Power and Politics in International Funding for Reproductive Health: the US Global Gag Rule

Abstract

Since 2001, the US government has used its power as a leading donor to family planning programmes to pursue policies in conflict with global agreements on reproductive rights. Prominent among these policies is the Mexico City Policy (or Global Gag Rule), which restricts non-governmental organisations (NGOs) in developing countries that receive USAID family planning funding from engaging in most abortion-related activities, even with their own funds. This paper reviews the history and political origins of the Gag Rule under several Republican party presidents. The Gag Rule has not achieved an overall reduction in abortions; rather, where it has disrupted family planning services, the policy is more likely to have increased the number of abortions. This paper concludes that the Gag Rule is a radical intrusion on the rights and autonomy of recipients of US funding. Regardless of whether or not it is rescinded in future, the underlying issues in the politics of US reproductive health assistance are likely to persist. NGOs that wish to free themselves from the constraints it imposes must find the means to end their dependence on USAID funding, including turning to other donors. NGOs should also take the lead in opposing policies such as the Gag Rule that violate global agreements.

Résumé

Depuis 2001, le Gouvernement américain utilise son pouvoir comme principal donateur des programmes de planification familiale pour prôner des politiques en conflit avec les accords mondiaux sur les droits génésiques. Parmi ces politiques figure en bonne place la ≪ politique de Mexico ≫ (ou règle du bâillon mondial) qui interdit aux organisations non gouvernementales (ONG) des pays en développement qui reçoivent un financement pour planification familiale de l'USAID de participer à la plupart des activités liées à l'avortement, même avec leurs fonds propres. Cet article retrace l'histoire et les origines politiques de cette interdiction sous plusieurs présidents républicains. Cette politique n'a pas réduit sensiblement les avortements; au contraire, là où elle a désorganisé les services de planification familiale, elle a probablement accru le nombre d'avortements. L'article en conclut que cette règle est une ingérence dans les droits et l'autonomie des bénéficiaires du financement américain. Qu'elle soit ou non levée à l'avenir, les questions fondamentales dans la politique de l'aide américaine à la santé génésique devraient demeurer. Les ONG qui souhaitent s'affranchir des constraintes que cette règle impose doivent trouver les moyens de mettre fin à leur dépendance financière de l'USAID, notamment en cherchant d'autres donateurs. Elles doivent aussi prendre la tête de l'opposition à de telles politiques, qui violent les accords internationaux.

Resumen

Desde el año 2001, el gobierno de EE.UU. ha usado su poder como uno de los donantes principales a los programas de planificación familiar, para poner en práctica polı́ticas opuestas a los acuerdos mundiales sobre los derechos reproductivos. Entre ellas se destaca la Polı́tica de la Ciudad de México (o Ley Mordaza), la cual prohibe que las organizaciones no gubernamentales (ONG) en los paı́ses en desarrollo que reciben financiamiento para planificación familiar de la USAID participen en la mayorı́a de las actividades relacionadas con el aborto, incluso con sus propios fondos. En este artı́culo se revisan la historia y los orı́genes polı́ticos de la Ley Mordaza bajo el mandato de varios presidentes del partido Republicano. La Ley Mordaza no ha logrado una disminución general en el ı́ndice de abortos; por lo contrario, donde ha obstaculizado los servicios de planificación familiar, es más probable que haya contribuido a su aumento. Se concluye que la Ley Mordaza es una invasión radical de los derechos y la autonomı́a de las entidades que reciben financiamiento de EE.UU. Que la ley se anule o no en el futuro, es probable que continúen los aspectos subyacentes en la polı́tica de EE.UU. con respecto a la ayuda financiera en salud reproductiva. Las ONG que desean liberarse de las restricciones que impone dicha ley deben encontrar los medios para dar fin a su dependencia del financiamiento de la USAID, por ejemplo acudiendo a otros donantes. Además, deben tomar la iniciativa de oponerse a las polı́ticas tales como la Ley Mordaza que violan los acuerdos mundiales.

Key Words:

• reproductive health policy and programmes
• donor assistance
• abortion law and policy
• reproductive rights
• United States of America

US policies against reproductive rights in recent years have taken a variety of forms, including opposition in international meetings to reaffirmation of the Programme of Action of the 1994 International Conference on Population and Development (ICPD), defunding of the United Nations Population Fund (UNFPA), and promotion of potentially harmful abstinence-based programmes in lieu of other proven strategies to reduce HIV/AIDS. A centre-piece of these policies is the Mexico City Policy, also known by its opponents as the Global Gag Rule. The Mexico City Policy derives its name from the location of the 1984 world population conference, at which the policy was first announced under the Reagan Administration, remaining in effect until the beginning of 1993. The policy was rescinded under the Clinton administration, until the Republican-dominated Congress adopted a version of it in 1999 legislation. When President George W Bush took office in January 2001, he reinstated it.¹ The Gag Rule provided reinforcement to another long-standing US policy, the Helms Amendment, that had already banned use of US foreign aid funds for most abortion-related activities.²

Under the Global Gag Rule, NGOs outside the US are not eligible for US family planning assistance through the US Agency for International Development (USAID) or the State Department if they use funding–from any other source–to perform abortions in cases other than rape, incest, or a threat to the life of the woman; provide counselling and referral for abortion; or lobby to make abortion legal or more available in their country. These restrictions effectively preclude such NGOs from providing safe abortion services even where it is legal in their own countries for indications not covered by the Gag, and from joining national movements to liberalise access to abortion.³

Significantly, the policy explicitly allows NGOs to continue to treat the complications of unsafe abortions (post-abortion care). It also allows referral of a pregnant woman elsewhere if she specifically asks where a safe, legal abortion can be obtained. Abortion-related research is also permitted.³ It should be further noted that as emergency contraception is not a form of abortion, it is legally allowed under the current Gag Rule.⁴ Moreover, the Gag Rule does not apply to other non-family planning US assistance such as child survival.⁵ Finally, the Gag Rule exempts governments receiving US assistance as well as US-based NGOs, whose activities are not limited if they are using non-USAID funds. However, if US NGOs are implementing overseas programmes with US funding, they are legally responsible for enforcing the Gag Rule's restrictions on their NGO partners in those countries.

This paper reviews the history of the Gag Rule, including its roots in US domestic abortion politics, and analyses the short and long-term damage the Gag Rule is causing to the health and lives of women in the developing world. We argue that the policy is more damaging now than when it was first introduced two decades ago and that it sets a dangerous policy precedent–interfering with the autonomy and private decision-making of NGOs and violating medical ethics and the human rights of pregnant women and health professionals. We further maintain that the Gag Rule violates the norms that the great majority of the international community have come to believe should govern donor–recipient relationships as well as the US government's own stated commitments to promoting civil society and women's human rights in overseas development assistance.

The politics of the Gag Rule in historical perspective

The Gag Rule was not established as a rational response to public health needs in the developing world nor even an effective strategy to reduce reliance on abortion by women in poor countries. Nor do the majority of American voters support the policy, as polls show.⁶ Important US professional groups have expressed their opposition to the policy, including the American Bar Association, the American College of Obstetricians and Gynecologists and the American Public Health Association. Throughout its history, the politics of the Gag Rule have been rooted in domestic political struggles over abortion, played out between anti-abortion and pro-choice factions of the Republican Party, between Republicans and Democrats, and between the Executive branch and Congress.

Republican presidents since 1984 have supported the Gag Rule, possibly in part because of their personal convictions on abortion, although these are hard to ascertain in any reliable way because of the political pressure they are under to appease the staunch opponents of abortion. In the face of this powerful political minority, supporting the Gag Rule has been a path of least resistance for many Republican (and some Democratic) leaders.⁷ While anti-abortion groups could not outlaw abortion after the US Supreme Court decision legalising it in 1973 (Roe v. Wade), they found in the 1970s that they could create a single-issue voting bloc, and they influenced policies for the next 30 years around federal and state funding in the area of abortion–including restrictions affecting poor women, women prisoners, health insurance of federal employees, women serving in the US military overseas, as well as the beneficiaries of US foreign assistance.⁸ And they could pursue efforts to defund the organisations that they had long opposed for their leadership in international family planning and that they perceived were spearheading efforts to liberalise women's rights to abortion–particularly the International Planned Parenthood Federation (IPPF). By the 1980s, UNFPA also became a target.

Consistent with the strategy to defund abortion services, the Helms Amendment to the US Foreign Assistance Act, adopted in 1973 soon after Roe v. Wade, put a block on any direct use of USAID funds for abortion activities by both governments and NGOs. The result of this law has been to institutionalise the stigmatisation of abortion in US foreign assistance for the last three decades.² The establishment of the first Gag Rule by President Reagan in 1984 reinforced this law. Together, these two policies have sought to freeze most abortion-related activities in international reproductive health programmes, regardless of whether US funds were channeled through governments or NGOs in developing countries.

At the beginning of the pro-choice Clinton Administration in January 1993, the Gag Rule was rescinded. Although the Helms Amendment remained in effect, the US government also supported a progressive policy position on abortion in the preparatory meetings for the ICPD and at the conference itself. It was during this period that USAID launched new initiatives to support treatment of abortion complications and awareness-raising and advocacy on the issue of unsafe abortion. The context soon changed, however, as conservative Republicans came to dominate both houses of the US Congress after the November 1994 election, setting the stage for heated struggles to enact the Gag Rule as law throughout the Clinton administration.^{9 10}

Year after year, an intensely committed anti-abortion minority in the House of Representatives sought to re-impose the policy. Their goal was not only to establish more abortion-related restrictions in foreign aid legislation, but also to limit the resources and influence of USAID's international family planning programme, the IPPF and UNFPA. For this ideological faction in Congress, opposition to government-supported family planning services, like abortion, grew from a set of beliefs about the role of modern contraception in promoting promiscuity, moral breakdown and the weakening of the traditional male-dominated family structure. (A few members of Congress who supported family planning while opposing abortion, nevertheless sought with varying effectiveness to de-link the two issues, by opposing the Gag Rule but supporting USAID's family planning programme.)

Anti-abortion leaders in Congress could not gain enough political support to eliminate the international family planning programme (as abortion opponents in the Reagan administration had unsuccessfully attempted in 1981). They could use their influence to bargain for reduced funding for it, however. In addition, they held other legislation hostage–the foreign assistance appropriations themselves, other omnibus spending bills, trade legislation, and payment of United Nations dues–in efforts to pressure the Clinton administration to accept the Gag Rule. A heavy price was paid each year from 1995–99, including in government shutdowns and delays in UN dues payments, as the Clinton administration continued to stand on principle and threatened to veto any bill that contained the policy. Family planning assistance was disrupted, with funds cut and subject to unprecedented Congressional interference with executive prerogatives: release of appropriated family planning funds was delayed and then disbursed in small monthly installments. Finally, in order for the Clinton administration to get Republican support for repayment of nearly $1 billion in US dues to the UN, an uneasy compromise was reached in 1999 on the Smith Amendment. Under this policy, which was in effect for a year, foreign NGOs had to certify compliance with Gag Rule restrictions, with non-certifying organisations such as IPPF permitted to receive funds up to a total of $15 million.¹¹

When Bush took office in January 2001, on the politically-charged anniversary of the Supreme Court's decision to legalise abortion, one of his first acts was to reinstate the full Gag Rule. Significantly, while the policy was extended in August 2003 to the State Department's support for family planning overseas (minor funding in the context of refugee relief programmes), the Administration decided in the same year not to extend it to HIV/AIDS funding, underscoring the lack of strong support for the Gag Rule when other values are seen to be at stake.¹²

Harmful effects of the Gag Rule

Reinstatement of the Gag Rule led almost immediately to withdrawal of funding for IPPF and a number of its member associations as well as for the affiliates of Marie Stopes International, due to the determination of these organisations not to accept the Gag Rule as a matter of principle. A few other NGOs are also known to have lost funding, although USAID does not provide information on how the policy is being implemented. At the same time, hundreds of NGOs are known to be receiving USAID assistance under the constraints of the Gag Rule in the more than 50 countries that receive US family planning assistance. Three years after the policy has been in place, it is still difficult to generalise about the magnitude of the harmful effects on women's health and access to family planning and other reproductive health services. In each country, the effects are determined by the political economy of reproductive health in that country–including how large a role is played by NGOs in both services and advocacy, the presence of other reproductive health donors, the salience of abortion as a policy issue, and the commitment of the national government to reproductive health. In countries such as Kenya, where there is more dependence on the United States as a donor and abortion is a controversial issue, the effects are worse than in countries such as India, where these conditions apply to a lesser degree.

With a high degree of certainty, it can be said that the Gag Rule has not achieved an overall reduction in abortions. By disrupting family planning services through effective NGO providers that reject the Gag Rule and lose their US funding, the policy is more likely to have increased the number of abortions. At the same time, the Gag Rule's limitations on NGOs that accept US funds are less likely to reduce abortions than to keep them clandestine and unsafe.

Effects of the Gag Rule in the changing environment of reproductive health

Changes in the environment of reproductive health care in developing countries suggest that the Gag Rule will be more damaging in its current implementation than in 1984–92 and when only a few organisations refused to accept its terms.^{13 14} The current Gag Rule appears to be the cause of more internal contradictions within the reproductive health community and a cause of conflict involving NGOs, governments, donor agencies and others.

First, the stakes are higher because of the increase in the number and diversity of NGOs receiving USAID funding for reproductive health services and advocacy. While more groups have given up USAID funding in order to avoid the Gag Rule, a larger number of other groups–estimated in the hundreds–are currently working under its actual and perceived limitations. For some NGOs, with no history of interest in abortion, accepting the terms of the Gag Rule was not an issue. For many other NGOs, however, the decision was excruciating, with future levels and types of services and institutional survival itself riding on the decision. Within the IPPF, which had permitted member associations to sign the Gag Rule in the Reagan era, there were heated struggles over whether to rescind membership altogether, which led to the decision that members who signed the Gag Rule should no longer receive central Federation funds.

Second, more countries have NGO-led movements to promote women's reproductive rights, including liberalisation of abortion laws and regulations (such as Kenya, Nigeria, India and Uruguay). For many NGOs that feel compelled for funding reasons to accept the Gag Rule, it is particularly painful to stand aside from national debates on abortion as well as to deny legal information and services to women. Moreover, because of these campaigns, a number of governments have already taken steps to expand legal indications for abortion, including Cambodia, Nepal, Benin, Ethiopia, Guinea and South Africa. Thus, compared with two decades ago, more countries permit abortion for indications broader than those allowed by the Gag Rule.¹⁵

Third, since the 1994 ICPD and the five-year review in 1999, many stakeholders, including the World Health Organization, have moved forward in implementing recommendations that health systems should help make abortion safe and accessible in circumstances where it is not against the law.¹⁶ IPPF has recently committed itself to increasing access to safe abortion as a priority goal. The International Federation of Gynecologists and Obstetricians has also endorsed ethical guidelines on abortion and, most recently, called on its members to advocate for women's sexual and reproductive rights and protect those rights in daily practice.¹⁷ The Gag Rule, which allows very few indications for abortion, is in clear conflict with these positions.

Fourth, the issue of HIV/AIDS has come to the forefront as a global health issue in the past decade. If family planning and HIV/AIDS interventions are increasingly integrated in service delivery settings, organisations that lose resources due to refusing the terms of the Gag Rule would lose funding for HIV prevention programmes and services as well.¹⁸

Finally, USAID has developed over the years an active post-abortion care programme, promoting greater awareness of unsafe abortion as a public health problem. While USAID seeks to maintain its role as a major donor to post-abortion care activities, the difficulties of collaboration between “gagged” and “ungagged” groups impedes progress in advocacy, training and research for post-abortion care.

Documenting the Gag Rule's effects

Soon after the Gag Rule was reinstated, the Global Gag Rule Impact Project, a group of organisations under the leadership of Population Action International (PAI), came together to document its effects at country level. Beginning in 2002, PAI, Ipas and Planned Parenthood Federation of America conducted research with assistance in gathering evidence in the field from Engender Health and Pathfinder International.¹⁹ The resulting case studies and other documentation entitled Access Denied: US Restrictions on International Family Planning describe the damage of the Gag Rule, focusing on Ethiopia, Kenya, Zambia and Romania. The findings corroborate evidence that others have assembled for these and other countries.^{20 21}

Access Denied gave particular attention to the effect on established family planning organisations in Kenya, Ethiopia and Zambia. Some of these organisations were forced to close clinics, terminate staff and cut both family planning and prevention and treatment services for STIs and HIV/AIDS, maternal health and well-baby care, sexual health education, and youth outreach programmes. The Gag Rule also led to the termination of all US contraceptive supply shipments to leading family planning organisations in 29 countries. In the absence of alternatives, women who relied on these services must certainly have suffered more unwanted pregnancies and more unsafe abortions, although the impact is difficult to quantify.¹⁹

Defenders of the Gag Rule have suggested that when NGO family planning service providers, such as IPPF member associations, reject the Gag Rule and turn down USAID family planning funds, USAID can turn to other NGOs who will provide the necessary contraceptive services while complying with the Gag Rule. However, the evidence from Access Denied suggests that these other NGOs may be less effective and experienced as service providers, and may not reach the same geographic areas. In some instances, USAID funds are being shifted to public sector facilities that tend to provide less user-oriented services than NGOs.¹⁹

In Romania, where legal abortion has been the major means of fertility regulation for many women, the Gag Rule contributed to the separation of contraceptive services from abortion-related services. This effectively reduced the opportunity to promote post-abortion contraceptive information and services, again probably contributing to more rather than fewer abortions.¹⁹

The Gag Rule has also had indirect and unintended effects. Uncertainty about what is permitted and the desire to avoid controversy has often resulted in over-interpretation of its restrictions and avoidance even of permitted activities by both US and developing country NGOs and USAID staff. Many NGOs, fearful of losing their US funding, have unnecessarily interpreted the policy to restrict other potentially controversial activities as well. One media organisation in Zambia, for example, eliminated a chapter on emergency contraception from a brochure it produced on contraceptive options.^{19 20}

Long-term effects

Clearly, the harms of the Gag Rule for women's health are both short-term and long-term. Over time, they impact differently on those who reject and those who accept the restrictions. In some countries, NGOs that lose USAID funding, such as the Family Guidance Association in Ethiopia, eventually find other donors. That too can be problematic in that some bilateral donors who have funded NGOs in the past have changed their funding philosophy, with health funds now channelled to governments under sector-wide approaches or more recently overall budget support. Moreover, donors who have been willing to step in and fill the gap for an NGO in response to the Gag Rule may not be prepared to provide sustained funding. International agencies such as UNFPA cannot be of much help as they mainly direct their funds through governments.

For those NGOs that do accept the terms of the Gag Rule in order to receive funding, a heavy price must be paid in their inability to provide women with unwanted pregnancies with appropriate services or counselling, or advocate for women's access to safe abortion care. This represented a key obstacle for some NGOs in Kenya and Ethiopia, where there have been ongoing local initiatives to reform abortion laws. Over the long term, in a number of countries where USAID is a major family planning donor and where most NGOs have accepted the Gag Rule, these restrictions will continue to have insidious effects on the availability of safe abortion care for women.

The Gag Rule as an illegitimate instrument of donor control

Bilateral and multilateral development assistance agencies often exercise the “power of the purse”. Restraints on this power may come through oversight from their legislative or other governing bodies, from internationally agreed human rights instruments or from other ethical norms and principles. At times, conditions associated with development assistance reach beyond the normally expected “power of the purse” and become mechanisms for manipulation, with serious harms to the recipients, who are in no position to raise their voices to demand accountability. The Gag Rule is one such mechanism–extreme in ignoring the norms that should govern donor assistance and coercive in its effects on NGOs that feel they need US family planning funds in order to survive and serve women. This control extends to NGOs' use of money from other donors, who are effectively prevented from funding or otherwise working with the US-funded NGOs on “forbidden” activities. These other donors could be governments or individuals, foreign donors or international organisations.

Groups who oppose termination of pregnancy may disagree that the Gag Rule overreaches, as they believe that public policies are morally justified in going to almost any lengths to stop abortion, including government interference with the private behaviour of entities that receive public funding. Abortion opponents might point to the precedents of other recent requirements that have been put on eligibility for US development assistance, under which recipients cannot engage in terrorism or drug trafficking, even with other resources.²² These other restrictions are more likely than the Gag Rule to be seen as morally justified because of nearly universal disapproval of the unlawful activities involved. By comparison, the Gag Rule takes a position on activities that are both lawful and command majority support in many countries. Significantly, no other donor government, even those with concerns about abortion, has emulated the US example of overtly restricting activities that they themselves do not fund.

Figure 1 Republican National Convention, USA, 2004

Interfering with professional judgement

The Gag Rule interferes with the professional judgement of health service professionals on matters related to the care they provide and personal to the individual being attended. The practice of medicine is bound by universal ethical principles–including non-maleficence (do no harm), the autonomy of capable persons and informed decision-making–and by local laws and norms of practice.²³ Further, an individual's views about appropriate medical options and personal behaviour regarding sex and reproduction, with abortion no exception, are influenced by religion, values and circumstances as well as by local culture and community acceptability. Such a topic is singularly inappropriate for a sweeping set of uniform ideological requirements and prohibitions attached to donor assistance.

Violating the human rights of pregnant women and health professionals

Whether a pregnant woman's access to safe abortion is a human right remains controversial, although a strong case has been made by some legal scholars, and UN human rights bodies have expressed themselves on this subject on a number of occasions.²⁴ Even in the absence of consensus on this fundamental question, it should be evident that under the Gag Rule, pregnant women whose circumstances compel them to rely on US-subsidised NGO services in their countries are being effectively deprived of access to care and information. International covenants establishing the right to health and to the benefits of scientific progress are thus violated, particularly since the Gag Rule does not recognise abortions where pregnancy threatens a woman's health.^{25 26} Governments may find it difficult to fill the breach, particularly when they lack adequate resources of their own and have limited ability to exercise their sovereignty in the context of donor dependency.

Under the Gag Rule, doctors and other health providers working in NGOs that depend on US family planning funds are unable to speak honestly and truthfully to patients or in professional or political arenas. Their right to speak and to give and receive information–principles guaranteed under the Universal Declaration of Human Rights and the Covenant on Civil and Political Rights, as well as the US Constitution–are effectively violated.²⁷

It is ironic that the US government should enforce a policy that so blatantly denies the health rights of women and freedom of speech, given its promotion of democracy, good governance and human rights in other US development assistance. Two of USAID's democracy and governance goals are to promote “strengthening the rule of law and respect for human rights” and “increased development of a politically active civil society”.²⁸ Establishment of the Millennium Challenge Corporation (MCC), promoted by the Bush administration, is intended to support countries that are ruling justly and that respect human rights, including women's human rights.^{29 30}

Setting a dangerous precedent

The Gag Rule may already be serving as a model for restricting eligibility for US funding in other areas, in support of the same underlying, ideologically conservative agenda. An example is language included in 2003 in the global HIV/AIDS authorisation bill adopted by the US Congress. Organisations inside and outside the US are ineligible for funding unless they include a statement in their grant agreements stating their opposition to the practices of prostitution and sex trafficking.^{31 32} Foreign NGOs must obey an even harsher restriction. In order to receive funding, they must enact a policy explicitly opposing prostitution and sex trafficking.³³ The consequences for organisations that direct services to sex workers on public health, humanitarian and human rights grounds remain to be seen.³⁴

The outlook for the future

The Gag Rule has neither broad-based political support nor a compelling public health or development rationale. If the Democratic party prevails in the November 2004 presidential election, the Gag Rule will be rescinded. It would still be likely to remain as a political bone of contention between the Executive branch and Congress, however, with continuing efforts to impose a legislated version, as occurred under Clinton. Also, because the Helms Amendment will still be in place, prohibitions will continue on the involvement of USAID in abortion and use of USAID funds to advance access to and quality of safe abortion care. Restoration of federal funding of abortion services domestically may be necessary before the Helms Amendment is likely to be repealed–both distant objectives unless political alignments shift markedly.

If Republicans prevail in the election, it is virtually assured that the Gag Rule will remain in place, at least until 2008. Opponents of the Gag Rule can nevertheless be encouraged by increasing condemnation of the Gag Rule by individual health and development leaders overseas, in both developing and European countries. A gathering of African health leaders in Addis Ababa in March 2003 called on African governments and the global community to oppose the policy.³⁵ In September 2003, the parliamentary assembly of the Council of Europe voted 89 to 8 to adopt a resolution calling for “enlightened debate with the United States on the harmful effects of the re-establishment of the Mexico City Policy in an attempt to encourage President George W Bush to cancel it”.³⁶ Other European policymakers have also expressed strong disagreement in a variety of fora.^{37 38} Isolation of the US in the arenas where the ten-year review of ICPD has been carried out has also sent a strong message about where other members of the international community stand on reproductive rights, including a number of key donors.

Within the US, in the fall of 2003, the Republican-controlled Senate adopted an amendment overturning the Gag Rule, an important indication of gaps in political support for the policy.³⁹ The Gag Rule also featured as an issue in the March for Women's Lives that attracted more than a million pro-choice supporters to Washington DC in April 2004. If domestic and global opposition continues to be expressed by NGOs as well as governments, it may serve at least to moderate the implementation of the policy and stand as an obstacle to extending similar “gags” to other types of US assistance.

Still, continuation of the Gag Rule threatens the lives and health of millions of women in developing countries. Experience with the Gag Rule also demonstrates the vulnerability of NGOs when they are heavily dependent on a single donor; many have agreed to work under its constraints, hoping that it will be temporary. It will be extremely important for independent women's advocacy groups and other supporters of reproductive rights, including other governments and donors, to build coalitions and speak out against US anti-choice policies, including the Gag Rule, if it remains in effect beyond 2004. Alternatively, if enlightened reproductive health policies emerge under a new administration, advocacy groups will need to support the new policies against organised attacks.

Significant change in the political equation in countries where the US government is a major family planning donor can occur only if enough NGOs find alternative sources of funding from local or international donors, or succeed with other income-generating measures. For this reason, it is essential for the international community to find new mechanisms and resources to lessen dependence of NGOs on US funding and support their critical work on behalf of women's reproductive health and rights.

Acknowledgements

We would like to thank Rachael N Pine for her contribution to this article, as well as Richard Cincotta, Maria de Bruyn, Kathy Hall-Martinez, Charlotte Hord Smith, Craig Lasher, Elizabeth Maguire, Alison McIntosh, and Wendy Turnbull for helpful comments on earlier versions. The paper is based in part on the work of the Global Gag Rule Impact Project, and we gratefully acknowledge the support for the Project from the Compton Foundation, John D and Catherine T MacArthur Foundation, Wallace Alexander Gerbode Foundation, Tides Foundation and Moriah Fund. The opinions are solely those of the authors, and not necessarily those of their organisations.