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: Published: Apr 20, 2007. Publicly Released: Apr 20, 2007.

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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 Development's (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 USAID's (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.

In fiscal years 2004 and 2005, Congress appropriated a total of $675.6 million to the CS/MH account. Individual USAID missions and USAID's 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, USAID's 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 GAO's 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. USAID's 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 methods' 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.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In a March 26, 2010 letter to GAO, USAID verified that its accounting system had been modified to incorporate the Foreign Assistance Framework and that the system now permits postings of allocations, obligations, and expenditures at the element level (which is the level of the CS/MH sub-account). Furthermore, given that State's planning system and USAID's accounting system are not integrated, USAID conducted a test in August 2009 of its budget execution controls. The testing found that budget allocations established by State - as well as updates and adjustments effected during the year - were captured by the responsible USAID bureaus and regularly tracked back to the budget data in USAID's accounting system. Overall, USAID's review concluded that compensating controls were in place to ensure the integrity of the budget data reflected in the accounting system.

    Recommendation: 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.

    Agency Affected: United States Agency for International Development

  2. Status: Closed - Implemented

    Comments: In our April 2007 report, 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), on USAID's Child Survival and Maternal Health (CS/MH) programs, we recommended that USAID assess the relative effectiveness of the agency's methods of disseminating information about CS/MH innovations and best practices, using existing tools such as their annual employee survey. In October 2008, USAID responded by including several pertinent questions in the Global Health Bureau's Professional Development Needs Assessment Questionnaire. (The Global Health Bureau provides the technical support for the CS/MH programs.) Specifically, the questionnaire solicited employee's opinions on the effectiveness of web-based networking and knowledge sharing, "State-of-the-Art" conferences, and e-learning courses, among other methods. The questionnaire also solicited employee suggestions for improving current means and methods of professional development.

    Recommendation: 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 Affected: United States Agency for International Development


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