The Impact of the Global Gag Rule in Tanzania

Publication date: 2005

THE IMPACT OF THE GLOBAL GAG RULE IN TANZANIA 2005 UPDATES NGOs in Tanzania are struggling just to sustain current levels of service since refusing the terms of the gag rule; meanwhile, demand for supplies and services is ever increasing. OVERVIEW Due to a cumulative loss of almost US$500,000 in funds from the U.S. Agency for International Development (USAID), two major family planning organizations in Tanzania have been forced to withdraw critical technical support from the government’s family planning programs. The Global Gag Rule has compounded contraceptive supply problems in the country and hinders the effectiveness of HIV/AIDS programming. Tanzania faces serious reproductive health challenges: women there have an average of 5.6 children, and maternal and infant mortality rates are dangerously high. These challenges are exacerbated by the HIV/AIDS epidemic and the high incidence of illegal abortion, which accounts for significant maternal mortality and morbidity. The gag rule undermines efforts to address these reproductive health issues at a time when the need for comprehensive family planning and reproductive health services is most critical. A CLOSER LOOK Population: 38.4 million (by 2005)1 Percentage of women aged 15-49: 47.2%2 Contraceptive prevalence (natural and modern methods): 25.4%3 HIV prevalence in adults aged 15-49: 8.8%4 Average births per woman: 5.115 Percentage of population aged 24 or younger: 65.9%6 Life expectancy: 43.3 years7 Abortion policy: Permitted only when necessary to save a woman’s life.8 • Three clinics in hard-to-reach areas lost funding in 2001 and will risk closure in 2005 as a result of the gag rule. • Two major family planning organizations have lost approximately $500,000 in USAID funds, prompting dramatic cutbacks in reproductive health services. • Critical technical support was cut short before family planning services were successfully integrated into government facilities, jeopardizing the future of family planning in Tanzania. • The loss of key staff and crucial training programs has intensified contraceptive supply problems. • Funding constraints imposed by the gag rule limit the ability of leading reproductive health agencies to effectively address the HIV/AIDS epidemic. KEY IMPACTS ON TANZANIA 2 Two local organizations — Chama Cha Uzazi na Malezi Bora Tanzania (UMATI) and Marie Stopes Tanzania (MST) — have been the primary non- governmental organizations (NGOs) offering family planning servic- es in Tanzania. Since the 1990s these organizations have trained staff in health clinics all over the country to provide high-quality family planning services. Much of this work has been supported with U.S. funds. In addition to running its own clinics, UMATI has focused on building capacity at government health facilities to pro- vide family planning, while MST has specialized in providing tech- nical support to the private sector institutions. UMATI’s mandate includes awareness-raising; training public and private sector serv- ice providers on family planning service provision; focusing on the long-term and permanent methods (LTPM) of contraception, including female and male sterilization and implants; and procure- ment and supply of contraceptives for the entire country. MST sup- ports private clinics and outreach programs that offer health edu- cation programming, voluntary counseling and testing (VCT) for HIV, condom distribution, and maternal and child health care. Prior to the reinstatement of the Global Gag Rule, UMATI and MST had been developing the capacity of providers at public and private clinics through training, monitoring and quality improvement ini- tiatives to offer family planning as part of their routine care. They had also encouraged clients to value and seek family planning serv- ices. The gag rule cut these efforts short at a critical juncture. “When a client comes to a clinic and finds no service provider, that is a cost. Politics are irrelevant to people who need services.” – the Country Director of a U.S. NGO 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 JEOPARDIZED MST lost almost 65 percent of its annual budget when it refused to accept the gag rule restrictions in 2001. Furthermore, given that the basket fund mechanism* accounts for most non-U.S. bilateral support, MST lost one of the few remaining sources of direct local support by foreign governments. MST has 18 health clinics and more than 80 outreach sites providing services in 20 districts throughout Tanzania. It is by far the largest provider of tubal ligations and Norplant insertions in the country, accounting for more than 70 percent of the total long-term and permanent contraceptive methods offered. While MST has been able to continue operating all 18 clinics thus far, the future of some of its most critically located clinics is uncertain due to lack of sufficient and consistent funds. Three clinics in particular face an uncertain future: the clinic in Musoma, Mara Region, and the clinics in Iringa and Makambo, Iringa Region – all supported by USAID prior to the gag rule. They are located in critical spots, on the edge of the hardest-to-reach areas of Tanzania. Poor infrastructure and limited health services already plague this area, making it difficult for people to receive care. The Canadian International Development Agency (CIDA) has provided interim support to these clinics from 2001 to 2004, but continued funding for coming years has not yet been identified. As a result, these three clinics risk closure in 2005. *Pioneered by the United Kingdom's Department for International Development (DFID) in 2000, “The Basket Fund” approach to bilateral aid refers to a central reposi- tory of funds given to a national government, which disburses funds for various projects at the district level. 4 EARLY 1970s UMATI begins to focus on youth (aged 10-24) as a primary target audience. 1960 1970 1980 1959 Family Planning Association of Dar es Salaam (FPAD), the first family planning program in Tanzania, is founded. A HISTORY OF FAMILY PLANNING SERVICES IN TANZANIA 1960 FPAD is officially registered. 1967 FPAD is renamed Chama Cha Uzazi na Malezi Bora kwa Wazazi wa Tanzania (later renamed again to UMATI) to reflect its national coverage and its focus on parents, in order to deter opponents who accused the FPAD of promoting promiscuity among unmarried and young people. 1969 UMATI becomes a member affiliate of the International Planned Parenthood Federation (IPPF). 1971 UMATI adopts its current name, which reflects a life cycle concept of reproductive health. 1974 The government inte- grates family planning with the Ministry of Health’s maternal and child health (MCH) services, which were run in the government structure, thus increas- ing access to family planning throughout the country. 1982 EngenderHealth begins working in Tanzania. It specializes in long-term and permanent methods of contraception. 1984 The Mexico City Policy is first introduced. UMATI signs a statement with the government of Tanzania, agreeing not to perform abortions, and thus is unaffected by the policy. 5 1990 2000 1993 The Mexico City Policy is repealed. UMATI continues to sign yearly agreements with the government of Tanzania, certify- ing that it will not perform abortions. 1990s The Ministry of Health estab- lishes a family planning unit within the department of preventative health services. 1993-94 EngenderHealth expands its sphere of work to include support to private sector facilities. 2000 The Department for International Development (DFID) – the British equivalent of USAID – begins “The Basket Fund” model of bilateral aid. Under this approach, which was adopted by several other European donors, a central repository of funds is given to the government of Tanzania to support activities such as family planning. The government administers the fund and money is disbursed at the district level. USAID is the only bilateral donor which does not follow the basket funding mechanism. 2001 The Mexico City Policy/Global Gag Rule is reinstated. Marie Stopes Tanzania refuses to abide by the terms of the gag rule, thereby forfeiting U.S. funds. Over a period of 12 months, USAID withdraws funds of US$170,000 that were to support MST health centers in Iringa, Musoma and Makabako. UMATI, meanwhile, agrees to the gag rule restrictions in order to continue its work with public health clinics. 2003 UMATI decides not to renew its agreement with USAID, citing the gag rule as problematic and aligning with other African family planning associations and the International Planned Parenthood Federation. 1989 Marie Stopes Tanzania, a member of the Marie Stopes International partnership, is established. 1997-98 The government of Tanzania begins a health sector reform program that decentralizes the financing, management and implementation of health programs. District-level governments have full decision-making power over use of health care funds. Local Government Units become the main project implementers and they contract other local and national NGOs. 2001: Global Gag Rule is reinstated. 6 KEY STAFF LOST AND SUPPLY PROBLEMS EXACERBATED By 2002, UMATI was supervising 98 public and private sector sites (clinics and hospitals), which were offering permanent and long- term methods of contraception. UMATI was also providing program support for capacity building, quality of care, training, and expend- able supplies for these sites. By 2003, when UMATI refused the terms of the gag rule, 33 sites were directed by the Ministry of Health or by local faith-based organizations. The loss of USAID support forced UMATI to lay off 13 percent of its staff, a majority of whom were experienced doctors and nurses responsible for coordinating capac- ity-building operations at government facilities. The resulting loss of human resources destabilized the entire program and disabled many government sites’ family planning services. The swift termination of UMATI medical staff brought an imme- diate end to monitoring and supervision of capacity building for government providers. Without support or assistance from UMATI coordinators, many government providers were unprepared to offer family planning services. Loss of key staff in UMATI has also exacerbated the lack of accu- rate data collection since the gag rule. Prior to the gag rule, UMATI and MST were responsible for routinely recording service statistics and using them to project future demand for contra- ceptive methods. Due to the abrupt withdrawal of personnel as a result of the gag rule, and without the necessary oversight of these key organizations, the supply system has languished. The resulting loss of human resources destabilized UMATI’s entire program. 7 HIV/AIDS SERVICES HAMPERED UMATI and MST both offer high-quality HIV/AIDS services integrated with their family planning programs and clinics, but thus far these organizations have not accessed USAID funding for HIV/AIDS activities. Although HIV/AIDS activities at both NGOs are still technically eligible for U.S. support, it has been perceived that the funding will not be applicable because their HIV/AIDS prevention and vol- untary testing and counseling (VCT) services are offered as part of an integrated, comprehensive family planning and reproductive health program. MST claims that funding given only for specific HIV/AIDS activities will fragment reproductive health service delivery and fail to achieve the intended goal: to mitigate the impact of the HIV/AIDS epidemic. Tanzania will receive considerable U.S. support for HIV/AIDS through the President’s Emergency Plan for AIDS Relief (PEPFAR) – a new five-year, $15 billion initiative to fight the HIV/AIDS pandemic. The inability of Tanzania’s leading fam- ily planning NGOs to access U.S. HIV/AIDS assistance because their HIV/AIDS services are fully integrated with existing reproductive health services illustrates the extent to which the gag rule has limited vital HIV/AIDS work in Tanzania, and will continue to do so for years to come. In addition, the fear and uncertainty created by the gag rule have compromised potential partnerships between estab- lished family planning providers and new HIV/AIDS organizations. The lack of collaboration limits the effectiveness of HIV/AIDS prevention and treatment strategies and precludes new organizations from utilizing the existing infrastructure of organizations, particularly in the private sector. CONCLUSION In Tanzania, institutions and clients alike are suffering as a result of the gag rule. Public providers have been unable to meet the demand for family planning due to the lack of training and/or necessary supplies, leaving vulnerable women at risk for unplanned pregnancies. The government has also suffered because it lacks adequate capacity to pro- vide family planning services of the same scope or quality as MST or UMATI. Against the backdrop of increasing demand for comprehensive reproductive health services, including HIV/AIDS services, MST and UMATI find them- selves struggling financially to sustain their current level of services, especially in hard-to-reach rural areas, and have few alternative funding sources to turn to for assistance. The gag rule has stunted these NGOs’ ability to strengthen and expand access to critical reproductive health services for Tanzania’s women and youth. The fear and uncertainty created by the gag rule have compromised potential partnerships between established family planning providers and new HIV/AIDS organizations. 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 2004 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: © 2000 Megan Drennan, courtesy of Photoshare (inside front cover, pg. 3) © Population Services International, courtesy of Photoshare (pgs. 6, 8) 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 Kristina Graff. • U.S. RESTRICTIONS ON INTERNATIONAL FAMILY PLANNING Printed on recycled paper with soy-based ink. February 2005. ISBN: 1-889735-29-9

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