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entitled 'Global Health: USAID Supported a Wide Range of Child and 
Maternal Health Activities, but Lacked Detailed Spending Data and a 
Proven Method for Sharing Best Practices' which was released on April 
20, 2007. 

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Report to Congressional Committees: 

United States Government Accountability Office: 

GAO: 

April 2007: 

Global Health: 

USAID Supported a Wide Range of Child and Maternal Health Activities, 
but Lacked Detailed Spending Data and a Proven Method for Sharing Best 
Practices: 

GAO-07-486: 

GAO Highlights: 

Highlights of GAO-07-486, a report to congressional committees 

Why GAO Did This Study: 

Every year, disease and other conditions kill about 10 million children 
younger than 5 years, and more than 500,000 women die from pregnancy 
and childbirth-related causes. To help improve their health, Congress 
created the Child Survival and Health Programs Fund. The 2006 Foreign 
Operations Appropriations Act directed GAO to review the U.S. Agency 
for International DevelopmentĂs (USAID) use of the fund for fiscal 
years 2004 and 2005. Committees of jurisdiction indicated their 
interest centered on the Child Survival and Maternal Health (CS/MH) 
account of the fund. GAO examined USAIDĂs (1) allocations, obligations, 
and expenditures of CS/MH funds; (2) activities undertaken with those 
funds; (3) methods for disseminating CS/MH information; and (4) 
response to challenges to its CS/MH programs. GAO conducted surveys of 
40 health officers, visited USAID missions in four countries, 
interviewed USAID officials, and reviewed data. 

What GAO Found: 

In fiscal years 2004 and 2005, Congress appropriated a total of $675.6 
million to the CS/MH account. Individual USAID missions and USAIDĂs 
Bureau for Global Health¨the bureau providing technical support for 
international public health throughout the agency¨were able to provide 
obligation and some expenditure data on these funds from their separate 
accounting systems. However, USAIDĂs Office of the Administrator did 
not centrally track the obligations and expenditures of USAID missions 
and bureaus. As a result, the Office of the Administrator was limited 
in its ability to determine whether CS/MH funds were used for allocated 
purposes during this period. According to USAID officials and GAOĂs 
analysis, the agency has recently taken steps to record these data for 
fiscal year 2007 and beyond, although the modifications to its 
accounting system are in its early phases and little data had been 
posted as of February 2007. 

Despite the lack of centralized financial data, GAO determined that 
USAID funded a wide variety of CS/MH efforts in 40 countries. USAIDĂs 
missions, regional bureaus, and Bureau for Global Health supported 
programs at the country, regional, and global level. These activities 
included immunizations, oral rehydration therapy to treat diarrhea, and 
prevention of postpartum hemorrhage. 

USAID used a variety of methods for disseminating information 
internally concerning CS/MH issues, such as electronic learning 
courses, biennial regional health conferences, and an online document 
database. However, USAID has not evaluated these methodsĂ relative 
effectiveness for disseminating innovations and best practices. GAO 
identified some drawbacks associated with several of these methods, 
such as limitations in access and topics covered. As a result, USAID 
health officers may not learn of new innovations and advances in a 
timely manner. 

USAID is taking steps to respond to numerous challenges to planning and 
implementing its CS/MH programs. First, responding to a global shortage 
of skilled health care workers, USAID supports efforts to enhance the 
skills of current health care workers and to train new health care 
workers. Second, because newborn and maternal health have typically 
received less international attention than child health, USAID 
established programs that focus on the needs of these two populations. 
Third, in response to numerous barriers to sustaining its CS/MH 
programs, such as uncertain funding and a lack of technical expertise 
among host governments and nongovernmental organizations, USAID adopted 
strategies to provide technical assistance and promote community 
involvement. 

What GAO Recommends: 

GAO recommends that USAID 
(1) test accounting system modifications to verify that CS/MH 
obligation and expenditure data will be recorded and traced back to 
CS/MH allocation data and (2) assess the effectiveness of existing 
communication methods for sharing global health best practices across 
missions. USAID generally concurred with GAOĂs findings and 
recommendations. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-486]. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact David Gootnick at (202) 
512-3149 or GootnickD@gao.gov. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

Budget Process and Congressional Directives Guided CS/MH Allocations, 
but USAID Lacked Centralized Obligation and Expenditure Data: 

USAID Supported a Wide Range of CS/MH Efforts: 

USAID Has Not Assessed the Relative Effectiveness of Its Methods of 
Disseminating Innovations and Best Practices for Internal Use: 

USAID Is Responding to Certain Child Survival and Maternal Health 
Program Challenges: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Allocation of Child Survival and Maternal Health Funds 
within USAID, Fiscal Years 2004 and 2005: 

Appendix III: Allocation of CS/MH Account Funds to Countries, Fiscal 
Years 2004 and 2005: 

Appendix IV: Mortality Statistics for Countries Receiving CS/MH Funds, 
Fiscal Years 2004 and 2005: 

Appendix V: Obligations and Expenditures for the Four Missions We 
Visited, Fiscal Years 2004 and 2005: 

Appendix VI: Comments from the U.S. Agency for International 
Development: 

GAO Comment: 

Appendix VII: GAO Contact and Staff Acknowledgments: 

Figures: 

Figure 1: Congressional Appropriations to the Child Survival and Health 
Programs Fund, by Account, Fiscal Years 2004 and 2005: 

Figure 2: Global Distribution of USAID's Child Survival and Maternal 
Health Funds, Fiscal Years 2004 and 2005: 

Figure 3: Organizational Chart of USAID Missions and Bureaus Involved 
in Supporting Child Survival and Maternal Health Activities, Fiscal 
Years 2004 and 2005: 

Figure 4: USAID Allocations of Child Survival and Maternal Health 
Funds, Fiscal Years 2004 and 2005: 

Figure 5: USAID's Allocation and Reporting Process for CS/MH Account, 
Fiscal Years 2004 and 2005: 

Figure 6: Health Care Worker Training: 

Abbreviations: 

ACCESS: Access to Clinical and Community Maternal, Neonatal and Women's 
Health Services: 

CSH Fund: Child Survival and Health Programs Fund: 

CS/MH: Child Survival and Maternal Health: 

NGO: nongovernmental organization: 

POPPHI: Prevention of Postpartum Hemorrhage Initiative: 

PPC: Bureau for Policy and Program Coordination: 

RACHA: Reproductive and Child Health Alliance: 

UNICEF: United Nations Children's Fund: 

USAID: U.S. Agency for International Development: 

WHO: World Health Organization: 

United States Government Accountability Office: 
Washington, DC 20548: 

April 20, 2007: 

The Honorable Patrick J. Leahy: 
Chairman: 
The Honorable Judd Gregg: 
Ranking Member: 
Subcommittee on State, Foreign Operations, and Related Programs: 
Committee on Appropriations: 
United States Senate: 

The Honorable Nita M. Lowey: 
Chair: 
The Honorable Frank R. Wolf: 
Ranking Minority Member: 
Subcommittee on State, Foreign Operations, and Related Programs: 
Committee on Appropriations: 
House of Representatives: 

Every year, disease and other mostly preventable conditions, such as 
diarrhea and malnutrition, kill more than 10 million children younger 
than 5 years old, including about 4 million infants in the first month 
of life.[Footnote 1] Ninety-nine percent of newborn deaths occur in 
developing countries, and about 75 percent of child deaths occur in sub-
Saharan Africa and South Asia.[Footnote 2] Mothers in developing 
regions also face significant health risks--for example, the lifetime 
risk of maternal death for women in sub-Saharan Africa is 175 times 
greater than for women in industrialized countries.[Footnote 3] To help 
lower maternal and child mortality rates globally, in 1997, Congress 
established the Child Survival and Health Programs Fund (CSH Fund), 
which includes the Child Survival and Maternal Health (CS/MH) 
account.[Footnote 4] The U.S. Agency for International Development 
(USAID), which administers the fund, currently finances CS/MH programs 
at headquarters and in 40 countries[Footnote 5] to support agency goals 
to improve global health, including maternal and child health.[Footnote 
6] 

In fiscal year 2006, Congress directed GAO to review USAID's use of 
appropriations to the CSH Fund for fiscal years 2004 and 2005.[Footnote 
7] We determined, through discussions with staff from the committees of 
jurisdiction, that congressional interest centered on USAID's use of 
CS/MH allocations for fiscal years 2004 and 2005--about $328 million 
and $348 million, respectively.[Footnote 8] This report reviews USAID's 
(1) allocations, obligations, and expenditures of CS/MH funds for 
fiscal years 2004 and 2005; (2) activities undertaken with those funds; 
(3) procedures for disseminating information related to CS/MH 
innovations and best practices; and (4) response to challenges in 
planning and implementing its CS/MH programs. 

To address these objectives, we surveyed USAID officials in the 40 
USAID countries receiving CS/MH funds to determine how they manage 
their activities and key challenges they face in the field. In 
addition, we reviewed documents such as USAID's CSH Fund progress 
reports, USAID's guidance for managing and implementing its maternal 
and child health activities, and USAID budget data. We also reviewed 
literature on interventions for improving maternal and child health, 
including three separate series from the British medical journal titled 
The Lancet, and reports on global maternal and child health issues from 
nongovernmental and multilateral sources, such as the United Nations 
Children's Fund (UNICEF) and Save the Children. At USAID's headquarters 
in Washington, D.C., we interviewed officials from the Bureau for 
Policy and Program Coordination (PPC), the Bureau for Global Health, 
regional bureaus, and the Office of the Controller. We also met with a 
number of officials representing nongovernmental and multilateral 
organizations, including the Global Health Council, the World Health 
Organization (WHO), and UNICEF. In addition, we interviewed USAID staff 
during visits to USAID missions in four countries--Cambodia, Ethiopia, 
India, and Mali--in Africa and Asia, the two continents with the 
highest maternal and child mortality rates. We conducted our work from 
April 2006 through March 2007 in accordance with generally accepted 
government auditing standards. (See app. I for more details on our 
objectives, scope, and methodology.) 

Results in Brief: 

In fiscal years 2004 and 2005, USAID allocated the majority of the CS/ 
MH account to support maternal and child health efforts in Africa, 
Asia, and Latin America and the Caribbean. However, the agency could 
not provide a complete accounting for its missions' and bureaus' 
obligations and expenditures of the allocated funds for this period. 
Countries in those three geographic regions received about 60 percent 
($405 million) of the approximately $676 million appropriated to the 
account, while the Bureau for Global Health and international 
partnerships it supports received the remaining 40 percent. In making 
these allocations, USAID was guided both by budgeting procedures, which 
considered factors such as countries' magnitude of need, and by 
congressional directives. However, as we also reported in 
1996,[Footnote 9] due to USAID's approach to tracking and accounting 
for such funds, it is not possible to determine how much was actually 
spent on CS/MH activities. Specifically, USAID did not centrally track 
its missions' and bureaus' CS/MH obligations and expenditures for 
fiscal years 2004 and 2005. Furthermore, the missions and bureaus had 
their own systems for capturing this information. According to U.S. 
government standards for internal control, program managers need 
sufficient data to determine whether they are meeting their agencies' 
strategic and annual performance plans and their goals for 
accountability for the effective and efficient use of 
resources.[Footnote 10] Because the Office of the Administrator did not 
require missions and bureaus to report their obligations and 
expenditures for the CS/MH account, it could not provide these data at 
our request and is limited in its ability to verify that the allocated 
CS/MH funds were used for their intended purposes during fiscal years 
2004 and 2005. In February 2007, USAID officials informed us of new 
modifications to its accounting system that are intended to allow the 
agency to record future maternal and child health obligations and 
expenditures. 

Despite the lack of centralized financial data, our work at USAID 
headquarters and in the field demonstrated that USAID supported 
numerous CS/MH efforts with the funds it allocated in fiscal years 2004 
and 2005. Missions supported CS/MH activities on the community and 
national levels--for example, providing funding to train community 
health workers and providing grants for government-run immunization, 
polio, and nutrition programs. Regional missions and bureaus conducted 
regional efforts, such as assessing maternal health activities in two 
West African countries, and supported regional strategies, for example, 
by funding the development of a WHO resolution to make newborn health a 
priority in the Americas. The Bureau for Global Health engaged in 
numerous CS/MH-related efforts: that is, providing technical support to 
missions by centrally managing some CS/MH programs at their request; 
supporting global CS/MH programs by managing partnerships and sharing 
expertise; administering a grants program for nongovernmental 
organizations; supporting international research on CS/MH 
interventions; funding surveys to provide population, health, and 
nutrition data; and providing global leadership in addressing child 
survival and maternal health. 

USAID used a variety of methods for disseminating information 
concerning CS/MH issues, such as electronic learning courses, biennial 
regional health conferences, and an online document database. However, 
we identified drawbacks associated with several of these methods, such 
as limitations in access and topics covered, and USAID has not 
evaluated the methods' relative effectiveness for disseminating 
innovations and best practices. As a result, USAID health officers may 
not learn of new innovations and advances in the maternal and child 
health fields in a consistent and timely manner. For example, according 
to USAID's annual employee survey in 2005, approximately 40 percent of 
mission officials within the three regional bureaus in our review did 
not agree that their respective regional bureau communicated "clearly, 
sufficiently, transparently, and in a timely manner." Furthermore, the 
survey showed that over 40 percent of the mission officials who 
responded to questions about the Bureau for Global Health did not agree 
that the bureau provided "quality state-of-the-art training 
opportunities." 

USAID is taking steps to respond to numerous challenges to planning and 
implementing its CS/MH programs. On the basis of reviews of expert 
reports, interviews with USAID officials and partner and donor 
representatives, and the results of our surveys, we identified three 
key challenges that USAID faces in planning and implementing CS/MH 
programs. First, responding to a global shortage of health care 
providers, USAID supports efforts to enhance the skills of current 
health care workers and to train new health care workers. For example, 
in Cambodia, USAID funds midwifery training on how to deal with 
obstetric complications. Second, because newborn and maternal health 
have typically received less international attention than child health, 
USAID established programs that focus on the needs of these two 
populations. For example, in 2004, USAID founded a program that focuses 
on increasing the coverage, access, and use of maternal and newborn 
health services; in 2006, the program was supporting interventions in 
nine countries and launching programs in four additional countries. 
Third, in response to numerous barriers to sustaining its CS/MH 
programs, such as uncertain funding and a lack of technical expertise 
among host governments and nongovernmental organizations, USAID adopted 
strategies to provide technical assistance and promote community 
involvement. For example, in India, USAID is funding efforts to help 
the Indian government develop and implement urban health plans and 
supporting the use of community volunteers to help implement urban 
health programs. 

We are making two recommendations to the USAID Administrator to improve 
the agency's administration of the CS/MH account and its implementation 
of CS/MH programs. First, to strengthen USAID's ability to oversee and 
record allocations from the CS/MH account to help ensure that those 
funds are used as intended, we are recommending that the agency test 
recent modifications to the principal accounting system to verify that 
CS/MH obligation and expenditure data will be recorded and properly 
traced back to the corresponding allocation data. Second, to provide 
for effective dissemination of information to USAID mission health 
officers about innovations and best practices in child survival and 
maternal health in a timely manner, we recommend that the USAID 
Administrator assess the relative effectiveness of the agency's current 
methods of disseminating this information through existing tools, such 
as the annual employee survey. 

We provided a draft of this report to USAID. In general, USAID agreed 
with our recommendations. In its response, the agency emphasized that 
its accounting system tracked obligations and expenditures at the level 
of the larger CSH Fund in fiscal years 2004 and 2005. Regarding our 
first recommendation, USAID agreed to conduct tests to determine 
whether its modified accounting system captures all CS/MH activities 
and to verify that the funds are being used for the purposes for which 
they were appropriated. Furthermore, USAID will verify immediately that 
the State Department's planning system accurately captures all CS/MH 
allocated funds. In response to our second recommendation, USAID stated 
that it plans to conduct a Training Needs Assessment in 2007-2008 that 
will address our concerns regarding evaluation of information 
dissemination methods. USAID also provided information regarding the 
role that grantees and contractors play in disseminating information. 
Furthermore, the agency provided additional detail on some of the 
training and information dissemination efforts that we described in the 
draft. We have incorporated this information in the report, as well as 
USAID's technical comments, where appropriate. (See app. VI for a 
reprint of USAID's comments and our response.) 

Background: 

Each year, nearly 10 million children die from preventable diseases and 
other causes and more than 500,000 women die from causes related to 
pregnancy and childbirth,[Footnote 11] particularly in developing 
countries.[Footnote 12] For example, in sub-Saharan Africa, 1 in 16 
women will die as a result of pregnancy or childbirth, compared with 1 
in 4,000 women in industrialized countries,[Footnote 13] and a mother 
is 30 times more likely to lose a newborn[Footnote 14] in the first 
month of life than a mother in an industrialized country.[Footnote 15] 
The Lancet, a peer-reviewed British medical journal, estimates that a 
set of 23 known treatments would cost $887 for every child's life 
saved. A subset of those medical treatments targeted for newborns-- 
which includes antibiotics for sepsis, resuscitation, and management of 
the newborn's temperature--would cost $784 for every infant's life 
saved.[Footnote 16] In addition, the WHO estimates that universal 
access to maternal and newborn care in 75 developing countries would 
cost $0.22 to $1.18 per person.[Footnote 17] 

Maternal health is closely linked to both newborn and child survival. 
According to a recent United Nations report,[Footnote 18] motherless 
newborns are 3 to 10 times more likely to die than are newborns with 
living mothers. The WHO reports that nearly three-quarters of all 
newborn deaths could be prevented if women received adequate nutrition 
and health care during pregnancy, labor, and the postnatal period. 
Although child mortality in developing countries decreased by about 20 
percent between 1990 and 2005,[Footnote 19] maternal mortality has 
remained unchanged,[Footnote 20] and newborn survival has seen less 
improvement than child survival overall.[Footnote 21] Newborn deaths 
currently account for 38 percent of all deaths in children younger than 
5 years old. 

In 1997, Congress established the CSH Fund and assigned USAID to 
administer it. Initially titled the Child Survival and Disease Programs 
Fund and renamed in fiscal year 2001, the fund includes six accounts, 
of which the CS/MH account comprised about 20 percent in fiscal years 
2004 and 2005. (See fig. 1.) 

Figure 1: Congressional Appropriations to the Child Survival and Health 
Programs Fund, by Account, Fiscal Years 2004 and 2005: 

[See PDF for image] 

Source: GAO analysis of USAID data. 

Note: Appropriated funds for the Global Fund for AIDS, Tuberculosis, 
and Malaria support the efforts of the Global Fund, which is an 
international organization that provides funding to programs to fight 
AIDS, tuberculosis, and malaria in affected countries. Appropriated 
funds for HIV/AIDS, in contrast, are directed toward USAID's own HIV/ 
AIDS programs and activities. 

[A] Congressional appropriations to the CS/MH account for fiscal years 
2004 and 2005 totaled $675 million, although the amounts USAID received 
differed slightly, due to rescission and reprogramming of funds. 

[End of figure] 

Over the years, Congress has continued to support basic child survival 
interventions, particularly immunizations and oral rehydration 
therapy,[Footnote 22] and particular initiatives, such as the promotion 
of breastfeeding. In 2000, the 192-member states of the United Nations, 
including the United States, agreed to work toward achieving the 
development goals of the Millennium Declaration. These goals include 
reducing the child mortality rate by two-thirds and reducing the 
maternal mortality rate by three-quarters from 1990 levels worldwide by 
2015. 

USAID Support for Child Survival and Maternal Health: 

USAID has carried out efforts to improve child survival and maternal 
health since its inception in 1961. In the 1960s, USAID began building 
health clinics and funding research on treatments for diarrheal disease 
and malaria prevention. In the 1970s, USAID began focusing on providing 
the appropriate health interventions for common health problems in 
communities with the greatest needs. The interventions related to child 
health included field studies on oral rehydration and vitamin A therapy 
and malaria research. In the 1980s, USAID focused its efforts on 
countries with especially high child mortality rates. 

One of USAID's current performance goals calls for "improved global 
health, including child, maternal, and reproductive health." Under this 
performance goal, child survival activities target the primary causes 
of child mortality: diarrheal disease, acute respiratory disease, 
malnutrition, malaria,[Footnote 23] vaccine-preventable diseases, and 
newborn diseases and conditions.[Footnote 24] USAID's work in maternal 
health includes addressing nutritional deficiencies during pregnancy; 
strengthening preparation for birth, including antenatal care; 
supporting safe delivery; and improving the management and treatment of 
life-threatening obstetrical complications. USAID addresses these 
causes and health issues through country, regional, and global 
strategies. 

As administrator of the CSH Fund, including the CS/MH account, USAID 
allocated funds for maternal and child health efforts in 40 countries, 
in Latin America, sub-Saharan Africa, and South Asia. Figure 2 
illustrates the global distribution of USAID's CS/MH funds. 

Figure 2: Global Distribution of USAID's Child Survival and Maternal 
Health Funds, Fiscal Years 2004 and 2005: 

[See PDF for image] 

Sources: GAO analysis of USAID data; Map Resources (map). 

[End of figure] 

USAID carries out CS/MH activities primarily through its country 
missions;[Footnote 25] regional missions and bureaus; and the Bureau 
for Global Health and the international partnerships it supports. 
Figure 3 shows the organizational structure of USAID entities involved 
in supporting CS/MH activities. 

Figure 3: Organizational Chart of USAID Missions and Bureaus Involved 
in Supporting Child Survival and Maternal Health Activities, Fiscal 
Years 2004 and 2005: 

[See PDF for image] 

Source: GAO analysis of USAID data. 

Note: In fiscal years 2004 and 2005, the three regional bureaus 
encompassed seven regional missions, two of which received CS/MH funds. 
Both of these regional missions are in the Bureau for Africa: the 
Regional Economic Development Services Office for East and Southern 
Africa, and the West Africa Regional Program, now known respectively as 
the East Africa and West Africa regional missions. Furthermore, in the 
cases of Burundi, Sierra Leone, and Somalia, USAID regional missions 
managed the assistance programs from a neighboring country. 

[End of figure] 

USAID defines the Bureau for Global Health's role as providing 
technical support to the field, state-of-the-art research and 
innovation, and global leadership in international public health. 
Included among the bureau's functions are centrally managing some of 
the CS/MH programs that the country missions fund and, along with the 
agency's regional bureaus, disseminating information on innovations in 
child survival and maternal health to USAID missions. According to 
USAID guidance, the bureau is to be the agency's repository for state- 
of-the-art thinking and innovations in health that can be disseminated 
and replicated at USAID missions around the world. 

Budget Process and Congressional Directives Guided CS/MH Allocations, 
but USAID Lacked Centralized Obligation and Expenditure Data: 

In fiscal years 2004 and 2005, USAID allocated the majority of the CS/ 
MH account to countries in Africa, Asia, and Latin America and to the 
Bureau for Global Health, guided by its budgeting process and 
congressional directives. However, USAID's Office of the Administrator, 
through its Office of the Controller, was unable to provide data on 
agency obligations and expenditures of the allocated CS/MH funds for 
those years, because such data were not collected from the missions and 
bureaus. The missions we visited and the Bureau for Global Health were 
able to provide data showing obligations and some expenditures from 
their separate accounting systems. According to U.S. government 
standards for internal control, program managers need financial data to 
determine whether they are meeting their agencies' goals for 
accountability for effective and efficient use of resources. Without a 
process to provide ready access to obligation and expenditure data, 
USAID has limited ability to report whether it is using the CS/MH funds 
to fulfill intended purposes. USAID is making changes to its accounting 
system that may enable it to report such information, but the system is 
in transition and has not been tested. 

USAID Allocations Followed Budget Process and Congressional Directives: 

In fiscal years 2004 and 2005, USAID allocated the majority of funds in 
the CS/MH account to countries in Africa, Asia and the Near East, and 
Latin America and the Caribbean and to the Bureau for Global Health. In 
allocating the funds, the agency considered various factors in its 
annual budgeting process as well as congressional directives. 

USAID Allocated Most CS/MH Funds to Africa, Asia, and Latin America and 
to the Bureau for Global Health: 

Of the $675.6 million appropriated to the CS/MH account in fiscal years 
2004 and 2005, $405.3 million (60 percent) was allocated to Africa, 
Asia and the Near East, and Latin America and the Caribbean. The 
remaining 40 percent went to the Bureau for Global Health and to 
international partnerships that the bureau supports. Figure 4 shows the 
total amounts and percentages of USAID's CS/MH allocations for fiscal 
years 2004 and 2005. (See app. II for amounts and percentages allocated 
in each of the 2 years.) 

Figure 4: USAID Allocations of Child Survival and Maternal Health 
Funds, Fiscal Years 2004 and 2005: 

[See PDF for image] 

Source: GAO analysis of USAID data. 

Note: In addition, USAID allocated funds directly to regions, 
international partnerships, and the Bureau for Global Health. However, 
some of the funds allocated to international partnerships and the 
Bureau for Global Health went to global programs with beneficiaries in 
the regions. International partnerships included the Global Alliance 
for Improved Nutrition, the Global Alliance for Vaccines and 
Immunization, the Kiwanis/UNICEF Partnership for Iodine Deficiency 
Disorder, and the Health Metrics Network. 

[A] The amounts shown in this figure total $675.0 million. In addition 
to these amounts, USAID also allocated $0.6 million, or 0.2 percent of 
the CS/MH account, to the Bureau for Democracy, Conflict and 
Humanitarian Assistance, and the Bureau for Policy and Program 
Coordination in fiscal year 2004. Taken with these amounts, USAID 
allocated a total of $675.6 million in fiscal years 2004 and 2005. 
Percentages in this figure total more than 100 percent due to rounding. 

[End of figure] 

USAID Budgeting Process and Congressional Directives Guided 
Allocations: 

USAID's PPC[Footnote 26] allocated CS/MH funds in fiscal years 2004 and 
2005 according to its budgeting process and congressional directives. 

USAID Budget Allocation Process: 

PPC used an annual budgeting process to guide its allocation of CS/MH 
funds. First, missions submitted their budget requests to the regional 
bureaus, which reviewed the requests and, after discussion with the 
missions, made any needed adjustments. The regional bureaus then 
submitted the budget requests to PPC,[Footnote 27] which in turn made 
final adjustments. Following consultation with the Office of Management 
and Budget, USAID submitted its budget request to Congress. After 
receiving an actual appropriation from Congress, PPC then made its 
decisions on allocations, including for the CS/MH account, throughout 
the agency. USAID officials told us that the majority of PPC's 
functions have been transferred to the State Department's Office of 
Foreign Assistance, which now oversees the budgetary administration of 
the CSH Fund. PPC's remaining functions have been transferred to 
USAID's existing Bureau for Management. 

As part of the budgeting process, PPC and the regional bureau requested 
and considered a variety of information from the missions.[Footnote 28] 
Our analysis showed that some of the factors PPC and the regional 
bureaus considered included: 

* the severity of a country's need for CS/MH programs, measured in part 
by its mortality rates (see apps. II to IV for mortality rate and 
allocation information, by country); 

* the magnitude of a country's need for CS/MH programs, measured, for 
example, by total number of child deaths or total population of women 
of reproductive age; 

* the potential national-level impact of allocated CS/MH funds; 

* a host country government's per capita expenditures for public 
health; 

* the capacity of the USAID mission to absorb funds; and: 

* U.S. national interest. 

The USAID official who oversaw the CS/MH allocations in fiscal years 
2004 and 2005 told us that, as the CSH Fund guidance requires, missions 
and bureaus reported how they planned to spend their CS/MH funds to a 
PPC database. According to the official, this database recorded CS/MH 
allocation information, but not obligation or expenditure information. 

Congressional Directives: 

In addition, USAID's allocation decisions took into account 
congressional directives--instructions from Congress written into law, 
or in a committee report, that appropriations should be allocated for a 
particular purpose. For example, in fiscal year 2004, USAID allocated 
$60 million to the Vaccine Fund[Footnote 29] in accordance with a 
directive in the Consolidated Appropriations Act of 2004.[Footnote 30] 
Similarly, in fiscal years 2004 and 2005, USAID set aside $32 million 
each year for polio in response to congressional interest.[Footnote 31] 
In general, we found that USAID addressed the directives in the 
committee reports. However, USAID sometimes faced challenges in 
addressing congressional directives. For example, USAID had difficulty 
in determining the most effective use of the $6 million that Congress 
directed it to use for fistula in Africa, due to a general lack of the 
necessary human and other resources in African countries. Some USAID 
officials said that congressional directives for the CS/MH account-- 
also the primary source of funds for general health systems 
strengthening--had allowed for the preservation of CS/MH funding over 
time. However, according to some officials of USAID and organizations 
implementing programs in cooperation with USAID, other major health 
initiatives have redirected attention, funding, and staff resources 
away from the CS/MH congressional directive. 

USAID Headquarters Lacked CS/MH Obligation and Expenditure Data Needed 
for Internal Control in Fiscal Years 2004 and 2005: 

USAID's Office of the Controller was unable to provide obligation and 
expenditure data for missions' and bureaus' fiscal years 2004 and 2005 
CS/MH programs and, therefore, had limited ability to report on the use 
of these funds and to exercise internal control[Footnote 32] at the CS/ 
MH account level. According to an official from the Office of the 
Controller, USAID's primary financial management and reporting system 
could provide obligation and expenditure data for the CSH Fund[Footnote 
33] and for each mission's strategic objectives.[Footnote 34] However, 
the official stated that the system could not provide such data for the 
CS/MH account and that the missions and bureaus were not required to 
report these data. 

During our audit work, the four country missions we visited and the 
Bureau for Global Health provided obligation and some expenditure data, 
which they recorded in information systems that were not part of 
USAID's formal accounting system. At the four country missions, we 
asked mission officials for obligations and expenditures for mission- 
managed and centrally managed programs for fiscal years 2004 and 2005. 
For mission-managed programs, officials provided both obligation and 
expenditure data. For centrally managed programs, all four missions 
provided obligation data; however, only one mission provided 
expenditure data, one mission provided expenditure estimates, and two 
missions' officials stated that they were unable to provide any 
expenditure data. (See app. V for mission data.) Although the Bureau 
for Global Health provided obligation data for these fiscal years for 
the CS/MH programs it managed, including programs it managed centrally 
for the missions, bureau officials stated that they were unable to 
provide expenditure information for any of the programs. (Fig. 5 shows 
USAID's allocation and reporting process for the CS/MH account in 
fiscal years 2004 and 2005.) 

Figure 5: USAID's Allocation and Reporting Process for CS/MH Account, 
Fiscal Years 2004 and 2005: 

[See PDF for image] 

Sources: GAO analysis of USAID data; Corel (clip art). 

[End of figure] 

Officials from USAID's Office of the Controller and the State 
Department's Office of Foreign Assistance told us that obtaining fiscal 
years 2004 and 2005 obligation and expenditure data for the CS/MH 
account would require a data call to each mission and bureau.[Footnote 
35] USAID officials also noted that such a request from headquarters 
could necessitate a subsequent data request to implementing partners, 
because missions have not consistently required implementing partners 
to report at the CS/MH level.[Footnote 36] USAID officials further 
observed that the agency's difficulty in providing such information is 
not unique to the CS/MH account. 

Because it did not have a system to collect agencywide obligation and 
expenditure data for the CS/MH account, USAID's internal control over 
its use of the account was limited. According to U.S. government 
standards for internal control, "Program managers need both operational 
and financial data to determine whether they are meeting their 
agencies' strategic and annual performance plans and meeting their 
goals for accountability for effective and efficient use of 
resources."[Footnote 37] Without ready access to its missions' and 
bureaus' CS/MH obligation and expenditure data, USAID was constrained 
in its ability to report that these funds were used according to the 
purposes for which they were allocated. 

USAID Is Making Changes to Its Accounting System, but the System Is in 
Transition and Has Not Been Tested: 

In a prior report, we found that USAID's approach to tracking and 
accounting for child survival funds made it difficult to determine 
precisely how much the U.S. government spent on child survival 
activities.[Footnote 38] In addition, other GAO work has identified 
long-standing challenges associated with USAID's financial management 
and reporting.[Footnote 39] 

In mid-February 2007, USAID officials told us that they are in the 
process of instituting changes begun in November 2006 to USAID's 
primary accounting system. These changes are intended to modify the 
system so that financial data can be accounted for under new 
elements[Footnote 40] to coincide with the new Foreign Assistance 
Framework--the road map for foreign assistance resource allocation and 
implementation.[Footnote 41] In November 2006, a USAID official from 
the Office of the Controller told us that the modified system would not 
be able to separate obligations and expenditures at the CS/MH level. In 
February 2007, however, USAID officials told us they had recently 
learned that the system will capture these data at that level from 
fiscal year 2007 going forward.[Footnote 42] In addition, they said 
that the modified system will be compatible with the State Department's 
new planning system, which records allocation information. The two 
systems are not integrated, although the USAID officials said that they 
can trace information between the two because both systems record 
financial information by element. According to USAID officials, in the 
future they will be able to verify that CS/MH funds are being used for 
their allocated purposes by tracing the obligation and expenditure 
information in their accounting system back to the corresponding 
allocation information in the State Department's planning system. 
State's system, however, only records new obligational authority 
data,[Footnote 43] so CS/MH funds invested in programs that began 
before fiscal year 2007 cannot be verified in this manner. 

USAID's switch to recording financial data by element may address our 
concern about the lack of agencywide CS/MH obligation and expenditure 
data. USAID officials told us, however, that the modifications to the 
accounting system are currently in transition. As of February 2007, the 
system contained little obligation information at the CS/MH level. For 
example, the total information on CS/MH obligations to countries was an 
obligation to Nigeria. The remaining CS/MH obligation information 
consisted of eight travel authorizations for the Bureau for Global 
Health and one for the Bureau for Latin America and the Caribbean. The 
USAID officials said that expenditure information will likely not be 
included until fiscal year 2008 or 2009, because funds appropriated to 
the CSH Fund are available for obligation until the end of the 
following fiscal year. Although USAID officials told us they believe 
that the modification to the accounting system will address the 
agency's long-standing financial reporting weaknesses, sufficient time 
has not elapsed to test whether CS/MH obligation and expenditure data 
will be properly recorded and traced back to the corresponding 
allocation data in State's planning system. 

USAID Supported a Wide Range of CS/MH Efforts: 

USAID supported various CS/MH efforts in fiscal years 2004 and 2005 
through its country missions, regional missions and bureaus, and Bureau 
for Global Health. At the community and country levels, USAID missions 
used CS/MH funds to improve the quality of health services; provide 
immunizations; and promote basic health care, including essential 
obstetric care and child health services. Regionally, USAID supported 
CS/MH activities and strategies over a geographic area, such as fistula 
repair in West Africa and making newborn health a priority in Latin 
America and the Caribbean. Finally, the Bureau for Global Health gave 
technical assistance and administered a grants program; conducted 
research on CS/MH issues, including treatment of diarrhea and clean 
cord care during delivery; and provided global leadership. 

Country Missions Supported Community-and Country-Level Efforts: 

USAID's country missions supported CS/MH activities at both the 
community and the country levels. 

Community-Level Activities: 

Our fieldwork and review of documentation demonstrated that USAID 
implemented a variety of CS/MH programs at the community level in the 
four countries that we visited. For example, the Mali mission used its 
CS/MH funds to support a program that works across the country to 
improve the quality of government health centers in the community. 
Similarly, the Afghanistan mission funded nongovernmental organizations 
(NGO) to train 6,200 community health care workers, about half of which 
are women, to provide referrals and basic health care to their 
neighbors. 

Country-Level Activities: 

In addition, 37 of the 40 mission health officials we surveyed told us 
that they worked on CS/MH activities with their host country's 
government. Our interviews and fieldwork showed that USAID missions 
supported host country governments' CS/MH efforts by granting funds 
directly to governments, providing technical assistance, and 
participating in government working groups. 

* Grants to governments. Country missions directly transferred funds 
from USAID to the host country. In one such agreement, which the Mali 
mission provided to us, the mission directly funds the government of 
Mali's immunization, polio, and nutrition programs in response to the 
government's budget request. 

* Technical assistance.[Footnote 44] In addition to funding their 
programs, USAID missions provided technical assistance to host country 
governments. For example, the Afghanistan mission helped the government 
of Afghanistan's Ministry of Public Health monitor and evaluate the 
Basic Package of Health Services Program, which included essential 
obstetric care and child health and family planning services. 

* Government working groups. USAID mission representatives participated 
in host country government donor coordination groups related to health. 
For example, the India mission chaired a donor group for the Indian 
government's flagship CS/MH program. 

Regional Missions and Bureaus Supported Regional CS/MH Activities and 
Strategies: 

USAID's regional missions and bureaus supported CS/MH initiatives in 
their geographic areas of responsibility. For example, the West Africa 
Regional Program (now known as the West Africa regional mission) 
assessed fistula repair activities in two West African countries and 
identified training, equipment, and cost support as areas of possible 
future work. 

In addition, the regional bureaus supported strategic plans for their 
areas of responsibility. For example, the Bureau for Latin America and 
the Caribbean provided funds to the WHO to support the development of a 
resolution to elevate newborn health as a priority in the 
Americas.[Footnote 45] Similarly, the Bureau for Africa commissioned an 
in-depth examination of USAID's child survival programs in sub-Saharan 
Africa, resulting in recommendations for improvement.[Footnote 46] 
Bureau for Africa officials told us that the bureau also reviewed the 
African missions' strategic plans and provided suggestions to 
strengthen the missions' community-level programming. 

Bureau for Global Health Engaged in Numerous CS/MH Efforts: 

The Bureau for Global Health engaged in a number of CS/MH-related 
activities in fiscal years 2004 and 2005. These activities included 
giving technical assistance to country missions, administering the 
Child Survival and Health Grants Program, providing global leadership, 
and supporting international research. 

Technical Assistance: 

The Bureau for Global Health provided technical assistance to missions 
by centrally managing CS/MH projects at the missions' request. For 
example, our fieldwork shows that the bureau managed several projects 
for the India mission. 

* The bureau managed a program for anemia reduction and vitamin A 
supplementation in the states of Uttar Pradesh and Jharkhand. 

* The bureau assisted Indian state governments and the government of 
India's Ministry of Health and Family Welfare with routine 
immunization. 

* The bureau supported IndiaCLEN, a research organization, to study 
injection safety. IndiaCLEN found that 74 percent of immunization 
injections were not administered safely; in response, the government of 
India introduced the use of autodisable syringes in its national 
immunization program. 

In addition, the Bureau for Global Health may contribute some or all of 
the funds for a project as "seed funds"--that is, funds to introduce or 
expand a treatment in a particular country or region. The bureau told 
us that seed funds may encourage the mission and host country through 
advocacy, policy dialogue, technical assistance, and development of 
standards of care and training curricula. (See sidebar.) 

Of the 40 missions we surveyed, 34 participated in these centrally 
managed projects. About one-half of those missions reported that, to a 
great or very great extent, they had decided to participate in the 
projects because the bureau provided technical expertise, assisted with 
procurement, or offered some or all of the funds for the project. 
According to financial records that we obtained during our fieldwork, 
the four missions we visited varied in the percentage of CS/MH funds 
they chose to send to headquarters for centrally managed projects. For 
example, whereas Cambodia invested very little of its fiscal year 2005 
CS/MH funds in centrally managed projects, India sent more than one- 
half of its funds to headquarters for such projects. 

Text box: Country-level Programs: Community Treatment of Pneumonia, 
Senegal: 

The Bureau for Global Health provided "seed funds" to introduce the 
community treatment of pneumonia in Senegal at the national level. The 
bureau collaborated with UNICEF, the USAID mission in Senegal, the 
government of SenegalĂs Ministry of Health, a local university, and a 
major pharmaceutical company to introduce and evaluate such an 
approach. The bureau also provided technical assistance to the ministry 
and the university to develop an evaluation approach. The bureau ceased 
funding the program at the close of fiscal year 2006. However, the 
program will continue with funds from UNICEF, the Ministry of Health, 
and the USAID mission in Senegal. In addition, at least four other 
African countries are replicating this approach.

[End of text box] 

Child Survival and Health Grants Program: 

The Bureau for Global Health administered the Child Survival and Health 
Grants Program, which provides 4-to 5-year grants to U.S.-based 
nongovernmental organizations and private voluntary organizations to 
improve child survival at the community level in host countries. Of the 
40 missions that received CS/MH funds in fiscal years 2004 and 2005, 30 
reported that Child Survival and Health Grants projects had been 
awarded to organizations working in their host countries. In some 
cases, the grants comprised a sizable portion of USAID's child survival 
funding in a country or region. For example, the Bureau for Africa 
reported that these grants comprised about one-fifth of USAID's total 
allocations for child survival across sub-Saharan Africa. 

USAID officials told us that grantees may pilot innovations (see 
sidebar) or work in a country's most rural and hard-to-reach areas. 
Also, in certain cases, grantees raised additional funds from sources 
outside the bureau. Of the 30 missions we surveyed that have grantees 
in their countries, 27 reported that the grantees used the grants to 
raise additional resources from sources other than the U.S. government. 
For example, a grantee in Guatemala received funds from the United 
Nations Development Programme to continue its project with a slightly 
different scope. 

Text box: Community-level Programs: Community Drug Cabinets, Mali: 

A recipient of a Child Survival and Health Grants Program grant in Mali 
is piloting an approach to bring essential drugs to the community level 
through its Community Drug Cabinets Program. This NGO supplies, 
initially free of charge, cabinets with essential health supplies to 
villages throughout the Sikasso region of Mali. The cabinets contain 
first aid kits and drugs to sustain sick children younger than 5 years 
old until they can reach a community health center. The cabinets also 
include preventative malaria treatment and contraceptives for pregnant 
women and women of reproductive age. Each community selects a primary 
and a backup manager of the cabinet to provide counseling and 
distribute the health supplies. 

[End of section] 

Global Leadership: 

The Bureau for Global Health's global leadership included managing 
partnerships, sharing expertise, and helping shape the global CS/MH 
agenda. 

* Managing partnerships. The bureau supported international 
partnerships that received funds from the CS/MH account. For example, 
to support The GAVI Alliance--an international partnership focused on 
increasing children's access to vaccines in poor countries, the 
bureau's immunization advisor served on the GAVI Secretariat's 
financing task force, technical working group, and coordination group 
for the Organization for Economic Coordination and Development. 

* Sharing expertise. The bureau made its global expertise in child 
survival and maternal health available to global organizations and 
working groups. For example, a bureau official told us that the 
director of the bureau's Office of Health, Infectious Diseases, and 
Nutrition represents USAID on the U.S. delegation to the UNICEF 
Executive Board. Similarly, the bureau's child health team leader is 
the interim chair of the Country Support Working Group and serves on 
the interim steering committee of the international Partnership for 
Maternal, Newborn and Child Health. 

* Shaping global agenda. The bureau supported efforts that directly 
helped shape the global CS/MH agenda for research and interventions. 
For example, in April 2005, the bureau organized a meeting with the WHO 
and UNICEF on micronutrients and health. According to a USAID report, 
this process of bringing together scientists, donors, and policymakers 
helped shape a global agenda for both clinical and programmatic 
research for service delivery of micronutrient programs.[Footnote 47] 
In addition, officials from both UNICEF and the Gates Foundation told 
us that they look to USAID to help set global CS/MH policies and 
strategies. The bureau also supported the publication of three series 
of articles on child survival, newborn health, and maternal health in 
the medical journal titled The Lancet, to inform global and national 
dialogue on these issues. For example, the bureau's maternal health 
team leader participated in the formal technical reviews of drafts of 
the maternal health series and hosted its launch in the United States. 
Similarly, the bureau publicized the launch of the series on newborn 
health in Nepal, Indonesia, and the United States. 

International Research: 

In fiscal years 2004 and 2005, the Bureau for Global Health supported 
several CS/MH-focused international research efforts. These efforts 
included studies of innovative CS/MH interventions and surveys to 
provide data for use in monitoring and evaluating child survival and 
health efforts. 

* Studies of CS/MH interventions. The bureau supported several research 
efforts that have resulted in internationally recognized measures and 
interventions for maternal and child health. For example, since 1996, 
the bureau has been instrumental in supporting research on the use of 
zinc in the treatment of diarrhea. This research led, in 2006, to the 
release of WHO and UNICEF policy guidelines recommending 10 to 14 days 
of zinc treatment for all cases of diarrhea in children between 2 
months and 5 years old. Furthermore, the bureau supported research in 
fiscal year 2005 that contributed to the development of three newborn 
indicators: essential newborn care,[Footnote 48] antibiotic treatment 
of newborn infection, and postnatal care within 3 days of birth. With 
respect to the latter, agency officials told us the bureau is working 
with the Gates Foundation's Saving Newborn Lives Project and other 
organizations to align the postnatal care indicator with new proposed 
Millennium Development Goals newborn indicators.[Footnote 49] The 
bureau also supported research on the efficacy of new treatments and 
their introduction in different countries.[Footnote 50] For example, 
the bureau funded a study in Nepal of an antiseptic that may prevent 
newborn infections resulting from the cutting of the umbilical cord 
during delivery. USAID reports that early results show promising impact 
on reducing newborn deaths. 

* Surveys. The bureau used CS/MH funds in part to finance the 
Demographic and Health Surveys--large-scale, nationally representative 
household surveys that provide population, health, and nutrition data. 
The survey data comprise such topics as infant, child, and maternal 
mortality; micronutrient deficiencies; health care access issues; 
vaccination coverage; and percentage of births attended by a skilled 
health professional. The country surveys take place approximately every 
5 years, allowing comparisons across time. As of January 2007, surveys 
had been completed in more than 70 countries. The WHO, UNICEF, and 
other donors rely on the survey data for monitoring and gathering 
statistics. For example, the WHO and UNICEF both use the surveys to 
supplement their own data. Furthermore, USAID implementing partner 
officials told us that other donors, as well as country governments, 
are beginning to contribute more funding to the surveys, recognizing 
the need for quantitative data as a basis for decisions on programs and 
policies. 

USAID Has Not Assessed the Relative Effectiveness of Its Methods of 
Disseminating Innovations and Best Practices for Internal Use: 

The Bureau for Global Health and regional bureaus and missions used 
several methods to disseminate information within USAID about new CS/MH 
interventions and best practices. These methods consist of electronic 
learning courses, State-of-the-Art training, online document databases, 
Web sites, regional workshops, and other informal methods. In addition, 
USAID's implementing partners disseminate information on innovations 
and best practices. However, we identified drawbacks associated with 
several of these methods. Furthermore, USAID has not assessed the 
relative efficacy of its methods and, as a result, may not be able to 
ensure that missions are apprised of innovations in the maternal and 
child health fields in a consistent and timely manner. 

USAID Disseminated Information Internally through Various Methods, 
Although Several Have Drawbacks: 

The Bureau for Global Health, along with the regional bureaus and 
missions, disseminated information on CS/MH innovations and best 
practices to USAID missions, using several methods. 

* Electronic learning courses. The bureau instituted an Electronic 
Learning (eLearning) Center to provide USAID health professionals and 
external partners with access to technical public health information. 
The center has offered Internet-based courses on topics such as 
antenatal care, essential newborn care, and malaria. However, one of 
the USAID officials in charge of the courses told us that some health 
officers were still unaware of the availability of the electronic 
learning courses 3 years after the center's inception. In responding to 
our draft report, USAID stated that a 2007 priority for the bureau is 
the marketing and communication of these electronic courses for health 
officers at field missions. 

* State-of-the-Art training. From the early 1990s to 2005, the bureau 
and regional bureaus and offices[Footnote 51] held biennial 
conferences, known as State-of-the-Art training, for USAID health 
officers in each region to share updated information on population and 
health developments, including CS/MH issues, and to discuss best 
practices. According to a 2004 study, this training was an important 
opportunity for mission staff to regularly interact with one another 
and network with headquarters staff.[Footnote 52] Furthermore, the 
training provided mission staff with the opportunity for face-to-face 
exchange on policy updates, programmatic procedures, and new processes. 
USAID officials in headquarters and in the field told us that this 
training was crucial for regularly sharing best practices and learning 
about new health innovations, practices, and policies. Twenty-seven of 
the 38 health officials who responded to this question on our survey 
said that the training greatly or very greatly facilitated the sharing 
of best practices. According to USAID officials, however, the agency 
canceled the training in 2006 for budgetary reasons related to evolving 
demands on operating expenses funds. USAID mission officials expressed 
concern that, since they must pay for travel to conferences out of 
their operating expenses budget, they would not be able to keep up with 
the latest innovations without more support for sharing best practices. 
Although USAID officials told us that they would like to reinstitute 
the training, its future status is uncertain. In its response to our 
draft report, USAID stated that discussions are under way to 
reinstitute the training--beginning with Africa in the near future--but 
added that decisions regarding the funding and holding of these 
conferences rest with the USAID Administrator and the leadership of the 
regional and Global Health bureaus. 

* Online document database. USAID maintains an online database of USAID 
documents called the Development Experience Clearinghouse. The database 
contains USAID-funded international development technical and program 
documentation, such as country reports, annual project reports, and 
strategic plans. In addition, USAID officials are required to submit 
program evaluation reports to the database. In our survey, however, 18 
of the 39 health officers who responded to this question told us either 
that they do not use the database for sharing best practices or that 
the database facilitates the sharing of best practices a little or not 
at all. 

* Web sites. USAID supports a number of Web sites that disseminate 
health-related information. For example, the MotherNewBorNet, begun in 
April 2005, seeks to facilitate translation of maternal and neonatal 
research into community-level action by fostering dialogue and 
documentation of learning across projects. However, this forum 
currently focuses on countries within one regional bureau. Similarly, 
other health-related Web sites that USAID supports either address a 
limited number of topics or restrict access to members. USAID also has 
its own intranet, through which it disseminates health information. Our 
survey showed that 22 of the 39 health officials who responded to this 
question believe that USAID's intranet facilitates the sharing of best 
practices, either moderately or greatly. 

* Regional workshops. The regional missions hold occasional workshops 
on health care topics for mission staff. However, these workshops are 
not held on a regular basis and do not consistently address maternal 
and child health issues. For example, because the Latin America and 
Caribbean regional missions do not receive CS/MH funds, their regional 
workshops do not deal directly with maternal and child health issues. 

* Informal communications methods. Regional bureaus and the Bureau for 
Global Health contact USAID missions via telephone conversations and e- 
mail communications, although the frequency of such communications 
varies. USAID's Bureau for Global Health also occasionally holds brief, 
"brown bag" seminars at its offices in Washington, D.C., to provide 
information on CS/MH-related innovations and best practices to USAID 
staff members. For example, a returning health officer from the 
Afghanistan mission recently gave a brown bag seminar on the Rural 
Expansion of Afghanistan's Community-based Health Care Program. In 
addition, the bureau occasionally hosts seminars at which USAID 
partners give presentations on CS/MH innovations and best practices. 
However, only USAID staff physically present in Washington, D.C., are 
able to benefit from these brown bags and seminars. Our survey found 
that 22 of the 37 health officers who responded to this question do not 
use brown bags at all as a means of gathering information. 

* Implementing partners. USAID supports some grantees and contractors 
who develop and disseminate information on CS/MH innovations and best 
practices. For example, in fiscal years 2004 and 2005, a grantee of the 
Bureau for Africa produced several publications for health officers, 
dealing with such topics as child survival in sub-Saharan Africa, 
community case management of childhood malaria, and various nutrition 
briefs. 

USAID Has Not Assessed Methods' Relative Effectiveness: 

USAID has not assessed the relative effectiveness of these mechanisms 
for disseminating innovations to its staff, according to USAID 
officials. As a result, although it assigned the Bureau for Global 
Health the role of disseminating health research and innovations, the 
agency does not know whether the mechanisms used by the bureau and 
other USAID entities are adequate to keep mission health officers 
apprised of the most current findings regarding CS/MH innovations. 
Furthermore, because of shortcomings related to the mechanisms, such as 
inconsistent use and limited staff access and topics covered, USAID 
staff may sometimes learn of important advances and innovations 
haphazardly. For example, according to USAID officials at the Ethiopia 
mission, the mission decided to institute a community-based health 
volunteers approach only after learning of it from a health official 
who had moved to Ethiopia from the Madagascar mission, where the 
approach had been used successfully. Another health officer who 
returned from the field in late 2006 said that before arriving at 
headquarters, she had not heard of USAID's research on using zinc to 
treat diarrheal illnesses, although it had been building the evidence 
base since 1996. Within the three regional bureaus in our review, 
approximately 40 percent of mission officials did not agree that their 
respective regional bureau communicated "clearly, sufficiently, 
transparently, and in a timely manner," according to USAID's annual 
employee survey for 2005.[Footnote 53] Furthermore, over 40 percent of 
mission officials who responded to questions about the Bureau for 
Global Health did not agree that the bureau provided "quality state-of- 
the-art training opportunities." 

USAID Is Responding to Certain Child Survival and Maternal Health 
Program Challenges: 

On the basis of reviews of expert reports, interviews with USAID 
officials and partner and donor representatives, and our survey 
results, we identified three key challenges that affect USAID's CS/MH 
programs: a global shortage of health care workers; a relative lack of 
international attention to maternal and newborn health, as compared 
with child survival; and difficulties in promoting sustainable CS/MH 
programs. USAID is involved in numerous efforts to respond to these 
challenges. First, to help address a global shortage of health care 
providers, USAID is supporting efforts to enhance the skills of current 
health care workers and to train new health care workers. Second, in 
response to the comparative lack of international attention to maternal 
and newborn health, USAID has launched programs that specifically 
consider the needs of mothers and newborns. Lastly, to help deal with 
barriers to program sustainability, USAID has adopted various 
strategies, such as providing technical assistance, leveraging its in- 
country presence, working with host country health ministries, 
supporting the development of products with potentially lasting 
effects, coordinating with the private sector, and promoting community 
involvement. 

USAID Is Supporting Efforts to Address Health Care Worker Shortage: 

To help address the effects of a global shortage of skilled health care 
workers, USAID supports the training of midwives and other health care 
workers. The results of our surveyed identified the health care worker 
shortage as a challenge for USAID: that is, 38 of 40 health officers in 
our surveys stated that the shortage of competent health care workers 
makes it difficult for their maternal and child health program to 
continue without USAID support.[Footnote 54] The WHO estimates a global 
shortage of almost 2.4 million doctors, nurses, and midwives.[Footnote 
55] The shortage is due to a variety of factors, including limited 
investment in health worker education; increasing migration by health 
workers from the poorest to the richest countries; and the impact of 
HIV/AIDS, which increases work burdens and health risks for many health 
workers. Many health workers also face challenges, such as poverty- 
level wages. According to the WHO, the health worker shortage is 
especially acute in Africa, because African countries have 24 percent 
of the global burden of disease[Footnote 56] but only 3 percent of the 
world's health workers. For example, Save the Children reports that the 
majority of Ghana's doctors actually practice overseas, with only an 
estimated 40 percent of doctors remaining in-country. Also, one-quarter 
of Malawi's health workers are expected to die from AIDS by 2011. The 
WHO estimates that Africa requires more than 800,000 additional 
doctors, nurses, and midwives to meet the Millennium Declaration Goal 
of reducing child mortality by two-thirds by 2015. 

According to a WHO report, evidence shows that rates of maternal, 
infant, and child survival; immunization coverage; and primary care 
outreach are linked to the number and quality of health care workers. 
For instance, an analysis by the Joint Learning Initiative[Footnote 57] 
suggests that a 10 percent increase in the number of health care 
providers per 1,000 people is correlated with a 5 percent decrease in 
maternal mortality. Similarly, decreases in the number of health care 
providers are associated with negative health outcomes--the WHO notes 
that child malnutrition has been shown to worsen when health sector 
reform results in staff cuts. 

USAID's support of efforts to train midwives and other health care 
workers includes the following: 

* Midwife training. In Cambodia, USAID is supporting efforts to upgrade 
midwives' skills. According to the Cambodian government, 50 percent of 
the health centers in Cambodia lack a midwife qualified to handle life- 
threatening obstretic complications.[Footnote 58] To help improve 
maternal health, USAID supports the Life Saving Skills training 
approach, which emphasizes the needed skills, and as of March 2006, 653 
midwives had received this training. The Cambodian Ministry of Health 
plans to adopt the Life Saving Skills training approach in its national 
midwifery training programs. 

* Other health care worker training. In Africa, USAID is supporting 
efforts such as training public health care workers. For example, in 
Ethiopia, USAID supported the Carter Center's Ethiopia Public Health 
Training Initiative (see fig. 6). This program develops and provides 
training materials--such as training modules and lecture notes--for 
health care workers, and supports training for health instructors in 
universities and health facilities. As of 2005, the program had 
developed 100 lecture notes, which are short textbooks that focus on 
specific health topics, and supported pedagogical training for 382 
health instructors. 

Figure 6: Health Care Worker Training: 

[See PDF for image] 

Source: GAO. 

[End of figure] 

USAID Is Working to Increase Attention to Maternal and Newborn Health: 

USAID has taken several steps to increase attention to maternal and 
newborn health. Specifically, the agency has established programs that 
focus on these populations, supported maternal health research, and 
incorporated maternal and newborn health into mission programs. USAID 
officials and representatives from implementing partners acknowledged 
that these areas have not received sufficient attention from the 
international community. Other donors, such as the United Nations 
Population Fund and the Gates Foundation, also told us that, relative 
to child survival, maternal and newborn health have been neglected. In 
a series of articles focused on maternal health, The Lancet has stated 
that Millennium Development Goal 5, which calls for a three-quarters 
reduction in maternal mortality by 2015, is the goal toward which the 
world has made the least amount of progress. 

USAID has established programs that specifically address the needs of 
mothers and newborns. For example: 

* In 2004, USAID established a maternal and newborn health program 
called Access to Clinical and Community Maternal, Neonatal and Women's 
Health Services (ACCESS). By 2006, ACCESS supported interventions in 9 
countries and was launching programs in 4 more countries. This program 
focuses on increasing the coverage, access, and use of maternal and 
newborn health services, such as antenatal care; treatment of obstetric 
complications; postpartum care for the mother and newborn; and newborn 
care, including umbilical cord care and early breastfeeding. For 
example, in Haiti and Cameroon, ACCESS supported training in essential 
maternal and newborn care for providers and trainers, while in Nepal, 
the program helped the government develop a national Skilled Birth 
Attendance policy. 

* In 2002, USAID began a special initiative to address postpartum 
hemorrhage, one of the major causes of maternal death. According to the 
WHO, postpartum hemorrhage causes at least 25 percent of all maternal 
deaths worldwide; in some developing countries, it is estimated to 
cause up to 60 percent of maternal deaths. USAID has expanded the 
number of countries with programs that target postpartum hemorrhage 
from 4 countries to 21. One such program is the Prevention of 
Postpartum Hemorrhage Initiative (POPPHI), which USAID launched in 
2004. POPPHI focuses on the primary intervention for preventing 
postpartum hemorrhage--that is, active management of the third stage of 
labor--which has been shown to significantly reduce blood loss and the 
need for blood transfusions.[Footnote 59] POPPHI has supported a number 
of activities, such as regional workshops for professional associations 
of obstetricians, gynecologists, and midwives, and is conducting a 
global survey on the use of the active management of the third stage of 
labor. 

USAID has also supported research on maternal health. For example, in 
2006, USAID supported the WHO's review of the major causes of maternal 
death. The study found that the major causes of maternal death vary by 
geographical region. In Africa, the leading cause of maternal death is 
hemorrhage, while in Latin America and the Caribbean, the leading cause 
is hypertension disorders. Prior to the study, one model of maternal 
mortality causes was used worldwide, without consideration of 
geographic differences. A USAID official told us that the study will 
help the agency determine which interventions to use in each region 
and, thus, allow it to target its maternal health programs more 
efficiently. 

At the mission level, USAID has also begun to include programs that 
concentrate on maternal and newborn health. For example: 

* The Mali mission requested that one of its major implementing 
partners, Assistance Technique Nationale, increase its program's focus 
on maternal health. 

* In Cambodia, the mission supports a national program of "maternal 
death audits"--investigations into the causes of specific maternal 
deaths--to gather information to help prevent future deaths. 

* The India mission supported the promotion of newborn care practices-
-such as the immediate drying and wrapping of the newborn and early 
breastfeeding--through CARE, an implementing partner. 

* The missions in Ethiopia and India support new interventions for 
newborn health. The mission in India is supporting research on both 
newborn disease surveillance and the government of India's introduction 
of a new health protocol--the Integrated Management of Newborn and 
Childhood Illness.[Footnote 60] The Ethiopian mission is also 
supporting the development of this protocol in Ethiopia. 

USAID Has Taken Steps to Support Sustainability: 

USAID has undertaken several efforts to address challenges to the 
sustainability of its CS/MH programs. These efforts include providing 
technical assistance, using its presence and connections in countries, 
working with host country governments, helping to develop products with 
potentially lasting effects, and promoting community involvement in CS/ 
MH efforts. 

In our survey results and interviews with USAID officials, we found 
that although challenges to the sustainability of CS/MH programs varied 
among countries, officials commonly cited challenges such as a lack or 
uncertainty of funding and a lack of technical expertise. For example, 
our survey showed that all 40 of the health officers surveyed found 
uncertainty over future funding levels to be a hindrance to their 
ability to effectively implement their maternal and child health 
programs.[Footnote 61] Likewise, a 2004 report prepared for USAID's 
Bureau for Africa also cites funding uncertainty as a challenge to 
sustainability. The report states that reductions and rapid shifts in 
funding levels for child survival and other health programs made it 
difficult for missions to plan and implement programs. Health officers 
at the USAID mission in Cambodia cited the Cambodian government's 
failure to devote sufficient funding to health as a challenge to 
sustainability. Our survey also indicated that 16 of 39 health officers 
were not confident that their maternal and child health programs would 
continue at their current level of quality without additional USAID 
assistance.[Footnote 62] In India, USAID officials told us that a lack 
of technical expertise was a major challenge to implementing and 
sustaining programs. In addition, out of 40 health officers, 35 or more 
cited corruption and the local populations' low educational level as 
factors that would make it difficult for their maternal and child 
health programs to continue without USAID support. Thirty-seven of 39 
health officers also cited a lack of other resources for the health 
system as a challenge. For example, the USAID mission in Mali told us 
that the population's low educational level is a challenge for 
sustainability because people must be educated about planning and 
budgeting for their own health needs. 

USAID's efforts to address such challenges to program sustainability 
include the following: 

* Providing technical assistance. USAID provides technical assistance 
to build and strengthen the local expertise needed for program 
sustainability. 

* In India, the Urban Health Resource Center, a USAID implementing 
partner, is coordinating the government of India's efforts to develop 
and implement urban health plans for cities of different sizes. These 
plans will help guide national and state governments in developing 
urban health programs for other cities. Also, the Urban Health Resource 
Center is helping the state government of Uttar Pradesh to develop 
models of public-private sector partnerships that can be replicated and 
expanded to reach a larger population. One such partnership mobilizes 
NGO volunteers to interact with community members to increase their use 
of public health services. 

* Similarly, the Ethiopian mission funded a project providing technical 
assistance to the Ministry of Health to develop a proclamation for 
health reform. The proclamation allows local health centers to retain 
user fees. It has been ratified in four regions, affecting 90 percent 
of the Ethiopian population. We visited one health center that has 
plans to increase drug availability with the new funds it has retained 
under the proclamation. 

* Working with implementing partners. USAID uses its in-country 
presence to develop relationships with implementing partners. For 
example: 

* According to a USAID report, the mission in Nigeria has cultivated 
relationships with all of the country's ethnic groups and requires its 
implementing partners to select local staff from all ethnic groups and 
geographic regions of the country. As a result, 99 percent of USAID- 
support project staff in Nigeria is local, which helps create a sense 
of local ownership. 

* USAID has developed long-standing relationships with some 
implementing partners. For example, in Bolivia, USAID has worked with 
PROSALUD, a nonprofit health services provider, for about 18+ 
years.[Footnote 63] 

* Some USAID-funded programs have transitioned into local NGOs. For 
example, the Cambodian staff of two USAID-funded projects later became 
local NGOs themselves--the Reproductive Health Association of Cambodia 
and the Reproductive and Child Health Alliance. A USAID official at the 
Cambodia mission told us that the mission targets support to local 
NGOs, rather than international NGOs, because the local organizations' 
programs build capacity. 

* USAID's presence in the field enables it to coordinate with 
implementing partners. For example, in India, the mission told us that 
the USAID coordinator for the maternal and child health activities in 
the state of Jharkhand visits project sites about once a month, and 
works with implementing partners' representatives as well as local 
government officials. Furthermore, in addition to holding regular 
meetings for its partners, the mission has developed a partners' guide, 
which is a publication containing brief descriptions of all USAID 
health partners and their activities. According to one health officer, 
the meetings and the guide have helped to foster a sense of a "USAID 
community" among the partners. 

* Working with host governments. USAID works with the countries' health 
ministries to coordinate CS/MH efforts. In our survey, 37 of 40 health 
officers reported working with their host country's health ministry to 
implement their maternal and child health programs. Also, in all four 
of the countries we visited, USAID supported the national governments' 
development of health policies. In Ethiopia, India, and Mali, the 
missions have chaired the governments' donor coordination groups. The 
Cambodian Ministry of Health chairs donor coordination groups, but 
according to mission staff and representatives from other donors, these 
groups are not an effective means for coordination. 

* Developing potentially lasting products. USAID seeks to support the 
development of products that can have long-lasting effects on maternal 
and child health. For example, USAID helped support the creation of a 
Family Health Card in Ethiopia. This pamphlet, which is meant to be 
used by parents and community health workers, includes information on 
topics such as antenatal care, immunizations, nutrition, treatment of 
diarrhea, and hygiene. The Family Health Card is being used by several 
implementing partners as well as the Ethiopian Ministry of Health. 
Also, USAID supported the development of a Child Survival Message Guide 
in Ethiopia. This guide, developed with the Ministry of Health and 
other partners, seeks to ensure that organizations working in health 
provide the public with consistent messages about child survival. The 
guide can also serve as the basis for other health efforts, because 
organizations can use the guide as a starting point for developing 
their own materials. 

* Working with the private sector. USAID works with private sector 
entities to promote the use of maternal and child health interventions. 
In our survey, 26 of 40 health officers reported working with for- 
profit businesses to implement their CS/MH programs. For example, the 
Point of Use Water Disinfection and Zinc Treatment Project, a USAID 
implementing partner in India, works with pharmaceutical manufacturers 
to promote the production of oral rehydration solution and zinc for the 
treatment of diarrhea, a leading cause of child mortality. 

* Promoting community involvement. USAID also promotes community 
involvement to strengthen program sustainability (see sidebar). 
Community volunteers play major roles in USAID's CS/MH programs in the 
four countries we visited. Community members may perform a variety of 
activities, such as encouraging families to get their children 
immunized, urging pregnant women to obtain antenatal care, and 
referring others to government health centers for treatment and other 
services. For example, the India mission supports the use of community 
volunteers as part of its urban health program. These volunteers help 
organize outreach "camps," during which certain health services, such 
as antenatal care, are offered in the local community. The volunteers 
also assist in setting up women's health groups, which are composed of 
women from the community. Among their other activities, these groups 
create and manage a "community health fund" that provides loans to 
community members to pay for emergency health services; the women's 
groups also encourage attendance at outreach camps. USAID policy urges 
the use of community members to promote health. For example, according 
to USAID officials, the Bureau for Africa asks missions to incorporate 
community involvement in their countries' work plans. 

Text Box: Community-Level Programs: Community Volunteers, Cambodia: 

The USAID mission in Cambodia works with several implementing partners 
who use a community-based approach to improving health. For example, 
the Reproductive and Child Health Alliance (RACHA), a USAID partner and 
local nongovernmental organization, works with community volunteers to 
provide health education and outreach activities, such as vitamin A 
distribution for children younger than 5 years old. Studies have shown 
that vitamin A supplementation, if received every 4 to 6 months, can 
reduce child mortality from all causes by as much as 23 percent. The 
photographs above show RACHA community volunteers distributing vitamin 
A supplements and educating fellow villagers on good health practices 
in the Pursat province. 

[End of text box] 

Conclusions: 

USAID's allocations from the Child Survival and Maternal Health account 
in fiscal years 2004 and 2005 helped fund wide-ranging efforts to lower 
maternal and child mortality in Africa, Asia and the Near East, and 
Latin America and the Caribbean. The agency's country and regional 
missions and bureaus conducted numerous local and regional CS/MH 
activities. The Bureau for Global Health, in addition to serving as a 
global leader of CS/MH efforts, provided technical support for these 
activities, supported CS/MH research, and disseminated innovations and 
best practices to the missions and regional bureaus. However, because 
the Office of the Administrator did not require its missions and 
bureaus to report their obligations and expenditures of CS/MH 
allocations, the office had limited ability to account for and report 
on the use of the funds. To oversee and determine whether the CS/MH 
account is being used for the purposes for which it is allocated, 
including addressing congressional directives, the Office of the 
Administrator needs improved access to this information. USAID 
officials told us that the agency is making changes to its accounting 
system to record obligations and expenditures in the CS/MH account. 
However, the system currently contains little CS/MH data, and USAID has 
not tested how these data are traced back to the corresponding 
allocation data in the State Department's planning system to determine 
if CS/MH funds are obligated and expended for their intended purposes. 

USAID has used various methods of disseminating health care innovations 
and best practices to its staff in the field to facilitate their 
efforts to improve maternal and child health. These methods have 
included, for example, electronic learning courses, biennial regional 
health conferences, an online database, and regional workshops. 
However, USAID has not assessed the relative effectiveness of its 
methods, some of which have drawbacks that may limit their usefulness. 
Given the urgent need to improve maternal and child health in 
developing countries, as well as the challenges confronting such 
efforts, it is essential that USAID use proven methods to ensure that 
staff at its missions and regional bureaus learn of CS/MH innovations 
and best practices in a timely and consistent manner. 

Recommendations for Executive Action: 

To enhance USAID's administration of the Child Survival and Programs 
Fund and implementation of CS/MH programs, we are making the following 
two recommendations to the USAID Administrator: 

* To strengthen USAID's ability to oversee and determine whether the 
Child Survival and Maternal Health account is used for the purposes for 
which the agency allocates it, including responding to congressional 
directives, the USAID Administrator should test recent modifications to 
the principal accounting system to verify that CS/MH obligation and 
expenditure data will be properly recorded and traced back to the 
corresponding allocation data in the State Department's planning 
system. 

* To provide for effective dissemination of information to USAID 
mission health officers about innovations and best practices in child 
survival and maternal health in a consistent and timely manner, the 
USAID Administrator should assess the relative effectiveness of the 
agency's current methods of disseminating this information using 
existing tools--for example, by including appropriate questions in the 
annual employee survey. 

Agency Comments and Our Evaluation: 

USAID provided written comments and technical suggestions and 
clarifications on a draft copy of this report. (See app. VI for a 
reprint of USAID's comments and our response.) Consistent with our 
report's discussion, the agency emphasized that while its accounting 
system did not track obligations and expenditures at the CS/MH level in 
fiscal years 2004 and 2005, it did capture obligation and expenditure 
information for the larger CSH Fund. Regarding our first 
recommendation, USAID stated that once its modified accounting system 
has captured sufficient funding information, the agency will conduct 
tests to determine whether this information captures all CS/MH 
activities, thus allowing for verification that the funds are being 
used for the purposes for which they were appropriated. USAID also said 
it will immediately verify that the State Department's planning system 
correctly captures all CS/MH allocated funds, including CS/MH funds 
that might not fall under the maternal and child health element or 
health program area. 

With respect to our second recommendation, USAID stated that it plans 
to conduct a Training Needs Assessment in 2007-2008 that will address 
our concerns and recommendation regarding evaluation of information 
dissemination methods. USAID also provided information regarding the 
role that grantees and contractors play in disseminating information on 
innovations and best practices. Furthermore, the agency provided 
additional detail on training and information dissemination efforts 
that we described in the draft, such as its electronic learning courses 
and state-of-the-art training. We have incorporated this information in 
the report, as well as USAID's technical comments and suggestions, 
where appropriate. 

We are sending copies of this report to interested congressional 
committees and the USAID Administrator. Copies of this report will be 
made available to other interested parties upon request. In addition, 
the report will be available at no charge on the GAO Web site at 
http://www.gao.gov. 

If you or your staffs 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. Key contributors to this report are 
listed in appendix VII. 

Signed by: 

David Gootnick: 
Director, International Affairs and Trade: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

The fiscal year 2006 Foreign Operations Appropriations Act directed GAO 
to review the U.S. Agency for International Development's (USAID) use 
of child survival and health funds for fiscal years 2004 and 2005. 
Discussions with staff from committees of jurisdiction indicated that 
congressional interest focused on the Child Survival and Maternal 
Health (CS/MH) account within the Child Survival and Health Programs 
Fund. 

As part of our efforts to obtain information to address our four 
objectives, we conducted two surveys between August and December 2006. 
The surveys included questions on financial reporting, the types of 
activities funded with CS/MH funds, coordination with host country 
governments, methods for sharing best practices, and challenges to 
implementing CS/MH programs. Both surveys were sent to all 40 USAID 
health officers who currently manage CS/MH programs. To develop the 
questions for both surveys, we reviewed documents from USAID's Bureau 
for Global Health and conducted interviews with mission health 
officers. We pretested both questionnaires with mission health 
officers. For the first survey, we conducted three pretests; for the 
second, we conducted two. We refined our questions on the basis of the 
feedback we obtained from the pretests. We achieved a 100 percent 
response rate for both surveys. We took steps in collecting and 
analyzing the survey data to minimize errors that might occur during 
these stages of the surveys. 

To examine USAID's financial data on CS/MH funds for fiscal years 2004 
and 2005, we reviewed budget data provided by the Office of the 
Controller, which provided data from USAID's primary financial 
management and reporting system; the Bureau of Policy and Program 
Coordination; the Bureau for Global Health; and the regional bureaus 
for Africa, Asia and the Near East, and Latin America and the 
Caribbean. We also conducted interviews with officials from those 
units, as well as the Office of the Inspector General, to understand 
how USAID accounted for its CS/MH funds. Finally, we reviewed financial 
data from USAID missions in Cambodia, Ethiopia, India, and Mali. We 
conducted field visits to these four countries from October to November 
2006. We selected these countries based on criteria that included (1) 
receipt of CS/MH account funding; (2) representation of Africa and 
Asia, the two geographic regions with the highest maternal and child 
mortality rates; (3) recommendations by USAID officials of some 
countries that faced "challenges" and others that had achieved 
"successes"; and (4) consideration of travel restrictions. 

To describe USAID's activities funded by the CS/MH account, we reviewed 
documentation from the Bureau for Global Health; the regional bureaus 
for Africa, Asia and the Near East, and Latin America and the 
Caribbean; and the USAID missions in our four field countries. We also 
interviewed USAID officials at each of these entities. In the four 
field countries, we observed some of USAID's CS/MH activities and 
interviewed host country government officials at both national and 
local levels, representatives from USAID implementing partners 
(including international and local nongovernmental organizations and 
faith-based organizations), and program beneficiaries. Lastly, to 
further develop our understanding of current CS/MH interventions and 
indicators, we attended global health conferences in Washington, D.C. 

To examine USAID's methods for sharing best practices, we reviewed 
USAID policies and documents and analyzed data from our two surveys. To 
familiarize ourselves with the electronic resources USAID uses to 
disseminate best practices, we accessed USAID's external Web site as 
well as other sites on the World Wide Web. We also interviewed USAID 
officials of the Bureau for Global Health, the regional bureaus, and 
the missions that we visited. 

To describe USAID's response to challenges in planning and implementing 
its CS/MH programs, we first identified key challenges by using data 
from our first survey and interviewing officials representing (1) 
USAID's three regional bureaus, the Bureau for Global Health, and our 
four field countries; (2) USAID's implementing partners; and (3) other 
donor organizations, such as the United Nations Children's Fund 
(UNICEF), United Nations Population Fund, and Gates Foundation. To 
obtain additional information on the global health worker shortage, we 
reviewed reports from nongovernmental and multilateral sources, such as 
Save the Children and the World Health Organization. In our examination 
of the challenges associated with maternal and newborn health, we 
reviewed reports, such as UNICEF's State of the World's Children 2007, 
and articles from the British medical journal titled The Lancet. To 
determine what steps USAID is taking to address the identified 
challenges, we interviewed USAID officials at the Bureau for Global 
Health, the three regional bureaus, and missions in our four field 
countries. We also reviewed USAID documentation, including work plans, 
annual reports, and program reports, such as the Bureau for Africa's 
Child Survival in Sub-Saharan Africa - Taking Stock. 

We assessed the reliability of financial data compiled and generated by 
USAID's Office of the Controller in Washington, D.C., and by the 
missions in our four field countries. We determined that the survey and 
financial data were sufficiently reliable for our analysis. 

We conducted our work from April 2006 through March 2007 in accordance 
with generally accepted government auditing standards. 

[End of section] 

Appendix II: Allocation of Child Survival and Maternal Health Funds 
within USAID, Fiscal Years 2004 and 2005: 

Dollars in millions. 

Country/Entity: Africa; 
Fiscal year: 2004: Amount: $78.6; 
Fiscal year: 2004: Percent: 24.0%; 
Fiscal year: 2005: Amount: $88.3; 
Fiscal year: 2005: Percent: 25.4%; 
Total: Amount: $166.9;
Total: Percent: 24.7%. 

Country/Entity: Asia and the Near East; 
Fiscal year: 2004: Amount: 79.6; 
Fiscal year: 2004: Percent: 24.2; 
Fiscal year: 2005: Amount: 80.5; 
Fiscal year: 2005: Percent: 23.2; 
Total: Amount: 160.0; 
Total: Percent: 23.7. 

Country/Entity: Latin America and the Caribbean; 
Fiscal year: 2004: Amount: 39.0; 
Fiscal year: 2004: Percent: 11.9; 
Fiscal year: 2005: Amount: 39.3; 
Fiscal year: 2005: Percent: 11.3; 
Total: Amount: 78.4; 
Total: Percent: 11.6. 

Country/Entity: International Partnerships; 
Fiscal year: 2004: Amount: 64.2; 
Fiscal year: 2004: Percent: 19.6; 
Fiscal year: 2005: Amount: 72.3; 
Fiscal year: 2005: Percent: 20.8; 
Total: Amount: 136.5; 
Total: Percent: 20.2. 

Country/Entity: Bureau for Global Health; 
Fiscal year: 2004: Amount: 66.0; 
Fiscal year: 2004: Percent: 20.1; 
Fiscal year: 2005: Amount: 67.1; 
Fiscal year: 2005: Percent: 19.3; 
Total: Amount: 133.1; 
Total: Percent: 19.7. 

Country/Entity: Other; 
Fiscal year: 2004: Amount: 0.6; 
Fiscal year: 2004: Percent: 0.2; 
Fiscal year: 2005: Amount: n/a; 
Fiscal year: 2005: Percent: n/a; 
Total: Amount: 0.6; 
Total: Percent: 0.1. 

Total; 
Fiscal year: 2004: Amount: $328.0; 
Fiscal year: 2004: Percent: -; 
Fiscal year: 2005: Amount: $347.5; 
Fiscal year: 2005: Percent: -; 
Total: Amount: $675.6; 
Total: Percent: -. 

Source: GAO analysis of USAID data. 

[End of table] 

[End of section] 

Appendix III: Allocation of CS/MH Account Funds to Countries, Fiscal 
Years 2004 and 2005: 

Country: Afghanistan; 
Fiscal year: 2004 (actual): $16,870; 
Fiscal year: 2005 (actual): $19,870; 
Fiscal year: 2006 (planned): $21,005. 

Country: Angola; 
Fiscal year: 2004 (actual): 2,700; 
Fiscal year: 2005 (actual): 1,200; 
Fiscal year: 2006 (planned): 1,483. 

Country: Bangladesh; 
Fiscal year: 2004 (actual): 10,800; 
Fiscal year: 2005 (actual): 9,412; 
Fiscal year: 2006 (planned): 6,683. 

Country: Benin; 
Fiscal year: 2004 (actual): 1,350; 
Fiscal year: 2005 (actual): 1,250; 
Fiscal year: 2006 (planned): 1,977. 

Country: Bolivia; 
Fiscal year: 2004 (actual): 4,475; 
Fiscal year: 2005 (actual): 4,752; 
Fiscal year: 2006 (planned): 5,787. 

Country: Burundi; 
Fiscal year: 2004 (actual): 200; 
Fiscal year: 2005 (actual): 300; 
Fiscal year: 2006 (planned): 692. 

Country: Cambodia; 
Fiscal year: 2004 (actual): 4,690; 
Fiscal year: 2005 (actual): 5,100; 
Fiscal year: 2006 (planned): 5,148. 

Country: Democratic Republic of the Congo; 
Fiscal year: 2004 (actual): 8,025; 
Fiscal year: 2005 (actual): 8,600; 
Fiscal year: 2006 (planned): 8,601. 

Country: Dominican Republic; 
Fiscal year: 2004 (actual): 4,000; 
Fiscal year: 2005 (actual): 3,861; 
Fiscal year: 2006 (planned): 3,237. 

Country: El Salvador; 
Fiscal year: 2004 (actual): 2,700; 
Fiscal year: 2005 (actual): 2,970; 
Fiscal year: 2006 (planned): 2,970. 

Country: Eritrea; 
Fiscal year: 2004 (actual): 1,600; 
Fiscal year: 2005 (actual): 5[A]; 
Fiscal year: 2006 (planned): 0[A]. 

Country: Ethiopia; 
Fiscal year: 2004 (actual): 4,600; 
Fiscal year: 2005 (actual): 6,090; 
Fiscal year: 2006 (planned): 7,257. 

Country: Ghana; 
Fiscal year: 2004 (actual): 3,200; 
Fiscal year: 2005 (actual): 3,200; 
Fiscal year: 2006 (planned): 2,719. 

Country: Guatemala; 
Fiscal year: 2004 (actual): 4,150; 
Fiscal year: 2005 (actual): 4,215; 
Fiscal year: 2006 (planned): 4,158. 

Country: Guinea; 
Fiscal year: 2004 (actual): 2,150; 
Fiscal year: 2005 (actual): 2,150; 
Fiscal year: 2006 (planned): 2,200. 

Country: Haiti; 
Fiscal year: 2004 (actual): 8,550; 
Fiscal year: 2005 (actual): 8,839; 
Fiscal year: 2006 (planned): 9,207. 

Country: Honduras; 
Fiscal year: 2004 (actual): 3,142; 
Fiscal year: 2005 (actual): 3,143; 
Fiscal year: 2006 (planned): 3,377. 

Country: India; 
Fiscal year: 2004 (actual): 12,600; 
Fiscal year: 2005 (actual): 14,222; 
Fiscal year: 2006 (planned): 12,852. 

Country: Indonesia; 
Fiscal year: 2004 (actual): 11,400; 
Fiscal year: 2005 (actual): 13,800; 
Fiscal year: 2006 (planned): 14,157. 

Country: Jamaica; 
Fiscal year: 2004 (actual): 544; 
Fiscal year: 2005 (actual): 539; 
Fiscal year: 2006 (planned): 497. 

Country: Kenya; 
Fiscal year: 2004 (actual): 1,000; 
Fiscal year: 2005 (actual): 1,000; 
Fiscal year: 2006 (planned): 989. 

Country: Liberia; 
Fiscal year: 2004 (actual): 1,200; 
Fiscal year: 2005 (actual): 1,200; 
Fiscal year: 2006 (planned): 1,582. 

Country: Madagascar; 
Fiscal year: 2004 (actual): 2,825; 
Fiscal year: 2005 (actual): 3,475; 
Fiscal year: 2006 (planned): 3,287. 

Country: Malawi; 
Fiscal year: 2004 (actual): 2,200; 
Fiscal year: 2005 (actual): 2,200; 
Fiscal year: 2006 (planned): 2,175. 

Country: Mali; 
Fiscal year: 2004 (actual): 2,900; 
Fiscal year: 2005 (actual): 3,780; 
Fiscal year: 2006 (planned): 3,658. 

Country: Mozambique; 
Fiscal year: 2004 (actual): 3,500; 
Fiscal year: 2005 (actual): 4,500; 
Fiscal year: 2006 (planned): 4,350. 

Country: Nepal; 
Fiscal year: 2004 (actual): 5,040; 
Fiscal year: 2005 (actual): 5,340; 
Fiscal year: 2006 (planned): 4,951. 

Country: Nicaragua; 
Fiscal year: 2004 (actual): 3,000; 
Fiscal year: 2005 (actual): 3,242; 
Fiscal year: 2006 (planned): 3,210. 

Country: Nigeria; 
Fiscal year: 2004 (actual): 7,000; 
Fiscal year: 2005 (actual): 8,650; 
Fiscal year: 2006 (planned): 3,856. 

Country: Pakistan; 
Fiscal year: 2004 (actual): 11,600; 
Fiscal year: 2005 (actual): 7,600; 
Fiscal year: 2006 (planned): 13,652. 

Country: Paraguay; 
Fiscal year: 2004 (actual): 0; 
Fiscal year: 2005 (actual): 0; 
Fiscal year: 2006 (planned): 1,102. 

Country: Peru; 
Fiscal year: 2004 (actual): 5,450; 
Fiscal year: 2005 (actual): 5,164; 
Fiscal year: 2006 (planned): 4,653. 

Country: Philippines; 
Fiscal year: 2004 (actual): 4,700; 
Fiscal year: 2005 (actual): 4,550; 
Fiscal year: 2006 (planned): 4,356. 

Country: Rwanda; 
Fiscal year: 2004 (actual): 1,100; 
Fiscal year: 2005 (actual): 1,400; 
Fiscal year: 2006 (planned): 2,224. 

Country: Senegal; 
Fiscal year: 2004 (actual): 2,500; 
Fiscal year: 2005 (actual): 2,600; 
Fiscal year: 2006 (planned): 2,422. 

Country: Sierra Leone; 
Fiscal year: 2004 (actual): 100; 
Fiscal year: 2005 (actual): 100; 
Fiscal year: 2006 (planned): 297. 

Country: Somalia; 
Fiscal year: 2004 (actual): 100; 
Fiscal year: 2005 (actual): 100; 
Fiscal year: 2006 (planned): 0. 

Country: South Africa; 
Fiscal year: 2004 (actual): 2,000; 
Fiscal year: 2005 (actual): 2,000; 
Fiscal year: 2006 (planned): 1,780. 

Country: Sudan; 
Fiscal year: 2004 (actual): 7,200; 
Fiscal year: 2005 (actual): 8,200; 
Fiscal year: 2006 (planned): 8,809. 

Country: Tanzania; 
Fiscal year: 2004 (actual): 2,500; 
Fiscal year: 2005 (actual): 3,500; 
Fiscal year: 2006 (planned): 3,312. 

Country: Uganda; 
Fiscal year: 2004 (actual): 2,260; 
Fiscal year: 2005 (actual): 2,260; 
Fiscal year: 2006 (planned): 2,135. 

Country: Zambia; 
Fiscal year: 2004 (actual): 4,420; 
Fiscal year: 2005 (actual): 4,420; 
Fiscal year: 2006 (planned): 4,271. 

Source: GAO analysis of USAID data. 

Note: We conducted site visits to the countries that are noted in 
bolded text. 

[A] USAID closed its activities in Eritrea on December 31, 2005, in 
response to the Government of Eritrea's request that USAID terminate 
development assistance programs in the country. 

[End of table] 

[End of section] 

Appendix IV: Mortality Statistics for Countries Receiving CS/MH Funds, 
Fiscal Years 2004 and 2005: 

Country: Afghanistan; 
Under 5 Mortality Rate (2003)[A]: 257; 
Neonatal Mortality Rate (2000)[B]: 60; 
Maternal Mortality Ratio (2000)[C]: 1,900. 

Country: Angola; 
Under 5 Mortality Rate (2003)[A]: 260; 
Neonatal Mortality Rate (2000)[B]: 54; 
Maternal Mortality Ratio (2000)[C]: 1,700. 

Country: Bangladesh; 
Under 5 Mortality Rate (2003)[A]: 69; 
Neonatal Mortality Rate (2000)[B]: 36; 
Maternal Mortality Ratio (2000)[C]: 380. 

Country: Benin; 
Under 5 Mortality Rate (2003)[A]: 154; 
Neonatal Mortality Rate (2000)[B]: 38; 
Maternal Mortality Ratio (2000)[C]: 850. 

Country: Bolivia; 
Under 5 Mortality Rate (2003)[A]: 66; 
Neonatal Mortality Rate (2000)[B]: 27; 
Maternal Mortality Ratio (2000)[C]: 420. 

Country: Burundi; 
Under 5 Mortality Rate (2003)[A]: 190; 
Neonatal Mortality Rate (2000)[B]: 41; 
Maternal Mortality Ratio (2000)[C]: 1,000. 

Country: Cambodia; 
Under 5 Mortality Rate (2003)[A]: 140; 
Neonatal Mortality Rate (2000)[B]: 40; 
Maternal Mortality Ratio (2000)[C]: 450. 

Country: Democratic Republic of the Congo; 
Under 5 Mortality Rate (2003)[A]: 205; 
Neonatal Mortality Rate (2000)[B]: 47; 
Maternal Mortality Ratio (2000)[C]: 990. 

Country: Dominican Republic; 
Under 5 Mortality Rate (2003)[A]: 35; 
Neonatal Mortality Rate (2000)[B]: 19; 
Maternal Mortality Ratio (2000)[C]: 150. 

Country: El Salvador; 
Under 5 Mortality Rate (2003)[A]: 36; 
Neonatal Mortality Rate (2000)[B]: 16; 
Maternal Mortality Ratio (2000)[C]: 150. 

Country: Eritrea; 
Under 5 Mortality Rate (2003)[A]: 85; 
Neonatal Mortality Rate (2000)[B]: 25; 
Maternal Mortality Ratio (2000)[C]: 630. 

Country: Ethiopia; 
Under 5 Mortality Rate (2003)[A]: 169; 
Neonatal Mortality Rate (2000)[B]: 51; 
Maternal Mortality Ratio (2000)[C]: 850. 

Country: Ghana; 
Under 5 Mortality Rate (2003)[A]: 95; 
Neonatal Mortality Rate (2000)[B]: 27; 
Maternal Mortality Ratio (2000)[C]: 540. 

Country: Guatemala; 
Under 5 Mortality Rate (2003)[A]: 47; 
Neonatal Mortality Rate (2000)[B]: 19; 
Maternal Mortality Ratio (2000)[C]: 240. 

Country: Guinea; 
Under 5 Mortality Rate (2003)[A]: 160; 
Neonatal Mortality Rate (2000)[B]: 48; 
Maternal Mortality Ratio (2000)[C]: 740. 

Country: Haiti; 
Under 5 Mortality Rate (2003)[A]: 119; 
Neonatal Mortality Rate (2000)[B]: 34; 
Maternal Mortality Ratio (2000)[C]: 680. 

Country: Honduras; 
Under 5 Mortality Rate (2003)[A]: 41; 
Neonatal Mortality Rate (2000)[B]: 18; 
Maternal Mortality Ratio (2000)[C]: 110. 

Country: India; 
Under 5 Mortality Rate (2003)[A]: 87; 
Neonatal Mortality Rate (2000)[B]: 43; 
Maternal Mortality Ratio (2000)[C]: 540. 

Country: Indonesia; 
Under 5 Mortality Rate (2003)[A]: 41; 
Neonatal Mortality Rate (2000)[B]: 18; 
Maternal Mortality Ratio (2000)[C]: 230. 

Country: Jamaica; 
Under 5 Mortality Rate (2003)[A]: 20; 
Neonatal Mortality Rate (2000)[B]: 10; 
Maternal Mortality Ratio (2000)[C]: 87. 

Country: Kenya; 
Under 5 Mortality Rate (2003)[A]: 123; 
Neonatal Mortality Rate (2000)[B]: 29; 
Maternal Mortality Ratio (2000)[C]: 1,000. 

Country: Liberia; 
Under 5 Mortality Rate (2003)[A]: 235; 
Neonatal Mortality Rate (2000)[B]: 66; 
Maternal Mortality Ratio (2000)[C]: 760. 

Country: Madagascar; 
Under 5 Mortality Rate (2003)[A]: 126; 
Neonatal Mortality Rate (2000)[B]: 33; 
Maternal Mortality Ratio (2000)[C]: 550. 

Country: Malawi; 
Under 5 Mortality Rate (2003)[A]: 178; 
Neonatal Mortality Rate (2000)[B]: 40; 
Maternal Mortality Ratio (2000)[C]: 1,800. 

Country: Mali; 
Under 5 Mortality Rate (2003)[A]: 220; 
Neonatal Mortality Rate (2000)[B]: 55; 
Maternal Mortality Ratio (2000)[C]: 1,200. 

Country: Mozambique; 
Under 5 Mortality Rate (2003)[A]: 158; 
Neonatal Mortality Rate (2000)[B]: 48; 
Maternal Mortality Ratio (2000)[C]: 1,000. 

Country: Nepal; 
Under 5 Mortality Rate (2003)[A]: 82; 
Neonatal Mortality Rate (2000)[B]: 40; 
Maternal Mortality Ratio (2000)[C]: 740. 

Country: Nicaragua; 
Under 5 Mortality Rate (2003)[A]: 38; 
Neonatal Mortality Rate (2000)[B]: 18; 
Maternal Mortality Ratio (2000)[C]: 230. 

Country: Nigeria; 
Under 5 Mortality Rate (2003)[A]: 198; 
Neonatal Mortality Rate (2000)[B]: 53; 
Maternal Mortality Ratio (2000)[C]: 800. 

Country: Pakistan; 
Under 5 Mortality Rate (2003)[A]: 103; 
Neonatal Mortality Rate (2000)[B]: 57; 
Maternal Mortality Ratio (2000)[C]: 500. 

Country: Peru; 
Under 5 Mortality Rate (2003)[A]: 34; 
Neonatal Mortality Rate (2000)[B]: 16; 
Maternal Mortality Ratio (2000)[C]: 410. 

Country: Philippines; 
Under 5 Mortality Rate (2003)[A]: 36; 
Neonatal Mortality Rate (2000)[B]: 15; 
Maternal Mortality Ratio (2000)[C]: 200. 

Country: Rwanda; 
Under 5 Mortality Rate (2003)[A]: 203; 
Neonatal Mortality Rate (2000)[B]: 45; 
Maternal Mortality Ratio (2000)[C]: 1,400. 

Country: Senegal; 
Under 5 Mortality Rate (2003)[A]: 137; 
Neonatal Mortality Rate (2000)[B]: 31; 
Maternal Mortality Ratio (2000)[C]: 690. 

Country: Sierra Leone; 
Under 5 Mortality Rate (2003)[A]: 283; 
Neonatal Mortality Rate (2000)[B]: 56; 
Maternal Mortality Ratio (2000)[C]: 2,000. 

Country: Somalia; 
Under 5 Mortality Rate (2003)[A]: 225; 
Neonatal Mortality Rate (2000)[B]: 49; 
Maternal Mortality Ratio (2000)[C]: 1,100. 

Country: South Africa; 
Under 5 Mortality Rate (2003)[A]: 66; 
Neonatal Mortality Rate (2000)[B]: 21; 
Maternal Mortality Ratio (2000)[C]: 230. 

Country: Sudan; 
Under 5 Mortality Rate (2003)[A]: 93; 
Neonatal Mortality Rate (2000)[B]: 29; 
Maternal Mortality Ratio (2000)[C]: 590. 

Country: Tanzania; 
Under 5 Mortality Rate (2003)[A]: 165; 
Neonatal Mortality Rate (2000)[B]: 43; 
Maternal Mortality Ratio (2000)[C]: 1,500. 

Country: Uganda; 
Under 5 Mortality Rate (2003)[A]: 140; 
Neonatal Mortality Rate (2000)[B]: 32; 
Maternal Mortality Ratio (2000)[C]: 880. 

Country: Zambia; 
Under 5 Mortality Rate (2003)[A]: 182; 
Neonatal Mortality Rate (2000)[B]: 40; 
Maternal Mortality Ratio (2000)[C]: 750. 

Source: GAO analysis of WHO and UNICEF data. 

Note: We conducted site visits to the countries that are noted in 
bolded text. 

[A] Under-5 Mortality Rate = Probability per 1,000 live births of child 
dying before age 5. 

[B] Neonatal Mortality Rate = (Neonatal deaths / live births) x 1,000. 

[C] Maternal Mortality Ratio = Maternal deaths per 100,000 live births. 

[End of table] 

[End of section] 

Appendix V: Obligations and Expenditures for the Four Missions We 
Visited, Fiscal Years 2004 and 2005: 

Mission-managed programs. 

Country: Cambodia; 
Fiscal year: 2004: Obligations: $3,971,330; 
Fiscal year: 2004: Expenditures: $3,573,002; 
Fiscal year: 2005: Obligations: $5,020,120; 
Fiscal year: 2005: Expenditures: $4,019,403. 

Country: Ethiopia; 
Fiscal year: 2004: Obligations: 2,531,597; 
Fiscal year: 2004: Expenditures: 2,469,984; 
Fiscal year: 2005: Obligations: 4,684,941; 
Fiscal year: 2005: Expenditures: 2,417,957. 

Country: India[A]; 
Fiscal year: 2004: Obligations: 4,295,000; 
Fiscal year: 2004: Expenditures: 8,445,506; 
Fiscal year: 2005: Obligations: 4,858,000; 
Fiscal year: 2005: Expenditures: 5,300,141. 

Country: Mali; 
Fiscal year: 2004: Obligations: 2,620,000; 
Fiscal year: 2004: Expenditures: 2,617,154;
Fiscal year: 2005: Obligations: 3,486,766; 
Fiscal year: 2005: Expenditures: 2,513,190. 

Centrally managed programs. 

Country: Cambodia; 
Fiscal year: 2004: Obligations: 718,610; 
Fiscal year: 2004: Expenditures: -; 
Fiscal year: 2005: Obligations: 150,000; 
Fiscal year: 2005: Expenditures: -. 

Country: Ethiopia; 
Fiscal year: 2004: Obligations: 400,000; 
Fiscal year: 2004: Expenditures: 400,000; 
Fiscal year: 2005: Obligations: 570,000; 
Fiscal year: 2005: Expenditures: 570,000. 

Country: India[A]; 
Fiscal year: 2004: Obligations: 8,731,000; 
Fiscal year: 2004: Expenditures: -; 
Fiscal year: 2005: Obligations: 9,942,000; 
Fiscal year: 2005: Expenditures: -. 

Country: Mali; 
Fiscal year: 2004: Obligations: 330,000; 
Fiscal year: 2004: Expenditures: 320,000; 
Fiscal year: 2005: Obligations: 493,000; 
Fiscal year: 2005: Expenditures: 318,000. 

Source: GAO analysis of USAID mission data. 

Note: Cambodia and India were unable to provide expenditure data for 
centrally managed programs. Ethiopia estimated its expenditures for 
centrally managed programs. The Bureau for Global Health, which managed 
these programs, was able to provide obligation data, totaling over $90 
million in fiscal years 2004 and 2005, but was unable to provide 
expenditure data. 

[A] India carried over unexpended funds from previous fiscal years, 
which caused greater expenditures than obligations in fiscal years 2004 
and 2005. 

[End of table] 

[End of section] 

Appendix VI: Comments from the U.S. Agency for International 
Development: 

Note: GAO comment supplementing those in the report text appears at the 
end of this appendix. 

USAID: 
From The American People: 

Apr 3 2007: 

Mr. David Gootnick: 
Director: 
International Affairs and Trade: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, D.C. 20548: 

Dear Mr. Gootnick: 

I am pleased to provide the U.S. Agency for International Development's 
(USAID) formal response to the draft GAO report entitled USAID 
Supported a Wide Range of Child and Maternal Health Activities but 
Lacked Detailed Spending Data and Proven Methods for Sharing Best 
Practices [GAO-07-486]. 

I would like to clarify that USAID tracks obligations and expenditures 
at the account level, e.g., the Child Survival and Health (CSH) 
account. In FY 2004 and FY 2005, the Agency accounting system did not 
track obligations and expenditures at the sub-account level, including 
Child Survival and Maternal Health (CS/MH) funds. Congress was aware of 
this situation and the Agency never presented its accounting system as 
reporting below the account level. Starting in FY 2007, changes in the 
accounting system will allow tracking of the CS/MH funds. 

Thank you for the opportunity to respond to the GAO draft report and 
for the courtesies extended by your staff in the conduct of this 
review. 

Sincerely, 

Signed by: 

Mosina H. Jordan: 
Counselor to the Agency: 

Enclosure: 
USAID Comments: 

cc: Rob Portman, Director, OMB: 

USAID Comments On Draft GAO 07-486: 

1. In response to your first recommendation, USAID will carry out the 
following longer term and immediate tests: 

A. Once there is sufficient obligation and expenditure information in 
Phoenix, reconcile the FY2007 CS/MH "sub-account" and cross-walk it 
over to the corresponding allocation information in the Foreign 
Assistance Coordination and Tracking System (FACTS). This test will 
determine whether the modifications in the Phoenix system to record 
obligations and expenditures by the elements[Footnote 64] of the 
Foreign Assistance Framework, as set out in FACTS, capture all the CS/ 
MH activities and allow for verification that these funds are being 
used for the purposes for which they were appropriated and allocated. 
This testing process might take a year and a half in order to have 
sufficient data, making it possible to close out the recommendation in 
the three-year window allowed. 

B. In addition to this longer term testing process, - USAID will verify 
immediately that FACTS correctly captures all of the CS/MH funding 
information, as the CSH guidance requires, including CS/MH funds in the 
Maternal and Child Health (MCH) element and CS/MH funds in other 
elements and in non-health areas. 

2. In response to your second recommendation, we would like to note the 
large amount of information about innovations and best practices in 
child survival and maternal health disseminated by the grantees and 
contractors of the Bureau of Global Health and the Regional 
Bureaus.[Footnote 65] 

This information is not fully covered in the draft report. Grantees and 
contractors develop and disseminate innovations and best practices in 
their respective fields of maternal and child health. Their 
dissemination activities are monitored and routinely evaluated. BASICS, 
for example, carried out a survey among key decision-makers in 
developing countries to determine the most effective means to deliver 
key information on new child survival approaches. 

In addition to the development and dissemination of innovations and 
best practices through the core-supported grantees and contractors 
described above, BGH, as the report observes, has activities 
specifically targeting Mission Health Officers. These activities are 
routinely monitored and evaluated, as described below. 

A. Electronic Learning Courses. The GAO report notes that some health 
officers were still unaware of the eLearning Courses. The report cites 
three courses relevant to CS/MH: Antenatal Care, Essential Newborn 
Care, and Malaria. Ten other courses, however, are available or near 
completion that also are relevant to CS/MH: Essential Newborn Care, 
Preventing Postpartum Hemorrhage, Diarrheal Disease, Pneumonia, 
Immunization Essentials, Preventing Mother-to-Child Transmission of 
HIV, Reduction of Maternal Mortality and Disability, Sick Newborn Care, 
Emergency Obstetrical Care, and Newborn Care. All eLearning courses are 
authored by USAID staff and contractors expert in the subject area and 
reviewed by and vetted with technical experts outside the agency. Each 
course describes current best practice and state-of-the-art research. 

The Agency tracks who is taking a given course, where the person is 
located, the person's role at USAID, and their score on the final exam 
(85% correct is required to pass). Each course requires a learner 
action plan and end-of-course evaluation to get a certificate of course 
completion. The evaluation data collected provides detailed feedback to 
the eLearning Administrator in the BGH and course authors on the 
appropriateness, usefulness, and timeliness of topics covered. Course 
content is updated annually, and an Administrator Mailbox installed in 
2006 allows users to communicate feedback and follow on questions 
directly to the BGH and course authors. In addition, the bureau 
regularly receives comments from other international health 
organizations on the quality, accessibility and usefulness of eLearning 
courses and website. 

As of March 2007, BGH had recorded 6,151 USAID users of its eLearning 
courses. The bureau set a 2007 priority for the marketing and 
communication of these courses to Population, Health, and Nutrition 
(PHN) Officers and Foreign Service Nationals (FSN) in USAID missions. 
The bureau is exploring ways to: 1) make the eLearning courses part of 
the professional development requirements for people both in Washington 
and the missions; 2) garner mission leadership support (time/ 
incentives/rewards) for PHN and FSN health staff to take the courses; 
and 3) continue funding development of courses in CS/MH areas to 
further address the needs in the field. 

B. State-of-the-Art-Trainings (SOTAs) The GAO report notes that a 
reduction of funds in USAID Regional Bureau budgets resulted in 
postponing SOTAs in 2006. In 2007 two Regional Bureaus, Asia and Near 
East and Europe and Eurasia are pursuing plans to hold regional 
trainings with support from the BGH. An ANE regional mini-university 
will include presentations and training on relevant "best practices" as 
well as increased access to e-learning courses. The E&E Regional Bureau 
Health team is working with the Social Transition team to develop cross-
sectoral and health-related training sessions. Discussions are underway 
in the BGH on re-instituting bi-annual SOTAs and holding a SOTA (or 
equivalent) in Africa in the near future. The decision regarding 
funding and holding SOTAs rests with the USAID Administrator, the 
leadership of the Regional Bureaus, and BGH. 

C. Assessing the Relative Effectiveness of the Agency's Current Methods 
USAID/BGH uses a range of methods to address different communications 
and learning requirements for diverse audiences in highly dispersed 
areas around the world. Consequently, information sharing, training, 
and communication methods are multiple and varied. Using a separate 
contractor, The BGH conducts a Training Needs Assessments of Washington 
and field health staff to capture information about their learning 
requirements, preferred training methods, and resources available to 
meet their needs. The information is captured through surveys, 
interviews, and focus groups. This information serves as a basis for 
new professional development and organizational development activities. 
BGH will conduct a Needs Assessment in the 2007-2008 time period that 
will address the information sharing, dissemination of best practices, 
and training concerns raised in the GAO report. 

The following is GAO's comment on the U.S. Agency for International 
Development's letter dated April 3, 2007. 

GAO Comment: 

1. USAID commented that the Bureau for Global Health conducts a 
Training Needs Assessment of Washington and field health staff to 
gather information about learning requirements and resources as well as 
training preferences. While we acknowledge that a second Needs 
Assessment in the 2007-2008 time frame could address our concerns 
regarding evaluation of information sharing methods, we also note that 
the first Training Needs Assessment was conducted in 2003 and 
concentrated mainly on Washington-based staff. For such an assessment 
to be effective, we encourage USAID to widely solicit input from its 
field health staff as well as to include relevant evaluation questions 
in its annual employee survey. 

[End of section] 

Appendix VII: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

David Gootnick, (202) 512-3149: 

Staff Acknowledgments: 

In addition to the individual named above, Audrey Solis (Assistant 
Director), Judith Williams, Theresa Chen, Heather MacDonald, Susan 
Tieh, Jeanette Franzel, Joel Grossman, Keith Kronin, Reid Lowe, and 
Grace Lui made key contributions to this report. Claude Adrien, J. 
Robert Ball, and B. Patrick Hickey also made technical contributions. 

FOOTNOTES 

[1] Robert E. Black, Saul S. Morris, and Jennifer Bryce, "Where and why 
are 10 million children dying every year?," The Lancet, vol. 361, no. 
9376 (2003). 

[2] Save the Children, State of the World's Mothers 2006 (Westport, CT: 
May 2006); and "Where and why are 10 million children dying every 
year?," 2. 

[3] World Health Organization, Facts and Figures from the World Health 
Report 2005 (2005). 

[4] Initially titled the Child Survival and Disease Programs Fund and 
renamed in fiscal year 2001, the CSH Fund includes six accounts: HIV/ 
AIDS; Infectious Diseases; Child Survival and Maternal Health; Family 
Planning and Reproductive Health; Vulnerable Children; and the Global 
Fund to fight AIDS, Tuberculosis, and Malaria. In addition, the fund 
grants money to international partnerships. 

[5] For fiscal years 2004 and 2005, USAID allocated CS/MH funds for 
programs in 41 countries. The U.S. mission in Eritrea, however, closed 
in December 2005, reducing the total number of countries that received 
CS/MH funds to 40. USAID also supports child survival and maternal 
health-related activities in countries through other funding streams, 
such as the Economic Support Fund, Assistance for Eastern Europe and 
the Baltics, the Freedom Support Act, and Pub. L. No. 480 Title II 
accounts. Although these programs follow the same "Guidance on the 
Definition and Use of the Child Survival and Health Programs Fund," 
they were outside the scope of our review. 

[6] USAID's overall performance goal for health is to "improve global 
health, including child, maternal, and reproductive health, and the 
reduction of abortion and disease, especially HIV/AIDS, malaria, and 
tuberculosis." 

[7] The Foreign Operations, Export Financing, and Related Programs 
Appropriations Act, 2006, Pub. L. No. 109-102, ║ 522, 119 Stat. 2171, 
2203. 

[8] The funds appropriated to the CSH Fund in fiscal years 2004 were 
available to be obligated until the end of the following fiscal year, 
September 30, 2005. Similarly, the funds appropriated to the fund in 
fiscal year 2005 were available to be obligated until September 30, 
2006. 

[9] GAO, Foreign Assistance: Contributions to Child Survival Are 
Significant, but Challenges Remain, GAO/NSIAD-97-9 (Washington, D.C.: 
Nov. 8, 1996), 7. 

[10] GAO, Standards for Internal Control in the Federal Government, 
GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999), 19. 

[11] Another 15 to 20 million women suffer from pregnancy-and 
childbirth-induced disabilities, including nerve damage, severe anemia, 
infertility, and obstetric fistula--an injury in which an abnormal 
opening forms between a woman's bladder and vagina, resulting in 
urinary incontinence. 

[12] "Where and why are 10 million children dying every year?," 2; and 
State of World's Mothers 2006, 3. 

[13] United Nations Children's Fund, The State of the World's Children 
2007 (New York: 2006). 

[14] The term "newborn" refers to the newborn baby and does not have a 
specific time period definition, but is often assumed to refer to the 
first month of life. 

[15] State of World's Mothers 2006. 

[16] Jennifer Bryce and Robert E. Black, "Can the world afford to save 
the lives of 6 million children each year?" The Lancet, vol. 365, no. 
9478 (2005). 

[17] World Health Organization, The World Health Report 2005 - Make 
Every Mother and Child Count, 1st ed. (Geneva: World Health 
Organization, 2005). 

[18] State of World's Children 2007. 

[19] According to UNICEF, child mortality in developing countries 
decreased from 105/1,000 live births in 1990 to 83/1,000 live births in 
2005. State of World's Children 2007. 

[20] On the basis of estimates of the maternal mortality ratio for 1990 
and 2000, maternal mortality has not improved. 

[21] A Lancet series notes that, between 1980 and 2000, child mortality 
after the first month of life fell by one-third. During that same 
period, the mortality rate for newborns in the first month of life was 
reduced by one-quarter. This means that the proportion of child deaths 
occurring in the first month of life increased. See Joy E. Lawn, Simon 
Cousens, and Jelka Zupan, "4 million neonatal deaths: When? Where? 
Why?," The Lancet, vol. 365, no. 9462 (2005). 

[22] Oral rehydration therapy is a treatment for dehydration caused by 
diarrhea and calls for providing oral rehydration salts--a mixture of 
water, salt, and glucose--and the recommended amount of fluids. 

[23] The CSH Fund guidance notes that most malaria-related activities 
are supported with funding from the infectious disease account of the 
fund. 

[24] Newborn diseases and conditions include low birth weight, birth 
asphyxia and injuries, and postpartum infection. 

[25] USAID does not have missions in Burundi, Eritrea, Sierra Leone, 
and Somalia. In these cases, the associated regional mission manages 
the country allocation. For example, the East Africa regional mission 
is responsible for managing Somalia's allocation. 

[26] PPC reported to the Office of the Administrator. 

[27] The Health Sector Council, which the Bureau for Global Health 
chairs, also reviewed the budget requests and provided feedback. The 
council has several subgroups, each with technical representatives, 
that provided recommendations to the regional bureaus. 

[28] The information requested by PPC differed from that requested by 
the regional bureaus; in addition, some of the information requested by 
the regional bureaus differed by region. 

[29] The Vaccine Fund, now renamed The GAVI Fund, is the financing arm 
to support the immunization goals of The GAVI Alliance, an 
international partnership focused on increasing children's access to 
vaccines in poor countries. 

[30] Consolidated Appropriations Act, 2004, Pub. L. No. 108-199, 118 
Stat. 3, 145. This act did not specify the CSH Fund account that USAID 
should use for this directive. However, in the accompanying report, the 
House expressed through a congressional directive that it wanted USAID 
to use funds from the CS/MH account (see H.R. Rep. 108-599, at 8 
(2004)). 

[31] The fiscal year 2005 conference report (H.R. Conf. Rep. No. 108- 
792, at 987) states that the House and the Senate "intend that 
$32,000,000 be made available to support the multilateral campaign to 
combat polio." The House and Senate reports for the Consolidated 
Appropriations Act of 2004 (H.R. Rep. No. 108-222 and S. Rep. No. 108- 
106) and the House, Senate, and Conference reports for the Consolidated 
Appropriations Act of 2005 (H.R. Rep. No. 108-599, S. Rep. No. 108-346, 
and H.R. Conf. Rep. No. 108-792) also demonstrate congressional 
interest in areas such as providing micronutrients and correcting 
iodine deficiency. 

[32] Internal control provides an organization with reasonable 
assurance that key management objectives--efficiency and effectiveness 
of operations, reliability of financial reporting, and compliance with 
applicable laws and regulations--are being achieved. See GAO/AIMD-00- 
21.3.1, 4. 

[33] According to a PPC official, the accounts within the CSH Fund are 
not broken out separately when they are allocated. Officials from PPC 
and USAID's Office of the Controller said that the agency's primary 
financial management and reporting system tracks obligations and 
expenditures from the overall fund. Two of the fund's six accounts, the 
HIV/AIDS and the Family Planning and Reproductive Health accounts, are 
specifically tracked within the system, but the remaining four accounts 
are grouped as "other CSH." As of January 2007, USAID was reforming its 
primary financial management and reporting system. 

[34] Missions' strategic objectives are the areas of measurable change 
that each mission intends to achieve through its development programs. 
Objectives may vary among missions, because each mission defines its 
own. In addition, missions may commingle funding streams to meet their 
objectives. For example, the Ethiopia mission's Health and Education 
strategic objective commingled the CS/MH, Basic Education, and 
Development Assistance Program funding streams. 

[35] The official from the Office of the Controller could not give us 
an estimate of how long such a data call would take. 

[36] As we reported in 2003, USAID is dependent on international 
organizations and thousands of partner institutions for data; 
therefore, it does not have full control over how data are collected, 
reported, or verified. 

[37] GAO/AIMD-00-21.3.1, 19. 

[38] GAO/NSIAD-97-9, 7. 

[39] GAO, Financial Management: Sustained Effort Needed to Resolve Long-
Standing Problems at U.S. Agency for International Development, GAO-03-
1170T (Washington, D.C.: Sept. 24, 2003); Major Management Challenges 
and Program Risks: U.S. Agency for International Development, GAO-03-
111 (Washington, D.C.: January 2003); Major Management Challenges and 
Program Risks: U.S. Agency for International Development, GAO-01-256 
(Washington, D.C.: Jan. 1, 2001); and Financial Management: Inadequate 
Accounting and System Project Controls at AID, GAO/AFMD-93-19 
(Washington D.C.: May 24, 1993). 

[40] The State Department's Office of Foreign Assistance defines an 
element as a broad category of program under a particular program area. 
For example, "Maternal and Child Health" is an element under the 
"Health" program area in the new Foreign Assistance Framework. 

[41] The Foreign Assistance Framework concentrates U.S. foreign 
assistance into five priority objectives: peace and security, governing 
justly and democratically, investing in people, economic growth, and 
humanitarian assistance. The Health program area falls within the 
investing in people objective. 

[42] An October 2006 memorandum from the State Department's Office of 
Foreign Assistance says that the proposed modification to USAID's 
accounting system is intended to accommodate State's new Foreign 
Assistance Framework. Under the modified accounting system, all money 
would be identified and USAID would be able to separate the sources of 
funds. USAID officials in the Bureau for Global Health, however, did 
not know about this memorandum until February 2007. Furthermore, due to 
a lack of internal communication, the Office of the Controller did not 
realize that recording information at the element level will, in fact, 
capture CS/MH data. 

[43] New obligational authority refers to the funding levels 
appropriated by Congress in a given year after certain legislatively 
mandated transfers or rescissions. 

[44] USAID defines technical assistance as the "provision of goods or 
services to developing countries and other USAID recipients in direct 
support of a development objective - as opposed to the internal 
management of the foreign assistance program." 

[45] World Health Organization, Pan American Health Organization, 
Neonatal Health in the Context of Maternal, Newborn and Child Health 
for the Attainment of the Millennium Development Goals of the United 
Nations Millennium Declaration (Washington, D.C.: 2006). 

[46] Support for Analysis and Research in Africa Project, Academy for 
Educational Development, Child Survival in Sub-Saharan Africa: Taking 
Stock, a report prepared at the request of the United States Agency for 
International Development (2005). 

[47] United States Agency for International Development, Report to 
Congress: Health-Related Research and Development Activities at USAID 
(Washington, D.C.: 2006). 

[48] Essential newborn care is a package of interventions that includes 
exclusive breastfeeding, clean delivery, umbilical cord care, warmth, 
and early recognition of and referral for complications. 

[49] The Millennium Development Goals were adopted by the United 
Nations General Assembly in the 2000 United Nations Millennium 
Declaration and are supported by the United States. A version of the 
goals, however, that differs in significant respects from what was 
agreed to at the United Nations in 2000 is widely in use. The maternal 
and child health goals, however, are the same in both versions--namely, 
to reduce maternal mortality by three-quarters, and under-5 child 
mortality by two-thirds by 2015. 

[50] United States Agency for International Development, Report to 
Congress: Health-Related Research and Development Activities at USAID 
(Washington, D.C.: 2005); and Health-Related Research and Development 
Activities at USAID. 

[51] Geographic offices are located within the regional bureaus and are 
responsible for coordinating country-related matters, including policy 
and strategy; project, nonproject, and food aid development, analysis, 
monitoring, implementation, and review; and personnel and budgeting. 

[52] Public Health Institute, Best Practices for USAID State-of-the-Art 
Trainings: Recommendations for PHN Sector State-of-the-Art Planners, 
Implementers, Presenters and Participants, a special report prepared at 
the request of USAID (October 2004). 

[53] According to USAID, all employees and contractors received their 
Employee Survey. In total, there were 5,368 responses. USAID only 
presents response rates for groups of employees. The response rates 
were 75 percent for foreign service employees, 64 percent for civil 
service employees, and 51 percent for foreign service national 
employees. 

[54] The term "difficult" refers to the USAID program representatives 
who replied "Somewhat Difficult," "Moderately Difficult," "Very 
Difficult," or "Extremely Difficult" to a survey question that also 
contained the categories "Condition Does Not Exist" and "A Little or 
Not at All Difficult." 

[55] World Health Organization, The World Health Report 2006: Working 
Together for Health (France, World Health Organization: 2006). 

[56] The global burden of disease is an estimate of the effect of 
disease, and it allows for comparisons across countries and regions. 
The WHO's Global Burden of Disease Project uses a summary measure--the 
disability-adjusted life year--to quantify the burden of disease. The 
number of disability-adjusted life years for a disease is the sum of 
the years of life lost due to premature mortality in the population and 
the years lost due to disability. 

[57] Joint Learning Initiative, Human Resources for Health: Overcoming 
the Crisis (Washington, D.C.: 2004). 

[58] Chan K. Chhuong, Della R. Sherratt, and Patrice White, 
Comprehensive Midwifery Review (Kingdom of Cambodia, Ministry of 
Health: September 2006). 

[59] Active management of the third stage of labor includes the 
following: administration of a uterotonic agent, such as oxytocin, 
which helps reduce blood loss; controlled cord traction, or gently 
pulling on the umbilical cord; and uterine massage after the placenta 
has been delivered. 

[60] The Integrated Management of Newborn and Childhood Illness 
strategy is an adaptation of the Integrated Management of Childhood 
Illness approach, which is based on studies that show that sick 
children often have more than one disease and emphasize the importance 
of considering other health factors, such as immunizations, when a sick 
child receives health care. This strategy incorporates the newborn, and 
includes home visits by health workers to educate mothers and families 
on (1) detecting newborn and child illnesses and (2) caring for sick or 
low birth weight newborns. 

[61] The term "a hindrance" refers to the USAID program representatives 
who replied "Some Hindrance," "A Moderate Hindrance," "A Great 
Hindrance," or "A Very Great Hindrance" to a survey question that also 
included the categories of "Condition Does Not Exist" and "Little or No 
Hindrance." 

[62] The term "not confident" refers to the USAID program 
representatives who replied "Hardly Confident or Not At All Confident" 
in response to a survey question that also included the categories of 
"Extremely Confident," "Very Confident," "Moderately Confident," and 
"Somewhat Confident." 

[63] According to a USAID official, PROSALUD currently has a 92 to 95 
percent cost recovery rate, and USAID hopes that it will reach 100 
percent cost recovery by December 2007. 

[64] Maternal and Child Health (MCH) is one of the eight elements of 
the health area in the Foreign Assistance Framework. 

[65] In FY2004 and FY2005, grantees and contractors in the BGH 
included: Basic Support for Institutionalizing Child Survival (BASICS 
III); Access to Clinical and Community Maternal, Neonatal and Women's 
Health Services (ACCESS); the Prevention of Postpartum Hemorrhage 
Initiative (POPPHI); the A2Z Micronutrient Project; LINKAGES 
(Breastfeeding, Lam, and Related Maternal and Young Child Nutrition; 
FANTA (Food and Nutrition Technical Assistance); Quality 
Assurance/Workforce Development; Hygiene Improvement, the Child 
Survival and Health Grants Program, The World Health Organization, 
UNICEF, and Country and Global Research Activities. In FY2004-2005, the 
Africa Bureau, through its grantee, the SARA project, provided Health 
Officers the following publications on innovations and best practices: 
1) A Guide to Research on Care-Seeking Childhood Malaria; 2) Child 
Survival in Sub-Saharan Africa - Taking Stock, An Overview; 3) 
Improving Community Case Management of Childhood Malaria; 4) Lives at 
Risk: Malaria and Pregnancy; 5) Nutrition Briefs; 6) Post abortion Care 
in Francophone Africa; 7) Utilizing the Potential of Formal and 
Informal Private Practitioners. 

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