The Center for Health and Gender Equity (CHANGE) created the Sexual and Reproductive Health and Rights Index: Grading U.S. Global Health Assistance to critically assess the U.S. government’s work on sexual and reproductive health and rights (SRHR) and hold it accountable to its commitments on SRHR by grading it annually.
In 1994, at the International Conference on Population and Development (ICPD) in Cairo, approximately 180 countries — including the United States — produced a human rights framework for development assistance that promoted the universal SRHR of women and girls for the first time. After ICPD, U.S. government strategies, policies, and United Nations (UN) stances reflected “sexual and reproductive health and reproductive rights.” It was not until 2015 that the U.S. government recognized sexual rights, and adopted the full term “sexual and reproductive health and rights” in official documents, international statements, and UN negotiations. This positioned the U.S. government on a path to fully embrace a global SRHR agenda.
Through an annual review, the SRHR Index provides public access to information from across U.S. government agencies and health funding streams related to support for global SRHR, and grades commitments, leadership, and funding levels and actions across a comprehensive set of SRHR issues.
This allows users of the SRHR Index to understand how the government is doing within a particular domain of SRHR, and across SRHR as a whole. This, in turn, allows advocates to use the grades to make targeted recommendations on how the government can better promote SRHR through its global health assistance and identify when positive or negative actions have been taken.
The SRHR Index uses standardized indicators to assess government policies, investments, and programs to grade how global health assistance is, or is not, promoting SRHR globally.
The SRHR Index measures the White House, U.S. Congress, U.S. Department of State, U.S. Agency for International Development (USAID), U.S. Department of Defense (DoD), and U.S. Department of Health and Human Services (HHS) across three domains that represent core funding streams of U.S. global health assistance: family planning (FP), maternal and child health (MCH), and HIV and AIDS. The SRHR Index considers policy and budget for each of these domains, as well as the availability and quality of information used to properly evaluate government actors in each domain.
Ratings are assigned to each policy and budget-related action taken by specific actors (within their scope of power). All actors receive a grade per domain in which they do relevant work. In addition, the U.S. government receives an overall grade for each domain and a final composite grade for SRHR in U.S. global health assistance. The SRHR Index also measures the availability of data needed to assign a grade. Known as the transparency grade, it represents the expectation that the federal government should make data about U.S. global health assistance available, accessible, and informative.
How data is scored allows the Index to compare what is being done with what can and should be done for SRHR in U.S. global health assistance based on international standards and human rights. It highlights how funding is distributed and analyzes the U.S. government’s global health assistance support for SRHR within its global SRHR programming and funding streams.
The SRHR Index reveals the scope and breadth of SRHR across U.S. global health assistance. It is designed to be sensitive to and reflective of both negative actions that contribute to restrictions on global SRHR (such as the Global Gag Rule — also known as the Mexico City Policy and, under the Trump administration, Protecting Life in Global Health Assistance — the Anti-Prostitution Loyalty Oath, and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) refusal clauses) and positive actions that contribute to SRHR (such as the Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe (DREAMS) Partnership and the Gender-Based Violence (GBV) Strategy).
In 2018, the Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights established a definition of SRHR with an actionable agenda built on existing international norms. The SRHR Index uses the Commission’s definition of SRHR and supports U.S. government adoption of the full definition and agenda.
The Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights defines SRHR as “a state of physical, emotional, mental and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction, or infirmity. Therefore, a positive approach to sexuality and reproduction should recognize the part played by pleasurable sexual relationships, trust and communication in promoting self-esteem and overall well-being. All individuals have a right to make decisions governing their bodies and to access services that support that right. Achieving sexual and reproductive health relies on realizing sexual and reproductive rights, which are based on the human rights of all individuals to:
Determining which SRHR domains to include in the SRHR Index was, in part, based on the definition of sexual and reproductive health (SRH) services. SRH services include the range of services necessary to enable all individuals to make informed decisions concerning their sexual activity and reproduction free from discrimination, coercion, or violence. The decision was further informed by consultation with stakeholders in the field, studying authoritative guidance instruments, and referencing existing SRH literature. Core components include:
The White House is the Executive Branch of the United States, headed by the president. Through powers vested, and restricted, by the U.S. Constitution, the president is responsible for executing the laws of the United States through policy. The White House submits an annual national budget request to the U.S. Congress that includes proposed expenses for global health and SRHR. Additional foreign and global health policy is also described in the administration’s National Security Strategy, Presidential Memoranda, and Executive Orders.1,2,3
To get an A+ grade, the White House should, through Executive Orders and Presidential Memoranda, and the signing or vetoing of legislation passed by Congress, enable U.S. global assistance that promotes FP, MCH, and HIV and AIDS programs that are evidence-informed, responsive to need, consistent with internationally-recognized human rights principles, and gender transformative. The White House should, in its proposed budget, request sufficient funding for U.S. global assistance to support family planning, MCH, and HIV and AIDS programs.
The U.S. Congress is the legislative body of the United States. Comprised of two chambers, the House and the Senate, each chamber works to pass legislation to be made into law. After it is passed through the bicameral process, legislation must be signed into law by the president. While the president sends Congress a proposed budget, Congress has the authority to authorize and appropriate funds for global health assistance, pass global health-specific legislation, and confirm appointees that will implement government global health policies and projects. Congress has an oversight role in global health assistance in which they are able to hold hearings on agencies’ policies and performance and request accountability reports.
To get an A+ grade, Congress should work to enact or retain legislation that enables, or repeal legislation that hinders, U.S. global assistance to promote FP, MCH, and HIV and AIDS programs that are evidence-informed, responsive to need, consistent with internationally recognized human rights principles, and gender transformative. Congress should appropriate sufficient funding for U.S. global assistance to support family planning (including in its UNFPA and USAID budget requests); maternal and child health programs, and HIV and AIDS (via the HIV and AIDS and Global Fund budgets).
Authorized by Congress and headed by a confirmed presidential nominee of a federal agency, the U.S. Agency for International Development (USAID) is housed within the Executive Branch and engages in international global development and humanitarian aid programs through a series of subdivisions within the agency. As an implementing agency, USAID must follow laws and policies obligated to it by Congress and the White House. USAID programs are susceptible to policy changes that can impact its work, such as Protecting Life in Global Health Assistance (also known as the expanded Global Gag Rule). Notable programs implemented by USAID include PEPFAR, the President’s Malaria Initiative (PMI), and Feed the Future.,4,5,6,7
To get an A+ grade, USAID should have internal policies and procedures that promote FP, MCH, and HIV and AIDS in a way that is evidence-based, responsive to need, consistent with internationally recognized human rights principles, and gender transformative.
Authorized by Congress and headed by a confirmed presidential nominee of a federal agency, the U.S. Department of State is housed within the Executive Branch and led by the secretary of state. The secretary of state implements the president’s foreign policy objectives through the Department of State. Housed within the Department of State are the Office of Global Women’s Issues, Office of the Global AIDS Coordinator, Bureau of Population, Refugees and Migration, Bureau of Democracy and Human Rights, and the Office to Monitor and Combat Trafficking in Persons.9,10,11,12,13
To get an A+ grade, the State Department should have internal policies and procedures that promote FP, MCH, and HIV and AIDS programs in a way that is evidence-based, responsive to need, consistent with internationally recognized human rights principles, and gender transformative. The State Department should spend the FP, MCH, and HIV and AIDS money allocated to it well.
Authorized by Congress and headed by a confirmed presidential nominee of a federal agency, the U.S. Department of Health and Human Services (HHS) is housed within the Executive Branch and its mission is to “protect the health of all Americans and provide essential human services.”14 Within HHS is the Office of Global Affairs and the Centers for Disease Control and Prevention (CDC) that implement programs to ensure global health security. Major programs implemented through the CDC include PEPFAR, PMI, and the Global Immunization Division.15,16,17,18 HHS creates policies through formal and informal rule-making and the interpretation of rules, including rules for projects and programs related to global health assistance.19,20
To get an A+ grade, HHS should have internal policies and procedures that promote global MCH and HIV and AIDS programs in a way that is evidence-based, responsive to need, consistent with internationally recognized human rights principles, and gender transformative. HHS should spend the MCH and HIV and AIDS money allocated to it well.
Authorized by Congress and headed by a confirmed presidential nominee, with the president serving as commander-in-chief, the U.S. Department of Defense (DoD) is the military and security division within the Executive Branch. In addition to its military function, the DoD is authorized to deliver humanitarian aid. The DoD is also an implementing agency for PEPFAR.22 The DoD can create policies through formal and informal rule-making and the interpretation of rules, which can impact projects and programs related to global health assistance.23,24
To get an A+ grade, the DoD should have internal policies and procedures that promote HIV and AIDS programs in a way that is evidence-based, responsive to need, consistent with internationally-recognized human rights principles, and gender transformative. The DoD should spend the HIV and AIDS money allocated to it well.
Family planning (FP) is the information, means, and methods that allow individuals to decide if and when to have children. This includes a wide range of contraceptives and methods, from pills, implants, intrauterine devices, surgical procedures that limit fertility, barrier methods (such as internal and male condoms), to the rhythm method and abstaining from sex. FP also includes information about how to become pregnant when it is desirable, as well as treatment of infertility.25
U.S. global health assistance investment in FP contributes to contraceptive services and supplies, preventing unwanted pregnancies, averting unsafe abortions and maternal death, providing post-abortion care, HPV vaccination and prevention, repair of obstetric fistula, sex education, and research.26
Maternal and child health (MCH) refers to the health of women during pregnancy, childbirth, and the postpartum period. Direct causes of maternal morbidity and mortality include hemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labor.27 MCH investments in U.S. global health assistance prevent and respond to maternal, newborn, and child mortality and morbidity, as well as promote respectful maternity care.28
HIV is a virus that is transmitted through certain bodily fluids and can lead to AIDS. Untreated, HIV can inhibit the body’s ability to fight off disease.29
Since 2003, the President’s Emergency Plan for AIDS Relief (PEPFAR) has been the largest U.S. global health assistance investment. PEPFAR supports programs to prevent the transmission of HIV, ensure that already infected individuals do not progress to AIDS, and that individuals with AIDS can access the care they need. This includes behavioral, structural, and biomedical prevention programs such as programs to keep adolescent girls in school and reduce gender-based violence, male and female condom distribution, and access to pre-exposure prophylaxis (PrEP), medications to decrease viral load counts including antiretrovirals, and provision of health care to reduce HIV-related deaths.30
— Geeta Rao Gupta, Ph.D. Founder and executive director, 3D Project for Girls and Women; senior fellow, United Nations Foundation
The Sexual and Reproductive Health and Rights Index shines a light on the siloed approach of the U.S. government to global health assistance. But the SRHR Index will also help government agencies move beyond silos to convergence in the implementation and delivery of programs. Global health programs must address the full spectrum of sexual and reproductive health and rights for women, girls, and everyone — and the SRHR Index will help U.S. programs do exactly that.”
— Steven W. Sinding, Ph.D. Former director, USAID Office of Population and Reproductive Health; former director general, International Planned Parenthood Federation
The Center for Health and Gender Equity (CHANGE) deserves our profound thanks and admiration for creating the Sexual and Reproductive Health and Rights Index: Grading U.S. Global Health Assistance. This carefully constructed and skillfully implemented and presented measurement of U.S. government performance in the field of sexual and reproductive health and rights is a great service to everyone who cares about our country’s commitment and contributions to this vitally important area of human rights and human well being. I hope that over time, the Index will contribute to significantly improved policies and programs across the entire range of U.S. government branches, departments, and agencies.”
— Brooke Wurst, M.S. CEO, Remote Harbor; executive director, The TRIAD Trust
The Sexual and Reproductive Health and Rights Index is extraordinary. It doesn’t just hold the various agencies ostensibly controlling policies and purse strings accountable to humanity, the American people, funding recipients, and each and every one of the millions of individuals whose health and wellness may depend on such funding, it is centered on actionability — it activates those who are in a position of privilege to demand compassionate, responsible, and responsive decisions from the government.”
— Mónica Roa activist; independent consultant; scholar, O’Neill Institute for National and Global Health Law at the Georgetown University Law Center; commissioner, Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights
In the face of the Trump administration’s campaign to reverse decades of sexual and reproductive health progress, including abortion access, the Sexual and Reproductive Health and Rights Index is critical for resisting and reversing those efforts. For the first time, advocates in the field will have a tool to hold the U.S. government accountable to international standards for health and human rights and to push for much-needed reforms in global health assistance.
— Chris Beyrer, M.D., M.P.H Desmond M. Tutu professor of public health and human rights, professor of epidemiology, international health, health, behavior and society, and nursing, and director, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health
I am thrilled by the potential impact the Sexual and Reproductive Health and Rights Index will have on making U.S. global health assistance more efficient and effective. By grading U.S. global health policies and funding related to sexual and reproductive health and rights (SRHR) based on evidence, human rights and gender responsiveness, the SRHR Index will be a critical tool for both government and advocates to understand how our U.S. investments can be strengthened to meet the needs of those who benefit from U.S. global health assistance.
The Center for Health and Gender Equity (CHANGE) is a U.S.-based nongovernmental organization that promotes sexual and reproductive health and rights as a means to achieve gender equality and empowerment of all women and girls, by shaping public discourse, elevating women’s voices, and influencing U.S. and global policies. We are guided by our vision of a world that respects, protects, and honors sexual and reproductive rights for all. Our work is grounded in and driven by a human rights framework at the intersection of multiple sectors including women’s rights, human rights, family planning, maternal health, HIV and AIDS, and gender-based violence.
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