YEAR 2021

US Agency for International Development

The United States Agency for International Development (USAID) received a 76 (C) with transparency and a 79 (C+) without transparency in 2021. On average, the actions graded across HIV and AIDS, maternal and child health (MCH), and family planning (FP) moderately promoted sexual and reproductive health and rights (SRHR). The decision to remove the Protecting Life in Global Health Assistance (PLGHA) section of the Automated Directives System (ADS) Chapter 303 without offering additional information or guidance about how to implement the policy change decreased the actor’s grade. The transparency of funding data was generally high across domains, but there were persistent transparency issues regarding ADS chapters, the Global Health eLearning courses, and the role of USAID’s global health programs in some whole-of-government actions. USAID’s HIV and AIDS grade was higher than the MCH and FP domain grades due to the disbursement of funding in a manner that was highly responsive to need in 2021.

A-

HIV & AIDS

USAID received an 86 (B) with transparency and a 90 (A-) without transparency in the HIV and AIDS domain in 2021. This domain grade was raised by actions outlining the Agency’s response to the COVID-19 pandemic in a manner that promoted SRHR, such as the USAID Implementation Plan for the U.S. COVID-19 Global Response and Recovery Framework and Issues and Recommendations on Gender-Based Violence Prevention and Response in COVID-19 Programming. The decision to remove the PLGHA section in ADS Chapter 303 without offering additional information or guidance for partners about how to adapt their programs significantly hindered SRHR. Overall, transparency was low for many actions graded in this domain because USAID did not indicate which content had been updated in 2021 from previous versions. USAID had a high level of transparency for funding data and disbursed HIV and AIDS funding in a manner that was highly responsive to need, which increased this actor’s grade in this domain in 2021.

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_Acting on the Call

The 2021 Acting on the Call Report documented the impacts of U.S. global health financial investments in and commitments to providing critical health services to women, children, and families around the world. This action described the adaptations USAID implemented through global MCH programs in response to the COVID-19 pandemic and climate change, which were responsive to need. Though this action mentioned USAID’s integrated approach to providing primary health care, information about integrated MCH and HIV and AIDS programs, such as prevention of mother-to-child transmission (PMTCT) activities funded by the President’s Emergency Plan for AIDS Relief (PEPFAR), were largely lacking from this Report. As complications from HIV remain a leading cause of death among women of reproductive age around the world, this action was not based in evidence or responsive to need in this domain. Neglecting to mention HIV beyond U.S. global health investments ignored the maternal and reproductive health needs of people living with HIV (PLHIV), including those that are breastfeeding. This action was gender accommodating as it reinforced a gender binary, used gendered language throughout, and did not address harmful social and gender norms that impact PLHIV who may be pregnant or breastfeeding. This action moderately hindered SRHR in the HIV and AIDS domain.

2021_ADS Chapter 200_2021.01.15

ADS Chapter 200 described USAID’s process of creating development policy, as well as the development policy universe that affects all USAID programs and actions. This chapter was edited in January 2021 to update the link for the Agency-wide Policy Framework, which is the Agency’s highest level policy document that guides decision-making across USAID. However, the URL for the current Agency Policy Framework was broken and the Agency Policy Framework was not available elsewhere on the website, which negatively affected transparency. This action neither hindered nor promoted SRHR in the HIV and AIDS domain.

2021_ADS Chapter 201_2021.09.21

ADS Chapter 201 defined USAID’s Program Cycle, which is the Agency’s operational model for planning, delivering, assessing, and adapting development programs that advance U.S. foreign policy. Several sections of ADS Chapter 201 were updated in September 2021, including an update to the definition of “activity design” to include policy dialogue, stakeholder coordination, and capacity building. ADS 201 included an updated Project Design and Implementation section that encouraged integration and coordination across projects for greater sustainability. Many of these edits were responsive to need and aligned with evidence and best practice. Additionally, the responsibilities of the Gender Advisor at the USAID Mission level were updated to include ensuring that “gender equality” was integrated into the design and implementation of activities, which was somewhat gender transformative. This ADS chapter still used gendered language like “female empowerment” and did not address efforts to empower people of diverse sexual orientation, gender identity or expression, or sex characteristics (SOGIESC). The updates to ADS Chapter 201 moderately promoted SRHR in the HIV and AIDS domain.

2021_ADS Chapter 303 Materials_2021.02.04

ADS Chapter 303 described USAID’s internal guidance, policy directives, procedures, and standards for grants and cooperative agreements with non-governmental organizations (NGOs), including those that were established with U.S. global health assistance funds. The main ADS chapter was updated, along with two mandatory references in February 2021: the Standard Provisions for U.S. Nongovernmental Organizations (303maa) and the Standard Provisions for Non-U.S. Nongovernmental Organizations (303mab). All three of these ADS Chapter 303 materials were updated to replace the section related to the implementation of Protecting Life in Global Health Assistance (PLGHA) with the word “Reserved.” No other sections in the ADS Chapter 303 materials were updated to indicate that PLGHA had been revoked by President Biden on January 28, 2021. It was extremely difficult to identify what content had been removed from that section as previous versions of ADS materials were not available on the website. The SRHR Index team referenced the previous version of all three ADS Chapter 303 documents to determine that the PLGHA section had been removed in its entirety. This was USAID’s opportunity to provide information about the policy’s revocation along with guidance for NGOs to implement the policy change and align their programs accordingly. USAID did not provide any information about the revocation of PLGHA in these documents, which negatively affected transparency . This action significantly hindered SRHR in the HIV and AIDS domain.

2021_ADS Chapter 303mab_2021.03.31

ADS Chapter 303mab, Standard Provisions for Non-U.S. Nongovernmental Organizations, was updated in March 2021 to update section M2. Accounting, Audit, and Records. A new subsection outlined the requirement that recipients of grant or cooperative agreement funding had to provide USAID and other U.S. government (USG) officials with “timely and reasonable access” to materials, records, and personnel necessary to complete audits and other oversight processes. This update would apply to U.S. global health programs, but it was unclear whether it would affect the implementation of activities related to SRHR. This action neither hindered nor promoted SRHR in this domain.

2021_ADS Chapter 303_2021.06.07

ADS Chapter 303 was updated again in June 2021 to revise section 303.4.2: Internal Mandatory References. However, none of the individual internal mandatory reference documents were highlighted to indicate that they had been updated, which negatively affected transparency. Highlighting updated content in ADS documents would have helped the reader understand which material had been edited in the revised version. This action neither promoted nor hindered SRHR in the HIV and AIDS domain.

2021_ADS Chapter 303 Materials_2021.07.29.

ADS Chapter 303 was revised in July 2021 to update Section 303.3.5.5: Unsolicited Concept Papers and Applications. The update provided a link to a new Internal Mandatory Reference document: Guide to Unsolicited Applications (303mbd). The Guide to Unsolicited Applications provided guidance and procedures for USAID’s review of unsolicited applications. According to this action, “unsolicited applications provide a method for organizations to submit unique, innovative, or proprietary approaches for solutions to development challenges.” USAID is responsible for determining whether funding such applications would be aligned with the Agency’s development objectives. The addition of this internal mandatory reference document could help ensure that USAID funds programs were responsive to need and not based solely on USAID’s procurement processes. This action was based in evidence and responsive to need as the materials clearly stated that all applications would be reviewed by the programmatic and technical officers to determine strategic alignment with Agency priorities. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_ADS Chapter 308_2021.02.26

ADS Chapter 308, entitled: Agreements with Public International Organizations (PIOs), was updated in February 2021 to state that “PIOs are important partners for the Agency, and many PIOs possess unique comparative advantages.” This action stated that USAID’s Operating Units (OUs) would work with PIOs whenever it was in the best interest of the Agency, which could have fostered partnerships that promoted SRHR through U.S. global health assistance. This action was updated to describe the Organizational Capacity Review process to ensure that the PIO’s organizational framework and operational capacity would add value to USAID’s work. This legal due diligence process was vital to successful partnerships. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_ADS Chapter 308mab_2021.06.15

ADS Chapter 308mab was a mandatory reference for ADS Chapter 308 entitled: Standard Provisions for Cost-Type Agreements with Public International Organizations (PIOs) and was revised in June 2021. Section M19. Sexual Exploitation and Sexual Abuse and Sexual Harassment was updated to outline USAID’s zero-tolerance policy for inaction to addressing sexual exploitation and abuse (SEA) and sexual harassment in all agreements with PIOs. This action required PIOs working in partnership with USAID to apply the Inter-Agency Standing Committee (IASC) Six Core Principles Relating to Sexual Exploitation and Abuse, referenced the United Nations Protocol on Allegations of Sexual Exploitation and Abuse Involving Implementing Partners, and defined a “victim/survivor-centered approach” to SEA and sexual harassment, which aligned this action with evidence and grounded it in human rights. The updated ADS Chapter 308mab stated the requirement for PIO partners to make “reasonable and adequate efforts to address gender inequality and other power imbalances” in their programing, which called for the integration of gender transformative approaches. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_ADS Chapter 312_2021.09.08

ADS Chapter 312 contained information on USAID-financed condoms, pharmaceuticals, and medical supplies designed for USAID technical and procurement staff as well as implementing partners. This chapter was updated to add medical gloves and syringes to the list of laboratory supplies that did not require ADS 312 approval and confirmed that certain USAID technical and programmatic staff had the delegated authority to make determinations about specific pharmaceuticals. It was unclear how these updates would impact the implementation of USAID’s global HIV and AIDS programs, so this action neither hindered nor promoted SRHR in this domain.

2021_Assessing Feasibility and Readiness for Cargo Drones in Health Supply Chains

This report shared the findings of scoping visits in Malawi that explored the feasibility of cargo drones to support global health supply chains with the long-term goal of avoiding stockouts, responding to emergency medical requests, and speeding up diagnostic sample delivery time to benefit global beneficiaries. This action was responsive to need due to supply chain distribution issues that resulted from the COVID-19 pandemic. This action explicitly stated that these findings would not be applicable across all contexts, but that the approach outlined in this report could be adapted for different limited-resource settings. This action suggested that a root cause analysis should be completed to improve project design and inform implementation, which was based in evidence. The guide discussed other best practices that were responsive to need, such as market research, scoping trips, and informational interviews with stakeholders at all levels, from the national government to community health workers. The action included guidance for engaging with community members and designing culturally appropriate community sensitization activities through a participatory approach, which was responsive to need. However, the guide did not include the human rights framework that should be considered when designing drone initiatives. It laid the foundation for future work that could be applied across U.S. global health programs. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Building Commitment and Capacity to End TB_Tuberculosis Report to Congress_FY2019

This report to Congress documented USAID’s progress toward preventing and treating tuberculosis (TB) and its related comorbidities (e.g., HIV infection and diabetes) around the world. This report was responsive to need as it described the current state of TB infection worldwide, outlined the results of USAID’s Global Accelerator to End TB to date, and described the next steps in USAID’s TB activities in response to the COVID-19 pandemic. PLHIV were mentioned as a key focus of preventative treatment for TB, and TB/HIV cases were reported in each of the country snapshots in the Appendix. However, it was not fully based in evidence as integrated TB/HIV services were not adequately incorporated throughout this action. The action was gender accommodating as it mentioned USAID’s efforts to address stigma, discrimination, gender disparities, and inclusiveness through TB programs, but did not provide additional details about these activities. This Report neither hindered nor promoted SRHR in the HIV and AIDS domain.

2021_Considerations for COVID-19 Response_Digital Accessibility

This action outlined the importance of digital accessibility, particularly during the COVID-19 pandemic, and offered key considerations for designing accessible digital interventions through a universal design approach which was based in evidence. These suggestions, such as involving disability advocacy organizations in digital design processes and adding alt-text to photos, were responsive to need, based in evidence, and aligned with human rights norms. This action built upon USAID’s first-ever Digital Strategy, which was released in 2020. This action acknowledged that lack of access due to disability was intersectional to other inequities, which was based in evidence, but was gender blind as it did not specify the ways in which a person’s gender could be a barrier to access. This action supported the ability of USAID’s global HIV and AIDS programs to be more inclusive of persons with disability. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Department of State and USAID_Fiscal Year (FY) 2022 Annual Performance Plan

The Fiscal Year (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. This action was highly responsive to need as it provided key status updates on the accomplishments of global HIV and AIDS programs, including new HIV diagnoses, the numbers of adults and children receiving ARVs, and the number of voluntary medical male circumcision (VMMC) procedures conducted per FY. The availability of these data supported evidence-based decision making, which was aligned with evidence and responsive to need. The Report was not fully responsive to need as specific programs for key populations (KPs) or adolescent girls and young women (AGYW) were not included in this action. Additionally, the HIV and AIDS indicators did not have FY 2022 targets. Setting targets at the beginning of the FY is an important way to measure progress and ensure that programs are performing well and are responsive to need. It was unclear why targets were not included for USAID’s global HIV and AIDS activities in FY 2022, so this action was not fully based in evidence and negatively affected transparency . The Report was gender accommodating as it used language that reinforced a gender binary. Progress related to cross-cutting SRHR issues like gender-based violence (GBV) and gender equality were included in this action, which was responsive to need. However, targets were not included for FY 2022, which was not responsive to need and negatively affected transparency. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Diversity, Equity, and Inclusion Strategy_Executive Summary

In 2021, USAID released the Executive Summary for the forthcoming Diversity, Equity, and Inclusion Strategy. The full Strategy was not publicly available at the time of grading, but the Executive Summary described USAID’s plan to enhance diversity across the Agency, promote inclusion and equity among Agency staff, and strengthen accountability for diversity, equity, and inclusion (DEI) efforts. This action described the methodology that USAID implemented to design the complete DEI Strategy, including stakeholder interviews, focus groups, listening sessions, and consultations at all levels of the Agency. While this approach and the overall goals of the DEI Strategy outlined in this action appeared to be responsive to need, based in evidence, and aligned with human rights, it did not explain how the complete Strategy would impact U.S. global health programs and operations. Though releasing this Executive Summary was responsive to need, this action likely would not have an impact before the complete Strategy was made available. This action neither hindered nor promoted SRHR in the HIV and AIDS domain.

2021_Family Planning and Reproductive Health Program Overview

This Overview detailed the scope of the Family Planning/Reproductive Health (FP/RH) Program at USAID and described the benefits of FP to women and children's health, reducing poverty, and lowering the incidence of HIV and AIDS. The Overview was guided by the principles of voluntarism and informed choice, which was responsive to need, based in evidence, and aligned with human rights. The Overview stated that the RH portfolio included integration with HIV programming and highlighted the impacts of FP on reducing HIV and AIDS by preventing new infections and mother-to-child transmission of HIV, which was responsive to need and based in evidence in this domain. While the Overview mentioned that addressing gender norms was within the RH portfolio, it was gender accommodating as it primarily used language that enforced a sex and gender binary. This Overview moderately promoted SRHR in the HIV and AIDS domain.

2021_Global Health eLearning Course_Antimicrobial Resistance_Part 1

This eLearning course explored antimicrobial resistance as it pertained to diseases such as TB, gonorrhea, malaria, and HIV. The Course described the potential reversal of progress made against these public health challenges, as well as the reality that resistance to common medications has increased in recent years, which has resulted in an increased burden on health systems. This action reported on the higher burden of resistance to specific HIV treatment regimens among women than men and emphasized the importance of fast-tracking the shift to prescribing dolutegravir-containing regimens for all PLHIV, including those who may have developed resistance to other HIV treatment regimens. This recommendation was responsive to need and based in evidence. However, this action did not advance SRHR beyond monitoring resistance to antibiotic treatments, including those that impact sexual and reproductive health (SRH) outcomes. It was gender accommodating as it used gendered language when discussing risk of antibiotic resistance. This action did not clarify which content was updated in the latest version of this eLearning course, which negatively affected transparency . This action neither promoted nor hindered SRHR in the HIV and AIDS domain.

2021_Global Health eLearning Course_Applying Segmentation to SBC in Family Planning

This eLearning course provided information about the benefits of incorporating segmentation—or dividing a population into subgroups with "meaningfully similar characteristics, and significant differences from other subgroups"—for the purposes of social and behavior change (SBC) research and programming. The Course primarily focused on incorporating SBC into FP programming, however the guidance in the Course could be applied to other areas of global health beyond FP. The Course covered several case studies where different SBC approaches could be used to address a wide range of contexts, which was responsive to need. However, it was not fully responsive to need as the Course mentioned HIV and AIDS in examples and case studies but did not provide specific guidance on applying segmentation strategies on applying segmentation strategies to FP activities related to HIV and AIDS outcomes. The Course received a low transparency score as it was not clear what was updated from previous versions of the training. The Course was gender accommodating as it used gendered language that reinforced a gender binary. The Course moderately promoted SRHR in the HIV and AIDS domain.

2021_Global Health eLearning Course_HIV/AIDS Legal and Policy Requirements

This eLearning course provided guidance about the legal and policy requirements that applied to global HIV programs supported by U.S. global health assistance funds. The Course provided information on a wide variety of topics including condoms, sex work, working with local partners such as faith-based organizations or law enforcement, VMMC, FP/HIV integrated services, restrictions related to abortion and involuntary sterilization, and ensuring compliance with these USG requirements. The Course provided useful information to support organizations with implementing these policies, which was responsive to need. However, it mostly focused on restrictions instead of what was allowed under U.S. policy. Though the Course was updated to remove all mentions of PLGHA, removing all references to this policy without providing information about its revocation or guidance for partners on how to implement programming in its absence was not consistent with evidence, responsive to need, or aligned with human rights. The Course highlighted opportunities to support programming such as FP/HIV integration across PEPFAR platforms, including PMTCT activities, KP programming, and DREAMS programming, which was also responsive to need, based in evidence, and aligned with human rights norms. While the Course supported the implementation of some gender transformative elements through DREAMS programming, it was gender accommodating as it used gendered language and did not include guidance on addressing gender norms in global HIV and AIDS programming. The Course did not highlight what was updated or changed for 2021, which negatively affected transparency . This action neither hindered nor promoted SRHR in this domain.

2021_Global Health eLearning Course_U.S. Family Planning and Abortion Requirements

The 2021 eLearning Course on U.S. Family Planning and Abortion Requirements provided an overview of the FP and abortion legislative and policy requirements that apply to U.S. foreign assistance funding and programs. The Course primarily focused on the principles of voluntarism and informed consent through the Tiahrt amendment, which was based in evidence and human rights norms as these principles are regarded as the standard for protecting the human rights of people that access FP services worldwide. The Course emphasized that it was the responsibility of USAID staff to discuss legislative abortion restrictions with implementing partners throughout the life of the award to ensure awareness of the restrictions, which was responsive to need. The Course specifically noted that programs cannot deny access to HIV and AIDS treatment based on FP use and emphasized that the requirements outlined in the course applied to HIV and AIDS programming, which was responsive to need. However, the Course did not clearly state which information was changed for 2021, which negatively affected transparency . Furthermore, it did not mention the Biden administration's policy to support SRHR globally. While the Course mentioned the revocation of the PLGHA policy, it stated that the policy was no longer in effect and that implementing partners still had to comply with other abortion-related restrictions, which was not enough detail or guidance for partners to understand how to implement this policy change. As a result, this action was not fully responsive to need, based in evidence, or consistent with human rights norms. The Course encouraged staff to "be aware of perceptions among program managers, clients, and providers that may suggest potential vulnerabilities," which was not responsive to need as it could lead to unnecessary oversight of people's personal or professional beliefs that would not be relevant to their implementation of abortion restrictions. The Course was gender blind as it did not include a meaningful or inclusive discussion of gender. This Course moderately hindered SRHR in the HIV and AIDS domain.

2021_Issues and Recommendations on Gender-Based Violence Prevention and Response in COVID-19 Programming

This action provided guidance and recommendations for how to include GBV prevention and response efforts in COVID-19-related programming. The action highlighted the increase in GBV during the pandemic, particularly in the form of online and offline harassment, SEA, child and early forced marriage (CEFM), female genital mutilation/cutting (FGM/C), LGBTQI+ abuse, and abuse towards female health workers. This action recognized the lack of health services available to GBV survivors due to health care supplies being diverted away from GBV and SRHR services in favor of COVID-19 mitigation and called for the integration of GBV prevention and response efforts into the health service response to COVID-19. This recommendation was responsive to need and based in evidence. The action provided recommendations for implementing GBV risk mitigation measures, which were responsive to need, based in evidence, and aligned with human rights norms. While SRH services were mentioned one time, the guidance should have explicitly included the promotion of SRHR as a vital component of the pandemic response. This action did not include considerations for HIV and AIDS programs, which was not responsive to need as it did not recognize the HIV-related services needed by GBV survivors. This action was somewhat gender transformative as it advocated for the implementation of SBC activities to promote healthy masculinities and gender equitable relationships, though it used language that reinforced a sex and gender binary. The Report 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 efforts led by USAID. 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 USAID, including global HIV and AIDS programs and 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 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 HIV and AIDS domain.

2021_United States Government Women, Peace, and Security (WPS) Congressional Report

The Women, Peace, and Security (WPS) Congressional Report provided Congress with an overview of progress specific USG agencies have 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, Department of Homeland Security (DHS), and the USAID: participation, protection, internal capabilities, and partnership. While improved global health outcomes were included as a positive impact of implementing the WPS Agenda, the contributions of USAID’s global HIV and AIDS programs to the WPS efforts were not meaningfully included in this action. However, the Report included GBV prevention and programming as a cross-cutting measure of progress towards achieving the WPS Agenda, which was responsive to need. The Report also highlighted USAID’s efforts to integrate WPS activities with other actions related to countering violent extremism and implementation of gender-sensitive interventions during the COVID-19 pandemic. It highlighted USAID's efforts to prevent CEFM and provide gender training for USAID personnel, which was responsive to need. The Report included specific and actionable milestones to measure the actor’s progress on these goals, which was responsive to need and could support evidence-based decision making in the future. 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 this domain.

2021_USAID 2021 Climate Readiness Plan In Reponse to Executive Order 14008

The 2021 USAID Climate Readiness Plan provided an overview of how USAID plans to implement the directives listed in Executive Order 14008, which called for a prioritization of the climate crisis in the United States and globally. The Plan detailed USAID's role in implementing climate solutions in countries most affected by climate change, as well as called for USAID programs to incorporate lessons learned from the COVID-19 response to build climate resilience. The Plan called for increased collaboration with Indigenous peoples, women and girls, youth, and other groups that are disproportionately impacted by the climate crisis, which was responsive to need and based in evidence. It outlined USAID’s commitment to implementing evidence-based decisions across the full scope of programs and revitalized USAID's approach to climate change adaptation, resilience, and mitigation targets. The Plan elaborated on how global health programs were being monitored for climate change vulnerabilities, particularly in relation to the availability of medical supplies for PEPFAR, infectious diseases, MCH and nutrition, and FP/RH programs, which was responsive to need and based in evidence. The Plan was gender accommodating because it acknowledged the gendered impacts of climate change but utilized gendered language that reinforced a gender binary. This Plan moderately promoted SRHR in the HIV and AIDS domain.

2021_USAID Health Systems Strengthening Learning Agenda

The USAID Health Systems Strengthening Learning Agenda provided a guide for how USAID’s global health programs should improve health system strengthening (HSS) programming. The Learning Agenda prioritized supporting high-performing health care; improving health system equity, quality, and resource optimization; advancing USAID's Vision for Health System Strengthening 2030; and supporting locally led efforts to develop sustainable, resilient health systems. These priorities were responsive to need and based in evidence. The Learning Agenda included questions for a variety of stakeholders that advance health system performance and resilience as well as prioritized health outcomes including controlling the HIV and AIDS epidemic. The Learning Agenda directed stakeholders to implement robust HSS research and programming efforts that were based in evidence, responsive to need, and aligned with human rights. The Learning Agenda could have included more detailed information and guidance about how to adequately incorporate SRHR in these efforts. The Learning Agenda was gender accommodating as it mentioned gender as a cross-cutting area of focus but did not specifically discuss the gender norms that impact health systems and people’s access to health services. The Learning Agenda moderately promoted SRHR in the HIV and AIDS domain.

2021_USAID Implementation Plan for the U.S. COVID-19 Global Response and Recovery Framework

The USAID Implementation Plan detailed the Agency's efforts to carry out the U.S. COVID-19 Global Response and Recovery Framework issued by the Biden administration in 2021. The Plan emphasized the importance of implementing essential public health programs, including those related to FP and sexual, reproductive, maternal, and child health as well as tuberculosis, malaria, and HIV, which were negatively impacted by COVID-19. The Plan included a section on how USAID will leverage existing global health programs and investments to respond to the pandemic and recover from its impacts to strengthen health systems, which was responsive to need, based in evidence, and aligned with human rights. The Plan did not include an adequate description of the metrics that would be used to measure health system recovery and the provision of vital health services, which was not responsive to need. The Plan noted the risk of backsliding on targets related to increasing gender equality and recognized the impact of the pandemic on cases of GBV as well as other increased inequities across marginalized groups. The Plan called for USAID programs to promote equity in COVID-19 responses and prioritize the voices of underserved communities, which included a wide range of demographic groups and emphasized a gender-responsive approach to decision making, which was responsive to need. The Plan included goals on combating social norms regarding GBV prevention but was largely gender accommodating as it used gendered language throughout and did not meaningfully provide guidance for programs to overcome the gender norms that impact COVID-19 recovery. The Plan moderately promoted SRHR in the HIV and AIDS domain.

2021_USAID Key Programming Questions to Address Gender and COVID-19 Infographic

This Infographic provided key questions to support USAID programs that implement gender inclusive programming related to COVID-19. The Infographic covered topics such as GBV; agriculture, food security, and nutrition; democracy, rights, and governance; environment; economic growth; health; child protection; education; and water, sanitation, and hygiene (WASH). The Infographic emphasized the importance of providing "essential and routine health services" because of the pandemic but did not explicitly mention SRH services. The lack of specificity in this definition could have siloed SRH services from other services included in this action. It addressed the increased inequities and vulnerabilities faced by women and marginalized groups across these issue areas due to the pandemic which was evidence-based, aligned with human rights, and responsive to need. The Infographic specifically mentioned "women and girls, men and boys, in all their diversity," which acknowledged the complexity of these identities in relation to people’s SOGIESC which was a gender inclusive approach to this issue. This action was gender accommodating as it recognized gender diversity but did not include questions to guide programs to overcome harmful gender norms. This action moderately promoted SRHR in this domain.

2021_USAID Memorandum Authorizing Disaster Relief Flexibilities to Reduce the Burden for Financial Assistance Pursuant to OMB Memorandum M-21-20

This Memorandum outlined the exceptions for USAID agreements and grant recipients that were impacted by the COVID-19 pandemic, including agreements that pertained to global health assistance. The Memorandum outlined the Agency’s authority to provide administrative relief not only to recipients with COVID-19-related financial assistance, but also to recipients that were implementing assistance awards unrelated to COVID-19. This was responsive to need as it recognized that partners may have had difficulty completing program activities due to the pandemic. The Memorandum provided guidelines for increased flexibility with System for Award Management (SAM) registration procedures; Notice of Funding Opportunity (NOFO) publication requirements; and pre-award costs, no-cost extensions, and submission of financial, performance, or other reports, which was responsive to partners' needs. This action supported the implementation of global HIV and AIDS programs that could be flexible and adaptable during the COVID-19 pandemic. This Memorandum moderately promoted SRHR in this domain.

2021_USAID Nutrition Report to Congress_FY 2021

The 2021 USAID Nutrition Report to Congress included an overview of the Agency's approach to providing nutrition care and progress made toward the World Health Assembly targets on nutrition. The Report referenced the 2021 Lancet series on maternal and child undernutrition, which emphasized the importance of good nutrition for survival and the need to focus on "mothers and children in the 1,000 days window from pregnancy to age two." This action emphasized USAID's evidence-based and multisectoral approach to nutrition programming and highlighted the "unfinished agenda" of deficiencies in vitamins and minerals, gaps in the delivery of nutrition interventions, and the importance of incorporating maternal nutrition in health and food systems, which was based in evidence and responsive to need. The Report did not include data or metrics about how nutrition programming was implemented within HIV and AIDS programming, which was lacking as nutrition is a cross-cutting issue that applies to PLHIV and people taking a biomedical HIV prevention method. Additionally, the Report was gender blind as it only referred to “pregnant and breastfeeding women,” which was not gender inclusive of the nutrition needs of pregnant people who do not identify as women. This Report neither hindered nor promoted SRHR in the HIV and AIDS domain.

2021_USAID Policy on Countering Trafficking in Persons

The USAID Policy on Countering Trafficking in Persons (C-TIP) outlined the principles that guided USAID's approach to implementing policies to combat trafficking in persons. The Policy defined USAID’s "survivor-centered and trauma informed" approach to supporting survivors of trafficking, which was responsive to need and based in evidence. It emphasized that survivors should receive shelter, food, counseling, health care, and legal assistance, which was responsive to need. It highlighted the adverse health outcomes that are common for survivors of trafficking, including work-related injuries or accidents, sexual and physical assault, sexually transmitted infections (STIs), infertility, forced abortion, substance abuse, chronic untreated medical conditions, malnutrition, and future victimization or perpetration of violence, which was based in evidence. These outcomes included issues relevant to SRH, which was responsive to need, but only mentioned "forced abortion," which was not inclusive of the need for safe abortion care in the case of an unwanted pregnancy resulting from trafficking or violence. The Policy was gender accommodating as it included efforts to promote gender equity to prevent and address trafficking in persons but used gendered language throughout the Policy and did not actively demonstrate efforts to combat gender norms that enable trafficking. This Policy moderately promoted SRHR in this domain.

2021_USAID Vision for Health System Strengthening 2030

The Vision for Health System Strengthening for 2030 highlighted USAID’s goals for implementing HSS activities across global health programs. The Vision incorporated equity into access to care and quality of care as well as emphasized the importance of collaborating with local partners to ensure the sustainability of health systems. The focus on addressing systemic barriers to providing equitable and essential care, especially for individuals that experience discrimination based on gender, age, and racial and ethnic disparities or other factors, was responsive to need and aligned with human rights. It promoted a definition of wellbeing that went beyond simply treating illnesses, which was based in evidence. The Vision cited the successes of programming related to the management of diseases such as TB and HIV and AIDS as a basis to translate technical guidance to address other burdens on health systems, which was based in evidence and responsive to need. The Vision documented progress made by different countries towards epidemic control of HIV and AIDS, as well as affirmed the need to invest in efforts to manage HIV as a chronic disease and provide client-centered care through a country's health system, which was responsive to need, based in evidence, and aligned with human rights. The Vision was somewhat gender transformative as it mentioned creating equitable gender norms as a facet of HSS, but used language that reinforced a sex and gender binary. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_USAID’s COVID-19 Response Ending The Global Pandemic and Building Back Better

This Report highlighted USAID's response to COVID-19 and included details about the five objectives that guided the Agency’s pandemic response, including investments. The Report explored the Agency’s experience providing access to vaccines, reducing morbidity and mortality from COVID-19, strengthening health systems, and addressing the increased needs of communities across sectors driven by the pandemic. The Report cited the Agency's efforts to support humanitarian responses by addressing GBV and providing primary and reproductive health services, which was responsive to need. The Report did not provide specific interventions or actions related to the implementation of activities that promote SRHR during the pandemic, so this action was not fully responsive to need, based in evidence, or consistent with human rights. The Report was gender aware as it recognized the impact of COVID-19 on women and girls but used gendered language and did not specifically address relevant gender norms. Throughout the Report, it was unclear how USAID’s global health programs were incorporated into the Agency’s COVID-19 response, which negatively affected transparency . If it was clear that the Report included objectives and results for USAID’s global health efforts, the Report would have promoted SRHR. However, given the lack of transparency, this Report neither promoted nor hindered SRHR in the HIV and AIDS domain.

2020_Acting Administrator John Barsa Letter to UN Secretary General Guterres_18 May 2020

John Barsa, Acting Administrator of USAID, sent this letter to António Guterres, the UN Secretary-General, in May 2020 to oppose the inclusion of SRH services with other essential services in the UN’s Global Humanitarian Response Plan (Global HRP) for the COVID-19 pandemic. The letter criticized the Global HRP because it recommended the distribution of “abortion-inducing drugs and abortion supplies” in local country settings. The letter called for the removal of all references to “‘sexual and reproductive health’ and its derivatives” from the Global HRP. This demand demonstrated USAID’s lack of commitment to providing comprehensive health services during a global pandemic. This action was not based in evidence or human rights as people still needed to access SRH services—including prevention, care, and treatment services for HIV and AIDS—during the COVID-19 pandemic. Furthermore, this letter was gender-blind because it did not acknowledge that women, girls, and gender-diverse people are disproportionately impacted by COVID-19 and could experience poor health outcomes such as HIV acquisition if they could not access adequate HIV and AIDS services. This action was rooted in anti-abortion rhetoric rather than evidence, need, or human rights norms, and siloed SRH services from other essential services in response to the pandemic. It significantly hindered SRHR in the HIV and AIDS domain.

2020_Acting on the Call

2020_ADS Chapter 303 Materials_2020.05.18

Chapter 303 of USAID’s Automated Directive System (ADS) governs the grants and cooperative agreements between USAID and non-governmental organizations (NGOs), which includes all of U.S. global health assistance. Two mandatory references for ADS Chapter 303 were updated on May 18, 2020: the Standard Provisions for U.S. NGOs (303maa) and the Standard Provisions for Non-U.S. NGOs (303mab). These updated mandatory references included a new section entitled: M12. Preventing Transactions with, or the Provision of Resources or Support to, Sanctioned Groups and Individuals. The updates to this section maintained that NGOs that received funding through USAID could not “engage in transactions with, or provide resources or support to, any individual or entity that is subject to sanctions” by the U.S. Department of the Treasury Office of Foreign Assets Control or the UN Security Council. Since the UN Security Council list was included as a third-party entity outside of the U.S. Department of the Treasury, this update was aligned with human rights statutes and was based in evidence. The use of the term “sanctioned groups and individuals” in lieu of the pejorative use of “terrorist” in prior versions of this reference may also have been based in evidence, but it was unclear what prompted this change to the ADS. It was also unclear if these sanctions would impact U.S. global health programming, so this update neither hindered nor promoted SRHR in the HIV and AIDS domain.

2020_ADS Chapter 303 Materials_2020.06.19

The updates to ADS Chapter 303: Grants and Cooperative Agreements to Non-Governmental Organizations that were released on June 19, 2020 were not related to SRHR. However, this version of ADS Chapter 303 included a new section entitled: 303.3.34 Abortion Restrictions (Effective Date: 05/29/2020), which had been added since the 2019 version that was graded by the SRHR Index. This section provided guidance for implementing the statutory and policy abortion restrictions that apply to all U.S. foreign assistance awards (e.g., Voluntary Population Planning Activities – Mandatory Requirements) and those that apply to only U.S. global health assistance (i.e., Protecting Life in Global Health Assistance [PLGHA]). This section included links to USAID resources that define and explain legislative and policy requirements related to global health, which could have supported the correct implementation of the PLGHA policy and other restrictions. However, this edit was not responsive to need, as it was unclear why the ADS was only updated to include this guidance in May 2020 when the PLGHA policy had been in effect since 2017 and other abortion restrictions have been in place since 1973. The May 29, 2020 version of ADS Chapter 303 had been replaced on USAID’s website by the June 19, 2020 version and was no longer available at the time of grading, which contributed to low transparency for this action as prior versions of ADS documents are not publicly available once a newer version is released. The updates made to these materials on June 19, 2020 neither promoted nor hindered SRHR in the HIV and AIDS domain.

2020_ADS Chapter 303 Materials_2020.08.18

Two ADS Chapter 303 materials were updated on August 18, 2020: the main ADS chapter itself and the Standard Provisions for Non-U.S. NGOs (303mab). Details regarding allowable cost share, information technology, and telecommunication services were added to the updated version of the main ADS chapter. While these updates may impact program management and some operations for global health programs, the updates neither promoted nor hindered SRHR in the HIV and AIDS domain. The 303mab was also updated to provide more information as well as specific guidance on implementing the prohibition of certain telecommunication and video surveillance services or equipment as was updated in the main ADS chapter. This new section included definitions and references for “covered telecommunication equipment or services,” “covered foreign country,” and “telecommunication costs,” as defined in the Code of Federal Regulations (CFR). This telecommunications prohibition was also included in the Department of Health and Human Services’ (HHS) General Terms and Conditions for Research and Non-Research Grants and Cooperative Agreements, though the HHS guidance included an exemption for PEPFAR funding until 2022 that was not mentioned in these ADS materials. It was unclear how this guidance would affect global health programs, so this action neither promoted nor hindered SRHR in the HIV and AIDS domain.

2020_ADS Chapter 303 Materials_2020.11.19

Two mandatory references for ADS Chapter 303 were updated on November 19, 2020: the Standard Provisions for Non-U.S. NGOs (303mab) and the Standard Provisions for Fixed Amount Awards to NGOs (303mat). Both mandatory reference documents contained one update that was relevant to SRHR: Section RAA6. Universal Identifier and System for Award Management. This section was rewritten to provide notice that the prior Data Universal Numbering System (DUNS) had been replaced by the new Unique Entity Identifier process, which allowed organizations to maintain a current registration in the System for Award Management (SAM) and receive federal funding. This section also included definitions, requirements, and exemptions for the application of this provision, which would enable the effective implementation of this provision. This updated provision was responsive to need because the DUNS process had been identified as burdensome for local organizations with limited administrative capacity as compared to large international NGOs. The streamlining of the SAM process could enable local and smaller organizations to participate in USAID’s global health programs. As such, this update moderately promoted SRHR in the HIV and AIDS domain.

2020_ADS Chapter 303 Materials_2020.12.17

Two ADS Chapter 303 materials were updated on December 17, 2020: the main ADS chapter itself and the Process for Transition Awards Mandatory Reference (303mbb). ADS Chapter 303 was updated to add the brand-new Mandatory Reference 303mbb, which provided guidance on how to make transition awards to local partners. The purpose of transition awards is to develop the capacity for local organizations to receive direct awards from USAID. The Definitions section of the main chapter was updated and defined “transition award” as an assistance award to a “local entity or locally established partner...that is or has been a subrecipient under a USAID assistance award.” The 303mbb Mandatory Reference provided guidance on how to make transition awards to promote self-reliance and strengthen the Agency's engagement with local partners. This process includes making an initial award followed by the transition award with clear roles for USAID staff, prime partners, and the local partner. The creation of the transition award process as explained in these ADS materials was responsive to need because local organizations have asked for support to receive U.S. funding directly as opposed to receiving funds through traditional agreements with prime partners who are often large international NGOs. The development of the transition award process was based in evidence and best practice and aligned with human rights. It supported the ability of USAID to substantially promote SRHR in the HIV and AIDS domain.

2020_ADS Chapter 308_2020.12.04

Updates to ADS Chapter 308, entitled: Agreements with Public International Organizations (PIOs), were released on December 4, 2020. Specifically, Section 308.3.2.1 Organizational Capacity Reviews (OCRs) provided an updated definition of an OCR: “a high-level assessment of whether or not a PIO is organizationally capable of adequately safeguarding USAID resources” and has the means to “highlight any significant concerns, considerations, or risks that should be taken into account in working with the PIO.” This section was also updated to add a requirement that OCRs should be updated at least every five years, but more frequently if specific circumstances warrant earlier reviews. The OCR process was also updated to include PIO policies related to sexual exploitation and abuse (SEA), internationally accepted accounting standards, and environmental and social safeguard policies and procedures. The inclusion of frequent monitoring and reporting of environmental safeguards was responsive to need and based in evidence, though external environmental standards were not explicitly defined. Climate change and other environmental factors can affect a person’s SRHR, so external references supporting this guidance should be included for transparency. This updated guidance was intended to ensure PIOs are maintaining a certain level of ethics and responsibility to reduce the risk or liability for USAID, however the evidence base and human rights framework was lacking throughout this section. It was unclear to which international standards, policies, and procedures PIOs would be held accountable when conducting an OCR. External references are necessary to ensure that PIO OCRs are objective and not subject to administration-level politics or influence. Without additional detail, this action neither hindered nor promoted SRHR in the HIV and AIDS domain.

2020_Agency Priority Goal Action Plan_Maternal and Child Health

The purpose of the Agency Priority Goal (APG) Action Plan on MCH is to report on USAID’s contributions to global efforts to prevent child and maternal deaths in fiscal year (FY) 2020. This action listed the technical teams at USAID that contributed to this reporting, which included representatives that work in population and reproductive health, malaria, nutrition, and health systems strengthening. However, the role of USAID’s HIV and AIDS technical staff and programs was not mentioned in the Plan, even though USAID is an implementing agency of the President’s Emergency Plan for AIDS Relief (PEPFAR) and provides services related to MCH. It should have incorporated PEPFAR programmatic data into existing USAID MCH data to reflect all of USAID’s MCH efforts. The Plan mentioned that HIV and AIDS is a contributor to under-five mortality and reported that improvements in ending preventable child and maternal deaths are the result of “increasingly effective efforts to link diverse health programs,” including HIV and AIDS. It did not report on any indicators related to HIV that might impact MCH outcomes, such as PMTCT or HIV prevention services for pregnant people, so the Plan did not reflect the full evidence base and was not responsive to need in the HIV and AIDS domain. The lack of reporting on HIV and AIDS throughout this Plan further siloed HIV from MCH programs, which moderately hindered SRHR in the HIV and AIDS domain.

2020_Considerations for USAID Mission Staff for Programmatic COVID-19 Preparedness and Response_Digital Technologies and Data Systems

USAID released this guidance on April 6, 2020 to help USAID Missions best respond to the COVID-19 pandemic through the use of digital interventions and data systems. Given the rapid development and publication of these guidelines and the fact that most of the recommendations in this action did not require modifications to current agreements, this action was responsive to need because Missions could implement the guidance as appropriate for the local context. Additionally, the role of USAID health programs was clearly defined: “support host country information systems, health worker education, identify health data needs, identify interoperability needs, and provide TA [technical assistance].” The Guidelines called for collaboration with host country governments to ensure that health workers continued to be paid and that data collection continued through health programs, which was responsive to need and would facilitate data-driven decision making. The Guidance described how gender dynamics interact with one’s access and use of digital technology, which was gender aware. However, there was no guidance for how digital interventions should be adapted to address the impacts of COVID-19 related to SRHR, including gender-based violence (GBV) and reduced access to HIV and AIDS services. As a result, this action neither promoted nor hindered USAID’s ability to support SRHR in the HIV and AIDS 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, including USAID’s global HIV and AIDS programs funded through PEPFAR. 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, this action was not released by PEPFAR (of which USAID is an implementing agency) 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. The Technical Update mentioned “male and female condoms” as the only contraceptive methods that can reduce the risk of sexually transmitted infection (STI) and HIV transmission, which was based in evidence but it was not gender transformative because it used the outdated “male and female” terminology instead of the gender inclusive “internal and external” terminology. This Technical Update substantially promoted SRHR in the HIV and AIDS domain.

2020_Department of State and USAID Agency Priority Goal Action Plan_HIV/AIDS

To report on their joint progress toward PEPFAR program goals, strategies, milestones, and indicators in fiscal year (FY) 2020, the APGs for HIV and AIDS were released quarterly by both the Department of State and USAID. APGs included providing client-centered treatment services; scaling up index testing and targeted HIV testing approaches; increasing access to voluntary medical male circumcision (VMMC) services; and providing comprehensive packages of health and social services for priority and key populations (KPs), including oral pre-exposure prophylaxis (PrEP) and education on risk reduction. These programmatic efforts and the indicators presented in the APGs were based in evidence and responsive to need. The APGs reflected commitment from PEPFAR to ensuring that data were collected thoroughly and accurately, while also maintaining accountability to targets which was responsive to need. The APGs were not gender transformative as they did not explicitly mention ongoing activities to address inequitable gender norms, such as the DREAMS program. It also did not reference any human rights principles or frameworks that guided them, which was lacking. The APGs moderately promoted SRHR in the HIV and AIDS 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 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 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. The Report mentioned specific activities, including: community-based mobilization, norms-change efforts, and safe spaces interventions, which were based in evidence, consistent with human rights norms, responsive to need, and gender transformative. The role of USAID in DREAMS implementation was not included in this action, which negatively affected transparency and was not responsive to need. 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 implemented with U.S. global health assistance, which contributed to low transparency. Additionally, 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 the HIV and AIDS 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, 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 discussed the joint efforts by the Department of State and USAID to achieve HIV and AIDS epidemic control within Performance Goal 3. It provided updates on PEPFAR’s progress towards the same indicators that were included in the APGs, including increasing ART enrollment and coverage, scaling up VMMC, and other targets in FY 2020. This Report did not explicitly state USAID’s specific contributions or progress toward each indicator, but rather presented these data at the PEPFAR level, including needing to pause, scale down, or refocus global HIV and AIDS programs due to COVID-19 restrictions. This element of the Report was highly responsive to need based on the presentation of programmatic data and the impact of COVID-19 on global HIV and AIDS programs, though the role of USAID in these achievements was unclear. However, the Report lacked a description of the evidence and human rights frameworks that guided PEPFAR programming. The Report included data on a few indicators that measured gender norm change, which were gender accommodating but not gender transformative because they focused on “males and females,” which reinforced a gender binary. This report moderately promoted SRHR in the HIV and AIDS domain.

2020_Expedited Procedures Package for Responding to Outbreaks of Contagious Infectious Disease

An Expedited Procedures Package (EPP) provides a blanket restriction on eligibility for both acquisition (e.g., contracts) and assistance (e.g., grants and cooperative agreements) mechanisms and allows for modifications to be made to existing USAID contracts and agreements without triggering competition requirements. This permitted USAID to maintain flexibility to respond rapidly and effectively to an outbreak of an infectious disease. Released on March 27, 2020, this EPP allowed USAID programs to apply for new funding as well as shift existing funds and programmatic priorities to quickly meet the changing needs created by the pandemic, Thus, the EPP was highly responsive to need. The EPP also made it easier to award emergency assistance to USAID programs and enabled USAID to engage with new as well as underused partners, private-sector partners, and community- and faith-based partners to effectively respond to the pandemic. This effort was aligned with evidence, best practice, and human rights. This action enabled USAID to rapidly provide financial and technical support to programs so they could address issues related to COVID-19. Since this EPP could be used by any implementing partner, programs could have adapted to provide SRHR services through the pandemic. This action moderately promoted SRHR in the HIV and AIDS domain.

2020_Global Health eLearning Course_Bureau for Global Health Environmental Management Process Training

The 2020 Global Health eLearning Course on USAID’s environmental management process equipped USAID technical staff (e.g., Program Managers, Agreement Officer’s Representatives/Contracting Officer’s Representatives, Activity Managers) and other stakeholders with an introduction to the Global Health Initial Environmental Examination process and a roadmap for planning and implementing health programs consistent with the Agency’s legal requirements. The Course outlined the processes for conducting environmental assessments, plans, and reports to monitor and mitigate the intended or unintended impact of global health programs on the environment. Agreements that included certain activities were instructed to consult with relevant host country agencies as well as follow necessary permit requirements and instructions, which was aligned with evidence and best practice. The Course used a case study to guide readers through the environmental examination process, which was responsive to need. While the Course mentioned that most health activities generally did not require a complete environmental examination in accordance with the Code of Federal Regulations (CFR), it stated that projects with a categorical exclusion still require annual screenings to identify changes to the program that could require additional environmental review. This annual review process for health programs promoted accurate reporting and mitigated any impact on the environment, which is responsive to need. Climate change and environmental issues have a significant impact on SRHR, so this Course moderately promoted SRHR in the HIV and AIDS domain.

2020_Global Health eLearning Course_HIV/AIDS Legal and Policy Requirements

The 2020 HIV/AIDS Legal and Policy Requirements Global Health eLearning Course provided an overview of the HIV and AIDS legislative and policy requirements that govern USAID-supported HIV and AIDS activities. The course was designed to help USAID staff, implementing partners, and host country government representatives understand the requirements related to medically accurate information about condoms, VMMC, FP and HIV integrated activities, abortion and involuntary sterilization restrictions, and other topics relevant to HIV and AIDS programs. The Course defined the tenets of voluntarism and informed choice, which are consistent with human rights, and included an informative table explaining the policies, requirements, and amendments that applied to specific types of funds and programs in 2020, which was responsive to need and based in evidence. The Course also explained the Protecting Life in Global Health Assistance (PLGHA) policy, though it did not include guidance on the March 2019 expansion, which was not responsive to need. Though complete detail about the PLGHA policy was lacking, the Course was informative and based in evidence as it provided references to external sources and other trainings to provide additional information. The Course did not provide an explanation of the impact of these policies on KPs but did clearly state that HIV and AIDS services should not be denied to sex workers, which was aligned with human rights norms and based in evidence. The Course was gender accommodating as there were few sections specifically related to gender outside of PMTCT though the Course used outdated gendered terms like “female condom,” which was not aligned with evidence nor was it gender transformative. This Course moderately promoted SRHR in the HIV and AIDS domain.

2020_Global Health eLearning Course_Protecting Life in Global Health Assistance and Statutory Abortion Restrictions-2020

The 2020 Global Health eLearning Center Course on the Protecting Life in Global Health Assistance (PLGHA) policy and other statutory abortion restrictions provided USAID staff and implementing partners with technical knowledge about the legal and policy restrictions on abortion-related activities and how to properly implement them through global health programs. The Course described the programs and activities to which the PLGHA policy and other statutory abortion restrictions apply. It also provided recommendations for how to ensure that programs are compliant with these restrictions and included guidance on how to investigate a violation. The Course included the specific exceptions in which health care providers can provide information on abortion and defined the affirmative duty of providers, which was responsive to need. The Course also clarified that the PLGHA policy did not apply to post-abortion care (PAC), which was responsive to need and consistent with human rights norms. The training included some compliance guidelines and was consistent with the May 2019 Standard Provision and data from the 2018 six-month review of the implementation of the PLGHA policy. However, it primarily provided guidance on what activities are not permitted under the policy and could have more clearly supported PAC, comprehensive FP, and other efforts that are not prohibited under the policy. The Course encouraged staff to "be aware of perceptions among program managers, clients, and providers that may suggest potential vulnerabilities," which was not responsive to need as it could lead to unnecessary oversight of people's personal or professional beliefs that are not relevant to their implementation of the PLGHA policy and other abortion restrictions. The Course was not fully responsive to need as it did not include implementation information specific to USAID’s global HIV and AIDS programs, including post-violence care during which programs may encounter people who became pregnant as a result of rape. Additionally, the Course was not gender transformative as it did not use gender inclusive language (e.g., “pregnant persons”). This Course moderately hindered SRHR in the HIV and AIDS domain.

2020_Global Health eLearning Course_U.S. Family Planning and Abortion Requirements

The 2020 Global Health eLearning Course on U.S. FP and abortion requirements provided technical guidance on abortion-related statutes that apply to all U.S. foreign assistance funds. The Course discussed the Helms Amendment but predominantly focused on requirements that apply specifically to FP assistance funds, particularly the Tiahrt Amendment. The Tiahrt Amendment dictates how USAID-supported FP programs deliver services. This component of the Course was based in evidence and human rights norms because the restrictions outlined in the Tiahrt Amendment have been endorsed by USAID and the WHO as a standard for protecting the human rights of people that access FP programs and services. The Course was responsive to need as it provided vital information on voluntarism and informed choice as the cornerstone of all FP programs implemented by USAID. It included guidance for providing proper counseling on FP, including offering contraceptives with method mix at each service delivery point. However, as the Tiahrt Amendment only applies to FP service delivery projects, the Course did not provide specific guidance for how to ensure clients have informed choice in other areas of global health programs that also offer FP services. In particular, the Tiahrt Amendment applies to FP/HIV integrated PEPFAR activities because they receive contraceptives procured by USAID. However, the Course did not explicitly acknowledge that the Tiahrt Amendment applies to these activities or provide guidance for how program staff should incorporate this Course into these activities. The Course was gender blind, as there were no mentions of gender or of how to implement these policies in a way that addressed unequal gender norms. While the Course was useful to guide FP activities, it was not informative on how this guidance should be adapted for HIV and AIDS programs. This Course moderately hindered SRHR in the HIV and AIDS domain.

2020_Guide for Adopting Remote Monitoring Approaches during COVID-19

USAID released the Guide for Adopting Remote Monitoring Approaches during COVID-19 in May 2020 and it provided information to USAID staff and implementing partners about when and how to employ remote monitoring techniques as programs continue to be implemented amidst COVID-19 restrictions. This Guide was responsive to need as it stated that awards should not be amended more than is necessary and that awards should remain in compliance with the initial award conditions. It also indicated that missions and partners should gather feedback from beneficiaries of activities that have been altered due to COVID-19 to remain informed of their current needs and make decisions regarding program adaptation. Regarding USAID’s HIV and AIDS programs, the Guide included changes to the Site Improvement through Monitoring System (SIMS) deadlines for monitoring and reporting on PEPFAR targets during COVID-19, which was responsive to need and based in evidence and human rights as the SIMS process is aligned with WHO guidelines and evidence. The Guide was gender accommodating as it called for implementing partners to monitor how the demographics of a target population may impact their access to and use of digital technology for remote monitoring based on gender, age, and disability and it directed implementers to “account for any biases” that may impact people’s access to digital technology. While this element of the Guide supported SRHR, it did not provide explicit guidance for implementing partners to overcome the barriers that people may experience due to their gender, age, or disability. This Guide supported the ability of USAID’s HIV and AIDS programs to make data-driven decisions through the use of remote monitoring approaches during the COVID-19 pandemic, which moderately promoted SRHR in the HIV and AIDS domain.

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 accessing 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. Several of USAID's approaches and projects contributed to this whole-of-government strategy, including USAID’s flexible approach to programmatic decisions to account for COVID-19, launching the Safe Migration in Central Asia project, and facilitating interagency coordination to streamline international and domestic grants. However, it was unclear whether these programs were funded through global health assistance, and therefore contributed to low transparency. Relevant global health programs within USAID were not included in this report, which ultimately ignored the HIV and AIDS service needs of those who are trafficked globally. The Report moderately hindered SRHR in the HIV and AIDS domain.

2020_Review of the Implementation of the Protecting Life in Global Health Assistance Policy (August 2020)

The second review of PLGHA summarized the history of the policy and presented findings from a review of the policy’s implementation throughout U.S. global health assistance programs since 2017. The Review found that in certain cases where USAID partners declined awards due to the PLGHA policy, the loss of trusted partners in-country resulted in difficulties replacing these partners and caused subsequent disruptions in healthcare services across technical areas. Specifically, the Review found that the loss of partners resulted in delays in the implementation and distribution of USAID’s services related to HIV and AIDS, MCH, voluntary FP, tuberculosis, and nutrition. Regarding HIV and AIDS, disruptions in healthcare services impacted the provision of HIV prevention, care, and treatment services for KPs in welcoming settings. The declinations of global health assistance due to the policy also had significant impacts on cross-cutting activities, such as cervical pre-cancer screening, mobile outreach for HIV testing, care, and treatment, and HIV and AIDS programs related to orphans and vulnerable children (OVCs) and voluntary male medical circumcision (VMMC). These findings confirmed that the implementation of the policy led to some disruption in service delivery, which USAID was required to navigate. While PLGHA itself did not promote SRHR, USAID’s role in providing mechanism-level data for this report was responsive to need and based in programmatic data and evidence, which provided a clear overview of USAID’s implementation of the policy. The Review moderately promoted SRHR in the HIV and AIDS 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, in collaboration with other U.S. implementing agencies including USAID, released the Strengthening Health Security Across the Globe annual report that identified the U.S. government’s contributions to global health security by country and U.S. government agency. Though several areas of global health were mentioned throughout the report, data related to HIV and AIDS were noticeably absent. PEPFAR was only mentioned in relation to infection prevention and control (IPC) programs to aid in the global response to COVID-19. USAID’s role in implementing global HIV and AIDS programs was not included in the Annual Report at all, which minimized the value of HIV prevention and treatment efforts in promoting global health security. Further, there was no mention of other areas of SRHR that impact health security such as FP, MCH, and GBV. SRHR is a critical aspect of health security. Neglecting to mention SRH issues in global health 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 advancing gender equity and countering harmful norms that affect women and girls. 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. This Report moderately hindered SRHR in the HIV and AIDS 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 (like USAID) 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 or integration with specific global health program areas, even though addressing HIV and AIDS, MCH, FP, and other cross-cutting SRHR issues is vital to promoting stability and security. Notably, it did not include guidelines for responding to GBV even though the risk of violence is often greater to women, girls, and gender-diverse people in fragile settings and conflict areas compared to peaceful settings. 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 Women, Peace, and Security (WPS) Strategy. This action moderately hindered SRHR in the HIV and AIDS domain.

2020_USAID Digital Strategy 2020-2024

The Digital Strategy described the Agency's vision for the responsible use of digital technology in international development and humanitarian work. The goal of this strategy was to sustain digital ecosystems that increase self-reliance as well as promote positive development and humanitarian assistance outcomes. The Strategy described the mechanisms through which USAID staff will achieve these goals and highlighted previous successes with incorporating digital technologies into the Agency's activities. The Strategy noted the importance of digital infrastructure amid COVID-19, which was responsive to need and based in evidence as it promoted the use of telemedicine to protect health care workers and patients while also providing vital health services. However, the Strategy did not describe the specific use of digital interventions to provide HIV and AIDS services. It would have been helpful to include examples of digital technologies used successfully by USAID’s HIV and AIDS programs funded through PEPFAR, making the absence of these examples a gap in this Strategy. The human rights basis was explicitly stated in the Strategy, as it detailed the potential for “digital authoritarianism” to infringe on human rights. The Strategy was gender aware because it acknowledged gender disparities and the “gender digital divide” which contributes to inequitable use of technology across genders. However, it used a gender binary to describe these impacts and did not use inclusive language. While the Digital Strategy set a positive tone for the use of emerging technologies and digital infrastructure in USAID's activities, it did not meaningfully include strategic thinking related to HIV and AIDS, and thus neither hindered nor promoted SRHR in the HIV and AIDS domain.

2020_USAID Gender Equality and Women’s Empowerment 2020 Policy

This Policy detailed USAID's investment in and commitment to supporting gender equality and women’s empowerment efforts to date. It outlined the strategic objectives and principles necessary for the Agency to achieve this vision and increase self-reliance in partner countries. The Policy referenced global health programs and cross-cutting issues related to SRHR, including activities to eliminate GBV, increase the capability of women and girls to exercise their “basic and legal rights fully,” and improve women and girls’ access to education and employment. While the section on HIV and AIDS identified the impacts of gender norms on women and girls’ rights, the section did not provide guidance for changing these gender norms and did not include specific guidance for engaging with gender diverse people, KPs, underserved communities, or others who might experience higher risk of HIV. This policy stated that harmful gender norms, inequalities, and GBV are drivers of HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa, which was consistent with evidence. However, this policy did not acknowledge the role of USAID in implementing programs that promote AGYW’s agency or support their ability to make autonomous decisions about engaging in consensual pleasurable sexual activity. The Policy was not grounded in human rights norms or responsive to need because of its exclusion of LGBTQI+ people and its basis in “unalienable rights,” which do not include all international human rights. Exclusion of LGBTQI+ people was not based in evidence as research shows that members of the LGBTQI+ community are at an increased risk of experiencing GBV and other inequitable gender norms that limit their access to health services, education, employment, and other measures of empowerment. The 2020 version of this policy was not responsive to need because it was less inclusive than the previous version from 2012, which explicitly included all people regardless of gender identity, disability status, HIV and AIDS status, geographic area, and migratory status. It also did not acknowledge the contributions of SRHR programs to gender equality efforts. Additionally, the Policy was not gender transformative due to its use of a gender binary and exclusion of LGBTQI+ people, but was gender accommodating because it acknowledged the impact of existing gender inequities in global health and development areas. This policy moderately hindered SRHR in the HIV and AIDS domain.

2020_USAID MOAA COVID-19 Implementing Partner Guidance_Frequently Asked Questions Published on 11.03.2020

This Guidance from the Bureau for Management Office of Acquisition and Assistance (MOAA) within USAID compiled all questions related to COVID-19 from implementing partners in one place. The Guidance was regularly updated throughout 2020, which was responsive to need. The primary section related to HIV and AIDS was the section about PEPFAR and USAID, which answered questions related to the roles of PEPFAR and USAID staff, outlined how PEPFAR programs could be used to respond to COVID-19, and provided external references for additional technical guidance for PEPFAR programs. The Guidance clarified differences between information from the Department of State's Global AIDS Coordinator (S/GAC) and USAID for program implementation, which was responsive to need. The Guidance was based in evidence and human rights norms as it referred to PEPFAR and USAID's standards for HIV and AIDS programming and USAID agreement processes to ensure that people living with HIV (PLHIV) continued to receive the care they needed during the COVID-19 pandemic. The Guidance was not gender transformative as it did not include guidance for adapting programs in response to the disproportionate impact of COVID-19 on women and girls as well as the rise in GBV, which was lacking. This Guidance moderately promoted SRHR in the HIV and AIDS domain.

2020_USAID Over the Horizon Landscape Analysis and Snapshot

The Snapshot described how USAID aimed to shift its programming to accommodate a world altered by the COVID-19 pandemic. It highlighted the persistence of inequities in access to essential services as well as the adverse impact of the pandemic among “vulnerable and marginalized groups,” but did not define these groups, establish the evidence base, or define the human rights framework as the foundation for this action. The Snapshot mentioned the increased risk of GBV due to COVID-19, which was based in evidence and responsive to need. The Snapshot listed USAID's responses to the pandemic and described the active USAID development policies, field consultations, partner roundtables, and collaborative research that was used to adapt operations to respond to COVID-19. However, USAID’s HIV and AIDS programming was not mentioned throughout this action, even though COVID-19 impacted the performance and achievement of its HIV and AIDS activities funded through PEPFAR. This action was gender accommodating because it aimed to increase women's participation in pandemic relief efforts but did not document the disproportionate impact of COVID-19 on women and girls beyond GBV. The Snapshot moderately hindered SRHR in the HIV and AIDS domain.

2020_USAID Policy on Promoting the Rights of Indigenous Peoples

This policy provided guidance for engagement and partnerships on projects that impact Indigenous Peoples and detailed USAID's efforts to engage them as “meaningful partners” in Agency program development processes. The Policy stated the importance of ensuring that activities like data collection are conducted in a way that is responsive to Indigenous Peoples' input and needs through the free, prior, and informed consent (FPIC) process, which is a vital component of Indigenous organizing that respects their rights and autonomy. The Policy was grounded in human rights as it included adherence to international standards of human rights as a central pillar but did not acknowledge the impact of colonization and occupation on the health and wellbeing of Indigenous communities. With respect to health outcomes, the Policy acknowledged that many Indigenous groups experience worse health outcomes compared to national or regional averages, which was based in evidence. The Policy posed potential solutions such as integrating programs and promoting cross-sectoral development approaches to expand the availability of assistance that Indigenous peoples could access, which was evidence-based and responsive to need. However, the Policy did not elaborate on these approaches or explain how USAID and implementing partners should implement these programs. The Policy did not discuss SRHR issues, including HIV and AIDS programs or GBV prevention and treatment, which was lacking. This Policy applied to all USAID activities, including global HIV and AIDS programs, so the lack of discussion on how these programs and activities should be adapted to better serve Indigenous peoples was a gap in USAID's approach. The Policy was not responsive to need or based in evidence in the HIV and AIDS domain. Additionally, the Policy was gender accommodating as it acknowledged cultural norms and other factors that could impact the decision-making rights of Indigenous women but did not provide adequate guidance for overcoming or changing those norms. This Policy neither promoted nor hindered SRHR through this domain.

2020_USAID Policy on Protection from Sexual Exploitation and Abuse (PSEA)

This policy detailed USAID's operating procedures to protect individuals from sexual exploitation and abuse (SEA). This policy applied to all USAID-funded services and activities, intended to center the needs and perspectives of survivors, and employed USAID's zero-tolerance policy for inaction on allegations of SEA. The Policy acknowledged the power dynamic that drives many instances of SEA and identified the need for increased attention for vulnerable groups including “women and children, and those most at risk of discrimination on the basis of disability, gender identity and sexual orientation, race, ethnicity, age, or religion.” This level of specificity indicated an inclusive understanding of how people's identities shape their experiences of SEA. The Policy was responsive to need and grounded in human rights norms as it prioritized the safety of people that participate in USAID programs. However, it was not evidence-based because evidence indicates that there are numerous health and SRHR needs that arise as a result of SEA that were not mentioned in this policy, such as HIV acquisition. Like GBV, SEA is a cross-cutting SRHR issue and warrants an integrated response for both prevention and treatment, which was lacking in this policy. The Policy was gender accommodating as it was inclusive of all peoples' experiences though did not adequately describe how the Policy would overcome gender norms that both contribute to SEA and prevent people from receiving care for SEA. This Policy moderately hindered SRHR in the HIV and AIDS domain.

2020_USAID Protecting Life in Global Health Assistance Letter to Implementing Partners_30 October 2020

Alma Golden, Assistant Administrator of the Bureau for Global Health within USAID, sent this letter to USAID implementing partners on October 30, 2020 to reiterate the importance of complying with abortion-related statutory and policy restrictions that apply to global health awards. The letter was somewhat responsive to need as it explained the difference between statutory restrictions related to abortion and the PLGHA policy, which are often confused. The letter detailed best practices to ensure compliance with these restrictions and directed recipients to access publicly available trainings and resources to understand the applicable restrictions. The letter also mandated that all implementing partners across domains submit documented evidence of their efforts to assure the compliance of foreign NGO sub-partners with the PLGHA policy within one month of the issuance of the letter, which was an extreme burden for implementing partners. The compliance reporting requirement outlined in the letter was not necessarily responsive to need as it was unclear what prompted this action or how this information would be used to influence the future implementation of the policy. This letter moderately hindered SRHR in the HIV and AIDS domain.

2020_USAID’s Women, Peace, and Security Implementation Plan

The Women, Peace, and Security (WPS) Implementation Plan outlined USAID's efforts to support the U.S. government’s WPS Strategy through development and humanitarian assistance. The Implementation Plan expanded on the role of USAID in fulfilling the WPS Strategy's focus on women and girls' empowerment to overcome crisis, conflict, and fragility. This Plan was somewhat based in evidence and responsive to need as it identified several factors that can promote women's empowerment but did not recognize the importance of addressing individual SRHR needs as part of this Plan. The main mentions of health outcomes related to SRHR throughout this Plan were in the context of GBV, as well as “teenage pregnancies” that result from violence. However, the exclusion of other areas of SRHR, such as HIV and AIDS, disregarded the importance of these health outcomes in empowering women and accomplishing the goals of the WPS Strategy. The Plan was not fully consistent with human rights norms as it excluded LGBTQI+ people in its efforts to achieve gender equality. Additionally, the Plan was gender accommodating as it worked to empower women within existing gender norms but did not use gender inclusive language throughout the Plan, nor did it outline a strategy for changing inequitable gender norms through USAID’s programs. This Plan moderately hindered SRHR in this domain.

2019_Acting on the Call

Acting on the Call is USAID's annual flagship report for reproductive, maternal, newborn, and child health services. As in the 2018 report, the 2019 report mentioned child mortality caused by HIV and AIDS in the country-level analyses, but the inclusion of HIV and AIDS programming was not included in a standardized way across all countries. For example, the country-specific section for Tanzania mentioned the following: “Integrated voluntary family planning within existing HIV care in 5,600 facilities and care delivery points, which increased the availability of voluntary family planning by 300 percent.” This was a unique case where HIV and AIDS programming was mentioned at the country level, so more country-level data is needed to document the intersections between maternal and child health and HIV and AIDS programs across the board. There was no mention of HIV as a leading cause of maternal death, nor any emphasis on the integration of HIV testing and treatment into antenatal care (ANC) services. Prevention of mother-to-child transmission (PMTCT) services and programs for orphans and vulnerable children (OVC) were not discussed, both of which directly contribute to maternal and child health outcomes. Overall, this report was responsive to need, but was not based in evidence or human rights principles, nor was not gender transformative. It substantially hindered SRHR because it did not address HIV and AIDS as a primary cause of maternal mortality globally. The exclusion of HIV and AIDS within this report reinforced the fragmented and siloed nature of U.S. global health programs across program and budget areas.

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 the Protecting Life in Global Health (PLGHA) would not change. This additional document asserted that the definition of financial assistance will remain unchanged and that organizations who sub-grant will 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 HIV and AIDS. 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. 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 also been shown to decrease access to HIV and AIDS services. 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 as well as incorporated new language on the donation of breastmilk in humanitarian crises. The chapter also included language regarding breastfeeding and HIV, and referenced the WHO guidance on this subject that was released in 2016. The update also included a shift away from the stigmatizing “HIV-infected” language and instead used the accepted language of “people living with HIV” (PLHIV). 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 take steps to ensure these policies were put in place (which could be achieved through the requirement for partners to report on the implementation of this guidance in their programs through mandatory performance reports). The guidance was gender blind because it ignored gender inequalities and stereotypes that could have influenced 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 pregnant and breastfeeding women (PBFW) who are living with HIV.

2019_ADS Chapter 303_Grants and Cooperative Agreements to Non-Governmental Organizations and Standard Provisions

This chapter of the Automated Directive System (ADS) governs 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 was 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 was the Standard Provisions for foreign NGOs, and the ADS 303mat was 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 (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 only 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 grantees and sub-grantees. However, this chapter of the ADS was still not based in evidence nor human rights and was not gender transformative, so therefore may or may not have impacted USAID’s ability to implement HIV and AIDS programs that promoted SRHR.

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 who 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 that received 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 the transparency grade, 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 highlighted HIV and AIDS programming within the context of reducing child transmission and included a testimony of a woman living with HIV in Tanzania to demonstrate the importance of USAID’s programming. However, the report did not discuss HIV and AIDS in a meaningful way. This report was responsive to need, as expressed by Congress, and based in evidence however there was no mention of human rights principles or gender norms. Overall, this document neither harmed nor promoted 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 concerns from the 2018 Department of State’s Six Month Review. The text of this document was similar to the 2018 FAQ document, though also included additional questions and answers (see questions 33-37). The document did not meaningfully discuss the impacts of the May 2019 expansion on HIV and AIDS prevention and treatment. 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 HIV and AIDS services. Overall, this document provided a substantial hindrance to SRHR.

2019_State and USAID Agency Priority Goal Action Plan_HIV/AIDS

The Agency Priority Goals (APGs) for HIV and AIDS were released by both the Department of State and USAID to hold the President's Emergency Plan For AIDS Relief (PEPFAR) accountable via quarterly reporting that included details around the goals, strategies, milestones, indicators, and progress made towards controlling the HIV epidemic in FY 2019. The 2019 APGs set goals to scale up antiretroviral therapy (ART) services, voluntary medical male circumcision (VMMC) services, and access to HIV and AIDS services for priority and key populations, including men who have sex with men (MSM), sex workers, transgender people, and adolescent girls and young women (AGYW). As a result, this plan was responsive to need and based in evidence and human rights. The APGs were not gender transformative as gender norms were not discussed. Overall, the APGs moderately promoted 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. 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 discussed the joint efforts by the Department of State and USAID to achieve HIV and AIDS epidemic control within the third goal. However, there is very little discussion of the data that was used to inform President's Emergency Plan For AIDS Relief (PEPFAR) programming or the human rights foundation for such programmatic decisions. The document did not provide a recommendation or detailed plan for the continuation of the success of HIV and AIDS prevention and treatment programming. This document was responsive to need but was not evidence based, based in human rights nor gender transformative. The Plan 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.

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 document was general and did not discuss any particular aspect of assistance, such as HIV and AIDS. There was one mention of HIV and AIDS as a foreign assistance success, but it was without a discussion of President's Emergency Plan For AIDS Relief (PEPFAR) as the main mechanism by which USAID has carried out these 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 also 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 HIV and AIDS 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. Within the 2018 report, HIV and AIDS was discussed strictly in the context of child mortality despite the fact that HIV is a leading contributor of maternal mortality worldwide. Evidence suggests that HIV and AIDS are key factors in maternal mortality and wellness and in child health through the prevention of maternal to child transmission (PMTCT). By leaving out HIV and AIDS data herein, the framework of this report reinforced the silos between maternal and child health, family planning, and HIV and AIDS programming that challenged USAID's ability to support integrated SRHR programs in 2018.

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_ADS Chapter 312sae_Condoms and Pharmaceuticals

The Automated Directives System (ADS) contains the operational policies that guide USAID's programs and operations. The Condoms and Pharmaceuticals ADS Help Document is an addendum to ADS Chapter 312 that was revised in 2018 to guide the procurement of condoms and pharmaceuticals by USAID’s Bureau for Global Health. The updated directive required that the procurement of all condoms (internal and external) be managed by the Office of HIV/AIDS. While this directive was detailed and informative and included the procurement of female (internal) condoms, it is unclear what prompted this update. As a result, it was challenging to gauge whether the guidance was responsive to need, evidence-based, human rights-based, or gender transformative. It was also unclear how the consolidation of procurement of all condoms under the Office of HIV/AIDS will impact USAID's HIV and AIDS programming and, therefore, SRHR overall, given that condoms are an important intervention in both family planning and maternal and child health.

2018_Protecting Life in Global Health Assistance FAQs_August 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 responsive to need in that they clarified areas of the policy that partners had expressed were vague or unclear. The FAQs were neither based in human rights principles nor evidence. The FAQs were also not gender transformative and substantially hindered USAID's ability to implement comprehensive HIV and AIDS programs that were evidence-informed, responsive to need, consistent with internationally-recognized human rights principles, and gender transformative.

2018_State and USAID Agency Priority Goal Action Plan_HIV/AIDS

The Agency Priority Goals (APGs) for HIV and AIDS hold the President’s Emergency Plan for Aids Relief (PEPFAR) accountable through quarterly reporting that includes details around the goals, strategies, milestones, indicators, and progress made towards controlling the HIV epidemic. Released by both the Department of State and USAID, these reports are useful for government transparency and are responsive to need and based in evidence and human rights. However, the APGs did not explain the role of USAID, specifically, in HIV and AIDS programming and only discussed PEPFAR-level successes and challenges. As a result, the APGs did not hinder or promote USAID's ability to support comprehensive HIV and AIDS programs, so the APGs did not increase or decrease USAID's score in this domain in 2018.

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 using USAID’s “whole-of-girl” approach (which “encompasses the interconnected events that resonate across a girl’s life from birth to adulthood”) to reduce gender disparities and gender-based violence (GBV) and increase capacity of women and girls through USAID’s programs. Though it did not explicitly mention USAID’s HIV and AIDS programs through the President’s Emergency Plan for Aids Relief (PEPFAR), this Plan provided a high-level overview of the programs, best practices, and indicators that were used to measure USAID’s progress in implementing the Adolescent Girl Strategy across programs, including HIV and AIDS. The Plan was responsive to need and based in evidence. The Plan 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 HIV and AIDS programs that moderately promoted SRHR.

2014_Acquisition and Assistance Policy Directive (AAPD)

2013_Counter-trafficking in Persons Field Guide

2012_Ending Child Marriage and Meeting the Needs of Married Children: The USAID Vision for Action

2012_Gender Equality and Female Empowerment Policy: USAID Policy

2012_United States Strategy to Prevent and Respond to Gender-based Violence Globally

2012_USAID Implementation of the United States National Action Plan on Women, Peace, and Security

Maternal and Child Health (MCH)

USAID received a 73 (C) with transparency and a 76 (C) without transparency in the Maternal and Child Health domain in 2021. This domain grade was raised by USAID’s Implementation Plan for the U.S. COVID-19 Global Response and Recovery Framework, which documented the impacts of the pandemic on MCH outcomes as well as outlined responses to protect global MCH programs that were based in evidence and responsive to need. This actor’s domain grade was decreased by the removal of the PLGHA section in ADS Chapter 303 without providing additional information or guidance for partners to adapt their programs accordingly, which significantly hindered SRHR. Overall, transparency was low for many actions graded in this domain because USAID did not indicate which content had been updated in 2021 from previous versions. USAID had a high level of transparency for funding data but did not disburse MCH funding in a manner that was responsive to need, which decreased this actor’s grade in this domain.

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_Acting on the Call

The 2021 Acting on the Call Report documented the impacts of U.S. global health financial investments in and commitments to providing critical health services to women, children, and families around the world. As stated in this report, USAID focuses on the goals of equity, quality, and resource optimization and integrated approach to primary health care to ensure that global MCH programs are implemented where burden is highest, which was responsive to need. This action described the adaptations USAID implemented through global MCH programs in response to the COVID-19 pandemic and climate change, which were responsive to need and based in evidence. The Report described USAID’s contributions to the 2030 Sustainable Development Goals (SDGs) as well as the alignment of this work with USAID’s Vision for Health System Strengthening 2030 report. This action documented the successful integration of MCH activities with those related to FP, breastfeeding support, nutrition, and malaria. It demonstrated USAID’s efforts to align global MCH programs with international standards and other global health investments, and adequately described the evidence base for USAID’s global MCH programs through the “Data in Focus” sections and annex that detailed the data and methodology. However, there was no mention of the human rights framework used to support USAID’s global MCH portfolio. Additionally, the Report was gender accommodating as it used gendered language throughout and did not meaningfully address harmful social and gender norms that impact people receiving MCH services. This action moderately promoted SRHR in the MCH domain.

2021_ADS Chapter 200_2021.01.15

ADS Chapter 200 described USAID’s process for creating development policy, as well as the development policy universe that affects all of the Agency’s programs and actions. This chapter was edited in January 2021 to update the link for the Agency-wide Policy Framework, which is the Agency’s highest level policy document and is intended to guide decision-making across USAID. However, the URL for the current Agency Policy Framework was broken and the Agency Policy Framework was not available elsewhere on USAID’s website, which negatively affected transparency. This action neither hindered nor promoted SRHR in the MCH domain.

2021_ADS Chapter 201_2021.09.21

ADS Chapter 201 defined the USAID Program Cycle, which is the Agency’s operational model for planning, delivering, assessing, and adapting development programs that advance U.S. foreign policy. Several sections of ADS Chapter 201 were updated in September 2021, including an update to the definition of “activity design” to include policy dialogue, stakeholder coordination, and capacity building. ADS 201 included an updated Project Design and Implementation section that encouraged integration and coordination across projects for greater sustainability. Many of these edits were responsive to need and aligned with evidence and best practice. Additionally, the responsibilities of the Gender Advisor at the USAID Mission level were updated to include ensuring that “gender equality” was integrated into the design and implementation of activities, which was only somewhat gender transformative. This ADS chapter still used gendered language like “female empowerment” and did not address efforts to empower people of diverse SOGIESC. The updates to ADS Chapter 201 moderately promoted SRHR in the MCH domain.

2021_ADS Chapter 303 Materials_2021.02.04

ADS Chapter 303 described USAID’s internal guidance, policy directives, procedures, and standards for grants and cooperative agreements with NGOs, including those that were established with U.S. global health assistance funds. The main ADS chapter was updated, along with two mandatory references in February 2021: the Standard Provisions for U.S. Nongovernmental Organizations (303maa) and the Standard Provisions for Non-U.S. Nongovernmental Organizations (303mab). All three of these ADS Chapter 303 materials were updated to replace the section related to the implementation of PLGHA with the word “Reserved.” No other sections in the ADS Chapter 303 materials were updated to indicate that PLGHA had been revoked by President Biden on January 28, 2021. It was extremely difficult to identify what content had been removed from that section as previous versions of USAID’s ADS materials were not available on the website. The SRHR Index team referenced the previous version of all three ADS Chapter 303 documents to determine that the PLGHA section had been removed in its entirety. This was USAID’s opportunity to provide information about the policy’s revocation along with guidance for NGOs to implement the policy change and align their programs accordingly. USAID did not provide any information about the revocation of PLGHA in these documents, which negatively affected transparency . This action significantly hindered SRHR in the MCH domain.

2021_ADS Chapter 303mab_2021.03.31

ADS Chapter 303mab, Standard Provisions for Non-U.S. Nongovernmental Organizations, was updated in March 2021 to update section M2. Accounting, Audit, and Records. A new subsection outlined the requirement that recipients of grant or cooperative agreement funding had to provide USAID and other USG officials with “timely and reasonable access” to materials, records, and personnel necessary to complete audits and other oversight processes. This update would apply to U.S. global health programs, but it was unclear whether it would affect the implementation of activities related to SRHR. This action neither hindered nor promoted SRHR in the MCH domain.

2021_ADS Chapter 303_2021.06.07

ADS Chapter 303 was updated again in June 2021 to revise section 303.4.2: Internal Mandatory References. However, none of the individual internal mandatory reference documents were highlighted in this section to indicate that they had been updated, which negatively affected transparency. Highlighting updated content in ADS documents would have helped the reader understand which material had been edited in the revised version. The action neither promoted nor hindered SRHR in the MCH domain.

2021_ADS Chapter 303 Materials_2021.07.29.

ADS Chapter 303 was revised in July 2021 to update Section 303.3.5.5: Unsolicited Concept Papers and Applications. The update provided a link to a new Internal Mandatory Reference document: Guide to Unsolicited Applications (303mbd), which provided guidance and procedures for USAID’s review of unsolicited applications. According to this action, “unsolicited applications provide a method for organizations to submit unique, innovative, or proprietary approaches for solutions to development challenges” and USAID is responsible for determining whether funding such applications would be aligned with the Agency’s development objectives. The addition of this internal mandatory reference document could help ensure that USAID funds programs that were responsive to need and not based solely on USAID’s procurement processes. This action was based in evidence and responsive to need as the materials clearly stated that all applications would be reviewed by the programmatic and technical officers to determine strategic alignment with Agency priorities. This action moderately promoted SRHR in the MCH domain.

2021_ADS Chapter 308_2021.02.26

ADS Chapter 308, entitled: Agreements with Public International Organizations (PIOs), was updated in February 2021 to state that “PIOs are important partners for the Agency, and many PIOs possess unique comparative advantages.” This action also stated that USAID’s OUs would work with PIOs whenever it was in the best interest of the Agency, which could have fostered partnerships that promoted SRHR through U.S. global health assistance. This action was updated to describe the Organizational Capacity Review process to ensure that a PIO’s organizational framework and operational capacity would add value to USAID’s work. This legal due diligence process was vital to successful partnerships. This action moderately promoted SRHR in the MCH domain.

2021_ADS Chapter 308mab_2021.06.15

ADS Chapter 308mab was a mandatory reference for ADS Chapter 308 entitled: Standard Provisions for Cost-Type Agreements with Public International Organizations (PIOs) and was revised in June 2021. Section M19. Sexual Exploitation and Sexual Abuse and Sexual Harassment was updated to outline USAID’s zero-tolerance policy for inaction to addressing SEA and sexual harassment in all agreements with PIOs. This action required PIOs working in partnership with USAID to apply the IASC Six Core Principles Relating to Sexual Exploitation and Abuse, referenced the United Nations Protocol on Allegations of Sexual Exploitation and Abuse Involving Implementing Partners, and defined a “victim/survivor-centered approach” to SEA and sexual harassment, which aligned this action with evidence and grounded it in human rights. The updated ADS Chapter 308mab also stated the requirement for PIO partners to make “reasonable and adequate efforts to address gender inequality and other power imbalances” in their programing, which called for the integration of gender transformative approaches. This action moderately promoted SRHR in the MCH domain.

2021_ADS Chapter 312_2021.09.08

ADS Chapter 312 contained information on USAID-financed condoms, pharmaceuticals, and medical supplies designed for USAID technical and procurement staff as well as implementing partners. This chapter was updated to add medical gloves and syringes to the list of laboratory supplies that did not require ADS 312 approval and confirmed that certain USAID technical and programmatic staff had the delegated authority to make determinations about specific pharmaceuticals. It was unclear how these updates would impact the implementation of USAID’s global MCH programs. This action neither hindered nor promoted SRHR in this domain.

2021_Assessing Feasibility and Readiness for Cargo Drones in Health Supply Chains

This Report shared the findings of scoping visits in Malawi that explored the feasibility of cargo drones to support global health supply chains with the long-term goal of avoiding stockouts, responding to emergency medical requests, and speeding up diagnostic sample delivery time to benefit global beneficiaries. This action was responsive to need due to supply chain distribution issues that resulted from the COVID-19 pandemic. This action explicitly stated that these findings would not be applicable across all contexts, but that the approach outlined in this report could be adapted for different limited-resource settings. This action suggested that a root cause analysis should be completed to improve project design and inform implementation, which was based in evidence. The guide discussed other best practices that were responsive to need such as market research, scoping trips, and informational interviews with stakeholders at all levels, from the national government to community health workers. The action included guidance for engaging with community members and designing culturally appropriate community sensitization activities through a participatory approach, which was responsive to need. However, the guide did not include the human rights framework that should be considered when designing drone initiatives. It laid the foundation for future work that could be applied across U.S. global health programs. This action moderately promoted SRHR in the MCH domain.

2021_Building Commitment and Capacity to End TB_Tuberculosis Report to Congress_FY2019

This Report to Congress documented USAID’s progress toward preventing and treating TB and its related comorbidities (e.g., HIV infection and diabetes) around the world. This action was responsive to need as it described the current state of TB infection worldwide, outlined the results of USAID’s Global Accelerator to End TB to date, and described the next steps in USAID’s TB activities in response to the COVID-19 pandemic. The number of children started on treatment for TB was included as a key indicator in each of the country snapshots in the Appendix. However, this action did not adequately describe the synergies between global MCH and TB programs, so it was not fully based in evidence in this domain. The action was gender accommodating as it mentioned USAID’s efforts to address stigma, discrimination, gender disparities, and inclusiveness through TB programs, but did not provide details of these efforts. This Report neither hindered nor promoted SRHR in this domain.

2021_Considerations for COVID-19 Response_Digital Accessibility

This action outlined the importance of digital accessibility, particularly during the COVID-19 pandemic, and offered key considerations for designing accessible digital interventions through a universal design approach which was based in evidence. These suggestions, such as involving disability advocacy organizations in digital design processes and adding alt-text to photos, were responsive to need, based in evidence, and aligned with human rights norms. This action built upon the USAID first-ever Digital Strategy, which was released in 2020. This action acknowledged that lack of access due to disability was intersectional to other inequities, which was based in evidence, but was gender blind as it did not specify the ways in which a person’s gender could be a barrier to access. This action supported the ability of USAID’s global MCH programs to be more inclusive of persons with disability. 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. The action was responsive to need as it included key milestones within USAID’s MCH efforts, such as the release of the 2020 Acting on the Call Report and the execution of data-driven reviews of country performance results in FY 2020. However, the MCH-specific indicators did not have FY 2022 targets. Setting targets at the beginning of the FY is an important way to measure progress and ensure that programs are performing well and are responsive to need. It was unclear why targets were not included for USAID’s global MCH activities in FY 2022, so this action was not fully based in evidence and negatively affected transparency . The Report was gender accommodating as it used language that reinforced a gender binary and excluded people who are pregnant and do not identify as women. This action moderately hindered SRHR in the MCH domain.

2021_Diversity, Equity, and Inclusion Strategy_Executive Summary

In 2021, USAID released the Executive Summary for the forthcoming Diversity, Equity, and Inclusion Strategy. The full Strategy was not publicly available at the time of grading, but the Executive Summary described USAID’s plan to enhance diversity across the Agency, promote inclusion and equity among Agency staff, and strengthen accountability for DEI efforts. This action described the methodology that USAID implemented to design the complete DEI Strategy, including stakeholder interviews, focus groups, listening sessions, and consultations at all levels of the Agency. While this approach and the overall goals of the DEI Strategy outlined in this action appeared to be responsive to need, based in evidence, and aligned with human rights, it did not explain how the complete Strategy would impact U.S. global health programs and operations. Though releasing this Executive Summary was responsive to need, this action likely would not have an impact before the complete Strategy was made available. This action neither promoted nor hindered SRHR in the MCH domain.

2021_Family Planning and Reproductive Health Program Overview

This Overview detailed the scope of the FP/RH Program at USAID and described the benefits of FP to women and children's health, reducing poverty, reducing high-risk pregnancies, and allowing time to space pregnancies. The Overview was guided by the principles of voluntarism and informed choice, which was responsive to need, based in evidence, and aligned with human rights. The Overview stated that the RH portfolio included integration with MCH programming and highlighted the impacts of FP on preventing mother-to-child transmission of HIV and preventing maternal and child deaths, which was responsive to need and based in evidence. While the Overview mentioned addressing gender norms in the RH portfolio, it was gender accommodating as it primarily used language that enforced a sex and gender binary. This Overview moderately promoted SRHR in the MCH domain.

2021_Global Health eLearning Course_Antimicrobial Resistance_Part 1

This eLearning course explored antimicrobial resistance as it pertained to diseases such as TB, pneumonia, gonorrhea, malaria, and HIV. The Course described the potential reversal of progress made against these public health challenges, as well as the reality that resistance to common medications has increased in recent years, which has resulted in an increased burden on health systems. The Course stated that pneumonia was a leading cause of death for children under five years of age in 2017. However, the Course did not include any other information specific to pregnancy or maternal health, which was a missed opportunity to highlight the impact of antimicrobial resistance on pregnant people and its effect on MCH outcomes. While this action was mostly based in evidence, it did not advance SRHR beyond monitoring resistance to antibiotic treatments, including those that impact SRH outcomes. It was gender accommodating as it used gendered language when discussing risk of antibiotic resistance. This action did not clarify which content was updated in the latest version of this eLearning course, which negatively affected transparency . This action neither promoted nor hindered SRHR in the MCH domain.

2021_Global Health eLearning Course_Applying Segmentation to SBC in Family Planning

This eLearning course provided information about the benefits of incorporating segmentation—or dividing a population into subgroups with "meaningfully similar characteristics, and significant differences from other subgroups"—for the purposes of SBC research and programming. The Course primarily focused on incorporating SBC into FP programming, however the guidance in the Course could be applied to other areas of global health beyond FP. The Course covered several case studies where different SBC approaches could be used to address a wide range of contexts, which was responsive to need. The Course included MCH and pregnancy outcomes in case studies and examples but was not responsive to need in this domain as it did not provide specific guidance on how to apply segmentation strategies to FP activities related to MCH. The Course received a low transparency score as it was not clear what was updated from previous versions of the training. The Course was gender accommodating as it used gendered language that reinforced a gender binary. The Course moderately promoted SRHR in the MCH domain.

2021_Global Health eLearning Course_HIV/AIDS Legal and Policy Requirements

This eLearning course provided guidance about the legal and policy requirements that applied to global HIV programs supported by U.S. global health assistance funds. The Course provided information on a wide variety of topics including condoms, sex work, working with local partners such as faith-based organizations or law enforcement, VMMC, FP/HIV integrated services, restrictions related to abortion and involuntary sterilization, and ensuring compliance with these USG requirements. The Course provided useful information to support organizations with implementing these policies, which was responsive to need. However, it mostly focused on restrictions instead of what was allowed under U.S. policy. Though the Course was updated to remove all mentions of PLGHA, removing all references to this policy without providing information about its revocation or guidance for partners on how to implement programming in its absence was not consistent with evidence, responsive to need, or aligned with human rights. The Course highlighted opportunities to support programming such as FP/HIV integration across PEPFAR’s focus areas, including PMTCT, safe and respectful pregnancy counseling, childbirth services, and antenatal care (ANC), which was responsive to need and based in evidence. While the Course included some gender transformative elements such as the implementation of DREAMS programming, it was gender accommodating as it used gendered language and did not include guidance on addressing gender norms in global MCH programming. The Course did not highlight what was updated or changed for 2021, which negatively affected transparency. This action neither hindered nor promoted SRHR in this domain.

2021_Global Health eLearning Course_U.S. Family Planning and Abortion Requirements

The 2021 eLearning Course on U.S. Family Planning and Abortion Requirements provided an overview of the FP and abortion legislative and policy requirements that apply to U.S. foreign assistance funding and programs. The Course primarily focused on the principles of voluntarism and informed consent through the Tiahrt amendment, which was based in evidence and human rights norms as these principles are regarded as the standard for protecting the human rights of people that access FP services worldwide. The Course emphasized that it was the responsibility of USAID staff to discuss legislative abortion restrictions with implementing partners throughout the life of the award to ensure awareness of the restrictions, which was responsive to need. The Course highlighted the provision of PAC as an example of providing integrated services across MCH and FP programs. However, it did not clearly state which information was changed for 2021, which negatively affected transparency . Furthermore, it did not mention the Biden administration's policy to support SRHR globally. While the Course mentioned the revocation of the PLGHA policy, it stated that the policy was no longer in effect and that implementing partners still had to comply with other abortion-related restrictions, which was not enough detail or guidance for partners to understand how to implement this policy change. As a result, this action was not fully responsive to need, based in evidence, or consistent with human rights norms. The Course encouraged staff to "be aware of perceptions among program managers, clients, and providers that may suggest potential vulnerabilities," which was not responsive to need as it could lead to unnecessary oversight of people's personal or professional beliefs that would not be relevant to their implementation of abortion restrictions. The Course was gender blind as it did not include a meaningful or inclusive discussion of gender. This Course moderately hindered SRHR in the MCH domain.

2021_Issues and Recommendations on Gender-Based Violence Prevention and Response in COVID-19 Programming

This action provided guidance and recommendations for how to include GBV prevention and response efforts in COVID-19-related programming. The action highlighted the increase in GBV during the pandemic, particularly in the form of online and offline harassment, SEA, CEFM, FGM/C, LGBTQI+ abuse, and abuse towards female health workers. This action recognized the lack of health services available to GBV survivors due to health care supplies being diverted away from GBV and SRHR services in favor of COVID-19 mitigation and called for the integration of GBV prevention and response efforts into the health service response to COVID-19. This recommendation was responsive to need and based in evidence. The action provided recommendations for implementing GBV risk mitigation measures, which was responsive to need, based in evidence, and aligned with human rights norms. While SRH services were mentioned one time, the guidance should have explicitly included the promotion of SRHR as a vital component of the pandemic response. This action did not mention MCH issues (outside of CEFM) or perinatal health services, which was not responsive to need or based in evidence as it did not recognize the MCH-related services needed by GBV survivors, particularly survivors who are pregnant. This action was somewhat gender transformative as it advocated for the implementation of SBC activities to promote healthy masculinities and gender equitable relationships, though it used language that reinforced a sex and gender binary. The Report 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 efforts led by USAID. 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 USAID's other global health security efforts, including those related to global 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 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_United States Government Women, Peace, and Security (WPS) Congressional Report

The WPS Congressional Report provided Congress with an overview of progress specific USG agencies have 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, the contributions of USAID’s global MCH programs to the WPS efforts were not meaningfully included in this action. However, the Report included GBV prevention and programming as a cross-cutting measure of progress towards achieving the WPS Agenda, which was responsive to need. The Report also highlighted USAID’s efforts to integrate WPS activities with other actions related to countering violent extremism and implementation of gender-sensitive interventions during the COVID-19 pandemic. It highlighted USAID's efforts to prevent CEFM and provide gender training for USAID personnel, which was responsive to need. The Report included specific and actionable milestones to measure the actor’s progress on these goals, which was responsive to need and could support evidence-based decision making in the future. 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.

2021_USAID 2021 Climate Readiness Plan In Reponse to Executive Order 14008

The 2021 USAID Climate Readiness Plan provided an overview of how USAID plans to implement the directives listed in Executive Order 14008, which called for a prioritization of the climate crisis in the United States and globally. The Plan detailed USAID's role in implementing climate solutions in countries most affected by climate change, as well as called for USAID programs to incorporate lessons learned from the COVID-19 response to build climate resilience. The Plan called for increased collaboration with Indigenous peoples, women and girls, youth, and other groups that are disproportionately impacted by the climate crisis, which was responsive to need and based in evidence. It outlined USAID’s commitment to implement evidence-based decisions across the full scope of programs and revitalize USAID's approach to climate change adaptation, resilience, and mitigation targets. The Plan elaborated on how global health programs were being monitored for climate change vulnerabilities, particularly in relation to the availability of medical supplies for PEPFAR, infectious diseases, MCH and nutrition, and FP/RH programs, which was responsive to need and based in evidence. The Plan was gender accommodating because it acknowledged the gendered impacts of climate change but utilized gendered language that reinforced a gender binary. This Plan moderately promoted SRHR in this domain.

2021_USAID Health Systems Strengthening Learning Agenda

The USAID Health Systems Strengthening Learning Agenda provided a guide for how USAID’s global health programs should improve HSS programming. The Learning Agenda prioritized supporting high-performing health care; improving health system equity, quality, and resource optimization; advancing USAID's Vision for Health System Strengthening 2030; and supporting locally led efforts to develop sustainable, resilient health systems. These priorities were responsive to need and based in evidence. The Learning Agenda included questions for a variety of stakeholders that advance health system performance and resilience as well as prioritized health outcomes including preventing child and maternal deaths. The Learning Agenda directed stakeholders to implement robust HSS research and programming efforts that were based in evidence, responsive to need, and aligned with human rights. The Learning Agenda could have included more detailed information and guidance about how to adequately incorporate SRHR in these efforts. The Learning Agenda was gender accommodating because it mentioned gender as a cross-cutting area of focus but did not specifically discuss the gender norms that impact health systems and people’s access to health services. The Learning Agenda moderately promoted SRHR in the MCH domain.

2021_USAID Implementation Plan for the U.S. COVID-19 Global Response and Recovery Framework

2021_USAID Key Programming Questions to Address Gender and COVID-19 Infographic

This Infographic provided key questions to support USAID programs that implement gender inclusive programming related to COVID-19. The Infographic covered topics such as GBV; agriculture, food security, and nutrition; democracy, rights, and governance; environment; economic growth; health; child protection; education; and WASH. The Infographic emphasized the importance of providing "essential and routine health services" because of the pandemic but did not explicitly mention SRH services. The lack of specificity in this definition could have siloed SRH services from other services included in this action. It addressed the increased inequities and vulnerabilities faced by women and marginalized groups across these issue areas due to the pandemic which was evidence-based, aligned with human rights, and responsive to need. The Infographic also specifically mentioned "women and girls, men and boys, in all their diversity," which acknowledged the complexity of these identities in relation to people’s SOGIESC which was a gender inclusive approach to this issue. This action was gender accommodating as it recognized gender diversity but did not include questions to guide programs to overcome harmful gender norms. This action moderately promoted SRHR in the MCH domain.

2021_USAID Memorandum Authorizing Disaster Relief Flexibilities to Reduce the Burden for Financial Assistance Pursuant to OMB Memorandum M-21-20

This Memorandum outlined the exceptions for USAID agreements and grant recipients that were impacted by the COVID-19 pandemic, including agreements that pertained to global health assistance. The Memorandum outlined the Agency’s authority to provide administrative relief not only to recipients with COVID-19-related financial assistance, but also to recipients that were implementing assistance awards unrelated to COVID-19. This was responsive to need as it recognized that partners may have had difficulty completing program activities due to the pandemic. The Memorandum also provided guidelines for increased flexibility with SAM registration procedures; NOFO publication requirements; and pre-award costs, no-cost extensions, and submission of financial, performance, or other reports, which was responsive to partners' needs. This action supported the implementation of global MCH programs that could be flexible and adaptable during the COVID-19 pandemic. This Memorandum moderately promoted SRHR in this domain.

2021_USAID Nutrition Report to Congress_FY 2021

The 2021 USAID Nutrition Report to Congress included an overview of the Agency's approach to providing nutrition care and progress made toward the World Health Assembly targets on nutrition. The Report referenced the 2021 Lancet series on maternal and child undernutrition, which emphasized the importance of good nutrition for survival and the need to focus on "mothers and children in the 1,000 days window from pregnancy to age two." The Report highlighted that no countries are on track to reach certain targets, such as anemia targets, and called for increased investment in maternal health and nutrition, which was based in evidence. The Report included data on other metrics such as stunting, wasting, and breastfeeding, which was responsive to need. This action emphasized USAID's evidence-based and multisectoral approach to nutrition programming and highlighted the "unfinished agenda" of deficiencies in vitamins and minerals, gaps in the delivery of nutrition interventions, and the importance of incorporating maternal nutrition in health and food systems, which was based in evidence and responsive to need. The Report did not include any data or metrics about how nutrition programming was implemented within MCH programming, which was lacking as nutrition is a cross-cutting issue that impacts MCH outcomes. Additionally, the Report was gender blind as it only referred to “pregnant and breastfeeding women,” which was not gender inclusive of the nutrition needs of pregnant people who do not identify as women. This Report moderately promoted SRHR in the MCH domain.

2021_USAID Policy on Countering Trafficking in Persons

The USAID Policy on C-TIP outlined the principles that guided USAID's approach to implementing policies to combat trafficking in persons. The Policy defined USAID’s "survivor-centered and trauma informed" approach to supporting survivors of trafficking, which was responsive to need and based in evidence. It emphasized that survivors should receive shelter, food, counseling, health care, and legal assistance, which was responsive to need. It highlighted the adverse health outcomes that are common for survivors of trafficking, including work-related injuries or accidents, sexual and physical assault, STIs, infertility, forced abortion, substance abuse, chronic untreated medical conditions, malnutrition, and future victimization or perpetration of violence, which was based in evidence. These outcomes included issues relevant to SRH, which was responsive to need, but only mentioned "forced abortion," which was not inclusive of the need for safe abortion care in the case of an unwanted pregnancy resulting from trafficking or violence. The Policy was gender accommodating as it included efforts to promote gender equity to prevent and address trafficking in persons but used gendered language throughout the Policy and did not actively demonstrate efforts to combat gender norms that enable trafficking. This Policy moderately promoted SRHR in this domain.

2021_USAID Report to Congress on Health Systems Strengthening for Fiscal Year 2020

This Report provided information to Congress about USAID's HSS efforts in FY 2020 across MCH and FP funding. The Report stated that USAID tracked the amount of funding made available for HSS activities within global health programs (excluding HIV and AIDS funding). The Report included a high level of specificity in reporting these data and called attention to specific country successes as well as mentioned challenges posed by the COVID-19 pandemic and highlighted the need for these programs to be flexible and adaptable, which was based in evidence and responsive to need. The Report was aligned with global HSS goals and included metrics for measuring USAID’s progress, which was based in evidence and promoted the implementation of HSS activities that were responsive to need. The Report moderately promoted SRHR in the MCH domain.

2021_USAID Vision for Health System Strengthening 2030

The Vision for Health System Strengthening for 2030 highlighted USAID’s goals for implementing HSS activities across global health programs. The Vision incorporated equity into access to care and quality of care as well as emphasized the importance of collaborating with local partners to ensure the sustainability of health systems. The focus on addressing systemic barriers to providing equitable and essential care, especially for individuals that experience discrimination based on gender, age, and racial and ethnic disparities or other factors, was responsive to need and aligned with human rights. It promoted a definition of wellbeing that went beyond simply treating illnesses, which was based in evidence. The Vision cited the successes of programming related to the management of diseases such as TB and HIV and AIDS as a basis to translate technical guidance to address other burdens on health systems, which was based in evidence and responsive to need. The Vision included MCH as an area where progress was made to date but highlighted strategies to promote MCH and nutrition as part of a future HSS strategy. The Vision was somewhat gender transformative as it mentioned creating equitable gender norms as a facet of HSS, but used language that reinforced a sex and gender binary. This action moderately promoted SRHR in the MCH domain.

2021_USAID’s COVID-19 Response Ending The Global Pandemic and Building Back Better

This Report highlighted USAID's response to COVID-19 and included details on the five objectives that guided the Agency’s pandemic response, including investments. The Report explored USAID’s experience providing access to vaccines, reducing morbidity and mortality from COVID-19, strengthening health systems, and addressing the increased needs of communities across sectors driven by the pandemic. The Report cited the Agency's efforts to support humanitarian responses by addressing GBV and providing primary and reproductive health services, which was responsive to need. The Report did not provide specific interventions or actions related to the implementation of activities that promote SRHR during the pandemic, so this action was not fully responsive to need, based in evidence, or consistent with human rights. The Report was gender aware as it recognized the impact of COVID-19 on women and girls but did not specifically address relevant gender norms and used gendered language. Throughout the Report, it was unclear how USAID’s global health programs were incorporated into the Agency’s COVID-19 response, which negatively affected transparency . If it was clear that the Report included objectives and results for USAID’s global health efforts, the Report would have promoted SRHR. This Report neither promoted nor hindered SRHR in the MCH domain.

2020_Acting Administrator John Barsa Letter to UN Secretary General Guterres_18 May 2020

John Barsa, Acting Administrator of USAID, sent this letter to António Guterres, the UN Secretary-General, in May 2020 to oppose the inclusion of SRH services with other essential services in the UN’s Global Humanitarian Response Plan (Global HRP) for the COVID-19 pandemic. The letter criticized the Global HRP because it recommended the distribution of “abortion-inducing drugs and abortion supplies” in local country settings. The letter also called for the removal of references to “‘sexual and reproductive health’ and its derivatives” from the Global HRP, which demonstrated USAID’s lack of commitment to providing comprehensive health services during a global pandemic. This action was not based in evidence or human rights because people still needed to access SRH services—including MCH services—during the COVID-19 pandemic. Furthermore, this letter was gender-blind because it did not acknowledge that women, girls, and gender-diverse people are disproportionately impacted by COVID-19 and could experience poor health outcomes such as maternal mortality and morbidity if they could not access adequate MCH services. This action was rooted in anti-abortion rhetoric rather than evidence, need, or human rights norms, and siloed SRH services from other essential services in response to the pandemic. It significantly hindered SRHR in the MCH domain.

2020_Acting on the Call

In honor of the International Year of the Nurse and the Midwife, the 2020 Acting on the Call Report published by USAID focused on the role that nurses and midwives play in improving quality of care and increasing equitable access to essential health care to reduce maternal, newborn, and child mortality. The Report set the stage to empower nurses and midwives to strengthen the health workforce and recognized the important role that midwives play in providing respectful, coordinated, and equitable MCH care, which was aligned with human rights and evidence. This Report documented the ways in which MCH services have been integrated with voluntary family planning (FP), nutrition, and water, sanitation, and hygiene (WASH) programs (e.g., safe water, waste management, toilet facilities), which was aligned with evidence and responsive to need. However, the connection between MCH and HIV and AIDS care was glaringly missing, which was not aligned with evidence or responsive to need. Additionally, the Report was gender accommodating as it used language that reinforced a gender binary but did not report on the specific MCH needs of LGBTQI+ populations. The evidence base for this report could have been more robust, as there were no references to World Health Organization (WHO) standards or other relevant sources that were used to guide or inform USAID’s MCH programming. The Report included clear reporting on the impact of COVID-19 on some of USAID’s MCH programs like immunization campaigns, but data on the specific impact of the pandemic on maternal health was lacking. The Report moderately promoted SRHR in the MCH domain.

2020_ADS Chapter 303 Materials_2020.05.18

2020_ADS Chapter 303 Materials_2020.06.19

The updates to ADS Chapter 303: Grants and Cooperative Agreements to Non-Governmental Organizations that were released on June 19, 2020 were not related to SRHR and therefore neither promoted nor hindered SRHR. However, this version of ADS Chapter 303 included a new section entitled: 303.3.34 Abortion Restrictions (Effective Date: 05/29/2020), which had been added since the 2019 version that was graded by the SRHR Index. This section provided guidance for implementing the statutory and policy abortion restrictions that apply to all U.S. foreign assistance awards (e.g., Voluntary Population Planning Activities – Mandatory Requirements) and those that apply to only U.S. global health assistance (i.e., Protecting Life in Global Health Assistance [PLGHA]). This section included links to USAID resources that define and explain legislative and policy requirements related to global health, which could have supported the correct implementation of the PLGHA policy and other restrictions. However, this edit was not responsive to need, as it was unclear why the ADS was only updated to include this guidance in May 2020, when PLGHA had been in effect since 2017 and other abortion restrictions have been in place since 1973. The May 29, 2020 version of ADS Chapter 303 had been replaced on its website by the June 19, 2020 version and was no longer available at the time of grading, which contributed to low transparency for this action as prior versions of ADS documents are not publicly available once a newer version is released. The updates made to these materials on June 19, 2020 neither promoted nor hindered SRHR in the MCH domain.

2020_ADS Chapter 303 Materials_2020.08.18

Two ADS Chapter 303 materials were updated on August 18, 2020: the main ADS chapter itself and the Standard Provisions for Non-U.S. NGOs (303mab). Details regarding allowable cost share, information technology, and telecommunication services were added to the updated version of the main ADS chapter. While these updates may impact program management and some operations for global health programs, the updates neither promoted nor hindered SRHR in the MCH domain. The 303mab was updated to provide more information as well as specific guidance on implementing the prohibition of certain telecommunication and video surveillance services or equipment as was updated in the main ADS chapter. This new section included definitions and references for “covered telecommunication equipment or services,” “covered foreign country,” and “telecommunication costs” as defined in the Code of Federal Regulations (CFR). This telecommunications prohibition was also included in the Department of Health and Human Services’ (HHS) General Terms and Conditions for Research and Non-Research Grants and Cooperative Agreements, though the HHS guidance included an exemption for PEPFAR funding until 2022 that was not mentioned in these ADS materials. It was unclear how this guidance would affect global health programs, so this action neither promoted nor hindered SRHR in the MCH domain.

2020_ADS Chapter 303 Materials_2020.11.19

Two mandatory references for ADS Chapter 303 were updated on November 19, 2020: the Standard Provisions for Non-U.S. NGOs (303mab) and the Standard Provisions for Fixed Amount Awards to NGOs (303mat). Both mandatory reference documents contained one update that was relevant to SRHR: Section RAA6. Universal Identifier and System for Award Management. This section was rewritten to provide written notice that the prior Data Universal Numbering System (DUNS) had been replaced by the new Unique Entity Identifier process, which allowed organizations to maintain a current registration in the System for Award Management (SAM) and receive federal funding. This section also included definitions, requirements, and exemptions for the application of this provision, which would enable the effective implementation of this provision. This updated provision was responsive to need because the DUNS process had been identified as burdensome for local organizations with limited administrative capacity as compared to large international NGOs. The streamlining of the SAM process could enable local and smaller organizations to participate in USAID’s global health programs. As such, this update moderately promoted SRHR in the MCH domain.

2020_ADS Chapter 303 Materials_2020.12.17

2020_ADS Chapter 308_2020.12.04

2020_Agency Priority Goal Action Plan_Maternal and Child Health

The purpose of the Agency Priority Goal (APG) Action Plan on MCH is to report on USAID’s contributions to the global effort to prevent child and maternal deaths in fiscal year (FY) 2020. This action listed the technical teams at USAID that contributed to this reporting, which included representatives that work in population and reproductive health, malaria, nutrition, and health systems strengthening. The Plan included an explanation of how each of the above technical areas contributed to the effective implementation of integrated health services. However, the role of USAID’s HIV and AIDS technical staff and programs within USAID was not mentioned in the Plan, even though USAID is an implementing agency of the President’s Emergency Plan for AIDS Relief (PEPFAR) and provides services related to MCH. It should have incorporated PEPFAR programmatic data into existing USAID MCH data to reflect all of USAID’s MCH efforts. Aside from the lack of meaningful integration with HIV and AIDS programs, the evidence base for the Plan was clear and robust throughout the report. It included a new annual indicator: “Absolute change in the rate of exclusive breastfeeding among children under six months in USAID’s 25 MCH priority countries.” This updated indicator was in line with guidance in USAID’s ADS Chapter 212 regarding breastfeeding, was responsive to need, and consistent with programmatic data and evidence. Language throughout the Plan was not gender transformative as it reinforced a gender binary. It did not report on the specific MCH needs of the LGBTQI+ community, which was a gap. The impact of COVID-19 on USAID’s MCH program performance and target achievement was also mentioned, which was responsive to need. The Plan moderately promoted SRHR in the MCH domain.

2020_Considerations for USAID Mission Staff for Programmatic COVID-19 Preparedness and Response_Digital Technologies and Data Systems

USAID released this guidance on April 6, 2020 to help USAID Missions best respond to the COVID-19 pandemic through the use of digital interventions and data systems. Given the rapid development and publication of these guidelines and the fact that most of the recommendations in this action did not require modifications to current agreements, this action was responsive to need because Missions could implement the guidance as appropriate for the local context. The role of USAID health programs was clearly defined: “support host country information systems, health worker education, identify health data needs, identify interoperability needs, and provide TA [technical assistance].” The Guidelines also called for collaboration with host country governments to ensure that health workers continued to be paid and that data collection continued through health programs, which was responsive to need and would facilitate data-driven decision making. The Guidance described how gender dynamics interact with one’s access and use of digital technology, which was gender aware. However, there was no guidance for how digital interventions should be adapted to address the impacts of COVID-19 related to SRHR, including gender-based violence (GBV) and reduced access to MCH services. As a result, this action neither promoted nor hindered USAID’s ability to support 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, including USAID’s global MCH programs. The Technical Update summarized updated guidance from the 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, this action was not released by PEPFAR (of which USAID is an implementing agency) 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 on counseling people who have just given birth about their contraceptive options. This was not fully consistent with MCH evidence or responsive to need in this domain because people who have given birth should be counseled on contraceptive options during the postpartum period. Additionally, the Technical Update was gender blind, as it did not use gender inclusive language or acknowledge the MCH needs of people who may not identify as women. As an implementer of global MCH programs, USAID had the opportunity to advocate for the integration of these efforts through this Technical Update. This action 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 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 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 activities that the USAID implements related to gender and MCH, including antenatal care (ANC), PMTCT, and HIV prevention and treatment services for pregnant and breastfeeding persons. 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 implemented with U.S. global health assistance. which contributed to low transparency. Additionally, 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 the MCH domain.

2020_Department of State and USAID_Fiscal Year (FY) 2020 Annual Performance Report

The 2020 Annual Performance Report outlined the Department of State and USAID’s progress toward strategic objectives, 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 presented data on USAID’s MCH activities within Performance Goal 3 and provided detailed explanations for indicator achievement in light of the COVID-19 pandemic, which was highly responsive to need and based on real-time programmatic data and evidence. The Report also included a new annual indicator: “Absolute change in the rate of exclusive breastfeeding among children under six months in USAID’s 25 MCH priority countries.” This updated indicator was in-line with guidance in USAID’s ADS Chapter 212 regarding breastfeeding, was responsive to need, and consistent with programmatic data and evidence. Indicators regarding GBV did not include considerations or disaggregates for people who experience violence during pregnancy, so these indicators were not fully responsive to need. This action was not gender transformative because language throughout the Report reinforced a gender binary. This report moderately promoted SRHR within the MCH domain.

2020_Expedited Procedures Package for Responding to Outbreaks of Contagious Infectious Disease

An Expedited Procedures Package (EPP) provides a blanket restriction on eligibility for both acquisition (e.g., contracts) and assistance (e.g., grants and cooperative agreements) mechanisms and allows for modifications to be made to existing USAID contracts and agreements without triggering competition requirements. This permitted USAID to maintain flexibility to respond rapidly and effectively to an outbreak of an infectious disease. Released on March 27, 2020, this EPP allowed USAID programs to apply for new funding as well as shift existing funds and programmatic priorities to quickly meet the changing needs created by the pandemic. Thus, the EPP was highly responsive to need. The EPP also made it easier to award emergency assistance to USAID programs and enabled USAID to engage with new as well as underused partners, private-sector partners, and community- and faith-based partners to most effectively respond to the pandemic. This effort was aligned with evidence, best practice, and human rights. This action enabled USAID to rapidly provide financial and technical support to programs so they could address issues related to COVID-19. Since this EPP could be used by any implementing partner, programs could have adapted to provide SRHR services through the pandemic. This action moderately promoted SRHR in the MCH domain.

2020_Global Health eLearning Course_Bureau for Global Health Environmental Management Process Training

The 2020 Global Health eLearning Course on USAID’s environmental management process equipped USAID technical staff (e.g., Program Managers, Agreement Officer’s Representatives/Contracting Officer’s Representatives, Activity Managers) and other stakeholders with an introduction to the Global Health Initial Environmental Examination process and a roadmap for planning and implementing health programs consistent with the Agency’s legal requirements. The Course outlined the processes for conducting environmental assessments, plans, and reports to monitor and mitigate the intended or unintended impact of global health programs on the environment. Agreements that included certain activities were instructed to consult with relevant host country agencies as well as follow necessary permit requirements and instructions, which was aligned with evidence and best practice. The Course used a case study to guide readers through the environmental examination process, which was responsive to need. While the Course mentioned that most health activities generally did not require a complete environmental examination in accordance with the Code of Federal Regulations (CFR), it stated that projects with a categorical exclusion still require annual screenings to identify changes to the program that could require additional environmental review. This annual review process for health programs promoted accurate reporting and mitigated any impact on the environment, which was responsive to need. Climate change and environmental issues have a significant impact on SRHR, so this Course moderately promoted SRHR in the MCH domain.

2020_Global Health eLearning Course_HIV/AIDS Legal and Policy Requirements

The 2020 HIV/AIDS Legal and Policy Requirements Global Health eLearning Course provided an overview of the HIV and AIDS legislative and policy requirements that govern USAID-supported HIV and AIDS activities. The Course was designed to help USAID staff, implementing partners, and host country government representatives understand the requirements related to medically accurate information about condoms, VMMC, FP and HIV integrated activities, abortion and involuntary sterilization restrictions, and other topics relevant to HIV and AIDS programs. The Course mentioned that women living with HIV should have access to PMTCT along with safe and respectful pregnancy counseling, ANC, and childbirth services, which was aligned with evidence and human rights. The Course defined the tenets of voluntarism and informed choice, which are consistent with human rights, and included an informative table explaining the policies, requirements, and amendments that applied to specific types of funds and programs in 2020, which was responsive to need and based in evidence. It explained the Protecting Life in Global Health Assistance (PLGHA) policy, though it did not include guidance on the March 2019 expansion, which was not responsive to need. Though complete detail about the PLGHA policy was lacking, the Course was informative and based in evidence as it provided references to external sources and other trainings to provide additional information. The Course was gender accommodating as there were few sections specifically related to gender outside of PMTCT though the Course used outdated gendered terms like “female condom,” which was not aligned with evidence nor was it gender transformative. This Course moderately promoted SRHR in the MCH domain.

2020_Global Health eLearning Course_Protecting Life in Global Health Assistance and Statutory Abortion Restrictions-2020

The 2020 Global Health eLearning Center Course on the Protecting Life in Global Health Assistance (PLGHA) policy and other statutory abortion restrictions provided USAID staff and implementing partners with technical knowledge about the legal and policy restrictions on abortion-related activities and how to properly implement them through global health programs. The Course described the programs and activities to which the PLGHA policy and other statutory abortion restrictions apply. It also provided recommendations for how to ensure that programs are compliant with these restrictions and included guidance on how to investigate a violation. The Course included the specific exceptions in which health care providers can provide information on abortion and defined the affirmative duty of providers, which was responsive to need. The Course clarified that PLGHA did not apply to post-abortion care (PAC), which was responsive to need and consistent with human rights norms. The Course included some compliance guidelines and was consistent with the May 2019 Standard Provision and data from the 2018 six-month review of the implementation of the PLGHA policy. However, it primarily provided guidance on what activities are not permitted under the policy and could have more clearly supported PAC, comprehensive FP, and other efforts that are not prohibited under the policy. The Course encouraged staff to “be aware of perceptions among program managers, clients, and providers that may suggest potential vulnerabilities,” which was not responsive to need as it could lead to unnecessary oversight of people’s personal or professional beliefs that are not relevant to their implementation of PLGHA and other abortion restrictions. The Course was not fully responsive to need as it did not include implementation information specific to USAID global MCH programs, including ANC visits during which programs may encounter people who became pregnant as a result of rape. Additionally, the Course was not gender transformative as it did not use gender inclusive language (e.g., “pregnant persons”). This Course moderately hindered SRHR within the MCH domain.

2020_Global Health eLearning Course_U.S. Family Planning and Abortion Requirements

The 2020 Global Health eLearning Course on U.S. FP and abortion requirements provided technical guidance on abortion-related statutes that apply to all U.S. foreign assistance funds. The Course discussed the Helms Amendment but predominantly focused on requirements that apply specifically to FP assistance funds, particularly the Tiahrt Amendment. The Tiahrt Amendment dictates how USAID-supported FP programs deliver services. This component of the Course was based in evidence and human rights norms because the restrictions outlined in the Tiahrt Amendment have been endorsed by USAID and the WHO as a standard for protecting the human rights of people that access FP programs and services. The Course was responsive to need as it provided vital information on voluntarism and informed choice as the cornerstone of all FP programs implemented by USAID. It included guidance about providing proper counseling on FP, including offering contraceptives with method mix at each service delivery point. The Course described the protections under the Tiahrt Amendment for people that access maternal health services who have had a certain number of live births and do not accept FP or contraceptives, which was consistent with human rights. The Course was gender blind, as there were no mentions of gender or of how to implement these policies in a way that addressed unequal gender norms. While this Course was useful to guide FP activities, it was not clear how this guidance should be adapted for integrated programs that also provide MCH services. This Course moderately promoted SRHR in the MCH domain.

2020_Guide for Adopting Remote Monitoring Approaches during COVID-19

USAID released the Guide for Adopting Remote Monitoring Approaches during COVID-19 in May 2020 and it provided guidance and information to USAID staff and implementing partners about when and how to employ remote monitoring techniques as programs continue to be implemented amidst COVID-19 restrictions. This Guide was responsive to need as it stated that awards should not be amended more than is necessary and that awards should remain in compliance with the initial award conditions. It indicated that missions and partners should gather feedback from beneficiaries of activities that have been altered due to COVID-19 to remain informed of their current needs and make decisions regarding program adaptation. The Guide did not provide specific details for how to adapt remote monitoring techniques or digital technology for MCH programs but did include updates to the Site Improvement through Monitoring System (SIMS) deadlines for monitoring and reporting on PEPFAR targets during COVID-19, which included monitoring of activities related to MCH, such as PMTCT and HIV prevention for pregnant people. The Guide was gender accommodating as it called for implementing partners to monitor how the demographics of a target population may impact their access to and use of digital technology for remote monitoring based on gender, age, and disability and it directed implementers to “account for any biases” that may impact people’s access to digital technology. While this element of the Guide supported SRHR, it did not provide explicit guidance for implementing partners to overcome the barriers that people may experience due to their gender, age, or disability. This Guide moderately promoted SRHR in the MCH domain.

2020_President’s Interagency Task Force: Report on U.S. Government Efforts to Combat Trafficking in Persons

This report discussed the U.S. government's 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 accessing 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. Several of USAID's approaches and projects contributed to this whole-of-government strategy, including the Agency’s flexible approach to programmatic decisions to account for COVID-19, launching the Safe Migration in Central Asia project, and facilitating interagency coordination to streamline international and domestic grants. However, it was unclear whether these programs were funded through global health assistance, and therefore contributed to low transparency. The Report moderately 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 PLGHA summarized the history of the policy and presented findings from a review of the policy’s implementation throughout U.S. global health assistance programs since 2017. The Review found that in certain cases where USAID partners declined awards due to the PLGHA policy, the loss of trusted partners in-country resulted in difficulties replacing these partners and caused subsequent disruptions in healthcare services across technical areas. Specifically, the Review found that the loss of partners resulted in delays in the implementation and distribution of USAID’s services related to HIV and AIDS, MCH, voluntary FP, tuberculosis, and nutrition. The Review acknowledged that the declination of awards impacted MCH services, however, USAID reported that the Agency worked around this obstacle to transition services to new recipients with “minimal disruption.” This indicated that USAID’s implementation of the policy and their ability to adapt to new partners was responsive to need. While the PLGHA policy itself did not promote SRHR, the role played by USAID in providing mechanism-level data for this report was responsive to need and based in programmatic data and evidence, which provided a clear overview of USAID’s implementation of the policy. The Review moderately promoted 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, in collaboration with other U.S. implementing agencies including USAID, released the Strengthening Health Security Across the Globe annual report that identified the U.S. government’s contributions to global health security by country and U.S. government agency. Though several areas of global health were mentioned throughout the report, programs related to MCH were noticeably absent. For example, the Report mentioned several infectious diseases that pose 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. There was no mention of other areas of SRHR that impact health security such as FP or GBV, so this report was not fully based in evidence. SRHR is a critical aspect of global health security. Neglecting to mention SRH 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 advancing gender equity and the countering of harmful norms that affect women and girls. 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. This Report moderately hindered SRHR in the MCH domain.

2020_United States Strategy to Prevent Conflict and Promote Stability

2020_USAID Digital Strategy 2020-2024

The Digital Strategy described the Agency's vision for the responsible use of digital technology in international development and humanitarian work. The goal of this strategy was to sustain digital ecosystems that increase self-reliance as well as promote positive development and humanitarian assistance outcomes. The Strategy described the mechanisms through which USAID staff will achieve these goals and highlighted previous successes with incorporating digital technologies into USAID’s activities. The Strategy also noted the importance of digital infrastructure amid COVID-19, which was responsive to need and based in evidence as it promoted the use of telemedicine to protect health care workers and patients while also providing vital health services. The Strategy included examples of successful uses of digital technology to support MCH activities, including the use of a smartphone-based app to treat children with severe malnutrition in Tanzania. It cited USAID’s use of geospatial analysis and mapping to support the “Saving Mothers Giving Life” program in Western Uganda, demonstrating a 30% decline in maternal mortality in the area, which was based in evidence and responsive to need. The human rights basis was explicitly stated in the Strategy, as it detailed the potential for “digital authoritarianism” to infringe on human rights. The Strategy was gender aware because it acknowledged gender disparities and the “gender digital divide” which contributes to inequitable use of technology across genders, though it used a gender binary to describe these impacts and did not use inclusive language. The Digital Strategy set a positive tone for the use of these technologies and digital infrastructure in USAID's MCH activities and moderately promoted SRHR in this domain.

2020_USAID Gender Equality and Women’s Empowerment 2020 Policy

This Policy detailed USAID’s investment in and commitment to supporting gender equality and women’s empowerment efforts to date. It outlined the strategic objectives and principles necessary for the Agency to achieve this vision and increase self-reliance in partner countries. The Policy referenced global health programs and cross-cutting issues related to SRHR, including activities to eliminate GBV, increase the capability of women and girls to exercise their “basic and legal rights fully,” and improve women and girls’ access to education and employment. Regarding MCH, the Policy described the impact of malaria and Zika during pregnancy on maternal and neonatal health outcomes and the inclusion of this data at the intersection of health areas like infectious diseases and MCH was based in evidence. The Policy also included other examples of the impact of gender inequality on MCH outcomes, such as the association between child and early forced marriage (CEFM) and poor maternal and newborn health outcomes, and the positive impacts of women’s education on lower maternal and infant mortality, which were based in evidence. The Policy was not grounded in human rights norms or responsive to need because of its exclusion of LGBTQI+ people and its basis in “unalienable rights,” which do not include all international human rights. Exclusion of LGBTQI+ people was not based in evidence as research shows that members of the LGBTQI+ community are at an increased risk of experiencing GBV and other inequitable gender norms compared to the general population that limit their access to health services, education, employment, and other measures of empowerment. The 2020 version of this policy was not responsive to need because it was less inclusive than the previous version from 2012, which explicitly included all people regardless of gender identity, disability status, HIV and AIDS status, geographic area, and migratory status. It did not acknowledge the contribution of SRHR programs to gender equality efforts. Additionally, the Policy was not gender transformative due to its use of a gender binary and exclusion of LGBTQI+ people, but was gender accommodating because it acknowledged the impact of existing gender inequities in global health and development areas. This policy moderately hindered SRHR in the MCH domain.

2020_USAID MOAA COVID-19 Implementing Partner Guidance_Frequently Asked Questions Published on 11.03.2020

This Guidance from the Bureau for Management Office of Acquisition and Assistance (MOAA) within USAID compiled all questions related to COVID-19 from implementing partners in one place with clear answers and guidance. The Guidance was regularly updated throughout 2020, which was responsive to need. The primary section related to global health program implementation was the section about PEPFAR and USAID Guidance, which answered questions related to the roles of PEPFAR and USAID staff, outlined how PEPFAR programs could be used to respond to COVID-19, and provided external references for additional technical guidance for PEPFAR programs. However, information about adapting the implementation of MCH activities, including those conducted through PEPFAR programs, was lacking, which was not responsive to need in this domain. The Guidance was not gender transformative as it did not include information about adapting programs in response to the disproportionate impact of COVID-19 on women and girls and the rise in GBV, which was a gap. Given the lack of detail regarding MCH activities, this Guidance neither promoted nor hindered SRHR in this domain.

2020_USAID Over the Horizon Landscape Analysis and Snapshot

This Snapshot described how USAID aimed to shift its programming to accommodate a world altered by the COVID-19 pandemic. The Snapshot highlighted the persistence of inequities in access to essential services as well as the adverse impact of the pandemic among “vulnerable and marginalized groups,” but did not define these groups, establish the evidence base, or define the human rights framework as the foundation for this action. The Snapshot mentioned the increased risk of GBV due to COVID-19, which was based in evidence and responsive to need. The Snapshot listed USAID's responses to the pandemic and described the active USAID development policies, field consultations, partner roundtables, and collaborative research that was used to adapt operations to respond to COVID-19. The action anticipated “significant backsliding” on progress toward development goals and listed MCH as an impacted program area, but despite this, specific adaptations for MCH activities and programs were not included in its strategic objectives or future recommendations, which was not responsive to need or based in evidence. This Snapshot was gender accommodating because it aimed to increase women’s participation in pandemic relief efforts but did not document the disproportionate impact of COVID-19 on women and girls beyond GBV. This Snapshot neither hindered nor supported USAID's ability to promote SRHR during the COVID-19 pandemic in the MCH domain.

2020_USAID Policy on Promoting the Rights of Indigenous Peoples

This policy provided guidance for engagement and partnerships on projects that impact Indigenous Peoples and detailed USAID’s efforts to engage them as “meaningful partners” in Agency program development processes. The Policy stated the importance of ensuring that activities like data collection are conducted in a way that is responsive to Indigenous Peoples’ input and needs through the free, prior, and informed consent (FPIC) process, which is a vital component of Indigenous organizing that respects their rights and autonomy. The Policy was grounded in human rights as it included adherence to international standards of human rights as a central pillar but did not acknowledge the impact of colonization and occupation on the health and wellbeing of Indigenous communities. With respect to health outcomes, the Policy acknowledged that many Indigenous groups experience worse health outcomes compared to national or regional averages, especially in areas relevant to MCH such as infant mortality and child malnutrition, which was based in evidence. The Policy posed potential solutions such as integrating programs and promoting cross-sectoral development approaches to expand the availability of assistance that Indigenous peoples could access, which was evidence-based and responsive to need. However, the Policy did not elaborate on these approaches or explain how USAID and implementing partners should implement these programs. There were several missed opportunities to discuss many SRHR issues, including maternal health outcomes and services like Indigenous midwifery and maternal mortality among Indigenous peoples. This Policy applied to all USAID activities, including global MCH programs, so the lack of discussion on how these programs and activities should be adapted to better serve Indigenous peoples was a gap in USAID's approach. The Policy was not responsive to need or based in evidence in the MCH domain. Additionally, the Policy was gender accommodating as it acknowledged cultural norms and other factors that could impact the decision-making rights of Indigenous women but did not provide adequate guidance for overcoming or changing those norms. This Policy neither promoted nor hindered SRHR in the MCH domain.

2020_USAID Policy on Protection from Sexual Exploitation and Abuse (PSEA)

This Policy detailed USAID's operating procedures to protect individuals from sexual exploitation and abuse (SEA). This policy applied to all USAID-funded services and activities. It intended to center the needs and perspectives of survivors and employed USAID's zero-tolerance policy for inaction on allegations of SEA. The Policy acknowledged the power dynamic that drives many instances of SEA and identified the need for increased attention for vulnerable groups including “women and children, and those most at risk of discrimination on the basis of disability, gender identity and sexual orientation, race, ethnicity, age, or religion.” This level of specificity indicated an inclusive understanding of how people’s identities shape their experiences of SEA. The Policy was responsive to need and grounded in human rights norms as it prioritized the safety of people that participate in USAID programs. However, it was not evidence-based because evidence indicates that there are numerous health and SRHR needs that arise as a result of SEA that were not mentioned in this policy, such as maternal mortality and morbidity. Like GBV, SEA is a cross-cutting SRHR issue and warrants an integrated response for both prevention and treatment, which was lacking in this policy. The Policy was gender accommodating as it was inclusive of all peoples’ experiences though did not adequately describe how the Policy would overcome gender norms that both contribute to SEA and prevent people from receiving care for SEA. This Policy moderately hindered SRHR in the MCH domain.

2020_USAID Protecting Life in Global Health Assistance Letter to Implementing Partners_30 October 2020

2020_USAID’s Women, Peace, and Security Implementation Plan

The Women, Peace, and Security (WPS) Implementation Plan outlined USAID's efforts to support the U.S. government’s WPS Strategy through development and humanitarian assistance. The Implementation Plan expanded on the role of USAID’s in fulfilling the WPS Strategy’s focus on women and girls’ empowerment to overcome crisis, conflict, and fragility to promote the self-reliance of partner countries. This Plan was somewhat based in evidence and responsive to need as it identified several factors that can promote women’s empowerment but did not recognize the importance of addressing individual SRHR needs as part of this Plan. The main mentions of health outcomes related to SRHR throughout this Plan were in the context of GBV, as well as “teenage pregnancies” that result from violence. However, the exclusion of other areas of SRHR, such as MCH, downplayed the importance of these health outcomes in empowering women and accomplishing the goals of the WPS Strategy. The Plan was not fully consistent with human rights norms as it excluded LGBTQI+ people in its efforts to achieve gender equality. Additionally, the Plan was gender accommodating as it worked to empower women within existing gender norms but did not use gender inclusive language throughout the Plan, nor did it outline a strategy for changing inequitable gender norms through USAID’s programs. This Plan moderately hindered SRHR in this domain.

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_August 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.

2015_Acting on the Call

2015_Ending Preventable Maternal Mortality: USAID Maternal Health Vision for Action Evidence for Strategic Approaches

2014_Acquisition and Assistance Policy Directive (AAPD)

2013_Counter-trafficking in Persons Field Guide

2012_Ending Child Marriage and Meeting the Needs of Married Children: The USAID Vision for Action

2012_Gender Equality and Female Empowerment Policy: USAID Policy

2012_United States Strategy to Prevent and Respond to Gender-based Violence Globally

2012_USAID Implementation of the United States National Action Plan on Women, Peace, and Security

D+

C-

Family Planning (FP)

USAID received a 67 (D+) with transparency and a 71 (C-) without transparency in the Family Planning domain in 2021. This domain grade was raised by actions outlining the Agency’s response to the COVID-19 pandemic in a manner that promoted SRHR, such as the USAID Implementation Plan for the U.S. COVID-19 Global Response and Recovery Framework and Issues and Recommendations on Gender-Based Violence Prevention and Response in COVID-19 Programming. The decision to remove the PLGHA section in ADS Chapter 303 without offering additional information or guidance for partners to adapt their programs significantly hindered SRHR. Overall, transparency was low for many actions graded in this domain because USAID did not indicate which content had been updated in 2021 from previous versions. USAID had a high level of transparency of funding data but did not disburse FP funding in a manner that was responsive to need, which decreased this actor’s grade in this domain.

The CHANGE data index grades government agencies on policies and funding impacting family planning, maternal and child health, and HIV & AIDS foreign assistance.

Selecting a document will download the file

2021_Acting on the Call

The 2021 Acting on the Call Report documented the impacts of U.S. global health financial investments in and commitments to providing critical health services to women, children, and families around the world. As stated in this report, USAID focuses on the goals of equity, quality, and resource optimization and integrated approach to primary health care to ensure that global MCH programs are implemented where burden is highest, which was responsive to need. This action described the adaptations implemented by USAID through global MCH programs in response to the COVID-19 pandemic and climate change, including the provision of contraceptives during COVID-19 lockdowns, which were responsive to need and based in evidence. This action included reporting on a few FP indicators, such as the usage of a modern method of contraception, and FP activities were meaningfully included throughout the Report as they pertained to promoting MCH and providing essential health care. However, there was no mention of the human rights framework USAID uses to support integrated FP/MCH programs. This action was gender accommodating as it used gendered language throughout (i.e., referred to women’s use of contraception) and did not address harmful social and gender norms that impact people receiving FP services. This action moderately promoted SRHR in the FP domain.

2021_ADS Chapter 200_2021.01.15

ADS Chapter 200 described USAID’s process for creating development policy, as well as the development policy universe that affects all of the Agency’s programs and actions. This chapter was edited in January 2021 to update the link for the Agency-wide Policy Framework, which is the Agency’s highest level policy document and was intended to guide decision-making across USAID. However, the URL for the current Agency Policy Framework was broken and the Agency Policy Framework was not available elsewhere on USAID’s website, which negatively affected transparency. This action neither hindered nor promoted SRHR in the FP domain.

2021_ADS Chapter 201_2021.09.21

ADS Chapter 201 defined the USAID Program Cycle, which is the Agency’s operational model for planning, delivering, assessing, and adapting development programs that advance U.S. foreign policy. Several sections of ADS Chapter 201 were updated in September 2021, including an update to the definition of “activity design” to include policy dialogue, stakeholder coordination, and capacity building. ADS 201 also included an updated Project Design and Implementation section that encouraged integration and coordination across projects for greater sustainability. Many of these edits were responsive to need and aligned with evidence and best practice. Additionally, the responsibilities of the Gender Advisor at the USAID Mission level were updated to include ensuring that “gender equality” was integrated into the design and implementation of activities, which was only somewhat gender transformative. This ADS chapter still used gendered language like “female empowerment” and did not address efforts to empower people of diverse SOGIESC. The updates to ADS Chapter 201 moderately promoted SRHR in the FP domain.

2021_ADS Chapter 303 Materials_2021.02.04

2021_ADS Chapter 303mab_2021.03.31

ADS Chapter 303mab, Standard Provisions for Non-U.S. Nongovernmental Organizations, was updated in March 2021 to update section M2. Accounting, Audit, and Records. A new subsection outlined the requirement that recipients of grant or cooperative agreement funding had to provide USAID and other USG officials with “timely and reasonable access” to materials, records, and personnel necessary to complete audits and other oversight processes. This update would apply to U.S. global health programs, but it was unclear whether it would affect the implementation of activities related to SRHR. This action neither hindered nor promoted SRHR in the FP domain.

2021_ADS Chapter 303_2021.06.07

ADS Chapter 303 was updated again in June 2021 to revise section 303.4.2: Internal Mandatory References. However, none of the individual internal mandatory reference documents were highlighted in this section to indicate that they had been updated, which negatively affected transparency. Highlighting updated content in USAID’s ADS documents would have helped the reader understand which material had been edited in the revised version. The action neither promoted nor hindered SRHR in the FP domain.

2021_ADS Chapter 303 Materials_2021.07.29.

ADS Chapter 303 was revised in July 2021 to update Section 303.3.5.5: Unsolicited Concept Papers and Applications. The update provided a link to a new Internal Mandatory Reference document: Guide to Unsolicited Applications (303mbd), which provided guidance and procedures for USAID’s review of unsolicited applications. According to this action, “unsolicited applications provide a method for organizations to submit unique, innovative, or proprietary approaches for solutions to development challenges” and USAID is responsible for determining whether funding such applications would be aligned with the Agency’s development objectives. The addition of this internal mandatory reference document could help ensure that USAID funds programs that were responsive to need and not based solely on USAID’s procurement processes. This action was based in evidence and responsive to need as the materials clearly stated that all applications would be reviewed by the programmatic and technical officers to determine strategic alignment with Agency priorities. This action moderately promoted SRHR in the FP domain.

2021_ADS Chapter 308_2021.02.26

ADS Chapter 308, entitled: Agreements with Public International Organizations (PIOs), was updated in February 2021 to state that “PIOs are important partners for the Agency, and many PIOs possess unique comparative advantages.” This action also stated that USAID’s OUs would work with PIOs whenever it was in the best interest of the Agency, which could have fostered partnerships that promoted SRHR through U.S. global health assistance. This action was updated to describe the Organizational Capacity Review process to ensure that a PIO’s organizational framework and operational capacity would add value to USAID’s work. This legal due diligence process was vital to successful partnerships. This action moderately promoted SRHR in this domain.

2021_ADS Chapter 308mab_2021.06.15

ADS Chapter 308mab was a mandatory reference for ADS Chapter 308 entitled: Standard Provisions for Cost-Type Agreements with Public International Organizations (PIOs) and was revised in June 2021. Section M19. Sexual Exploitation and Sexual Abuse and Sexual Harassment was updated to outline USAID’s zero-tolerance policy for inaction to addressing SEA and sexual harassment in all agreements with PIOs. This action required PIOs working in partnership with USAID to apply the IASC Six Core Principles Relating to Sexual Exploitation and Abuse, referenced the United Nations Protocol on Allegations of Sexual Exploitation and Abuse Involving Implementing Partners, and defined a “victim/survivor-centered approach” to SEA and sexual harassment, which aligned this action with evidence and grounded it in human rights. The updated ADS Chapter 308mab also stated the requirement for PIO partners to make “reasonable and adequate efforts to address gender inequality and other power imbalances” in their programing, which called for the integration of gender transformative approaches. This action moderately promoted SRHR in the FP domain.

2021_ADS Chapter 312_2021.09.08

ADS Chapter 312 contained information on USAID-financed condoms, pharmaceuticals, and medical supplies designed for USAID technical and procurement staff as well as implementing partners. This chapter was updated to add medical gloves and syringes to the list of laboratory supplies that did not require ADS 312 approval and confirmed that certain USAID technical and programmatic staff had the delegated authority to make determinations about specific pharmaceuticals. It was unclear how these updates would impact the implementation of USAID’s global FP programs. This action neither hindered nor promoted SRHR in the FP domain.

2021_Assessing Feasibility and Readiness for Cargo Drones in Health Supply Chains

This report shared the findings of scoping visits in Malawi that explored the feasibility of cargo drones to support global health supply chains with the long-term goal of avoiding stockouts, responding to emergency medical requests, and speeding up diagnostic sample delivery time to benefit global beneficiaries. This action was responsive to need due to supply chain distribution issues that resulted from the COVID-19 pandemic. This action explicitly stated that these findings would not be applicable across all contexts, but that the approach outlined in this report could be adapted for different limited-resource settings. This action also suggested that a root cause analysis should be completed to improve project design and inform implementation, which was based in evidence. The guide discussed other best practices that were responsive to need such as market research, scoping trips, and informational interviews with stakeholders at all levels, from the national government to community health workers. The action included guidance for engaging with community members and designing culturally appropriate community sensitization activities through a participatory approach, which was responsive to need. However, the guide did not include the human rights framework that should be considered when designing drone initiatives. It laid the foundation for future work that could be applied across U.S. global health programs. This action moderately promoted SRHR in the FP domain.

2021_Considerations for COVID-19 Response_Digital Accessibility

This action outlined the importance of digital accessibility, particularly during the COVID-19 pandemic, and offered key considerations for designing accessible digital interventions through a universal design approach which was based in evidence. These suggestions, such as involving disability advocacy organizations in digital design processes and adding alt-text to photos, were responsive to need, based in evidence, and aligned with human rights norms. This action built upon USAID’s first-ever Digital Strategy, which was released in 2020. This action acknowledged that lack of access due to disability was intersectional to other inequities, which was based in evidence, but was gender blind as it did not specify the ways in which a person’s gender could be a barrier to access. This action supported the ability of USAID’s global FP programs to be more inclusive of persons with disability. This action moderately promoted SRHR in this 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. The FP-specific indicators were included within the section that focused on USAID’s global MCH programs. Like the MCH indicators, FY 2022 targets were not listed for the FP indicators in this action. Setting targets at the beginning of the FY is an important way to measure progress to ensure that programs are performing well and are responsive to need. It was unclear why targets were not included for USAID’s global FP activities in FY 2022, so this action was not fully based in evidence and negatively affected transparency . The Report was gender accommodating as it used language that reinforced a gender binary. It also implied that only “mothers” use contraception, and thus excluded other people that use contraception, which was not responsive to need or based in evidence. This action moderately hindered SRHR in the FP domain.

2021_Diversity, Equity, and Inclusion Strategy_Executive Summary

In 2021, USAID released the Executive Summary for the forthcoming Diversity, Equity, and Inclusion Strategy. The full Strategy was not publicly available at the time of grading, but the Executive Summary described USAID’s plan to enhance diversity across the Agency, promote inclusion and equity among Agency staff, and strengthen accountability for DEI efforts. This action described the methodology that USAID implemented to design the complete DEI Strategy, including stakeholder interviews, focus groups, listening sessions, and consultations at all levels of the Agency. While this approach and the overall goals of the DEI Strategy outlined in this action appeared to be responsive to need, based in evidence, and aligned with human rights, it did not explain how the complete Strategy would impact U.S. global health programs and operations. Though releasing this Executive Summary was responsive to need, this action likely would not have an impact before the complete Strategy was made available. This action neither promoted nor hindered SRHR in the FP domain.

2021_Family Planning and Reproductive Health Program Overview

This Overview detailed the scope of the FP/RH Program at USAID and described the benefits of FP to women and children's health, reducing poverty, preventing HIV infections, reducing high-risk pregnancies, and allowing time to space pregnancies. The Overview was guided by the principles of voluntarism and informed choice, which was responsive to need, based in evidence, and aligned with human rights. The Overview stated that the RH portfolio was integrated with MCH, HIV, and GBV programming, as well as highlighted the impacts of FP on preventing mother-to-child transmission of HIV and maternal and child deaths, which was responsive to need and based in evidence. However, the Overview included the mitigation of the impacts of population dynamics as a benefit of FP, which promoted population control and was not in line with best practices or human rights. It listed "decreases abortion" as a benefit of FP, which stigmatized abortion care and did not recognize the importance of post-abortion care (PAC) in RH programming. This action did not mention whether emergency contraception (EC) was a component of USAID’s FP/RH program, which was lacking. Additionally, the Overview highlighted USAID’s “successful” programming of FP/RH health assistance when the GGR was in effect from 2017 to 2021 but did not reference the negative impacts of the GGR on FP programs, including the fragmentation of health services when prime partners declined to certify the policy. As a result, this action was not fully based in evidence in this domain. While the Overview mentioned addressing gender norms in the RH portfolio, it was gender accommodating as it primarily used language that enforced a sex and gender binary. This Overview moderately promoted SRHR in the FP domain overall because it outlined the evidence and human rights framework USAID uses to support FP/RH programs rooted in voluntarism and informed choice.

2021_Global Health eLearning Course_Antimicrobial Resistance_Part 1

This eLearning course explored antimicrobial resistance as it pertained to diseases such as TB, gonorrhea, malaria, and HIV. The Course described the potential reversal of progress made against these public health challenges, as well as the reality that resistance to common medications has increased in recent years, which has resulted in an increased burden on health systems. The Course included the complications associated with untreated gonorrhea and the increasing resistance to several antibiotic treatments. However, the Course did not discuss the effectiveness of contraceptive methods in preventing gonorrhea, which was not responsive to need or based in evidence. The action did not advance SRHR beyond monitoring resistance to antibiotic treatments, which may impact SRH outcomes related to fertility, pregnancy prevention, or sexual pleasure. It was gender accommodating as it used gendered language when discussing risk of antibiotic resistance. This action did not clarify which content was updated in the latest version of this eLearning course, which negatively affected transparency . This action neither promoted nor hindered SRHR in the FP domain.

2021_Global Health eLearning Course_Applying Segmentation to SBC in Family Planning

This eLearning course provided information about the benefits of incorporating segmentation—or dividing a population into subgroups with "meaningfully similar characteristics, and significant differences from other subgroups"—for the purposes of SBC research and programming. The Course primarily focused on incorporating SBC into FP programming, however the guidance in the Course could be applied to other areas of global health beyond FP. The Course covered several case studies where different SBC approaches could be used to address a wide range of contexts, which was responsive to need. The Course emphasized the need to use segmentation to ensure that messages and services are specifically designed to reach a target audience and use resources effectively, which was based in evidence and responsive to need. The Course highlighted the opportunity to segment by socio-demographic data but stated that optimal segmentation is through a combination of behaviors and attitudes that better reflect the community, which was based in evidence and responsive to need. The Course received a low transparency score as it was not clear what was updated from previous versions of the training. The Course was gender accommodating as it used gendered language that reinforced a gender binary. The Course moderately promoted SRHR in the FP domain.

2021_Global Health eLearning Course_HIV/AIDS Legal and Policy Requirements

This eLearning course provided guidance about the legal and policy requirements that applied to global HIV programs supported by U.S. global health assistance funds. The Course provided information on a wide variety of topics including condoms, sex work, working with local partners such as faith-based organizations or law enforcement, VMMC, FP/HIV integrated services, restrictions related to abortion and involuntary sterilization, and ensuring compliance with these USG requirements. The Course provided useful information to support organizations with implementing these policies, which was responsive to need. However, it mostly focused on restrictions instead of what was allowed under U.S. policy at the time. Though the Course was updated to remove all mentions of PLGHA, removing all references to this policy without providing information about its revocation or guidance for partners on how to implement programming in its absence was not consistent with evidence, responsive to need, or aligned with human rights. The Course highlighted opportunities to support programming such as FP/HIV integration across PEPFAR programs and provided information about which commodities could be purchased with PEPFAR funding, which was responsive to need, based in evidence, and aligned with human rights norms. While the Course included some gender transformative elements such as the implementation of DREAMS programming, it was gender accommodating as it used gendered language and did not include guidance on addressing gender norms in FP/HIV integrated programming. The Course did not highlight what was updated or changed for 2021, which negatively affected transparency . This action neither promoted nor hindered SRHR in the FP domain.

2021_Global Health eLearning Course_U.S. Family Planning and Abortion Requirements

The 2021 eLearning Course on U.S. Family Planning and Abortion Requirements provided an overview of the FP and abortion legislative and policy requirements that apply to U.S. foreign assistance funding and programs. The Course primarily focused on the principles of voluntarism and informed consent through the Tiahrt amendment, which was based in evidence and human rights norms as these principles are regarded as the standard for protecting the human rights of people that access FP services worldwide. The Course emphasized that it was the responsibility of USAID staff to discuss legislative abortion restrictions with implementing partners throughout the life of the award to ensure awareness of the restrictions, which was responsive to need. However, it did not clearly state which information was changed for 2021, which negatively affected transparency . Furthermore, it did not mention the Biden administration's policy to support SRHR globally. It also did not include vaginal rings as a method of contraception, and therefore was not reflective of the full scope of contraceptive methods available. While the Course mentioned the revocation of the PLGHA policy, it stated that the policy was no longer in effect and that implementing partners still had to comply with other abortion-related restrictions, which was not enough detail or guidance for partners to understand how to implement this policy change. As a result, this action was not fully responsive to need, based in evidence, or consistent with human rights norms. The Course encouraged staff to "be aware of perceptions among program managers, clients, and providers that may suggest potential vulnerabilities," which could lead to unnecessary oversight of people's personal or professional beliefs that would not be relevant to their implementation of abortion restrictions. The Course was gender blind as it did not include a meaningful or inclusive discussion of gender. This Course moderately hindered SRHR in the FP domain.

2021_Issues and Recommendations on Gender-Based Violence Prevention and Response in COVID-19 Programming

This action provided guidance and recommendations for how to include GBV prevention and response efforts in COVID-19-related programming. The action highlighted the increase in GBV during the pandemic, particularly in the form of online and offline harassment, SEA, CEFM, FGM/C), LGBTQI+ abuse, and abuse towards female health workers. This action recognized the lack of health services available to GBV survivors due to health care supplies being diverted away from GBV and SRHR services in favor of COVID-19 mitigation and called for the integration of GBV prevention and response efforts into the health service response to COVID-19. This recommendation was responsive to need and based in evidence. The action provided recommendations for implementing GBV risk mitigation measures, which were responsive to need, based in evidence, and aligned with human rights norms. While SRH services were mentioned one time, the guidance should have explicitly included the promotion of SRHR as a vital component of the pandemic response. The Report did not mention FP, sexual health, contraception services, including EC, which was not responsive to need as it did not recognize the FP-related services that may be needed by GBV survivors. This action was somewhat gender transformative as it advocated for the implementation of SBC activities to promote healthy masculinities and gender equitable relationships, though it used language that reinforced a sex and gender binary. The Report moderately promoted SRHR in the FP domain.

2021_Population, Environment, And Development Integration

This Fact Sheet provided an overview of USAID's Population, Environment, and Development (PED) approaches to integrated development solutions. The Report detailed the strategic objectives of this approach and the cross-sectoral benefits of PED approaches. It included voluntary FP as a cornerstone of this approach, which was aligned with human rights norms. It promoted efforts to increase resilience of women and households following crises and emphasized the importance of integrating FP, nutrition, and income generation to increase community resilience, which was responsive to need, but did not explicitly promote SRHR. The Report mentioned the importance of managing population growth and dynamics by increasing women's engagement in conservation and natural resource management and decreasing population-driven pressures on the environment. This inclusion promoted a "population control" mindset and was not based in evidence, human rights, or best practices. The Report was gender accommodating as it recognized the importance of women and girls' empowerment and agency to foster development and better health outcomes but reinforced a sex and gender binary. This action neither hindered nor promoted SRHR in the FP 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 efforts led by USAID. 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 USAID's other global health security efforts, including those related to global FP 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 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 FP domain.

2021_United States Government Women, Peace, and Security (WPS) Congressional Report

The WPS Congressional Report provided Congress with an overview of progress specific USG agencies have 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 partnership. While improved global health outcomes were included as a positive impact of implementing the WPS Agenda, USAID’s global FP, contraception, and sexual health programs were not mentioned, though these areas are essential to the successful implementation of the WPS Agenda. However, the Report included GBV prevention and programming as a cross-cutting measure of progress towards achieving the WPS Agenda, which was responsive to need. The Report also highlighted USAID’s efforts to integrate WPS activities with other actions related to countering violent extremism and implementation of gender-sensitive interventions during the COVID-19 pandemic. It highlighted USAID's efforts to prevent CEFM and provide gender training for USAID personnel, which was responsive to need. The Report included specific and actionable milestones to measure the actor’s progress on these goals, which was responsive to need and could support evidence-based decision making in the future. 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 FP domain.

2021_USAID 2021 Climate Readiness Plan In Reponse to Executive Order 14008

The 2021 USAID Climate Readiness Plan provided an overview of how USAID plans to implement the directives listed in Executive Order 14008, which called for a prioritization of the climate crisis in the United States and globally. The Plan detailed USAID's role in implementing climate solutions in countries most affected by climate change, as well as called for USAID programs to incorporate lessons learned from the COVID-19 response to build climate resilience. The Plan called for increased collaboration with Indigenous peoples, women and girls, youth, and other groups that are disproportionately impacted by the climate crisis, which was responsive to need and based in evidence. It outlined USAID’s commitment to implement evidence-based decisions across the full scope of programs and revitalize USAID's approach to climate change adaptation, resilience, and mitigation targets. The Plan elaborated on how global health programs were being monitored for climate change vulnerabilities, particularly in relation to the availability of medical supplies for PEPFAR, infectious diseases, MCH and nutrition, and FP/RH programs, which was responsive to need and based in evidence. The Plan was gender accommodating because it acknowledged the gendered impacts of climate change but utilized gendered language that reinforced a gender binary. This Plan moderately promoted SRHR in the FP domain.

2021_USAID Health Systems Strengthening Learning Agenda

The USAID Health Systems Strengthening Learning Agenda provided a guide for how USAID’s global health programs should improve HSS programming. The Learning Agenda prioritized supporting high-performing health care; improving health system equity, quality, and resource optimization; advancing USAID's Vision for Health System Strengthening 2030; and supporting locally led efforts to develop sustainable, resilient health systems. These priorities were responsive to need and based in evidence. The Learning Agenda included questions for a variety of stakeholders that advance health system performance and resilience as well as prioritized health outcomes. It did not include FP/RH as priority health outcomes to focus on, which was lacking. The Learning Agenda directed stakeholders to implement robust HSS research and programming efforts that were based in evidence, responsive to need, and aligned with human rights. The Learning Agenda could have included more detailed information and guidance on how to adequately incorporate SRHR in these efforts. The Learning Agenda was gender accommodating as it mentioned gender as a cross-cutting area of focus but did not specifically discuss the gender norms that impact health systems and people’s access to health services. This Agenda moderately promoted SRHR in the FP domain.

2021_USAID Implementation Plan for the U.S. COVID-19 Global Response and Recovery Framework

2021_USAID Key Programming Questions to Address Gender and COVID-19 Infographic

This Infographic provided key questions to support USAID programs that implement gender inclusive programming related to COVID-19. The Infographic covered topics such as GBV; agriculture, food security, and nutrition; democracy, rights, and governance; environment; economic growth; health; child protection; education; and WASH. The Infographic emphasized the importance of providing "essential and routine health services" because of the pandemic but did not explicitly mention SRH services. The lack of specificity in this definition could have siloed SRH services from other services included in this action. It addressed the increased inequities and vulnerabilities faced by women and marginalized groups across these issue areas due to the pandemic which was evidence-based, aligned with human rights, and responsive to need. The Infographic also specifically mentioned "women and girls, men and boys, in all their diversity," which acknowledged the complexity of these identities in relation to people’s SOGIESC which was a gender inclusive approach to this issue. This action was gender accommodating as it recognized gender diversity but did not include questions to guide programs to overcome harmful gender norms. Overall, this action moderately promoted SRHR in this domain.

2021_USAID Memorandum Authorizing Disaster Relief Flexibilities to Reduce the Burden for Financial Assistance Pursuant to OMB Memorandum M-21-20

This Memorandum outlined the exceptions for USAID agreements and grant recipients that were impacted by the COVID-19 pandemic, including agreements that pertain to global health assistance. The Memorandum outlined the Agency’s authority to provide administrative relief not only to recipients with COVID-19-related financial assistance, but also to recipients that were implementing assistance awards unrelated to COVID-19. This was responsive to need as it recognized that partners may have had difficulty completing program activities due to the pandemic. The Memorandum also provided guidelines for increased flexibility with SAM registration procedures; NOFO publication requirements; and pre-award costs, no-cost extensions, and submission of financial, performance, or other reports, which was responsive to partners' needs. This action supported the implementation of global FP programs that could be flexible and adaptable during the COVID-19 pandemic. This Memorandum moderately promoted SRHR in this domain.

2021_USAID Nutrition Report to Congress_FY 2021

The 2021 USAID Nutrition Report to Congress included an overview of the Agency's approach to providing nutrition care and progress made toward the World Health Assembly targets on nutrition. The Report referenced the 2021 Lancet series on maternal and child undernutrition, which emphasized the importance of good nutrition for survival and the need to focus on "mothers and children in the 1,000 days window from pregnancy to age two." This action emphasized USAID's evidence-based and multisectoral approach to nutrition programming and highlighted the "unfinished agenda" of deficiencies in vitamins and minerals, gaps in the delivery of nutrition interventions, and the importance of incorporating maternal nutrition in health and food systems, which was based in evidence and responsive to need. The Report did not include any data or metrics about how nutrition programming was implemented within FP programming, which was lacking as nutrition is a cross-cutting issue that applies to people of reproductive age that may be using contraception or planning to get pregnant. Additionally, the Report was gender blind as it only referred to “pregnant and breastfeeding women,” which was not gender inclusive of the nutrition needs of pregnant people who do not identify as women. This Report neither hindered nor promoted SRHR in the FP domain.

2021_USAID Policy on Countering Trafficking in Persons

The USAID Policy on C-TIP outlined the principles that guided USAID's approach to implementing policies to combat trafficking in persons. The Policy defined USAID’s "survivor-centered and trauma informed" approach to supporting survivors of trafficking, which was responsive to need and based in evidence. It emphasized that survivors should receive shelter, food, counseling, health care, and legal assistance, which was responsive to need. It highlighted the adverse health outcomes that are common for survivors of trafficking, including work-related injuries or accidents, sexual and physical assault, STIs, infertility, forced abortion, substance abuse, chronic untreated medical conditions, malnutrition, and future victimization or perpetration of violence, which was based in evidence. These outcomes included issues relevant to SRH, which was responsive to need, but only mentioned "forced abortion," which was not inclusive of the need for safe abortion care in the case of an unwanted pregnancy. The Policy was gender accommodating as it included efforts to promote gender equity to prevent and address trafficking in persons but used gendered language throughout the Policy and did not actively demonstrate efforts to combat gender norms that enable trafficking. This Policy moderately promoted SRHR in the FP domain.

2021_USAID Report to Congress on Health Systems Strengthening for Fiscal Year 2020

2021_USAID Vision for Health System Strengthening 2030

The Vision for Health System Strengthening for 2030 highlighted USAID’s goals for implementing HSS activities across global health programs. The Vision incorporated equity into access to care and quality of care as well as emphasized the importance of collaborating with local partners to ensure the sustainability of health systems. The focus on addressing systemic barriers to providing equitable and essential care, especially for individuals that experience discrimination based on gender, age, and racial and ethnic disparities or other factors, was responsive to need and aligned with human rights. It promoted a definition of wellbeing that went beyond simply treating illnesses, which was based in evidence. The Vision cited the successes of programming related to the management of diseases such as TB and HIV and AIDS as a basis to translate technical guidance to address other burdens on health systems, which was based in evidence and responsive to need. The Vision mentioned current progress made towards reducing the unmet need for FP but highlighted the high unmet need in communities with the least access to trained and supported frontline health workers. The Vision highlighted the importance of connecting global health issue areas, such as FP, to address unmet need for health services, which was based in evidence. The Vision was somewhat gender transformative as it mentioned creating equitable gender norms as a facet of HSS, but used language that reinforced a sex and gender binary. This action moderately promoted SRHR in the FP domain.

2021_USAID’s COVID-19 Response Ending The Global Pandemic and Building Back Better

This Report highlighted USAID's response to COVID-19 and included details on the five objectives that guided the Agency’s pandemic response, including investments. The Report explored USAID’s experience providing access to vaccines, reducing morbidity and mortality from COVID-19, strengthening health systems, and addressing the increased needs of communities across sectors driven by the pandemic. The Report cited the Agency's efforts to support humanitarian responses by addressing GBV and providing primary and reproductive health services, which were responsive to need. The Report did not provide specific interventions or actions related to the implementation of activities that promote SRHR during the pandemic, so this action was not fully responsive to need, based in evidence, or consistent with human rights. The Report was gender aware as it recognized the impact of COVID-19 on women and girls but did not specifically address relevant gender norms and used gendered language. Throughout the Report, it was unclear how USAID’s global health programs were incorporated into the Agency’s COVID-19 response, which negatively affected transparency . If it was clear that the Report included objectives and results for USAID’s global health efforts, the Report would have promoted SRHR. This Report neither promoted nor hindered SRHR in the FP domain.

2020_Acting Administrator John Barsa Letter to UN Secretary General Guterres_18 May 2020

John Barsa, Acting Administrator of USAID, sent this letter to António Guterres, the UN Secretary-General, in May 2020 to oppose the inclusion of SRH services with other essential services in the UN’s Global Humanitarian Response Plan (Global HRP) for the COVID-19 pandemic. The letter criticized the Global HRP because it recommended distributing “abortion-inducing drugs and abortion supplies” in local country settings. The letter called for the removal of references to “‘sexual and reproductive health’ and its derivatives” from the Global HRP, which demonstrated USAID’s lack of commitment to providing comprehensive health services during a global pandemic. This action was not based in evidence or human rights because people still need to access SRH services—including FP services—during the COVID-19 pandemic. Furthermore, this letter was gender-blind because it did not acknowledge that women, girls, and gender-diverse people are disproportionately impacted by COVID-19 and could experience poor health outcomes such as unintended pregnancy if they could not access adequate FP services. This action was rooted in anti-abortion rhetoric rather than evidence, need, or human rights norms, and siloed SRH services from other essential services in the response to the pandemic. It significantly hindered SRHR in the FP domain.

2020_Acting on the Call

In honor of the International Year of the Nurse and the Midwife, USAID’s 2020 Acting on the Call Report focused on the role that nurses and midwives play in improving quality of care and increasing equitable access to essential health care to reduce maternal, newborn, and child mortality. The importance of providing voluntary FP was a cornerstone of this report and the extensive documentation of the integration of USAID’s FP and MCH programs in this report was responsive to need, consistent with human rights norms, and based in evidence. For example, postpartum FP was mentioned as an integrated service within postnatal care visits, which was aligned with evidence and best practice. The Report also described the integration of FP counseling with infant immunization visits. FP data (e.g., contraceptive prevalence rate) were reported for each country-specific section, which was highly responsive to need. The Report was gender accommodating as it used language that reinforced a gender binary but did not report on the specific FP needs of LGBTQI+ populations. The Report also reported on the impact of COVID-19 on some of USAID’s MCH programs, but data on the specific impact of the pandemic on FP/MCH integrated programs was lacking. The Report moderately promoted SRHR in the FP domain.

2020_ADS Chapter 303 Materials_2020.05.18

2020_ADS Chapter 303 Materials_2020.06.19

The updates to ADS Chapter 303: Grants and Cooperative Agreements to Non-Governmental Organizations that were released on June 19, 2020 were not related to SRHR and therefore neither promoted nor hindered SRHR. However, this version of ADS Chapter 303 included a new section entitled: 303.3.34 Abortion Restrictions (Effective Date: 05/29/2020), which had been added since the 2019 version that was graded by the SRHR Index. This section provided guidance for implementing the statutory and policy abortion restrictions that apply to all U.S. foreign assistance awards (e.g., Voluntary Population Planning Activities – Mandatory Requirements) and those that apply to only U.S. global health assistance (i.e., Protecting Life in Global Health Assistance [PLGHA]). This section included links to USAID resources that define and explain legislative and policy requirements related to global health, which could have supported the correct implementation of PLGHA and other restrictions. However, this edit was not responsive to need, as it was unclear why the ADS was only updated to include this guidance in May 2020, when PLGHA had been in effect since 2017 and other abortion restrictions have been in place since 1973. The May 29, 2020 version of ADS Chapter 303 had been replaced on its website by the June 19, 2020 version and was no longer available at the time of grading, which contributed to low transparency for this action as prior versions of ADS documents are not publicly available once a newer version is released. The updates made to these materials on June 19, 2020 neither promoted nor hindered SRHR in the FP domain.

2020_ADS Chapter 303 Materials_2020.08.18

Two ADS Chapter 303 materials were updated on August 18, 2020: the main ADS chapter itself and the Standard Provisions for Non-U.S. NGOs (303mab). Details regarding allowable cost share, information technology, and telecommunication services were added to the updated version of the main ADS chapter. While these updates may impact program management and some operations for global health programs, the updates neither promoted nor hindered SRHR in the FP domain. The 303mab was updated to provide more information as well as specific guidance on implementing the prohibition of certain telecommunication and video surveillance services or equipment as was updated in the main ADS chapter. This new section included definitions and references for “covered telecommunication equipment or services,” “covered foreign country,” and “telecommunication costs” as defined in the Code of Federal Regulations (CFR). This telecommunications prohibition was also included in the Department of Health and Human Services’ (HHS) General Terms and Conditions for Research and Non-Research Grants and Cooperative Agreements, though the HHS guidance included an exemption for PEPFAR funding until 2022 that was not mentioned in these ADS materials. It was unclear how this guidance would affect global health programs, so this action neither promoted nor hindered SRHR in the FP domain.

2020_ADS Chapter 303 Materials_2020.11.19

Two mandatory references for ADS Chapter 303 were updated on November 19, 2020: the Standard Provisions for Non-U.S. NGOs (303mab) and the Standard Provisions for Fixed Amount Awards to NGOs (303mat). Both mandatory reference documents contained one update that was relevant to SRHR: Section RAA6. Universal Identifier and System for Award Management. This section was rewritten to provide written notice that the prior Data Universal Numbering System (DUNS) had been replaced by the new Unique Entity Identifier process, which allowed organizations to maintain a current registration in the System for Award Management (SAM) and receive federal funding. This section also included definitions, requirements, and exemptions for the application of this provision, which would enable the effective implementation of this provision. This updated provision was responsive to need because the DUNS process had been identified as burdensome for local organizations with limited administrative capacity as compared to large international NGOs. The streamlining of the SAM process could enable local and smaller organizations to participate in USAID’s global health programs. As such, this update moderately promoted SRHR in the FP domain.

2020_ADS Chapter 303 Materials_2020.12.17

Two ADS Chapter 303 materials were updated on December 17, 2020: The main ADS chapter itself and the Process for Transition Awards Mandatory Reference (303mbb). ADS Chapter 303 was updated to add the brand-new Mandatory Reference 303mbb, which provided guidance on how to make transition awards to local partners. The purpose of transition awards is to develop the capacity for local organizations to receive direct awards from USAID. The Definitions section of the main chapter was updated and defined “transition award” as an assistance award to a “local entity or locally established partner…that is or has been a subrecipient under a USAID assistance award.” The 303mbb Mandatory Reference provided guidance on how to make transition awards to promote self-reliance and strengthen the Agency's engagement with local partners. This process includes making an initial award followed by the transition award with clear roles for USAID staff, prime partners, and the local partner. The creation of the transition award process as explained in these ADS materials was responsive to need because local organizations have asked for support to receive U.S. funding directly as opposed to receiving funds through traditional agreements with prime partners who are often large international NGOs. The development of the transition award process was based in evidence and best practice and aligned with human rights. It supported the ability of USAID to substantially promote SRHR in the FP domain.

2020_ADS Chapter 308_2020.12.04

2020_Agency Priority Goal Action Plan_Maternal and Child Health

The purpose of the Agency Priority Goal (APG) Action Plan on MCH is to report on USAID’s contributions to the global effort to prevent child and maternal deaths in fiscal year (FY) 2020. This action listed the technical teams at USAID that contributed to this reporting, which included representatives that work in population and reproductive health, malaria, nutrition, and health systems strengthening. The Plan included an explanation of how each of the above technical areas contributed to the effective implementation of integrated health services with a focus on FP activities. The APG included three indicators related to FP-specific data: one indicator to track the prevalence rate of modern contraceptive use and two indicators that monitor the timing and completeness of contraceptive commodity shipments, which was based in programmatic data and responsive to need. The use of modern contraceptive methods was primarily linked to a reduction in unintended pregnancies, decreased population growth, and reduced maternal and child mortality in this action. The Plan was only somewhat rooted in human rights as FP is also a tool to promote autonomy, sexual wellbeing, and pleasure for people who can become pregnant, which was not reflected. Language throughout the Plan was not gender transformative as it reinforced a gender binary. It did not use inclusive language such as “pregnant persons,” and did not report on the specific FP needs of the LGBTQI+ community, which was a gap. The Plan moderately promoted SRHR in the FP domain.

2020_Considerations for USAID Mission Staff for Programmatic COVID-19 Preparedness and Response_Digital Technologies and Data Systems

USAID released this guidance on April 6, 2020 to help USAID Missions best respond to the COVID-19 pandemic through the use of digital interventions and data systems. Given the rapid development and publication of these guidelines and the fact that most of the recommendations in this action did not require modifications to current agreements, this action was responsive to need because Missions could implement the guidance as appropriate for the local context. The role of USAID health programs was clearly defined: “support host country information systems, health worker education, identify health data needs, identify interoperability needs, and provide TA [technical assistance].” The Guidelines also called for collaboration with host country governments to ensure that health workers continued to be paid and that data collection continued through health programs, which was responsive to need and would facilitate data-driven decision making. The Guidance described how gender dynamics interact with one’s access and use of digital technology, which was gender aware. However, there was no guidance for how digital interventions should be adapted to address the impacts of COVID-19 related to SRHR, including gender-based violence (GBV) and reduced access to FP programs. As a result, this action neither promoted nor hindered USAID’s ability to support SRHR in the FP 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, including USAID’s global FP programs. 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, this action was not released by PEPFAR (of which USAID is an implementing agency) 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 FP programs accordingly. The Technical Update emphasized the importance of improving contraceptive method choice, including emergency contraception, which promoted SRHR because it supported the provision of all methods. The Technical Update mentioned “male and female condoms” as the only contraceptive methods that can reduce the risk of sexually transmitted infection (STI) and HIV transmission, which was based in evidence but it was not gender transformative because it used the outdated “male and female” terminology instead of the gender inclusive “internal and external” terminology. The Technical Update also adequately accounted for the importance of FP/HIV integration but outlined a gender-binary approach to FP programs and did not include information regarding how the FP needs of the LGBTQI+ community might intersect with their HIV risk. This Technical Update substantially promoted SRHR in the FP 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 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 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 USAID’s role in implementing these activities, including providing FP as a core component of post-GBV care and integrating GBV screening into contraceptive counseling. 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 implemented with U.S. global health assistance, which contributed to low transparency. Additionally, 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 the FP domain.

2020_Department of State and USAID_Fiscal Year (FY) 2020 Annual Performance Report

The 2020 Annual Performance Report outlined the Department of State and USAID’s progress toward strategic objectives, 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. This action reported on three indicators related to FP-specific data: prevalence rate of modern contraceptive use and monitoring of the timing and completeness of contraceptive commodity shipments, which was based in programmatic data and responsive to need. The Report also explained how COVID-19 impacted target achievement, which was highly responsive to need. However, FP/HIV integration activities and indicators were not included in reporting across USAID’s global HIV and AIDS programs which was a gap. Indicators that monitored FP/HIV activities should be included as a mechanism to monitor this important aspect of PEPFAR programs implemented by USAID. The Report included data on a few indicators that measured gender norm change, which were gender accommodating and not gender transformative because they focused on “males and females” which reinforced a gender binary. This report moderately promoted SRHR in the FP domain.

2020_Expedited Procedures Package for Responding to Outbreaks of Contagious Infectious Disease

An Expedited Procedures Package (EPP) provides a blanket restriction on eligibility for both acquisition (e.g., contracts) and assistance (e.g., grants and cooperative agreements) mechanisms and allows for modifications to be made to existing USAID contracts and agreements without triggering competition requirements. This permitted USAID to maintain flexibility to respond rapidly and effectively to an outbreak of an infectious disease. Released on March 27, 2020, the EPP allowed USAID programs to apply for new funding as well as shift existing funds and programmatic priorities to quickly meet the changing needs created by the pandemic. Thus, the EPP was highly responsive to need. The EPP also made it easier to award emergency assistance to USAID programs and enabled USAID to engage with new as well as underused partners; private-sector partners; and community- and faith-based partners to effectively respond to the pandemic. This effort was aligned with evidence, best practice, and human rights. This action enabled USAID to rapidly provide financial and technical support to programs so they could address issues related to COVID-19. Since this EPP could be used by any implementing partner, programs could have adapted to provide SRHR services through the pandemic. This action moderately promoted SRHR in the FP domain.

2020_Global Health eLearning Course_Bureau for Global Health Environmental Management Process Training

2020_Global Health eLearning Course_HIV/AIDS Legal and Policy Requirements

The 2020 HIV/AIDS Legal and Policy Requirements Global Health eLearning Course provided an overview of the HIV and AIDS legislative and policy requirements that govern USAID-supported HIV and AIDS activities. The Course was designed to help USAID staff, implementing partners, and host country government representatives understand the requirements related to medically accurate information about condoms, VMMC, FP and HIV integrated activities, abortion and involuntary sterilization restrictions, and other topics relevant to HIV and AIDS programs. The FP/HIV integration section of the course mentioned that a variety of contraceptive methods should be available, but the ECHO Trial results were not discussed so this section was not fully based in evidence. The Course defined the tenets of voluntarism and informed choice, which are consistent with human rights, and included an informative table explaining the policies, requirements, and amendments that applied to specific types of funds and programs in 2020, which was responsive to need and based in evidence. The Course explained the Protecting Life in Global Health Assistance (PLGHA) policy, though it did not include guidance on the March 2019 expansion, which was not fully responsive to need. Though complete detail about the PLGHA policy was lacking, the Course was informative and based in evidence as it provided references to external sources and other trainings to provide additional information. The Course was gender accommodating as it mostly used gender neutral language, except for a few outdated gendered terms like “female condom,” which was not aligned with evidence nor was it gender transformative. This Course moderately promoted SRHR in the FP domain.

2020_Global Health eLearning Course_Protecting Life in Global Health Assistance and Statutory Abortion Restrictions-2020

The 2020 Global Health eLearning Center Course on the Protecting Life in Global Health Assistance (PLGHA) policy and other statutory abortion restrictions provided USAID staff and implementing partners with technical knowledge about the legal and policy restrictions on abortion-related activities as well as how to properly implement them through global health programs. The Course described the programs and activities to which PLGHA and other statutory abortion restrictions apply. It also provided recommendations for how to ensure that programs are compliant with these restrictions and included guidance on how to investigate a violation. The Course included the specific exceptions in which health care providers can provide information on abortion and defined the affirmative duty of providers, which was responsive to need. The Course clarified that the PLGHA policy did not apply to post-abortion care (PAC), which was responsive to need and consistent with human rights norms. The Course included some compliance guidelines and was consistent with the May 2019 Standard Provision and data from the 2018 six-month review of the implementation of PLGHA. However, it primarily provided guidance on what activities are not permitted under the policy and could have more clearly supported PAC, comprehensive FP, and other efforts that are not prohibited under the policy. The Course encouraged staff to "be aware of perceptions among program managers, clients, and providers that may suggest potential vulnerabilities," which was not responsive to need as it could lead to unnecessary oversight of people's personal or professional beliefs that are not relevant to their implementation of the PLGHA policy and other abortion restrictions. With respect to FP programs, the Course was responsive to need as it included several scenarios specific to FP programming that included detailed guidance on how to address a variety of circumstances that could arise when implementing these restrictions. Additionally, the Course was not gender transformative as it did not use gender inclusive language (e.g., “pregnant persons”). This Course moderately hindered SRHR in the FP domain.

2020_Global Health eLearning Course_Protecting Life in Global Health Assistance and Statutory Abortion Restrictions-2020

The 2020 Global Health eLearning Course on U.S. FP and abortion requirements provided technical guidance on abortion-related statutes that apply to all U.S. foreign assistance funds. The Course discussed the Helms Amendment but predominantly focused on requirements that apply specifically to FP assistance funds, particularly the Tiahrt Amendment. The Tiahrt Amendment dictates how USAID-supported FP programs deliver services. This component of the Course was based in evidence and human rights norms because the restrictions outlined in the Tiahrt Amendment have been endorsed by USAID and the WHO as a standard for protecting the human rights of people that access FP programs and services. The Course was responsive to need as it provided vital information on voluntarism and informed choice as the cornerstone of all FP programs implemented by USAID. It included guidance for providing proper counseling on FP, including offering contraceptives with method mix at each service delivery point. The Course described the protections under the Tiahrt Amendment for people that access maternal health services who have had a certain number of live births and do not accept FP or contraceptives, which was consistent with human rights. The Course was gender blind, as there were no mentions of gender or of how to implement these policies in a way that addressed unequal gender norms. This Course was useful for implementers of FP activities to fully understand their responsibilities in ensuring voluntarism and informed choice with respect to counseling on and providing contraceptives through FP programs. This Course moderately promoted SRHR in the FP domain.

2020_Guide for Adopting Remote Monitoring Approaches during COVID-19

USAID released the Guide for Adopting Remote Monitoring Approaches during COVID-19 in May 2020 and it provided guidance and information to USAID staff and implementing partners about when and how to employ remote monitoring techniques as programs continue to be implemented amidst COVID-19 restrictions. This Guide was responsive to need as it stated that awards should not be amended more than is necessary and that awards should remain in compliance with the initial award conditions. It also indicated that missions and partners should gather feedback from beneficiaries of activities that have been altered due to COVID-19 to remain informed of their current needs and make decisions regarding program adaptation. The Guide did not provide specific details for how to adapt remote monitoring techniques or the use of digital technology for FP programs but did include updates to the Site Improvement through Monitoring System (SIMS) deadlines for monitoring and reporting on PEPFAR during COVID-19, which includes monitoring of FP activities including integrated FP/HIV service provision. The Guide was gender accommodating as it called for implementing partners to monitor how the demographics of a target population may impact their access to and use of digital technology for remote monitoring based on gender, age, and disability and it directed implementers to “account for any biases” that may impact people’s access digital technology. While this element of the Guide supported SRHR, it did not provide explicit guidance for implementing partners to overcome the barriers that people may experience due to their gender, age, or disability. This Guide supported the ability of USAID’s FP programs to make data-driven decisions through the use of remote monitoring approaches during the COVID-19 pandemic, which moderately promoted SRHR in the FP domain.

2020_President’s Interagency Task Force: Report on U.S. Government Efforts to Combat Trafficking in Persons

This report discussed the U.S. government's 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. Several of USAID's approaches and projects contributed to this whole-of-government strategy, including USAID’s flexible approach to programmatic decisions to account for COVID-19, launching the Safe Migration in Central Asia project, and facilitating interagency coordination to streamline international and domestic grants. However, it was unclear whether these programs were funded through global health assistance, and therefore contributed to low transparency. The Report moderately hindered SRHR in the FP domain.

2020_Review of the Implementation of the Protecting Life in Global Health Assistance Policy (August 2020)

The second review of the PLGHA policy summarized the history of the policy and presented findings from a review of the policy’s implementation throughout U.S. global health assistance programs since 2017. The Review found that in certain cases where USAID partners declined awards due to the PLGHA policy, the loss of trusted partners in-country resulted in difficulties replacing these partners and caused subsequent disruptions in healthcare services across technical areas. Specifically, the Review found that the loss of partners resulted in delays in the implementation and distribution of USAID’s services related to HIV and AIDS, MCH, voluntary FP, tuberculosis, and nutrition. The Review reported on USAID's struggle to find replacements for partners to lead the FP programs that had been implemented by International Planned Parenthood Federation (IPPF) and Marie Stopes International (MSI) when both organizations declined to certify the policy in 2017. While the Review did not explicitly state that there were gaps in service delivery as a result of these declinations, it was clear that the inability of USAID to find replacements to cover the full scope of the two organizations' work would have impacted FP services. While the PLGHA policy itself did not promote SRHR, USAID’s role in providing mechanism-level data for this report was responsive to need and based in programmatic data and evidence, which provided a clear overview of USAID’s implementation of the policy. The Review moderately promoted SRHR in the FP 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, in collaboration with other U.S. implementing agencies including USAID, released the Strengthening Health Security Across the Globe annual report that identified the U.S. government’s contributions to global health security by country and U.S. government agency. Though several areas of global health were mentioned throughout the report, programs related to FP were noticeably absent. There was no mention of other areas of SRHR that impact health security such as MCH or GBV, so this report was not based in evidence. SRHR is a critical aspect of global health security. Neglecting to mention SRH 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 advancing gender equity and countering harmful norms that affect women and girls. 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. This Report moderately hindered SRHR in the FP domain.

2020_United States Strategy to Prevent Conflict and Promote Stability

The United States released the Strategy to Prevent Conflict and Promote Stability 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 (like USAID) 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 or integration with specific global health program areas, even though addressing HIV and AIDS, MCH, FP, and other cross-cutting SRHR issues is vital to promoting stability and security. Notably, it did not include guidelines for responding to GBV even though the risk of violence is often greater to women, girls, and gender-diverse people in fragile settings and conflict areas compared to peaceful settings. 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, the Strategy 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 Women, Peace, and Security (WPS) Strategy. This Strategy moderately hindered SRHR in the FP domain.

2020_USAID Digital Strategy 2020-2024

The Digital Strategy described the Agency's vision for the responsible use of digital technology in international development and humanitarian work. The goal of this strategy was to sustain digital ecosystems that increase self-reliance as well as promote positive development and humanitarian assistance outcomes. The Strategy described the mechanisms through which USAID staff will achieve these goals and highlighted previous successes with incorporating digital technologies into the Agency's activities. The Strategy also noted the importance of digital infrastructure amid COVID-19, which was responsive to need and based in evidence as it promoted the use of telemedicine to protect health care workers and patients while also providing vital health services. However, the Strategy did not describe the specific use of digital interventions to support FP programs, however, so the Strategy was not based in evidence or responsive to need in this domain. It would have been helpful to include examples of digital technologies used successfully by USAID’s global FP programs, making the absence of these examples a gap in this Strategy. The human rights basis was explicitly stated in the Strategy, as it detailed the potential for “digital authoritarianism” to infringe on human rights. The Strategy was gender aware because it acknowledged gender disparities and the “gender digital divide” which contributes to inequitable use of technology across genders. However, it used a gender binary to describe these impacts and did not use inclusive language. While the Digital Strategy set a positive tone for the use of emerging technologies and digital infrastructure in USAID's activities, it did not meaningfully include strategic thinking related to FP and thus neither hindered nor promoted SRHR in the FP domain.

2020_USAID Gender Equality and Women’s Empowerment 2020 Policy

This Policy detailed USAID's investment in and commitment to supporting gender equality and women’s empowerment efforts to date. It outlined the strategic objectives and principles necessary for the Agency to achieve this vision and increase self-reliance in partner countries. The Policy referenced global health programs and cross-cutting issues related to SRHR, including activities to eliminate GBV, increase the capability of women and girls to exercise their “basic and legal rights fully,” and improve women and girls’ access to education and employment. The Policy promoted voluntarism and informed choice, the core tenets of USAID's FP programming, which was based in evidence and consistent with human rights norms. However, the Policy primarily referenced the use of FP by couples which ignored the fact that individuals who are not married or part of a couple also have a need for FP. The Policy also used outdated terminology that reinforces a gender binary, such as “male and female condoms,” which was not gender transformative or based in evidence. The Policy was not fully grounded in human rights norms or responsive to need because of its exclusion of LGBTQI+ people and its basis in “unalienable rights,” which do not include all international human rights. Exclusion of LGBTQI+ people was not based in evidence as research shows that members of the LGBTQI+ community are at an increased risk of experiencing GBV and other inequitable gender norms that limit their access to health services, education, employment, and other measures of empowerment. The 2020 version of this policy was not responsive to need because it was less inclusive than the previous version from 2012, which explicitly included all people regardless of gender identity, disability status, HIV and AIDS status, geographic area, and migratory status. It did not acknowledge the contributions of SRHR programs to gender equality efforts. Additionally, the Policy was not gender transformative due to its use of a gender binary and exclusion of LGBTQI+ people, but was gender accommodating because it acknowledged the impact of existing gender inequities in global health and development areas. This policy moderately hindered SRHR in the FP domain.

2020_USAID MOAA COVID-19 Implementing Partner Guidance_Frequently Asked Questions Published on 11.03.2020

This Guidance from the Bureau for Management Office of Acquisition and Assistance (MOAA) within USAID compiled all questions related to COVID-19 from implementing partners in one place with clear answers and guidance. The Guidance was regularly updated throughout 2020, which was responsive to need. The primary section related to global health program implementation was the section about PEPFAR and USAID Guidance, which answered questions related to the roles of PEPFAR and USAID staff, outlined how PEPFAR programs could be used to respond to COVID-19, and provided external references for additional technical guidance for PEPFAR programs. However, there was no information about adapting the implementation of FP programs, including FP/HIV integration activities conducted through PEPFAR programs, which was not responsive to need. The Guidance was not gender transformative as it did not include information for adapting programs in response to the disproportionate impact of COVID-19 on women and girls and the rise in GBV, which was a gap. This Guidance neither promoted nor hindered SRHR in the FP domain.

2020_USAID Over the Horizon Landscape Analysis and Snapshot

This Snapshot described how USAID aimed to shift its programming to accommodate a world altered by the COVID-19 pandemic. The Snapshot highlighted the persistence of inequities in access to essential services as well as the adverse impact of the pandemic among “vulnerable and marginalized groups,” but did not define these groups, establish the evidence base, or define the human rights framework as the foundation for this action. The Snapshot mentioned the increased risk of GBV due to COVID-19, which was based in evidence and responsive to need. The Snapshot listed USAID's responses to the pandemic and described the active USAID development policies, field consultations, partner roundtables, and collaborative research that was used to adapt operations to respond to COVID-19. However, adaptations to USAID’s global FP programming were not mentioned throughout this action, even though COVID-19 has impacted the ability of USAID to provide equitable FP services. As a result, the Snapshot was not fully responsive to need or based in evidence in this domain. This action was gender accommodating because it aimed to increase women's participation in pandemic relief efforts but did not document the disproportionate impact of COVID-19 on women and girls beyond GBV. The Snapshot moderately hindered SRHR in the FP domain.

2020_USAID Policy on Promoting the Rights of Indigenous Peoples

This policy provided guidance for engagement and partnerships on projects that impact Indigenous Peoples and detailed USAID's efforts to engage them as “meaningful partners” in Agency program development processes. The Policy stated the importance of ensuring that activities like data collection are conducted in a way that is responsive to Indigenous Peoples' input and needs through the free, prior, and informed consent (FPIC) process, which is a vital component of Indigenous organizing that respects their rights and autonomy. The Policy was grounded in human rights as it included adherence to international standards of human rights as a central pillar but did not acknowledge the impact of colonization and occupation on the health and wellbeing of Indigenous communities. With respect to health outcomes, the Policy acknowledged that many Indigenous groups experience worse health outcomes compared to national or regional averages, which was based in evidence, but it did not discuss specific FP-related health outcomes. The Policy posed potential solutions such as integrating programs and promoting cross-sectoral development approaches to expand the availability of assistance that Indigenous peoples could access, which was evidence-based and responsive to need. However, the Policy did not elaborate on these approaches or explain how USAID and implementing partners should implement these programs. This Policy applied to all USAID activities, including global FP programs, so the lack of discussion on how these programs and activities should be adapted to better serve Indigenous peoples was a gap in USAID's approach and the Policy was not responsive to need or based in evidence in this domain. Additionally, the Policy was gender accommodating as it acknowledged cultural norms and other factors that could impact the decision-making rights of Indigenous women but did not provide adequate guidance for overcoming or changing those norms. This Policy neither promoted nor hindered SRHR in the FP domain.

2020_USAID Policy on Protection from Sexual Exploitation and Abuse (PSEA)

This policy detailed USAID operating procedures to protect individuals from sexual exploitation and abuse (SEA). This policy applied to all USAID-funded services and activities. It intended to center the needs and perspectives of survivors and employed USAID's zero-tolerance policy for inaction on allegations of SEA. The Policy acknowledged the power dynamic that drives many instances of SEA and identified the need for increased attention for vulnerable groups including “women and children, and those most at risk of discrimination on the basis of disability, gender identity and sexual orientation, race, ethnicity, age, or religion.” This level of specificity indicated an inclusive understanding of how people's identities shape their experiences of SEA. The Policy was responsive to need and grounded in human rights norms as it prioritized the safety of people that participate in USAID programs. However, it was not evidence-based because evidence indicates that there are numerous health and SRHR needs that arise as a result of SEA that were not mentioned in this policy, such as unintended pregnancy. Like GBV, SEA is a cross-cutting SRHR issue and warrants an integrated response for both prevention and treatment, which was lacking in this policy. Additionally, the Policy was gender accommodating as it was inclusive of all peoples' experiences though did not adequately describe how the Policy would overcome gender norms that both contribute to SEA and prevent people from receiving care for SEA. This Policy moderately hindered SRHR in the FP domain.

2020_USAID Protecting Life in Global Health Assistance Letter to Implementing Partners_30 October 2020

Alma Golden, Assistant Administrator of the Bureau for Global Health within USAID, sent this letter to USAID implementing partners on October 30, 2020 to reiterate the importance of complying with abortion-related statutory and policy restrictions that apply to global health awards. The letter was somewhat responsive to need as it explained the difference between statutory restrictions related to abortion and PLGHA, which are often confused. The letter detailed best practices to ensure compliance with these restrictions and directed recipients to access publicly available trainings and resources to understand the applicable restrictions. The letter also mandated that all implementing partners across domains submit documented evidence of their efforts to assure the compliance of foreign NGO sub-partners with the PLGHA policy within one month of the issuance of the letter, which was an extreme burden for implementing partners. The compliance reporting requirement outlined in the letter was not responsive to need as it was unclear what prompted this action or how this information would be used to influence the future implementation of the policy. This letter moderately hindered SRHR in FP domain.

2020_USAID’s Women, Peace, and Security Implementation Plan

The Women, Peace, and Security (WPS) Implementation Plan outlined USAID's efforts to support the U.S. government’s WPS Strategy through development and humanitarian assistance. The Implementation Plan expanded on the role of USAID in fulfilling the WPS Strategy's focus on women and girls' empowerment to overcome crisis, conflict, and fragility. This Plan was somewhat based in evidence and responsive to need as it identified several factors that can promote women's empowerment but did not recognize the importance of addressing individual SRHR needs as part of this Plan. The main mentions of health outcomes related to SRHR throughout this Plan were in the context of GBV, as well as “teenage pregnancies” that result from violence. However, the exclusion of other areas of SRHR, such as FP, downplayed the importance of these health outcomes in empowering women and accomplishing the goals of the WPS Strategy. The Plan was not fully consistent with human rights norms as it excluded LGBTQI+ people in its efforts to achieve gender equality. Additionally, the Plan was gender accommodating as it worked to empower women within existing gender norms but did not use gender inclusive language. The Plan also did not outline a strategy for changing inequitable gender norms through USAID’s programs. This Plan moderately hindered SRHR in the FP domain.

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 cited country-level annual progress toward family planning targets and provided recommendations to advance family planning in numerous country-specific snapshots in a way that was somewhat responsive to need. However, a commitment to family planning was not uniform across all countries. Though contraceptive prevalence rate was recorded throughout the report, there was no discussion or explanation as to why this was the only relevant family planning indicator included in the report. There was also a lack of discussion around the integration of maternity care and family planning care in all countries. The report was based on evidence collected by USAID, but did not reference international human rights norms and did not include gender transformative language. With regard to family planning, this report moderately hindered 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 will remain unchanged and that organizations who sub-grant will 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 family planning. 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. The document was not evidence-based, grounded 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 actually increase the rate of abortion in country, many of which are unsafe. 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 as well as incorporated new language on the donation of breastmilk in humanitarian crises. The chapter included language regarding the Lactational Amenorrhea Method (LAM) as a method of postpartum contraception, however did not cite data that proved the referenced 98 percent rate of efficacy of this method. It did not adequately provide guidance about facilitating modern contraceptive use for pregnant and breastfeeding women. 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 take steps to ensure these policies were put in place (which could be achieved through the requirement for partners to report on the implementation of this guidance in their programs through mandatory performance reports). 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 family planning 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, and included additional guidance regarding the consequences of violation of the PLGHA policy as well as 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 grantees and sub-grantees. However, this chapter of the ADS was 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 is the Standard Provisions for Cost-Type Agreements with Public International Organizations and specifies the mandatory policies and guidelines that PIOs who receive funding from USAID must follow. 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 highlighted some of USAID’s success and strategies moving forward but did not specifically discuss family planning except in the listing of expenses. 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. 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 focused on intersecting issues such as family planning, nutrition, and malaria. The document discussed family planning within some of the indicators as a key intervention to decrease maternal deaths. It also mentioned a decreasing trend in modern contraceptive use in priority countries and an increase in teenage pregnancy, but did not provide the data to explain what has caused both of these challenges. There was no mention of the importance of method mix and comprehensive information about family planning by healthcare providers, which is particularly relevant in settings with a large presence of faith-based providers who have the ability to opt out of the provision of some modern contraceptive methods. This document was responsive to need and somewhat based in human rights and evidence. The document was not gender transformative but gender aware, as it referenced challenges to contraceptive uptake but did not take steps to address them. As such, it only moderately promoted SRHR through USAID’s family planning programming.

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 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 family planning. 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 been shown to actually increase the rate of abortion in country, many of which are unsafe. 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 did not discuss family planning, despite the fact that USAID is one of the largest funders of family planning programs globally. Within this domain, the Report was not based in evidence or human rights and was not responsive to need, as family planning was not included as a part of the FY 2020 Performance Plan. 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. Overall, this report neither hindered nor promoted 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 general and did not discuss any particular aspect of global health assistance, though there was one mention of voluntary family planning within the context of USAID’s mandate of “doing no harm” through its programs. This Framework 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 Framework was not gender transformative, as it contained very little detail 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 family planning 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 cited country-level annual progress toward family planning targets and provided recommendations to advance family planning in each country context in a manner that was responsive to need. At the same time, the 2018 report, when compared to the 2017 version, included more language regarding USAID's "Journey to Self-Reliance" framework for program countries. This language is consistent with the Trump administration's efforts to reduce U.S. funds for global health as a means to increase the incentive for countries to increase domestic funding. This method of achieving self reliance is neither evidence-based nor sustainable and, given this context, the addition of self reliance language in the report was concerning. Though Acting on the Call reports on both family planning and maternal and child health data, the report did not provide substantial detailed analysis of USAID’s family planning programming. The evaluation of family planning efforts was not included within each country analysis. Additionally, the 2018 report did not mention gender norms or human rights principles as they apply to family planning.

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 seems 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 quarterly updates on family planning commodity delivery and an overview of family planning programs implemented by USAID. The 2018 APGs were responsive to need and evidence-based in that they cited statistics regarding family planning that have informed the APGs. However, this report was lacking references to international human rights norms and did not include discussions surrounding gender norms in family planning programs. There was only one mention of family planning in each of the quarterly and annual indicators without any programmatic detail or guidance. These mentions of family planning were geared toward families and spacing of births, neither of which may apply to people who give birth outside of traditionally defined families or for people who seek contraceptives for purposes other than spacing births. The cited family planning indicator, "Absolute change in modern contraceptive prevalence rate," did not include any consideration for access to contraceptives for key populations, specifically, and did not account for the role of gender norms in shaping family planning and contraceptive access.

2018_Protecting Life in Global Health Assistance FAQs_August 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 responsive to need in that they clarified areas of the policy that partners had expressed were vague or unclear. The FAQs were neither based in human rights principles nor evidence. The FAQs were also not gender transformative and substantially hindered USAID's ability to implement comprehensive family planning and SRHR programs that were evidence-informed, responsive to need, consistent with internationally-recognized human rights principles, and gender transformative.

2017_ADS Chapter 303maa_Standard Provisions for U.S. Nongovernmental Organizations

The Standard Provisions for U.S. Non-governmental organization (NGO) Recipients outlined the standard provisions for all global health activities conducted by U.S. NGOs that received global health assistance funds from USAID. This document is part of the Automated Directive System (ADS), which is the standard operating procedure for USAID. The Standard Provisions provided the first instructions for the implementation of the Protecting Life in Global Health Assistance (PLGHA) policy and explained the requirements of foreign NGOs that receive U.S. global health assistance funds. This partial revision of ADS Chapter 303maa was responsive to need and provided guidance for implementing PLGHA for USAID staff and implementing partners since the Trump Administration’s expansion of the Mexico City Policy. The Standard Provisions explained the limitations placed on U.S.-based NGOs: U.S.-based NGOs that receive U.S. global health assistance funding may not provide any health assistance to foreign NGOs who perform or promote abortion as a method of family planning and must ensure that their sub-grantees do not sub-grant to foreign NGOs that violate the PLGHA policy. While USAID did not have control over the policy language itself, USAID could control the guidance they released regarding the implementation of the policy. The Standard Provisions also stated that foreign NGOs that receive U.S. global health assistance funds cannot perform or actively promote abortions as a method of family planning or provide funding to other foreign NGOs that do so. If a foreign NGO is found to be in violation of the policy, the provisions stated that their funding will be terminated. Though this updated Standard Provision was responsive to need, this document did not include adequate guidance or definitions regarding terms such as “financial support” and “passive referral.”

2017_ADS Chapter 303mab_Standard Provisions for Non-U.S. Nongovernmental Organizations

The Standard Provisions for non-U.S. NGO Recipients outlined the standard provisions for all global health activities conducted by international NGOs that received global health assistance funds from USAID. This document is part of the ADS, which is the standard operating procedure for USAID. The Standard Provisions provided the first instructions for the implementation of the PLGHA policy and explained the requirements of foreign NGOs that receive U.S. global health assistance funds. This partial revision of ADS Chapter 303mab was responsive to need and provided guidance for implementing the PLGHA policy for USAID staff and implementing partners since the Trump Administration’s expansion of the Mexico City Policy. The Standard Provisions stated that foreign NGOs that receive U.S. global health assistance funds cannot perform or actively promote abortions as a method of family planning or provide funding to other foreign NGOs that do so. If a foreign NGO is found to be in violation of the policy, the provisions stated that their funding will be terminated. The Standard Provisions also explained the limitations placed on U.S.-based NGOs: U.S.-based NGOs that receive U.S. global health assistance funding may not provide any health assistance to foreign NGOs who perform or promote abortion as a method of family planning and must ensure that their sub-grantees do not sub-grant to foreign NGOs that violate the PLGHA policy. While USAID did not have control over the policy language itself, USAID could control the guidance they released regarding the implementation of the policy. Though this updated Standard Provision was responsive to need, this document did not include adequate guidance or definitions regarding terms such as “financial support” and “passive referral.”

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 using 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 family planning programs, this Plan provided a high-level overview of the programs, best practices, and indicators that were 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. The Implementation 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 family planning programs that moderately promoted SRHR.

2014_Acquisition and Assistance Policy Directive (AAPD)

2014_ADS Chapter 201mau_Guidance on the Definition and Use of the Global Health Programs Account

2014_USAID Guidance for Implementing the Siljander Amendment

2013_Counter-trafficking in Persons Field Guide

2012_Ending Child Marriage and Meeting the Needs of Married Children: The USAID Vision for Action

2012_Gender Equality and Female Empowerment Policy: USAID Policy

2012_United States Strategy to Prevent and Respond to Gender-based Violence Globally

2012_USAID Implementation of the United States National Action Plan on Women, Peace, and Security

2004_USAID Post-Abortion Care Strategy

1999_Guidance for Implementing the “Tiahrt” Requirements for Voluntary Family Planning Projects

1982_USAID Policy Paper: Population Assistance