Gag Reflex: Melinda Gates Isn't the Only Funder Worried About the Mexico City Policy

Since Trump's election, Bill and Melinda Gates—along with the foundation they run—have said little about the new administration's policies, including the executive order banning immigrants from seven Muslim-majority countries.

But this week, the Gateses finally spoke up, expressing concern about how Trump's "America First" stance might imperil U.S. development aid. They're also deeply worried about the administration's reinstatement last month of the Mexico City Policy, the global gag rule (GGR) that states that the U.S. “does not consider abortion an acceptable element of family planning programs,” and that it will “no longer contribute to separate nongovernmental organizations which perform or actively promote abortion as a method of family planning in other nations.”

This latest reinstatement of the GGR—as with other iterations of the policy—targets family planning programs. Trump’s version, however, extends to “global health assistance furnished by all U.S. government departments or agencies.” Meaning, the policy now applies to all global health organizations that receive funding from any US government agency. The full text of the memorandum can be found here.

Financially speaking, foreign NGOs risk losing US government funding if they give counsel about, perform or actively promote abortions—even though they are using money they’ve received from other sources to do so. Meaning if a foreign NGO even talks about abortion, it cannot receive funding from any U.S. department or agency for any health program.

In an interview with Bloomberg Television that aired yesterday in which she spoke with barely controlled rage, Melinda Gates said, "I'm personally concerned about the Mexico City Policy." And it isn't just continued access to contraception that worries Gates, who's been a champion of greater investments in family planning. She also noted that the expanded rule could affect health organizations that provide drugs to combat HIV, malaria and other diseases. She pointed to its possible effects on the work of the Global Fund, supported by a wide range of governments (including the U.S.) and many private donors, which she said had saved 20 million lives, in part by setting up health clinics around poor countries that distributed HIV/AIDS drugs. "And because we're implementing a policy, all of sudden, a clinic's going to be shut down?" Gates asked, in disbelief. She slammed the new policy as out of step both with American values (including a belief in "life") and its national security.

As part of the GGR, organizations can elect to sign a pledge stating that they will not discuss abortion. Sounds simple enough. However, in many countries, family planning and other health services are performed in one clinic and signing such a pledge would necessitate the separation of family planning and reproductive health services from other health services. In an interview with Vox, Suzanne Ehlers, president and CEO of the global health organization PAI, “The administrative and bureaucratic burden,” of doing so would be “staggering.”

How much U.S. aid money might be affected by the Mexico City policy, and how might philanthropy make up the difference? These are urgent questions right now.

Before moving forward, let’s untangle a few things.

U.S. NGOs will continue to be eligible for global health assistance whether they provide abortion services or not. The Helms Amendment has prohibited the use of U.S. taxpayer money to fund abortions overseas since 1973. However, U.S. NGOs receiving U.S. government funding will have to enforce GGR policies on their foreign NGO partners.

Last year, U.S. appropriations for global family planning and reproductive health programs alone totaled over $607 million. This includes a $32.5 million designation for the United Nations Population Fund (UNFPA). What that figure does not include is funding for other global health programs that could be negatively impacted by the GGR.

Cutting that funding stream off will be devastating for many NGOs and catastrophic for others. This will affect not only the smaller organizations but also the global health giants that are among the top recipients of USAID grants—many of which are sounding off against the policy.

Pathfinder International, a global health outfit that works to expand access to contraception, promote healthy pregnancies, and halt the spread of HIV, called the global gag rule a “punitive policy that risks women’s lives around the world.”

In 2015, Pathfinder received $70 million in funding from USAID. It also receives plenty of funding from other sources. The Gates Foundation has awarded the group over $43 million in grants over the years. The Susan Thomson Buffett Foundation, which is the biggest overall player in global family planning philanthropy, gave Pathfinder over $20 million in 2015 alone. The Hewlett Foundation has been another big backer.

Pathfinder itself won’t stand to lose its funding from USAID or any other government agency. But the organization heavily backs local health centers, clinics, and community health workers in their efforts to provide increased access to family planning information and services—which can often include information and services related to abortion.

Prior to the latest reestablishment of the GGR, Pathfinder could provide funding to these local NGOs for things like contraceptives and health screenings even if the local clinics offered abortion services. Now, this is no longer the case as the latest iteration applies to funding for all health services. So, for example, if a health clinic in rural Ghana offers services or counseling related to abortion, but also offers vaccinations and necessary medications for diseases like diabetes or malaria, it stands to lose its Pathfinder funding altogether.

These cuts could put intense pressure on Buffett, Hewlett, and other funders to do more, including Gates, which has become a growing leader in the family planning field in recent years, with Melinda embracing this as her top cause, along with women's empowerment broadly. In 2012, the foundation—along with the Department of International Development (DFID), USAID, and UNFPA—launched Family Planning 2020 (FP2020), a global campaign fighting for the rights of women and girls around the world to decide for themselves when and if they have children. Since 2013, the Gates Foundation has awarded around $24 million in grants to support FP2020's mission of providing 120 million women and girls with access to modern contraceptives by 2020, no matter their circumstances and no matter where they live.

DKT International, another powerhouse in global family planning and a leading FP2020 partner, received a $37.5 million loan/grant combination from Gates at the end of last year. Buffett is another big funder of this organization, and the Hewlett and Packard foundations have also provided support, although at lower levels. DKT provided services to some 30 million couples last year alone. Chris Purdy, DKTs CEO, has called the gag rule “insidious,” and expressed uncertainty about U.S funding for FP2020. Purdy also made a point about how counterproductive the rule is likely to be on curtailing abortions.

The great irony in this is that you will have more women who don’t have access to family planning who are going to get pregnant and will have to go and get an abortion. So the very thing they are trying to prevent is probably going to increase because of the very thing they’re doing.

Sexual and reproductive health outfits aren’t the only ones that stand to lose here. Let’s take a look at how the rule could potentially impact Gavi.

Gavi’s stated mission is “Saving children’s lives and protecting people’s health by increasing equitable use of vaccines in lower-income countries.” This international alliance receives financial backing from a host of governments as well as donors like Gates and the Children’s Investment Fund Foundation (CIFF).

Last year, CIFF awarded Gavi a $25 million grant for HPV vaccinations for adolescent girls, focusing on sub-Saharan Africa. HPV is a sexually transmitted infection. In the course of Gavi affiliates’ HPV vaccination work in partnership with CIFF, which most assuredly involves discussions about sexual and reproductive health, another top priority of CIFF. If any of the local clinics supported by Gavi—which received around $800 million in U.S. government funding in 2016—talks about abortion, the clinic risks losing all Gavi funding.

As I mentioned, CIFF is a huge backer of sexual and reproductive health programs around the world. Marie Stopes International, which provides contraception services and supplies, as well as abortion services for women around the world, is another major CIFF grantee impacted by the GGR.

CIFF has partnered with Marie Stopes for projects totaling $28 million. The Gates has awarded the organization over $61 million in grants over the years and it has also received millions of dollars in funding for the Buffett Foundation. In addition, in 2015, Marie Stopes received £23.4 million from USAID. Given that the main mission of Marie Stopes is to provide not only contraception but “safe abortion to women and girls living in urban and rural communities all over the world,” the organization itself stands to lose a huge chunk of its U.S. government funding—potentially putting pressure on private funders to make up the difference.

A number of other global family planning and health groups not discussed here stand to be affected by the new gag rule.

Some may argue that philanthropic organizations and private donors could step in to fill what will likely be a gaping hole left should the U.S. pull its funding. Surely, the pressure will be on for them to do so, and many will do more.

But after looking at the numbers, it's clear the funding gap is way beyond what private donors could fill.