Constraints to providing quality comprehensive reproductive and sexual health care
Ensuring access to and availability of quality reproductive and sexual health care in the various stages of forcibly displaced situations technically seems straightforward: needs can be identified and services can be fit to these needs. However, there are a few key obstacles that prevent the care from being accessed by individuals who are most in need of these services.
The 'Global Gag Rule'
Anti-abortion proponents in the USA have supported the Mexico City Policy, also known as the 'Global Gag Rule' by those who oppose it, since the Reagan administration. It was dropped during the Clinton administration but continues to be strongly enforced under the current Bush administration. The rule prohibits federal funding to overseas organizations for family planning if they use any of their non-US funds to provide abortion-related activities, including providing information about abortion through counselling or advocacy. While the rule is promoted as anti-abortion in attempts to reduce the incidence of abortions, and calls for a separation between family planning services and abortion-related activities, the reality is not so clear-cut when providing comprehensive RSH services, as these two often overlap. Furthermore, evidence from The Centre for Reproductive Rights and Population Action International shows that the Global Gag Rule is detrimental to women’s lives ( Cohen 2003 ). Studies show that providing comprehensive RSH services that include post-abortion family planning services are more effective at reducing abortion rates than not providing information or access ( Cohen 2001 ).
Even in countries where abortion is broadly legal, the USA maintains its anti-abortion stance and is able to control and prohibit necessary funds to indigenous organizations that support all types of reproductive and sexual healthcare services including family planning, ante-natal and post-natal care, not only pro-abortion related activities. The rule forces indigenous NGOs who provide reproductive health care to choose between providing legal abortion-related services in their own country and stopping unsafe, illegal abortions, or foregoing eligibility for US funding to provide desperately needed family planning services. (US-based intermediaries are themselves not subject to the restrictions but are responsible for their overseas partners' compliance.) Fundamentally, it means that millions of women in developing countries are denied access to essential RSH care.
However, a turn for the opponents of the Gag Rule occurred when the rule was attempted to be applied to the US President’s US$15 billion global HIV/AIDS initiative. It was found that the Gag Rule could not be applied without hindering other components of RSH service provision linked to HIV prevention and management services. Therefore, the Gag Rule does not apply to organizations who legally support abortion-related activities and receive funding for HIV/AIDS activities, yet it remains in place if the same organization applies for USAID’s family planning funding ( Cohen 2003 ).
It is easy to see how this legislation can affect reproductive and sexual health services for forcibly displaced populations. For example, while President Bush promoted his five-year, US$15 billion anti-AIDS initiative, his administration and members of Congress successfully de-funded the United Nations Population Fund (UNFPA) for the second year, depriving developing nations of US$34 million for family planning ( UNFPA 2003 ). The other blow was delivered by the US State Department to the RHRC, who planned to deliver a programme to young people displaced by armed conflict in Angola and the Congo. Due to the fact that one of the Consortium’s partners, Marie Stopes International (MSI), continues to provide safe abortions and is therefore ineligible for US family planning funds, the entire Consortium has been penalized ( Cohen 2003 ). As a direct consequence to MSI ,a loss of more than US$3 million to the MSI Partners in Africa has resulted in the closure of three centres in Kenya, an outreach programme servicing poor communities in Ethiopia, and further centres in Tanzania.
Funding and reproductive health research
Short-term funding is common in emergency situations and in the post-conflict rehabilitation stage, but it can affect the level of expertise that a programme can attain. Improved donor commitments to RSH together with longer-term funding must be attained in emergency situations in order that better RSH programs are implemented rather than piecemeal approaches to service provision ( RHRC 2003 ). The lack of donor commitment not only affects direct programming, but it can also limit an NGO’s capacity and policies for future directions in RSH ( RHRC 2003 ). Without ongoing funding for technical assistance and capacity building, an NGO’s ability to deliver quality services and meet evolving RSH needs is severely limited. The NGO CARE is attempting to provide RSH services in Eastern Congo, and conducted a population-based survey on a variety of RSH issues in 2002 to help plan RSH services. However, the combination of poor security and short-term funding (twelve months or less) makes research into RSH needs difficult ( Traore and Grant 2003 ). Yet at the same time, research is necessary to guide program development and advocate for additional donor support ( see section 5.1 for a case study).
In post-conflict settings, many of the issues are the same. Research is desperately needed to understand the magnitude of destruction of the physical infrastructure as well as discontinuation of RSH service delivery. Yet, donors’ sense of urgency to rebuild and revitalize buildings and services has led to rapid and often uncoordinated, piecemeal programmes (UNRISD, Rebuilding wartorn societies, 1993, p. 21, cited in WHO 2000 ). The transition from emergency to development is laden with challenges for RSH providers to ensure continuity of services and quality of care that only additional research, lessons learned, and best practices can assist with. Donor support for RSH in emergencies, as well as the transitional phase afterwards, must include research as well as service delivery in order to provide the right services to individuals in need.
Ongoing research is paramount to providing quality RSH care in all stages of displacement, for all aspects of care. Some areas, such as safe motherhood, particularly linked to issues of maternal mortality have been on the international agenda longer, and thus have had more research input to various programmatic aspects and are more widely implemented. Other, newer areas, such as SGBV and services for men, where there is insufficient research and activities to thoroughly address these issues (especially in the case of SGBV), clearly require longer-term commitments ( Ward 2002 ). With insufficient information, it is difficult to prioritize how best to use limited funds, and in the worst case, these activities may be forgone altogether in order to provide more tried and tested services.