Sexual and Reproductive Health and Rights in the Global Gag Rule Era
In January 2017, the Global Gag Rule (GGR) was signed into law through an Executive Order by U.S. President Donald Trump. The GGR aims to block U.S. federal funding for non-governmental organizations (NGOs) and groups that provide abortion counseling, make referrals, and/or advocate to decriminalize abortion or expand abortion services as a method of family planning. This policy requires non-American NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” with any of their funding (including non-U.S funds) as a condition for receiving U.S global health assistance.
Historically, Republican presidents have reinstated the GGR and Democratic presidents have overturned it as they have shuffled in and out of power. It was reinstated during President George W. Bush’s tenure in office, rescinded by President Bill Clinton in 1993, remained inactive during President Barack Obama’s tenure from 2008–2016, and was recently reinstated in 2017 by President Donald Trump, whose version of the law is the most extensive ever.
The GGR got its start in 1984 at the International Conference on Population in Mexico, when President Ronald Reagan declared that health interventions must be respectful of religious and cultural values. This statement was ultimately used as a means of shunning using abortion as a family planning method:
“… When dealing with nations which support abortion with funds not provided by the United States Government, the United States will contribute to such nations through segregated accounts which cannot be used for abortion. Moreover, the United States will no longer contribute to separate nongovernmental organizations which perform or actively promote abortion as a method of family planning in other nations. With regard to the United Nations Fund for Population Activities (UNFPA), the U.S. will insist that no part of its contribution be used for abortion.” -Ronald Reagan, on the Global Gag Rule (also known as the “Mexico City Policy”)
The U.S. government has long sought to exercise control over abortion and the bodily integrity of women and girls through legislation. In 1973, the Helms Amendment was introduced to prohibit U.S. foreign funding to be used for abortion as a family planning method or to entice any person to perform an abortion. This amendment emphasized that:
- No U.S. funds dedicated to foreign assistance should be used to pay for abortion as a method of family planning.
- None of the funds may be used to pay for the performance of involuntary sterilizations as a method of family planning or provide any financial incentive to any person to undergo sterilizations.
- None of the funds shall be used to pay for any biomedical research relating to the performance of, abortions or involuntary sterilization as family planning methods or means.
Scope and Coverage of the Current Global Gag Rule
In the Presidential Memorandum issued in January 2017 under Trump’s administration, the scope of the GGR policy was not explicit, but it was later clarified in the “Protecting Life in Global Health Assistance Plan.” Unlike previous versions, the current version of the policy applies to recipients of family planning funding and recipients of all global health assistance under U.S. government departments or agencies. This means that: “For the first time ever, organizations that provide counseling, referrals, or services or advocate for safe abortion with their own funding will be banned from all global health funding from the U.S. government.” The ban thus directly impacts funding for international health programs including HIV/AIDS, maternal and child health, malaria, family planning, and global health security. In earlier versions of the GGR, PEPFAR, one of the biggest funders for HIV/AIDs programs in many countries including Uganda, was excluded, but in the 2017 version, it was “gagged’’ since it is under the Department of State in the President’s Cabinet.
Implications of GGR on Sexual and Reproductive Health and Rights (SRHR) in Uganda
In Uganda, the restrictive legal environment on abortion and the limited national health budget does not guarantee SRH service delivery, and abortion remains highly stigmatized. Like in many other countries in the world, despite the legal restrictions, abortions occur in Uganda anyway, often in environments and with methods that put women and girls at higher risk. In fact, according to Uganda’s New Vision, 1500 women die annually due to unsafe abortions, more than 93,000 women were hospitalized for complications from unsafe abortion in Uganda in 2013, and more than 10% of the country’s maternal deaths were due to unsafe abortion. Rather than curbing abortion, the GGR will inevitably increase these numbers.
In the 2013–2014 Uganda Health Accounts National Health Expenditure, it was reported that 41% of Uganda’s current health expenditure is financed by development partners, primarily bilateral donors. Of the funding provided through health financing by development partners, 49% of funds go to preventive care. This is the scope of the impact of the GGR in Uganda — an entire 20% of the health sector’s preventative care will be lost.
The report further indicates that the government of Uganda depends on $6.7 million (USD) in donor funding for sexual and reproductive health (SRH) supplies. According to the Ministry of Health, there remains an estimated gap of $9 million (USD) for family planning commodities overall. Through outside funding, many NGOs have been trying to close this funding gap for SRH. The statement of the current GGR has delivered a huge blow to these efforts, causing many organizations to scale back services or even close offices. For example, Uganda Health Marketing Group (UHMG) accounts for 80% of SRH supplies in Uganda and is funded by the USAID project AFFORD. Because the SRH services provided by UHMG, through their 256 clinics countrywide, are “gagged” by the GGR, those accessing SRH commodities there will not be counseled on options related to abortion, even in cases where abortion is legal.
The Ugandan government’s outreach project offering breast and cervical cancer screenings and promoting the use of Sayana Press, a new brand of injectable contraceptives, has been halted. The GGR is also likely to further hinder advocacy efforts for progressive health policies such as the sexuality education policy that would ultimately curb maternal deaths caused by unsafe abortions in Uganda. Furthermore, the policy is already adversely affecting Uganda’s commitments of providing access to family planning in line with the government’s National Family Planning Action Plan and Family Planning 2020 Commitments because of reduced or lost funding to NGOs that were the leading SRH service providers. Ultimately, the GGR is a major setback to the realization of Universal Health Coverage by 2030, as most Ugandans will have to either pay for SRH services from private service providers or go without services if they cannot afford to do so.
The Way Forward
Rural Aid Foundation, the organization I co-lead with my fellow Global Health Corps alumna Caroline Achola, has been partnering with the Alert Fund for Youth to raise awareness about the GGR and its implications on access to SRH services for young people in Uganda.
We have already conducted a project inception meeting with civil society and community organizations as well as adolescent girls and young women, and have begun documenting their health challenges as a result of the Global Gag Rule. Using a community-led approach, we supported them in developing and presenting a petition to protect young Ugandan’s access to sexual reproductive health services and rights. The petition was presented to the Vice-Chairperson of the Parliamentary Health Committee requesting that the Ugandan government:
- Close the funding gap for reproductive health services for youths in Uganda by allocating alternative local funding.
- Conduct an impact assessment on the implications of GGR on access to reproductive health service provision in Uganda and present a summary paper to the full Parliament.
The Vice-Chairperson on the Health Committee of Parliament made a commitment to present the petition to the health committee and also present it on the floor.
The GGR poses a threat to sexual reproductive health service delivery and this will likely hinder the realization of Universal Health Coverage by 2030. States must understand the implications and make informed decisions for SRHR policy change and financing to protect young people and other vulnerable populations to ensure no one is left behind.
Frank Ategeka was a 2018–2019 Global Health Corps fellow at the Center for Health, Human Rights and Development in Uganda.
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