Emergency Contraception in Peru: Shifting Government and Donor Policies and Influences

Abstract

Inclusion of emergency contraception in national family planning programmes is consistent with international agreements that countries should strive to ensure access to a wide range of contraceptive methods and promote voluntary, informed choice. Yet in 2005, USAID/Peru requested that its NGO grantees in Peru take a “neutral” position on emergency contraception in activities or materials that involve its funds. For many decades, donor countries have viewed conservative religious forces in low-income countries as an obstacle to expanding family planning programmes. Today, however, far-right organisations in the United States are having an unprecedented influence on US public policy, including in countries such as Peru. This article analyses shifts in USAID/Peru's policy on emergency contraception in Peru since 1992. In Peru today, there is widespread official and public support for making emergency contraception available. Given USAID's long support for family planning internationally and in Peru, the current policy appears to be the result of attacks by US far-right organisations carried out in synergy with sympathetic US public officials and anti-choice Peruvian allies.

Résumé

Inclure la contraception d'urgence dans les programmes nationaux de planification familiale est conforme aux accords internationaux qui obligent les pays à assurer l'accès à un vaste éventail de méthodes contraceptives et à promouvoir un choix consenti et bien informé. Pourtant, en 2005, l'USAID/Pérou a demandé que les ONG bénéficiant de ses subventions au Pérou adoptent une position « neutre » sur la contraception d'urgence dans les activités ou les matériels utilisant ses fonds. Longtemps, les pays donateurs ont considéré les forces religieuses conservatrices dans les pays à faible revenu comme un obstacle à l'élargissement des programmes de planification familiale. Aujourd'hui, les organisations d'extrême droite aux États-Unis ont une influence sans précédent sur la politique publique américaine, par exemple au Pérou. Cet article analyse les changements dans la politique d'USAID/Pérou sur la contraception d'urgence au Pérou depuis 1992. Aujourd'hui au Pérou, un vaste mouvement officiel et public souhaite que la contraception d'urgence devienne disponible. Compte tenu du soutien apporté de longue date par l'USAID à la planification familiale au niveau international et au Pérou, la politique actuelle semble le résultat des attaques d'organisations d'extrême droite menées en synergie avec des fonctionnaires américains sympathisants et des alliés péruviens opposés à l'avortement.

Resumen

La inclusión de la anticoncepción de emergencia en los programas nacionales de planificación familiar concuerda con los acuerdos internacionales en que los países deben esforzarse por garantizar acceso a una amplia gama de métodos anticonceptivos y promover decisiones informadas y voluntarias. No obstante, en 2005, USAID/Perú solicitó que sus ONG beneficiarias en Perú asumieran una posición “neutral” respecto a la anticoncepción de emergencia en actividades o materiales financiados con sus fondos. Por muchas décadas, en los países donantes las fuerzas religiosas conservadoras en países de bajos ingresos han sido consideradas como un obstáculo a la ampliación de los programas de planificación familiar. Hoy día, sin embargo, las organizaciones ultraderechistas en Estados Unidos ejercen una influencia sin precedentes en las políticas públicas de EE.UU., incluso en países como Perú. En este artículo se analizan los cambios en las polticas de USAID/Perú respecto a la anticoncepción de emergencia en Perú desde 1992. Actualmente, en Perú existe un gran apoyo extendido, tanto oficial como público, para ampliar el acceso a la anticoncepción de emergencia. En vista de que USAID lleva muchos años apoyando la planificación familiar a nivel internacional y en Perú, las políticas actuales parecen ser el resultado de ataques de organizaciones ultraderechistas de EE.UU., realizados en sinergía con funcionarios públicos simpatizantes y aliados peruanos contra el derecho a decidir.

Key Words:

• emergency contraception
• reproductive health policy and programmes
• reproductive rights
• Peru
• United States

Emergency contraception is on the WHO Model List of Essential Medicines and the Interagency List of Essential Medicines for Reproductive Health.* Moreover, its inclusion in national family planning programmes is consistent with international agreements such as the 1994 ICPD Programme of Action, which mandates that countries strive to ensure access to a wide range of contraceptive methods and promote voluntary, informed choice.

Emergency contraception is considered a contraceptive by the US Agency for International Development (USAID),¹ and USAID has long played a critical role in improving access to all contraceptive methods, including emergency contraception, in low-income countries. For example, it has lent technical and legal support to the International Consortium for Emergency Contraception, a collaborative effort of major US international health organisations to increase availability of and access to the method in low-income countries (Personal communication, Elizabeth Westley, Coordinator, International Consortium for Emergency Contraception, 23 January 2007).

Emergency contraception has been approved by the government in Peru since 2001.² Yet in November 2005, the Peruvian mission of USAID sent a letter to all its NGO grantees requesting that they “maintain a neutral position” regarding emergency contraception, “not giving preference to any position in any circumstances that involves USAID financing, for example, information materials or planned events, among others.” ³

The aim of this article is to analyse the reasons for several shifts in USAID/Peru's policy on emergency contraception within the context of changes in government policy on family planning in Peru and the United States and the increasing influence of ultra-conservative forces on US foreign assistance abroad where they can gain a foothold.⁴⁵ For many decades, donor countries have viewed conservative religious forces in low-income countries as an obstacle to expanding family planning programmes. Today, however, far-right organisations in the US are having an unprecedented influence on US public policy, including in developing countries such as Peru. The information is drawn from on-going monitoring conducted by the authors of reproductive health and rights policies in Peru over a number of years.

USAID and family planning policy in Peru 1970s–1990s

For 30 years, USAID has been the main foreign donor to family planning in Peru.⁶ Until the 1990s, the Peruvian government had a weak commitment to providing family planning services.⁷ USAID/Peru* gave contraceptive supplies and technical assistance to private non-governmental organizations (NGOs) to deliver family planning services, primarily through clinic-based programmes. The amount of funding was based on the number of contraceptive years of protection achieved, which encouraged an emphasis on long-term methods, such as the IUD.⁶

Around the time of the International Conference on Population and Development (ICPD) in 1994, although it continued to focus on family planning, USAID/Peru funding policy began to reflect a more comprehensive and user-centred approach to reproductive health, including preventing unwanted pregnancy, improving women's health and ensuring informed choice in contraceptive use.^8–10

At the same time, the Peruvian government began to improve access to contraceptive services among groups that had been marginalised from these services in rural and peri-urban areas in the Andean Highlands and Amazon Basin. Contraception was offered free of charge, and tubal ligation and vasectomy were legalised.¹¹ Emergency contraception had been included within Peru's national family planning norms in 1992,¹² but policy prioritised increasing the availability of contraceptives for ongoing rather than emergency use, and no institutionalised efforts were made to provide emergency contraception.⁸ In the mid-1990s, USAID transferred a large portion of its family planning assistance to Peru's public health sector, in recognition of the fact that it had become the main provider of health services, including for contraception.⁹

The Fujimori government shifted the expanding national family planning programme towards fulfilling demographic objectives by 1996. This led to now well-known abuses, particularly in relation to sterilisation, which was sometimes delivered without adequate quality of care or voluntary and informed choice. Peruvian women's rights organisations and the Public Ombudsman's Office on Women's Rights led efforts to expose the problems and propose reforms.^13–15

The problems resulting from Fujimori's sterilisation policy prompted Catholic church officials, lay groups and far-right policymakers in Peru to demand that the national family planning programme be shut down immediately and sterilisation removed from the list of approved methods.¹⁶¹⁷ In January 1998, David Morrisson of the US-based NGO Population Research Institute (PRI) travelled to Peru to collect information on abuses, taking testimony from far-right politicians in Peru who were opposed to family planning in Peru, among others, and to find out if USAID was involved in funding these abuses.^18–21

Morrison did not even meet with officials at USAID/Peru,⁸ yet upon returning to the US, PRI sent its evidence to right-wing US Congressman Chris Smith, urging that USAID's family planning efforts in Peru be suspended.²² Smith sent a member of his own staff to Peru to investigate.²³ In February 1998, another US far-right group, the Latin American Alliance for the Family, sent its director to Peru to investigate, again without meeting USAID/Peru.²⁴ On 25 February, a sub-committee of the Committee on International Relations, US House of Representatives, of which Smith was chairperson, held a hearing on “The Peruvian Population Control Program”.²⁵ This set a pattern for efforts by US far-right NGOs working with Peruvian far-right policymakers to influence US and Peruvian policymakers as well as USAID in-country policy.

The religious or Christian right in the US has its origins in the 1970s, developing in opposition to, among many other political issues, sexual and reproductive rights.²⁶ They seek to restrict access to modern contraception and abortion and promote abstinence for prevention of unintended pregnancy, HIV and other sexually transmitted infections.²⁷ Since the 1990s, these US organisations, alongside the Catholic church hierarchy, have become increasingly involved in spreading their agenda internationally, particularly in low-income countries.⁴⁵ In Peru, their strategies have included harassing USAID/Peru, UNFPA, US cooperating agencies and Peruvian organisations while lending support to ultra-conservative Peruvian policymakers, NGOs and Catholic church officials.²⁸²⁹

The charges they have made against USAID/Peru have generally been either that they are funding forced sterilisations or the promotion of abortion.^30–32 Claims like these are sent to sympathetic members of the US Congress, such as Chris Smith and Todd Tiahrt, who convey the charges to USAID headquarters and demand explanations. USAID headquarters then communicate the charges to USAID/Peru, who are required to provide proof against the charges, usually with some form of investigation, internal or external.³³³⁴

In 1998, the US Congressional investigation of USAID's programme in Peru concluded that its funding had not supported the abuses committed by the Peruvian government. Moreover, it did not acquiesce to the far right demand to suspend funding to Peru's family planning programme. Instead, USAID/Peru intensified its commitment to various measures already underway, designed to improve the quality of care and safeguard informed and voluntary choice in government contraceptive services. For example, it sped up the distribution of, and training on, new family planning norms for health care providers. It also increased funding to the Public Ombudsman on Women's Rights, which it had been funding since it was formed in 1996 to monitor and investigate violations of reproductive rights by government institutions and public programmes. In this instance, the funding was to monitor the government's family planning services.^35–39 Nonetheless, certain concessions to the far-right agenda were apparently made.

Policies on emergency contraception vacillate: 1997–2001

According to a 2005 letter from USAID/Peru to partner organisations, the mission adopted a “neutrality” policy regarding emergency contraception in 1997.

“Our work in public health frequently entails confronting diverse issues, some of which generate controversy. USAID considers that, in Peru, the issue of emergency contraceptive pills is one of those; thus, since 1997, it has established a policy of neutrality on this issue.” ³

At the time, Susana Chávez, co-author of this paper, directed the Reproductive Health Unit at the USAID-funded project, ReproSalud. She was not informed of this change of policy by officials at USAID/Peru or at cooperating agencies working with the Ministry of Health. Instead, when she attempted to develop project materials based on Peru's national family planning norms, which included emergency contraception, she was informed by them that the Ministry of Health had removed emergency contraception from the norms at USAID's insistence. Similarly, after having funded a successful pilot model of post-abortion care in the Daniel Carrion Hospital, USAID/Peru discontinued its funding and DFID funded the scaling-up of these services between 1998 and 2001.⁴⁰

In 1999, however, USAID/Peru had new staff who were concerned with improving access to both emergency contraception and post-abortion care.⁴¹ Their stance was shared by Peruvian health officials appointed by the transitional government that took over in 2000, when President Fujimori abandoned his post. During that time, Peruvian reproductive rights organisations, including Centro de la Mujer Peruana Flora Tristán, APROPO and INPPARES, carried out an advocacy initiative in favour of emergency contraception.⁴² In response, the Ministry of Health appointed a high-level commission to evaluate the re-incorporation of emergency contraception into the national family planning norms. The measure was approved on 13 July 2001; the Minister of Health signed a Ministerial Resolution mandating the distribution of emergency contraception in the public health system.² USAID/Peru supported this measure by funding JHPIEGO, a US health and family planning organisation affiliated with Johns Hopkins University, to provide technical assistance to the Health Ministry during the policymaking process. USAID/Peru documented this support in a public letter, thereby facilitating civil society lobbying efforts.⁴¹

USAID/Peru also enjoyed a brief respite from attacks by far-right organisations in the US. In 2000 and 2001, two official audits had been conducted of its family planning assistance, in response to ultra-conservative pressure in the US,⁴³ which found that the mission's programmes complied fully with US law and did not fund forced sterilisation or promote abortion.⁴⁴⁴⁵

Support for emergency contraception stalled by ultra-conservatives: 2001–2003

In 2001, the Bush administration took office and the sphere of influence of ultra-conservative organisations expanded to the White House,⁴⁶⁴⁷ leading to the reinstatement of the Global Gag Rule, prohibiting all foreign NGOs receiving US government family planning assistance from using those or any other funds to engage in providing legal abortions, deliver counselling and information or lobby to decriminalise abortion.⁴⁸ On many occasions since then, anti-choice groups have used their amplified, inaccurate interpretation of what constitutes abortion, which includes emergency contraception, tubal ligation, vasectomy, the IUD and hormonal contraceptive pills, to claim that USAID/Peru (among many others) was promoting abortion and therefore violating the Global Gag Rule.⁴⁹

Six months after the Bush administration took office, in July 2001, newly-elected president, Alejandro Toledo, appointed two ultra-conservative physicians, Luis Solari* and Fernando Carbone,^† as Minister and Vice-Minister of Health, respectively. Six months later, Carbone was put in charge of the Health Ministry and Solari returned to the congress. Between 2001 and 2003, both men implemented policies designed to limit access to reproductive health information, methods and services. Among these measures, they refused to fulfil the Ministerial Resolution requiring the distribution of emergency contraception in the public health services.⁵⁰ In December 2001, however, they did allow the approval of the commercial sale of Postinor 2, which has been available since 2002 in pharmacies and private medical services.⁵⁰⁵¹

The Public Ombudsman on Women's Rights continued its role of monitoring the government family planning programme and documented the effects of these restrictive public policies.³⁹⁵² Peruvian reproductive rights organisations also mobilised in opposition to the government's anti-choice policies and demanded the implementation of the Ministerial Resolution on emergency contraception.⁵⁰

Solari and Carbone succeeded in blocking USAID/Peru's support to NGOs to make emergency contraception available,⁴² drawing on their ties with ultra-conservatives in the US, who in turn put pressure on USAID officials in Peru. In March 2002, Chris Smith visited Peru as the keynote speaker at the first celebration of the “Day of the Unborn Child”, which Solari had pushed through the Peruvian congress a few months earlier.⁵⁰ During his visit, he pressured USAID/Peru officials not to support emergency contraception.⁴² USAID/Peru officials, who had supported making emergency contraceptive available, began to argue that their hands were tied because the method constituted a “gray area” under the Global Gag Rule.⁴²⁵³ On the other hand, USAID/Peru was once again able to support efforts to scale up and improve the quality of post-abortion care, by incorporating it as a component within a wider range of emergency obstetric interventions in public health services.

National consensus on emergency contraception: 2003–2004

Civil society opposition to far-right health policies met with success in July 2003, when President Toledo announced that his government would develop family planning programmes in line with WHO guidelines and replaced Dr Carbone with Dr Alvaro Vidal as Health Minister. Vidal was supportive of reproductive health policies, yet he was unable to withstand the pressure from ultra-conservative members of Peru's national congress, including Dr Hector Chávez Chuchón, then president of the Congressional Committee on Health, and Dr Luis Solari. Moreover, Vidal met with tremendous internal resistance from ultra-conservatives within the Health Ministry who had been hired under Solari and Carbone and still occupied key posts.⁵⁰

Instead of implementing the Ministry Resolution on emergency contraception, Vidal established yet another high-level commission to evaluate whether it should be made available in the public sector. The commission consisted of 14 governmental and civil society institutions.⁵⁴ In addition, the Public Ombudsman on Women's Rights conducted a legal assessment of the Ministerial Resolution, to determine whether it was consistent with the human rights protected by the Constitution.⁵⁵

The most important outcome of 2003–04 was a national debate involving all major institutions and sectors on whether emergency contraception should be made available in the public health services. Each of the government ministries involved in the high-level commission – the Ministries of Justice, Health, and Women and Social Development, and the Public Ombudsman – were required to take a position on emergency contraception. And all of them recognised it as a contraceptive method and endorsed its distribution in government programmes. Moreover, in December 2003, both the high-level commission and the Public Ombudsman released evaluations in favour of making emergency contraception available in the public health services.⁵⁴⁵⁵ The Ombudsman's report stated that denying access to emergency contraception in public services constituted a violation of anti-discrimination articles in the Constitution.⁵⁵

Similarly, women's community-based organisations, health NGOs and associations of medical professionals concluded that it should be made available in the public services, including the Peruvian Medical Association, Peruvian Society of Obstetrics and Gynecology, and Peruvian Society of Fertility and Reproduction. WHO, the Pan-American Health Organization and UNFPA also all expressed public support for making emergency contraception available in public services in Peru. Finally, opinion polls found that the Peruvian population widely supported emergency contraception. In one poll, 47% of women respondents said they would use emergency contraception if needed.⁵⁶

Thus, a broad-based consensus in favour of making emergency contraception available within the public sector was reached by early 2004, when President Toledo appointed Dr Pilar Mazzetti as Health Minister. Dr Mazzetti was unwavering in her commitment to improving the quality of and access to contraceptive services and information, including emergency contraception. She pursued this path for two and a half years until Toledo's administration came to an end. The current Minister of Health, Dr Carlos Vallejos Sologuren, appointed by President Alan Garcia in July 2006, is continuing the efforts begun by Dr Mazzetti.

Several court cases were also heard on emergency contraception in this period. A case filed by reproductive rights advocates in 2002, while Dr Carbone was Health Minister, called upon the Ministry to implement the resolution on emergency contraception and offer the method in the public health services. In 2004, while Dr Mazzetti was Health Minister, the court ruled in favour of the claimants. A counter-resolution by anti-choice advocates, that the Health Ministry not distribute emergency contraception because it was a form of abortion, was also filed.* Dr Mazzetti's appeal led the judge to dismiss the first, favourable ruling. In response, reproductive rights advocates took the case to the Supreme Court, which, in late 2006, ruled in their favour, ordering the Health Ministry to provide emergency contraception. Because the ruling came from the highest court in Peru, it guarantees Peruvian women access to emergency contraception.⁵⁷

USAID/Peru restricts use of its funds for emergency contraception since 2005

In early 2004, Peru's public health system began to incorporate emergency contraception into its services. Many stakeholders expected that USAID/Peru would contribute to this effort as part of its continuing family planning programme support. Yet, this did not happen. While the context in Peru for reproductive health and rights had become favourable, attacks by US far-right groups worsened. PRI began to focus on attacking emergency contraception, condemning USAID for supporting emergency contraception provision as well as the efforts of Peru's health minister to make emergency contraception available in the public sector.⁵⁸⁵⁹

Late in 2004, PRI set up a Latin American office in Lima. In 2005, its director sent a letter to USAID in Washington DC, accusing two Peruvian grantees of USAID/Peru of violating the Global Gag Rule by carrying out activities with US family planning funds that included emergency contraception.⁶⁰ The one organisation was the Public Ombudsman on Women's Rights, who had indeed used USAID/Peru funds to reprint the findings of its legal assessment of the Ministerial Resolution on emergency contraception. The other was the Movimiento Manuela Ramos, a feminist NGO, that was using USAID/Peru funds for the television programme, The Women's Bar, in which emergency contraception was a topic of discussion in several episodes. USAID/Peru had been funding Movimiento Manuela Ramos to produce this programme since 2002, with the aim of informing the general public and fostering public opinion in favour of women's rights, including reproductive rights.

In response to PRI, Kent Hill, the Assistant Administrator of USAID's Bureau of Global Health in Washington, replied:

“Because ECPs are contraceptives and not abortifacients, they are not prohibited by any abortion-related laws or policies that affect USAID's family planning or other development assistance.” ¹

However, he added that USAID/Peru's policy was one of neutrality, both “prior to and following the Peruvian Ministry of Health's decision to make ECPs publicly available”. In this regard, he wrote, USAID/Peru had “not knowingly made, financed or authorized its implementers to make or finance any public statements or publications regarding ECPs with USAID funds”. He assured PRI that USAID/Peru would request that both organisations devolve USAID funds used for these activities.¹

USAID/Peru staff did raise the issue with them both and told them that emergency contraception should henceforth be excluded from their USAID-funded work. This was followed by a letter to all of USAID/Peru's partners on 30 November 2005, which said:

“Our work in public health frequently entails confronting diverse issues, some of which generate controversy. USAID considers that, in Peru, the issue of emergency contraceptive pills is one of those; thus, since 1997, it has established a policy of neutrality on this issue. We believe that it is up to Peruvian institutions, organizations, citizens and public officials to address this issue in its entirety. USAID/Peru continues to have a neutral position regarding emergency contraceptive pills. Neutrality implies maintaining a high-level civic debate on this important public policy issue. Therefore, through this letter, we reiterate once again, our request to our grantees, that in using our funds, you maintain a neutral position, not giving preference to any position in any circumstances that involves USAID financing, for example, information materials or planned events, among others.” ³

In response, Peruvian reproductive rights advocates sent letters and held meetings with USAID/Peru officials to express their concerns about this stance,⁶¹⁶² backed by international support from the Center for Health and Gender Equity, Ipas, International Planned Parenthood Federation, the Latin American Federation of Societies of Obstetrics and Gynecology and the Latin American Consortium on Emergency Contraception.^63–65 In January 2006, in a meeting with representatives of PROMSEX and APPRENDE, a USAID/Peru official said that its policy was that it did not consider emergency contraception a priority for improving health and reducing poverty in Peru.

However, in early February 2006 a further letter from Kent Hill in Washington clarified that USAID/Peru's policy of neutrality actually referred only to participating in public debate and not to supporting emergency contraception in service delivery:

“Since 1997, USAID has had a policy not to participate in the public debate with respect to ECPs and has refrained from all public comment, either in favour of or against ECPs in Peru. Since that time, USAID/Peru also has requested that its partners not use their USAID funding to express any policy position on ECPs… [The prohibition] should in no way be construed to say that USAID or its partners cannot support provision of information about ECPs to women receiving services from Peru's family planning program where ECPs are now approved.” ⁶⁶

Not content with this partial reversal of policy in favour of emergency contraceptive service delivery, more than 20 Peruvian organisations sent a letter to Kent Hill that same month,⁶⁷ arguing that a restriction on engaging in public debate on emergency contraception had never previously been applied by USAID/Peru, and that many of us had actively and visibly participated in such debate. On the other hand, we said, in spite of what this latest letter says, USAID/Peru has consistently blocked the inclusion of counselling and provision of emergency contraception in service manuals, information materials and training supported with USAID/Peru funds. At this writing, a year later, we have not yet received a response from USAID in Washington or Peru.

Conclusions

There is of course no such thing as a neutral position when it comes to supporting or not supporting access to a method of contraception, and that includes emergency contraception. But emergency contraception has been a kind of lightning rod in Peru and elsewhere, falsely identified as an abortifacient and condemned out of hand as such. In the context of shifting policies on emergency contraception on the part of the Peruvian government, anti-choice fundamentalism emanating from the US White House since 2001 and increasing harassment by far-right NGOs such as PRI working with sympathetic US public officials and their Peruvian allies, USAID/Peru has been in a difficult position for many years. In spite of its important support to improve access to quality family planning services in Peru, USAID/Peru's policy on emergency contraception has also shifted more than once, not least with its own changes of staff. What is most unfortunate is that in the past few years, while a consensus has been consolidated in Peru in favour of emergency contraception, the climate in the United States has grown more negative. The bottom line seems to be that a USAID mission must first and foremost be sensitive to the political climate in the US, even sometimes at the expense of the policies it aims to support.

Acknowledgements

We are grateful for the valuable comments and suggestions of Angeles Cabria, Director, Observatorio de Salud Pública de Cantabira, Spain. This article is a revised version of the report Las migajas bajo el mantel: la política fundamentalista de USAID y el caso de la Anticoncepción de Oral de Emergencia (AOE) en el Perú. Lima: PROMSEX, 2006. At: <www.promsex.org/files/aoepromsexusaid.pdf>.

International Consortium for Emergency Contraception website home page

Notes

* At: <http://whqlibdoc.who.int/hq/2005/a87017_eng.pdf> and <www.who.int/medicines/publications/essentialmedicines/WHO-PSM-PAR-2006.1.pdf>, respectively.

* USAID in Washington DC sets the overarching goals of the agency, but country-level missions have a high degree of autonomy to fund programmes that they consider appropriate in the national context (Personal communication, several USAID officials).

* At: <www.feyfamilia.com/#top> accessed 19 February 2007.

† At: <http://hli.org/peru.html>, accessed 19 February 2007.

* The organisation is Sin Componenda, at: <www.sincomponenda.org>.