In a Weak State

Faith-based health providers are set to benefit greatly under the Trump administration. Only a few months into office, President Trump announced an expansion to the Mexico City Policy, commonly called the “global gag rule,” attaching its restrictions to nearly all state-provided global health funding. Under this expansion, the funding covered by the policy is now about $9 billion, up from the $600 million of its last implementation. To receive any of the restricted aid, a nongovernmental orga­nization (NGO) operating abroad cannot provide or promote abortion as a family planning method, regardless of the source of funding that ultimately pays for or promotes abortion services. Many faith-based organizations (FBOs) are already in “compliance” with the global gag rule and will not have to restructure or funda­mentally alter the healthcare they provide to receive aid. Other organizations will face financial and logistical hurdles—to significant, detrimental and quantifiable public health effects.

Faith-based health providers are a major component of health services delivery in many developing countries, especially in sub-Saharan Africa. The World Health Organization estimates that 40 percent of the healthcare services in sub-Saharan Africa are provided by the faith-based sector,¹ and that between 30 and 70 percent of the health infra­structure in Africa is owned by faith-based organizations.²

Because of their extensive networks and infrastructure, faith-based providers are a critical component of health service delivery in many resource-constrained countries where governments and the private sector lack the funding to provide services. They have robust infrastruc­tures and funding streams, critical entry points through local congregations, long-standing ties to the communities they serve and extensive in-country con­tacts throughout the civil and private sector, all of which make them valuable providers of care in resource-scarce countries.

At the same time, some faith-based providers use conservative interpreta­tions of religious teachings to deny access to critical care, including family planning, abortion and HIV & AIDS pre­vention services, particularly condom distribution and counseling about condom use. This has obvious implica­tions for women and girls in relation to unrealized reproductive and sexual rights and health. Faith-based providers also sometimes discriminate against populations that need particular care and support, like sex workers or men who have sex with men.

Few areas of healthcare are as noncon­troversial as the promotion and provision of appropriate forms of family planning. Nongovernmental organizations around the world recognize the value of family planning in contributing to the health of women and children through the pre­vention of child pregnancy, the appro­priate spacing of pregnancy and the prevention of unwanted pregnancy and unsafe abortion. The provision of family planning also provides numerous social and economic benefits, including allowing girls to finish school and allowing women to contribute to the family income, thereby improving finan­cial security for women and the well-being of their communities.

Despite the benefits of family plan­ning, there remains a large, unmet demand for contraception around the world. It is estimated that there are 222 million women in the developing world at risk of unintentional pregnancy who are using either a traditional, highly unreliable method of contraception or no contraception. Filling the unmet need for contraception would prevent 21 million unplanned births, 26 million abortions, nearly 80,000 maternal deaths and one million infant deaths.³

Only one faith group, the Roman Catholic hierarchy, is opposed to the use of all modern methods of family plan­ning. The encyclical Humanae Vitae, issued in 1968 by Pope Paul VI, prohibits all contraceptives and decrees that Cath­olics may only use natural family plan­ning (NFP) methods. Pope John Paul II, who was hugely influential on the Cath­olic church’s development policies, called the promotion of contraceptives in developing countries “attacks” on the family and part of a “culture of death.”⁴ As a result of this fundamentalist doc­trine, Catholic FBOs and healthcare pro­viders are banned from counseling about or dispensing modern methods of con­traception, including oral contracep­tives, barrier devices such as condoms or diaphragms, long-acting methods such as IUDs or contraceptive implants and contraceptive sterilization.

Only one faith group, the Roman Catholic hierarchy, is opposed to the use of all modern methods of family plan­ning.

Catholic FBOs assert, however, that NFP methods are a viable substitute for modern contraceptives, and have long pressured aid agencies to fund NFP pro­grams. Yet, NFP methods have failure rates ranging between 12 and 24 percent, far higher than modern contraceptives.⁵ For example, such methods can be inef­fective for women with irregular men­strual cycles. In addition, these methods are based on attempting to time sexual intercourse to a woman’s time of natural infertility during her menstrual cycle, and abstaining from sex during fertile periods. Many women lack the power in their intimate relationships to negotiate in this way, especially in contexts of pov­erty and low employment.

These issues around abstinence and a requirement for a shared desire to pre­vent conception make NFP methods unrealistic for many, especially in con­texts of gender inequality and related social and cultural norms, which dictate women are subordinate to men in mar­riage and must tolerate high levels of violence.

By contrast, the United Methodist Church’s Ganta Hospital in Liberia tackled the problem of low rates of con­traceptive use and high rates of child and maternal death by training community health workers to counsel women on the full range of contraceptive methods and to ensure a secure contraceptive supply. As a result, the percentage of women using modern methods of contraception increased from 15 to 61 percent between 2011 and 2012.⁶

The provision of safe abortion is no less an essential reproduction health ser­vice than access to contraception. Nearly 22 million women experience an unsafe abortion in any given year, and about 85 percent of unsafe abortions occur in the developing world. As a result, 47,000 women die each year, a full 13 percent of all maternal deaths.⁷

Yet Catholic, evangelical and Muslim FBOs oppose abortion because of reli­gious dictates. Increasingly, they have leveraged their institutional power to exclude abortion from the range of reproductive health services that they offer in return for their cooperation in family planning programs. Politically powerful Catholic bishops conferences in the developing world have also worked to conflate abortion and contraception, and to suggest that programs to expand access to contraceptives are backdoor attempts to promote abortion. When the Nigerian minister of health recently announced plans to work with NGOs to expand access to contraceptives, the Nigerian Catholic bishops charged that this plan was a deceptive program being foisted on the Nigerian people in the name of better maternal health: “Our country must reject this relentless offer of anti-life incentives under the guise of foreign aid in order not to destroy our beautiful culture,” said the bishops in August 2016.

Even in countries like Kenya, where access to abortion has been liberalized, the control of most hospitals by faith-based health systems means that as a practical reality, access to safe abortion is limited; most women are forced to resort to unsafe, illegal practitioners.

Secular organizations addressing reproductive health have to operate in this very challenging context. Major funders in international health and development like the Bill and Melinda Gates Foundation have made a major push into funding family planning ser­vices, yet the controversy around abor­tion has led Melinda Gates to suggest on the Impatient Optimist blog that the question of abortion should be dealt with separately, reasoning that the debate about abortion threatens to “get in the way” of family planning.

Faith-based providers were among the first to open their doors to AIDS patients in the early years of the epidemic, pro­viding compassionate care when others shunned people with the disease. One in five organizations engaged in providing HIV & AIDS services is faith-based, and FBOs tend to excel in mitigating the impact of HIV & AIDS by providing care, treatment and support to people infected with HIV, especially in areas with a poor public health infrastructure.⁸

Where they tend to fall short is effec­tively working to change risky behaviors because many FBOs focus exclusively on abstinence and faithfulness as prevention strategies and fail to deliver comprehen­sive prevention messages that include the use of condoms to prevent HIV. They also fall short in addressing women’s partic­ular vulnerability to HIV & AIDS because of “the entrenched inequality” of women within some faith traditions.⁹

Among FBOs, Catholic providers once again have the most serious shortfalls in the provision of HIV & AIDS prevention services because the Catholic hierarchy completely forbids the use of condoms. As a result, even in circumstances in which other conservative faith-based providers condone condoms, such as with a married couple in which one partner is HIV positive, Catholic faith-based providers are constrained from making such sound public health recom­mendations. This is especially problem­atic because approximately 25 percent of HIV & AIDS care throughout the world is provided by organizations affiliated with the Catholic church.¹⁰

The Catholic hierarchy has also aggressively lobbied to have special pro­tections created for its refusal to provide comprehensive HIV & AIDS prevention services. When the US Congress created the historic PEPFAR (President’s Emer­gency Plan for AIDS Relief ) in 2003 to provide $15 billion for international aid to combat HIV & AIDS in select countries, the US Conference of Catholic Bishops successfully lobbied for the insertion of a “conscience clause” that exempted FBOs from endorsing or using prevention methods with which they had a religious or moral objection. This exemption clause gave FBOs the green light to receive millions in public funding for HIV & AIDS prevention strategies that omitted men­tion of condoms.

When the PEPFAR program was reau­thorized in 2008, lobbying by the Cath­olic bishops and Catholic Relief Services resulted in a delinking of family plan­ning services and HIV & AIDS prevention and an expanded conscience clause that allowed FBOs to refuse to refer patients to organizations that distribute con­doms, a contradiction of long-standing US policy that FBOs that refused to pro­vide certain contraceptive services needed to refer patients to providers that did.

All too often, however, the good they do is compromised by conservative
interpretation of religious teachings that are used to deny services and
discriminate.

Public health advocates say that desir­able behavioral changes that can help prevent HIV, such as reducing the number of sexual partners and delaying the age that young adults first have sex, can be achieved through nonideological public health interventions that stress women’s empowerment and equality and provide fact-based sexual education, including counseling about condoms.¹¹

The limitations on the services pro­vided by FBOs, and their insistence on stigmatizing certain populations, raises important questions about whether public, taxpayer-funded aid is going to the most effective programs, or whether it is being unfairly directed to ideologi­cally conservative, but politically pow­erful programs. In reality, funders like PEPFAR tend to defer to FBOs to ensure their own funding streams, which often come from politically conservative sources like the US Congress; and for the simple fact that FBOs are already on the ground and providing services in many developing countries. The coop­eration of global aid agencies like UNAIDS with FBOs tends to give the latter legiti­macy. Despite the limitations of ideolog­ically based approaches, in September 2015, PEPFAR and UNAIDS launched a two-year, $4 million initiative to strengthen the capacity of FBOs. In essence, this allows FBOs to qualify for more funding and integrate themselves further into HIV & AIDS service-delivery structures, reinforcing their faith-based policies as assistance.

FBOs have the potential to be valuable partners in the provision of reproductive and sexual health services in the devel­oping world. All too often, however, the good they do is compromised by conser­vative interpretation of religious teach­ings that are used to deny services and discriminate. An increased focus on transparency in funding and antidis­crimination policies would ensure that valuable public health finances are being well spent.

A major step forward would be a con­scious effort to support organizations and movements promoting healthcare for all from the perspectives of realizing wom­en’s and men’s basic right to access appro­priate healthcare, including reproductive healthcare, and the realization of sexual and reproductive rights. This does not mean refusing to work with FBOs, but rather also choosing to work with secular organizations grounded in promoting equality, justice and human rights in order to fully meet the United Nations’ Sustainable Development Goals.