The Mexico City Policy, which the U.S. government announced at the United Nations Conference on Population in Mexico City in 1984, required foreign NGOs to agree they would not, as a condition for receiving U.S. assistance for family planning, perform or actively promote abortion as a method of family planning. As shown in figure 1, subsequent administrations have rescinded or reinstated the policy through executive branch action, typically through presidential memoranda. In a January 2017 Presidential Memorandum, the Trump Administration reinstated and expanded the Mexico City Policy, directing the Secretary of State in coordination with the Secretary of Health and Human Services to implement a plan to extend the requirements of the reinstated policy to all global health assistance furnished by all departments or agencies to the extent allowable by law. Consequently, the policy, later renamed PLGHA, applies to billions of dollars in annual U.S. global health assistance—such as HIV/AIDS, maternal and child health, and malaria— rather than only family planning and reproductive health assistance, which received about $560 million in GHP account funding in fiscal year 2018. State reported that USAID, State, and DOD began applying the PLGHA policy as of May 15, 2017, and HHS applied the policy as of May 31, 2017. The affected departments and agencies applied the policy to: (1) All existing grants and cooperative agreements that provide global health assistance that received new funding after May 2017. Agencies established a PLGHA standard provision for inclusion in relevant grants and cooperative agreements for global health assistance requiring foreign NGOs to agree that, during the term of the award, they would not perform or actively promote abortion as a method of family planning in foreign countries, or provide financial support to any foreign NGO that does. Agency officials stated that after the policy was implemented, when additional funds were to be obligated to relevant awards with foreign NGOs, these organizations would be required to accept the PLGHA terms and conditions to receive these additional funds, or decline the award. (2) All new grants and cooperative agreements that provide global health assistance awarded after May 2017, according to a State report. The PLGHA terms and conditions apply to foreign NGOs that receive global health assistance prime awards or sub-awards. Prime awardees, including U.S. NGOs, may not provide assistance under the awards to any foreign NGOs that perform or actively promote abortion as a method of family planning, are required to include the PLGHA standard provision in sub-awards to foreign NGOs, and may be held liable for the sub- awardee’s failure to comply with the conditions of the policy. According to UN reporting, the legality of abortion varies among countries receiving U.S. global health assistance. This may result in some countries legally permitting abortion services that are not permitted under the PLGHA policy, according to NGO representatives we met with. The representatives noted that under these circumstances, foreign NGOs would be prohibited under the policy from providing such services, even with non-U.S. funds, as a condition of receiving U.S. global health assistance. Additionally, in March 2019, the Secretary of State clarified that foreign NGOs that accept U.S. global health assistance may not provide financial support, “with any source of funds and for any purpose, to another foreign NGO that performs, or actively promotes, abortion as a method of family planning.” According to agency officials, the PLGHA terms and conditions do not apply under the following circumstances: Global health contracts. State reported that the executive branch is taking steps to develop a PLGHA contract clause through a formal rule-making process required to revise the Federal Acquisition Regulation. Awards funded out of the Food for Peace program. Water Supply and Sanitation assistance funded from the Development Assistance account. Assistance provided directly by U.S.-based organizations. The PLGHA policy does apply, however, to sub-awards made by U.S.- based organizations to foreign NGOs. Assistance provided directly to national governments, such as ministries of health. Assistance to multilateral organizations. This includes but is not limited to U.S. global health funds provided to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund) and the Joint United Nations Program on HIV/AIDS (UNAIDS). In a May 2017 briefing on the PLGHA policy, State noted that humanitarian assistance, including State Department migration and refugee assistance activities, USAID disaster and humanitarian relief activities, and U.S. Department of Defense disaster and humanitarian relief were also all excluded from the policy. State also noted that the Secretary of State, in consultation with the Secretary of HHS, may authorize additional case-by-case exemptions to the policy. Congress provided about $8.7 billion for the Global Health Programs account (GHP) in fiscal year 2018, most of which supported HIV/AIDS assistance managed by State and implemented through transfers of funds to several agencies and contributions to multilateral organizations (see table 1). Because of the various exclusions described above, not all global health funds are subject to the PLGHA policy. In particular, State’s fiscal year 2018 contribution of $1.35 billion to the Global Fund is not subject to the policy because it is a multilateral institution. USAID and CDC had the most global health assistance awards subject to the PLGHA policy, representing more planned funding than other agencies (see table 2). In total, U.S. agencies reported that they applied the PLGHA policy to 1,309 prime awards active in May 2017 or made through September 2018. There were 761 active awards when agencies implemented the policy in May 2017, and 548 new awards that began after they implemented the policy. Most awards started in fiscal year 2016 or later, although some started earlier. Average award duration varied among agencies. The estimated total value of these 1,309 awards was almost $29 billion across multiple fiscal years, of which about $12 billion was planned funding that had not yet been obligated as of September 30, 2018, and is subject to the PLGHA policy upon acceptance of the PLGHA terms and conditions. USAID awards represented 50 percent of planned funds that were not yet obligated for awards subject to the PLGHA policy, while CDC awards represented 46 percent of such funds. Other HHS component agencies’ awards subject to the policy combined represented almost 4 percent of planned funds that were not yet obligated. DOD and State awards represented less than 1 percent of these funds. State’s awards were relatively numerous but shorter-term and of smaller dollar value than other agencies’ awards. Agencies reported that, as of September 30, 2018, over $8 billion of the more than $12 billion in estimated planned funding (over 66 percent) for awards subject to PLGHA that were active between May 2017 and September 2018 was for HIV/AIDS assistance (see table 3). All DOD and State planned funding, and almost all HHS planned funding, supported HIV/AIDS assistance. USAID reported that its planned funding was distributed across several global health areas including HIV/AIDS, family planning and reproductive health, maternal and child health, and tuberculosis. Agencies reported that over $8 billion of the more than $12 billion (over 66 percent) of the estimated planned funding for awards subject to PLGHA that were active between May 2017 and September 2018 was for awards in Africa (see table 4). Awards in Asia accounted for the second highest level of planned funding for an individual region at almost $600 million (5 percent). Global awards implemented in more than one region represented about $3 billion in planned funding (26 percent). By global health assistance area and region, HIV/AIDS assistance in Africa accounted for the most planned funding that had not yet been obligated for awards subject to PLGHA: over $6 billion of about $12 billion (52 percent) (see table 5). The next largest category was global HIV/AIDS assistance awards, which accounted for over $1 billion (13 percent). The top 10 countries receiving the most estimated planned funding that had not yet been obligated under awards subject to PLGHA accounted for over $6 billion of more than $12 billion (54 percent) (see table 6). All 10 countries are in sub-Saharan Africa. Of these countries, South Africa had the most planned funding remaining (over $2.4 billion) that was subject to the policy. See appendix II for more details on the locations of awards subject to PLGHA. USAID identified 53 awards—six prime awards and 47 sub-awards in which NGOs declined to accept PLGHA terms and conditions. CDC identified one prime award in which an NGO declined to accept the policy’s terms and conditions. These prime and sub-awards had about $153 million in estimated planned funding remaining that was not obligated at the end of fiscal year 2018 (see table 7). DOD and State did not identify any declinations. The remaining planned funding that was not obligated as of September 30, 2018, represents an estimate of the amount that had been planned for the awards but which was not obligated under these awards because awardees declined to accept the terms and conditions of the PLGHA policy, according to the agencies. USAID identified six prime awards in which NGOs declined to accept PLGHA terms and conditions resulting in an estimated $94 million in planned funding that was not obligated as of September 30, 2018. These six prime awards, presented in table 8, supported different global health assistance areas. Three of the awards were global in scope, two provided assistance to India, and one provided assistance to Zimbabwe. The two largest of the six prime awards declined were global awards to Marie Stopes International (MSI) and International Planned Parenthood Federation (IPPF), both of which publicly stated that they could not meet the conditions of PLGHA because abortion services or referrals are part of reproductive health care services they provide and a right to which their patients are entitled. Together, these two awards had about $79 million remaining in planned funding that was not obligated as of September 30, 2018. The primary objective of these two awards was to increase access to and use of family planning products and services, although the award to MSI also supported maternal and child health and HIV/AIDS and the IPPF award supported HIV/AIDS in addition to family planning and reproductive health, according to information provided by USAID. According to MSI and IPPF representatives, these two awards both included, among other activities, mobile family planning and reproductive health outreach activities that reached underserved rural populations in multiple countries. While MSI and IPPF were able to obtain some funding from other donors when the USAID awards were suspended, the additional funds fell far short of the funds provided by USAID, according to the organizations’ representatives, resulting in reductions in family planning services they provided to recipient countries. CDC identified one prime award in which an NGO declined to accept the PLGHA terms and conditions. According to CDC, this award had about $8.4 million remaining of a 5-year, $10.5 million award ceiling for delivery of HIV services in sexual and reproductive health clinics and in confidential clinics for commercial sex workers in Ethiopia. USAID identified 47 global health sub-awards in which foreign NGOs declined to accept the PLGHA policy’s terms and conditions and thus ceased receiving U.S. funding under those awards following implementation of the PLGHA policy (see table 9). The planned funding that was not obligated for these sub-awards amounted to about $51 million, as of September 30, 2018. As shown in table 9, sub-awards with NGOs that declined to accept the PLGHA terms and conditions involved multiple global health assistance areas. Family planning and reproductive health represented the largest share of planned sub-award value involving declinations, followed by awards supporting multiple global health areas and HIV/AIDS. Sub-awards involving declinations also addressed maternal and child health, tuberculosis, and nutrition assistance. According to data provided by USAID, sub-awards in which NGOs declined the PLGHA terms and conditions occurred in multiple regions, but primarily in countries in Africa. USAID identified 32 sub-awards implemented in African countries involving NGOs that declined the PLGHA terms and conditions following implementation of the policy. The estimated total value of these sub-awards was about $56 million, of which more than half (about $32 million) remained as planned funding that was not obligated as of September 30, 2018 (see table 10). Of the 47 sub-awards for which the PLGHA terms and conditions were declined, 26 were declined by affiliates of either IPPF or MSI. The estimated total award value of these 26 sub-awards amounted to over half of the value of the 47 sub-awards (see figure 2). Four countries had the largest estimated amount of sub-award funds declined by NGOs, with at least $8 million in planned funding that was not obligated as of September 30, 2018 (see table 11). For example, two declined sub-awards implemented in Senegal had a combined $9.7 million in planned funding that was not obligated as of September 30, 2018. These two sub-awards were implemented by an MSI affiliate that, among other services, used the USAID funds to operate mobile family planning clinics for beneficiaries in rural, underserved areas. According to MSI representatives, these sub-awards did not involve abortion services, which MSI indicated are illegal in Senegal. However, the NGO declined the sub-award because of its affiliation with MSI, according to the representatives. Bangladesh had the most sub-awards in which NGOs declined the PLGHA terms and conditions with five. Total planned funding that was not obligated for these five sub-awards amounted to about $9 million as of September 30, 2018. These awards supported multiple areas of global health assistance including family planning and reproductive health, tuberculosis, nutrition, and maternal and child health. We provided a draft of this report to DOD, HHS, State, and USAID, and for review and comment. In their written comments, reproduced in appendix III, USAID stated that it found our estimates of the number and value of awards subject to PLGHA and those in which NGOs declined to accept PLGHA the terms and conditions to be reasonable given the data available. USAID also elaborated on limitations with available data, which we believe are consistent with the data limitations we describe in this report. DOD, HHS, and State did not provide written comments. In addition, HHS, State, and USAID provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees and the Secretaries of Defense, Health and Human Services, and State, and the Administrator of the U.S. Agency for International Development. In addition, the report is available at no charge on the GAO website at http://www.gao.gov . If you or your staff have any questions about this report, please contact me at (202) 512-3149 or gootnickd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix IV. Our objectives were to identify (1) global health assistance awards that U.S. agencies determined to be subject to the terms and conditions of the U.S. government’s Protecting Life in Global Health Assistance (PLGHA) policy requiring foreign non-governmental organizations (NGOs) to agree that they would not perform or actively promote abortions as a method of family planning, and (2) planned funding for awards involving NGOs that declined to accept the terms and conditions of this policy. To identify the global health assistance awards subject to the terms and conditions of the PLGHA policy, we obtained data from the Departments of State (State), Health and Human Services (HHS), and Defense (DOD), and the U.S. Agency for International Development (USAID) on all relevant awards active when the policy was first implemented in May 2017 or awarded through September 30, 2018. We identified the relevant agencies based on a February 2018 State report on the initial implementation of PLGHA and discussions with each agency to identify affected component agencies. Component agencies within HHS that identified awards subject to the PLGHA included the Centers for Disease Control and Prevention (CDC), the National Institutes of Health, the Health Resources and Services Administration, and Substance Abuse and Mental Health Services. Within DOD, the Department of the Army and the DOD HIV/AIDS Prevention Program identified awards subject to the policy. To obtain information that was as complete and consistent as possible from each relevant agency on all awards subject to the PLGHA terms and conditions, we created a data collection instrument. This instrument asked the agencies to identify all awards that were subject to the PLGHA, that were either active in May 2017 when the PLGHA policy was first implemented or that were new awards through the end of fiscal year 2018 (September 30, 2018). We analyzed the responses to our data collection instrument to describe the number and estimated total value of the awards, the amount obligated as of September 30, 2018 and the estimated amount of planned funding that was not yet obligated for these awards, the implementing agency, the type of global health assistance, and the recipient countries. Agencies defined estimated total award value as either award ceilings or total award amounts for the life of the award including both funding that recipient organizations may have obligated prior to the PLGHA policy as well as funding that organizations have not yet received but may receive in future years. We asked the agencies to categorize the type of global health assistance based on the Foreign Assistance Standardized Program Structure and Definitions, which State updated in 2016. During the development of this data collection instrument, we discussed drafts with each of the agencies and made modifications as appropriate. We provided definitions for each data element requested that allowed for variations in the ways these agencies collect and record data on awards. To estimate the value of planned funds not yet obligated and therefore subject to the PLGHA policy, we subtracted the obligated amount from the estimated total award value of each award. While this calculation provides an estimate of the funds subject to the PLGHA, it is limited by two factors. First, while planned award funding that was not already obligated before May 2017 when PLGHA was first implemented was made subject to the PLGHA policy, agencies did not have obligations data as of May 2017 readily available but were able to readily identify obligations as of September 30, 2018. Therefore, information provided on planned funding that was not yet obligated as of September 30, 2018, may not capture all of the funding made subject to the PLGHA policy because it does not include obligations between May 2017 and September 30, 2018, for NGOs that accepted PLGHA terms and conditions. Second, estimates of total award value can change over time, according to agency officials. For example, awards could have extensions with additional funding not yet reflected in the estimated total award values agencies provided us. In addition, the estimated total award values the agencies provided could be based on a maximum or ceiling for some awards, which may overstate actual amounts. To identify the prime and sub-awards active in May 2017 that involved NGOs that declined the PLGHA terms and conditions, we developed additional data collection instruments—one for prime awards between agencies and NGOs and one for sub-awards between prime awardees and NGOs—to request information on these awards from the relevant agencies. We followed the same process described above to develop these two additional instruments to identify estimated total value of the awards, obligated amounts as of September 30, 2018, the implementing agency, the type of global health assistance, and the recipient countries. USAID identified 53 declined prime or sub-awards and CDC identified one. For these agencies, identifying these awards involved contacting staff based in overseas posts. The other agencies reported to us that they had no awards in which NGOs declined the PLGHA terms and conditions. A USAID official also noted that the sub-award amounts they provided to us could vary from year to year, which would affect the amounts of remaining planned funding that was not obligated as of September 30, 2018. Nevertheless, we relied on these amounts to estimate the amount of planned funding that was not obligated under these awards as of the end of fiscal year 2018 because the NGOs declined to accept the PLGHA terms and conditions. Efforts taken by prime awardees to replace declined sub-awards were not part of our review. In addition to meeting and corresponding with USAID and CDC officials to discuss awards involving declinations, we interviewed representatives of Marie Stopes International (MSI) and International Planned Parenthood Federation (IPPF)—two prime awardees that publicly declined to accept the terms and conditions of the PLGHA policy. These two NGOs declined the two largest of the six prime awards declined and their local affiliates were implementers of many of the sub-awards that were declined. We discussed with MSI and IPPF the characteristics of these two awards and the accuracy of USAID’s data provided to us on them. We examined the reliability of the data on awards identified by the agencies through testing for logical assumptions such as whether award start dates preceded their end dates, and whether an award’s estimated total value met or exceeded the total amount of funding that had been obligated to it. In addition, we met with agency officials to discuss and correct any discrepancies in the award data they provided. However, we did not independently verify the awards identified or the funds associated with each award. Overall, we found the data on awards subject to the PLGHA policy and in which NGOs declined the terms and conditions of the policy to be sufficiently reliable for the purposes of delineating the agencies, assistance areas, countries, estimated total value of awards, and obligations. As noted earlier, we also calculated the amounts of planned funding that were not obligated as of September 30, 2018, to estimate the amount of funding subject to the policy. We conducted this performance audit from April 2018 to March 2020 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Global health awards that agencies identified as subject to the PLGHA terms and conditions amounted to almost $29 billion in estimated total award value. This amount includes funding that agencies had obligated before implementing the PLGHA policy in May 2017 as well as funding across multiple fiscal years and for potential award extensions. Agencies reported that about $12 billion in funding was not yet obligated as of September 30, 2018. Award funding included assistance to specific countries, as well as awards that were regional or global in scope (see table 12). David Gootnick (202) 512-3149 or gootnickd@gao.gov In addition to the individual named above, Leslie Holen (Assistant Director), Howard Cott, Martin de Alteriis, Kelsey Griffiths, Christopher Keblitis, Andrew Kurtzman, Michael McAtee, Aldo Salerno, Fatima Sharif, and Alexander Welsh made significant contributions to this report.

Summary: The United States is the world's largest donor of global health assistance. Congress provided about $8.7 billion for the Global Health Programs (GHP) account in fiscal year 2018. In 2017, the President reinstated and expanded a policy, which now requires foreign NGOs to agree that, as a condition of receiving global health assistance, they will not perform or actively promote abortion as a method of family planning or provide financial support during the award term to other foreign NGOs that conduct such activities. The Reagan administration first implemented this policy, known as the Mexico City Policy, in 1984, and subsequent administrations have rescinded and reinstated it. The Mexico City Policy initially applied only to family planning and reproductive health assistance, which received about $560 million of GHP funds in fiscal year 2018. Upon reinstating the policy, the Trump Administration renamed it PLGHA and applied it to all global health assistance to the extent allowable by law. GAO was asked to review the implementation of the PLGHA policy. This report identifies (1) global health assistance awards that U.S. agencies determined to be subject to the U.S. government's PLGHA policy requiring foreign NGOs to agree that they would not perform or actively promote abortion as a method of family planning, and (2) planned funding for awards involving NGOs that declined to accept the terms and conditions of this policy. GAO analyzed data provided by U.S. agencies of awards subject to the PLGHA policy and awards in which NGOs declined to accept the terms and conditions of this policy. U.S. agencies reported to GAO that from May 2017 through fiscal year 2018, they applied the Protecting Life in Global Health Assistance (PLGHA) policy to over 1,300 global health awards. The policy's restrictions on performing or actively promoting abortion as a method of family planning applied to active awards that received new funding after the policy was implemented, and all funding for new awards made after May 2017. As of September 30, 2018, about $12 billion in estimated planned award funding was subject to the policy. The U.S. Agency for International Development (USAID), with over $6 billion, and the Centers for Disease Control and Prevention (CDC), with over $5 billion, awarded about 96 percent of this amount. Agencies implemented these awards across multiple geographic regions and global health assistance areas. About two-thirds of estimated planned funding subject to the policy supported HIV/AIDS assistance, while the remaining third supported other global health areas, such as maternal and child health, and family planning and reproductive health. Over two-thirds of planned funding subject to the policy was for awards in Africa. U.S. agencies identified seven prime awards and 47 sub-awards in which non-governmental organizations (NGOs) declined to accept the terms and conditions of the PLGHA policy, and these awards had about $153 million remaining in estimated planned funding not obligated as of September 30, 2018. The seven prime awards that were declined included six USAID awards and one CDC award and amounted to about $102 million of the $153 million in estimated planned funding that was not obligated. Marie Stopes International and the International Planned Parenthood Foundation declined the two largest of these awards, resulting in about $79 million in planned funding that was not obligated. These two awards included, among other activities, mobile family planning and reproductive health outreach activities to underserved, rural populations in multiple countries. USAID identified all of the 47 sub-awards that were declined, which had a total of about $51 million in planned funds that was not obligated. Thirty-two of the 47 subawards were intended for Africa. by Global Health Assistance Area Source: GAO analysis of agency reported data | GAO-20-347