You Show Me Yours, and I’ll Show You Mine: President Unveils International Family Planning Funding Increase in Budget Request

The president’s budget request for fiscal year (FY) 2024 sent to Capitol Hill on March 9 singles out international family planning and reproductive health (FP/RH) programs as one of the only funding increases proposed among all global health sectors contained in the State Department and foreign operations appropriations section of the budget.

The FY 2024 request includes $619.3 million for bilateral FP/RH programs and an additional $57.5 million for a U.S. contribution to the United Nations Population Fund (UNFPA). These add up to a total bilateral and multilateral funding request of $676.8 million — a $69 million (11%) increase over the funding level appropriated by Congress for FY 2023 in December.

For the first time ever, international FP/RH programs are highlighted in the main volume of the federal budget, which states: “The Budget also increases investments in high-impact and lifesaving voluntary family planning and reproductive health programs to address significant unmet global needs for these services.” Normally, discussion of the value and cost-effectiveness of international FP/RH programs is confined and relegated to the supplementary documents devoted to U.S. foreign assistance programs.

To address escalating threats to contraceptive access and reproductive health care in the United States in the wake of the Dobbs decision overturning the constitutional right to abortion, the main volume also calls out the whopping 79% increase above the 2023 enacted level proposed for the Title X domestic family planning program.

The detailed appendix accompanying the proposal from the Biden-Harris administration rejected calls from advocates for robust changes in foreign policy that could advance sexual and reproductive health and rights (SRHR). This includes declining — for a third year in a row — to recommend eliminating the Helms amendment, which restricts U.S. foreign assistance funds from being used to provide abortion services overseas. Nevertheless, the request includes two important technical fixes, reiterated from the prior two years, to improve the effectiveness of U.S. foreign assistance funds and ensure that FP/RH programs receive the same treatment as other global health sectors.

But curb your enthusiasm: Pundits always describe the budget requests of presidents of both parties as being “dead on arrival” when the document reaches Congress. With an extremist faction now calling the shots in the House Republican caucus in the 118^th Congress, President Biden’s third budget submission is arriving even deader than usual.

Ironically, since international FP/RH funding has been stuck at the same level for the last 13 years, it may provide a level of protection from inevitable House Republican attacks if politically pragmatic appropriators continue to default to the status quo.

Funding Request

In the president’s FY 2024 budget request, bilateral FP/RH assistance is requested in both the Global Health Programs (GHP) account and from the Economic Support Fund (ESF). Within the GHP account, FP/RH funding is earmarked explicitly at $600 million in budget documents. The GHP request represents a $76 million increase above the current GHP allocation within the FY 2023 enacted level. The more than 8% increase requested within the GHP account, administered by the Office of Population and Reproductive Health (PRH) and country missions within the U.S. Agency for International Development (USAID), is a positive development.

However, information on the allocation of additional bilateral economic assistance from ESF for FP/RH activities has yet to be publicly released. Nevertheless, well-informed sources have indicated that $19.3 million of ESF has been designated to support FP/RH programs in a very small number of strategically important countries.

Advocates have argued that investments in FP/RH projects through the GHP account are likely to be a more effective channel than ESF allocations to the governments of U.S. friends and allies, as one may question whether such plus ups of national health budgets are dictated more by political considerations than by programmatic need. Although the final FY 2023 spending package reverted to the breakdown between GHP and ESF that has persisted for more than a decade, it was noteworthy that — for the second year in a row — both the House and Senate versions of the State Department and foreign operations appropriations bill chose to allocate all bilateral FP/RH funding through the GHP account with no ESF designated for FP/RH activities.

The budget request proposes $57.5 million for a U.S. core contribution to UNFPA within the International Organization and Programs (IO&P) account managed by the State Department. If enacted, the amount requested for UNFPA would represent a $25 million — or a nearly 77% — increase above the current FY 2023 level. Sizable increases have been proposed in all three of President Biden’s budget requests, making good on his pledge to boost funding to UNFPA after four years of U.S. contributions being withheld during the Trump-Pence administration.

As detailed in the State Department and USAID congressional budget justification (CBJ), FP/RH is again included in the “preventing maternal and child deaths” thematic area (p. 110), 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 rationale for FP/RH programs is very similar, but not identical, to that contained in last year’s CBJ, which represented a 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 their citizens to essential health care.

The combined $676.8 million that is being requested for bilateral and multilateral FP/RH assistance represents a $69 million or 11% increase above the current level of $607.5 million, the annual amount at which FP/RH funding has stagnated for the last 13 fiscal years. But it is important to acknowledge the context for the proposed increase for FP/RH.

While the president’s budget request includes a total of $10.93 billion for State Department and USAID global health programs — a $370 million or 3% increase over the FY 2023 enacted level — virtually the entire proposed increase is devoted to global health security efforts. SRHR advocates should perhaps consider themselves fortunate, as the budget requests for every other global health sector funded under the bilateral GHP account are either flat or cut, including the allocations for bilateral maternal and child health, nutrition, HIV/AIDS and tuberculosis. Regardless, the proposed budget allocations for global health programs — whether up, down or level — fail to meet the moment as the COVID-19 pandemic continues and ongoing global health crises and challenges persist.

Nevertheless, the requested amount for FP/RH in particular 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).

However, according to a recently updated analysis from the Guttmacher Institute, even at the current level of U.S. investments in FP/RH programs, funding of $607.5 million appropriated by Congress in FY 2022 (of which $32.5 million was a contribution to UNFPA) delivered measurable results and made the following possible:

• 27 million women and couples received contraceptive services and supplies;
• 1 million unintended pregnancies, including 3.6 million unplanned births, were averted;
• 9 million unsafe abortions were averted; and
• 15,000 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:

• 1 million women and couples would receive contraceptive services and supplies;
• 4 million fewer unintended pregnancies, including 12.7 million fewer unplanned births, would occur;
• 6 million fewer unsafe abortions would take place; and
• 54,000 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 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. It is important to read the fine print.

Deleting the Hyde amendment but retaining the Helms amendment

For the third 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 117^th 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 reinstated to reach agreement on the massive spending package in both years.

Like the prior two 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 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 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, will be reintroduced in the House and Senate later in March.

Inserting technical fixes to allow for FP/RH programs to continue in countries where U.S. foreign aid has been cut off and for contraceptive procurement using the HIV/AIDS Working Capital Fund

Like the last two years, the Biden budget request for FY 2024 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.

First, recent coup d’etats in Mali and Guinea and the resulting cutoff of U.S. foreign assistance to these countries’ governments in 2021 are just the latest illustrations of the fact that only one global health program — 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. In contrast, child survival, HIV/AIDS and other disease-specific programs have long been exempted from these country assistance prohibitions.

Two “coups” in Burkina Faso during 2022, the most recent in October, provide an even more 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. A recent commentary in the Wilson Center’s New Security Beat argued the case from the perspective of political demography that restricting access to FP/RH services in the event of a coup is exactly the wrong response in countries whose political instability is linked to persistently youthful age structures.

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.” 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.

Second, 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.

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 2024.

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 2024 contribution level of $57.5 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

Since the beginning of the year, the president has been calling on congressional Republicans to reveal their own budget plan since they threaten to block extension of the federal debt ceiling and create a risk of the U.S. government defaulting on its financial obligations and tanking the American economy unless draconian spending cuts are agreed to by the president and their Democratic counterparts. The president has shown his plan, now it’s the GOP’s turn to show theirs.

So far, Speaker Kevin McCarthy has declined to spell out House Republican budget priorities. Members of the House Freedom Caucus, composed of the most extreme elements of the GOP caucus, have stepped into the vacuum to offer their own radical proposal, which — among other demands on student loan forgiveness, COVID response, climate change, federal energy regulation and the IRS — would cut and cap discretionary spending at FY 2022 levels for 10 years. If enacted, such a cap would gut non-defense discretionary programs, including U.S. foreign assistance, particularly if Republican defense hawks spare Pentagon spending from any reduction.

Further complicating the task of raising the debt ceiling and avoiding a government shutdown in September is the deal that Kevin McCarthy made to secure the speakership: floor consideration of all 12 spending bills with open rules allowing unlimited amendments. It’s a recipe for two years of chaos, drama and dysfunction, in which continuing resolutions keeping the government running on autopilot would perhaps not be the worst outcome for international FP/RH funding and policy. What are two more years of the status quo in this treacherous political environment in Congress?