure that their foreign partner organization is not engaged in any of the prohibited activities, even without any U.S. government assistance.

The Global Gag Rule is not—and has never been—about U.S. taxpayer funding for abortion. It is about the Trump administration placing politics above the health and lives of women around the world. As in the past, the Global Gag Rule will not prevent abortion. What it is doing is shuttering clinics. Communities are losing access to their most trusted and skilled health care providers. The ability of women and their families to access contraceptives, safe delivery and newborn care or HIV testing, counseling and treatment are being limited.


Evidence of Harmful Impacts

PAI has documented the impact of the Global Gag Rule for decades in our research series Access Denied. With the reinstatement and massive expansions of the policy under the Trump administration, we have conducted fact-finding trips in eight countries (Burkina Faso, Ethiopia, India, Kenya, Nepal, Nigeria, Senegal and Uganda) to record the effects thus far. These documentation efforts have complemented the work other NGOs and research institutions have also undertaken to monitor the impacts of the policy.

While it will take years for the full scope of the policy’s impact to appear, our four published case studies confirm the policy has already caused harm to NGOs, health systems and women and their communities. Given the role NGOs play in sexual and reproductive health service provision and advocacy in the countries receiving U.S. global health assistance, they—and consequently the wider health system—are affected by the policy.

Below are some key preliminary findings that demonstrate the policy’s harmful impacts on women’s health and its further repercussions on wider health services and systems, as documented by PAI:

Contraceptives out of reach: The Global Gag Rule has affected the ability of vulnerable populations, including those in rural areas and young people, to access the voluntary contraception of their choice. These groups rely heavily on the private sector, especially NGOs, for reproductive health services and contraception, including some of the most trusted and best-equipped organizations that will not comply with the policy.

  • Reproductive Health Uganda lost $300,000 in 2017—30% of its budget—and was forced to end U.S.-funded projects to strengthen advocacy, rights-based services and introduce injectable contraceptive Sayana Press to 6,000 adolescents seeking protection against unwanted pregnancy.
  • ABBEF, the International Planned Parenthood Federation (IPPF) member in Burkina Faso, was forced in 2017 to prematurely end its U.S.-supported pilot initiative to distribute contraceptives in secondary schools where there is a huge family planning need.
  • Marie Stopes International (MSI) received 17% of its donor income from USAID at the time the Global Gag Rule was reinstated. These funds were exclusively used for voluntary contraception services and the loss of funding has impacted work with poor and marginalized communities most in need of accessing services.
  • Marie Stopes Ethiopia, with its expertise reaching remote communities, ended its U.S.- funded program providing vasectomies and tubal ligations to rural populations. No other organization has the technical skills and expertise to provide the same quality of service and choice.
  • Marie Stopes International (MSI) affiliate FRHS India, which has not had U.S. funding since 2005 and does not provide abortion services, had to shut down a program in Uttar Pradesh as MSI redirected “core” funds to countries harder hit by the Global Gag Rule.

Fewer points of service: Organizations that chose not to comply with the Global Gag Rule were forced to close clinics and end services as a result of funding deficits, disproportionately affecting vulnerable groups including youth, people living with HIV/AIDS and rural populations.

  • IPPF had 53 projects in 32 countries funded by U.S assistance in 2017. Its projects were managed by its member associations that provide essential and life-saving healthcare to underserved and marginalized communities. For some of those member associations, service delivery decreased by up to 42% from 2016 to 2017, in part due to the reinstatement of the Global Gag Rule.
  • In 2018 the IPPF member Family Guidance Association of Ethiopia would have had to close 10 confidential, sex worker-friendly clinics once funded by the U.S. Centers for Disease Control and Prevention if not for short-term replacement funding from the government of the Netherlands.
  • In 2018, Marie Stopes Senegal lost approximately 45% of its budget due to the Global Gag Rule. Without replacement funds, this meant that its outreach services would reach 20% fewer clients for family planning, provide at least 30% fewer cervical cancer screenings and offer nearly 30% fewer STI treatments than in the previous year. These services are critical because adolescents and young people rely heavily on the private sector for sexual and reproductive health in Senegal.
  • USAID had been funding ten Marie Stopes mobile outreach teams in Burkina Faso, which ended in April 2018. While other donors have stepped in to support the organization, as of November 2019, three mobile outreach teams are no longer operational in the country’s most volatile zones, cutting populations off from health services.
  • In Uganda, with the closeout of a U.S. funded program, in 2017 MSI projected that it would have had to cut 27 mobile health teams across the country—a key, integrated service for hard-to-reach populations. Five outreach teams had to shut down, with 12 more at risk.

Stalled efforts to improve health outcomes: NGOs compliant with the Global Gag Rule must often discontinue working with noncompliant organizations on critical initiatives to advance health care access and quality. Stigma and confusion around the technical complexities of the policy also lead NGOs to self-censor and overly restrict their activities, including those allowable under the policy, out of caution.

  • In Uganda, an NGO working with family planning providers and advocates through the Uganda Family Planning Commission to Decrease Maternal Mortality Due to Unsafe Abortion stopped engaging in the work out of fear of reprisals.
  • Efforts by an NGO that trains health workers in Nepal to integrate abortion provision with other basic health services faltered because partner organizations complying with the policy were no longer available.
  • An NGO in Ethiopia lost not only U.S. funding due to the Global Gag Rule, but also its partnerships with two compliant prime recipient organizations that had provided subgrants for programmatic work and an estimated 550,000 Euros annually in contraceptive supplies.
  • In Ethiopia, the largest network representing midwives—often the first points of service for reproductive health—had to stop safe abortion care training that reduces maternal mortality, due to compliance with the Global Gag Rule. The organization can no longer train the public sector on safe abortion care, proving the Global Gag Rule reaches beyond NGOs to affect the wider health system.
  • In several countries, PAI heard from NGOs complying with the Global Gag Rule stating their unwillingness to continue providing or participating in trainings on postabortion care out of fear of the policy. Postabortion care is a service that is entirely permissible under the Global Gag Rule and is integral to saving lives.

Administrative burdens: The Global Gag Rule creates a heavy operational burden for NGOs— both compliant and noncompliant. They must spend valuable resources on unanticipated overhead, time seeking clarification from funders and other costs, which detracts from service provision and directly impacts clients and beneficiaries.

  • One Ugandan NGO’s implementation of services fell four to six months behind because of staff time and resources spent on legal and administrative fees and office and personnel changes in efforts to comply with the Global Gag Rule. The organization also lost knowledgeable technical staff in key geographic locations, impacting the most vulnerable populations.
  • A U.S. organization’s local affiliate in Nigeria shut down a key women’s health program because of compliance-associated costs of duplicating operational structures to function under the Global Gag Rule. It lost over 40 staff as a result.
  • WaterAid, which decided not to comply with the Global Gag Rule, expended many hours of additional work on the part of in-country, regional fundraising and U.S. policy and fundraising staff to ascertain sources of funding for multiple USAID grants. USAID responses have been delayed, confusing and on occasion completely incorrect—at times asserting that the policy would apply to funding streams not subject to the Global Gag Rule or remaining unresponsive throughout award timelines.

Opportunity costs: The Global Gag Rule unsettles plans for organizations working to sustain and grow operations, topples local government efforts to prioritize and improve quality and accessibility of health care and imposes extraordinary burdens and disruptions on non-U.S. donors—all resulting in diminished and delayed programs at the expense of reaching beneficiaries.

  • Reproductive Health Uganda operates in almost 50% of Ugandan refugee camps, serving as the main sexual and reproductive health organization in the settlements. Because of the Global Gag Rule, the NGO has had to scale back humanitarian services, diverting $100,000 per year from providing sexual and reproductive health care in refugee camps.
  • In Nepal, the two lead reproductive health NGOs were forced to close their respective U.S.-funded projects in 2018 due to the Global Gag Rule and USAID allegedly struggled to find new partners willing to subvert the constitutional mandate guaranteeing the right to abortion. As a result, efforts to improve disadvantaged populations’ family planning access, provider trainings, quality assurance and public health sector contraceptive supply chain will be lost. Both NGOs have withdrawn from 22 districts, and one will have to lay off 140 staff as a result.
  • A Dutch-funded project of $9 million over four years for comprehensive abortion care in Ethiopia was terminated in 2017 because the lead organization was complying with the Global Gag Rule and could no longer carry out the work.
  • The United Kingdom’s Department for International Development dedicated 90 million pounds over four years in Ethiopia for work with the Ministry of Health to provide modern family planning services. Because of the Global Gag Rule, one NGO could no longer continue working with the other recipients. The program came to a nine-month halt to redesign the grant in a way that fragmented safe abortion care from the rest of the reproductive health portfolio, delaying the rollout of services.


PAI’s research on the Global Gag Rule was initiated early in the policy’s rollout, while several foreign NGOs were still closing out their U.S. government programs, in the process of finding stopgap funding from non-U.S. government donors and determining how compliance or noncompliance would affect their work. As a result, quantifiable loss for activities and beneficiaries remains unknown and may be difficult to determine because of a range of factors, including timing and replacement funding. The confusion and fear that the policy has engendered among NGOs also meant that certain organizations receiving U.S. government funding were unwilling to be interviewed and consequently the impact to their activities is unknown. With the March 2019 expanded interpretation of the policy, there may be additional effects that will need to be captured as foreign NGOs and non-U.S. government donors adapt to those changes.

Even at an early stage, this policy has disrupted contraceptive uptake and health services, stalled efforts to improve health outcomes and placed administrative burdens that derail the efficacy of U.S. investments in women’s health. Private NGO providers are vital for service delivery to at-risk populations, including adolescents and youth, people living with HIV/AIDS, rural communities and sex workers. The reduction in U.S. global health assistance going to qualified, trusted NGO providers negatively impacts the health system broadly in countries receiving U.S. funding and potentially the health and lives of women, girls and community members.

The harmful impacts of the Global Gag Rule, as documented by PAI and several other organizations and research institutions, underscores the urgent need to end the Trump administration’s expansive Global Gag Rule. Though the harm caused by the policy likely can never be fully undone, repealing the policy would allow trusted and effective organizations to once again compete for critical U.S. global health assistance to rebuild clinical and referral networks and reestablish their partnership and advocacy networks to ensure women, girls and their communities have access to critical health services.

However, it is not enough to end the Trump administration’s Global Gag Rule. For nearly 36 years, this policy has bounced between being in effect and repealed every time there is a change in the party affiliation of the White House. This creates an uncertain environment for organizations, who rely on the United States as the world’s largest global health donor but can never trust the United States’ long-term commitment. Every presidential election here brings with it a concern among health organizations around the world that a much needed or innovative new project could be terminated early, that knowledgeable and trusted staff would have to be let go and that clinics could be shut down.

The Global Gag Rule must be brought to a permanent end. Congressional action is needed to not only end the current iteration of the policy but to ensure that future administrations cannot reinstate the policy when they come into office. For this reason, PAI calls on the Committee to take up the Global Health Empowerment and Rights Act, introduced by Rep. Lowey (D-NY-17) and cosponsored by 190 members of the House of Representatives, for consideration, and urges it passage by the full chamber.

Thank you once again Chairman Engel, Ranking Member McCaul and Members of the Committee. PAI looks forward to working with you to ensure that U.S. foreign policy, specifically global health programs, puts women in charge of their sexual and reproductive health.

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