First Takes: Global Gag Rule & Kenya

Within the first week of assuming office, US President Donald Trump reinstated the Mexico City Policy, also known as the Global Gag Rule. Simply, this policy prohibits any entity that receives US Government (USG) funding from carrying out any abortion-related activity, regardless of the source of funds. 

This Mexico City Policy is a partisan affair that’s passed in DC, and plays out internationally on women’s bodies. Ever since it was enacted by President Reagan in 1984, it has enjoyed Republican support with Democrats opposing it. Following its passing, all Republican Presidents have since reinstated it, with Democratic presidents rescinding it every time there’s a President from the Democratic Party in charge.

The problem with this Policy is that studies show that abortion rates increased when the Policy was in effect. This is largely because organisations that provide reproductive health services tend to provide the entire slew of reproductive health services including information and in some cases, access to abortion. Where they are defunded, they can no longer provide information on contraception which leads to an increase in unwanted pregnancies and safe abortions. Indeed, during the launch of the She Decides Initiative that’s aimed at meeting the shortfall from the Global Gag, Minister Liliane Ploumen of the NL pointed out what activists have long known: Denial of safe abortion services leads to increase in unsafe abortions- not less abortions.  

The Policy leaves a wake of 'collateral damage' as it's too blunt an instrument to provide any meaningful differentiation of ‘abortion services’. It prevents any sort of service related to abortion, so for instance, an abortion referral by a health practitioner to a woman who’s been raped or is at risk of death, jeopardises the funding of all other health services. It doesn’t matter if the referral is done in a crisis health outreach clinic funded 100% by non USG funding. It’s sledgehammer policy that puts the millions of Kenyans who access health care in Kenya at risk.  

In the Kenyan context, this is particularly worrying.  About half of the pregnancies in Kenya are unintended pregnancies. About 40% of these lead to an abortion which translated to about 460,000 abortions in 2012. Kenya has made great strides in reducing maternal mortality, but conservative estimates show that around 1,600 women still die every year from complications from abortion. We have also made great strides in increasing information and access to contraception, but a lot of work still remains to be done because we still live in a country where 29% of Kenyan men believe that access to contraceptives ‘makes women promiscuous’. This is also a profoundly anti-poor policy where safe abortions in Kenya, at about $200 are largely out of reach of poor people.

Kenya Public Health Exposure to Global Gag Rule

While previous Republican administrations brought back the Policy, unlike his predecessors, President Trump also expanded the Policy.  This current executive order in addition to legislating on how non-US NGOs can operate, it also includes “all global health facilities”. While the Trump administration has since clarified how the non-US NGOs should act, there is still no information on how the “global health facilities’ clause should be interpreted. Does this for instance also include Government facilities? This would mean that GoK medical practitioner cannot provide referrals or provide safe abortions without forfeiting all GoK health funding including vaccinations, malaria treatment etc. 

In the absence of these guidelines from the Trump Administration, lifesaving health interventions stand at risk. It is not hyperbole to state that this is a matter of life and death for many Kenyans in the coming years. This is because the USG remains the largest funder of health in the world. It is expected that there will be a global funding shortfall around $600m for the next four years because of the reinstating of this policy. While Initiatives like She Decides have stepped up to fill the gap, it is unlikely that they will completely make up the shortfall. 

For Kenya, exposure to the Global Gag Policy is potentially quite high. The USG currently provides almost across the board support to the health sector including health services, population and nutrition support for the people of Kenya. 

The policy has in the past been shown to increase censorship and self-censorship by civil society on the abortion issue; to skew the abortion debate with a lot of bias and misinformation on abortion; to expose women to unsafe abortions and to decrease women’s access to reproductive health services.  Unsafe abortions are a critical public health issue, and the isolation of groups working on providing information and access to these services is a regrettable and unfortunate development. 

In addition to the climate of censorship and fear it engenders, the Policy promises to profoundly impact health services. This is because of our dependence on foreign funding- especially USG funding to supplement our national health budgets. 

To illustrate, of the approximately 60B allocated to health in the 206/7 budget, about 29B of this goes to recurrent spending, and 31B to development expenditure. About 62% of health development spending is financed by development partners with much of this being support for Reproductive health services, immunisations and health systems support. 

The US Government remains the largest bilateral donor for health globally. Regionally, Kenya is one of the biggest recipients of this (after Ethiopia) where e.g. USAID in 2016 disbursed $265m for health in Kenya. Of this, about $233m was for population and reproductive health services $233m and $25m for basic health. Defunding of these programmes would be have major implications on Kenyan Government health spending.

For NGOs working on this sector, while still early days yet, many of the health providers e.g. Marie Stopes & Planned Parenthood have already stated that they will not accept funding from the USG under the Global Gag conditions. This also puts at risk Hivos programmes providing critical support to key populations on HIV/AIDS because of other work that we do e.g. provision of information on safe post-abortion care by other partners. 

Musings on way forward:
The Policy is unlikely to be rescinded as long as there is a Republican President in the US. Supporting the advocacy efforts of US allies in limiting the effect of this policy might be the only avenue still available to us. 

Domestically, we need to have a sober discussion on our domestic spending priorities and how we finance then. As a country, we chronically under-spend on health. The total national health budget allocation for the 2016/7 fiscal year was 3.6% (down from 3.7% in the previous year). Total health expenditures for 2016/7 was at 7.6% way below the 15% target set by the Abuja Declaration. While the counties are currently spending about 25% of their budgets on health, we need to not only resource the sector appropriately, but also plan on how to wean ourselves off donor spending which is a profoundly unsustainable way of financing such a critical health sector. Where over 60% of our health budget is dependent on development partners for funding, we end up with a situation where we become anxious foreign election trend watchers, and less domestic health policy planners.  In a world of growing nationalism and the rise of conservatism, it becomes even more important that we prioritise domestic health care funding. 

This is especially more urgent because the re-classification as a lower middle income country means that many development partners are moving away from aid to trade. For the health sector, this has also meant a growing interest by development partners in investing in the private & commercial health sector and divesting from the public health sector. This is a development that should be of great concern to public health actors in the country. In a country where out of pocket health spending has proven to be catastrophic with about 1 million Kenyans falling below the poverty line because of health spending, it’s imperative that our tax shillings are directed towards a health system built on policies designed around Kenyan priories and needs. 

More immediately, we can provide material and moral support for initiatives like She Decides which have sprung up as the moral alternative to the Global Gag Rule. Countries that have rallied to fill this decency gap include the Netherlands, Belgium, Canada, the Gates Foundation and private donations from individuals from multiple groups in many countries across the world. The presence of shining stars like  Cape Verde and the absence of some like the UK to me shows that this is more than an economic argument, and more a “do right” attitude displayed by these countries. Despite a dearth of resources, and competing exigencies like the current drought, insecurity and a host of other clear and present priorities, it would be good if as a country, we also stepped up on this issue, and provided moral leadership for the region.