Impacts on Affected Countries

Zambia

download updated Zambia case study (.pdf – 146KB)

download the original Zambia case study (includes background on USAID in Zambia and the initial impact of GGR) (.pdf – 146KB)

Download the factsheet (.pdf – 88KB)

Overview

Zambia’s primary private family planning provider – the Planned Parenthood Association of Zambia (PPAZ) – was the only organization in the country to refuse the terms of the gag rule, and has since suffered severe consequences. Over the past four years, PPAZ has lost 26 out of 68 staff members and has had to narrow its range of services. The financial losses caused by the gag rule have made it impossible for PPAZ to meet the growing demand for reproductive health services in the country.

Furthermore, the continuing impact of the gag rule has coincided with a general erosion of donor attention to reproductive health in Zambia.

The Zambia Integrated Health Program (ZIHP) – a major project funded by the U.S. Agency for International Development (USAID) to provide integrated family planning, HIV and malaria services – was terminated in 2004. The Health Services and Systems Strengthening Project (HSSP) was awarded in August 2004 as a follow-on project to ZIHP. While HSSP addresses the same issues as ZIHP did, the project works primarily in the public health sector and does not provide subgrants to non-overnmental organizations (NGOs) or community-based organizations.

“We certainly had to scale down our activities…and we cannot reach enough people.”

–Staff, Zambian NGO

The most enduring impact of the Global Gag Rule on PPAZ is the organization’s inability to expand in the face of rapidly growing need. Due to the loss of U.S. funds, PPAZ provides services at levels equal to or lesser than in 2001. In a country where young people under age 24 comprise almost 70 percent of the population, PPAZ’s inability to expand and meet the needs of youth will undoubtedly have devastating consequences. Young people are at the highest risk of HIV transmission and, more than any other group, need access to services and information regarding HIV prevention and family planning.

PPAZ has not received any U.S. funds since its refusal of the terms of the gag rule. If PPAZ were financially capable, it would strengthen reproductive health service provision in clinics with prevention of mother-to-child transmission (PMTCT) programs and begin to provide post-abortion care. But due to the severe lack of funds, none of this work is currently possible.

Integration of HIV/AIDS and Family Planning Services Inhibited

“The primary mode of [HIV] transmission in Zambia is sex, so you really can’t talk about HIV without talking about reproductive health. We have tried to use this approach with most people we collaborate with. So it’s not difficult to integrate the two. Even the Minister of Health is going for integration.”

–Staff, Zambian NGO

There is a general consensus by Zambian health providers that HIV/AIDS and reproductive health services should and must be coordinated. However, the sheer amount of HIV/AIDS assistance – as compared to family planning assistance – and its emphasis on treatment, combined with decreased importance placed on family planning and reproductive health in general, have limited the potential for greater coordination.

The Global Gag Rule restrictions further marginalize family planning in the current context. In fiscal year (FY) 2001 Zambia received US$12.9 million in U.S. HIV/AIDS funds. By FY2005, this amount had increased more than six-fold to total $84 million.

In contrast, U.S. funding levels for family planning remain small and have declined in recent years. In FY2004 (the most recent year for which figures are available), USAID family planning assistance to Zambia totaled $3.6 million, down from a high of $5 million in FY2001. U.S. HIV/AIDS assistance, meanwhile, is expected to increase 50 percent in FY2006 – totalling more than $120 million.

Family planning providers are eager to expand HIV/AIDS prevention activities as part of their comprehensive reproductive health programs. However, there is a strong sense among Zambian providers that U.S. policies either do not allow or do not encourage such integration. The Global Gag Rule appears to have added to this uncertainty, and synergies between family planning and HIV prevention efforts are not as strong as they ought to be.

Many health providers contend that HIV/AIDS and reproductive health efforts are approached as entirely separate initiatives, especially in the case of PMTCT programs. There are strong synergies between reproductive health and HIV prevention efforts in PMTCT programs because the most effective way to reduce HIV infection rates in infants is to prevent primary HIV infection in pregnant women and prevent unintended pregnancy in HIV-infected women. Barrier methods, and especially condoms, are crucial to both of these elements of PMTCT programs. Still, “people have a hard time linking PMTCT and family planning,” commented one provider.

Programmatically, integration presents a challenge because many health workers view themselves as HIV service providers, as opposed to family planning providers.

Organizations receiving U.S. HIV/AIDS assistance have been instructed on a narrow definition of HIV money that excludes family planning and prohibits the purchase of contraceptives with HIV/AIDS funds. On the ground, this translates into an increasing focus on antiretroviral drugs and treatment, with diminishing attention to HIV prevention and comprehensive reproductive health services.

Enhanced coordination between family planning and HIV/AIDS is further inhibited by PPAZ’s inability to partner with organizations that receive U.S. funds. While the gag rule does not apply to U.S. HIV/AIDS assistance,
the policy is often misinterpreted to apply to all USAID assistance. Hence, in refusing the terms of the gag rule, PPAZ is widely – and mistakenly – viewed as ineligible to partner with U.S.-funded organizations. This misperception persists in Zambia and elsewhere, and most likely results in lost opportunities to prevent new infections and reach women and youth in particular.

“We are worried about having to sign something that will force us to show that the money is not being used for any integrated programs. There was one NGO receiving U.S. money which was going to give us funds…but then they wanted to make us sign onto the gag rule and promise that we wouldn’t use the funds for certain things. This disturbed us.”

–Staff, Zambian NGO

Supply Shortages Exacerbated

Access to contraceptive supplies has decreased in most rural areas as a result of PPAZ ending many community-based distribution programs due to funding shortages. In other parts of the country, supply shortages also exist in varying degrees. The most serious shortage seems to lie with the supply of Norplant®. Even under the ZIHP project last year, Norplant® purchased by USAID ran out within four months.

Today, PPAZ primarily receives contraceptives from the International Planned Parenthood Federation (IPPF), as well as some contraceptives – notably condoms – from the United Nations Population Fund (UNFPA) and the Ministry of Health. The fundamental problem for family planning providers in Zambia is that, in general, there is less money with which to buy contraceptives, and donors are simply purchasing fewer contraceptives.

The lack of funding for contraceptive supplies is reflective of the more general shift among donors’ focus from reproductive health to HIV/AIDS.

Currently, PPAZ reports it is not experiencing a shortage of oral contraceptives. A potential shortfall of HIV test kits for voluntary counseling and testing services has been cushioned by donated kits from the Japan International Cooperation Agency, the Japanese equivalent of USAID. Ideally, however, PPAZ would like to have its own test kits and is therefore looking for alternative sources.

Conclusion

“Reproductive health money is dwarfed by HIV/AIDS money. We face a perpetual battle to keep RH on the agenda.”

–Staff, U.S. NGO

The Global Gag Rule has cut U.S. support to the primary private family planning provider in Zambia, a country already lacking in family planning and reproductive health providers. The gag rule has struck PPAZ at a time when the overall trend in donor financing is shifting away from reproductive health and toward HIV/AIDS efforts, in a segregated fashion.

Family planning providers such as PPAZ are in despair, given that HIV prevention cannot be tackled effectively unless broader sexual and reproductive health issues are addressed. Zambians’ health, especially that of the rapidly growing youth population, is threatened by poor funding policies and lack of attention to reproductive health. PPAZ’s challenge is to generate enough funds to expand and meet the needs of youth, but the organization refuses to give up hope:

“We see a future for ourselves. We don’t foresee closing any clinics. We have enough staff now – about 42. I believe we can survive even without U.S. funds – the key is to get more partners.”

–Staff, Zambian NGO

Data Sources

United Nations Population Division, World Population Prospects, the 2004 Revision. Available at: http://esa.un.org/unpp/ (accessed April 15, 2005).

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. Available at: http://www.unaids.org/bangkok2004/report_pdf.html (accessed April 15, 2005).

United Nations Population Division, World Population Prospects, the 2004 Revision. Available at: http://esa.un.org/unpp/ (accessed April 15, 2005).

Ironically, far from preventing abortions in Zambia, the Global Gag Rule is contributing to more unwanted pregnancies, as well as a higher incidence of HIV/AIDS.