Slowing progress: the US Global Gag Rule undermines access to contraception in Madagascar

Sampling and recruitment of participants

At the central level in Antananarivo, key informants were recruited from the MOH department responsible for SRH programmes, the parastatal responsible for logistics and commodity management, and NGOs that provided SRH services. At the regional and district levels, respondents were selected from the following groups: MOH managerial teams including directors of various family health programmes (SRH, HIV, malaria, community health); contraceptive service providers from both public and private health facilities and regional representatives of NGOs supporting SRH service delivery. At the community level, we recruited participants from areas previously served by a non-certifying NGO’s outreach teams: CHWs who provided contraceptive education and referrals, and current or previous contraceptive clients. CHWs reached out to their own clients asking if they would be willing to speak to an interviewer, and then introduced those who agreed to an interviewer. In total, 219 in-depth interviews were conducted with 259 participants (Table 1). Some MOH teams were interviewed as a small group.

Study procedures

INSPC and Columbia researchers developed semi-structured interview guides for four categories of participants: MOH representatives, NGO representatives, health providers, and clients. Guides were developed based on the hypothesised impact of the GGR, informed in part by research on previous iterations of the policy.²⁸ The guides addressed potential changes in funding, technical support, supplies and service utilisation with respect to contraception, post-abortion care and other health services. Clients were asked about changes in the access, availability and cost of contraceptive methods and services. The interview guides were piloted in a district that was not included in the study, and subsequently modified for clarification. Four teams of three trained interviewers experienced in SRH research conducted the interviews in local languages or French, according to the respondent’s preference. Before each interview, interviewers provided an explanation of the study from an information sheet, stated that participation would have no effect on their job status or access to health services, and obtained verbal consent to participate in an audio-recorded interview. The interviews took place at three time periods: central level interviews in May–June 2019, regional and district level interviews in July–August 2019 and February–March 2020.

Data analysis

Interviews were transcribed, translated into French, checked for accuracy and de-identified before being uploaded into NVivo 12 (QSR International) for coding. Researchers from INSPC and Columbia University (fluent in French and English) read a sample of transcripts to develop a draft codebook based on the themes in the interview guides and then coded several transcripts together. A team of three INSPC researchers independently coded a sub-set of transcripts, met to establish inter-coder reliability, and identified additional codes if needed. They then coded the remaining transcripts independently. After coding, researchers conducted thematic content analysis to identify emerging themes related to how the GGR impacted NGOs, providers and clients. Authors fluent in English and French wrote the final analysis in this paper in English.

We obtained ethical approval from the National Ethical Committee for Biomedical Research of Madagascar (007-MSANP/CERBM) and the Institutional Review Board of Columbia University (AAAR6802).

Impacts on NGOs

We interviewed Antananarivo-based representatives of eight non-governmental or international organisations involved in SRH service delivery in Madagascar. Most of the representatives had limited knowledge of the GGR; however, the major MOH partners for contraception were more familiar with the GGR and its impact.

When the large non-certifying NGO mentioned previously lost its USAID funding in mid-2017, it was forced to end support to over 100 public and 90 private health facilities, return 12 vehicles used for mobile outreach teams, and end its contraceptive voucher programme for adolescents. In addition, the NGO no longer received contraceptive commodities from USAID. When USAID recalled the 12 vehicles used for outreach, it transferred them to a US NGO. Although the non-certifying NGO returned the vehicles to USAID in mid-2017, the US NGO reported receiving them and additional USAID funding only in January 2019, leaving a gap of well over a year. The non-certifying NGO’s outreach services served an average of 200,000 clients and the voucher programme reached 25,000 young people annually.

Although the non-certifying NGO was able to replace some of the vehicles via a private donation, they lacked funding to cover training, salaries, and maintenance for the mobile clinics. The $3.5 million they received from USAID represented nearly half of their total funding in 2017; they managed to replace about $1 million of this lost funding in 2018. The imposition of the GGR also entailed significant transaction costs to this NGO. When they lost their USAID funding, their leadership spent around 50% of their time – 80% of the country director’s time – trying to fill the funding gap created by the GGR. These transaction costs were incurred by other NGOs as well. For example, a US NGO also described time spent on administrative efforts to create a clear separation between their USG and other funding streams, so that the GGR would not impact those funded activities, even though US NGOs are not subject to the GGR. To fully separate financial management, they had to increase the number of staff and duplicate some roles.

Respondents from non-certifying NGOs described that they continued to participate in a contraceptive task force convened by the MOH that included USG-funded NGOs. However, one also commented that national contraception workshops at which all partners presented their commodity needs to the MOH and donors had now split into separate events for USG partner NGOs and other NGOs.

Impacts on providers in the health system

We conducted 165 interviews with providers in 8 regions, including regional and district MOH (n = 38) and NGO representatives (n = 33), public and private/NGO providers (n = 61) and CHWs (n = 33) (Table 1). Many participants described ways in which the defunding of a major non-certifying NGO partner affected their work (Figure 1). Few major differences were noted between public versus private providers. Thus, in the following paragraphs, references to “providers” includes those from both public and private health facilities unless otherwise specified.

Several respondents mentioned the reduction in outreach visits provided by the large non-certifying NGO. For example, in one region the non-certifying NGO reduced the number of outreach teams from two to one; this team now had to cover six districts, resulting in fewer visits to each. These outreach teams served clients in some of the poorest and hardest-to-reach areas of Madagascar, and were often the only providers of LARC or permanent methods. The end of outreach services from the non-certifying NGO meant women living in these areas no longer had access to contraception, unless they travelled further and spent more money to obtain it. A regional MOH representative remarked that this NGO’s outreach services reached very isolated communities, areas that the MOH could not reach, and represented a substantial loss when they ended.

In addition to the end of the outreach services, district and regional MOH representatives lamented the reduction in the number of public health centres that received support from the NGO for contraception from “many” to four in one district and by half in another district due to the funding reduction. Another regional representative commented on reduced outreach services and the impact on contraceptive prevalence and increased numbers of women coming to antenatal care with unintended pregnancies as a result.

“The [non-certifying NGO] can reach isolated areas with its outreach teams … And we at the regional level, we work with the health system at the health facility level, but not in the fokontany [collection of villages] through the advanced [outreach] strategy like the [non-certifying NGO] did … [Women] asked about the failure of the outreach vehicle to come through because people don’t always have the time to reach the health facility. So, if you are in the bush, you always hear these questions, especially complaints from clients following the end of these outreach visits these days, especially where the health center and hospital is several kilometers away.” (Regional MOH representative 20, Betsiboka)

As mentioned earlier, although USAID reportedly transferred 12 vehicles from the non-certifying NGO to a US NGO, there were substantial delays before the US NGO launched the outreach teams. Some of the new outreach teams were deployed to different areas, abandoning those served by the non-certifying NGO. We do not know if the number of beneficiaries remained the same as participants did not share this detail. In addition, some providers expressed frustration that the US NGO imposed different practices, such as not providing stipends to CHWs for community mobilisation prior to the outreach team’s arrival. One public provider also noted that, in addition to hosting outreach team visits, they had also received contraceptive supplies from the non-certifying NGO, something the US NGO did not provide. A CHW who educated the community about contraception and the timing of the NGO mobile outreach team visits said they had not done any community mobilisation in the past year due to the departure of the non-certifying NGO.

“Then, there were still the outreach teams that came here and this causes us problems because the CHWs are already used to receiving motivation [stipend] from them, and if there is no motivation, … financial, I mean, they do their job badly … Since the [US NGO] announced that there will be certain changes, and in particular with respect to the question of motivation, CHWs have lost their diligence.” (Public provider 32, Atsimo-Atsinanana)

“I didn’t do any awareness raising in 2019 because the [NGO outreach team] didn’t come this year.” (Community health worker 14, Betsiboka)

Public and private providers supported by the non-certifying NGO described reductions in staff stipends, training, supplies and supervision resulting from the loss of US funding. Some NGO-supported facilities reduced the number of health workers providing contraception. Providers expressed concern about decreases in the quality of care they provided. One community-based midwife previously affiliated with the non-certifying NGO said the funding cuts forced her to reduce the number of sites she visited by half. The loss of training from the non-certifying NGO meant that providers no longer received updates to clinical practice. In addition, new staff hired to replace those who left did not receive training, inhibiting their ability to provide LARCs to clients.

“[Regarding training] We don’t know any more what has changed in terms of new recommendations on prescription, reception of clients, contraception. In medicine, there is always new knowledge, changes … Therefore, your knowledge is outdated, we no longer receive knowledge updates.” (Public provider 25, Betsiboka)

“A comment on contraception in terms of training, because we have a new additional provider who is trained neither on long-acting methods, nor on Depo Provera, nor on the management of adverse side effects … So, she should be trained. In addition, at the time of our collaboration with [non-certifying NGO], we had CHWs who approached women about contraception.” (Public provider 27, Betsiboka)

Participants described problems with the contraceptive commodity supply chain across Madagascar that were a persistent national issue, further exacerbated by the GGR. They reported periodic stockouts of contraceptive injectables, pills and implants. Several public providers said that the non-certifying NGO supplemented their MOH supplies by providing buffer stock to avoid stockouts. However, once that support ended, they too experienced stockouts of multiple methods.

“There were no pills, no injectables, no Implanon [implant]. The MOH district office did not provide us with any products, all the more [important] since [non-certifying NGO] doesn’t collaborate with us anymore.” (Public provider 27, Betsiboka)

“In addition, we were in cooperation with [non-certifying NGO] so they provided us with products. When our stocks ran out, [non-certifying NGO] gave us the products so there was no shortage. But currently, we are no longer in collaboration with [non-certifying NGO], so they no longer visit us.” (Public provider 40, Anosy)

Providers reported that when they were stocked out of a woman’s preferred method, they offered her a different method that was in stock, or sent her to a pharmacy to purchase it and bring it back so they could administer it (in the case of injectables). In addition, health workers in different regions described providing contraceptive commodities and services free or at low cost when they received support from the non-certifying NGO, especially for lower income and young women who received vouchers. However, with the loss of support, clients were now asked to pay for their method, and sometimes also the necessary supplies needed to safely inject or insert the contraceptive method. Several providers commented that while purchasing the method was feasible for some, women coming from rural areas and adolescent women were often unable to pay the cost. Health workers, CHWs and regional and district MOH representatives described a drastic and noticeable decrease in contraceptive utilisation in the population as result of the stockouts and increased costs.

“The impacts are really tangible concerning FP [family planning]. Because people are already used to free FP services. Then, when they were asked to buy them, the numbers lost to follow-up increased. Many women are lost to follow-up. And even our coverage rate has decreased, decreased, decreased. We can even say that the impacts in our district were catastrophic because of this disruption of products.” (District MOH representative 34, Androy)

Many providers described elevated frustration and disappointment amongst their contraceptive clients about the cost of services that were once provided for free, as well as the unavailability of their preferred methods. Multiple providers talked about the ways in which this situation resulted in decreased client trust in them and the health facilities. One private provider referred to deceptive and unsafe practices among some drug sellers which would further erode women’s trust in contraception.

“Yes, we have monthly meetings … with the CHWs. We took the initiative to educate people to continue to come pick up methods at the health center despite the frequent stockouts. And these situations lead the community to lose confidence in us. To avoid this, we try and try to explain the reality to the community … What is sad is that it’s us who come into conflict with the community. This is one of the major problems with our health system.” (Public provider 32, Atsimo-Atsinanana)

“At a certain point, both we and the public health center had a stockout. At that time, those who had methods sold them at very high prices. And then some of them divided one vial of Depo into two doses for sale … . Women complained that they got pregnant even while using Depo.” (Private provider 1, Itasy)

Several providers reported seeing an increase in the number of unintended pregnancies, including among adolescents, demonstrated by an increase in the number of antenatal care visits. They also described seeing increasing numbers of post-abortion care clients after unsafe abortions; one provider noted that the majority of these cases were adolescents.

“What is happening is that … the fact that people who are used to free care must now pay affects them a lot. Since after the free care ended, users had two choices: either they change methods or they decide to stop. And we can assess the effects by the increase in the number of ANC [antenatal care] visits. Especially among the under 18 year olds. High risk pregnancies are on the rise. This weighs on our health facility since there are complications to prevent.” (Public provider 32, Atsimo-Atsinanana)

Impact on contraceptive clients

We interviewed 44 current or previous contraceptive users in eight regions. Consistent with reports from providers, the vast majority of clients interviewed reported increased difficulties obtaining their preferred method while a few reported no change in their access to contraception.

Many clients described multiple obstacles when attempting to procure contraceptive methods and services in the past year. Women reported looking in multiple pharmacies and health facilities when their regular provider was stocked out of their preferred method, often the injectable. Some were able to purchase the method in a pharmacy, but sometimes the pharmacy too was stocked out. In some cases, women had to purchase methods at local grocery stores or from unqualified providers. While a black market for contraceptives always existed, the sale of these products by unregulated informal suppliers appeared to increase in some locations with the advent of GGR. Others reported a different experience each time they came for their next dose, making it difficult to continue uninterrupted method use: sometimes it was available, sometimes they had to go buy it in a pharmacy, and sometimes they just had to stop using contraception or switch methods because they couldn’t find it at all.

“Since 2018, I started to use the [injectable] irregularly following the stockouts. As usual, at each stockout, we had to go to the pharmacy, but sometimes the pharmacy didn’t have it either.” (Contraceptive client 36, Atsimo-Atsinanana)

“I used the injectable and when I came here, there was none and they told me to go buy it in the pharmacy. I bought it at the pharmacy and I came back here for the injection. After 3 months, I came back and the method was available, and after that, there was none, so I stopped the injectable.” (Contraceptive client 42, Androy)

“I didn’t change health centers, but I changed services because I was using the injectable, so I changed to the method in the arm [implant] because they had no more injectables.” (Contraceptive client 17, Menabe)

Increased cost was a common barrier described, an insurmountable one for many. Most clients reported receiving their method previously at no or a very low cost. Many women reported current prices that were two to five times the original price, up to 5000 Malagasy Ariary (∼US$1.35), placing them out of reach (average daily wage is 3000 Ariary).

“I was using the injectable but then they started charging for it, but I still made an effort to continue because I already have too many children. I am mostly used to injectables, they were free before. Now, they are no longer free, so I changed and use oral pills now.” (Contraceptive client 44, Anosy)

The high cost created problems for many women who described having to choose between using contraceptives and buying food for their families. These choices often resulted in an unintended pregnancy. Women explained that they had to find additional work to earn money to purchase their contraceptive method.

“[Buying the method has been a] problem because the money is needed to buy food for the family, but you have to take some out to buy the method.” (Contraceptive client 18, Betsiboka)

“And now, there are none at the public health center, so the injectable is so expensive. It costs 3000 Ariary at the pharmacy. And because we are poor, we didn’t go to school, we can’t find a job with a good income. So, we work as a launderer, we look for jobs that require heavy labor during the day to find money for the injectable. We sell wood to get money for the injectable. For this purpose, we have no more to survive on. And now, I’m pregnant when I didn’t want to be. You know, with the difficulty of life, the lack of money, you can’t find the money, and suddenly, I’m pregnant.” (Contraceptive client 39, Androy)

“Life is hard here. During times of cultivation, when it’s not raining, there is no income generating activity you can do. To have money, you have to sell your plates [a sign of severe poverty in Madagascar] and buy new ones only when the harvest is good.” (Contraceptive client 42, Androy)

Overall, clients reported inconsistent contraceptive use because of the stockouts and increased cost. In some cases, clients purchased their method at the pharmacy until they could no longer afford to, then obtained condoms from the CHW until those too were stocked out, ultimately attempting the calendar method, switching methods or stopping altogether. Some clients reported switching methods again because the calendar method was just too difficult to implement with their partner. Others complained of side effects after switching methods, especially to pills, which led them to stop use. Some women resorted to using traditional but ineffective or dangerous methods to prevent pregnancy and ended up pregnant.

“Some make a decoction, they go to the midwife and make a decoction whereas there are side effects; they think it may work but are then disappointed when after 6 months they end up pregnant. This happens.” (Contraceptive client 22, Bongolava)

Women also described frustration with the health workers who could not explain why they did not have the methods as expected, nor when they expected to have them or why they had to pay more for them.

“They [health workers] said that they already ordered the contraceptive products but that we have to wait. But up to now, women are tired of looking everywhere for the products because sometimes we can find them and sometimes we can’t. Some changed their method and chose Implanon [implant], others accepted pills unwillingly. But me, I only want the injectable.” (Contraceptive client 15, Atsimo-Atsinanana)

As also mentioned by the providers, many women described that they themselves, and other women they knew, ended up with an unintended pregnancy because they had to stop using contraception.

“But this one is the daughter of my husband’s brother, and I asked her why did you do that? You already have many children and you know that life is hard. She told me that she couldn’t get the injectable at the hospital and tried the thing in the arm [implant], but removed it because she couldn’t tolerate it and suddenly, she got pregnant.” (Contraceptive client 18, Betsiboka)

“Some were not careful, and they got pregnant like my sister – she got pregnant.” (Contraceptive client 35, Vatovavy Fitovinany)

“To be honest, I’m not ready yet to have another child, not ready yet but … here it is, it’s like that now.” (Contraceptive client 24, Bongolava)

Women reported additional consequences of their unintended pregnancy, including increased economic difficulties and hardship. One young woman said that she had to quit school because she became pregnant.

“I am sad [because of my pregnancy] especially because I had to quit my studies.” (Contraceptive client 41, Androy)

“As a result, I got pregnant since the method wasn’t there. Food is already difficult to find, and we aren’t able to buy medicines because there are none in this health center. The truth is that I didn’t choose to get pregnant; it’s because of the stockout.” (Contraceptive client 43, Androy)

A few clients also described that they or other women they knew terminated their unintended pregnancy. One woman said she had too many children already, and described her efforts to continue her preferred method (injectable). She became pregnant and induced abortion by drinking some concoction. She ended up seeking post-abortion care at a health facility after – another cost she could not afford.

Interviewer: And if everything had a fee in the end, why not buy the method that you prefer?

Respondent: Because I didn't have enough money ... I got pregnant, but I had an abortion. (Contraceptive client 44, Anosy)

Limitations

This study has several limitations. While we were able to interview many of the main NGOs working on SRH, we were unable to secure interviews with several non-US NGOs working on other health issues that received USG global health funding and may have been impacted by the GGR. A few NGOs working on SRH were only interviewed at district or regional level where knowledge of the GGR was lower. Many respondents had limited knowledge of the GGR, which contributed to difficulties in attribution. As mentioned above, multiple factors affected stockouts in Madagascar, further complicating attribution. However, we conducted interviews in districts previously served by a major NGO that lost USG funding when it declined to certify GGR. The provider transcripts were scrutinised for references to affected NGOs or service providers supported by them to ensure that quotes referred to GGR impacts. The contraceptive clients were largely unaware of the GGR, and also less likely to mention an NGO. However, we recruited clients in areas served by providers supported by the affected NGOs and therefore believe that many of the difficulties they referred to were the result of, or at least exacerbated by, the GGR.