The Mexico City policy was reinstated and broadened by Trump in his first week in office, January 2017, and renamed in May (when the implementation plan of the policy was announced) as Protecting Life in Global Health Assistance (PLGHA). The Mexico City policy, better known as the ‘Global Gag Rule’ (GGR), was first implemented by Reagan, a Republican, in 1984. Democrats typically rescinded the policy, when they were in power. The Mexico city policy prohibits foreign non-governmental organizations that receive certain categories of US government (USG) FP assistance from using these funds or other funds for performing, providing counseling, refereeing or advocating for safe abortions as a method of family planning. PLGHA expanded the Mexico City policy by applying it to most US global health assistance. Late March 2019, the Trump administration further expanded this policy. As noted by Schaaf et al in a recent article, the policy now applies to approximately $11 billion in USG global health assistance, compared with approximately $400–500 million in FP funding under the administration of George W Bush. Other sources mention a figure of almost $9 billion in US foreign assistance. Whatever the exact figure, PLGHA concerns a lot of money.
Before zooming in on the Kenyan situation, let me first provide you with some stats on the global picture with respect to abortions. A 2017 Lancet article estimated global abortions at about 56 million every year. About 25 million of these were unsafe, with 24.3 million of these in developing countries. Clearly, unsafe abortions remain a huge problem in LMICs, including in my country.
The Kenyan laws prohibit abortion – abortion may only be granted to a pregnant woman or girl, when she needs emergency treatment, in the opinion of a trained health professional, or her life or health is in danger. Abortion is a sensitive and contentious issue in my country (as in many sub-Saharan countries), with religious, moral and political dimensions. At the same time, though, it is also very much a public health concern. Despite its illegality, a report from a few years ago showed that an estimated 464,690 induced abortions occurred in Kenya in 2012, corresponding to an induced abortion rate of 48 abortions per 1000 women of reproductive age (15-49 years), and an induced abortion ratio of 30 abortions per 100 births in 2012. In Nairobi, about 60 percent of all acute gynecological hospital admissions are due to complications from unsafe abortion, such as perforation of the uterus or infection caused by unsterilized equipment.
Against this already dire abortion backdrop, what has been the impact of PLGHA in Kenya?
International Women Health Coaliton (IWHC) works in partnership with grantee partners in Kenya, Nepal, Nigeria, and South Africa to provide a comprehensive (and ongoing) look at the impact of the policy on women, marginalized communities, health care providers, and civil society. Earlier this year, the IWHC released a study, “ Crisis In Care: Year Two Impact of Trump’s Global Gag Rule”, on the impact of the policy so far. The report revealed that among others, the policy is exacerbating the existing barriers to access of services and is therefore harmful to the health and well-being of women, young people, and marginalized communities, such as LGBTQI, rural, poor, and religious minority communities; is creating funding gaps, and also causing the fragmentation of health services, and halting critical health programs, including those strengthening the delivery of government services that are fulfilled by the NGOs. In addition, as has been the case in past iterations of the Mexico city policy, due to overinterpretation of the policy, some certifying NGOs self-censor or limit activities far beyond what the policy requires. The IWHC report listed some other major concerns which I certainly also recognize in the Kenyan day-to-day context.
Kenya’s family planning costed implementation plan ( FP- CIP 2017-2020) estimated the 4-year budget at Ksh 30.8 billion (US $305 million). Most of this budget comes from international donor assistance, so obviously quite some NGOs in Kenya have been affected by PLGHA. Family Health Options Kenya (FHOK) for example, one of the largest sexual and reproductive health providers in the country, decided not to comply with the rules. They had to close down 17 clinics and outreach activities were also impacted since many employees were sent home. Most of the outreach services, which were funded by USAID in countries like Uganda, Senegal, Madagascar, Pakistan and Myanmar, and also Kenya, have already stopped. Some of the NGOs such as FHOK managed to get some alternative funding, via International Planned Parenthood Federation (IPPF)’s GGR emergency grant (funded through individual donations, governments, NGOs, multilateral agencies, corporations, trusts and foundations), and so outreach services were able to start again, but only at about half capacity. Other funding has been sought from ‘She Decides’, a now global movement that provides a political platform to ‘support the fundamental rights of girls and women to decide freely and for themselves about their sexual lives’. In 2017, Rutgers, a Dutch NGO within the SheDecides movement, awarded half a million Euros for 2 years to the Reproductive Health Network Kenya (RHNK), a network that works towards reducing maternal mortality and morbidity caused by unsafe abortion. But as you can imagine, this alternative funding, even if it’s much appreciated, does not fully compensate for the enormous (financial and other) impact of PLGHA.
This year marks the 25th anniversary of the International Conference on Population and Development (ICPD) in Cairo, where 179 governments adopted a landmark Programme of Action which set out to empower women and girls for their sake, and for the benefit of their families, communities and nations. From 12-14 November, the governments of Kenya and Denmark and UNFPA are co-convening the Nairobi Summit on ICPD25, a high-level conference to mobilize the political will and financial commitments we urgently need to finally and fully implement the ICPD Programme of Action. These commitments will be centred around achieving zero unmet need for family planning information and services, zero preventable maternal deaths, and zero sexual and gender-based violence and harmful practices against women and girls. Under one of its signature sessions, “Ensuring Safe Pregnancy and Childbirth for All Women and Newborns”, its focus will be on evidence-based strategies for accelerating progress by improving quality, coverage and equity in maternity care through an effective, well-functioning primary health care system, including safe abortion.
Let’s hope the Kenyan government will capitalize on its role as a host to announce substantial progress on access to safe abortion. Hopefully they will also announce a bigger domestic budget for SRHR, as it’s clear international donors are even less reliable than before, given the current global SRHR backlash.
As we wrap up this short Editorial, International Safe Abortion Day is underway (28th of September). The RHNK network, which supports the Kenyan rules on abortion, but at the same time (and yes, that’s a bit of contradiction 🙂 advocates for tackling the huge public health need of unsafe abortions, fully supports this day of global action for legal and safe abortion.