GAO

United States General Accounting Office

Report to the Chairman, Committee on 

Foreign Relations, U.S. Senate

October 2000 FOREIGN 

ASSISTANCE

USAID Compliance 

With Family Planning 

Restrictions

GAO-01-3

Page 1 GAO-01-3 Foreign Assistance

United States General Accounting Office

Washington, D.C. 20548

October 2, 2000

The Honorable Jesse A. Helms

Chairman, Committee on Foreign Relations

United States Senate

Dear Mr. Chairman:

The United States has provided international family planning assistance 

through the U.S. Agency for International Development (USAID) since the 

mid-1960s. The United States remains the world’s single largest contributor 

to family planning programs in developing countries. U.S. law prohibits the 

use of international family planning funds for abortion-related activities 

and requires that all family planning programs supported by USAID be 

voluntary.

In response to your request, we determined (1) how much family planning 

assistance USAID provided in fiscal years 1996-99 and planned to provide 

in fiscal year 2000 and (2) what procedures USAID has established to 

ensure that family planning assistance funds are not used for prohibited 

activities and whether USAID follows these procedures. We recently 

briefed your staff on our review of USAID’s international family planning 

assistance program. This report summarizes the content of that briefing.

To gain a firsthand view of USAID family planning activities, we visited five 

cooperating agencies that were providing USAID-funded family planning 

services and visited USAID-assisted family planning service providers in 

Bolivia, Honduras, and Peru. We selected the five cooperating agencies that 

were most likely to have programs involving direct interaction with family 

planning patients—and consequently greater potential for prohibited 

activities.1

 We selected Bolivia and Peru based on the large size of USAID’s 

family planning programs in these countries and congressional interest. We 

selected Honduras to prepare for the more comprehensive work in Bolivia 

and Peru.

1

The five cooperating agencies we visited either provided direct family planning services or 

oversaw other direct service providers, and they accounted for about $41 million of the 

$65.7 million in assistance that USAID’s Family Planning Services Division managed in fiscal 

year 1999. They were the Cooperative for Assistance and Relief Everywhere (CARE) in 

Atlanta, Georgia; Pathfinder International in Boston, Massachusetts; AVSC International in 

New York, New York; Save the Children in Washington, D.C.; and the International Planned 

Parenthood Federation in London, the United Kingdom.
Page 2 GAO-01-3 Foreign Assistance

Results in Brief USAID provided family planning assistance totaling $432 million in fiscal 

year 1996 and $385 million in each of fiscal years 1997-99. During these

4 years, USAID provided approximately two-thirds of this assistance 

through over 40 cooperating agencies funded centrally from Washington, 

D.C., and the remaining third through nongovernmental organizations and 

through government-to-government programs funded by its overseas 

missions. For fiscal year 2000, USAID planned to provide $372.5 million in 

family planning assistance, allocating the funds roughly the same as in the 

previous 4 years. 

USAID has established multiple procedures to ensure that family planning 

funds are not used for prohibited activities, including specifying the 

restrictions in family planning grants, contracts, and cooperative 

agreements; disseminating policy guidance in writing and in training 

sessions; reviewing the work plans and progress reports of family planning 

projects; making periodic visits to clinics and service providers’ offices; 

and evaluating and auditing projects. With the exception of some 

accounting and clerical errors that we identified, USAID had complied with 

these procedures for the five selected cooperating agencies and the 

projects in Bolivia, Honduras, and Peru that we reviewed. The accounting 

and clerical errors we identified were quickly resolved and did not have any 

material effect on USAID’s ability to ensure compliance with the 

restrictions. During our in-country site visits to family planning service 

providers’ offices and to health facilities supported by USAID, we found no 

evidence that inappropriate services were being offered.

Background Since 1965, the United States has provided family planning assistance to 

help couples determine the number and spacing of their children, reduce 

unintended pregnancies, promote maternal and child health, and stabilize 

world population. The United States contributes almost one-half of all 

donor funding to family planning programs in more than 60 countries. In 

July 2000, the Congressional Research Service reported that USAID has 

expended over $6.6 billion on international family planning assistance
Page 3 GAO-01-3 Foreign Assistance

during the last 35 years.2 USAID assistance ranges from providing 

contraceptives to researching new means of regulating fertility to 

supporting clinic-based programs for directly delivering family planning 

services to patients.

USAID funds family planning assistance through both its Office of 

Population in Washington, D.C., and its overseas missions. The USAID 

Office of Population manages projects through a network of cooperating 

agencies that include nongovernmental organizations, private firms, 

universities, and research and educational organizations, among others. 

USAID’s overseas missions manage projects through nongovernmental 

organizations and through government-to-government programs.

The underlying principles of U.S. family planning assistance are 

voluntarism and informed consent, and legislation specifically prohibits the 

use of USAID funds to perform abortions as a method of family planning or 

to motivate or coerce anyone to practice abortions.3

 Although the abortion 

prohibition is long-standing, specific U.S. government policies for 

supporting international family planning programs have fluctuated over the 

years. Under the Reagan administration, the U.S. government adopted a 

policy at the 1984 United Nations International Conference on Population 

in Mexico City that denied U.S. funds to foreign nongovernmental 

organizations that perform or promote abortion, regardless of the source of 

the money used for these activities. In 1993, the Clinton administration 

lifted this restriction. Since 1995, family planning funding levels and various 

types of restrictions have been negotiated annually between the President 

and the Congress.

Family Planning 

Assistance in Fiscal 

Years 1996-2000

After providing $432 million in family planning assistance in fiscal year 

1996, USAID provided $385 million, or about 11 percent less, during each of 

fiscal years 1997-99. Planned fiscal year 2000 funding was $372.5 million—

about 14 percent less than in fiscal year 1996. Congress initially provided 

2

Population Assistance and Family Planning Programs: Issues for Congress, Congressional 

Research Service, IB96026 (July 2000), http://www.loc.gov/crs/crsproducts.html.

3

The current restriction, included in section 518 of the fiscal year 2000 Foreign Operations 

Appropriations Act, prohibits (1) using funds to pay for abortions or involuntary 

sterilizations or to motivate or coerce any person to practice abortions or undergo 

sterilization and (2) funding any research that relates to the methods or performance of 

abortion or involuntary sterilization.
Page 4 GAO-01-3 Foreign Assistance

$385 million for USAID’s family planning program in fiscal year 2000 and 

restricted providing any of the funds to foreign nongovernmental or 

multilateral organizations that engage in abortion-related activities. The 

legislation allowed the President to waive this restriction for up to 

$15 million of the appropriation but required that $12.5 million be deducted 

from the total family planning appropriation if he did so. Because the 

President exercised the waiver, USAID’s family planning funding for fiscal 

year 2000 was reduced to $372.5 million.

USAID manages a substantial portion of its family planning assistance 

program through contracts, grants, and cooperative agreements to over 40 

cooperating agencies that it funds centrally from its Office of Population in 

Washington. Table 1 shows the amounts of centrally managed family 

planning assistance provided by USAID in fiscal years 1996-99 and planned 

for 2000.

Table 1: Centrally Managed Family Planning Assistance in Fiscal Years 1996-2000

a

Because family planning assistance funds are available for obligation over 2 years, a portion of each 

fiscal year’s funding may have been obligated in the subsequent year.

b

Fiscal year 1996 figures include both funds specifically appropriated for family planning assistance 

and other funds that the USAID Administrator made available for such use that year.

c

Fiscal year 2000 figures are estimates.

Source: USAID.

Dollars in millions

Fiscal yeara 1996b 1997 1998 1999 2000c

Centrally managed 

assistance $287.5 $256.5 $244.3 $238.2 $221.5

As a percentage of total 

assistance 67% 67% 63% 62% 59%

Total assistance $432.0 $385.0 $385.0 $385.0 $372.5
Page 5 GAO-01-3 Foreign Assistance

USAID’s overseas missions manage the remainder of the agency’s family 

planning assistance funds through contracts, grants, and cooperative 

agreements to nongovernmental organizations and through 

government-to-government programs. In fiscal year 1999, the largest 10 

family planning assistance programs4

 managed by USAID’s overseas 

missions were in Bangladesh, India, the Philippines, Bolivia, Egypt, Peru, 

Haiti, Nepal, Jordan, and West and Central Africa.5

 Table 2 shows the 

amounts of family planning assistance that USAID funded through its 

overseas missions in fiscal years 1996-99 and planned for 2000.

Table 2: Overseas Mission-Funded Family Planning Assistance in Fiscal Years 

1996-2000

a

Because family planning assistance funds are available for obligation over 2 years, a portion of each 

fiscal year’s funding may have been obligated in the subsequent year.

b

Fiscal year 1996 figures include both funds specifically appropriated for family planning assistance 

and other funds that the USAID Administrator made available for such use that year.

c

Fiscal year 2000 figures are estimates.

Source: USAID.

4

USAID refers to the funds that are directly managed by overseas missions as bilateral 

funds. In addition to those projects that the overseas missions directly manage, the missions 

often use the services of centrally managed projects in support of their country-specific 

programs—a funding mechanism termed field support. Our ranking of the top 10 overseas 

programs includes both bilateral and field support funds.

5

This USAID mission has a regional focus, covering four countries in West and Central 

Africa: Burkina Faso, Cameroon, Cote D’Ivoire, and Togo.

Dollars in millions

Fiscal yeara 1996b 1997 1998 1999 2000c

Mission-funded 

assistance

$144.5 $128.5 $140.7 $146.6 $151.0

As a percentage of total 

assistance

33% 33% 37% 38% 41%

Total assistance $432.0 $385.0 $385.0 $385.0 $372.5
Page 6 GAO-01-3 Foreign Assistance

USAID Compliance 

With Family Planning 

Restrictions

U.S. law prohibits the use of international family planning assistance funds 

for performing or for research regarding abortions or involuntary 

sterilizations. Various restrictions have also been included in annual 

appropriations acts, including a prohibition on using funds to lobby for or 

against abortion. For fiscal year 2000, USAID was also limited to providing 

a total of $15 million (or less) to foreign nongovernmental and multilateral 

organizations that perform or lobby regarding abortions with funds from 

other sources. USAID has established the following procedures to ensure 

compliance with family planning restrictions:

• Includes the restrictions as standard provisions in its grants, contracts, 

and cooperative agreements.

• Disseminates written policy guidance on the restrictions to its overseas 

missions and to other participating entities (for example, cooperating 

agencies, nongovernmental organizations, and foreign governments).

• Sponsors workshops and training sessions for its participating entities 

to ensure that they are aware of the restrictions.

• Reviews participating entities’ annual work plans and various progress 

reports to ensure that project activities comply with the restrictions.

• Periodically visits clinics, other service delivery sites, and service 

providers’ offices.

• Conducts end-of-project evaluations.

For some large and lengthy projects, USAID also conducts mid-project 

evaluations, and for projects that exceed $300,000 annually, USAID requires 

annual external audits. In addition, the USAID Inspector General’s Office 

conducts audits of selected projects.

We found based on our work that USAID had complied with its policies and 

procedures for ensuring the proper use of family planning funds at the five 

cooperating agencies and the projects in Bolivia, Honduras, and Peru that 

we visited. Our review of family planning project agreements, work plans, 

progress reports, evaluations, trip reports, and audits indicated that USAID 

had exercised detailed and systematic oversight of projects. During our 

meetings with representatives of the various cooperating agencies, 

nongovernmental organizations, and foreign governments, the officials 

demonstrated a comprehensive understanding of the relevant family 

planning restrictions and how they applied to their own projects. During 

our site visits to in-country health facilities supported by USAID, we found 

no evidence that inappropriate services were being offered. Patients whom 
Page 7 GAO-01-3 Foreign Assistance

we interviewed at these health facilities reported no coercion or prohibited 

services being offered to them.

To comply with the $15 million cap on providing fiscal year 2000 funds to 

foreign nongovernmental organizations that engage in abortion-related 

activities with funds from sources other than the U.S. government, USAID 

asked organizations subject to the limitation to (1) certify that they did not 

plan to engage in such activities or (2) decline to certify to that effect. As of 

August 1, 2000, nine nongovernmental organizations had declined to certify, 

involving about $8.4 million in fiscal year 2000 funds.6

 To date, the cap has 

not restricted USAID family planning activities. However, USAID expects 

the amount subject to the cap to increase as it develops and signs 

agreements for additional projects using fiscal year 2000 funds, and it will 

continue its monitoring efforts to ensure compliance.

Although USAID complied with its policies and procedures for ensuring the 

proper use of family planning funds, we identified two situations involving 

accounting and clerical errors during our fieldwork. Neither had any 

material effect on USAID’s ability to ensure compliance with family 

planning restrictions.

• In an effort to make certain that the International Planned Parenthood 

Federation complied with restrictions on USAID funding, the Federation 

and USAID agreed that USAID funds would be used only to support 

Federation affiliates that do not engage in any abortion-related 

activities. In early 2000, the Federation discovered, through its own 

monitoring procedures, that it had inadvertently provided about 

$700,000 in USAID funds to two affiliates in India and Uganda that, 

among other family planning services, engage in abortion-related 

activities. The Federation corrected the accounting errors by 

transferring the appropriate amount of non-USAID funds into its USAID 

account and using the funds for other affiliates in accordance with its 

agreement with USAID.

• In Bolivia and Peru, due to computer data-entry errors and other 

oversights, various family planning restrictions were omitted from 

agreements with nongovernmental organizations in 1997 and/or 1998. 

However, as of April and May 2000—when we conducted our 

6

Five million dollars for the International Planned Parenthood Federation, $2.5 million for 

the World Health Organization (WHO), and $870,000 for seven smaller nongovernmental 

organizations.
Page 8 GAO-01-3 Foreign Assistance

fieldwork—the missions had discovered these errors and amended the 

agreements that were still in force. After our visit, USAID built into its 

family planning Web site a direct link to the relevant standard 

provisions. USAID also sent guidance to its overseas missions and 

cooperating agencies, reminding them of the requirement to include the 

restrictions in all agreements.

Also, during our review, allegations surfaced that the Peruvian government 

had recently engaged in inappropriate sterilizations.7

 USAID officials 

acknowledged that there may have been a few instances involving poorly 

trained health workers in isolated parts of Peru. USAID officials said the 

Peruvian government has taken appropriate action when such cases are 

substantiated. In any case, USAID assistance was not involved. In addition, 

during our site visits to health clinics and conversations with patients at 

these facilities, we found no evidence to suggest that inappropriate 

sterilization activities were encouraged or permitted. 

Agency Comments In written comments on a draft of this report, USAID said that the report 

was a thorough and objective review of its family planning assistance 

program (see app. I). USAID also provided technical comments that we 

have incorporated, as appropriate.

Scope and 

Methodology

To determine how much family planning assistance USAID provided in 

fiscal years 1996-99 and planned to provide in 2000, we reviewed USAID 

program and financial documentation and interviewed USAID officials. We 

analyzed USAID’s family planning assistance obligations for fiscal years 

1996-99. We also analyzed USAID’s preliminary estimates of its family 

planning assistance obligations for fiscal year 2000. In Washington, D.C., 

we interviewed officials in USAID’s Center for Population, Health, and 

Nutrition, including the Office of Population. We also interviewed officials 

in USAID’s Bureau for Asia and the Near East, the Bureau for Europe and 

the New Independent States, and the Bureau for Latin America and the 

Caribbean.

7

Peru had a national family planning campaign in 1996 and 1997 that included inappropriate 

sterilization activities, such as establishing quantitative national targets for surgical 

contraception and sterilizing patients without their informed consent. USAID did not fund 

or support these activities. In 1998, Peru abandoned the campaign, and USAID helped Peru 

develop and implement reforms.
Page 9 GAO-01-3 Foreign Assistance

To determine what procedures USAID has established to ensure that family 

planning assistance funds are not used for prohibited activities, we 

interviewed USAID officials; reviewed applicable laws and USAID 

regulations, guidelines, and handbooks; and examined project 

documentation. In Washington, D.C., we interviewed officials in USAID’s 

Center for Population, Health, and Nutrition, including the Office of 

Population, the Family Planning Services Division, and the Research 

Division, and we interviewed officials in USAID’s Office of General Counsel 

and Office of Procurement. We also polled 45 USAID overseas missions to 

validate the information obtained in Washington, D.C. 

To determine whether USAID followed its procedures, we (1) visited five 

cooperating agencies funded through USAID’s Office of Population and 

(2) examined USAID family planning programs funded by USAID’s 

overseas missions in three countries. Specifically:

• We visited 5 of the 11 cooperating agencies managed by the Office of 

Population’s Family Planning Services Division. We focused on 

cooperating agencies in this division because of the likelihood of their 

having programs entailing direct interaction with family planning 

patients—and thus greater potential for prohibited activities. The five 

cooperating agencies we visited either provided direct family planning 

services or oversaw other direct service providers, and they accounted 

for about $41 million of the $65.7 million in assistance that the Family 

Planning Services Division managed in fiscal year 1999. The other six 

cooperating agencies in the Division were involved in research, training, 

and other activities not likely to involve direct service delivery. We 

visited the Cooperative for Assistance and Relief Everywhere (CARE) in 

Atlanta, Georgia; Pathfinder International in Boston, Massachusetts; 

AVSC International in New York, New York; Save the Children in 

Washington, D.C.; and the International Planned Parenthood Federation 

in London, the United Kingdom. At each of these cooperating agencies, 

we met with officials and examined cooperative agreements, work 

plans, periodic progress reports, evaluations, trip reports, financial 

records, and audits to determine whether USAID and the cooperating 

agencies were following procedures established to ensure compliance 

with family planning restrictions.

• The three country programs that we examined were in Bolivia, 

Honduras, and Peru. Bolivia and Peru were selected based upon the 

large size of USAID’s programs in these countries—they were among the 

top 10 that received family planning assistance in fiscal year 1999—and 

congressional interest. Honduras was selected to prepare for the more 
Page 10 GAO-01-3 Foreign Assistance

extensive work in Bolivia and Peru. In each country, we met with 

cognizant officials and reviewed 100 percent of the active files for the 

major projects involving direct service delivery. We examined 

cooperative agreements, work plans, periodic progress reports, 

evaluations, trip reports, financial records, and audits to determine 

whether USAID and the project participants were following procedures 

established to ensure compliance with family planning restrictions. We 

also visited service providers’ offices and clinics and interviewed 

patients to determine whether there was any evidence of inappropriate 

services being offered. In addition:

• In Bolivia, we met with officials from all five major projects and 

visited five of their clinics. We also met with the in-country 

representatives of three U.S.-based cooperating agencies.

• In Honduras, we met with officials from all four major projects and 

visited three of their clinics. We also met with the in-country 

representatives of two U.S.-based cooperating agencies.

• In Peru, we met with officials from five of the six major projects and 

visited six of their clinics. We also met with the in-country 

representatives of three U.S.-based cooperating agencies.

We performed our work from November 1999 through August 2000 in 

accordance with generally accepted government auditing standards.

As agreed with your office, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days from the 

date of this letter. At that time, we will send copies to the Honorable J. 

Brady Anderson, the Administrator of USAID, and interested congressional 

committees. We will make copies available to others upon request.
Page 11 GAO-01-3 Foreign Assistance

Please contact me at (202) 512-4268 if you or your staff have any questions 

about this report. An additional GAO contact and staff acknowledgments 

are listed in appendix II.

Sincerely yours,

Jess T. Ford, Director

International Affairs and Trade 
Page 12 GAO-01-3 Foreign Assistance

Appendix I

Comments From the U.S. Agency for Apendxies

International Development ApendxiI
Appendix I

Comments From the U.S. Agency for 

International Development

Page 13 GAO-01-3 Foreign Assistance
Page 14 GAO-01-3 Foreign Assistance

Appendix II

GAO Contact and Staff Acknowledgments ApendxiI

GAO Contact A.H. Huntington, III (202) 512-4140

Acknowledgments In addition to the contact named above, David Artadi, Joseph Brown, 

Michael Courts, James Strus, and Adam Vodraska made key contributions 

to this report.

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