The Impact of the Global Gag Rule in Ghana

Publication date: 2005

THE IMPACT OF THE GLOBAL GAG RULE IN GHANA 2005 UPDATES THE GLOBAL GAG RULE PREVENTS leading reproductive health organizations in Ghana from effectively engaging in crucial partnerships. 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 pro- grams 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 counseling (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. A CLOSER LOOK Population: 21.8 million (by 2005)1 Percentage of women aged 15-49: 50.3%2 Contraceptive prevalence (natural and modern methods): 22.0%3 HIV prevalence in adults aged 15-49: 3.1%4 Average births per woman: 4.115 Percentage of population aged 24 or younger: 60.6%6 Life expectancy: 57.9 years7 Abortion policy: Abortion is permitted to protect the woman’s mental health, as well as her life and physical health. It is also permitted in cases of rape, incest, and fetal impairment.8 • A loss of US$200,000 in funding has forced a major family planning organization to significantly reduce its rural outreach activities. • Approximately 1,700 community-based agents have been denied the support needed to provide important family planning services to rural areas. • Three clinics serving peri-urban and rural communities lost funding in 2003. While these clinics remain open, the nursing staff has been reduced by more than 40 percent, severely limiting the number of clients served. • Restrictions imposed by the gag rule have terminated key partnerships and abruptly interrupted an innovative adolescent reproductive health program. • The gag rule has dramatically limited the vital coordination of HIV/AIDS with family planning and reproductive health services. KEY IMPACTS ON GHANA 2 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 servic- es 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 capaci- ty of reproductive health organizations and building a strong net- work of reproductive health service providers throughout Western Africa. Both EngenderHealth and AYA view PPAG as an indispen- sable partner for developing and maintaining relationships in the rural communities, and for promoting family planning services in remote districts. More than 1,327 communities in Ghana have been affected by the Global Gag Rule. The Global Gag Rule was reinstated by President George W. Bush on his first day in office in January 2001. Officially termed the Mexico City Policy, these restrictions mandate that no U.S. family planning assistance can be provided to foreign NGOs that use funding from any other source to: perform abortions in cases other than a threat to the woman’s life, rape or incest; provide counseling and referral for abortion; or lobby to make abortion legal or more available in their country. Called the “gag” rule because it stifles free speech and public debate on abortion-related issues, the policy forces a cruel choice on foreign NGOs: accept U.S. assistance to provide essential health services – but with restrictions that may jeopardize the health of many patients – or reject the policy and lose vital U.S. funds, contraceptive supplies and technical assistance. Our continuing research shows the gag rule is eroding family planning and reproductive health services in develop- ing countries. There is no evidence that it has reduced the incidence of abortion globally. On the contrary, it impedes the very services that help women avoid unwanted pregnancy from the start. ABOUT THE GLOBAL GAG RULE 3 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 $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 commu- nities 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. 4 1960 1970 1980 1980s EngenderHealth and other U.S. NGOs begin work in Ghana with USAID funding to provide technical assistance in family planning and reproductive health. A HISTORY OF FAMILY PLANNING SERVICES IN GHANA 1966 USAID begins a family planning and health technical assis- tance program. 1967 The Planned Parenthood Association of Ghana is formed with the mandate of providing appropriate and quality sexual and reproductive health services. 1968 PPAG is officially affiliated with the International Planned Parenthood Federation. 1969 The Government of Ghana develops a population strategy aimed at lowering the fertility rate, reducing infant and maternal mor- tality rates, and ensuring more balanced develop- ment of all regions of the country through the use of voluntary, modern contraceptive methods. 5 1990 2000 1984 The Mexico City Policy is first introduced. 1992 USAID adopts a new country-wide mission strategy which focuses on, among other things, family planning and HIV/AIDS prevention. 1993 The Mexico City Policy is repealed. The Ghana Social Marketing Foundation is incorporated as a Private Voluntary Organization. 1994 The Government of Ghana establishes the National Population Council to revise and apply the population policy. Its mandate includes coordinating, monitoring and evaluat- ing all population pro- grams and activities in the country, and integrating the population program into the national development plan. 1999 PPAG, with funding from USAID, imple- ments a $2.8 million Community-Based Sexual and Reproductive Health Services project in 9 of 10 regions in the country. 2001 The Mexico City Policy/Global Gag Rule is reinstated. PPAG reluctantly decides to accept the terms of the gag rule so as to continue its highly successful community-based health program, funded exclu- sively by USAID. The African Youth Alliance begins a five-year program in Ghana. The program is led by Pathfinder, PATH and UNFPA and is funded by The Bill & Melinda Gates Foundation with the goal of improving adolescent reproductive health services and reducing the spread of HIV/AIDS. 2003 PPAG’s multi-year USAID-funded family planning outreach program comes to an end. PPAG makes the difficult decision not to renew their project with USAID because of the gag rule, thereby forfeiting U.S. funds, technical assistance and contra- ceptive supplies. 6 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 incor- porating 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 proj- ect 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 meet- ings 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 distrib- ute manual vacuum aspiration (MVA) kits to reproductive health service providers throughout Ghana. MVA kits are a safe and effec- tive 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. Given the massive reduction in the number of clients served through clinics and outreach activities, the number of people receiving important HIV/AIDS information has decreased. 7 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 abor- tion 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 clinic 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 organ- izations 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 out- reach support, these organizations are unable to move for- ward and expand programming in spite of the continuing increase in demand for services. By preventing regional partnerships, the gag rule is crippling efforts to address reproductive health and HIV/AIDS in a coordinated and effective manner. 8 SOURCES 1United Nations Population Division, World Population Prospects, the 2002 Revision. Available at: (accessed Oct. 28, 2004). 2Id. 3United Nations Population Division, Dept. of Economic & Social Affairs, World Contraceptive Use 2003 Wall Chart, ST/ESA/SER.A/227, 2004. 4UNAIDS Report on the Global AIDS Epidemic 2004. Available at: (accessed Oct. 28, 2004). 5United Nations Population Division, World Population Prospects, the 2002 Revision. Available at: (accessed Oct. 28, 2004). 6Id. 7Id. 8Center for Reproductive Rights, The World’s Abortion Laws, June 2004. Available at: (accessed Oct. 28, 2004). Photo credits: © Wendy Turnbull/PAI THE GLOBAL GAG RULE IMPACT PROJECT is a collaborative research effort led by Population Action International in partnership with Ipas, Planned Parenthood Federation of America, and the International Planned Parenthood Federation and with assistance in gathering the evidence of impact in the field from EngenderHealth and Pathfinder International. Recognizing the historic leadership role of the United States in supporting voluntary family planning and related health care internationally, the project's objective is to document the effects of the Global Gag Rule on the availability of life-saving family planning services, as well as efforts to address other major threats to public health, including HIV/AIDS and maternal deaths due to unsafe abortion. The project received its funding solely from private sources. The Global Gag Rule Impact Project gratefully acknowledges the research and writing of consultant Katherine Suellentrop. • U.S. RESTRICTIONS ON INTERNATIONAL FAMILY PLANNING Printed on recycled paper with soy-based ink. February 2005. ISBN: 1-889735-27-2

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