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
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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 [email protected]. 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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www.gao.gov/cgi-bin/getrpt?GAO-07-486.

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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
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