    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 (20-APR-07, GAO-07-486).

    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.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-07-486
        ACCNO:   A68525
      TITLE:     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
         DATE:   04/20/2007
      SUBJECT:   Appropriated funds
    	     Children
    	     Financial analysis
    	     Foreign aid programs
    	     Funds management
    	     Health care programs
    	     Health research programs
    	     Information management
    	     Internal controls
    	     International relations
    	     Mortality
    	     Program evaluation
    	     Program management
    	     Strategic planning
    	     Africa
    	     AID Child Survival and Diseases Program
    	     Fund

    	     Asia
    	     Caribbean
    	     Latin America

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    GAO-07-486

         * [1]Results in Brief
         * [2]Background

              * [3]USAID Support for Child Survival and Maternal Health

         * [4]Budget Process and Congressional Directives Guided CS/MH All

              * [5]USAID Allocations Followed Budget Process and Congressional

                   * [6]USAID Allocated Most CS/MH Funds to Africa, Asia, and
                     Latin
                   * [7]USAID Budgeting Process and Congressional Directives
                     Guided

                        * [8]USAID Budget Allocation Process
                        * [9]Congressional Directives

              * [10]USAID Headquarters Lacked CS/MH Obligation and Expenditure D
              * [11]USAID Is Making Changes to Its Accounting System, but the Sy

         * [12]USAID Supported a Wide Range of CS/MH Efforts

              * [13]Country Missions Supported Community- and Country-Level Effo

                   * [14]Community-Level Activities
                   * [15]Country-Level Activities

              * [16]Regional Missions and Bureaus Supported Regional CS/MH Activ
              * [17]Bureau for Global Health Engaged in Numerous CS/MH Efforts

                   * [18]Technical Assistance
                   * [19]Child Survival and Health Grants Program
                   * [20]Global Leadership
                   * [21]International Research

         * [22]USAID Has Not Assessed the Relative Effectiveness of Its Met

              * [23]USAID Disseminated Information Internally through Various Me
              * [24]USAID Has Not Assessed Methods' Relative Effectiveness

         * [25]USAID Is Responding to Certain Child Survival and Maternal H

              * [26]USAID Is Supporting Efforts to Address Health Care Worker Sh
              * [27]USAID Is Working to Increase Attention to Maternal and Newbo
              * [28]USAID Has Taken Steps to Support Sustainability

         * [29]Conclusions
         * [30]Recommendations for Executive Action
         * [31]Agency Comments and Our Evaluation
         * [32]GAO Comment
         * [33]GAO Contact
         * [34]Staff Acknowledgments
         * [35]GAO's Mission
         * [36]Obtaining Copies of GAO Reports and Testimony

              * [37]Order by Mail or Phone

         * [38]To Report Fraud, Waste, and Abuse in Federal Programs
         * [39]Congressional Relations
         * [40]Public Affairs

    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

    Contents

    Letter 1

    Results in Brief 3
    Background 6
    Budget Process and Congressional Directives Guided CS/MH Allocations, but
    USAID Lacked Centralized Obligation and Expenditure Data 13
    USAID Supported a Wide Range of CS/MH Efforts 21
    USAID Has Not Assessed the Relative Effectiveness of Its Methods of
    Disseminating Innovations and Best Practices for Internal Use 28
    USAID Is Responding to Certain Child Survival and Maternal Health Program
    Challenges 32
    Conclusions 41
    Recommendations for Executive Action 41
    Agency Comments and Our Evaluation 42
    Appendix I Objectives, Scope, and Methodology 44
    Appendix II Allocation of Child Survival and Maternal Health Funds within
    USAID, Fiscal Years 2004 and 2005 47
    Appendix III Allocation of CS/MH Account Funds to Countries, Fiscal Years
    2004 and 2005 48
    Appendix IV Mortality Statistics for Countries Receiving CS/MH Funds,
    Fiscal Years 2004 and 2005 50
    Appendix V Obligations and Expenditures for the Four Missions We Visited,
    Fiscal Years 2004 and 2005 52
    Appendix VI Comments from the U.S. Agency for International Development 53
    GAO Comment 58
    Appendix VII GAO Contact and Staff Acknowledgments 59

    Figures

    Figure 1: Congressional Appropriations to the Child Survival and Health
    Programs Fund, by Account, Fiscal Years 2004 and 2005 9
    Figure 2: Global Distribution of USAID's Child Survival and Maternal
    Health Funds, Fiscal Years 2004 and 2005 11
    Figure 3: Organizational Chart of USAID Missions and Bureaus Involved in
    Supporting Child Survival and Maternal Health Activities, Fiscal Years
    2004 and 2005 12
    Figure 4: USAID Allocations of Child Survival and Maternal Health Funds,
    Fiscal Years 2004 and 2005 14
    Figure 5: USAID's Allocation and Reporting Process for CS/MH Account,
    Fiscal Years 2004 and 2005 18
    Figure 6: Health Care Worker Training 34

    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

    This is a work of the U.S. government and is not subject to copyright
    protection in the United States. It may be reproduced and distributed in
    its entirety without further permission from GAO. However, because this
    work may contain copyrighted images or other material, permission from the
    copyright holder may be necessary if you wish to reproduce this material
    separately.

    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.^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.^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.^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.^4 The U.S. Agency for International
    Development (USAID), which administers the fund, currently finances CS/MH
    programs at headquarters and in 40 countries^5 to support agency goals to
    improve global health, including maternal and child health.^6

    1Robert 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).

    ^2Save 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.

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

    In fiscal year 2006, Congress directed GAO to review USAID's use of
    appropriations to the CSH Fund for fiscal years 2004 and 2005.^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.^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.)

    ^4Initially 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.

    ^5For 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.

    ^6USAID'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."

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

    ^8The 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.

    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,^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.^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.

    ^9GAO, Foreign Assistance: Contributions to Child Survival Are
    Significant, but Challenges Remain, [41]GAO/NSIAD-97-9 (Washington, D.C.:
    Nov. 8, 1996), 7.

    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."

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

    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,^11 particularly in developing countries.^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,^13 and a mother is 30 times more likely to lose a newborn^14 in
    the first month of life than a mother in an industrialized country.^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.^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.^17

    11Another 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.

    Maternal health is closely linked to both newborn and child survival.
    According to a recent United Nations report,^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,^19 maternal mortality has remained unchanged,^20 and newborn
    survival has seen less improvement than child survival overall.^21 Newborn
    deaths currently account for 38 percent of all deaths in children younger
    than 5 years old.

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

    ^14The 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.

    ^15State of World's Mothers 2006.

    ^16Jennifer 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).

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

    ^18State of World's Children 2007.

    ^19According 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.

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

    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.)

    ^21A 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).

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

    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.

    ^aCongressional 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.

    Over the years, Congress has continued to support basic child survival
    interventions, particularly immunizations and oral rehydration therapy,^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.

    ^22Oral 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.

    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,^23 vaccine-preventable diseases, and newborn
    diseases and conditions.^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.

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

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

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

    USAID carries out CS/MH activities primarily through its country
    missions;^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.

    ^25USAID 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.

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

    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.

    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

    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.

    ^aThe 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.

      USAID Budgeting Process and Congressional Directives Guided Allocations

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

    ^26PPC reported to the Office of the Administrator.

        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,^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.^28 Our analysis
    showed that some of the factors PPC and the regional bureaus considered
    included

               o 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);
               o 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;
               o the potential national-level impact of allocated CS/MH funds;
               o a host country government's per capita expenditures for public
               health;

    ^27The 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.

    ^28The 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.

               o the capacity of the USAID mission to absorb funds; and
               o 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^29 in
               accordance with a directive in the Consolidated Appropriations Act
               of 2004.^30 Similarly, in fiscal years 2004 and 2005, USAID set
               aside $32 million each year for polio in response to congressional
               interest.^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.

    ^29The 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.

    ^30Consolidated 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)).

    ^31The 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.

    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^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^33 and for each mission's
               strategic objectives.^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.)

    ^32Internal 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/
    [49]AIMD-00-21.3.1 , 4.

    ^33According 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.

    ^34Missions' 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.

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

               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.^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.^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."^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.

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

    ^36As 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.

    ^37GAO/ [50]AIMD-00-21.3.1 , 19.

               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.^38 In addition, other GAO work has identified
               long-standing challenges associated with USAID's financial
               management and reporting.^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^40 to coincide with the new Foreign Assistance
               Framework--the road map for foreign assistance resource allocation
               and implementation.^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.^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,^43
               so CS/MH funds invested in programs that began before fiscal year
               2007 cannot be verified in this manner.

    ^38 [51]GAO/NSIAD-97-9 , 7.

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

    ^40The 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.

    ^41The 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.

    ^42An 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.

               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.

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

               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.

               o 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.
               o Technical assistance.^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.

    ^44USAID 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."

               o 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.^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.^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.

    ^45World 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).

    ^46Support 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).

                 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.

               o The bureau managed a program for anemia reduction and vitamin A
               supplementation in the states of Uttar Pradesh and Jharkhand.
               o The bureau assisted Indian state governments and the government
               of India's Ministry of Health and Family Welfare with routine
               immunization.
               o 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.

    		     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.

    		     Global Leadership

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

               o 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.
               o 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.
               o 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.^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.

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

                 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.

               o 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,^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.^49 The bureau also supported research on the efficacy
               of new treatments and their introduction in different
               countries.^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.
               o 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.

    ^48Essential 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.

    ^49The 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.

    ^50United 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.

    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.

               o 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.
               o State-of-the-Art training. From the early 1990s to 2005, the
               bureau and regional bureaus and offices^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.^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.
               o 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.

    ^51Geographic 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.

    ^52Public 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).

               o 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.
               o 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.
               o 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.
               o 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.^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."

    ^53According 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.

               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.^54 The WHO estimates a global shortage of almost 2.4
               million doctors, nurses, and midwives.^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^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.

    ^54The 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."

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

               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^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:

               o 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.^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.

    ^56The 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.

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

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

    		   o 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

    		   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:

               o 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.

    		   o 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.^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.

    ^59Active 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.

               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:

               o The Mali mission requested that one of its major implementing
               partners, Assistance Technique Nationale, increase its program's
               focus on maternal health.
               o 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.
               o 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.
               o 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.^60 The Ethiopian mission is also
               supporting the development of this protocol in Ethiopia.

    ^60The 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.

               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.^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.^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.

    ^61The 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."

    ^62The 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."

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

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

                            o 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.
                            o 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.

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

                            o 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.
                            o 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 1/2 years.^63
                            o 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.
                            o 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.

               o 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.
               o 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.

    ^63According 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.

               o 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.
               o 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.

    		   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:

               o 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.
               o 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.

               David Gootnick
    		   Director, International Affairs and Trade

    		   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.

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

    Dollars in millions
                                            Fiscal year
                                        2004               2005           Total
    Country/Entity              Amount Percent Amount Percent  Amount Percent
    Africa                       $78.6   24.0%  $88.3   25.4%  $166.9   24.7%
    Asia and the Near East        79.6    24.2   80.5    23.2   160.0    23.7
    Latin  America   and   the    39.0    11.9   39.3    11.3    78.4    11.6
    Caribbean
    International Partnerships    64.2    19.6   72.3    20.8   136.5    20.2
    Bureau for Global Health      66.0    20.1   67.1    19.3   133.1    19.7
    Other                          0.6     0.2    n/a     n/a     0.6     0.1
    Total                       $328.0       - $347.5       -  $675.6       -

               Source: GAO analysis of USAID data.

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

                                                      Fiscal year
    Country                         2004 (actual) 2005 (actual) 2006 (planned)
    Afghanistan                           $16,870       $19,870        $21,005
    Angola                                  2,700         1,200          1,483
    Bangladesh                             10,800         9,412          6,683
    Benin                                   1,350         1,250          1,977
    Bolivia                                 4,475         4,752          5,787
    Burundi                                   200           300            692
    Cambodia                                4,690         5,100          5,148
    Democratic  Republic   of   the         8,025         8,600          8,601
    Congo
    Dominican Republic                      4,000         3,861          3,237
    El Salvador                             2,700         2,970          2,970
    Eritrea                                 1,600           5^a            0^a
    Ethiopia                                4,600         6,090          7,257
    Ghana                                   3,200         3,200          2,719
    Guatemala                               4,150         4,215          4,158
    Guinea                                  2,150         2,150          2,200
    Haiti                                   8,550         8,839          9,207
    Honduras                                3,142         3,143          3,377
    India                                  12,600        14,222         12,852
    Indonesia                              11,400        13,800         14,157
    Jamaica                                   544           539            497
    Kenya                                   1,000         1,000            989
    Liberia                                 1,200         1,200          1,582
    Madagascar                              2,825         3,475          3,287
    Malawi                                  2,200         2,200          2,175
    Mali                                    2,900         3,780          3,658
    Mozambique                              3,500         4,500          4,350
    Nepal                                   5,040         5,340          4,951
    Nicaragua                               3,000         3,242          3,210
    Nigeria                                 7,000         8,650          3,856
    Pakistan                               11,600         7,600         13,652
    Paraguay                                    0             0          1,102
    Peru                                    5,450         5,164          4,653
    Philippines                             4,700         4,550          4,356
    Rwanda                                  1,100         1,400          2,224
    Senegal                                 2,500         2,600          2,422
    Sierra Leone                              100           100            297
    Somalia                                   100           100              0
    South Africa                            2,000         2,000          1,780
    Sudan                                   7,200         8,200          8,809
    Tanzania                                2,500         3,500          3,312
    Uganda                                  2,260         2,260          2,135
    Zambia                                  4,420         4,420          4,271

               Source: GAO analysis of USAID data.

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

               ^aUSAID 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.

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

                                                   Neonatal
                           Under 5 Mortality Mortality Rate    Maternal Mortality
    Country                 Rate (2003)^a       (2000)^b        Ratio (2000)^c
    Afghanistan                       257             60                 1,900
    Angola                            260             54                 1,700
    Bangladesh                         69             36                   380
    Benin                             154             38                   850
    Bolivia                            66             27                   420
    Burundi                           190             41                 1,000
    Cambodia                          140             40                   450
    Democratic Republic               205             47                   990
    of the Congo
    Dominican Republic                 35             19                   150
    El Salvador                        36             16                   150
    Eritrea                            85             25                   630
    Ethiopia                          169             51                   850
    Ghana                              95             27                   540
    Guatemala                          47             19                   240
    Guinea                            160             48                   740
    Haiti                             119             34                   680
    Honduras                           41             18                   110
    India                              87             43                   540
    Indonesia                          41             18                   230
    Jamaica                            20             10                    87
    Kenya                             123             29                 1,000
    Liberia                           235             66                   760
    Madagascar                        126             33                   550
    Malawi                            178             40                 1,800
    Mali                              220             55                 1,200
    Mozambique                        158             48                 1,000
    Nepal                              82             40                   740
    Nicaragua                          38             18                   230
    Nigeria                           198             53                   800
    Pakistan                          103             57                   500
    Peru                               34             16                   410
    Philippines                        36             15                   200
    Rwanda                            203             45                 1,400
    Senegal                           137             31                   690
    Sierra Leone                      283             56                 2,000
    Somalia                           225             49                 1,100
    South Africa                       66             21                   230
    Sudan                              93             29                   590
    Tanzania                          165             43                 1,500
    Uganda                            140             32                   880
    Zambia                            182             40                   750

               Source: GAO analysis of WHO and UNICEF data.

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

               ^aUnder-5 Mortality Rate = Probability per 1,000 live births of
               child dying before age 5.

               ^bNeonatal Mortality Rate = (Neonatal deaths / live births) x
               1,000.

               ^cMaternal Mortality Ratio = Maternal deaths per 100,000 live
               births.

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

                                                  Fiscal year
                                         2004                           2005
    Country                 Obligations Expenditures Obligations Expenditures
    Mission-managed
    programs
    Cambodia                 $3,971,330   $3,573,002  $5,020,120   $4,019,403
    Ethiopia                  2,531,597    2,469,984   4,684,941    2,417,957
    India^a                   4,295,000    8,445,506   4,858,000    5,300,141
    Mali                      2,620,000    2,617,154   3,486,766    2,513,190
    Centrally      managed
    programs
    Cambodia                    718,610            -     150,000            -
    Ethiopia                    400,000      400,000     570,000      570,000
    India^a                   8,731,000            -   9,942,000            -
    Mali                        330,000      320,000     493,000      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.

               ^aIndia carried over unexpended funds from previous fiscal years,
               which caused greater expenditures than obligations in fiscal years
               2004 and 2005.

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

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

    See comment 1.

    GAO Comment

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

                            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.

    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, Etana Finkler, and B. Patrick Hickey also
               made technical contributions.

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

    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

    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.

    [57]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 GAO's findings and recommendations.

    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.

    References

    Visible links
      41. http://www.gao.gov/cgi-bin/getrpt?GAO/NSIAD-97-9
      42. http://www.gao.gov/archive/2000/ai00021p.pdf
      49. http://www.gao.gov/archive/2000/ai00021p.pdf
      50. http://www.gao.gov/archive/2000/ai00021p.pdf
      51. http://www.gao.gov/cgi-bin/getrpt?GAO/NSIAD-97-9
      52. http://www.gao.gov/cgi-bin/getrpt?GAO-03-1170T
      53. http://www.gao.gov/cgi-bin/getrpt?GAO-03-111
      54. http://www.gao.gov/cgi-bin/getrpt?GAO-01-256
      55. http://www.gao.gov/cgi-bin/getrpt?GAO/AFMD-93-19
    *** End of document. ***