Devendra Amgai lost his job in November. The 42-year-old public health professional was working in one of Nepal’s more remote districts, distributing contraceptives to women.

The project was proving successful. With little alternative access to medicines or healthcare, local women were seeking out the clinic in ever-increasing numbers.

Yet four months before Amgai’s contract was due to end, the district office in Rasuwa was closed.

“I was not prepared for it. I have two small kids and my wife does not work. I am the only one who earns money,” he says.

Amgai was one of 150 Family Planning Association Nepal (FPAN) staff to lose their jobs over the past year because of Donald Trump’s reinstatement of the Mexico City policy – or the “global gag rule”.

Two and a half years after it was reintroduced, the rule is starting to have a profound effect across Nepal.

Under the policy, any organisation outside the US receiving American funding has to agree not to carry out abortions or even use money sourced from elsewhere to do any work associated with terminations, including talking about them.

A report published by the Centre for Research on Environment Health and Population Activities and the International Women’s Health Coalition said the rule threatened Nepal’s progress in improving its reproductive health services, and would damage any future programmes across the country.

The scheme Amgai worked on, the support for international family planning organisations 2 (Sifpo) project, received $5.5m (£4.5m) funding from USAid. It was launched in 2015 with 150 staff and 270 paid community volunteers running mobile outreach services from government health facilities in 11 districts. More than 233,000 people have benefited from the programme.

The director general of FPAN, KP Bista, says although the four-year project was due to end in March this year, “we were pressurised to close it sooner”.

“We tried our best to save our staff’s jobs and the four new branch offices … but we did not get money from anywhere.”

Bista added: “FPAN is in a real crisis. This year, we will hardly be able to provide half of the services that [we have] in past years.”

FPAN is Nepal’s oldest NGO and a major partner in the government’s national family planning programmes. It started family planning services in 1959, before the ministry of health was even formed. It is a member association of the International Planned Parenthood Federation (IPPF), which has refused to sign up to the gag rule and lost millions in funding as a result.

“We need around $9m to fully operate all our programmes and branches but now we are running only a $4m budget. We got core funding from the International Planned Parenthood Federation, but even IPPF is cutting our money every year. This year we got only around $1.2m and last year we received $1.5m, which is not even enough to run our offices,” says Bista.

The cuts are a direct result of the global gag rule, he says. The lack of money has meant it can’t partner with the government to set up family planning centres in 20 districts this year.

Bista added: “The truth is we have not allocated budget for [all FPAN] staff salaries for this October, November and December because we don’t have budget.” As well as the 150 Sifpo job losses, more than 100 staff vacancies have not been refilled.

“We all know USAid is the biggest funder, but the door to get their money is closed to us due to the gag rule.”

Nepal legalised abortion in 2002 and has relatively liberal laws. Terminations are available up to 12 weeks on request, and up to 18 weeks in cases of rape or incest, and at any time if the pregnancy poses a danger to the woman’s life, her physical or mental health or if there is a foetal abnormality.

In 2017, Nepal made all abortion services free at government health facilities. There are roughly 1,400 authorised abortion clinics currently operating in all 77 districts of Nepal.

However, a report from the Center for Research on Environment, Health and Population Activities (CREHPA) says 58% of abortions in Nepal are performed illegally.

That was the experience of 31-year-old Gita Dahal (not her real name). Dahal is a sex worker in Kathmandu. Six months ago she paid $12 for abortion pills.

“After three days of taking the pills I got massive bleeding and I was taken to hospital, where I stayed for nine days. The hospital charged me $200, which was not a small amount for me, but thank God I’m alive today,” she says.

Dahal didn’t know abortion was free or legal. “Many NGO workers come to ask for our blood to test [for] HIV, but no one gives us information we really need, even if we ask,” she says.

The work of Jagriti Mahila Maha Sang (JMMS), a large network of female sex workers, is being restricted by the global gag. It is not able to provide information most needed by sex workers because it is funded by Fhi360, which in turn is funded by USAid.

A former staff member at JMMS member organisation, Rama Pradhan (name changed) says she was “strictly restricted in talking about abortion or related topics by her office”.

A former sex worker turned social worker, she says: “I used to feel so bad when I was unable to give the information which was most important to them. I have gone through some deadly abortions and I know sex workers are the ones who are always most vulnerable.

“We choose between an unsafe and illegal abortion or have an unwanted baby because very few sex workers know that abortion is legal and free in Nepal. Now this gag rule is making the situation worse.”

Beyond the grassroots level, the impact of the global gag rule is also being felt at national level – specifically, in drawing up the government’s 10-year road map for improving maternal mortality. One of the partners is USAid.

“They say government programmes are not affected by the gag rule, but it’s not true. If the government is making a long-term strategy to improve maternal mortality, it should contain all components, like family planning and abortion, all factors of maternal mortality. But I have observed in many meetings that USAid is denying [an] abortion component and the government seems undecided,” said Madhabi Bajracharya, programme adviser of NGO Ipas.

Dr Mahesh Puri, associate director of CREHPA, says that at meetings about the road map, USAid delegates were not allowing use of the word abortion, “which can be very dangerous”, he added.

“The reality is, many government programmes on sexual and reproductive health rights are run through NGOs in Nepal. If the NGOs are affected by the gag rule then it’s obviously government programmes and government [will be] affected by GGR,” he says.

RP Biccha, director general of the government’s family welfare division, who is leading the maternal mortality policy, remains resolute. “Donors may try to push their agenda, but we the government are committed to abortion being legal and free in Nepal,” he says.

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Rojita Adhikari

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