When the U.S. Pulls the Plug on Funding, What Happens To Reproductive Health Providers?

A note about this series: Global Press Journal reporters around the world examined their communities’ approaches to reproductive health, including values and priorities and how international policies impact them. Read the other stories in this month-long series here.

SURKHET, NEPAL — Kaushila BK and her husband, Dilip BK, have a son and a daughter.

They say they can’t afford any more children.

The family lives in Matela, a village in an area of western Nepal that is a major source of cheap labor for neighboring India. Dilip is one of hundreds of thousands of Nepalese who work in India, and he spends much of each year there. (The surname BK, a shortened version of the caste name Bishwakarma, is so common in this part of the country that people tend to go by their first names.)

Because Dilip is away so much, he doesn’t want his wife to take contraception. If she did, he says, she’d be more likely to sleep around while he’s gone.

Kaushila has had two abortions. It was the only way to avoid having another child, she says, but those procedures wreak havoc on her body. (Abortion is legal up to the twelfth week of pregnancy in Nepal.)

In 2018, though, there was a glimmer of hope: Dilip agreed to get a vasectomy. A reproductive health program offered the procedure, as well as tubal ligations for women, all free of charge in this rural, cash-strapped region. The couple planned that he would get the vasectomy the next time he returned home from India.

But in the time Dilip was abroad, the ripple effects of a decision made by a man about 7,000 miles away led to the closure of the health program. By late 2018, the program’s workers had packed up.

The program, called Support for International Family Planning and Health Organizations 2 (SIFPO2), was supposed to run at least a year longer, says Vijay Gyawali, a program coordinator.

Now once again, Kaushila is left without options.

“We do not have money to do it in the hospital,” she says, referring to the vasectomy.

The man who made the decision that could lead to Kaushila’s third abortion is U.S. President Donald Trump. In January of 2017, he signed the Mexico City Policy, known as the Global Gag Rule by its opponents, which withholds U.S. aid money from organizations that provide abortions, information about abortions or details on where to get an abortion.

[What is the Mexico City Policy?]

But in Nepal, there’s more to the story of why women end their pregnancies. While the Mexico City Policy will likely keep Dilip from getting a vasectomy and sparing his wife from having another abortion, his willingness to have that procedure is unusual in rural Nepal. Most men wouldn’t consider a vasectomy, even as they refuse to allow their wives to take birth control. Men here tend to believe that women are fickle, and liable to turn to another man whenever the opportunity presents itself.

In the Surkhet district, the rate of contraceptive use is going down while the abortion rate is going up – and neither has anything to do with Trump’s policy.

“I scold four women every day for taking medicine for abortion without a doctor’s advice,” says Dr. Amit Singh, a gynecologist who works in the area.

Data shared with Global Press Journal showed the number of women using contraception in the Surkhet area dropped from 2,700 in 2017 to 2,300 in 2018, according to data from the Surkhet District Public Health Office. Meanwhile, the number of women seeking legal abortions rose from 2,500 in 2017 to 3,000 in 2018.

The situation in Nepal’s Surkhet District is just one example that illustrates why it’s so difficult to determine the full impact of the Mexico City Policy. Advocates for abortion, including International Planned Parenthood Federation (IPPF) and Marie Stopes International (MSI), among others, say women across the globe could die without adequate access to reproductive healthcare. For them, the policy jeopardizes the human rights of women by allocating billions of dollars of aid money only to organizations that sign an agreement noting that they won’t so much as provide information about abortion, even if they don’t actually offer that procedure.

Global Press Journal reporters around the world spent five months searching for evidence of the policy’s impact, but discovered that key details are kept under wraps or are nearly impossible to connect. Officials at some organizations stonewalled GPJ reporters’ efforts to get information about the policy’s impacts.

Researchers who study reproductive health access say the policy has undoubtedly had a negative impact on gains made in the family planning sector around the world. But they also note that reproductive health advocates and organizations that provide those services are increasingly self-censoring their public statements because the topic is so politically sensitive.

The ‘Chilling Effect’

While money may be changing hands in accordance with the updated policy, that doesn’t necessarily mean that it isn’t being used for reproductive health in the same ways it was before.

“I don’t like when people say, ‘Hundreds of thousands of women are going to die because this policy was enacted,’” says Margaret Giorgio, who is researching the effects of the policy in Uganda and Ethiopia for the Guttmacher Institute, a major clearinghouse of reproductive health information.

“I don’t know if that’s true,” she adds. “I’m a scientist, and I believe in science, and I want to actually tell the truth.”

Most of the research on the policy is qualitative, Giorgio says, referring to information that focuses on characteristics or experiences. That research is important, she says, but it doesn’t result in quantitative, or numbers-based, data.

In reality, many organizations that provide reproductive health services don’t want to share data at all.

At Planned Parenthood Association of Zambia, IPPF’s division there, a key official bluntly told a GPJ reporter that she would not share those details because the issue had already taken up too much of her time.

“We have talked about the impact of the gag rule and we will not keep talking about it,” the executive director told GPJ. “It’s time we focused on moving forward.”

Researchers told GPJ that such reluctance might be due to what they’re calling a “chilling effect.” According to a 2018 report released by the Center for Health and Gender Equity, a U.S.-based advocacy organization, the effect occurs when organizations are “over-restricting their activities to avoid being found out of compliance” with the rule.

Emily Maistrellis, a researcher at Columbia University who studies the impact of the policy, says she has found examples of the chilling effect at family planning conferences, in academic journals and in training programs.

“There’s a climate in which people are more reluctant to participate because they’re nervous about what may be happening above them, and who might be watching or what the repercussions may be,” she says.

Sarah Shaw, MSI’s head of advocacy, says that the effect is especially palpable in Uganda, where the government has long opposed abortion. Now, she says, there’s more “institutional opposition” of MSI’s work.

“We’re seeing increasing criticism from the Ministry of Health,” she says. “We’re having to justify what we’re doing. We’re challenged on the fact that we do provide post abortion care, which is permitted worldwide. Post-abortion care is emergency medical treatment.”

The effect stretches around the world, even impacting local agencies with little or no direct connection to U.S. funding.

Katswe Sistahood, a sexual and reproductive health organization that works with women in marginalized communities in Zimbabwe, doesn’t receive U.S. funding because it promotes abortion access, even though abortion is largely illegal in Zimbabwe.

Talent Jumo, the director of Katswe Sistahood, says her organization is part of networks with other organizations that have signed on to the policy. When they meet, she says, she is careful about what she says because she doesn’t want to make it appear that those partner organizations are pushing to legalize abortion in Zimbabwe.

“People decide to go mute or they actually pull out,” Jumo says, referring to the networks.

Are Health Programs Ending?

Health workers are afraid to talk about their programs and services, which leads to a lack of solid data on how the policy impacts people around the world. But one thing is certain, says Jennifer Sherwood, a researcher at amfAR, The Foundation for AIDS Research.

“Everything we do know points to harm,” she says.

A 2011 study published by Stanford University researchers found that women in sub-Saharan Africa were twice as likely to have abortions while George W. Bush, a Republican, was the U.S. president, compared to when Bill Clinton, a Democrat, was U.S. president. The policy was in place under Bush, but not under Clinton.

As of now, there isn’t any data available to show whether that trend is repeating itself. But organizations that have lost U.S. funding say there’s no doubt that the policy has serious health consequences.

“We have, on last count, around 30 countries impacted and a real range of projects,” says Tia Jeewa, a senior official at IPPF.

The programs impacted include those focused on sex education for young people as well as HIV testing, management, prevention and treatment, Jeewa says.

There’s no doubt that U.S. dollars will no longer fund those programs, but it’s not clear whether they were disbanded or if funding for them was found elsewhere.

MSI, a major reproductive health services organization that performs abortions in countries where the procedure is legal, estimates that the policy will lead to 1.8 million unintended pregnancies, 600,000 “unsafe abortions” and 4,600 avoidable maternal deaths – and that estimate only applies to the impact on MSI’s work. (The phrase “unsafe abortion” is used by the World Health Organization to refer to terminations that occur without the help of a skilled professional, or in a non-medical environment.)

But those numbers are based on a modeling tool developed to measure impact based on past experiences.

“We always use the word ‘estimate.’ This is a model, and as with every model, we have assumptions on the basis of which numbers are being generated,” says Anisa Berdellima, a senior manager for health impact and sustainability at MSI.

Each year, MSI releases new versions of the figures that are adjusted versions of the original estimate, not new data based on how the policy is actually affecting their programs. The new versions also don’t account for new funding streams.

Sherwood, the researcher, says she knows of a male circumcision program in eSwatini (formerly Swaziland) that completely shut down. Circumcision is a key strategy in curbing HIV rates.

“This is a compelling example because circumcision has nothing to do with abortion services and is a known HIV prevention technique in high-prevalence areas,” Sherwood said.

In Uganda, programs that focused on getting condoms and other contraceptives to sex workers were jeopardized, says Jackson Chekweko, the executive director of Reproductive Health Uganda. The organization has new funders, Chekweko says, but they don’t make up the full $2 million it received each year from the U.S. government.

In many cases, though, the impact isn’t so clear-cut.

Until recently, the Zimbabwean organization SAfAIDS ran a U.S.-funded program that worked to protect orphans and vulnerable children from HIV/AIDS. When the Mexico City Policy was signed in 2017, SAfAIDS had to hand over the program, including seven vehicles and 20 staff members, to FHI 360, a U.S.-based organization, says Rouzeh Eghtessadi, a SAfAIDS deputy director.

Eghtessadi says the SAfAIDS annual budget is around $9 million, but it will ultimately lose $7 million in direct funding and $15 million in assets due to the handover. Even so, she says, the organization refuses to comply with the U.S. policy, even though abortion is largely illegal in Zimbabwe anyway.

“Our fundamental vision and mission is sexual and reproductive health and rights,” she says. “These are all rights – we cannot pick and choose.”

SAfAIDS managed to recoup some of its losses. It continues to receive funding from UNAIDS, the European Union and a handful of governments and international aid agencies, and regained some of its lost USAID funding from Sweden, which increased its family planning budget in response to the Mexico City Policy. In the meantime, the program SAfAIDS once ran is now operated by FHI 360.

New Money

SAfAIDS’ situation is common across the globe. When U.S. funding dried up, other funders took note and worked to fill the gap. Organizations that lost funding when Trump signed the policy have also publicized their concerns about women’s health so effectively that many of them have made up most or all of that money. For the short term, at least, donations from other governments and major donors have filled the gap.

Lilianne Ploumen, a Dutch politician, founded SheDecides in 2017, after Trump signed the Mexico City Policy. Belgium, Sweden and Denmark joined that effort to mobilize funding for family planning. By January 2018, the movement had raised $450 million for reproductive healthcare.

In 2017, Canada doubled its commitment to sexual and reproductive health and rights over three years, providing 650 million Canadian dollars (about $482 million) to family planning efforts. The Guttmacher Institute estimated that Canada’s commitment to family planning averted 387,000 unintended pregnancies over the course of a year, including 187,000 unplanned births, and 108,000 abortions provided in unsafe conditions.

Meanwhile, the U.K. pledged £225 million (about $291 million) to family planning programs every year for the next five years, which represents a 25% increase from previous commitments.

IPPF, which has an annual budget of about $125 million, estimated that it would lose $100 million over four years due to the policy, but Jeewa says new funding has helped fill that gap.

“There’s been a huge amount of resilience in trying to keep services open for as long as possible [and] to divert services,” she says. “We’ve received some emergency funding from various donors. There has been a lot of support in that regard.”

MSI lost about 17% of its donor income, but Shaw says it recouped much of that money, at least for the short-term. (The organization had an annual budget of £296 million (about $382 million) in 2017.)

“European donors have stepped up, a lot of private individuals have stepped up, [and] Canada has stepped up,” she says. “So we’ve actually managed to fill a lot of the gap.”

The organization is fully funded through the end of 2019.

In one case, an organization recouped some of its lost money through crowdfunding. The Dutch foundation Rutgers raised €500,000 (about $558,000) in 2017 and gave that money to the Reproductive Health Network Kenya, which lost all of its U.S. funding.

Nelly Munyasia, a program manager at that organization, told GPJ via email that the money from Rutgers went toward training dozens of healthcare providers and other workers who focus on rural and hard-to-reach areas of Kenya.

Still, reproductive health advocates say U.S. funding was something of a gold standard when it comes to amount and consistency.

“The real challenge is that no donor government can match the weight and might of the U.S. government,” says Jonathan Rucks, Senior Director for Policy and Advocacy at PAI, a U.S.-based family planning advocacy agency that does not receive U.S. government funding.

Shaw says that though MSI has made up much of its lost funding, it’s struggling to replace money that went to programs in East Africa. Many European funders prefer to give money to efforts in Africa’s Sahel region. She says that’s because the Sahel is an origin point for many migration routes into Europe. Funding programs there boosts those European countries’ domestic agendas, she says.

Naisola Likimani, who heads SheDecides, says a shift away from reliance on U.S. funding is long overdue.

“We are definitely waking up to the fact that we have made ourselves vulnerable to policy decisions by the U.S.,” she says.

In Nepal, More Abortions

In Nepal, where Kaushila BK says she’ll be forced to get a third abortion if she gets pregnant again, analysis by PAI found that U.S. money has been a major reason for fewer infant deaths, improvements to clean water access and more. The country received nearly $36 million in 2017 – nearly all of it for public health initiatives.

The SIFPO2 program that provided vasectomies to men in Surkhet district was a $10 million, four-year effort. Before it closed, one of two organizations that was part of the SIFPO2 program trained 257 health workers to provide long-acting contraceptives. The other organization provided 43,000 of the 80,000 contraceptive implants that were inserted in Nepal in 2017, according to PAI research that was taken from anonymous interviews.

Pratima Shahi, a 30-year-old mother of two children, was not one of those women who received contraceptives. Shahi says she’s had 15 abortions, all of them because her husband doesn’t want her to take contraception. Like Kaushila, her husband worries she’ll be unfaithful while he’s away working in India if she knows she won’t get pregnant.

“It’s easier to take pills for abortion rather than to quarrel with my husband over birth control methods,” Shahi says. “I take an abortion pill as soon as I get a symptom of pregnancy.”

Correction: An earlier version of this story incorrectly stated the conversion between Canadian and U.S. dollars and the correct currency raised by SheDecides. Global Press Journal regrets these errors.