The CHANGE data index grades government agencies on policies and funding impacting family planning, maternal and child health, and HIV & AIDS foreign assistance.
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2019_Acting on the Call
Acting on the Call is USAID's annual flagship report for reproductive, maternal, newborn, and child health services. The 2019 report focused largely on maternal health more than other domains, but still did not meaningfully discuss respectful maternity care or maternity care for LGBTQI+ people, people living with disabilities, or people who have been impacted by genital cutting. The report discussed the importance of respect for all patients and providers but did not specifically discuss respectful maternity care and the disrespect and abuse faced by people receiving maternal and child health services. There was no explanation of how respect for all patients and providers was being integrated into country-level programming. The report was based on programmatic data collected by USAID and reports on indicators that were commonly accepted in the maternal and child health field. The report did not reference international human rights norms nor did it include gender transformative
language. In contrast, the language reinforced the established gender binary and did not discuss or move to address the structural barriers to respectful maternal health care. With regard to maternal and child health, this report moderately promoted SRHR.
2019_Additions to the Answers to FAQs Related to the Revised Standard Provision for Grants and Cooperative Agreements to Implement the PLGHA Policy_June 2019
These additional Frequently Asked Questions (FAQs) were released in June 2019 after the assurance by Secretary Pompeo in March 2019 that the language surrounding financial assistance in the guidance on the implementation of Protecting Life in Global Health Assistance (PLGHA) would not change. This additional document asserted that the definition of financial assistance would remain unchanged and that organizations who sub-grant would be required to ensure their subgrantee’s compliance with the policy. Similar to the original FAQ document, there was no discussion of the impacts of this policy or its expansion on maternal and child health. This document was somewhat responsive to need as it includes additional questions and answers based on confusion expressed by recipients of U.S. global health assistance. The document was not evidence-based, based in international human rights, or gender transformative
as it was based on the PLGHA policy which has been shown to be harmful globally, particularly to women and girls. The PLGHA policy has been shown to decrease access to maternal care while increasing rates of unsafe abortion. Overall, this document provided a substantial hindrance to SRHR.
2019_ADS Chapter 212_Breastfeeding and Infant and Young Child Nutrition Promotion, Protection, and Support
This Automated Directive System (ADS) chapter was updated in its entirety for the first time since 2012 and addressed USAID’s priorities and positions related to breastfeeding and child nutrition. The update expanded the chapter’s guidance regarding infant and young child nutrition and incorporated new language on the donation of breastmilk in humanitarian crises. The chapter referenced WHO guidelines and accepted normative guidance from agencies such as the Department of Health and Human Services (HHS) and implementers, such as PATH. This document was responsive to need and based in human rights and evidence. However, the document was not gender transformative
. Though it discussed the importance of policies on paid family leave or workplace breastfeeding, it did not ensure these policies were put in place (which could have been achieved through the requirement for partners to report on the implementation of this guidance in their programs through mandatory performance reports). The guidance, including the description of Kangaroo Mother Care, included gendered language that was not inclusive. The guidance was gender blind because it ignored gender inequalities and stereotypes that might influence a person’s ability to adhere to this guidance, such as a pregnant person who is transgender. Overall, this chapter moderately promoted SRHR with regard to guidance for PBFW and USAID’s maternal and child health programs.
2019_ADS Chapter 303_Grants and Cooperative Agreements to Non-Governmental Organizations and Standard Provisions
This chapter of the Automated Directive System (ADS) governed the grants and cooperative agreements between USAID and NGOs and included three reference documents that were updated in 2019: the ADS 303maa, 303mab, and 303mat. The ADS 303maa is the Standard Provisions that specified the expectations of U.S.-based NGOs that receive funding from USAID through grants and cooperative agreements. The ADS 303mab is the Standard Provisions for foreign NGOs, and the ADS 303mat is the Standard Provisions for fixed amount awards to NGOs. These provisions were updated in 2019 to incorporate the newly expanded Protecting Life in Global Health Assistance (PLGHA) policy, including additional guidance regarding the consequences of violation of the PLGHA policy and a new requirement for prime partners to ensure compliance with PLGHA among all sub-partners, regardless of donor. With regard to violations of the policy, the updated ADS allowed for USAID to determine “consistent with 2 CFR 200.338, that other corrective action is warranted” while the previous version only listed termination of the USAID award and repayment of funds as a consequence of a PLGHA violation. Given that USAID was required to implement the PLGHA policy, the Agency was graded for their implementation of the policy and not for the existence of the policy. All of the ADS 303 updates were responsive to need, as it was clear that USAID attempted to address some of the confusion surrounding the policy, particularly amongst primes and sub-primes. However, this chapter of the ADS was still not based in evidence or human rights and was not gender transformative
2019_ADS Chapter 308_Agreements with Public International Organizations and Standard Provisions
This chapter of the Automated Directive System (ADS) governed the agreements between USAID and Public International Organizations (PIOs) (such as UNAIDS, UNICEF, WHO, etc.) and included one reference document that was updated in 2018 and 2019: the ADS 308mab. The ADS 308mab was the Standard Provisions for Cost-Type Agreements with Public International Organizations and specified the mandatory policies and guidelines that must be followed by PIOs that receive funding from USAID. The provisions were updated in August 2018 to require abortion-related restrictions to be included in all health awards. In previous iterations of the ADS 308mab, these restrictions were only required to be included in awards that funded family planning activities. As such, the 2018 update of the ADS 308mab constituted an expansion of the implementation of pre-existing statutory requirements regarding abortion and involuntary sterilization. This updated language expanded the PIO programs to which these pre-existing statutory requirements apply. The 2018 update also added a new requirement that the PIO receiving U.S. funds “must insert this provision in all subsequent subawards and contracts” whereas this was not required in prior versions of the ADS 308mab. The 2018 updates to the ADS 308mab substantially hindered SRHR. The updates released in November 2019 were not related to SRHR. The references to voluntarism and the prohibition of involuntary sterilization in this chapter were based in evidence and human rights, however the expansion of the implementation of abortion restrictions and the expansion of these restrictions to all health awards was not based in evidence or human rights, was not responsive to need, nor was gender transformative
Note: The 308mab was updated in August 2018 but CHANGE has been unable to confirm that this version was ever uploaded onto USAID’s website as required by law. Instead, the 2014 version of the document was replaced in 2019 with the 2019 version of the document with the 2018 edits included but not highlighted as new. For this reason, USAID was significantly docked in transparency
as this lack of transparency by USAID hindered the ability of grantees, sub-grantees, partners and civil society to access and respond to the ADS accordingly.
2019_Agency Financial Report_Fiscal Year 2019
This document was in response to congressionally mandated reporting on the spending of USAID. The report highlights some of USAID’s success and strategies moving forward and referenced maternal and child health as a crosscutting theme across malaria programs and other global health efforts. This document was responsive to need (as expressed by Congress) and based in evidence. However, there was no discussion of human rights principles or gender norms in this report. Overall, this document neither hindered nor promoted SRHR.
2019_Agency Priority Goal Action Plan_Maternal and Child Health
The Agency Priority Goals (APGs) for Maternal and Child Health provide a quarterly overview of maternal and child health programs implemented by USAID in FY 2019. The goals in this report included intersecting issues such as family planning, nutrition, and malaria. Similar to the 2018 plan, the 2019 APGs included many family planning and child health-focused indicators with only one indicator focused on the health of the person giving birth. As such, the APGs did not provide a holistic account of maternal health needs. This indicator (the number of births in healthcare settings) was also incomplete as it did not take into account the experience of the person giving birth nor did it monitor the prevalence of disrespect and abuse. Programs and activities to promote respectful maternity care should be included in USAID’s maternal and child health goals. This document was responsive to need and based in human rights and evidence, but was not gender transformative
. The APGs acknowledged gender inequalities, as they referenced gendered challenges to promoting maternal health but did not make addressing them an APG. Overall, the APGs did not promote SRHR.
2019_Protecting Life in Global Health Assistance Frequently Asked Questions and Answers_September 2019
The Protecting Life in Global Health Assistance (PLGHA) FAQ document was updated in September 2019 to provide clarity on the implementation of the May 2019 expansion of PLGHA as well as address questions and confusion from the 2018 Department of State’s Six Month Review. The text of this document was similar to the 2018 FAQ document but also included additional questions and answers (see questions 33-37). The document did not meaningfully discuss the impacts of the May 2019 expansion on maternal and child health. Similar to the 2018 FAQs, this document aimed to provide clarity on the policy but left many questions unanswered. This document was somewhat responsive to need as it included additional questions and answers based on confusion expressed by recipients of U.S. global health assistance, specifically regarding the definition of “financial assistance” and the applicability of the policy to technical assistance. The document was not evidence-based, was not grounded in international human rights, and was not gender transformative
as it was based on the PLGHA policy which has been shown to be harmful globally, particularly to women and girls. The PLGHA policy has also been shown to decrease access to maternal care while increasing rates of unsafe abortion. Overall, this document provided a substantial hindrance to SRHR.
2019_State and USAID FY 2018 Annual Performance Report_FY 2020 Annual Performance Plan
This document shared the goals and timelines for FY 2020 as well as evaluated and summarized the progress of State and USAID in achieving various strategic goals in FY 2018. These goals included global health and gender programs across all three domains. The FY 2020 Performance Plan elements were included throughout the report along with reporting on standard indicators for each Performance Goal under the 4 Strategic Objectives. The Report provided an overview of USAID’s efforts in this area, as USAID was the main implementer of maternal and child health programs globally. Within this domain, the Report was not based in evidence or human rights nor was it responsive to need, as maternal and child health was not included as a part of the Annual Performance Plan. The Plan was also not gender transformative
, as it mentioned the disadvantages of a “gender-blind system” within Strategic Goal Two but perpetuated such a system by not including a gendered lens throughout the document. Overall, this document neither hindered nor promoted USAID’s ability to support maternal and child health programs that promote SRHR.
2019_USAID Policy Framework: Ending the Need for Foreign Assistance
This document discussed USAID's new policy framework to achieve self-reliance through a three-step approach. The framework was very general and did not discuss any particular aspect of assistance such as maternal and child health. Maternal and child health was briefly mentioned as a success of foreign assistance and within the context of USAID as “doing no harm” through its programs. This policy was responsive to need in that it reflected conversations about democratizing foreign assistance and creating more sustainable systems, however the framework did not mention the evidence or international human rights norms that should be the foundation of such programs. This policy framework was not gender transformative
, as it contained very little about the role of gender in a country's "Journey to Self-Reliance." USAID’s Policy Framework moderately hindered the ability of USAID to support maternal and child health programs that promote SRHR.
2018_Acting on the Call
Acting on the Call is USAID's annual flagship report for reproductive, maternal, newborn, and child health services. The 2018 report offered thorough country-level analyses of data around maternal and child health outcomes that were evidence-based and responsive to need but were not gender transformative
. The report did not discuss the importance of implementing programming and policies to champion respectful maternity care as a means to address disrespect and abuse. Instead, the report focused largely on USAID's "Journey to Self-Reliance" framework and provided detailed country-level updates including: population-level statistics, intervention coverage, child mortality, nutrition, and health systems strengthening. While the report aimed to improve maternal and child health through the strengthening of health systems, it did not address the importance of a patient-centered approach, which includes respectful maternity care, gender transformative
programming, and the improvement of working conditions for health care workers.
2018_Acquisition and Assistance Strategy
As USAID’s first-ever Acquisition and Assistance (A&A) Strategy, this guidance document increased the accountability and transparency
. of USAID's procurement, partnering, and project management processes across the Agency. The goal of this Strategy was to streamline "approaches to design and procurement" and develop "new and innovative methods of collaboration" to advance USAID's Journey to Self-Reliance mandate. The Strategy was responsive to need and evidence-based because it cited the current make-up of USAID foreign assistance funding recipients and set specific goals to diversify this partner base. Many of the strategies and shifts put forward in the report incorporated feedback received from smaller and/or local partners. The Strategy also demonstrated a commitment to human rights norms, specifically to the right of self determination, by actively incorporating local partners in the design, procurement, and implementation of USAID's programming. Though the Strategy referenced the importance of "diverse" partners, it did not define who these partners were except for a specific mention of faith-based organizations. Women's rights and human rights groups should also be explicitly mentioned as underutilized partners because of their important role in advancing SRHR for all populations. This Strategy indicated a meaningful effort by USAID to ensure that local partners and recipient countries are included and supported throughout the Journey to Self-Reliance. However, this effort by USAID seemed to be in direct conflict with the Trump Administration's strategy of decreasing appropriated funds as a means to ‘motivate’ self reliance and haphazardly decrease U.S. involvement in foreign assistance. It is unclear in this Strategy how USAID aims to reconcile this conflict.
2018_Agency Priority Goal Action Plan_Maternal and Child Health
The Agency Priority Goals (APGs) for Maternal and Child Health provide a quarterly overview of MCH programs implemented by USAID. The goals in this report include intersecting issues such as family planning, nutrition, and malaria. The APGs are responsive to need and evidence-based, but are not gender transformative
. The APGs are predominantly child health-focused with "All cause under 5 mortality" as a primary indicator of success in maternal and child health programming. Using this indicator as the primary indicator for maternal and child health actively disregards the health, human rights, wellbeing, and childbirth experience of the woman. The addition of the indicator "Absolute change in total percentage of births delivered in a health facility" in the FY2018 APGs will further strengthen this reporting mechanism. Efforts to promote respectful maternity care could be strengthened, though the APGs do include changing attitudes of health care workers as a maternal and child health strategy.
2018_Protecting Life in Global Health Assistance FAQs_September 2018
The PLGHA FAQs provided detailed guidance on the implementation of Trump's expanded Global Gag Rule for implementing partners as of September 2018. The FAQs were not responsive to need, evidence-based, human rights-based or gender transformative
within this domain. The FAQs received a lower grade within this domain compared to Family Planning and HIV and AIDS because they did not mention maternal and child health programming specifically, despite the unique impacts this policy could have on maternal and child health programs. The FAQs significantly hindered USAID's ability to support comprehensive maternal and child health programming.
2017_Acting on the Call
Acting on the Call is USAID's annual flagship report that covers USAID’s reproductive, maternal, newborn, and child health programs. The 2017 report provided data that was strongly grounded in evidence and human rights principles and was responsive to need. It discussed USAID’s focus on ending preventable maternal and child mortality and morbidity through the provision of health services including family planning, antenatal care (ANC), and immunizations. It also prioritized the strengthening of health systems at all levels to reduce health disparities and achieve equitable care. The report specifically mentioned the importance of integrating family planning and HIV and AIDS care into maternal and child health, and noted the intersection of these domains as vital to comprehensive SRHR programming. This report was gender transformative
and addressed the need for gender-sensitive policies, the eradication of gender norms, and the promotion of women into decision-making roles.
2016_Acting on the Call
Acting on the Call is USAID's annual flagship report for the Agency’s reproductive, maternal, newborn, and child health programs and services. The 2016 report was based on programmatic evidence and human rights principles and was responsive to need as it promoted respectful maternity care through facility interventions, dissemination of patient rights materials, and outlined priority actions that seek to address barriers to maternal health. It specifically addressed the importance of “dignified and respectful care during childbirth” and how it is crucial in decreasing maternal mortality rates. However, the report could have been more evidence-based by advocating for improved communication between patients and medical staff and advocated for the transformation of patient care at more than just the systems level (e.g. the provider-patient level). Additionally, this report was gender transformative because it called for increased gender-sensitive services and addressed the importance of male engagement in maternal and child health efforts.
2016_USAID Adolescent Girl Strategy Implementation Plan
The USAID Adolescent Girl Strategy Implementation Plan was launched in partnership with three other U.S. implementing agencies as part of the first U.S. Global Strategy to Empower Adolescent Girls in 2015. The Plan moderately promoted SRHR, noting the importance of utilizing USAID’s “whole-of-girl” approach to reduce gender disparities and GBV and increase capacity of women and girls through USAID’s programs. Though it did not explicitly describe USAID’s maternal and child health programs, this Plan provided a high-level overview of the programs, best practices, and indicators that would be used to measure USAID’s progress in implementing the Adolescent Girl Strategy across all USAID programs. The Plan was responsive to need and based in evidence, particularly related to the implementation of activities to end child marriage, meet the needs of married children, and provide services to children in adversity. The Plan also referenced USAID’s ongoing work on gender (e.g., implementing USAID’s 2012 Gender Equality and Female Empowerment Policy) and directly acknowledged the importance of incorporating activities that foster gender equity in all USAID programs. This Plan supported the ability of USAID to implement maternal and child health programs that moderately promoted SRHR.