Mexico City Policy Revisited
Restrictions on U.S. assistance reduce key health services in supported countries
by Hank Trout
In 1984, the Reagan Administration instituted the Mexico City Policy, officially titled Protecting Life in Global Health Assistance, which prohibits any non-U.S.-based or foreign nongovernmental organizations from receiving U.S. government health funding unless the organization certifies that it does not provide abortion services, provide counseling or referrals for abortions, or advocate for the liberalization of abortion laws with any source of funding. Since 1984, the policy has been rescinded by every Democratic president and reinstated by every Republican president, including the Republican currently in the White House who expanded the reach of the policy even further.
The iteration of the Mexico City Policy put in place during the George W. Bush administration (2001–09) applied only to U.S. government global heath assistance for family planning, a budget line of approximately $600 million annually. For the first time, however, the expanded policy instituted in 2017 now applies to nearly all U.S. government global health assistance (approximately $8.8 billion per year). The majority of this budget is appropriated to HIV programming through the President’s Emergency Plan for AIDS Relief (PEPFAR), at approximately $5.4 billion in 2018.
Jennifer Sherwood and her colleagues at amfAR, in collaboration with the Johns Hopkins Bloomberg School of Public Health, have undertaken the first study to document how the expanded Mexico City Policy has impacted PEPFAR partner grants. The results of that study were recently released.
The study conducted hour-long interviews and online electronic surveys with representatives of 286 PEPFAR partners, including country directors, program managers, or other best-suited respondents identified by the organization, from May 24 to September 30, 2018. The study concentrated on five major issues: the implementing partner’s scope of services, funding, awareness of the expanded Mexico City Policy, any operational changes related to the policy, and Global Health Policy and subpartner information.
Researchers found that most current PEPFAR partners were aware of the expanded policy provisions, of which 28%, operating in thirty-one of the forty-five countries, reported at least one reduction in services related to the expanded policy. These changes included reducing or stopping a variety of services, advocacy initiatives, or trainings related to sexual and reproductive health topics. The most common reduction was to the provision of sexual and reproductive health information and pregnancy counseling, reported by twenty-eight implementing partners globally. Other common reductions were to the provision of information about legal abortion services and to sexual and reproductive health community trainings or advocacy. The most severe reductions occurred in countries with more liberal abortion laws. Although less common, reductions in service delivery also were reported, including delivery of condoms, cervical cancer screening, and HIV testing and counseling.
Changes related to the expanded policy were most common among sub-Saharan African implementing partners, specifically in South Africa, Kenya, Mozambique, Malawi, Uganda, and Zambia. The researchers identified several recurring “themes” that arose from the interviews and surveys, including,
• Compliance does not mean agreement. Researchers found that even those PEPFAR partners who made changes to their services in light of the expanded Mexico City Policy did not agree with the policy. One current South African implementing partner said, “We can’t risk it. We don’t want to lose PEPFAR funding, it’s our mainstay. I think for a lot of parties it became a big challenge because they had to give up some money——either U.S. or their other funds. There are problems with U.S. funding, but there really is no substitute of that size.”
• Lack of alignment with best practices. PEPFAR partners complained that the expanded policy is out of step with known best practices in reproductive and sexual health. Those partners are no longer providing information about the termination of pregnancy, and so women and young girls are forced to undergo illegal, dangerous abortions. The same partners have stopped distributing family planning information, which particularly affects young people.
• Inadequate training and information. PEPFAR partners expressed confusion over the expanded policy, due to inadequate or contradictory information from the Administration. This confusion often led to over-implementation of the policy.
• Increased disparities. The expanded policy affects areas and populations that already have limited access to sexual and reproductive health services, such as young people, pregnant girls and young women, sex workers, men who have sex with men, and populations in rural areas.
If the goal of the expanded Mexico City Policy was to curtail abortions, it has failed miserably. The study showed that PEPFAR partners’ changes consist of reductions in sexual and reproductive health information and service delivery, but not a reduction in abortions. There is ample evidence that the Mexico City Policy has led to increased abortion rates, fueled by declines in contraceptive access, which create a higher reliance on illegal, unsafe abortion to prevent birth.
The researchers concluded that, counter to the goals of U.S. global health assistance, the expanded Mexico City Policy regarding the funding of abortion and related services actually decreases global access to sexual and reproductive health information and the availability of integrated services that are established best practices. They suggest that the policy should be repealed to maximize U.S. investments in global HIV programming.
Hank Trout, Senior Editor, edited Drummer, Malebox, and Folsom magazines in the early 1980s. A long-term survivor of HIV/AIDS (diagnosed in 1989), he is a forty-year resident of San Francisco, where he lives with his husband Rick. Follow him on Twitter @HankTroutWriter.