Impact of the Trump Administration’s Global Gag Rule on Sexual and Reproductive Health in Uganda

The Trump administration’s “global gag rule,” though now defunct, impinged on gains in sexual and reproductive health in Uganda that were made prior to the policy’s implementation. From May 2017 to January 2021, the policy prohibited US global health funding for non-US NGOs that provide abortion services; offer abortion information, counseling or referrals; or advocate abortion liberalization. Versions of the global gag rule have been repeatedly instated by US presidents from the Republican party and rescinded by Democratic presidents since 1984.

This fact sheet presents findings from a longitudinal study that used a quasi-experimental design to assess the impacts of the recent global gag rule on sexual and reproductive health service delivery and outcomes in Uganda. Changes in service delivery between 2017 and 2019 were assessed using data from 287 health facilities (223 of which were public) that provide family planning services, and changes in women’s health outcomes between 2018 and 2019 were assessed using data from a community-based panel of 2,755 women of reproductive age (15–49).

Impact on NGOs providing sexual and reproductive health services

• Because abortion is highly restricted in Uganda, most NGOs providing sexual and reproductive health services were not engaged in activities affected by the gag rule and were able to continue providing services after its implementation. However, some NGOs were forced to reorganize their activities to comply with the policy.

• Two large NGOs refused to comply with the gag policy and lost US government funding, resulting in the following reductions in services:

  • Programs were cut or scaled back. These included targeted programs providing sexual and reproductive health services to adolescents and to women living in rural areas, and a program that provided contraceptive-related training, and the provision of technical assistance to public health facilities and communities.

  • Service coverage was reduced for a mobile outreach program providing contraceptive care at public health facilities.

Impact on family planning services

Funding-related changes to NGO operations after the gag rule was implemented affected family planning services primarily by reducing the number of community health workers engaged to support family planning services.

• The overall number of community health workers engaged to provide family planning services decreased in the first year after the gag rule came into effect. Compared with facilities in other districts, facilities where NGOs reduced their services had an average of four fewer community health workers providing family planning services

• No changes were documented for other services, such as provision of long-acting reversible contraceptives (LARCs) or provision of integrated family planning with postabortion care or HIV services. This may have been a result of NGOs’ resiliency or the study’s inability to measure changes in caseloads for these services.

Impact on reproductive health outcomes

Uganda had seen steady increases in LARC use and decreases in unplanned births prior to the gag rule going into effect. These trends slowed or leveled off between 2018 and 2019 in districts where NGOs had scaled back services after having lost US funding.

• The proportion of women using LARC methods did not increase as rapidly in districts with reduced services as it did in districts without funding-related service changes.

• The decrease in unplanned births stagnated among women in districts with scaled-back services but continued to decline (by about three percentage points) among women in other districts.

Impact on postabortion care in public health facilities

The limits the gag rule placed on abortion did not reduce postabortion care provision in the first year after the policy’s implementation (from 2018 to 2019) but may have driven an uptick in the need for postabortion care during that period.

• Public health facilities’ capacity to provide postabortion care improved slightly, with capacity at Health Center IIIs increasing from 81% to 93%.

• The annual number of postabortion care cases rose 16% at public health facilities, an increase that outstripped population growth.

Recommendations

The government of Uganda has made progress in meeting women’s family planning needs over the past several decades, but the 2017 imposition of the global gag rule may have contributed to a slowdown in such progress. Action is needed to ensure that if the gag rule is reinstated by a future US administration, the provision of essential family planning services in Uganda is protected and the causes of unsafe abortion are addressed.

• Proactive policies should be considered in Uganda to ensure that both the public and private sector can continue to provide family planning services and that NGOs can continue to offer essential technical support to public health facilities.

  • Public funding for and provision of family planning services should be increased.

  • The Ugandan government should continue its support for incorporating family planning into health coverage programs.

  • The Ugandan government should work to reduce reliance on US funding by diversifying the donor pool supporting family planning.

• The US Congress should permanently repeal the gag rule to ensure that this policy cannot be reinstated and thus continue to erode the sexual and reproductive health and rights of women in Uganda and around the world.

• If the gag rule is reinstated, the Ugandan government, civil society and international NGOs should work collectively to ensure that all Ugandan NGOs are informed about the harmful effects this policy can have and what services are allowed under the policy.

• The Ugandan government must continue to support efforts to achieve gender equality and recognize that it cannot be achieved without the realization of sexual and reproductive health and rights.