United States General Accounting Office

GAO Report to the Chairman, Subcommittee

on International Operations and Human

Rights, Committee on International

Relations, House of Representatives

November 1996 FOREIGN

ASSISTANCE

Contributions to Child

Survival Are

Significant, but

Challenges Remain

G O A

years

1921 - 1996

GAO/NSIAD-97-9

GAO United States

General Accounting Office

Washington, D.C. 20548

National Security and

International Affairs Division

B-272263 

November 8, 1996

The Honorable Christopher H. Smith

Chairman, Subcommittee on International

 Operations and Human Rights

Committee on International Relations

House of Representatives

Dear Mr. Chairman:

In response to your request, we have reviewed the U.S. Agency for

International Development’s (USAID) child survival activities. You were

concerned whether child survival funds were being used to fund activities

other than those emphasized in the authorizing legislation. Specifically, we

(1) assessed how child survival funds are being used and (2) identified

USAID’s child survival activities and accomplishments.

Background According to a 1995 World Health Organization (WHO) report, the three

major threats to the survival of children under age 5 in developing

countries are diarrheal dehydration, acute respiratory infections (e.g.,

pneumonia), and vaccine-preventable diseases. WHO’s 1995 report stated

that 13.3 million children under age 5 died in developing countries in 1985

and that 12.2 million children under age 5 died in 1993. Figure 1 shows the

causes of death for children under age 5 in developing countries, and

figure 2 shows 1994 mortality rates for children under age 5 worldwide.

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Figure 1: Causes of Death Among

Children Under Age 5 in Developing

Countries, 1985 and 1993

Number of deaths in millions

0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Acute respiratory infections

Diarrhea

Vaccine-preventable diseases

Neonatal and perinatal

Other

Causes of death

3.2

3.0 3.0

2.7 2.9

1.8

2.9 3.0

1.4

1.7

1985

1993

Note: Neonatal and perinatal causes include birth asphyxia, neonatal tetanus, congenital

anomalies, birth trauma, prematurity, and neonatal sepsis and meningitis. Other causes include

malaria, accidents, malnutrition, congenital syphilis, meningitis, human immunodeficiency virus

(HIV)-related complications, and other causes.

Source: WHO.

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Page 3 GAO/NSIAD-97-9 Foreign Assistance
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Figure 2: Mortality Rates in 1994 for Children Under 5 Years of Age and Countries That Received USAID Mission-Level

Child Survival Funding in 1994 or 1995

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

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Since 1954, USAID and its predecessor agencies have been involved in

activities to improve child survival in the developing countries. Since the

passage of Public Law 480 in 1954, U.S. food assistance has been provided

to children and pregnant and lactating women. In the 1960s, USAID began

building health clinics and funding research on treatments for diarrheal

disease and the prevention of malaria. One of the specific objectives of the

Foreign Assistance Act of 1961, the primary legislation governing U.S.

foreign aid, was to reduce infant mortality.

In the 1970s, USAID began to focus on providing appropriate health

interventions for common health problems in communities with the

greatest needs. Activities related to child health included field studies on

oral rehydration and vitamin A therapy and malaria research.

In 1984, Congress enacted legislation requiring a program designed to

address child survival.1

 Section 104(c)(2)(A) of the act, as amended,

provides in relevant part that:

“In carrying out the purposes of this subsection, the President shall promote, encourage,

and undertake activities designed to deal directly with the special health needs of children

and mothers. Such activities should utilize simple, available technologies which can

significantly reduce childhood mortality, such as improved and expanded immunization

programs, oral rehydration to combat diarrhoeal diseases, and education programs aimed

at improving nutrition and sanitation and at promoting child spacing.”

Because the statutory language is broad and emphasizes but does not limit

USAID to the specified interventions, USAID has considerable latitude in

developing child survival activities appropriate to the community being

served.

In February 1985, in response to the authorizing legislation, some of

USAID’s ongoing child health efforts were consolidated into a child survival

program. USAID provided mission-level child survival assistance to 31

countries in 1985, but it placed special emphasis on 22 countries that had

especially high mortality rates. For each of these 22 countries, USAID

developed a detailed child survival strategy, in cooperation with the host

government, to deal with the country’s specific needs and circumstances.

USAID’s policy was to sustain bilateral child survival funding in these

countries for at least 3 to 5 years and provide technical support and

training on a priority basis.

1

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

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Over the years, the congressional appropriations committees have

continued to emphasize the importance of the basic interventions

mentioned in the authorizing statute, particularly immunizations and oral

rehydration therapy. In some years, the committees have also directed

USAID to support particular activities, including the promotion of

breastfeeding, research and development of vaccines, and prevention of

vitamin A and other micronutrient deficiencies through food fortification,

tablets, and injections.

USAID’s child survival program has evolved in the 1990s to where it no

longer is a separate program, but is encompassed within USAID’s

sustainable development strategy as a component of its population,

nutrition, and health sector. (See app. I for a more detailed description of

USAID’s current child survival objectives and approach.)

Results in Brief Since 1985, USAID has classified obligations totaling over $2.3 billion for

activities in at least 83 countries as child survival. However, due to the way

Congress directs funding to child survival, particularly since 1992, and

USAID’s approach to tracking and accounting for such funds, it is not

possible to determine precisely how much is actually being spent on child

survival activities. Between 1985 and 1995, USAID reported that it spent

about $1.6 billion, or 67 percent of the child survival funds, for four types

of activities: immunizations, diarrheal disease control, nutrition, and

health systems development. USAID also reported that about 41 percent of

the total amount identified as child survival has been used to address the

three major threats to children under age 5 in the developing countries:

diarrheal dehydration, acute respiratory infections, and

vaccine-preventable diseases.2

USAID has also included as child survival some of the funds it has spent on

activities such as health care financing, health systems development, and

vector control.3

 During our field visits, we also noted that part of the cost

of rehabilitating a railroad bridge and constructing a water tower in

Mozambique and carrying out urban sewerage projects in Egypt were

identified as child survival expenditures. USAID said the projects in

Mozambique were critical for reducing child mortality because they

supported access to water, food, and health services.

2

These diseases are related to activities emphasized in the 1984 authorizing legislation, which included

immunizations, oral rehydration, and nutrition.

3

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

Page 7 GAO/NSIAD-97-9 Foreign Assistance
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USAID and other donors have made important contributions toward

improving child mortality rates in many countries. In 9 of the 10 countries

receiving the most USAID mission-level child survival assistance since 1985,

mortality rates for children age 5 and under have dropped. In addition, 5 of

these 10 countries achieved mortality rates by 1994 of 70 or fewer deaths

per 1,000 live births—a goal set for the year 2000 at the World Summit for

Children.4

 Both USAID and independent evaluations have pointed out

successes, such as collaboration with other donors to immunize children

and promote oral rehydration therapy in the treatment of diarrheal

disease. In the four countries we visited—Bolivia, Guatemala, Egypt, and

Mozambique—USAID provided child survival assistance for some activities

that directly benefited children.

In fiscal year 1995, USAID’s child survival funding was used in 17 countries

that had an under-5 mortality rate of 70 or fewer deaths per 1,000 live

births. USAID mission-level funding for child survival in these countries was

$89.5 million, or 31 percent of the total child survival funding obligated in

that year. On the other hand, many countries that were far from achieving

the goal, such as those in sub-Saharan Africa, did not receive assistance

for child survival. According to USAID, most of these countries did not

receive assistance because USAID did not have a program in the country,

had closed out assistance, or was in the process of closing out assistance

due to budgetary or legal reasons or because sustainable development

programs were not considered feasible. USAID has continued child survival

activities in countries that have achieved better than average under-5

mortality rates because some of these countries still have pockets of

populations with severe problems. Additionally, according to USAID, some

countries that have improved their mortality rates need continued support

to sustain the levels achieved.

How Child Survival

Funds Are Used

Between fiscal years 1985 and 1995, USAID reported that it obligated over

$2.3 billion for the child survival program. Child survival projects and

other activities attributed to child survival may be funded through USAID’s

overseas missions directly or through its four regional bureaus or its

central bureaus (see table 1).5

4

The goal was stated as a reduction of 1990 under-5 mortality rates by one-third or to a level of 70

deaths per 1,000 live births, whichever is greater.

5

Central bureaus is an informal term used to distinguish some USAID headquarters bureaus from the

regional (geographic) bureaus that are responsible for USAID missions. Primarily, the central bureaus

that fund child survival activities are (1) the Bureau for Humanitarian Response and (2) the Bureau for

Global Programs, Field Support, and Research. (Other central bureaus include the Bureau for Policy

and Program Coordination and the Bureau for Management.)

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

1985-95

Dollars in thousands

Fiscal year

Central

programs Africa

Asia and the

Near East

Europe and

the New

Independent

States

Latin America

and the

Caribbean Total

1985 $44,695 $27,242 $27,287 0 $33,009 $132,233

1986 30,452 30,203 56,181 0 38,774 155,610

1987 39,655 36,650 59,586 0 48,579 184,470

1988 42,795 36,347 39,148 0 54,329 172,619

1989 42,228 67,548 52,477 0 41,095 203,348

1990 47,840 45,379 44,746 $2,311 45,311 185,587

1991 59,574 57,342 67,424 3,549 63,237 251,126

1992 98,639 60,220 45,723 6,704 61,162 272,448

1993 102,995 61,931 54,107 12,285 60,087 291,405

1994 94,010 48,973 39,578 19,378 41,204 243,143

1995 107,104 58,234 47,818 44,227a 28,431 285,815

Total $709,987 $530,069 $534,075 $88,454 $515,218 $2,377,804

Note: Numbers may not add due to rounding.

aUSAID officials said that fiscal year 1995 data available from the Bureau for Europe and the New

Independent States were not final, as of August 1996, and therefore may not be accurate.

Source: USAID/Center for International Health Information.

The number of countries receiving mission-level child survival assistance

in a single fiscal year increased from 31 in 1985 to about 43 in 1995. During

this 11-year period, USAID provided mission-level assistance on a

continuing basis for some countries, such as Egypt, whereas other

countries received funding in only 1 year. A total of 83 developing

countries received some mission-level child survival funding during this

period. The amounts ranged from $9,000 for Oman to $137 million for

Egypt. As shown in table 2, of the 10 countries that have received the most

child survival assistance from USAID missions, 5 were in the Latin America

and Caribbean region, 4 were in the Asia and Near East region, and 1 was

in the Africa region.

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Table 2: Ten Countries Receiving the Most USAID Mission-Level Assistance Attributed to Child Survival and Their Mortality

Rates for Children Under Age 5

Funding Under-5 mortality ratea

Dollars in thousands

Country Region FY 1985-95 FY 1995 1980 1994

Egypt Asia/Near East $136,860 $27,001 180 52

El Salvador Latin America/ Caribbean 81,230 2,587 120 56

Haiti Latin America/ Caribbean 78,440 10,887 195 127

India Asia/Near East 68,772 900 177 119

Mozambique Africa 62,494 9,793 269 277

Bolivia Latin America/ Caribbean 60,566 3,264 170 110

Philippines Asia/Near East 58,194 0 70 57

Honduras Latin America/ Caribbean 53,550 2,201 100 54

Peru Latin America/ Caribbean 50,443 1,388 130 58

Bangladesh Asia/Near East 48,001 2 211 117

aThe mortality rate represents the number of deaths per 1,000 live births.

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

USAID Supports Activities

Through Many

Organizations

USAID provides funding to other organizations to implement health and

population services. USAID guidance states that U.S. assistance must help

build the capacity to develop and sustain host country political

commitment to health and population programs, as well as enhance the

ability of local organizations to define policies and design and manage

their own programs. USAID’s policy is to involve both the public and private

sectors and give special attention to building, supporting, and empowering

nongovernmental organizations (NGO) wherever feasible.

USAID-supported child survival activities involve U.S. and foreign

not-for-profit NGOs, including private voluntary organizations (PVO);

universities; for-profit contractors; multilateral organizations; and U.S. and

foreign government agencies. Figure 3 shows that U.S. NGOs received

about 45 percent of fiscal year 1994 child survival funding.6

 At least 35 U.S.

PVOs and 22 other U.S. NGOs participated in USAID’s child survival programs

6

This special analysis was performed by USAID with fiscal year 1994 data. Data for other fiscal years

were not readily available.

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during that year as primary grantees.7 For-profit businesses and host

country governments together accounted for another one-quarter of the

funding. The remainder went to multilateral organizations, such as UNICEF;

U.S. government agencies, including the Centers for Disease Control and

Prevention; and indigenous NGOs.

7

Because some primary grantees and contractors may have awarded subgrants or subcontracts to

other organizations, a complete count of organizations involved was not readily available. In addition,

the data included only organizations that received funding obligations in 1994, excluding any

organizations with ongoing USAID programs that received funding in previous years but did not

receive any in 1994.

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Figure 3: Types of Organizations That

Received USAID Child Survival Funds,

Fiscal Year 1994

45% • U.S. PVOs and NGOs 

($110.4 million)

14%•

For-profit firms ($35.1 million)

13%•

Host country government agencies

($32.7 million)

•

9%

Multilateral organizations 

($21.9 million)

•

5%

U.S. government agencies 

($12.9 million)

•

5%

Unspecified ($11.1 million)

•

4%

Universities ($9.1 million)

•

5%

Indigenous PVOs and NGOs 

($11.6 million)

Note: The total of these obligations does not correspond to those in table 1 because the data

used to develop this chart came from a different source. However, the difference is not material

(less than 1 percent).

Source: USAID.

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USAID generally uses the different types of organizations for different

purposes or for implementing different types of activities. No one single

group or organization typically performs the full range of activities that the

agency sponsors. For example, in all the countries we visited, PVOs were

involved at the community level with direct delivery of some of the basic

health interventions. In Guatemala, a for-profit contractor provided

technical assistance for the computer hardware and software programs

that USAID installed in the Ministry of Health to computerize its health data.

Funding Supports

Different Types of

Activities

Between 1985 and 1995, activities related to the three major causes of

death among young children—acute respiratory infections, diarrheal

diseases, and vaccine-preventable diseases—received about $972 million,

or 41 percent of the child survival funds. Table 3 shows funding levels

attributed to child survival by type of activity from 1985 to 1995.

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Table 3: USAID Funding by Type of

Child Survival Activity, Fiscal Years

1985-95

Dollars in thousands

Activity 1985 1986 1987

Immunization $30,313 $50,370 $50,898

Nutritiona 27,534 22,261 26,319

Diarrheal disease control/oral rehydration

therapy 38,060 34,769 45,200

Health systems development N/A N/A N/A

Child spacing/high-risk births 6,346 7,540 10,001

Water quality/health N/A N/A N/A

Acute respiratory infections N/A N/A N/A

Maternal healthb N/A N/A N/A

Malaria N/A N/A N/A

Health care financing N/A N/A N/A

Orphans and displaced children N/A N/A N/A

Vector control and tropical diseases N/A N/A N/A

Environmental health N/A N/A N/A

Other 29,980 40,670 52,052

Total $132,233 $155,610 $184,470

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7 1988 1989 1990 1991 1992 1993 1994 1995 Total

8 $38,495 $44,017 $32,184 $37,785 $51,752 $67,378 $58,903 $36,236 $498,331

9 25,542 31,386 29,192 51,041 51,692 52,284 43,903 80,684 441,838

0 37,469 42,996 29,653 31,904 39,053 38,252 26,037 26,855 390,248

A N/A 22,293 21,600 41,393 58,170 46,085 40,406 26,967 256,914

16,144 13,567 11,475 17,092 13,135 21,412 17,259 15,154 149,125

A N/A 10,289 10,119 10,547 14,593 12,260 15,293 11,059 84,160

A N/A 5,907 5,990 9,582 14,058 15,096 14,868 18,391 83,892

A N/A 4,889 9,317 10,178 8,197 8,685 6,766 18,338 66,370

A N/A 5,530 6,746 9,812 9,395 11,946 8,456 10,877 62,762

A N/A N/A 6,332 9,970 8,139 5,892 6,215 12,474 49,022

A N/A N/A N/A N/A 3,429 9,874 2,844 19,025 35,172

A N/A 1,124 1,733 2,353 835 2,241 2,193 6,681 17,160

A N/A N/A N/A N/A N/A N/A N/A 3,075 3,075

2 54,969 21,350 21,246 19,469 N/A N/A N/A N/A 239,736

0 $172,619 $203,348 $185,587 $251,126 $272,448 $291,405 $243,143 $285,815 $2,377,804

Note: N/A indicates an activity category that was not specified in USAID coding procedures

during that year. Before 1989, many of the activities that were not listed as separate categories

were included in the “other” category. Numbers may not add due to rounding.

aNutrition is further broken out into the following activity areas: micronutrients; vitamin A;

breastfeeding; growth monitoring and weaning foods; nutrition management, planning, and

policy; and other nutrition.

bBefore 1989, maternal health activities were supported under the high-risk birth category.

Source: USAID/Center for International Health Information.

Identifying Amounts

Used Specifically for

Child Survival Is

Difficult

USAID is unable to determine with any degree of precision how much

funding is actually being used for child survival activities because (1) of

the way Congress has directed funding; (2) USAID guidance allows

considerable flexibility and variation in attributing child survival funds;

(3) the amounts reported are based on estimated percentages of projected

budgets, which sometimes are not adjusted at the end of the year to reflect

any changes that may have occurred; and (4) the amounts reported are not

directly based on specific project expenditures. USAID plans a new

information management system that may improve the precision of the

data for its child survival activities.

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From fiscal year 1985, when the child survival program officially began,

through fiscal year 1995, appropriations statutes have mandated spending

of at least $1.8 billion for child survival activities. From fiscal years 1985 to

1991, funds appropriated by Congress for child survival went into a

separate functional account under USAID’s development assistance

account. Additionally, for several years prior to fiscal year 1992, the

appropriations laws not only earmarked money for child survival, but the

appropriations committees’ reports also expressed the intention that other

accounts within the development assistance account should provide

substantially more money for child survival activities. Beginning in fiscal

year 1992, the functional account was eliminated and subsequent laws

appropriating moneys to USAID contained an earmark for child survival

activities that could be drawn from any USAID assistance account. Since

1991, Congress has substantially increased the level of funds designated

for child survival through earmarks (from $100 million in direct

appropriations in fiscal year 1991 to $250 million in fiscal year 1992).

USAID issued guidance in 1992 and 1996 about the types of activities that

were allowed to be attributed to child survival. Additionally, the agency’s

budget office issues annual instructions for reporting on project activities.

These instructions name types of activities that may be attributed to child

survival and give broad discretion to USAID officials to determine the

percentage of funding that can be reported as child survival. However, the

instructions do not provide specific indicators for determining attribution,

such as the percent of children in the population served for water projects.

Moreover, some mission officials responsible for recording project

activities told us that the guidance for making attributions was not clear to

them.

In our discussions with USAID officials, we found that the process of

attributing funds to child survival activities was imprecise and that

mistakes occurred. As a result, the percentage of funds designated as child

survival varied widely for similar activities. For example, USAID used child

survival funds for the construction of water systems in all four countries

we visited. USAID guidance suggested 30 percent of the total budget of

water and sewerage projects as an appropriate level to attribute to child

survival, but child survival funds comprised from 3 to 100 percent of the

funding for some of these projects.

According to an official at the USAID mission in Egypt, the mission has a

policy of attributing 3 percent of sewerage projects and 6 percent of water

projects to child survival. In contrast, the Health Sector II project in

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Honduras attributed 70 percent of the $16.9 million water and sanitation

component to child survival. According to a mission official, the

justification for this level of attribution was that children under age 5

comprised approximately 70 percent of the deaths due to water-borne

diseases in rural areas. Another activity funded by this project was the

construction of area warehouses. About $72,000, which was 26 percent of

the cost, was attributed to child survival. The justification USAID provided

for this attribution was that these warehouses, which were used to store

medical supplies, have contributed to the decline in the infant mortality

rate in Honduras.

The funding amounts reported as child survival are based on estimated

percentages of total project obligations for types of child survival activities

carried out under individual projects. These estimates are made by project

or budget officers and are supposed to be based on a knowledge of project

plans and activities. However, mission officials told us that they generally

did not change the activity assignments or percentages, even though

changes in available funding or project plans may occur during the year.

For example, $800,000 in child survival funding was attributed to a basic

education project in Ethiopia in 1994. A mission official told us that the

child survival activity did not actually take place, but the reports provided

to us by USAID included child survival funding for this project.

USAID reports on funds attributed to child survival and other activities are

not based on expenditures. USAID stated that its activity reporting system

was never intended to track expenditures for programs and that Congress

was aware that reported funding represented estimates of obligations.

However, according to USAID officials, a new information system is

underway that will link budgets, obligations, and expenditures and enable

the agency to track funds more accurately.

USAID officials said that the new system would be able to link some child

survival assistance with actual expenditures in cases in which a distinct

child survival activity has been defined. However, in other cases, reported

funding will continue to be based on the project manager’s estimate of the

percentage of funding attributable to child survival. USAID began

implementing the new system in July 1996 for all new commitments made

at headquarters, and it plans to extend the system to the overseas missions

by October 1996.

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USAID’s Contribution

to Child Survival

USAID has made significant contributions, in collaboration with other

donors, in reducing under-5 mortality rates. Among the 10 countries

receiving the most USAID mission-level child survival assistance, all but one

improved their under-5 mortality rate between 1980 and 1994. Five

countries achieved the World Summit goal of 70 or fewer deaths per 1,000

live births. The number of deaths from the three major causes of under-5

mortality declined during this time, but the largest decrease was for

vaccine-preventable diseases.

USAID can claim some far-reaching accomplishments in immunizations.

Between 1985 and 1994, 26 of the 59 countries that received some

mission-level assistance specifically for immunization activities achieved

USAID’s goal of 80-percent immunization rates.8 Through collaboration with

the Pan American Health Organization (PAHO), UNICEF, Rotary

International, other international organizations, and the individual

countries, USAID helped to bring about the eradication of poliomyelitis in

the Americas. USAID’s Children’s Vaccine Initiative project supports a

revolving fund, called the Vaccine Independence Initiative, that is managed

by PAHO and UNICEF. This fund, which received $3.8 million of child survival

funding between 1992 and 1995, is used to help developing countries

purchase vaccines.

One of USAID’s most important accomplishments in diarrheal disease

control occurred before 1985 with the discovery that oral rehydration salts

could be used to treat the dehydration that occurs with diarrheal diseases

and causes death. USAID has also had positive results in efforts to increase

usage of oral rehydration therapy, although only four countries where

USAID has provided mission-level child survival assistance have usage rates

above 80 percent.9

USAID’s recent diarrheal disease control efforts have been aimed at

promoting sustainability by transferring technology to developing

countries so that they can manufacture the salts. USAID has also

contributed to research on the importance of vitamin A supplementation

and efforts to incorporate vitamin A into local food supplies around the

world.

8

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

9

The Interagency Coordinating Committee, which was created to work on the World Summit goals and

includes USAID, PAHO, UNICEF, and other international agencies, agreed to a goal of 80 percent for

the use of oral rehydration therapy in cases of diarrhea in children under 5. However, USAID stated in

its 1991 Child Survival Report to Congress that the goal was for 45 percent of diarrheal episodes to be

treated with oral rehydration therapy.

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USAID’s Center for Development Information and Evaluation (CDIE)

concluded in a 1993 report that USAID’s child survival activities had

achieved many successes and made a significant contribution in

expanding child survival services and reducing infant mortality in many

countries.10 The CDIE report cited the importance of USAID’s role in

vaccinations and stated that the agency had supported other major donors,

such as UNICEF, through coordination and the provision of needed

resources. Another evaluation conducted independently by RESULTS

Educational Fund and the Bread for the World Institute concluded in a

January 1995 report that USAID’s child survival activities had made an

important contribution to reducing deaths among children under age 5 in

countries receiving USAID assistance.11

In the four countries we visited, USAID’s contributions through child

survival activities were evident. For example, in Mozambique, USAID

supports PVOs that provide child survival services and other types of

humanitarian and development assistance. We visited several sites where

World Vision Relief and Development was implementing a child survival

project. Among the activities we observed were vaccinations for children

under age 3, monitoring of children’s growth, prenatal examinations, and

the construction of latrines.

In Bolivia, PROSALUD health clinics we visited offered general medical

services; childbirth and pediatric care; immunizations; family planning;

and dental, pharmacy, and laboratory services. PROSALUD is a Bolivian

private, nonprofit organization initiated and operated with USAID child

survival funds. Between 1991 and 1996, USAID provided the PROSALUD

project with $6.5 million, of which $6.2 million, or 95 percent, was

attributed to child survival. The 26 PROSALUD clinics and its hospital

charge small user fees that enable the organization to partially self-finance

its operations.

We also visited Andean Rural Health Care, a U.S. PVO that provides

community health care in Bolivia through clinics and volunteers. The

volunteers are trained at the health centers on how to make home visits to

10CDIE conducted evaluations of child survival activities between 1989 and 1993 in six countries:

Indonesia, Morocco, Haiti, Bolivia, Egypt, and Malawi. These countries were selected for evaluation

because they represented 27 percent of the countries that received special emphasis on child survival,

including sustained funding. Also, they were considered representative of the range of agency

experience with regard to regions, approaches, program sizes, and country conditions.

11RESULTS Educational Fund and the Bread for the World Institute are educational and research

organizations that focus on hunger and poverty issues, including the provision of low-cost health care

measures in developing countries. They do not receive funds from USAID. Their January 1995 report,

Putting Children First, was based on a review of 1991 USAID activities.

Page 19 GAO/NSIAD-97-9 Foreign Assistance
B-272263 

(1) provide families with oral rehydration salts, (2) treat diarrheal diseases

and acute respiratory infections, (3) promote vaccinations by health

center staff, and (4) monitor the growth and health of family members (see

fig. 4).

Page 20 GAO/NSIAD-97-9 Foreign Assistance
B-272263 

Figure 4: An Andean Rural Health Care

Volunteer in Bolivia Weighing an Infant

During a Home Visit

Page 21 GAO/NSIAD-97-9 Foreign Assistance
B-272263 

In Guatemala, we visited a clinic operated by APROFAM, which is a

private, nonprofit organization that provides family planning services as

well as selected maternal-child health services, such as pre- and postnatal

care, child growth monitoring, and oral rehydration therapy. Under the

current USAID grant, APROFAM received about $2.5 million in child

survival funding, representing 15 percent of its total USAID funds. We also

visited a pharmaceutical plant in Guatemala where USAID provided

equipment and technical assistance to manufacture packets of oral

rehydration salts used in the treatment of diarrheal disease dehydration

(see fig. 5). The packets are to be distributed through Ministry of Health

facilities. This plant was a component of USAID’s $20 million child survival

project started in 1985 to assist the Ministry of Health.

Page 22 GAO/NSIAD-97-9 Foreign Assistance
B-272263 

Figure 5: USAID-Funded Equipment at

a Plant That Manufactures Oral

Rehydration Salts in Guatemala

Page 23 GAO/NSIAD-97-9 Foreign Assistance
B-272263 

In Egypt, we visited urban and rural health clinics that administered

vaccinations and oral rehydration therapy and had laboratories that were

equipped to perform medical tests. According to USAID officials, these

health clinics also provided treatment for acute respiratory infections and

family planning activities.

Additional Activities

Address Child Survival

Objectives

For fiscal years 1993-95, USAID reportedly spent about $478.9 million, or 

58 percent of child survival funding, on interventions that directly address

the causes of death of children under the age of 5—immunizations,

diarrheal disease control, nutrition, and acute respiratory infections.

However, the amounts used for immunizations and diarrheal disease

control were less in 1994 and 1995 than they had been in 1993. During the

same period, USAID spent about $341.5 million on such areas as health

systems development, health care financing, water quality, and

environmental health (a new area).

In Mozambique, USAID attributed child survival funds for the construction

of a water supply system in Chimoio by the Adventist Development and

Relief Agency to serve as many as 25,000 residents (see fig. 6). About

$2.5 million, or 40 percent, of the project’s almost $6.2 million cost was

attributed to child survival. USAID described this project as an exception

where such infrastructure activities would be appropriately attributed to

child survival.

Page 24 GAO/NSIAD-97-9 Foreign Assistance
B-272263 

Figure 6: Water Tower in Mozambique

That Was Partially Funded as Child

Survival

Since 1992, the USAID mission in Egypt has designated as child survival

about $6.5 million for water and wastewater infrastructure development.12

Egypt’s sewerage projects include the design, construction, and operation

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

Page 25 GAO/NSIAD-97-9 Foreign Assistance
B-272263 

of wastewater treatment plants and systems, and water projects include

the construction of water treatment plants, which provide potable water to

urban areas.

The 1993 USAID/CDIE report recommended that water infrastructure

projects not be funded as child survival because child survival resources

were not considered adequate to construct enough water systems to have

a measurable impact on national health indicators. The report also stated

that the results of other child survival interventions appear to be greater

than the results obtained from investing in water and sanitation and that

oral rehydration therapy and interventions related to acute respiratory

infections should be given higher priority.

In Mozambique, reconstruction of a railroad bridge crossing the Zambezi

River between Sena and Mutarara was considered child survival (see 

fig. 7). The goal of this project was to rehabilitate roads so that land

movement of food and other relief assistance, the return of displaced

persons and refugees, and drought recovery activities could occur. The

railroad bridge was modified to accommodate vehicles and pedestrian

traffic. Of the project’s $10.8 million budget, $1.9 million was attributed to

child survival as nutrition in 1993 and 1994.

Figure 7: Railroad Bridge in

Mozambique That Was Repaired With

Child Survival Funding

Page 26 GAO/NSIAD-97-9 Foreign Assistance
B-272263 

Although the railroad bridge in Mozambique was considered a nutrition

intervention, other infrastructure projects that have used child survival

funding were classified as water quality/health, health systems

development, and health care financing. Between 1993 and 1995, USAID

attributed about $38.6 million in child survival funds to water

quality/health, $113.5 million to health systems development, and

$24.6 million to health care financing. Examples of activities related to

health systems development include the construction of warehouses for

government medical supplies in Honduras. An example of a health care

financing activity in Bolivia is PROSALUD, which USAID established to be a

self-financing health care provider.

USAID attributed $30 million of the international disaster assistance funds

to child survival in fiscal year 1995. The projects that USAID’s budget office

counted as child survival included activities that benefited children, such

as health and winterization activities in the former Yugoslavia, a water

drilling program in northern Iraq, an emergency medical and nutrition

project for displaced persons in Sudan, the purchase of four water

purification/chlorination systems in Djibouti, and community health care

in two regions of Somalia. Additionally, the conference report

accompanying the fiscal year 1996 foreign operations appropriations act

authorized USAID to attribute $30 million of disaster assistance funding to

child survival.

USAID Does Not Assist

Some Countries With

Severe Child Survival

Problems

USAID’s guidance states that child survival assistance will be provided to

countries with mortality rates for children under age 5 at or above 150 per

1,000 live births. However, USAID does not provide assistance to some of

the 30 countries with the most serious under-5 mortality problems. For

example, many countries in sub-Saharan Africa, which have the most

serious child survival problems, do not receive USAID child survival

assistance for mission-level projects. According to USAID, the agency does

not have a mission in these countries, had closed out assistance, or was in

the process of closing out assistance because of budgetary or legal reasons

or because sustainable development programs were not considered

feasible. (See app. II for details regarding under-5 mortality rates and

amounts of USAID mission-level assistance for developing countries.)

On the other hand, USAID attributes mission-level child survival funds to

activities in 17 countries that have a mortality rate of 70 or fewer deaths

per 1,000 live births. In fiscal year 1995, USAID used about $89.5 million of

child survival funding for activities in these 17 countries. Among these

Page 27 GAO/NSIAD-97-9 Foreign Assistance
B-272263 

countries were several in the former Soviet Union, including Georgia,

which had an under-5 mortality rate of 27 per 1,000 live births. By contrast,

in fiscal year 1995, USAID used $53.4 million of child survival funding in 

15 of the 30 countries that had the most serious problems with under-5

mortality—rates above 150 per 1,000 live births.

In 1995, Egypt continued to have the largest share of mission-level

assistance attributed to child survival ($27 million), as it has over the last

decade.13 UNICEF reported Egypt’s under-5 mortality rate in 1994 as 52;

however, USAID indicated that its most recent data showed that the rate

was 80.6.

Agency Comments

and Our Evaluation

In commenting on a draft of this report, USAID indicated that it focused its

child survival efforts in countries with high rates of under-5 mortality and

other factors that indicated a great need for assistance. USAID stated that

(1) national mortality rates are averages that often mask pockets of high

child mortality, (2) the achievement of a target mortality rate is not a

reason to stop support of efforts because gains need to be sustainable, and

(3) child survival programs are not in some of the most needy countries

because of legal, budgetary, and sustainability reasons.

USAID issued new guidance in April 1996 that indicates that infrastructure is

not generally considered to be an appropriate use of child survival funds.

USAID stated that the infrastructure cases we cited, all of which began

before April 1996, were isolated examples. USAID further stated that the

bridge rehabilitation and water works construction projects in

Mozambique were needed to reduce child mortality after the civil turmoil

in that country.

USAID also commented that its current financial reporting system was

never intended to be used to track any program area on an expenditure

basis. USAID indicated that a new information management system that is

being implemented has been designed to track funding for each activity by

linking budgets, obligations, procurements, and expenditures.

After reviewing USAID’s comments, we have deleted the recommendations

that we presented in our draft report. In its comments and subsequent

discussions, USAID provided us with sufficiently detailed information to

adequately explain the reasons why some countries with very severe child

13Egypt receives Economic Support Funds related to the Camp David Accords. These funds have been

used for child survival as well as other projects related to different agency objectives.

Page 28 GAO/NSIAD-97-9 Foreign Assistance
B-272263 

mortality problems do not receive direct U.S. aid and others with lower

mortality rates do. USAID’s new operating procedures have the potential to

address, for the most part, how its child survival activities will be linked to

USAID’s objectives and how its project activities will be measured. Our

concern that USAID’s new information management system provide

accurate obligation and expenditure data is being addressed by USAID. We

are still concerned, however, about the clarity of the guidance provided to

USAID’s activity managers for determining the percentage of funding and

expenditures attributable to child survival when a broader activity

contributes to USAID’s child survival objectives. We are, however, making

no specific recommendations in these areas.

USAID also provided clarifications and corrections to the draft, and we have

incorporated these changes where appropriate. USAID’s comments are in

appendix III.

Scope and

Methodology

To understand the extent, nature, and progress of USAID’s child survival

activities, we reviewed the authorizing and appropriations legislation for

1985-95 and the accompanying committee reports and selected USAID

project documents, including planning and program implementation

documents, internal and external project evaluations, funding reports,

health activity reports, and project files. We also held extensive

discussions with officials from USAID, WHO, PAHO, UNICEF, USAID contractors,

PVOs, and host governments and program beneficiaries. We visited USAID

missions in Bolivia, Egypt, Guatemala, and Mozambique to directly

observe the nature of USAID’s child survival activities being implemented in

the field. We selected these countries because they received significant

child survival funding, had various types of child survival projects, and

provided regional differences. During our fieldwork, we analyzed data for

most of the USAID missions’ ongoing projects and visited 63 project sites. In

addition to the fieldwork, we also talked with USAID project officers in two

other countries.

We analyzed USAID strategic objectives, program goals, and funding

documentation to determine the linkage between funds attributed to child

survival and USAID’s child survival objectives. We analyzed the most recent

data on USAID funding attributed to child survival for 1985-95, which we

obtained from the contractor that operates USAID’s Center for International

Health Information. At the time of our review, obligation data for fiscal

year 1995 were not fully validated; therefore, some of the fiscal year 1995

obligation data are subject to change. According to USAID officials, the 1995

Page 29 GAO/NSIAD-97-9 Foreign Assistance
B-272263 

data had to be recoded, and the process was not completed by

August 1996.

We conducted our review between May 1995 and August 1996 in

accordance with generally accepted government auditing standards.

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

earlier, we plan no distribution of this report until 30 days after the date of

this letter. We will then send copies of this report to the Administrator,

USAID; the Director, Office of Management and Budget; the Secretary of

State; and other interested congressional committees. We will also make

copies available to others on request.

Please contact me at (202) 512-4128 if you or your staff have any questions

concerning this report. Major contributors to this report are listed in

appendix IV.

Sincerely yours,

Benjamin F. Nelson

Director, International Relations 

and Trade Issues

Page 30 GAO/NSIAD-97-9 Foreign Assistance
Page 31 GAO/NSIAD-97-9 Foreign Assistance
Contents

Letter 1

Appendix I 

Child Survival

Objectives and

Program Guidance

34

Appendix II 

Under-5 Mortality

Rates and USAID

Mission-Level Funding

in Developing

Countries

38

Appendix III 

Comments From the

U.S. Agency for

International

Development

43

Appendix IV 

Major Contributors to

This Report

55

Tables Table 1: Obligations for USAID Child Survival Activities Through

Central Programs and by Geographic Region, Fiscal Years

1985-95

9

Table 2: Ten Countries Receiving the Most USAID Mission-Level

Assistance Attributed to Child Survival and Their Mortality Rates

for Children Under Age 5

10

Table 3: USAID Funding by Type of Child Survival Activity, Fiscal

Years 1985-95

14

Page 32 GAO/NSIAD-97-9 Foreign Assistance
Contents

Figures Figure 1: Causes of Death Among Children Under Age 5 in

Developing Countries, 1985 and 1993

2

Figure 2: Mortality Rates in 1994 for Children Under 5 Years of

Age and Countries That Received USAID Mission-Level Child

Survival Funding in 1994 or 1995

4

Figure 3: Types of Organizations That Received USAID Child

Survival Funds, Fiscal Year 1994

12

Figure 4: An Andean Rural Health Care Volunteer in Bolivia

Weighing an Infant During a Home Visit

21

Figure 5: USAID-Funded Equipment at a Plant That Manufactures

Oral Rehydration Salts in Guatemala

23

Figure 6: Water Tower in Mozambique That Was Partially Funded

as Child Survival

25

Figure 7: Railroad Bridge in Mozambique That Was Repaired With

Child Survival Funding

26

Abbreviations

AIDS acquired immune deficiency syndrome

CDIE Center for Development Information and Evaluation

HIV human immunodeficiency virus

NGO nongovernmental organization

PAHO Pan American Health Organization

PVO private voluntary organization

UNICEF U.N. Children’s Fund

USAID U.S. Agency for International Development

WHO World Health Organization

Page 33 GAO/NSIAD-97-9 Foreign Assistance
Appendix I 

Child Survival Objectives and Program

Guidance

Objectives In February 1985, in response to the legislation authorizing child survival

activities, the U.S. Agency for International Development (USAID)

established the child survival program to consolidate some of the agency’s

ongoing efforts related to reducing deaths among children in developing

countries. Although USAID provided mission-level child survival assistance

to 31 countries in 1985, it placed special emphasis on 22 countries that had

especially high mortality rates.

The child survival program for these 22 countries was originally guided by

USAID’s Child Survival Task Force. This task force helped to develop a

detailed child survival strategy for each country, in cooperation with the

host government, to deal with the country’s specific needs and

circumstances.

USAID’s policy was to sustain mission-level child survival funding in these

countries for at least 3 to 5 years and provide technical support and

training on a priority basis. Special attention was also to be given to

program monitoring and evaluation and coordination with private

voluntary organizations (PVO), international organizations, and other U.S.

agencies.

From 1985 to 1991, child survival appropriations went into a functional

account for child survival set up under an overall development assistance

account. Beginning in fiscal year 1992, Congress designated a specific

amount for child survival, which could be drawn from any USAID

appropriation. In the 1990s, child survival was incorporated into USAID’s

broad strategy for development assistance. According to the agency’s 1995

Guidelines for Strategic Plans, USAID’s current emphasis is on sustainable

and participatory development, partnerships, and the use of integrated

approaches.1

The agency’s five goals are to encourage broad-based economic growth,

build democracy, stabilize world population and protect human health,

protect the environment, and provide humanitarian assistance.

USAID’s population, health, and nutrition sector has priority objectives in

four areas: family planning, child survival, maternal health, and reducing

sexually transmitted diseases and human immunodeficiency virus

(HIV)/acquired immune deficiency syndrome (AIDS).

1

These guidelines, also known as implementation guidelines, are supplementary references to the 1994

Strategies for Sustainable Development to help shape the development of or revisions to unit strategic

plans.

Page 34 GAO/NSIAD-97-9 Foreign Assistance
Appendix I 

Child Survival Objectives and Program

Guidance

Agency guidelines indicate that the core of the sector is family planning

but that balanced strategies are encouraged. USAID’s guidance on child

survival states that activities are to focus on the principal causes of death

and severe lifelong disabilities, and programmatic emphasis should be on

children under the age of 3. Further, the guidance states that child survival

service delivery is to be focused on the community; the primary health

care system; and, to a limited extent, the first-level hospitals. Emphasis is

to be on enabling caretakers to take effective action on behalf of their

children’s well-being and ensuring gender equity in children’s access to

preventive and curative health. Although USAID considers health and

population services to be important, the agency does not provide them

directly; instead, it tries to improve the capacity, infrastructure, systems,

and policies that support these services in a sustainable way.

In its 1994 Strategies for Sustainable Development,2 USAID stated that the

agency’s population and health programs would concentrate on countries

that contribute the most to global population and health problems3

 and

have population and health conditions that impede sustainable

development.4

 Agency guidance states that any of the following key

factors indicate the need to consider developing strategic objectives that

address family planning, child survival, maternal health, and reduction of

sexually transmitted diseases and HIV/AIDS:

• annual total gross domestic product growth less than 2 percent higher

than annual population growth over the past 10 years,

• unmet need for contraception at or above 25 percent of married women of

childbearing age,

• total fertility rate above 3.5 children per woman,

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

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

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

2

This document provides USAID’s vision for achieving sustainable development and explains its goals

and objectives.

3

According to the guidance, these countries have large numbers of very young and older women

bearing children; many closely spaced births; high numbers of infant, child, and maternal deaths; high

female illiteracy; large numbers of women with an articulated but unmet need for family planning

services; and large numbers of persons infected with HIV or increasing rates of HIV infection.

4

These countries have fertility and population growth rates that outstrip the country’s ability to

provide adequate food and social services, growth rates that threaten the environment, significant

reproductive health problems due to heavy reliance on unsafe abortions, health conditions that impede

the ability of children to learn and the ability of adults to produce and participate, increasing rates of

HIV infection, and significant gender gaps in education.

5

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

Page 35 GAO/NSIAD-97-9 Foreign Assistance
Appendix I 

Child Survival Objectives and Program

Guidance

• prevalence of sexually transmitted diseases at or above 10 percent among

women aged 15 to 30.

Because USAID has identified global population growth as an issue of

strategic priority agencywide, guidance states that strategies directed at

family planning, child survival, maternal health, and reduction of sexually

transmitted diseases and HIV/AIDS—all of which must be considered

together—will receive particular attention in those countries where the

unmet need for contraception is the greatest. USAID stated that other

concerns would also include under-5 mortality, maternal mortality,

prevalence of sexually transmitted diseases, and stunting.

USAID’s long-term goal is to contribute to a cooperative global effort to

stabilize world population growth and protect human health. Its

anticipated near-term results over a 10-year period are (1) significant

improvement in women’s health, (2) a reduction in child mortality by

one-third, (3) a reduction of maternal mortality rates by one-half, and 

(4) a decrease in the rate of new HIV infections.

Program Guidance USAID issued guidance in 1992 and 1996 about the types of activities that

are allowable uses of child survival funds. The guidance named specific

types of activities that may be considered to fall under the child survival

program and gave broad discretion to USAID officials to determine the

proportion of funding that could be reported as child survival. The annual

instruction manual for coding activities and special interests further

specifies how activities are to be reported.

According to agency guidance and instructions, some activities are

automatically funded in their entirety as child survival. These activities are

• diarrheal disease control and related research,

• immunization and child-related vaccine research,

• child spacing/high-risk births,6

• acute respiratory infection,

• vitamin A,

• breastfeeding promotion,

• growth monitoring and weaning foods,

• micronutrients, and

6

Child spacing and high-risk birth activities may be funded by either child survival or population funds.

According to the guidance, these activities may be financed with child survival funds only when the

emphasis of the project is on reducing infant and child mortality rates. Population funds should be

used when the project is primarily designed to provide options for limiting family size.

Page 36 GAO/NSIAD-97-9 Foreign Assistance
Appendix I 

Child Survival Objectives and Program

Guidance

• orphans and displaced children.

Other activities can be partially funded as child survival. USAID’s guidance

stated that project managers could decide the percentage for the following

activities that could be reported as child survival, even though suggested

percentages were provided for some:

• health systems development;

• nutrition management, planning, and policy;

• other nutrition activities;

• health care financing;

• environmental health;

• vector control;

• water and sanitation;

• women’s health; and

• malaria research and control.

Page 37 GAO/NSIAD-97-9 Foreign Assistance
Appendix II 

Under-5 Mortality Rates and USAID

Mission-Level Funding in Developing

Countries

Under-5 mortality ratea Child survival fundsb

Dollars in thousands

Country Status 1980 1994

1994 Under-5

population 

(in millions) 1985-95 1995

Niger 1 320 320 1.8 $21,148 $2,500

Angola 2 261 292 2.1 1,830 0

Sierra Leone 3 301 284 0.8 127 113

Mozambique 1 269 277 2.8 62,494 9,793

Afghanistan 3 280 257 3.3 30,959 0

Guinea-Buissau 2 290 231 0.2 0 0

Guinea 2c 276 223 1.3 0 0

Malawi 1 290 221 2.1 22,949 3,562

Liberia 4 235 217 0.6 6,900 0

Mali 1 310 214 2.1 42,880 5,346

Gambia 4 278 213 0.2 122 0

Somalia 3 246 211 1.8 9,559 2,339

Zambia 1 160 203 1.7 4,200 4,200

Chad 3 254 202 1.1 9,532 0

Eritrea 1 260 200 0.6 7,149 519

Ethiopia 1 260 200 10.3 20,194 6,664

Mauritania 3 249 199 0.4 581 0

Bhutan 3 249 193 0.3 0 0

Nigeria 1 196 191 20.1 29,218 1,016

Zaire 4 204 186 8.3 12,365 0

Uganda 1 181 185 4.2 15,476 2,119

Cambodia 1 330 177 1.8 33,978 8,494

Burundi 3 193 176 1.2 2,941 0

Central African Republic 3 202 175 0.6 7,369 1,360

Burkina Faso 3 246 169 1.8 3,311 0

Madagascar 1 216 164 2.6 5,540 3,308

Tanzania 1 202 159 5.2 2,270 2,090

Lesotho 3 173 156 0.3 293 0

Gabon 3 194 151 0.2 0 0

Cote d’Ivoire 3 170 150 2.8 2,153 0

Benin 2 176 142 1.0 553 0

Rwanda 1 222 139 1.4 5,202 1,447

Laos 3 190 138 0.9 0 0

Pakistan 1 151 137 23.6 37,153 3,067

Togo 3 175 132 0.7 11,403 0

(continued)

Page 38 GAO/NSIAD-97-9 Foreign Assistance
Appendix II 

Under-5 Mortality Rates and USAID

Mission-Level Funding in Developing

Countries

Under-5 mortality ratea Child survival fundsb

Dollars in thousands

Country Status 1980 1994

1994 Under-5

population 

(in millions) 1985-95 1995

Ghana 2 155 131 3.0 $2,088 0

Haiti 1 195 127 1.1 78,440 $10,887

Sudan 4 200 122 4.6 10,579 0

India 1 177 119 116.6 68,772 900

Nepal 1 180 118 3.5 12,893 1,229

Bangladesh 1 211 117 17.1 48,001 2

Senegal 1 221 115 1.4 12,738 1,553

Yemen 2 210 112 2.7 9,346 0

Bolivia 1 170 110 1.1 60,566 3,264

Cameroon 3 173 109 2.2 14,833 0

Congo 3 125 109 0.5 0 0

Myanmar (Burma) 1 146 109 6.4 3,344 100

Swaziland 3 151 107 0.1 3,004 0

Libyan Arab Jamahiriya 4 150 95 0.9 0 0

Papua New Guinea 3 95 95 0.6 800 0

Kenya 1 112 90 5.1 21,353 312

Turkmenistan 2 N/A 87 0.6 79 0

Tajikistan 2 N/A 81 1.0 1,262 0

Zimbabwe 2 125 81 1.9 2,796 0

Indonesia 1 128 80 21.9 42,234 3,006

Namibia 2 114 78 0.2 0 0

Mongolia 2 112 76 0.3 0 0

Iraq 4 83 71 3.3 0 0

Guatemala 1 136 70 1.8 46,790 903

South Africa 1 91 68 5.6 3,883 3,883

Nicaragua 1 143 68 0.8 22,075 2,661

Algeria 3 145 65 3.6 0 0

Uzbekistan 2 N/A 64 3.2 124 0

Brazil 2 93 61 17.8 0 0

Guyana 2 88 61 0.1 0 0

Peru 1 130 58 2.9 50,443 1,388

Philippines 2 70 57 9.2 58,194 0

Ecuador 1 101 57 1.4 23,325 1,183

El Salvador 1 120 56 0.8 81,230 2,587

Morocco 1 145 56 3.4 16,843 1,400

Kyrgyzstan 2 N/A 56 0.6 159 0

(continued)

Page 39 GAO/NSIAD-97-9 Foreign Assistance
Appendix II 

Under-5 Mortality Rates and USAID

Mission-Level Funding in Developing

Countries

Under-5 mortality ratea Child survival fundsb

Dollars in thousands

Country Status 1980 1994

1994 Under-5

population 

(in millions) 1985-95 1995

Turkey 3 141 55 7.5 0 0

Botswana 3 94 54 0.2 $392 0

Honduras 1 100 54 0.9 53,550 $2,201

Egypt 1 180 52 8.1 136,860 27,001

Azerbaijan 1 N/A 51 0.8 10,894 9,150

Iran 4 126 51 10.4 0 0

Kazakhstan 2 N/A 48 1.6 484 0

Vietnam 3 105 46 10.1 0 0

Dominican Republic 1 94 45 1.0 13,985 1,195

China 4 65 43 107.3 0 0

Albania 2 57 41 0.4 0 0

Belize 3 56 41 0.03 4,755 0

Lebanon 1 40 40 0.4 875 395

Syrian Arab Republic 4 73 38 2.6 0 0

Moldova 2 N/A 36 0.4 29 0

Saudi Arabia 3 90 36 2.8 0 0

Paraguay 2 61 34 0.7 0 0

Tunisia 3 102 34 1.0 40 0

Thailand 3 61 32 5.4 1,748 0

Armenia 1 N/A 32 0.4 19,476 15,356

Macedonia 2 69 32 0.2 0 0

Mexico 2 87 32 11.8 0 0

Solomon Islands 3 56 32 0.1 500 0

Russian Federation 2 N/A 31 8.4 5,650 0

North Korea 4 43 31 2.6 0 0

Romania 1 36 29 1.3 2,461 2,141

Georgia 1 N/A 27 0.4 19,495 17,226

Argentina 3 41 27 3.3 0 0

Oman 3 95 27 0.4 9 0

Latvia 3 N/A 26 0.2 0 0

Ukraine 2 N/A 25 3.0 1,558 0

Jordan 2 66 25 0.9 9,700 0

Venezuela 3 42 24 2.8 0 0

Estonia 3 N/A 23 0.1 0 0

Yugoslavia 3 44 23 0.7 0 0

Mauritius 3 42 23 0.1 0 0

(continued)

Page 40 GAO/NSIAD-97-9 Foreign Assistance
Appendix II 

Under-5 Mortality Rates and USAID

Mission-Level Funding in Developing

Countries

Under-5 mortality ratea Child survival fundsb

Dollars in thousands

Country Status 1980 1994

1994 Under-5

population 

(in millions) 1985-95 1995

Belarus 2 N/A 21 0.6 $31 0

Uruguay 3 42 21 0.3 0 0

United Arab Emirates 3 64 20 0.2 0 0

Lithuania 2 N/A 20 0.3 0 0

Panama 2 31 20 0.3 0 0

Trinidad and Tobago 3 40 20 0.1 0 0

Bulgaria 2 25 19 0.5 0 0

Sri Lanka 2 52 19 1.8 1,370 0

Colombia 2 59 19 3.9 0 0

Bosnia and Herzegovina 2 38 17 0.2 0 0

Poland 2 24 16 2.5 1,991 0

Costa Rica 3 29 16 0.4 0 0

Chile 3 35 15 1.5 1,440 0

Slovakia 2 N/A 15 0.4 0 0

Malaysia 3 42 15 2.7 0 0

Croatia 1 23 14 0.3 355 $355

Hungary 2 26 14 0.6 0 0

Kuwait 3 35 14 0.2 0 0

Jamaica 1 39 13 0.3 3,562 501

Cuba 4 26 10 0.9 0 0

Czech Republic 2 N/A 10 0.7 0 0

South Korea 3 18 9 3.5 0 0

Slovenia 3 18 8 0.1 0 0

Hong Kong 3 13 6 0.3 0 0

Singapore 3 13 6 0.2 0 0

(Table notes on next page)

Page 41 GAO/NSIAD-97-9 Foreign Assistance
Appendix II 

Under-5 Mortality Rates and USAID

Mission-Level Funding in Developing

Countries

Legend:

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

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

year 1995.

3 USAID had no presence in the country and supported no mission-level programs, as of

August 1996, although some funding may be provided through regional or other mechanisms.

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

Note: N/A in the table is used for countries for which the information was not available, primarily

because these countries did not exist in 1980. Fiscal year 1995 child survival funding data were

current as of July 30, 1996. USAID officials said that figures reported for missions under the

Bureau for Europe and the New Independent States were not final at that time and may not be

accurate. The table does not include the West Bank/Gaza area, which received $585,900 in

USAID mission-level funding between 1985 and 1995.

aThe mortality rate represents the number of deaths per 1,000 live births for children under age 5,

or the probability of dying between birth and exactly 5 years of age.

bMission-level assistance is obligated by USAID field missions. These amounts do not include

USAID central or regional funds that may also have gone to these countries.

cUSAID is designing a child survival program for Guinea to start after the beginning of fiscal year

1997, according to a USAID official.

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

Page 42 GAO/NSIAD-97-9 Foreign Assistance
Appendix III 

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.

Page 43 GAO/NSIAD-97-9 Foreign Assistance
Appendix III 

Comments From the U.S. Agency for

International Development

See p. 28.

Now in app. II.

Now on p. 27.

Page 44 GAO/NSIAD-97-9 Foreign Assistance
Appendix III 

Comments From the U.S. Agency for

International Development

See p. 28.

Page 45 GAO/NSIAD-97-9 Foreign Assistance
Appendix III 

Comments From the U.S. Agency for

International Development

Now on pp. 7 and 26.

Now on p. 24.

See pp. 28 and 29.

Page 46 GAO/NSIAD-97-9 Foreign Assistance
Appendix III 

Comments From the U.S. Agency for

International Development

Page 47 GAO/NSIAD-97-9 Foreign Assistance
Appendix III 

Comments From the U.S. Agency for

International Development

See comment 1.

Now on pp. 7 and 13.

Now on p. 27.

See comment 1.

Page 48 GAO/NSIAD-97-9 Foreign Assistance
Appendix III 

Comments From the U.S. Agency for

International Development

Now on p. 36.

Now on p. 36.

Page 49 GAO/NSIAD-97-9 Foreign Assistance
Appendix III 

Comments From the U.S. Agency for

International Development

Now on p. 34.

Now on p. 36.

Now on p. 36.

See comment 1.

See comment 1.

Now on p. 34.

Now on pp. 7 and 15.

Page 50 GAO/NSIAD-97-9 Foreign Assistance
Appendix III 

Comments From the U.S. Agency for

International Development

Now on p. 15.

Now on pp. 16 and 17.

Page 51 GAO/NSIAD-97-9 Foreign Assistance
Appendix III 

Comments From the U.S. Agency for

International Development

See comment 1.

See comment 1.

Now on p. 15.

Now on p. 1.

Page 52 GAO/NSIAD-97-9 Foreign Assistance
Appendix III 

Comments From the U.S. Agency for

International Development

Now on p. 8.

Now on p. 24.

Now on p. 28.

Now on p. 17.

Page 53 GAO/NSIAD-97-9 Foreign Assistance
Appendix III 

Comments From the U.S. Agency for

International Development

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

GAO Comment 1. We have revised this report since the time we provided it to USAID for

comment. As a result, there are some instances in which the information

discussed in USAID’s letter is no longer included in our report.

Page 54 GAO/NSIAD-97-9 Foreign Assistance
Appendix IV 

Major Contributors to This Report

National Security and

International Affairs

Division, Washington,

D.C.

Jess T. Ford

Ronald A. Kushner

Sherlie S. Svestka

Ann L. Baker

David M. Bruno

Neyla Arnas

Karen S. Blum

Office of the General

Counsel

Richard Seldin

(711137) Page 55 GAO/NSIAD-97-9 Foreign Assistance
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