United States Government Accountability Office

GAO Report to Congressional Committees

GLOBAL HEALTH

USAID Supported a 

Wide Range of Child 

and Maternal Health 

Activities, but Lacked 

Detailed Spending 

Data and a Proven 

Method for Sharing 

Best Practices 

April 2007 

 

GAO-07-486 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

April 2007

GLOBAL HEALTH

USAID Supported a Wide Range of Child 

and Maternal Health Activities, but 

Lacked Detailed Spending Data and a 

Proven Method for Sharing Best 

Practices 

Highlights of GAO-07-486, a report to 

congressional committees 

Every year, disease and other 

conditions kill about 10 million 

children younger than 5 years, and

more than 500,000 women die from

pregnancy and childbirth-related 

causes. To help improve their 

health, Congress created the Child 

Survival and Health Programs 

Fund. The 2006 Foreign Operations 

Appropriations Act directed GAO 

to review the U.S. Agency for 

International Development’s 

(USAID) use of the fund for fiscal 

years 2004 and 2005. Committees of

jurisdiction indicated their interest 

centered on the Child Survival and

Maternal Health (CS/MH) account 

of the fund. GAO examined

USAID’s (1) allocations,

obligations, and expenditures of 

CS/MH funds; (2) activities

undertaken with those funds; 

(3) methods for disseminating 

CS/MH information; and 

(4) response to challenges to its 

CS/MH programs. GAO conducted

surveys of 40 health officers, 

visited USAID missions in four 

countries, interviewed USAID

officials, and reviewed data. 

In fiscal years 2004 and 2005, Congress appropriated a total of $675.6 million 

to the CS/MH account. Individual USAID missions and USAID’s Bureau for 

Global Health—the bureau providing technical support for international 

public health throughout the agency—were able to provide obligation and 

some expenditure data on these funds from their separate accounting 

systems. However, USAID’s Office of the Administrator did not centrally 

track the obligations and expenditures of USAID missions and bureaus. As a 

result, the Office of the Administrator was limited in its ability to determine 

whether CS/MH funds were used for allocated purposes during this period. 

According to USAID officials and GAO’s analysis, the agency has recently 

taken steps to record these data for fiscal year 2007 and beyond, although 

the modifications to its accounting system are in its early phases and little 

data had been posted as of February 2007. 

Despite the lack of centralized financial data, GAO determined that USAID 

funded a wide variety of CS/MH efforts in 40 countries. USAID’s missions, 

regional bureaus, and Bureau for Global Health supported programs at the 

country, regional, and global level. These activities included immunizations, 

oral rehydration therapy to treat diarrhea, and prevention of postpartum 

hemorrhage. 

USAID used a variety of methods for disseminating information internally 

concerning CS/MH issues, such as electronic learning courses, biennial 

regional health conferences, and an online document database. However, 

USAID has not evaluated these methods’ relative effectiveness for 

disseminating innovations and best practices. GAO identified some 

drawbacks associated with several of these methods, such as limitations in 

access and topics covered. As a result, USAID health officers may not learn 

of new innovations and advances in a timely manner. 

USAID is taking steps to respond to numerous challenges to planning and 

implementing its CS/MH programs. First, responding to a global shortage of 

skilled health care workers, USAID supports efforts to enhance the skills of 

current health care workers and to train new health care workers. Second, 

because newborn and maternal health have typically received less 

international attention than child health, USAID established programs that 

focus on the needs of these two populations. Third, in response to

numerous barriers to sustaining its CS/MH programs, such as uncertain 

funding and a lack of technical expertise among host governments and 

nongovernmental organizations, USAID adopted strategies to provide 

technical assistance and promote community involvement. 

What GAO Recommends

GAO recommends that USAID 

(1) test accounting system 

modifications to verify that CS/MH 

obligation and expenditure data

will be recorded and traced back to 

CS/MH allocation data and 

(2) assess the effectiveness of 

existing communication methods

for sharing global health best 

practices across missions. USAID 

generally concurred with GAO’s 

findings and recommendations.

www.gao.gov/cgi-bin/getrpt?GAO-07-486.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact David Gootnick 

at (202) 512-3149 or GootnickD@gao.gov. 
Contents 

Letter 1

Results in Brief 3

Background 6

Budget Process and Congressional Directives Guided CS/MH 

Allocations, but USAID Lacked Centralized Obligation and 

Expenditure Data 13 

USAID Supported a Wide Range of CS/MH Efforts 21 

USAID Has Not Assessed the Relative Effectiveness of Its Methods 

of Disseminating Innovations and Best Practices for Internal Use 28 

USAID Is Responding to Certain Child Survival and Maternal 

Health Program Challenges 32 

Conclusions 41

Recommendations for Executive Action 41 

Agency Comments and Our Evaluation 42 

Appendix I Objectives, Scope, and Methodology 44 

Appendix II Allocation of Child Survival and Maternal Health 

Funds within USAID, Fiscal Years 2004 and 2005 47 

Appendix III Allocation of CS/MH Account Funds to Countries, 

Fiscal Years 2004 and 2005 48 

Appendix IV Mortality Statistics for Countries Receiving CS/MH 

Funds, Fiscal Years 2004 and 2005 50 

Appendix V Obligations and Expenditures for the Four Missions 

We Visited, Fiscal Years 2004 and 2005 52 

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

Development 53 

GAO Comment 58 

Page i GAO-07-486 Global Health
Appendix VII GAO Contact and Staff Acknowledgments 59 

Figures 

Figure 1: Congressional Appropriations to the Child Survival and 

Health Programs Fund, by Account, Fiscal Years 2004 and 

2005 9

Figure 2: Global Distribution of USAID’s Child Survival and

Maternal Health Funds, Fiscal Years 2004 and 2005 11 

Figure 3: Organizational Chart of USAID Missions and Bureaus 

Involved in Supporting Child Survival and Maternal Health 

Activities, Fiscal Years 2004 and 2005 12 

Figure 4: USAID Allocations of Child Survival and Maternal Health 

Funds, Fiscal Years 2004 and 2005 14 

Figure 5: USAID’s Allocation and Reporting Process for CS/MH 

Account, Fiscal Years 2004 and 2005 18 

Figure 6: Health Care Worker Training 34 

Abbreviations 

ACCESS Access to Clinical and Community Maternal, Neonatal 

and Women’s Health Services 

CSH Fund Child Survival and Health Programs Fund 

CS/MH Child Survival and Maternal Health 

NGO nongovernmental organization 

POPPHI Prevention of Postpartum Hemorrhage Initiative

PPC Bureau for Policy and Program Coordination 

RACHA Reproductive and Child Health Alliance 

UNICEF United Nations Children’s Fund 

USAID U.S. Agency for International Development 

WHO World Health Organization 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 

Page ii GAO-07-486 Global Health
United States Government Accountability Office

Washington, DC 20548 

April 20, 2007

The Honorable Patrick J. Leahy 

Chairman 

The Honorable Judd Gregg 

Ranking Member 

Subcommittee on State, Foreign Operations, 

 and Related Programs 

Committee on Appropriations 

United States Senate 

The Honorable Nita M. Lowey 

Chair 

The Honorable Frank R. Wolf 

Ranking Minority Member 

Subcommittee on State, Foreign Operations, 

 and Related Programs 

Committee on Appropriations 

House of Representatives 

Every year, disease and other mostly preventable conditions, such as 

diarrhea and malnutrition, kill more than 10 million children younger than 

5 years old, including about 4 million infants in the first month of life.1

Ninety-nine percent of newborn deaths occur in developing countries, and 

about 75 percent of child deaths occur in sub-Saharan Africa and South 

Asia.2

 Mothers in developing regions also face significant health risks—for 

example, the lifetime risk of maternal death for women in sub-Saharan 

Africa is 175 times greater than for women in industrialized countries.3

 To

help lower maternal and child mortality rates globally, in 1997, Congress 

established the Child Survival and Health Programs Fund (CSH Fund), 

 1

Robert E. Black, Saul S. Morris, and Jennifer Bryce, “Where and why are 10 million 

children dying every year?,” The Lancet, vol. 361, no. 9376 (2003). 

2

Save the Children, State of the World’s Mothers 2006 (Westport, CT: May 2006); and 

“Where and why are 10 million children dying every year?,” 2.

3

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

Page 1 GAO-07-486 Global Health
which includes the Child Survival and Maternal Health (CS/MH) account.4

The U.S. Agency for International Development (USAID), which 

administers the fund, currently finances CS/MH programs at headquarters 

and in 40 countries5

 to support agency goals to improve global health, 

including maternal and child health.6

In fiscal year 2006, Congress directed GAO to review USAID’s use of 

appropriations to the CSH Fund for fiscal years 2004 and 2005.7

 We 

determined, through discussions with staff from the committees of 

jurisdiction, that congressional interest centered on USAID’s use of CS/MH 

allocations for fiscal years 2004 and 2005—about $328 million and $348 

million, respectively.8

 This report reviews USAID’s (1) allocations, 

obligations, and expenditures of CS/MH funds for fiscal years 2004 and 

2005; (2) activities undertaken with those funds; (3) procedures for 

disseminating information related to CS/MH innovations and best 

practices; and (4) response to challenges in planning and implementing its 

CS/MH programs. 

To address these objectives, we surveyed USAID officials in the 40 USAID 

countries receiving CS/MH funds to determine how they manage their 

 4

Initially titled the Child Survival and Disease Programs Fund and renamed in fiscal year 

2001, the CSH Fund includes six accounts: HIV/AIDS; Infectious Diseases; Child Survival 

and Maternal Health; Family Planning and Reproductive Health; Vulnerable Children; and 

the Global Fund to fight AIDS, Tuberculosis, and Malaria. In addition, the fund grants

money to international partnerships. 

5

For fiscal years 2004 and 2005, USAID allocated CS/MH funds for programs in 41 

countries. The U.S. mission in Eritrea, however, closed in December 2005, reducing the 

total number of countries that received CS/MH funds to 40. USAID also supports child

survival and maternal health-related activities in countries through other funding streams,

such as the Economic Support Fund, Assistance for Eastern Europe and the Baltics, the 

Freedom Support Act, and Pub. L. No. 480 Title II accounts. Although these programs

follow the same “Guidance on the Definition and Use of the Child Survival and Health 

Programs Fund,” they were outside the scope of our review. 

6

USAID’s overall performance goal for health is to “improve global health, including child,

maternal, and reproductive health, and the reduction of abortion and disease, especially 

HIV/AIDS, malaria, and tuberculosis.” 

7

The Foreign Operations, Export Financing, and Related Programs Appropriations Act, 

2006, Pub. L. No. 109-102, § 522, 119 Stat. 2171, 2203. 

8

The funds appropriated to the CSH Fund in fiscal years 2004 were available to be obligated 

until the end of the following fiscal year, September 30, 2005. Similarly, the funds

appropriated to the fund in fiscal year 2005 were available to be obligated until 

September 30, 2006. 

Page 2 GAO-07-486 Global Health
activities and key challenges they face in the field. In addition, we 

reviewed documents such as USAID’s CSH Fund progress reports, 

USAID’s guidance for managing and implementing its maternal and child 

health activities, and USAID budget data. We also reviewed literature on 

interventions for improving maternal and child health, including three 

separate series from the British medical journal titled The Lancet, and 

reports on global maternal and child health issues from nongovernmental

and multilateral sources, such as the United Nations Children’s Fund 

(UNICEF) and Save the Children. At USAID’s headquarters in Washington,

D.C., we interviewed officials from the Bureau for Policy and Program 

Coordination (PPC), the Bureau for Global Health, regional bureaus, and 

the Office of the Controller. We also met with a number of officials 

representing nongovernmental and multilateral organizations, including 

the Global Health Council, the World Health Organization (WHO), and 

UNICEF. In addition, we interviewed USAID staff during visits to USAID 

missions in four countries—Cambodia, Ethiopia, India, and Mali—in 

Africa and Asia, the two continents with the highest maternal and child 

mortality rates. We conducted our work from April 2006 through March 

2007 in accordance with generally accepted government auditing 

standards. (See app. I for more details on our objectives, scope, and 

methodology.) 

In fiscal years 2004 and 2005, USAID allocated the majority of the CS/MH 

account to support maternal and child health efforts in Africa, Asia, and 

Latin America and the Caribbean. However, the agency could not provide 

a complete accounting for its missions’ and bureaus’ obligations and 

expenditures of the allocated funds for this period. Countries in those 

three geographic regions received about 60 percent ($405 million) of the 

approximately $676 million appropriated to the account, while the Bureau 

for Global Health and international partnerships it supports received the 

remaining 40 percent. In making these allocations, USAID was guided both

by budgeting procedures, which considered factors such as countries’ 

magnitude of need, and by congressional directives. However, as we also 

reported in 1996,

9

 due to USAID’s approach to tracking and accounting for

such funds, it is not possible to determine how much was actually spent 

on CS/MH activities. Specifically, USAID did not centrally track its 

missions’ and bureaus’ CS/MH obligations and expenditures for fiscal 

Results in Brief 

 9

GAO, Foreign Assistance: Contributions to Child Survival Are Significant, but

Challenges Remain, GAO/NSIAD-97-9 (Washington, D.C.: Nov. 8, 1996), 7. 

Page 3 GAO-07-486 Global Health
years 2004 and 2005. Furthermore, the missions and bureaus had their own 

systems for capturing this information. According to U.S. government 

standards for internal control, program managers need sufficient data to

determine whether they are meeting their agencies’ strategic and annual 

performance plans and their goals for accountability for the effective and 

efficient use of resources.10 Because the Office of the Administrator did not 

require missions and bureaus to report their obligations and expenditures 

for the CS/MH account, it could not provide these data at our request and 

is limited in its ability to verify that the allocated CS/MH funds were used 

for their intended purposes during fiscal years 2004 and 2005. In February

2007, USAID officials informed us of new modifications to its accounting 

system that are intended to allow the agency to record future maternal and 

child health obligations and expenditures. 

Despite the lack of centralized financial data, our work at USAID 

headquarters and in the field demonstrated that USAID supported 

numerous CS/MH efforts with the funds it allocated in fiscal years 2004 

and 2005. Missions supported CS/MH activities on the community and 

national levels—for example, providing funding to train community health

workers and providing grants for government-run immunization, polio, 

and nutrition programs. Regional missions and bureaus conducted 

regional efforts, such as assessing maternal health activities in two West 

African countries, and supported regional strategies, for example, by 

funding the development of a WHO resolution to make newborn health a 

priority in the Americas. The Bureau for Global Health engaged in 

numerous CS/MH-related efforts: that is, providing technical support to 

missions by centrally managing some CS/MH programs at their request; 

supporting global CS/MH programs by managing partnerships and sharing 

expertise; administering a grants program for nongovernmental 

organizations; supporting international research on CS/MH interventions; 

funding surveys to provide population, health, and nutrition data; and

providing global leadership in addressing child survival and maternal 

health. 

USAID used a variety of methods for disseminating information 

concerning CS/MH issues, such as electronic learning courses, biennial

regional health conferences, and an online document database. However, 

we identified drawbacks associated with several of these methods, such as 

 10GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1

(Washington, D.C.: November 1999), 19. 

Page 4 GAO-07-486 Global Health
limitations in access and topics covered, and USAID has not evaluated the 

methods’ relative effectiveness for disseminating innovations and best 

practices. As a result, USAID health officers may not learn of new 

innovations and advances in the maternal and child health fields in a 

consistent and timely manner. For example, according to USAID’s annual 

employee survey in 2005, approximately 40 percent of mission officials 

within the three regional bureaus in our review did not agree that their 

respective regional bureau communicated “clearly, sufficiently, 

transparently, and in a timely manner.” Furthermore, the survey showed 

that over 40 percent of the mission officials who responded to questions 

about the Bureau for Global Health did not agree that the bureau provided 

“quality state-of-the-art training opportunities.” 

USAID is taking steps to respond to numerous challenges to planning and 

implementing its CS/MH programs. On the basis of reviews of expert 

reports, interviews with USAID officials and partner and donor 

representatives, and the results of our surveys, we identified three key

challenges that USAID faces in planning and implementing CS/MH 

programs. First, responding to a global shortage of health care providers, 

USAID supports efforts to enhance the skills of current health care 

workers and to train new health care workers. For example, in Cambodia, 

USAID funds midwifery training on how to deal with obstetric 

complications. Second, because newborn and maternal health have 

typically received less international attention than child health, USAID 

established programs that focus on the needs of these two populations. 

For example, in 2004, USAID founded a program that focuses on 

increasing the coverage, access, and use of maternal and newborn health 

services; in 2006, the program was supporting interventions in nine 

countries and launching programs in four additional countries. Third, in 

response to numerous barriers to sustaining its CS/MH programs, such as 

uncertain funding and a lack of technical expertise among host 

governments and nongovernmental organizations, USAID adopted 

strategies to provide technical assistance and promote community 

involvement. For example, in India, USAID is funding efforts to help the 

Indian government develop and implement urban health plans and 

supporting the use of community volunteers to help implement urban 

health programs. 

We are making two recommendations to the USAID Administrator to 

improve the agency’s administration of the CS/MH account and its 

implementation of CS/MH programs. First, to strengthen USAID’s ability to 

oversee and record allocations from the CS/MH account to help ensure 

that those funds are used as intended, we are recommending that the 

Page 5 GAO-07-486 Global Health
agency test recent modifications to the principal accounting system to 

verify that CS/MH obligation and expenditure data will be recorded and 

properly traced back to the corresponding allocation data. Second, to 

provide for effective dissemination of information to USAID mission 

health officers about innovations and best practices in child survival and 

maternal health in a timely manner, we recommend that the USAID 

Administrator assess the relative effectiveness of the agency’s current 

methods of disseminating this information through existing tools, such as 

the annual employee survey. 

We provided a draft of this report to USAID. In general, USAID agreed 

with our recommendations. In its response, the agency emphasized that its 

accounting system tracked obligations and expenditures at the level of the 

larger CSH Fund in fiscal years 2004 and 2005. Regarding our first 

recommendation, USAID agreed to conduct tests to determine whether its 

modified accounting system captures all CS/MH activities and to verify 

that the funds are being used for the purposes for which they were 

appropriated. Furthermore, USAID will verify immediately that the State 

Department’s planning system accurately captures all CS/MH allocated 

funds. In response to our second recommendation, USAID stated that it 

plans to conduct a Training Needs Assessment in 2007-2008 that will 

address our concerns regarding evaluation of information dissemination 

methods. USAID also provided information regarding the role that 

grantees and contractors play in disseminating information. Furthermore, 

the agency provided additional detail on some of the training and 

information dissemination efforts that we described in the draft. We have 

incorporated this information in the report, as well as USAID’s technical 

comments, where appropriate. (See app. VI for a reprint of USAID’s 

comments and our response.) 

Each year, nearly 10 million children die from preventable diseases and 

other causes and more than 500,000 women die from causes related to 

pregnancy and childbirth,11 particularly in developing countries.12 For 

Background 

 11Another 15 to 20 million women suffer from pregnancy- and childbirth-induced 

disabilities, including nerve damage, severe anemia, infertility, and obstetric fistula—an 

injury in which an abnormal opening forms between a woman’s bladder and vagina,

resulting in urinary incontinence. 

12“Where and why are 10 million children dying every year?,” 2; and State of World’s

Mothers 2006, 3. 

Page 6 GAO-07-486 Global Health
example, in sub-Saharan Africa, 1 in 16 women will die as a result of 

pregnancy or childbirth, compared with 1 in 4,000 women in industrialized 

countries,13 and a mother is 30 times more likely to lose a newborn14 in the 

first month of life than a mother in an industrialized country.15 The Lancet, 

a peer-reviewed British medical journal, estimates that a set of 23 known 

treatments would cost $887 for every child’s life saved. A subset of those 

medical treatments targeted for newborns—which includes antibiotics for 

sepsis, resuscitation, and management of the newborn’s temperature—

would cost $784 for every infant’s life saved.16 In addition, the WHO 

estimates that universal access to maternal and newborn care in 75

developing countries would cost $0.22 to $1.18 per person.17

Maternal health is closely linked to both newborn and child survival. 

According to a recent United Nations report,18 motherless newborns are 3 

to 10 times more likely to die than are newborns with living mothers. The 

WHO reports that nearly three-quarters of all newborn deaths could be 

prevented if women received adequate nutrition and health care during 

pregnancy, labor, and the postnatal period. Although child mortality in 

developing countries decreased by about 20 percent between 1990 and 

2005,

19 maternal mortality has remained unchanged,20 and newborn 

 13United Nations Children’s Fund, The State of the World’s Children 2007 (New York:

2006). 

14The term “newborn” refers to the newborn baby and does not have a specific time period

definition, but is often assumed to refer to the first month of life. 

15State of World’s Mothers 2006. 

16Jennifer Bryce and Robert E. Black, “Can the world afford to save the lives of 6 million 

children each year?” The Lancet, vol. 365, no. 9478 (2005). 

17World Health Organization, The World Health Report 2005 – Make Every Mother and 

Child Count, 1st ed. (Geneva: World Health Organization, 2005). 

18State of World’s Children 2007. 

19According to UNICEF, child mortality in developing countries decreased from 105/1,000 

live births in 1990 to 83/1,000 live births in 2005. State of World’s Children 2007.

20On the basis of estimates of the maternal mortality ratio for 1990 and 2000, maternal 

mortality has not improved. 

Page 7 GAO-07-486 Global Health
survival has seen less improvement than child survival overall.21 Newborn 

deaths currently account for 38 percent of all deaths in children younger 

than 5 years old. 

In 1997, Congress established the CSH Fund and assigned USAID to 

administer it. Initially titled the Child Survival and Disease Programs Fund 

and renamed in fiscal year 2001, the fund includes six accounts, of which 

the CS/MH account comprised about 20 percent in fiscal years 2004 and 

2005. (See fig. 1.) 

 21A Lancet series notes that, between 1980 and 2000, child mortality after the first month of 

life fell by one-third. During that same period, the mortality rate for newborns in the first 

month of life was reduced by one-quarter. This means that the proportion of child deaths

occurring in the first month of life increased. See Joy E. Lawn, Simon Cousens, and Jelka 

Zupan, “4 million neonatal deaths: When? Where? Why?,” The Lancet, vol. 365, no. 9462 

(2005). 

Page 8 GAO-07-486 Global Health
Figure 1: Congressional Appropriations to the Child Survival and Health Programs 

Fund, by Account, Fiscal Years 2004 and 2005 

Infectious Diseases, $385 million

Global Fund to fight AIDS, Tuberculosis,

and Malaria, $650 million

HIV/AIDS, $867 million

(2%) Vulnerable Children, $58 million

Child Survival and Maternal Health,

$675 milliona

Family Planning and Reproductive Health,

$751 million

19%

20%

11%

22%

26%

Source: GAO analysis of USAID data.

All other accounts in the Child Survival and Health Programs Fund

Child Survival and Maternal Health account

Total: $3.4 billion

Note: Appropriated funds for the Global Fund for AIDS, Tuberculosis, and Malaria support the efforts 

of the Global Fund, which is an international organization that provides funding to programs to fight 

AIDS, tuberculosis, and malaria in affected countries. Appropriated funds for HIV/AIDS, in contrast, 

are directed toward USAID’s own HIV/AIDS programs and activities.

a

Congressional appropriations to the CS/MH account for fiscal years 2004 and 2005 totaled $675 

million, although the amounts USAID received differed slightly, due to rescission and reprogramming

of funds. 

Over the years, Congress has continued to support basic child survival 

interventions, particularly immunizations and oral rehydration therapy,22

and particular initiatives, such as the promotion of breastfeeding. In 2000, 

the 192-member states of the United Nations, including the United States,

 22Oral rehydration therapy is a treatment for dehydration caused by diarrhea and calls for

providing oral rehydration salts—a mixture of water, salt, and glucose—and the 

recommended amount of fluids. 

Page 9 GAO-07-486 Global Health
agreed to work toward achieving the development goals of the Millennium 

Declaration. These goals include reducing the child mortality rate by twothirds and reducing the maternal mortality rate by three-quarters from 

1990 levels worldwide by 2015. 

USAID Support for Child 

Survival and Maternal 

Health 

USAID has carried out efforts to improve child survival and maternal 

health since its inception in 1961. In the 1960s, USAID began building 

health clinics and funding research on treatments for diarrheal disease and 

malaria prevention. In the 1970s, USAID began focusing on providing the 

appropriate health interventions for common health problems in 

communities with the greatest needs. The interventions related to child 

health included field studies on oral rehydration and vitamin A therapy 

and malaria research. In the 1980s, USAID focused its efforts on countries 

with especially high child mortality rates. 

One of USAID’s current performance goals calls for “improved global 

health, including child, maternal, and reproductive health.” Under this 

performance goal, child survival activities target the primary causes of 

child mortality: diarrheal disease, acute respiratory disease, malnutrition, 

malaria,23 vaccine-preventable diseases, and newborn diseases and 

conditions.24 USAID’s work in maternal health includes addressing 

nutritional deficiencies during pregnancy; strengthening preparation for 

birth, including antenatal care; supporting safe delivery; and improving the 

management and treatment of life-threatening obstetrical complications. 

USAID addresses these causes and health issues through country, 

regional, and global strategies. 

As administrator of the CSH Fund, including the CS/MH account, USAID 

allocated funds for maternal and child health efforts in 40 countries, in 

Latin America, sub-Saharan Africa, and South Asia. Figure 2 illustrates the 

global distribution of USAID’s CS/MH funds. 

 23The CSH Fund guidance notes that most malaria-related activities are supported with 

funding from the infectious disease account of the fund. 

24Newborn diseases and conditions include low birth weight, birth asphyxia and injuries, 

and postpartum infection. 

Page 10 GAO-07-486 Global Health
Figure 2: Global Distribution of USAID’s Child Survival and Maternal Health Funds, Fiscal Years 2004 and 2005 

Countries that received Child Survival and Maternal Health allocations

Sources: GAO analysis of USAID data; Map Resources (map).

USAID carries out CS/MH activities primarily through its country 

missions;25 regional missions and bureaus; and the Bureau for Global 

Health and the international partnerships it supports. Figure 3 shows the 

organizational structure of USAID entities involved in supporting CS/MH 

activities. 

 25USAID does not have missions in Burundi, Eritrea, Sierra Leone, and Somalia. In these 

cases, the associated regional mission manages the country allocation. For example, the 

East Africa regional mission is responsible for managing Somalia’s allocation. 

Page 11 GAO-07-486 Global Health
Figure 3: Organizational Chart of USAID Missions and Bureaus Involved in Supporting Child Survival and Maternal Health 

Activities, Fiscal Years 2004 and 2005 

Bureau for Policy and

Program Coordination

20 missions

2 regional

missions

Office of the

Administrator

8 missions

Bureau for Global Health

Bureau for Africa

Bureau for Asia

and the Near East

Bureau for Latin America

and the Caribbean

Chief Financial Officer

9 missions

Responsible for policy and program

coordination across USAID,

including administration of

CS/MH funds

Oversee all country and regional missions in a particular geographic area

Support a program of assistance in a particular country

Support a program of assistance across a number of countries in a geographic area

Includes Office of the Controller

Based in USAID headquarters

Based in the field

Source: GAO analysis of USAID data.

Supports international partnerships

and provides leadership and 

technical expertise for child survival 

and maternal health within USAID

Note: In fiscal years 2004 and 2005, the three regional bureaus encompassed seven regional 

missions, two of which received CS/MH funds. Both of these regional missions are in the Bureau for 

Africa: the Regional Economic Development Services Office for East and Southern Africa, and the 

West Africa Regional Program, now known respectively as the East Africa and West Africa regional 

missions. Furthermore, in the cases of Burundi, Sierra Leone, and Somalia, USAID regional missions 

managed the assistance programs from a neighboring country. 

USAID defines the Bureau for Global Health’s role as providing technical 

support to the field, state-of-the-art research and innovation, and global 

leadership in international public health. Included among the bureau’s 

Page 12 GAO-07-486 Global Health
functions are centrally managing some of the CS/MH programs that the 

country missions fund and, along with the agency’s regional bureaus, 

disseminating information on innovations in child survival and maternal 

health to USAID missions. According to USAID guidance, the bureau is to

be the agency’s repository for state-of-the-art thinking and innovations in 

health that can be disseminated and replicated at USAID missions around 

the world. 

In fiscal years 2004 and 2005, USAID allocated the majority of the CS/MH 

account to countries in Africa, Asia, and Latin America and to the Bureau 

for Global Health, guided by its budgeting process and congressional 

directives. However, USAID’s Office of the Administrator, through its 

Office of the Controller, was unable to provide data on agency obligations 

and expenditures of the allocated CS/MH funds for those years, because 

such data were not collected from the missions and bureaus. The missions 

we visited and the Bureau for Global Health were able to provide data

showing obligations and some expenditures from their separate 

accounting systems. According to U.S. government standards for internal 

control, program managers need financial data to determine whether they 

are meeting their agencies’ goals for accountability for effective and 

efficient use of resources. Without a process to provide ready access to 

obligation and expenditure data, USAID has limited ability to report 

whether it is using the CS/MH funds to fulfill intended purposes. USAID is 

making changes to its accounting system that may enable it to report such 

information, but the system is in transition and has not been tested. 

In fiscal years 2004 and 2005, USAID allocated the majority of funds in the 

CS/MH account to countries in Africa, Asia and the Near East, and Latin

America and the Caribbean and to the Bureau for Global Health. In 

allocating the funds, the agency considered various factors in its annual 

budgeting process as well as congressional directives. 

Of the $675.6 million appropriated to the CS/MH account in fiscal years 

2004 and 2005, $405.3 million (60 percent) was allocated to Africa, Asia 

and the Near East, and Latin America and the Caribbean. The remaining 

40 percent went to the Bureau for Global Health and to international 

partnerships that the bureau supports. Figure 4 shows the total amounts 

and percentages of USAID’s CS/MH allocations for fiscal years 2004 and

2005. (See app. II for amounts and percentages allocated in each of the 

2 years.) 

Budget Process and 

Congressional 

Directives Guided 

CS/MH Allocations, 

but USAID Lacked 

Centralized Obligation 

and Expenditure Data 

USAID Allocations 

Followed Budget Process 

and Congressional 

Directives 

USAID Allocated Most CS/MH 

Funds to Africa, Asia, and Latin 

America and to the Bureau for 

Global Health 

Page 13 GAO-07-486 Global Health
Figure 4: USAID Allocations of Child Survival and Maternal Health Funds, Fiscal 

Years 2004 and 2005 

Bureau for Global Health supported international partnerships that received CS/MH funds

25%

24%

20%

12%

20%

Source: GAO analysis of USAID data.

Total: $675.6 milliona

Africa, $166.9

Bureau for Global Health, $133.1

Asia and the Near East, $160.0

Latin America and the Caribbean, $78.5

International partnerships, $136.5

Note: In addition, USAID allocated funds directly to regions, international partnerships, and the 

Bureau for Global Health. However, some of the funds allocated to international partnerships and the 

Bureau for Global Health went to global programs with beneficiaries in the regions. International 

partnerships included the Global Alliance for Improved Nutrition, the Global Alliance for Vaccines and 

Immunization, the Kiwanis/UNICEF Partnership for Iodine Deficiency Disorder, and the Health Metrics 

Network.

a

The amounts shown in this figure total $675.0 million. In addition to these amounts, USAID also

allocated $0.6 million, or 0.2 percent of the CS/MH account, to the Bureau for Democracy, Conflict 

and Humanitarian Assistance, and the Bureau for Policy and Program Coordination in fiscal year

2004. Taken with these amounts, USAID allocated a total of $675.6 million in fiscal years 2004 and 

2005. Percentages in this figure total more than 100 percent due to rounding. 

USAID’s PPC26 allocated CS/MH funds in fiscal years 2004 and 2005 

according to its budgeting process and congressional directives. 

USAID Budgeting Process and 

Congressional Directives 

Guided Allocations 

 26PPC reported to the Office of the Administrator. 

Page 14 GAO-07-486 Global Health
USAID Budget Allocation Process 

PPC used an annual budgeting process to guide its allocation of CS/MH 

funds. First, missions submitted their budget requests to the regional 

bureaus, which reviewed the requests and, after discussion with the 

missions, made any needed adjustments. The regional bureaus then 

submitted the budget requests to PPC,27 which in turn made final 

adjustments. Following consultation with the Office of Management and 

Budget, USAID submitted its budget request to Congress. After receiving

an actual appropriation from Congress, PPC then made its decisions on 

allocations, including for the CS/MH account, throughout the agency. 

USAID officials told us that the majority of PPC’s functions have been 

transferred to the State Department’s Office of Foreign Assistance, which

now oversees the budgetary administration of the CSH Fund. PPC’s 

remaining functions have been transferred to USAID’s existing Bureau for

Management. 

As part of the budgeting process, PPC and the regional bureau requested 

and considered a variety of information from the missions.28 Our analysis 

showed that some of the factors PPC and the regional bureaus considered 

included 

• the severity of a country’s need for CS/MH programs, measured in part by 

its mortality rates (see apps. II to IV for mortality rate and allocation 

information, by country);

• the magnitude of a country’s need for CS/MH programs, measured, for 

example, by total number of child deaths or total population of women of 

reproductive age; 

• the potential national-level impact of allocated CS/MH funds; 

• a host country government’s per capita expenditures for public health; 

 27The Health Sector Council, which the Bureau for Global Health chairs, also reviewed the 

budget requests and provided feedback. The council has several subgroups, each with

technical representatives, that provided recommendations to the regional bureaus. 

28The information requested by PPC differed from that requested by the regional bureaus; 

in addition, some of the information requested by the regional bureaus differed by region. 

Page 15 GAO-07-486 Global Health
• the capacity of the USAID mission to absorb funds; and 

• U.S. national interest. 

The USAID official who oversaw the CS/MH allocations in fiscal years 

2004 and 2005 told us that, as the CSH Fund guidance requires, missions 

and bureaus reported how they planned to spend their CS/MH funds to a 

PPC database. According to the official, this database recorded CS/MH 

allocation information, but not obligation or expenditure information. 

Congressional Directives 

In addition, USAID’s allocation decisions took into account congressional 

directives—instructions from Congress written into law, or in a committee 

report, that appropriations should be allocated for a particular purpose. 

For example, in fiscal year 2004, USAID allocated $60 million to the 

Vaccine Fund29 in accordance with a directive in the Consolidated 

Appropriations Act of 2004.30 Similarly, in fiscal years 2004 and 2005, 

USAID set aside $32 million each year for polio in response to 

congressional interest.31 In general, we found that USAID addressed the 

directives in the committee reports. However, USAID sometimes faced 

challenges in addressing congressional directives. For example, USAID 

had difficulty in determining the most effective use of the $6 million that 

Congress directed it to use for fistula in Africa, due to a general lack of the 

necessary human and other resources in African countries. Some USAID 

officials said that congressional directives for the CS/MH account—also 

the primary source of funds for general health systems strengthening—had 

 29The Vaccine Fund, now renamed The GAVI Fund, is the financing arm to support the

immunization goals of The GAVI Alliance, an international partnership focused on 

increasing children’s access to vaccines in poor countries.

30Consolidated Appropriations Act, 2004, Pub. L. No. 108-199, 118 Stat. 3, 145. This act did

not specify the CSH Fund account that USAID should use for this directive. However, in the 

accompanying report, the House expressed through a congressional directive that it 

wanted USAID to use funds from the CS/MH account (see H.R. Rep. 108-599, at 8 (2004)). 

31The fiscal year 2005 conference report (H.R. Conf. Rep. No. 108-792, at 987) states that the

House and the Senate “intend that $32,000,000 be made available to support the multilateral 

campaign to combat polio.” The House and Senate reports for the Consolidated 

Appropriations Act of 2004 (H.R. Rep. No. 108-222 and S. Rep. No. 108-106) and the House,

Senate, and Conference reports for the Consolidated Appropriations Act of 2005 (H.R. Rep. 

No. 108-599, S. Rep. No. 108-346, and H.R. Conf. Rep. No. 108-792) also demonstrate 

congressional interest in areas such as providing micronutrients and correcting iodine

deficiency. 

Page 16 GAO-07-486 Global Health
allowed for the preservation of CS/MH funding over time. However, 

according to some officials of USAID and organizations implementing 

programs in cooperation with USAID, other major health initiatives have 

redirected attention, funding, and staff resources away from the CS/MH 

congressional directive.

USAID’s Office of the Controller was unable to provide obligation and 

expenditure data for missions’ and bureaus’ fiscal years 2004 and 2005 

CS/MH programs and, therefore, had limited ability to report on the use of 

these funds and to exercise internal control32 at the CS/MH account level. 

According to an official from the Office of the Controller, USAID’s primary 

financial management and reporting system could provide obligation and 

expenditure data for the CSH Fund33 and for each mission’s strategic

objectives.34 However, the official stated that the system could not provide 

such data for the CS/MH account and that the missions and bureaus were 

not required to report these data. 

During our audit work, the four country missions we visited and the 

Bureau for Global Health provided obligation and some expenditure data,

which they recorded in information systems that were not part of USAID’s 

formal accounting system. At the four country missions, we asked mission 

officials for obligations and expenditures for mission-managed and 

centrally managed programs for fiscal years 2004 and 2005. For missionmanaged programs, officials provided both obligation and expenditure 

USAID Headquarters 

Lacked CS/MH Obligation 

and Expenditure Data 

Needed for Internal 

Control in Fiscal Years 

2004 and 2005 

 32Internal control provides an organization with reasonable assurance that key

management objectives—efficiency and effectiveness of operations, reliability of financial 

reporting, and compliance with applicable laws and regulations—are being achieved. See

GAO/AIMD-00-21.3.1, 4. 

33According to a PPC official, the accounts within the CSH Fund are not broken out 

separately when they are allocated. Officials from PPC and USAID’s Office of the 

Controller said that the agency’s primary financial management and reporting system 

tracks obligations and expenditures from the overall fund. Two of the fund’s six accounts, 

the HIV/AIDS and the Family Planning and Reproductive Health accounts, are specifically 

tracked within the system, but the remaining four accounts are grouped as “other CSH.” As

of January 2007, USAID was reforming its primary financial management and reporting 

system. 

34Missions’ strategic objectives are the areas of measurable change that each mission 

intends to achieve through its development programs. Objectives may vary among 

missions, because each mission defines its own. In addition, missions may commingle 

funding streams to meet their objectives. For example, the Ethiopia mission’s Health and 

Education strategic objective commingled the CS/MH, Basic Education, and Development 

Assistance Program funding streams. 

Page 17 GAO-07-486 Global Health
data. For centrally managed programs, all four missions provided 

obligation data; however, only one mission provided expenditure data, one 

mission provided expenditure estimates, and two missions’ officials stated 

that they were unable to provide any expenditure data. (See app. V for 

mission data.) Although the Bureau for Global Health provided obligation 

data for these fiscal years for the CS/MH programs it managed, including

programs it managed centrally for the missions, bureau officials stated 

that they were unable to provide expenditure information for any of the 

programs. (Fig. 5 shows USAID’s allocation and reporting process for the 

CS/MH account in fiscal years 2004 and 2005.) 

Figure 5: USAID’s Allocation and Reporting Process for CS/MH Account, Fiscal 

Years 2004 and 2005 

Funds appropriated

to the CSH Fund

USAID

Office of the Administrator

Missions and the

Bureau for Global Health

Implementing Partners

Budget processes

and congressional 

directives guided 

CS/MH allocation

Direction of distribution of funds

Lack of reporting on Child Survival and Maternal Health expenditures

Sources: GAO analysis of USAID data; Corel (clip art).

Office of the

Controller

Bureau for Policy

and

Program Coordination

Page 18 GAO-07-486 Global Health
Officials from USAID’s Office of the Controller and the State Department’s 

Office of Foreign Assistance told us that obtaining fiscal years 2004 and 

2005 obligation and expenditure data for the CS/MH account would 

require a data call to each mission and bureau.35 USAID officials also noted

that such a request from headquarters could necessitate a subsequent data

request to implementing partners, because missions have not consistently

required implementing partners to report at the CS/MH level.36 USAID 

officials further observed that the agency’s difficulty in providing such 

information is not unique to the CS/MH account. 

Because it did not have a system to collect agencywide obligation and 

expenditure data for the CS/MH account, USAID’s internal control over its 

use of the account was limited. According to U.S. government standards 

for internal control, “Program managers need both operational and 

financial data to determine whether they are meeting their agencies’ 

strategic and annual performance plans and meeting their goals for 

accountability for effective and efficient use of resources.”37 Without ready 

access to its missions’ and bureaus’ CS/MH obligation and expenditure 

data, USAID was constrained in its ability to report that these funds were 

used according to the purposes for which they were allocated.

 35The official from the Office of the Controller could not give us an estimate of how long

such a data call would take. 

36As we reported in 2003, USAID is dependent on international organizations and thousands

of partner institutions for data; therefore, it does not have full control over how data are

collected, reported, or verified. 

37GAO/AIMD-00-21.3.1, 19.

Page 19 GAO-07-486 Global Health
In a prior report, we found that USAID’s approach to tracking and 

accounting for child survival funds made it difficult to determine precisely 

how much the U.S. government spent on child survival activities.38 In 

addition, other GAO work has identified long-standing challenges 

associated with USAID’s financial management and reporting.

39

In mid-February 2007, USAID officials told us that they are in the process 

of instituting changes begun in November 2006 to USAID’s primary 

accounting system. These changes are intended to modify the system so 

that financial data can be accounted for under new elements40 to coincide

with the new Foreign Assistance Framework—the road map for foreign 

assistance resource allocation and implementation.41 In November 2006, a

USAID official from the Office of the Controller told us that the modified 

system would not be able to separate obligations and expenditures at the 

CS/MH level. In February 2007, however, USAID officials told us they had 

recently learned that the system will capture these data at that level from 

fiscal year 2007 going forward.42 In addition, they said that the modified 

system will be compatible with the State Department’s new planning 

USAID Is Making Changes 

to Its Accounting System, 

but the System Is in 

Transition and Has Not 

Been Tested 

 38GAO/NSIAD-97-9, 7. 

39GAO, Financial Management: Sustained Effort Needed to Resolve Long-Standing 

Problems at U.S. Agency for International Development, GAO-03-1170T (Washington, D.C.:

Sept. 24, 2003); Major Management Challenges and Program Risks: U.S. Agency for

International Development, GAO-03-111 (Washington, D.C.: January 2003); Major 

Management Challenges and Program Risks: U.S. Agency for International Development, 

GAO-01-256 (Washington, D.C.: Jan. 1, 2001); and Financial Management: Inadequate 

Accounting and System Project Controls at AID, GAO/AFMD-93-19 (Washington D.C.: 

May 24, 1993). 

40The State Department’s Office of Foreign Assistance defines an element as a broad 

category of program under a particular program area. For example, “Maternal and Child 

Health” is an element under the “Health” program area in the new Foreign Assistance 

Framework. 

41The Foreign Assistance Framework concentrates U.S. foreign assistance into five priority 

objectives: peace and security, governing justly and democratically, investing in people, 

economic growth, and humanitarian assistance. The Health program area falls within the 

investing in people objective. 

42An October 2006 memorandum from the State Department’s Office of Foreign Assistance 

says that the proposed modification to USAID’s accounting system is intended to

accommodate State’s new Foreign Assistance Framework. Under the modified accounting

system, all money would be identified and USAID would be able to separate the sources of 

funds. USAID officials in the Bureau for Global Health, however, did not know about this

memorandum until February 2007. Furthermore, due to a lack of internal communication,

the Office of the Controller did not realize that recording information at the element level 

will, in fact, capture CS/MH data. 

Page 20 GAO-07-486 Global Health
system, which records allocation information. The two systems are not 

integrated, although the USAID officials said that they can trace 

information between the two because both systems record financial 

information by element. According to USAID officials, in the future they 

will be able to verify that CS/MH funds are being used for their allocated 

purposes by tracing the obligation and expenditure information in their 

accounting system back to the corresponding allocation information in the 

State Department’s planning system. State’s system, however, only records 

new obligational authority data,43 so CS/MH funds invested in programs 

that began before fiscal year 2007 cannot be verified in this manner. 

USAID’s switch to recording financial data by element may address our 

concern about the lack of agencywide CS/MH obligation and expenditure 

data. USAID officials told us, however, that the modifications to the 

accounting system are currently in transition. As of February 2007, the 

system contained little obligation information at the CS/MH level. For 

example, the total information on CS/MH obligations to countries was an 

obligation to Nigeria. The remaining CS/MH obligation information 

consisted of eight travel authorizations for the Bureau for Global Health 

and one for the Bureau for Latin America and the Caribbean. The USAID 

officials said that expenditure information will likely not be included until 

fiscal year 2008 or 2009, because funds appropriated to the CSH Fund are 

available for obligation until the end of the following fiscal year. Although

USAID officials told us they believe that the modification to the 

accounting system will address the agency’s long-standing financial 

reporting weaknesses, sufficient time has not elapsed to test whether 

CS/MH obligation and expenditure data will be properly recorded and 

traced back to the corresponding allocation data in State’s planning 

system. 

USAID supported various CS/MH efforts in fiscal years 2004 and 2005 

through its country missions, regional missions and bureaus, and Bureau 

for Global Health. At the community and country levels, USAID missions 

used CS/MH funds to improve the quality of health services; provide 

immunizations; and promote basic health care, including essential 

obstetric care and child health services. Regionally, USAID supported 

CS/MH activities and strategies over a geographic area, such as fistula 

USAID Supported a 

Wide Range of CS/MH 

Efforts

 43New obligational authority refers to the funding levels appropriated by Congress in a 

given year after certain legislatively mandated transfers or rescissions. 

Page 21 GAO-07-486 Global Health
repair in West Africa and making newborn health a priority in Latin 

America and the Caribbean. Finally, the Bureau for Global Health gave 

technical assistance and administered a grants program; conducted 

research on CS/MH issues, including treatment of diarrhea and clean cord

care during delivery; and provided global leadership. 

USAID’s country missions supported CS/MH activities at both the 

community and the country levels. 

Our fieldwork and review of documentation demonstrated that USAID 

implemented a variety of CS/MH programs at the community level in the 

four countries that we visited. For example, the Mali mission used its 

CS/MH funds to support a program that works across the country to 

improve the quality of government health centers in the community. 

Similarly, the Afghanistan mission funded nongovernmental organizations

(NGO) to train 6,200 community health care workers, about half of which 

are women, to provide referrals and basic health care to their neighbors. 

In addition, 37 of the 40 mission health officials we surveyed told us that 

they worked on CS/MH activities with their host country’s government. 

Our interviews and fieldwork showed that USAID missions supported host 

country governments’ CS/MH efforts by granting funds directly to 

governments, providing technical assistance, and participating in 

government working groups. 

Country Missions 

Supported Communityand Country-Level Efforts 

Community-Level Activities 

Country-Level Activities 

• Grants to governments. Country missions directly transferred funds from 

USAID to the host country. In one such agreement, which the Mali mission 

provided to us, the mission directly funds the government of Mali’s 

immunization, polio, and nutrition programs in response to the 

government’s budget request. 

• Technical assistance.44 In addition to funding their programs, USAID 

missions provided technical assistance to host country governments. For 

example, the Afghanistan mission helped the government of Afghanistan’s 

Ministry of Public Health monitor and evaluate the Basic Package of 

 44USAID defines technical assistance as the “provision of goods or services to developing

countries and other USAID recipients in direct support of a development objective - as

opposed to the internal management of the foreign assistance program.” 

Page 22 GAO-07-486 Global Health
Health Services Program, which included essential obstetric care and child 

health and family planning services.

• Government working groups. USAID mission representatives participated

in host country government donor coordination groups related to health.

For example, the India mission chaired a donor group for the Indian 

government’s flagship CS/MH program. 

USAID’s regional missions and bureaus supported CS/MH initiatives in 

their geographic areas of responsibility. For example, the West Africa 

Regional Program (now known as the West Africa regional mission) 

assessed fistula repair activities in two West African countries and 

identified training, equipment, and cost support as areas of possible future 

work. 

In addition, the regional bureaus supported strategic plans for their areas 

of responsibility. For example, the Bureau for Latin America and the 

Caribbean provided funds to the WHO to support the development of a 

resolution to elevate newborn health as a priority in the Americas.45

Similarly, the Bureau for Africa commissioned an in-depth examination of 

USAID’s child survival programs in sub-Saharan Africa, resulting in 

recommendations for improvement.46 Bureau for Africa officials told us 

that the bureau also reviewed the African missions’ strategic plans and 

provided suggestions to strengthen the missions’ community-level 

programming. 

The Bureau for Global Health engaged in a number of CS/MH-related 

activities in fiscal years 2004 and 2005. These activities included giving

technical assistance to country missions, administering the Child Survival

and Health Grants Program, providing global leadership, and supporting 

international research. 

Regional Missions and 

Bureaus Supported 

Regional CS/MH Activities 

and Strategies 

Bureau for Global Health 

Engaged in Numerous 

CS/MH Efforts 

 45World Health Organization, Pan American Health Organization, Neonatal Health in the

Context of Maternal, Newborn and Child Health for the Attainment of the Millennium 

Development Goals of the United Nations Millennium Declaration (Washington, D.C.: 

2006). 

46Support for Analysis and Research in Africa Project, Academy for Educational 

Development, Child Survival in Sub-Saharan Africa: Taking Stock, a report prepared at 

the request of the United States Agency for International Development (2005). 

Page 23 GAO-07-486 Global Health
The Bureau for Global Health provided technical assistance to missions by 

centrally managing CS/MH projects at the missions’ request. For example, 

our fieldwork shows that the bureau managed several projects for the 

India mission. 

Technical Assistance 

• The bureau managed a program for anemia reduction and vitamin A 

supplementation in the states of Uttar Pradesh and Jharkhand. 

• The bureau assisted Indian state governments and the government of 

India’s Ministry of Health and Family Welfare with routine immunization. 

• The bureau supported IndiaCLEN, a research organization, to study 

injection safety. IndiaCLEN found that 74 percent of immunization 

injections were not administered safely; in response, the government of 

India introduced the use of autodisable syringes in its national 

immunization program. 

In addition, the Bureau for Global Health may contribute some or all of the 

funds for a project as “seed funds”—that is, funds to introduce or expand a 

treatment in a particular country or region. The bureau told us that seed 

funds may encourage the mission and host country through advocacy, 

policy dialogue, technical assistance, and development of standards of 

care and training curricula. (See sidebar.) 

Of the 40 missions we surveyed, 34 participated in these centrally managed

projects. About one-half of those missions reported that, to a great or very 

great extent, they had decided to participate in the projects because the 

bureau provided technical expertise, assisted with procurement, or 

offered some or all of the funds for the project. According to financial

records that we obtained during our fieldwork, the four missions we 

visited varied in the percentage of CS/MH funds they chose to send to 

headquarters for centrally managed projects. For example, whereas 

Cambodia invested very little of its fiscal year 2005 CS/MH funds in 

centrally managed projects, India sent more than one-half of its funds to 

headquarters for such projects. 

The Bureau for Global Health administered the Child Survival and Health 

Grants Program, which provides 4- to 5-year grants to U.S.-based 

nongovernmental organizations and private voluntary organizations to 

improve child survival at the community level in host countries. Of the 40 

missions that received CS/MH funds in fiscal years 2004 and 2005, 30 

reported that Child Survival and Health Grants projects had been awarded 

to organizations working in their host countries. In some cases, the grants 

The Bureau for Global Health provided 

“seed funds” to introduce the community 

treatment of pneumonia in Senegal at the 

national level. The bureau collaborated with 

UNICEF, the USAID mission in Senegal, the 

government of Senegal’s Ministry of Health, 

a local university, and a major 

pharmaceutical company to introduce and 

evaluate such an approach. The bureau also 

provided technical assistance to the ministry 

and the university to develop an evaluation 

approach. The bureau ceased funding the 

program at the close of fiscal year 2006. 

However, the program will continue with 

funds from UNICEF, the Ministry of Health, 

and the USAID mission in Senegal. In 

addition, at least four other African countries

are replicating this approach.

Country-Level Programs: Community 

Treatment of Pneumonia, Senegal

Child Survival and Health 

Grants Program 

Page 24 GAO-07-486 Global Health
comprised a sizable portion of USAID’s child survival funding in a country 

or region. For example, the Bureau for Africa reported that these grants 

comprised about one-fifth of USAID’s total allocations for child survival 

across sub-Saharan Africa. 

USAID officials told us that grantees may pilot innovations (see sidebar) 

or work in a country’s most rural and hard-to-reach areas. Also, in certain

cases, grantees raised additional funds from sources outside the bureau.

Of the 30 missions we surveyed that have grantees in their countries, 27 

reported that the grantees used the grants to raise additional resources 

from sources other than the U.S. government. For example, a grantee in

Guatemala received funds from the United Nations Development 

Programme to continue its project with a slightly different scope. 

Source: GAO.

Community-Level Programs:

Community Drug Cabinets, Mali

A recipient of a Child Survival and Health 

Grants Program grant in Mali is piloting an 

approach to bring essential drugs to the 

community level through its Community Drug 

Cabinets Program. This NGO supplies, 

initially free of charge, cabinets with essential 

health supplies to villages throughout the 

Sikasso region of Mali. The cabinets contain 

first aid kits and drugs to sustain sick children 

younger than 5 years old until they can reach 

a community health center. The cabinets also 

include preventative malaria treatment and 

contraceptives for pregnant women and 

women of reproductive age. Each community 

selects a primary and a backup manager of 

the cabinet to provide counseling and 

distribute the health supplies.

Page 25 GAO-07-486 Global Health
The Bureau for Global Health’s global leadership included managing 

partnerships, sharing expertise, and helping shape the global CS/MH 

agenda. 

Global Leadership 

• Managing partnerships. The bureau supported international partnerships 

that received funds from the CS/MH account. For example, to support The 

GAVI Alliance—an international partnership focused on increasing 

children’s access to vaccines in poor countries, the bureau’s immunization 

advisor served on the GAVI Secretariat’s financing task force, technical 

working group, and coordination group for the Organization for Economic 

Coordination and Development. 

• Sharing expertise. The bureau made its global expertise in child survival 

and maternal health available to global organizations and working groups.

For example, a bureau official told us that the director of the bureau’s 

Office of Health, Infectious Diseases, and Nutrition represents USAID on 

the U.S. delegation to the UNICEF Executive Board. Similarly, the 

bureau’s child health team leader is the interim chair of the Country 

Support Working Group and serves on the interim steering committee of 

the international Partnership for Maternal, Newborn and Child Health. 

• Shaping global agenda. The bureau supported efforts that directly helped 

shape the global CS/MH agenda for research and interventions. For 

example, in April 2005, the bureau organized a meeting with the WHO and

UNICEF on micronutrients and health. According to a USAID report, this 

process of bringing together scientists, donors, and policymakers helped 

shape a global agenda for both clinical and programmatic research for 

service delivery of micronutrient programs.47 In addition, officials from 

both UNICEF and the Gates Foundation told us that they look to USAID to 

help set global CS/MH policies and strategies. The bureau also supported 

the publication of three series of articles on child survival, newborn 

health, and maternal health in the medical journal titled The Lancet, to 

inform global and national dialogue on these issues. For example, the 

bureau’s maternal health team leader participated in the formal technical 

reviews of drafts of the maternal health series and hosted its launch in the 

United States. Similarly, the bureau publicized the launch of the series on 

newborn health in Nepal, Indonesia, and the United States. 

 47United States Agency for International Development, Report to Congress: Health-Related

Research and Development Activities at USAID (Washington, D.C.: 2006).

Page 26 GAO-07-486 Global Health
In fiscal years 2004 and 2005, the Bureau for Global Health supported 

several CS/MH-focused international research efforts. These efforts 

included studies of innovative CS/MH interventions and surveys to provide 

data for use in monitoring and evaluating child survival and health efforts.

International Research 

• Studies of CS/MH interventions. The bureau supported several research 

efforts that have resulted in internationally recognized measures and 

interventions for maternal and child health. For example, since 1996, the 

bureau has been instrumental in supporting research on the use of zinc in

the treatment of diarrhea. This research led, in 2006, to the release of WHO 

and UNICEF policy guidelines recommending 10 to 14 days of zinc 

treatment for all cases of diarrhea in children between 2 months and 5 

years old. Furthermore, the bureau supported research in fiscal year 2005 

that contributed to the development of three newborn indicators: essential 

newborn care,48 antibiotic treatment of newborn infection, and postnatal 

care within 3 days of birth. With respect to the latter, agency officials told 

us the bureau is working with the Gates Foundation’s Saving Newborn 

Lives Project and other organizations to align the postnatal care indicator

with new proposed Millennium Development Goals newborn indicators.49

The bureau also supported research on the efficacy of new treatments and 

their introduction in different countries.50 For example, the bureau funded 

a study in Nepal of an antiseptic that may prevent newborn infections 

resulting from the cutting of the umbilical cord during delivery. USAID 

reports that early results show promising impact on reducing newborn 

deaths. 

• Surveys. The bureau used CS/MH funds in part to finance the 

Demographic and Health Surveys—large-scale, nationally representative 

household surveys that provide population, health, and nutrition data. The 

survey data comprise such topics as infant, child, and maternal mortality; 

 48Essential newborn care is a package of interventions that includes exclusive 

breastfeeding, clean delivery, umbilical cord care, warmth, and early recognition of and 

referral for complications. 

49The Millennium Development Goals were adopted by the United Nations General 

Assembly in the 2000 United Nations Millennium Declaration and are supported by the

United States. A version of the goals, however, that differs in significant respects from what 

was agreed to at the United Nations in 2000 is widely in use. The maternal and child health

goals, however, are the same in both versions—namely, to reduce maternal mortality by 

three-quarters, and under-5 child mortality by two-thirds by 2015. 

50United States Agency for International Development, Report to Congress: Health-Related

Research and Development Activities at USAID (Washington, D.C.: 2005); and HealthRelated Research and Development Activities at USAID. 

Page 27 GAO-07-486 Global Health
micronutrient deficiencies; health care access issues; vaccination 

coverage; and percentage of births attended by a skilled health

professional. The country surveys take place approximately every 5 years,

allowing comparisons across time. As of January 2007, surveys had been 

completed in more than 70 countries. The WHO, UNICEF, and other 

donors rely on the survey data for monitoring and gathering statistics. For 

example, the WHO and UNICEF both use the surveys to supplement their 

own data. Furthermore, USAID implementing partner officials told us that 

other donors, as well as country governments, are beginning to contribute 

more funding to the surveys, recognizing the need for quantitative data as

a basis for decisions on programs and policies. 

The Bureau for Global Health and regional bureaus and missions used 

several methods to disseminate information within USAID about new 

CS/MH interventions and best practices. These methods consist of 

electronic learning courses, State-of-the-Art training, online document 

databases, Web sites, regional workshops, and other informal methods. In 

addition, USAID’s implementing partners disseminate information on 

innovations and best practices. However, we identified drawbacks 

associated with several of these methods. Furthermore, USAID has not 

assessed the relative efficacy of its methods and, as a result, may not be 

able to ensure that missions are apprised of innovations in the maternal 

and child health fields in a consistent and timely manner. 

The Bureau for Global Health, along with the regional bureaus and 

missions, disseminated information on CS/MH innovations and best 

practices to USAID missions, using several methods. 

• Electronic learning courses. The bureau instituted an Electronic Learning

(eLearning) Center to provide USAID health professionals and external 

partners with access to technical public health information. The center has 

offered Internet-based courses on topics such as antenatal care, essential 

newborn care, and malaria. However, one of the USAID officials in charge

of the courses told us that some health officers were still unaware of the 

availability of the electronic learning courses 3 years after the center’s 

inception. In responding to our draft report, USAID stated that a 2007 

priority for the bureau is the marketing and communication of these 

electronic courses for health officers at field missions. 

USAID Has Not 

Assessed the Relative 

Effectiveness of Its 

Methods of 

Disseminating 

Innovations and Best 

Practices for Internal 

Use 

USAID Disseminated 

Information Internally 

through Various Methods, 

Although Several Have 

Drawbacks 

Page 28 GAO-07-486 Global Health
• State-of-the-Art training. From the early 1990s to 2005, the bureau and 

regional bureaus and offices51 held biennial conferences, known as Stateof-the-Art training, for USAID health officers in each region to share 

updated information on population and health developments, including 

CS/MH issues, and to discuss best practices. According to a 2004 study,

this training was an important opportunity for mission staff to regularly 

interact with one another and network with headquarters staff.52

Furthermore, the training provided mission staff with the opportunity for 

face-to-face exchange on policy updates, programmatic procedures, and 

new processes. USAID officials in headquarters and in the field told us that 

this training was crucial for regularly sharing best practices and learning 

about new health innovations, practices, and policies. Twenty-seven of the 

38 health officials who responded to this question on our survey said that 

the training greatly or very greatly facilitated the sharing of best practices. 

According to USAID officials, however, the agency canceled the training in

2006 for budgetary reasons related to evolving demands on operating 

expenses funds. USAID mission officials expressed concern that, since 

they must pay for travel to conferences out of their operating expenses 

budget, they would not be able to keep up with the latest innovations 

without more support for sharing best practices. Although USAID officials 

told us that they would like to reinstitute the training, its future status is 

uncertain. In its response to our draft report, USAID stated that 

discussions are under way to reinstitute the training—beginning with 

Africa in the near future—but added that decisions regarding the funding 

and holding of these conferences rest with the USAID Administrator and 

the leadership of the regional and Global Health bureaus. 

• Online document database. USAID maintains an online database of 

USAID documents called the Development Experience Clearinghouse. The 

database contains USAID-funded international development technical and 

program documentation, such as country reports, annual project reports, 

and strategic plans. In addition, USAID officials are required to submit 

program evaluation reports to the database. In our survey, however, 18 of 

the 39 health officers who responded to this question told us either that 

 51Geographic offices are located within the regional bureaus and are responsible for 

coordinating country-related matters, including policy and strategy; project, nonproject, 

and food aid development, analysis, monitoring, implementation, and review; and 

personnel and budgeting. 

52Public Health Institute, Best Practices for USAID State-of-the-Art Trainings: 

Recommendations for PHN Sector State-of-the-Art Planners, Implementers, Presenters 

and Participants, a special report prepared at the request of USAID (October 2004). 

Page 29 GAO-07-486 Global Health
they do not use the database for sharing best practices or that the 

database facilitates the sharing of best practices a little or not at all. 

• Web sites. USAID supports a number of Web sites that disseminate healthrelated information. For example, the MotherNewBorNet, begun in April 

2005, seeks to facilitate translation of maternal and neonatal research into

community-level action by fostering dialogue and documentation of 

learning across projects. However, this forum currently focuses on 

countries within one regional bureau. Similarly, other health-related Web 

sites that USAID supports either address a limited number of topics or 

restrict access to members. USAID also has its own intranet, through 

which it disseminates health information. Our survey showed that 22 of

the 39 health officials who responded to this question believe that USAID’s 

intranet facilitates the sharing of best practices, either moderately or 

greatly. 

• Regional workshops. The regional missions hold occasional workshops on 

health care topics for mission staff. However, these workshops are not 

held on a regular basis and do not consistently address maternal and child 

health issues. For example, because the Latin America and Caribbean 

regional missions do not receive CS/MH funds, their regional workshops 

do not deal directly with maternal and child health issues. 

• Informal communications methods. Regional bureaus and the Bureau for 

Global Health contact USAID missions via telephone conversations and email communications, although the frequency of such communications 

varies. USAID’s Bureau for Global Health also occasionally holds brief, 

“brown bag” seminars at its offices in Washington, D.C., to provide 

information on CS/MH-related innovations and best practices to USAID 

staff members. For example, a returning health officer from the 

Afghanistan mission recently gave a brown bag seminar on the Rural 

Expansion of Afghanistan’s Community-based Health Care Program. In 

addition, the bureau occasionally hosts seminars at which USAID partners 

give presentations on CS/MH innovations and best practices. However, 

only USAID staff physically present in Washington, D.C., are able to 

benefit from these brown bags and seminars. Our survey found that 22 of

the 37 health officers who responded to this question do not use brown 

bags at all as a means of gathering information. 

• Implementing partners. USAID supports some grantees and contractors 

who develop and disseminate information on CS/MH innovations and best 

practices. For example, in fiscal years 2004 and 2005, a grantee of the 

Bureau for Africa produced several publications for health officers, 

dealing with such topics as child survival in sub-Saharan Africa, 

Page 30 GAO-07-486 Global Health
community case management of childhood malaria, and various nutrition 

briefs. 

USAID has not assessed the relative effectiveness of these mechanisms for 

disseminating innovations to its staff, according to USAID officials. As a 

result, although it assigned the Bureau for Global Health the role of 

disseminating health research and innovations, the agency does not know 

whether the mechanisms used by the bureau and other USAID entities are 

adequate to keep mission health officers apprised of the most current 

findings regarding CS/MH innovations. Furthermore, because of 

shortcomings related to the mechanisms, such as inconsistent use and 

limited staff access and topics covered, USAID staff may sometimes learn 

of important advances and innovations haphazardly. For example, 

according to USAID officials at the Ethiopia mission, the mission decided 

to institute a community-based health volunteers approach only after 

learning of it from a health official who had moved to Ethiopia from the 

Madagascar mission, where the approach had been used successfully. 

Another health officer who returned from the field in late 2006 said that 

before arriving at headquarters, she had not heard of USAID’s research on 

using zinc to treat diarrheal illnesses, although it had been building the 

evidence base since 1996. Within the three regional bureaus in our review, 

approximately 40 percent of mission officials did not agree that their 

respective regional bureau communicated “clearly, sufficiently, 

transparently, and in a timely manner,” according to USAID’s annual 

employee survey for 2005.

53 Furthermore, over 40 percent of mission 

officials who responded to questions about the Bureau for Global Health 

did not agree that the bureau provided “quality state-of-the-art training 

opportunities.” 

USAID Has Not Assessed 

Methods’ Relative 

Effectiveness 

 53According to USAID, all employees and contractors received their Employee Survey. In 

total, there were 5,368 responses. USAID only presents response rates for groups of 

employees. The response rates were 75 percent for foreign service employees, 64 percent

for civil service employees, and 51 percent for foreign service national employees. 

Page 31 GAO-07-486 Global Health
On the basis of reviews of expert reports, interviews with USAID officials 

and partner and donor representatives, and our survey results, we 

identified three key challenges that affect USAID’s CS/MH programs: a 

global shortage of health care workers; a relative lack of international 

attention to maternal and newborn health, as compared with child 

survival; and difficulties in promoting sustainable CS/MH programs. 

USAID is involved in numerous efforts to respond to these challenges. 

First, to help address a global shortage of health care providers, USAID is 

supporting efforts to enhance the skills of current health care workers and

to train new health care workers. Second, in response to the comparative 

lack of international attention to maternal and newborn health, USAID has 

launched programs that specifically consider the needs of mothers and 

newborns. Lastly, to help deal with barriers to program sustainability, 

USAID has adopted various strategies, such as providing technical 

assistance, leveraging its in-country presence, working with host country 

health ministries, supporting the development of products with potentially 

lasting effects, coordinating with the private sector, and promoting 

community involvement.

To help address the effects of a global shortage of skilled health care 

workers, USAID supports the training of midwives and other health care 

workers. The results of our surveyed identified the health care worker 

shortage as a challenge for USAID: that is, 38 of 40 health officers in our 

surveys stated that the shortage of competent health care workers makes 

it difficult for their maternal and child health program to continue without 

USAID support.54 The WHO estimates a global shortage of almost 2.4 

million doctors, nurses, and midwives.55 The shortage is due to a variety of

factors, including limited investment in health worker education; 

increasing migration by health workers from the poorest to the richest 

countries; and the impact of HIV/AIDS, which increases work burdens and 

health risks for many health workers. Many health workers also face 

challenges, such as poverty-level wages. According to the WHO, the health

worker shortage is especially acute in Africa, because African countries 

USAID Is Responding 

to Certain Child 

Survival and Maternal 

Health Program 

Challenges 

USAID Is Supporting 

Efforts to Address Health 

Care Worker Shortage 

 54The term “difficult” refers to the USAID program representatives who replied “Somewhat 

Difficult,” “Moderately Difficult,” “Very Difficult,” or “Extremely Difficult” to a survey 

question that also contained the categories “Condition Does Not Exist” and “A Little or Not

at All Difficult.” 

55World Health Organization, The World Health Report 2006: Working Together for Health 

(France, World Health Organization: 2006). 

Page 32 GAO-07-486 Global Health
have 24 percent of the global burden of disease56 but only 3 percent of the 

world’s health workers. For example, Save the Children reports that the 

majority of Ghana’s doctors actually practice overseas, with only an 

estimated 40 percent of doctors remaining in-country. Also, one-quarter of 

Malawi’s health workers are expected to die from AIDS by 2011. The WHO 

estimates that Africa requires more than 800,000 additional doctors, 

nurses, and midwives to meet the Millennium Declaration Goal of reducing 

child mortality by two-thirds by 2015.

According to a WHO report, evidence shows that rates of maternal, infant, 

and child survival; immunization coverage; and primary care outreach are

linked to the number and quality of health care workers. For instance, an

analysis by the Joint Learning Initiative57 suggests that a 10 percent 

increase in the number of health care providers per 1,000 people is 

correlated with a 5 percent decrease in maternal mortality. Similarly, 

decreases in the number of health care providers are associated with 

negative health outcomes—the WHO notes that child malnutrition has 

been shown to worsen when health sector reform results in staff cuts. 

USAID’s support of efforts to train midwives and other health care 

workers includes the following: 

• Midwife training. In Cambodia, USAID is supporting efforts to upgrade 

midwives’ skills. According to the Cambodian government, 50 percent of 

the health centers in Cambodia lack a midwife qualified to handle lifethreatening obstretic complications.58 To help improve maternal health, 

USAID supports the Life Saving Skills training approach, which 

emphasizes the needed skills, and as of March 2006, 653 midwives had 

received this training. The Cambodian Ministry of Health plans to adopt

the Life Saving Skills training approach in its national midwifery training 

programs. 

 56The global burden of disease is an estimate of the effect of disease, and it allows for 

comparisons across countries and regions. The WHO’s Global Burden of Disease Project 

uses a summary measure—the disability-adjusted life year—to quantify the burden of 

disease. The number of disability-adjusted life years for a disease is the sum of the years of 

life lost due to premature mortality in the population and the years lost due to disability. 

57Joint Learning Initiative, Human Resources for Health: Overcoming the Crisis

(Washington, D.C.: 2004). 

58Chan K. Chhuong, Della R. Sherratt, and Patrice White, Comprehensive Midwifery

Review (Kingdom of Cambodia, Ministry of Health: September 2006). 

Page 33 GAO-07-486 Global Health
• Other health care worker training. In Africa, USAID is supporting efforts 

such as training public health care workers. For example, in Ethiopia, 

USAID supported the Carter Center’s Ethiopia Public Health Training 

Initiative (see fig. 6). This program develops and provides training 

materials—such as training modules and lecture notes—for health care 

workers, and supports training for health instructors in universities and 

health facilities. As of 2005, the program had developed 100 lecture notes, 

which are short textbooks that focus on specific health topics, and 

supported pedagogical training for 382 health instructors. 

Figure 6: Health Care Worker Training

USAID has taken several steps to increase attention to maternal and 

newborn health. Specifically, the agency has established programs that 

focus on these populations, supported maternal health research, and 

incorporated maternal and newborn health into mission programs. USAID 

officials and representatives from implementing partners acknowledged 

that these areas have not received sufficient attention from the 

international community. Other donors, such as the United Nations 

Population Fund and the Gates Foundation, also told us that, relative to 

Carter Center medical library at Awassa University, Awassa, Ethiopia.

Source: GAO.

USAID Is Working to 

Increase Attention to 

Maternal and Newborn 

Health 

Page 34 GAO-07-486 Global Health
child survival, maternal and newborn health have been neglected. In a 

series of articles focused on maternal health, The Lancet has stated that 

Millennium Development Goal 5, which calls for a three-quarters reduction 

in maternal mortality by 2015, is the goal toward which the world has 

made the least amount of progress. 

USAID has established programs that specifically address the needs of 

mothers and newborns. For example: 

• In 2004, USAID established a maternal and newborn health program called 

Access to Clinical and Community Maternal, Neonatal and Women’s 

Health Services (ACCESS). By 2006, ACCESS supported interventions in 9 

countries and was launching programs in 4 more countries. This program 

focuses on increasing the coverage, access, and use of maternal and 

newborn health services, such as antenatal care; treatment of obstetric 

complications; postpartum care for the mother and newborn; and newborn 

care, including umbilical cord care and early breastfeeding. For example, 

in Haiti and Cameroon, ACCESS supported training in essential maternal 

and newborn care for providers and trainers, while in Nepal, the program 

helped the government develop a national Skilled Birth Attendance policy.

• In 2002, USAID began a special initiative to address postpartum 

hemorrhage, one of the major causes of maternal death. According to the 

WHO, postpartum hemorrhage causes at least 25 percent of all maternal 

deaths worldwide; in some developing countries, it is estimated to cause 

up to 60 percent of maternal deaths. USAID has expanded the number of 

countries with programs that target postpartum hemorrhage from 4 

countries to 21. One such program is the Prevention of Postpartum 

Hemorrhage Initiative (POPPHI), which USAID launched in 2004. POPPHI 

focuses on the primary intervention for preventing postpartum 

hemorrhage—that is, active management of the third stage of labor—

which has been shown to significantly reduce blood loss and the need for 

blood transfusions.59 POPPHI has supported a number of activities, such as 

regional workshops for professional associations of obstetricians, 

gynecologists, and midwives, and is conducting a global survey on the use 

of the active management of the third stage of labor. 

 59Active management of the third stage of labor includes the following: administration of a 

uterotonic agent, such as oxytocin, which helps reduce blood loss; controlled cord traction, 

or gently pulling on the umbilical cord; and uterine massage after the placenta has been 

delivered. 

Page 35 GAO-07-486 Global Health
USAID has also supported research on maternal health. For example, in 

2006, USAID supported the WHO’s review of the major causes of maternal 

death. The study found that the major causes of maternal death vary by

geographical region. In Africa, the leading cause of maternal death is 

hemorrhage, while in Latin America and the Caribbean, the leading cause

is hypertension disorders. Prior to the study, one model of maternal 

mortality causes was used worldwide, without consideration of 

geographic differences. A USAID official told us that the study will help 

the agency determine which interventions to use in each region and, thus, 

allow it to target its maternal health programs more efficiently.

At the mission level, USAID has also begun to include programs that 

concentrate on maternal and newborn health. For example: 

• The Mali mission requested that one of its major implementing partners, 

Assistance Technique Nationale, increase its program’s focus on maternal 

health. 

• In Cambodia, the mission supports a national program of “maternal death

audits”—investigations into the causes of specific maternal deaths—to 

gather information to help prevent future deaths.

• The India mission supported the promotion of newborn care practices—

such as the immediate drying and wrapping of the newborn and early 

breastfeeding—through CARE, an implementing partner. 

• The missions in Ethiopia and India support new interventions for newborn 

health. The mission in India is supporting research on both newborn 

disease surveillance and the government of India’s introduction of a new 

health protocol—the Integrated Management of Newborn and Childhood 

Illness.60 The Ethiopian mission is also supporting the development of this 

protocol in Ethiopia. 

 60The Integrated Management of Newborn and Childhood Illness strategy is an adaptation

of the Integrated Management of Childhood Illness approach, which is based on studies

that show that sick children often have more than one disease and emphasize the 

importance of considering other health factors, such as immunizations, when a sick child 

receives health care. This strategy incorporates the newborn, and includes home visits by 

health workers to educate mothers and families on (1) detecting newborn and child 

illnesses and (2) caring for sick or low birth weight newborns. 

Page 36 GAO-07-486 Global Health
USAID has undertaken several efforts to address challenges to the 

sustainability of its CS/MH programs. These efforts include providing 

technical assistance, using its presence and connections in countries, 

working with host country governments, helping to develop products with 

potentially lasting effects, and promoting community involvement in 

CS/MH efforts. 

In our survey results and interviews with USAID officials, we found that 

although challenges to the sustainability of CS/MH programs varied among 

countries, officials commonly cited challenges such as a lack or 

uncertainty of funding and a lack of technical expertise. For example, our 

survey showed that all 40 of the health officers surveyed found uncertainty 

over future funding levels to be a hindrance to their ability to effectively 

implement their maternal and child health programs.61 Likewise, a 2004 

report prepared for USAID’s Bureau for Africa also cites funding 

uncertainty as a challenge to sustainability. The report states that 

reductions and rapid shifts in funding levels for child survival and other 

health programs made it difficult for missions to plan and implement 

programs. Health officers at the USAID mission in Cambodia cited the 

Cambodian government’s failure to devote sufficient funding to health as a 

challenge to sustainability. Our survey also indicated that 16 of 39 health 

officers were not confident that their maternal and child health programs 

would continue at their current level of quality without additional USAID 

assistance.62 In India, USAID officials told us that a lack of technical 

expertise was a major challenge to implementing and sustaining programs. 

In addition, out of 40 health officers, 35 or more cited corruption and the 

local populations’ low educational level as factors that would make it 

difficult for their maternal and child health programs to continue without 

USAID support. Thirty-seven of 39 health officers also cited a lack of other 

resources for the health system as a challenge. For example, the USAID 

mission in Mali told us that the population’s low educational level is a 

challenge for sustainability because people must be educated about 

planning and budgeting for their own health needs. 

USAID Has Taken Steps to 

Support Sustainability 

 61The term “a hindrance” refers to the USAID program representatives who replied “Some 

Hindrance,” “A Moderate Hindrance,” “A Great Hindrance,” or “A Very Great Hindrance” to

a survey question that also included the categories of “Condition Does Not Exist” and 

“Little or No Hindrance.” 

62The term “not confident” refers to the USAID program representatives who replied 

“Hardly Confident or Not At All Confident” in response to a survey question that also 

included the categories of “Extremely Confident,” “Very Confident,” “Moderately 

Confident,” and “Somewhat Confident.” 

Page 37 GAO-07-486 Global Health
USAID’s efforts to address such challenges to program sustainability 

include the following: 

• Providing technical assistance. USAID provides technical assistance to 

build and strengthen the local expertise needed for program sustainability. 

• In India, the Urban Health Resource Center, a USAID implementing 

partner, is coordinating the government of India’s efforts to develop 

and implement urban health plans for cities of different sizes. These 

plans will help guide national and state governments in developing 

urban health programs for other cities. Also, the Urban Health 

Resource Center is helping the state government of Uttar Pradesh to 

develop models of public-private sector partnerships that can be 

replicated and expanded to reach a larger population. One such 

partnership mobilizes NGO volunteers to interact with community 

members to increase their use of public health services. 

• Similarly, the Ethiopian mission funded a project providing technical 

assistance to the Ministry of Health to develop a proclamation for 

health reform. The proclamation allows local health centers to retain 

user fees. It has been ratified in four regions, affecting 90 percent of the

Ethiopian population. We visited one health center that has plans to 

increase drug availability with the new funds it has retained under the 

proclamation. 

• Working with implementing partners. USAID uses its in-country 

presence to develop relationships with implementing partners. For 

example: 

• According to a USAID report, the mission in Nigeria has cultivated 

relationships with all of the country’s ethnic groups and requires its 

implementing partners to select local staff from all ethnic groups and 

geographic regions of the country. As a result, 99 percent of USAIDsupport project staff in Nigeria is local, which helps create a sense of 

local ownership. 

Page 38 GAO-07-486 Global Health
• USAID has developed long-standing relationships with some 

implementing partners. For example, in Bolivia, USAID has worked 

with PROSALUD, a nonprofit health services provider, for about 181⁄2 

years.63

• Some USAID-funded programs have transitioned into local NGOs. For 

example, the Cambodian staff of two USAID-funded projects later 

became local NGOs themselves—the Reproductive Health Association 

of Cambodia and the Reproductive and Child Health Alliance. A USAID 

official at the Cambodia mission told us that the mission targets 

support to local NGOs, rather than international NGOs, because the 

local organizations’ programs build capacity. 

• USAID’s presence in the field enables it to coordinate with 

implementing partners. For example, in India, the mission told us that 

the USAID coordinator for the maternal and child health activities in 

the state of Jharkhand visits project sites about once a month, and 

works with implementing partners’ representatives as well as local 

government officials. Furthermore, in addition to holding regular 

meetings for its partners, the mission has developed a partners’ guide, 

which is a publication containing brief descriptions of all USAID health 

partners and their activities. According to one health officer, the 

meetings and the guide have helped to foster a sense of a “USAID 

community” among the partners. 

• Working with host governments. USAID works with the countries’ health

ministries to coordinate CS/MH efforts. In our survey, 37 of 40 health 

officers reported working with their host country’s health ministry to 

implement their maternal and child health programs. Also, in all four of 

the countries we visited, USAID supported the national governments’ 

development of health policies. In Ethiopia, India, and Mali, the missions 

have chaired the governments’ donor coordination groups. The 

Cambodian Ministry of Health chairs donor coordination groups, but 

according to mission staff and representatives from other donors, these 

groups are not an effective means for coordination. 

• Developing potentially lasting products. USAID seeks to support the 

development of products that can have long-lasting effects on maternal 

and child health. For example, USAID helped support the creation of a 

Family Health Card in Ethiopia. This pamphlet, which is meant to be used 

 63According to a USAID official, PROSALUD currently has a 92 to 95 percent cost recovery 

rate, and USAID hopes that it will reach 100 percent cost recovery by December 2007. 

Page 39 GAO-07-486 Global Health
by parents and community health workers, includes information on topics

such as antenatal care, immunizations, nutrition, treatment of diarrhea, 

and hygiene. The Family Health Card is being used by several

implementing partners as well as the Ethiopian Ministry of Health. Also, 

USAID supported the development of a Child Survival Message Guide in 

Ethiopia. This guide, developed with the Ministry of Health and other 

partners, seeks to ensure that organizations working in health provide the 

public with consistent messages about child survival. The guide can also 

serve as the basis for other health efforts, because organizations can use 

the guide as a starting point for developing their own materials. 

Source: GAO.

Source: GAO.

The USAID mission in Cambodia works with 

several implementing partners who use a

community-based approach to improving 

health. For example, the Reproductive and 

Child Health Alliance (RACHA), a USAID 

partner and local nongovernmental 

organization, works with community 

volunteers to provide health education and 

outreach activities, such as vitamin A 

distribution for children younger than 5 years

old. Studies have shown that vitamin A 

supplementation, if received every 4 to 6 

months, can reduce child mortality from all 

causes by as much as 23 percent. The 

photographs above show RACHA community 

volunteers distributing vitamin A supplements

and educating fellow villagers on good health 

practices in the Pursat province. 

Community-Level Programs:

Community Volunteers, Cambodia

• Working with the private sector. USAID works with private sector entities 

to promote the use of maternal and child health interventions. In our 

survey, 26 of 40 health officers reported working with for-profit businesses 

to implement their CS/MH programs. For example, the Point of Use Water 

Disinfection and Zinc Treatment Project, a USAID implementing partner in 

India, works with pharmaceutical manufacturers to promote the 

production of oral rehydration solution and zinc for the treatment of 

diarrhea, a leading cause of child mortality. 

• Promoting community involvement. USAID also promotes community 

involvement to strengthen program sustainability (see sidebar). 

Community volunteers play major roles in USAID’s CS/MH programs in the 

four countries we visited. Community members may perform a variety of 

activities, such as encouraging families to get their children immunized, 

urging pregnant women to obtain antenatal care, and referring others to 

government health centers for treatment and other services. For example, 

the India mission supports the use of community volunteers as part of its 

urban health program. These volunteers help organize outreach “camps,” 

during which certain health services, such as antenatal care, are offered in

the local community. The volunteers also assist in setting up women’s 

health groups, which are composed of women from the community. 

Among their other activities, these groups create and manage a 

“community health fund” that provides loans to community members to 

pay for emergency health services; the women’s groups also encourage 

attendance at outreach camps. USAID policy urges the use of community 

members to promote health. For example, according to USAID officials, 

the Bureau for Africa asks missions to incorporate community 

involvement in their countries’ work plans. 

Page 40 GAO-07-486 Global Health
USAID’s allocations from the Child Survival and Maternal Health account

in fiscal years 2004 and 2005 helped fund wide-ranging efforts to lower 

maternal and child mortality in Africa, Asia and the Near East, and Latin

America and the Caribbean. The agency’s country and regional missions 

and bureaus conducted numerous local and regional CS/MH activities. The 

Bureau for Global Health, in addition to serving as a global leader of 

CS/MH efforts, provided technical support for these activities, supported 

CS/MH research, and disseminated innovations and best practices to the 

missions and regional bureaus. However, because the Office of the 

Administrator did not require its missions and bureaus to report their 

obligations and expenditures of CS/MH allocations, the office had limited 

ability to account for and report on the use of the funds. To oversee and 

determine whether the CS/MH account is being used for the purposes for 

which it is allocated, including addressing congressional directives, the 

Office of the Administrator needs improved access to this information. 

USAID officials told us that the agency is making changes to its accounting 

system to record obligations and expenditures in the CS/MH account. 

However, the system currently contains little CS/MH data, and USAID has 

not tested how these data are traced back to the corresponding allocation

data in the State Department’s planning system to determine if CS/MH 

funds are obligated and expended for their intended purposes. 

USAID has used various methods of disseminating health care innovations

and best practices to its staff in the field to facilitate their efforts to 

improve maternal and child health. These methods have included, for 

example, electronic learning courses, biennial regional health conferences, 

an online database, and regional workshops. However, USAID has not 

assessed the relative effectiveness of its methods, some of which have 

drawbacks that may limit their usefulness. Given the urgent need to 

improve maternal and child health in developing countries, as well as the 

challenges confronting such efforts, it is essential that USAID use proven 

methods to ensure that staff at its missions and regional bureaus learn of 

CS/MH innovations and best practices in a timely and consistent manner. 

To enhance USAID’s administration of the Child Survival and Programs 

Fund and implementation of CS/MH programs, we are making the 

following two recommendations to the USAID Administrator:

Conclusions 

Recommendations for 

Executive Action 

• To strengthen USAID’s ability to oversee and determine whether the Child 

Survival and Maternal Health account is used for the purposes for which 

the agency allocates it, including responding to congressional directives, 

the USAID Administrator should test recent modifications to the principal 

Page 41 GAO-07-486 Global Health
accounting system to verify that CS/MH obligation and expenditure data 

will be properly recorded and traced back to the corresponding allocation 

data in the State Department’s planning system. 

• To provide for effective dissemination of information to USAID mission 

health officers about innovations and best practices in child survival and 

maternal health in a consistent and timely manner, the USAID 

Administrator should assess the relative effectiveness of the agency’s 

current methods of disseminating this information using existing tools—

for example, by including appropriate questions in the annual employee 

survey. 

USAID provided written comments and technical suggestions and 

clarifications on a draft copy of this report. (See app. VI for a reprint of 

USAID’s comments and our response.) Consistent with our report’s 

discussion, the agency emphasized that while its accounting system did 

not track obligations and expenditures at the CS/MH level in fiscal years 

2004 and 2005, it did capture obligation and expenditure information for 

the larger CSH Fund. Regarding our first recommendation, USAID stated

that once its modified accounting system has captured sufficient funding 

information, the agency will conduct tests to determine whether this 

information captures all CS/MH activities, thus allowing for verification 

that the funds are being used for the purposes for which they were 

appropriated. USAID also said it will immediately verify that the State 

Department’s planning system correctly captures all CS/MH allocated 

funds, including CS/MH funds that might not fall under the maternal and

child health element or health program area. 

With respect to our second recommendation, USAID stated that it plans to

conduct a Training Needs Assessment in 2007-2008 that will address our 

concerns and recommendation regarding evaluation of information 

dissemination methods. USAID also provided information regarding the 

role that grantees and contractors play in disseminating information on 

innovations and best practices. Furthermore, the agency provided 

additional detail on training and information dissemination efforts that we 

described in the draft, such as its electronic learning courses and state-ofthe-art training. We have incorporated this information in the report, as 

well as USAID’s technical comments and suggestions, where appropriate. 

Agency Comments 

and Our Evaluation 

Page 42 GAO-07-486 Global Health
We are sending copies of this report to interested congressional 

committees and the USAID Administrator. Copies of this report will be 

made available to other interested parties upon request. In addition, the 

report will be available at no charge on the GAO Web site at 

http://www.gao.gov. 

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

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

Offices of Congressional Relations and Public Affairs may be found on the 

last page of this report. Key contributors to this report are listed in 

appendix VII. 

David Gootnick 

Director, International Affairs and Trade 

Page 43 GAO-07-486 Global Health
Appendix I: Objectives, Scope, and Appendix I: Objectives, Scope, and Methodology 

Methodology 

The fiscal year 2006 Foreign Operations Appropriations Act directed GAO 

to review the U.S. Agency for International Development’s (USAID) use of 

child survival and health funds for fiscal years 2004 and 2005. Discussions 

with staff from committees of jurisdiction indicated that congressional 

interest focused on the Child Survival and Maternal Health (CS/MH) 

account within the Child Survival and Health Programs Fund. 

As part of our efforts to obtain information to address our four objectives, 

we conducted two surveys between August and December 2006. The 

surveys included questions on financial reporting, the types of activities 

funded with CS/MH funds, coordination with host country governments, 

methods for sharing best practices, and challenges to implementing 

CS/MH programs. Both surveys were sent to all 40 USAID health officers 

who currently manage CS/MH programs. To develop the questions for both 

surveys, we reviewed documents from USAID’s Bureau for Global Health

and conducted interviews with mission health officers. We pretested both

questionnaires with mission health officers. For the first survey, we 

conducted three pretests; for the second, we conducted two. We refined 

our questions on the basis of the feedback we obtained from the pretests. 

We achieved a 100 percent response rate for both surveys. We took steps 

in collecting and analyzing the survey data to minimize errors that might 

occur during these stages of the surveys. 

To examine USAID’s financial data on CS/MH funds for fiscal years 2004 

and 2005, we reviewed budget data provided by the Office of the 

Controller, which provided data from USAID’s primary financial 

management and reporting system; the Bureau of Policy and Program 

Coordination; the Bureau for Global Health; and the regional bureaus for 

Africa, Asia and the Near East, and Latin America and the Caribbean. We 

also conducted interviews with officials from those units, as well as the 

Office of the Inspector General, to understand how USAID accounted for 

its CS/MH funds. Finally, we reviewed financial data from USAID missions 

in Cambodia, Ethiopia, India, and Mali. We conducted field visits to these 

four countries from October to November 2006. We selected these 

countries based on criteria that included (1) receipt of CS/MH account

funding; (2) representation of Africa and Asia, the two geographic regions

with the highest maternal and child mortality rates; (3) recommendations 

by USAID officials of some countries that faced “challenges” and others 

that had achieved “successes”; and (4) consideration of travel restrictions. 

To describe USAID’s activities funded by the CS/MH account, we reviewed 

documentation from the Bureau for Global Health; the regional bureaus 

for Africa, Asia and the Near East, and Latin America and the Caribbean;

Page 44 GAO-07-486 Global Health
Appendix I: Objectives, Scope, and 

Methodology 

and the USAID missions in our four field countries. We also interviewed 

USAID officials at each of these entities. In the four field countries, we 

observed some of USAID’s CS/MH activities and interviewed host country 

government officials at both national and local levels, representatives from 

USAID implementing partners (including international and local 

nongovernmental organizations and faith-based organizations), and 

program beneficiaries. Lastly, to further develop our understanding of 

current CS/MH interventions and indicators, we attended global health

conferences in Washington, D.C. 

To examine USAID’s methods for sharing best practices, we reviewed 

USAID policies and documents and analyzed data from our two surveys. 

To familiarize ourselves with the electronic resources USAID uses to 

disseminate best practices, we accessed USAID’s external Web site as well 

as other sites on the World Wide Web. We also interviewed USAID officials 

of the Bureau for Global Health, the regional bureaus, and the missions 

that we visited. 

To describe USAID’s response to challenges in planning and implementing 

its CS/MH programs, we first identified key challenges by using data from 

our first survey and interviewing officials representing (1) USAID’s three 

regional bureaus, the Bureau for Global Health, and our four field 

countries; (2) USAID’s implementing partners; and (3) other donor 

organizations, such as the United Nations Children’s Fund (UNICEF), 

United Nations Population Fund, and Gates Foundation. To obtain 

additional information on the global health worker shortage, we reviewed 

reports from nongovernmental and multilateral sources, such as Save the 

Children and the World Health Organization. In our examination of the 

challenges associated with maternal and newborn health, we reviewed 

reports, such as UNICEF’s State of the World’s Children 2007, and articles 

from the British medical journal titled The Lancet. To determine what 

steps USAID is taking to address the identified challenges, we interviewed

USAID officials at the Bureau for Global Health, the three regional 

bureaus, and missions in our four field countries. We also reviewed USAID 

documentation, including work plans, annual reports, and program 

reports, such as the Bureau for Africa’s Child Survival in Sub-Saharan 

Africa – Taking Stock. 

We assessed the reliability of financial data compiled and generated by 

USAID’s Office of the Controller in Washington, D.C., and by the missions 

in our four field countries. We determined that the survey and financial

data were sufficiently reliable for our analysis. 

Page 45 GAO-07-486 Global Health
Appendix I: Objectives, Scope, and 

Methodology 

We conducted our work from April 2006 through March 2007 in

accordance with generally accepted government auditing standards. 

Page 46 GAO-07-486 Global Health
Appendix II: Allocation of Child Survival and 

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

Maternal Health Funds within USAID, Fiscal 

Years 2004 and 2005 

Dollars in millions 

Fiscal year

2004 2005 Total

Country/Entity Amount Percent Amount Percent Amount Percent

Africa $78.6 24.0% $88.3 25.4% $166.9 24.7%

Asia and the Near East 79.6 24.2 80.5 23.2 160.0 23.7

Latin America and the Caribbean 39.0 11.9 39.3 11.3 78.4 11.6

International Partnerships 64.2 19.6 72.3 20.8 136.5 20.2

Bureau for Global Health 66.0 20.1 67.1 19.3 133.1 19.7

Other 0.6 0.2 n/a n/a 0.6 0.1

Total $328.0 - $347.5 - $675.6 -

Source: GAO analysis of USAID data. 

Page 47 GAO-07-486 Global Health
Appendix III: Allocation of CS/MH Account 

Funds to Countries, Fiscal Years 2004 and 

2005 

Fiscal year 

Country 2004 (actual) 2005 (actual) 2006 (planned)

Afghanistan $16,870 $19,870 $21,005

Angola 2,700 1,200 1,483

Bangladesh 10,800 9,412 6,683

Benin 1,350 1,250 1,977

Bolivia 4,475 4,752 5,787

Burundi 200 300 692

Cambodia 4,690 5,100 5,148

Democratic Republic of the Congo 8,025 8,600 8,601

Dominican Republic 4,000 3,861 3,237

El Salvador 2,700 2,970 2,970

Eritrea 1,600 5a0a

Ethiopia 4,600 6,090 7,257

Ghana 3,200 3,200 2,719

Guatemala 4,150 4,215 4,158

Guinea 2,150 2,150 2,200

Haiti 8,550 8,839 9,207

Honduras 3,142 3,143 3,377

India 12,600 14,222 12,852

Indonesia 11,400 13,800 14,157

Jamaica 544 539 497

Kenya 1,000 1,000 989

Liberia 1,200 1,200 1,582

Madagascar 2,825 3,475 3,287

Malawi 2,200 2,200 2,175

Mali 2,900 3,780 3,658

Mozambique 3,500 4,500 4,350

Nepal 5,040 5,340 4,951

Nicaragua 3,000 3,242 3,210

Nigeria 7,000 8,650 3,856

Pakistan 11,600 7,600 13,652

Paraguay 0 0 1,102

Peru 5,450 5,164 4,653

Philippines 4,700 4,550 4,356

Rwanda 1,100 1,400 2,224

Appendix III: Allocation of CS/MH Account 

Funds to Countries, Fiscal Years 2004 and 

2005 

Page 48 GAO-07-486 Global Health
Appendix III: Allocation of CS/MH Account 

Funds to Countries, Fiscal Years 2004 and 

2005 

Fiscal year 

Country 2004 (actual) 2005 (actual) 2006 (planned)

Senegal 2,500 2,600 2,422

Sierra Leone 100 100 297

Somalia 100 100 0

South Africa 2,000 2,000 1,780

Sudan 7,200 8,200 8,809

Tanzania 2,500 3,500 3,312

Uganda 2,260 2,260 2,135

Zambia 4,420 4,420 4,271

Source: GAO analysis of USAID data. 

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

a

USAID closed its activities in Eritrea on December 31, 2005, in response to the Government of 

Eritrea’s request that USAID terminate development assistance programs in the country. 

Page 49 GAO-07-486 Global Health
Appendix IV: Mortality Statistics for

Countries Receiving CS/MH Funds, Fiscal

Years 2004 and 2005 

Country

Under 5 Mortality Rate 

(2003)

a

Neonatal Mortality Rate 

(2000)b

Maternal Mortality Ratio

(2000)c

Afghanistan 257 60 1,900

Angola 260 54 1,700

Bangladesh 69 36 380

Benin 154 38 850

Bolivia 66 27 420

Burundi 190 41 1,000

Cambodia 140 40 450

Democratic Republic of the Congo 205 47 990

Dominican Republic 35 19 150

El Salvador 36 16 150

Eritrea 85 25 630

Ethiopia 169 51 850

Ghana 95 27 540

Guatemala 47 19 240

Guinea 160 48 740

Haiti 119 34 680

Honduras 41 18 110

India 87 43 540

Indonesia 41 18 230

Jamaica 20 10 87

Kenya 123 29 1,000

Liberia 235 66 760

Madagascar 126 33 550

Malawi 178 40 1,800

Mali 220 55 1,200

Mozambique 158 48 1,000

Nepal 82 40 740

Nicaragua 38 18 230

Nigeria 198 53 800

Pakistan 103 57 500

Peru 34 16 410

Philippines 36 15 200

Rwanda 203 45 1,400

Senegal 137 31 690

Sierra Leone 283 56 2,000

Appendix IV: Mortality Statistics for 

Countries Receiving CS/MH Funds, Fiscal 

Years 2004 and 2005 

Page 50 GAO-07-486 Global Health
Appendix IV: Mortality Statistics for

Countries Receiving CS/MH Funds, Fiscal

Years 2004 and 2005 

Country

Under 5 Mortality Rate 

(2003)

a

Neonatal Mortality Rate 

(2000)b

Maternal Mortality Ratio

(2000)c

Somalia 225 49 1,100

South Africa 66 21 230

Sudan 93 29 590

Tanzania 165 43 1,500

Uganda 140 32 880

Zambia 182 40 750

Source: GAO analysis of WHO and UNICEF data.

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

a

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

b

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

c

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

Page 51 GAO-07-486 Global Health
Appendix V: Obligations and Expenditures for

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

for the Four Missions We Visited, Fiscal Years 

2004 and 2005 

Fiscal year

2004 2005 

Country Obligations Expenditures Obligations Expenditures

Mission-managed programs

 Cambodia $3,971,330 $3,573,002 $5,020,120 $4,019,403

 Ethiopia 2,531,597 2,469,984 4,684,941 2,417,957

 Indiaa4,295,000 8,445,506 4,858,000 5,300,141

 Mali 2,620,000 2,617,154 3,486,766 2,513,190

Centrally managed programs

 Cambodia 718,610 - 150,000 -

 Ethiopia 400,000 400,000 570,000 570,000

 Indiaa8,731,000 - 9,942,000 -

 Mali 330,000 320,000 493,000 318,000

Source: GAO analysis of USAID mission data. 

Note: Cambodia and India were unable to provide expenditure data for centrally managed programs. 

Ethiopia estimated its expenditures for centrally managed programs. The Bureau for Global Health, 

which managed these programs, was able to provide obligation data, totaling over $90 million in fiscal 

years 2004 and 2005, but was unable to provide expenditure data.

a

India carried over unexpended funds from previous fiscal years, which caused greater expenditures 

than obligations in fiscal years 2004 and 2005. 

Page 52 GAO-07-486 Global Health
Appendix VI: Comments from the U.S. Agency for International Development 

Page 53 GAO-07-486 

Appendix VI: Comments from the U.S. 

Agency for International Development 

Note: GAO comment 

supplementing those in 

the report text appears at 

the end of this appendix. 

Global Health
Appendix VI: Comments from the U.S. Agency for International Development 

Page 54 GAO-07-486 Global Health
Appendix VI: Comments from the U.S. Agency for International Development 

Page 55 GAO-07-486 Global Health
Appendix VI: Comments from the U.S. Agency for International Development 

Page 56 GAO-07-486 Global Health
Appendix VI: Comments from the U.S. Agency for International Development 

See comment 1. 

Page 57 GAO-07-486 Global Health
Appendix VI: Comments from the U.S. Agency

for International Development 

The following is GAO’s comment on the U.S. Agency for International 

Development’s letter dated April 3, 2007. 

1. USAID commented that the Bureau for Global Health conducts a 

Training Needs Assessment of Washington and field health staff to 

gather information about learning requirements and resources as well 

as training preferences. While we acknowledge that a second Needs 

Assessment in the 2007-2008 time frame could address our concerns 

regarding evaluation of information sharing methods, we also note that 

the first Training Needs Assessment was conducted in 2003 and 

concentrated mainly on Washington-based staff. For such an 

assessment to be effective, we encourage USAID to widely solicit input 

from its field health staff as well as to include relevant evaluation 

questions in its annual employee survey. 

GAO Comment 

Page 58 GAO-07-486 Global Health
Appendix VII: GAO Contact and Staff 

Acknowledgments 

Page 59 GAO-07-486 Global Health 

David Gootnick, (202) 512-3149 

In addition to the individual named above, Audrey Solis (Assistant 

Director), Judith Williams, Theresa Chen, Heather MacDonald, Susan Tieh, 

Jeanette Franzel, Joel Grossman, Keith Kronin, Reid Lowe, and Grace Lui 

made key contributions to this report. Claude Adrien, J. Robert Ball, Etana 

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

Appendix VII: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Staff 

Acknowledgments 

(320407) 
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