U.S. global health aid policy and family planning in sub-Saharan Africa

Abstract

The Trump administration reinstated and expanded the Mexico City Policy (MCP) in 2017 as the Protecting Life in Global Health Assistance (PLGHA) policy, forbidding international organizations receiving all U.S. health assistance from promoting abortion. Existing evidence suggests that abortion rates rise under the MCP, but the direct effect of U.S. funding restrictions on supply and use of family planning has received less attention. By studying PLGHA's impact on health service delivery providers and women in eight sub-Saharan African countries, we are able to fill this gap. We find that health facilities provide fewer family planning services, including emergency contraception, and that women are less likely to use contraception and more likely to have given birth recently under the policy. These findings suggest that PLGHA has important unintended consequences that are detrimental to reproductive health and the autonomous decision-making of health service providers and women.

Fig. 1.. Effect of Protecting Life in Global Health Assistance (PLGHA) on Service Delivery.

(A) Results for whether facilities provide family planning methods. (B) Results for whether facilities charge for family planning methods. (C) Results for whether facilities experienced a recent stockout of family planning methods. (D) Results for the average length of stockouts. (E) Results for how facilities support community health volunteers (CHV) and mobile outreach programs. (F) Results for facility provision of other health services. In each panel, the dot represents the coefficient on the interaction term between PLGHA_t × High_c, which measures the effect of PLGHA in high-exposure countries, estimated on a different facility-level outcome, and captures the relative effect of being in a more exposed country when PLGHA’s funding restricted were imposed. Each country’s exposure to the PLGHA is classified as “High” if it received above the median per capita global health assistance or “Low” if it received below the median per capita global health assistance. The coefficient estimate is also reported above each dot, with SEs in parentheses. The horizontal lines are 95% confidence intervals, and the dashed vertical line is at 0. N = 15,490 facility-year observations. p.p, percentage points.

Fig. 2.. Effect of Protecting Life in Global Health Assistance (PLGHA) on women.

Each dot represents the coefficient on the interaction term between PLGHA_t × High_c, which measures the effect of PLGHA in high-exposure countries, estimated on a different woman-level outcome, and captures the relative effect of living in a more exposed country when PLGHA’s funding restricted were imposed. Each country’s exposure to the PLGHA is classified as High if it received above the median per capita global health assistance or Low if it received below the median per capita global health assistance. Above each dot, we report the coefficient and SEs in parentheses. The horizontal lines are 95% confidence intervals, and the dashed vertical line is at 0. N = 249,289 woman-year observations. p.p, percentage points.