Reproductive Justice and the Politics of Abortion: the Early Impact of the Protecting Life in Global Health Assistance Policy in Uganda

Reproductive Justice and the Politics of Abortion: The Early Impact of the Protecting Life in Global Health Assistance Policy in Uganda

Georgia Maynard (11178892) [email protected]

Word count: 23,183 Date of submission: July 2018

University of Amsterdam Graduate School of Social Sciences International Development Studies

Supervisor: Esther Miedema, Ph.D. Second Reader: Courtney Vegelin, Ph.D.

This thesis is dedicated in memory of Alison, none of this would have been possible without her.

“I am an adamant supporter of reproductive rights. Reproductive decision- making is incredibly complex and the only person who has the right to decide whether to continue or terminate a pregnancy is the pregnant woman herself.”

Alison Piepmeier, Ph.D.

December 11, 1972 – August 12, 2016

Acknowledgements

First and foremost, I would like to thank those who I cannot name: the health workers who participated in this study and described how the Protecting Life in Global Health Assistance policy affects their important work in the field of sexual and reproductive health and rights in Uganda. Weebale, thank you, for sharing your insights and experiences with me; neyanzizza, I am grateful, for your trust, courage, and candor.

Thank you to my supervisor, Esther, who provided invaluable feedback and advice throughout the research process. Her endless patience and obliging willingness to read draft after draft helped this thesis come to fruition. I would also like to extend my thanks to Courtney for her guidance throughout the program and her critique as second reader. This thesis would not exist without her input in the final stages.

My deepest gratitude goes to my parents, Monique and Donald, for their unwavering support and unconditional love. Thanks to my sister, Caitlin, who challenges me in the ways I learn the most from. The path here was not linear and it truly takes a village; I am honored by those who help fortify my own.

Finally, special thanks to the many cats who have encouraged (and more often distracted) me along the way, Lucille, Persephone, Mr. Biscuits, and the fourteen felines who shared their home with me on Mbuya Hill.

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Abstract:

On January 23, 2017, President Donald Trump reinstated the Mexico City policy, an executive order that requires foreign non-governmental organizations (NGOs) to certify that they will not engage in any abortion-related work as a condition for remaining eligible to receive foreign assistance from the United States. The Reagan-era policy expanded by the Trump-Pence administration, now referred to as the Protecting Life in Global Health Assistance (PLGHA) policy, affects more than USD$10.3 billion of bilateral assistance allocated for a wide range of programs. Critics of the so-called “global gag rule,” argue that the policy does not achieve its intended purpose of reducing rates of abortion. On the contrary, evidence has shown that when the policy was in place in the past it has been associated with increased rates of abortion.

Studies conducted by research and advocacy organizations show that the PLGHA policy is already having a detrimental effect on sexual and reproductive health and rights (SRHR). With a view to exploring the real-life implications of the PLGHA in Uganda, this study sought to determine how NGOs understand and interpret the provisions of the PLGHA policy and analyze the impact of the policy decisions they made based upon their interpretation on SRHR, civil society, and political discourse in Uganda. Eighteen in-depth semi-structured interviews were conducted with Ugandan health workers employed by eight NGOs headquartered in Kampala. Four of which have refused to comply with the PLGHA policy, two have complied, and the remaining two have not yet determined their position on compliance. Participants reported confusion regarding understanding the provisions of the PLGHA policy, structural and programmatic adjustments in response, and fears of increased rates of unsafe abortion and associated maternal mortality as a result.

The findings of this study present compelling empirical evidence substantiating claims that the policy has unintended adverse effects upon access to, and availability of, health services. Central to this study is an understanding of how health workers conceptualize the PLGHA policy, as their perceptions of the policy itself shape the ways in which they respond to it. The evidence further demonstrates that the adverse effects of the PLGHA policy are exasperated by poor communications regarding the exact provisions of the policy, resulting in NGOs resorting to their own interpretation of the policy and the potential of losing significant funding.

Keywords: Mexico City policy, Protecting Life in Global Health Assistance policy, Global Gag Rule, Uganda, United States (U.S.), reproductive justice; Sexual and Reproductive Health and Rights (SRHR), abortion;

List of Acronyms and Abbreviations

CEHURD Center for Health, Human Rights and Development

CRR Center for Reproductive Rights

CRS Congressional Research Services

CSO Civil Society Organization

DOS Department of State

ICPD International Conference on Population and Development

IPPF International Planned Parenthood Federation

MCP Mexico City Policy

MDGs Millennium Development Goals

MOH Ministry of Health

MSI Marie Stopes International

MSU Marie Stopes Uganda

NGO Non-Governmental Organization

PAI Population Action International

PLGHA Protecting Life in Global Health Assistance

POA Program of Action

UN United Nations

UNFPA United Nations Population Fund

U.S. United States

USAID United States Agency for International Development

RHU Reproductive Health Uganda

SDGs Sustainable Development Goals

SRHR Sexual and Reproductive Health and Rights

WHO World Health Organization

Table of Contents Chapter One: Introduction ...... 1 1.1 Background of the Study ...... 1 1.1.1 Contextualizing the Problem of Unsafe Abortion ...... 3 1.2 Existing Evidence and Gaps in Knowledge ...... 5 1.3 Purpose of the Study ...... 9 1.4 Structure of the Thesis ...... 11 1.5 Concluding Remarks...... 11 Chapter Two: Overview of the PLGHA Policy and Study Setting ...... 13 2.1 Introduction ...... 13 2.2 Overview of the PLGHA Policy ...... 13 2.2.1 Introduction of the Mexico City Policy ...... 13 2.2.2 The Politics of the Policy ...... 14 2.2.3 The PLGHA Policy Expanded by Trump in 2017 ...... 15 2.3 Country Context: Uganda ...... 18 2.3.1 Setting of the Study ...... 19 2.3.2 The Legal Status of Abortion in Uganda ...... 22 2.4 Conclusion ...... 24 Chapter Three: Theoretical Framework ...... 25 3.1 Introduction ...... 25 3.2 Reproductive Justice ...... 25 3.2.1 Defining Reproductive Justice ...... 25 3.2.2 The Inadequacy of “Choice” ...... 27 3.2.3 The Challenges and Possibilities of Using Human Rights to Improve Access to Safe Abortion ...... 28 3.2.4 The Critical Constructivist Approach: From “Choice” to Context ...... 31 3.6 Conclusion ...... 34 Chapter Four: Methodological Framework ...... 35 4.1 Introduction ...... 35 4.2 Research Question and Sub-Questions ...... 35 4.2 Data Collection ...... 36 4.2.1 Sampling Strategies ...... 36 4.2.2 Participant Observation ...... 38 4.2.2 Semi-Structured In-Depth Interviews ...... 39 4.2.3 Document Analysis...... 40 4.3 Data Analysis ...... 41 4.4 Limitations of the Study ...... 41 4.5 Ethical Considerations ...... 42 4.6 Conclusion ...... 43 Chapter Five: Ugandan Health Workers’ on the Impact of the PLGHA Policy ...... 44 5.1 Introduction ...... 44 5.1.1 Understanding the PLGHA Policy ...... 44 5.2 How do Ugandan health workers see U.S. government policies on SRHR, the PLGHA policy in particular, affecting SRHR in Uganda?...... 47 5.2.1 In Relation to the Legal Status of Abortion...... 47 5.2.2 Reinforcing Structural Barriers to SRH-Related Services ...... 48 5.2.3 SRHR: The Concept of Rights as Applied to Sexuality and Reproduction ...... 52 5.3 How do Ugandan health workers see U.S. government policies on SRHR, the PLGHA policy in particular, affecting civil society organizations in Uganda? ...... 54 5.4 How do Ugandan health workers see U.S. government policies on SRHR, the PLGHA policy in particular, affecting political discourse in Uganda? ...... 55 5.5 Efforts to Mitigate the Effects of the PLGHA Policy ...... 57 5.6 Conclusion ...... 58 Chapter Six: Discussion of Findings, Recommendations, and Conclusion ...... 59 6.1 Introduction ...... 59 6.2 Discussion of Findings ...... 59 6.2.1 Impact of PLGHA Policy on SRHR in Uganda ...... 60 6.2.2 Impact of PLGHA Policy on Ugandan Civil Society ...... 63 6.2.3 Impact of the PLGHA Policy on Political Discourse in Uganda ...... 64 6.3 Recommendations for Policy, Practice, & Research ...... 65 6.3.1 U.S. Government ...... 65 6.3.2 Recipients of U.S. Global Health Assistance ...... 66 6.3.3 Donor Governments and International/Regional Organizations ...... 66 6.3.4 UN Agencies ...... 66

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6.3.5 Governments in Countries that Receive U.S. Global Health Assistance ...... 66 6.3.6 Researchers ...... 66 6.4 Conclusion ...... 67 Appendix A: United States Policy Statement at the ICPD 1984 ...... 69 Appendix B: Memorandum of January 23, 2017 ...... 76 Appendix C: Standard Provisions for Non-U.S. Nongovernmental Organizations ...... 77 References ...... 87

Chapter One: Introduction 1.1 Background of the Study

In the aftermath of the 2016 presidential election in the United States of America, fears and anxieties over the status of reproductive rights both domestically and abroad proliferate and the current administration has done little to assuage them (Girard, 2017; Starrs, 2017). Within days of the inauguration of Donald J. Trump as President of the United States in January 2017, the incoming Trump-Pence administration took drastic steps to undercut and dismantle U.S. support for sexual and reproductive health and rights (SRHR) around the world (Barot, 2017). Access to sexual and reproductive health services, including safe and legal abortion, faces old and new threats and global health advocates are rightfully concerned that the current administration threatens to derail efforts to advance women’s health and rights and decades of progress are at risk (Girard, 2017). This is perhaps best exemplified by President Trump’s decision to reinstate an executive order expanding antiabortion restrictions to U.S. foreign aid.

On January 23, 2017, President Trump reinstated “the Mexico City policy” (hereinafter, “the MCP”), a U.S. government policy that, when in effect, has required recipients of foreign assistance to certify that they will not “perform or actively promote abortion as a method of family planning,” as a condition for receiving U.S. global health assistance (United States Agency for International Development [USAID], 2017: 85) (see Appendix B for the full January 23, 2017 Memorandum). The policy, first introduced by the Reagan administration at the second International Conference on Population and Development (ICPD) in Mexico City in 1984, has been rescinded and reinstated by subsequent administrations along party lines (see Appendix A for the original policy statement at the ICPD in 1984). Under the Trump administration, the MCP has been renamed “the Protecting Life in Global Health Assistance policy” (hereinafter, “the PLGHA policy”), and its scope is expanded to all of U.S. bilateral global health assistance furnished by all agencies and departments, including funding for HIV/AIDS under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), maternal and child health, infectious diseases including malaria, tuberculosis, nutrition, global health security, family planning, and reproductive health (USAID, 2017) (see Appendix C for the Standard Provisions for Non-Governmental Organizations).

The funding crisis provoked by the Trump administration is but one facet of the challenges that the ascendancy of conservative populist nationalism has created in relation to SRHR, and abortion rights in particular. Following the decision to reinstate the PLGHA policy, in April 2017, the Trump administration announced it would no longer fund the United Nations Population Fund (UNFPA), which supports reproductive health programs in more than 150 countries (Barot, 2017). The stated reason for this blocking of funds is that the UNFPA uses funding to support coercive abortion and sterilization, a claim that has been repeatedly disproven, including by a team sent by the U.S. Department of State (Barot & Cohen, 2017). Preceding the decision to leave the United Nations Human Rights Council in June 2018, U.S. government officials were instructed to pare back passages that focus on reproductive rights and gender- and race-based discrimination in annual global human rights reports. Additionally, for fiscal year 2019, the Trump administration proposed slashing funding for international family planning by 50 percent (Barot, 2017).

The global health community is concerned that U.S. policymakers are making decisions that could reverse gains for equality, reproductive health, rights, and justice worldwide (Girard, 2017). The United States has historically been the largest donor of global health assistance and the leading implementer of health programs in the world (U.S. Mission to Uganda, 2017). With a budget request proposal for USD$10.3 billion in 2017 in funding for global health, the U.S. remains the world’s largest source of global health financing (Singh & Karim, 2017). These anti-abortion decisions and policies will have a profound impact in recipient countries that often rely on external donor financing for health. Activists and academics posit that harmful policies and shortsighted funding cuts to international assistance impact the most vulnerable populations disproportionately and undermine cornerstones of U.S. foreign policy centered on human rights.

The direct impact of the PLGHA policy on the capacity of health workers to serve their communities is multiplied by the perceived vagueness of the policy language coupled with the fear of transgressing policy mandates by financially vulnerable organizations. How individuals understand and interpret the PLGHA policy affects the ways in which they respond to it, perhaps even more so if they perceive it to be entirely prohibitive of any abortion-related work. In this way, NGOs often self-censor or make adjustments that would not be required by the PLGHA policy. NGOs that depend upon official aid for their existence and ability to provide services and forced to choose between adjusting their service provision practices in hopes of being assessed as compliant or refusing the world’s single largest source of development aid in order to maintain their ability to determine their own work practices.

1.1.1 Contextualizing the Problem of Unsafe Abortion

Abortion is a universal phenomenon that has been commonly practiced in most parts of the world throughout recorded history, yet it remains a deeply divisive and contentious issue (Shah and Åhman, 2009; Shah, Åhman, & Ortayli, 2014). Despite the universality of abortion practice, debate on the topic of abortion is fraught with social, political, economic, and legal complexities. The ubiquity of abortion, despite legal restrictions and social conventions, demonstrates that women will resort to abortion irrespective of its legal status and stigma (Shah and Åhman, 2009; Shah, Åhman, & Ortayli, 2014).

Recent worldwide estimates indicate that approximately 56 million abortions occur each year, almost half of which (25 million) are classified as unsafe (Sedgh et al., 2016). The World Health Organization (WHO) defines unsafe abortion as, “a procedure for terminating an unintended pregnancy by either individuals without the necessary skills or in an environment that does not conform to the minimum medical standards, or both” (World Health Organization [WHO], 1992: 3). Unsafe abortion and inadequate post-abortion care are significant contributors to maternal morbidity and mortality worldwide (Benson, Andersen, & Samandari, 2011; Faundes & Shah, 2015). Almost seven million women around the world seek treatment in health facilities due to complications from unsafe abortion, and between 22,800 and 31,000 women die each year, making unsafe abortion one of the world’s major preventable causes of maternal mortality (Bearak et al., 2018; Grimes et al., 2006). Unsafe abortion is a pervasive public health issue and ending the preventable pandemic of unsafe abortion is an urgent human rights imperative (Grimes et al., 2006).

The vast majority of unsafe abortions occur in developing countries (97 percent) where abortion is legally restricted whereas legal abortion has emerged as one of the safest medical procedures in the industrialized world (Grimes et al., 2006). A woman’s likelihood of having an induced abortion is almost the same whether she lives in a developed (26 per 1,000) or a developing country (29 per 1,000), the main difference is safety (Shah and

Åhman, 2009). Legal restrictions do not eliminate the practice or need for abortion; when faced with unwanted or unintended pregnancies, women resort to induced abortion irrespective of legal restrictions (Shah & Åhman, 2009).

Information on the incidence of induced abortion, whether legal and safe or illegal and unsafe, is critical to identifying policy and programmatic needs aimed at reducing unintended pregnancy and addressing its consequences (Shah & Åhman, 2009). Understanding the magnitude of unsafe abortion and related to maternal mortality and morbidity is critical to addressing this major yet neglected public health problem (Shah & Åhman, 2009). In particular, ascertaining the magnitude of abortion in places where it is legally restricted is essential to understanding the toll it takes on women’s health and lives (Singh et al., 2017). Estimating the magnitude of unsafe abortion is complex due to the scarcity of reliable data; induced abortion is generally stigmatized and frequently censured by religious teachings or ideologies, which makes women reluctant to admit to having had an induced abortion (Shah & Åhman, 2009). This problem is exacerbated in settings where induced abortion is restricted and inaccessible or legal but difficult to obtain (Shah & Åhman, 2009).

Despite significant reductions in pregnancy-related deaths in Uganda over the past two decades, the high number of maternal deaths remains a major public health challenge. An estimated 314,300 abortions took place in Uganda in 2013, accounting for 14% of all pregnancy outcomes, a slight increase from 294,000 in 2003 (Prada et al., 2016). Ugandan law explicitly allows abortion to save a woman’s life, however, the laws and policies on abortion are interpreted inconsistently making it difficult for providers to determine when and how they can provide services and information in accordance with the law. The legal status of abortion in Uganda is complex as the laws and policies governing abortion lack clarity and consistency. Therefore, it is difficult for providers and women to provide and obtain an abortion (Center for Health, Human Rights and Development [CEHURD], 2016).

In Uganda, more than half of pregnancies are unintended (52%) and roughly a quarter of these unintended pregnancies end in abortion each year (Prada et al., 2016). This is in part due to the unmet need for contraception which research has shown contributes to the high rate of unintended pregnancy (Singh et al., 2017). Meeting women’s contraceptive needs is a critical strategy to help avoid unintended pregnancies (Singh et al., 2017). Essential to the topic of abortion is an understanding of the linkages between contraceptive prevalence, the unmet need for family planning, unplanned pregnancies, and unsafe abortion (Shah & Åhman, 2009).

The PLGHA policy forces NGOs to make an untenable choice: to either stop abortion-related work or lose critical funding from the U.S. Both decisions lead to cuts in health services. The policy is referred to derisively by opponents as the “Global Gag Rule,” because it prohibits foreign NGOs from using non-U.S. funds to provide information about abortion as a method of family planning and to lobby a foreign government to legalize abortion. The policy prohibits foreign NGOs from providing advice and information about and offering referral for abortion, promoting changes in a country’s laws or policies related to abortion, and conducting public information campaigns about abortion (USAID, 2017). The policy does not prohibit providing advice and information about and offering referral for abortion in cases where the pregnancy either poses a risk to the life of the mother or resulted from incest or rape. Further, the policy provisions to not restrict service provision when responding to a question about where a safe and legal abortion may be obtained when a woman who is already pregnant clearly states that she has already decided to have an abortion (this is referred to as passively providing information versus actively providing information) (USAID, 2017).

Civil society organizations, including NGOs and health workers, have recognized the threats to women’s health and established the capacity to provide contraception and health care services. Despite the clear need for such services, the evidence of the consequences of refusing health services to women, the PLGHA policy has been seen to restrict and reduce access to health care directly, through reductions in funding, or indirectly through coercive action that forces health workers to amend service provision according to their interpretation of the policy.

1.2 Existing Evidence and Gaps in Knowledge

There has been some research published about the impact of the MCP in the past and more recently studies have been conducted on the early effects of the PLGHA policy since January 2017. To date, only two quantitative studies have examined the association between the

MCP and rates of self-induced abortion (see: Bendavid, Avila, & Miller, 2011 and Jones, 2011). There is no scientific evidence suggesting that the MCP has successfully achieves its intended goal of reducing rates of abortion. The 2011 quantitative analysis found a strong association between the MCP and abortion rates in 20 countries in sub-Saharan Africa between 1994 and 2008 (see Figure 1 below) (Bendavid et al., 2011). Countries were categorized by exposure to the MCP which was determined by the amount of foreign assistance they received from the United States. The study found that the rate of induced abortion rose in countries with high exposure to the MCP relative to those with low exposure (Bendavid et al., 2011). The researchers found patterns indicating that the MCP was associated with increases in induced abortion rates likely because foreign NGOs that declined U.S. funding as a result of the MCP – often key providers of health services – had fewer resources to support family planning services, particularly contraceptives (Bendavid et al., 2011: 877). Increased access to and use of contraception has been shown to be key to preventing unintended pregnancies and thereby reducing abortion, including unsafe abortion (Singh et al., 2017).

Figure 1 Association Between Exposure to the MCP and Rate of Self-Induced Abortion in Sub-Saharan Africa (Bendavid et al., 2011).

That same year, a second quantitative study endeavored to determine whether or not the MCP accomplished its aim of reducing the use of abortion in Ghana (Jones, 2011). The researcher reported that there was no statistically significant evidence that the U.S. policy reduced the use of abortion, however, the rate of conception among rural women increased by 12 percent when the policy was in effect (Jones, 2011). With pregnancy increasing at a time when contraceptive access is restricted, nearly 20 percent of the additional pregnancies of rural women ended in abortion, yielding a 50 percent increase in the share of pregnancies aborted (Jones, 2011). After presenting the evidence, Jones concluded: “any further efforts to reinstate this policy could only be considered a wrongheaded political stunt,” as the MCP did not achieve its purported purpose in the case of Ghana (Jones, 2011).

Several qualitative studies have sought to explain how the effects of the policy take shape. Following President George W. Bush’s reinstatement of the MCP in 2001, Population Action International (PAI) conducted research in four countries (Ethiopia, Kenya, Romania, and Zambia) to determine whether and how the restrictions affected reproductive health services in countries with differing legal statuses of abortion (Population Action International [PAI], 2001). This study found that the MCP “forces a cruel choice” that results in reduced access to family planning and related sexual and reproductive health services due to clinic closures and scaled back service provision (PAI, 2001). A key finding was commodity insecurity; PAI reported that the MCP resulted in the loss of U.S.-funded contraceptives in 29 countries, including Uganda (PAI, 2001). A similar report was published by the Center for Reproductive Rights (CRR), on the impact of the MCP in Ethiopia, Kenya, Peru, and Uganda (Center for Reproductive Rights [CRR], 2001). The study found that the MCP contributed to the problem of unsafe abortion by preventing NGOs from providing comprehensive sexual and reproductive health services (CRR, 2001). The lead researcher argued that the MCP infringed upon the right to free speech, prevented democratic participation, and curtailed the development of civil society (CRR, 2001).

In addition to studies conducted by research and advocacy organizations, the U.S. government has commissioned reports to monitor and evaluate the implementation and enforcement of the MCP in 1990 and a more recent six-month review of the PLGHA policy in February 2018 (Blane & Friedman, 1990; U.S. Department of State, 2018). The report published in 1990 (Blane & Friedman) sought to determine whether NGOs were in compliance with the provisions of the MCP, whether the provisions were understood by the recipients, and to determine the impact the MCP had on family planning programs (Blane & Friedman, 1990). Six countries (Pakistan, Bangladesh, Brazil, Kenya, Egypt, and Turkey) were included in the report (Blane & Friedman, 1990). The study concluded that most recipients had not been “affected significantly” by the MCP, however, the authors reported that NGOs were overly cautious based on concerns that “any association with abortion-related activities” could jeopardize funding (Blane & Friedman, 1990: vvi). The researchers found

that the over cautiousness was due to the confusing legal language and consequently recommended the U.S. government take steps to ensure that the provisions are understood by recipients (Blane & Friedman, 1990). In February 2018, the U.S. government released a six-month review of the PLGHA policy documenting the implementation, enforcement, and impact of the policy, as well as identifying challenges that have arisen and recommended actions to address them (U.S. Department of State, 2018). Acknowledging that less than six months of the PLGHA policy implementation is too early to assess the full scope of the policy, the report found that partners presented with the standard provision have “largely accepted the policy,” however, feedback and discussions with U.S. government staff indicates that further guidance is needed to clarify the terms of the standard provision (U.S. Department of State, 2018: 2).

The most reports on the ramifications of the current iteration of the PLGHA policy find that negative effects are already taking shape. In 2018, the Human Rights Watch (HRW) wrote a letter to former Secretary of State, Rex Tillerson, with the findings of their study on the early impact of the expanded PLGHA policy conducted in Uganda and Kenya (Human Rights Watch [HRW], 2018). According to HRW, a lack of information about the policy and an overreach in its implementation has resulted in reductions of key SRH-related services from well-established organizations (HRW, 2018). As was the case of this study, the researchers highlighted the concerns from health workers about the likelihood of increase unsafe abortions and associated maternal deaths (HRW, 2018). The Center for Health and Gender Equity (CHANGE) has also published a report mapping the development and implementation of the MCP and explores the immediate impacts of the PLGHA policy in Mozambique and Zimbabwe yielding similar findings, with a focus on the impact on human rights (Center for Health and Gender Equity [CHANGE], 2018). Another study conducted by the International Women’s Health Coalition’s (IWHC) report, documents the effects of the PLGHA policy in Kenya, Nigeria, and South Africa, reviewing the impact in different legal contexts (International Women’s Health Coalition [IWHC], 2018). In 2018, PAI documented the preliminary impacts of the PLGHA policy on SRHR in Uganda and Nigeria. The overarching themes evident in these reports published by research and advocacy organizations suggest that the PLGHA policy is already affecting the provision of SRH-related services, particularly by those who choose to forgo funding from the U.S. Both quantitative and qualitative evidence shows that the reinstatement of the MCP in the past has been positively associated with increased abortion rates in affected countries, and more recent studies suggest that the expansion of the PLGHA policy has magnified its effects. Critics and activists have opposed the policy on the grounds that it undermines the full basis for bodily autonomy and integrity by denying the availability of comprehensive SRH-related services and the violation of human rights, including reproductive rights. Equally important, the PLGHA policy is counter to achieving key goals reflected in development agendas, including the 2030 Sustainable Development Goals (SDGs).

The PLGHA policy is taking shape as many NGOs around the world and in Uganda are determining whether to comply with the provisions or forgo funding. As the PLGHA policy is still in its early stages of implementation and enforcement, it is imperative that researchers continue to study the implications of the policy through analytical frameworks. Research on how civil society organizations conceptualize the PLGHA policy in relation to their decision- making processes can help elucidate key issues identified in this study. Further research exploring the gap in knowledge as to how health workers interpret and respond to the PLGHA policy could help policymakers address the pervasive problem of confusion and misinterpretation of the policy.

More research on the impact of the PLGHA policy is necessary to determine the long-term effects of the policy in recipient countries. While a number of the studies mentioned above have provided critical insights into the effects of the policy on the ground, future research must take into account the context-specific implications of the PLGHA policy within each country setting. Drawing on the reproductive justice framework, this study explicitly analyzes the impact of the PLGHA policy in Uganda through a critical constructivist approach moving from individual choice to context. Reproductive justice is based on human rights frameworks that identify rights to bodily integrity and self-determination, and the obligation of government to ensure that the conditions enable individuals to be able to make those decisions. In addressing the PLGHA policy in the context of the preventable pandemic of unsafe abortion, this thesis seeks to address the conditions that allow it to proliferate in Uganda.

1.3 Purpose of the Study

As donors, governments, and NGOs form partnerships to address the issue of unsafe abortion, the need for a stronger focus on the evaluation of interventions has become evident (Benson, 2005). As policies are translated into services provided, donors and policymakers must ensure that funds are used efficiently, policies are evidence-based, and progress in access and quality can be measured (Benson, 2005). Monitoring and evaluation abortion-related policies and services can be challenging due to the lack of information readily available, partially due to the stigmatization of abortion and the often unsafe and private conditions in which it is practiced, however, it is clear that more research must be done to ascertain the impact of the PLGHA policy.

The purpose of the study was to explore how health workers in Uganda understand and interpret U.S. government policies on SRHR in light of the January 2017 expansion of the PLGHA policy. The study also examined health workers perspectives on how changes to service provision, either in terms of ability to provide adequate levels of service or of the elimination of those services perceived to be non-compliant, will affect reproductive health, rights, and justice in Uganda.

The findings of this study show that the unprecedented expansion of the PLGHA policy is causing confusion among civil society organizations. As a result of the decision to forego funding, programs and clinics are closing, civil society organizations and coalitions are disbanding, and the political discourse in Uganda is skewed in favor of ideologically-driven morality politics. Health workers fear that the reinstatement of the PLGHA policy and subsequent programmatic shifts made by NGOs will result in reduced service provision and a rise in unwanted pregnancies, unsafe abortion, and associated maternal morbidity and mortality.

This qualitative study was conducted over the course of eight weeks in Uganda between June and August 2017. In-depth semi-structured interviews were conducted with 18 participants representing eight NGOs working in the field of SRHR. The research question guiding this study was: How are U.S. government policies on SRHR, the PLGHA policy in particular, understood and interpreted by civil society organizations, and what implications do they have for reproductive rights and justice in Uganda? This question seeks to reframe the issue and link the issue of anti-abortion regulations to the broader development agenda, as there is substantial evidence indicating that a myriad of social, economic, and political aspects improve when women control their own fertility.

While it is too early to fully understand the long-term consequences of the PLGHA policy, the primary source data gathered for this report contributes to a growing body of research demonstrating that the policy has dire consequences for health. The hope is that policymakers, public health advocates, and health workers will use the report’s findings to develop informed policies and practices that could help reduce unintended pregnancies and alleviate the negative impact of unsafe abortion on the health and lives of Ugandan women.

1.4 Structure of the Thesis

This thesis is composed of six chapters, the first of which has introduced the PLGHA policy and established the problem of unsafe abortion, and proceeds as follows. The second chapter (Chapter Two) provides a historical overview of the politics of the PLGHA policy and describes the Ugandan context of the study setting. Chapter Three presents the theoretical framework of the study and explores the use of reproductive justice theory in contextualizing the effects of the PLGHA policy in Uganda. The fourth chapter (Chapter Four) outlines the methodological approach of this research, including the limitations of the study and the ethical considerations. Chapter Five presents the empirical data gathered during fieldwork conducted in Uganda. Finally, the sixth chapter (Chapter Six) discusses the findings of the study in relation to theory, summarizes the key findings in response to the main research question, and concludes with recommendations for policy, practice, and future research.

1.5 Concluding Remarks

This introductory chapter has situated the reinstatement of the PLGHA policy under the Trump administration in 2017 within the larger context of the pandemic of unsafe abortion. The findings of the study suggest that there is a widespread lack of understanding and confusion regarding the standard provisions of the policy, causing NGOs to impose unnecessary restrictions in order to avoid any inadvertent violation of the policy. Remarkably, the majority of the NGOs that participated in this study have opted to forgo funding from the United States and refused to comply with the provisions of the PLGHA

11 policy. This shows tremendous agency on the parts of Ugandan health workers and civil society organizations that communicated their determination to continue to provide comprehensive sexual and reproductive health services. A key component of this decision is an ongoing commitment to international human rights standards and a firm belief that women must have the right to information and abortion-related services.

Among the consequences of the PLGHA policy, as NGOs adjust to funding shifts as a result of the decision to refuse funding from the U.S., Ugandan health workers report clinic closures, scaled back outreach efforts, funding cuts for contraception provision, and reduced programming as a direct result of the PLGHA policy. Participants fear that the programmatic adjustments will reinforce structural barriers to the provision of SRH-related care and ultimately result in increased rates of unintended pregnancy, unsafe abortion, and associated maternal mortality and morbidity. Not only does the PLGHA policy impact the ability of NGOs to provide care, it shapes civil society in Uganda and prevents organizations that have formed coalitions to address the issue of unsafe abortion and associated maternal mortality. The effects of fractured relationships between client and provider, as well as civil society organizations, will likely have ramifications for the political discourse in Uganda.

Chapter Two: Overview of the PLGHA Policy and Study Setting 2.1 Introduction

The purpose of this contextual chapter is twofold: first, to provide the historical background underlying and informing the reinstatement and expansion of the PLGHA policy in January 2017, and second, to describe the setting of the study to understand the implications of the policy within the context in Uganda. Section 2.2 provides an overview of the evolution of the MCP from its conception under the Reagan administration in 1984 and the policy’s political trajectory until its expansion as the PLGHA policy under the Trump administration in 2017. As Lowi (1988) points out, there is an “intimacy” of the “historical association between the type of policy and the type of politics that tends to be associated with it,” and therefore the political history of the policy is explored here (Lowi, 1988: xii). The second half of this chapter (Section 2.3) provides an account of the social, economic, political, and legal context in Uganda as it relates to the topic of this study, including an overview of the legal status of abortion.

2.2 Overview of the PLGHA Policy

This section describes the political history of the PLGHA policy. The sub-sections detail the introduction of the MCP in 1984 (sub-section 2.2.1), the politics of the policy (sub-section 2.2.2), and the expansion as the PLGHA policy in January 2017 (sub-section 2.2.3). The political trajectory of the MCP and now PLGHA policy is necessary to understand the various approaches to reproductive health policy making and practice that will be discussed in the following chapter (Chapter Three).

2.2.1 Introduction of the Mexico City Policy

The Reagan administration first introduced the Mexico City policy statement at the ICPD in August 1984, when the head of the U.S. delegation, Ambassador James Buckley, asserted that countries experiencing rapid population growth should reduce government interference in their economies and that this would create economic growth and in turn, reduce fertility (U.S. Policy Statement, 1984). Despite a longstanding history of support for population control policies, the U.S. delegation at the conference adjusted the United States official position and declared population growth a “neutral phenomenon” that could either

help or hinder development (U.S. Policy Statement, 1984). Months prior to the conference, in May 1984, the Director of the Office of Population, Steven Sinding, received an early draft of the policy statement and confronted the Director of USAID regarding the “wholesale change” in U.S. policy: “to say that population is a neutral factor is to completely disregard 20 years of U.S. policy, which is that rapid population growth is a development problem,” and he confronted the Director regarding the international commitment to help alleviate the pressure of population growth in developing countries (North & Sinding, 2004: 69).

Previous decades of U.S. discourse on population and development had promulgated the importance of government programs to reduce the rate of population growth. Finkle and Crane, two researchers who attended the conference, found that key stakeholders at the ICPD believed the U.S. delegation was guided by “broad ideological aims and short-run political considerations,” rather than a genuine interest in SRH-related issues (Finkle & Crane, 1985: 2). Finkle and Crane reported that most conference participants had “an awareness that an American presidential campaign was under way,” and furthermore, “they believed that the position was designed to enhance President Reagan’s reelection chances” (Finkle & Crane, 1985, p. 15).

2.2.2 The Politics of the Policy

Since the Reagan administration first introduced the MCP, the decision to reinstate or rescind the policy has been a political flashpoint for incoming presidents, tackled within the first week of their term. Historically, Republican presidents have reinstated the policy and Democratic presidents have rescinded the policy. After the MCP was first introduced at the UN ICPD in 1984 by President Reagan, it remained in effect until it was rescinded by President Clinton through executive action (for an overview of the policy’s historical trajectory see Table 2 on the following page). However, during his second term, Republicans gained control of the Congress and the MCP was reinstated legislatively as part of an arrangement to pay the U.S. debt to the United Nations. On January 22, 2011, two days after his inauguration, President Bush reinstated the MCP and some members of congress opposed the reinstatement and sought any early vote to overturn the policy using expedited procedures under the Congressional Review Act regarding agency rules (Nowels, 2001).

Table 2: Trajectory of the MCP & PLGHA Policy Years In effect? Presidential Administration Executive (E) or (Party Affiliation) Congressional (C) Action? 1985 – 1989 Yes Reagan (R) E 1989 – 1993 Yes Bush (R) E 1993 – 1999 Sept. No Clinton (D) E 1999 Oct. – 2000 Yes* Clinton (D) C Sept. 2000 Oct. – 2001 No Clinton (D) E 2001 – 2009 Yes Bush (R) E 2009 – 2017 No Obama (D) E 2017 – present Yes Trump (R) E * Note: A modified version of the policy was applied by Congress as a part of a broader arrangement to pay the U.S. debt to the UN.

2.2.3 The PLGHA Policy Expanded by Trump in 2017

On January 23, 2017, President Trump reinstated and expanded the Mexico City policy via presidential memorandum (see Appendix B for the full Presidential Memorandum of January 23, 2017) and renamed it the PLGHA policy, delivering on a campaign promise to the Religious Right (see Figure 2 on the following page). In May 2017, the Trump administration approved the full implementation plan for the PLGHA policy. The PLGHA policy is more far- reaching and restrictive than any previous iteration of the MCP, impacting not only reproductive health programs (USD$575 million in U.S. family planning assistance) as it had in the past but all of global health assistance (an estimated USD$10.3 billion in U.S. global health assistance), a more than 15-fold increase (U.S. Department of State, 2017).

Figure 2 President Trump signs the PLGHA policy with Vice President, Mike Pence, to his right and other key policymakers by his side (Sachs-Pool, 2017).

The PLGHA policy currently applies to all foreign NGOs (international, regional, or local) as a condition of receiving foreign assistance from the U.S., either directly or as a sub-recipient through another organization (USAID, 2017). Foreign NGOs include international and regional NGOs that are based outside of the U.S. and local NGOs in assisted countries (USAID, 2017). While U.S. NGOs are not directly subject to the policy, they must ensure the compliance of foreign NGOs they provide funding (USAID, 2017). The policy does not apply to foreign governments, public international organizations, or multilateral organizations (USAID, 2017). Previously, the policy only applied to funding provided by the U.S., however, now the policy applies to all of the funding an NGO receives. This means that the PLGHA policy affects funding from other sources, not only the U.S. Table 3 on the following pages displays definitions of key terms of the PLGHA policy.

Table 3: Definitions of Key Terms of the PLGHA Policy Abortion is a method it is for the purpose of Includes: Does not include: of family planning spacing births - abortions performed for the physical or - abortions performed if the mother when… mental state of the mother would be endangered if the fetus were carried to term or abortions following rape or incest To perform abortions operate a facility where means to… abortions are performed as a method of family planning To actively promote for an organization to Includes: Does not include: abortion means… commit resources, - operating a family planning counseling - abortion in cases where the pregnancy financial or other, in a service that provides advice and either poses a risk to a woman’s life or is substantial or information regarding the benefits and the result of incest or rape; continuing effort to availability of abortion as a method of - treatment of injuries or illnesses caused increase the availability family planning; by legal or illegal abortions (e.g., post- or use of abortion as a - providing advice that abortion is an abortion care); method of family available option in the event that other - and responding to a question regarding planning methods of family planning are not used where a safe, legal abortion may be or are not successful or encouraging obtained if the question is specifically women to consider abortion; asked by a woman who is already - lobbying a foreign government to pregnant, she clearly states that she has legalize (or continue legality of) or make already decided to have a legal available abortion as a method of family abortion, and the family planning planning; counselor reasonably believes that the - and conducting a public information ethics of the medical profession in the campaign regarding the benefits and/or country requires a response regarding availability of abortion as a method of where it may be obtained safely. family planning. Source: PLGHA Policy Standard Provisions (2017) (see Appendix C for a full list).

In the United States, domestic efforts to remove the policy have consisted of legal challenges and introducing legislation to permanently repeal the policy. However, the four legal challenges to the MCP since its initial instatement in 1984 have all been unsuccessful (CHANGE, 2018). The Global Health, Empowerment and Rights (HER) Act, introduced in the Senate by Senator Jeanne Shaheen (D-NH) and in the House by Representative Nita Lowey (D-NY) in 2018, would permanently repeal the PLGHA policy. According to Senator Shaheen, the PLGHA policy is “extremely short sighted” and illustrates the Trump administration’s “willingness to ignore decades of research in favor of ideological politics” (Shaheen, 2017). The passage of the HER Act would also nullify any future policy that would breach it (Shaheen, 2017).

In the international sphere, the former Dutch Minister of Foreign Trade and Development Cooperation, Lilianne Plouman, announced the launch of the She Decides initiative on January 24, 2017, the day after the PLGHA policy was reinstated. As a response to the U.S. president’s decision, She Decides seeks to raise financial and political support for the fundamental rights of girls and women to make their own reproductive decisions. This call to action is backed by more than 50 governments and has raised more than USD$450 million in new funding to support SRHR. However, the funds raised cannot hope to fill the gap left.

2.3 Country Context: Uganda

This study was conducted in the Republic of Uganda, a landlocked country in sub-Saharan Africa. The United States established diplomatic relations with Uganda in 1962 after the country gained formal independence from the United Kingdom (U.S. Mission to Uganda, 2017). The U.S. Mission to Uganda is composed of several offices and organizations, including the United States Department of State (DOS), the United States Agency for International Development (USAID), Center for Disease Control and Prevention (CDC), Peace Corps, National Institute of Health (NIH), the Department of Defense (DOD), and the President’s Emergency Plan for AIDS Reduction (PEPFAR) (U.S. Mission to Uganda, 2017).

The current president of Uganda, Yoweri Museveni, has been in office since 1985. In the last five years, the government of Uganda has made commitments to improve family planning outcomes. For instance, in 2012, President Museveni pledged USD$5 million annually to

contraceptive supplies at the 2012 London Family Planning Summit (Family Planning 2020, 2017). Two years later, in 2014, the Ministry of Health further developed the Uganda Family Planning Costed Implementation Plan 2015-2020 (MOH, 2014). Despite the commitments and demonstrable progress the government has made to improve SRH-related issues, unsafe abortion continues to endanger the lives of women in Uganda. With little funding allocated from the government, civil society plays an integral role in addressing sexual and reproductive health-related issues, such as abortion (Cleeve et al., 2017).

Uganda’s legal and policy framework supports the existence and operation of civil society organizations. Two instruments regulate their activities: 1) the 1995 Constitution, which provides guarantees to the right of association and recognizes the existence and role of civil society organizations and 2) the 2006 NGO Registration (Amendment) Bill. Civil society in Uganda depends on funding and interests of donors as 95 percent of all funding comes from external sources. Civil society organizations have played a crucial role in fostering political participation in restricted political space.

The following subsections describe the setting of the study in Uganda, and the relevant SRH- related aspects as they relate to the topic of this study.

2.3.1 Setting of the Study

Uganda has one of the youngest and fastest growing populations in the world (Prada et al., 2016). Currently at 41.49 million, the total population nearly doubled in 25 years, growing from 17.38 million in 1990 to 39.03 million in 2015 (Prada et al., 2016: 9). 78 percent of the population is 30 years old or younger and almost half of the population is under the age of 14 (UBOS, 2017). Although fertility trends in Uganda have dramatically decreased since the 1980s from a total fertility rate of 7.4 in 1988-1989 to 5.4 in 2016, desired fertility remains above actual fertility rate (UBOS, 2016: 13). According to Prada et al. (2017), measures of fertility preferences as well as contraceptive use, limited contraceptive availability, and the unmet need for contraception indicate that the rate of abortion in Uganda is likely to remain high.

Family planning allows people to attain their desired number of children and determine the spacing of pregnancies achieved through the use of contraceptive methods. Contraceptive

methods are classified as modern (the intrauterine contraceptive device (IUD), injectables, male and female condoms, emergency contraception etc.) or traditional (rhythm, withdrawal, and folk methods). In 2016, 39 percent of married women reported using a modern method and 4 percent of married women reported using a traditional method (UBOS, 2016). Among sexually active unmarried women, 51 percent report using a contraceptive method (47 percent are using a modern method and 4 percent using a traditional method) (UBOS, 2016). The most commonly used method among both married women (19 percent) and unmarried women (21 percent) are injectables (UBOS, 2016).

Fertility is highly valued in Uganda and the timing of a pregnancy is equally important (Cleeve et al., 2017). As men often have more decision-making power as well as financial resources, their attitudes can significantly influence women’s access to sexual and reproductive health care (Kaye, 2006; Moore, Jagwe-Wadda, & Bankole, 2011). The unmet need for family planning is defined as the percentage of women of reproductive age who want to stop or delay childbearing but are not using any method of family planning. In 2016, nearly seven in ten married women in Uganda (67 percent) have a demand for family planning services and 83 percent of unmarried women have a demand for family planning services (UBOS, 2016).

Uganda’s maternal mortality ratio remains one of the highest in the world at more than 336 for every 100,000, meaning that for every 1,000 births in Uganda there are just over three maternal deaths (WHO, 2016; UBOS, 2016). The WHO uses the International Classification of Disease (ICD)-10 definition of maternal-related death: “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes” (WHO, 2015).

Economically, 54 percent of Uganda’s entire government budget is from overseas development assistance and the U.S. is Uganda’s largest bilateral donor (World Bank, 2017; Department of State, 2017). In 2015, USAID spent $591 million in Uganda, thereby making it the seventh-largest recipient in the region (USAID, 2017). Although there are opportunities for political engagement, the Ugandan state is characterized by weak bureaucracy and dependence on external donors (Lister, 2003).

Uganda’s health system faces challenges of inadequate human resources, training and infrastructure, medicines and health supplies, and health financing shortfalls (The Republic of Uganda, 2016). The government of Uganda depends on USD$6.7 million annually in donor funding for reproductive health supplies and the Ministry of Health estimates a gap of USD$9 million in funding for family planning commodities (The Republic of Uganda, 2016). USAID-supported UHMG has played a critical role in improving commodity quantification, supply, and distribution, and now provides 80 percent of supplies in Uganda.

In the last decade, U.S.-supported initiatives have focused on increasing the availability and quality of family planning services, including contraceptives. In 2017, USAID funded the provision of 350,000 contraceptive implants, more than 4 million injectable contraceptives, approximately 1.4 million condoms, and over 4 million oral contraceptives (USAID, 2017). In addition, the Uganda Health Marketing Group (UHMG) founded out of the USAID-funded AFFORD project in 2006, has become a self-sustaining NGO (USAID, 2017).

The two largest reproductive health providers in Uganda, Reproductive Health Uganda (RHU) and Marie Stopes International (MSI) Uganda, have publicly stated that they will refuse to comply with the conditions of the PLGHA policy and forego funding from the United States (RHU, 2017; MSI, 2017). RHU, a member association of the IPPF estimates that the withdrawal in funding will lead to an additional 20,000 maternal deaths, 4.8 million unintended pregnancies, and 1.7 million unsafe abortions worldwide (International Planned Parenthood Federation [IPPF], 2016). MSI Uganda may need to reduce its presence by 60 percent and estimates that more than 2 million women will no longer have access to contraception services as a result, and this will lead to 2.5 million unintended pregnancies, 870,000 unsafe abortions, and 6,900 avoidable maternal deaths (Marie Stopes International [MSI], 2018).

“Unless we fill the USD$80 million gap created by the global gag rule, it will deprive millions of women of the contraception they need to prevent an unintended pregnancy,” said Marjorie Newman-Williams, the vice-president of MSI in a press release (Edwards, 2018). Rosemary Gillepsie, the interim director general of the IPPF, has emphasized the importance of individuals within the health community and highlighted the essential trust and

21 relationship between communities and their health providers (Edwards, 2018). Funding from other donors, including the She Decides initiative, have enabled the IPPF and MSI to continue some of its operations that were previously funded by the U.S., however most of the money has been used to cover the UNFPA funding loss and only 8 percent has reached IPPF and MSI (Edwards, 2018).

2.3.2 The Legal Status of Abortion in Uganda

The legal status of abortion in an individual country is essential to understanding the ways in which the PLGHA policy will affect reproductive health and rights in context-specific settings. Determining the legal status of abortion is often a complex task due to the wide variations in the sources of abortion law. Laws pertaining to abortion are often addressed in multiple statutes, codes, and regulations, all of which apply simultaneously. As a result, the legal status of abortion in Uganda is ambiguous and oftentimes confusing as the laws and policies are interpreted inconsistently (CEHURD, 2016).

The Constitution of the Republic of Uganda was adopted in 1995 and heralded as a progressive document in its recognition of the rights of every citizen, including provisions for historically marginalized populations (Cheney, 2012). Notably, the Constitution of Uganda is one of only four African countries that directly addresses the termination of pregnancy in its founding document (see Box 1 below) (CRR, 2012).

Box 1: The Constitution of Uganda Article 22(2) 1. No person shall be deprived of life intentionally except in execution of a sentence passed in a fair trial by a court of competent jurisdiction in respect of a criminal offence under the laws of Uganda and the conviction and sentence have been confirmed by the highest appellate court. 2. No person has the right to terminate the life of an unborn child except as may be authorized by law. Source: The Constitution of Uganda (1995)

Under the Penal Code of June 15, 1950 (see Box 2 below), a vestige of Uganda’s colonial past, the performance of abortion is prohibited except to save the life of a pregnant woman (The Republic of Uganda, 2007). The provisions of the Penal Code cite criminal sentences for any person who intends to procure the miscarriage of a woman and a pregnant woman who undertakes the same act or consents to its performance. Court cases have since expanded the interpretation of life to include the preservation of physical and mental health (The Republic of Uganda, 2007).

Box 2: The Penal Code Act, Cap. 120 Laws of Uganda Section 141. Attempts to procure abortion. Any person who, with intent to procure the miscarriage of a woman whether she is or is not with child, unlawfully administers to her or causes her to take any poison or other noxious thing, or uses any force of any kind, or uses any other means, commits a felony and is liable to imprisonment for fourteen years.

Section 142. Procuring miscarriage. Any woman who, being with child, with intent to procure her own miscarriage, unlawfully administers to herself any poison or other noxious thing, or uses any force of any kind, or uses any other means, or permits any such things or means to be administered to or used on her, commits a felony and is liable to imprisonment for seven years.

Section 143. Supplying drugs, etc. to procure abortion. Any person who unlawfully supplies to or procures for an person anything, knowing that it is intended to be unlawfully used to procure the miscarriage of a woman, whether she is or is not with child, commits a felony and is liable to imprisonment for three years.

Section 224. Surgical operation. A person is not criminally responsible for performing in good faith and with reasonable care and skill a surgical abortion upon any person for his or her benefit, or upon an unborn child for the preservation of the mother’s life, if the performance of the operation is reasonable having regard to the patient’s state at the time, and to all the circumstances of the case. Source: The Penal Code (Amendment) Act 2007 (Chapter 120, Act 8 of 2007).

The Ministry of Health has also issued National SRHR Policy Guidelines and Service Standards (2012) to specify the circumstances under which abortion is permitted, which includes rape, incest, defilement, or if the woman has HIV (CEHURD, 2016). The guidelines also include post-abortion care, however, information on the guidelines is not widely disseminated, and stigma remains high for issues surrounding abortion and post-abortion care (CEHURD, 2016).

Understanding the legality framework is an important step to understanding the broader context of what is permitted by law in Uganda and how the PLGHA policy will affect the legal right to abortion. To summarize, the table below (Table 3) outlines the grounds on which abortion is permitted in Uganda and under the PLGHA policy.

Table 3: Abortion Exceptions in Uganda and under the PLGHA Policy Ugandan Penal Code 2012 Guidelines PLGHA Policy

Life endangerment Yes Yes Yes To preserve physical No Yes No health To preserve mental No Yes No health Rape or incest No Yes Yes Fetal impairment No Yes No Economic or social No No No reasons Available on request No No No

2.4 Conclusion

This chapter has provided background information pertaining to this study. First, an brief summary of the politics underlying the PLGHA policy and a brief historical overview of its trajectory from the MCP to the PLGHA policy. Second, a description of the study setting and the relevant SRH-related topics in Uganda, including information about the legal status of abortion. The following chapter explores the theoretical framework guiding this study. Chapter Three: Theoretical Framework 3.1 Introduction

The aim of this study was to analyze the understandings and interpretations of Ugandan health workers in response to the reinstatement and expansion of the PLGHA policy in January 2017. The theoretical approaches underpinning this study are grounded in feminist discourses of reproductive rights and justice, a critical intersection of reproductive health, human rights, and social justice. This chapter defines the concept of reproductive justice and examines its use as a theoretical framework. Later in the chapter is a discussion of the challenges and possibilities of human rights-based approaches to reproduction through a sex equality approach. Access to safe abortion is a matter of human rights, democracy, and public health, and restrictions on such access is a major cause of death and injury with significant costs for development.

3.2 Reproductive Justice

3.2.1 Defining Reproductive Justice

The term “reproductive justice” was coined by a group of African-American feminists at a national pro-choice conference in Chicago in 1994, shortly after the landmark ICPD in Cairo, that established the concept of reproductive rights as a key component of the international human rights movement (Ross, 2017). The aim of the group, who referred to themselves as the Women of African Descent for Reproductive Justice, was to conceptualize reproductive rights struggles through a lens of social justice with a central focus on the context-specific nature of reproductive decision-making (Ross, 2017). The resulting framework repositioned reproductive rights in a political context of intersecting race, gender, and class oppressions (Roberts, 2015). As Loretta Ross, a founding member of the reproductive justice movement, points out, reproductive justice was not supposed to replace reproductive health (service provision) or reproductive rights (legal advocacy) frameworks, rather, it originated as an amplifying concept to shed light on the intersectional forms of oppression that threaten women’s bodily integrity (Ross, 2017).

The reproductive justice framework provides a model based on three interconnected human rights values: the right to not have children, the right to have children, and the right to parent those children, while advocating for the enabling conditions to realize these rights (Ross, 2017). As reproductive oppression affects individual’s lives in multiple ways, a multi- dimensional approach to addressing reproductive injustice is necessary. There are three main frameworks for fighting reproductive injustices: reproductive health through service delivery, reproductive rights addressing legal protections, and reproductive justice focusing on organizing resistance through the application of international human rights standards. While the frameworks are distinct in their approaches, they work in unison to provide a complementary and comprehensive solution.

Reproductive justice scholars posit that intersecting forces produce differing reproductive experiences and the framework is rooted in the belief that systemic inequality shapes decision making, particularly for vulnerable and marginalized people (Ross, 2017). They further maintain that the reproductive rights framework, a model that works to protect an individual’s legal right to reproductive health services, fails to take into account the context in which individuals make choices (Roberts, 2015). Theorists argue that the ability of any individual to determine their own reproductive destiny is directly linked to the conditions of their community (Ross, 2017).

Reproductive justice acknowledges the centrality of bodies while avoiding biological essentialism that centers gender and racial subordination. Reproductive justice theory reconceptualizes the politics of reproduction by addressing how bodies are gendered and how they are racially identified to analyze hierarchical reproduction relations imposed by the ideology of white supremacy. Theorists challenge the perception that racialized notions of female bodies are “suitable for regulation by the state” (Ross, 2017: 185).

Reproductive justice as a theoretical approach has helped explain the phenomena at the intersection of race, class, and gender in reproductive politics (Ross, 2017). According to Ross, the framework “examines the meanings assigned to reproductive relations and externally imposed policies and practices” (Ross, 2017: 287). Reproductive justice is an approach that aims to improve reproductive health, rights, and justice beyond pro-choice politics using the human rights framework (Ross, 2017). SisterSong, the pioneering reproductive justice group, believes that the United States “must pass the laws and make the changes necessary to live up to international commitments,” (Ross, 2017). Laws and policies play a role in shaping the conditions that enable women to seek reproductive health services and effectuate reproductive rights; international human rights frameworks mandate that the states create enabling conditions for women to access safe and legal abortion.

3.2.2 The Inadequacy of “Choice”

The mainstream reproductive rights movement has been premised upon the notion that women have a constitutional right to reproductive autonomy, a central component of liberal approaches to reproductive rights (Ehrenreich, 2008). Individualistic approaches to reproductive rights propagate the importance of “choice” and a belief that each individual should be free from governmental control over decisions regarding whether to and when to have children (Ehrenreich, 2008). The rhetoric of “choice” has privileged predominantly white middle-class women who have the ability to choose from a range of reproductive options that are often unavailable to poor and low-income women (Roberts, 2015). Choice- based arguments put forward by the pro-choice advocacy community posit that legal abortion is and should be an individual, constitutional right protected against political shifts.

The reproductive justice movement calls for the recognition of the limitations and inadequacy of emphasizing choice by the reproductive rights framework (Ehrenreich, 2008). A social model of human behavior does not assume that individuals make decisions in a vacuum or that “choices” are equally free for everyone. Due to existing social inequalities, the range of options individuals have differ greatly, shaping the ability to exercise rights. Piepmeier states that reproduction should not be defined by “choice,” a concept that ignores the broader contexts that shape reproduction (Piepmeier, 2013). Despite constraints that all women may experience, some women have much more limited choices than others.

The use of the concept of choice has been criticized by academics and activists. For example, Petchesky (1986), in her influential consideration of the limits of choice, refers to “a woman’s right to control her own body,” and argues that such bodily and decisional autonomy should be limited (Petchesky, 1986: 7). As Petchesky points out, “the idea of ‘a

27 woman’s right to choose’ as the main principle of reproductive freedom is insufficient and problematic at the same time as it is politically compelling” (Petchesky, 1986: 6-7). She points out that the principle evades moral questions of under what conditions and for what purposes reproductive decisions should be made.

The reproductive justice movement represents a radical shift from “choice” to “justice,” locating women’s autonomy and self-determination in international human rights frameworks rather than the constitutionally limited concepts of individual rights and privacy. Petchesky (1980) suggests that the critical issue for feminists is not the content of women’s choices, or even the “right to choose” itself, rather it is the social conditions under which choices are made. Pointing out, “the ‘right to choose’ means very little when women are powerless’ (Petchesky, 1980: 674). Rather than focusing on the question of “choice,” Petchesky argues that we should instead focus on how to transform the social conditions of those choosing (Petchesky, 1980). Petchesky says, for most of history women’s choices have been exercised in a framework in which reproduction and motherhood determine their relationship to the rest of society (Petchesky, 1980).

3.2.3 The Challenges and Possibilities of Using Human Rights to Improve Access to Safe Abortion

In the 1970s and 1980s, women’s rights activists around the world formed international and regional networks and developed feminist understandings of reproductive rights. In the 1990s, scholars began appropriating international human rights mechanisms to advance many SRHR-related issues, including abortion rights, as well as other issues relating to gender equality.

The promotion of reproductive rights gained momentum largely due to the two UN conferences, the ICPD held in Cairo in 1994 and the Fourth World UN Conference on Women in Beijing in 1995, and the resulting documents mentioned in target 5.6 (Barot, 2014; Galati, 2015). According to global health experts with the Guttmacher Institute, the two groundbreaking framework documents produced from the ICPD and Beijing represented major progress for the recognition of individual choice and rights characterized by the centrality of debates on abortion (Barot, 2014; Galati, 2015; Joffe, 2009: 6). While the Cairo and Beijing conferences did not create any mechanisms for implementing these recommendations, they established a critical precedent in the international community by situating abortion and reproductive health in the context of basic human rights (Joffe, 2009: 7). At the landmark ICPD in 1994, the resulting Program of Action defined reproductive rights as:

“[Embracing] certain human rights that are already recognized in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence.”

Paragraph 7.3, United Nations, 1994

While the ICPD POA does not include access to safe, legal abortion as a necessary part of reproductive health and rights, it does recognize unsafe abortion as a major public health concern and urges governments to adopt policies and practices that make abortion safe (ICPD, 1994). Petchesky argues that while the POA enshrines what she refers to as an “almost feminist vision” of reproductive rights and gender equality, it remains a mainstream model of development “under which that vision cannot possibly be realized” (Petchesky, 1995: 1). According to Petchesky, the key weakness of the Cairo POA reflects the continued dominance of donor countries (particularly the U.S.) over global policies (Petchesky, 1995). Petchesky identifies a “fault line” for feminists, which she describes as the gap between politics of the body and politics of social development and economic transformation (Petchesky, 1995). Petchesky argues that access to abortion is a condition of women’s liberation and she posits that the issue of abortion really “has to do with the possibility for women, especially young women, to be sexual beings,” in a context where contraception provision is inadequate and heterosexual relations are often undependable (Petchesky, 1981: 210).

Current debates on reproduction and health in the field of international development typically revolve around notions of human rights and emphasize the importance of gender equity (Corrȇa, Petchesky, and Parker, 2008; Miedema et al., 2014). Grounded in international human rights law, the global development agenda prioritizes advancing access to safe and legal abortion (UNDP, 2015). 2015 marked the beginning of a new development agenda, built on the progress made under the Millennium Development Goals (MDGs), and created through participatory processes with civil society to establish the Sustainable Development Goals (SDGs) (UNDP, 2015). The SDGs for 2030

renew commitments under the MDGs to reduce maternal mortality, achieve universal access to SRHR, ensure reproductive rights, and achieve gender equality (UNDP, 2015).

The 2030 global development agenda promise focused commitment to improve the lives of women and girls. Rights based discourses have influenced and shaped the language of aid and development in such a way that organizations in Africa have been able to make significant and positive changes. Pugh et al., (2017) maintain that it is inevitable that the PLGHA policy will hamper and potentially reverse gains in achieving the goals and targets of the 2030 Sustainable Development Agenda. They insist that SRHR-related policies, programs, and services depend on data, evidence, and human rights rather than ideology (Pugh et al., 2017).

Bodily integrity, or the right to control one’s own body, is at the core of reproductive freedom (Correa & Petchesky, 1994). To affirm the right of women to have “control over” or “ownership” of their bodies connotes the body as an essential part of one’s self, whose health and wellbeing are necessary for active participation in social life (Correa & Petchesky, 1994). The efficacy of framing abortion advocacy in terms of rights has been challenged by critics who point out that the value and meaning of rights is inextricably linked to the political and social context (Correa & Petchesky, 1994). Correa and Petchesky argue that reproductive rights are “meaningless” without enabling conditions through which they can be realized (Correa & Petchesky, 1994: 298).

Dixon-Mueller maintains that violations of human rights are deeply rooted within the family system, bolstered by male privilege, and justified by religious texts or appeals to tradition (Dixon-Mueller, 1993). These inequalities are rarely addressed in public policies and international agreements. “External control over other peoples’ reproduction is a tool of domination and oppression” (Ross, 2017: 292).

Reproductive rights are irreducibly personal and political; while they can never be realized without enabling social, economic, political, and legal conditions, their site is individual women’s bodies (Petchesky, 1990; Correa & Petchesky, 1994). Correa and Petchesky’s analysis argues that individual liberty and the social justice dimensions of rights are inextricably linked (Correa & Petchesky, 1994). Correa and Petchesky call for the integration of rights with health and development agendas to radically transform the distribution of resources, power, and wellbeing within and among countries (Correa & Petchesky, 1994).

Ross argues that the election of President Trump represents a “distinct political movement with comprehensible characteristics and definable strengths and weaknesses,” and reproductive justices offers a strategy for building a coherent human rights movement that incorporates race, gender, and class (Ross, 2017: 306). Reproductive justice theorist, Ross, points out that a number of activists are skeptical of the “usefulness of the human rights framework,” in favor or practicing “their own particular form of American exceptionalism,” supported by the notion that the U.S. government has consistently undermined the UN (Ross, 2017: 278). Ross points out the hypocrisy of the U.S. using language of human rights in diplomatic demands while simultaneously violating such standards, a challenge she posits only U.S. activists can address (Ross, 2017).

The human rights appeal to social justice advocates to examine power, inequality, and the role of the state and nonstate actors in perpetuating violations. Human rights offer a strong moral argument for setting standards for how people show be treated and what everybody deserves as a member of human society, regardless of their identity. Human rights present political possibilities for bringing together social justice movements under a unifying ideological platform not based on identity but shared humanity.

3.2.4 The Critical Constructivist Approach: From “Choice” to Context

The critical constructivist approach to reproductive justice moves beyond liberal individualist approach, shifting the focus from “choice” and individual rights to context (Ehrenreich, 2008). The critical constructivist approach to reproductive justice posits that the substantive conditions that characterize reproductive health and lives is the central indicator of equality (Ehrenreich, 2008). According to the critical constructivist perspective, individual choices are to a degree socially constructed in that they are a function of pre- existing conditions over which individuals have limited control. In a world of social, economic, and political inequality, ideals of free choice often perpetuate those underlying in equalities (Ehrenreich, 2008).

The reproductive decisions individuals make are often choices between limited and equally unsatisfactory alternatives. This is not to say that women lack any decisional control over their reproductive lives whatsoever; the point of critical constructivist theory is that making choices cannot be equated with autonomy – or with justice and equality. Reproductive decisions are socially constructed, not only in the sense that they are a function of the social conditions that structure individual’s lives, but also in the sense that those conditions are themselves produced by governmental policies and practices.

Reproductive justice advocates realize that having a right in an abstract sense is not sufficient; an individual must also have the means to access that right (Beckman, 2017). A right to make one’s own choices about reproduction is much more meaningful to individuals who have the social, economic, and political resources to effectuate those choices.

Critical analysis through the reproductive justice framework focuses on the concrete conditions that limit choices, the role of law and public policy in helping to create those conditions, and the gendered power dynamics that inform and are reinforced by the regulation of human reproduction. Government policies help create the conditions that shape individual options and affect individual choices. The liberal approach views the law as a tool used to regulate social practices and argues that regulation unfairly limits choice and violates individual rights (Ehrenreich, 2008). Critical constructivists counter that this model is fundamentally flawed in that it does not consider the role of the law in creating the conditions of society (Ehrenreich, 2008). Critical constructivists posit that law and society are interrelated and reproductive law and policy play a central role in maintaining a system of sex-based inequality (Ehrenreich, 2008).

By the mid-1980s, lawyers and legal scholars began analyzing abortion restrictions in an equality framework (MacKinnon, 1983, 1987, 1991; Law, 1984; Ginsburg, 1989). During this period, a new conceptualization of the abortion right emerged. As Catharine MacKinnon (1979) argues, “the policy or practice in question integrally contributes to the maintenance of an underclass or deprived position because of gender status” (MacKinnon, 1979: 117). MacKinnon (1983) conceptualizes issues of inequality such as gender-differentiated practices such as abortion-restrictive regulation as central to the subordination of women (MacKinnon, 1983: 646-55). According to Siegel (1995), this paradigm shift facilitated equal protection challenges to abortion restrictions. Siegel (1995) makes the case for understanding abortion as a sex equality right through the use of feminist theory and a critique of mainstream discourse about the abortion right through an individualist framework that focuses on the physiology of reproduction (Siegel, 1995). Furthermore, Siegel (1995) reconceptualizes the abortion right in a sex equality framework built upon social construction theory. Analysis of abortion restrictions draws upon and contributes to social construction theory – the body of feminist theory exploring the social organization of reproductive relations. In her analysis of abortion restrictions as gender status regulation, Siegel maintains that “those who seek to protect unborn life want to regulate the conduct of women who fail to act as good mothers should” (Siegel, 1995: 56). Through an exploration of the socio-historical aspects of abortion, Siegel contends that laws criminalizing abortion compel motherhood as a form of gender status regulation. She points out that regulation directed at women’s reproductive conduct reflects societal judgments about women.

Law and Rackner (1987) assert that the right to reproductive freedom is the core issue of women’s equality and contend that women denied control of their reproductive capacity suffer socially, economically, and politically (Law & Rackner, 1987: 193). Similarly, Connell argues that the institutionalized control of women’s reproductive capacities is at the core of patriarchal gender orders (Connell, 2011: 1677). Law and Rackner maintain that laws and policies that seek to restrict women’s access to abortion must be analyzed in terms of their actual impact on women’s lives and on women’s abilities to achieve equality (Law & Rackner, 1987: 201). Denying women control over their reproductive capacity reinforces socially prescribed roles that designate women as nurturers who occupy the private sphere (Law & Rackner, 1987: 202). The relevance of this conceptualization of laws and policies restricting access to abortion is important to the analysis of the impact of the PLGHA policy in that the researcher sought to understand the reality of the implications of the policy in Uganda.

In recent years, debates over reproductive health and rights involving domestic and international policies have become so politicized that Cohen believes the underlying principles and values have become obscured (Cohen, 2004). Family planning and programs that support contraceptive services are discussed almost exclusively in terms of the extent to which they reduce (or, some would argue, increase) the number of abortions that may later occur (Cohen, 2004). The political argument over abortion hinges on the conflict between the legal right of women to bodily integrity and self-

determination and the putative right of a developing human fetus to be born. While these are important and legitimate policy debates, Cohen (2004) points out that the largely ignore the practical realities of why abortion and contraception are issues in women’s lives. These arguments are indicative of the political nature of abortion itself and the debate surrounding reproductive rights that must take into account the context within which an individual would make a decision to seek, obtain, or provide an abortion.

3.6 Conclusion

This chapter has outlined the theoretical underpinnings guiding this research. The overarching body of scholarship this thesis draws on relates to the notion of reproductive justice, which accounts for diversity and differences among people and examines multiple experiences of injustice and insubordination. The ambiguity, flexibility, and open-endedness of the reproductive justice framework provides an evolving approach to examining reproductive health policy. The linkages between sex equality and human rights provides a framework for understanding abortion as a reproductive right. In conjunction with reproductive justice theory, this approach can move beyond the notion of individual choice and abstract conceptions of rights to understand restrictive abortion policy in the context of Uganda. In addressing the preventable pandemic of unsafe abortion, this thesis seeks to address the conditions that allow it to proliferate. We must address public health issues from within a human rights framework and social justice approach.

Chapter Four: Methodological Framework 4.1 Introduction

This chapter outlines the methodological framework of the study. The chapter is composed of five sections detailing the qualitative methods used for data collection, data analysis, reflections on the limitations of the study, and ethical considerations. The first section (Section 4.1) begins by identifying the research questions this study seeks to answer. Section 4.2 describes the sampling strategies and methods of data collection. Section 4.3 describes the process of data analysis and coding technique. The following section (Section 4.4) discusses the limitations of the study. Section 4.5 reviews the ethical considerations undertaken throughout the research process. Finally, the chapter concludes with reflections on the methodological approach of this study.

4.2 Research Question and Sub-Questions

The researcher determined the research questions and methods with the goal of maximizing the usefulness of the study’s data. A literature review of past studies on the impact of the MCP helped inform the development of the research questions in conjunction with input from the supervisor and local supervisor, as well as identifying gaps in knowledge.

Main research question: How are U.S. government policies on SRHR, the PLGHA policy in particular, understood and interpreted by civil society organizations, and what implications do they have for reproductive rights and justice in Uganda?

Sub-question 1: How do Ugandan health workers see U.S. Government policies on SRHR, the PLGHA policy in particular, affecting SRHR in Uganda?

Sub-question 2: How do U.S. Government policies on SRHR, the PLGHA policy in particular, affect civil society organizations in Uganda?

Sub-question 3: How do U.S. Government policies on SRHR, the PLGHA policy in particular, affect political discourse about SRHR in Uganda?

Sub-question 4: How are organizations in Uganda that work to defend and expand access to SRHR mitigating these effects?

4.2 Data Collection

To answer the above questions, the researcher used a multiple-method qualitative approach to explore the understandings and interpretations of Ugandan health workers in light of the reinstatement of the PLGHA policy in January 2017. The fieldwork for this study was carried over a period of two months (June 2017 – August 2017) in Uganda’s capital city, Kampala (see Figure 2 below).

Figure 2 Map of Uganda (PAI, 2018)

4.2.1 Sampling Strategies

The decision to conduct the study in Uganda was based on the following criteria: 1) Uganda receives a substantial amount of official development assistance from the U.S., the majority of which is earmarked for health, 2) Uganda’s government depends on the foreign assistance disbursed by the U.S. and therefore the PLGHA policy will have a significant impact, 3) the SRHR-related issues that continue to impede access to reproductive health and rights in Uganda, and 4) the likelihood that NGOs would face the decision whether or not to comply with the PLGHA policy and forego critical funding.

Prior to departure to the field, the researcher contacted civil society organizations that had previously received support from the U.S. and arranged introductory meetings with representatives of a wide range of NGOs. NGOs were identified using ForeignAssistance.gov, a database providing information about U.S. government foreign assistance funds across agencies. NGOs that had previously partnered with the U.S. on past projects were selected because they would likely face the decision whether to comply with the PLGHA policy when their existing contracts expire. This process was facilitated by a local supervisor who works with a prominent human rights-based NGO that provides quality comprehensive reproductive health services and advocates for reproductive rights. The local supervisor helped identify potential NGOs and participants, helped to develop the interview guide, and assisted with the pilot testing of the data collection tools.

The sampling procedure of participants for this study was purposive. With reference to the aim of the research, respondents were selected on the basis that they would be able to provide data relevant to the research questions (Bryman, 2016). The researcher hoped to have at least two representatives from each NGO involved in the study and it was important to have gender balance. The participants selected are involved in multiple areas of work with NGOs, including medical service provision, outreach efforts, counseling, and advocacy.

To better understand different sets of social actors’ perspectives on the PLGHA policy, multiple methods were used for data collection. The qualitative methods of data collection that were used to gather information in this study were: participant observation, semi- structured in-depth interviews, and document analysis. Using multiple methods was a strategy for improving the understanding of accounts given by different actors as well as providing means to triangulate data to and increase the ‘trustworthiness’ of the study (Lincoln & Guba, 1985).

It must be noted that in addition to the 18 participants of this study representing eight NGOs in Uganda and the informal conversations with the UNFPA country representative, the researcher spoke off the record with three representatives from the U.S. Mission to Uganda: a foreign service officer with the Department of State, a reproductive health officer with USAID, and a locally employed staff member who has worked with the Embassy’s reproductive health office for more than two decades. The representatives from the U.S. Mission to Uganda permitted the researcher to use information derived from informal conversations to inform the development of this thesis.

4.2.2 Participant Observation

Participant observation was used as a means of establishing connections with NGOs in Uganda and gaining a better understanding of health workers perspectives in their frame of reference. Upon arrival in Uganda, meetings with NGOs were organized to determine whether health workers would be interested in participating in the study. Gaining the trust of individuals who would be able to provide information pertinent to this study was particularly challenging due to the nature of the PLGHA policy, as many health workers were reluctant to participate in a study because they believed their involvement could jeopardize U.S. funding. This point illustrates what is often described to as the “chilling effect” of the policy, referring to the silencing or “gagging” of civil society organizations (Barot & Cohen, 2015; PAI, 2018; HRW, 2018; CHANGE, 2018; IWHC, 2018).

In order to establish trust and build a rapport with members of civil society organizations, the researcher attended public events related to the subject of this thesis. For example, the public dialogue, Family Planning: Empowering People, Developing the Nation, hosted by the UNFPA and Ugandan Ministry of Health (see Figure 3 on the following page). This provided the researcher with the opportunity to approach the head of the UNFPA in Uganda, who provided invaluable insights into the relationship between the U.S. government and UN agencies in Uganda.

Figure 4 Public Dialogue on Family Planning (Maynard, 2017)

Observation also served as a means to sensitize the researcher to the ways in which the health workers operate within the context of their NGO. As the researcher discovered, observation also offered the possibility of examining to what extent people said was consistent with their actions. For example, a health worker reported that their NGO had nothing to do with abortion in any way (Health Worker, interview, July 3, 2017). The health worker explained that they were extremely cautious to prevent any inadvertent violation of the PLGHA policy, however, during another interview a health worker gave the researcher a pamphlet published by the same NGO on the dangers of unsafe abortion.

4.2.2 Semi-Structured In-Depth Interviews

Semi-structured in-depth individual interviews lasting between one and two hours were conducted with 18 health workers representing eight NGOs. All of the interviews were conducted in English, recorded digitally with the permission of the participants, and transcribed within 24 hours of the interview taking place. Each interview took place on a second occasion after the initial meeting with the participant to ensure that their participation was truly voluntary. The interviews took place in an enclosed room of the NGO they work with to ensure privacy.

Preliminary documentary analysis of similar studies on the effects of the MCP conducted by policy and research organizations (PAI, 2011; CRR, 2003) as well as the U.S. government (Blane & Friedman, 1990) during the Bush administration helped inform the development of a single interview guide. In addition to the broad open-ended questions that applied to all of the NGOs that participated, specific questions were tailored to the NGO. A single interview guide was created with questions arranged by category with a final section that asked specific questions about NGOs in particular. The local supervisor provided invaluable information into the dynamics of civil society organizations and the reality of the work they do. Table 4 below provides an overview of the research participants.

Table 4: Overview of the Study Participants NGO Compliance Participant Sex Age 1 M 26 1 No 2 M 31 3 F 20 4 M 24 2 No 5 F 42 39

6 F 28 7 F 25 3 No 8 M 24 9 M 39 4 No 10 M 25 11 F 22 5 Yes 12 M 28 13 F 30 6 Yes 14 M 29 15 M 26 7 N/A 16 F 31 17 M 24 8 N/A 18 M 33 Here N/A denotes that the NGO has not yet had the opportunity to reenter a contract with the U.S. government and therefore has not determined whether or not they will comply with the PLGHA policy.

The goal of the semi-structured interviews was to have a guided conversation with a purpose. Open-ended questions were used to elicit responses from participants in their own words. The loosely structured nature of the interviews enabled the interview to pursue thoughts or ideas shared by the interviewee in more detail. A major advantage of using interviews to collect data was the flexibility it afforded the researcher in asking questions. Interviewing is particularly useful when exploring situations wherein the information is not available in any other form, such as when exploring perceptions, understandings, and interpretations (Collumbien et al., 2012). This is especially true for sensitive subjects, such as abortion (Collumbien et al., 2012).

4.2.3 Document Analysis

The final method of data collection was the analysis of the contents of existing documents, such as speeches by politicians in favor or oppose of the MCP and PGLHA policy, policy papers, hearings on the MCP (Senate Hearing, 2001; Congressional Hearing, 2007), and Congressional Research Services reports (Nowels, 2001; Nowels, 2005; Blanchfield, 2017). Content analysis is a systematic set of procedures for the analysis of the contents of texts.

U.S. congressional and senatorial hearings function as the primary formal method by which committees collect and analyze information relevant to legislative policymaking. Hearings include oral testimonies from witnesses and questioning of the witnesses by members of government. Notably, there have been three hearings on the MCP which enabled health workers with affected NGOs to testify.

4.3 Data Analysis

Analysis of qualitative data is interpretative and inductive, meaning that it draws inferences from observations in the data. The data gathered included field notes from participant observation, transcripts from semi-structured interviews, and analyses of documents. The grounded theory method of qualitative data analysis involves the open coding of texts whereby codes are attached to selections in the data (Bryman, 1999). Using concept indicators, the outcomes indicated causal schemes, clusters of attributes, and narratives or accounts of events (Bryman, 1999). Through familiarization, the process of reading and re- reading transcripts, the researcher identified important themes. The researcher grouped the major findings thematically to determine. Once the themes were identified, the researcher used the raw data to extract illustrative quotes to provide examples of how a theme was present in the Uganda context.

Due to the centrality of the notion of rights in the research, theoretical framework of this study, and data gathered, the researcher was particularly focused when examining the ways in which participants engaged with this concept.

4.4 Limitations of the Study

Qualitative methodology depends heavily on the interpretations of the researcher and is therefore subject to the presuppositions and biases of the researcher themselves. The initial documentary analysis revealed evidence of the PLGHA policy’s negative effects in recipient countries and therefore the researcher anticipated a similar or potentially worse response as a result of the expansion. Efforts to reduce potential respondent bias included a reflexive approach, data triangulation, and a systematic research process.

Bias stemming from the researcher’s background and assumptions was of particular concern to this study. Therefore, the researcher strived to adopt a reflexive approach that involved reflecting on how her background and personal politics might influence research participants. Throughout the research process, the researcher considered her own personal politics could potentially affect the ways in which the data was gathered and subsequently

41 interpreted. To mitigate the effects of bias, the researcher took detailed notes after each interview and revisited the data repeatedly. Throughout the fieldwork process, the researcher was almost always the only non-Ugandan present and her identity certainly played a role in data collection. A constructivist approach necessitates the recognition of the role of the researcher themselves in the study and how their own values and norms must be considered. In an effort to mitigate these effects, open-ended questions were used to gain insight into how service providers themselves perceive the PLGHA policy and to enable participants to describe in their own words what the policy means to them. Additionally, authenticity can be fostered through the use of multiple methods and triangulation. The tripartite methods of data collection provided a range of responses.

4.5 Ethical Considerations

An essential component of conducting research is considering the ethical issues that may arise and ensuring there are protective measures to mitigate the unintended consequences. The participants involved in this study were informed of the purpose of the research, how the data could be used, and the anonymity protection measures in place. This was made clear to ensure that participants were able to make informed decisions about their participation in the study. Participants were given the freedom to withdraw from the study at any stage, the right to not respond to any question they did not want to, or to withdraw from the process entirely at any point. Verbal and written consent was obtained from all of the participants.

The importance of the confidentiality and anonymity protection measures were paramount for this study. Health workers employed by two of the NGOs involved in the study that agreed to the PLGHA policy expressed fears of potentially violating the policy and losing critical funding. All of the participants of this study were assigned a random number that appeared on all documents in place of their name or any other personally identifiable information.

A challenge throughout the research process was remaining objective despite the researcher’s own personal politics. Positionality is the practice of a researcher delineating their own position in relation to the study, with the implication that this position may influence aspects of the research, such as the data collected or the way in which it is interpreted (Cohen et al., 2007). As a white Western researcher, and almost always the only non-Ugandan present, the researcher was perceived as an outsider as well as a potential source of information to help health workers better understand the provisions of the PLGHA policy. Despite an in-depth analysis of the actual provisions of the policy, the researcher did not feel able to say decisively whether or not particular programs would violate the policy.

4.6 Conclusion

This chapter has explained the methodological approach of this study and the limitations and ethical considerations of the study. The following chapter (Chapter Five) presents the empirical data gathered for this study.

Chapter Five: Ugandan Health Workers’ on the Impact of the PLGHA Policy 5.1 Introduction

This chapter presents the findings from the empirical data gathered through 18 semi- structured in-depth interviews with health workers working with eight NGOs engaged in SRHR in Uganda. This thesis sought to analyze how Ugandan health workers understand and interpret reproductive health policy in light of the 2017 reinstatement and expansion of the PLGHA policy and what this means for the status of reproductive rights and justice in Uganda. The sub-questions guiding this research focus on three areas of impact: SRHR, civil society, and political discourse in Uganda, and the fourth sub-question addresses the efforts made by NGOs to mitigate the effects of the policy.

First, this chapter explores how health workers understand the PLGHA policy and how they interpret the restrictions it places on the provision of SRH-related services in Uganda. Section 5.2 addresses sub-question 1 and examines the effects of the PLGHA policy on SRHR, elucidating how health workers conceptualize the notion of rights in relation to the legal status of abortion in Uganda. Section 5.3 addresses sub-question 2 and how the PLGHA policy shapes civil society organizations. Section 5.4 addresses sub-question 3 and how the PLGHA policy affects political discourse in Uganda. Section 5.5 addresses sub-question 4 and discusses how health workers intend to mitigate the effects of the policy. Finally, the chapter concludes with remarks on the empirical data gathered.

As explained in the ethical considerations section (Section 4.5) of the methodological framework (Chapter Four), all personally identifiable information of the participants has been removed in order to protect NGOs from punitive responses by the U.S. government. The emphasis on privacy is reiterated here to ensure the confidentiality and anonymity of the participants, which was an important concern for those involved as well as the researcher herself. Even if an organization chose to refuse and forgo funding from the United States, the climate of silence and fear surrounding the PLGHA policy creates a tension between those organizations and others who have accepted the provisions of the policy.

5.1.1 Understanding the PLGHA Policy

To explore Ugandan health workers’ understandings and interpretations of the policy, participants were asked to describe the PLGHA policy, to explain what it permits and prohibits, and whether the NGO they work with had been faced with the decision to comply with the policy. Of the eight NGOs that participated in this study, four (4/8) reported refusing funding from the U.S, two (2/8) reported complying with the provisions of the policy in order to maintain funding from the U.S., and two had not yet had the opportunity to enter a new contract with the U.S. government (2/8). NGOs that refuse to comply with the provisions of the PLGHA policy are affected in that they forego crucial funding that they often depend on from the U.S.

Throughout the interviews, participants from all eight NGOs expressed difficulty understanding what exactly the PLGHA policy permits and prohibits. Often participants who had worked with civil society organizations through several iterations of the MCP said that they did not know how to interpret the PLGHA policy in light of its expansion.

“This policy is not the one that we know – we do not know what we can or cannot do.” (Health Worker, interview, July 17, 2017).

The health worker, a medical service provider, went on to explain that even though the clinic where they work does not perform abortions and has not ever provided abortion services due to the legal restrictions in Uganda, the NGO had to stop an educational program about the dangers of unsafe abortion when the MCP was last in place during the Bush administration in 2001 due to funding cuts as a direct result of refusing to comply with the provisions of the policy (Health Worker, interview, July 17, 2017).

Notably, the PLGHA policy does contain exceptions for services, advocacy, and counseling and referrals for abortion in cases of rape, incest, and if the woman’s life is at risk, however, most of the health workers who participated in this study believed that the policy is entirely prohibitive of any abortion-related work. The PLGHA policy also permits post-abortion care, however, six of the participants (6/18) believed that they could no longer provide information about post-abortion care as a result of the policy. During an interview with a health worker, they explained that they believed the NGO they work with was ineligible as they continue to provide post-abortion care (Health Worker, interview, June 26, 2017).

“[name of NGO] as an organization does not carry out abortions, but we do post-abortion care.” (Health Worker, interview, June 26, 2017)

Two-thirds of the participants (12/18) involved in this study reported not receiving any direct communication from the U.S. government grant administrators in relation to the reinstatement of the PLGHA policy, as their contracts with the U.S. government had not yet expired. An informal conversation with a representative from the U.S. Embassy in Kampala indicated that the standard provisions would be included in all future agreements between NGOs and the U.S. government, and provided information for an online course created by USAID. However, this information has not been widely publicized or disseminated and none of the NGOs that participated in this study reported any knowledge of the resources available regarding the PLGHA policy.

The lack of communication between the U.S. mission to Uganda tasked with enforcing and implementing the PLGHA policy in-country parallels the findings of similar studies conducted in other sub-Saharan countries (CHANGE, 2018; PAI, 2018; HRW, 2018). Researchers have found that fears of violating the policy has resulted in over-cautiousness whereby NGOs place excessive restrictions on their own programs in order to prevent any inadvertent breach of contract (CHANGE, 2018; PAI, 2018; HRW, 2018). This was the case of this study, whereby participants believed post-abortion care is not permitted and they would not be able to provide these services if they agreed to the provisions of the PLGHA policy.

As a result, all of the respondents asked the researcher about her perspective of the scope and implementation of the PLGHA policy what it would mean for their NGO, given the lack of communication from the U.S. Mission to Uganda. The identity of the researcher as a white westerner with U.S. citizenship and involvement with the U.S. Embassy in Kampala was often perceived as a potential resource or potential means of communication with the U.S. government. Many of the participants asked the researcher questions about how the PLGHA policy would affect specific programs and whether they could discuss abortion at all, as it was common to interpret the policy as entirely prohibitive. The questions asked by participants to the researcher regarding the PLGHA policy was due to her identity as a citizen of the U.S., and is indicative of the confusion participants reported regarding the legal language of the policy. 5.2 How do Ugandan health workers see U.S. government policies on SRHR, the PLGHA policy in particular, affecting SRHR in Uganda?

The first sub-question asks how health workers believe the PLGHA policy affects sexual and reproductive health and rights in Uganda. The following sub-sections focus on specific themes that health workers identified as particularly challenging or concerning components of the policy as they perceive it. The first addresses how the PLGHA policy affects SRHR in relation to the legal status of abortion, the second concerns how the policy reinforces structural barriers to SRH-related services, and the third, involves conceptions of human rights as applied to sexuality and reproduction in light of the reinstatement of the PLGHA policy.

5.2.1 In Relation to the Legal Status of Abortion

The laws pertaining to abortion in Uganda are often interpreted to be entirely prohibitive, yet participants reported that patients would likely seek an abortion regardless of the legal status (Health Worker, interview, July 12, 2017; Health Worker, interview, July 17, 2017). When asked about how the PLGHA policy would affect women’s access to abortion most participants contended that a woman would attempt to find an unsafe abortion. In situations where women do not seek professional medical help, “What about those who do not call the doctor and they carry it out themselves?” asked a health worker during an interview (Health Worker, interview, June 24, 2017). All of the participants commented on the prevalence of unsafe abortion despite legal restrictions. “If a woman is determined to abort, you can never stop her,” said a participant involved in outreach efforts with an NGO that targets hard to reach populations (Health Worker, interview, July 1, 2017). “When you stop giving safe abortion and post-abortion care, women will still go for abortion. This will claim the lives of Ugandan women.” (Health Worker, interview, July 12, 2017).

Often health workers identified a causal pathway between preventing women from accessing SRH services and the decision-making process for seeking an abortion. Commenting on the legal status of abortion one health worker said: “It is illegal to abort, eh? But it is happening in Uganda” (Health Worker, interview, July 14, 2017). Participants in this study shared personal stories of their experiences treating patients with complications

following an unsafe abortion and often described the conditions in which people seek abortions. “The conditions will worsen because young girls and some women will resort to going for unsafe abortion — this will be the death of these innocent people.” (Health Worker, interview, July 12, 2017).

When asked to about the “innocence” of women and girls who resort to unsafe abortion the health worker explained that not every person becomes pregnant by choice and they described the “impossible choice” women face (Health Worker, interview, July 12, 2017). Another participant discussed the legal status of abortion in relation to the “goodness” or “badness” of abortion itself: “Abortion is not bad – but it is illegal. People in Uganda do it, but they face imprisonment,” per the Penal Code of 1950, service providers would also face criminal charges for providing an abortion (Health Worker, interview, June 28, 2017). Health workers often feared the legal repercussions of obtaining and providing abortion in Uganda, a problem which participants stated would be exacerbated by the PLGHA policy. Among the participants, there was a broad consensus that abortion is illegal in all cases and those who procure or provide abortions could face criminal charges, a widespread misconception in Uganda that is relevant to how the PLGHA policy is interpreted. A participant working with an NGO that had an existing contract with the US government but had not had the opportunity to enter into a new contract confirmed that their NGO does discuss abortion, clarifying that they work within the law. “We do the promotion of safe abortion. We give information about abortion -- within the legal [framework]. We may not necessarily refuse funding… but it is not illegal to give information” (Health Worker, interview, June 12, 2017). During an informal conversation at the U.S. Embassy, a reproductive health expert said that the PLGHA policy would have no impact in Uganda because the law only permits abortion to save the life of a pregnant woman (Senior Official, interview, July 12, 2017). This is inaccurate as the PLGHA policy applies to NGOs regardless of their ability to provide safe and legal abortion. The PLGHA policy places restrictions on advocacy and public health campaigns, such as raising awareness about the dangers of unsafe abortion and providing information about the legal provision of post-abortion care. The PLGHA policy applies to all of global health assistance, even if the national laws of a country do not permit abortion.

5.2.2 Reinforcing Structural Barriers to SRH-Related Services Respondents consistently expressed their fears and concerns that the adjustments to service provision as a result of the PLGHA policy will have deleterious effects on women’s health. As the majority of the NGOs that participated in this study had chosen to refuse to comply with the PLGHA policy, health workers were grappling with the substantial funding deficit. Many of the Ugandan health workers involved in this study feared that the funding shifts would lead to a reduction of services, noting the structural and programmatic adjustments already occurring, and result in increased rates of unintended pregnancy, unsafe abortion and associated maternal mortality. Participants in this study were asked whether NGOs made adjustments or anticipated changes as a result of the decision to forego funding from the U.S. Every respondent indicated that the funding shift lead them to adjust programs, or eliminate them entirely, either out of fear that they would be viewed as potentially ineligible for funding from the U.S. if they had not already refused or as a result of the funding cuts if they did in fact refuse.

A representative from a leading NGO in Uganda reported that the budget was cut by 30 percent as a direct result of the PLGHA policy and the decision to not comply (Health Worker, interview, July 17, 2017). A participant spoke about the current impact of the PLGHA policy on programs:

“Some of our programs have stopped. One ended in May [2017] and another we were planning to roll out in September [2017]. The Sayana Press, it is an injectable, a popular method among young people.” (Health Worker, interview, July 17, 2017).

Sayana Press, or the Subcutaneous DMPA, is an injectable contraceptive that is administered every three months. Injectable forms of contraception are among the most popular methods of family planning in Uganda, which a health worker explained was due to the ability for a woman to administer it covertly without their partner’s knowledge (Health Worker, interview, July 17, 2017). The participant described a lack of reproductive decision- making power on behalf of women as a reason for not using more “obvious” forms of contraception, such as condoms or the pill, as a primary cause of unintended pregnancy (Health Worker, interview, July 17, 2017). Both female and male health workers reported limited negotiating capacity for women with regards to contraception and fertility preferences.

“Due to that global gag rule, most women in Uganda are going to be affected, especially because some of the[m] can be impregnated by force. This is the case in rural areas, or slums in the city, and some find themselves going for abortion.” (Health Worker, interview, July 12, 2017).

The quote above exemplifies a theme evident in many of the participant responses about the prevalence of gender-based violence in Uganda and the lack of “choice” in sexuality and reproduction. When asked about how the PLGHA policy was affecting women seeking abortion-related services in hard to reach areas, the health worker said: “Most of women in rural areas of Uganda don’t receive information about reproductive health, it has got worse since the policy is in place” (Health Worker, interview, July 12, 2017). This, they explained was due to the scaled back outreach efforts to hard to reach areas. “An outreach program to rural regions has been cut because it was funded by U.S.,” and they anticipated cuts in the future as the alternate funding secured would not be able to fill the gap (Health Worker, interview, July 12, 2017).

An informal conversation with a representative from the Dutch Ministry of Foreign Affairs who is on the She Decides task force revealed that donors are conflicted with the decision to fund organizations that have chosen to comply with the policy (Senior Policy Advisor, informal conversation, ). It was explained that if organizations agree to the PLGHA policy then they are unable reach certain goals and targets set by their own mission to reduce rates of unsafe abortion through the provision of safe and legal abortion services. In the event that an NGO refuses to comply, policymakers are concerned that alternate funding sources cannot fill the gap left by the U.S..

Figure 5 Ugandan Health Worker Outreach Program in Bukoto

A health worker engaged in outreach efforts visited clinic branches in rural areas that are in danger of closing due to the funding the NGO lost after refusing to sign the PLGA policy, as they viewed the standard provisions as incompatible with the mission of the NGO (Health Worker, interview, July 13, 2017). This participant reported at least two small clinics in remote areas have closed since January 2017, and said, “Our [clinics] are closing and whole communities will lose care,” particularly in places where there are no alternatives (Health Worker, interview, July 13, 2017).

“We had to end a program that builds the capacity of the health structure to deliver sexual reproductive health services using a rights-based approach. Now the funding is gone.” (Health Worker, interview, July 17, 2017).

According to the participant, 27 mobile health teams and five outreach teams had been stopped as a direct result of the PLGHA policy (Health Worker, interview, July 13, 2017).

A health worker who has been employed by an NGO through multiple iterations of the policy and complied previously said, “In the past we have stopped programs that talk about abortion in case someone from USAID will see them” (Health Worker, interview, July 3, 2017). According to the provisions of the PLGHA policy, U.S. government officials can visit a clinic at any time and inspect their documents. If found in violation of the conditions of the PLGHA policy, funding will be immediately withdrawn, and the NGO must reimburse the U.S.

government for the funding that has already been allocated. The participant working with an organization that was in the process of deciding whether to comply stated that this is especially worrisome as the majority of their funding comes from the U.S. (Health Worker, interview, June 12, 2017). If they are found in violation of the PLGHA policy, they could not afford to return the funding if it had already been spent (Health Worker, interview, June 12, 2017).

Among the most harrowing stories were medical service providers describing situations in which they felt that due to Ugandan national law they were unable to provide an abortion. Perceiving laws pertaining to abortion as entirely prohibitive and the atmosphere of fear that pervades the health community in Uganda was described by participants and perpetuated through the effects of the PLGHA policy. A doctor working at a clinic in central Kampala told the following story:

“A girl came in and told me that she wanted help to abort. I told her, ‘This baby might help you in the future,’ and she said, ‘Thank you, but you’ve not helped me.’ The next day there was an emergency — they brought in the girl, she tried to abort but she was dying. I am telling you it was a lesson, had I given her a safe abortion… my hands were tied. I wish I could help. If I could give her an abortion she would have life.” (Health Worker, interview, August 14, 2017).

One health worker commented on the double standard and victim-blaming women face in Ugandan society: “When it comes to sex people won’t think anything of the man. He is human, and he has temptations, but they condemn the girl for pregnancy” (Health Worker, interview, June 22, 2017). “Where are the men? Where is he? Why are they not trying to imprison him?” a health worker asked, “He was the one that made them pregnant. The men influence them to abort, by either giving them money or helping them” (Health Worker, June 24, 2017). She went on to ask: “When you imprison the girl who is aborting, have you solved the problem?” (Health Worker, interview, June 24, 2017).

5.2.3 SRHR: The Concept of Rights as Applied to Sexuality and Reproduction

As discussed in the theoretical framework of this thesis (Chapter Three), international development discourse tends to be grounded in notions of rights, and most of the NGOs taking part in this study (6/8) drew on rights-based approaches and identified abortion as a reproductive right that should be both accessible and available. Health workers often framed their responses in terms of rights-based approaches to reproductive health, speaking of abortion as an essential reproductive right, which directly conflicted with the PLGHA policy. One health worker said: “Even though abortion is mostly illegal, it is a human right. But abortion can be done. There are guidelines and it must be done by a professional and qualified doctor,” distinguishing between safe and unsafe abortion in accordance with the guidelines of the WHO (Health Worker, interview, July 17, 2017).

All participants supported the right abortion to some extent, whether or not they believed the procedure could actually be legally obtained. During an interview, when asked about what the PLGHA policy means in the context of the legal status of abortion in Uganda, a participant said: “If you are saying abortion is illegal, then you are saying these people are not in a position to access their rights” (Health Worker, interview, July 12, 2017). When asked to elaborate on the right to abortion, the health worker explained that the NGO they work with employs a rights-based approach to providing reproductive health care that could not be reconciled with the conditions imposed by the PLGHA policy (Health Worker, interview, July 12, 2017). The NGO they worked with could not abide by the provisions of the PLGHA policy and therefore refused to comply (Health Worker, interview, July 12, 2017).

Figure 6 Leading Provider of SRH-related Services and Member Affiliate of the IPPF, RHU, has publicly stated the NGO will not comply with the PLGHA Policy (Maynard, 2017)

International health organizations advocate for human rights-based approaches that recognize access to and availability of safe abortion as a reproductive right, and many of the 53

NGOs in Uganda adopt rights-based approaches that participants reported were incongruent with the provisions of the PLGHA policy. A health worker with a prominent NGO in Uganda said, “Our core values are rights-based approaches, informed choices, and we are result-oriented,” and they explained that the NGO could not comply with the PLGHA policy because the provision that abortion is not to be included as a method of family planning directly conflicts with the mission of the NGO (Health Worker, interview, July 17, 2017).

Despite a firm belief in the concept of rights and inclusion of reproductive rights in human rights law, many health workers shared their personal convictions about abortion. Abortion was often described as immoral and unacceptable, yet in some cases the only available option. “I support abortion, to some extent,” said one health worker with an NGO whose mission emphasizes the importance of rights, “If the woman is dying, sometimes abortion is saving a life” (Health Worker, interview, July 17, 2017).

Many of the health workers described the reasons why women seek abortions and the discussed the drivers of unsafe abortion. A health worker identified many reasons a woman would consider having an abortion:

“A woman will have an abortion because she does not want to drop out of school, job security, family or peer pressure, rape or sexual assault, when that baby is the result of incest, when you are not ready to become a parent. It is her decision because […] girls are responsible.” (Health Worker, interview, June 19, 2017).

This quote highlights the important linkages between reproductive rights and women’s livelihoods. Another respondent stated that a person should be able to make their own decisions, emphasizing the importance of decision-making in reproductive health matters:

“A woman has a reason for making her own decisions, she has a right to knowledge and power to make her own choice. It will have a devastating effect – there will be a rise of unintended pregnancy which will lead to abortion.” (Health Worker, interview, July 17, 2017).

The above quote illustrates the theme of rights-based approaches that emphasize individual choice, coupled with the fear of adverse health outcomes.

5.3 How do Ugandan health workers see U.S. government policies on SRHR, the PLGHA policy in particular, affecting civil society organizations in Uganda? Regardless of whether NGOs agreed to the standard provisions of the PLGHA policy, every respondent expressed their fear that even their participation in inter-group efforts to reduce unsafe abortion could be interpreted as a violation of the restrictions imposed by the PLGHA policy. Since 2012, the Coalition to Stop Maternal Mortality Due to Unsafe Abortion (CSMMUA), managed by the Center for Health, Human Rights and Development (CEHURD), has been engaged in advocacy, primarily to clarify the legal and policy framework on abortion (HEPS Uganda, 2016). Six of the eight NGOs involved in this study participated in the coalition in 2016. The mission of the coalition is to end unsafe abortion by “working for improved laws and policies, promoting a more conducive environment for service delivery, increasing access to services for prevention and management of unwanted pregnancy, and fighting abortion stigma and discrimination through education and advocacy,” and the team includes advocates, service providers, and legal experts (CEHURD, 2016).

Advocacy was described as a particularly challenging component of SRHR-related work in Uganda. “The work of advocating is not a simple thing. It is one of the hardest things we do at [name of NGO]). This [policy] means that we cannot do what we are supposed to do,” said a health worker when asked about how the policy affects civil society organizations in Uganda as the NGO they work with decided to forgo funding from the U.S. (Health Worker, interview, June 24, 2017). Their organization has been part of several networks and coalitions of civil society stakeholders working in the field of sexual and reproductive health that do not know if they can continue to participate if topics or other NGOs discuss abortion. “We are part of a coalition of organizations that works to end unsafe abortion and maternal mortality — can we still do this? We do not know, can we associate if we agree but another does not?” asked a health worker (Health Worker, interview, July 2, 2017).

5.4 How do Ugandan health workers see U.S. government policies on SRHR, the PLGHA policy in particular, affecting political discourse in Uganda?

The PLGHA policy expansion has also shaded Ugandan’s perspectives and wider attitudes towards the United States. Participants were asked about their thoughts on the United States’ foreign policy shifts instigated by President Trump and how it shapes their perspectives on development assistance provided by the U.S. in relation to reproductive health and rights in Uganda.

“Are you hearing [their] government trying to prohibit safe abortion? We are saying, let us educate people. To reduce the incidence of death in community, let us do it within the law.” (Health Worker, interview, June 12, 2017).

“This is what [their] governments say: you’re not supposed to be given a service.” (Health Worker, interview, June 18, 2017).

Another health worker commented specifically on the power of the United States and questioned the decision to reinstate the PLGHA policy. “America considers itself as the most powerful. Why would they remove funds in organizations that deal in abortion or information about it? This clearly indicates that it is no longer the most superior” (Health Worker, interview, July 12, 2017). When asked to elaborate on the point that the U.S. is “no longer the most superior,” the health worker asked, “What developed nation prevents access to safe abortion?” (Health Worker, interview, July 12, 2017). A theme that became evident throughout the interviews with participants from each category of agreement or disagreement with the policy was the frustration at the unilateral power of the U.S. to reinstate the policy without input from the civil society organizations impacted by the decision.

Another health worker commented on the funding shifts and the relationship between donor and recipient countries: “donors are trying to make African countries self-sustaining. This is one of the things Trump is trying to push. Donald Trump is affecting our work. The funding from Americans is changing and we must change with it” (Health Worker, interview, July 7, 2017). Participants stressed the importance of the diversification of funding in their comments lamenting the unilateral power of the United States.

A female participant pointed out the gender disparities in political power in both the United States and Uganda:

“Most of the legislators are male. If we had more women in power they would understand. Men are there discussing things they do not understand — things that do not affect them.” (Health Worker, interview, June 24, 2017).

This quote succinctly communicates what many participants discussed with the researcher pertaining to frustrations with lobbying their national government and the perceived inability to communicate with the United States government regarding policies that affect people’s lives in Uganda. This quote in particular highlights the intersection of gender and power. 5.5 Efforts to Mitigate the Effects of the PLGHA Policy

When health workers expressed concern regarding the impact of the PLGHA policy on SRHR in Uganda, they were asked if there were strategies that they thought would be effective for mitigating the effects of the PLGHA policy. As described in this chapter, health workers reported that the PLGHA policy would affect SRHR, civil society, and political discourse in Uganda. The proposed strategies for reducing the impact of the PLGHA policy involved establishing trust with patients, education, contraception and family planning, and the liberalization of abortion laws.

A counselor with an NGO that provides services and advocates for reproductive rights said: “We need comprehensive abortion care. We need service providers to create a relationship where a client can reach out to them, how can they with this policy?” (Health Worker, interview, August 10, 2017). Several health workers brought up the importance of the relationship between providers and patients and establishing trust that enables patients to seek medical help. Another health worker commented on service provision between patient and client: “The relationship between the service provider and people must be good, otherwise it is not good service. We need to be able to talk about it. We need to encourage counseling, pre- and post-abortion” (Health Worker, interview, August 14, 2017). This was explained as a crucially important component for stigmatized subjects that are taboo.

Participants emphasized the importance of providing education and raising awareness about the dangers of unsafe abortion. During an interview with an NGO that focuses on youth participation, an outreach coordinator said:

“Girls will go to the garden for cassava sticks but instead of planting it in the earth she will plant it in herself. These things happen, and we die. We don’t look at the cause. We don’t try to prevent it. We are taking care of symptoms not the cause. They should be given the knowledge to figure out what to do.” (Health Worker, interview, July 14, 2017).

Participants advocated for comprehensive SRHR, including the provision of safe and legal abortion services. Crucial to the provision of services was the relationship between the provider and the patient. Several health workers brought up the importance of the relationship between providers and patients and establishing trust that enables patients to seek medical help. This was explained as an integrally important component for stigmatized subjects that are taboo.

Participants stressed the importance of access to and availability of contraception and noted the dependence on U.S. provision of contraceptives. When asked about strategies for preventing unsafe abortion a health worker emphasized the unmet need for contraception in Uganda (Health Worker, interview, July 27, 2017). “We need to be able to break the cycle of abortion through contraception,” and they added: “No country has risen from poverty without access to contraception” (Health Worker, interview, July 27, 2017). Another health worker proposed a solution: “What we should do if we want to eradicate abortion is inform women about family planning methods, make family planning methods accessible, and legalize abortion” (Health Worker, interview, June 24, 2017).

Several participants stressed the importance of legalizing abortion in order to prevent the incidence of unsafe abortion. “To save our sisters we must legalize abortion and making it a part of family planning,” said a health worker engaged in advocacy (Health Worker, interview, June 24, 2017). The same health worker pointed out, “Statistics show that where abortion is legalized there is less abortion” (Health Worker, interview, June 24, 2017).

To summarize, the proposed strategies for mitigating the effects of the PLGHA policy range from establishing and maintaining trust with the public, education and increasing awareness, contraception provision, and the liberalization of abortion laws.

5.6 Conclusion

This chapter has presented the empirical data gathered during the fieldwork conducted in Uganda between June and August 2017. NGOs report a confusion regarding the expansion of the PLGHA policy and determining what exactly is permitted and prohibited. The findings of this study indicate that NGOs are affected whether they decide to comply with the PLGHA policy or refuse funding from the United States. The impact of the policy shapes SRHR, civil society, and political discourse in Uganda.

The following chapter (Chapter Six) discusses the findings of this study in conjunction with the theoretical framework underpinning this research.

Chapter Six: Discussion of Findings, Recommendations, and Conclusion 6.1 Introduction

This concluding chapter synthesizes the answers to the sub-questions in order to answer the main research question: “How are U.S. government policies on SRHR, the PLGHA policy in particular, understood and interpreted by civil society organizations, and what implications do they have for reproductive rights and justice in Uganda?” The purpose of this study was to explore the effects of the reinstatement of the PLGHA policy on SRHR, civil society, and political discourse in Uganda through the understandings and interpretations of health workers, and how the policy shapes reproductive health, rights, and justice in Uganda through a reproductive justice framework.

This chapter provides an answer to the study’s main research question by integrating concepts discussed in the theoretical framework (Chapter Three) in dialogue with the empirical data (Chapter Five) gathered in the field. Having presented the study’s major empirical findings, the following sections serve to critically discuss these findings and derive theoretical and practical implications. The discussion of the findings is done so through the three areas of impact identified: SRHR, civil society, and political discourse in Uganda, and considers the implications for reproductive rights and justice more broadly in the context of the global development agenda. Section 6.3 lists the recommendations for policy, practice, and future research. Finally, the chapter concludes with reflections on the research process.

6.2 Discussion of Findings

To answer the main research question having to do with how the PLGHA policy affects reproductive rights and justice in Uganda based on the perceptions of Ugandan health workers, civil society organizations largely oppose the U.S. government’s policy restricting funding to NGOs that engage in abortion-related work. All of the participants involved in this study reported negative effects as a direct result of the PLGHA policy, regardless of whether the NGO they work with chose to comply or forgo funding from the United States. As the majority of the NGOs involved in this study reported refusing to comply with the policy, the participants primarily described adjusting to the loss of funding. The overwhelming consensus among civil society organizations is that the PLGHA policy is already having a

damaging impact on SRHR, civil society, and political discourse in Uganda in that it has a silencing effect on NGOs, results in a funding loss, inhibits advocacy for the liberalization of abortion laws, and the funding loss results in scaled back programming, particularly in hard to reach areas.

The Ugandan health workers who participated in this study expressed confusion and misunderstanding regarding the provisions of the policy and a lack of communication with the U.S. government pertaining to the PLGHA policy’s implementation and enforcement. The confusion and lack of information about the PLGHA policy exists at multiple levels and among various stakeholders. Interviews with directors of NGOs, as well as with program managers and health providers, revealed mixed levels of knowledge about the PLGHA policy. All participants expressed some lack of clarity or confusion, suggesting potentially deleterious effects on organizational decision making, as well as the ability of individuals to serve clients.

As a result of the confusion, the fear of crossing an unclear boundary leads organizations to over-interpret the PLGHA policy and to unnecessarily restrict themselves. Participants reported eliminating programs or stopping specific initiatives that would be permitted under the standard provisions of the PLGHA policy.

Numerous authors have argued that a fundamental difficulty within programs that focus on rights is the way that those rights are conceptualized beyond the abstract and individualistic terminology (Miedema, Maxwell, & Aggleton, 2011). The ambiguous and abstract language of rights leaves a significant space for interpretation, much like the language of the PLGHA policy. NGOs involved in this study often centered their beliefs on abstract notions of rights with little to no acknowledgement of the need for the concept to be understood as context- specific. The challenge of moving beyond a seemingly rhetorical sense of rights, and the right to choose in particular, arises from a disregard for the importance of social relationships as opposed to individual entitlements.

6.2.1 Impact of PLGHA Policy on SRHR in Uganda

Current debates on reproduction and health emphasize the importance of advancing access to safe and legal abortion as a part of the effort to ensure SRHR around the world (Barot, 2017). Through global agreements and international human rights law, governments are committed to reducing rates of unsafe abortion; according to international human rights norms, governments that deny women access to safe abortion violate women’s human rights. Progress towards the SDGs will consequently be slowed by the imposition of the PLGHA policy. The SDGs include commitments to reduce maternal mortality (target 3.1) and ensure universal access to SRHR in accordance with the POA of the ICPD and the Beijing Platform for Action (UNDP, 2015). As such and given the United States (and Uganda) are signatories, the PLGHA policy is incompatible with internationally recognized human rights agreements and commitments. As previously mentioned, the Cairo and Beijing conferences did not identify safe, legal abortion as a component of reproductive rights. However, they did recognize unsafe abortion as a major public health concern and urged governments to adopt policies and practices that will lead to safe abortion practices (ICPD, 1994; UN, 1995).

The final report on the MDGs noted that Goal 5 for “improving maternal health” remains an unfinished agenda largely due to the slow progress in preventing maternal deaths globally (Tanyag, 2017). The high concentration of maternal deaths among poor and rural women and girls reveals global inequalities in resource distribution not only by gender hierarchies, but also by class, race, and other social identities. Alicia Ely Yamin points out, “No global health issue may more acutely capture the culmination of conspiring inequities within, as well as between, countries than maternal mortality” (Yamin, 2017). Restrictions to bodily autonomy and integrity, such as the PLGHA policy, exacerbate prevailing structural barriers to accessing health services and improving wellbeing. At the same time, the PLGHA policy reinforces the continued marginalization and discrimination of women and girls on the basis of their reproductive identity. In Uganda, civil society has been crucial in filling in the gaps and mitigating health inequalities. They do so by providing services to marginalized populations and communities through programs, such as the ones participants described ending (Tanyag, 2017).

The PLGHA policy itself clearly does not support the right to abortion as it explicitly states that the U.S. government does not view abortion as an acceptable component of family planning. However, analysis of restrictive abortion regulations in terms of human rights- based approaches are inadequate as they do not address the larger context in which that right could be effectuated. The funding gap and subsequent adjustments NGOs make to

61 continue to provide services in Uganda affect a wide range of sexual and reproductive health-related services, thereby increasing the conditions that contribute to adverse health outcomes.

The impact of the PLGHA policy on SRHR in Uganda is multi-faceted. Not only does the expanded PLGHA policy affect all of global health assistance disbursed by any agency with the U.S. government but the effects are not limited to abortion-related work. No matter how tangential abortion is to an NGOs projects and programs, they are ineligible for funding if they perform abortions or actively promote abortion in any way. Despite the clause that permits the “passive” promotion of abortion, the three requirements for a health worker to be able to provide information or the performance of an abortion to a woman who is determined to abort and has clearly stated her intentions further confuses health workers who understandably question how they would be able to prove the circumstances. Additionally, the clause requires health workers to do so if it is in accordance with the national laws of their country, which is an already complex aspect of Ugandan law.

Interviews with health workers demonstrated that the PLGHA policy caused programmatic and structural adjustments that negatively affect their ability to provide services. Participants indicated that as a direct result of the PLGHA policy and decision to forego funding, clinics are closing, outreach efforts are scaled back, and specific programs, such as injectables, are ending. Despite the global response to the funding shifts, the amount raised to fill the gap is insufficient to compensate for the loss of funding left in the wake of the decision to reinstate the PLGHA policy. The majority of the funding raised by the She Decides initiative has been dedicated to providing the UNFPA with alternate funding sources rather than the NGOs directly affected (Edwards, 2018).

Health workers indicated that vulnerable populations will be disproportionately affected, particularly, marginalized women who are poor or live in rural areas. Reproductive justice theory stresses the intersectionality of social conditions. This exacerbates structural barriers to reaching already hard to reach populations will little access to health services and information. The scaled back outreach efforts to rural areas will not only prevent raising awareness about the dangers of unsafe abortion, but it will spillover to other programs. This will shape women’s abortion seeking behavior and instill negative attitudes towards seeking services, reduced knowledge of services, and lower confidence in obtaining services. As noted by health workers, the effect of the policy on relationships between provider and patient will be negatively impacted.

As many health workers expressed their frustration at not being able to provide comprehensive reproductive health services as a result. This was particularly poignant when medical service providers shared stories of women seeking abortions and they were unable to provide them. One doctor said they felt as though their hands were tied and he could not help her. The despair he felt later when she was on his operating table after an unsafe abortion translated into frustration at the legal barriers to safe abortion.

As numerous scholars have argued, sexual and reproductive health, including family planning, is vital to the fulfillment of human rights (Barot & Cohen, 2017; Girard, 2017). Access to sexual and reproductive health services enables individuals to plan their sexual and reproductive lives, an essential aspect of human dignity and freedom. As declared at the landmark UN conferences on women, population, and development in Cairo in 1994 and Beijing in 1995, the right to control the number, spacing, and timing of one’s children is fundamental to exercising reproductive rights (Barot, 2017). Moreover, the right to family planning enables individuals to exercise other human rights, such as gender equality – for example, by enabling women to expand their opportunities, increase their negotiating power, and raise their socioeconomic status.

6.2.2 Impact of PLGHA Policy on Ugandan Civil Society

The data illustrates the potential long-lasting impacts of the PLGHA policy on civil society. Civil society organizations in Uganda were found to rely on partnerships with a range of donors to maximize their resources and to deliver a wide range of services. In every interview, the researcher heard concerns about how the PLGHA policy could damage or dismantle coalitions and referral networks. Health workers reported that critical partnerships are lost as NGOs that receive U.S. funding stop collaborating with those who continue to work on abortion. Disruptions to collaboration and partnerships between NGOs affects the ability of civil society organizations to do their work effectively. NGOs that have agreed to the PLGHA policy are concerned that participation in activities with organizations that have refused to comply with the policy could jeopardize their own funding.

Some organizations that were approached to participate in the study declined requests for interviews in reference to their need to abide by the provisions of the PLGHA policy. Those who participated despite complying with the policy reported that they were adjusting their work and censoring themselves.

6.2.3 Impact of the PLGHA Policy on Political Discourse in Uganda

The PLGHA policy has sparked international anger at the Trump administration and critics of the policy have accused the U.S. of ideological imperialism, legislating morality, and violating democratic principles (PAI, 2018). The reinstatement of the PLGHA policy and the silencing effect it has on civil society organizations distorts the debate on abortion in Uganda. Organizations that actively promote abortion remain ineligible for U.S. global health assistance, however, their anti-abortion counterparts are eligible for funding. By curtailing the right to free speech and association, the PLGHA policy creates a hostile environment to work tied to abortion in any way. Latham (2017) argues that the PLGHA policy imposes conditions on NGOs that would be unconstitutional if imposed on domestic recipients of aid, similar to the findings of the Center for Reproductive Rights report (CRR, 2003).

The PLGHA policy prohibits NGOs from advocating for the liberalization of abortion laws in their own country. Advocacy was described as an especially difficult part of NGOs work due to the current political discourse surrounding the right to abortion in Uganda. Advocacy to legalize abortion would enable women to use safe abortion services, thereby reducing maternal morbidity and mortality, increasing reproductive choice, and reducing the chance of repeat unintended pregnancy and unsafe abortion. As participants involved in this study pointed out, in countries where there are less restrictive laws on abortion there are lower rates of abortion as well as maternal mortality and morbidity.

A woman’s ability to make choices about her own body and fertility, which requires access to modern contraception and safe abortion services, is a fundamental component of gender equality, economic development, and progress. Gender equality and access to family planning is not just a women’s issue, it is a health issue as well as an economic issue, and a prerequisite for development. When the conditions surrounding girls and women enable them to make choices about their own lives they have the possibility to create a better economic future for themselves, their families, their communities, and their societies. Legalizing abortion and policies that support the provision legal abortion would contribute to making more abortions safe. Improved access to post-abortion care could prevent abortion complications. While it is considered a positive aspect that the PLGHA policy does not have to do with post-abortion care, the nature of the policy prevents health workers from providing it.

The NGOs that participated in this study exercised immense agency in deciding to forgo funding from the U.S., the leading funder of global health in the world. As a result of this decision, NGOs have sought alternative sources of funding and participants emphasized the importance of the diversification of funding. When discussing strategies to mitigate the effects of the policy, participants noted the need to diversify their sources of funding. Participants often expressed discontent at the unilateral power of the United States to impose the PLGHA policy.

6.3 Recommendations for Policy, Practice, & Research

Taking into account the proposed strategies for mitigating the effects of the PLGHA policy by Ugandan health workers involved in this study, the following sub-sections outline the policy, practice, and research recommendations and are organized by target audience: the U.S. government, recipients of U.S. global health assistance, donor governments, UN agencies, governments in countries that receive U.S. global health assistance, and future researchers endeavoring to study the impact of the PLGHA policy .

6.3.1 U.S. Government

● Permanently repeal the PLGHA policy through legislation. Congress must pass legislation to terminate the current iteration of the PLGHA policy and permanently end the President’s ability to reinstate the policy in the future. This effort has been led by Representative Nita M. Lowey (D-NY) and Senator Jeanne Shaheen (D-NH) and the introduction of the Global Health, Empowerment and Rights (HER) Act which would allow foreign NGOs receiving U.S. funding to use their non-U.S. funds for medical services, including safe abortion, and would nullify any U.S. policy that contravenes it (Global Health, Empowerment and Rights [HER] Act, S. 210, 115th Cong. [2017]; Global HER Act, H.R. 671, 115th Cong. [2017]).

● As long as the PLGHA policy is in effect, develop and disseminate clear guidelines for implementation with all recipients of U.S. global health assistance. Until the PLGHA policy is repealed, U.S. government agencies must provide clearer and more consistent guidelines for organizations. ● As long as the PLGHA policy is in effect, U.S. government review processes must be comprehensive and transparent to assess the impact of the policy.

6.3.2 Recipients of U.S. Global Health Assistance

● Ensure that staff understand the PLGHA policy. ● Document the impact of the PLGHA policy on their organization’s and other’s work.

6.3.3 Donor Governments and International/Regional Organizations

● Increase funding to organizations that have been affected by the PLGHA policy. ● Governments should push back on U.S. foreign policies that negatively affect health.

6.3.4 UN Agencies

● Publicly speak out against the PLGHA policy and other restrictions on official development assistance that undermine the autonomy of countries and organizations and their ability to provide comprehensive SRH services. ● Include information about the impact of the PLGHA policy in reports and other materials that address gender equality, SRHR, and health issues.

6.3.5 Governments in Countries that Receive U.S. Global Health Assistance

● Increase funding for health to fill gaps in services and information as a result of the PLGHA policy. ● Document the impact of the PLGHA policy on population health and health systems. ● Actively advocate with the U.S. government to remove the PLGHA policy. ● Governments should push back on U.S. foreign policies that negatively affect health in their country.

6.3.6 Researchers • The usage of analytical frameworks can provide nuanced insights into the realities and complexities of how the PLGHA policy is translated into service provision in country contexts.

6.4 Conclusion

This thesis documented the early impact of the PLGHA policy on civil society in Uganda within six months of the policy’s implementation. The findings of this study indicate that due to funding loss, the PLGHA policy is having a negative effect on the ability of civil society organizations to provide comprehensive sexual and reproductive health care, infringes upon the reproductive rights of women, and impedes advocacy for the liberalization of abortion laws in Uganda. The fears expressed by participants of increased rates of unintended pregnancy, subsequent abortions, and associated maternal mortality and morbidity as a result of the programmatic adjustments that are already being made describe the reality of the impact of the PLGHA policy on the ground.

Reflecting on the theoretical approach of this thesis, a reproductive justice framework provides a concrete basis for building coalitions with organizations fighting for justice and for systemic change in policy, health, and rights. Writing this thesis was a challenging experience and took longer than anticipated. It was especially difficult grappling with the many theoretical frameworks that could potentially shed light on the preventable pandemic of unsafe abortion in this context, as well as the difficulty of identifying the most appropriate theoretical approach for the study. This reflects the complexities of the issue of abortion and the policies that regulate the practice. Furthermore, I seriously underestimated the momentous task of doing justice to the data gathered. The nature of the subject proved taxing in and of itself, however, it was the determination to do justice to the research that complicated matters.

The findings of this study complement similar studies conducted by research and policy organizations on the impact of the PLGHA policy in Uganda and other recipient countries. The consistency in these findings demonstrates the scope of the devastating effects of the PLGHA policy and warrants a comprehensive review of the policy’s implementation and enforcement. This research has emphasized that the implementation of the PLGHA policy is in its early stages and this study cannot hope to ascertain the long-term effects of the policy.

Although the long-term consequences of the PLGHA policy cannot be determined at this stage, some clear effects have emerged that are consistent with the findings of similar studies in other country contexts. Further research will be required to determine the full effects of the policy.

The chaos that each previous iteration of the MCP wreaked on global health has been magnified by the expanded version of the PLGHA policy. Restricting access to abortion will not stop women from seeking them and finding a way that likely means putting themselves at an even greater risk. The implications of the PLGHA policy for reproductive health, rights, and justice are dire and action must be taken to mitigate the effects of this harmful policy.

Appendix A: United States Policy Statement at the ICPD 1984

Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session) Mexico, D.F. August 16-13, 1984.

POLICY STATEMENT: INTERNATIONAL CONFERENCE ON POPULATION.

INTRODUCTION

For many years, the United States has supported, and helped to finance, programs of family planning, particularly in developing countries. This Administration has continued that support but has placed it within a policy context different from that of the past. It is sufficiently evident that the current exponential growth in global population cannot continue indefinitely. There is no question of the ultimate need to achieve a condition of population equilibrium. The differences that do exist concern the choice of strategies and methods for the achievement of that goal. The experience of the last two decades not only makes possible but requires a sharper focus for our population policy. It requires a more refined approach to problems which appear today in quite a different light than they did twenty years ago.

First and most important, population growth is, of itself, a neutral phenomenon. It is not necessarily good or ill. It becomes an asset or a problem only in conjunction with other factors, such as economic policy, social constraints, need for manpower, and so forth. The relationship between population growth and economic development is not necessarily a negative one. More people do not necessarily mean less growth. Indeed, in the economic history of many nations, population growth has been an essential element in economic progress.

Before the advent of governmental population programs, several factors had combined to create an unprecedented surge in population over most of the world. Although population levels in many industrialized nations had reached or were approaching equilibrium in the period before the Second World War, the baby boom that followed in its wake resulted in a dramatic, but temporary, population “tilt” toward youth. The disproportionate number of infants, children, teenagers, and eventually young adults, did strain the social infrastructure

of schools, health facilities, law enforcement, and so forth. However, it also helped sustain strong economic growth, despite occasionally counterproductive government policies.

Among the developing nations, a coincidental population increase was caused by entirely different factors. A tremendous expansion of health services – from simple inoculations to sophisticated surgery – saved millions of lives every year. Emergency relief, facilitated by modern transport, helped millions to survive flood, famine, and drought, The sharing of technology, the teaching of agriculture and engineering and improvements in educational standards generally, all helped to reduce mortality rates, especially infant mortality, and to lengthen life spans.

This demonstrated not poor planning or bad policy but human progress in a new era of international assistance, technological advance, and human compassion. The population boom was a challenge; it need not have been a crisis. Seen in its broader context, it required a measured, modulated response. It provoked an overreaction by some, largely, because it coincided with two negative factors which, together, hindered families and nations in adapting to their changing circumstances.

The first of these factors was governmental control of economies, a development which effectively constrained economic growth. The post-war experience consistently demonstrated that, as economic decision-making was concentrated in the hands of planners and public officials, the ability of average men and women to work towards a better future was impaired, and sometimes crippled. In many cases, agriculture was devastated by government price-fixing that wiped out rewards for labor. Job creation in infant industries was hampered by confiscatory taxes. Personal industry and thrift were penalized, while dependence upon the state was encouraged. Political considerations made it difficult for an economy to adjust to changes in supply and demand or to disruptions in world trade and finance. Under such circumstances, population growth changed from an asset in the development of economic potential to a peril.

One of the consequences of this "economic statism" was that it disrupted the natural mechanism for slowing population growth in problem areas. The world's more affluent nations have reached a population equilibrium without compulsion and, in most cases, even before it was government policy to achieve it. The controlling factor in these cases has been the adjustment, by individual families, of reproductive behavior to economic opportunity and aspiration. Historically, as opportunities and the standard of living rise, the birth rate falls. In many countries, economic freedom has led to economically rational behavior.

That pattern might be well under way in many nations where population growth is today a problem, if counterproductive government policies had not disrupted economic incentives, rewards, and advancement. In this regard, localized crises of population growth are, in part, evidence of too much government control and planning, rather than too little. The second factor that turned the population boom into a crisis was confined to the western world. It was an outbreak of an anti-intellectualism, which attacked science, technology, and the very concept of material progress. Joined to a commendable and long overdue concern for the environment, it was more a reflection of anxiety about unsettled times and an uncertain future. In its disregard of human experience and scientific sophistication, it was not unlike other waves of cultural anxiety that have swept through western civilization during times of social stress and scientific exploration.

The combination of these two factors — counterproductive economic policies in poor and struggling nations, and a pessimism among the more advanced — led to a demographic overreaction in the 1960's and 1970's. Scientific forecasts were required to compete with unsound, extremist scenarios, and too many governments pursued population control measures without sound economic policies that create the rise in living standards historically associated with decline in fertility rates. This approach has not worked, primarily because it has focused on a symptom and neglected the underlying ailments. For the last three years, this Administration has sought to reverse that approach. We recognize that, in some cases, immediate population pressures may require short-term efforts to ameliorate them. But population control programs alone cannot substitute for the economic reforms that put a society on the road toward growth and, as an aftereffect, toward slower population increase as well.

Nor can population control substitute for the rapid and responsible development of natural resources. In commenting on the Global 2000 report, this Administration in 1981 disagreed with its call 'for more governmental supervision and control, stating that:

'Historically, that has tended to restrict the availability of resources and to hamper the development of technology, rather than to assist it. Recognizing the seriousness of environmental and economic problems, and their relationship to social and political pressures, especially in the developing nations, the Administration places a priority upon technological advance and economic expansion, which hold out the hope of prosperity and stability of a rapidly changing world. That hope can be realized, of course, only to the extent that government's response to problems, whether economic or 'ecological, respects and enhances individual freedom, which make true progress possible and worthwhile.'

Those principles underlie this country's approach to the International Conference on Population to be held in Mexico City in August.

POLICY OBJECTIVES

The world's rapid population growth is a recent phenomenon. Only several decades ago, the population of developing countries was relatively stable, the result of a balance between high fertility and high mortality. There are now 4.5 billion people in the world, and six billion

71 are projected by the year 2000. Such rapid growth places tremendous pressures on governments without concomitant economic growth.

The International Conference on Population offers the U.S. an opportunity to strengthen the international consensus on the interrelationships between economic development and population, which has emerged since the last such conference in Bucharest in 1974. Our primary objective will be to encourage developing countries to adopt sound economic policies and, where appropriate, population policies consistent with respect for human dignity and family values. As President Reagan stated in his message to the Mexico City Conference:

'We believe population programs can and must be truly voluntary, cognizant of the rights and responsibilities of individuals and families, and respectful of religious and cultural values. When they are, such programs can make an important contribution to economic and social development, to the health of mothers and children, and to the stability of the family and of society. '

U.S. support for family planning programs is based on respect for human life, enhancement of human dignity, and strengthening of the family. Attempts to use abortion, involuntary sterilization, or other coercive measures in family planning must be shunned, whether exercised against families within a society or against nations within the family of man.

The United Nations Declaration of the Rights of the Child (1959) calls for legal protection for children before birth as well as after birth. In keeping with this obligation, the United States does not consider abortion an acceptable element of family planning programs and will no longer contribute to those of which it is a part. Accordingly, when dealing with nations which support abortion with funds not provided by the United States Government, the United States will contribute to such nations through segregated accounts which cannot be used for abortion. Moreover, the United States will no longer contribute to separate nongovernmental organizations which perform or actively promote abortion as a method of family planning in other nations. With regard to the United Nations Fund for Population Activities (UNFPA), the U.S. will insist that no part of its contribution be used for abortion. The U.S. will also call for concrete assurances that the UNFPA is not engaged in, or does not provide funding for, abortion or coercive family planning programs; if such assurances are not forthcoming, the U.S. will redirect the amount of its contribution to other, non-UNFPA, family planning programs.

In addition, when efforts to lower population growth are deemed advisable, U.S. policy considers it imperative that such efforts respect the religious beliefs and culture of each society, and the right of couples to determine the size of their own families. Accordingly, the U.S. will not provide family planning funds to any nation which engages in forcible coercion to achieve population growth objectives. U.S. Government authorities will immediately begin negotiations to implement the above policies with the appropriate governments and organizations.

It is time to put additional emphasis upon those root problems which frequently exacerbate population pressures, but which have too often been given scant attention. By focusing upon real remedies for underdeveloped' economies, the International Conference on Population can reduce demographic issues to their proper place. It is an important place, but not the controlling one. It requires our continuing attention within the broader context of economic growth and of the economic freedom that is its prerequisite.

POPULATION, DEVELOPMENT, AND ECONOMIC POLICIES

Conservative projections indicate that, in the sixty years from 1950 to 2010, many Third World countries will experience four-, five-, or even six-fold increases in the size of their populations. Even under the assumption of gradual declines in birth rates, the unusually high proportion of youth in the Third World means that the annual population growth in many of these countries will continue to increase for the next several decades. [page 6]

Sound economic policies and a market economy are of fundamental importance to the process of economic development. Rising standards of living contributed in a major way to the demographic transition from high to low rates of population growth which occurred in the U.S. and other industrialized countries over the last century.

The current situation of many developing countries, however, differs in certain ways from conditions in 19th century Europe and the U.S. The rates and dimensions of population growth are much higher now, the pressures on land, water, and resources are greater, the safety-valve of migration is more restricted, and, perhaps most important, time is not on their side because of the momentum of demographic change.

Rapid population growth compounds already serious problems faced by both public and private sectors in accommodating changing social and economic demands. It diverts resources from needed investment, and increases the costs and difficulties of economic development. Slowing population growth is not a panacea for the problems of social and economic development. It is not offered as a substitute for sound and comprehensive development policies which encourage a vital private sector, it cannot solve problems of hunger, unemployment, crowding, or social disorder.

Population assistance is an ingredient of a comprehensive program that focuses on the root causes of development failures. The U.S. program as a whole, including population assistance, lays the basis for well-grounded, step-by-step initiatives to improve the wellbeing of people in developing countries and to make their own efforts, particularly through expanded private sector initiatives, a key building block of development programs.

Fortunately, a broad international consensus has emerged since the 1974 Bucharest World Population Conference that economic development and population policies are mutually reinforcing.

By helping developing countries slow their population growth through support for effective voluntary family planning programs, in conjunction with sound economic policies, U.S. population assistance contributes to stronger saving and investment rates, speeds the development of effective markets and related employment opportunities, reduces the potential resource requirements of programs to improve the health and education of the people, and hastens the achievement of each country's graduation from the need for external assistance.

The United States will continue its long-standing commitment to development assistance, of which population programs are a part. We recognize the importance of providing our assistance within the cultural, economic, and political context of the countries we are assisting, and in keeping with our own values.

HEALTH AND HUMANITARIAN CONCERNS

Perhaps the most poignant consequence of rapid population growth is its effect on the health of mothers and children. Especially in poor countries, the health and nutrition status of women and children is linked to family size. Maternal and infant mortality rises with the number of births and with births too closely spaced. In countries as different as Turkey, Peru, and Nepal, a child born less than two years after its sibling is twice as likely to die before it reaches the age of five, than if there were an interval of at least four years between the births. Complications of pregnancy are more frequent among women who are very young or near the end of their reproductive years. In societies with widespread malnutrition and inadequate health conditions, these problems are reinforced; numerous and closely spaced births lead to even greater malnutrition of mothers and infants.

It is an unfortunate reality that, in many countries, abortion is used as a means of terminating unwanted pregnancies. This is unnecessary and repugnant; voluntary family assistance programs can provide a humane alternative to abortion for couples who wish to regulate the size of their family, and evidence from some developing countries indicates a decline in abortion as such services become available.

The basic objective of all U.S. assistance, including population programs, is the betterment of the human condition – improving the quality of life of mothers and children, of families, and of communities for generations to come. For we recognize that people are the ultimate resource – but this means happy and healthy children, growing up with education, finding productive work as young adults, and able to develop their full mental and physical potential. U.S. aid is designed to promote economic progress in developing countries through encouraging sound economic policies and freeing of individual initiative. Thus, the U.S. supports a broad range of activities in various sectors, including agriculture, private enterprise, science and technology, health, population, and education. Population assistance amounts to about ten percent of total development assistance.

TECHNOLOGY AS A KEY TO DEVELOPMENT

The transfer, adaptation, and improvement of modern know-how is central to U.S. development assistance. People with greater know-how are people better able to improve their lives. Population assistance ensures that a wide range of modern' demographic technology is made available to developing countries and that technological improvements critical for successful development receive support.

The efficient collection, processing, and analysis of data derived from census, survey, and vital statistics programs contribute to better planning in both the public and private sectors.

Appendix B: Memorandum of January 23, 2017

Appendix C: Standard Provisions for Non-U.S. Nongovernmental Organizations

RAA29. PROTECTING LIFE IN GLOBAL HEALTH ASSISTANCE (MAY 2017)

APPLICABLITY: This provision is applicable to those awards using federal funding predictably for international health activities with a primary purpose or effect of benefitting a foreign country, typically funded from the GHP, ESF, AEECA, or successor accounts, as applicable, including awards reported on under the Health category of the Foreign Assistance Standardized Program Structure, except those under program area HL.8, Water Supply and Sanitation, the American Schools and Hospitals Abroad Program, or programs funded by Food for Peace. This provision applies whenever implementation of the activity involves assistance to or implemented by foreign non- governmental organizations.

PROTECTING LIFE IN GLOBAL HEALTH ASSISTANCE (MAY 2017).

a) Ineligibility of Foreign Non-governmental Organizations that Perform or Actively Promote Abortion as a Method of Family Planning

This provision is in two parts: I, applicable to foreign non-governmental organizations; and II, applicable to U.S. non-governmental organizations. Both part I and part II should be included in awards.

I. Grants and Cooperative Agreements with Foreign Non-governmental Organizations (1) The recipient agrees that it will not, during the term of this award, perform or actively promote abortion as a method of family planning in foreign countries or provide financial support to any other foreign non-governmental organization that conducts such activities. For purposes of this paragraph (a), a foreign non- governmental organization is a for-profit or not-for-profit non-governmental organization that is not organized under the laws of the United States, any State of the United States, the District of Columbia, or the Commonwealth of Puerto Rico, or any other territory or possession of the United States. (2) The recipient agrees that authorized representatives of USAID may, at any reasonable time, announced or unannounced, consistent with 2 CFR Part 200: (i) inspect the documents and materials maintained or prepared by the recipient in the usual course of its operations that describe the health activities of the recipient, 77

including reports, brochures, and service statistics; (ii) observe the health activities conducted by the recipient, (iii) consult with healthcare personnel of the recipient; and (iv) obtain a copy of audited financial statements or reports of the recipient, as applicable. (3) In the event USAID has reasonable cause to believe that the recipient may have violated its undertaking not to perform or actively promote abortion as a method of family planning, the recipient must make available to USAID such books and records and other information as USAID may reasonably request to determine whether a violation of that undertaking has occurred, consistent with 2 CFR Part 200. (4) Health assistance furnished to the recipient under this award must be terminated if the recipient violates any undertaking required by this paragraph (a), and the recipient must refund to USAID any unexpended amounts furnished to the recipient under this award, plus an amount equivalent to that used by the recipient to perform or actively promote abortion as a method of family planning while receiving funding under this award. The amount to be refunded to USAID under this subparagraph (4) may not exceed the total amount of health assistance furnished under this award. (5) The recipient may not furnish health assistance under this award to another foreign non-governmental organization (the subrecipient) unless: (i) subrecipient agrees, by entering into such subaward, that it does not perform or actively promote abortion as a method of family planning in foreign countries and will not provide financial support to any other foreign non-governmental organization that conducts such activities; and (ii) such foreign non-governmental organization’s agreement contains the same terms and conditions as described in subparagraph (6) below. (6) Prior to entering into an agreement to furnish health assistance to a foreign non- governmental organization under this award, the recipient must ensure that such agreement with the subrecipient includes the following terms: (i) The subrecipient will not, while receiving assistance under this award, perform or actively promote abortion as a method of family planning in foreign countries or provide financial support to other foreign non- governmental organizations that conduct such activities; (ii) The recipient and authorized representatives of USAID may, at any reasonable time, announced or unannounced, consistent with 2 CFR Part 200: (A) inspect the documents and materials maintained or prepared by the subrecipient in the usual course of its operations that describe the health activities of the subrecipient, including reports, brochures, and service statistics; (B) observe health activities conducted by the subrecipient; (C) consult with healthcare personnel of the subrecipient; and (D) obtain a copy of audited financial statements or reports of the subrecipient, as applicable; (iii) In the event that the recipient or USAID has reasonable cause to believe that a subrecipient may have violated its undertaking not to perform or actively promote abortion as a method of family planning, the recipient will review the health program of the subrecipient to determine whether a violation of such undertaking has occurred. The subrecipient must make available to the recipient such books and records and other information as may be reasonably requested to conduct the review. USAID may review the health program of the subrecipient under these circumstances, and the subrecipient must provide access on a timely basis to USAID to such books and records and other information upon request, consistent with 2 CFR Part 200; (iv) Health assistance provided to the subrecipient under this award must be terminated if the subrecipient violates any award terms under subparagraphs (6)(i)-(iii), above, and the subrecipient must refund to the recipient any unexpended amounts furnished to the subrecipient under this award, plus an amount equivalent to that used by the subrecipient to perform or actively promote abortion as a method of family planning while receiving funding under this award, up to the total amount of health assistance furnished to the subrecipient under this award; and (v) The subrecipient may furnish health assistance under this award to another foreign non-governmental organization only if: (A) such foreign non- governmental organization agrees, by entering into such agreement, that it will not perform or actively promote abortion as a method of family planning in foreign countries and will not provide financial support to any other foreign non-governmental organization that conducts such activities, and (B) such foreign non-governmental organization’s agreement contains the same terms and conditions as those provided by the subrecipient to the recipient as described in subparagraphs (6)(i)-(iv), above. (7) Where the terms and conditions of the award require USAID approval of subawards, the recipient must include a description of the due diligence performed by the recipient on the subrecipient before furnishing health assistance under this award. (8) The recipient is liable to USAID for a refund for a violation by the subrecipient of any requirement of this paragraph (a) only if: (i) the recipient knowingly furnishes health assistance under this award to a subrecipient that performs or actively promotes abortion as a method of family planning, or (ii) the subrecipient did not abide by its award terms required by subparagraphs (6)(i)-(iii), above, and the recipient failed to make reasonable due diligence efforts prior to furnishing health assistance to the

subrecipient, or (iii) the recipient knows or has reason to know, by virtue of the monitoring that the recipient is required to perform under the terms of this award, that a subrecipient has violated any of the award terms required by subparagraphs (6)(i)-(iii), above, and the recipient fails to terminate health assistance to the subrecipient, or fails to require the subrecipient to terminate assistance furnished under a subaward that violates any award terms required by subparagraphs (6)(i)- (iii), above. (9) The recipient acknowledges that USAID may make independent inquiries in the community served by the recipient or a subrecipient under this award regarding whether it performs or actively promotes abortion as a method of family planning. (10) The following definitions apply for purposes of paragraph (a): (i) Abortion is a method of family planning when it is for the purpose of spacing births. This includes, but is not limited to, abortions performed for the physical or mental health of the mother and abortions performed for fetal abnormalities, but does not include abortions performed if the life of the mother would be endangered if the fetus were carried to term or abortions performed following rape or incest. (ii) “To perform abortions” means to operate a facility where abortions are provided as a method of family planning. Excluded from this definition is the treatment of injuries or illnesses caused by legal or illegal abortions, for example, post-abortion care. (iii) “To actively promote abortion” means for an organization to commit resources, financial or other, in a substantial or continuing effort to increase the availability or use of abortion as a method of family planning. (A) This includes, but is not limited to, the following activities: (I) Operating a service-delivery site that provides, as part of its regular program, counseling, including advice and information, regarding the benefits and/or availability of abortion as a method of family planning; (II) Providing advice that abortion as a method of family planning is an available option or encouraging women to consider abortion (passively responding to a question regarding where a safe, legal abortion may be obtained is not considered active promotion if a woman who is already pregnant specifically asks the question, she clearly states that she has already decided to have a legal abortion, and the healthcare provider reasonably believes that the ethics of the medical profession in the host country requires a response regarding where it may be obtained safely and legally); (III) Lobbying a foreign government to legalize or make available abortion as a method of family planning or lobbying such a government to continue the legality of abortion as a method of family planning; and (IV) Conducting a public information campaign in foreign countries regarding the benefits and/or availability of abortion as a method of family planning. (B) Excluded from the definition of active promotion of abortion as a method of family planning are referrals for abortion as a result of rape or incest, or if the life of the mother would be endangered if she were to carry the fetus to term. Also excluded from this definition is the treatment of injuries or illnesses caused by legal or illegal abortions, for example, post- abortion care. (C) Action by an individual acting in the individual’s capacity shall not be attributed to an organization with which the individual is associated, provided that the individual is neither on duty nor acting on the organization’s premises, and the organization neither endorses nor provides financial support for the action and takes reasonable steps to ensure that the individual does not improperly represent that he or she is acting on behalf of the organization. (iv) Furnishing health assistance to a foreign non-governmental organization includes the transfer of funds made available under this award or goods or services financed with such funds, but does not include the purchase of goods or services from an organization or the participation of an individual in the general training programs of the recipient or subrecipient. (v) To “control” an organization means to possess the power to direct, or cause the direction of, the management and policies of an organization. (11) In determining whether a foreign non-governmental organization is eligible to be a recipient or subrecipient of health assistance under this award, the action of separate non-governmental organizations shall not be imputed to the recipient or subrecipient, unless, in the judgment of USAID, a separate non-governmental organization is being used purposefully to avoid the provisions of this paragraph (a). Separate non-governmental organizations are those that have distinct legal existence in accordance with the laws of the countries in which they are organized. Foreign organizations that are separately organized shall not be considered separate, however, if one is controlled by the other. The recipient may request the USAID Agreement Officer’s approval to treat as separate the health activities of two or more

organizations, which would not be considered separate under the preceding sentence. The recipient must provide a written justification to USAID that the health activities of the organizations are sufficiently distinct to warrant not imputing the activity of one to the other. (12) Health assistance may be furnished under this award by a recipient or subrecipient to a foreign government or parastatal even though the government or parastatal includes abortion in its health program, provided that no such assistance may be furnished under this award in support of the abortion activity of the government or parastatal and any funds transferred to the government or parastatal must be placed in a segregated account to ensure that such funds may not be used to support the abortion activity of the government or parastatal. (13) For the avoidance of doubt, in the event of a conflict between a term of this paragraph (a) and an affirmative duty of a healthcare provider required under local law to provide counseling about and referrals for abortion as a method of family planning, compliance with such law shall not trigger a violation of this paragraph (a). II. Grants and Cooperative Agreements with U.S. Non-governmental Organizations (1) The recipient (A) agrees that it will not furnish health assistance under this award to any foreign non-governmental organization that performs or actively promotes abortion as a method of family planning in foreign countries; and (B) further agrees to require that such subrecipients do not provide financial support to any other foreign non-governmental organization that conducts such activities. For purposes of this paragraph (a), a foreign non-governmental organization is a for-profit or not-for- profit non-governmental organization that is not organized under the laws of the United States, any State of the United States, the District of Columbia, or the Commonwealth of Puerto Rico, or any other territory or possession of the United States. (2) Prior to entering into an agreement to furnish health assistance to a foreign non- governmental organization (subrecipient) under this award, the recipient must ensure that such agreement with the subrecipient includes the following terms: (i) The subrecipient will not, while receiving assistance under this award, perform or actively promote abortion as a method of family planning in foreign countries or provide financial support to other foreign non- governmental organizations that conduct such activities; (ii) The recipient, and authorized representatives of USAID may, at any reasonable time, announced or unannounced, consistent with 2 CFR Part 200: (A) inspect the documents and materials maintained or prepared by the subrecipient in the usual course of its operations that describe the health activities of the subrecipient, including reports, brochures, and service statistics; (B) observe the health activities conducted by the subrecipient; (C) consult with healthcare personnel of the subrecipient; and (D) obtain a copy of audited financial statements or reports of the subrecipient, as applicable; (iii) In the event that the recipient or USAID has reasonable cause to believe that a subrecipient may have violated its undertaking not to perform or actively promote abortion as a method of family planning, the recipient will review the health program of the subrecipient to determine whether a violation of such undertaking has occurred. The subrecipient must make available to the recipient such books and records and other information as may be reasonably requested to conduct the review. USAID may review the health program of the subrecipient under these circumstances, and the subrecipient must provide access on a timely basis to USAID to such books and records and other information upon request, consistent with 2 CFR part 200; (iv) Health assistance provided to the subrecipient under this award must be terminated if the subrecipient violates any award terms required by subparagraphs (2)(i)-(iii), above, and the subrecipient must refund to the recipient any unexpended amounts furnished to the subrecipient under this award, plus an amount equivalent to that used by the subrecipient to perform or actively promote abortion as a method of family planning while receiving funding under this award, up to the total amount of health assistance furnished to the subrecipient under this award; and (v) The subrecipient may furnish health assistance under this award to another foreign non-governmental organization only if: (A) such foreign non- governmental organization agrees, by entering into such agreement, that it will not perform or actively promote abortion as a method of family planning in foreign countries and will not provide financial support to any other foreign non-governmental organization that conducts such activities; and (B) such foreign non-governmental organization’s agreement contains the same terms and conditions as those provided by the subrecipient to the recipient as described in subparagraphs (2)(i)-(iv), above. (3) Where the terms and conditions of the award require USAID approval of subawards, the recipient must include a description of the due diligence performed by the recipient on the subrecipient before furnishing health assistance under this award. (4) The recipient is liable to USAID for a refund for a violation by the subrecipient of any requirement of this paragraph (a) only if: (i) the recipient knowingly furnishes health assistance under this award to a subrecipient that performs or actively promotes abortion as a method of family planning; or (ii) the subrecipient did not abide by its

award terms required by subparagraphs (2)(i)-(iii), above, and the recipient failed to make reasonable due diligence efforts prior to furnishing health assistance to the subrecipient; or (iii) the recipient knows or has reason to know, by virtue of the monitoring that the recipient is required to perform under the terms of this award, that a subrecipient has violated any of the award terms required by subparagraphs (2)(i)-(iii), above, and the recipient fails to terminate health assistance to the subrecipient, or fails to require the subrecipient to terminate assistance furnished under a subaward that violates any award terms required by subparagraphs (2)(i)- (iii), above. (5) The recipient acknowledges that USAID may make independent inquiries in the community served by a subrecipient under this award regarding whether such subrecipient performs or actively promotes abortion as a method of family planning. (6) The following definitions apply for purposes of this paragraph (a): (i) Abortion is a method of family planning when it is for the purpose of spacing births. This includes, but is not limited to, abortions performed for the physical or mental health of the mother and abortions performed for fetal abnormalities, but does not include abortions performed if the life of the mother would be endangered if the fetus were carried to term or abortions performed following rape or incest. (ii) “To perform abortions” means to operate a facility where abortions are provided as a method of family planning. Excluded from this definition is the treatment of injuries or illnesses caused by legal or illegal abortions, for example, post-abortion care. (iii) “To actively promote abortion” means for an organization to commit resources, financial or other, in a substantial or continuing effort to increase the availability or use of abortion as a method of family planning. (A) This includes, but is not limited to, the following activities: (I) Operating a service-delivery site that provides, as part of its regular program, counseling, including advice and information, regarding the benefits and/or availability of abortion as a method of family planning; (II) Providing advice that abortion as a method of family planning is an available option or encouraging women to consider abortion (passively responding to a question regarding where a safe, legal abortion may be obtained is not considered active promotion if a woman who is already pregnant specifically asks the question, she clearly states that she has already decided to have a legal abortion, and the healthcare provider reasonably believes that the ethics of the medical profession in the host country requires a response regarding where it may be obtained safely and legally); (III)Lobbying a foreign government to legalize or make available abortion as a method of family planning or lobbying such a government to continue the legality of abortion as a method of family planning; and (IV) Conducting a public-information campaign in foreign countries regarding the benefits and/or availability of abortion as a method of family planning. (B) Excluded from the definition of active promotion of abortion as a method of family planning are referrals for abortion as a result of rape or incest, or if the life of the mother would be endangered if she were to carry the fetus to term. Also excluded from this definition is the treatment of injuries or illnesses caused by legal or illegal abortions, for example, post- abortion care. (C) Action by an individual acting in the individual’s capacity shall not be attributed to an organization with which the individual is associated, provided that the individual is neither on duty nor acting on the organization’s premises, and the organization neither endorses nor provides financial support for the action and takes reasonable steps to ensure that the individual does not improperly represent that he or she is acting on behalf of the organization. (iv) Furnishing health assistance to a foreign non-governmental organization includes the transfer of funds made available under this award or goods or services financed with such funds, but does not include the purchase of goods or services from an organization or the participation of an individual in the general training programs of the recipient or subrecipient. (v) To “control” an organization means to possess the power to direct, or cause the direction of, the management and policies of an organization. (7) In determining whether a foreign non-governmental organization is eligible to be a subrecipient of health assistance under this award, the action of separate non- governmental organizations shall not be imputed to the sub-recipient, unless, in the judgment of USAID, a separate non-governmental organization is being used purposefully to avoid the provisions of this paragraph (a). Separate non- governmental organizations are those that have distinct legal existence in accordance with the laws of the countries in which they are organized. Foreign organizations that are separately organized shall not be considered separate, however, if one is

controlled by the other. The recipient may request the USAID Agreement Officer’s approval to treat as separate the health activities of two or more organizations, which would not be considered separate under the preceding sentence. The recipient must provide a written justification to USAID that the health activities of the organizations are sufficiently distinct to warrant not imputing the activity of one to the other. (8) Health assistance may be furnished under this award by a recipient or subrecipient to a foreign government or parastatal even though the government or parastatal includes abortion in its health program, provided that no such assistance may be furnished under this award in support of the abortion activity of the government or parastatal and any funds transferred to the government or parastatal must be placed in a segregated account to ensure that such funds may not be used to support the abortion activity of the government or parastatal. (9) For the avoidance of doubt, in the event of a conflict between a term of this paragraph (a) and an affirmative duty of a healthcare provider required under local law to provide counseling about and referrals for abortion as a method of family planning, compliance with such law shall not trigger a violation of this paragraph (a).

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