Dismantled partnerships and coordination
Across the three countries, we found that the GGR fractured collaboration between organisations and facilities. This commonly occurred when the GGR prohibited a partnership, or when an NGO declined to certify the policy and subsequently lost USG funding, which limited their ability to partner. NGO representatives described disruptions to partnerships with community-based organisations and public and private health facilities that relied on them for financial and material support. Respondents linked these disruptions to service delivery impacts related to HIV, contraception, comprehensive abortion care and child health.
In Kenya and Nepal, NGOs that did and did not certify the GGR indicated that the policy threatened their sustainability by reducing the number of donor-funded projects for which they were eligible. NGOs reported severing partnerships with organisations with which they had established, trusting relationships because of the policy. In addition, whether or not an organisation certified the GGR became more important than their capacity as a project partner:
Usually the [partner organizations] are selected based on the following things- organizational policy and guidelines, organizational aim, experience, program coverage, their reviews from other partners, their history etc… This time we selected a few CBOs [community-based organizations] and among them, three of the organizations could not work with us as they were supported by USAID…since the USAID support was larger than ours and the local CBOs had to decide between the two of us, they continued work with USAID support. (Nepal, US-based NGO representative)
This participant went on to explain that their NGO had to reduce the geographic coverage of their work on abortion because they could not replace all of the initially selected CBO partners. In all three settings, non-certifying NGOs reported being forced to change their operations in order to accommodate smaller budgets and fewer partnerships. In Kenya, NGO representatives reflected on how the GGR’s impact on partnerships ultimately stymied the objectives and achievements of global health projects:
Because they [sub-grantee] have been denied funding, what we have been doing with them, now the indicators have dropped, the achievements have dropped. (Kenya, non-certifying NGO representative)
Work we could have done around integration in HIV programs is what is affected because they [certifying NGOs] might not want to…those are the ones who receive a lot of US government funding and…they might not be comfortable partnering with us. (Kenya, non-certifying NGO representative)
In Madagascar, although our results suggest that fewer NGO partnerships were dismantled by the GGR than in the two other countries studied, impacts of those that did end caused significant damage to the health system. The MOH’s primary NGO partner for contraceptive services declined to certify the GGR, subsequently lost USG funding, and was in turn forced to stop supporting nearly 200 public and private health facilities.
Previously, [non-certifying NGO] had a clinic in our town. In addition to the services, they provided training for midwives and [public health center] managers. We had a lot of these [NGO-supported public health centers] but their number has dwindled…[The non-certifying NGO] can no longer provide training for these facilities. [Their loss of USAID funding] has led to a decline in their activities and even the closure of several of their health facilities as well as layoffs. (Madagascar, MOH district representative)
NGO representatives in all three countries described the negative consequences of searching for and transitioning projects to replacement partners. Respondents in Kenya and Nepal described this work as tedious and time consuming, indicating that spending time recruiting new partners caused major disturbances in their normal workflow. In Madagascar, a protracted transition of USAID funding and supplies from the aforementioned non-certifying NGO to a US-based NGO left a number of hard-to-reach communities without mobile outreach SRH services for well over a year.
While the GGR mostly disrupted partnerships which hindered service delivery, some Kenyan organisations described how it contributed to a strengthening of some SRHR advocacy partnerships. For example, a number of SRHR organisations in Kenya—particularly those that were not subject to the GGR because they received no USG funding—expressed the perspective that the GGR engendered a newfound sense of comradery, and reinvigorated advocacy collaborations within local civil society:
I feel like we’ve strengthened partnerships as a result of the GGR. So we really have partnerships with a number of organizations within the local SRHR movement and [because of] the GGR we’ve been forced to kind of galvanize ourselves and really sit back and really re-strategize on how to address these issues. (Kenya, NGO representative)
Chilling effects on SRHR advocacy, policy debate, and referrals
In Kenya and Nepal, we found evidence of a ‘chilling effect’, whereby certifying NGOs applied unnecessary restrictions to their work to ensure compliance with the GGR and prevent scrutiny from USG donors. The chilling effect manifested in several ways: self-censorship and reduced participation in coalitions and meetings, and limitations beyond GGR requirements on referrals and service provision by certifying NGOs and affiliated facilities. Experiences indicative of the chilling effect were not reported in Madagascar.
Many NGO respondents lamented the disruptions to coalition, advocacy, and meeting environments caused by the GGR. Because of the chilling effect, USG-funded organisations were often reluctant, or even unwilling to attend meetings with organisations that did abortion-related work, even when the meetings were unrelated to abortion. Some certifying NGO representatives described feeling gagged in SRHR advocacy spaces where they used to be vocal, and in turn, respondents from non-certifying NGOs reflected on the loss of these partners in their coalition work.
Representatives from non-certifying NGOs reported that meetings hosted by certifying NGOs no longer included them. In Nepal, some groups working on abortion were even excluded from national policy discussions convened by the Ministry of Public Health:
…we were not invited for the policy discussion session; we had to make a separate effort for our entry. Along with us, none of the other NGOs working on abortion were invited to the discussion […] As per the information we have received, certain people [in the government] are influenced by USAID and are avoiding the abortion component. (Nepal, US-based NGO representative)
NGO and facility-level respondents described how the chilling effect ultimately had negative consequences for SRH clients. For example, several organisations that certified the GGR in Kenya and Nepal reportedly stopped providing referrals to non-certifying NGOs for services that are not restricted by the policy, such as contraception, post-abortion care, and abortion in cases of rape or incest or when the pregnancy endangers the woman’s life. Several organisations halted referrals for these allowable services altogether after certifying the GGR. One respondent in Kenya discussed the consequences of this overinterpretation:
At that point the understanding of the Global Gag Rule was that they [non-certifying NGO] could not do any [post-abortion care] referrals and therefore they were not able to help the others because they felt gagged and they did not know to what extent they were supposed to provide information to these women and say go to this place or go to that place. So from their end, the impact that they have seen is deaths. (Kenya, Certifying NGO representative)
Weakened service delivery infrastructures and consequences for clients
The data reveal that the GGR impacted SRH service delivery in all three countries, with public and private facilities experiencing similar changes, even though the policy did not apply to direct USG-public sector funding agreements. Across the three countries, MOH, facility and NGO respondents described health system weaknesses—such as contraceptive stock outs and staff transfers—which predated the Trump Administration’s GGR, but reported that the GGR exacerbated them by limiting the external supports provided by NGOs which they deemed imperative for health systems’ functionality.
Measures adopted by NGOs in the wake of GGR-induced funding losses included closing clinics, reducing staff stipends and supervision, and decreasing the number of staff providing outreach services, abortion and contraception, as well as the frequency at which these services were offered. In addition, NGO-facilitated training opportunities for providers diminished, which in turn harmed morale and limited quality of care:
After the limiting of funding you find that motivation of staff [diminishes]… training for example …you need a backup training that will assist you to gain knowledge and upgrade knowledge. So the reduction of the funding has really affected [us] because such training has stopped; so you find that there is no chance of you accessing the knowledge. (Kenya, public provider)
Public sector providers in Madagascar and Nepal described being unable to offer the full range of contraceptive methods without trainings previously offered by non-certifying NGOs. In both countries, a USAID-funded project intended to strengthen public sector provision of contraception ended early because the implementing NGOs did not certify the GGR. In turn, provider trainings on long-acting, reversible contraception (LARC) and permanent methods could not be completed as planned, leaving some public facilities without the capacity to meet client demands:
…none of the service providers of this health post have obtained IUCD [intra-uterine copper device] insertion training. One received SBA [skilled birth attendant] training and is expected to deliver the IUCD service but she is not confident about her skill in delivering IUCD. Due to that, we have been focusing only on implant while offering counselling to the client regarding the available range of family planning services. (Nepal, public provider)
Since 2018, we have sensitized many more women to use long-term methods, including tubal ligation. Since [the re-introduction of the GGR], the number of [trained] providers has decreased and when the women came for the tubal ligation… they left without even benefiting from this ligation. Some became pregnant because of it. (Madagascar, public provider)
Another consequence of the USAID-funded project’s early closure in both settings was a decline in public sector mobile outreach services in remote and underserved areas. Not having adequate budgets to organise contraceptive outreach themselves, both governments had come to rely on the non-certifying NGOs to fill the gaps. Without their support, some district governments in Nepal were unable to provide any contraceptive outreach services in 2018.
In addition to these impacts on providers and service delivery, interviewees in all countries described dealing with problems related to contraceptive supply chains that were compounded by the GGR. Delays in receiving commodities and stockouts of certain methods were mainly attributed to ongoing issues with national infrastructures. However, many providers and facility managers explained that supplementary stock provided by NGOs typically offset those challenges and that GGR-driven reductions in NGO support created sizeable gaps:
In addition, we cooperated with [non-certifying NGO] so they provided us with products. When our stocks were exhausted, [non-certifying NGO] gave us the products so there was no shortage. But currently, we are no longer in collaboration with [non-certifying NGO]. (Madagascar, public provider)
You see, the MOH normally supplies commodities quarterly, so when commodities are out of stock, you must wait for a time for you to receive them. So we do other things, like NGOs were coming in and try to sponsor [commodities], facilitate [the stocking of commodities] and things kept moving on; but since the [Global Gag] rule, [stock] has reduced because many NGOs have withdrawn their support, you see. (Kenya, public provider)
Due to contraceptive stockouts and/or lack of capacity to provide LARCs, public sector and NGO providers in each country reported asking contraceptive clients to return at a later date, transfer to another facility, or purchase supplies or commodities at a pharmacy and return to the facility so that the method could be safely administered. At the same time, clinic closures and service delivery changes caused by the GGR further shrank referral points for comprehensive SRH. In Kenya and Madagascar, several public and private facilities began charging clients for contraceptive services to cope with NGO funding losses. Providers expressed concern for the well-being of their clients, knowing that these costs were prohibitive for many of them:
When [women] could no longer afford the pills, many ended up giving birth. Among those who used to come to me, many became pregnant. (Madagascar, community-based midwife)
The GGR’s ultimate effects were on clients; long-term impacts reported in Madagascar include unintended pregnancies and distrust in the health system:
I couldn't find any [contraceptive method]. I had just 1,000 ariary and we can't devote it to that because we can't let our children sleep without eating. … Then after, the deadline for meeting with the midwife passed. And I got pregnant. (Madagascar, client)
The service also becomes bad, the confidence of the women decreases because when they arrive at the site they do not get the product because of the stockout. (Madagascar, MOH representative)
Some [clients] complain a lot [when their preferred method is unavailable], but we try to convince them to use other contraceptive methods that are available at the time. Some of them don't want to, and so they just don't. It is mainly young people who complain, because for them FP was free. They say that we sensitized them to practice FP, and when they are finally ready to do it, the products are not even there. They think that we are wasting their time. It’s as though we’re the ones lying when it’s the very products that are not available. (Madagascar, public provider)
