Age of distrust: impact of hegemonic policy decisions on sexual and reproductive health and rights

Rajat Khosla and Pascale Allotey argue in The Lancet that marginalised people are becoming more distrustful of global health systems. Conservative, top-down policymaking is reinforcing healthcare inequality. Communities' needs and lived realities are less prioritised. In turn, marginalised groups are more sceptical that global health systems reflect their needs.  

This is evident in sexual and reproductive health policymaking. The article highlights ‘Global Gag Rule’, as a key example of conservative policy harming global health. Also known as the Mexico City Policy, it was first created by then-US president Ronald Reagan in 1984. US President Donald Trump reinstated it in 2017 and again in 2025. It prohibits NGOs receiving US funding from providing abortion services or information. Powerful donors such as the US use their funding power to reshape public health priorities in African countries. African countries heavily depend on aid to deliver key health services including HIV services, maternal healthcare and family planning. 

This approach to global health governance has led to higher rates of unwanted pregnancies and unsafe abortions. These decisions force healthcare providers to close programmes that deliver life saving care including integrated HIV and SRHR services. The US government and other key donors are reducing funding for global health. This is forcing local public health actors in Africa, to “choose between funding and comprehensive health-care delivery”, as Khosla and Allotey put it. This decision stops communities at a higher risk of HIV from accessing preventive services. If more people contract HIV, they will depend on HIV services, also affected by decreased funding, for survival. 

This moment forces public health actors to reduce their vulnerability to funding uncertainty by strengthening regional cooperation. This crisis also offers us the chance to reimagine a global health governance shaped by communities. From the Global Gag rule to national age-related policies and laws across Africa that limit PrEP access where it's needed the most – global health needs to align its priorities with the realities on the ground. 

Health workers are at the frontlines of community engagement. They know marginalised people’s struggles and needs – the lived realities that should shape global health governance. Healthcare providers are also central to providing rights-based care. This improves health outcomes and ensures essential SRHR and HIV services to the most marginalised which is essential to rebuilding trust in global health.