One year on, full impact of 'global gag rule' begins to emerge

LONDON — The long-term impacts of the “global gag rule” are beginning to emerge as a major family planning provider projects that approximately 2 million women will be denied sexual and reproductive health services as a result of the order reinstated this time last year.

Family planning and global health experts warn that the full consequences will continue to unfold.

Marie Stopes International, which provides contraception and abortion services in 33 developing countries, has calculated it faces an $80 million funding gap as a result of the decision, which slashed 17 percent of its donor income.

Poor and marginalized communities in Madagascar, Zimbabwe, and Uganda, in particular, are feeling the effects of the expanded policy most keenly. MSI has already closed some services in these countries.

Under the expanded version of the “global gag rule” introduced by President Donald Trump soon after his inauguration in January 2017, foreign NGOs that receive any United States global health assistance are prohibited from performing or promoting “abortion as a method of family planning.” That includes offering legal advice or counselling related to abortion.

Some foreign organizations such as MSI have chosen to forgo U.S. funding and continue their work in women’s health — but the loss of resources could result in an additional 2.5 million unintended pregnancies, 870,000 unsafe abortions, and 6,900 avoidable maternal deaths, the organization claims, leading to a 107 million pounds ($150 million) increase in direct health care costs.

“Unless we can fill the $80 million gap created by the global gag rule, it will deprive millions of women of the contraception they need to prevent an unintended pregnancy, and it is the world’s poorest women and girls who will bear the brunt,” Marjorie Newman-Williams, Marie Stopes International’s vice-president, said in a press release.

MSI’s projections offer the first rigorous estimate of the policy’s impact at an organizational level made publicly available. However, experts say confusion still surrounds the policy and how it will be implemented; and that it may still be too early to tell how many people and how much money will be affected.

Implementers also say it is impossible to estimate the true impact since many aspects are unquantifiable.

“The impact is not just about the size of project or country. Each individual service works through delivering health care, gaining trust with local communities, advocating for health improvements and educating and empowering people to take control of their lives,” according to Rosemary Gillespie, interim director general of the International Planned Parenthood Federation, the world's largest sexual and reproductive health NGO, which believes it stands to lose $100 million in funding as a result of the gag rule.

“The human cost — people not being able to make choices about their lives — is beyond figures,” she added.

The fact that the Trump administration’s version of the policy applies to non-U.S. NGOs receiving any U.S. health assistance — rather than just family planning as with previous iterations of the policy — has also made it more difficult to predict the impact, experts say. According to the Kaiser Family Foundation, at least 1,275 foreign NGOs and approximately $2.2 billion in global health funding could be subject to the rule.

“We didn't know if it would be 500, if it would be 1,000, if it would be over a thousand, at our minimum estimate,” explained Jen Kates, vice president and director of global health and HIV policy at KFF. She added that “the reach is bigger than some people probably expected.”

In addition, the policy may require at least 469 U.S. NGOs to ensure that their foreign NGO subrecipients, which received $831 million from 2013 to 2015, are in compliance.

The U.S. government is expected to publish a six-month review of the policy’s impact next week.

But, while representing only a single organization, the MSI data suggests the policy will put some of the Sustainable Development Goals — which call for universal access to sexual reproductive health by 2030 — firmly out of reach. Recent data from the Guttmacher Institute suggests there remain 214 million women and girls worldwide who want to avoid or delay pregnancy but do not have access to contraception.

The most marginalized at risk

According to MSI, women in Africa will be hit hardest by the funding cuts, with some of the impacts already being felt. In Madagascar, MSI said it has already had to close a voucher program offering sexual and reproductive health services to poor women and adolescents, and warned that 22 outreach teams and 150 public sector franchises are also at risk of closure. Similarly in Zimbabwe, it has halved its outreach sites to 600, and said more cuts are likely. In Uganda, which has some of the most restrictive national family planning policies in the world, MSI may need to reduce its presence by 60 percent.

Bridge funding from other donors, including money raised from the She Decides initiative launched by the Dutch government in the wake of the order, have enabled MSI to continue some of its operations previously funded by the U.S.

In some instances, U.S. organizations not impacted by the gag rule, such as Population Services International, have taken over areas of MSI’s work, according to John Lotspeich, MSI’s director of partnerships and resource mobilization.

However, this is neither an ideal nor tenable solution in the long run, Lotspeich said, since other providers lack some of MSI’s specialized services, and few organizations are dedicated solely to family planning.

IPPF told Devex that its member organizations are already feeling the impact of the gag rule in 29 countries and said the cuts are affecting “a whole range of sexual and reproductive health and rights projects and activities … including family planning, HIV, sexual and gender-based violence, and tuberculosis health care,” according to Gillespie.
The most vulnerable populations, including those who would normally be unable to access services “due to stigma, poverty, location, violence, or HIV status” will be hardest hit, she added.

For example, in Mozambique, IPPF’s member organization has lost 60 percent of its funding, has been forced to cut its staff by nearly half, to close 18 of its youth friendly clinics, and “release” 650 peer educators, Gillespie said. In Swaziland, the group has lost a quarter of its funding, and as a result is now only able to serve four towns out of a previous 14. In Botswana, 60 percent of funding is under threat, and while one clinic has already been closed, seven others have been scaled back to “bare minimum,” Gillespie said.

Need to diversify funding

The She Decides movement, launched one day after the expanded “global gag rule” was announced, has since mobilized approximately $450 million in additional funding, mainly from European donors, benefiting organizations such as MSI and IPPF.

However, this is not enough to cover the funding gap, Lotspeich said. Most of the money has been used to cover the United Nations Population Fund, which also lost the U.S. — its second-largest donor — as a supporter last spring. Just 8 percent of the She Decides funding pot has reached IPPF and MSI.

She Decides has elicited a “broad global response,” Lotspeich said, but “we don’t want people to think this has solved the issue for organizations like us.”

It is important to “diversify how we fund ourselves … so as not to be vulnerable to another seismic funding shift like this,” he added.

One method is to “reframe” the family planning agenda so it is no longer seen as a health issue, but is instead linked to the broader development agenda, he suggested, since “all sorts of other things happen when a woman can control her fertility.”

Robin Gorna, co-lead of the She Decides support unit, agreed that the money raised so far is insufficient to counteract the “unprecedented” damage Trump’s policy will have. She also praised donors for “stepping up to the plate,” and the many organizations that are “using creative and clever ways to keep services open.”

Uncertainties of an expanded rule

The fact that the rule has been expanded to include all non-U.S. NGOs receiving U.S. health assistance has made it more difficult to predict the policy’s long-lasting and full effects, explained Kates.

Questions still remain about how the policy will play out, and how NGOs will respond to the loss of funding, Kates added. Disseminating information about the policy’s specifics is also challenging.

“Getting information out about what is actually required is still a challenge. We have heard that anecdotally,” she said. “It is still uncertain what this will mean on the ground, in terms of organizations that decide not to comply, and forgo funding, or to continue to receive U.S. funds and curtail services.”

According to Gorna, the expansion of the rule to include health assistance could also undermine progress made in recent years towards offering combined services, as organizations working on diseases such as malaria, tuberculosis and HIV will no longer be able to offer family planning as a related service.

“As a global development community we’ve come to understand the need to link everything we do … but now that has to stop because this rule makes it impossible to deliver services in the way we know has the best impact,” Gorna said. “We are going to see integrated services become siloed again, as it’s the only way to protect resources. This is the travesty.”

Complementary funding programs between the U.S. and other bilaterals are also likely to be discontinued as a result of the policy.

Loss of leadership

Jamie Vernaelde, senior research and policy analyst at U.S.-based family planning advocacy group PAI, said its research in Nigeria and Uganda revealed that local implementing organizations are confused about whether the rule applies to them, and how it is being rolled out. They also pointed to a “lack of communication” from the U.S. government and their contracting organizations.

“Right now, everyone is trying to iron out what the policy means to them,” Vernaelde said. Local organizations that work with marginalized groups, such as sex workers and LGBTI communities, demonstrated the most confusion.

“Some still don’t know what the policy is and some didn’t even know if they have signed it,” she said. This could lead to issues down the line if a group finds out it is not in compliance and has to pay back funds.”

However, it is not only small organizations that are feeling the brunt of the policy, Vernaelde said. Large U.S. implementing NGOs have complained about a huge “administrative burden,” even when choosing to comply with the rule.

“There’s also the greater issue of the U.S. as an ally for integrated health services and family planning,” Vernaelde said, explaining that the gag rule “means that family planning advocacy organizations in countries with an already restrictive family planning space are having to navigate without an ally.” In some cases, the U.S. position is also “emboldening the opposition” to women’s choice, she added.

Former director of the U.S. Agency for International Development’s Office of Population and Reproductive Health, Duff Gillespie, echoed this when he warned that the gag rule could result in U.S. officials adopting a more regressive attitude towards women’s rights in developing countries.

"One of my concerns is the chilling effect, not just of the “global gag rule,” but of the administration’s hostility toward women’s issues [and] reproductive health; international family planning will influence what mission directors and other senior personnel do in country,” he said at an event hosted by the Center for Global Development in Washington, D.C., on Wednesday.

“Political leadership and the career leadership ... that should encourage the ministries of finance … to adopt local ownership [for family planning] are going to be less likely to do so under this administration than under previous administrations,” he said. “I think that is a grave threat for progress in this area.”

Amy Lieberman and Michael Igoe contributed reporting to this article.