February 5, 2020

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

On behalf of the International Women’s Health Coalition, I submit this statement for the hearing record.

The International Women’s Health Coalition (IWHC) thanks the Committee for its attention to this critical issue. IWHC has worked to protect and promote the health and human rights of women and girls globally for over 35 years. We do this work, in large part, through close, long-term partnerships with grantee organizations around the world. Local organizations are not only the most effective driver of change, they also know best what’s happening in their community – their voices and experiences are critical to understanding the full impacts of US health and development policy.

Any discussion of the challenges facing women around the world must focus on the devastating impacts of the Trump Administration’s anti-reproductive health policies, particularly the Protecting Life in Global Health Assistance Policy, also called the Global Gag Rule. This dangerous and discriminatory policy, as established by this Administration, prohibits foreign NGOs from receiving US global health funds if they perform, counsel, or refer patients for abortion care, or if they advocate for the liberalization of abortion laws. This rule applies to what they do with their own, non-US government funding, and it applies irrespective of national laws. The Global Gag Rule denies women health care, undermines U.S. global health investments, and forces providers to make heartbreaking choices about whether to provide women with the services they need or forgo US funding altogether.

For the past three years, IWHC has worked in partnership with local organizations in Kenya, Nepal, Nigeria, and South Africa to document the consequences of this policy. As part of this documentation project, IWHC and partners have conducted over 275 interviews with those impacted by the policy, including health care providers, members of civil society, and government officials.

With three years of data, IWHC’s research clearly confirms what previous studies have found: the Global Gag Rule harms women’s health. It decimates health systems, makes quality health care more difficult to access, and has lasting impacts on civil society organizations and their work.

The policy forces providers to choose between taking critical funding for a wide range of health initiatives and providing the full spectrum of legal reproductive health care to women. As clinics lose their funding, contraception, maternity care, and care for cancer and HIV, among other critical services, become out of reach. These impacts fall disproportionately on the most vulnerable and marginalized.

To date, IWHC’s documentation project has detailed a number of key findings:

The policy is harmful to the health and well-being of women, young people, and marginalized communities, such as LGBTQI, rural, poor, and religious minority communities. 

The policy is making health services less accessible, affecting not only comprehensive abortion care, post-abortion care, and contraceptive services but also other sexual and reproductive health and related services, including HIV/AIDS testing and treatment, antenatal care, screening for cervical cancer, breast cancer, prostate cancer, and support for survivors of gender-based violence.

IWHC’s documentation project demonstrates how a loss of funding has forced health services to retrench staff, close clinics and reduce community outreach. These impacts affect all women in a community, but they have particularly severe consequences for already marginalized groups. IWHC’s research has emphasized that young people, LGBTQI individuals, poor women and girls, and other groups already facing barriers to health care are disproportionately affected by clinic closures.

Across multiple countries, our research has documented how the policy is also impacting services for survivors of gender-based violence (GBV). While the policy permits abortion-related services in cases of rape, incest, or life endangerment, interviews conducted as part of this project consistently showed that this distinction is poorly understood in the field. In practice, service providers over-implement the policy. For example, in Nigeria, IWHC’s partners have recently documented how prime recipients of US funds are forcing government-run sexual assault referral centers to sign the policy but failing to provide without proper information or training about its implementation. Even if not over-implemented, the policy itself has serious implications on GBV programming: for example, in South Africa, IWHC has documented that organizations that specialize in providing integrated services for survivors of gender-based violence are losing funding and closing as a result of the Global Gag Rule, creating significant gaps in quality services and making it harder for survivors to access care.

The policy is creating funding shortfalls, causing the fragmentation of health services, and halting critical health programs, including those strengthening the delivery of government services.

IWHC’s research has consistently found that NGOs play critical roles in ensuring the health of communities not only through direct service provision, but also by providing technical and financial assistance to governments, building capacity among health workers, and strengthening health systems. The Global Gag Rule has increasingly created gaps that can be difficult and time-intensive, if not impossible, to fill.

In the most recent phase of documentation, we have found increasing instances where US policy and funding creates a barrier for national governments seeking to meet their own health objectives. In Nepal, where the government has committed to improving sexual and reproductive health access, the Global Gag Rule and a loss of funding and partnerships for civil society organizations has meant that the government has, in turn, increasingly struggled to find effective implementing partners in pursuit of its stated health goals. By making it harder for governments to meet their obligations to their own citizens, the Global Gag Rule is infringing upon the sovereignty of other countries.

In addition, our research demonstrates that the policy is causing a loss of skilled professionals in sexual and reproductive health fields, a deficit that will have long-lasting repercussions. In the most recent phase our research, our interviews uncovered increasing evidence suggesting that the loss of funding for reproductive health care, coupled with growing stigma driven by US policy may be driving skilled professionals and students into other fields, creating a gap that will be felt long after the policy was ended. Across multiple countries, we have documented growing concerns about a reduced number of providers of sexual and reproductive health services, the interruption of training programs for health care providers, and a growing inability to meet demand for reproductive health services.

A further long-term concern is the policy’s effect on health systems, and specifically the splintering of integrated health services, which has been well documented by IWHC and by others. Despite years of investment by the US and other global health donors in a health care delivery model where people can access multiple services for patients in a single location, the Global Gag Rule – a policy that targets one specific health service – is causing breakdowns in integrated health systems. In practice, the policy is driving wedges between sexual and reproductive health providers and other health services, a division that is perhaps most acutely felt in the HIV care, treatment, and prevention fields.

The policy is harming civil society work and collaboration by burdening organizations, shrinking civil society spaces, silencing voices, and creating distrust.

The burden of implementing and monitoring the requirements of the policy bears heavily on organizations that have implement and closely monitor compliance. Organizations that sign the policy report being forced to restructure, re-train staff, and re-write manuals and informational materials; in addition, they face increased internal monitoring and compliance measures.

Further, the policy is fracturing partnerships and coalitions and limiting civil society’s ability to work together effectively, hindering their ability to do work ranging from service provision to advocacy and holding governments accountable. Due to the so-called “chilling effect” that it creates, the policy has opened up new divisions in civil society organizations, particularly between organizations that are gag compliant and those that are not; it has also reinforced existing silos between sexual and reproductive health and other sectors. IWHC’s research has documented cases where the exit of organizations that lose US funding leave gaps in expertise on technical working groups. In addition, the growing competition for increasing scarcity of resources is leading to further breakdown in longstanding civil society partnerships.

This civil society fracturing has very immediate impacts on the quality of services available to local communities and the ability of civil society organizations to carry out their work. In many cases, organizations that sign the policy and lose sub-grantee partners because those organizations opt not to sign, report that finding new, qualified partners can be challenging and time consuming, and, in some cases, impossible.

Confusion and misunderstanding about the policy are still common among key stakeholders.

Three years into implementation of the Global Gag Rule, IWHC continues to document widespread misunderstanding, lack of clarity, and confusion around the policy. Stakeholders, including leaders of organizations receiving US global health funding, reported a lack of knowledge about the policy’s specifics, a dearth of training from both US agencies and prime implementers, and a lack of awareness about the policy’s limits and exceptions.

IWHC’s documentation has found that implementers often interpret the policy as being broader than it is; in particular, organizations reported little awareness that the policy allows for the provision of post-abortion care or referrals for services in cases of rape and incest. Specifically, across all four countries, several organization receiving US global health funding interpreted the policy as allowing “absolutely no opportunity” for providing any information, service, or referral relating to abortion. Even when prompted, many organizations did not or could not explain that the policy does not apply to abortion in cases of rape, incest, and when the woman’s life is in danger, and that it allows for post-abortion care.

This lack of awareness and understanding is amplified by widespread fear about being found to be in violation of the policy. Organizations report avoiding of any areas of work that may be considered risky, even when permitted by the policy. The confusion and fear combine to create further barriers to health care for women.

These findings, together, paint a picture of ever-increasing and extremely serious consequences of a bad US policy. Across all four countries, throughout three years of research, IWHC has heard countless examples of how this policy is impacting individual communities and providers. Perhaps nowhere are the consequences of the policy more apparent than in Western Kenya, where the Kisumu Medical and Education Trust (KMET), an IWHC partner organization, faced a devastating choice about whether or not to sign the policy.  The Global Gag Rule put KMET in an untenable position: forgo US funding and scale back medical services and close clinics or cease to offer rural Kenyan women the full range of reproductive health services to which they’re legally entitled. Whichever option KMET chose, Kenyan women would lose options, and would suffer health consequences.

KMET is far from alone. Another Kenyan organization eliminated their community outreach programs due to loss of funding under the policy, a change that meant many patients could now no longer seek health care. An organization in Nigeria is no longer able to provide free contraception, meaning that, in a country where over half the population lives below the poverty line, the cost was now prohibitive for many people. In Nepal, a long-term project focused on strengthening health systems to deliver family planning services in remote areas, was forced to end early – because the only two organizations capable of implementing this project could not sign the policy. The evidence clearly indicates that, as long as the Protecting Life in Global Health Assistance/Global Gag Rule policy is in place, United States policy is making it harder for women around the world to access quality health care.

As the Committee examines challenges to women’s health globally, IWHC strongly urges Members to consider the evidence around the devastating impacts of this policy, and to pursue a permanent legislative solution to ending it. The Global HER Act (HR 1055) would permanently end the Global Gag Rule and ensure that facts and best practices, rather than ideology, drive US funding decisions. The Global HER Act would make sure that organizations cannot be disqualified from receiving US funding because they provide legal abortion services with their own, non-US government funding. IWHC strongly supports this legislation and urges the Committee to advance this important bill.

The full findings from the first two years of our documentation project are available on our website, IWHC.org, and the report from the third year will be released in the coming months.  For additional information, please contact Nina Besser Doorley at nbesser@iwhc.org.

Thank you for your attention to this important issue.

Sincerely,

Nina Besser Doorley
Associate Director of Advocacy and Policy
International Women’s Health Coalition