An Ethical Approach to International Aid for Reproductive Health Services

A Roundtable Conversation

Mick Hume, Moderator
Thoraya Obaid
Dr. Anders Nordström
Kavita Ramdas
Dr. Lawrence Oteba
Dr. Barbara Crane

Winter 2008-2009

In January 2009, Catholics for Choice convened a roundtable conversation on the ethics of international development aid for reproductive health services. An edited transcript follows.

Mick Hume: It’s a very timely moment for us to be discussing an ethical approach to international development aid in terms of sexual and reproductive health and to examine the competing interests and agendas that are at work in that field.

As the last days of the Bush years pass, we can look back on a period that has been characterized by controversy in this area as in other areas of foreign policy, with accusations that the American administration has sought to impose its own morality on international health and rights issues.

Two issues come to mind. First, the Bush administration reinstated the “Global Gag Rule,” which means that any foreign NGO seeking US aid funding cannot use their own money to provide, promote or advocate for legal abortion services in their own countries. This stands in stark contrast to the admirable tradition of the First Amendment that the American administration supports for its own citizens.

The second controversial aspect has been PEPFAR, the President’s Emergency Plan for aids Relief that has insisted that large amounts of HIV-prevention funding go to abstinence-only-until-marriage programs, and is often channeled through faith groups.

With this background in mind, what has the Bush administration’s approach to development aid meant to you in practice? How, if at all, might you hope to see the emphasis changed under the Obama presidency?
Thoraya Obaid: In addition to the gag rule, we also have the Kemp-Kasten Amendment that prevents funding coming from the US Congress to UNFPA. The gag rule applies to IPPF and others and the Kemp-Kasten Amendment applies to UNFPA. We have lost funding as a result. We need to see how this will be handled as the new administration develops. Having said this, we do expect change and change that we all can work with. I think the financial crisis is going to loom heavily on the president and on the US…Within that context we are hoping that the Obama administration will give high priority to social sectors and of course provide support to the sectors under the reproductive health agenda and those with links to HIV prevention. He has made statements that are in line with the ICPD agenda on sexual and reproductive health. We are optimistic.

Anders Nordström: I think it’s extremely important here to focus on evidence. In terms of maternal deaths, we know that unsafe abortions are killing a number of women. This is a medical issue. This is a health problem. And this is a public health challenge. We must challenge political opposition. It’s also a matter of— and this is very much going into the ethical dimension of what you allow at home and what you provide for your own population—why are you denying similar rights to those in other countries? In Sweden we provide free and safe abortions to the Swedish population and of course we would like to see that available in Kenya and Uganda and Tanzania as well. And one of our main concerns now with the US policy is on this specific issue.
Kavita Ramdas: As someone who runs a publicly supported charitable foundation, our situation is somewhat different. We raise all the money that we give away each year primarily from individuals and private foundations. So, our experience of the Bush administration’s positions on development aid came as a result of watching what happened when many organizations, which for a long time had access to funding from UNFPA, then found it was suddenly cut…The Global Fund for Women also had this experience with PEPFAR and its emphasis on abstinence only as well as restrictions on contraceptive funding.
With regards to the new administration, I have some reservations in particular because of the connections with faith-based groups. I think that while President Obama has made statements that lead us to believe he could be an ally for the women’s rights movement globally, I also believe that he has been so eager to emphasize his strong roots in the faith community, almost bending over backwards to prove how Christian he is. We might find ourselves with more of a challenge on our hands than we expect and shouldn’t necessarily assume that it’s going to be smooth sailing from here on out.
Lawrence Oteba: I’m sitting in Nairobi where almost 40 percent of the maternal mortality rate, about 590 deaths per 100,000 women, can be attributed to unsafe abortion…Most of the family planning programs in African countries, including Kenya, took a terrible beating when the gag rule was introduced. The most effective intervention for women’s health, the continued distribution of contraceptives, was drastically downsized or shut down completely. And this meant that the contraceptive demands of most African women were not met. The unmet need rose and that resulted in increased fertility rates and unplanned pregnancies.

Speaking for Nairobi and most African countries, I think we are putting a lot of hope in Obama. Sometimes I think we hope for too much given the challenges that he faces in his own backyard with the US economy…However, I think that anything this administration brings to the table will, for most African countries, be better than what they have seen from the Bush years, especially in the reproductive health sector.

We do have to be cautious about African culture and the African context and how the conditions on aid that come from our more liberal donors affect our sexual and reproductive health programs.
Barbara Crane: I think it is important to understand the Bush administration’s policies in a wider context…The gag rule was really only one part of Bush’s very zealous and intrusive actions around reproductive rights…But, there were also some good things about the Bush administration’s legacy in sexual and reproductive health and it is fair to say that funding for family planning continued. There was support for post-abortion care. There was continuing support for NGO work in the area of sexual and reproductive health and that record must not be lost. These issues are complex.
When the Obama administration comes in it will not be enough simply to undo the Bush policies that we’ve been discussing, the really egregious ones… And if we are to make progress on these policies the Obama administration is going to need to hear from women around the world and from governments and other donors on the impact that these policies are having. A lot has changed in the world in 35 years and it’s time to revisit all of the policies that impact sexual and reproductive health, not just the Bush administration’s policies.
Mick Hume: A specific point was raised about the problem of government funding for faith-based organizations and churches of various denominations in the developing world. In many parts of the world these organizations are sometimes the only organizations available for the distribution of aid and have very good community connections. But at the same time there is always a danger that it will turn towards proselytizing.

Given that there is a separation of church and state in the American constitution, should the American government be funding faith-based groups to carry out policies in the developing world? Isn’t it the case that Obama’s connections with faith-based groups mean that policy is likely to continue?

Thoraya Obaid: The issue is not whether faith-based organizations should be funded by government or not. In some countries faith-based organizations provide almost 60 percent of health and education services. They are there. People believe in them. People go to them for services and for advice.
When we talk about faith-based organizations we should not lump them under one category. They are really very different. They vary in the terms of their methods, in terms of their ideologies and in terms of their practices. We have examples where we have worked with faith-based organizations that provide condoms and that provided advice and counseling to young people on sexuality and so on.
So, dealing with the issue of faith-based organizations…we need to see where we can work together with them and what opportunities there are with other groups that are working in the area.
Anders Nordström: From the Swedish perspective, both the government and Sida, we provide support for a number of Swedish faith-based organizations in exactly the kind of spirit that Thoraya was describing.

Kavita Ramdas: I think there are ways in which you can hold faith-based organizations accountable to a certain standard that we can agree on…It isn’t a question of just working with all faith-based organizations or none but rather dealing with it on a case-by-case basis.
Barbara Crane: There can be a way to work together—even with faith-based organizations that don’t share our views—from the point of view of immediate needs as well as in a longer term strategy of engaging them, possibly changing their views and understanding the role they play on these issues…It can be strategic to engage with them.
In the international refugee and humanitarian response context, faith-based organizations play such an important role. There has been a huge problem in addressing sexual and reproductive health and one that I think we need to come back to as a community and work with the Obama administration because a great deal of funding comes from the US government.
Mick Hume: We have already discussed the imposition of an American political agenda or an American administration’s political agenda onto people in developing countries.

Is it just for an administration to say, “Well, we were elected and our supporters feel very strongly about certain issues and taxpayers’ dollars ought to be channeled in a direction which reflects the opinions and political views on which we were elected”? Is that a legitimate point of view? Is that democracy or is it something else?

Kavita Ramdas: One has to again be very careful about this. One of the big issues with Obama’s election is that he reached across a traditional divide between people who might be called liberal in the United States, where what is considered left might be conservative in other parts of the world. But he also got votes from a very wide section of people who don’t necessarily all agree on any number of issues, and I would say don’t necessarily agree on the issue of foreign assistance with reference to…issues of sexual and reproductive rights. So, we can’t just assume that there is a clear mandate.
Barbara Crane: The Bush policies were the policies of a minority that supported the election of the Bush administration. It’s not clear that they would represent the majority opinion of American taxpayers… Any government has to be accountable to the constitution, to the law, to international human rights and to basic ethical principles. Things like the doctor-patient relationship and other kind of norms should be respected. So, I don’t think that the Bush policies were a fair reflection of a democratic outcome or process.

Lawrence Oteba: We need to consider what Americans may have been told their money is going to do in the developing world. When aid comes to developing countries, instead of achieving the objectives that the American taxpayers are thinking about, it negates gains made in the sexual and reproductive health of African women. I don’t think the American people would stand for that. We need to look at how aid and the conditions imposed on aid affect the sexual and reproductive health of African women.

Mick Hume:
 I’d like to ask a couple of questions from the other side of the coin, the more liberal attitudes towards development aid. European and specifically Scandinavian approaches to international aid are much more progressive. Programs that incorporate education about sexuality, homosexuality, particular sexual practices, gender equality, human rights and so on, are a very familiar liberal agenda.
Is this still a question of applying strings to aid? Is it merely a different form of projecting our own teaching, our own values on other people, our own view or vision of the world? And is that more ethical than what the Bush administration and its supporters have been doing and advocating?

Anders Nordström:
 First, I think one should recognize that no development corporations are free from values and there is a political dimension to all development agencies. And, of course, in Sweden or other Scandinavian countries, we have our values, we have our political priorities. On top of that agenda is the respect for human rights, a clear focus on the poorest of the poor.
So the answer is yes if you consider that those are values we think should be addressed in countries where there are major inequality gaps. And those are political issues from our government side. In some ways you’re right that we also—I wouldn’t of course call it imposing values—but we do have values.

I think we are trying to combine our values with a respectful dialogue where we talk about why we believe in those values but also how we aim to improve respect for human rights, democracy, health or whatever it is. Then, of course, that dialogue needs to be built on mutual respect. So, if we face a government that does not share those basic principles of respect for human rights and other things, we will then come to the conclusion that either we can’t work with the government or we can work with the country in other ways.

But, yes, my basic point is that we are not free from values either.
Mick Hume: Would you accept that the aid that you are giving is also conditional, it also has conditions attached to it that people need to comply with in regards to certain forms of education or certain values in order to receive the full benefit of what you’re offering them?

Anders Nordström: If I were to answer in a very simple way, the answer would be yes. But not on the detailed level that I think you’re looking for in terms of exactly how you go about it in the details of the programs. I don’t think we have those kinds of conditions. We are generally working at the higher level: looking at policy issues, looking at broader programs, providing broader support, and joining with other partners.

But, of course, if there are major breaches of human rights, if there are major issues with corruption, then we will say that we are not going to work here. These are absolute conditions: you respect conscience people’s equal value and you place importance on gender equality. We do believe that it is important for development both from an efficiency point of view but also from an ethical point of view.
So, yes. But I wouldn’t call it conditions. We are a partner. We work with countries and we work with organizations. If we don’t share the values with a partner or organization, then we don’t work together.
Mick Hume: I’ll ask you one more thing because obviously we are talking about the Scandinavian approach and you are our Scandinavian spokesperson here.

When we began talking about the Bush administration’s approach you made the point very clearly that you objected to the politicization of what used to be health issues. Are you saying that what you object to is that form of politicization?
Anders Nordström: Yes. I think you misunderstood me. What I do not agree with is, of course, the policies and content of the Bush administration. But what I said is that all countries will come with their own values, with their own policies and politics and priorities in terms of development. And all countries do this, including the US. I think the US should and I hope the US will change its policy priorities. But it will still come with policy priorities and that is natural for all governments.
Thoraya Obaid: I think the difference that we need to see is that what you call liberal views are views that have been adopted on an international basis. Countries have adopted the mandates that emerged from the International Conference on Population and Development and that are in the Convention on the Elimination of Discrimination against Women. So, if, for example, Sweden is providing support, it is providing support within a framework or a mandate that they or the recipient country has also accepted by signing onto it.
In that sense, it is not so much a condition but instead support for a political position that was taken publicly. The conflicts come in the context of the program. Is the government willing to legalize abortion or not? How does it deal with gay people? How does it deal with young people’s sexuality?

And here I come back to the problem that if these issues are so sensitive that we need to look at the context of each country or of each community, then how can we move this internationally accepted human rights agenda in a context that will bring change from inside?
In many ways there is a difference between a Bush administration saying “no” to something that has been accepted internationally and [other countries saying “yes”] to moral positions that are in line with what has been adopted internationally.
Anders Nordström: It is one of our great expectations that the new administration in the US will become more of a multilateral player and accept that we have multilateral agreements, that we have multilateral negotiations, for example at the World Health Organization. There will be negotiations, there will different views and we will be able to take resolutions and agree among members, and the administration will be keener to be a multilateral player. All governments will have different views feeding into this process. Then, we will continue to work on our specific issues that possibly go a bit further than international agreements go today. But we recognize them as an important platform and we respect them. I have a lot of hope in the US becoming a more dynamic and important multilateral player.
Mick Hume: Dr. Oteba, would you like to say something on the issue of the African cultural context and how one should deal with that?
Lawrence Oteba: Again, the issue here is the context in which the program is being implemented. When you look at what the Bush administration has done, it’s mainly put barriers in the way of sexual and reproductive health.
On the other hand, what we are calling the liberal conditionalities, from the Scandinavian perspective, are really not conditionalities of fact.
We have to realize that countries like Kenya and Uganda are probably a century behind where Sweden is, for instance. If we look at a project or aid for sexual and reproductive health issues, it is likely that the way it is done in Sweden is totally different from how it will be done in East Africa. Therefore, when you have technical assistance coming from the North to the South and that technical assistance has no concept of the different kind of relationships in the South, then you are bound to have communities up in arms against the very organizations that are supposed to be helping them.

Mick Hume: So, how do we feel about the idea of respecting local customs and cultural practices? Are they just something that should be bulldozed out of the way in pursuit of the greater good?

Kavita Ramdas: As an organization that funds locally-based women’s organizations in 167 countries plus around the world, I think it’s very important not to fall into this trap of assuming that there is such a thing as Western values versus other values and that Western values are somehow being imposed.
Our experience is that if you really listen to people in their own communities who are setting their own agendas and determining their own priorities, the aspirations for greater equality and greater justice are not something that is somehow unique to the Western world. Western civilization didn’t wake up one morning and say, “Oh yes. Women’s rights: that was something we meant to include in our civilization.”
It was because women in those countries fought and persevered over a long period of time. That same process is happening in many other parts of the world, and I think there is a difference between saying we are imposing these rights and the ability to actually listen to people in their own communities who are demanding a different level of engagement.

Mick Hume: I completely appreciate your point about the universality of human aspirations and rights, but at the same time would you agree that in many of these communities you will find extreme cultural practices around marriage, sex education, the age of marriage and female genital mutilation. So, what do we do about them?

Kavita Ramdas: 
I think what you do about them is to support people within those communities who are raising questions and who want to change those practices from the perspective of where they are. It’s not that you fly in a swat team and wipe out a certain cultural practice. You listen to where people are at and what changes they want to see and you begin to support them.

It’s a question of having an approach that is sensitive enough and respectful enough to understand that these things change over a period of time—as they did in the West. They didn’t change overnight in the West and they will not change overnight in the rest of the world.

Barbara Crane:
 I would like to take it one step further. When we see actual injuries to physical and mental health occurring in a certain cultural context, it may require a response or action, an immediate intervention that isn’t the same as looking at it as a long-term process of change. And it’s not an easy choice to make. It has to be made within each context.
Thoraya Obaid: The most important lesson is that when we talk about culture it is from a common understanding. When you say that we need to take culture into consideration, it means we accept culture as it is. Cultures are dynamic. People make cultures and therefore people can change cultures. It is important to provide communities with the necessary support and an environment that allows them to question, to find solutions—their own solutions.

I think this whole issue of looking at culture in a negative light tends to backfire on the positive aspects of our agendas. And therefore we need to look also at what is positive in a community. How can you reinforce the positive so people can work together to change the negative?
Mick Hume: If we try and situate this issue of development aid in relation to sexual and reproductive health in the broader picture of a new era, why then should people accept that aid ought to be focused on these areas rather than being concentrated on clean water, on energy, on food, on the basic day-to-day needs of people in the developing world?

How would you respond to the idea that there’s a privileging of sexual and reproductive health issues over the more immediate demands of people which might reflect an agenda created in the West than in the countries themselves?

Finally, what would ethical approach to development aid look like today?
Anders Nordström: I think sexual and reproductive health issues are definitely priorities if we listen to our reporting countries. They are not priorities from us or from other parts of the world. When mothers are dying, that’s not a nonpriority in African countries or Asian countries. These are definitely immediate priorities in all countries. I don’t think it’s an either/or situation. It’s not about giving this area a more privileged position than another. Of course, clean water is important, roads are important, infrastructure is important, trade is important. It’s a matter of getting the balance right. And it’s important that the sexual and reproductive health agenda does not get jeopardized and neglected because of the political sensitivity that comes with it.
Thoraya Obaid: On this issue of priorities, the cause of all of this is poverty, whether it’s drinking water or maternal mortality. It’s all about fighting poverty, not only monetary, financial or economic poverty but also the poverty of life itself.
Second, I would hope that in this new international aid environment we can listen more to the people and allow them to make more choices about how they want to move forward in their own way. I’m very wary of international aid emphasizing or overemphasizing the role of the private sector. I would like to see an approach that invests more and more into community-owned health and education services so the community feels that they all need services and that they have an interest in ensuring they are high-quality services.
Lawrence Oteba: In talking about developing countries, the poorest of the poor, the big question in discussing ethical aid and sexual health is what really impacts sexual and reproductive health in Africa.

If you’re talking about resources, it’s the issues of poverty. Resources are dwindling and young women have to support their families, especially now with the HIV/AIDS pandemic. At the end of the day, society takes advantage of these young women and that is one of the major contributors to poor sexual and reproductive health.

Kavita Ramdas:
 What we would like to see with regard to development aid both in the United States as well as from other Western countries is for them to aspire to consistency with existing international conventions and the international global consensus on women’s human rights. Countries need to apply them in terms of how we use and apply standards for foreign aid assistance.
Barbara Crane: Using resources as a carrot and sometimes as a stick is important in this context. We can never remove the provision of development assistance from the context of power and politics. These questions will always be complicated by that reality. But we have a generation of young women and men coming of age in Africa and around the developing world. Their health, their well-being, their reproductive decisions are crucial to the long-term global development process and prospects. For that reason, prioritizing sexual and reproductive health and rights in development assistance is going to remain a critical challenge.

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