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.”

Dr. George Rosenkranz —a world-renowned scientist who devoted his life to improving global health and established a prize to foster innovative research among emerging Stanford scholars — leaves behind an extraordinary legacy of science and humanitarianism.

Rosenkranz was 102 when he died Sunday after a prolific scientific career, one that would forever change the course of women’s reproductive lives.

A Hungarian Jew who fled the Nazis during World War II and eventually emigrated to Mexico, Rosenkranz was one of three scientists who pioneered the chemical compounds that led to the birth control pill. He was also instrumental in developing medicines to fight venereal diseases.

His family established The Dr. George Rosenkranz Prize in 2010 at the Freeman Spogli Institute for International Studies; the prize is administered by Stanford Health Policy. The $100,000 award goes to researchers working to improve health care in the developing world.

The beloved figure often made it to the campus symposiums that honored the prize winners.

Image

The first Rosenkranz Prize was awarded in 2010 to SHP’s Eran Bendavid, an infectious disease physician and associate professor of medicine. He used his award to study whether U.S. money spent on malaria and HIV programs in sub-Saharan Africa translated into better health outcomes for women and their children.

“George has galvanized a community of global health researchers at Stanford,” said Bendavid. “We now have a community of scholars whose focus on critical issues in other countries has been powerfully enabled by George's legacy. He and his family have been an inspiration for us and, by extension, our students. The spirit of promoting promising young researchers is something we all benefit from. His is a wonderful name and a legacy to be attached to.”

Other Rosenkranz Prize winners honor his legacy with remembrances:

“There are very few people who have changed the world as much as Dr. Rosenkranz; his work in synthesizing and bringing oral contraception to market changed how people form families, and empowered women around the world.” — Mike Baiocchi, a Stanford statistician and the 2017 winner.

“The Rosenkranz Prize helped our young lab take risks where we might not have been able to; risks that have paid off intellectually,” said Baiocchi, whose team is conducting the largest-ever randomized trial to measure the impact of No Means No Worldwide project, which is training 300,000 boys and girls in Kenya and Malawi to prevent rape and teen pregnancy.

“The prize money allowed us to bring two of our statistics PhD students to Kenya to visit the communities they have been working with, to present their work to the stakeholders. This has built a passion for in these students, who have each launched their own Kenya-based study to examine means for reducing gender-based violence.”

“Dr. Rosenkranz's professional and personal legacy are closely intertwined. By his example, I and many other Rosenkranz scholars have been enabled to marry what sometimes feel like dueling passions: social justice and rigorous scholarship. I feel so fortunate to have met Dr. Rosenkranz and hope that many others will continue to be inspired by his message of equity, global fellowship, and excellence.” — Ami Bhatt, the 2016 winner who is building the first multi-country microbiome research project focused on noncommunicable disease risk in Africa.

*****

“As a Mexican awardee of the Rosenkranz prize it is a privilege to be part of the legacy of one of the most prominent Mexican scientists, whose generous support was a vital seed to create my research laboratory on Human Genomics in Mexico.” — Andrés Moreno Estrada, the 2012 winner who is analyzing the DNA of indigenous groups in Latin American, one of the most underrepresented populations in the field of genetics.

*****

“The prize was a huge boost to my career as an early stage researcher. It allowed me to do work in India on antimicrobial resistance (AMR) at a time when the topic was not a high priority for global funding agencies. The project led to a series of a collaborations with a large public hospital in India. There were several publications as a result of this partnership, and the studies we performed were innovative and informative on the prevalence on AMR in community-dwelling individuals.” — Marcella Alsan, one of two 2015 prize winners.

Asia Health Policy Program Director Karen Eggleston and colleagues examine China’s progress in enhancing financial protection under its social health insurance to achieve universal health coverage.

In 2009, China launched comprehensive health system reforms to address challenges such as increasing rates of non-communicable diseases and population aging, problems with health financing and healthcare delivery, and overall growing health expectations of its people. Promoting universal health coverage by building a social health insurance system was a central pillar of the reforms.

After a decade of system reforms, has the Chinese government made good on its commitment to bolster universal health coverage? In a new article published in a BMJ collection, a team of four co-authors including Karen Eggleston, APARC’s deputy director and director of the Asia Health Policy Program, evaluates China’s progress towards enhancing financial protection of social health insurance and identifies the main gaps that need to be filled to achieve universal health coverage. Their article is part of a special BMJ collection with Peking University that marks the tenth anniversary of China’s health system reforms by analyzing their accomplishments and challenges ahead.

The 2009 reforms aimed to cover the entire Chinese population with one of three (since 2012 one of two) basic social health schemes. To provide added financial protection to patients with critical illnesses, catastrophic medical insurance was initially launched in 2012 and implemented nationally in 2015. Eggleston and her co-authors determine that the expansion of health insurance has had several major successes. First, it improved access to and use of healthcare. In 2011, China achieved near-universal health insurance coverage, with more than 95% of the Chinese population covered by health insurance. Moreover, the annual inpatient hospital admission rate increased from 3.6% in 2003 to 17.6% in 2017, and admission rates for outpatient services were much higher than the global average.

Second, the expansion of health insurance coverage reduced the share of out-of-pocket heath expenses in total health expenditure, thus raising the level of financial protection. Third, catastrophic medical insurance was also effective in supplementing the basic social health insurance schemes and provided extra financial protection to a range of vulnerable groups. By 2017, more than a billion people in China were covered by such insurance.

However, much remains to be done. Out-of-pocket health expenditures remain fairly high and are one of the main reasons for catastrophic health expenses and low financial protection in China, which disproportionately affect deprived populations. Catastrophic medical insurance currently does not target underprivileged people, while medical aid is relatively small in scale and covers only a minority of patients with catastrophic health expenses.

Eggleston and her colleagues conclude that the Chinese government should focus on underprivileged populations within the current insurance system and enhance their financial protection as an important element of targeted poverty alleviation. Such targeting, the researchers emphasize, requires a clear and integrated policy encompassing the basic social health insurance schemes, catastrophic medical insurance, medical aid, and improved healthcare efficiency.

Mariam Noorulhuda has seen health disparities up close in the developing world, particularly in Afghanistan, where she interned at a hospital in Kabul last summer.

“There was a shortage of trained health-care professionals, especially women, poor facility conditions, and insecurity,” she said. “Our hospital was minutes away from multiple bombings.”

Noorulhuda is a rising senior and one of six Stanford undergraduates chosen for the inaugural class of Stanford Health Policy Undergraduate Research Fellows. From a variety of disciplines, they will spend this summer partnered with SHP faculty to work on research projects. The students were chosen for their desire to blend health policy with their own undergraduate studies.

Noorulhuda’s Story

Mariam Noorulhuda

That is when she lost another brother, as health-care infrastructure was demolished after much of the capital was destroyed in bombings. When the Taliban targeted her father for his resistance efforts, they fled again and were granted asylum in the United States in 1997. Though raised in the Bay Area, many family members remain in Afghanistan.

“Much of my family has been affected by the brutal impact that war has on health — not entirely through bombs and bullets per say — but through indirect effects like displacement and virtually nonexistent health systems,” said Noorulhuda, a history major with a minor in human rights.

She will work with SHP’s Eran Bendavid, an infectious diseases physician and associate professor of medicine who focuses on the impact of health policies and outcomes in developing countries. He is the fellowship coordinator for this inaugural summer program.

Impact of Health Policy

"There is a growing recognition that health policy impacts just about every facet of human experience and well-being, and we see students picking up on that earlier and earlier,” said Bendavid. “The scholarship at SHP — from the effects of gun ownership or armed conflict to quality of care and guideline development — is an exceptional environment for gaining experience and a deep-dive into health policy research."

The fellowships were made possible with generous support from Stanford political scientist Scott Sagan, and his wife Sujitpan Bao Lamsam, vice chairman of Kasikornbank in Thailand. Sagan is a senior fellow at the Center for International Security and Cooperation who focuses on nuclear strategy, the ethics of war and the safety of hazardous technology.

“One of the great strengths of Stanford is the opportunity for undergraduates to get deeply involved in faculty research projects,” said Sagan, whose daughter Charlotte Sagan (BA, `15) was a research assistant in health policy while at Stanford. “We wanted to help create such opportunities for future students.”

Tiffany Liu

Tiffany Liu just finished her freshman year and has yet to declare her major, though she’s thinking symbolic systems, the study of human-computer interaction.

“Both fields incorporate so many diverging perspectives and methods in order to solve salient issues,” said Liu, who will work with Jason Wang, an associate professor of pediatrics who looks at the use of innovative technology to improve quality of care and health outcomes.

“I’m eager to engage in health policy research through a mix of technical and non-technical methods — we can process and analyze data in so many more interesting ways using computers, and yet we can’t ever lose the humanistic aspect of health initiatives,” Liu said.

Nikhil Shankar, also a rising senior, is an economics major. He jumped at the health policy fellowships because he believes applied economics can have “real-world impact.”

He will be working with SHP’s Grant Miller, a senior fellow at the Freeman Spogli Institute for International Studies and director of the Stanford King Center on Global Development. They will examine the impact of population policy on child health outcomes by gender in China.

Nikhil Shankar

Health-care inequality driven by factors beyond the control of individuals is something that troubles Andrea Banuet, a human biology major and another a rising senior.

“Factors such as socioeconomic status, age, ethnic and racial backgrounds should not determine the type of care an individual can attain — but the really sad reality is that in many parts of our country, it does.”

She believes that policy informed by research has the power to combat institutional biases and promote change in health-care accessibility. She will be working Kathryn M. McDonald, executive director of CHP/PCOR, an expert on health-care quality and patient safety.

Conrad Milhaupt is another rising senior with a double major in economics and public policy.

“I have a passion for the intersection of economics, politics and policy, with a particular focus on health and environmental policy,” said Milhaupt, who will work with SHP’s Jay Bhattacharya, a professor of medicine and economics.

Milhaupt took Bhattacharya’s health economics class in his sophomore year and became intrigued by the discrepancies in costs for health services with only marginal differences in outcomes. He is particularly interested in health care in rural America and ways that changes to our public-private insurance mix may improve access to care and help manage costs.

“Ultimately, I am driven to study this topic by my belief that health care is a human right and that health is an integral aspect of every individual’s life,” he said.

Conrad Milhaupt

Calvin Tolbert, with funding from the Office of the Vice Provost for Teaching and Learning, will work with Eric Sun, an economist and assistant professor of anesthesiology who researches consolidation in physician markets and the economics of pain treatments.

Tolbert is a rising junior majoring in economics and classics, with a minor in mathematics.

“The thing that initially drew me to economics was the fact that it was both math-intensive and pertinent to public policy, which is a keen interest of mine,” he said.

He will be working on a project that looks at physician compensation across countries and the wide gap in costs and access to medical care and drugs.

“This is an area that first caught my eye, when I read accounts of medical tourism in the news, including both people from developing countries who come to America for serious procedures and Americans who visit other countries to receive treatment due to the expense of medical care in this country.”