NGOs scramble to safeguard programs in wake of Trump's expanded 'global gag rule'

The reinstatement and amplification of a Reagan-era anti-abortion rule has some of the world’s largest nongovernmental women’s health care providers considering which of their programs to shutter.

U.S. President Donald Trump on Monday signed an executive order restoring and intensifying the “global gag rule,” an anti-abortion policy that bars any NGO abroad that receives U.S. government funding from performing abortion services — even if it’s legal in that respective country — or giving information about abortions as a means of family planning.

The policy was first signed by President Ronald Reagan in 1984 and has since become a political football struck down by Democrats and reinstated under Republican leadership. But Trump’s Jan. 23 memorandum takes it further, expanding on previous iterations by restricting funding to all organizations that receive global health funding, rather than only family planning providers — potentially including maternal health programs, efforts to fight Zika, and the PEPFAR program to prevent and treat HIV and AIDS. With this addition, global health NGO PAI estimates the rule could impact $9 billion in U.S. funds, 15 times as much funding as it did under President George W. Bush.

Current internal conversations at Marie Stopes International — which provides contraception and safe abortion services in 37 countries around the world— are tinged with disappointment, but they’re also resolute, Marjorie Newman-Williams, MSI’s director of international operations, told Devex.

Even though the move was widely expected, it still leaves foreign global health NGOs with two hard options: Continue to accept U.S. funds and be prohibited from providing abortion counseling, referrals or engaging in advocacy efforts and from providing abortions outside of the three exceptions; or refuse U.S. funds and look for alternative sources of funding to keep health clinic doors open.

Marie Stopes will choose the latter option by refusing $30 million in U.S. funding, and is one of more than 130 organizations that have already condemned the policy. Now Marie Stopes — and fellow large family planning providers who refuse to agree to the new terms — will begin the process of closing projects, severing partnerships and calculating the number of lives this will leave at risk. At the same time, they must reach out to alternative funders to save as many programs as possible. For other, smaller U.S.-funded sub-grantees and local groups, the options for resisting the rule and staying open are even slimmer.

The U.S. has been a generous reproductive health funder, spending about $600 million a year on international assistance for family planning and reproductive health programs. U.S. funding for contraception last year helped prevent 6 million unintended pregnancies, 2.3 million abortions and 11,000 maternal deaths, according to the Guttmacher Institute.

More women will die across the developing world following the reinstatement of the global gag rule, family planning experts tell Devex. Marie Stopes estimates that without alternative funding, the loss of its services alone will result in 6.5 million unintended pregnancies, 2.2 million abortions, 2.1 million unsafe abortions and 21,700 maternal deaths — just from 2017 to 2020.

In 2017, U.S. Agency for International Development funding would have helped the organization reach 1.5 million women in some of the poorest, most underserved countries in the world, according to Newman-Williams.

Instead, they’re rebalancing staff priorities in order to devote more time to reviving relationships with less likely donors, hoping to offset the damage of losing their third largest funding source, after the U.K. Department for International Development and an anonymous private foundation.

“We have reengaged with some of our funders who perhaps we haven’t received funding from recently,” Newman-Williams said, adding that they currently have their eye on Canada.  

But they’ll need to consider reducing their global footprint, and many of the organization’s rural outreach programs — which are almost entirely U.S.-funded and target the poorest women — are likely to be shut down entirely.

U.S.-based implementers such as Pathfinder International, meanwhile, must now parse through all U.S.-funded project sub-awardees and local partners, who will need to decide for themselves whether they want to agree to the new terms. Pathfinder receives U.S. government funding in all but a handful of the countries in which it works. While the global gag rule does not apply to the reproductive health-focused NGO since it is a U.S.-based organization, it stifles which partners they can work with to most effectively deliver services, explained Senior Policy Analyst Kiki Kalkstein.

The gag rule will affect far more programming than just abortion or contraception access, especially considering the push under the Obama administration for aid to take more integrated forms, Kalkstein noted. The same U.S.-funded clinic offering contraception in a developing country may also be the one offering HIV or nutrition services — none of which could refer a woman in need of an abortion to find the appropriate care under the gag rule, and all of which could face closure upon refusal of it.

Pathfinder’s internal mapping of these partners isn’t yet complete, but they can look to the impact of past gag rules to assess the potential effects, Kalkstein said. The last time the policy was implemented, they were forced to cut ties with strong partners such as the Family Guidance Association of Ethiopia, for example, which hampered the group’s ability to deliver contraceptives.

Organizations that refuse to comply with the global gag rule lose their USAID funding, which can result in the loss of service via clinics, contraceptive supplies, technical support and equipment. A 2010 study from the Leitner Center for International Law and Justice at Fordham Law School, for example, found the global gag rule negatively impacted Ethiopia’s efforts to mitigate the high rates of unsafe abortion.

Those sorts of findings anger Serra Sippel, president of the Washington, D.C.-based Center for Health and Gender Equity: “We have evidence, studies have been conducted on the past global gag rules,” she told Devex. “We know, for example, that global gag rules in the past are associated with increased abortion rates and have prevented girls from accessing contraception… it’s more horrible that [the U.S. administration] made this decision knowing these facts.”

Like Marie Stopes, the International Planned Parenthood Federation, which provides reproductive health and family planning services in over 180 countries, is currently focused on filling gaps to mitigate the damaging effects the policy will likely have on the women they serve.

Because IPPF refuses to agree to the gag rule, the health care and lifesaving services it offers will suffer from the loss of $100 million it currently receives from the U.S., said Yilma Melkamu, director of programs at IPPF.

They are still in the midst of assessing programs, but already they must close a project in collaboration with the Ministry of Health of Nepal that supports sexual and reproductive health care services in mobile clinics. A family planning and HIV services program they support in Kenya must be shuttered, along with a community based family planning program in Togo.

Innovation will suffer as well, he added.

“When the policy from the U.S. side is conducive… during that time is when we innovate,” he told Devex. In addition to the negative impact the policy will have on the individual lives of its clients, IPPF will put innovation — such as testing new strategies to strengthen supply chains or engaging in experimentation to better involve the private sector in family planning — on hold.

Organizations haven’t received instruction as to when the policy will go into effect, but IPPF expects it will have time for staff contract termination, project close outs and handovers, Melkamu noted. If going by fiscal year, Marie Stopes expects to start closing projects that they can’t identify alternative funding for by June and July.

Melkamu stressed the need for the family planning community to continue to advocate to respect both individual and national rights — something the gag rule undermines, especially in nations where abortion is legal.

“If we work in Ethiopia where abortion is legal to some extent, we have to respect that and provide services,” he said. “We cannot turn back because of this rule and that rule… we have to respect national laws. We will continue to work with national governments and work together to fill the gap however we can.”

If organizations sound resolute, it’s likely because they’ve already looked into alternatives to combat the limiting policy, Newman-Williams explained

There is little potential for contractual maneuvering to get around the global gag rule.

“We spent a good amount of time thinking about that,” Newman-Williams said. “We came to the conclusion that the level of effort required to tie yourself up in this process of trying to find ways around the policy and register new organizations… the degree of legal maneuvers required, the energy would probably be better spent saying ‘this is our position, we are clear,’ and turn our energies into finding ways to finance our services.”

Marie Stopes won’t just be looking at other donors, but also exploring health financing more broadly by becoming a provider on pass through contracts, or those where a donor provides funding directly to a government, which then contracts to them.

But immediate next steps for the family planning leader involve putting their heads down and implementing the significant programs in their charge this year, she said. They will move to close contracts with the U.S. government responsibly, seeking to ensure that the women who will no longer be covered by them find a way to receive care, and focusing particularly on countries such as Madagascar, whose program relies heavily on U.S. government funding and stands to be reduced by 50 percent.

“If the U.S. is going down an isolationist path, which it well might, and it’s pulling back from its engagement in the world, this is one expression of that,” Newman-Williams said. “But foreign aid as a whole is miniscule first of all in the overall scheme of U.S. government budgets, and reproductive health within foreign aid is 0.00 percent of that already very small pot of money.”

A few hundred million dollars will be saved, she said, and women will die.

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