Foreign Assistance: Contributions to Child Survival Are Significant, but
Challenges Remain (Letter Report, 11/08/96, GAO/NSIAD-97-9).

Pursuant to a congressional request, GAO reviewed the U.S. Agency for
International Development's (AID) child survival activities and
accomplishments, focusing on how child survival funds are being used to
support AID objectives.

GAO found that: (1) between 1985 and 1995, AID reported that it spent
about $1.6 billion to support immunizations, diarrheal disease control,
nutrition, and health systems development projects in developing
countries; (2) AID also reported that 41 percent of the total amount
identified as child survival has been used to address three major health
threats to children under age 5, including diarrheal dehydration, acute
respiratory diseases, and vaccine-preventable diseases; (3) AID and
other donors have made important contributions toward improving child
mortality rates in many countries; (4) mortality rates for children age
5 and under have dropped in 9 of the 10 countries receiving the most
child survival assistance; (5) in fiscal year 1995, AID child survival
funding was used in 17 countries that had an under-5 mortality rate of
70 or fewer deaths per 1,000 live births; (6) AID mission-level funding
for child survival activities in these countries totalled $89.5 million;
(7) most of the countries that did not receive child survival assistance
were far from achieving the goal of 70 or fewer deaths per 1,000 live
births, did not have a child survival program in the country, or had no
sustainable development programs; and (8) some countries that have
improved their child mortality rates need continued support to sustain
the levels achieved.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  NSIAD-97-9
     TITLE:  Foreign Assistance: Contributions to Child Survival Are 
             Significant, but Challenges Remain
      DATE:  11/08/96
   SUBJECT:  Developing countries
             Children
             Federal aid to foreign countries
             Community health services
             Immunization programs
             Disease detection or diagnosis
             Infectious diseases
             Funds management
             Preschoolers
             Infants
IDENTIFIER:  AID Children's Survival Assistance Program
             Bolivia
             Guatemala
             Egypt
             Mozambique
             AID Children's Vaccine Initiative
             
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Cover
================================================================ COVER


Report to the Chairman, Subcommittee on International Operations and
Human Rights, Committee on International Relations, House of
Representatives

November 1996

FOREIGN ASSISTANCE - CONTRIBUTIONS
TO CHILD SURVIVAL ARE SIGNIFICANT,
BUT CHALLENGES REMAIN

GAO/NSIAD-97-9

Foreign Assistance

(711137)


Abbreviations
=============================================================== ABBREV

  AIDS - acquired immune deficiency syndrome
  CDIE - Center for Development Information and Evaluation
  HIV - human immunodeficiency virus
  NGO - nongovernmental organization
  PAHO - Pan American Health Organization
  PVO - private voluntary organization
  UNICEF - U.N.  Children's Fund
  USAID - U.S.  Agency for International Development
  WHO - World Health Organization

Letter
=============================================================== LETTER


B-272263

November 8, 1996

The Honorable Christopher H.  Smith
Chairman, Subcommittee on International
 Operations and Human Rights
Committee on International Relations
House of Representatives

Dear Mr.  Chairman: 

In response to your request, we have reviewed the U.S.  Agency for
International Development's (USAID) child survival activities.  You
were concerned whether child survival funds were being used to fund
activities other than those emphasized in the authorizing
legislation.  Specifically, we (1) assessed how child survival funds
are being used and (2) identified USAID's child survival activities
and accomplishments. 


   BACKGROUND
------------------------------------------------------------ Letter :1

According to a 1995 World Health Organization (WHO) report, the three
major threats to the survival of children under age 5 in developing
countries are diarrheal dehydration, acute respiratory infections
(e.g., pneumonia), and vaccine-preventable diseases.  WHO's 1995
report stated that 13.3 million children under age 5 died in
developing countries in 1985 and that 12.2 million children under age
5 died in 1993.  Figure 1 shows the causes of death for children
under age 5 in developing countries, and figure 2 shows 1994
mortality rates for children under age 5 worldwide. 

   Figure 1:  Causes of Death
   Among Children Under Age 5 in
   Developing Countries, 1985 and
   1993

   (See figure in printed
   edition.)

Note:  Neonatal and perinatal causes include birth asphyxia, neonatal
tetanus, congenital anomalies, birth trauma, prematurity, and
neonatal sepsis and meningitis.  Other causes include malaria,
accidents, malnutrition, congenital syphilis, meningitis, human
immunodeficiency virus (HIV)-related complications, and other causes. 

Source:  WHO. 


   Figure 2:  Mortality Rates in
   1994 for Children Under 5 Years
   of Age and Countries That
   Received USAID Mission-Level
   Child Survival Funding in 1994
   or 1995

   (See figure in printed
   edition.)



   (See figure in printed
   edition.)

   Source:  U.N.  Children's Fund
   (UNICEF) and USAID/Center for
   International Health
   Information. 

   (See figure in printed
   edition.)

Since 1954, USAID and its predecessor agencies have been involved in
activities to improve child survival in the developing countries. 
Since the passage of Public Law 480 in 1954, U.S.  food assistance
has been provided to children and pregnant and lactating women.  In
the 1960s, USAID began building health clinics and funding research
on treatments for diarrheal disease and the prevention of malaria. 
One of the specific objectives of the Foreign Assistance Act of 1961,
the primary legislation governing U.S.  foreign aid, was to reduce
infant mortality. 

In the 1970s, USAID began to focus on providing appropriate health
interventions for common health problems in communities with the
greatest needs.  Activities related to child health included field
studies on oral rehydration and vitamin A therapy and malaria
research. 

In 1984, Congress enacted legislation requiring a program designed to
address child survival.\1 Section 104(c)(2)(A) of the act, as
amended, provides in relevant part that: 

     "In carrying out the purposes of this subsection, the President
     shall promote, encourage, and undertake activities designed to
     deal directly with the special health needs of children and
     mothers.  Such activities should utilize simple, available
     technologies which can significantly reduce childhood mortality,
     such as improved and expanded immunization programs, oral
     rehydration to combat diarrhoeal diseases, and education
     programs aimed at improving nutrition and sanitation and at
     promoting child spacing."

Because the statutory language is broad and emphasizes but does not
limit USAID to the specified interventions, USAID has considerable
latitude in developing child survival activities appropriate to the
community being served. 

In February 1985, in response to the authorizing legislation, some of
USAID's ongoing child health efforts were consolidated into a child
survival program.  USAID provided mission-level child survival
assistance to 31 countries in 1985, but it placed special emphasis on
22 countries that had especially high mortality rates.  For each of
these 22 countries, USAID developed a detailed child survival
strategy, in cooperation with the host government, to deal with the
country's specific needs and circumstances.  USAID's policy was to
sustain bilateral child survival funding in these countries for at
least 3 to 5 years and provide technical support and training on a
priority basis. 

Over the years, the congressional appropriations committees have
continued to emphasize the importance of the basic interventions
mentioned in the authorizing statute, particularly immunizations and
oral rehydration therapy.  In some years, the committees have also
directed USAID to support particular activities, including the
promotion of breastfeeding, research and development of vaccines, and
prevention of vitamin A and other micronutrient deficiencies through
food fortification, tablets, and injections. 

USAID's child survival program has evolved in the 1990s to where it
no longer is a separate program, but is encompassed within USAID's
sustainable development strategy as a component of its population,
nutrition, and health sector.  (See app.  I for a more detailed
description of USAID's current child survival objectives and
approach.)


--------------------
\1 Section 104(c)(2) of the Foreign Assistance Act, as amended, 22
U.S.C.  2151b(c)(2). 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :2

Since 1985, USAID has classified obligations totaling over $2.3
billion for activities in at least 83 countries as child survival. 
However, due to the way Congress directs funding to child survival,
particularly since 1992, and USAID's approach to tracking and
accounting for such funds, it is not possible to determine precisely
how much is actually being spent on child survival activities. 
Between 1985 and 1995, USAID reported that it spent about $1.6
billion, or 67 percent of the child survival funds, for four types of
activities:  immunizations, diarrheal disease control, nutrition, and
health systems development.  USAID also reported that about 41
percent of the total amount identified as child survival has been
used to address the three major threats to children under age 5 in
the developing countries:  diarrheal dehydration, acute respiratory
infections, and vaccine-preventable diseases.\2

USAID has also included as child survival some of the funds it has
spent on activities such as health care financing, health systems
development, and vector control.\3 During our field visits, we also
noted that part of the cost of rehabilitating a railroad bridge and
constructing a water tower in Mozambique and carrying out urban
sewerage projects in Egypt were identified as child survival
expenditures.  USAID said the projects in Mozambique were critical
for reducing child mortality because they supported access to water,
food, and health services. 

USAID and other donors have made important contributions toward
improving child mortality rates in many countries.  In 9 of the 10
countries receiving the most USAID mission-level child survival
assistance since 1985, mortality rates for children age 5 and under
have dropped.  In addition, 5 of these 10 countries achieved
mortality rates by 1994 of 70 or fewer deaths per 1,000 live
births--a goal set for the year 2000 at the World Summit for
Children.\4 Both USAID and independent evaluations have pointed out
successes, such as collaboration with other donors to immunize
children and promote oral rehydration therapy in the treatment of
diarrheal disease.  In the four countries we visited--Bolivia,
Guatemala, Egypt, and Mozambique--USAID provided child survival
assistance for some activities that directly benefited children. 

In fiscal year 1995, USAID's child survival funding was used in 17
countries that had an under-5 mortality rate of 70 or fewer deaths
per 1,000 live births.  USAID mission-level funding for child
survival in these countries was $89.5 million, or 31 percent of the
total child survival funding obligated in that year.  On the other
hand, many countries that were far from achieving the goal, such as
those in sub-Saharan Africa, did not receive assistance for child
survival.  According to USAID, most of these countries did not
receive assistance because USAID did not have a program in the
country, had closed out assistance, or was in the process of closing
out assistance due to budgetary or legal reasons or because
sustainable development programs were not considered feasible.  USAID
has continued child survival activities in countries that have
achieved better than average under-5 mortality rates because some of
these countries still have pockets of populations with severe
problems.  Additionally, according to USAID, some countries that have
improved their mortality rates need continued support to sustain the
levels achieved. 


--------------------
\2 These diseases are related to activities emphasized in the 1984
authorizing legislation, which included immunizations, oral
rehydration, and nutrition. 

\3 Vector control involves controlling organisms, such as insects,
that transmit diseases. 

\4 The goal was stated as a reduction of 1990 under-5 mortality rates
by one-third or to a level of 70 deaths per 1,000 live births,
whichever is greater. 


   HOW CHILD SURVIVAL FUNDS ARE
   USED
------------------------------------------------------------ Letter :3

Between fiscal years 1985 and 1995, USAID reported that it obligated
over $2.3 billion for the child survival program.  Child survival
projects and other activities attributed to child survival may be
funded through USAID's overseas missions directly or through its four
regional bureaus or its central bureaus (see table 1).\5



                                     Table 1
                     
                       Obligations for USAID Child Survival
                     Activities Through Central Programs and
                     by Geographic Region, Fiscal Years 1985-
                                        95

                              (Dollars in thousands)

                                            Europe and
                                               the New         Latin
Fisca                            Asia and                    America
l         Central                the Near  Independent       and the
year     programs      Africa        East       States     Caribbean       Total
-----  ----------  ----------  ----------  -----------  ------------  ==========
1985      $44,695     $27,242     $27,287            0       $33,009    $132,233
1986       30,452      30,203      56,181            0        38,774     155,610
1987       39,655      36,650      59,586            0        48,579     184,470
1988       42,795      36,347      39,148            0        54,329     172,619
1989       42,228      67,548      52,477            0        41,095     203,348
1990       47,840      45,379      44,746       $2,311        45,311     185,587
1991       59,574      57,342      67,424        3,549        63,237     251,126
1992       98,639      60,220      45,723        6,704        61,162     272,448
1993      102,995      61,931      54,107       12,285        60,087     291,405
1994       94,010      48,973      39,578       19,378        41,204     243,143
1995      107,104      58,234      47,818     44,227\a        28,431     285,815
================================================================================
Total    $709,987    $530,069    $534,075      $88,454      $515,218  $2,377,804
--------------------------------------------------------------------------------
Note:  Numbers may not add due to rounding. 

\a USAID officials said that fiscal year 1995 data available from the
Bureau for Europe and the New Independent States were not final, as
of August 1996, and therefore may not be accurate. 

Source:  USAID/Center for International Health Information. 

The number of countries receiving mission-level child survival
assistance in a single fiscal year increased from 31 in 1985 to about
43 in 1995.  During this 11-year period, USAID provided mission-level
assistance on a continuing basis for some countries, such as Egypt,
whereas other countries received funding in only 1 year.  A total of
83 developing countries received some mission-level child survival
funding during this period.  The amounts ranged from $9,000 for Oman
to $137 million for Egypt.  As shown in table 2, of the 10 countries
that have received the most child survival assistance from USAID
missions, 5 were in the Latin America and Caribbean region, 4 were in
the Asia and Near East region, and 1 was in the Africa region. 



                                     Table 2
                     
                      Ten Countries Receiving the Most USAID
                      Mission-Level Assistance Attributed to
                     Child Survival and Their Mortality Rates
                             for Children Under Age 5

                              (Dollars in thousands)


                             FY 1985-
Country       Region               95    FY 1995         1980          1994
------------  ------------  ---------  ------------  ------------  -------------
Egypt         Asia/Near      $136,860    $27,001         180            52
               East
El Salvador   Latin            81,230     2,587          120            56
               America/
               Caribbean
Haiti         Latin            78,440     10,887         195            127
               America/
               Caribbean
India         Asia/Near        68,772      900           177            119
               East
Mozambique    Africa           62,494     9,793          269            277
Bolivia       Latin            60,566     3,264          170            110
               America/
               Caribbean
Philippines   Asia/Near        58,194       0             70            57
               East
Honduras      Latin            53,550     2,201          100            54
               America/
               Caribbean
Peru          Latin            50,443     1,388          130            58
               America/
               Caribbean
Bangladesh    Asia/Near        48,001       2            211            117
               East
--------------------------------------------------------------------------------
\a The mortality rate represents the number of deaths per 1,000 live
births. 

Source:  USAID/Center for International Health Information and
UNICEF. 


--------------------
\5 Central bureaus is an informal term used to distinguish some USAID
headquarters bureaus from the regional (geographic) bureaus that are
responsible for USAID missions.  Primarily, the central bureaus that
fund child survival activities are (1) the Bureau for Humanitarian
Response and (2) the Bureau for Global Programs, Field Support, and
Research.  (Other central bureaus include the Bureau for Policy and
Program Coordination and the Bureau for Management.)


      USAID SUPPORTS ACTIVITIES
      THROUGH MANY ORGANIZATIONS
---------------------------------------------------------- Letter :3.1

USAID provides funding to other organizations to implement health and
population services.  USAID guidance states that U.S.  assistance
must help build the capacity to develop and sustain host country
political commitment to health and population programs, as well as
enhance the ability of local organizations to define policies and
design and manage their own programs.  USAID's policy is to involve
both the public and private sectors and give special attention to
building, supporting, and empowering nongovernmental organizations
(NGO) wherever feasible. 

USAID-supported child survival activities involve U.S.  and foreign
not-for-profit NGOs, including private voluntary organizations (PVO);
universities; for-profit contractors; multilateral organizations; and
U.S.  and foreign government agencies.  Figure 3 shows that U.S. 
NGOs received about 45 percent of fiscal year 1994 child survival
funding.\6 At least 35 U.S.  PVOs and 22 other U.S.  NGOs
participated in USAID's child survival programs during that year as
primary grantees.\7

For-profit businesses and host country governments together accounted
for another one-quarter of the funding.  The remainder went to
multilateral organizations, such as UNICEF; U.S.  government
agencies, including the Centers for Disease Control and Prevention;
and indigenous NGOs. 

   Figure 3:  Types of
   Organizations That Received
   USAID Child Survival Funds,
   Fiscal Year 1994

   (See figure in printed
   edition.)

Note:  The total of these obligations does not correspond to those in
table 1 because the data used to develop this chart came from a
different source.  However, the difference is not material (less than
1 percent). 

Source:  USAID. 

USAID generally uses the different types of organizations for
different purposes or for implementing different types of activities. 
No one single group or organization typically performs the full range
of activities that the agency sponsors.  For example, in all the
countries we visited, PVOs were involved at the community level with
direct delivery of some of the basic health interventions.  In
Guatemala, a for-profit contractor provided technical assistance for
the computer hardware and software programs that USAID installed in
the Ministry of Health to computerize its health data. 


--------------------
\6 This special analysis was performed by USAID with fiscal year 1994
data.  Data for other fiscal years were not readily available. 

\7 Because some primary grantees and contractors may have awarded
subgrants or subcontracts to other organizations, a complete count of
organizations involved was not readily available.  In addition, the
data included only organizations that received funding obligations in
1994, excluding any organizations with ongoing USAID programs that
received funding in previous years but did not receive any in 1994. 


      FUNDING SUPPORTS DIFFERENT
      TYPES OF ACTIVITIES
---------------------------------------------------------- Letter :3.2

Between 1985 and 1995, activities related to the three major causes
of death among young children--acute respiratory infections,
diarrheal diseases, and vaccine-preventable diseases--received about
$972 million, or 41 percent of the child survival funds.  Table 3
shows funding levels attributed to child survival by type of activity
from 1985 to 1995. 



                                                                       Table 3
                                                       
                                                       USAID Funding by Type of Child Survival
                                                            Activity, Fiscal Years 1985-95

                                                                (Dollars in thousands)

Activity                          1985      1986      1987      1988      1989      1990      1991      1992      1993      1994      1995      Total
----------------------------  --------  --------  --------  --------  --------  --------  --------  --------  --------  --------  --------  =========
Immunization                   $30,313   $50,370   $50,898   $38,495   $44,017   $32,184   $37,785   $51,752   $67,378   $58,903   $36,236   $498,331
Nutrition\a                     27,534    22,261    26,319    25,542    31,386    29,192    51,041    51,692    52,284    43,903    80,684    441,838
Diarrheal disease control/      38,060    34,769    45,200    37,469    42,996    29,653    31,904    39,053    38,252    26,037    26,855    390,248
 oral rehydration therapy
Health systems development         N/A       N/A       N/A       N/A    22,293    21,600    41,393    58,170    46,085    40,406    26,967    256,914
Child spacing/high-risk          6,346     7,540    10,001    16,144    13,567    11,475    17,092    13,135    21,412    17,259    15,154    149,125
 births
Water quality/health               N/A       N/A       N/A       N/A    10,289    10,119    10,547    14,593    12,260    15,293    11,059     84,160
Acute respiratory infections       N/A       N/A       N/A       N/A     5,907     5,990     9,582    14,058    15,096    14,868    18,391     83,892
Maternal health\b                  N/A       N/A       N/A       N/A     4,889     9,317    10,178     8,197     8,685     6,766    18,338     66,370
Malaria                            N/A       N/A       N/A       N/A     5,530     6,746     9,812     9,395    11,946     8,456    10,877     62,762
Health care financing              N/A       N/A       N/A       N/A       N/A     6,332     9,970     8,139     5,892     6,215    12,474     49,022
Orphans and displaced              N/A       N/A       N/A       N/A       N/A       N/A       N/A     3,429     9,874     2,844    19,025     35,172
 children
Vector control and tropical        N/A       N/A       N/A       N/A     1,124     1,733     2,353       835     2,241     2,193     6,681     17,160
 diseases
Environmental health               N/A       N/A       N/A       N/A       N/A       N/A       N/A       N/A       N/A       N/A     3,075      3,075
Other                           29,980    40,670    52,052    54,969    21,350    21,246    19,469       N/A       N/A       N/A       N/A    239,736
=====================================================================================================================================================
Total                         $132,233  $155,610  $184,470  $172,619  $203,348  $185,587  $251,126  $272,448  $291,405  $243,143  $285,815  $2,377,80
                                                                                                                                                    4
-----------------------------------------------------------------------------------------------------------------------------------------------------
Note:  N/A indicates an activity category that was not specified in
USAID coding procedures during that year.  Before 1989, many of the
activities that were not listed as separate categories were included
in the "other" category.  Numbers may not add due to rounding. 

\a Nutrition is further broken out into the following activity areas: 
micronutrients; vitamin A; breastfeeding; growth monitoring and
weaning foods; nutrition management, planning, and policy; and other
nutrition. 

\b Before 1989, maternal health activities were supported under the
high-risk birth category. 

Source:  USAID/Center for International Health Information. 


   IDENTIFYING AMOUNTS USED
   SPECIFICALLY FOR CHILD SURVIVAL
   IS DIFFICULT
------------------------------------------------------------ Letter :4

USAID is unable to determine with any degree of precision how much
funding is actually being used for child survival activities because
(1) of the way Congress has directed funding; (2) USAID guidance
allows considerable flexibility and variation in attributing child
survival funds; (3) the amounts reported are based on estimated
percentages of projected budgets, which sometimes are not adjusted at
the end of the year to reflect any changes that may have occurred;
and (4) the amounts reported are not directly based on specific
project expenditures.  USAID plans a new information management
system that may improve the precision of the data for its child
survival activities. 

From fiscal year 1985, when the child survival program officially
began, through fiscal year 1995, appropriations statutes have
mandated spending of at least $1.8 billion for child survival
activities.  From fiscal years 1985 to 1991, funds appropriated by
Congress for child survival went into a separate functional account
under USAID's development assistance account.  Additionally, for
several years prior to fiscal year 1992, the appropriations laws not
only earmarked money for child survival, but the appropriations
committees' reports also expressed the intention that other accounts
within the development assistance account should provide
substantially more money for child survival activities.  Beginning in
fiscal year 1992, the functional account was eliminated and
subsequent laws appropriating moneys to USAID contained an earmark
for child survival activities that could be drawn from any USAID
assistance account.  Since 1991, Congress has substantially increased
the level of funds designated for child survival through earmarks
(from $100 million in direct appropriations in fiscal year 1991 to
$250 million in fiscal year 1992). 

USAID issued guidance in 1992 and 1996 about the types of activities
that were allowed to be attributed to child survival.  Additionally,
the agency's budget office issues annual instructions for reporting
on project activities.  These instructions name types of activities
that may be attributed to child survival and give broad discretion to
USAID officials to determine the percentage of funding that can be
reported as child survival.  However, the instructions do not provide
specific indicators for determining attribution, such as the percent
of children in the population served for water projects.  Moreover,
some mission officials responsible for recording project activities
told us that the guidance for making attributions was not clear to
them. 

In our discussions with USAID officials, we found that the process of
attributing funds to child survival activities was imprecise and that
mistakes occurred.  As a result, the percentage of funds designated
as child survival varied widely for similar activities.  For example,
USAID used child survival funds for the construction of water systems
in all four countries we visited.  USAID guidance suggested 30
percent of the total budget of water and sewerage projects as an
appropriate level to attribute to child survival, but child survival
funds comprised from 3 to 100 percent of the funding for some of
these projects. 

According to an official at the USAID mission in Egypt, the mission
has a policy of attributing 3 percent of sewerage projects and 6
percent of water projects to child survival.  In contrast, the Health
Sector II project in Honduras attributed 70 percent of the $16.9
million water and sanitation component to child survival.  According
to a mission official, the justification for this level of
attribution was that children under age 5 comprised approximately 70
percent of the deaths due to water-borne diseases in rural areas. 
Another activity funded by this project was the construction of area
warehouses.  About $72,000, which was 26 percent of the cost, was
attributed to child survival.  The justification USAID provided for
this attribution was that these warehouses, which were used to store
medical supplies, have contributed to the decline in the infant
mortality rate in Honduras. 

The funding amounts reported as child survival are based on estimated
percentages of total project obligations for types of child survival
activities carried out under individual projects.  These estimates
are made by project or budget officers and are supposed to be based
on a knowledge of project plans and activities.  However, mission
officials told us that they generally did not change the activity
assignments or percentages, even though changes in available funding
or project plans may occur during the year.  For example, $800,000 in
child survival funding was attributed to a basic education project in
Ethiopia in 1994.  A mission official told us that the child survival
activity did not actually take place, but the reports provided to us
by USAID included child survival funding for this project. 

USAID reports on funds attributed to child survival and other
activities are not based on expenditures.  USAID stated that its
activity reporting system was never intended to track expenditures
for programs and that Congress was aware that reported funding
represented estimates of obligations.  However, according to USAID
officials, a new information system is underway that will link
budgets, obligations, and expenditures and enable the agency to track
funds more accurately. 

USAID officials said that the new system would be able to link some
child survival assistance with actual expenditures in cases in which
a distinct child survival activity has been defined.  However, in
other cases, reported funding will continue to be based on the
project manager's estimate of the percentage of funding attributable
to child survival.  USAID began implementing the new system in July
1996 for all new commitments made at headquarters, and it plans to
extend the system to the overseas missions by October 1996. 


   USAID'S CONTRIBUTION TO CHILD
   SURVIVAL
------------------------------------------------------------ Letter :5

USAID has made significant contributions, in collaboration with other
donors, in reducing under-5 mortality rates.  Among the 10 countries
receiving the most USAID mission-level child survival assistance, all
but one improved their under-5 mortality rate between 1980 and 1994. 
Five countries achieved the World Summit goal of 70 or fewer deaths
per 1,000 live births.  The number of deaths from the three major
causes of under-5 mortality declined during this time, but the
largest decrease was for vaccine-preventable diseases. 

USAID can claim some far-reaching accomplishments in immunizations. 
Between 1985 and 1994, 26 of the 59 countries that received some
mission-level assistance specifically for immunization activities
achieved USAID's goal of 80-percent immunization rates.\8 Through
collaboration with the Pan American Health Organization (PAHO),
UNICEF, Rotary International, other international organizations, and
the individual countries, USAID helped to bring about the eradication
of poliomyelitis in the Americas.  USAID's Children's Vaccine
Initiative project supports a revolving fund, called the Vaccine
Independence Initiative, that is managed by PAHO and UNICEF.  This
fund, which received $3.8 million of child survival funding between
1992 and 1995, is used to help developing countries purchase
vaccines. 

One of USAID's most important accomplishments in diarrheal disease
control occurred before 1985 with the discovery that oral rehydration
salts could be used to treat the dehydration that occurs with
diarrheal diseases and causes death.  USAID has also had positive
results in efforts to increase usage of oral rehydration therapy,
although only four countries where USAID has provided mission-level
child survival assistance have usage rates above 80 percent.\9

USAID's recent diarrheal disease control efforts have been aimed at
promoting sustainability by transferring technology to developing
countries so that they can manufacture the salts.  USAID has also
contributed to research on the importance of vitamin A
supplementation and efforts to incorporate vitamin A into local food
supplies around the world. 

USAID's Center for Development Information and Evaluation (CDIE)
concluded in a 1993 report that USAID's child survival activities had
achieved many successes and made a significant contribution in
expanding child survival services and reducing infant mortality in
many countries.\10 The CDIE report cited the importance of USAID's
role in vaccinations and stated that the agency had supported other
major donors, such as UNICEF, through coordination and the provision
of needed resources.  Another evaluation conducted independently by
RESULTS Educational Fund and the Bread for the World Institute
concluded in a January 1995 report that USAID's child survival
activities had made an important contribution to reducing deaths
among children under age 5 in countries receiving USAID
assistance.\11

In the four countries we visited, USAID's contributions through child
survival activities were evident.  For example, in Mozambique, USAID
supports PVOs that provide child survival services and other types of
humanitarian and development assistance.  We visited several sites
where World Vision Relief and Development was implementing a child
survival project.  Among the activities we observed were vaccinations
for children under age 3, monitoring of children's growth, prenatal
examinations, and the construction of latrines. 

In Bolivia, PROSALUD health clinics we visited offered general
medical services; childbirth and pediatric care; immunizations;
family planning; and dental, pharmacy, and laboratory services. 
PROSALUD is a Bolivian private, nonprofit organization initiated and
operated with USAID child survival funds.  Between 1991 and 1996,
USAID provided the PROSALUD project with $6.5 million, of which $6.2
million, or 95 percent, was attributed to child survival.  The 26
PROSALUD clinics and its hospital charge small user fees that enable
the organization to partially self-finance its operations. 

We also visited Andean Rural Health Care, a U.S.  PVO that provides
community health care in Bolivia through clinics and volunteers.  The
volunteers are trained at the health centers on how to make home
visits to (1) provide families with oral rehydration salts, (2) treat
diarrheal diseases and acute respiratory infections, (3) promote
vaccinations by health center staff, and (4) monitor the growth and
health of family members (see fig.  4). 

   Figure 4:  An Andean Rural
   Health Care Volunteer in
   Bolivia Weighing an Infant
   During a Home Visit

   (See figure in printed
   edition.)

In Guatemala, we visited a clinic operated by APROFAM, which is a
private, nonprofit organization that provides family planning
services as well as selected maternal-child health services, such as
pre- and postnatal care, child growth monitoring, and oral
rehydration therapy.  Under the current USAID grant, APROFAM received
about $2.5 million in child survival funding, representing 15 percent
of its total USAID funds.  We also visited a pharmaceutical plant in
Guatemala where USAID provided equipment and technical assistance to
manufacture packets of oral rehydration salts used in the treatment
of diarrheal disease dehydration (see fig.  5).  The packets are to
be distributed through Ministry of Health facilities.  This plant was
a component of USAID's $20 million child survival project started in
1985 to assist the Ministry of Health. 

   Figure 5:  USAID-Funded
   Equipment at a Plant That
   Manufactures Oral Rehydration
   Salts in Guatemala

   (See figure in printed
   edition.)

In Egypt, we visited urban and rural health clinics that administered
vaccinations and oral rehydration therapy and had laboratories that
were equipped to perform medical tests.  According to USAID
officials, these health clinics also provided treatment for acute
respiratory infections and family planning activities. 


--------------------
\8 The immunization goal applies to the third dose of diphtheria,
pertussis, and tetanus. 

\9 The Interagency Coordinating Committee, which was created to work
on the World Summit goals and includes USAID, PAHO, UNICEF, and other
international agencies, agreed to a goal of 80 percent for the use of
oral rehydration therapy in cases of diarrhea in children under 5. 
However, USAID stated in its 1991 Child Survival Report to Congress
that the goal was for 45 percent of diarrheal episodes to be treated
with oral rehydration therapy. 

\10 CDIE conducted evaluations of child survival activities between
1989 and 1993 in six countries:  Indonesia, Morocco, Haiti, Bolivia,
Egypt, and Malawi.  These countries were selected for evaluation
because they represented 27 percent of the countries that received
special emphasis on child survival, including sustained funding. 
Also, they were considered representative of the range of agency
experience with regard to regions, approaches, program sizes, and
country conditions. 

\11 RESULTS Educational Fund and the Bread for the World Institute
are educational and research organizations that focus on hunger and
poverty issues, including the provision of low-cost health care
measures in developing countries.  They do not receive funds from
USAID.  Their January 1995 report, Putting Children First, was based
on a review of 1991 USAID activities. 


      ADDITIONAL ACTIVITIES
      ADDRESS CHILD SURVIVAL
      OBJECTIVES
---------------------------------------------------------- Letter :5.1

For fiscal years 1993-95, USAID reportedly spent about $478.9
million, or
58 percent of child survival funding, on interventions that directly
address the causes of death of children under the age of
5--immunizations, diarrheal disease control, nutrition, and acute
respiratory infections.  However, the amounts used for immunizations
and diarrheal disease control were less in 1994 and 1995 than they
had been in 1993.  During the same period, USAID spent about $341.5
million on such areas as health systems development, health care
financing, water quality, and environmental health (a new area). 

In Mozambique, USAID attributed child survival funds for the
construction of a water supply system in Chimoio by the Adventist
Development and Relief Agency to serve as many as 25,000 residents
(see fig.  6).  About $2.5 million, or 40 percent, of the project's
almost $6.2 million cost was attributed to child survival.  USAID
described this project as an exception where such infrastructure
activities would be appropriately attributed to child survival. 

   Figure 6:  Water Tower in
   Mozambique That Was Partially
   Funded as Child Survival

   (See figure in printed
   edition.)

Since 1992, the USAID mission in Egypt has designated as child
survival about $6.5 million for water and wastewater infrastructure
development.\12 Egypt's sewerage projects include the design,
construction, and operation of wastewater treatment plants and
systems, and water projects include the construction of water
treatment plants, which provide potable water to urban areas. 

The 1993 USAID/CDIE report recommended that water infrastructure
projects not be funded as child survival because child survival
resources were not considered adequate to construct enough water
systems to have a measurable impact on national health indicators. 
The report also stated that the results of other child survival
interventions appear to be greater than the results obtained from
investing in water and sanitation and that oral rehydration therapy
and interventions related to acute respiratory infections should be
given higher priority. 

In Mozambique, reconstruction of a railroad bridge crossing the
Zambezi River between Sena and Mutarara was considered child survival
(see
fig.  7).  The goal of this project was to rehabilitate roads so that
land movement of food and other relief assistance, the return of
displaced persons and refugees, and drought recovery activities could
occur.  The railroad bridge was modified to accommodate vehicles and
pedestrian traffic.  Of the project's $10.8 million budget, $1.9
million was attributed to child survival as nutrition in 1993 and
1994. 

   Figure 7:  Railroad Bridge in
   Mozambique That Was Repaired
   With Child Survival Funding

   (See figure in printed
   edition.)

Although the railroad bridge in Mozambique was considered a nutrition
intervention, other infrastructure projects that have used child
survival funding were classified as water quality/health, health
systems development, and health care financing.  Between 1993 and
1995, USAID attributed about $38.6 million in child survival funds to
water quality/health, $113.5 million to health systems development,
and $24.6 million to health care financing.  Examples of activities
related to health systems development include the construction of
warehouses for government medical supplies in Honduras.  An example
of a health care financing activity in Bolivia is PROSALUD, which
USAID established to be a self-financing health care provider. 

USAID attributed $30 million of the international disaster assistance
funds to child survival in fiscal year 1995.  The projects that
USAID's budget office counted as child survival included activities
that benefited children, such as health and winterization activities
in the former Yugoslavia, a water drilling program in northern Iraq,
an emergency medical and nutrition project for displaced persons in
Sudan, the purchase of four water purification/chlorination systems
in Djibouti, and community health care in two regions of Somalia. 
Additionally, the conference report accompanying the fiscal year 1996
foreign operations appropriations act authorized USAID to attribute
$30 million of disaster assistance funding to child survival. 


--------------------
\12 USAID has provided over $2 billion for water and wastewater
projects in Egypt since 1975. 


      USAID DOES NOT ASSIST SOME
      COUNTRIES WITH SEVERE CHILD
      SURVIVAL PROBLEMS
---------------------------------------------------------- Letter :5.2

USAID's guidance states that child survival assistance will be
provided to countries with mortality rates for children under age 5
at or above 150 per 1,000 live births.  However, USAID does not
provide assistance to some of the 30 countries with the most serious
under-5 mortality problems.  For example, many countries in
sub-Saharan Africa, which have the most serious child survival
problems, do not receive USAID child survival assistance for
mission-level projects.  According to USAID, the agency does not have
a mission in these countries, had closed out assistance, or was in
the process of closing out assistance because of budgetary or legal
reasons or because sustainable development programs were not
considered feasible.  (See app.  II for details regarding under-5
mortality rates and amounts of USAID mission-level assistance for
developing countries.)

On the other hand, USAID attributes mission-level child survival
funds to activities in 17 countries that have a mortality rate of 70
or fewer deaths per 1,000 live births.  In fiscal year 1995, USAID
used about $89.5 million of child survival funding for activities in
these 17 countries.  Among these countries were several in the former
Soviet Union, including Georgia, which had an under-5 mortality rate
of 27 per 1,000 live births.  By contrast, in fiscal year 1995, USAID
used $53.4 million of child survival funding in
15 of the 30 countries that had the most serious problems with
under-5 mortality--rates above 150 per 1,000 live births. 

In 1995, Egypt continued to have the largest share of mission-level
assistance attributed to child survival ($27 million), as it has over
the last decade.\13 UNICEF reported Egypt's under-5 mortality rate in
1994 as 52; however, USAID indicated that its most recent data showed
that the rate was 80.6. 


--------------------
\13 Egypt receives Economic Support Funds related to the Camp David
Accords.  These funds have been used for child survival as well as
other projects related to different agency objectives. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :6

In commenting on a draft of this report, USAID indicated that it
focused its child survival efforts in countries with high rates of
under-5 mortality and other factors that indicated a great need for
assistance.  USAID stated that (1) national mortality rates are
averages that often mask pockets of high child mortality, (2) the
achievement of a target mortality rate is not a reason to stop
support of efforts because gains need to be sustainable, and (3)
child survival programs are not in some of the most needy countries
because of legal, budgetary, and sustainability reasons. 

USAID issued new guidance in April 1996 that indicates that
infrastructure is not generally considered to be an appropriate use
of child survival funds.  USAID stated that the infrastructure cases
we cited, all of which began before April 1996, were isolated
examples.  USAID further stated that the bridge rehabilitation and
water works construction projects in Mozambique were needed to reduce
child mortality after the civil turmoil in that country. 

USAID also commented that its current financial reporting system was
never intended to be used to track any program area on an expenditure
basis.  USAID indicated that a new information management system that
is being implemented has been designed to track funding for each
activity by linking budgets, obligations, procurements, and
expenditures. 

After reviewing USAID's comments, we have deleted the recommendations
that we presented in our draft report.  In its comments and
subsequent discussions, USAID provided us with sufficiently detailed
information to adequately explain the reasons why some countries with
very severe child mortality problems do not receive direct U.S.  aid
and others with lower mortality rates do.  USAID's new operating
procedures have the potential to address, for the most part, how its
child survival activities will be linked to USAID's objectives and
how its project activities will be measured.  Our concern that
USAID's new information management system provide accurate obligation
and expenditure data is being addressed by USAID.  We are still
concerned, however, about the clarity of the guidance provided to
USAID's activity managers for determining the percentage of funding
and expenditures attributable to child survival when a broader
activity contributes to USAID's child survival objectives.  We are,
however, making no specific recommendations in these areas. 

USAID also provided clarifications and corrections to the draft, and
we have incorporated these changes where appropriate.  USAID's
comments are in appendix III. 


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :7

To understand the extent, nature, and progress of USAID's child
survival activities, we reviewed the authorizing and appropriations
legislation for 1985-95 and the accompanying committee reports and
selected USAID project documents, including planning and program
implementation documents, internal and external project evaluations,
funding reports, health activity reports, and project files.  We also
held extensive discussions with officials from USAID, WHO, PAHO,
UNICEF, USAID contractors, PVOs, and host governments and program
beneficiaries.  We visited USAID missions in Bolivia, Egypt,
Guatemala, and Mozambique to directly observe the nature of USAID's
child survival activities being implemented in the field.  We
selected these countries because they received significant child
survival funding, had various types of child survival projects, and
provided regional differences.  During our fieldwork, we analyzed
data for most of the USAID missions' ongoing projects and visited 63
project sites.  In addition to the fieldwork, we also talked with
USAID project officers in two other countries. 

We analyzed USAID strategic objectives, program goals, and funding
documentation to determine the linkage between funds attributed to
child survival and USAID's child survival objectives.  We analyzed
the most recent data on USAID funding attributed to child survival
for 1985-95, which we obtained from the contractor that operates
USAID's Center for International Health Information.  At the time of
our review, obligation data for fiscal year 1995 were not fully
validated; therefore, some of the fiscal year 1995 obligation data
are subject to change.  According to USAID officials, the 1995 data
had to be recoded, and the process was not completed by August 1996. 

We conducted our review between May 1995 and August 1996 in
accordance with generally accepted government auditing standards. 


---------------------------------------------------------- Letter :7.1

As arranged with your office, unless you publicly announce its
contents earlier, we plan no distribution of this report until 30
days after the date of this letter.  We will then send copies of this
report to the Administrator, USAID; the Director, Office of
Management and Budget; the Secretary of State; and other interested
congressional committees.  We will also make copies available to
others on request. 

Please contact me at (202) 512-4128 if you or your staff have any
questions concerning this report.  Major contributors to this report
are listed in appendix IV. 

Sincerely yours,

Benjamin F.  Nelson
Director, International Relations
and Trade Issues


CHILD SURVIVAL OBJECTIVES AND
PROGRAM GUIDANCE
=========================================================== Appendix I

OBJECTIVES

In February 1985, in response to the legislation authorizing child
survival activities, the U.S.  Agency for International Development
(USAID) established the child survival program to consolidate some of
the agency's ongoing efforts related to reducing deaths among
children in developing countries.  Although USAID provided
mission-level child survival assistance to 31 countries in 1985, it
placed special emphasis on 22 countries that had especially high
mortality rates. 

The child survival program for these 22 countries was originally
guided by USAID's Child Survival Task Force.  This task force helped
to develop a detailed child survival strategy for each country, in
cooperation with the host government, to deal with the country's
specific needs and circumstances. 

USAID's policy was to sustain mission-level child survival funding in
these countries for at least 3 to 5 years and provide technical
support and training on a priority basis.  Special attention was also
to be given to program monitoring and evaluation and coordination
with private voluntary organizations (PVO), international
organizations, and other U.S.  agencies. 

From 1985 to 1991, child survival appropriations went into a
functional account for child survival set up under an overall
development assistance account.  Beginning in fiscal year 1992,
Congress designated a specific amount for child survival, which could
be drawn from any USAID appropriation.  In the 1990s, child survival
was incorporated into USAID's broad strategy for development
assistance.  According to the agency's 1995 Guidelines for Strategic
Plans, USAID's current emphasis is on sustainable and participatory
development, partnerships, and the use of integrated approaches.\1

The agency's five goals are to encourage broad-based economic growth,
build democracy, stabilize world population and protect human health,
protect the environment, and provide humanitarian assistance. 

USAID's population, health, and nutrition sector has priority
objectives in four areas:  family planning, child survival, maternal
health, and reducing sexually transmitted diseases and human
immunodeficiency virus (HIV)/acquired immune deficiency syndrome
(AIDS). 

Agency guidelines indicate that the core of the sector is family
planning but that balanced strategies are encouraged.  USAID's
guidance on child survival states that activities are to focus on the
principal causes of death and severe lifelong disabilities, and
programmatic emphasis should be on children under the age of 3. 
Further, the guidance states that child survival service delivery is
to be focused on the community; the primary health care system; and,
to a limited extent, the first-level hospitals.  Emphasis is to be on
enabling caretakers to take effective action on behalf of their
children's well-being and ensuring gender equity in children's access
to preventive and curative health.  Although USAID considers health
and population services to be important, the agency does not provide
them directly; instead, it tries to improve the capacity,
infrastructure, systems, and policies that support these services in
a sustainable way. 

In its 1994 Strategies for Sustainable Development,\2 USAID stated
that the agency's population and health programs would concentrate on
countries that contribute the most to global population and health
problems\3 and have population and health conditions that impede
sustainable development.\4 Agency guidance states that any of the
following key factors indicate the need to consider developing
strategic objectives that address family planning, child survival,
maternal health, and reduction of sexually transmitted diseases and
HIV/AIDS: 

  -- annual total gross domestic product growth less than 2 percent
     higher than annual population growth over the past 10 years,

  -- unmet need for contraception at or above 25 percent of married
     women of childbearing age,

  -- total fertility rate above 3.5 children per woman,

  -- mortality rate for children under age 5 at or above 150 per
     1,000 live births,

  -- stunting in at least 25 percent of children under age 5,\5

  -- maternal mortality rate at or above 200 deaths per 100,000 live
     births, and

  -- prevalence of sexually transmitted diseases at or above 10
     percent among women aged 15 to 30. 

Because USAID has identified global population growth as an issue of
strategic priority agencywide, guidance states that strategies
directed at family planning, child survival, maternal health, and
reduction of sexually transmitted diseases and HIV/AIDS--all of which
must be considered together--will receive particular attention in
those countries where the unmet need for contraception is the
greatest.  USAID stated that other concerns would also include
under-5 mortality, maternal mortality, prevalence of sexually
transmitted diseases, and stunting. 

USAID's long-term goal is to contribute to a cooperative global
effort to stabilize world population growth and protect human health. 
Its anticipated near-term results over a 10-year period are (1)
significant improvement in women's health, (2) a reduction in child
mortality by one-third, (3) a reduction of maternal mortality rates
by one-half, and
(4) a decrease in the rate of new HIV infections. 

PROGRAM GUIDANCE

USAID issued guidance in 1992 and 1996 about the types of activities
that are allowable uses of child survival funds.  The guidance named
specific types of activities that may be considered to fall under the
child survival program and gave broad discretion to USAID officials
to determine the proportion of funding that could be reported as
child survival.  The annual instruction manual for coding activities
and special interests further specifies how activities are to be
reported. 

According to agency guidance and instructions, some activities are
automatically funded in their entirety as child survival.  These
activities are

  -- diarrheal disease control and related research,

  -- immunization and child-related vaccine research,

  -- child spacing/high-risk births,\6

  -- acute respiratory infection,

  -- vitamin A,

  -- breastfeeding promotion,

  -- growth monitoring and weaning foods,

  -- micronutrients, and

  -- orphans and displaced children. 

Other activities can be partially funded as child survival.  USAID's
guidance stated that project managers could decide the percentage for
the following activities that could be reported as child survival,
even though suggested percentages were provided for some: 

  -- health systems development;

  -- nutrition management, planning, and policy;

  -- other nutrition activities;

  -- health care financing;

  -- environmental health;

  -- vector control;

  -- water and sanitation;

  -- women's health; and

  -- malaria research and control. 


--------------------
\1 These guidelines, also known as implementation guidelines, are
supplementary references to the 1994 Strategies for Sustainable
Development to help shape the development of or revisions to unit
strategic plans. 

\2 This document provides USAID's vision for achieving sustainable
development and explains its goals and objectives. 

\3 According to the guidance, these countries have large numbers of
very young and older women bearing children; many closely spaced
births; high numbers of infant, child, and maternal deaths; high
female illiteracy; large numbers of women with an articulated but
unmet need for family planning services; and large numbers of persons
infected with HIV or increasing rates of HIV infection. 

\4 These countries have fertility and population growth rates that
outstrip the country's ability to provide adequate food and social
services, growth rates that threaten the environment, significant
reproductive health problems due to heavy reliance on unsafe
abortions, health conditions that impede the ability of children to
learn and the ability of adults to produce and participate,
increasing rates of HIV infection, and significant gender gaps in
education. 

\5 Stunting is height for age at least two standard deviations below
mean. 

\6 Child spacing and high-risk birth activities may be funded by
either child survival or population funds.  According to the
guidance, these activities may be financed with child survival funds
only when the emphasis of the project is on reducing infant and child
mortality rates.  Population funds should be used when the project is
primarily designed to provide options for limiting family size. 


UNDER-5 MORTALITY RATES AND USAID
MISSION-LEVEL FUNDING IN
DEVELOPING COUNTRIES
========================================================== Appendix II

                              (Dollars in thousands)


                                                 1994 Under-
                                                           5
                                                  population
                                                         (in
Country              Status      1980      1994    millions)   1985-95      1995
-------------------  ------  --------  --------  -----------  --------  --------
Niger                     1       320       320          1.8   $21,148    $2,500
Angola                    2       261       292          2.1     1,830         0
Sierra Leone              3       301       284          0.8       127       113
Mozambique                1       269       277          2.8    62,494     9,793
Afghanistan               3       280       257          3.3    30,959         0
Guinea-Buissau            2       290       231          0.2         0         0
Guinea                  2\c       276       223          1.3         0         0
Malawi                    1       290       221          2.1    22,949     3,562
Liberia                   4       235       217          0.6     6,900         0
Mali                      1       310       214          2.1    42,880     5,346
Gambia                    4       278       213          0.2       122         0
Somalia                   3       246       211          1.8     9,559     2,339
Zambia                    1       160       203          1.7     4,200     4,200
Chad                      3       254       202          1.1     9,532         0
Eritrea                   1       260       200          0.6     7,149       519
Ethiopia                  1       260       200         10.3    20,194     6,664
Mauritania                3       249       199          0.4       581         0
Bhutan                    3       249       193          0.3         0         0
Nigeria                   1       196       191         20.1    29,218     1,016
Zaire                     4       204       186          8.3    12,365         0
Uganda                    1       181       185          4.2    15,476     2,119
Cambodia                  1       330       177          1.8    33,978     8,494
Burundi                   3       193       176          1.2     2,941         0
Central African           3       202       175          0.6     7,369     1,360
 Republic
Burkina Faso              3       246       169          1.8     3,311         0
Madagascar                1       216       164          2.6     5,540     3,308
Tanzania                  1       202       159          5.2     2,270     2,090
Lesotho                   3       173       156          0.3       293         0
Gabon                     3       194       151          0.2         0         0
Cote d'Ivoire             3       170       150          2.8     2,153         0
Benin                     2       176       142          1.0       553         0
Rwanda                    1       222       139          1.4     5,202     1,447
Laos                      3       190       138          0.9         0         0
Pakistan                  1       151       137         23.6    37,153     3,067
Togo                      3       175       132          0.7    11,403         0
Ghana                     2       155       131          3.0    $2,088         0
Haiti                     1       195       127          1.1    78,440   $10,887
Sudan                     4       200       122          4.6    10,579         0
India                     1       177       119        116.6    68,772       900
Nepal                     1       180       118          3.5    12,893     1,229
Bangladesh                1       211       117         17.1    48,001         2
Senegal                   1       221       115          1.4    12,738     1,553
Yemen                     2       210       112          2.7     9,346         0
Bolivia                   1       170       110          1.1    60,566     3,264
Cameroon                  3       173       109          2.2    14,833         0
Congo                     3       125       109          0.5         0         0
Myanmar (Burma)           1       146       109          6.4     3,344       100
Swaziland                 3       151       107          0.1     3,004         0
Libyan Arab               4       150        95          0.9         0         0
 Jamahiriya
Papua New Guinea          3        95        95          0.6       800         0
Kenya                     1       112        90          5.1    21,353       312
Turkmenistan              2       N/A        87          0.6        79         0
Tajikistan                2       N/A        81          1.0     1,262         0
Zimbabwe                  2       125        81          1.9     2,796         0
Indonesia                 1       128        80         21.9    42,234     3,006
Namibia                   2       114        78          0.2         0         0
Mongolia                  2       112        76          0.3         0         0
Iraq                      4        83        71          3.3         0         0
Guatemala                 1       136        70          1.8    46,790       903
South Africa              1        91        68          5.6     3,883     3,883
Nicaragua                 1       143        68          0.8    22,075     2,661
Algeria                   3       145        65          3.6         0         0
Uzbekistan                2       N/A        64          3.2       124         0
Brazil                    2        93        61         17.8         0         0
Guyana                    2        88        61          0.1         0         0
Peru                      1       130        58          2.9    50,443     1,388
Philippines               2        70        57          9.2    58,194         0
Ecuador                   1       101        57          1.4    23,325     1,183
El Salvador               1       120        56          0.8    81,230     2,587
Morocco                   1       145        56          3.4    16,843     1,400
Kyrgyzstan                2       N/A        56          0.6       159         0
Turkey                    3       141        55          7.5         0         0
Botswana                  3        94        54          0.2      $392         0
Honduras                  1       100        54          0.9    53,550    $2,201
Egypt                     1       180        52          8.1   136,860    27,001
Azerbaijan                1       N/A        51          0.8    10,894     9,150
Iran                      4       126        51         10.4         0         0
Kazakhstan                2       N/A        48          1.6       484         0
Vietnam                   3       105        46         10.1         0         0
Dominican Republic        1        94        45          1.0    13,985     1,195
China                     4        65        43        107.3         0         0
Albania                   2        57        41          0.4         0         0
Belize                    3        56        41         0.03     4,755         0
Lebanon                   1        40        40          0.4       875       395
Syrian Arab               4        73        38          2.6         0         0
 Republic
Moldova                   2       N/A        36          0.4        29         0
Saudi Arabia              3        90        36          2.8         0         0
Paraguay                  2        61        34          0.7         0         0
Tunisia                   3       102        34          1.0        40         0
Thailand                  3        61        32          5.4     1,748         0
Armenia                   1       N/A        32          0.4    19,476    15,356
Macedonia                 2        69        32          0.2         0         0
Mexico                    2        87        32         11.8         0         0
Solomon Islands           3        56        32          0.1       500         0
Russian Federation        2       N/A        31          8.4     5,650         0
North Korea               4        43        31          2.6         0         0
Romania                   1        36        29          1.3     2,461     2,141
Georgia                   1       N/A        27          0.4    19,495    17,226
Argentina                 3        41        27          3.3         0         0
Oman                      3        95        27          0.4         9         0
Latvia                    3       N/A        26          0.2         0         0
Ukraine                   2       N/A        25          3.0     1,558         0
Jordan                    2        66        25          0.9     9,700         0
Venezuela                 3        42        24          2.8         0         0
Estonia                   3       N/A        23          0.1         0         0
Yugoslavia                3        44        23          0.7         0         0
Mauritius                 3        42        23          0.1         0         0
Belarus                   2       N/A        21          0.6       $31         0
Uruguay                   3        42        21          0.3         0         0
United Arab               3        64        20          0.2         0         0
 Emirates
Lithuania                 2       N/A        20          0.3         0         0
Panama                    2        31        20          0.3         0         0
Trinidad and Tobago       3        40        20          0.1         0         0
Bulgaria                  2        25        19          0.5         0         0
Sri Lanka                 2        52        19          1.8     1,370         0
Colombia                  2        59        19          3.9         0         0
Bosnia and                2        38        17          0.2         0         0
 Herzegovina
Poland                    2        24        16          2.5     1,991         0
Costa Rica                3        29        16          0.4         0         0
Chile                     3        35        15          1.5     1,440         0
Slovakia                  2       N/A        15          0.4         0         0
Malaysia                  3        42        15          2.7         0         0
Croatia                   1        23        14          0.3       355      $355
Hungary                   2        26        14          0.6         0         0
Kuwait                    3        35        14          0.2         0         0
Jamaica                   1        39        13          0.3     3,562       501
Cuba                      4        26        10          0.9         0         0
Czech Republic            2       N/A        10          0.7         0         0
South Korea               3        18         9          3.5         0         0
Slovenia                  3        18         8          0.1         0         0
Hong Kong                 3        13         6          0.3         0         0
Singapore                 3        13         6          0.2         0         0
--------------------------------------------------------------------------------
Legend: 

1 USAID has a presence in the country and a child survival program. 

2 USAID has a presence in the country, but no activities were
attributed to child survival in fiscal year 1995. 

3 USAID had no presence in the country and supported no mission-level
programs, as of August 1996, although some funding may be provided
through regional or other mechanisms. 

4 USAID was legally restricted from operating in these countries as
of 1996. 

Note:  N/A in the table is used for countries for which the
information was not available, primarily because these countries did
not exist in 1980.  Fiscal year 1995 child survival funding data were
current as of July 30, 1996.  USAID officials said that figures
reported for missions under the Bureau for Europe and the New
Independent States were not final at that time and may not be
accurate.  The table does not include the West Bank/Gaza area, which
received $585,900 in USAID mission-level funding between 1985 and
1995. 

\a The mortality rate represents the number of deaths per 1,000 live
births for children under age 5, or the probability of dying between
birth and exactly 5 years of age. 

\b Mission-level assistance is obligated by USAID field missions. 
These amounts do not include USAID central or regional funds that may
also have gone to these countries. 

\c USAID is designing a child survival program for Guinea to start
after the beginning of fiscal year 1997, according to a USAID
official. 

Source:  The U.N.  Children's Fund and USAID/Center for International
Health Information. 




(See figure in printed edition.)Appendix III
COMMENTS FROM THE U.S.  AGENCY FOR
INTERNATIONAL DEVELOPMENT
========================================================== Appendix II

the end of this appendix. 



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)


The following is GAO's comment on USAID's letter dated July 23, 1996. 

GAO COMMENT

1.  We have revised this report since the time we provided it to
USAID for comment.  As a result, there are some instances in which
the information discussed in USAID's letter is no longer included in
our report. 


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix IV

NATIONAL SECURITY AND
INTERNATIONAL AFFAIRS DIVISION,
WASHINGTON, D.C. 

Jess T.  Ford
Ronald A.  Kushner
Sherlie S.  Svestka
Ann L.  Baker
David M.  Bruno
Neyla Arnas
Karen S.  Blum

OFFICE OF THE GENERAL COUNSEL

Richard Seldin


*** End of document. ***