On 23 January 2017, on his first working day in office, U.S. President Donald Trump issued a directive reinstating and dramatically expanding the “Mexico City Policy” adopted under all previous Republican administrations since 1984.

According to Human Rights Watch (HRW), U.S. law has banned using U.S. foreign aid for abortion-related activities since 1973. However, the Mexico City Policy is a separate rule that goes further, and requires foreign NGOs receiving U.S. funding for family planning programs to certify that they do not use their own non-U.S. funds to provide abortion services; counsel patients about the option of abortion or refer them for abortion; or advocate for the liberalization of abortion laws.

HRW said that under previous Republican administrations, the restrictions in the Mexico City Policy applied specifically to U.S. family planning and reproductive health funds, which currently amount to about $575.0 million a year. President Trump’s policy extends restrictions to an estimated $8.8 billion in U.S. global health assistance, including funding support for maternal and child health, nutrition, HIV/AIDS (including PEPFAR, the President’s Plan for Emergency Relief for AIDS), prevention and treatment of tuberculosis, malaria (including the President’s Malaria Initiative), infectious diseases, neglected tropical diseases, and even to water, sanitation and hygiene programs.

This policy is widely known as the “global gag rule” due to the restrictions it places on how organizations use their own funds, including through limiting conversations that health providers can have with their patients and preventing them from pressing for changes in abortion laws in their own countries.

The U.S. policy has had a devastating impact. In January, London-based Marie Stopes International announced that it faces a funding gap of $80.0 million in the 37 countries where it works, with more than two million women at risk for the loss of contraception services, and about 870,000 at risk for unsafe abortions. In Zimbabwe, where the health system is in tatters amid a plummeting economy, Marie Stopes has cut in half its outreach sites (from 1,200 to 600). “That means I will have children against my will,” one affected mother of four told country director Abebe Shibru, who said they had been reaching at least 150,000 women per year.

According to the Associated Press (AP), foreign health workers say that Trump’s expansion of the global gag rule is especially damaging because NGOs increasingly offer a range of services in such communities. Closing an outreach center often means that treatment for HIV and other diseases, for both men and women, disappears as well.

“The architects of the Trump global gag rule have created a policy that will disrupt and reverse the United States’ long-held development goal of improving health worldwide,” the U.S.-based Guttmacher Institute said.

After decades of the on-again, off-again nature of the previous global gag rule, with Republican presidents applying it and Democratic ones rescinding it, people working in family planning had some idea of what was coming under Trump –– until he expanded the restrictions, that is.

“For the rest of the global health community this is a huge wake-up call,” said Robin Gorna, with SheDecides, a global movement that sprang up last year to raise money to help fill the U.S. gap and brought in $450 million throughout 2017. “The HIV community, for example, was ill-prepared for it. … It’s really exceptionally problematic.” SheDecides launched its fundraising drive in March 2017 at a conference in Brussels, Belgium attended by 50 governments from around the world.

Also in January, the International HIV/AIDS Alliance said it is losing up to $60 million in funding over the next three years. The Alliance said that these losses translate into a loss of sexual and reproductive health and rights programs for women and girls, along with human rights–based HIV prevention programs with and for men who have sex with men; community-led harm reduction programs by and for people who use drugs; programs that aim to eliminate sexual violence and human rights violations among sex workers; and, treatment literacy and adherence for people living with HIV, among others.

“The end of AIDS is possible,” the Alliance said, ‘but the Mexico City Policy seriously compromises this progress and fuels AIDS-related morbidity and mortality, as well as unwanted pregnancies and unsafe abortions.”

“As the implementation of the policy continues, the Alliance will be unrelenting as we document the impact of the global gag rule on the everyday lives of women around the world, especially those from marginalised groups such as female sex workers, those using drugs, transgender women and adolescent girls and young women who experience sexual violence,” said Christine Stegling, the Alliance executive director.

According to the Kaiser Family Foundation, at least 1,275 foreign NGOs could be affected by the expanded global gag rule.

The International Planned Parenthood Federation (IPPF), which provides HIV screening and treatment and screening for gender-based violence in 29 countries, said that it expects to lose $100.0 million in funding. Amodefa (the Mozambican Association for Family Development), an IPPF associate, is losing 60% of its funding because of Trump’s decision.

It has lost 43 staffers and 650 peer educators; and 18 youth clinics and 72  mobile clinics have shut down. “We estimate [a] half million people across our HIV, tuberculosis, malaria and family planning projects will be affected,” Amodefa executive director Santos Simione said in December.

In Burundi, the Association Burundaise pour le Bien-Etre Familial (ABUBEF) provides a range of essential services, with a strong focus on HIV. Around 84,000 people are living with HIV in Burundi, of whom 12,000 are children under 14. An article on the website of the IPPF on 23 January said that the withdrawal of U.S. funding due to the global gag rule will drastically reduce and, in some instances, close ABUBEF’s vital healthcare services and programs. The article estimated that the loss of funding to ABUBEF through the global gag rule will deny 117,016 people access to safe sexual and reproductive healthcare. ABUBEF currently supports over 2,000 people with antiretroviral treatment, who will also be affected by the cuts.

According to AP, the Family Life Association of Swaziland is losing one-quarter of its funding and has lost 12 staffers and 26 outreach workers. In Botswana, 60% of the funding for the Botswana Family Welfare Association is at risk as various contracts end. It has lost more than 70% of skilled staff. “Women are basically stranded,” said Amos Simpano, director of clinical services for Family Health Options Kenya. The organization has stopped providing outreach services to about 76,000 women and has closed one of its clinics. Last year, Simpano toured the U.S. to address the issue, meeting with members of Congress, policy makers and others. His organization has called the expanded global gag rule a “death sentence” as women seek unsafe abortions or kill themselves while others without contraception put themselves at risk of disease. Trump also ended U.S. funding for the U.N. Population Fund, the main supplier of contraceptives in Kenya, Simpano said.

Implications for the Global Fund

The Global Fund is not directly affected by the global gag rule. According to Population Action International and other sources, the rule does not apply to foreign governments and multilateral entities, including the Global Fund and Gavi, the Vaccine Alliance.

However, the Global Fund will be affected in other ways. For one thing, supporting reproductive, maternal, newborn, child and adolescent health interventions is a key objective of the Global Fund Strategy 2017–2022, so what happens to programs providing reproductive and other health services matters even if they are not being funded by the Global Fund.

In addition, the Global Fund may be indirectly affected as a result of programs having to close that provided HIV prevention as part of their services. However, Aidspan is not aware of any discussion about this kind of impact.

The U.S. is the largest contributor to the Global Fund.