EBOLA RECOVERY

USAID Has Initiated 

or Completed Most 

Projects, but a 

Complete Project 

Inventory Is Still 

Needed for Evaluating 

Its Efforts

Report to Congressional Committees

March 2018

GAO-18-350

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-350, a report to 

congressional committees

March 2018

EBOLA RECOVERY

USAID Has Initiated or Completed Most Projects, but 

a Complete Project Inventory Is Still Needed for 

Evaluating Its Efforts

What GAO Found

As of September 30, 2017, of the $1.6 billion that the U.S. Agency for 

International Development (USAID) had obligated for the Ebola outbreak, $411.6

million was obligated for 131 Ebola recovery projects. Of the $411.6 million, 

USAID obligated the largest amount—about $247.6 million (60 percent)—from 

the Economic Support Fund account for recovery projects to support health 

systems recovery, governance and economic crisis mitigation, and Ebola 

survivors, among others. USAID obligated about $118.5 million from the 

International Disaster Assistance account for food security projects, such as food 

assistance and agricultural market support, and $45.5 million from the Global 

Health Programs account for Ebola survivor and world health reform projects.

As of September 2017, USAID had completed 62 of its 131 planned Ebola 

recovery projects, had 65 projects that were ongoing, and had 4 planned projects 

that it had not yet started. Of the 62 completed projects, USAID had completed 

39 within original time frames and budgeted costs and extended 23. Of the 65

ongoing projects, USAID expected to implement 46 within original time frames 

and costs, but had extended 19. USAID extended projects, in part, to complete 

host-government actions, hire staff, finalize project activities, and continue and 

expand food assistance.

In 2016, USAID contracted for an evaluation of its Ebola recovery activities. 

Although the contractor has completed some design elements for the evaluation, 

USAID had not ensured that a complete and accurate inventory of USAID’s

Ebola recovery projects had been compiled for the evaluation as of December 

2017. USAID intends to use the information and lessons learned from this 

evaluation to inform and improve its ability to respond to future global health 

emergencies. GAO’s comparison of the contractor’s inventory with USAID data 

provided to Congress found a number of discrepancies that USAID officials could 

not explain with certainty. USAID policy states that information collected should 

be of sufficient quality to be useful for the intended users. Until USAID ensures 

that the contractor develops a complete and accurate inventory of USAID’s 

Ebola recovery projects, USAID will not have assurance that the resulting

evaluation will be of sufficient quality.

Health Facilities Rehabilitated in Sierra Leone by a USAID Ebola Recovery Project

View GAO-18-350. For more information, 

contact David B. Gootnick at (202) 512-3149 

or gootnickd@gao.gov.

Why GAO Did This Study

The 2014-2015 Ebola outbreak in West 

Africa caused long-term second-order 

impacts, including disruptions to health 

systems, job loss, and food insecurity.

Congress appropriated about $2.5 

billion for USAID and the Department 

of State (State), in part, for 

international efforts to prevent, prepare 

for, and respond to an Ebola outbreak 

and mandated that the agencies report 

to congressional committees on the 

use of the funds. As of September

2017, USAID had allocated almost all 

of the appropriated Ebola funds. In 

2016, USAID contracted for an 

evaluation of Ebola recovery activities.

The fiscal year 2015 appropriations act 

included a provision for GAO to 

conduct oversight of USAID and State 

activities supported with funds from the 

Ebola response and preparedness

appropriations. GAO’s 2016 report 

(GAO-17-35) focused on USAID and 

State funding for Ebola response and 

preparedness. This report examines 

(1) obligations for USAID’s Ebola 

recovery projects, (2) the status of

USAID’s implementation of these 

projects, and (3) USAID’s evaluation of 

Ebola recovery efforts. GAO analyzed 

USAID funding data as of September 

30, 2017, which are the latest data 

provided to Congress, reviewed project 

documents and evaluation plans,

interviewed agency officials, and 

conducted fieldwork in Guinea, Liberia,

and Sierra Leone.

What GAO Recommends

The Administrator of USAID should 

ensure that a complete and accurate 

inventory of Ebola recovery projects is 

compiled for the ongoing evaluation.

USAID concurred with GAO’s 

recommendation.
Page i GAO-18-350 Ebola Recovery

Letter 1

Background 4

USAID Obligated $412 Million for 131 Projects across 7 

Categories of Ebola Recovery Assistance 8

Almost Half of USAID’s Ebola Recovery Projects Had Been 

Completed; the Remaining Were Ongoing, or Not Yet Started, 

as of September 2017 16

USAID Has Initiated an Evaluation of Its Ebola Recovery 

Activities, but It Has Not Yet Ensured that Its Contractor Has 

Compiled a Complete and Accurate Inventory of Recovery 

Projects 25

Conclusions 28

Recommendation for Executive Action 28

Agency Comments and Our Evaluation 28

Appendix I Objectives, Scope, and Methodology 30

Appendix II Summaries of Selected U.S. Agency for International Development 

Ebola Recovery Projects 34

Appendix III Department of State and Centers for Disease Control and Prevention 

Ebola Recovery Projects for West Africa 44

Appendix IV Funding for U.S. Agency for International Development and Dept of 

State Ebola Response and Recovery Projects 47

Appendix V Comments from the U.S. Agency for International Development 50

Appendix VI GAO Staff Acknowledgments 52

Contents
Page ii GAO-18-350 Ebola Recovery

Tables

Table 1: Total Numbers of USAID Ebola Recovery Projects by 

Implementation Status and Geographic Area, as of 

September 2017 8

Table 2: Ebola Recovery Projects That USAID Had Completed 

within Originally Planned Time Frames and Budgeted 

Costs, as of September 2017 17

Table 3: Completed Ebola Recovery Projects That USAID Had 

Extended beyond Originally Planned Time Frames and 

Budgeted Costs, as of September 2017 18

Table 4: Ongoing USAID Ebola Recovery Projects on Track for 

Meeting Originally Planned Time Frames and Budgeted 

Costs, as of September 2017 22

Table 5: Ongoing Ebola Recovery Projects That USAID Had 

Extended beyond Originally Planned Time Frames and 

Budgeted Costs, as of September 2017 23

Table 6: USAID Bureau for Global Health-Funded Ebola Recovery 

Project: Maternal and Child Survival Program: Human 

Resources for Health in Liberia Project 35

Table 7: USAID Bureau for Global Health-Funded Ebola Recovery 

Project: Advancing Partners and Communities, Post 

Ebola Health Services Strengthening in Sierra Leone 36

Table 8: USAID Bureau for Global Health-Funded Ebola Recovery 

Project: Strengthening Routine Immunization in Liberia 37

Table 9: USAID Mission in Guinea-Funded Ebola Recovery 

Project: Health Finance and Governance 38

Table 10: USAID Bureau for Global Health-Funded Ebola 

Recovery Project: Modula S Infection Isolation 

Containerized Living Unit Clinic 39

Table 11: USAID Bureau for Global Health-Funded Ebola 

Recovery Project: Africa Stop Ebola Music and Media 

Campaign to Raise Public Health Awareness in Guinea 40

Table 12: USAID Global Development Lab-Funded Ebola 

Recovery Project: Mobile Solutions, Technical Assistance, 

and Research, Liberia 40

Table 13: USAID Global Development Lab-Funded Ebola 

Recovery Project: Ebola Recovery Technical Assistance 

and Guidance Development for Health Information 

Systems Work for Reproductive Health in Sierra Leone 41

Table 14: USAID Office of Food for Peace-Funded Ebola 

Recovery Project: Emergency Food Assistance for EbolaAffected Families in Liberia—Margibi and Bong Counties 42
Page iii GAO-18-350 Ebola Recovery

Table 15: USAID Office of Food for Peace-Funded Ebola 

Recovery Project: Kailahun Food for Emergency Ebola 

Virus Disease Support in Sierra Leone 42

Table 16: Fiscal Year 2015 Appropriation for USAID and State 

Ebola Response and Preparedness, by Account and 

Period of Availability 47

Table 17: Status of USAID and State Allocations for Ebola 

Response and Preparedness from the Department of 

State, Foreign Operations, and Related Programs 

Appropriations Act, 2015, by Appropriation Account, as of 

September 30, 2017 48

Figures

Figure 1: Percent Change in Gross Domestic Product for Sierra 

Leone, Liberia, and Guinea, 2010-2015 6

Figure 2: Obligations for USAID Ebola Recovery Projects by 

Appropriation Account, as of September 30, 2017 10

Figure 3: Solar Panel at a Health Facility in Sierra Leone Installed 

as Part of a USAID Ebola Recovery Project 12

Figure 4: Health Facility in Liberia at Which a USAID Ebola 

Recovery Project Funds Trainings for Midwives and 

Laboratory Technicians 13

Figure 5: USAID’s Obligations for Ebola Recovery Projects, as of 

September 30, 2017 14

Figure 6: USAID’s Obligations for Ebola Recovery Projects, 

February 2015—September 2017 15

Figure 7: Vaccination Poster at Health Clinic in Liberia Provided 

by a USAID Ebola Recovery Project 19

Figure 8: Community Health Center in Sierra Leone Rehabilitated 

by a USAID Ebola Recovery Project 20

Figure 9: Water Well at a Maternal and Child Health Post in Sierra 

Leone Installed by a USAID Ebola Recovery Project 20
Page iv GAO-18-350 Ebola Recovery

Abbreviations

ADS Automated Directives System 

CDC Centers for Disease Control and Prevention

CIO Contributions to International Organizations

ESF Economic Support Fund

FFP Office of Food for Peace

GDP gross domestic product

GHP Global Health Programs

IDA International Disaster Assistance

INCLE International Narcotics and Law Enforcement

Lab Global Development Lab

PKO Peacekeeping Operations

State Department of State

UNICEF United Nations Children’s Fund 

USAID U.S. Agency for International Development

WHO World Health Organization

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Page 1 GAO-18-350 Ebola Recovery

441 G St. N.W.

Washington, DC 20548

March 28, 2018

The Honorable Lindsey Graham

Chairman

The Honorable Patrick J. Leahy

Ranking Member

Subcommittee on State, Foreign Operations, and Related Programs

Committee on Appropriations

United States Senate

The Honorable Hal Rogers

Chairman

The Honorable Nita M. Lowey

Ranking Member

Subcommittee on State, Foreign Operations, and Related Programs

Committee on Appropriations

House of Representatives

The 2014-2015 Ebola outbreak led to an estimated 28,600 Ebola cases 

and more than 11,300 deaths. It also caused long-term disruptions to 

health systems, adverse economic effects, and other second-order 

impacts in the three primarily affected countries in West Africa—Guinea, 

Liberia, and Sierra Leone.1 Specifically, the outbreak resulted in a 

redirection of these countries’ scarce health-care resources to Ebola 

response efforts, job loss, disruptions to trade, reduced agricultural

production, decreased household purchasing power, and increased food 

insecurity.

In September 2014, the President announced a four-pillar U.S. 

government strategy to address the impacts of the Ebola outbreak.2 The 

second pillar of the strategy focuses on mitigating the second-order 

 1

The direct impacts of the Ebola outbreak in West Africa were increased morbidity and 

mortality. As of June 2016—the most recent date for which the World Health Organization 

(WHO) has reported data—the outbreak had resulted in more than 28,600 confirmed, 

probable, and suspected cases of Ebola and more than 11,300 deaths in the three 

primarily affected countries. 

2

The four pillars of the U.S. Government Strategy for Reducing Transmission of the Ebola 

Virus Disease in West Africa are (1) controlling the outbreak, (2) mitigating the secondorder impacts of the crisis, (3) building coherent leadership and operations, and (4) 

strengthening global health security. 

Letter
Page 2 GAO-18-350 Ebola Recovery

impacts of the outbreak, including efforts to assist in the primarily affected 

countries’ recovery. In November 2014, the President submitted a request 

to Congress for additional funds to enable the U.S. government to 

implement the strategy, including a request for funding to support Ebola 

recovery projects to address the second-order impacts in the three 

primarily affected countries. In December 2014, Congress enacted the 

Department of State, Foreign Operations, and Related Programs 

Appropriations Act, 2015 (the Act), which appropriated about $2.5 billion 

to the U.S. Agency for International Development (USAID) and the 

Department of State (State) for necessary expenses to assist countries 

affected by, or at risk of being affected by, the Ebola outbreak, among 

other things.3 The Act also required State, in consultation with USAID, to 

periodically submit reports to congressional committees on the proposed 

uses of the funds on a country and project basis.4 USAID and, to a lesser 

extent, State have allocated portions of funding from that appropriation for 

Ebola recovery projects to address the second-order impacts and assist 

the three primarily affected countries’ recovery.

The Act also includes a provision for GAO to conduct oversight of USAID 

and State activities supported with funds from the Ebola response and 

preparedness appropriation. In November 2016, we reported on USAID’s 

and State’s funding for Ebola response and preparedness activities.5 This 

report examines (1) obligations for USAID’s Ebola recovery projects, (2) 

the status of USAID’s implementation of these projects, and (3) USAID’s 

evaluation of Ebola recovery efforts.

 3

Pub. L. No. 113-235, Div. J, Title IX, 128 Stat 2130, 2692 (Dec. 16, 2014). In addition, the 

Act appropriated funding for efforts to mitigate the risk of illicit acquisition of the Ebola 

virus and to promote biosecurity practices associated with Ebola response efforts.

4

The Act requires State, in consultation with USAID, to submit a report to the Senate and 

House Committees on Appropriations on the proposed uses of the funds on a country and 

project basis, for which the obligation of funds is anticipated, no later than 30 days after 

enactment. It further requires State, in consultation with USAID, to update and submit 

these reports every 30 days until September 30, 2016, and every 180 days thereafter, 

until all funds have been fully expended. In the reports, USAID and State are required to 

include (1) information detailing how the estimates and assumptions contained in the 

previous reports have changed, and (2) obligations and expenditures on a country and 

project basis. The most recent report is as of September 30, 2017.

5

GAO, Emergency Funding for Ebola Response: Some USAID Reimbursements Did Not 

Comply with Legislative Requirements and Need to Be Reversed, GAO-17-35 

(Washington, D.C.: Nov. 2, 2016).
Page 3 GAO-18-350 Ebola Recovery

To examine obligations for USAID’s Ebola recovery projects, we reviewed 

USAID’s and State’s reports to congressional committees mandated by 

the Act and USAID’s strategic framework for Ebola recovery. We focus 

this report on USAID because it has allocated more than $2.3 billion (91 

percent) of the approximately $2.5 billion appropriated and has 

implemented most of the Ebola recovery projects funded from the 

appropriation. We conducted interviews with USAID and State officials to 

determine the projects that they identified as supporting Ebola recovery. 

We analyzed USAID’s obligations data and information that USAID 

reported as supporting Ebola recovery as of September 30, 2017, the 

most recent data and information that USAID and State have reported for

congressional committees.6 To examine the status of USAID’s 

implementation of Ebola recovery projects, we analyzed agency data on 

the implementation of Ebola recovery projects and the amounts of funding 

that USAID had obligated for these projects in its most recent report to 

Congress. To gain more in-depth information and context on the 

implementation of Ebola recovery projects, we selected a nongeneralizable sample of 10 Ebola recovery projects that USAID had 

reported in Pillar 2 as of July 1, 2016.7 We selected projects such that the 

sample would achieve a mix of projects by country; USAID office, bureau, 

and mission; and category of USAID’s strategic framework for Ebola 

recovery.8 We reviewed documents for our sample of projects and, where 

possible, conducted site visits in Guinea, Liberia, and Sierra Leone to 

examine project implementation. To identify the numbers and types of 

Ebola recovery projects that USAID had planned and implemented, we 

also analyzed funding data from USAID’s reports to Congress. We 

assessed the reliability of the data that USAID reported for its 

implementation of Ebola recovery projects and its obligations for such 

projects. We requested and reviewed information from agency officials 

 6

In a draft of this report that we provided to USAID and State for comment, we reported 

funding data that were current, as of March 31, 2017. State subsequently provided 

updated data, as of September 30, 2017. We updated our report accordingly.

7

We selected our sample of projects from among those that USAID had reported as of 

July 1, 2016 because we had assessed the reliability of the project data and information 

that USAID had reported as of that date during our prior work. In addition, to allow for an 

assessment of the implementation, we sought to select projects that had either begun 

implementation or had been completed. For more information about our 10 selected 

projects, see appendix II. 

8

The categories of USAID’s strategic framework for Ebola recovery are (1) health systems 

recovery, (2) emergency non-Ebola health services, (3) governance and economic crisis 

mitigation, (4) innovation and communications technology, and (5) food security.
Page 4 GAO-18-350 Ebola Recovery

regarding the underlying financial data systems and the checks and 

reviews used to generate the data to ensure its accuracy and reliability. 

We also compared the data to USAID’s documentation from selected 

projects to assess the reliability of USAID funding and project data. When 

we found discrepancies, we contacted agency officials and obtained 

information from them necessary to resolve the discrepancies. Based on 

these steps, we determined that the data we used were sufficiently 

reliable for the purposes of reporting the numbers of recovery projects 

and obligations. We also conducted fieldwork in Guinea, Liberia, and 

Sierra Leone, interviewing USAID officials, implementing partners, and 

host country officials about the planning and implementation of projects. 

To examine USAID’s evaluation of Ebola recovery efforts, we compared 

the evaluation plan prepared by USAID’s contracted evaluator 

(contractor) to criteria for designing effective evaluations.9 We also 

interviewed USAID officials and contractor staff in Washington, D.C. to 

discuss the evaluation plan details, including the methods, measures, and 

analysis plans for each objective. See appendix I for more details on our 

scope and methodology.

We conducted this performance audit from November 2016 to March 

2018 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate, evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

In addition to its direct impacts of increased morbidity and mortality, the 

Ebola outbreak also caused longer-term second-order impacts in all three 

primarily affected countries, including impacts on health systems, 

economies, governance, and food security.

 9

GAO, Designing Evaluations: 2012 Revision, GAO-12-208G (January 2012); Centers for 

Disease Control and Prevention, Framework for Program Evaluation in Public Health

(Atlanta, GA: Sept. 17, 1999).

Background

Second-Order Impacts of 

the Ebola Outbreak in 

Guinea, Liberia, and 

Sierra Leone
Page 5 GAO-18-350 Ebola Recovery

The Ebola outbreak overwhelmed the health systems and affected the 

quality and availability of health-care services in Guinea, Liberia, and 

Sierra Leone, which already had limited numbers of health-care workers 

and weak health-care infrastructure, according to WHO. Before the 

outbreak, the World Health Organization (WHO) estimated that there 

were 1 or 2 doctors per 100,000 people in the three countries; for 

example, WHO estimated that there were approximately 50 doctors in 

Liberia for a population of about 4.5 million. The quality and availability of 

care deteriorated as health-care workers succumbed to Ebola, and 

patients and health-care workers avoided health facilities for fear of 

contracting the disease. Health-care workers in the three primarily 

affected countries were 21 to 32 times more likely to be infected with 

Ebola than the general population. According to WHO, as of May 2015 

health-care workers constituted about 4 percent of those infected in the 

three countries and, of those health-care workers infected, about twothirds died.

The outbreak also caused health resources to be diverted from other 

basic health services. For example, the United Nations Children’s Fund 

(UNICEF) reported that the outbreak contributed to a drop in vaccination 

coverage, resulting in a significant number of children being exposed to 

the risks of contracting vaccine-preventable diseases. The number of 

children in Sierra Leone receiving basic immunizations declined by 21 

percent in 2014, following the outbreak, according to UNICEF.

All three countries experienced serious economic consequences from the 

Ebola outbreak, according to USAID. The closure of international borders 

in response to the outbreak hampered economic activity by limiting and 

restricting the movement of people, goods, and services. As a result, 

USAID noted that Guinea, Liberia, and Sierra Leone experienced market 

disruption, reduced agricultural production, and decreased household 

purchasing power. The gross domestic product (GDP) growth in all three 

countries declined in 2015 following the outbreak, most markedly in Sierra 

Leone (see fig. 1).

Impact on Health Systems

Impact on Economies, 

Governance, and Food 

Security
Page 6 GAO-18-350 Ebola Recovery

Figure 1: Percent Change in Gross Domestic Product for Sierra Leone, Liberia, and 

Guinea, 2010-2015

All three countries’ governance and public management was already 

generally weak before the outbreak, according to World Bank indicators, 

and during the outbreak, their governments faced challenges in providing 

basic public services. As Ebola spread in West Africa in 2014 and early 

2015, food security became a concern in the three primarily affected 

countries, according to USAID. Travel bans created market disruptions 

and shortfalls in agricultural production. Food prices increased while 

household incomes and purchasing power decreased, resulting in food 

insecurity, according to USAID. Additionally, the outbreak occurred at the 

beginning of the planting season, which further affected agricultural 

markets and food supplies.

In June 2015, USAID designed a strategic framework in part to explain 

the objectives of its Ebola projects to internal and external stakeholders, 

such as agency officials, Congress, and implementing partners, according 

to USAID officials. USAID derived the Ebola recovery portion of its 

strategic framework from Pillar 2 of the U.S. government strategy for 

USAID’s Strategic 

Framework for Ebola 

Recovery and Number 

and Status of Projects
Page 7 GAO-18-350 Ebola Recovery

Reducing Transmission of the Ebola Virus Disease in West Africa. 

Specifically, the overall objective of Pillar 2 of USAID’s strategic 

framework is to address the second-order impacts of the outbreak by 

preventing the loss of development gains and strengthening key 

institutions and infrastructure whose weaknesses enabled the rapid 

spread of Ebola or slowed the response.

USAID’s strategic framework for Ebola recovery consists of five project 

categories, which have the following goals:

• Health systems recovery. Improve the delivery of services and 

health-care commodities, enhance the management of health crises 

through revised protocols and response capabilities, and address 

health-care workforce issues.

• Emergency non-Ebola health services. Restart health services to 

pre-Ebola outbreak levels and communicate the risks of Ebola to 

mobilize the population to change its behaviors.

• Governance and economic crisis mitigation. Improve public 

services, governance, elections processes, water and sanitation, and 

social protection systems.

• Innovation, technology, and partnership. Attract innovations, new 

technologies, and partnerships to address response and recovery 

challenges, as well as improve health information systems.

• Food security. Increase food access for groups impacted by Ebola 

and increase food availability through the recovery of local food 

production and agricultural markets.

According to USAID, after developing the strategic framework in June 

2015, it programmed Ebola funds for Ebola survivor and world health 

reform projects, which have the following goals:

• Ebola survivors. Support the procurement of medicines and supplies 

for Ebola survivors and build the capacity of health-care services to 

monitor and treat Ebola survivors.

• World health reform. Strengthen WHO’s ability to lead and 

coordinate an effective response to ongoing and future health 

emergencies.
Page 8 GAO-18-350 Ebola Recovery

As of September 2017, USAID had implemented the largest number of 

recovery projects in Liberia.10 Table 1 shows the numbers of completed, 

ongoing, and planned USAID recovery projects by geographic area.

Table 1: Total Numbers of USAID Ebola Recovery Projects by Implementation Status and Geographic Area, as of September 

2017

Geographic 

area

Number of completed 

projects

Number of ongoing 

projects

Number of planned 

projects not yet initiated

Total

Liberia 20 29 2 51

Regional 25 13 0 38

Sierra Leone 8 14 0 22

Guinea 9 9 2 20

Total 62 65 4 131

Source: GAO analysis of U.S. Agency for International Development (USAID) data. | GAO-18-350

Note: Geographic areas are shown in order of the total numbers of completed, ongoing, and planned 

USAID Ebola recovery projects.

USAID had obligated approximately $411.6 million for 131 Ebola recovery 

projects as of September 30, 2017, from three different appropriations 

accounts: the Economic Support Fund (ESF) account, the International 

Disaster Assistance (IDA) account, and the Global Health Programs 

(GHP) account.11 USAID obligated the largest amount of funding from the 

ESF account. USAID’s funding for Ebola recovery projects supported 

seven categories of assistance: health systems recovery, emergency 

non-Ebola health services, governance and economic crisis mitigation, 

innovation and communications technology, food security, world health 

reform, and Ebola survivors. Food security projects received the largest 

share of Ebola recovery funds.

 10Regional Ebola recovery projects encompass multiple countries. 

11We report obligations from the Act in accordance with USAID’s and State’s reporting to 

Congress because the reports are the source of our data. The obligations data in this 

report are as of September 30, 2017 because USAID’s and State’s most recent report for

Congress is as of that date.

USAID Obligated 

$412 Million for 131 

Projects across 7 

Categories of Ebola 

Recovery Assistance
Page 9 GAO-18-350 Ebola Recovery

As of September 30, 2017, of the $1.6 billion that USAID had obligated 

for the Ebola outbreak, USAID had obligated $411.6 million for 131 Ebola 

recovery projects that we identified.12 Of the $411.6 million, USAID 

obligated the largest amount—$247.6 million (60 percent)—from the ESF 

account. Figure 2 shows USAID’s obligations for its recovery projects by 

account.

 12State and the Centers for Disease Control and Prevention (CDC) have also implemented

Ebola recovery projects funded from the Act, as of September 30, 2017. For more 

information about State and CDC Ebola recovery projects, see appendix III. For additional 

information about the status of USAID’s and State’s reported allocations from the Act by 

appropriation account, see appendix IV. 

USAID Has Funded Ebola 

Recovery Projects through 

Three Appropriations 

Accounts
Page 10 GAO-18-350 Ebola Recovery

Figure 2: Obligations for USAID Ebola Recovery Projects by Appropriation Account, 

as of September 30, 2017

USAID obligated funding from the ESF account for recovery projects to 

support health systems recovery, emergency non-Ebola health services, 

governance and economic crisis mitigation, innovation and 

communications technology, and Ebola survivors. For example, USAID 

obligated

• $2.0 million for a project to provide routine immunizations to more 

than 130,000 children under 5 years of age and more than 130,000 

pregnant women in Liberia;

• $17.0 million for a project to restore routine health services in Sierra 

Leone by (a) installing water and sanitation and solar power 

infrastructure at more than 300 health facilities, (b) providing medical 

ESF Account
Page 11 GAO-18-350 Ebola Recovery

equipment, and (c) training more than 900 health-care professionals 

on reproductive, maternal, newborn, and child health and infection 

prevention and control practices (see fig. 3);

• $10.0 million for a project to improve the quality of pre-service 

education for midwives and laboratory personnel in Liberia (see fig. 

4);

• $6.0 million for a project to support health finance and governance in 

Guinea, which assessed the financial management of the Ministry of 

Health and updated the ministry’s administrative and financial 

procedures, and provided management trainings to 65 senior health 

officials;

• $1.5 million for projects to develop health information system 

strategies in Guinea, Liberia, and Sierra Leone, including embedding 

expert advisors in each country’s Ministry of Health; and

• $1 million for an Ebola survivor and transmission prevention project in 

Liberia to build the capacity of specialty care services to treat and 

monitor survivors.
Page 12 GAO-18-350 Ebola Recovery

Figure 3: Solar Panel at a Health Facility in Sierra Leone Installed as Part of a USAID 

Ebola Recovery Project
Page 13 GAO-18-350 Ebola Recovery

Figure 4: Health Facility in Liberia at Which a USAID Ebola Recovery Project Funds 

Trainings for Midwives and Laboratory Technicians

USAID obligated $118.5 million from the IDA account for food security 

projects, such as food assistance and agricultural market support. For 

example, USAID obligated approximately $4.6 million in IDA funding for 

an emergency food security project in Liberia that increased 5,000 Ebolaaffected households’ access to food through unconditional cash transfers 

delivered by a mobile money service provider. The project also provided 

seed kits for six crop varieties to 4,000 of these households. In addition, 

USAID obligated approximately $9.9 million for an emergency food 

security project in Sierra Leone that provided unconditional cash transfers 

to more than 10,300 households and conditional cash transfers to 400 

small-scale agricultural traders to support the restocking of food supplies 

in areas affected by the Ebola outbreak. As a condition for receiving 

assistance, the small-scale agricultural traders participated in business 

trainings.

USAID obligated $45.5 million from the GHP account for Ebola survivor 

and world health reform projects. The Ebola survivor project provides 

training to local medical staff to ensure long-term care for Ebola survivors 

in Liberia. USAID intends the world health reform project to guide WHO to 

IDA Account

GHP Account
Page 14 GAO-18-350 Ebola Recovery

reform its structures and processes to support its capacity to respond to 

future disease outbreaks and health emergencies.

As of September 2017, USAID had obligated the greatest amount of 

funding for food security projects, followed by projects supporting 

governance and economic crisis mitigation, and emergency non-Ebola 

health services. Figure 5 below depicts Ebola recovery project categories 

as a percentage of total obligations.

Figure 5: USAID’s Obligations for Ebola Recovery Projects, as of September 30,

2017

Note: This figure does not include Ebola recovery projects that the Centers for Disease Control and 

Prevention are implementing through an interagency agreement with USAID. The interagency 

agreement contains $80 million in obligations for Ebola, including obligations for Ebola recovery 

projects.

As shown in figure 6, USAID began obligating funds for food security in 

early 2015 in order to meet immediate food security needs and began 

obligating funds for other types of Ebola recovery activities in May 2015. 

Food Security Projects 

Received the Largest 

Share of Ebola Recovery 

Obligations
Page 15 GAO-18-350 Ebola Recovery

USAID obligated funds for Ebola survivor projects in May 2016 after 

identifying the level of need for survivor care.

Figure 6: USAID’s Obligations for Ebola Recovery Projects, February 2015—

September 2017

Appendix II provides additional information on USAID Ebola recovery 

projects, including detailed information on our sample of 10 selected 

recovery projects.
Page 16 GAO-18-350 Ebola Recovery

As of September 2017, USAID had completed 62 of its 131 planned 

Ebola recovery projects, had 65 projects that were ongoing, and had 4 

planned projects that it had not yet started.13 Of the 62 completed 

projects, USAID completed 39 within originally planned time frames and 

budgeted costs and extended the remaining 23. Of the 65 ongoing 

projects, USAID expected to implement 46 within original time frames and 

costs, but extended 19. USAID extended projects, in part, to complete 

host-government actions, hire staff, finalize project activities, and continue 

and expand food assistance.

USAID had completed more than half of its 62 completed Ebola recovery 

projects within originally planned time frames and budgeted costs, as of 

September 2017. Table 2 shows the numbers of recovery projects that 

each USAID bureau, office, or mission had completed within original time 

frames and the obligations for such projects, as of that date.

 13We report project time frame data as of September 2017 because we obtained data on 

the implementation status of Ebola recovery projects from USAID bureaus, offices, and 

missions as of that date.

Almost Half of 

USAID’s Ebola 

Recovery Projects 

Had Been 

Completed; the 

Remaining Were 

Ongoing, or Not Yet 

Started, as of 

September 2017

USAID Had Completed 62 

Ebola Recovery Projects 

as of September 2017, 

Most within Originally 

Planned Time Frames and 

Budgeted Costs
Page 17 GAO-18-350 Ebola Recovery

Table 2: Ebola Recovery Projects That USAID Had Completed within Originally Planned Time Frames and Budgeted Costs, as 

of September 2017

(Dollars in thousands)

USAID bureau, 

office, or 

mission

Number of projects Types of projects Total obligations

Global 

Development 

Lab

21 Governance and economic crisis 

mitigation

Innovation and communications 

technology 

4,430

Bureau for 

Global Health

11 Innovation and communications 

technology Health systems 

recovery Emergency non-Ebola 

health services

25,818

Office of Food for 

Peace

4 Food security 30,145

USAID/Liberia 2 Emergency non-Ebola health 

services

Governance and economic crisis 

mitigation

5,600

USAID/Guinea 1 Governance and economic crisis 

mitigation

500

Total 39 — 66,493

Source: GAO analysis of U.S. Agency for International Development (USAID) data and information. | GAO-18-350

Note: We report obligations for funding appropriated in the Department of State, Foreign Operations, 

and Related Programs Appropriations Act, 2015 in accordance with USAID’s and State’s reporting to 

Congress because the reports are the source of our data. The obligations data are as of September 

30, 2017 because USAID’s and State’s most recent report for Congress is as of that date. Amounts 

shown may not sum to totals because of rounding.

Table 3 shows the 23 completed projects that USAID bureaus and offices 

had extended beyond original time frames and the obligations for such 

projects, as of September 2017. On average, the length of time originally 

planned for these projects was 12 months. USAID had extended these 

projects by an average of about 6 months and added a total of $6.6 

million to 4 of the projects, as of September 2017.
Page 18 GAO-18-350 Ebola Recovery

Table 3: Completed Ebola Recovery Projects That USAID Had Extended beyond Originally Planned Time Frames and 

Budgeted Costs, as of September 2017

(Dollars in thousands)

USAID bureau, 

office, or 

mission

Number of 

projects

Types of projects Initial 

obligations

Additional obligations 

for cost extensions 

Total obligations

Bureau for Global 

Health

16 Innovation and 

communications 

technology

Emergency non-Ebola 

health services

33,774 81 33,855

Office of Food for 

Peace

6 Food security 33,894 6,451 40,345

Global Development 

Lab

1 Innovation and 

communications 

technology

100 43 143

Total 23 — 67,768 6,574a 74,343

Source: GAO analysis of U.S. Agency for International Development (USAID) data and information. | GAO-18-350

Notes: We report obligations for funding appropriated in the Department of State, Foreign Operations, 

and Related Programs Appropriations Act, 2015 in accordance with USAID’s and State’s reporting to 

Congress because the reports are the source of our data. The obligations data are as of September

30, 2017 because USAID’s and State’s most recent report for Congress is as of that date. Amounts 

shown may not sum to totals because of rounding.

a

USAID added a total of approximately $6.6 million in obligations for 4 of the 23 completed projects, 

as of September 30, 2017.

As of September 2017, USAID’s Bureau for Global Health had approved 

time frame extensions for 16 completed projects to allow time to develop 

innovations, complete host-government actions, and finalize project 

activities. The bureau approved these extensions for 10 of these projects 

to allow additional time to develop, test, or modify innovations to help 

health-care workers provide better care and stop the spread of Ebola. For 

example, the bureau approved an extension of approximately 4 months 

for one project to develop a modular Ebola treatment unit to complete 

required tests of the unit’s performance at testing facilities that were not 

readily available to conduct such tests, according to USAID officials. In 

addition, the bureau approved time frame extensions for 2 projects to 

obtain host-government approvals and complete actions needed to 

implement project activities. For example, the bureau approved an 

extension for a selected recovery project that supported immunization 

services of Liberia’s Ministry of Health by 7 months because of delays in 

the ministry’s implementation of the project’s activities. According to 

project staff, the project required additional time to engage with the 

ministry to develop and disseminate materials and messages about the 
Page 19 GAO-18-350 Ebola Recovery

importance of immunization, and to conduct vaccine distribution and 

waste management at local health facilities. Figure 7 shows a poster 

displayed at a health facility supported by the project to inform mothers 

about the importance of child immunizations. In addition, the bureau 

approved an extension of 3 months for a project to refurbish health 

facilities and improve access to maternal and child health services in 

Sierra Leone. Figure 8 shows a refurbished health facility supported by 

the selected project. According to project staff, the project had 

experienced delays in completing renovation activities—such as installing 

water towers and pumps and drilling boreholes to meet the health 

facilities’ water needs for infection prevention—because of challenges in 

locating suitable sites for drilling at health facilities and the rainy season. 

Figure 9 shows a water well installed at a health facility supported by the 

selected project.

Figure 7: Vaccination Poster at Health Clinic in Liberia Provided by a USAID Ebola 

Recovery Project
Page 20 GAO-18-350 Ebola Recovery

Figure 8: Community Health Center in Sierra Leone Rehabilitated by a USAID Ebola 

Recovery Project

Figure 9: Water Well at a Maternal and Child Health Post in Sierra Leone Installed by 

a USAID Ebola Recovery Project
Page 21 GAO-18-350 Ebola Recovery

USAID’s Office of Food for Peace (FFP) had approved time frame 

extensions for 6 completed projects and obligated an additional $6.5 

million for 2 of the 6 projects, as of September 2017. Specifically, FFP 

approved these extensions for 4 projects to address ongoing food 

security needs in existing Ebola-affected areas, according to USAID 

officials. For example, FFP approved an extension of 3 months for a 

selected emergency food assistance project in Liberia to conduct an 

additional cash transfer to the project’s existing 5,000 beneficiary 

households to address short-term food assistance needs during the lean 

period. In addition, FFP approved extensions of 12 and 15 months and 

obligated an additional $6.5 million for 2 projects to address continued 

food security needs of Ebola-affected populations currently receiving 

assistance and to expand assistance to additional beneficiaries, 

according to USAID officials.

USAID’s Global Development Lab (Lab) had approved a time frame 

extension of 3 months for one completed project and obligated an 

additional $42,956 to complete the project’s activities, as of September 

2017. The project assessed the use of data and digital technologies in 

crisis response, resulting in the publication of a final report providing 

recommendations on the use of data and digital systems for future 

response efforts. The Lab approved the extension to provide time for 

editing and design of the published report, according to these officials.

More than half of USAID’s 65 ongoing projects were expected to meet 

originally planned time frames and budgeted costs, as of September 

2017. Table 4 shows the number of ongoing recovery projects for each 

bureau, office, or mission that were on track for meeting original time 

frames and costs and the obligations for such projects, as of September 

2017.

USAID Had Started but 

Not Yet Completed 65 

Ebola Recovery Projects 

as of September 2017, 

with Most Expected to 

Meet Original Time 

Frames and Costs
Page 22 GAO-18-350 Ebola Recovery

Table 4: Ongoing USAID Ebola Recovery Projects on Track for Meeting Originally Planned Time Frames and Budgeted Costs, 

as of September 2017

(Dollars in thousands)

USAID bureau, 

office, or mission

Number of projects Types of projects Total obligations

Global 

Development Lab

27 Governance and economic crisis 

mitigation

Innovation and communications 

technology

Ebola survivors

38,536

Bureau for Global 

Health

11 Innovation and communications 

technology

Emergency non-Ebola health 

services

Health systems recovery

Ebola survivors

51,030

USAID/Liberia 4 Governance and economic crisis 

mitigation

29,911

USAID/Guinea 2 Governance and economic crisis 

mitigation

12,000

USAID/Sierra 

Leone

1 Governance and economic crisis 

mitigation

4,000

Office of U.S. 

Foreign Disaster 

Assistance

1 World health reform 35,000

Total 46 — 170,477

Source: GAO analysis of U.S. Agency for International Development (USAID) data and information. | GAO-18-350

Note: We report obligations for funding appropriated in the Department of State, Foreign Operations, 

and Related Programs Appropriations Act, 2015 in accordance with USAID’s and State’s reporting to 

Congress because the reports are the source of our data. The obligations data are as of September 

30, 2017 because USAID’s and State’s most recent report for Congress is as of that date. Amounts 

shown may not sum to totals because of rounding.

As of September 2017, USAID had extended 19 ongoing projects by an 

average of approximately 12 months beyond the projects’ originally 

planned average time frames of about 15 months. USAID had obligated 

an additional $22.8 million to 6 of the 19 projects. Table 5 shows the 

numbers of ongoing projects that each bureau, office, or mission had 

extended beyond original time frames and costs and the additional 

obligations for such projects, as of September 2017.
Page 23 GAO-18-350 Ebola Recovery

Table 5: Ongoing Ebola Recovery Projects That USAID Had Extended beyond Originally Planned Time Frames and Budgeted 

Costs, as of September 2017

Dollars in thousands

USAID bureau, 

office, or 

mission

Number of 

projects

Types of projects Initial 

obligations

Additional 

obligations for cost 

extensions 

Total obligations

Bureau for 

Global Health

8 Emergency non-Ebola 

health services

Health systems recovery

41,508 0 41,508

Office of Food for 

Peace

6 Food security 25,202 22,791 47,993

Global 

Development 

Lab

4 Innovation and 

communications 

technology

Governance and 

economic crisis mitigation

2,362 0 2,362

USAID/Guinea 1 Governance and 

economic crisis mitigation

1,000 0 1,000

Total 19 — 70,072 22,791 92,863

Source: GAO analysis of U.S. Agency for International Development (USAID) data and information. | GAO-18-350

Note: We report obligations for funding appropriated in the Department of State, Foreign Operations, 

and Related Programs Appropriations Act, 2015 in accordance with USAID’s and State’s reporting to 

Congress because the reports are the source of our data. The obligations data are as of September 

30, 2017 because USAID’s and State’s most recent report for Congress is as of that date. Amounts 

shown may not sum to totals because of rounding.

As shown in table 5, USAID’s Bureau for Global Health had approved 

time frame extensions for 8 ongoing projects, as of September 2017. The 

bureau approved these extensions for 4 projects to allow time to obtain 

host-government approvals and actions needed to implement project 

activities. For example, the bureau approved an extension of 18 months 

for one project to restore routine health service delivery and strengthen 

infection prevention and control in Liberia. The extension allowed 

additional time to support the project’s ongoing renovation work at health 

facilities, which had been delayed because of difficulty in obtaining 

approvals from the Ministry of Health, according to project staff. In 

addition, the bureau approved an extension of 9 months for a selected 

recovery project that supports the governance and financial management 

of the health system in Guinea to allow additional time to coordinate with 

Ministry of Health officials and other partners to implement project 

activities. The implementation of the project’s activities requires hostgovernment officials’ approvals of draft plans and strategies to improve 

the capacity of institutions to conduct oversight and improve the Ministry 
Page 24 GAO-18-350 Ebola Recovery

of Health’s internal and external communications; however, project staff 

noted that delays in officials’ reviews of draft documents affected the 

timeliness of the approvals. The bureau extended the remaining 4 

projects because of delays in procuring supplies and hiring staff with the 

skills to manage the project and to allow additional time to complete 

ongoing project activities, according to USAID officials.

FFP approved time frame extensions and obligated an additional $22.8 

million for 6 ongoing food security projects to address continued needs of 

Ebola-affected populations currently receiving assistance and to expand 

assistance to additional beneficiaries. For example, FFP approved an 

extension of 23 months and obligated an additional $5.6 million for a 

selected food assistance project in Sierra Leone. The additional time and 

funding allowed the implementing partner to continue cash transfers to 

the project’s 6,445 household beneficiaries and expand assistance to an 

additional 3,873 households whose ability to purchase food remained 

limited primarily because of the loss of employment and currency 

depreciation.

The Lab approved time frame extensions for 4 ongoing recovery projects 

because of delays in hiring staff to manage the project, and to allow 

additional time to implement project activities. For example, the Lab 

approved an extension of 4 months for a selected project in Liberia to 

develop a digital salary payment system for health-care workers to allow 

them to continue working in the hospitals and clinics without needing to 

be away from work for a lengthy period of time to receive payments. The 

project had experienced lower enrollment of health-care workers than 

expected, primarily because of a lack of understanding and trust in the 

system among health-care workers, according to project staff. The Lab 

approved the time frame extension so that the implementing partner and 

the Ministry of Health could collaborate on a more targeted approach to 

health-care worker enrollment, according to USAID officials.

USAID had planned 4 Ebola recovery projects that it had not yet started, 

as of September 2017. USAID had obligated $7.4 million to these 4 

projects, as of September 30, 2017. Specifically, the mission in Guinea 

has planned one governance and economic crisis mitigation project and 1

health systems recovery project, and the Lab has planned 2 innovation 

and communications technology projects in Liberia.
Page 25 GAO-18-350 Ebola Recovery

USAID has initiated an evaluation of its recovery activities, but it has not 

yet ensured that its contracted evaluator (contractor) has compiled a 

complete and accurate inventory of USAID’s recovery projects. In 2016, 

USAID contracted for an evaluation of its Ebola recovery efforts. USAID 

intends to use the information and lessons learned from this evaluation to 

inform and improve its ability to respond to future global health 

emergencies. The contractor has developed several key aspects of the 

study design. However, as of December 2017, USAID had not ensured 

that the contractor compiled a complete and accurate inventory of 

USAID’s recovery projects. USAID policy states that information collected 

should be of sufficient quality to be useful for the intended users. Without 

a complete and accurate inventory of USAID’s Ebola recovery projects, 

USAID does not have assurance that the resulting evaluation will be of 

sufficient quality.

The purpose of the evaluation14 is to assess the overall performance of 

USAID’s Ebola recovery activities in achieving Pillar 2’s objective.15

According to the contractor’s evaluation design plan, the contractor plans 

to determine

• how the Pillar 2 activities in Guinea, Liberia, and Sierra Leone are 

contributing to the achievement of the mission and the Pillar 2 of 

USAID’s Strategic Framework’s objective;

• the extent to which Pillar 2 accomplishments are still observable after 

the projects are completed, and why;

• whether there were unanticipated barriers or consequences of Pillar 2 

investments, and if opportunities were seized or missed; and

• any lessons that were learned regarding how to use the strengths of 

USAID’s development mechanisms in a complex emergency.

 14The evaluation is part of the Ebola Pillar II Monitoring, Evaluation, and Learning Project. 

According to USAID guidance, a monitoring, evaluation, and learning project report is an 

essential step in managing USAID’s process of assessing and reporting progress toward 

achieving project outputs and outcomes, and to identify what evaluation questions will be 

addressed through evaluation.

15As described in the contractor’s evaluation design plan, this evaluation is a macro-level 

evaluation in that the overall performance of Pillar 2 activities is evaluated. It is not 

intended to measure performance at the individual project level. USAID’s Bureau for 

Global Health and Global Development Lab are conducting separate evaluations that will 

include assessments of performance at the project level.

USAID Has Initiated 

an Evaluation of Its 

Ebola Recovery 

Activities, but It Has 

Not Yet Ensured that 

Its Contractor Has 

Compiled a Complete 

and Accurate 

Inventory of Recovery 

Projects

USAID Has Contracted for

an Evaluation of Its Ebola 

Recovery Activities
Page 26 GAO-18-350 Ebola Recovery

USAID intends to use the information and lessons learned from the 

evaluation to inform and improve its ability to respond effectively and 

efficiently to future global health emergencies. The contractor plans to 

submit its first report on the evaluation’s findings in March 2018.16

The contractor’s evaluation design plan calls for the evaluation to be 

organized into three phases:

• In the first phase, the contractor would conduct a review to summarize 

what activities had been implemented using Pillar 2 funds. Using 

categories of activities that the contractor and USAID agreed upon, 

the contractor would (1) identify project-level activities that were under 

way or completed, and were implemented between April 2015 and 

March 31, 2017, and (2) assign each project-level activity to a 

category.17 To carry out these tasks, according to the design plan, the 

contractor is to compile an inventory of USAID’s Ebola recovery 

projects, including detailed information on each project’s stakeholders, 

locations, scale, and other descriptive information.

• In the second phase, the contractor would collect and analyze data 

from a variety of sources to assess the performance of selected main 

activities in achieving Pillar 2’s objective.18 The contractor told us that 

it has developed an initial inventory of projects through in-person 

interviews with USAID staff and stakeholders in Washington, D.C., 

and in the three countries, and by reviewing project documentation.

• In the third phase, the contractor would assess the overall combined 

effects of Pillar 2 activities on the objective of Pillar 2 recovery efforts.

 16A second performance evaluation report, due in 2019, would provide an assessment of 

overall summative outcome questions. As defined by USAID’s Glossary of Evaluation 

Terms, a summative evaluation would assess the program in its later stages or after it has 

been completed to (1) assess its impact, (2) identify the factors that affected its 

performance, (3) assess the sustainability of its results, and (4) draw lessons that may 

inform other interventions.

17The second and third phases of the contractor’s work are to build on the results of the 

first phase. In the second phase, the contractor will focus on assessing the performance of 

selected main activities that are completed or under way. It will identify and describe 

accomplishments and lessons learned from Pillar 2 investments. In the third phase, the 

contractor plans to assess the overall combined effects of Pillar 2 activities on the 

objective of Pillar 2 recovery efforts. 

18The contractor is selecting main activities based on geographic coverage, funding 

levels, and implementation status of the projects that comprise the categories of activities.
Page 27 GAO-18-350 Ebola Recovery

Although USAID’s contractor has developed several key evaluation 

design details, some over the course of our review, USAID has yet to 

ensure that the contractor compiled a complete and accurate inventory of 

USAID’s Pillar 2 recovery projects. We compared the contractor’s study 

design plan to criteria for developing effective evaluations (see app. I for 

criteria).19 Based on this analysis, we identified elements that were 

incomplete or unclear in the contractor’s evaluation design plan. When we 

brought these issues to USAID’s and the contractor’s attention, they took 

steps to further develop these design details and provided additional 

documentation to us to demonstrate the steps that they had taken. 

Specifically, the contractor provided an updated version of the evaluation 

plan that includes the sampling methodology for a survey and control 

group; the contractor also developed a data analysis plan that further 

identifies indicators for the outcome measures and data sources for the 

indicators.

However, as of December 2017, USAID had not ensured that the 

contractor compiled a complete and accurate inventory of Pillar 2 projects 

that was to be completed as part of the evaluation’s first phase. When we 

compared the contractor’s most recent inventory, as of December 2017, 

to the inventory of Pillar 2 projects that USAID had included in its reports 

to congressional committees, we found major differences in terms of the 

nature and number of projects included. For example, we identified at 

least 10 projects in the contractor’s inventory that USAID had not included 

in the lists of recovery projects it reported to congressional committees, 

including projects related to solid waste management and malaria control. 

We also found that the contractor’s inventory omitted projects that USAID 

had identified as Pillar 2 projects in those reports, including Ebola 

innovation projects implemented by the Lab and by the Bureau for Global 

Health.

As of December 2017, USAID officials were uncertain as to why the 

contractor’s most recent inventory differed from the inventory that USAID 

had provided in the congressional reports. USAID and contractor officials 

subsequently told us that the contractor was continuing to finalize the 

inventory. USAID guidance for monitoring and reporting criteria cites the 

importance of ensuring that the information collected is of sufficient 

 19USAID and the contractor refer to the evaluation design plan document as an “Inception 

Report.”

USAID’s Contractor Has 

Developed Several Key 

Aspects of the Evaluation 

Design, but USAID Has 

Not Ensured that the 

Contractor Compiled a 

Complete and Accurate 

Inventory of USAID’s Pillar 

2 Projects
Page 28 GAO-18-350 Ebola Recovery

quality to be useful for intended users and of ensuring that the evaluation 

design, measures, and analysis plans are appropriate for the evaluation 

questions. Unless this inventory is complete and accurate, the 

contractor’s evaluation may not be able to reliably assess the extent to 

which Pillar 2 activities are on track to achieve the Pillar 2 objective. Thus,

USAID does not have assurance of the quality of the evaluation findings.

As the Ebola outbreak in West Africa subsided, USAID initiated more than 

130 projects aimed at helping three West African countries recover from 

the outbreak’s devastating second-order effects on their economies, 

health care systems, and food security. When the scope and nature of 

recovery needs grew to include greater support for Ebola survivors, 

USAID initiated projects to meet those needs. To inform its response to 

any future Ebola outbreak or similar global health emergency, USAID has 

contracted for an evaluation of its Ebola recovery activities to assess 

whether those activities contributed to its efforts to achieve its Ebola 

recovery objective. This evaluation relies on an inventory of USAID’s 

Ebola recovery projects. However, to date, USAID has not ensured that 

the contractor compiled a complete and accurate inventory of USAID’s 

Ebola recovery projects. Without such an inventory, USAID does not have 

assurance of the quality of the evaluation’s findings.

The Administrator of USAID should take steps to ensure that USAID’s 

contractor compiles a complete and accurate inventory of Ebola recovery 

projects prior to finalizing its analysis. (Recommendation 1)

We provided a draft of this report to USAID, State, and CDC for comment. 

In its formal comments, provided in appendix V, USAID agreed with our 

findings and recommendation. USAID noted that all Ebola recovery 

projects should be included in the evaluation. USAID further noted that it 

is collaborating with the contractor to help ensure that the contractor will 

compile a complete and accurate inventory of Ebola recovery projects 

prior to finalizing its analysis. State and CDC did not provide formal 

comments. USAID, State, and CDC provided technical comments, which 

we incorporated throughout the report, as appropriate.

We are sending copies of this report to the appropriate congressional 

committees, the Administrator of the U.S. Agency for International 

Development, the Secretary of State, and other interested parties. In 

Conclusions

Recommendation for 

Executive Action

Agency Comments 

and Our Evaluation
Page 29 GAO-18-350 Ebola Recovery

addition, the report is available at no charge on the GAO website at 

http://www.gao.gov

If you or your staff have any questions about this report, please contact 

me at (202) 512-3149 or gootnickd@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix VI.

David B. Gootnick

Director, International Affairs and Trade
Appendix I: Objectives, Scope, and 

Methodology

Page 30 GAO-18-350 Ebola Recovery

The Department of State, Foreign Operations, and Related Programs 

Appropriations Act, 2015 (the Act) included a provision for us to conduct 

oversight of the U.S. Agency for International Development’s (USAID) 

and the Department of State’s (State) activities to prevent, prepare for, 

and respond to the 2014 Ebola outbreak.1 We examined (1) obligations 

for USAID’S Ebola recovery projects, (2) the status of USAID’s 

implementation of these projects, and (3) USAID’s evaluation of Ebola 

recovery efforts.

To examine obligations for USAID’s Ebola recovery projects, we reviewed 

USAID’s and State’s reports to the Senate and House Committees on 

Appropriations mandated by the Act from February 3, 2015 to September 

30, 2017.2 We analyzed USAID’s obligations data and project information 

that it reported as supporting Ebola recovery, as of September 30, 2017, 

the most recent data and information that USAID and State have reported 

for congressional committees.3 We focused this report on USAID 

because it has allocated more than $2.3 billion (91 percent) of the 

approximately $2.5 billion appropriated and has implemented most of the 

Ebola recovery projects funded from the appropriation. We also reviewed 

U.S. government-wide and USAID strategy documents for Ebola 

response and recovery in order to determine the categories of Pillar 2 of 

the U.S. government strategy for Reducing Transmission of the Ebola 

Virus Disease in West Africa—mitigation of the second-order impacts of 

the crisis—and the projects that support these categories. Additionally, 

we interviewed USAID officials in Washington, D.C. from the Bureau for 

Africa, Office of Food for Peace, Office of U.S. Foreign Disaster 

Assistance, Global Development Lab, and Bureau for Global Health to 

identify each bureau’s or office’s Ebola recovery projects. We also 

interviewed State officials from the Bureau of International Narcotics and 

Law Enforcement Affairs, and the Office of U.S. Foreign Assistance 

Resources to identify each bureau’s or office’s Ebola recovery projects. 

We analyzed USAID’s obligations data and information that USAID 

reported as supporting the categories of Pillar 2—health systems 

 1

Pub. L. No. 113-235, Div. J, Title IX, 128 Stat. 2130, 2692 (Dec. 16, 2014). 

2

We report funding from the Act for Ebola in accordance with USAID’s and State’s 

reporting to Congress. USAID and State have reported to Congress on Ebola funding from 

February 3, 2015 to September 30, 2017.

3

In a draft of this report that we provided to USAID and State for comment, we reported 

funding data that were current as of March 31, 2017. State subsequently provided 

updated data as of September 30, 2017. We updated our report accordingly.

Appendix I: Objectives, Scope, and 

Methodology
Appendix I: Objectives, Scope, and 

Methodology

Page 31 GAO-18-350 Ebola Recovery

recovery, emergency non-Ebola health systems, governance and 

economic crisis mitigation, innovation and communications technology, 

and food security—as well as Ebola survivors and world health reform 

projects that agency officials had identified as supporting Ebola recovery. 

Our calculations of obligations for Ebola recovery projects do not include 

funding for program support or for monitoring and evaluation. We also 

reviewed Centers for Disease Control and Prevention (CDC) and State 

documents and interviewed USAID, CDC, and State officials in Guinea, 

Liberia, and Sierra Leone to identify each agency’s Ebola recovery 

projects.

To examine the status of USAID’s implementation of Ebola recovery 

projects, we analyzed agency data on the implementation of Ebola 

recovery projects and the amounts of funding that USAID had obligated 

for these projects. We also requested and obtained data and information 

from USAID on the progress of implementation of the Ebola recovery 

projects that USAID had reported as of September 2017. We analyzed 

the data and information from USAID to determine the extent to which 

recovery projects had met planned time frames and budgeted costs. We 

reviewed agency documentation of the agency’s time frame and cost 

extensions for extended projects to determine the reasons for the 

extensions. We also analyzed USAID’s obligations data in the report to 

the Senate and House Committees on Appropriations mandated by the 

Act to identify the numbers and types of Ebola recovery projects that 

USAID had planned and implemented and the amounts of funding 

obligated for these projects, as of September 30, 2017. In addition, to 

gain more in-depth information and context on the implementation of 

Ebola recovery projects, we selected a non-generalizable sample of 10 

USAID recovery projects. For the non-generalizable sample of projects, 

we reviewed project documents, including, among other things, 

implementing partners’ annual and quarterly reports to determine project 

activities and examine project implementation. We selected our nongeneralizable sample of 10 projects from the 84 Ebola recovery projects 

that USAID had reported in Pillar 2 as of July 1, 2016.4 We selected 

projects to achieve a mix of projects by country; USAID office, bureau, 

and mission; and category of USAID’s strategic framework for Ebola 

 4

We selected our sample of projects from among those that USAID had reported as of 

July 1, 2016 because we had assessed the reliability of the project data and information 

that USAID had reported as of that date during our prior work. In addition, to allow for an 

assessment of the implementation, we sought to select projects that had either begun 

implementation or had been completed.
Appendix I: Objectives, Scope, and 

Methodology

Page 32 GAO-18-350 Ebola Recovery

recovery.5 In addition, we conducted fieldwork in Guinea, Liberia, and 

Sierra Leone. During our fieldwork in these countries, we met with USAID 

mission officials, USAID’s implementing partners, host government 

officials, and project beneficiaries. Where possible, we conducted site 

visits to our selected projects in Guinea, Liberia, and Sierra Leone to 

examine implementation.

We assessed the reliability of the data that USAID reported for its 

implementation of Ebola recovery projects and its obligations for such 

projects. We requested and reviewed information from agency officials 

regarding the underlying financial data systems and the checks and 

reviews used to generate the data and ensure its accuracy and reliability. 

We also compared the data to USAID’s documentation for selected 

projects to assess the reliability of USAID funding and project data. When 

we found data discrepancies, we contacted relevant agency officials in 

Washington, D.C., Guinea, Liberia, or Sierra Leone, and obtained 

information from them necessary to resolve the discrepancies.6 In 

addition, we have assessed the reliability of these data in our prior work 

and have found them to be reliable for the purposes of examining 

USAID’s and State’s obligations and disbursements of the appropriated 

funds.7 As a result of these steps, we determined that the data were 

sufficiently reliable for our purposes of reporting the numbers of Ebola 

recovery projects and obligations for these projects, as of September 30, 

2017.

To examine USAID’s evaluation of Ebola recovery efforts, we reviewed 

USAID’s contracted evaluator’s (contractor) evaluation design plan 

document and subsequent revisions and compared its contents to 

standards regarding key elements of evaluation design plans. We 

identified these standards in sources including USAID’s policies and 

requirements for monitoring and evaluation in the Automated Directives 

System (ADS), Chapter 201; Evaluation: Learning from Experience, 

 5

The categories of USAID’s strategic framework for Ebola recovery are (1) health systems 

recovery, (2) emergency non-Ebola health services, (3) governance and economic crisis 

mitigation, (4) innovation and communications technology, and (5) food security.

6

As a result of our efforts to ensure data reliability, the data that we report for obligations 

may differ from the data that USAID has reported to congressional committees.

7

GAO, Emergency Funding for Ebola Response: Some USAID Reimbursements Did Not 

Comply with Legislative Requirements and Need to Be Reversed, GAO-17-35 

(Washington, D.C.: Nov. 2, 2016).
Appendix I: Objectives, Scope, and 

Methodology

Page 33 GAO-18-350 Ebola Recovery

USAID Evaluation Policy, 2016 Update;

8 GAO’s Designing Evaluations: 

2012 Revision;

9 and the Centers for Disease Control and Prevention’s 

Framework for Program Evaluation in Public Health.

10 We also 

interviewed USAID officials and contractor staff in Washington, D.C. to 

discuss the evaluation plan details, including the methods, measures, and 

analysis plan.

We conducted this performance audit from November 2016 to March 

2018 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

 8

U.S. Agency for International Development, Evaluation: Learning From Experience. 

USAID Evaluation Policy, 2016 Update (Washington, D.C.: October 2016).

9

GAO, Designing Evaluations: 2012 Revision, GAO-12-208G (January 2012). 

10Centers for Disease Control and Prevention, Framework for Program Evaluation in 

Public Health (Atlanta, GA: Sept. 17, 1999). 
Appendix II: Summaries of Selected U.S. 

Agency for International Development Ebola 

Recovery Projects

Page 34 GAO-18-350 Ebola Recovery

The following is a summary of information on U.S. Agency for 

International Development (USAID) Ebola recovery projects, including the 

project objectives and examples of project activities for the 10 projects 

that we selected by country; USAID office, bureau, and mission; and the 

components of USAID’s strategic framework for Ebola recovery. USAID’s 

Bureau for Global Health, Global Development Lab, Office of Food for 

Peace, Office of U.S. Foreign Disaster Assistance, and missions in 

Liberia, Guinea, and Sierra Leone obligated $411.6 million for the 131 

recovery projects, as of September 2017. The recovery projects support 

health systems recovery, emergency non-Ebola health services, 

governance and economic crisis mitigation, innovation and 

communications technology, food security, Ebola survivor transmission 

prevention, and world health reform projects.

As of September 30, 2017, USAID had obligated approximately $60.1 

million for 16 health system recovery projects to improve the ability of 

health systems in Ebola-affected countries to manage health crises, 

improve service delivery, and increase demand for health services within 

communities. USAID’s Bureau for Health obligated funding for projects to 

procure and deliver commodities to health facilities, train and strengthen 

the curriculum for community health-care workers and other health 

professionals in collaboration with the ministries of health; and support 

governance, finance, and human resources for health systems. For 

example, the overall goal of the Maternal and Child Survival Program: 

Human Resources for Health in Liberia is to improve the competency of 

midwives and laboratory technicians through the strengthening of preservice training institutions. The project supports the development of a 

health and laboratory workforce that may address Liberia’s maternal and 

child health needs and prevent future outbreaks of Ebola and other 

infectious diseases. As of September 30, 2017, the Bureau for Global 

Health had obligated $10.0 million for this project, which began in April 

2016 and is scheduled to end in June 2018. Table 6 provides summary 

information about selected project activities.

Appendix II: Summaries of Selected U.S.

Agency for International Development Ebola 

Recovery Projects

Health Systems Recovery
Appendix II: Summaries of Selected U.S. 

Agency for International Development Ebola 

Recovery Projects

Page 35 GAO-18-350 Ebola Recovery

Table 6: USAID Bureau for Global Health-Funded Ebola Recovery Project: Maternal and Child Survival Program: Human 

Resources for Health in Liberia Project

Project objectives Selected project activities

Objective 1: Increase the quality of instruction at targeted preservice training institutions by upgrading the technical 

competencies and teaching skills of faculty, including preceptors,

and by strengthening curricula, course materials, and delivery of 

both didactic and clinical training.

Objective 2: Strengthen the learning environment at targeted preservice training institutions and clinical teaching sites in a 

comprehensive way through improved access to high-quality 

instructional resources, equipment, and technology.

• Sponsored a 3-day interactive leadership management 

training for managers of midwifery and lab pre-service 

education institutions.

• Conducted 4-day management training workshop for 12 

laboratory preceptors and faculty from three supported preservice training institutions to improve management and 

quality systems in laboratories and skills labs and to ensure 

continuous improvement of management and quality systems 

in laboratories. 

• Conducted a 3-day curriculum finalization workshop to 

confirm the adequacy of an updated curriculum for meeting 

pre-service education training needs. Fifty participants 

attended the workshop, representing six project-supported 

pre-service institutions for midwives and medical laboratory 

technicians.

• Assisted faculty in the preparation of course schedules and 

lesson planning for courses, including emergency 

preparedness, teaching in midwifery, and pediatrics. 

Source: GAO analysis of U.S. Agency for International Development’s (USAID) implementing partner project documentation. | GAO-18-350

As of September 30, 2017, USAID’s Bureau for Global Health and the 

USAID mission in Liberia had obligated $68.3 million for 12 recovery 

projects to restore regional emergency health services to ensure that 

basic health services are accessible to the populations most in need and 

to re-establish and sustain routine health service delivery. These recovery 

projects also focus on increasing the utilization of health services and 

expanding health worker capacity and capability, and providing technical 

assistance to rebuild sustainable capacity, including activities to address 

adverse effects on maternal and child health. For example, the overall 

goal of the Advancing Partners and Communities: Strengthening Health 

Services as Part of the Post-Ebola Transition in Sierra Leone project is to 

improve the access to and availability of quality routine health services at 

community levels. As of September 30, 2017, the Bureau for Global 

Health had obligated $17.0 million for the project, which began in August 

2015 and was completed in September 2017 (see table 7). In another 

example, the overall objective of the Strengthening Immunization in 

Liberia project is to contribute to the reduction of mortality rates for 

children under 5 in Liberia by restoring immunization services and 

addressing gaps in immunizations created as a result of the Ebola 

outbreak (see table 8). As of September 30, 2017, the Bureau for Global 

Emergency Non-Ebola 

Health Services
Appendix II: Summaries of Selected U.S. 

Agency for International Development Ebola 

Recovery Projects

Page 36 GAO-18-350 Ebola Recovery

Health had obligated $2.0 million for the project, which began in July 2015 

and was completed in July 2017.

Table 7: USAID Bureau for Global Health-Funded Ebola Recovery Project: Advancing Partners and Communities, Post Ebola 

Health Services Strengthening in Sierra Leone

Project objectives Selected project activities

Objective 1: Improve regulatory and policy environment to enable 

increased service delivery at health posts and community levels.

Objective 2: Increase capacity and effectiveness of the health 

workforce and community platforms to provide quality 

reproductive, maternal, neonatal, and child health services, 

including infection prevention control, and water and sanitation 

health guidelines.

Objective 3: Improve physical and operational conditions of 

community, maternal, and child health posts to enhance quality, 

safety, and access to health services.

• Disseminated water, sanitation, and hygiene standards and 

guidelines approved by Sierra Leone’s Ministry of Health and 

Sanitation nationwide. 

• Trained more than 900 health professionals and 1,500 

community health workers on reproductive, maternal, 

newborn, and child health and infection prevention and 

control practices.

• Conducted a data quality review on the completeness, 

consistency, and reliability of the Ministry of Health and 

Sanitation’s Health Information Management System data for 

305 health facilities.

• Rehabilitated 110 health posts to enhance infection 

prevention and control, and water, sanitation, and hygiene 

standards.

• Installed solar lighting systems in 108 health facilities, drilled 

26 bore holes, and drilled or rehabilitated 62 wells to provide 

water to health facilities.

• Distributed minor medical equipment and furniture to 305 

health posts, including delivery kits, delivery beds, 

stethoscopes, resuscitators, instrument trays, and patient 

privacy screens. 

Source: GAO analysis of U.S. Agency for International Development’s (USAID) implementing partner project documentation. | GAO-18-350
Appendix II: Summaries of Selected U.S. 

Agency for International Development Ebola 

Recovery Projects

Page 37 GAO-18-350 Ebola Recovery

Table 8: USAID Bureau for Global Health-Funded Ebola Recovery Project: Strengthening Routine Immunization in Liberia

Project objective Selected project activities

Attain and maintain national routine immunization coverage of 85 

percent in the target population, including in hard-to-reach areas, 

as measured by the third dose of Pentavalent vaccine.

• Procured and installed 40 solar refrigerators for health 

facilities to maintain the vaccination cold chain.

• Provided routine immunizations for approximately 

160,840 children aged 0 to 11 months, including polio, 

bacillus calmette-guerin, penta, pneumococcal 

conjugate, yellow fever, and measles vaccines.

• Trained 60 health facility vaccinators, 7 district 

supervisors, and 17 cold chain officers on solar 

refrigerator installation and maintenance.

• Conducted community outreach on the importance of 

routine vaccinations by distributing 1,000 posters and 

broadcasting on 30 radio stations across Liberia.

Source: GAO analysis of U.S. Agency for International Development’s (USAID) implementing partner project documentation. | GAO-18-350

As of September 30, 2017, USAID’s Global Development Lab (Lab) and 

USAID missions in Guinea, Liberia, and Sierra Leone had obligated 

approximately $71.1 million for recovery projects to support economic, 

social, and governance programs and address the effects of immediate

job loss and other income opportunities, and to strengthen infrastructure 

and critical institutions, including governance institutions. These recovery 

projects included private sector partnerships to support education and 

livelihood development for youths and women and provide financial and 

technical support to local small and medium enterprises in Ebola-affected 

communities by enabling them to access finance and technical assistance 

through small loans. In addition, these recovery projects support 

legitimate, participatory, transparent, and peaceful elections to help 

rebuild political trust and strengthen the practices of citizen participation in 

key political processes in support of Ebola recovery efforts. For example, 

the overall goal of the Health Finance and Governance project in Guinea 

is to strengthen Guinea’s health system to enhance the functioning of 

institutions and programs and improve the country’s capacity to deliver 

better health services to the population (see table 9). As of September 30, 

2017, the mission in Guinea had obligated $1.0 million for this project, 

which began in June 2016 and is scheduled to end in June 2018.

Governance and 

Economic Crisis Mitigation
Appendix II: Summaries of Selected U.S. 

Agency for International Development Ebola 

Recovery Projects

Page 38 GAO-18-350 Ebola Recovery

Table 9: USAID Mission in Guinea-Funded Ebola Recovery Project: Health Finance and Governance

Project objectives Selected project activities

Objective 1: Improve institutional capacity of health governance 

across the health system.

Objective 2: Enable a health financing environment and improve 

the Ministry of Health’s capacity to efficiently mobilize and 

manage resources to foster greater coverage of quality health 

services.

Objective 3: Improve the institutional capacity of the Ministry of 

Health to effectively manage human resources. 

• Conducted an audit of the ability of central health units, 

regional and district health management teams, and the 

Ministry of Health to carry out core functions. Finalized 

audit findings and recommendations in October 2016 

and began development of a roadmap to implement the 

audit recommendations.

• Conducted a strategic planning workshop with 33 preservice training institutions to develop a draft national 

plan for pre-service training institutions. 

• Completed an evaluation of the financial management of 

the Ministry of Health. The project included the 

development of a 3-year road map to strengthen the 

programmatic and financial management of the Ministry 

of Health.

• Supported a forum between Guinea’s Health 

Commission and officials of the Ministry of Health to 

assess the execution of the health budget and 

pharmaceutical industry reform, and other issues raised 

by civil society representatives.

Source: GAO analysis of U.S. Agency for International Development’s (USAID) implementing partner project documentation. | GAO-18-350

As of September 30, 2017, USAID’s Bureau for Global Health and the 

Lab had obligated $29.9 million for 54 recovery projects to develop and 

test innovations and technologies to address the Ebola outbreak and to 

prepare for future outbreaks. These recovery projects supported 

innovations to redesign a protective suit to enable health-care workers to 

spend more time with patients and lessen exposure to contamination, 

develop rapidly deployable Ebola treatment units and easy-to-assemble

decontamination chambers, and strengthen digital infrastructure, 

including mobile telephone networks, digital payment systems, and health 

data systems. For example, the Bureau for Global Health obligated 

$500,000 for the Modula S Infection Isolation Containerized Living Unit 

Clinic recovery project, which began in May 2015 and was completed in 

December 2015. The overall objective of the project was to develop 

modular, rapidly deployable treatment units that used technology to 

moderate temperature and simplified decontamination for safer and more 

comfortable conditions for treating patients (see table 10).

The Bureau for Global Health obligated $268,455 for another recovery 

project, Africa Stop Ebola Music and Media Campaign to Raise Public 

Health Awareness, which began in May 2015 and was completed in 

Innovation and 

Communications 

Technology
Appendix II: Summaries of Selected U.S. 

Agency for International Development Ebola 

Recovery Projects

Page 39 GAO-18-350 Ebola Recovery

August 2015 (see table 11). The overall objective of the project was to 

conduct a music and media campaign to change behaviors about humanto-human transmission of Ebola in West Africa through the recording of a 

song in local languages to promote communities’ adoption of behaviors 

that prevent Ebola transmission. In addition, as of September 30, 2017, 

the Lab had obligated $562,113 for the Mobile Solutions Technical 

Assistance and Research in Liberia recovery project, which began in 

June 2016 and is scheduled to end in March 2018 (see table 12). The 

overall objective of the project is to assist the Government of Liberia in 

increasing the efficiency of government payments by enabling the use of 

mobile money payments for health-care worker salary and stipend 

disbursements. The Lab also obligated $399,986 for the Ebola Recovery 

Technical Assistance and Guidance Development for Health Information 

Systems Work for Reproductive Health recovery project, which began in 

October 2015 and was completed in September 2016. The overall 

objective of the project was to strengthen health information systems and 

facilitate the Sierra Leone Ministry of Health and Sanitation’s application 

of digital tools for programmatic needs and health system challenges (see 

table 13).

Table 10: USAID Bureau for Global Health-Funded Ebola Recovery Project: Modula S Infection Isolation Containerized Living 

Unit Clinic

Project objective Selected project activities

Develop modular and rapidly deployable 

treatment units that use technology to 

moderate unit temperature and simplify 

decontamination efforts for safer, more 

comfortable conditions.

• Developed a modular Ebola treatment unit that allows the internal temperature 

to be cooler than outside air temperature in hot climates.

• Tested the modular treatment unit and found it to have a lifespan of 25 years. 

• Constructed the surfaces of the treatment unit out of anti-bacterial and anti-viral 

materials to improve the overall safety of health-care workers and patients. 

Source: GAO analysis of U.S. Agency for International Development’s (USAID) implementing partner project documentation. | GAO-18-350
Appendix II: Summaries of Selected U.S. 

Agency for International Development Ebola 

Recovery Projects

Page 40 GAO-18-350 Ebola Recovery

Table 11: USAID Bureau for Global Health-Funded Ebola Recovery Project: Africa Stop Ebola Music and Media Campaign to 

Raise Public Health Awareness in Guinea

Project objective Selected project activities

Use music to educate audiences about how 

to stop the spread of Ebola and reduce 

stigmatization of survivors and family 

members of Ebola victims.

• Sponsored a song contest in Guinea to engage local artists, health-care

workers, and the media in educating community members about the 

transmission of Ebola. 

• More than 100 health-care workers participated in the project by educating 

song contest participants about Ebola or by attending the final song contest 

event.

• The winning song from the Africa Stop Ebola competition was played on radio 

and broadcast on television more than 5,000 times.

Source: GAO analysis of U.S. Agency for International Development’s (USAID) implementing partner project documentation. | GAO-18-350

Table 12: USAID Global Development Lab-Funded Ebola Recovery Project: Mobile Solutions, Technical Assistance, and 

Research, Liberia

Project objectives Selected project activities

Objective 1: Design and plan the 

conversion of health-care worker salary and 

stipend disbursements to mobile money 

payments.

Objective 2: Support the establishment and 

implementation of a consolidated payment 

platform and processes for disbursement of 

Ministry of Health payroll through mobile 

money payments.

Objective 3: Support the measured scaleup and adoption of digital payments by 

salaried and contract health-care workers, 

as well as other types of health-care worker 

payments, where opportunities exist.

• Contracted the services of a consultant to map salary, benefits, and stipend 

payment streams within the Ministry of Health and the broader health sector to 

develop a plan to introduce and scale up mobile money payments for health 

workers. 

• Conducted a technical assessment and feasibility study on linking Liberia’s 

Ministry of Health functional system with mobile network operators.

• Conducted research to inform the strategy and scale for mobile money 

payments for health-care workers in Liberia and disseminated the results of the 

research with the Ministry of Health for decision-making about payment 

streams and the targeting of geographic areas for mobile money payments to 

health-care workers. 

• Disbursed mobile money payments to more than 300 Ministry of Health staff, 

as of June 2017.

Source: GAO analysis of U.S. Agency for International Development’s (USAID) implementing partner project documentation. | GAO-18-350
Appendix II: Summaries of Selected U.S. 

Agency for International Development Ebola 

Recovery Projects

Page 41 GAO-18-350 Ebola Recovery

Table 13: USAID Global Development Lab-Funded Ebola Recovery Project: Ebola Recovery Technical Assistance and 

Guidance Development for Health Information Systems Work for Reproductive Health in Sierra Leone

Project objectives Selected project activities

Objective 1: Establish a process to review 

digital information and communications 

technology assets that are high priority for 

health systems recovery.

Objective 2: Establish a guidance tool for 

defining, reviewing, and operationalizing 

functional requirements based on identified 

health system constraints.

Objective 3: Establish standards for health 

information systems minimum content to 

ensure value, and facilitate interoperability 

between systems.

Objective 4: Develop and test processes 

and guidance tools to ensure their validity.

Objective 5: Determine content 

functionality and interoperability 

requirements related to maternal and child 

health in development and deployment of 

routine health information system tools. 

• Conducted an inventory of digital health projects implemented to determine the 

existing digital information communication and technology assets in Sierra 

Leone.

• Developed a web platform—Digital Health Atlas—to enable the government to 

more efficiently monitor and manage the deployment of digital health systems 

in-country.

• Initiated the mapping of different data elements that existed on government 

health management information systems to facilitate interoperability by 

identifying data points needed by the government and linking these data with 

those collected digitally by nongovernmental organizations.

• Hosted a meeting of international experts to define and come to consensus on 

the parameters of digital strategies for a reproductive, maternal, newborn, and 

child health tool kit, which the project developed and tested in Sierra Leone.

• Developed a report on opportunities for strategic investments in digital health 

for reproductive, maternal, newborn, child, and adolescent health in Sierra 

Leone to guide the Ministry of Health and Sanitation’s planning and 

prioritization of investments in digital health systems.

Source: GAO analysis of U.S. Agency for International Development’s (USAID) implementing partner project documentation. | GAO-18-350

As of September 30, 2017, USAID’s Office of Food for Peace (FFP) had 

obligated approximately $118.5 million for 16 recovery projects to address 

decreases in agricultural production and sales and food availability as 

well as reductions in household incomes and income generation 

opportunities. These recovery projects support household and market 

recovery by stimulating local food production and market functions by 

providing cash transfers to vulnerable households and vouchers for 

agricultural inputs to support household food production. For example, the 

overall objective of the Emergency Food Assistance for Ebola Affected 

Families in Liberia was to increase access to food through unconditional 

cash transfers and increased agricultural production for households 

directly and indirectly affected by Ebola in two Liberian counties. FFP 

obligated approximately $4.6 million for the project, which began in 

August 2015 and was completed in February 2017 (see table 14). 

Similarly, the overall objective of the Kailahun Food for Emergency Ebola 

Virus Disease Support in Sierra Leone is to address reduced access to 

food caused by the Ebola outbreak by providing unconditional cash 

transfers to households directly and indirectly affected by the Ebola 

outbreak. The project also provides conditional cash transfers to smallFood Security
Appendix II: Summaries of Selected U.S. 

Agency for International Development Ebola 

Recovery Projects

Page 42 GAO-18-350 Ebola Recovery

scale traders to support the restocking and recapitalization of businesses 

for food supplies in the Kailahun District in northeast Sierra Leone. The 

project began in March 2015 and was completed in December 2017 (see 

table 15).

Table 14: USAID Office of Food for Peace-Funded Ebola Recovery Project: Emergency Food Assistance for Ebola-Affected 

Families in Liberia—Margibi and Bong Counties

Project objective Selected project activities

Increase household access to and 

availability of food.

• Assisted 5,000 Ebola-affected households, comprising more than 25,000 

individuals, to increase access to food through monthly unconditional cash 

transfers using mobile money payments. 

• Provided 4,000 of the 5,000 Ebola-affected households with a seed kit 

containing maize, eggplant, okra, hot pepper, cucumber, and bitter ball seeds, 

as well as trainings on agronomic best practices.

Source: GAO analysis of U.S. Agency for International Development’s (USAID) implementing partner project documentation. | GAO-18-350

Table 15: USAID Office of Food for Peace-Funded Ebola Recovery Project: Kailahun Food for Emergency Ebola Virus Disease 

Support in Sierra Leone

Project objectives Selected project activities

Objective 1: Improve ability of households 

to cope with shocks.

Objective 2: Reestablish and expand 

market and trade engagement among 

small-scale female traders in Kailahun.

Objective 3: Enhance human and 

institutional capacity development for 

increased agricultural sector productivity.

• Provided unconditional cash transfers to more than 10,300 households directly 

and indirectly affected by the Ebola outbreak to facilitate access to food for 

households with reduced agricultural production, earned income, and market 

access as a result of market disruptions stemming from the Ebola outbreak.

• Provided conditional cash transfers to 400 predominantly female small-scale 

traders to support restocking and recapitalization of businesses for food 

supplies in target areas; as a condition for receiving assistance, traders 

participated in entrepreneurship and business training, including trainings on 

basic bookkeeping and sound business practices.

Source: GAO analysis of U.S. Agency for International Development’s (USAID) implementing partner project documentation. | GAO-18-350

As of September 30, 2017, USAID’s Bureau for Global Health and the 

Lab had obligated approximately $28.8 million for recovery projects to 

prevent further Ebola transmission, support clinical care, and ensure that 

research results around transmission are incorporated into new 

guidelines for health-care workers. For example, the Bureau for Global 

Health obligated funding for recovery projects to research stigmatization 

of survivors and establish systems to track survivors and facilitate their 

referral to professionals trained to identify and prevent retransmission 

when they need medical services. In addition, the Lab obligated funding 

Ebola Survivor 

Transmission Prevention 

and World Health Reform
Appendix II: Summaries of Selected U.S. 

Agency for International Development Ebola 

Recovery Projects

Page 43 GAO-18-350 Ebola Recovery

for recovery projects to train local clinicians and medical specialists 

capable of supporting disease surveillance activities and providing longterm care for Ebola survivors.

In addition, USAID’s Office of U.S. Foreign Disaster Assistance obligated 

$35.0 million for the World Health Organization (WHO) Emergencies 

Program to strengthen WHO’s ability to lead and coordinate an effective 

response to health emergencies. In collaboration with other donors, the 

project intends to guide WHO to reform structures and processes to 

effectively respond to global infectious disease outbreaks and other 

humanitarian emergencies. Specifically, the project will help support the 

establishment of the new WHO Outbreaks and Health Emergencies unit, 

develop coordination mechanisms and incident management systems 

within WHO’s agencies, and reinforce WHO’s leadership during 

humanitarian emergencies.
Appendix III: Department of State and Centers 

for Disease Control and Prevention Ebola 

Recovery Projects for West Africa

Page 44 GAO-18-350 Ebola Recovery

As of September 30, 2017, the Department of State (State) had obligated 

$32.9 million for recovery projects to support security sector emergency 

response capabilities in Guinea, Liberia, and Sierra Leone, and fund postEbola economic development and treatment programs in Sierra Leone.1

In addition, as of September 30, 2017, the U.S. Agency for International 

Development (USAID) had obligated $80 million to the Centers for 

Disease Control and Prevention (CDC) for Ebola recovery projects for 

West Africa through an interagency agreement.

As of September 30, 2017, State had obligated $32.2 million that it 

transferred from the Economic Support Fund (ESF) account of the 

Department of State, Foreign Operations, and Related Programs 

Appropriations Act, 2015, to State’s International Narcotics Control and 

Law Enforcement (INCLE) and Peacekeeping Operations (PKO) 

accounts for Ebola recovery projects.2 State obligated $30.0 million in 

INCLE account funds for recovery projects to strengthen the capacity of 

the civilian security sector to respond to and prevent the reemergence of 

Ebola in Guinea and Liberia. Specifically, State obligated $10.0 million in 

INCLE account funds to document and teach lessons learned and best 

practices to civilian security personnel and develop guidance on how to 

respond to the reemergence of Ebola in Guinea. In addition, the project is 

intended to provide communications equipment to law enforcement 

agencies and supports coordination between public health authorities and 

the media through curriculum development, practical exercises and 

trainings. The project also facilitates improvement in collaboration among 

security services, the military, and civilian agencies for public health 

emergency response. State obligated $20.0 million in INCLE account 

funds for a project in Liberia to support security services’ engagement 

with local communities to mitigate disputes and provide stability following 

epidemics and other crises, as well as another project in Liberia to 

establish a secure radio network that the government may use to 

communicate emergency response during crises, including health 

epidemics. State obligated $2.2 million in PKO account funding to support 

the construction of patrol bases with medical screening facilities along the 

 1

We report funding from the Department of State, Foreign Operations, and Related 

Programs Appropriations Act, 2015, for Ebola in accordance with USAID and State’s 

reporting to Congress because the reports are the source of our data. The most recent 

report for Congress is as of September 30, 2017.

2

Pub. L. No. 113-235, Div. J, Title IX, 128 Stat 2130, 2692 (Dec. 16, 2014).

Appendix III: Department of State and 

Centers for Disease Control and Prevention 

Ebola Recovery Projects for West Africa

State Obligated $32.9 

Million for Ebola Recovery 

Projects for West Africa
Appendix III: Department of State and Centers 

for Disease Control and Prevention Ebola 

Recovery Projects for West Africa

Page 45 GAO-18-350 Ebola Recovery

international border of Sierra Leone and train military personnel 

controlling the border on how to conduct medical screenings.

State obligated $700,000 in ESF account funds for recovery projects in 

Sierra Leone that support economic stabilization and expand treatment 

for Ebola and other diseases. State obligated $500,000 for a recovery 

project that provides 26 small grants of approximately $10,000 to $50,000 

to local organizations to implement small business initiatives in 

underserved areas of Sierra Leone. For example, the project provided 

grants to local organizations to implement projects to restart agricultural 

programs that were suspended or diminished during the Ebola outbreak. 

In addition, the project provides grants to small businesses to support 

employment opportunities to vulnerable populations, particularly Ebola 

survivors and family members of Ebola victims. Also, State obligated 

$200,000 for a recovery project to upgrade the treatment facility for Ebola 

and viral hemorrhagic fevers at a hospital in Sierra Leone, including 

increasing water storage for decontamination and enhancing the capacity 

and controls for medical waste.

As of September 30, 2017, USAID’s Bureau for Global Health had 

obligated $80 million for 15 CDC Ebola recovery projects for West Africa 

through an interagency agreement. The May 2016 interagency 

agreement obligated funding from the ESF account for CDC projects to 

build capacity to respond to infectious disease outbreaks in Guinea, 

Liberia, and Sierra Leone and high-risk, non-affected border countries. 

Specifically, USAID’s interagency agreement with CDC funded such 

activities as strengthening disease surveillance, laboratory and 

emergency operations systems, workforce development, health 

communications and care networks, border health security, infection 

control, and outbreak response.

Most of the funding provided through USAID’s interagency agreement 

with CDC funded recovery projects in the three primarily affected 

countries—Guinea, Liberia, and Sierra Leone. CDC funded 5 recovery 

projects in Guinea, 4 in Liberia, and 6 in Sierra Leone. For example, CDC

funded recovery projects in Guinea that provided trainings on public 

health emergency preparedness, evaluated the training curriculum for 

laboratory professionals, and identified focal points for health information 

sharing among Guinea, Liberia, and Sierra Leone. In addition, CDC 

funded recovery projects in Liberia that provided training and guidance for 

laboratory operations and infection prevention control, and provided 

transport of specimens to laboratories. CDC also funded recovery 

USAID Obligated $80 

Million for CDC Ebola 

Recovery Projects for 

West Africa
Appendix III: Department of State and Centers 

for Disease Control and Prevention Ebola 

Recovery Projects for West Africa

Page 46 GAO-18-350 Ebola Recovery

projects in Sierra Leone that supplied hospitals with laboratory equipment 

and provided trainings to health-care workers on specimen management.
Appendix IV: Funding for U.S. Agency for 

International Development and Dept of State 

Ebola Response and Recovery Projects

Page 47 GAO-18-350 Ebola Recovery

In December 2014, Congress appropriated approximately $2.5 billion for

the U.S. Agency for International Development (USAID) and Department 

of State (State) for necessary expenses to assist countries affected by—

or at risk of being affected by—the Ebola outbreak, among other things.1

Congress made the funds available from different accounts and subject to 

different periods of availability (see table 16).

Table 16: Fiscal Year 2015 Appropriation for USAID and State Ebola Response and Preparedness, by Account and Period of 

Availability

(Dollars in millions)

Appropriations account Period of availability for obligation Dollar amount appropriated

International Disaster Assistance Until expended 1,436.3

Economic Support Fund Until September 30, 2016a 711.7

Global Health Programs Until expended 312.0

Diplomatic and Consular Programs Until September 30, 2016 36.4

USAID Operating Expenses Until September 30, 2016 19.0

USAID Office of Inspector General Until expended 5.6

Nonproliferation, Antiterrorism, Demining, 

and Related Programs

Until September 30, 2016a 5.3

Total 2,526.4

Source: Department of State, Foreign Operations, and Related Programs Appropriations Act, 2015. | GAO-18-350

a

For appropriations for the Economic Support Fund and Nonproliferation, Antiterrorism, Demining, 

and Related Programs accounts, funds remain available for an additional 4 years from the data on 

which the availability of such funds would have otherwise expired, if such funds are initially obligated 

before the expiration of their respective periods of availability. Pub. L. No. 113-235, Div. J, § 7011 

(Dec. 16, 2014). Amount shown may not sum to total because of rounding.

As of September 30, 2017, USAID and State had obligated approximately 

$1.9 billion (77 percent) of the $2.4 billion that they had allocated from the 

Act. Table 17 shows USAID’s and State’s reported allocations from the 

Act by appropriation account, as of September 30, 2017.

 1

Pub. L. No. 113-235, Div. J., Title IX (Dec. 16, 2014). In addition, the Act appropriated 

funding for efforts to prevent, prepare for, and respond to the Ebola outbreak; address 

economic and stabilization requirements resulting from the Ebola outbreak; mitigate the 

risk of illicit acquisition of the Ebola virus; and promote biosecurity practices associated 

with Ebola outbreak response efforts.

Appendix IV: Funding for U.S. Agency for 

International Development and Dept of State 

Ebola Response and Recovery Projects
Appendix IV: Funding for U.S. Agency for 

International Development and Dept of State 

Ebola Response and Recovery Projects

Page 48 GAO-18-350 Ebola Recovery

Table 17: Status of USAID and State Allocations for Ebola Response and Preparedness from the Department of State, Foreign 

Operations, and Related Programs Appropriations Act, 2015, by Appropriation Account, as of September 30, 2017

Dollars in thousands

Appropriation account Allocations Unobligated 

balances

Percentage 

obligated

Unliquidated 

obligations

Disbursements Percentage 

of obligations 

disbursed

International Disaster 

Assistancea 1,347,281 441,230 67 65,344 840,707 93

Economic Support Fundb 561,675 10c 100 294,793 266,872d 48

Global Health Programse 389,416 101,182 74 196,852 91,382 32 

Nonproliferation, AntiTerrorism, Demining, and 

Related Programs

5,300 0 100 914 4,386 83 

Operating Expensesf 11,515 65g 99 4,201 7,249 63

International Narcotics 

Control and Law 

Enforcementh

30,000 0 100 29,612 388 1

Peacekeeping Operationsi 2,200 0 100 0 0 0

Office of Inspector General 5,626 255 95 665 4,706 88

Diplomatic & Consular 

Programs

36,420 534j 99 0 35,886 100 

Contributions to 

International Organizationsk 19,948 0 100 0 19,948 100

Total 2,409,381 543,277 77 592,381 1,271,523 68

Source: GAO analysis of U.S. Agency for International Development (USAID) and Department of State (State) data. | GAO-18-350

Notes: The calculations in this table are based on USAID’s and State’s most recently reported 

allocations, obligations, and disbursements. Disbursements differ from the data in USAID’s monthly 

reporting, as they reflect corrections that we made, based on our analysis. State allocates Ebola 

funding from the Nonproliferation, Anti-Terrorism, Demining, and Related Programs, Diplomatic & 

Consular Programs, International Narcotics Control and Law Enforcement (INCLE), Peacekeeping 

Operations (PKO), and Contributions to International Organizations (CIO) accounts. USAID allocates 

Ebola funding from all other accounts listed in this table, with the exception of $700,000 from the 

Economic Support Fund (ESF) account, which State has programmed for Ebola recovery and viral 

hemorrhagic fever treatment in Sierra Leone. The Continuing Appropriations and Military 

Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2017, and Zika Response 

and Preparedness Act (Pub. L. No. 114-223, Sept. 29, 2016) rescinded $7.5 million from the 

Operating Expenses account, as well as $109.5 million from bilateral economic assistance accounts, 

which are the International Disaster Assistance (IDA), ESF, and Global Health Programs (GHP) 

accounts. USAID determined the amounts rescinded from the IDA, ESF, and GHP accounts.

Amounts shown may not sum to totals because of rounding.

a

IDA account allocations are lower than the amount in the IDA appropriation for Ebola response and 

preparedness because USAID rescinded $69 million in response to a provision requiring a rescission 

from bilateral economic assistance in the Continuing Appropriations and Military Construction, 

Veterans Affairs, and Related Agencies Appropriations Act, 2017, and Zika Response and 

Preparedness Act (Pub. L. No. 114-223, Sept. 29, 2016). In addition, State transferred $19.9 million 

from the IDA account to the CIO account for the U.S. contribution to the United Nations Mission for 

Ebola Emergency Response on June 1, 2015. These allocations are listed in this table under the CIO 

account.
Appendix IV: Funding for U.S. Agency for 

International Development and Dept of State 

Ebola Response and Recovery Projects

Page 49 GAO-18-350 Ebola Recovery

b

ESF account allocations are lower than the amount in the ESF appropriation for Ebola response and 

preparedness for two reasons. First, USAID and State made three transfers of ESF funding. In July 

and August 2016, State notified the relevant congressional committees that it intended to transfer 

$2.2 million to the PKO account and $30 million to the INCLE account. On September 9, 2016, 

USAID notified the relevant congressional committees that it intended to transfer $106.5 million to the 

Global Health Programs (GHP) account. Second, rescissions as a result of the Continuing 

Appropriations and Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 

2017, and Zika Response and Preparedness Act affected the ESF account. USAID rescinded $11.4 

million from the ESF account. In addition, USAID reprogrammed a portion of its ESF Ebola funds. 

USAID notified the relevant congressional committees on April 8, 2016 that it intended to reprogram 

$295 million in ESF Ebola funds for Zika response activities and for the CDC’s international Ebola 

response.

c

According to USAID officials, these funds were obligated within the period of availability and remain 

available for obligation for an additional 4 years.

d

Some disbursements reflected here are based on accruals from quarterly financial invoices provided 

by USAID’s implementing partners. These data may not yet be reflected in USAID’s financial system 

records on disbursements for Ebola response and preparedness from the Department of State, 

Foreign Operations, and Related Programs Appropriations Act, 2015 (Pub. L. No. 113-235, Dec. 16, 

2014).

e

GHP account allocations are $77.4 million greater than the amount in the GHP appropriation for 

Ebola response and preparedness because of a transfer from the ESF account and a rescission. On 

September 9, 2016, USAID notified the relevant congressional committees that it intended to transfer 

$106.5 million to the GHP account. As a result of the rescissions in the Continuing Appropriations and 

Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2017, and Zika 

Response and Preparedness Act, USAID rescinded $29 million in GHP funding transferred from the 

ESF account.

f

Operating Expenses account allocations are lower than the amount in the Operating Expenses 

appropriation for Ebola response and preparedness because of a rescission of approximately $7.5 

million in the Continuing Appropriations and Military Construction, Veterans Affairs, and Related 

Agencies Appropriations Act, 2017, and Zika Response and Preparedness Act (Pub. L. No. 114-223, 

Sept. 29, 2016).

g

According to USAID officials, these funds have expired and are no longer available for new 

obligations.

h

INCLE account funds were not appropriated for Ebola response and preparedness in the 

Department of State, Foreign Operations, and Related Programs Appropriations Act, 2015. Instead, 

State transferred ESF Ebola funding to the INCLE account in 2016, pursuant to transfer authority 

included in the appropriations act. On August 10, 2016, State notified the relevant congressional 

committees of its intent to transfer $30 million in Ebola ESF funding to the INCLE account.

i

PKO account funds were not appropriated for Ebola response and preparedness in the Department 

of State, Foreign Operations, and Related Programs Appropriations Act, 2015. Instead, State 

transferred ESF Ebola funding to the PKO account in 2016, pursuant to transfer authority included in 

the appropriations act. On July 27, 2016, State notified the relevant congressional committees of its 

intent to transfer $30 million in Ebola ESF funding to the INCLE account.

j

According to State officials, Diplomatic and Consular Programs account funds have expired and are 

no longer available for new obligations.

k

Allocations for the CIO account are a transfer from the IDA account to the CIO account for the U.S. 

contribution to the United Nations Mission for Ebola Emergency Response on June 1, 2015.
Appendix V: Comments from the U.S. Agency 

for International Development

Page 50 GAO-18-350 Ebola Recovery

Appendix V: Comments from the U.S. 

Agency for International Development
Appendix V: Comments from the U.S. Agency 

for International Development

Page 51 GAO-18-350 Ebola Recovery
Appendix VI: GAO Staff Acknowledgments

Page 52 GAO-18-350 Ebola Recovery

David B. Gootnick, (202) 512-3149 or gootnickd@gao.gov

In addition to the contact named above, Valérie L. Nowak (Assistant 

Director), Bradley Hunt (Analyst-in-Charge), Rachel Dunsmoor, Ashley 

Alley, Debbie Chung, Christopher Keblitis, Amber Sinclair, and Pierre 

Toureille made key contributions to this report.

Appendix VI: GAO Staff Acknowledgments

GAO Contact

Staff 

Acknowledgments

(101248)
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