Malawi has seen a lack of access to HIV services in some areas, a siloing of health care, and a hold on legislation as a result of U.S. global health assistance policies.
The “global gag rule,” or Mexico City Policy, which states that foreign NGOs that receive any U.S. global health funding are prohibited from engaging in abortion-related activities, including providing counseling or education, hampers sexual and reproductive health services around the world. In Malawi, the policy has impacted policy and health more broadly, according to a report released last week.
“The global gag rule in Malawi, it is a death sentence for poor, rural women,” said Brian Ligomeka, director of the Centre for Solutions Journalism in Malawi, at an event last week. He shared the story of a young girl who was raped and wanted to seek emergency contraception, but the clinic near her had closed because of the global gag rule. This drove her to a traditional healer, whose treatment to end her pregnancy led to her death.
Previous versions of the policy applied only to family planning funding. The Trump administration went further, applying these restrictions to nearly all federal global health assistance, including HIV funding through the U.S. President's Emergency Plan for AIDS Relief.
Another advocate from Malawi, Emma Kaliya, director of the Malawi Human Rights Resource Centre, described a culture of intimidation resulting from the expanded global gag rule.
“It's like putting everybody at ransom,” she said. “It really undermines the dignity and respect of other member states and also organizations that work there because it affects the efficiency and effectiveness of our operations.”
Local staff working for U.S.-funded organizations or projects have pressured her to sign a letter saying her organization would agree to the global gag rule to get funding. She has refused, Kaliya said, adding that she didn’t like that Malawians were pushed to do another country’s bidding.
The reinforcement of negative attitudes toward women’s reproductive choices, known as a chilling effect, was evident even as The Center for Health and Gender Equity conducted its research last summer across five districts in Malawi. Several prime and subprime U.S. partners told the CHANGE team they could not participate in the research because of the global gag rule, said Bergen Cooper, director of policy research at CHANGE.
What local civil society organizations and program beneficiaries reported is that the global gag rule is causing the siloing of health care, as well as negatively impacting localization efforts, HIV services, and local government policy.
U.S. policies are directly impacting citizens far away, and while U.S. investment in health in Malawi is impressive, it is put at risk by some of those policies, said Karl Hoffman, president and CEO of Population Services International, at an event last week.
“As the world moves slowly, unsteadily, and unevenly toward better integration of health services, more effective utilization of scarce public resources — be they national or international — and more impactful health programming to sustain the productive rise of the population of Malawi, policies matter,” he said. “Policies imposed by the Trump administration have the effect of frustrating that integration, that effective utilization, that optimization of our investments.”
Others sexual and reproductive health advocates said the global gag rule has hurt efforts to further integrate health care.
The U.S. government and U.S. global health assistance has been moving toward integration to provide clinics people can visit to get a range of services, from prenatal care to HIV and malaria treatment. Many of the clinics that have closed in Malawi offered more than sexual and reproductive care, Ligomeka said.
“In some cases it was the only clinic in that area, which means the entire community now will be affected because they have nowhere they will access medical and health services,” he said.
The global gag rule serves to undermine some global health objectives, because sexual reproductive health and rights issues are so “interconnected that when you pick out one of the things in that continuum, then you will not achieve your target,” Ligomeka said.
The U.S. has also been making a push to localize more of its aid delivery and work with an increasing number of local organizations — efforts undermined by the global gag rule, said Beirne Roose-Snyder, director of public policy at CHANGE.
Many local organizations are now excluded from being able to receive U.S. funding — often the same organizations led by and serving hard to reach key populations, she said.
While it's too soon for data on the impact of the global gag rule on HIV incidence and prevalence rates, the disruption to programs and access to treatment in Malawi is already raising concerns for advocates.
People who were getting medicines from clinics that closed are highly likely to default on their treatment, and others are at higher risk of contracting the virus without access to services and education that would prevent transmission, Ligomeka said.
“What is happening is that the policy’s actually increasing the transmission of HIV and AIDS,” he said.
CHANGE has seen an impact across a range of HIV services and is able to document what happens when clinics close, but the quantitative data won’t be available for years.
The research looked specifically at the impact on PEPFAR’s DREAMS partnership, which had shown success in Malawi. In one case, a clinic closed when the local partner could not comply with the global gag rule. The community was left without programming until a new international implementer was brought on board.
The report also looked at PEPFAR’s Linkages program, which targets key populations, specifically female sex workers. In Malawi, an organization that had been running the program did not comply with the global gag rule and went from operating in 12 districts to operating in eight.
“These are organizations who have built up the trust of the community and another partner can’t step in the next day,” Cooper said.
The global gag rule has had a chilling effect on local policies in Malawi, specifically a piece of legislation that would have amended the country’s abortion rules.
In Malawi, abortion is legal only when the life of the pregnant person is in danger. Getting an abortion otherwise can result in a prison sentence of between seven and 14 years. But in 2015 the Termination of Pregnancy Bill was introduced in the Malawian parliament to change the law and allow for safe abortion services “in the cases of rape, incest, fetal anomaly, and danger to the mental or physical health or life of the pregnant person.”
The bill was making progress, but the former minister of health slowed the bill “due to its potential to negatively impact the government of Malawi’s relationship with the U.S. government,” the report says.
The U.S. is the largest bilateral donor to Malawi. More than 90% of the funding the Trump administration requested in its fiscal year 2020 budget request for the country was slated to go toward health programming, the majority of which would fund PEPFAR, according to the report.
“Trump’s expanded GGR has halted national progress toward abortion law reform in Malawi and has undermined both national legislative process and national sovereignty,” the report says.
The government was worried it would lose U.S. funding if the new law was passed, so the bill was tabled, Ligomeka said.