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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2021_2021 Annual PEPFAR Treatment Report to Congress
The Annual Treatment Report from PEPFAR provides information to Congress on PEPFAR-supported treatment programs as required by Section 7611 (g) of Title 22 of the U.S. Code. The 2021 Report focused on the programmatic adaptations PEPFAR implemented in response to the COVID-19 pandemic to ensure that treatment programs were not disrupted. Adaptations included MMD of ARVs, the decentralization of drug delivery, the use of virtual platforms like telemedicine, and the implementation of efforts to empower communities, which were responsive to need, based in evidence, and aligned with human rights. The Report mentioned the decision to increase the number of people living with HIV (PLHIV) on dolutegravir-containing ARV regimens which was based in evidence, however there was no mention of the importance of ensuring these regimens are available for pregnant PLHIV. As a result, this action was not fully based in evidence, human rights, or responsive to need. The Report did not include treatment data related to specific populations, such as orphans and vulnerable children (OVCs) or the outcomes of prevention of mother to child transmission (PMTCT) of HIV activities, which was an oversight because these programs and activities are critical to the success of PEPFAR. The Report was gender blind, as there was little mention of gender. The Report moderately hindered SRHR in the MCH domain.
2021_Country_Regional Operational Plan 2021 (COP/ROP 2021) Virtual Meeting Handbook
This Virtual Meeting Handbook outlined the ways in which the OGAC streamlined the COP/ROP 2021 process in response to the COVID-19 pandemic. The COP/ROP 2021 process was shortened and conducted virtually for the first time, which was highly responsive to need due to the pandemic and this action ensured that PEPFAR stakeholders at all levels had timely information about this process. This action detailed the revised framework for ensuring meaningful stakeholder engagement by mandating transparent discussions with PEPFAR leadership during town halls with stakeholders at all levels and involving partner country governments, communities, CSOs, multilateral partners, and the private sector, which was responsive to need. This action included guiding principles for PEPFAR during the COVID-19 pandemic that were responsive to need and consistent with evidence and human rights norms, such as protecting program gains, ensuring site safety, and mitigating COVID-19’s impact on OVC and PMTCT activities. This action moderately promoted SRHR in the MCH domain.
2021_Department of State and USAID_Fiscal Year (FY) 2022 Annual Performance Plan
The FY 2022 Annual Performance Plan outlined progress made by the Department of State and USAID toward strategic objectives and performance goals in previous years. The Plan outlined each agency’s plans for achieving the goals articulated in their joint strategic plan moving forward. Though the MCH-specific indicators only included data from USAID, this action was graded across domains for the Department of State because of this actor’s leadership of PEPFAR which includes activities related to MCH, as well as cross-cutting issues including GBV. While the availability of these data was important for evidence-based decision making in the HIV and AIDS domain, indicators that measured the outcomes of PMTCT or other HIV activities related to MCH were not included in this action. As a result, this action was not fully responsive to need or based in evidence or human rights in this domain. The Department of State’s contributions to cross-cutting SRHR issues like gender equality and GBV prevention and response were included in this action, which was responsive to need. However, no targets were included for FY 2022, which was not responsive to need and negatively affected transparency
. Additionally, the Plan was gender accommodating as it used language that reinforced a gender binary. This action neither promoted nor hindered SRHR in this domain.
2021_Guiding Principles for the Next Phase of PEPFAR
The Guiding Principles outlined the program’s goals as of January 20, 2021, and presented PEPFAR’s progress to date, including national progress toward achieving the 90-90-90 and 95-95-95 targets in specific countries. This action detailed the impact of COVID-19 on PEPFAR programs, as well as outlined programmatic adaptations that OUs implemented to overcome the impacts of the pandemic, which was responsive to need and based in evidence. The Guiding Principles focused on providing people-centered HIV prevention, care, and treatment services but did not mention OVC, PMTCT, or other PEPFAR activities related to MCH, which was not responsive to need or aligned with evidence. This action did not mention the human rights framework that underpins PEPFAR programming, nor did it discuss the importance of integrated services and UHC in advancing PEPFAR’s goals, specifically for pregnant and breastfeeding persons or persons of reproductive age. This action was gender accommodating as it included language that reinforced a gender binary. This action moderately hindered SRHR in the MCH domain.
2021_PEPFAR 2021 Annual Report to Congress
The PEPFAR 2021 Annual Report to Congress detailed the achievements of PEPFAR and challenges to delivering people-centered HIV services, particularly in light of the COVID-19 pandemic. This action outlined country-specific progress toward the 90-90-90 targets, documented PEPFAR’s efforts to strengthen health systems, and advocated for integrated GBV programs, which was responsive to need and based in evidence. This action highlighted the importance of addressing barriers to accessing care and working with community- and KP-led indigenous organizations to promote human rights, which was responsive to need and promoted SRHR. The Report included outcomes of PMTCT and OVC programs and mentioned pregnant and breastfeeding women (PBFW) as a priority population, which was responsive to need and based in evidence. The action supported dolutegravir-containing regimens as the preferred treatment regimen for women of childbearing age. The “Preventing Infections in Women” section mentioned the strengthening of platforms through which women seek care, including antenatal care (ANC) platforms to support women’s access to PrEP or PMTCT services, which was responsive to need. This action was gender accommodating as it used language that reinforced a gender binary (e.g., PBFW and women of childbearing age). This action moderately promoted SRHR in the MCH domain.
2021_PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR Countries
On February 11, 2021, OGAC released an updated version of the COP/ROP 2021 Guidance that revised four sections of this critical PEPFAR guiding document. Section 5.9.4 was updated to cross out the text related to the PLGHA policy. The action included the following information: “Implementation of Protecting Life in Global Health Assistance in PEPFAR Programs has been deleted as the policy was rescinded by President Biden in January 2021” but did not provide stakeholders with any additional information about what the revocation meant for OUs or ongoing awards. Though this update was timely, it lacked specificity and guidance for stakeholders to understand how the revocation of PLGHA (also known as the GGR) impacts their work, so it was only somewhat responsive to need and was not based in evidence or human rights. This action significantly hindered SRHR in the MCH domain.
2021_PEPFAR COP/ROP 2021 Frequently Asked Questions
This FAQs document provided regular updates on the COP/ROP 2021 process after it was temporarily paused earlier in 2021. This action included information about civil society and community engagement and provided answers to questions that were specific to technical areas, all of which were responsive to need and based in evidence. For example, this action included FAQs that supported pediatric use of dolutegravir-containing regimens, as well as distinctions between OVC and DREAMS funding, which were responsive to need and based in evidence. The action included one question related to the impact of “new policies of the Biden-Harris Administration, such as the rescission of the Mexico City Policy” on the COP/ROP 2021 process. The answer said that “PEPFAR funding and partners are no longer subject to these policy requirements and instead should follow those outlined in the January 28, 2021 Executive Order” and included a hyperlink to the executive action. This answer did not include additional information or guidance for stakeholders to understand how the revocation of this policy impacts their work with PEPFAR, which was not responsive to need. This action moderately hindered SRHR in the MCH domain.
2021_PEPFAR COP/ROP 2021 Temporary Pause FAQs
This FAQs document was released on February 17, 2021 and confirmed the Biden administration’s commitment to PEPFAR as well as provided an explanation for the temporary pause of the COP/ROP 2021 process. This action also reaffirmed OGAC’s commitment to completing a data-driven COP/ROP 2021 process and ensuring that there were no disruptions in HIV services at the start of FY 2022. Many of the process-specific questions included in this action were also included in the previous action, including a question that highlighted the sections that were updated in the February 2021 version of the COP/ROP 2021 Guidance. Most of the questions were procedural and not technical, so this action neither promoted nor hindered SRHR in the MCH domain.
2021_PEPFAR Core Program and Policy Priorities
The PEPFAR Core Program and Policy Priorities outlined the focus areas of PEPFAR under the Biden administration. The action included key priorities on HIV prevention and treatment: data-driven HIV testing strategies such as support for KPs, gender equity and equality, cooperation and partnership with community stakeholders and public health leadership, and the strengthening of global health security. These priorities were responsive to need, based in evidence, and aligned with human rights norms. Notably, the action included a priority to promote and protect SRHR, including through the revocation of PLGHA. This action provided a high-level framework for PEPFAR’s focus areas, so information about how PEPFAR would implement the revocation would not be included in this action. However, this action was not fully responsive to need as the priorities did not specifically include MCH outcomes outside of eliminating the "vertical transmission of HIV and pediatric AIDS.” The action stated the importance of improving appropriate linkages to and integration of HIV services with other related global health programs but did not specifically mention MCH as a related program. Gender transformative
elements were highlighted in the section on “HIV prevention, clinical, and health systems programs,” and in the Department of State’s commitments to DEIA. This action moderately promoted SRHR in the MCH domain.
2021_PEPFAR DREAMS Guidance_Updated March 2021
The PEPFAR DREAMS Guidance provided updated guidance for implementing DREAMS programming for AGYW in 2021. The Guidance highlighted the importance of multi-sector engagement across government leadership and community partners, evidence-based decision making across DREAMS programming, and overall prioritization of DREAMS implementation. The Guidance was based in evidence and human rights as it referenced a variety of peer-reviewed external resources as well as international agreements and frameworks. The Guidance included information about parenting and caregiving programs, discussions on pregnancy prevention, linkages to DREAMS through PMTCT and ANC clinics, and affirmed the need for PrEP to be prioritized for young women, "including those who are pregnant or breastfeeding or who may be having transactional sex," which promoted MCH services within DREAMS programming and was responsive to need. However, the Guidance did not mention safe abortion services when addressing unintended pregnancy, which was an oversight and did not reflect the full package of services that should be provided to DREAMS recipients following the revocation of the GGR. It was gender transformative
as it called for changing unequal gender and power dynamics. However, this Guidance used gendered language when mentioning condoms and pregnancy, did not affirm the right to sexual pleasure, and did not include LGBTQI+ women and girls, which was an oversight. This Guidance significantly promoted SRHR in the MCH domain.
2021_PEPFAR FY21 Site Improvement through Monitoring System (SIMS) Materials_Version 4.1
The PEPFAR SIMS tool provides a standardized approach for monitoring program quality at PEPFAR-supported sites that perform service and non-service delivery functions. The FY21 Implementation Guide, Above-Side Assessment Tool, and Site Assessment Tool were updated in 2021, though the changes from the previous version were not clearly stated, which negatively affected transparency
. The Above-Site and Site Assessment Tools included CEEs that assessed the site against a set of standard technical requirements, which were based in evidence. The major apparent change in the CEEs was the removal of assessment modules related to the implementation of PLGHA in the Above-Site Assessment Tool. This module was removed without explanation. A new module was not added to ensure that PEPFAR-supported sites stopped implementing the policy after its revocation, which was not responsive to need or consistent with evidence and human rights norms. The Guide and CEEs incorporated PMTCT, ANC, and labor and delivery services, which was based in evidence and responsive to need. It included guidance for SIMS assessors to not participate in or condone discriminatory practices based on gender, race, ethnicity, caste, religion, sexual orientation, disability, or socio-economic status, which was based in evidence and responsive to need. The CEEs were somewhat gender transformative
because they included guidelines and standards for evaluating interventions related to changing unequal gender norms, but used language that reinforced a gender binary. The SIMS materials updated in 2021 moderately promoted SRHR in the MCH domain.
2021_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.6)
The MER Indicator Reference Guide is reviewed and updated annually to streamline and prioritize the standard indicators used across PEPFAR programs. The 2021 Guide introduced trainings for USG and implementing partner staff on indicators across technical areas, which was responsive to need. The Guide referenced updates to the MER indicators such as new disaggregations, provided updated reporting frequencies, and clarified definitions, which were responsive to need. Several indicators were updated to add additional pediatric age and sex disaggregations as well as reflect the current approved pediatric HIV treatment regimen, which was responsive to need. This action moderately promoted SRHR in the MCH domain.
2021_Prioritizing Sexual and Reproductive Health and Reproductive Rights in U.S. Foreign Policy
Secretary of State Blinken delivered this Press Statement on prioritizing SRHR in U.S. foreign policy, which mentioned how the Department of State would implement the presidential memorandum that rescinded PLGHA. Though this action mentioned the revocation of the GGR, it did not provide guidance for programs about adapting their work to align with the presidential memorandum, which was not responsive to need and was a missed opportunity to highlight the Department of State's specific responsibility to promote SRHR as the funding agency of global health assistance. The action highlighted the reinstatement of funding to the UNFPA, the withdrawal of the United States from the Geneva Consensus Declaration, and the increased access to vital health services, including “maternal health and voluntary family planning” services. These actions were responsive to need, based in evidence, and based in human rights. This action affirmed the United States' commitment to making pregnancy and childbirth safer through strengthening health systems and partnering with governments, the private sector, and international and non-governmental organizations, which was responsive to need and based in evidence. This action was gender accommodating, as it acknowledged gender inequities but used language that promoted a gender binary and only recognized SRHR for women and girls, even though SRHR is vital for all people. The action moderately promoted SRHR in this domain.
2021_Strengthening Health Security Across the Globe_Progress and Impact of United States Government Investments in the Global Health Security Agenda
This Report detailed the progress and impact of the USG’s investments in global health security during FY 2020, including those led by the Department of State. The Report detailed the distribution of Congressional appropriations to advance global health security efforts in 19 partner countries to respond to disease outbreaks and prevent future outbreaks whenever possible. The Report did not mention other global health security efforts by the Department of State as it pertained to MCH services. Though the Report focused on global health security, SRHR and other cross-cutting issues such as GBV were not mentioned. The exclusion of these cross-cutting issues was not based in evidence as the inclusion of SRHR and gender equity promotes global health security. This exclusion was not responsive to need as SRHR services are often the first set of "essential services" to be neglected in a health emergency, as notably evidenced by the initial global response to COVID-19. The Report was gender blind as it made only one mention of gender in the context of OneHealth
. This action moderately hindered SRHR in the MCH domain.
2021_Trafficking In Persons Report_ Human Trafficking in the Context of a Global Pandemic
The 2021 Trafficking in Persons Report detailed the approach outlined by the Department of State to combat human trafficking, with additional detail about these activities in the context of the COVID-19 pandemic. The Report outlined lessons learned from the pandemic and called for "comprehensive, trauma- and survivor-informed, and victim-centered anti-trafficking responses during the pandemic." The Report stated that global crises such as COVID-19, climate change, and enduring discriminatory policies and practices disproportionately impact people who are already oppressed by other injustices and increase people’s vulnerability to exploitation, which was based in evidence and responsive to need. While the Report recognized that survivors of trafficking are hesitant to interact with carceral systems, it promoted prosecution and a carceral approach to trafficking, which was not responsive to need. The Report briefly mentioned pregnancy-related interventions but did not meaningfully include global MCH outcomes and programming, which was a missed opportunity to highlight the Department of State’s global MCH efforts. The Report moderately hindered SRHR in this domain.
2021_United States Government Women, Peace, and Security (WPS) Congressional Report
The WPS Congressional Report provided Congress with an overview of progress made in implementing the WPS Agenda globally since 2019. The Report evaluated progress in advancing the WPS Strategy's four lines of effort across the Department of State, DoD, DHS, and USAID: participation, protection, internal capabilities, and partnerships. While improved global health outcomes were included as a positive impact of implementing the WPS Agenda, MCH outcomes were only briefly mentioned. The Report included GBV prevention and programming as a measure of progress towards achieving the WPS Agenda, which was responsive to need. The Report highlighted an initiative by the Department of State to lead a data-driven MEL exercise on its WPS efforts, which was based in evidence and responsive to need. The Report included specific and actionable milestones to measure progress, which was responsive to need. The Report included several gender transformative
elements such as enhancing gender-sensitive data analytics, recognizing "the intersectionalities inhabited by women," and supporting initiatives to address and overhaul harmful gender norms. However, it was predominantly focused on women which reinforced a gender binary. The Report moderately promoted SRHR in the MCH domain.
2020_Contraception for Women at High Risk of HIV Technical Update
The purpose of this Technical Update was to explain the implications of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial results on “reproductive health programming” funded through U.S. global health assistance. The Technical Update summarized updated guidance from the World Health Organization (WHO) regarding the use of contraception by women at high risk of acquiring HIV, which had been revised based on the ECHO Trial findings. Though the WHO released its revised guidance in August 2019 shortly after the ECHO Trial results were published, the Department of State (as the funding agency for PEPFAR) did not publish this Technical Update until December 2020. Because of this delay, the action was not fully responsive to need. The Technical Update was aligned with international human rights norms and evidence (e.g., quality of care, voluntarism, informed choice, differentiated service delivery models, patient-centered approaches free of stigma and discrimination) and included specific programmatic and policy guidance for working closely with diverse stakeholders to adapt global HIV and family planning (FP) programs accordingly. While the Technical Update stated that women who receive FP counseling should receive information about HIV prevention, it did not include guidance about counseling people who have just given birth about their contraceptive options, and thus was not consistent with evidence or responsive to need in this domain. Additionally, the Technical Update was gender blind, as it did not use gender inclusive language. As the funding agency for global MCH funds, the Department of State had the opportunity to integrate these efforts across implementing agencies through this Technical Update. This Technical Update only moderately promoted SRHR in the MCH domain.
2020_Department of State and USAID Joint Report to Congress on U.S. Foreign Assistance Gender-Related Programming_Fiscal Years 2017 and 2018
The Department of State and USAID submitted this joint report to Congress on gender-related programming funded through all types of U.S. foreign assistance in fiscal year (FY) 2017 and 2018 as required by the Department of State, Foreign Operations, and Related Programs Appropriations Act, 2019. It reported on $110 million of PEPFAR funds that were used during those two fiscal years to provide gender-based violence (GBV) prevention services as well as the full package of post-GBV care, including HIV and violence prevention services in communities and schools where the DREAMS program was being implemented. However, the Report did not include information about the gender-related activities that the Department of State funds through PEPFAR or other mechanisms that are related to MCH, including antenatal care (ANC) and HIV prevention and treatment services for pregnant and breastfeeding people. This report also included information about numerous other programs and funding types across both the Department of State and USAID, but there was insufficient information to determine if those other programs were considered U.S. global health assistance, which contributed to low transparency. U.S. global health funds were not explicitly included in the funding table at the end of the report, which also contributed to low transparency. This report neither promoted nor hindered SRHR in this domain.
2020_Department of State and USAID_Fiscal Year (FY) 2020 Annual Performance Report
The 2020 Annual Performance Report outlined Department of State and USAID’s progress toward strategic objectives, Agency Priority Goals (APGs), and performance goals in FY 2020 in accordance with their joint strategic plan. These goals included global health and gender-related programs across all three domains for both actors. The Report provided data on USAID’s MCH activities within Performance Goal 3 but did not adequately include the Department of State’s MCH activities that were conducted through PEPFAR or other gender-related programs funded through U.S. global health assistance. MCH activities and indicators should be included as a mechanism to monitor this important aspect of PEPFAR programs. The Report included data on a few indicators that measured gender norm change, but they were gender accommodating and not gender transformative
because they focused on “males and females” which reinforced a gender binary. Additionally, indicators regarding GBV did not include considerations or disaggregates for people that experience violence during pregnancy. Due to the lack of meaningful reporting of MCH activities through PEPFAR, this report neither hindered nor promoted SRHR in the MCH domain.
2020_Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family
Along with 33 largely authoritarian governments, the United States signed the Geneva Consensus Declaration, a nonbinding declaration to advance the Trump administration’s anti-abortion agenda. Secretary of State Pompeo and Secretary of Health and Human Services Azar jointly participated in the signing ceremony on behalf of the Trump administration. The Declaration cited several international human rights documents to bolster its position that abortion was not to be included in any sexual and reproductive health (SRH) or universal health coverage programs. However, the Declaration did not recognize pregnant people’s right to bodily autonomy. It was also not aligned with evidence as evidence suggests that restricting access to safe abortion services results in increased rates of unsafe abortion, which can contribute to maternal morbidity and mortality. This action was not responsive to need and was not gender transformative
because it reinforced a gender binary throughout and ignored gender inequalities and other systemic issues that might impact people's ability to access SRHR services, including MCH services. In fact, both the language used and the exclusion of SRHR were so deeply rooted in patriarchal structures that the Declaration was gender exploitative. The Declaration also failed to acknowledge the human rights of those in the LGBTQI+ community, which threatened to roll back progress made on recognizing the health needs of pregnant people who may not identify as women and/or those who identify as LGBTQI+. The stance of the Administration as demonstrated by the Department of State signing onto this Declaration substantially hindered the ability of U.S. global health assistance to promote SRHR in the MCH domain.
2020_Guiding Principles for the Next Phase of PEPFAR
This Guiding Principles document outlined the progress made by PEPFAR toward the 90-90-90 targets as of December 1, 2020, including programmatic adaptations to respond to COVID-19. This action included the approaches PEPFAR plans to implement to contribute to Sustainable Development Goal (SDG) 3 and achieve epidemic control by 2030. The Guiding Principles briefly mentioned linking HIV services to other “relevant health issues” without explicitly naming these health issues. This action did not explicitly mention evidence or human rights norms related to MCH that may have been incorporated into the development of these principles. Given the evidence base that HIV continues to be one of the leading causes of maternal death globally, it was vital that this action explicitly mention the ways that MCH services are included in PEPFAR programming already like prevention of mother-to-child transmission (PMTCT), ANC, and HIV prevention, care, and treatment efforts for pregnant and breastfeeding people. The Guiding Principles were not gender transformative
, as they did not meaningfully discuss gender or the gender transformative components of DREAMS and other key programs. Conversely, the Guiding Principles described the impact of COVID-19 on specific populations and documented how PEPFAR programs adapted their implementation to continue to serve clients, which was highly responsive to need. The Guiding Principles neither hindered nor promoted SRHR in this domain.
2020_PEPFAR 2020 Annual Report to Congress
The PEPFAR Annual Report to Congress provided a comprehensive overview of PEPFAR and its accomplishments as of 2020. It outlined the evidence base for PEPFAR's programs and the methods used to make data-informed decisions including disaggregating all data by sex, age, and geography through the Monitoring, Evaluation, and Reporting (MER) system. The report noted the importance of adhering to guidance from the WHO (e.g., providing Dolutegravir-containing regimens for all women of childbearing age), which was responsive to need and based in evidence. According to this report, PEPFAR implemented a comprehensive PMTCT cascade of interventions, which included antenatal services, HIV testing, and use of antiretroviral therapy (ART) for life; safe childbirth practices and appropriate breastfeeding; and infant HIV testing and other postnatal care services. This cascade was aligned with evidence and human rights. PEPFAR also prioritized oral PrEP for prevention and viral load monitoring for pregnant and breastfeeding women (PBFW) as key interventions to ensure that risk of HIV transmission to a fetus during pregnancy remained low, which was based in evidence and responsive to need. With regard to MCH, the Report was comprehensive, based in evidence, and aligned with human rights norms that recognize that one’s pregnancy or ability to get pregnant should not prevent them from accessing care. However, much of the language was gender blind and reinforced a gender binary instead of using more inclusive language like "pregnant and breastfeeding persons" instead of “pregnant and breastfeeding women.” The Report moderately promoted SRHR in the MCH domain.
2020_PEPFAR 2020 Country Operational Plan Guidance for all PEPFAR Countries
Each year, the Office of Global AIDS Coordinator (OGAC) releases the PEPFAR Country Operational Plan (COP) Guidance, which includes the programmatic and policy guidance for global HIV and AIDS activities and provides the basis for the approval of annual bilateral funding for PEPFAR country and regional programs. The 7 Minimum Program Requirements included in the 2020 COP Guidance were aligned with international human rights norms and evidence and were designed to ensure that PEPFAR programs are responsive to need. The 2020 COP Guidance included the importance of integrating PrEP for adolescent girls and young women (AGYW) and targeted HIV testing at ANC clinics. The Guidance worked to improve retention among PBFW using integrated services during pregnancy and postpartum to promote adherence and retention in care. It also called for additional measures like maternal retesting to achieve the elimination of mother to child transmission (MTCT), which was evidence-based. However, programmatic adaptations for persons with disability were not meaningfully included in the 2020 COP Guidance, which may impact people’s access to MCH services. While the Guidance provided a thorough focus on couple-based services, it used language that promoted a gender binary and largely excluded discussion of pregnant people seeking care who are not married, part of a couple, or identify as women. The 2020 COP Guidance also focused on the key challenges for children, specifically, the pediatric treatment gap, high rates of sexual violence against adolescent girls, and the risk to children posed by inadequate adult HIV treatment retention as well as low viral suppression rates. The Guidance included instructions for families with someone living with HIV to seek services specifically for orphans and vulnerable children (OVC) to streamline service provision and inform other programs, like DREAMS. The 2020 COP Guidance moderately promoted SRHR through PEPFAR country and regional programs with respect to MCH.
2020_PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR Countries
In advance of the COP review process that took place in early 2021, the PEPFAR 2021 Country and Regional Operational Plan Guidance was released in December 2020. The 2021 COP Guidance emphasized the importance of integrating services to create "one stop shops" for integrated MCH and HIV services, which would promote SRHR. The 2021 COP Guidance contained extensive sections about PMTCT, integration of ANC into HIV and AIDS programs, and other MCH activities including guidance for OVC programs, early infant diagnosis (EID), and services for HIV-exposed infants (HEI). Many of these suggestions were consistent with the 2020 COP Guidance, and remained aligned with evidence, PEPFAR program data, and international human rights norms. The 2021 COP Guidance also advocated for the incorporation of oral PrEP at every point of service accessed by PBFW and their eligible partners. However, throughout the 2021 COP Guidance, the language related to MCH was very gendered (e.g., the Guidance does not use “pregnant and breastfeeding persons”) and was not gender transformative
in relation to MCH activities. One significant issue was that MCH was not included in the section outlining the impact of COVID-19 on PEPFAR programs, even though the impact of the pandemic on pregnancy and postpartum care, services for OVC, and child and newborn care was documented prior to the release of the 2021 COP Guidance. Additionally, programmatic adaptations for persons with disability were not meaningfully included in the 2021 COP Guidance, which may have impacted people’s access to MCH services. This action moderately promoted SRHR in the MCH domain.
2020_PEPFAR FY21 Site Improvement through Monitoring System (SIMS) Version 4.1
The PEPFAR Site Improvement through Monitoring System (SIMS) tool provides a standardized approach to monitoring program quality at PEPFAR-supported sites that perform service and non-service delivery functions. The FY21 SIMS Implementation Guide and Assessment Tools set a high standard for how PEPFAR-supported sites are evaluated for program quality. With respect to MCH, the FY21 SIMS Implementation Guide and Assessment Tools included new guidance on PMTCT services, the prioritization of OVC programs during COVID-19, and the integration of HIV testing, prevention, and treatment at every point of service accessed by PBFW. The updates also allowed for virtual assessments during COVID-19, which was responsive to need and ensured that the pandemic did not prevent monitoring visits from happening. They also included guidance on implementing the Protecting Life in Global Health Assistance (PLGHA) policy, which helped evaluators know if the policy was relevant to the site assessment and ensured that the PLGHA policy was being appropriately implemented. The Above-Site and Site Assessment Tools included Core Essential Elements (CEEs) that assess the site against the standard requirements. The CEEs covered a range of topics related to MCH, and the standards used in the CEEs were based in evidence, consistent with human rights, and responsive to need. The CEEs also explicitly included services specifically for PBFW, people at antenatal clinics, infants, and children. It also included evidence-based and gender aware standards on adolescent-friendly services, specifically for AGYW living with HIV who are pregnant. The guidelines and standards for evaluating gender norms interventions were somewhat gender transformative
, but much of the gendered language adhered to a gender binary and was not inclusive. This action moderately promoted SRHR in the MCH domain.
2020_PEPFAR Guidance for Implementing Safe and Ethical Index Testing Services
The Guidance provided an overview of PEPFAR's Index Testing Services and set the minimum requirements for index testing to ensure that index testing protocols going forward would be aligned with human rights norms, evidence, and best practices. This guidance was responsive to need because it was developed in response to the directive in the 2020 COP Guidance to pause index testing due to human rights and confidentiality concerns. It included the WHO's 5C standards (i.e., consent; counseling; confidentiality; correct test results; and connection to HIV prevention, care, and treatment services) as guiding principles for PEPFAR’s index testing programs. The guidelines for intimate partner violence (IPV) screening included a question to be directed to “female clients” asking if they had ever been “beaten” while pregnant. While this question was extremely important given that the risk of IPV during pregnancy is high according to evidence, it was not gender transformative
as it only focused on female clients. This reinforced a gender binary as well as the harmful assumption that only “females” or women can get pregnant. This question was the only mention of maternal health throughout this guidance, which was a significant gap considering the intersections between pregnancy, HIV, and the risk of IPV. The Guidance also included a recommendation that “biologic children of HIV-positive individuals” are included in screenings for emotional IPV and index testing. This approach was based in evidence and promoted SRHR for children that are engaged in the index testing process. This guidance moderately promoted SRHR in the MCH domain.
2020_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.5)
The Monitoring, Evaluation, and Reporting (MER) Indicator Reference Guide aims to streamline and prioritize indicators for PEPFAR programs and is reviewed on an annual basis to ensure that indicators are aligned with PEPFAR initiatives, responsive to need, and consistent with evidence and human rights. In 2020, some of the MER indicators were updated, but it was unclear what evidence or programmatic data prompted these changes. One of the oral PrEP indicators (PrEP_NEW) included new language: "Any process to determine PrEP eligibility should include questions about a client’s exposure to or risk of gender-based violence and intimate partner violence, with appropriate interventions or referrals provided as needed." While this update protected the human rights of those that experience violence, pregnancy could have been mentioned as an additional risk factor for GBV. The Guide also included new guidelines for estimating the viral load testing coverage for pregnant women, which was not gender transformative
as it used binary language. Furthermore, this language, along with most of the updates made to the Guide in 2020, were not gender transformative. This version of the MER Indicator Reference Guide moderately promoted SRHR in the MCH domain.
2020_PEPFAR Technical Guidance in Context of COVID-19 Pandemic_18 November 2020
Between March and November 2020, PEPFAR regularly released revised versions of this Technical Guidance to support PEPFAR programming throughout the COVID-19 pandemic and ensure that programs remained consistent with recommendations from the WHO and U.S. Centers for Disease Control and Prevention (CDC). The Guidance was responsive to need, consistent with human rights, and was often aligned with evidence, even as the evidence base shifted throughout the first year of the COVID-19 pandemic. The Technical Guidance prioritized HIV treatment services over prevention services to ensure uninterrupted care for children, adolescents, PBFW, and adults. It also provided key guidance on continuing PrEP for all target populations through multi-month dispensing (MMD) and other mechanisms which was responsive to need and based in evidence. To assist programs with adapting to COVID-19 lockdowns and service disruptions, the Technical Guidance recommended that clinic-based HIV testing continue through ANC clinics as well as encouraged the scale up of HIV self-testing for pregnant people through community health workers and mentor-mother groups, which was responsive to need and consistent with evidence and human rights. The Technical Update encouraged gender transformative
work through DREAMS and GBV programming to continue within the constraints of COVID-19 protocols and restrictions. However, the Technical Guidance did not mention the disproportionate impact of COVID-19 and GBV on women and girls. The Technical Guidance moderately promoted SRHR through PEPFAR’s MCH activities as programs adapted their operations during the COVID-19 pandemic.
2020_President’s Interagency Task Force: Report on U.S. Government Efforts to Combat Trafficking in Persons
This report discussed U.S. government efforts to end trafficking in the United States and globally. This strategy prioritized the needs and perspectives of those who have been trafficked, called for innovations in data gathering, and promoted education and public awareness activities related to human trafficking. While the health impacts of trafficking were mentioned, the Report centered on domestic efforts to combat trafficking even though the actions described in this whole-of-government report would impact global health assistance programs and activities. The Report described its carceral approach to combating trafficking including prosecution, which relies heavily on law enforcement to prevent trafficking even though these systems do not consistently protect the rights of marginalized groups. This report did not define or provide the evidence base for the “victim-centered and trauma-informed approach” it purported to take in its approaches to combating human trafficking, which was significantly lacking. The Report did not integrate international human rights standards as it conflated commercial sex work and trafficking for the purposes of sex, which ultimately denies sex workers their rights and can impede efforts to prevent trafficking. The carceral approach outlined in this report posed additional risks and barriers for sex workers that needed to access health services due to the fear of prosecution or being targeted by law enforcement. While this report briefly mentioned gender, it was largely gender blind and made no mention of how trafficking impacts people in the LGBTQI+ community. The Department of State reported that it opened applications for projects to address the impacts of COVID-19 on efforts to combat trafficking, which was responsive to need. In 2020, the Department of State also updated the introductory course for personnel on human trafficking, but the Report did not make clear if or how health needs of trafficking survivors were incorporated into this training. The Report did not sufficiently explain which actions were undertaken with U.S. global health funds, which was also a transparency issue. The Report moderately hindered SRHR in the MCH domain.
2020_Report of the Commission on Unalienable Rights
This Report was released by Secretary Pompeo's Commission on Unalienable Rights. The Report defined “fundamental” or “unalienable” rights as those detailed in the Declaration of Independence. It cited the Universal Declaration of Human Rights (UDHR) of 1948 as the standard for the human rights that should be protected worldwide. The Report claimed that the expansion of human rights beyond what was detailed in UDHR has weakened the “claims of human rights” and left disadvantaged groups more vulnerable to rights violations. This assertion was not based in evidence, as there is no evidence to support this claim. It was also not aligned with human rights norms as it ignored the rights not explicitly stated in the Declaration of Independence or UDHR, such as sexual and reproductive rights and the rights of LGBTQI+ people, persons with disability, and displaced persons. To this end, the Report touted “natural law,” which has been historically used to oppose sexual and reproductive rights and the rights of LGBTQI+ people. This report was not responsive to need, because even though marginalized groups around the world are currently experiencing violations of their human rights, the Commission's approach did not adequately describe how the Department of State would work to protect human rights beyond what is explicitly stated in UDHR. The Report was not gender transformative
, as the rights of women, girls, and gender diverse people were almost entirely excluded. The language used throughout the report was largely gender blind, and arguably gender exploitative as it upheld patriarchal structures by not recognizing the compendium of human rights declarations and modern advances in gender equality. The narrow definition of human rights could have negative implications on the implementation of global MCH programs. The Report on the Commission on Unalienable Rights substantially hindered SRHR in the MCH domain.
2020_Review of the Implementation of the Protecting Life in Global Health Assistance Policy (August 2020)
The second review of the Protecting Life in Global Health Assistance (PLGHA) policy summarized the history of the policy and documented its implementation throughout U.S. global health assistance programs. The Review found that in certain cases where partners declined awards, the loss of trusted partners in-country resulted in difficulties replacing these partners and subsequent disruptions in health care services across technical areas. Specifically, the review found that the loss of partners resulted in delays in implementation and distribution of services related to HIV and AIDS, MCH, voluntary FP, tuberculosis, and nutrition, as well as programs providing HIV services for KPs. These findings reinforced the harm of this policy and confirmed that the implementation of the policy led to some disruption in service delivery. This review was somewhat based in evidence as it directly reflected agency-level data. The data collection for this review ended in May 2019, so this was only somewhat responsive to need given that there was no data to document the impact of the policy from May 2019 to August 2020 when the Review was released. However, the Review provided valuable information on how the policy was being implemented that had not been included in the first review. The Review was not gender transformative
, as it did not document whether the policy was being implemented in a way that addressed or affected gender norms and dynamics. The Review moderately hindered SRHR in the MCH domain.
2020_Strengthening Health Security Across the Globe: Progress and Impact of U.S. Government Investments in the Global Health Security Agenda, 2019 Annual Report
In 2020, the Department of State released the Strengthening Health Security Across the Globe annual report that identified the U.S. government contributions to global health security by country and U.S. government actor. Though several areas of global health were mentioned throughout the Report, global MCH efforts were noticeably absent. For example, the Report mentioned several infectious diseases that posed a threat to health security, including the Zika virus. However, this was a missed opportunity for this report to highlight the impact of infectious diseases like Zika on pregnancy, childhood immunizations, and other aspects of SRH. The exclusion of SRHR throughout the report contributed to the increased development of siloes that exclude SRHR from other areas of global health, such as disease outbreaks. SRHR is a critical aspect of health security. Neglecting sexual and reproductive health in security discussions can contribute to negative health impacts and human rights violations for women, girls, gender-diverse people, and other marginalized groups. The Report was largely gender blind, as it ignored the fact that health security is unattainable without gender equity and the countering of harmful norms that affect women and girls. As a result, this Report moderately hindered SRHR in this domain.
2020_The Department of State’s Plan to Implement the U.S. Strategy on Women, Peace, and Security 2020-2023
The 2019 United States' Strategy on Women, Peace, and Security (WPS) was developed in response to the Women, Peace, and Security Act of 2017. This Plan laid out the approach undertaken by the Department of State to make progress on three strategic objectives related to WPS from 2020 to 2023. The Plan largely excluded health activities in general, including technical areas related to SRHR. However, it did mention the importance of preventing GBV, including sexual violence and early and forced marriage. The Plan did not address pregnancy as a potential outcome of sexual violence, or the resulting MCH services those who experience violence may need. It also did not mention the impact of pregnancy on people's ability to engage in peace and security efforts. The Plan was responsive to need as the objectives were informed by the global need for women's empowerment efforts. However, the exclusion of maternal and child health was not evidence-based nor consistent with human rights frameworks. The Plan was somewhat gender transformative
as it recognized and sought to combat gender norms through a systemic approach, but the Plan used language that reinforced a gender binary and was not inclusive of those who are impacted by the issues detailed in the report who do not identify as women. It was unclear which activities and programming mentioned in the Plan were considered U.S. global health assistance, which was a transparency issue. The Plan neither promoted nor hindered SRHR in the MCH domain.
2020_United States Strategy to Prevent Conflict and Promote Stability
The United States released this Strategy in accordance with the Global Fragility Act of 2019 to promote “peaceful, self-reliant nations.” The Department of State was identified as the lead agency to oversee and implement this Strategy with the assistance of other supporting U.S. government agencies to create impactful and sustainable programs in fragile settings. While the Strategy was responsive to need, it did not adequately address the SRHR and the broader health needs of people in conflict settings. The Strategy failed to explain its engagement with specific global health areas, even though HIV and AIDS, MCH, FP, and other cross-cutting SRHR issues are vital to promoting stability and security. Notably, it did not include GBV, which is often a greater risk to women, girls, and gender-diverse people in fragile settings and conflict areas. The Strategy also stated that it was grounded in evidence and human rights, but it did not include an explanation of the evidence base or human rights framework that informed it. Additionally, it was not gender transformative
. Instead, the language in this action promoted a gender binary, ignored the role of gender inequalities on experiences of violence, and only mentioned women in the context of the WPS Strategy. While the latter was an important inclusion, gender was not meaningfully included in other areas of the Strategy. This action moderately hindered SRHR in the MCH domain.
2019_PEPFAR 2019 Annual Report to Congress
The President's Emergency Plan For AIDS Relief (PEPFAR) Annual Report to Congress provided an overview of the PEPFAR program’s accomplishments to date and discussed the program’s future directions. This report largely summarized high-level known information about PEPFAR programs. The report provided critical information about maternal and child health programming through PEPFAR, including viral load monitoring for PBFW, maternal retention in treatment, orphan and vulnerable children (OVC) programs, and prevention of mother-to-child transmission (PMTCT) programs. Within this domain, the report was responsive to need and based in evidence and human rights norms. Some HIV and AIDS services were included in antenatal care (ANC) programming such as opt-out HIV testing, and reported activities were based in evidence and international human rights norms. The document was not gender transformative
as it did not discuss the impact of gender norms with PEPFAR’s maternal health programming. Overall, the Annual Report moderately promoted SRHR.
2019_PEPFAR 2019 Country Operational Plan Guidance for all PEPFAR Countries
Released annually by the Office of the Global AIDS Coordinator, the Country Operational Plan (COP) Guidance outlines the plan for global HIV and AIDS activities funded by the President's Emergency Plan For AIDS Relief (PEPFAR) and provides the basis for the approval of annual bilateral HIV and AIDS funding for partner countries. The 2019 COP Guidance did not adequately emphasize the importance of integration of HIV and antenatal care (ANC) services. The guidance was not gender transformative
but demonstrated gender awareness through the use of gender-neutral language such as “clients” or “patients” and the discussion of the impact of gender norms on HIV and AIDS prevention and treatment within DREAMS programming. However, the guidance was based in evidence and human rights norms as well as was responsive to need. The document continued to provide comprehensive guidance on the implementation of PEPFAR programs for all populations and, within this domain, emphasized the importance of point-of-care programs for PBFW and prevention of mother-to-child transmission (PMTCT) activities. Overall, the Guidance moderately promoted SRHR.
2019_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.4)
The President's Emergency Plan For AIDS Relief (PEPFAR) Monitoring, Evaluation, and Reporting (MER) guidance included the indicators used to monitor and evaluate PEPFAR. All PEPFAR programs were evaluated according to their performance within these indicators and metrics, and this guide helped country teams and PEPFAR implementing partners understand the M&E process. In 2019, some of the MER indicators were updated, but it remains unclear what prompted these changes. The document included a few maternal health related indicators, and particularly focused on prevention of mother-to-child transmission (PMTCT) and antenatal care (ANC), as well as included pregnancy status as a disaggregate group across various treatment indicators. Within this domain, the guidance was evidence-based, based in human rights, and responsive to need. However, the guide was not gender transformative
but gender aware, as it included some consideration of structural factors, such as family situation, on HIV prevention and treatment but did not move to address these barriers.
2019_Protecting Life in Global Health Assistance Frequently Asked Questions and Answers_September 2019
The Protecting Life in Global Health Assistance (PLGHA) FAQs document was updated in 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 PLGHA Six Month Review. The text of this document was similar to the 2018 FAQ document though 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 the availability of maternal health services. 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 mentioned maternal and child health within the USAID Agency Priority Goals but did not discuss the role of the Department of State in the funding of maternal and child health policies or programs. The Report provided an opportunity for the Department of State to clarify its role in both humanitarian and non-humanitarian maternal and child health activities, but it failed to seize that opportunity. Within this domain, the Report was not based in evidence or human rights and was not responsive to need beyond standard Congressional reporting requirements. The Plan was 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. This Report neither promoted nor hindered SRHR with regard to the Department of State’s maternal and child health programs.
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 services. The FAQs significantly hindered the Department of State's ability to support comprehensive maternal and child health programming in 2018.
2018_Protecting Life in Global Health Assistance Six Month Review
The PLGHA Six Month Review summarized the PLGHA policy and identified solutions to challenges that had arisen in the process of PLGHA implementation. The review was responsive to need in that it addressed concerns expressed by partners affected by the policy, but was not evidence-based, based in human rights principles, or gender transformative
. The review received a lower grade within this domain compared to Family Planning and HIV and AIDS because the review did not mention maternal and child health programming specifically, despite the unique impacts this policy could have on maternal and child health services. The Six Month Review significantly hindered the Department of State's ability to support comprehensive maternal and child health programming in 2018.
2016_Department of State Implementation Plan for the U.S. Adolescent Girls Strategy
The Department of State Implementation Plan for the U.S. Adolescent Girls Strategy 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. This Plan acknowledged the impact of forced marriage, especially early or childhood marriage, and the impact of FGC on the health of AGYW. Specifically, it stated that these practices lead to poor maternal health outcomes, including high morbidity and mortality rates from pregnancy and birth complications, trauma, and other diseases and infections. The Plan provided details on "preserv[ing] the rights of married and pregnant girls and adolescent mothers to attend school" and "remov[ing] barriers to sexual and reproductive health and comprehensive, accessible, youth-friendly health services" to prevent early pregnancy. Though the Plan was responsive to need and grounded in human rights principles, it did not incorporate significant evidence-based programming because it did not address how to meet the clinical needs or provide maternity care of pregnant AGYW. This Plan is gender transformative
in that it promoted gender equality by decreasing early marriage and pregnancy through educational empowerment. This Strategy moderately promoted SRHR through the Department of State’s maternal and child health programs.