Re: Early Impact of the Protecting Life in Global Health Assistance Policy in Kenya and Uganda

October 13, 2017

The Honorable Rex Tillerson

Secretary of State

U.S. Department of State

2201 C Street NW

Washington, DC 20520

Re: Early Impact of the Protecting Life in Global Health Assistance Policy in Kenya and Uganda

Dear Secretary Tillerson:

We are writing to share our initial research findings and recommendations on early implications of the US government’s “Protecting Life in Global Health Assistance” policy [hereinafter “the policy”].  This research included interviews with representatives of 45 organizations in Kenya and Uganda that currently receive US global health funding, many of whom had planned to apply for renewals or new funds in the coming year. These organizations provide health services or conduct health advocacy and range from small community-based organizations to large nongovernmental organizations (NGOs) that work in many different countries. We have been in touch with USAID during this process and have incorporated information provided by USAID in an October 11, 2017 letter responding to our research queries.

As you know, over many decades, the US government has made deep and long-term investments in Kenya and Uganda that have saved lives and contributed to important health gains. However, both countries still confront high incidence of HIV/AIDS and poor reproductive health indicators including high rates of preventable maternal deaths.

We have outlined our key findings below on how early impact of the policy is already beginning to undermine local health systems and health gains and have attached a detailed summary of our research for your consideration ahead of the six-month review of the policy scheduled for November.

Key Findings

Lack of information about the policy and overreach in implementation.

Most of the representatives, and almost all of those from groups that are directly implementing programs, said that their organizations have not received any direct communications or explanations of the policy from US government grant administrators. In its response letter to us, USAID noted that it has provided trainings on the policy to staff, published the standard provisions added to grants and cooperative agreements on its website, and created an online course. However, these have not met the need for public outreach, which should include widely-disseminated, user-friendly guidelines that explain the policy in detail. Despite this effort by USAID, many organizations we interviewed had questions about the scope and implementation of the policy, particularly on whether the policy applied to them; on access to US government-funded commodities; and, for those that choose to comply with the policy, on whether they could partner and meet with groups that do not. Several of the concerns and expected program shifts raised by these groups suggested an overly broad understanding of the policy’s restrictions, for example, ending community outreach on the risks of unsafe abortion.

Reductions of key sexual and reproductive health services from well-established organizations that cannot easily be replaced.

Family Health Options Kenya (FHOK) runs 16 healthcare facilities in Kenya, providing three million health services in 2016. FHOK will forego US funds to avoid being bound by the policy’s restrictions, and said this means about 60 percent of its funding will be lost or is under threat and they may have to cut as many as half of its services. FHOK has already canceled 100 planned outreach programs, including for cervical cancer screening, HIV testing, and family planning counseling, that typically reach 100 people each time. Due to losing US funds, FHOK has already, in August, closed one clinic, in Kenya’s coastal region, that typically served 50 individuals a day and specialized in providing women with long-acting contraceptives such as intrauterine contraceptive devices (IUCDs). FHOK is particularly worried about being forced to close additional clinics or reduce services where they are the only provider and there are no comparable alternatives, for example in a slum in Nairobi. Groups that are losing US funding were initially chosen as grantees or subgrantees because they were the best placed and qualified to do the work, and often there may not be comparable alternatives.

Loss of training and technical support to government clinics providing safe and legal abortion care, including under circumstances permissible under the policy, and post-abortion care.

Although government entities receiving US funds are exempt from the policy, many will be indirectly harmed and weakened. We interviewed four organizations in Kenya that provide training, equipment, and legal support to government clinics to provide safe abortion care.  All expressed concerns about the capacity of these clinics to continue to provide safe abortion care in cases permissible under national law, including in cases of rape, incest, or to save the life of the mother, without this support. For example, an organization that supports government clinics said the Kenyan ministry of health does not equip their facilities with abortion-related commodities.

Concerns from healthcare providers about the likelihood of increased unsafe abortions and associated maternal deaths.

Many of the health care providers we spoke to outlined the reasons they expected to see increased unsafe abortions and associated maternal deaths, including the cuts in community outreach and education efforts, drops in referrals, cuts to clinics and services where there is no likely replacement, uncertainty about accessibility of commodities, and the reduced capacity of government clinics that rely on NGO support to provide health services including safe abortion care.

Weakening of partnerships and coalitions working to end maternal mortality.

In Uganda, several members of the Coalition to End Maternal Mortality through Unsafe Abortion say they will have to leave the coalition as a result of the policy’s restrictions, weakening the strength and breadth of efforts to end preventable maternal deaths. Many groups that are planning to comply with the policy’s restrictions in order to keep their US funds also expressed confusion about the extent to which they could still attend meetings or trainings offered by groups that do not adhere to the policy’s requirements.

Negative impacts for PEPFAR’s work with key populations.

Sex worker organizations felt they had to make cruel programmatic choices as a result of this policy. For instance, we interviewed groups who had to choose between funds for lifesaving antiretroviral therapy for their members or lifesaving reproductive health services. Both are desperately needed. These programming shifts and choices undermine hard-won relationships of trust developed with a key population on the frontlines of efforts to fight HIV.

A six-month review is insufficient to monitor impacts.

Many organizations have not yet come up for initiation or renewals of grants and have not yet had to cut or shift their programs and advocacy. A six-month review cannot provide a meaningful assessment of the policy’s full impacts. The upcoming review should emphasize this fact and outline plans for subsequent and comprehensive assessments of impact.

Recommendations

This expansive policy is detrimental to the contributive role the US government has proudly played in building sustainable health systems and saving lives. In order to reverse these harmful and negative effects we believe President Trump should rescind this draconian policy. Until that time, however, the State Department, USAID, and other US agencies that provide global health funding should take every step to ensure that harmful consequences, such as setbacks in the prevention and treatment of HIV, and increased maternal deaths and injuries are avoided, including through:

• Conducting a comprehensive, transparent, annual review of the policy to assess its impact and outlining actions it will take to address harms. The review should include robust consultation with a wide variety of stakeholders and assess changes in health outcomes such as injuries and deaths from unsafe abortions. 
• Disseminating clear and detailed information about the policy and compliance requirements in an accessible way to organizations, including sub-recipients and others with no direct contact with grant administrators. Ensure that organizations that have certified compliance have a full understanding of the policy and are not driven by misunderstanding to unnecessarily curtail their programs.
• Strengthening sexual and reproductive health programs, including for post-abortion care services and for safe abortion care in the case of incest, rape and to save the life of the woman.
• Utilizing the Secretary’s power to grant case-by-base exemptions to mitigate the harm to US investments in global health and security.

We appreciate your attention to these important issues and would be happy to meet to discuss them further.

Sincerely,

Sarah Margon                                                 Nisha Varia

Washington Director                                       Advocacy Director, Women’s Rights

Cc

Mark Green, administrator, US Agency for International Development

Brenda Fitzgerald, MD, director, Centers for Disease Control and Prevention

Early Impact of the Protecting Life in Global Health Assistance Policy in Kenya and Uganda

Introduction

In January 2017, United States President Donald Trump issued a “Presidential Memorandum Regarding the Mexico City Policy,” reinstating and dramatically expanding the “Mexico City Policy” that has been adopted by every Republican administration since 1984.[1]

In May, the US State Department renamed this policy “Protecting Life in Global Health Assistance.”[2] Under this policy, foreign non-governmental organizations receiving US global health assistance must certify that they do not use their own, non-US funds to provide abortion services except in cases of rape, incest, or to save the life of the woman, counsel patients about the option of abortion or refer them for abortion, or advocate for the liberalization of abortion laws.

When the Mexico City Policy was previously in effect, it applied specifically to US family planning funds, approximately US$575 million in fiscal year 2016. President Trump’s policy extends restrictions to an estimated $8.8 billion in US global health assistance, including funding support for family planning and reproductive health, maternal and child health, nutrition, HIV/AIDS—including the President’s Emergency Plan for AIDS Relief (PEPFAR), prevention and treatment of tuberculosis, malaria (including the President’s Malaria Initiative), infectious diseases, neglected tropical diseases, and to water, sanitation, and hygiene programs.

Given that the US government is implementing this rule on a rolling basis as new awards are initiated or existing programs are renewed, it is too early to know the full scope of which organizations will comply or not, how their programs will be affected, and any resulting health impacts.  The US Agency for International Development (USAID) announced the guidance for implementing the policy for family planning funds in March, and the State Department released the standard provisions for grants and cooperative agreements for the rest of global health assistance in May. The public rulemaking for contracts has not begun.

Human Rights Watch conducted research to gauge understanding of the policy in Kenya and Uganda—two countries with poor reproductive health indicators, high incidence of HIV/AIDS, and heavy reliance on US health assistance—and to develop an initial picture of anticipated shifts or cuts in programming. This research did not examine health outcomes as it is too early to document such impacts.

Methodology

A Human Rights Watch women’s rights researcher visited Kampala and Nairobi in July 2017. The researcher interviewed, in person or via telephone, representatives of 24 organizations in Kenya and 21 organizations in Uganda. Human Rights Watch targeted for interviews organizations that would be affected by the policy.

These organizations vary greatly in size from small community-based organizations to large nongovernmental organizations (NGOs) that work in many different countries. Most interviewees worked at organizations providing clinical services or supporting government clinics, performing outreach work with vulnerable populations, or conducting health advocacy. Most organizations that we interviewed are national organizations and a smaller number are regional or global. We also interviewed some US organizations that partner with foreign organizations through subgrants and agreements, both non-profit and for-profit.

Many organizations requested to remain anonymous, and we have respected their wishes here.

Health Indicators in Kenya and the Scope of US Assistance

The United States is an influential actor promoting access to quality health services in Kenya, and has contributed to health gains in recent years. Kenya is the top recipient of USAID funds in the region.[3] In 2015 USAID invested $941 million in Kenya, including $511 million on health and population, of which $117 million were PEPFAR funds.[4] In 2016, 64 percent of the HIV/AIDS sector was supported by PEPFAR funds.[5]

Kenya’s 2014 Demographic and Health Survey estimated the country’s maternal mortality ratio at 362 deaths per 100,000 live births.[6] Maternal deaths account for 14 percent of all deaths of women ages 15 to 49.[7] An estimated 18 percent of all married women ages 15 to 49 have an unmet need for modern contraception.[8] Increased access to contraception reduces unwanted pregnancies, unsafe abortions, and maternal deaths and injuries.[9] Forty-two percent of Kenyans are under 15 years old and family planning needs are likely to grow as this population enters its childbearing years.[10]

Despite a decline in new HIV infections, Kenya continues to have one of the highest burdens of HIV infections in the world by total numbers, and is among the six highest in the world.[11] Prevalence is higher among women (6.3 percent) than men (5.5 percent).[12] Fifty-one percent of new infections in 2015 were of young people between 15 to 24 years, and women outnumbered men in total infections that year.[13] Sex workers have the highest prevalence rate (29 percent) and most are female.[14]

Legal Status of Abortion and Estimates of Unsafe Abortions

The 2010 Kenyan constitution liberalized access to abortion, allowing for abortion if the life or the health of the pregnant woman is in danger.[15] Kenya’s 2016 health bill defines health broadly as social, psychological and physical well-being and not just the absence of disease.[16]

However, in 2013, the Director of Medical Services withdrew the government’s 2012 guidelines for reducing morbidity and mortality from unsafe abortion, banned the use of Medabon, a drug used in medical abortions, and banned safe abortion trainings for health care professionals.[17]

Kenya’s penal code retains a seven-year imprisonment clause for a woman who unlawfully attempts an abortion, fourteen years for persons who unlawfully administer an abortion, and three years for unlawfully supplying drugs or instruments for an abortion.[18]

Unsafe abortions are among the top five causes for maternal mortality in Kenya, accounting for about 10 percent of maternal deaths.[19] All over the world, women and girls access dangerous abortions when they cannot access safe abortion care.[20] A government study in Kenya found that there were an estimated 464,690 induced abortions in 2012, or 48 induced abortions per 1,000 women of reproductive age, higher than other countries in the region.[21]  Many of these abortions result in injury or death.[22] Post abortion care, which can save a woman’s life, can often be poor quality.[23] Women often delay for up to a week before seeking medical help because of stigma and fear of legal action. Young women and girls are those most often affected. Almost half—48 percent—of women and girls seeking assistance after unsafe abortions in Kenya are 25 years or younger.[24]

Health workers and advocates Human Rights Watch interviewed reported widespread confusion in the health sector as to when legal abortions can be provided. Interviewees agreed that, in general, most government facilities do not provide safe abortion care for preservation of health, and that patients usually only go to government facilities to get an abortion if they already know that a particular doctor or clinic will treat them.  

Health Indicators in Uganda and the Scope of US Assistance

Fifty-four percent of Uganda’s whole government budget is from overseas development assistance and the US government is by far the largest donor.[25] In 2015, USAID spent $591 million in Uganda, making it the seventh-largest recipient in the region.[26] USAID spent $360 million on health and population, of which $150 million were PEPFAR funds.[27] The US increased their spending on HIV/AIDS programs to $402 million for 2017.[28] In Uganda, US global health funds pay for 890,000 HIV positive Ugandans’ anti-retroviral treatment, about 93 percent of such patients.[29]

Uganda’s maternal mortality rate is 336 deaths per 100,000 live births.[30] The unmet need for family planning is estimated to be at 32 percent for unmarried sexually active women and at 28 percent for married women.[31] Comprehensive family planning is key for young people. Thirty-three percent of women ages 20 to 24 had a baby before they were 18 years old.[32]

Despite gains in slowing the epidemic, Uganda’s HIV prevalence is at 6.5 percent, the tenth-highest in the world.[33] In 2016, there were 1.4 million people living with HIV, and 28,000 deaths due to AIDS-related illnesses.[34] ART coverage is estimated at 67 percent.[35] As in Kenya, HIV affects young women and girls disproportionately. HIV prevalence for young women ages 15 to 24 was estimated at 3.8 percent and 1.9 percent for young men.[36]

Legal Status of Abortion and Estimates of Unsafe Abortion

The government estimated that 8 percent of maternal deaths in 2010 were due to abortions.[37] Despite legal restrictions, an estimated 314,300 abortions took place in 2013.[38] This translates to 14 percent of all pregnancies.[39]

The law in Uganda on termination of pregnancy is highly restrictive, and, together with Ugandan Ministry of Health and other government guidelines, confusing and unclear. Under the constitution “no person has the right to terminate the life of an unborn child except as may be authorized by law.”[40] The penal code broadly prohibits abortions but makes an exception to save the life of the woman, but no further laws have been provided to clarify this or other exceptions.[41] The penal code includes imprisonment for up to 14 years for those who administer unlawful abortions, and seven years for a woman or girl intending to abort.[42]

Court cases expanded the interpretation of exceptions to save the life of the woman to include preservation of a woman’s physical and mental health.[43] The 2006 National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights provided for abortion in cases of severe maternal illnesses, severe foetal abnormalities, cervical cancer, HIV-positive women requesting a termination and rape, incest and defilement.[44] An effort among government officials, civil society, and advocate doctors, which lasted into 2016, to produce a new set of guidelines, “Reducing Maternal Morbidity and Mortality from Unsafe Abortion in Uganda: Standards and Guidelines,” has stalled.  Many health providers and women are not aware of the health interpretation, and there remains uncertainty about whether, “an apparent clinical life risk will be seen as such under the law, especially if there are conflicting medical opinions on the level of risk a woman is facing….  This lack of clarity has made legal abortion difficult to obtain and to provide.”[45]

In 2013, an estimated 128,682 women were treated for abortion complications and an estimated 314,304 induced abortions occurred.[46]. These are unlikely to represent the full numbers as many women may not seek health assistance for their injuries due to stigma or fear of legal repercussions. The cost to the health system is significant, at some $13.9 million a year.[47]

Human Rights Watch Findings on Early Impacts of the Policy

Lack of information about the policy and overreach in implementation.

Few of the representatives we spoke to had received any direct communications or explanations of the policy from US government grant administrators, and almost none of those who are directly working with communities to implement programs, usually sub-recipients to the “prime” organization receiving grants and awards.

In its October 11, 2017 letter to us, USAID noted that it has provided trainings on the policy to its staff, published the standard provisions added to grants and cooperative agreements on its website, and created an online course. However, these have not met the need for public outreach, for example widely-disseminated, user-friendly guidelines that explain the policy in detail.

Many organizations had questions about the policy’s scope and implementation, particularly on whether the policy applied to specific parts of their programming, on access to US government-funded commodities, and on their ability, under the policy, to partner and meet with groups that provide or talk about abortions. Several of the concerns and expected program shifts raised by these groups suggested an over-interpretation of the policy’s restrictions.

Several organizations were unsure whether they could safely provide abortions or referrals for abortions in cases of rape, incest, or endangerment of the mother’s life, or post-abortion care without threatening their US funds even though these activities would not violate the policy. Representatives had questions about the parameters of the restrictions on advocacy, for example if they could conduct advocacy on legal reforms to establish or clarify abortion exceptions in Kenyan and Ugandan law.

Several groups said they would no longer be able to speak publicly or were ending community outreach and training programs on the risks of unsafe abortion. One group said they would no longer be able to sign letters protesting the policy, although making such statements would not violate the compliance requirements as long as the letters do not advocate for liberalizing abortion laws.

In Uganda, seven organizations told Human Rights Watch that, concerned that women and girls will otherwise seek unsafe abortions, they frequently refer women and girls to healthcare workers who then make their own medical assessment as to whether they can provide an abortion under Ugandan law. Their understanding is that they will no longer be able to do this if they comply with the policy’s requirements.

A representative from an organization that provides free testing and counseling for HIV said they did not want to comply with the policy’s requirements but had no choice but to do so as all of their funding is from PEPFAR. Previously they linked HIV services with comprehensive family planning and sexual and reproductive health advice, however because of confusion over what referral services they can provide now, they have canceled training for more than 30 staff on providing family planning or abortion referrals to other providers.[48] The representative said, “some clients are coming and only getting testing and counselling, nothing on family planning because of this.”

Reductions of key sexual and reproductive health services from well-established organizations that cannot easily be replaced.

Among our interviewees, at least two major healthcare providers in Kenya and two major healthcare providers in Uganda said that they face significant cuts to their overall budget because they will not sign funding agreements requiring compliance with the policy.

Family Health Options Kenya (FHOK), an International Planned Parenthood Federation affiliate, runs 16 healthcare facilities, including in underserved communities, and provided 3 million health services in 2016.[49] FHOK has decided to forego US funds to avoid being bound by the policy’s restrictions on abortion. The organization said this means about about 60 percent of its funding is already known to be lost or under threat and they may have to cut up to half of their services. A representative said, “More than half of what we expected this year has already gone, and we are expecting it to get worse…  More than 100 outreach efforts have already been stopped. At least 100 people are normally reached with services every one of these trips, they have no other access to healthcare… We are their primary contact.” These outreach services include cervical cancer screening, HIV testing, and family planning counseling. FHOK has already closed one clinic, in August, in Kenya’s coastal region, due to lack of funds. They are particularly worried about being forced to close further clinics or reduce services where they are the only provider, for example in a slum in Nairobi.

In Uganda, Reproductive Healthcare Uganda (RHU), another International Planned Parenthood Federation affiliate NGO specializing in sexual and reproductive healthcare, serves some 1.2 million people a year, including through 17 clinics. The organization will now lose funding for three programs previously supported by US global health funds.[50] For example, RHU will no longer participate in the USAID-funded Advocacy for Better Health program administered by PATH, which supports 21 partner organizations to strengthen local communities’ ability to advocate for better government health services. The organization has lost roughly $500,000 a year as a result. Representatives of RHU noted that the loss is not just financial, as they had built relationships and made important progress with local communities. For example, they supported communities to advocate successfully to ensure that a local government clinic stay open for all working hours; to ensure an ethnic group was no longer shut out from services; and to improve supply chains to prevent stock outs. They will now end their work on this program.

RHU also lost funding for a program that built knowledge of human rights principles in sexual and reproductive healthcare among government workers, for example privacy, confidentiality and informed choice in contraceptive methods. “We had built that project to be sustainable, it’s a real pity we had to end our work,” said RHU’s director, Jackson Chekweko.[51]

In Uganda, the USAID Advocacy for Better Health program is losing at least one other key partner chosen because of the quality of their work. The Center for Health, Human Rights and Development, which will not sign funding agreements requiring compliance with the policy, plays an important role in Uganda’s health advocacy community. A representative said, “We will lose funds and an important advocacy presence on maternal health work, it was a really great program.”[52]

In countries like Uganda or Kenya where, in many regions, healthcare is limited, the loss or reduction in programming even in just a few organizations can be felt broadly. NGO representatives in both countries, where sexual and reproductive healthcare indicators are poor, saw the loss of programming from large sexual and reproductive healthcare organizations as a cause for considerable concern. A leader of a Ugandan organization that works with young people, providing mentorship and linking them with health information and services said that they only referred girls and young women to three organizations because of their youth-friendly approach. Two of these, including Reproductive Healthcare Uganda, have been affected by the policy and will likely have to cut services.

Loss of training and technical support to government clinics providing safe and legal abortion care, including for instances permissible under the policy, and post-abortion care.

We interviewed four organizations in Kenya that provide training, equipment, and legal support to government clinics to provide safe abortion care and post-abortion care. Three of these organizations expect they will sign funding agreements requiring compliance with the policy. All four expressed concerns about the capacity of these clinics to provide safe abortion care in legally permissible cases, including to save the life of the mother, without their support.

One regional health organization said it intends to comply with the policy to protect its funding in rural areas where it is the only health care provider. US health funds comprise roughly 40 percent of its budget. They noted that in one of the regions where they work, they are the main organization providing government healthcare workers with trainings and equipment to provide safe abortion care and post-abortion care in compliance with Kenyan law. They expect significant disruptions to this work.

Another large health organization that focuses on maternal, child, and family health and HIV services said they would likely sign funding agreements requiring compliance with the policy given about 80 percent of their budget relies on US global health assistance. A senior member of the organization said, “We will just have to forget about the women who will suffer, [other donor] money is just not enough, we won’t be able to reach the community at all.”[53]  They have trained and equipped almost 70 government staff to provide safe abortion care across many government clinics, and they provide safe abortion care according to Kenyan law in their own clinic. The representative noted that given confusion about Kenya’s laws, government staff are hesitant to provide abortion services and have needed both training and legal support. She said, “The doctors are really afraid of the law and were turning women away [and] the ministry of health does not supply abortion related commodities to their facilities.” She fears they will stop providing safe-abortion care without their support.

A third example is Reproductive Health Network Kenya (RHNK), which trains a membership network of doctors, nurses and midwives across Kenya on safe abortion care and works to increase access to family planning in poor areas.[54] The organization helps ensure that healthcare providers stay within the law with regards to abortion and have access to legal assistance. RHNK’s primary donor relies heavily on US global health funds and will have to reduce the support it provides to partners because it will not agree to the policy’s restrictions. As a result, RHNK’s budget has dropped from about 30 to 35 million Kenyan shillings (around USD$300,000) a year to about 9 million Kenyan shillings (around USD$87,000). A representative said that many of their projects have ground to a halt. “We have not been able to assess any facilities to check that they are operating totally lawfully, supervise any of the doctors or other staff, no new member has received training,” the program director said. “We had to lay off two staff,” she added.[55] They provided commodities like manual vacuum aspiration kits, couches, autoclaves, speculums and other equipment to doctors, midwives and other health care workers, including in the government system. They expect these workers will now struggle to obtain this equipment.

A Kenyan organization that works with orphans and vulnerable children said that they were considering giving up their work on access to safe abortion care to be able to receive PEPFAR grants. The organization works with government health clinics. “All the 20 facilities we support now have a safe abortion care provider, a doctor or a nurse or clinical officer,” he said. “We also provide them with misoprostol and mifepristone and manual vacuum aspirators.”[56] He said these government clinics would struggle to continue to provide safe abortion care without their support.

Weakening of partnerships and coalitions working to end maternal mortality.

In Uganda, the policy will hurt the diversity, strength, and reach of the advocacy community working to end maternal mortality through unsafe abortion. The Coalition to Stop Maternal Mortality Through Unsafe Abortion, founded in mid-2012, is run by the Center for Health Human Rights and Development (CEHURD). CEHURD and some 20 members of the coalition campaign for a less restrictive law on abortion and for the Ugandan government to provide clarity on the legal status of abortion through legislation and guidelines. The body has worked with the ministry of health to provide standards and guidelines.[57] The coalition also conducts advocacy meetings with parliamentarians and other politicians, and its members speak in the media and produce reports that provide public information on the dangers of unsafe abortion.

At least four organizations expect that they will have to leave the coalition or scale back their participation. One large Ugandan organization had previously advocated for government providers to be correctly equipped to provide abortions and post abortion care. A representative said, “We do not want to drop from the coalition, we see cases of unsafe abortion every day.”[58] Another organization that is still weighing its options said they may have to sign funding agreements requiring compliance with the policy but that doing so would conflict deeply with their values. “We support the right to safe abortion care and our members have been trained in providing this service, understanding its importance, and in post abortion care,” she said. “Our [staff] are working at the community level, they really see the harm caused by unsafe abortion.”[59]

Concerns from healthcare providers that these restrictions, resulting cuts, and shifts in programming will result in increased unsafe abortions and associated maternal deaths.

Human Rights Watch interviewed several healthcare providers whose organizations will be complying with the policy but who said that they were dismayed to end lifesaving safe abortion care services for women and girls and anticipated an increase in unsafe abortions, injuries and deaths of women and girls in the communities they serve. “Simply: women will die,” one service provider said.[60] “We already lost a peer educator to unsafe abortion, she was HIV-positive and when she got pregnant it was too much for her to bear, she was desperate,” the head of an organization working with HIV-positive women in Uganda said. ‘This is what we were trying to stop, but now we have to stop.”[61] They also feared the loss of hard-won trust from the communities they work in, and that by suddenly stopping their provision of safe abortion information and services, confusion in the communities they serve would only increase. They said the policy exacerbates the ambiguity of abortion laws in both countries and where key governments standards and guidelines for safe abortion care are missing.

One organization in Kenya had trained community volunteers about safe abortion, and now, “It is going to be very embarrassing if a woman is sick and needs an abortion that we cannot treat her now, although we used to do this… We’re in a real fix.”[62] The representative said their clinics provided roughly 3,000 safe abortions a year and that cases of post-abortion care had reduced by about half in the past year. “[Now] we will begin to see cases of incomplete abortions go up. (Like) before we began our work when we were seeing terrible things, women with sticks stuck in their uteruses and vaginas, perforated uteruses, heavy bleeding and infections.”

Trust For Indigenous Culture And Health (TICAH) receives no US global health funds. Among its programs is a hotline for women and girls, and as part of this work provides referrals to women and girls on where they can get safe abortion care. They note that the policy means there will be fewer clinics and a limited geographic spread where women and girls can safely access abortion care. Furthermore, their partners may have to begin charging fees whereas they currently provide services for free or at a reduced price. “This may put safe abortion care out of reach for some ... they will go to the quacks.”[63]

Negative impacts for PEPFAR’s work with key populations.

The President’s Emergency Plan for Aids Relief [PEPFAR] website says: “PEPFAR stands firmly and unequivocally with and for key populations. These groups include gay men and other men who have sex with men, people who inject drugs, sex workers, transgender persons, and prisoners.” These marginalized and stigmatized groups often struggle to access healthcare.

In Kenya, Human Rights Watch interviewed two organizations led by sex workers as well as three working closely with and providing medical services to sex workers.”.  These organizations planned to comply with the policy’s requirements, but were concerned about ending safe abortion work with their members or patients.

One of these organizations links sex workers to HIV/AIDS services, economic empowerment programs, and health rights training. Sixty percent of their budget relies upon PEPFAR funds, including through DREAMS, a PEPFAR program that targets young women and adolescent girls in 10 countries in sub-Saharan Africa. The organization’s director said the choice was painful: “We had to take PEPFAR money because our women are dying of HIV… [But] we [also] have women and girls dying in the slums because they can’t get safe abortions, they take drugs, insert needles into their private parts,” she said. “Every year we lose two to five girls [or women], this work has a high risk of unwanted pregnancy.”[64] They will cancel a planned project targeting sex workers on family planning, other sexual and reproductive healthcare, and safe abortion care.

Another organization, which works with around 4,000 sex workers plans to end trainings and awareness-raising around unsafe abortion and referrals to safe abortion services. A representative said, “It’s bad because safe abortion care is very much needed by sex workers.”[65] A third organization relies on PEPFAR funds for about half of its budget, and said, “We are in the middle of planning on scaling up PrEP [pre-exposure prophylaxis] to 12,000 sex workers, we cannot just stop such an important project, we’re very tied into this money.”[66] The organization has eight drop-in centers which will no longer now provide referrals for safe abortion services and will stop training sex worker peer educators on safe abortion referrals.

A Kenyan NGO that campaigns for women’s health rights, including safe abortion care, works with adolescents and young women to raise awareness of their rights and health as part of PEPFAR’s DREAMS innovation challenge.[67] The organization is already halfway through its grant and has built relationships based on trust between and with groups of girls and young women. The organization has also created informal group meetings where young women and adolescent girls can talk openly about sex, their bodies, boys and men, and their rights. “But an unintended consequence of this work is that girls are asking for safe abortions, and info about that,” she said. “To not tell them about [safe abortion] services is breaking trust.” The organization will receive a new tranche of funding at the end of 2017 when it may have to review how openly staff can talk with women and girls.