Tempered Great Expectations—President Requests Modest Increase in International Family Planning Budget

As detailed in the State Department and USAID CBJ, FP/RH is again included in the “preventing maternal and child deaths” thematic area (p. 119), one of the three objectives of the GHP account, along with “controlling the HIV/AIDS epidemic” and “combatting infectious disease threats.” The text of the rational for FP/RH programs is virtually identical to that contained in last year’s CBJ, which represented a marked departure from the rationale for investments during the prior administration that was, as one might suspect, more deferential to governments’ religious and cultural sensitivities and less concerned about the rights of citizens to essential health care.

The president’s budget request includes a total of $9.8 billion for State Department and USAID global health programs, a $733 million cut below the FY 2023 enacted level. As reported by the Kaiser Family Foundation, the entire decline in the request is the result of a decreased U.S. contribution to the Global Fund to Combat AIDS, Tuberculosis (TB), and Malaria. SRHR advocates should perhaps consider themselves fortunate as the budget requests for every other global health sector funded under the bilateral GHP account, except maternal and child health, are flat and stuck at the FY 2023 enacted level, including the requests for bilateral HIV, TB, nutrition, vulnerable children, neglected tropical diseases, and global health security activities. Peer advocates for other global health sectors are deeply troubled and disappointed that not many—if any—of the hundreds of millions of dollars held back from the Global Fund contribution were apparently reallocated to other bilateral global health programs at a time of ongoing global health crises and challenges.

Nevertheless, the modest proposed increase for FP/RH falls far short of the marker laid down by SRHR advocates, which recommend an expenditure of $1.736 billion as the U.S. fair share of the total financial investment necessary to address the current unmet need for modern contraception of 218 million women in low- and middle-income countries (LMICs) who want to avoid pregnancy but are not using a modern contraceptive method, while continuing to meet the needs of 705 million existing contraceptive users.

However, according to a recently updated analysis from the Guttmacher Institute, even at the current level of U.S. investments in FP/RH programs, the $607.5 million in funds appropriated by Congress in FY 2023 (of which $32.5 million was a contribution to UNFPA) delivered measurable results and made the following possible:

• 24.2 million women and couples received contraceptive services and supplies;
• 8.1 million unintended pregnancies, including 3.2 million unplanned births, were averted;
• 2.6 million unsafe abortions were averted; and
• 14,000 maternal deaths were prevented.

With an additional investment of $1.13 billion in U.S. international FP/RH assistance — which would bring the total funding to $1.74 billion — the following would result:

• 84.8 million women and couples would receive contraceptive services and supplies;
• 28.4 million fewer unintended pregnancies, including 11.3 million fewer unplanned births, would occur;
• 9.2 million fewer unsafe abortions would take place; and
• 49,000 fewer maternal deaths would occur.

Not only do strategic investments in sexual and reproductive health save lives but they also make economic sense—for every additional $1 spent on contraceptive care, $3.70 is saved on maternal and newborn care because of declines in the number of unintended pregnancies.

Policy Recommendations

Accompanying the main volume of the president’s budget request each year is a massive appendix that outlines in exacting detail the executive branch’s recommendations for additions, deletions and revisions to the text of the current appropriations legislation. Interestingly, in the absence of an enacted FY 2024 spending package, the administration has chosen to essentially rewrite the statutory language governing State Department operations and foreign assistance program in the manner that they would if left to their own devices, excluding some old boilerplate and adding some new provisions.

DELETING THE HYDE AMENDMENT BUT RETAINING THE HELMS AMENDMENT

For the fourth year, the Biden budget request does not contain the infamous Hyde amendment — a provision in the annual Labor, Health and Human Services, Education appropriations bill that has barred states from using federal Medicaid funds to provide abortion, except in cases of life endangerment, rape or incest, since 1976.

Important progress in the campaign to remove the Hyde amendment from annual appropriations legislation was made during the 117th Congress, as neither the House nor Senate versions of the bill in FY 2022 and FY 2023 contained the provision. Unfortunately, the removal of the Hyde amendment was sacrificed in the final omnibus bills as part of the bad deals with Senate Republicans that led to all policy “riders” on domestic and international reproductive health and rights being dropped.

Like the prior three years, global SRHR advocates were disappointed that the Biden budget appendix did not move to strike the Helms amendment included in the appropriations bill that restricts the use of foreign assistance to provide “abortion as a method of family planning.” However, it is important to note that in the budget appendices submitted by Democratic presidents over the last 30 years, only President Clinton proposed deleting Helms, and even then, only recommended partial deletions on three occasions, the last time 25 years ago in FY 1999. Since then, neither Presidents Obama nor Biden have proposed that the Helms amendment be removed from appropriations legislation in their budget requests.

The Helms amendment is also part of the permanent authorizing statute for overseas aid programs — the Foreign Assistance Act of 1961 — and not just an appropriations “rider” like Hyde. Deletion of the reiterations of Helms included in foreign aid appropriations bills since FY 1980 would not end its enforcement, absent it being struck from the Foreign Assistance Act.

That fact did not prevent House Democratic appropriations champions from removing the two repetitions of Helms from their version of the FY 2022 and FY 2023 spending bills, which, like the Hyde amendment, were reinstated in the final omnibus bills. A bill to accomplish the objective of amending the permanent law, the Abortion is Health Care Everywhere Act, was reintroduced in the 118th Congress in both the House, led by lead sponsor Jan Schakowsky (D-IL) with 158 cosponsors, and in the Senate, led by Senator Cory Booker (D-NJ) joined by 24 cosponsors.

INSERTING TECHNICAL LANGUAGE “FIXES”

Like the last three years, the Biden budget request for FY 2025 proposes to reword two boilerplate provisions in the annual State Department and foreign operations appropriations bill to expand their application to funding for bilateral FP/RH programs and contraceptive commodities.

Unfortunately, neither the House nor Senate versions of the FY 2024 bill included these two technical fixes, the latter because of the no new policy “riders” agreement between Senate Appropriations Chair Patty Murray (D-WA) and Vice Chair Susan Collins (R-ME). As a result, no changes will be made in either in the final FY 2024 spending legislation that will emerge in the next few days.

Advocates will be working to break the linkage that has regrettably developed during endgame spending negotiations with abortion-related provisions and finally succeed in persuading congressional appropriators to make these two small — but significant — technical language fixes for FY 2025.

Allow FP/RH programs to continue in countries where U.S. foreign aid has been cut off

Coup d’etats in four countries since 2021—in Mali, Guinea, Burkina Faso, and Niger—and the resulting cutoff of U.S. foreign assistance to these countries’ governments are just the latest illustrations of the fact that only one global health sector funded by the GHP account — FP/RH — is not exempt from a variety of prohibitions on assistance that can and have been enforced against governments that launch coups, engage in nuclear proliferation, default on loans from the U.S. government, expropriate U.S. assets and commit other serious misdeeds.The flurry of recent “coups,” whether officially declared that by the State Department or not, provide a timely example of why a technical language change to include FP/RH programs under a broad global health exemption from country aid prohibitions remains critically important. In order for the U.S. government to be consistent in its efforts to use the leverage of a foreign aid cut-off on a country to encourage changes in national policy or behavior—but in not at the same time punishing citizens for the actions of their government—it would be entirely appropriate that the exemption currently granted only to child survival, HIV/AIDS, and other disease programs be extended to the full spectrum of life-saving global health activities. (According to USAID staff, maternal health has always been considered a part of child survival for purposes of this exemption.)

What should be a noncontroversial technical change to enable FP/RH to be covered under the exemption from country aid restrictions involves simply changing a few words so that the provision in the annual appropriations bill reads “global health programs” rather than “child survival activities or disease programs.” (It was recently learned that water and sanitation programs also lack “notwithstanding” authority and would benefit from broadening the statutory language to encompass all facets of global health.)

Although included in both the House and Senate versions of the FY 2023 bill and requested by the president in the FY 2023 budget appendix, the change failed to survive the decision to not deviate from the legislative status quo in the negotiations over the final omnibus spending bill.

Allow for contraceptive procurement using the HIV/AIDS Working Capital Fund

 Appropriations legislation only allows “child survival, malaria and tuberculosis and emerging infectious disease” programs to use the HIV/AIDS Working Capital Fund to procure and distribute pharmaceutical commodities for use in U.S. government-funded health programs “to the same extent as HIV/AIDS pharmaceuticals and other products.” However, the HIV/AIDS Working Capital Fund cannot be utilized to procure or distribute contraceptives and other reproductive health supplies.A simple wording change — adding “other global health” — to the existing statute had been requested in the appendix to the president’s FY 2023 budget request and inserted in both the House and Senate versions of the bill. This would broaden the fund’s eligibility to allow USAID to procure contraceptive commodities using this mechanism if it chooses and eliminate another instance in which FP/RH programs are subjected to discriminatory treatment in appropriations legislation without legitimate programmatic justification. Unfortunately, the FY 2023 omnibus reverted to existing law.

CONDITIONS APPLIED TO THE UNFPA CONTRIBUTION

The Biden budget appendix does not include the entire section of the bill containing all of the long-standing boilerplate restrictions on the U.S. voluntary contribution to UNFPA including: the requirement that UNFPA maintain U.S. funds in a segregated account, none of which may be spent in China; no funding for abortion; dollar-for-dollar reduction in the U.S. contribution by the amount of funds UNFPA furnishes to China; and the reprogramming of any funds withheld from UNFPA due to the “operation of any provision of law” to bilateral family planning, maternal and reproductive health programs.

However, the Biden budget appendix does contain the 1985 Kemp-Kasten amendment, unjustifiably interpreted during Republican administrations to cut off U.S. financial contributions to UNFPA, but it does not propose any modifications to the language.

In not including the entire UNFPA section of the bill, the Biden budget appendix removed the existing statutory earmark of $32.5 million for UNFPA from the IO&P account. As a result, the FY 2025 contribution level of $44.5 million only appears in the State Department-USAID CBJ, accompanied by a forceful justification for the increase being proposed by the administration. The CBJ states that UNFPA “advances the U.S. government’s strategic foreign policy goals to empower women, build democracy, and encourage broad-based economic growth through advancing global health and human rights and expanding access to voluntary family planning, reducing global maternal and child mortality, and preventing gender-based violence.”

What’s Next

It’s a well-worn cliché inside the Beltway that the budget requests of presidents of both parties are declared “dead on arrival” when the document reaches Congress. With an extremist faction still calling the shots in the House Republican caucus, President Biden’s latest budget submission is arriving in full rigor mortis.

Of more immediate concern to SRHR advocates is whether international FP/RH funding will remain at the same level as it has been at for the last 13 years or face a cut—whether as part of an across-the-board reduction or specifically targeted for discriminatory treatment—at the conclusion of the FY 2024 appropriations process in the next few days.

Prior to a midnight Friday deadline, Congress needs to pass a “minibus” spending package encompassing six appropriations bills, including for State Department and foreign operations, to avoid a partial government shutdown when the current continuing resolution expires.

After a delay caused by intense wrangling over border security funding and policy, a final spending deal has been reached between the White House and Congress. But the agreement needs to be turned into legislative text, now expected to be released tomorrow. Only then will the final FY 2024 funding level for bilateral and multilateral FP/RH programs be revealed and the fate of House Republican anti-SRHR policy riders known. Stay tuned.