A U.S. foreign policy that cuts money to nongovernmental organizations performing or promoting abortions abroad has actually led to an increase in abortions, according to Stanford researchers who have conducted the most comprehensive academic study of the policy’s impact.

Eran Bendavid and Grant Miller — both associate professors at Stanford University School of Medicine and core faculty members at Stanford Health Policy — and doctoral candidate Nina Brooks find that abortions increased among women living in African countries where NGOs, such as the International Planned Parenthood Federation, were most vulnerable to the policy’s requirements.

The policy, widely known as the Mexico City Policy, explicitly prohibits U.S. foreign aid from flowing to any NGO that will not abide by the policy’s main condition: no performing or discussing abortion as a method of family planning, even if just in the form of education or counseling.

The policy has been a political hot potato since its inception. Enacted under Ronald Reagan in 1984, it’s been enforced by subsequent Republican administrations while Democrats in the White House revoked the policy within days of taking office.

The study by Brooks, Bendavid and Miller, published June 27 in The Lancet Global Health, looked at the policy’s effects in more than two dozen African countries over a span of 20 years under three presidents: Bill Clinton, George W. Bush and Barack Obama. It finds that, when the policy was in place during the Bush years, abortions were 40 percent higher relative to the Clinton and Obama administrations.

When the policy was suspended during Obama’s two terms, the research shows that the upward trend in abortion rates reversed.

“Our research suggests that a policy that is supported by taxpayers ostensibly wishing to drive down abortion rates worldwide does the opposite,” said Bendavid, a faculty affiliate of the Stanford King Center on Global Development, which is part of the Stanford Institute for Economic Policy Research (SIEPR).

A key reason for the uptick in abortions is that many NGOs affected by the policy also provide contraceptives – and funding cuts mean birth control is harder to get, said Brooks.

“By undercutting the ability to supply modern contraceptives, the unintended consequence is that abortion rates increase,” she said.

And the policy’s scope has expanded under the Trump administration. While it originally restricted aid directed only toward providing family planning and reproductive health services, President Trump has extended the policy to cover any group engaged in global health, including organizations providing services for HIV or child health – not just family planning.

Groundbreaking Research

The stakes are high. America is the world’s largest provider of development assistance and spent about $7 billion on international health aid in 2017. Many women in sub-Saharan Africa depend on this aid for contraceptives.

In sub-Saharan Africa, NGOs are often primary providers of family planning services. Two of the world’s largest family planning organizations – International Planned Parenthood Federation and Marie Stopes International – have forfeited large sums of U.S. cash for refusing to comply with the policy, according to news reports.

The research findings were based on records of nearly 750,000 women in 26 sub-Saharan African countries from 1995 to 2014. When the policy was in effect under George W. Bush, contraceptive use fell by 14 percent, pregnancies rose by 12 percent and abortions rose by 40 percent relative to the Clinton and subsequent Obama years – an impact sharply timed with the policy and in proportion to the importance of foreign assistance across sub-Saharan Africa.

The paper is the second study of the rule’s impact by Bendavid and Miller, who are both faculty members of Stanford Health Policy. The research is also one of the very few evidence-based analyses of the policy.

Their earlier research, the first quantitative, large-scale effort to examine the policy’s impacts, looked at a smaller set of African countries during the Clinton and Bush administrations and also found an increase in abortion rates when the policy was enacted in 2001.

“Our latest study strengthened our earlier findings because we were able to look at what happens when the rule was turned off, then on, and then off again,” said Bendavid, referring to the policy’s whipsawing under Clinton, Bush and then Obama.

Miller, who is the director of the King Center and a SIEPR senior fellow, says the team’s research reveals a deeply flawed policy.

“We set out to provide the best and most rigorous evidence on the consequences of this policy,” he said. “What we found is a clear-cut case of government action that everyone on all sides of the abortion debate should agree is not desirable.”

Signs of a Global Pushback

Brooks also notes that their findings may underestimate the rule’s full impact.

“The excess abortions performed due to the policy are more likely to be performed unsafely, potentially harming women beyond pregnancy terminations,” she said.

Under Trump, the international response to U.S. funding cuts has shifted. Norway, Canada and several other countries have pledged to increase funding of international NGOs affected by the policy – though not by enough to cover the expected shortfall, says Miller.

“This shows us,” he said, “that despite the intense partisanship in the U.S. over the rule and its implementation, there are ways that policymakers around the world can offset its effects – by ensuring higher levels of family planning funding, for example.”

Most studies that look at whether democracy improves global health rely on measurements of life expectancy at birth and infant mortality rates. Yet those measures disproportionately reflect progress on infectious diseases — such as malaria, diarrheal illnesses and pneumonia — which relies heavily on foreign aid.

A new study led by Stanford Health Policy's Tara Templin and the Council on Foreign Relations suggests that a better way to measure the role of democracy in public health is to examine the causes of adult mortality, such as noncommunicable diseases, HIV, cardiovascular disease and transportation injuries. Little international assistance targets these noncommunicable diseases. 

When the researchers measured improvements in those particular areas of public health, the results proved dramatic.

“The results of this study suggest that elections and the health of the people are increasingly inseparable,” the authors wrote.

A paper describing the findings was published today in The Lancet. Templin, a graduate student in the Department of Health Research and Policy, shares lead authorship with Thomas Bollyky, JD, director of the Global Health Program at the Council on Foreign Relations.

“Democratic institutions and processes, and particularly free and fair elections, can be an important catalyst for improving population health, with the largest health gains possible for cardiovascular and other noncommunicable diseases,” the authors wrote.

Templin said the study brings new data to the question of how governance and health inform global health policy debates, particularly as global health funding stagnates.

“As more cases of cardiovascular diseases, diabetes and cancers occur in low- and middle-income countries, there will be a need for greater health-care infrastructure and resources to provide chronic care that weren’t as critical in providing childhood vaccines or acute care,” Templin said.

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Free and fair elections for better health

In 2016, the four mortality causes most ameliorated by democracy — cardiovascular disease, tuberculosis, transportation injuries and other noncommunicable diseases — were responsible for 25 percent of total death and disability in people younger than 70 in low- and middle-income countries. That same year, cardiovascular diseases accounted for 14 million deaths in those countries, 42 percent of which occurred in individuals younger than 70.

Over the past 20 years, the increase in democratic experience reduced mortality in these countries from cardiovascular disease, other noncommunicable diseases and tuberculosis between 8-10 percent, the authors wrote.

“Free and fair elections appear important for improving adult health and noncommunicable disease outcomes, most likely by increasing government accountability and responsiveness,” the study said.

The researchers used data from the Global Burden of Diseases, Injuries, and Risk Factors Study; V-Dem; and Financing Global Health databases. The data cover 170 countries from 1970 to 2015.

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Watch: Some of the authors of the study discuss the significant their findings: 

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Foreign aid often misdirected

And yet, this connection between fair elections and global health is little understood.

“Democratic government has not been a driving force in global health,” the researchers wrote.  “Many of the countries that have had the greatest improvements in life expectancy and child mortality over the past 15 years are electoral autocracies that achieved their health successes with the heavy contribution of foreign aid.”

They note that Ethiopia, Myanmar, Rwanda and Uganda all extended their life expectancy by 10 years or more between 1996 and 2016. The governments of these countries were elected, however, in multiparty elections designed so the opposition could only lose, making them among the least democratic nations in the world.

Yet these nations were among the top two-dozen recipients of foreign assistance for health.

Only 2 percent of the total development assistance for health in 2016 was devoted to noncommunicable diseases, which was the cause of 58 percent of the death and disability in low-income and middle-income countries that same year, the researchers found.

“Although many bilateral aid agencies emphasize the importance of democratic governance in their policy statements,” the authors wrote, “most studies of development assistance have found no correlation between foreign aid and democratic governance and, in some instance, a negative correlation.”

Autocracies such as Cuba and China, known for providing good health care at low cost, have not always been as successful when their populations’ health needs shifted to treating and preventing noncommunicable diseases. A 2017 assessment, for example, found that true life expectancy in China was lower than its expected life expectancy at birth from 1980 to 2000 and has only improved over the past decade with increased government health spending. In Cuba, the degree to which its observed life expectancy has exceeded expectations has decreased, from four-to-seven years higher than expected in 1970 to three-to-five years higher than expected in 2016.

“There is good reason to believe that the role that democracy plays in child health and infectious diseases may not be generalizable to the diseases that disproportionately affect adults,” Bollyky said. Cardiovascular diseases, cancers and other noncommunicable diseases, according to Bollyky, are largely chronic, costlier to treat than most infectious diseases, and require more health care infrastructure and skilled medical personnel.  

The researchers hypothesize that democracy improves population health because:

1. When enforced through regular, free and fair elections, democracies should have a greater incentive than autocracies to provide health-promoting resources and services to a larger proportion of the population;
2. Democracies are more open to feedback from a broader range of interest groups, more protective of media freedom and might be more willing to use that feedback to improve their public health programs;
3. Autocracies reduce political competition and access to information, which might deter constituent feedback and responsive governance.

Various studies have concluded that democratic rule is better for population health, but almost all of them have focused on infant and child mortality or life expectancy at birth.

Over the past 20 years, the average country’s increase in democracy reduced mortality from cardiovascular disease by roughly 10 percent, the authors wrote. They estimate that more than 16 million cardiovascular deaths may have been averted due to an increase in democracy globally from 1995 to 2015. They also found improvements in other health burdens in the countries where democracy has taken hold: an 8.9 percent reduction in deaths from tuberculosis, a 9.5 percent drop in deaths from transportation injuries and a 9.1 percent mortality reduction in other noncommunicable disease, such as congenital heart disease and congenital birth defects.

“This study suggests that democratic governance and its promotion, along with other government accountability measures, might further enhance efforts to improve population health,” the study said. “Pretending otherwise is akin to believing that the solution to a nation’s crumbling roads and infrastructure is just a technical schematic and cheaper materials.”

The other researchers who contributed to the study are Matthew Cohen, Diana Schoder, Joseph Dieleman and Simon Wigley, from CFR, the University of Washington-Seattle and Bilkent University in Turkey, respectively.

Funding for the research came from Bloomberg Philanthropies and the Bill & Melinda Gates Foundation. Stanford’s Department of Health Research and Policy also supported the work.

When a 2010 study concluded that about half the money given to international governments for providing health care services isn’t used as intended, skeptics who argued that foreign aid is largely wasted were handed a powerful piece of data to bolster their claims.

But Stanford researchers Rajaie S. Batniji and Eran Bendavid say those findings are flawed. In an article featured in the May 8th edition of PLoS Medicine, Batniji and Bendavid say the two-year-old study by researchers at the University of Washington should not be used to guide decisions about how much money to give and who should get it.

“We can’t say that there’s absolutely no displacement of foreign aid, but these earlier findings are too tenuous for the basis of policy,” said Batniji, an affiliate of the Center on Democracy, Development, and the Rule of Law at the Freeman Spogli Institute for International Studies.

Batniji and Bendavid, an affiliate of FSI’s Stanford Health Policy and an assistant professor of medicine, are taking on the 2010 study – which appeared in the Lancet – at a critical time for foreign assistance programs.

The United States, which gives about half of all the world’s health aid, plans to chop its $10 billion budget by about 4 percent in the coming fiscal year. That’s the first cut in more than a decade. And officials have shown no signs of switching their preference of bypassing national governments as recipients of health aid, funneling more than half of U.S. support to non-governmental organizations instead.

Batniji and Bendavid decided to re-analyze the data used by the University of Washington researchers after meeting with policymakers who pointed to the study as a cautionary tale of foreign governments that waste and mismanage money earmarked for health programs.

“People were citing the Lancet piece, saying this was starting to shape how they thought about giving money,” said Batniji, who is also a resident physician at Stanford Medical Center. “But when we started asking questions about what the actual displacement looks like, the answers didn’t seem very compelling or reasonable.”

Taking a fresh look at the same numbers used for the 2010 study – public financing data culled from the World Health Organization and the International Monetary Fund – the researchers saw a different story emerge about the use of foreign aid in the health sector.

Once Batniji and Bendavid excluded conflicting and outlying data, such as huge discrepancies between WHO and IMF estimates and information about countries that were getting very small amounts of money from other countries, “there was no significant displacement of foreign aid,” Bendavid said.

The Stanford researchers’ findings are poised to influence a debate among policymakers and donors over whether it’s more efficient to give international assistance slated for health spending to government agencies or NGOs.

“We want to free donors of feeling that if they give money directly to governments, the money will be offset and used for an unintended purpose,” Batniji said. “The concern about displacement really amplifies the demands we make on governments for how they use the money. And that is at odds with a recent movement to let foreign governments set their own agendas for how to spend money.”

The research conducted by Batniji and Bendavid was supported by FSI’s Global Underdevelopment Action Fund and the Dr. George Rosenkranz Prize awarded to Bendavid in 2010.

Philanthropist and software giant Bill Gates spoke to a Stanford audience last week about the importance of foreign aid and product innovation in the fight against chronic hunger, poverty and disease in the developing world.

His message goes hand-in-hand with the ongoing work of researchers at Stanford’s Freeman Spogli Institute for International Studies. Much of that work is supported by FSI’s Global Underdevelopment Action Fund, which provides seed grants to help faculty members design research experiments and conduct fieldwork in some of the world’s poorest places.

Four FSI senior fellows – Larry Diamond, Jeremy Weinstein, Paul Wise and Walter Falcon – respond to some of the points made by Gates and share insight into their own research and ideas about how to advance and secure the most fragile nations.

Without first improving people’s health, Gates says it’s harder to build good governance and reliable infrastructure in a developing country. Is that the best way to prioritize when thinking about foreign aid?

Larry Diamond: I have immense admiration for what Bill Gates is doing to reduce childhood and maternal fatality and improve the quality of life in poor countries.  He is literally saving millions of lives.  But in two respects (at least), it's misguided to think that public health should come "before" improvements in governance.  

First, there is no reason why we need to choose, or why the two types of interventions should be in conflict.  People need vaccines against endemic and preventable diseases – and they need institutional reforms to strengthen societal resistance to corruption, a sociopolitical disease that drains society of the energy and resources to fight poverty, ignorance, and disease.  

Second, good governance is a vital facilitator of improved public health.  When corruption is controlled, public resources are used efficiently and justly to build modern sanitation and transportation systems, and to train and operate modern health care systems.  With good, accountable governance, public health and life expectancy improve much more dramatically.  When corruption is endemic, life-saving vaccines, drugs, and treatments too often fall beyond the reach of poor people who cannot make under-the-table payments. 

Foreign aid has come under criticism for not being effective, and most countries have very small foreign aid budgets. How do you make the case that foreign aid is a worthy investment?

Jeremy M. Weinstein: While foreign aid may be a small part of most countries’ national budgets, global development assistance has increased markedly in the past 50 years. Between 2000 and 2010, global aid increased from $78 billion to nearly $130 billion – and the U.S. continues to be the world’s leading donor.

The challenge in the next decade will be to sustain high aid volumes given the economic challenges that now confront developed countries. I am confident that we can and will sustain these volumes for three reasons.

First, a strong core of leading voices in both parties recognizes that promoting development serves our national interest. In this interconnected world, our security and prosperity depend in important ways on the security and prosperity of those who live beyond our borders.

Second, providing assistance is a reflection of our values – it is these humanitarian motives that drove the unprecedented U.S. commitment to fighting HIV/AIDS during the Bush Administration.

Perhaps most importantly, especially in tight budget times, development agencies are learning a great deal about what works in foreign assistance, and are putting taxpayers’ dollars to better use to reduce poverty, fight disease, increase productivity, and strengthen governance – with increasing evidence to show for it.

Some of the most dire situations in the developing world are found in conflict zones. How can philanthropists and nongovernmental organizations best work in places with unstable governments and public health crises? Is there a role for larger groups like the Gates Foundation to play in war-torn areas?

Paul H. Wise: As a pediatrician, the central challenge is this: The majority of preventable child deaths in Sub-Saharan Africa and in much of the world occur in areas of political instability and poor governance. 

This means that if we are to make real progress in improving child health we must be able to enhance the provision of critical, highly efficacious health interventions in areas that are characterized by complex political environments – often where corruption, civil conflict, and poor public management are the rule. 

Currently, most of the major global health funders tend to avoid working in such areas, as they would rather invest their efforts and resources in supportive, well-functioning locations.  This is understandable. However, given where the preventable deaths are occurring, it is not acceptable. 

Our efforts are directed at creating new strategies capable of bringing essential services to unstable regions of the world.  This will require new collaborations between health professionals, global security experts, political scientists, and management specialists in order to craft integrated child health strategies that respect both the technical requirements of critical health services and the political and management innovations that will ensure that these life-saving interventions reach all children in need.

Gates says innovation is essential to improving agricultural production for small farmers in the poorest places. What is the most-needed invention or idea that needs to be put into place to fight global hunger?

Walter P. Falcon: No single innovation will end hunger, but widespread use of cell phone technology could help.

Most poor agricultural communities receive few benefits from agricultural extension services, many of which were decimated during earlier periods of structural reform. But small farmers often have cell phones or live in villages where phones are present.

My priority innovation is for a  $10 smart phone, to be complemented with a series of very specific applications designed for transferring knowledge about new agricultural technologies to particular regions.  Using the wiki-like potential of these applications, it would also be possible for farmers from different villages to teach each other, share critical local knowledge, and also interact with crop and livestock specialists.

Language and visual qualities of the applications would be key, and literacy problems would be constraining.  But the potential payoff seems enormous.