Impacts on Affected Countries

Tanzania

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Overview

Due to a cumulative loss of almost US$500,000 in funds from the U.S. Agency for International Development (USAID), two major family planning organizations in Tanzania have been forced to withdraw critical technical support from the government's family planning programs. The Global Gag Rule has compounded contraceptive supply problems in the country and hinders the effectiveness of HIV/AIDS programming.

Tanzania faces serious reproductive health challenges: women there have an average of 5.6 children, and maternal and infant mortality rates are dangerously high. These challenges are exacerbated by the HIV/AIDS epidemic and the high incidence of illegal abortion, which accounts for significant maternal mortality and morbidity. The gag rule undermines efforts to address these reproductive health issues at a time when the need for comprehensive family planning and reproductive health services is most critical.

Two local organizations – Chama Cha Uzazi na Malezi Bora Tanzania (UMATI) and Marie Stopes Tanzania (MST) – have been the primary nongovernmental organizations (NGOs) offering family planning services in Tanzania. Since the 1990s these organizations have trained staff in health clinics all over the country to provide high-quality family planning services. Much of this work has been supported with U.S. funds.

In addition to running its own clinics, UMATI has focused on building capacity at government health facilities to provide family planning, while MST has specialized in providing technical support to the private sector institutions. UMATI's mandate includes awareness-raising; training public and private sector service providers on family planning service provision; focusing on the long-term and permanent methods (LTPM) of contraception, including female and male sterilization and implants; and procurement and supply of contraceptives for the entire country.

MST supports private clinics and outreach programs that offer health education programming, voluntary counseling and testing (VCT) for HIV, condom distribution, and maternal and child health care.

Prior to the reinstatement of the Global Gag Rule, UMATI and MST had been developing the capacity of providers at public and private clinics, through training, monitoring and quality improvement initiatives, to offer family planning as part of their routine care. They had also encouraged clients to value and seek family planning services. The gag rule cut these efforts short at a critical juncture.

Family Planning Services Jeopardized

MST lost almost 65 percent of its annual budget when it refused to accept the gag rule restrictions in 2001. Furthermore, given that the basket fund mechanism* accounts for most non-U.S. bilateral support, MST lost one of the few remaining sources of direct local support by foreign governments.

MST has 18 health clinics and more than 80 outreach sites providing services in 20 districts throughout Tanzania. It is by far the largest provider of tubal ligations and Norplant insertions in the country, accounting for more than 70 percent of the total long-term and permanent contraceptive methods offered.

While MST has been able to continue operating all 18 clinics thus far, the future of some of its most critically located clinics is uncertain due to lack of sufficient and consistent funds. Three clinics in particular face an uncertain future: the clinic in Musoma, Mara Region, and the clinics in Iringa and Makambo, Iringa Region – all supported by USAID prior to the gag rule. They are located in critical spots, on the edge of the hardest-to-reach areas of Tanzania. Poor infrastructure and limited health services already plague this area, making it difficult for people to receive care.

The Canadian International Development Agency (CIDA) has provided interim support to these clinics from 2001 to 2004, but continued funding for coming years has not yet been identified. As a result, these three clinics risk closure in 2005.

Key Staff Lost and Supply Problems Exacerbated

By 2002, UMATI was supervising 98 public and private sector sites (clinics and hospitals), which were offering permanent and long-term methods of contraception. UMATI was also providing program support for capacity building, quality of care, training, and expendable supplies for these sites. By 2003, when UMATI refused the terms of the gag rule, 33 sites were directed by the Ministry of Health or by local faith-based organizations. The loss of USAID support forced UMATI to lay off 13 percent of its staff, a majority of whom were experienced doctors and nurses responsible for coordinating capacity-building operations at government facilities. The resulting loss of human resources destabilized the entire program and disabled many government sites' family planning services.

The swift termination of UMATI medical staff brought an immediate end to monitoring and supervision of capacity building for government providers. Without support or assistance from UMATI coordinators, many government providers were unprepared to offer family planning services.

Loss of key staff in UMATI has also exacerbated the lack of accurate data collection since the gag rule. Prior to the gag rule, UMATI and MST were responsible for routinely recording service statistics and using them to project future demand for contraceptive methods. Due to the abrupt withdrawal of personnel as a result of the gag rule, and without the necessary oversight of these key organizations, the supply system has languished.

HIV/AIDS Services Hampered

UMATI and MST both offer high-quality HIV/AIDS services integrated with their family planning programs and clinics, but thus far these organizations have not accessed USAID funding for HIV/AIDS activities. Although HIV/AIDS activities at both NGOs are still technically eligible for U.S. support, it has been perceived that the funding will not be applicable because their HIV/AIDS prevention and VCT services are offered as part of an integrated, comprehensive family planning and reproductive health program. MST claims that funding given only for specific HIV/AIDS activities will fragment reproductive health service delivery and fail to achieve the intended goal: to mitigate the impact of the HIV/AIDS epidemic.

Tanzania will receive considerable U.S. support for HIV/AIDS through the President’s Emergency Plan for AIDS Relief (PEPFAR) – a new five-year, $15 billion initiative to fight the HIV/AIDS pandemic. The inability of Tanzania's leading family planning NGOs to access U.S. HIV/AIDS assistance because their HIV/AIDS services are fully integrated with existing reproductive health services illustrates the extent to which the gag rule has limited vital HIV/AIDS work in Tanzania, and will continue to do so for years to come.

In addition, the fear and uncertainty created by the gag rule has compromised potential partnerships between established family planning providers and new HIV/AIDS organizations. The lack of collaboration limits the effectiveness of HIV/AIDS prevention and treatment strategies and precludes new organizations from utilizing the existing infrastructure of organizations, particularly in the private sector.

Conclusion

In Tanzania, institutions and clients alike are suffering as a result of the gag rule. Public providers have been unable to meet the demand for family planning due to the lack of training and/or necessary supplies, leaving vulnerable women at risk for unplanned pregnancies. The government has also suffered because it lacks adequate capacity to provide family planning services of the same scope or quality as MST or UMATI.

Against the backdrop of increasing demand for comprehensive reproductive health services, including HIV/AIDS services, MST and UMATI find themselves struggling financially to sustain their current level of services, especially in hard-to-reach rural areas, and have few alternative funding sources to turn to for assistance. The gag rule has stunted these NGOs' ability to strengthen and expand access to critical reproductive health services for Tanzania’s women and youth.

Notes

*Pioneered by the United Kingdom's Department for International Development (DFID) in 2000, "The Basket Fund" approach to bilateral aid refers to a central repository of funds given to a national government, which disburses funds for various projects at the district level.

A Closer Look Sources

United Nations Population Division, World Population Prospects, the 2002 Revision. Available at: http://esa.un.org/unpp/ (accessed Oct. 28, 2004).

United Nations Population Division, Dept. of Economic & Social Affairs, World Contraceptive Use 2003 Wall Chart, ST/ESA/SER.A/227, 2004.

UNAIDS 2004 Report on the Global AIDS Epidemic 2004. Available at: http://www.unaids.org/bangkok2004/report_pdf.html (accessed Oct. 28, 2004).

United Nations Population Division, World Population Prospects, the 2002 Revision. Available at: http://esa.un.org/unpp/ (accessed Oct. 28, 2004).

Center for Reproductive Rights, The World’s Abortion Laws, June 2004. Available at: http://www.reproductiverights.org/pub_fac_abortion_laws.html (accessed Oct. 28,2004).

"When a client comes to a clinic and finds no service provider that is a cost. Politics are irrelevant to people who need services."

– Country Director
of a Tanzanian NGO