About the Index | The Sexual and Reproductive Health and Rights Index

The Sexual and Reproductive Health and Rights Index: Grading U.S. Global Health Assistance—also known as the SRHR Index—critically assesses and holds the U.S. government accountable to its work on sexual and reproductive health and rights (SRHR) in U.S. global health assistance. Originally created by the Center for Health and Gender Equity (CHANGE) in partnership with the Global Women’s Institute at the George Washington University, Fòs Feminista is continuing to support this valuable resource.

Why the SRHR Index is Needed

At the International Conference on Population and Development (ICPD) in Cairo in 1994, approximately 180 countries—including the United States—produced a human rights framework for development assistance that—for the first time—promoted the universal SRHR of women and girls. After ICPD, related U.S. government strategies, policies, and United Nations (UN) statements included the term “sexual and reproductive health and reproductive rights.” However, it was not until 2015 that the U.S. government recognized sexual rights and adopted the full term “sexual and reproductive health and rights” in official documents, international statements, and UN negotiations. Additionally, on January 28, 2021 the Biden administration committed to supporting SRHR domestically and globally, which would include the implementation of U.S. global health programs that promote SRHR. This positioned the U.S. government on a path to fully embrace a global SRHR agenda, but the U.S. government has not always upheld this commitment.

“It is the policy of my Administration to support women’s and girls’ sexual and reproductive health and rights in the United States, as well as globally.”
– President Biden, Memorandum on Protecting Women’s Health at Home and Abroad Pacific Science Center¹

On an annual basis, the SRHR Index reviews and analyzes global health actions across key U.S. government agencies and funding streams related to SRHR. The SRHR Index grades each actor’s commitment, leadership, funding levels, and transparency across a comprehensive set of SRHR issues and ensures that this information is publicly available.

This allows SRHR Index users to understand U.S. government actions not only within a particular domain of SRHR, but also across SRHR more broadly. Advocates can use the SRHR Index grades to understand when the U.S. government has taken positive or negative actions related to SRHR and global health. Advocates can then use the SRHR Index to make targeted recommendations about how the government can better promote SRHR through its global health assistance policies, programs, and funding decisions.

How the SRHR Index Works

The SRHR Index uses standardized indicators to assess government policies, investments, and other actions released each year. This scoring process results in a grade that reflects the level to which global health assistance did, or did not, promote SRHR globally that year.

The SRHR Index measures six actors: the White House, U.S. Congress, U.S. Department of State, U.S. Agency for International Development (USAID), U.S. Department of Health and Human Services (HHS), and U.S. Department of Defense (DoD) across three domains that represent core funding streams of U.S. global health assistance: HIV and AIDS, maternal and child health (MCH), and family planning (FP). The SRHR Index analyzes each actor’s publicly available actions (e.g., a policy, report, technical guidance) and budgets or investments for each of these domains, as well as the availability and quality of the data related to each domain.

Each action is scored individually and budget data are analyzed to determine an actor’s grade in the domain(s) in which they work. Actors are only graded on what is within their scope of work. For example, DoD is only graded within the HIV and AIDS domain because that is the only domain of global health in which they work.

In addition, the U.S. government receives an overall grade for each domain as well as a cumulative grade that represents the level to which U.S. global health assistance either promoted or hindered SRHR that year.

The SRHR Index also measures the availability of data needed to calculate a grade through what is referred to as a “transparency grade.” The transparency grade represents the expectation that the federal government should make data about U.S. global health assistance publicly available, accessible, and informative.

The SRHR Index uses international standards, evidence, and human rights to analyze global health policies, programming, and funding streams and generate grades that compare what is being done with what can and should be done to promote SRHR within U.S. global health assistance.

The SRHR Index reveals the scope and breadth of work related to SRHR across U.S. global health assistance. It is designed to be sensitive to and reflective of negative and positive actions that restrict or promote global SRHR.

Definition of SRHR

In 2018, the Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights established a definition of SRHR with an actionable agenda built on existing international norms. The SRHR Index uses the Commission’s definition of SRHR and supports U.S. government’s adoption of the full definition and agenda.

The Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights defines SRHR as “a state of physical, emotional, mental and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction, or infirmity. Therefore, a positive approach to sexuality and reproduction should recognize the part played by pleasurable sexual relationships, trust and communication in promoting self-esteem and overall well-being. All individuals have a right to make decisions governing their bodies and to access services that support that right. Achieving sexual and reproductive health relies on realizing sexual and reproductive rights, which are based on the human rights of all individuals to:

have their bodily integrity, privacy and personal autonomy respected
freely define their own sexuality, including sexual orientation and gender identity and expression
decide whether and when to be sexually active
choose their sexual partners
have safe and pleasurable sexual experiences
decide whether, when and whom to marry
decide whether, when and by what means to have a child or children, and how many children to have
have access over their lifetimes to the information, resources, services and support necessary to achieve all the above, free from discrimination, coercion, exploitation and violence.”

The SRHR domains included in the SRHR Index were determined by the established definition of sexual and reproductive health (SRH) services. SRH services include the range of services necessary to enable all individuals to make informed decisions concerning their sexual activity and reproduction free from discrimination, coercion, and violence. The decision was further informed by consultation with stakeholders in the field, the study of authoritative guidance instruments, and references to existing SRH literature. Core SRH components include:

Comprehensive FP and contraceptive services, including emergency contraception.
Maternal health, including prenatal care, skilled attendance at birth, antenatal care, emergency obstetric care, and respectful maternity care.
Prevention and treatment of infertility.
Safe abortion and post-abortion care (PAC).
Prevention, care, and treatment of sexually transmitted infections (STIs) including HIV and AIDS, reproductive tract infections, and reproductive cancers.
Prevention and treatment of gender-based violence (GBV), including screening, counseling, and referral, as well as the elimination of harmful traditional practices, such as female genital cutting/mutilation (FGC/M) and child, early, and forced marriage (CEFM).

Actors

The White House

The White House leads the Executive Branch of the United States and is headed by the president. Through powers vested and restricted by the U.S. Constitution, the president is responsible for executing the laws of the United States through policy. The President may do so by signing legislation passed by Congress, issuing presidential memoranda or executive orders, or releasing policies via the National Security Council.² The White House also submits an annual budget request to the U.S. Congress that includes proposed expenses for global health and SRHR.³ These recommendations from the president are considered by Congress in the annual appropriations process.

To receive an A+ grade, the White House should promote SRHR in U.S. global assistance through HIV and AIDS, MCH, and FP programs that are evidence-informed, responsive to need, consistent with internationally recognized human rights principles, and gender transformative. The president should sign Executive Orders and Presidential Memoranda, release whole-of-government reports and guidance, and sign or veto legislation passed by Congress that promote SRHR. The White House should also request sufficient funding for U.S. global assistance to support SRHR through global HIV and AIDS, MCH, and FP programs in its proposed budget.

U.S. Congress

The U.S. Congress is the legislative body of the United States. Consisting of two chambers (the House of Representatives and the Senate), each chamber works to pass legislation to be made into law. After it is passed through the bicameral process, legislation must be signed into law by the president. While the president sends Congress a proposed budget, Congress has the authority to authorize and appropriate funds for global health assistance, pass global health-specific legislation, and confirm appointees that will implement global health policies and programs. Congress also has an oversight role in global health assistance through which members can convene oversight and investigative hearings about agencies’ policies and performance, as well as request accountability reports.

To receive an A+ grade, Congress should work to enact or retain legislation that enables—or repeal legislation that hinders—U.S. global assistance that promotes SRHR through HIV and AIDS, MCH, and FP programs that are evidence-informed, responsive to need, consistent with internationally recognized human rights principles, and gender transformative. Congress should also appropriate sufficient funding for U.S. global assistance to support HIV and AIDS, MCH, and FP programs.

U.S. Department of State

Authorized by Congress and headed by a confirmed presidential nominee, the U.S. Department of State is housed within the Executive Branch and led by the Secretary of State.⁴ The Department of State is the funding agency for U.S. global health assistance and the Secretary of State implements the president’s foreign policy objectives through the Department of State and related implementing agencies, including USAID, HHS, and DoD. Housed within the Department of State are relevant bureaus and offices, including the Office of Global Women’s Issues (GWI),⁵ Office of the Global AIDS Coordinator (OGAC or S/GAC),⁶ Bureau of Population, Refugees and Migration (PRM),⁷ Bureau of Democracy and Human Rights,⁸ and the Office to Monitor and Combat Trafficking in Persons.⁹ A notable program managed by S/GAC within the Department of State is the President’s Emergency Plan for AIDS Relief (PEPFAR). The Department of State receives a budget grade based upon the responsiveness to need of its disbursed global health funds within each domain.

To receive an A+ grade, the Department of State should enact or retain internal policies, procedures, and guidance that promote SRHR through global HIV and AIDS, MCH, and FP programs in a way that is evidence-based, responsive to need, consistent with internationally recognized human rights principles, and gender transformative. The Department of State should also allocate U.S. global health assistance funding that is responsive to need in each country and therefore promotes SRHR through global HIV and AIDS, MCH, and FP programs.

U.S. Agency for International Development (USAID)

Authorized by Congress and headed by a confirmed presidential nominee, USAID is housed within the Executive Branch and led by the USAID administrator.¹⁰ The Agency engages in international development and humanitarian aid programs through a series of bureaus and offices that issue policy and guidance as well as implement programs, such as the Bureau for Global Health.¹¹ As an implementing agency of U.S. global health assistance, USAID must follow the laws and policies passed or instituted by Congress and the White House. USAID programs are susceptible to policy changes that can impact its work, such as the Protecting Life in Global Health Assistance Policy (also known as the expanded Global Gag Rule).¹² USAID works in various health areas, including HIV and AIDS programs through PEPFAR,¹³ the President’s Malaria Initiative (PMI),¹⁴ FP and reproductive health,¹⁵ and MCH.¹⁶

To receive an A+ grade, USAID should enact or retain internal policies, procedures, and guidance that promote SRHR through global HIV and AIDS, MCH, FP programs in a way that is evidence-based, responsive to need, consistent with internationally recognized human rights principles, and gender transformative. USAID should also disburse U.S. global health assistance funding that is responsive to need in each country and therefore promotes SRHR through global HIV and AIDS, MCH, and FP programs.

U.S. Department of Health and Human Services (HHS)

Authorized by Congress and headed by a confirmed presidential nominee, HHS is housed within the Executive Branch and led by the Secretary of Health and Human Services. HHS “protects the health of all Americans and provides essential human services”¹⁷ and creates policies through formal and informal rule-making and the interpretation of rules, including rules for projects and programs related to global health assistance passed or instituted by Congress and the White House.¹⁸ HHS contains numerous functional sections related to global health, including the Office of Global Affairs (OGA),¹⁹ and the Center for Global Health within the Centers for Disease Control and Prevention (CDC) that implement global health programs.²⁰ The primary health areas in which the CDC works are HIV and AIDS programs through PEPFAR,²¹ malaria programs through PMI, parasitic diseases,²² and immunizations.²³ HHS receives a budget grade based on the level to which its global health funds are disbursed in a manner that is responsive to need in each domain. This actor is only graded in the HIV and AIDS and MCH domains because it does not implement global FP programs.

To receive an A+ grade, HHS should have internal policies, procedures, and guidance that promote SRHR through global HIV and AIDS and MCH programs in a way that is evidence-based, responsive to need, consistent with internationally recognized human rights principles, and gender transformative. HHS should also disburse HIV and AIDS and MCH funding that is responsive to need.

U.S. Department of Defense (DoD)

Authorized by Congress and headed by a confirmed presidential nominee, with the president serving as Commander-in-Chief, DoD is the military and security division within the Executive Branch and led by the Secretary of Defense.²⁴ In addition to its military function, DoD is authorized to deliver humanitarian aid and is an implementing agency for PEPFAR.²⁵ DoD can create policies through formal and informal rulemaking as well as the interpretation of rules, which can impact projects and programs related to global health assistance.²⁶ The DoD receives a budget grade based upon the level to which its HIV and AIDS funds are disbursed in a manner that is responsive to need. This actor is only graded in the HIV and AIDS domain because it does not work in global MCH or FP.

To receive an A+ grade, the DoD should have internal policies, procedures, and guidance that promote SRHR through global HIV and AIDS programs that are evidence-based, responsive to need, consistent with internationally recognized human rights principles, and gender transformative. The DoD should spend HIV and AIDS funding at the country level that is responsive to need.

Domains

HIV and AIDS

HIV is a virus that is transmitted through certain bodily fluids and can lead to AIDS. Untreated, HIV can inhibit the body’s ability to fight off disease.²⁷

Since 2003, PEPFAR has been the largest commitment by any nation to address a single disease in history. PEPFAR supports programs that prevent the transmission of HIV, ensure that people living with HIV (PLHIV) do not progress to AIDS, and help individuals with AIDS access the care they need. Programs may incorporate behavioral, structural, or biomedical interventions, such as those intended to keep adolescent girls in school and reduce GBV; distribute internal and external condoms; and support access to pre-exposure prophylaxis (PrEP), medications to decrease viral load counts including antiretrovirals, and health care that reduces HIV-related deaths.²⁸

Maternal and Child Health (MCH)

MCH refers to a person’s health during pregnancy, childbirth, and the postpartum period. Direct causes of maternal morbidity and mortality include hemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labor.²⁹

MCH investments through U.S. global health assistance prevent and respond to maternal, newborn, and child mortality and morbidity, as well as promote respectful maternity care.³⁰

Family Planning (FP)

FP is the information, means, and methods that allow individuals to decide if and when to have children. FP refers to a wide range of contraceptive methods including oral contraceptive pills (including emergency contraception), implants, intrauterine devices, surgical procedures that limit fertility, barrier methods (such as internal and external condoms), the rhythm method, and abstaining from sex. FP also includes information about pregnancy intention as well as treatment for infertility.³¹

U.S. global health assistance investments in global FP programs contribute to creating a consistent inventory of contraceptive services and supplies, preventing unwanted pregnancies, averting unsafe abortions and maternal mortality, providing post-abortion care (PAC), human papillomavirus (HPV) vaccination and prevention, repairing obstetric fistula, administering sex education, and conducting research.³²

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About Fòs Feminista

Together with more than 170 partner organizations across the globe, we are dedicated to expanding access to rights-based sexual and reproductive health care, education, and advocacy. This includes implementing community-based strategies that make sexual and reproductive healthcare more accessible to the most marginalized women, girls, and gender-diverse people, developing comprehensive sexuality education programs, and mobilizing communities to defend their sexual and reproductive rights.

Fòs Feminista carries forward the work and partnerships of the three organizations – IPPFWHR, IWHC, and CHANGE – that formed a feminist alliance in June 2021 with a vision to advance sexual and reproductive health, rights, and justice through an intersectional feminist lens and a commitment to the leadership from the Global South.

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Swetha Sridhar: [email protected]

¹ Memorandum on Protecting Women’s Health at Home and Abroad, 86 Fed. Reg. 33,077 (Jan. 28, 2021).

² The White House, Interim National Security Strategic Guidance (March 2021), available at https://www.whitehouse.gov/wp-content/uploads/2021/03/NSC-1v2.pdf; See also Presidential Memorandum Regarding the Mexico City Policy, 82 Federal Register 8495 (Jan. 25, 2017); See also The White House, National Strategy on Gender Equity and Equality (2021), https://www.whitehouse.gov/wp-content/uploads/2021/10/National-Strategy-on-Gender-Equity-and-Equality.pdf.

³ The White House, Budget of the U.S. Government, Fiscal Year 2023 (2022), available at https://www.govinfo.gov/app/collection/budget.

⁴ USA.Gov, U.S. Department of State, available at https://www.usa.gov/federal-agencies/u-s-department-of-state.

⁵ U.S. Department of State, Office of Global Women’s Issues (2021), available at https://www.state.gov/bureaus-offices/secretary-of-state/office-of-global-womens-issues.

⁶ U.S. Department of State, Office of the U.S. Global AIDS Coordinator and Health Diplomacy (2022), available at https://www.state.gov/pepfar/.

⁷ U.S. Department of State, Bureau of Population, Refugees, and Migration (2021), available at https://www.state.gov/bureaus-offices/under-secretary-for-civilian-security-democracy-and-human-rights/bureau-of-population-refugees-and-migration/”.

⁸ U.S. Department of State, Bureau of Democracy, Human Rights, and Labor (2021), available at https://www.state.gov/bureaus-offices/under-secretary-for-civilian-security-democracy-and-human-rights/bureau-of-democracy-human-rights-and-labor/.

⁹ U.S. Department of State, Office to Monitor and Combat Trafficking in Persons (2022), available at https://www.state.gov/bureaus-offices/under-secretary-for-civilian-security-democracy-and-human-rights/office-to-monitor-and-combat-trafficking-in-persons/.

¹⁰ United States Agency for International Development (USAID), Who We Are (2019), available at https://www.usaid.gov/who-we-are.

¹¹ USAID, Global Health (2022), available at https://www.usaid.gov/global-health.

¹² CHANGE, Trump’s Global Gag Rule: Policy and Research Brief 1 (March 2021), available at https://srhrforall.org/download/trumpsglobal-gag-rule-policy-and-research-brief/?wpdmdl=2335&refresh=61df0ae9930631642007273.

¹³ USAID, HIV and AIDS (2022), available at https://www.usaid.gov/global-health/health-areas/hiv-and-aids.

¹⁴ USAID, Malaria (2021), available at https://www.usaid.gov/global-health/health-areas/malaria.

¹⁵ USAID, Family Planning and Reproductive Health (2021), available at https://www.usaid.gov/global-health/health-areas/family-planning.

¹⁶ USAID, Maternal and Child Health (2021), available at https://www.usaid.gov/global-health/health-areas/maternal-and-child-health.

¹⁷ USA.Gov, U.S. Department of Health and Human Services (2021), available at https://www.usa.gov/federal-agencies/u-s-department-of-health-and-human-services.

¹⁸ The Office of the Federal Register, A Guide to the Rulemaking Process, available at https://www.federalregister.gov/uploads/2011/01/the_rulemaking_process.pdf [hereinafter Office of the Federal Register, The Rulemaking Process].

¹⁹ Department of Health and Human Services (HHS), Office of Global Affairs (OGA) (2022), available at https://www.hhs.gov/about/agencies/oga/index.html.

²⁰ Centers for Disease Control and Prevention (CDC), Center for Global Health (2022), available at https://www.cdc.gov/globalhealth/index.html.

²¹ CDC, Global HIV and TB (2022), available at https://www.cdc.gov/globalhivtb/.

²² CDC, Parasites (2022), available at https://www.cdc.gov/parasites/.

²³ CDC, Global Immunization (2022), available at
https://www.cdc.gov/globalhealth/immunization/index.html.

²⁴ USA.gov, U.S. Department of Defense, available at https://www.usa.gov/federal-agencies/u-s-department-of-defense.

²⁵ Health.mil, Department of Defense HIV/AIDS Prevention Program (2022), available at https://health.mil/Military-Health-Topics/Combat-Support/Public-Health/DHAPP.

²⁶ Office of the Federal Register, The Rulemaking Process, supra note 18.

²⁷ CDC, About HIV/AIDS (2022), available at https://www.cdc.gov/hiv/basics/whatishiv.html; See also UNAIDS, HIV and AIDS: Basic Facts (2021), available at https://www.unaids.org/en/frequently-asked-questions-about-hiv-and-aids.

²⁸ The United States President’s Emergency Plan for AIDS Relief (PEPFAR), Our Priorities (2021), available at https://www.state.gov/our-priorities-pepfar/.

²⁹ World Health Organization (WHO), Maternal mortality (2019), available at https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.

³⁰ Henry J. Kaiser Family Foundation (KFF), The U.S. Government and Global Maternal and Child Health Efforts (2021), available at https://www.kff.org/global-health-policy/fact-sheet/the-u-s-government-and-global-maternal-and-child-health/ See also R. Rima Jolivet et. al, Upholding Rights Under COVID-19: The Respectful Maternity Care Charter (2020), available at https://www.hhrjournal.org/2020/05/upholding-rights-under-covid-19-the-respectful-maternity-care-charter/.

³¹ United Nations Population Fund (UNFPA), Family Planning (2022), available at https://www.unfpa.org/family-planning; See also WHO, Family planning/contraception methods (2020), available at http://www.who.int/news-room/fact-sheets/detail/family-planning-contraception.

³² KFF, The U.S. Government and International Family Planning & Reproductive Health Efforts (2021), available at https://www.kff.org/global-health-policy/fact-sheet/the-u-s-government-and-international-family-planning-reproductive-health-efforts/; See also Guttmacher Institute, Just the Numbers: The Impact of U.S. International Family Planning Assistance, 2021 (2021), available at https://www.guttmacher.org/just-numbers-impact-us-international-family-planning-assistance-2021.