How Many Foreign NGOs Are Subject to the Expanded Mexico City Policy?

Introduction

On January 23, 2017, President Trump reinstated the Mexico City Policy (MCP), renamed “Protecting Life in Global Health Assistance” (see the KFF explainer). In the past, when in effect, the policy required foreign non-governmental organizations (NGOs)¹ to certify that they would not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S. funds) as a condition for receiving U.S. government global family planning assistance. This included both foreign NGOs receiving U.S. funding directly, as “prime recipients,”² or indirectly, as “sub-recipients.”³ Furthermore, it required U.S. NGOs to ensure that any foreign NGO sub-recipients were in compliance. Under the Trump Administration, the policy’s scope has been significantly expanded beyond these conditions. It now includes most other U.S. bilateral global health assistance and, pending the outcome of a rule-making process, additional funding agreements (in the past, it applied to cooperative agreements and grants;⁴ the Administration intends to also apply it to contracts).⁵ As such, the policy applies to more than $7 billion, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly.

At this time, many questions remain about the potential impact of the expanded policy. One key unknown is the size of the universe of affected NGOs. We undertook this analysis to begin to answer that question. Using ForeignAssistance.gov data obtained from USAID,⁶ we identified NGO prime recipients of U.S. global health assistance in the most recent three-year period for which such data were available (FY 2013- FY 2015).⁷ We categorized them into U.S. and foreign NGOs. We included bilateral global health funding obligated by USAID (including funding that had been transferred to USAID from the Department of State) through grants, cooperative agreements, and contracts (contracts were included even though the rule-making process has not yet been initiated⁸) that would have been subject to the MCP. We then analyzed data from USAspending.gov to identify NGO sub-recipients of the top NGO prime recipients of U.S. global health assistance over the same period.⁹ This allowed us to create a database of foreign NGOs that would have been subject to the expanded MCP if the policy had been in effect during that three-year period, as well as U.S. NGOs that would have been required to ensure that their foreign NGO sub-recipients were in compliance. We also quantified the effect of expanding the policy beyond its prior conditions on the number of affected NGOs.

Our findings should be considered a minimum estimate since we only looked at sub-recipients of the top prime recipients of funding (and not all prime recipients report sub-recipient data). Indeed, based on a prior analysis we conducted, most U.S. global health assistance flows first to U.S.-based organizations before reaching foreign NGOs.¹⁰ In addition, we did not include NGOs that received global health funding transferred from State or other agencies to the Department of Health and Human Services in this analysis (although such funding is subject to the policy¹¹). At the same time, it is important to note that while all foreign NGOs will be required to certify compliance with the MCP as a condition of receiving U.S. global health assistance, only some carry out activities that are prohibited by the policy; however, available data did not allow us to assess this issue. See full methodology in Appendix A.

Findings

Overview

We found that had the expanded Mexico City Policy been in effect during the FY 2013 – FY 2015 period:

• At least 1,275 foreign NGOs – 639 as prime recipients of U.S. global health assistance and 658 as sub-recipients – would have been subject to the policy.¹² See Figure 1.

• Together, they accounted for approximately $2.2 billion¹³ in funding subject to the policy, including $1.36 billion to prime recipients and $831 million¹⁴ to sub-recipients.
• This funding supported foreign NGO efforts in at least 91 countries, including many countries that allow for legal abortion in at least one case not permitted by the MCP (see KFF analysis), and across all major global health program areas: family planning/reproductive health (FP/RH), maternal and child health (MCH), nutrition, HIV, TB, malaria, global health security, and other threats, including NTDs. HIV had the greatest number of foreign NGO prime recipients (470), followed by MCH (105) and FP/RH (82). See Table 1.

• HIV also accounted for the greatest amount of affected funding ($873 million), though this represented just 8% of HIV program area funding obligated over the period. The TB program had the greatest share of its program funding affected (35%), though this represented a much smaller amount of funding ($194 million). For FP/RH funding, 11% (or $175 million) was subject to the policy.¹⁵ See Table 2. These variations largely reflect the extent to which different program areas rely on foreign NGOs as prime recipients of aid, which was most common in the case of the TB program.

Table 2: Foreign NGO Prime Recipients: Amount & Share of Program Area Funding Subject to Mexico City Policy, FY 2013-FY 2015
Program Area	Total Program Area Funding	Prime Recipient Funding Subject to MCP* (% of Total)
FP/RH	$1.54 billion	$175 million (11%)
MCH	$2.27 billion	$75 million (3%)
Nutrition	$490 million	$6 million (1%)
HIV	$11.24 billion	$873 million (8%)
Tuberculosis	$554 million	$194 million (35%)
Malaria	$1.62 billion	$31 million (2%)
Global Health Security	$388 million	$1 million (<1%)
Other Threats, inc. NTDs	$413 million	$6 million (2%)
NOTES: * Does not include funding not subject to the MCP, including support for the Food for Peace (FFP) and American Schools and Hospitals Abroad (ASHA) programs and certain WASH efforts as well as support via agreements other than cooperative agreements, grants, and contracts. Sub-recipients not included.

• In addition to foreign NGOs, at least 469 U.S. NGOs that received U.S. global health assistance during this period (including 391 who were prime recipients) would have been required to ensure that their foreign NGO sub-recipients were in compliance. See Figure 2.

Newly Subject NGOs and Funding

Looking at prime recipients only, we also quantified the effect of expanding the policy beyond its prior conditions on the number of affected NGOs (available data on sub-recipients did not permit this level of analysis). We found that the expansion of the policy beyond family planning assistance and to contracts greatly increased its reach:

• Among prime recipients alone, most affected foreign NGOs (587 of 639, or 92%) and most funding ($1.2 billion of $1.36 billion, or 88%) would not have been subject to the policy under its pre-expansion terms. See Figure 3.

• Of the 587 newly subject to the policy, 557 received non-family planning global health assistance only (i.e., MCH, nutrition, HIV, TB, malaria, global health security, and other threats, including NTDs) and 401 received funding through contracts only.^16,17 See Figure 4.

• Of the 391 U.S. NGOs prime recipients that would have had to ensure certification by and monitor compliance of their foreign NGO sub-recipients, most (321, or 82%) would have had to do this for the first time due to the expansion.¹⁸

Conclusion

Our analysis finds that the expansion of the Mexico City Policy by the Trump Administration greatly increased its reach, affecting a much greater number of foreign NGOs and funding than prior iterations. This is particularly the case given the Administration’s intent to expand the policy to include contracts, pending the outcome of a rule-making process. Importantly, while our analysis provides an initial estimate of the number of foreign NGOs that would be subject to the policy, it does not represent the entire universe, due to data limitations in identifying sub-recipients of U.S. support. Such an accounting would be important for more fully understanding the scope and impact. Furthermore, this analysis does not assess the extent to which affected NGOs carry out activities prohibited by the policy, some of whom may choose to end such activities or forgo U.S. funding. Ultimately, this next layer of analysis will be critical to assessing the impact of the expanded policy on the people served by U.S. global health programs, as the policy continues to be rolled-out.