YEAR 2021

Maternal and Child Health (MCH)

The U.S. Government received a 76 (C) with transparency and an 81 (B-) without transparency for the Maternal and Child Health (MCH) domain across all actors in 2021. Though global MCH efforts were meaningfully included in the National Strategy on Gender Equity and Equality, MCH was omitted from some whole-of-government actions as well as key agency-level actions from both the Department of State and the United States Agency for International Development (USAID). In many cases, agency-level actions reinforced a gender binary and did not use inclusive language such as “pregnant and breastfeeding persons,” which excluded the experiences of all people who can become pregnant and was therefore gender accommodating. The lack of data on global MCH programs or activities in agency-level and whole-of-government actions in 2021 reinforced the siloed nature of global health programs and did not support the implementation of integrated programming based in evidence and human rights. Low transparency of actions graded in this domain across actors as well as lack of funding information for the Department of Health and Human Services (HHS) global MCH efforts also negatively affected the overall MCH domain grade in 2021.

B-

White House

The White House received an 80 (B-) with transparency and an 85 (B) without transparency in the Maternal and Child Health (MCH) domain in 2021. The White House requested adequate funding for USAID’s global MCH programs, UNIFEM (now UN Women), and the United Nations Children’s Emergency Fund (UNICEF). Generally, actions graded in this domain meaningfully referenced global MCH programs, which supported the ability of U.S. global health assistance to promote SRHR through the MCH domain. The National Strategy on Gender Equity and Equality meaningfully included issues across MCH, including global investments in the SDGs, client-centered services, integrating obstetric care with other SRH services, and the impact of climate change on pregnant people. The White House demonstrated a moderate level of transparency of MCH policies but a low level of transparency for the availability of funding information in this domain in 2021.

The Fòs Feminista 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_American Rescue Plan Act (H.R.1319)

Signed into law by President Biden, the American Rescue Plan Act appropriated additional U.S. global health funding for specific implementing agencies to prevent, prepare for, and respond to the COVID-19 pandemic, as well as support public health surveillance to respond to other emerging infectious disease threats globally. It included contributions to support multilateral vaccine development partnerships and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Though it was unclear if the additional funding for USAID’s global health programs appropriated by this Act would include global MCH programming, these funds could have supported USAID’s response to the impacts of COVID-19 on issues related to SRHR. This action had transparency in this domain. Overall, this action was responsive to need and based in evidence and human rights, though it was not gender transformative. This law should have included a call for data to be disaggregated by sex and/or gender to inform responses to COVID-19 given the disproportionate impacts of the pandemic on women, girls, and gender-diverse people. This action moderately promoted SRHR in the MCH domain.

2021_Executive Order on Establishment of the White House Gender Policy Council

This EO detailed the Biden administration's commitment to gender equity and equality in the United States and globally. It established the White House Gender Policy Council to coordinate activities across the USG that are related to advancing gender equity and economic security, mitigating discrimination, increasing access to health care, preventing GBV, addressing the effects of COVID-19 on women and girls, and promoting SRHR, including MCH. This action was based in evidence and human rights because it included a directive for the Gender Policy Council to develop and publish a gender strategy and create clear guidelines for reviewing current policies and programs and revoking those that did not align with the administration’s position on SRHR. It was also responsive to need because it directed the Gender Policy Council to update outdated or harmful policies such as the 2020 Gender Equality and Women’s Empowerment Policy and the Strategy to Prevent and Respond to GBV, both of which were published by USAID. This directive to the Council acknowledged the specific needs of "underserved communities" and extended the focus beyond women and girls, which demonstrated a commitment to creating gender transformative policies by addressing systemic biases and creating policies that advance equity. This action specifically mentioned the importance of promoting SRHR and laid the groundwork for the forthcoming whole-of-government strategy to advance gender equity and equality through specific global health programs, including MCH programs. This action significantly promoted SRHR in the MCH domain.

2021_Executive Order on Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation

This EO stated the goal of the Biden administration "to prevent and combat discrimination on the basis of gender identity or sexual orientation" and directed USG agencies to revise, suspend, or rescind any actions that were not consistent with the administration’s nondiscrimination policy. It also instructed all heads of agencies to design additional actions as needed to implement the policy to combat overlapping forms of discrimination, including race and disability. This EO was responsive to need and consistent with human rights because it sought to address actions implemented during past administrations that discriminated against people because of their gender identity and/or sexual orientation, which is a violation of people’s human rights. It also directed heads of USG agencies to develop plans to carry out the requirements of this EO within 100 days of the Order, which was actionable and responsive to need. This action was gender transformative as it affirmed people’s gender and sexuality, and aimed to prevent discrimination across all U.S. government agencies, which was responsive to need and based in evidence. Though this action did not explicitly mention global health programs such as those related to MCH, the whole-of-government approach to combating discrimination moderately promoted SRHR in the MCH domain.

2021_Executive Order on Tackling the Climate Crisis at Home and Abroad

This EO outlined President Biden's plan to prioritize the climate crisis in U.S. policy. It confirmed the re-engagement by the United States with the Paris Agreement and called for USG agencies engaged in international work to develop implementation plans that integrate climate considerations into their work, which was responsive to need. It established the National Climate Task Force to "facilitate the organization and deployment of a Government-wide approach to combat the climate crisis." Though this action was generally responsive to need because of the urgent imperative to respond to climate change, it did not discuss the direct impacts of climate change on specific sectors within health, including SRHR. As it relates to MCH, this action was not based in evidence because it did not mention the impact of climate change on SRHR outcomes, especially for pregnant and breastfeeding persons. It also did not explicitly mention the human rights frameworks that would guide the USG’s response to climate change though there was a strong emphasis on environmental justice and the disproportionate impact of climate change on specific marginalized populations. The EO was gender blind as it did not mention the disproportionate impact of climate change on women, girls, and gender-diverse people. Though this was a critical step in addressing climate change, SRHR was not meaningfully included as a cross-cutting issue so this action neither promoted nor hindered SRHR in the MCH domain.

2021_Fact Sheet_Advancing Disability Inclusive Democracy in the United States and Globally

This Fact Sheet detailed the commitments made by the Biden administration to prioritizing "disability inclusive democracy" globally across the Federal government. The White House appointed a U.S. Special Advisor on International Disability Rights and expressed support for novel projects and partnerships, which includes global health programs managed by USAID. The goals of these projects were to develop inclusive international health systems that could provide assistive products for people living with disability and support people who have been impacted by COVID-19 through quality, equitable, and inclusive teaching and learning tools. Notably missing from this action was a directive to incorporate disability rights in SRHR and global MCH programming, making this action only somewhat based in evidence and responsive to need in this domain. While the inclusion of people with disabilities strengthens democracy and promotes human rights, there was no mention of gender in this action, which was gender blind. As a result, this action only moderately promoted SRHR in this domain.

2021_Fact Sheet_President Biden’s Global COVID-19 Summit_Ending the Pandemic and Building Back Better

This Fact Sheet detailed the commitments made by the Biden administration at the Global COVID-19 Summit, which included enhancing equitable global access to vaccines, increasing treatment options for people with COVID-19, establishing sustainable health security to prevent and respond to future pandemics, and aligning global targets to end the COVID-19 pandemic. Though these commitments were largely responsive to need, this action did not mention leveraging investments in global MCH programming or other cross-cutting SRHR programs that were impacted by COVID-19. This action was gender blind because it did not mention the disproportionate impact of COVID-19 on women, girls, and gender-diverse people. Additionally, the action did not mention cross-cutting issues such as GBV which have worsened during the pandemic. This action neither hindered nor promoted SRHR in the MCH domain.

2021_Fact Sheet_United States to Announce Commitments to the Generation Equality Forum

This Fact Sheet outlined the domestic and global commitments made by the Biden administration at the Generation Equality Forum, including policy and resource commitments to prevent and respond to all forms of GBV, strengthen women’s economic security, and protect and advance SRHR. This action was responsive to need and based in human rights as it was rooted in the Beijing Platform for Action and aligned with global priorities, including those related to climate, science and technology, leadership and democracy, and education. It summarized the administration’s actions related to global health, such as revoking the GGR and restoring funding to UNFPA, which were consistent with human rights, based in evidence, and responsive to need. This action did not acknowledge global MCH programs or advocate for the provision of comprehensive SRH services with U.S. global health funding, which was a missed opportunity. Though the action emphasized the importance of combating harmful gender norms, it used language that reinforced a gender binary and excluded LGBTQI+ people. This action moderately promoted SRHR in the MCH domain.

2021_Memorandum on Advancing the Human Rights of Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Persons Around the World

This Presidential Memorandum outlined the Biden administration’s policy to end violence and discrimination based on SOGIESC across the USG and around the world. It directed USG agencies that engage in international work to review and rescind policies that are inconsistent with the administration’s stance on this issue, which was responsive to need and supported the implementation of policies based in evidence and human rights. It was highly responsive to need as it directed "all agencies engaged abroad to ensure that United States diplomacy and foreign assistance promote and protect the human rights of LGBTQI+ persons," including in the making of funding decisions, which would include global MCH programs. This memorandum was gender transformative because it intended to combat harmful gender norms and end discrimination towards persons of diverse SOGIESC, but it was generally confined to implementation "as appropriate and consistent with applicable law," which could be restrictive depending on the country context. This action did not address the ways in which violence and discrimination are barriers to accessing comprehensive SRH services, such as antenatal care or childhood immunizations. This action moderately promoted SRHR in the MCH domain.

2021_Memorandum on Protecting Women’s Health at Home and Abroad

This Presidential Memorandum stated that it is the policy of the Biden administration to "support women’s and girls’ sexual and reproductive health and rights in the United States, as well as globally." This action marked the first time that a U.S. administration has actively supported SRHR at the presidential level. This action was responsive to need, consistent with human rights norms, and based in evidence because it directed USG agencies to immediately waive the GGR, which the previous administration had expanded to apply to all U.S. global health assistance funding, including global MCH programs. Though immediately revoking the GGR significantly promoted SRHR, this action did not provide a timeline for suspending, revising, or rescinding any policies or actions that conflicted with the directives in this memorandum, including updating ongoing awards to remove the GGR provision, which was not responsive to need. This action withdrew the United States from the Geneva Consensus Declaration and directed USG agencies that were involved in foreign assistance programs to "ensure adequate funds are being directed to support women’s health needs globally," including SRHR services, which was highly responsive to need and based in evidence and human rights. While clearly advocating for global programs that provide women’s SRHR services promoted SRHR, limiting this action to "women’s health needs" was reductive and gender aware as doing so did not affirm the rights of all people to access SRHR services regardless of their gender or sex. The Memorandum did not mention access to safe abortion services as a priority for the administration, which further stigmatized abortion services. Nevertheless, this action significantly promoted SRHR in the MCH domain.

2021_Memorandum on Restoring Trust in Government Through Scientific Integrity and Evidence-Based Policymaking

This Presidential Memorandum stated the Biden administration’s policy to "make evidence-based decisions guided by the best available science and data" across the federal government, which was based in evidence and responsive to need. This action specifically directed USG agencies to "review and expeditiously update any agency policies, processes, and practices issued or published since January 20, 2017, that prevent the best available science and data from informing the agency’s evidence-based and iterative development and equitable delivery of policies and programs." However, solely focusing on anti-science policies from the previous administration was not sufficient, as the review should extend much further to ensure that policies being implemented today are based in evidence, regardless of when they were passed. Looking forward, this action directed USG agencies to develop scientific integrity policies that support policymaking based in evidence and listed several approaches and methodologies that could inform this process, including qualitative research, community engagement, and social and behavioral approaches. While SRHR and global health programs were not explicitly mentioned, enforcing evidence-based decision making at all levels of government ultimately benefited global MCH programs. This action moderately promoted SRHR in this domain.

2021_Memorandum on Revitalizing America’s Foreign Policy and National Security Workforce, Institutions, and Partnerships

This Presidential Memorandum directed USG agencies to implement policies that revitalize the national security and foreign policy workforce and institutions under the core principles of integrity, transparency, DEIA, modernization, service, and accountability. The Memorandum called for the creation of an Interagency Working Group on the National Security Workforce chaired by the Principal Deputy National Security Advisor to ensure that workers are recruited and retained to promote the success of the programs implemented by USG agencies. The action also required USG agency leadership to meet with partners on a quarterly basis, which promoted transparency , though it did not include directives for transitioning power or funding to local partners, which was a missed opportunity to diversify the partner base. This action advocated for including a wide diversity of voices and perspectives in foreign policy, which was based in evidence and responsive to need. It was responsive to need as it provided greater workplace resources to minimize staff burnout and turnover, which often impact the continuity of global MCH programs. However, the Memorandum did not explicitly include directives or support for health care workers even though they are critical to ensuring national security and the success of U.S. foreign policy, especially global health assistance. The policy was gender accommodating as it included protections for all USG staff regardless of gender identity, including LGBTQI+ individuals, though it did not include measures to combat gender norms within the workplace. This action moderately promoted SRHR in the MCH domain.

2021_Memorandum on the Presidential Determination with Respect to the Efforts of Foreign Governments Regarding Trafficking in Persons

This Presidential Memorandum restricted which forms of U.S. foreign assistance could be received by other countries depending on their compliance with the minimum standards for the elimination of trafficking in persons as defined in the TVPA. The Memorandum stated that the USG will not provide "nonhumanitarian, nontrade-related assistance"—which includes global health assistance—to specific countries that do not meet these minimum standards, with some exceptions to allow for global health funding, as well as "development assistance that directly addresses basic human needs" on a country-by-country basis. This policy was not based in evidence or responsive to need as cutting off global health assistance for these countries would pose a barrier for survivors of trafficking to receiving essential health care, including MCH services. It promoted a carceral approach to preventing and addressing trafficking, which relies on law enforcement to prevent and prosecute trafficking even though justice systems do not consistently protect the human rights and health needs of survivors. The action was gender blind as it did not explicitly recognize the disproportionate impact of trafficking on women and girls. Overall, by leveraging global health assistance as a tool to coerce compliance with TVPA, this action moderately hindered SRHR in the MCH domain.

2021_National Action Plan to Combat Human Trafficking

The National Action Plan to Combat Human Trafficking outlined a roadmap for how the United States should address trafficking domestically and in foreign policy. The Plan focused on the four pillars of anti-trafficking efforts: prevention, protection, prosecution, and partnership, and emphasized a commitment to gender and racial equity, workers' rights, fair trade, and providing support to underserved communities. Regarding SRHR and other health outcomes, the Plan was largely domestically focused. It included provisions that applied to global health assistance, but global MCH programs were not mentioned. The Plan was responsive to need as it recognized the disproportionate impact of trafficking on "racial and ethnic minorities, women and girls, LGBTQI individuals, vulnerable migrants, and others from historically marginalized and underserved communities." However, the Plan promoted policies that reduced demand for products or services from forced labor, which was not based in evidence as these policies often lead to the prosecution of sex workers and the violation of their rights. Other aspects of the Plan included centering the expertise of survivors and adopting inclusive policies for programs to decrease systemic disparities that negatively impact marginalized communities or increase their vulnerability to trafficking, which was responsive to need as well as based in evidence and human rights norms. While this action used language that enforced the gender binary, it also mentioned LGBTQI+ populations, making the Plan gender accommodating. Since the Plan's focus was mostly within the United States, it neither promoted nor hindered global SRHR in the MCH domain.

2021_National Strategy for the COVID-19 Response and Pandemic Preparedness

The National Strategy for the COVID-19 Response and Pandemic Preparedness detailed the Biden administration's interagency plan to promote pandemic recovery efforts across domestic and foreign policy. Goal 7, "Restore U.S. leadership globally and build better preparedness for future threats," contained the Strategy's specific initiatives related to foreign policy and global health assistance. The Strategy directed the creation of publicly accessible performance dashboards to establish an evidence-based approach to evaluating progress towards COVID-19 prevention and recovery, which was responsive to need and based in evidence. Even though it recognized the disproportionate impact of the pandemic on women and girls, this action was gender accommodating as it reinforced a gender binary, did not include LGBTQI+ persons, and did not challenge gender inequities and norms that intensified as a result of the pandemic. The Strategy committed to promoting SRHR and included cross-cutting issues that have been impacted by COVID-19, including GBV, tuberculosis, and immunizations. It mentioned COVID-19’s secondary impacts on global MCH programs, though it did not provide specifics of how global health programs should respond to the impact of the pandemic on these health services. The Strategy moderately promoted SRHR in the MCH domain.

2021_National Strategy on Gender Equity and Equality

The National Strategy on Gender Equity and Equality detailed the whole-of-government approach to promote gender equity both domestically and globally. The Strategy laid out several plans to increase access to health care (including SRH services), advocate for gender equity and equal representation in leadership, and respond to GBV and climate change. The Strategy named the domestic and global promotion of SRHR as a priority. The Strategy called for the end of the GGR and promoted the provision of integrated SRH programs, which was responsive to need. However, it did not explicitly call on Congress to permanently repeal the GGR, which was a necessary action that would significantly promote SRHR globally. The action affirmed the right to access safe abortion care, which was responsive to need but only applied to the domestic implementation of the Strategy. The Strategy committed to working in partnership with "foreign governments and multi-lateral organizations, and non-governmental actors—including faith-based groups, civil society, and private sector organizations" using an intersectional approach to addressing discrimination and advancing gender equity, which was based in evidence and responsive to need. The action included a section on advancing human rights by working to eliminate practices that undermine gender equity, such as FGM/C, CEFM, and GBV. Many aspects of the Strategy were gender transformative, such as the inclusion of people of all genders (i.e., transgender women and girls, gender nonbinary and nonconforming people, and men and boys) and support for programs to implement cultural and gender norms change. However, the Strategy still used language that reinforced a gender binary when mentioning pregnancy and maternal health. The Strategy meaningfully included issues across MCH throughout, including global investments in the SDGs, client-centered services, integrating obstetric care with other SRH services, and the impact of climate change on pregnant people. The Strategy significantly promoted SRHR in the MCH domain.

2021_Report on the Impact of Climate Change on Migration

This Report provided an overview of the impact of climate change on migration to inform a proposal for how United States foreign assistance could and should address the impacts of climate change on displaced persons. The Report included quality health services as part of the social services package that the USG could provide to partner governments that receive migrant populations, but it did not discuss access to health services for displaced persons in detail. The Report acknowledged the barriers faced by people related to intersectional forms of discrimination and named the expertise of agencies like the Department of State and USAID for providing technical guidance to integrate the unique needs of people with marginalized identities into foreign assistance. The Report stated that planning and policy decisions should include engagement with marginalized populations to ensure that funding and programmatic decisions were responsive to need. It emphasized the importance of multilateral engagement through the SDGs, the Paris Agreement, U.N. resolutions, and the role of civil society, which was based in evidence and human rights norms, and was responsive to need. However, the role of U.S. global health funding or programs, including MCH programs, was not clear in this report. The Report recognized gender as a factor in the context of GBV, and included "women, girls, and gender diverse persons," which was gender accommodating. This report neither hindered nor promoted SRHR in the MCH 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. 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 mentioned the impact of COVID-19 on MCH outcomes but did not meaningfully discuss investments in MCH programs to promote global health security. 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 the COVID-19 pandemic. The Report was gender blind as it made only one mention of gender in the context of the OneHealth approach. This action moderately hindered SRHR in the MCH domain.

2021_U.S. COVID-19 Global Response and Recovery Framework

This Framework built upon the National Strategy for the COVID-19 Response and Pandemic Preparedness' Goal 7: "Restore U.S. leadership globally and build better preparedness for future threats." The Framework prioritized disseminating safe and effective COVID-19 vaccinations, addressing food insecurity, reducing GBV, and recognizing the impact of the pandemic on women and girls, youth, displaced persons, and underserved populations. It highlighted cross-cutting principles such as humility, multilateralism, partnerships, DEI, evidence-based and risk-based decision making, transparency, and accountability. Through its focus on underserved communities and implementing systemic, fair, just, and impartial treatment of all, the Framework was based in human rights norms. While the objectives listed were based in evidence and responsive to need, the Framework did not name any specific actors, deliverables, or timelines in accordance with the objectives, which was not responsive to need. The Framework acknowledged gender inequality and the importance of repairing the harm of the pandemic that worsened these inequities, which was gender accommodating. This Framework moderately promoted SRHR in the MCH domain.

2021_U.S. International Climate Finance Plan

The U.S. International Climate Finance Plan outlined a whole-of-government approach to providing and mobilizing financial resources to aid other countries in recusing and avoiding greenhouse gas emissions and building resilience against the impacts of climate change. The Plan included improving human health as a positive impact of climate finance and directed USG departments and agencies that engage in global health to analyze the impacts of climate change on human health, which was responsive to need. The Plan called for USG agencies to align their partnerships and financial investments with what is needed to achieve the goals included in the Paris Agreement, which was based in evidence. The Plan also included time-bound and specific goals and deliverables that apply to USG agencies that would benefit global health assistance and programming, which was responsive to need. However, the Plan did not specifically mention the impacts of climate change on SRHR, including maternal and newborn health, or the potential positive impacts of climate finance on promoting SRHR, so the benefits of implementing this plan would likely have indirect effects on SRHR. The Plan mentioned women and girls once but was otherwise gender blind as evidence indicates that climate change has specific negative impacts on pregnant and breastfeeding people. This Plan neither hindered nor promoted SRHR in the MCH domain.

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

The WPS Congressional Report provided Congress with an overview of progress made in implementing the WPS Agenda globally since 2019. The Report evaluated progress in advancing the WPS Strategy's four lines of effort across the Department of State, DoD, DHS, and USAID: participation, protection, internal capabilities, and partnerships. While improved health outcomes were included as a positive impact of implementing the WPS Agenda, MCH outcomes were only briefly mentioned. The Report included GBV prevention and programming as a cross-cutting measure of progress towards achieving the WPS Agenda, which was responsive to need. The Report emphasized the importance of evidence-based implementation and decision-making, which was rooted in evidence and best practices, and included specific and actionable milestones to measure progress, which was responsive to need. The Report included several gender transformative elements such as enhancing gender-sensitive data analytics, recognizing "the intersectionalities inhabited by women," and supporting initiatives to address and overhaul harmful gender norms. However, it was predominantly focused on women which reinforced a gender binary. The Report moderately promoted SRHR in the MCH domain.

2020_Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (H.R. 6074)

The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 became law on March 6, 2020 and appropriated an additional $435 million in Global Health Programs (GHP) funds for the Department of State and USAID to “prevent, prepare for, and respond to” the COVID-19 pandemic through September 30, 2022. This action was highly responsive to need because it was passed early in the pandemic and provided much-needed funds to support the initial global health response to the pandemic. The decision to appropriate additional funds to support pandemic response efforts was also based in evidence and human rights. This action moderately promoted the ability of U.S. global health assistance to support HIV and AIDS programs that could address the impacts of COVID-19 related to SRHR.

2020_Executive Order on Advancing International Religious Freedom

This Executive Order (EO) referenced foreign assistance funding for international religious freedom and directed the Department of State and USAID to prioritize religious freedom in the planning and implementation of U.S. foreign policy and within foreign assistance programs. The EO directed the Secretary of the Treasury to identify the economic tools that could be used to pressure other country governments to comply with this EO, including "realigning foreign assistance" though it was unclear how this could affect global health assistance programs. This EO was not evidence-based, responsive to need, or aligned with human rights standards as it prioritized religious freedom over evidence, global health needs, and human rights. Further, it was gender blind as it made no mention of gender and ignored the reality that religious freedom has been used in some settings to hinder gender equity. The EO did not mention global MCH programs, nor did it consider how the directive might engage with other areas of global health, which contributed to the siloed approach to global health and resulted in a transparency issue. This EO moderately hindered the ability of U.S. global health assistance to support MCH programs that are evidence-informed, responsive to need, consistent with internationally-recognized human rights principles, gender transformative, and promote SRHR.

2020_Executive Order on Combating Race and Sex Stereotyping

This EO directed recipients of federal grants to agree not to use federal funds for workplace trainings that promote "divisive concepts," such as "race or sex stereotyping." The EO specifically directed the Office of Personnel Management (OPM) to review training programs that were developed for agency employees to ensure compliance with this action. This EO was not based in evidence or human rights norms as it ignored the impact of white supremacy, systemic racism, and colonization on the health and human rights of Black, Indigenous, People of Color (BIPOC) communities around the world. Furthermore, the EO adhered to a gender binary and did not encourage a gender transformative approach to discussing power and privilege based on race and sex. While this action did not provide technical guidance related to MCH, it directed agencies to pose restrictions on the types of trainings that could be supported by federal funds for global health grants and cooperative agreements. Therefore, this EO moderately hindered the ability of U.S. global health assistance to promote SRHR in the MCH domain.

2020_Executive Order on Ensuring Access to United States Government COVID-19 Vaccines

This EO dictated how COVID-19 vaccines should be distributed in the United States and abroad. It specified that vaccines should only be distributed outside of the United States upon determination that there was “sufficient” supply for Americans who “choose to be vaccinated.” It directed the Secretary of the Department of Health and Human Services (HHS), the Secretary of State, and Administrator of USAID to facilitate international access to COVID-19 vaccines developed in the United States, though it was unclear if U.S. global health assistance funds would be used to implement this effort. It specified that vaccines should be distributed to “allies, partners, and others, as appropriate and consistent with applicable law.” This demonstrated a vague and potentially inequitable approach to vaccine distribution during a global pandemic when solidarity is required to ensure equitable access to vaccines globally. This approach was not aligned with evidence or international human rights norms and was not responsive to need as this type of American exceptionalism is dangerous and deadly for those who live in countries that are not allies with the United States. It was also gender blind because it did not mention the disproportionate impact of COVID-19 on women, girls, and gender-diverse people, nor did it mention the impact that the global distribution of vaccines would have on women, girls, and people with diverse sexual orientation, gender identity, gender expression, and sex characteristics (SOGIESC). As a result, it moderately hindered the ability of U.S. global health assistance to promote SRHR in this domain.

2020_Executive Order on Rebranding United States Foreign Assistance to Advance American Influence

This EO directed federal agencies to ensure that all U.S. foreign assistance was marketed as “American aid,” and displayed logos and other imagery that “embod[y] the values and generosity of the American people. While this EO did not explicitly mention global health, it applied to all foreign assistance which includes global health awards. At its core, this EO created a burden for recipients of foreign assistance. It potentially hindered the ability of global health award recipients to provide health services to people in communities that have anti-American views, where “American aid” branding may have been a deterrent or barrier to people seeking services. This EO prioritized the United States’ influence over ensuring that U.S. foreign assistance is evidence-based, responsive to need, and grounded in human rights norms. It was gender blind because it made no mention of gender in the context of U.S. global health assistance programs. The lack of explicit mention of specific global health programs, including those related to MCH, presented a transparency issue given that the EO would apply to all global health awards. This EO moderately hindered the ability of U.S. global health assistance to support MCH programs that were evidence-informed, responsive to need, consistent with internationally-recognized human rights principles, gender transformative, and promote SRHR.

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 could impede efforts to prevent trafficking. The carceral approach outlined in this report posed additional risks and barriers for sex workers that needed to access health services due to the fear of prosecution or being targeted by law enforcement. While this report briefly mentioned gender, it was largely gender blind and made no mention of how trafficking impacts people in the LGBTQI+ community. The Report moderately hindered SRHR in the MCH domain.

2020_Presidential Determination with Respect to the Efforts of Foreign Governments Regarding Trafficking in Persons

This Presidential Memorandum applied restrictions on the types of U.S. assistance permissible to different countries based on whether they were compliant with the Trafficking Victims Protection Act of 2000 (TVPA). Based on this memorandum, governments who did not meet the minimum standards for the elimination of trafficking in persons (as defined in the TVPA) would be barred from receiving U.S. non-humanitarian, non-trade assistance, which includes global health assistance. In the context of this policy, global health assistance was explicitly used as a diplomatic tool to pressure foreign governments to comply with the conditions of the TVPA. This policy was not responsive to need because cutting off global health assistance would act as a barrier for people engaged in sex work or people who are trafficked from receiving MCH services in specific countries. It was not aligned with human rights norms because the minimum standards to which governments were being asked to adhere enforced a carceral approach to trafficking, which relies heavily on law enforcement to prevent trafficking even though these systems do not consistently protect the rights of marginalized groups that may be trafficked. This poses great risks to those engaged in commercial sex work as it creates barriers to accessing health services due to fear of prosecution or targeting from law enforcement. The Policy was also gender blind, as it made no mention of the impact of gender on its approach or determinations. This Presidential Memorandum hindered the ability of U.S. global health assistance to promote SRHR in the MCH domain.

2020_Preventing Hoarding of Health and Medical Resources To Respond to the Spread of COVID–19

This EO directed the Secretary of the Department of Health and Human Services (HHS) to take action to prevent the hoarding of personal protective equipment (PPE) and other supplies to respond to the spread of COVID-19. This EO was intended to be a positive preventative measure by the White House to ensure that there was enough PPE available to those who needed it at the beginning of the pandemic, however the specification for what constituted ‘hoarding’ of PPE was vague and could be difficult to implement accurately. It did not mention gender issues or make accommodations for groups who are disproportionately impacted by COVID-19 like women, girls, and gender-diverse people. This EO contributed to confusion regarding what could be procured with U.S. global health assistance funds across implementing agencies and partner organizations. More information is needed on how funds should be used to purchase PPE and what constituted “hoarding.” The EO neither promoted nor hindered SRHR in the MCH domain.

2020_The National Action Plan to Combat Human Trafficking

The National Action Plan to Combat Human Trafficking set the U.S. government priorities related to human trafficking. The Plan prioritized a “victim-centered, trauma-informed, and culturally competent” approach to supporting trafficking survivors in alignment with the standards set by the Office for Victims of Crime within the Department of Justice which are based in evidence. The Plan also recognized that survivors of trafficking should be able to access comprehensive medical and mental health services, including those related to HIV and AIDS, but it did not mention MCH or other SRHR health issues and it conflated trafficking with sex work which was not consistent with evidence. This National Action Plan was not consistent with international human rights norms beyond reference to the Palermo Protocol because it was based on the Trump administration’s framing of unalienable rights. The Plan also promoted a carceral approach to trafficking, which is based on neither evidence nor human rights and jeopardizes the health and wellbeing of sex workers. The Plan mentioned that “people of all ages, genders, races, religions, and nationalities” including “LGBT+” individuals are disproportionately impacted by trafficking, which was based in evidence and was gender accommodating. This whole-of-government approach was primarily focused on domestic issues and programs, and it was unclear if the role of U.S. global health funding or programs were considered here, which is a transparency issue. This Plan neither hindered nor promoted the ability of the U.S. global health assistance to support SRHR in the MCH domain.

2020_Women’s Global Development and Prosperity Initiative_Annual Report 2019-2020

This report described the accomplishments of the Women's Global Development and Prosperity (W-GDP) Initiative in its first year of implementation. The Initiative was based on President Trump’s America First policy and was designed to support USAID’s work toward countries’ self-reliance. Though this was the first whole-of-government report about women’s economic empowerment, it reinforced silos between economic empowerment and health because it did not include a discussion about MCH or health more broadly. While gender-based violence (GBV) was mentioned, the report made no mention of its connection to health, even though GBV is a cross-cutting SRHR issue. The Report called for removing “cultural barriers” to women's economic empowerment but did not identify the barriers or describe them, which contributed to low transparency. The Report was gender aware because it mentioned women's barriers to economic empowerment but reinforced a gender binary and did not acknowledge the needs of LGBTQI+ communities or others who might also benefit from economic empowerment efforts. Elements of this report were based in evidence and human rights, though details about health and SRHR were significantly lacking. Further, it was unclear if the W-GDP Initiative impacted or engaged with global MCH programs during its first year of implementation because the types of funds used by this initiative were not explicitly mentioned, which was a transparency issue. This report neither hindered nor promoted the ability of U.S. global health assistance to support SRHR in the MCH domain.

2019_Global Health Innovation Act of 2017 (H.R.1660)

This law signed by the President instituted a new requirement for the Administrator of USAID to report to Congress about USAID’s investment in and development of global health technologies. The passage of this bill indicated White House and Congressional interest in global health technologies and implemented a mechanism to hold USAID accountable to continuous innovation of such technologies. While HIV and AIDS technologies were explicitly mentioned, this Act did not require USAID to report on other technologies that USAID may be developing, such as maternal and child health technologies or multi-purpose family planning and/or HIV and AIDS technologies. It is possible that without explicit mention of these technologies, they may be omitted from reporting. This law was responsive to need and evidence-based, as it emphasized the importance of global health technologies and innovation in achieving global health goals. The Act did not reference human rights principles or the need for more women and girl-centered technologies. Overall, this law neither promoted nor harmed SRHR with regard to maternal and child health.

2019_United States Government Global Health Security Strategy

This document was a cross-agency Strategy to improve global health security both in the U.S. and globally. The Strategy discussed the importance of disease prevention and treatment and outlined the role of the U.S. and other funders invested in strengthening health systems in countries that may not currently have the capacity to respond to outbreaks. This Strategy was high-level and did not specifically discuss any relevant global health program areas. Maternal and child health was mentioned once as evidence of the success of U.S. global health programs to date, but did not include a description of the role of U.S. global health assistance in these efforts. The Strategy also did not provide any context or discussion of the continuing gaps in maternal and child health programming with regard to global health security. This Strategy was responsive to need and evidence-based, as it referenced global standards regarding global health security and data showing the need to strengthen health systems throughout the Strategy. The document was neither gender transformative nor based in international human rights norms, as it did not discuss the role of gender norms in global health security or specifically reference human rights principles that frame global health security efforts. Overall, this Strategy’s silence on maternal and child health did not harm nor promote SRHR. Future policy documents outlining global health strategies should provide specific details about relevant programs that contribute to global health security.

2019_United States Strategy on Women, Peace, and Security

The U.S. Strategy on Women, Peace, and Security was the operationalization of the Women, Peace, and Security Act of 2017 and was intended to "increase women’s meaningful leadership in political and civic life by helping to ensure they are empowered to lead and contribute, equipped with the necessary skills and support to succeed, and supported to participate through access to opportunities and resources." However, the Strategy dismissed the important role of maternal and child health in the health, wellbeing, and participation of women and girls in decision-making processes and institutions both during times of conflict and peace. Even though the Department of State and USAID were named as relevant actors, the lack of discussion of health—specifically of maternal and child health—was an obvious gap, especially given the prevalence of gender-based violence (GBV) and lack of access to respectful maternity care in crisis settings. This Strategy was responsive to need as it addressed the lack of representation of women in conflict resolution and peacebuilding processes. However, the Strategy was not grounded in evidence as evidence shows the key role of women's health in country stability. The Strategy was not grounded in human rights, as the document cited "the United States Government’s interpretation of the laws of armed conflict and International Human Rights Law'' which may have implied that human rights principles were not being followed as written. Lastly, this Strategy was not gender transformative because it recognized but did not take steps to address the root causes of gender inequity within conflict and post-conflict settings, nor did it advocate strongly for the inclusion of all populations in these efforts. It is possible that this Strategy, once implemented, could create avenues for significant gender transformation but the current version of the Strategy is narrow in a way that ultimately harms women and girls.

2017_Presidential Memorandum of January 23, 2017_The Mexico City Policy (Expanded Global Gag Rule)

President Trump reinstated and expanded the Mexico City Policy, often known as the Global Gag Rule, and renamed it the Protecting Life in Global Health Assistance (PLGHA) policy. When in place under previous administrations, the policy applied only to international family planning assistance, whereas Trump’s version of the policy "extend(s) the requirements... to global health assistance furnished by all departments or agencies." Research has documented the harms of this policy in previous administrations when the policy was in effect, and the expansion of this policy via this 2017 Presidential Memorandum demonstrated a disregard for evidence and international human rights norms. This policy spurred a chain of events that significantly reduced community and government engagement in HIV prevention, care, and treatment programs and prohibits beneficiaries from accessing key services in many countries that receive U.S. global health assistance. The expansion of the PLGHA policy was against evidence, need, and human rights principles and was not gender transformative; this policy was gender blind, as it did not discuss the role of gender norms on the promotion of SRHR through U.S. global health assistance programs.

2016_The United States National Action Plan on Women, Peace, and Security

The United States National Action Plan on Women, Peace, and Security described what the U.S. continues to do to empower women as equal partners in preventing conflict and building peace in countries threatened and affected by war, violence, and insecurity. The Plan moderately promoted SRHR by calling for better access to "clinical care and reproductive health services such as family planning, HIV testing, counseling and treatment, and maternal health" and aimed to “reduce maternal mortality by 30 percent…through... prenatal care and services, obstetric care, voluntary family planning, HIV testing and counseling, nutritional support, and safe water, sanitation and hygiene interventions.” Despite the Plan's focus on conflict and security, it did not go in-depth about the impact of conflict on maternal and child health. This Plan is moderately gender transformative, as it called for more gender equality and inclusivity in all initiatives, especially regarding “members of marginalized groups, including youth, ethnic, racial or religious minorities, persons with disabilities, displaced persons and indigenous peoples, lesbian, gay, bisexual, transgender, and intersex (LGBTI) individuals, and people from all socioeconomic strata.” It also discussed the distinct health needs of ex-combatants and former violent extremists who are female, specifically stating that these women have a difficult time adhering to traditional gender norms upon their return from combat. This National Action Plan supported the U.S. government's ability to promote SRHR with regard to maternal and child health programs and funding.

2015_U.S. Statement to UN Women Executive Board Recognizing Sexual Rights

2015_United States Global Strategy to Empower Adolescent Girls

2012_Executive Order-Preventing and Responding to Violence Against Women and Girls Globally

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

2011_United States National Action Plan on Women, Peace, and Security

2009_Statement by the President on Global Health Initiative

B+

Congress

Congress received an 89 (B+) with transparency and a 94 (A) without transparency in the Maternal and Child Health (MCH) domain in 2021. Congress appropriated adequate levels of funding for the United Nations Children’s Emergency Fund (UNICEF), UNIFEM (now UN Women), and global MCH programs implemented by the United States Agency for International Development (USAID). Though it was unclear if global MCH programs were included in the additional funds Congress appropriated for USAID’s global health programs, the American Rescue Plan Act moderately increased Congress’ grade in this domain because it appropriated additional global health assistance funds to respond to the impacts of COVID-19, which could include issues that are related to SRHR. Congress demonstrated a low level of transparency of policy data and high transparency of funding information related to MCH globally in 2021.

The Fòs Feminista 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_American Rescue Plan Act (H.R.1319)

The American Rescue Plan Act appropriated additional U.S. global health funding for specific implementing agencies to prevent, prepare for, and respond to the COVID-19 pandemic, as well as support public health surveillance to respond to other emerging infectious disease threats globally. It included contributions to support multilateral vaccine development partnerships and a contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria. Though it was unclear if the additional funding for USAID’s global health programs appropriated by this Act included global MCH programming, these funds could support USAID’s response to the impacts of COVID-19 on issues related to SRHR. This action had low transparency in this domain. This action was responsive to need and based in evidence and human rights. This law was not gender transformative, as it should have included a call for data to be disaggregated by sex and/or gender to inform responses to COVID-19 given the disproportionate impacts of the pandemic on women, girls, and gender-diverse people. This action moderately promoted SRHR in the MCH domain.

2020_Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (H.R. 6074)

The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 became law on March 6, 2020, and appropriated an additional $435 million in Global Health Programs (GHP) funds for the Department of State and United States Agency for International Development (USAID) to “prevent, prepare for, and respond to” the COVID-19 pandemic through September 30, 2022. This action was highly responsive to need because it was passed early in the pandemic and provided much-needed funds to support the initial global health response to the pandemic. The appropriation of additional funds to support pandemic response efforts was also based in evidence and human rights. This action moderately promoted the ability of U.S. global health assistance to support MCH programs that could address the impacts of COVID-19 related to SRHR.

2019_Global Health Innovation Act of 2017 (H.R.1660)

This law instituted a new requirement for the Administrator of USAID to report to Congress on USAID’s investment in and development of global health technologies. The passage of this bill indicated Congressional interest in global health technologies and implemented a mechanism to hold USAID accountable to continuous innovation of such technologies. While HIV and AIDS technologies were explicitly mentioned, this Act did not include a request for details about other technologies that USAID could have been developing, such as maternal and child health technologies or multi-purpose family planning and/or HIV and AIDS technologies. It is possible that without explicit mention of these technologies, they may be omitted from reporting. This law was responsive to need and evidence-based, as it emphasized the importance of global health technologies and innovation in achieving global health goals. The Act did not reference human rights principles or the need for more women and girl-centered technologies. Overall, this law neither promoted nor harmed SRHR with regard to maternal and child health.

2004_Medically Accurate Information on Condoms_Consolidated Appropriations Act, 2004 (H.R. 2673)

1961_The Foreign Assistance Act of 1961

Department of State

The Department of State received a 44 (F) with transparency and a 50 (F) without transparency in the Maternal and Child Health (MCH) domain in 2021. This domain grade was raised by the meaningful inclusion of MCH activities in the PEPFAR Core Program and Policy Priorities and the updated March 2021 DREAMS Guidance, which were both responsive to need, based in evidence, aligned with human rights norms, and gender transformative. The February 2021 COP/ROP Guidance and other COP/ROP-related materials did not promote SRHR in the MCH domain because they did not include adequate information for partners to understand the revocation of PLGHA and adapt their programs accordingly. This domain grade was low overall because the actions did not include data about MCH programs or activities across the board, which reinforced the siloed nature of global health programs, negatively affected transparency, and hindered SRHR. In the budget evaluation, the Department of State allocated MCH funds in a manner that was somewhat in accordance with country-level maternal mortality, which moderately promoted SRHR in the MCH domain in 2021.

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

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2021_2021 Annual PEPFAR Treatment Report to Congress

The Annual Treatment Report from PEPFAR provides information to Congress on PEPFAR-supported treatment programs as required by Section 7611 (g) of Title 22 of the U.S. Code. The 2021 Report focused on the programmatic adaptations PEPFAR implemented in response to the COVID-19 pandemic to ensure that treatment programs were not disrupted. Adaptations included MMD of ARVs, the decentralization of drug delivery, the use of virtual platforms like telemedicine, and the implementation of efforts to empower communities, which were responsive to need, based in evidence, and aligned with human rights. The Report mentioned the decision to increase the number of people living with HIV (PLHIV) on dolutegravir-containing ARV regimens which was based in evidence, however there was no mention of the importance of ensuring these regimens are available for pregnant PLHIV. As a result, this action was not fully based in evidence, human rights, or responsive to need. The Report did not include treatment data related to specific populations, such as orphans and vulnerable children (OVCs) or the outcomes of prevention of mother to child transmission (PMTCT) of HIV activities, which was an oversight because these programs and activities are critical to the success of PEPFAR. The Report was gender blind, as there was little mention of gender. The Report moderately hindered SRHR in the MCH domain.

2021_Country_Regional Operational Plan 2021 (COP/ROP 2021) Virtual Meeting Handbook

This Virtual Meeting Handbook outlined the ways in which the OGAC streamlined the COP/ROP 2021 process in response to the COVID-19 pandemic. The COP/ROP 2021 process was shortened and conducted virtually for the first time, which was highly responsive to need due to the pandemic and this action ensured that PEPFAR stakeholders at all levels had timely information about this process. This action detailed the revised framework for ensuring meaningful stakeholder engagement by mandating transparent discussions with PEPFAR leadership during town halls with stakeholders at all levels and involving partner country governments, communities, CSOs, multilateral partners, and the private sector, which was responsive to need. This action included guiding principles for PEPFAR during the COVID-19 pandemic that were responsive to need and consistent with evidence and human rights norms, such as protecting program gains, ensuring site safety, and mitigating COVID-19’s impact on OVC and PMTCT activities. This action moderately promoted SRHR in the MCH domain.

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

The FY 2022 Annual Performance Plan outlined progress made by the Department of State and USAID toward strategic objectives and performance goals in previous years. The Plan outlined each agency’s plans for achieving the goals articulated in their joint strategic plan moving forward. Though the MCH-specific indicators only included data from USAID, this action was graded across domains for the Department of State because of this actor’s leadership of PEPFAR which includes activities related to MCH, as well as cross-cutting issues including GBV. While the availability of these data was important for evidence-based decision making in the HIV and AIDS domain, indicators that measured the outcomes of PMTCT or other HIV activities related to MCH were not included in this action. As a result, this action was not fully responsive to need or based in evidence or human rights in this domain. The Department of State’s contributions to cross-cutting SRHR issues like gender equality and GBV prevention and response were included in this action, which was responsive to need. However, no targets were included for FY 2022, which was not responsive to need and negatively affected transparency. Additionally, the Plan was gender accommodating as it used language that reinforced a gender binary. This action neither promoted nor hindered SRHR in this domain.

2021_Guiding Principles for the Next Phase of PEPFAR

The Guiding Principles outlined the program’s goals as of January 20, 2021, and presented PEPFAR’s progress to date, including national progress toward achieving the 90-90-90 and 95-95-95 targets in specific countries. This action detailed the impact of COVID-19 on PEPFAR programs, as well as outlined programmatic adaptations that OUs implemented to overcome the impacts of the pandemic, which was responsive to need and based in evidence. The Guiding Principles focused on providing people-centered HIV prevention, care, and treatment services but did not mention OVC, PMTCT, or other PEPFAR activities related to MCH, which was not responsive to need or aligned with evidence. This action did not mention the human rights framework that underpins PEPFAR programming, nor did it discuss the importance of integrated services and UHC in advancing PEPFAR’s goals, specifically for pregnant and breastfeeding persons or persons of reproductive age. This action was gender accommodating as it included language that reinforced a gender binary. This action moderately hindered SRHR in the MCH domain.

2021_PEPFAR 2021 Annual Report to Congress

The PEPFAR 2021 Annual Report to Congress detailed the achievements of PEPFAR and challenges to delivering people-centered HIV services, particularly in light of the COVID-19 pandemic. This action outlined country-specific progress toward the 90-90-90 targets, documented PEPFAR’s efforts to strengthen health systems, and advocated for integrated GBV programs, which was responsive to need and based in evidence. This action highlighted the importance of addressing barriers to accessing care and working with community- and KP-led indigenous organizations to promote human rights, which was responsive to need and promoted SRHR. The Report included outcomes of PMTCT and OVC programs and mentioned pregnant and breastfeeding women (PBFW) as a priority population, which was responsive to need and based in evidence. The action supported dolutegravir-containing regimens as the preferred treatment regimen for women of childbearing age. The “Preventing Infections in Women” section mentioned the strengthening of platforms through which women seek care, including antenatal care (ANC) platforms to support women’s access to PrEP or PMTCT services, which was responsive to need. This action was gender accommodating as it used language that reinforced a gender binary (e.g., PBFW and women of childbearing age). This action moderately promoted SRHR in the MCH domain.

2021_PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR Countries

On February 11, 2021, OGAC released an updated version of the COP/ROP 2021 Guidance that revised four sections of this critical PEPFAR guiding document. Section 5.9.4 was updated to cross out the text related to the PLGHA policy. The action included the following information: “Implementation of Protecting Life in Global Health Assistance in PEPFAR Programs has been deleted as the policy was rescinded by President Biden in January 2021” but did not provide stakeholders with any additional information about what the revocation meant for OUs or ongoing awards. Though this update was timely, it lacked specificity and guidance for stakeholders to understand how the revocation of PLGHA (also known as the GGR) impacts their work, so it was only somewhat responsive to need and was not based in evidence or human rights. This action significantly hindered SRHR in the MCH domain.

2021_PEPFAR COP/ROP 2021 Frequently Asked Questions

This FAQs document provided regular updates on the COP/ROP 2021 process after it was temporarily paused earlier in 2021. This action included information about civil society and community engagement and provided answers to questions that were specific to technical areas, all of which were responsive to need and based in evidence. For example, this action included FAQs that supported pediatric use of dolutegravir-containing regimens, as well as distinctions between OVC and DREAMS funding, which were responsive to need and based in evidence. The action included one question related to the impact of “new policies of the Biden-Harris Administration, such as the rescission of the Mexico City Policy” on the COP/ROP 2021 process. The answer said that “PEPFAR funding and partners are no longer subject to these policy requirements and instead should follow those outlined in the January 28, 2021 Executive Order” and included a hyperlink to the executive action. This answer did not include additional information or guidance for stakeholders to understand how the revocation of this policy impacts their work with PEPFAR, which was not responsive to need. This action moderately hindered SRHR in the MCH domain.

2021_PEPFAR COP/ROP 2021 Temporary Pause FAQs

This FAQs document was released on February 17, 2021 and confirmed the Biden administration’s commitment to PEPFAR as well as provided an explanation for the temporary pause of the COP/ROP 2021 process. This action also reaffirmed OGAC’s commitment to completing a data-driven COP/ROP 2021 process and ensuring that there were no disruptions in HIV services at the start of FY 2022. Many of the process-specific questions included in this action were also included in the previous action, including a question that highlighted the sections that were updated in the February 2021 version of the COP/ROP 2021 Guidance. Most of the questions were procedural and not technical, so this action neither promoted nor hindered SRHR in the MCH domain.

2021_PEPFAR Core Program and Policy Priorities

The PEPFAR Core Program and Policy Priorities outlined the focus areas of PEPFAR under the Biden administration. The action included key priorities on HIV prevention and treatment: data-driven HIV testing strategies such as support for KPs, gender equity and equality, cooperation and partnership with community stakeholders and public health leadership, and the strengthening of global health security. These priorities were responsive to need, based in evidence, and aligned with human rights norms. Notably, the action included a priority to promote and protect SRHR, including through the revocation of PLGHA. This action provided a high-level framework for PEPFAR’s focus areas, so information about how PEPFAR would implement the revocation would not be included in this action. However, this action was not fully responsive to need as the priorities did not specifically include MCH outcomes outside of eliminating the "vertical transmission of HIV and pediatric AIDS.” The action stated the importance of improving appropriate linkages to and integration of HIV services with other related global health programs but did not specifically mention MCH as a related program. Gender transformative elements were highlighted in the section on “HIV prevention, clinical, and health systems programs,” and in the Department of State’s commitments to DEIA. This action moderately promoted SRHR in the MCH domain.

2021_PEPFAR DREAMS Guidance_Updated March 2021

The PEPFAR DREAMS Guidance provided updated guidance for implementing DREAMS programming for AGYW in 2021. The Guidance highlighted the importance of multi-sector engagement across government leadership and community partners, evidence-based decision making across DREAMS programming, and overall prioritization of DREAMS implementation. The Guidance was based in evidence and human rights as it referenced a variety of peer-reviewed external resources as well as international agreements and frameworks. The Guidance included information about parenting and caregiving programs, discussions on pregnancy prevention, linkages to DREAMS through PMTCT and ANC clinics, and affirmed the need for PrEP to be prioritized for young women, "including those who are pregnant or breastfeeding or who may be having transactional sex," which promoted MCH services within DREAMS programming and was responsive to need. However, the Guidance did not mention safe abortion services when addressing unintended pregnancy, which was an oversight and did not reflect the full package of services that should be provided to DREAMS recipients following the revocation of the GGR. It was gender transformative as it called for changing unequal gender and power dynamics. However, this Guidance used gendered language when mentioning condoms and pregnancy, did not affirm the right to sexual pleasure, and did not include LGBTQI+ women and girls, which was an oversight. This Guidance significantly promoted SRHR in the MCH domain.

2021_PEPFAR FY21 Site Improvement through Monitoring System (SIMS) Materials_Version 4.1

The PEPFAR SIMS tool provides a standardized approach for monitoring program quality at PEPFAR-supported sites that perform service and non-service delivery functions. The FY21 Implementation Guide, Above-Side Assessment Tool, and Site Assessment Tool were updated in 2021, though the changes from the previous version were not clearly stated, which negatively affected transparency. The Above-Site and Site Assessment Tools included CEEs that assessed the site against a set of standard technical requirements, which were based in evidence. The major apparent change in the CEEs was the removal of assessment modules related to the implementation of PLGHA in the Above-Site Assessment Tool. This module was removed without explanation. A new module was not added to ensure that PEPFAR-supported sites stopped implementing the policy after its revocation, which was not responsive to need or consistent with evidence and human rights norms. The Guide and CEEs incorporated PMTCT, ANC, and labor and delivery services, which was based in evidence and responsive to need. It included guidance for SIMS assessors to not participate in or condone discriminatory practices based on gender, race, ethnicity, caste, religion, sexual orientation, disability, or socio-economic status, which was based in evidence and responsive to need. The CEEs were somewhat gender transformative because they included guidelines and standards for evaluating interventions related to changing unequal gender norms, but used language that reinforced a gender binary. The SIMS materials updated in 2021 moderately promoted SRHR in the MCH domain.

2021_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.6)

The MER Indicator Reference Guide is reviewed and updated annually to streamline and prioritize the standard indicators used across PEPFAR programs. The 2021 Guide introduced trainings for USG and implementing partner staff on indicators across technical areas, which was responsive to need. The Guide referenced updates to the MER indicators such as new disaggregations, provided updated reporting frequencies, and clarified definitions, which were responsive to need. Several indicators were updated to add additional pediatric age and sex disaggregations as well as reflect the current approved pediatric HIV treatment regimen, which was responsive to need. This action moderately promoted SRHR in the MCH domain.

2021_Prioritizing Sexual and Reproductive Health and Reproductive Rights in U.S. Foreign Policy

Secretary of State Blinken delivered this Press Statement on prioritizing SRHR in U.S. foreign policy, which mentioned how the Department of State would implement the presidential memorandum that rescinded PLGHA. Though this action mentioned the revocation of the GGR, it did not provide guidance for programs about adapting their work to align with the presidential memorandum, which was not responsive to need and was a missed opportunity to highlight the Department of State's specific responsibility to promote SRHR as the funding agency of global health assistance. The action highlighted the reinstatement of funding to the UNFPA, the withdrawal of the United States from the Geneva Consensus Declaration, and the increased access to vital health services, including “maternal health and voluntary family planning” services. These actions were responsive to need, based in evidence, and based in human rights. This action affirmed the United States' commitment to making pregnancy and childbirth safer through strengthening health systems and partnering with governments, the private sector, and international and non-governmental organizations, which was responsive to need and based in evidence. This action was gender accommodating, as it acknowledged gender inequities but used language that promoted a gender binary and only recognized SRHR for women and girls, even though SRHR is vital for all people. The action moderately promoted SRHR in this domain.

2021_Strengthening Health Security Across the Globe_Progress and Impact of United States Government Investments in the Global Health Security Agenda

This Report detailed the progress and impact of the USG’s investments in global health security during FY 2020, including those led by the Department of State. The Report detailed the distribution of Congressional appropriations to advance global health security efforts in 19 partner countries to respond to disease outbreaks and prevent future outbreaks whenever possible. The Report did not mention other global health security efforts by the Department of State as it pertained to MCH services. Though the Report focused on global health security, SRHR and other cross-cutting issues such as GBV were not mentioned. The exclusion of these cross-cutting issues was not based in evidence as the inclusion of SRHR and gender equity promotes global health security. This exclusion was not responsive to need as SRHR services are often the first set of "essential services" to be neglected in a health emergency, as notably evidenced by the initial global response to COVID-19. The Report was gender blind as it made only one mention of gender in the context of OneHealth. This action moderately hindered SRHR in the MCH domain.

2021_Trafficking In Persons Report_ Human Trafficking in the Context of a Global Pandemic

The 2021 Trafficking in Persons Report detailed the approach outlined by the Department of State to combat human trafficking, with additional detail about these activities in the context of the COVID-19 pandemic. The Report outlined lessons learned from the pandemic and called for "comprehensive, trauma- and survivor-informed, and victim-centered anti-trafficking responses during the pandemic." The Report stated that global crises such as COVID-19, climate change, and enduring discriminatory policies and practices disproportionately impact people who are already oppressed by other injustices and increase people’s vulnerability to exploitation, which was based in evidence and responsive to need. While the Report recognized that survivors of trafficking are hesitant to interact with carceral systems, it promoted prosecution and a carceral approach to trafficking, which was not responsive to need. The Report briefly mentioned pregnancy-related interventions but did not meaningfully include global MCH outcomes and programming, which was a missed opportunity to highlight the Department of State’s global MCH efforts. The Report moderately hindered SRHR in this domain.

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

The WPS Congressional Report provided Congress with an overview of progress made in implementing the WPS Agenda globally since 2019. The Report evaluated progress in advancing the WPS Strategy's four lines of effort across the Department of State, DoD, DHS, and USAID: participation, protection, internal capabilities, and partnerships. While improved global health outcomes were included as a positive impact of implementing the WPS Agenda, MCH outcomes were only briefly mentioned. The Report included GBV prevention and programming as a measure of progress towards achieving the WPS Agenda, which was responsive to need. The Report highlighted an initiative by the Department of State to lead a data-driven MEL exercise on its WPS efforts, which was based in evidence and responsive to need. The Report included specific and actionable milestones to measure progress, which was responsive to need. The Report included several gender transformative elements such as enhancing gender-sensitive data analytics, recognizing "the intersectionalities inhabited by women," and supporting initiatives to address and overhaul harmful gender norms. However, it was predominantly focused on women which reinforced a gender binary. The Report moderately promoted SRHR in the MCH domain.

2020_Contraception for Women at High Risk of HIV Technical Update

The purpose of this Technical Update was to explain the implications of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial results on “reproductive health programming” funded through U.S. global health assistance. The Technical Update summarized updated guidance from the World Health Organization (WHO) regarding the use of contraception by women at high risk of acquiring HIV, which had been revised based on the ECHO Trial findings. Though the WHO released its revised guidance in August 2019 shortly after the ECHO Trial results were published, the Department of State (as the funding agency for PEPFAR) did not publish this Technical Update until December 2020. Because of this delay, the action was not fully responsive to need. The Technical Update was aligned with international human rights norms and evidence (e.g., quality of care, voluntarism, informed choice, differentiated service delivery models, patient-centered approaches free of stigma and discrimination) and included specific programmatic and policy guidance for working closely with diverse stakeholders to adapt global HIV and family planning (FP) programs accordingly. While the Technical Update stated that women who receive FP counseling should receive information about HIV prevention, it did not include guidance about counseling people who have just given birth about their contraceptive options, and thus was not consistent with evidence or responsive to need in this domain. Additionally, the Technical Update was gender blind, as it did not use gender inclusive language. As the funding agency for global MCH funds, the Department of State had the opportunity to integrate these efforts across implementing agencies through this Technical Update. This Technical Update only moderately promoted SRHR in the MCH domain.

2020_Department of State and USAID Joint Report to Congress on U.S. Foreign Assistance Gender-Related Programming_Fiscal Years 2017 and 2018

The Department of State and USAID submitted this joint report to Congress on gender-related programming funded through all types of U.S. foreign assistance in fiscal year (FY) 2017 and 2018 as required by the Department of State, Foreign Operations, and Related Programs Appropriations Act, 2019. It reported on $110 million of PEPFAR funds that were used during those two fiscal years to provide gender-based violence (GBV) prevention services as well as the full package of post-GBV care, including HIV and violence prevention services in communities and schools where the DREAMS program was being implemented. However, the Report did not include information about the gender-related activities that the Department of State funds through PEPFAR or other mechanisms that are related to MCH, including antenatal care (ANC) and HIV prevention and treatment services for pregnant and breastfeeding people. This report also included information about numerous other programs and funding types across both the Department of State and USAID, but there was insufficient information to determine if those other programs were considered U.S. global health assistance, which contributed to low transparency. U.S. global health funds were not explicitly included in the funding table at the end of the report, which also contributed to low transparency. This report neither promoted nor hindered SRHR in this domain.

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

The 2020 Annual Performance Report outlined Department of State and USAID’s progress toward strategic objectives, Agency Priority Goals (APGs), and performance goals in FY 2020 in accordance with their joint strategic plan. These goals included global health and gender-related programs across all three domains for both actors. The Report provided data on USAID’s MCH activities within Performance Goal 3 but did not adequately include the Department of State’s MCH activities that were conducted through PEPFAR or other gender-related programs funded through U.S. global health assistance. MCH activities and indicators should be included as a mechanism to monitor this important aspect of PEPFAR programs. The Report included data on a few indicators that measured gender norm change, but they were gender accommodating and not gender transformative because they focused on “males and females” which reinforced a gender binary. Additionally, indicators regarding GBV did not include considerations or disaggregates for people that experience violence during pregnancy. Due to the lack of meaningful reporting of MCH activities through PEPFAR, this report neither hindered nor promoted SRHR in the MCH domain.

2020_Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family

Along with 33 largely authoritarian governments, the United States signed the Geneva Consensus Declaration, a nonbinding declaration to advance the Trump administration’s anti-abortion agenda. Secretary of State Pompeo and Secretary of Health and Human Services Azar jointly participated in the signing ceremony on behalf of the Trump administration. The Declaration cited several international human rights documents to bolster its position that abortion was not to be included in any sexual and reproductive health (SRH) or universal health coverage programs. However, the Declaration did not recognize pregnant people’s right to bodily autonomy. It was also not aligned with evidence as evidence suggests that restricting access to safe abortion services results in increased rates of unsafe abortion, which can contribute to maternal morbidity and mortality. This action was not responsive to need and was not gender transformative because it reinforced a gender binary throughout and ignored gender inequalities and other systemic issues that might impact people's ability to access SRHR services, including MCH services. In fact, both the language used and the exclusion of SRHR were so deeply rooted in patriarchal structures that the Declaration was gender exploitative. The Declaration also failed to acknowledge the human rights of those in the LGBTQI+ community, which threatened to roll back progress made on recognizing the health needs of pregnant people who may not identify as women and/or those who identify as LGBTQI+. The stance of the Administration as demonstrated by the Department of State signing onto this Declaration substantially hindered the ability of U.S. global health assistance to promote SRHR in the MCH domain.

2020_Guiding Principles for the Next Phase of PEPFAR

This Guiding Principles document outlined the progress made by PEPFAR toward the 90-90-90 targets as of December 1, 2020, including programmatic adaptations to respond to COVID-19. This action included the approaches PEPFAR plans to implement to contribute to Sustainable Development Goal (SDG) 3 and achieve epidemic control by 2030. The Guiding Principles briefly mentioned linking HIV services to other “relevant health issues” without explicitly naming these health issues. This action did not explicitly mention evidence or human rights norms related to MCH that may have been incorporated into the development of these principles. Given the evidence base that HIV continues to be one of the leading causes of maternal death globally, it was vital that this action explicitly mention the ways that MCH services are included in PEPFAR programming already like prevention of mother-to-child transmission (PMTCT), ANC, and HIV prevention, care, and treatment efforts for pregnant and breastfeeding people. The Guiding Principles were not gender transformative, as they did not meaningfully discuss gender or the gender transformative components of DREAMS and other key programs. Conversely, the Guiding Principles described the impact of COVID-19 on specific populations and documented how PEPFAR programs adapted their implementation to continue to serve clients, which was highly responsive to need. The Guiding Principles neither hindered nor promoted SRHR in this domain.

2020_PEPFAR 2020 Annual Report to Congress

The PEPFAR Annual Report to Congress provided a comprehensive overview of PEPFAR and its accomplishments as of 2020. It outlined the evidence base for PEPFAR's programs and the methods used to make data-informed decisions including disaggregating all data by sex, age, and geography through the Monitoring, Evaluation, and Reporting (MER) system. The report noted the importance of adhering to guidance from the WHO (e.g., providing Dolutegravir-containing regimens for all women of childbearing age), which was responsive to need and based in evidence. According to this report, PEPFAR implemented a comprehensive PMTCT cascade of interventions, which included antenatal services, HIV testing, and use of antiretroviral therapy (ART) for life; safe childbirth practices and appropriate breastfeeding; and infant HIV testing and other postnatal care services. This cascade was aligned with evidence and human rights. PEPFAR also prioritized oral PrEP for prevention and viral load monitoring for pregnant and breastfeeding women (PBFW) as key interventions to ensure that risk of HIV transmission to a fetus during pregnancy remained low, which was based in evidence and responsive to need. With regard to MCH, the Report was comprehensive, based in evidence, and aligned with human rights norms that recognize that one’s pregnancy or ability to get pregnant should not prevent them from accessing care. However, much of the language was gender blind and reinforced a gender binary instead of using more inclusive language like "pregnant and breastfeeding persons" instead of “pregnant and breastfeeding women.” The Report moderately promoted SRHR in the MCH domain.

2020_PEPFAR 2020 Country Operational Plan Guidance for all PEPFAR Countries

Each year, the Office of Global AIDS Coordinator (OGAC) releases the PEPFAR Country Operational Plan (COP) Guidance, which includes the programmatic and policy guidance for global HIV and AIDS activities and provides the basis for the approval of annual bilateral funding for PEPFAR country and regional programs. The 7 Minimum Program Requirements included in the 2020 COP Guidance were aligned with international human rights norms and evidence and were designed to ensure that PEPFAR programs are responsive to need. The 2020 COP Guidance included the importance of integrating PrEP for adolescent girls and young women (AGYW) and targeted HIV testing at ANC clinics. The Guidance worked to improve retention among PBFW using integrated services during pregnancy and postpartum to promote adherence and retention in care. It also called for additional measures like maternal retesting to achieve the elimination of mother to child transmission (MTCT), which was evidence-based. However, programmatic adaptations for persons with disability were not meaningfully included in the 2020 COP Guidance, which may impact people’s access to MCH services. While the Guidance provided a thorough focus on couple-based services, it used language that promoted a gender binary and largely excluded discussion of pregnant people seeking care who are not married, part of a couple, or identify as women. The 2020 COP Guidance also focused on the key challenges for children, specifically, the pediatric treatment gap, high rates of sexual violence against adolescent girls, and the risk to children posed by inadequate adult HIV treatment retention as well as low viral suppression rates. The Guidance included instructions for families with someone living with HIV to seek services specifically for orphans and vulnerable children (OVC) to streamline service provision and inform other programs, like DREAMS. The 2020 COP Guidance moderately promoted SRHR through PEPFAR country and regional programs with respect to MCH.

2020_PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR Countries

In advance of the COP review process that took place in early 2021, the PEPFAR 2021 Country and Regional Operational Plan Guidance was released in December 2020. The 2021 COP Guidance emphasized the importance of integrating services to create "one stop shops" for integrated MCH and HIV services, which would promote SRHR. The 2021 COP Guidance contained extensive sections about PMTCT, integration of ANC into HIV and AIDS programs, and other MCH activities including guidance for OVC programs, early infant diagnosis (EID), and services for HIV-exposed infants (HEI). Many of these suggestions were consistent with the 2020 COP Guidance, and remained aligned with evidence, PEPFAR program data, and international human rights norms. The 2021 COP Guidance also advocated for the incorporation of oral PrEP at every point of service accessed by PBFW and their eligible partners. However, throughout the 2021 COP Guidance, the language related to MCH was very gendered (e.g., the Guidance does not use “pregnant and breastfeeding persons”) and was not gender transformative in relation to MCH activities. One significant issue was that MCH was not included in the section outlining the impact of COVID-19 on PEPFAR programs, even though the impact of the pandemic on pregnancy and postpartum care, services for OVC, and child and newborn care was documented prior to the release of the 2021 COP Guidance. Additionally, programmatic adaptations for persons with disability were not meaningfully included in the 2021 COP Guidance, which may have impacted people’s access to MCH services. This action moderately promoted SRHR in the MCH domain.

2020_PEPFAR FY21 Site Improvement through Monitoring System (SIMS) Version 4.1

The PEPFAR Site Improvement through Monitoring System (SIMS) tool provides a standardized approach to monitoring program quality at PEPFAR-supported sites that perform service and non-service delivery functions. The FY21 SIMS Implementation Guide and Assessment Tools set a high standard for how PEPFAR-supported sites are evaluated for program quality. With respect to MCH, the FY21 SIMS Implementation Guide and Assessment Tools included new guidance on PMTCT services, the prioritization of OVC programs during COVID-19, and the integration of HIV testing, prevention, and treatment at every point of service accessed by PBFW. The updates also allowed for virtual assessments during COVID-19, which was responsive to need and ensured that the pandemic did not prevent monitoring visits from happening. They also included guidance on implementing the Protecting Life in Global Health Assistance (PLGHA) policy, which helped evaluators know if the policy was relevant to the site assessment and ensured that the PLGHA policy was being appropriately implemented. The Above-Site and Site Assessment Tools included Core Essential Elements (CEEs) that assess the site against the standard requirements. The CEEs covered a range of topics related to MCH, and the standards used in the CEEs were based in evidence, consistent with human rights, and responsive to need. The CEEs also explicitly included services specifically for PBFW, people at antenatal clinics, infants, and children. It also included evidence-based and gender aware standards on adolescent-friendly services, specifically for AGYW living with HIV who are pregnant. The guidelines and standards for evaluating gender norms interventions were somewhat gender transformative, but much of the gendered language adhered to a gender binary and was not inclusive. This action moderately promoted SRHR in the MCH domain.

2020_PEPFAR Guidance for Implementing Safe and Ethical Index Testing Services

The Guidance provided an overview of PEPFAR's Index Testing Services and set the minimum requirements for index testing to ensure that index testing protocols going forward would be aligned with human rights norms, evidence, and best practices. This guidance was responsive to need because it was developed in response to the directive in the 2020 COP Guidance to pause index testing due to human rights and confidentiality concerns. It included the WHO's 5C standards (i.e., consent; counseling; confidentiality; correct test results; and connection to HIV prevention, care, and treatment services) as guiding principles for PEPFAR’s index testing programs. The guidelines for intimate partner violence (IPV) screening included a question to be directed to “female clients” asking if they had ever been “beaten” while pregnant. While this question was extremely important given that the risk of IPV during pregnancy is high according to evidence, it was not gender transformative as it only focused on female clients. This reinforced a gender binary as well as the harmful assumption that only “females” or women can get pregnant. This question was the only mention of maternal health throughout this guidance, which was a significant gap considering the intersections between pregnancy, HIV, and the risk of IPV. The Guidance also included a recommendation that “biologic children of HIV-positive individuals” are included in screenings for emotional IPV and index testing. This approach was based in evidence and promoted SRHR for children that are engaged in the index testing process. This guidance moderately promoted SRHR in the MCH domain.

2020_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.5)

The Monitoring, Evaluation, and Reporting (MER) Indicator Reference Guide aims to streamline and prioritize indicators for PEPFAR programs and is reviewed on an annual basis to ensure that indicators are aligned with PEPFAR initiatives, responsive to need, and consistent with evidence and human rights. In 2020, some of the MER indicators were updated, but it was unclear what evidence or programmatic data prompted these changes. One of the oral PrEP indicators (PrEP_NEW) included new language: "Any process to determine PrEP eligibility should include questions about a client’s exposure to or risk of gender-based violence and intimate partner violence, with appropriate interventions or referrals provided as needed." While this update protected the human rights of those that experience violence, pregnancy could have been mentioned as an additional risk factor for GBV. The Guide also included new guidelines for estimating the viral load testing coverage for pregnant women, which was not gender transformative as it used binary language. Furthermore, this language, along with most of the updates made to the Guide in 2020, were not gender transformative. This version of the MER Indicator Reference Guide moderately promoted SRHR in the MCH domain.

2020_PEPFAR Technical Guidance in Context of COVID-19 Pandemic_18 November 2020

Between March and November 2020, PEPFAR regularly released revised versions of this Technical Guidance to support PEPFAR programming throughout the COVID-19 pandemic and ensure that programs remained consistent with recommendations from the WHO and U.S. Centers for Disease Control and Prevention (CDC). The Guidance was responsive to need, consistent with human rights, and was often aligned with evidence, even as the evidence base shifted throughout the first year of the COVID-19 pandemic. The Technical Guidance prioritized HIV treatment services over prevention services to ensure uninterrupted care for children, adolescents, PBFW, and adults. It also provided key guidance on continuing PrEP for all target populations through multi-month dispensing (MMD) and other mechanisms which was responsive to need and based in evidence. To assist programs with adapting to COVID-19 lockdowns and service disruptions, the Technical Guidance recommended that clinic-based HIV testing continue through ANC clinics as well as encouraged the scale up of HIV self-testing for pregnant people through community health workers and mentor-mother groups, which was responsive to need and consistent with evidence and human rights. The Technical Update encouraged gender transformative work through DREAMS and GBV programming to continue within the constraints of COVID-19 protocols and restrictions. However, the Technical Guidance did not mention the disproportionate impact of COVID-19 and GBV on women and girls. The Technical Guidance moderately promoted SRHR through PEPFAR’s MCH activities as programs adapted their operations during the COVID-19 pandemic.

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

This report discussed U.S. government efforts to end trafficking in the United States and globally. This strategy prioritized the needs and perspectives of those who have been trafficked, called for innovations in data gathering, and promoted education and public awareness activities related to human trafficking. While the health impacts of trafficking were mentioned, the Report centered on domestic efforts to combat trafficking even though the actions described in this whole-of-government report would impact global health assistance programs and activities. The Report described its carceral approach to combating trafficking including prosecution, which relies heavily on law enforcement to prevent trafficking even though these systems do not consistently protect the rights of marginalized groups. This report did not define or provide the evidence base for the “victim-centered and trauma-informed approach” it purported to take in its approaches to combating human trafficking, which was significantly lacking. The Report did not integrate international human rights standards as it conflated commercial sex work and trafficking for the purposes of sex, which ultimately denies sex workers their rights and can impede efforts to prevent trafficking. The carceral approach outlined in this report posed additional risks and barriers for sex workers that needed to access health services due to the fear of prosecution or being targeted by law enforcement. While this report briefly mentioned gender, it was largely gender blind and made no mention of how trafficking impacts people in the LGBTQI+ community. The Department of State reported that it opened applications for projects to address the impacts of COVID-19 on efforts to combat trafficking, which was responsive to need. In 2020, the Department of State also updated the introductory course for personnel on human trafficking, but the Report did not make clear if or how health needs of trafficking survivors were incorporated into this training. The Report did not sufficiently explain which actions were undertaken with U.S. global health funds, which was also a transparency issue. The Report moderately hindered SRHR in the MCH domain.

2020_Report of the Commission on Unalienable Rights

This Report was released by Secretary Pompeo's Commission on Unalienable Rights. The Report defined “fundamental” or “unalienable” rights as those detailed in the Declaration of Independence. It cited the Universal Declaration of Human Rights (UDHR) of 1948 as the standard for the human rights that should be protected worldwide. The Report claimed that the expansion of human rights beyond what was detailed in UDHR has weakened the “claims of human rights” and left disadvantaged groups more vulnerable to rights violations. This assertion was not based in evidence, as there is no evidence to support this claim. It was also not aligned with human rights norms as it ignored the rights not explicitly stated in the Declaration of Independence or UDHR, such as sexual and reproductive rights and the rights of LGBTQI+ people, persons with disability, and displaced persons. To this end, the Report touted “natural law,” which has been historically used to oppose sexual and reproductive rights and the rights of LGBTQI+ people. This report was not responsive to need, because even though marginalized groups around the world are currently experiencing violations of their human rights, the Commission's approach did not adequately describe how the Department of State would work to protect human rights beyond what is explicitly stated in UDHR. The Report was not gender transformative, as the rights of women, girls, and gender diverse people were almost entirely excluded. The language used throughout the report was largely gender blind, and arguably gender exploitative as it upheld patriarchal structures by not recognizing the compendium of human rights declarations and modern advances in gender equality. The narrow definition of human rights could have negative implications on the implementation of global MCH programs. The Report on the Commission on Unalienable Rights substantially hindered SRHR in the MCH domain.

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

The second review of the Protecting Life in Global Health Assistance (PLGHA) policy summarized the history of the policy and documented its implementation throughout U.S. global health assistance programs. The Review found that in certain cases where partners declined awards, the loss of trusted partners in-country resulted in difficulties replacing these partners and subsequent disruptions in health care services across technical areas. Specifically, the review found that the loss of partners resulted in delays in implementation and distribution of services related to HIV and AIDS, MCH, voluntary FP, tuberculosis, and nutrition, as well as programs providing HIV services for KPs. These findings reinforced the harm of this policy and confirmed that the implementation of the policy led to some disruption in service delivery. This review was somewhat based in evidence as it directly reflected agency-level data. The data collection for this review ended in May 2019, so this was only somewhat responsive to need given that there was no data to document the impact of the policy from May 2019 to August 2020 when the Review was released. However, the Review provided valuable information on how the policy was being implemented that had not been included in the first review. The Review was not gender transformative, as it did not document whether the policy was being implemented in a way that addressed or affected gender norms and dynamics. The Review moderately hindered SRHR in the MCH domain.

2020_Strengthening Health Security Across the Globe: Progress and Impact of U.S. Government Investments in the Global Health Security Agenda, 2019 Annual Report

In 2020, the Department of State released the Strengthening Health Security Across the Globe annual report that identified the U.S. government contributions to global health security by country and U.S. government actor. Though several areas of global health were mentioned throughout the Report, global MCH efforts were noticeably absent. For example, the Report mentioned several infectious diseases that posed a threat to health security, including the Zika virus. However, this was a missed opportunity for this report to highlight the impact of infectious diseases like Zika on pregnancy, childhood immunizations, and other aspects of SRH. The exclusion of SRHR throughout the report contributed to the increased development of siloes that exclude SRHR from other areas of global health, such as disease outbreaks. SRHR is a critical aspect of health security. Neglecting sexual and reproductive health in security discussions can contribute to negative health impacts and human rights violations for women, girls, gender-diverse people, and other marginalized groups. The Report was largely gender blind, as it ignored the fact that health security is unattainable without gender equity and the countering of harmful norms that affect women and girls. As a result, this Report moderately hindered SRHR in this domain.

2020_The Department of State’s Plan to Implement the U.S. Strategy on Women, Peace, and Security 2020-2023

The 2019 United States' Strategy on Women, Peace, and Security (WPS) was developed in response to the Women, Peace, and Security Act of 2017. This Plan laid out the approach undertaken by the Department of State to make progress on three strategic objectives related to WPS from 2020 to 2023. The Plan largely excluded health activities in general, including technical areas related to SRHR. However, it did mention the importance of preventing GBV, including sexual violence and early and forced marriage. The Plan did not address pregnancy as a potential outcome of sexual violence, or the resulting MCH services those who experience violence may need. It also did not mention the impact of pregnancy on people's ability to engage in peace and security efforts. The Plan was responsive to need as the objectives were informed by the global need for women's empowerment efforts. However, the exclusion of maternal and child health was not evidence-based nor consistent with human rights frameworks. The Plan was somewhat gender transformative as it recognized and sought to combat gender norms through a systemic approach, but the Plan used language that reinforced a gender binary and was not inclusive of those who are impacted by the issues detailed in the report who do not identify as women. It was unclear which activities and programming mentioned in the Plan were considered U.S. global health assistance, which was a transparency issue. The Plan neither promoted nor hindered SRHR in the MCH domain.

2020_United States Strategy to Prevent Conflict and Promote Stability

The United States released this Strategy in accordance with the Global Fragility Act of 2019 to promote “peaceful, self-reliant nations.” The Department of State was identified as the lead agency to oversee and implement this Strategy with the assistance of other supporting U.S. government agencies to create impactful and sustainable programs in fragile settings. While the Strategy was responsive to need, it did not adequately address the SRHR and the broader health needs of people in conflict settings. The Strategy failed to explain its engagement with specific global health areas, even though HIV and AIDS, MCH, FP, and other cross-cutting SRHR issues are vital to promoting stability and security. Notably, it did not include GBV, which is often a greater risk to women, girls, and gender-diverse people in fragile settings and conflict areas. The Strategy also stated that it was grounded in evidence and human rights, but it did not include an explanation of the evidence base or human rights framework that informed it. Additionally, it was not gender transformative. Instead, the language in this action promoted a gender binary, ignored the role of gender inequalities on experiences of violence, and only mentioned women in the context of the WPS Strategy. While the latter was an important inclusion, gender was not meaningfully included in other areas of the Strategy. This action moderately hindered SRHR in the MCH domain.

2019_PEPFAR 2019 Annual Report to Congress

The President's Emergency Plan For AIDS Relief (PEPFAR) Annual Report to Congress provided an overview of the PEPFAR program’s accomplishments to date and discussed the program’s future directions. This report largely summarized high-level known information about PEPFAR programs. The report provided critical information about maternal and child health programming through PEPFAR, including viral load monitoring for PBFW, maternal retention in treatment, orphan and vulnerable children (OVC) programs, and prevention of mother-to-child transmission (PMTCT) programs. Within this domain, the report was responsive to need and based in evidence and human rights norms. Some HIV and AIDS services were included in antenatal care (ANC) programming such as opt-out HIV testing, and reported activities were based in evidence and international human rights norms. The document was not gender transformative as it did not discuss the impact of gender norms with PEPFAR’s maternal health programming. Overall, the Annual Report moderately promoted SRHR.

2019_PEPFAR 2019 Country Operational Plan Guidance for all PEPFAR Countries

Released annually by the Office of the Global AIDS Coordinator, the Country Operational Plan (COP) Guidance outlines the plan for global HIV and AIDS activities funded by the President's Emergency Plan For AIDS Relief (PEPFAR) and provides the basis for the approval of annual bilateral HIV and AIDS funding for partner countries. The 2019 COP Guidance did not adequately emphasize the importance of integration of HIV and antenatal care (ANC) services. The guidance was not gender transformative but demonstrated gender awareness through the use of gender-neutral language such as “clients” or “patients” and the discussion of the impact of gender norms on HIV and AIDS prevention and treatment within DREAMS programming. However, the guidance was based in evidence and human rights norms as well as was responsive to need. The document continued to provide comprehensive guidance on the implementation of PEPFAR programs for all populations and, within this domain, emphasized the importance of point-of-care programs for PBFW and prevention of mother-to-child transmission (PMTCT) activities. Overall, the Guidance moderately promoted SRHR.

2019_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.4)

The President's Emergency Plan For AIDS Relief (PEPFAR) Monitoring, Evaluation, and Reporting (MER) guidance included the indicators used to monitor and evaluate PEPFAR. All PEPFAR programs were evaluated according to their performance within these indicators and metrics, and this guide helped country teams and PEPFAR implementing partners understand the M&E process. In 2019, some of the MER indicators were updated, but it remains unclear what prompted these changes. The document included a few maternal health related indicators, and particularly focused on prevention of mother-to-child transmission (PMTCT) and antenatal care (ANC), as well as included pregnancy status as a disaggregate group across various treatment indicators. Within this domain, the guidance was evidence-based, based in human rights, and responsive to need. However, the guide was not gender transformative but gender aware, as it included some consideration of structural factors, such as family situation, on HIV prevention and treatment but did not move to address these barriers.

2019_Protecting Life in Global Health Assistance Frequently Asked Questions and Answers_September 2019

The Protecting Life in Global Health Assistance (PLGHA) FAQs document was updated in 2019 to provide clarity on the implementation of the May 2019 expansion of PLGHA as well as address questions and confusion from the 2018 Department of State’s PLGHA Six Month Review. The text of this document was similar to the 2018 FAQ document though included additional questions and answers (see questions 33-37). The document did not meaningfully discuss the impacts of the May 2019 expansion on maternal and child health. Similar to the 2018 FAQs, this document aimed to provide clarity on the policy but left many questions unanswered. This document was somewhat responsive to need as it included additional questions and answers based on confusion expressed by recipients of U.S. global health assistance specifically regarding the definition of “financial assistance” and the applicability of the policy to technical assistance. The document was not evidence-based, was not grounded in international human rights, and was not gender transformative as it was based on the PLGHA policy which has been shown to be harmful globally, particularly to women and girls. The PLGHA policy has also been shown to decrease the availability of maternal health services. Overall, this document provided a substantial hindrance to SRHR.

2019_State and USAID FY 2018 Annual Performance Report_FY 2020 Annual Performance Plan

This document shared the goals and timelines for FY 2020 as well as evaluated and summarized the progress of State and USAID in achieving various strategic goals in FY 2018. These goals included global health and gender programs across all three domains. The FY 2020 Performance Plan elements were included throughout the Report along with reporting on standard indicators for each Performance Goal under the 4 Strategic Objectives. The Report mentioned maternal and child health within the USAID Agency Priority Goals but did not discuss the role of the Department of State in the funding of maternal and child health policies or programs. The Report provided an opportunity for the Department of State to clarify its role in both humanitarian and non-humanitarian maternal and child health activities, but it failed to seize that opportunity. Within this domain, the Report was not based in evidence or human rights and was not responsive to need beyond standard Congressional reporting requirements. The Plan was not gender transformative, as it mentioned the disadvantages of a “gender-blind system” within Strategic Goal Two but perpetuated such a system by not including a gendered lens throughout the document. This Report neither promoted nor hindered SRHR with regard to the Department of State’s maternal and child health programs.

2018_Protecting Life in Global Health Assistance FAQs_September 2018

The PLGHA FAQs provided detailed guidance on the implementation of Trump's expanded Global Gag Rule for implementing partners as of September 2018. The FAQs were not responsive to need, evidence-based, human rights-based, or gender transformative within this domain. The FAQs received a lower grade within this domain compared to Family Planning and HIV and AIDS because they did not mention maternal and child health programming specifically, despite the unique impacts this policy could have on maternal and child health services. The FAQs significantly hindered the Department of State's ability to support comprehensive maternal and child health programming in 2018.

2018_Protecting Life in Global Health Assistance Six Month Review

The PLGHA Six Month Review summarized the PLGHA policy and identified solutions to challenges that had arisen in the process of PLGHA implementation. The review was responsive to need in that it addressed concerns expressed by partners affected by the policy, but was not evidence-based, based in human rights principles, or gender transformative. The review received a lower grade within this domain compared to Family Planning and HIV and AIDS because the review did not mention maternal and child health programming specifically, despite the unique impacts this policy could have on maternal and child health services. The Six Month Review significantly hindered the Department of State's ability to support comprehensive maternal and child health programming in 2018.

2016_Department of State Implementation Plan for the U.S. Adolescent Girls Strategy

The Department of State Implementation Plan for the U.S. Adolescent Girls Strategy was launched in partnership with three other U.S. implementing agencies as part of the first U.S. Global Strategy to Empower Adolescent Girls in 2015. This Plan acknowledged the impact of forced marriage, especially early or childhood marriage, and the impact of FGC on the health of AGYW. Specifically, it stated that these practices lead to poor maternal health outcomes, including high morbidity and mortality rates from pregnancy and birth complications, trauma, and other diseases and infections. The Plan provided details on "preserv[ing] the rights of married and pregnant girls and adolescent mothers to attend school" and "remov[ing] barriers to sexual and reproductive health and comprehensive, accessible, youth-friendly health services" to prevent early pregnancy. Though the Plan was responsive to need and grounded in human rights principles, it did not incorporate significant evidence-based programming because it did not address how to meet the clinical needs or provide maternity care of pregnant AGYW. This Plan is gender transformative in that it promoted gender equality by decreasing early marriage and pregnancy through educational empowerment. This Strategy moderately promoted SRHR through the Department of State’s maternal and child health programs.

2012_U.S. Department of State Policy Guidance: Promoting Gender Equality to Achieve our National Security and Foreign Policy Objectives

2012_United States Department of State Implementation Plan of the National Action Plan on Women, Peace, and Security

US Agency for International Development

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 Fòs Feminista 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

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 this 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 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

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 MCH 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 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

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 MCH 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 MCH 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 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

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 MCH 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 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

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 MCH 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’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+

Department of Health and Human Services

HHS received a 59 (F) with transparency and a 68 (D+) without transparency in the Maternal and Child Health (MCH) domain in 2021. This domain grade was raised by the action: “CDC Virtual Training Prepares Mentors and Peer Educators to Respond to Disclosures of Violence” because it was based in evidence, consistent with human rights, and responsive to need. However, several ARs and the General Terms and Conditions for Research and Non-Research neither promoted nor hindered SRHR because it was unclear whether these actions were relevant to the global MCH programs within HHS. AR 35 noted that the PLGHA policy had been revoked, but did not provide additional guidance or directives for implementing partners to adapt their programs to align with the policy change, which moderately hindered SRHR. The CDC Global Immunization Strategic Framework did not mention the connection between vaccine-preventable diseases (VPDs) and MCH outcomes or SRHR generally, which was not based in evidence or responsive to need. Funding data for global MCH efforts implemented by HHS were not publicly available at the time of grading, which contributed to the low transparency grade in the MCH domain in 2021.

The Fòs Feminista 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_CDC Additional Requirement – 1: Human Subjects Requirements

AR 1 outlined the regulations that institutions must follow if they engage in projects involving research with human subjects. AR 1 applied to all CDC projects that conducted human subjects research and provided guidance for institutions to obtain the necessary approvals as well as included hyperlinks to the specific CFR sections that protect human research subjects. AR 1 applied to all CDC projects and was consistent with human rights, based in evidence, and responsive to need. Requiring the protection of human subjects helped to ensure that the rights of people enrolled in global research projects related to MCH were protected. Specific protections for human subjects across genders were not included in AR 1, nor did it include considerations for other protected classes or specific populations that may warrant extra protections as human subjects. This action moderately promoted SRHR in the MCH domain.

2021_CDC Additional Requirement – 2: Requirements for Inclusion of Women and Racial and Ethnic Minorities in Research

AR 2 outlined the requirements for CDC-supported research projects that involved human subjects and the inclusion of "individuals of both sexes and the various racial and ethnic groups" whenever feasible and appropriate. AR 2 referred to the Federal Register to provide additional guidance on the application of this requirement. AR 2 was responsive to need and based in evidence because it promoted the ethical inclusion of women and racial and ethnic minorities in research. However, it was gender exploitative as it reinforced a sex and gender binary and did not acknowledge other identities that may be underrepresented in human subjects research. To more fully promote inclusivity, AR 2 should have been more inclusive of people of diverse SOGIESC in human subjects research. Nevertheless, the inclusion of underrepresented groups across racial and ethnic minorities is important for research as it applies to global health programs, including global MCH programs. AR 2 moderately promoted SRHR in the MCH domain.

2021_CDC Additional Requirement – 4: HIV/AIDS Confidentiality Provisions

AR 4 outlined requirements for the protection of personal data collected through HIV and AIDS surveillance activities across all CDC projects. The requirements promoted the confidentiality and security provisions of HIV and AIDS surveillance data, which was based in evidence, consistent with human rights norms, and responsive to need. However, it was unclear if the requirements applied to domestic programs only or if they also applied to global HIV and AIDS programs, which did not promote transparency given that PEPFAR programs often include prevention of mother-to-child transmission (PMTCT) activities and other efforts related to MCH. This action neither hindered nor promoted SRHR in the MCH domain.

2021_CDC Additional Requirement – 5: HIV Program Review Panel Requirements

AR 5 provided the requirements for creating and selecting members of a program review panel for HIV and AIDS research, projects, and other activities. AR 5 required that projects that included funding for a conference must receive approval for all conference materials from the panel. This action did not promote transparency as it was unclear what the intended purpose and responsibilities of the program review panel were nor was it clear if this requirement applied to global health programs, including MCH activities that may be included in PEPFAR programs. This action neither hindered nor promoted SRHR in the MCH domain.

2021_CDC Additional Requirement – 6: Patient Care

AR 6 stated that all “STD or HIV infected patients” participating in CDC-funded projects were to be linked to a local care system to provide medical care, counseling, social services, and therapy. This guidance was based in evidence and human rights and was responsive to need. However, the use of outdated language such as “HIV infected patients” was stigmatizing and did not reflect current best practices. While AR 6 provided necessary guidance, it did not provide any external references for additional guidance or protocols to guide the implementation of relevant programs. AR 6 moderately promoted SRHR in the MCH domain.

2021_CDC Additional Requirement – 25: Data Management and Access

AR 25 outlined the requirements for project recipients that conduct data collection with federal funds to develop, submit, and comply with a DMP for the collection and generation of public health data. It provided detail on inclusion and exclusion criteria for the DMP and explained which projects were required to submit a DMP. AR 25 was based in evidence and was responsive to need as the availability of public health data could promote innovation and advance global health priorities, including those related to MCH. It also promoted transparency by minimizing the possibility for data to be misrepresented. AR 25 moderately promoted SRHR in the MCH domain.

2021_CDC Additional Requirement – 28: Inclusion of Persons Under the Age of 21 in Research

AR 28 provided clear guidelines and expectations for the inclusion of persons under 21 in all CDC-funded research, including global health research. AR 28 stated that if a project intentionally does not involve persons under 21, they must provide a particular reason or justification for this exclusion. AR 28 was based in evidence and best practices and was aligned with human rights norms because it emphasized the inclusion of young people in research, which would include research related to SRHR. AR 28 moderately promoted SRHR in the MCH domain.

2021_CDC Additional Requirement – 35: Protecting Life in Global Health Assistance is waived, effective January 28, 2021

AR 35 announced the revocation of PLGHA, also known as the GGR. Though announcing the removal of this policy was responsive to need, AR 35 did not provide additional guidance or directives for implementing partners that were impacted by the policy to adapt their programs to align with the policy change. Through AR 35, HHS and CDC could have released information that addressed questions from implementing partners and other stakeholders impacted by the policy as it applied to CDC grants, but this was not done. Additionally, it was unclear when AR 35 was updated to reflect the revocation of PLGHA, which did not promote transparency . Therefore, AR 35 moderately hindered SRHR in the MCH domain.

2021_CDC Additional Requirement – 36: Certificates of Confidentiality

AR 36 provided guidance on issuing Certificates of Confidentiality to participants engaged in biomedical, behavioral, clinical, or other research activities that contain identifiable information, as required by the Public Health Service Act. AR 36 defined which kinds of information collected through research were considered sensitive, the responsibilities of data collection teams to protect these types of data, and how to use the collected data responsibly. AR 36 was based in evidence and human rights norms and was responsive to need because it provided necessary protections for sensitive data collected through CDC research, including global health research. However, AR 36 did not explicitly mention SRHR, so the benefits for SRHR research may have only been indirect. AR 36 neither promoted nor hindered SRHR in this domain.

2021_CDC Additional Requirement – 37: Prohibition on certain telecommunications and video surveillance services or equipment for all awards issued on or after August 13, 2020

AR 37 provided information about the prohibition of the use of federal grant or cooperative agreement funds from HHS to procure or obtain telecommunication and video surveillance services or equipment from specific companies. This telecommunications prohibition mirrors that which can be found in the August 2021 version of the HHS General Terms and Conditions for Research and Non-Research Grants and Cooperative Agreements. AR 37 included relevant references to the CFR and provided recommendations for how recipients should implement AR 37 and maintain compliance with these restrictions throughout the course of their agreement. It was unclear how this guidance would affect the ability of HHS programs to promote SRHR through its global MCH efforts. This action neither promoted nor hindered SRHR in the MCH domain.

2021_CDC Global Health Strategy 2019-2021

The Executive Summary of the CDC Global Health Strategy for 2019 through 2021 was updated in January 2021 to include the CDC’s response to the COVID-19 pandemic and emerging threats to global health. The rest of the Strategy was unchanged, so only the Executive Summary was graded in 2021. The updated Executive Summary mentioned that COVID-19 has had “far-reaching social and economic impacts, including disruption of essential healthcare services” and the upending of global health programs, including those that provided HIV and AIDS services. It also highlighted the importance of supporting diverse partnerships and collaboration across sectors. This updated content was based in evidence and responsive to need, though it was gender blind because there was no mention of the pandemic’s disproportionate impact on women, girls, gender-diverse people, or people living with HIV (PLHIV), specifically. The exclusion of SRHR and gender in the Executive Summary contributed to the silos that isolate SRHR from other global health issues, which was not based in human rights or evidence. Given the high-level nature of this action, however, it would likely have very little effect on the CDC’s ability to promote SRHR through its global health programs. This action neither promoted nor hindered SRHR in the HIV and AIDS domain.

2021_CDC Global Immunization Strategic Framework 2021_2030

This action guided the CDC’s investments in strengthening global immunization program capacity and scientific expertise to support the control, elimination, and eradication of vaccine-preventable diseases (VPDs) through 2030. This action linked the importance of immunization to primary care for children and adolescents, which would include health care visits for services related to SRHR such as human papillomavirus (HPV) vaccination for adolescents but lacked explicit mention of the connection between these issues. It only mentioned “pregnant women” in the context of expanding existing immunization approaches and did not provide additional information about the importance of immunizations during pregnancy, which was not responsive to need or based in evidence. It provided details on vaccine research for vector-borne diseases including malaria and Zika, which was related to MCH because such diseases could be transmitted sexually and could impact the health of pregnant and breastfeeding persons. Zika, malaria, and chikungunya could also be transmitted from the pregnant person to the fetus and contribute to poor birth outcomes. However, the action did not mention the connection between these diseases and MCH outcomes or SRHR generally, so it was not based in evidence or responsive to need. This action was gender blind as there was no meaningful mention of gender and the language used reinforced a gender binary. This action neither promoted nor hindered SRHR in the MCH domain.

2021_CDC Strategy for Global Response to COVID-19 2020-2023

This Strategy defined the CDC’s programmatic priorities and outlined the criteria for monitoring and evaluating the CDC’s health security efforts both domestically and internationally in the context of COVID-19. This action included high-level goals to guide the CDC’s immediate response to COVID-19 and prepare for future health threats. The principles and objectives outlined in the Strategy were generally based in evidence and responsive to need (e.g., the principle of leveraging existing global health programs and investments as a part of outbreak response). It mentioned the importance of coordinating pandemic response activities with the provision of essential health services, including MCH programs, which was responsive to need, based in evidence, and aligned with human rights. However, it did not define the pandemic’s disproportionate impacts on specific populations beyond labeling them as “vulnerable,” so it was not fully based in evidence and was gender blind. This action moderately promoted SRHR in the MCH domain.

2021_CDC Virtual Training Prepares Mentors and Peer Educators to Respond to Disclosures of Violence

This CDC Success Story reported on a virtual training program to prevent and respond to GBV through the PEPFAR DREAMS programs. The CDC adapted the LIVES training created by the WHO into the LOVES Virtual Training Program, which was based in evidence and consistent with human rights. The slight adjustments between the two trainings were made to acknowledge potential safety concerns of the mentors as well as the AGYW as well as consider what was reasonably within a mentor’s control, which was responsive to need. The LOVES Virtual Training Program trained mentors to immediately respond with empathy to disclosures of violence among AGYW, which was responsive to need and based in evidence and human rights. The LOVES training package included pre-recorded training materials and videos, as well as three live interactive virtual sessions, which was responsive to need because mentors could complete the training virtually during the COVID-19 pandemic. The action lacked detail on the level to which this training had been introduced across DREAMS sites and did not include the outcomes of the training. DREAMS includes gender transformative components and this training supported immediate responses to disclosures of GBV and challenged gender norms that enable violence. This action moderately promoted SRHR in the MCH domain.

2021_CDC’s Center for Global Health Responds to Outbreaks

This action highlighted the ways in which the CDC’s Center for Global Health has leveraged existing capacities to address COVID-19 and described how programs have adapted to the pandemic in order to continue addressing ongoing global health threats. This action discussed the general importance of leveraging PEPFAR programs in outbreak response and outlined how the CDC has adapted global HIV and AIDS programs to continue to provide health services during COVID-19. The action listed innovations that the CDC has instituted during the COVID-19 pandemic, such as differentiated service delivery models, MMD of ART, and community-based service delivery options. While these innovations were based in evidence, consistent with human rights, and responsive to need in a general sense, this action did not include details about any innovations related to the prevention of mother-to-child transmission (PMTCT) of HIV or adaptations to global MCH programs in response to the pandemic. This action did not mention the impact of the pandemic on key and priority populations, including pregnant and breastfeeding persons, so it was gender blind and not fully responsive to need. Due to the lack of inclusion of information about MCH innovations and the impact of the pandemic on MCH services, this action moderately hindered SRHR in the MCH domain.

2021_General Terms and Conditions for Non-Research Grant and Cooperative Agreements

2021_General Terms and Conditions for Research Grant and Cooperative Agreements_Revised August 2021

The General Terms and Conditions list the federal regulations and policies, funding restrictions and limitations, and reporting requirements that apply to HHS research grants and cooperative agreements. The updated version from August 2021 included guidance for regular financial and performance reporting, requirements for a data management plan, audit requirements, key personnel guidelines, guidance for acknowledgement of federal funding, and CDC staff responsibilities for award management. The General Terms and Conditions provided technical guidance for research awards, including a definition of human subjects and confidentiality requirements, which were consistent with human rights norms and research ethics. This action was responsive to need because it provided guidance for how awards should be managed, but there was no indication of which information had been changed from the previous version, and prior versions were not available on the website for comparison, which did not promote transparency and was not responsive to need. This action neither hindered nor promoted SRHR in the MCH 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 completed by HHS and CDC. 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 mentioned the impact of COVID-19 on MCH outcomes, but it did not meaningfully discuss HHS or CDC investments in MCH programs to promote global health security. Though the Report focused on global health security, SRHR and other cross-cutting issues such as GBV were not mentioned. This was not based in evidence as the inclusion of SRHR and gender equity promotes global health security. This exclusion was not responsive to need as SRHR services are often the first set of “essential services” to be neglected in a health emergency, as notably evidenced by the initial global response to COVID-19. The Report made one mention of gender in the context of OneHealth, and was therefore gender blind. This action moderately hindered 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 the HHS’s global MCH 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, PEPFAR implementing agencies, including HHS and the Centers for Disease Control and Prevention (CDC), did not publish this Technical Update until December 2020. Because of this delay, the action was not fully responsive to need. The Technical Update was aligned with international human rights norms and evidence (e.g., quality of care, voluntarism, informed choice, differentiated service delivery models, patient-centered approaches free of stigma and discrimination) and included specific programmatic and policy guidance for working closely with diverse stakeholders to adapt global HIV and family planning (FP) programs accordingly. While the Technical Update stated that women who receive FP counseling should receive information about HIV prevention, it did not include guidance about counseling people who had 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 immediately after giving birth. This Technical Update did not include guidance for incorporating this update into HHS’s global MCH portfolio, which was an oversight that further siloed MCH efforts from related global health programs. This Technical Update was consistent with human rights norms, but not all available evidence and the language was gender blind so it moderately promoted SRHR in this domain.

2020_General Terms and Conditions for Non-Research Grants and Cooperative Agreements

The General Terms and Conditions list the federal regulations and policies, funding restrictions and limitations, and reporting requirements that apply to HHS non-research grants and cooperative agreements. The version that was updated in December 2020 included information about regular financial and performance reporting, requirements for a data management plan, audit requirements, key personnel guidelines, guidance for acknowledgement of federal funding, and CDC staff responsibilities for award management. The General Terms and Conditions did not include specific technical guidance related to evidence or human rights. However, it was responsive to need because it provided guidance about how awards should be managed. This action also included the same prohibition on the purchase of certain telecommunications and video surveillance services or equipment as was included in the United States Agency for International Development (USAID) Automated Directive System (ADS) Chapter 303. It also mentioned an exemption for PEPFAR funding until 2022, which was not included in ADS Chapter 303. This exemption likely had little effect on HHS’s ability to promote SRHR through its global MCH efforts. Though this action was revised in December 2020, there was no indication of which information had been changed from the prior version and prior versions are not available on the website for comparison, which contributed to low transparency. This action neither hindered nor promoted SRHR in the MCH domain.

2020_General Terms and Conditions for Research Grants and Cooperative Agreements

The General Terms and Conditions list the federal regulations and policies, funding restrictions and limitations, and reporting requirements that apply to HHS research grants and cooperative agreements. The version that was updated in December 2020 included information about regular financial and performance reporting, requirements for a data management plan, audit requirements, key personnel guidelines, acknowledgement of federal funding, and CDC staff responsibilities for award management. The General Terms and Conditions provided technical guidance for research awards, including a definition of human subjects and confidentiality requirements, which were consistent with human rights norms and research ethics. This action included the same prohibition of the purchase of certain telecommunications and video surveillance services or equipment as was included in USAID’s ADS Chapter 303. It also mentioned an exemption for PEPFAR funding until 2022, which was not included in ADS Chapter 303. This exemption likely had little effect on the ability of HHS to promote SRHR through its global MCH efforts. Though this action was revised in December 2020, there was no indication of which information had been changed from the prior version, and prior versions are not available on the website for comparison, which contributed to very low transparency. This action neither hindered nor promoted the ability of HHS to support SRHR in the MCH domain.

2020_Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family

Along with 33 largely authoritarian governments, the United States signed the Geneva Consensus Declaration, a nonbinding declaration to advance the Trump administration’s anti-abortion agenda. Secretary of State Pompeo and Secretary of Health and Human Services Azar jointly participated in the signing ceremony on behalf of the Trump administration. The Declaration cited several international human rights documents to bolster its position that abortion was not to be included in any sexual and reproductive health (SRH) or universal health coverage programs. However, the Declaration did not recognize pregnant people’s right to bodily autonomy. It was also not aligned with evidence as evidence suggests that restricting access to safe abortion services results in increased rates of unsafe abortion, which can contribute to maternal morbidity and mortality. This action was not responsive to need and was not gender transformative because it reinforced a gender binary throughout the Declaration and ignored gender inequalities and other systemic issues that might impact people's ability to access SRHR services, including MCH services. In fact, both the language used and the exclusion of SRHR were so deeply rooted in patriarchal structures that the Declaration was gender exploitative. The Declaration also failed to acknowledge the human rights of those in the LGBTQI+ community, which threatened to roll back progress made on recognizing the health needs of pregnant people who may not identify as women and/or those who identify as LGBTQI+. The stance of the Administration as demonstrated by HHS signing onto this Declaration substantially hindered the ability of HHS to promote 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. The Report did not sufficiently explain which actions were undertaken with U.S. global health funds, which was a transparency issue. The Report moderately hindered SRHR in the MCH domain.

2020_Strengthening Health Security Across the Globe: Progress and Impact of U.S. Government Investments in the Global Health Security Agenda, 2019 Annual Report

In 2020, the Department of State, in collaboration with other U.S. implementing agencies including HHS and CDC 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 actor. Though several areas of global health were mentioned throughout the Report, global MCH efforts were noticeably absent. For example, the Report mentioned several infectious diseases that 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. SRHR is a critical aspect of health security. Neglecting 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 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. The Report was largely gender blind, as it ignored the fact that health security is unattainable without gender equity and the countering of harmful norms that affect women, girls, and gender diverse people. This Report moderately hindered SRHR in this domain.

2020_Violence Against Children and Youth Survey Country Process

The Violence Against Children and Youth Survey (VACS) Country Process action laid out the strategy for engaging countries in this process. The guidance included considerations for programmatic response, ethical standards, process sustainability, survey support, partner support, and in-country capacity. There were very few mentions of SRHR-related topics, and no consideration of the MCH service needs of participants, or how survey participants would be referred to relevant health services if they reported experiencing violence while being surveyed. However, this guidance was evidence-based and consistent with human rights because it cited the recommendations from the World Health Organization (WHO) on ethics and safety regarding patients' rights as guiding principles in developing these surveys. This action also noted the importance of connecting findings from the VACS with evidence-based and evidence-informed policies and programs to prevent and respond to violence to form the basis for a National Action Plan, which is a distinct opportunity to decrease violence and promote SRHR at the country level. This action stated that participants in these surveys should be offered services that included free programs, services, and amenities based on their country's response plan, which was responsive to need and grounded in human rights. The guidance was not gender transformative as it instructed interviewers to only engage with participants of the same sex, which overlooked the experiences of participants who experienced violence from people of the same sex. There were no discussions of gender norms or other policies that might impact people's experiences of violence, which was gender blind. This Country Process action moderately promoted SRHR in the MCH domain.

2019_CDC Global Health Strategy_2019-2021

This Strategy included a brief description of maternal and child health programs carried out by the CDC and presented programmatic and global evidence that highlighted the importance of these programs as a broad contributor to global health. The Strategy discussed the strengthening of health systems through the Saving Mothers, Giving Life Initiative, and the CDC’s role in developing new tools and techniques to address maternal and child health needs. The integration of maternal and child health efforts with HIV and AIDS or family planning was not discussed in the Strategy, which reinforced the siloed nature of these programs. The information moderately promoted SRHR with regard to CDC's maternal and child health programming, though it did not include a gender transformative approach to maternal and child health.

2019_Joint Statement on the Nairobi Summit on the ICPD25

This Statement by the U.S. Secretary of Health and Human Services Alex Azar only affirmed the specific elements of the International Conference on Population and Development (ICPD) Programme of Action that aligned with the Trump Administration’s ideology. It asserted that any outcomes of the Nairobi Summit—including any discussions or decisions related to SRHR—were not to be considered reflective of Member State consensus. Though this Statement might not immediately impact the implementation of global health programs related to SRHR, including those related to maternal and child health, it reflects the U.S. government’s stance on SRHR generally and amplifies and emboldens anti-SRHR ideals globally. This Statement operated within traditional gender norms and was based on ideology, not evidence or international human rights norms. Furthermore, the Statement conflicted with comprehensive sexuality education "that fails to adequately engage parents" and mentioned the importance of "giving young people the skills to avoid sexual risk" which suggested support for abstinence-only programs. The language did not promote autonomy and agency of all people to engage in sexual experiences free of shame, coercion, and violence, and substantially hindered SRHR.

2019_Joint Statement_Item 12.8: Global Strategy for Womens, Childrens, Adolescents Health (2016-2030)

This Statement denounced "ambiguous" terms such as "the right to sexual and reproductive health (and its derivatives)" at a World Health Assembly meeting to discuss the WHO Global Strategy for Women’s, Children’s, and Adolescents’ Health. This Statement highlighted the role of the family over the rights of the individual and did not include inclusive language regarding gender or the specific health needs of key populations. The Statement did not mention maternal and child health as a relevant health issue for women, adolescents, and children. This Statement was not based in evidence or international human rights norms and substantially hindered SRHR.

2019_U.S. Commitment Statement to the Nairobi Summit on ICPD25

This Commitment Statement undermined international human rights norms related to SRHR and their supporting processes, including the U.S. government’s own commitments under the International Conference on Population and Development Programme of Action. This Commitment Statement sought to excuse the U.S. government from its commitments to comprehensive SRHR included in the International Conference on Population and Development Programme of Action under the guise of protecting "the inherent value of every human life -- both born and unborn". and the role of "caring fathers" and faith-based orgniazations in supporting women and girls’ access to healthcare. This Statement included an account of some relevant U.S. global health or development initiatives that contributed to ICPD, including the statement that the U.S. government is the largest bilateral funder for family planning and "that hasn't changed." This language assumed that only couples were using family planning to “either achieve or prevent pregnancy", however is not the only situation in which someone would want to use family planning. This statement moderately hindered SRHR because it was not based in evidence or international human rights norms and was not gender transformative.

2019_U.S. Government Statement at the U.N. High Level Meeting on Universal Health Coverage

This Statement emphasized the U.S. government’s commitment to universal health coverage (UHC) but condemned the inclusion of SRHR language and sexual education that "diminishes the protective role of the family in improving health." This Statement also rejected that there is an international right to abortion. Though language included here may be more immediately related to domestic U.S. health policy, it directly translates to the ideology being used to shape U.S. global health assistance through the Protecting Life in Global Health Assistance (PLGHA) policy and other mechanisms. This Statement substantially hindered SRHR because it did not discuss maternal and child health as a vital health issue, was not based in evidence or international human rights norms, and was not gender transformative.

2018_Protecting Life in Global Health Assistance FAQs_August 2018

The PLGHA FAQs provided detailed guidance on the implementation of the expanded Global Gag Rule for implementing partners as of September 2018. HHS was graded based on the "HHS Specific Information" section on page 17 that outlined how HHS administered grants according to the Code of Federal Regulations (CFR). The information offered in this section did not have an effect on the ability of HHS to implement maternal and child health programs that were evidence-based, responsive to need, consistent with internationally-recognized human rights principles, and gender transformative.

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Maternal and Child Health (MCH)

White House

Congress

Department of State

US Agency for International Development

Department of Health and Human Services

Department of Defense