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Global Health Assistance: Awardees' Declinations of U.S. Planned Funding Due to Abortion-Related Restrictions

GAO-20-347 Published: Mar 18, 2020. Publicly Released: Mar 18, 2020.
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Fast Facts

In 2017, the U.S. government reinstated and expanded a policy that requires foreign nongovernmental organizations (NGOs) to agree not to perform or promote abortion as a condition for receiving U.S. global health assistance. This assistance supports family planning, HIV/AIDS prevention and treatment, and other health areas.

We found 54 instances in which NGOs did not accept this policy, resulting in about $150 million in declined funding.

The policy applied to over 1,300 global health projects as of September 2018, with an estimated $12 billion in planned U.S. assistance.

Policy History

Illustration of policy milestone timeline

Illustration of policy milestone timeline

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What GAO Found

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.

Prime and Sub-Awards in Which Non-Governmental Organizations Declined PLGHA Conditions,
by Global Health Assistance Area

Dollars in thousands

Global health
assistance area

Prime and sub-
award total
estimated value

funds (as of

Estimated planned
funding not obligated
(as of 9/30/2018)









Family Planning & Reproductive Health












Maternal & Child Health








Source: GAO analysis of agency reported data | GAO-20-347

Note: Numbers may not add up due to rounding.

Why GAO Did This Study

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.

For more information, contact David Gootnick at (202) 512-3149 or

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AbortionsAccess to health careAIDSAIDS preventionReproductive health careChild healthDisease controlGlobal healthNongovernmental organizationsHealth careMalariaReproductive health careTuberculosis