Investigating the early impact of the Trump Administration's Global Gag Rule on sexual and reproductive health service delivery in Uganda

Background: The Global Gag Rule (GGR), reinstated by President Trump in January 2017, makes non-U.S. non-governmental organizations ineligible for U.S. foreign assistance if they provide access to or information about abortion. While evidence suggests previous iterations of the GGR negatively impacted sexual and reproductive health outcomes, no studies have quantitatively assessed the impacts of the Trump administration's GGR. Methods: We constructed a panel dataset of facilities (76% public) using 2017/2018 Performance Monitoring and Accountability 2020 service delivery point (SDP) surveys in Uganda. Based on information from stakeholder meetings, we classified districts as more or less exposed to the GGR; 45% (N = 34) of study districts were classified as “more exposed”, which corresponded to 145 “more exposed” and 142 “less exposed” health facilities in our sample. We assessed changes in provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, engagement with community health workers (CHWs), service integration, and quality of care from 2017 (pre-GGR) to 2018 (post-GGR). Multivariable regression models were estimated, and difference-in-differences impact estimators were determined by calculating predicted probabilities from interaction terms for exposure and survey round. Findings: We observed no immediate impact of the GGR on the provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, service integration, or quality of care. We did observe a significant impact of the policy on the average number of CHWs, with “more exposed” facilities engaging 3.8 fewer CHWs post-GGR (95% CI:-7.31,-0.32). Conclusions: The reduction in CHWs could reduce contraceptive use and increase unintended pregnancies in Uganda. The lack of other significant findings may not be surprising given the short post-GGR observation window. Rapid organizational responses and stopgap funding from foreign governments may have mitigated any immediate impacts on service delivery in the short term. The true impact may not be felt for many years, as stopgap funding potentially ebbs and service providers adapt to new funding environments.