Emergency Funding for Ebola Response: Some USAID Reimbursements Did Not Comply with Legislative Requirements and Need to Be Reversed
Released: 2016-11-02T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: In March 2014, the World Health Organization reported an Ebola outbreak in West Africa and, as of June 2016, reported that the outbreak had resulted in more than 11,000 deaths in Guinea, Liberia, and Sierra Leone. USAID and State initially funded Ebola activities using funds already appropriated. In December 2014, Congress appropriated approximately $2.5 billion to USAID and State, in part, for international efforts to prevent, prepare for, and respond to an Ebola outbreak and mandated that the agencies report periodically on their use of the funds. Congress also allowed the agencies to reimburse accounts for obligations incurred for Ebola activities prior to the fiscal year 2015 appropriation.

The Act also included a provision for GAO to conduct oversight of USAID and State activities to prevent, prepare for, and respond to the Ebola outbreak. This report examines (1) USAID's and State's obligations and disbursements for Ebola activities and (2) the extent to which USAID made reimbursements in accordance with the fiscal year 2015 appropriations act. GAO analyzed USAID and State funding, reviewed documents on Ebola activities, and interviewed agency officials.

section_title: What GAO Found
paragraphs: As of July 1, 2016, the U.S. Agency for International Development (USAID) and the Department of State (State) had obligated 58 percent and disbursed more than one-third of the $2.5 billion appropriated for Ebola activities. In the early stages of the U.S. response in West Africa, USAID obligated $883 million to control the outbreak, and State obligated $34 million for medical evacuations, among other activities. Subsequently, the United States shifted focus to mitigating second-order impacts, such as the deterioration of health services and food insecurity, and strengthening global health security. Accordingly, USAID obligated $251 million to restore health services, among other activities, and $183 million for activities such as strengthening disease surveillance, while State obligated $5 million for biosecurity activities.

Of 271 reimbursements that USAID made for obligations incurred prior to the enactment of the Department of State, Foreign Operations, and Related Programs Appropriations Act, 2015 (the Act), USAID made 21 reimbursements, totaling over $60 million, that were not in accordance with the Act. These 21 reimbursements represent roughly 15 percent of the $401 million that USAID obligated for reimbursements, of the almost $1.5 billion that had been obligated as of July 1, 2016 (see fig.). For these 21 reimbursements, USAID did not reimburse the same appropriation accounts as the accounts from which it originally obligated the funds, and therefore it did not have legal authority to make these reimbursements. In addition, four reimbursements were for obligations that USAID did not document were for Ebola activities. In reviewing the reimbursements, GAO found that USAID does not have written policies or procedures for staff to follow in making and documenting reimbursements. As a result, USAID does not have a process that could provide reasonable assurance that it complies with reimbursement provisions of applicable appropriations laws, such as the reimbursement provisions in the Act.

section_title: What GAO Recommends
paragraphs: GAO is making four recommendations, including that USAID should reverse reimbursements not made in accordance with the Act and develop written policies and procedures for its reimbursement process. USAID concurred with GAO's recommendations.

section_title: Letter
paragraphs: In March 2014, the World Health Organization (WHO) initially reported the  occurrence of a rapidly evolving Ebola virus disease outbreak in West  Africa. By August 2014, the outbreak had become the largest since the  virus was first discovered, according to WHO. Although Ebola outbreaks  have occurred sporadically in Africa since 1976, there were more Ebola  cases and deaths during the 2014 outbreak than in all of the previous  outbreaks combined. In August 2014, the WHO Director-General  declared the Ebola outbreak in West Africa a Public Health Emergency of  International  Concern. As of June 2016, the outbreak had resulted in  more than 28,600 confirmed, probable, or suspected cases of Ebola and more than 11,300 deaths in the West African countries primarily  affected—Guinea, Liberia, and Sierra Leone, according to WHO. These  countries were particularly vulnerable because they had weak health  systems and only recently emerged from long periods of conflict and  instability. The U.S. Agency for International  Development (USAID) noted  that the outbreak caused second-order effects, including immediate  disruptions to the three countries’ health systems, reduced economic  activity, job loss, and food insecurity.

In response to the outbreak, USAID and the Department of State (State),  along with other U.S. agencies and international and nongovernmental  organizations, took urgent steps to reduce the transmission of the Ebola  virus and provide emergency treatment and care to infected persons. In  addition, USAID and State initiated efforts to address second-order  effects and better prepare international health systems for future  outbreaks. USAID and State initiated Ebola response and preparedness  activities (Ebola activities) using current and prior year appropriations. In  December 2014, Congress enacted the Department of State, Foreign  Operations, and Related Programs Appropriations Act, 2015 (the Act),  which provided approximately $2.5 billion to USAID and State for  necessary expenses to prevent, prepare for, and respond to an Ebola  outbreak. The Act also directed State, in consultation with USAID, to  submit periodic reports to the Senate and House Committees on  Appropriations on the proposed uses of these funds on a country and  project basis. In addition, the Act authorized USAID and State to use the  funds to reimburse accounts for the obligations made for Ebola activities  prior to the December 16, 2014, enactment of the legislation.

The Act also included a provision for GAO to conduct oversight of USAID  and State activities to prevent, prepare for, and respond to the Ebola  outbreak and reimbursements made pursuant to specific provisions in the  Act. This report examines (1) USAID’s and State’s obligations and disbursements for Ebola activities and (2) the extent to which USAID  made reimbursements in accordance with the requirements of the fiscal  year 2015 appropriations act.

To examine USAID’s and State’s obligations and disbursements for Ebola  activities, we analyzed the agencies’ funding data from their reports to  Congress to determine each agency’s allocations, obligations, and  disbursements for Ebola activities from the fiscal year 2015  appropriation. We also reviewed the agencies’ reports to Congress to  identify agencies’ reported use of the funds. To examine USAID’s  reimbursements, we analyzed USAID data and documentation to  determine the dates and amounts of obligations that the agency incurred  for Ebola activities prior to the enactment of the Act, the appropriation  accounts that funded the obligations, and the amounts of the  reimbursements. In addition, we interviewed USAID and State officials  about the collection and reporting of the funding data and the agencies’  use of funding for Ebola activities. We also reviewed USAID policies for  financial management. Finally, we assessed the extent to which the  reimbursements were consistent with the provisions of the Act and met  internal control standards. To assess the reliability  of the funding data, we  obtained data from the financial data system that USAID used to report  the funding data and conducted interviews with USAID and State officials.  When we found data discrepancies, we contacted agency officials and  collaborated with them to resolve the discrepancies. We determined that  the data we used were sufficiently reliable for our purposes. See  appendix I for more information about how we assessed the data’s  reliability and our overall scope and methodology.

We conducted this performance audit from June 2015 to November 2016  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: The 2014 Ebola Outbreak in West Africa
paragraphs: The Ebola outbreak was first identified in the remote Guinean village of  Meliandou  in December 2013 and subsequently spread to neighboring  Sierra Leone and Liberia and later to other African countries, including  Mali, Nigeria, and Senegal (see fig. 1). Guinea, Liberia, and Sierra Leone  experienced the largest number of confirmed, probable, or suspected  cases and deaths. As of June 2016, WHO reported 28,616 confirmed,  probable, or suspected Ebola cases and 11,310 deaths in these three  countries since the onset of the outbreak (see fig. 2). WHO reported the  majority of these cases and deaths between August 2014 and December  2014. After 2014, the number of new cases began to decline, and on  March 29, 2016, the WHO Director-General terminated the Public Health  Emergency of International Concern designation related to Ebola in West  Africa and recommended lifting the temporary restrictions to travel and  trade with Guinea, Liberia, and Sierra Leone. However, seven confirmed  and three probable cases were reported in Guinea, and three confirmed  cases of Ebola were reported in Liberia in March 2016 and April 2016,  respectively. Figure 3 shows the numbers of confirmed, probable, and  suspected Ebola cases and deaths in Guinea, Liberia, and Sierra Leone  by month from August 2014 to December 2015.

USAID noted that the Ebola outbreak caused disruptions to health  systems and adverse economic impacts in Guinea, Liberia, and Sierra  Leone. Health-care resources in these countries were diverted from other  programs to Ebola response efforts, and some patients and health-care  workers avoided health facilities for fear of contracting the disease.  USAID also noted that these countries experienced job loss, disruptions  to trade, reduced agricultural production, decreased household  purchasing power, and increased food insecurity as a consequence of the  outbreak. The closure of international borders in response to the outbreak  hampered economic activity by limiting trade and restricting the  movement of people, goods, and services. In addition, the Ebola outbreak  occurred at the beginning of the planting season, which affected  agricultural markets and food supplies.

section_title: U.S. Role in Response to the Outbreak
paragraphs: U.S. efforts to respond to the Ebola outbreak in West Africa began in  March 2014 when the Centers for Disease Control and Prevention (CDC)  deployed personnel to help with initial response efforts. In August 2014,  the U.S. ambassador to Liberia and the U.S. chiefs of mission in Guinea  and Sierra Leone declared disasters in each country. Following the  declarations, USAID and CDC deployed medical experts to West Africa to  augment existing staff in each of the affected countries. In August 2014, a  USAID-led Disaster Assistance Response Team (DART) deployed to  West Africa. USAID-funded  organizations began to procure and  distribute relief commodities and establish Ebola treatment units, and  CDC began laboratory testing in West Africa. In September 2014, the  Department of Defense (DOD) began direct support to civilian-led  response efforts under Operation United Assistance.

In September 2014, the President announced the U.S. government’s  strategy to address the Ebola outbreak in the three primarily affected  West African countries. The National Security Council, the Office of  Management and Budget, USAID, and State developed an interagency  strategy that has been revised over time to reflect new information about  the outbreak and changes in international response efforts. The strategy  is organized around four pillars and their associated activities (see   table 1).

Multiple  U.S. agencies have played a role in the U.S. government’s  response to the Ebola outbreak in West Africa. USAID managed and  coordinated the overall U.S. effort to respond to the Ebola outbreak  overseas, and State led diplomatic efforts related to the outbreak. CDC  led the medical and public health component of the U.S. government’s  response efforts. For example, CDC provided technical assistance and  disease control activities with other U.S. agencies and international  organizations. In addition, CDC assisted in disease surveillance and  contact tracing to identify and monitor individuals who had come into  contact with an Ebola patient. DOD coordinated U.S. military efforts with  other agencies, international organizations, and nongovernmental  organizations. DOD also constructed Ebola treatment facilities,  transported medical supplies and medical personnel, trained health-care  workers, and deployed mobile laboratories to enhance diagnostic  capabilities in the field. Other federal agencies, including the Department  of Agriculture, also contributed to the overall U.S. response.

Although U.S. response efforts have focused primarily on Liberia, the  United States has been engaged in all three primarily affected West  African countries. The U.S. government also undertook response efforts  in Mali following an Ebola outbreak in that country in October 2014.  Currently, U.S. response efforts include regional activities that  encompass multiple countries, including activities to build the capacity of  West African countries to prepare for and respond to infectious disease  outbreaks.

section_title: Funding the U.S. Government’s Response to the Outbreak
paragraphs: Prior to the fiscal year 2015 appropriation, USAID and State funded  activities in response to the Ebola outbreak using funds already  appropriated. On December 16, 2014, Congress appropriated  approximately $5.4 billion in emergency funding for Ebola preparedness  and response to multiple U.S. agencies as part of the Consolidated and  Further Continuing Appropriations Act, 2015 (the fiscal year 2015  consolidated appropriations act). Within the fiscal year 2015  consolidated appropriations act, Congress provided approximately $2.5  billion to USAID and State for necessary expenses to assist countries  affected by, or at the risk of being affected by, the Ebola outbreak and for  efforts to mitigate the risk of illicit acquisition of the Ebola virus and to  promote biosecurity practices associated with Ebola outbreak response  efforts. These funds were made available from different accounts and  are subject to different periods of availability  (see table 2).

The Act requires State, in consultation with USAID, to submit reports to  the Senate and House Committees on Appropriations on the proposed  uses of the funds on a country and project basis, for which the obligation  of funds is anticipated, no later than 30 days after enactment. These  reports are to be updated and submitted every 30 days until September  30, 2016, and every 180 days thereafter until all funds have been fully  expended. The reports are to include (1) information detailing how the  estimates and assumptions contained in the previous reports have  changed and (2) obligations and expenditures on a country and project  basis.

In addition, Section 9002 of the Department of State, Foreign Operations,  and Related Programs Appropriations Act, 2015, authorized USAID and  State to use funds appropriated for the Global Health Programs (GHP),  International  Disaster Assistance (IDA), and Economic Support Fund  (ESF) accounts to reimburse appropriation accounts administered by  USAID and State for obligations incurred to prevent, prepare for, and  respond to the Ebola outbreak prior to enactment of the Act. USAID  reports that it has made reimbursements totaling $401 million for  obligations made prior to the Act, using $371 million from the IDA account  and $30 million from the ESF account of the fiscal year 2015  appropriation. USAID reports that these obligations were incurred by the  Office of U.S. Foreign Disaster Assistance (OFDA); the Office of Food for  Peace (FFP); the Bureau for Global Health; and missions in Liberia,  Guinea, and Senegal. Figure 4 shows USAID’s reported obligations by  office and bureau. State reported that it did not reimburse funding for  obligations made prior to the act.

section_title: USAID and State Have Obligated 58 Percent and Disbursed More than One-Third of $2.5 Billion in Ebola Funding
paragraphs: As of July 1, 2016, USAID and State had obligated 58 percent and  disbursed more than one-third of the $2.5 billion appropriated by the  Department of State, Foreign Operations, and Related Programs  Appropriations Act, 2015 for Ebola response and preparedness  activities. USAID and State obligated funds from various appropriation  accounts for Ebola activities during different stages of the response, with  the largest shares of funding going to Pillar 1 activities to control the  outbreak and to support regional Ebola activities in multiple countries. In  response to the Ebola outbreak, USAID obligated funds from the IDA  account, and State obligated funds from the Diplomatic & Consular  Programs (D&CP) account. As the U.S. government shifted its focus to mitigating second-order impacts and strengthening global health security,  USAID obligated funds from the ESF and GHP accounts, and State  obligated Nonproliferation, Antiterrorism, Demining, and Related  Programs (NADR) account funds for biosecurity activities.
subsections: section_title: USAID and State Have Obligated 58 Percent and Disbursed More than One- Third of Their Appropriated Funding for Ebola Response and Preparedness Activities
paragraphs: As of July 1, 2016, USAID  and State had obligated  a total of almost $1.5  billion  (58 percent) and disbursed $875 million (35 percent) of the $2.5  billion  appropriated for Ebola response and preparedness activities (see  fig. 5).

USAID and State used different appropriation accounts to fund Ebola  activities. As shown in table 3 below, USAID allocated the greatest  amount of funding for Ebola activities from the IDA account, followed by  the ESF and GHP accounts. State allocated funding from the NADR  account and D&CP account for Ebola activities.

USAID notified the relevant congressional committees on April 8, 2016,  that it intended to obligate $295 million in ESF Ebola funds, of which  USAID and State would reprogram  $215 million for international  response activities related to Zika, including $78 million to the CDC for  Zika response activities, and $80 million for the CDC’s international  coordination of response efforts related to Ebola. As USAID obligates  funding for Zika activities, the unobligated balances in the ESF account  will continue to decrease. ESF funds appropriated in the Act must have  been obligated by September 30, 2016. See figure 6 below for  obligations and disbursements by appropriation account, as of July 1,  2016.

USAID and State used different appropriation accounts to fund Ebola  activities across the four pillars of the U.S. government’s Ebola strategy.  For example, USAID primarily used IDA account funds to control the  outbreak (Pillar 1), ESF account funds to mitigate second-order impacts  of Ebola (Pillar 2), and GHP account funds to strengthen global health  security (Pillar 4). USAID allocated all of the funding from the Operating  Expenses account to building coherent leadership and operations (Pillar  3). As of July 1, 2016, USAID had obligated more than 60 percent of  funds allocated for Pillars 1, 2, and 4 and obligated just under 50 percent  of the funds allocated for Pillar 3; USAID and State had disbursed 85  percent of Pillar 1 obligations. See table 4 for the status of allocated  funding by Ebola strategy pillar.

USAID allocated the greatest amount of funding to activities to control the  Ebola outbreak (Pillar 1) and allocated approximately similar amounts of  funding to mitigate the second-order impacts of Ebola (Pillar 2) and to  strengthen global health security (Pillar 4). Figure 7 shows allocations,  obligations, and disbursements by Ebola strategy pillar, as of July 1,  2016. See appendix II for trends in obligations and disbursements by  Ebola strategy pillar, as of July 1, 2016.

USAID allocated the largest share of its funding to support regional Ebola  activities. Ebola funding for regional activities includes all five  appropriation accounts administered by USAID from the fiscal year 2015  appropriation (IDA, ESF, GHP, USAID Operating Expenses, and USAID’s  Office of Inspector General) and State’s NADR account. The GHP  account represents 42 percent of obligated funding for regional activities,  while ESF and IDA represent approximately 29 percent and 21 percent of  such funding, respectively. See table 5 below for the status of allocated  Ebola funding by geographic area.

Of the three countries most affected by the Ebola virus, USAID obligated  and disbursed the most funding for Liberia, as the U.S. government took  a lead role in Ebola response efforts in this country. Figure 8 shows  allocations, obligations, and disbursements for Liberia, compared with  Sierra Leone and Guinea. See appendix III  for trends in obligations and  disbursements for each country, as of July 1, 2016.

section_title: In Response to the Ebola Outbreak, USAID Obligated IDA Funds, and State Obligated D&CP Funds
paragraphs: Prior to the enactment of the Act in December 2014, USAID had obligated  $401 million to respond to the Ebola outbreak. USAID obligated the  majority of this funding from the IDA account for Pillar 1 activities to  control the outbreak in Liberia. State did not obligate any funding prior to  the Act but began obligating D&CP funding to respond to the Ebola  outbreak in April 2015.
subsections: section_title: IDA Account
paragraphs: During the early stages of the response to the Ebola outbreak, USAID  obligated IDA funds for the majority of its Ebola activities, both before and  after it received funding for Ebola activities from the Act. By February 2015, USAID had obligated more than $550 million in IDA funding. USAID  obligated IDA account funding at a lower rate after July 1, 2015, as  USAID began to shift its focus to recovery activities. As of July 1, 2016,  USAID had obligated more than 60 percent of IDA account funding and  disbursed more than 80 percent of obligations.

USAID used the majority of IDA funds to control the outbreak in Liberia  (Pillar 1). Activities to control the outbreak included providing care to  Ebola patients; supporting safe burials; promoting infection prevention  and control at health facilities; distributing Ebola protection and treatment  kits; and conducting Ebola awareness, communication, and training  programs. USAID obligated approximately 60 percent of IDA funds for  Liberia as of July 1, 2016, which reflects the U.S. government’s lead role  in responding to the Ebola outbreak in that country.

USAID plans to use the remaining approximately 40 percent of  unobligated IDA funds for future Ebola response activities as needed.  According to USAID officials, since April 2016, OFDA has programmed  IDA funding to provide support for maintaining a residual response  capacity and for transitioning to long-term development efforts. According  to OFDA officials, these activities will require a modest amount of funding  in fiscal year 2017. OFDA officials also noted that the unobligated IDA  balance would remain available to address any new cases or outbreaks  of Ebola that spread beyond the ability of the host governments to contain  them.

section_title: D&CP Account
paragraphs: State obligated most of its D&CP account funding to respond to the Ebola  outbreak in early 2015. In February 2015, State notified the relevant  congressional committees of its intention to allocate $33 million of $36  million in D&CP account funding to the Office of Medical Services. By the  end of May 2015, the Office of Medical Services had obligated 97 percent  of its allocated funding and disbursed all of its obligated funding for  medical evacuations; overseas hospitalization expenses; and personal  protective equipment, among other things. State’s Bureau of  Administration, which provided grants to international schools affected by  the Ebola outbreak, obligated 95 percent of its allocated D&CP funding by  the end of April 2015. State’s Africa Bureau also obligated funding in the  early stages of the Ebola response, as it provided support for State’s  Ebola Coordination Unit and U.S. embassies affected by Ebola. The  Africa Bureau obligated more than half of its D&CP funding for Ebola  activities by the end of July 2015. As of June 30, 2016, State had  obligated 94 percent of the D&CP account funding and disbursed 99  percent of its obligated funding.

section_title: To Mitigate Second-Order Impacts and Strengthen Global Health Security, USAID Obligated ESF and GHP Funds, While State Obligated NADR Funds for Biosecurity Activities
paragraphs: USAID started to focus its efforts on mitigating second-order impacts of  the outbreak and strengthening global health security between June 1,  2015, and October 1, 2015, using funding from the ESF and GHP  accounts. As of May 1, 2015, State began obligating NADR funds for  biosecurity activities.
subsections: section_title: ESF Account
paragraphs: USAID increased obligations of ESF by approximately $68 million  between June 1, 2015, and October 1, 2015, as USAID offices such as  the Bureau for Global Health and the U.S. Global Development Lab  obligated ESF funds for activities to mitigate the second-order impacts of  the outbreak (Pillar 2). USAID disbursements of ESF funding were less  than $5 million until September 1, 2015. As of July 1, 2016, USAID had  obligated $251 million from the ESF account for Ebola activities, which  represented 35 percent of its total allocated funding from the ESF  account.

Of the ESF funding that USAID obligated to mitigate the second-order  impacts of Ebola, USAID obligated the majority of such funding for  activities in Liberia, Sierra Leone, and Guinea. Such activities included  the development of facilities to decontaminate health-care workers and  equipment, restoring routine health services, and strengthening health  information systems to better respond to future disease outbreaks.  Approximately 45 percent of obligated ESF funds supported such  activities in Liberia, while 22 percent and 17 percent funded activities in  Sierra Leone and Guinea, respectively.

section_title: GHP Account
paragraphs: As the numbers of new Ebola cases declined, USAID also began to focus  on longer-term efforts to strengthen global health security, using funding  from the GHP account. Accordingly, USAID reported no obligations of  GHP funding before June 1, 2015 and no disbursements until August 1,  2015. As of July 1, 2016, USAID had obligated 59 percent and disbursed  10 percent of its GHP account funds for Ebola response activities. The  Bureau for Global Health, which programs the majority of GHP funding,  added all of its GHP funding for Ebola activities to existing awards.  Because of the method of payment used for these awards, funding from  older appropriations is used first. As a result, the percentage of GHP  funding that USAID has disbursed from the fiscal year 2015 appropriation  for Ebola activities is the lowest (10 percent) of any account. GHP funding  appropriated in the Act does not expire, so USAID can obligate and  disburse these funds in future fiscal years.

USAID has obligated all of the funding in the GHP account to strengthen  global health security (Pillar 4). Such activities included building  laboratory capacity, strengthening community surveillance systems to  detect and monitor Ebola and other diseases, and building the capacity of  West African governments to prepare for and respond to infectious  disease outbreaks. Nearly all GHP funding is regional funding rather than  funding for a specific Ebola-affected country. For trends in obligations and  disbursements of IDA, ESF, and GHP funds for Ebola from February 3,  2015 to July 1, 2016, see appendix IV.

section_title: NADR Account
paragraphs: State’s Bureau of International Security and Nonproliferation  did not begin  obligating funding from the NADR account until May 1, 2015, and did not  disburse any NADR funds until September 1, 2015, for biosecurity  activities. Such activities included training on biosecurity best practices  and strategies for Ebola sample management as well as conducting  biosecurity risk assessments. All NADR funding supports regional  activities in West Africa rather than activities in a single country. As of  July 1, 2016, State had obligated all of its NADR funding and disbursed  40 percent of obligated funding from this account.

section_title: USAID Made Reimbursements That Were Not in Accordance with the Provisions of the Act, and USAID Has Not Developed Reimbursement Policies
paragraphs: Twenty-one of USAID’s 271 reimbursements for obligations incurred prior  to the enactment of the Department of State, Foreign Operations, and  Related Programs Appropriations Act, 2015, were not in accordance with  the reimbursement provisions of the Act. These 21 transactions account  for over $60 million, or roughly 15 percent, of the approximately $401  million reimbursed. Because USAID did not have the legal authority to  make the reimbursements that were not in accordance with the  reimbursement provisions in the Act, these reimbursements represent  unauthorized transfers. As of October 2016, USAID had not determined  whether it had budget authority to support the obligations against the  accounts that were improperly reimbursed, possibly resulting in a violation  of the Antideficiency Act. In addition, USAID has not developed written  policies or procedures to guide staff on appropriate steps to take for the  reimbursement process. Such policies or procedures could provide  USAID with reasonable assurance that it will comply with reimbursement  provisions and mitigate the risk of noncompliance.
subsections: section_title: Twenty-One of USAID’s 271 Reimbursements Were Not Made In Accordance with the Provisions of the Act
paragraphs: Of 271 reimbursements that USAID made for obligations incurred prior to  the enactment of the Act, USAID made 21 reimbursements (totaling over  $60 million) that were not in accordance with the Act. These 21  reimbursements represent roughly 15 percent of the approximately $401  million that USAID obligated for reimbursements, of the almost $1.5 billion  that had been obligated as of July 1, 2016. USAID made the other 250  reimbursements (totaling about $341 million) in accordance with the  reimbursement provisions of the Act for funds that OFDA and FFP  obligated prior to enactment of the Act. To assess whether USAID’s  reimbursements were in accordance with the Act, we reviewed USAID  documentation to determine whether each reimbursement met the four  provisions described in the text box below.

Reimbursement Provisions of the Department of State, Foreign  Operations, and Related Programs Appropriations Act, 2015

The reimbursement was made to the same appropriation account as  the account from which the U.S. Agency for International  Development originally obligated the funds.

The obligation was incurred prior to the December 16, 2014,  enactment of the Act.

The obligation was incurred to prevent, prepare for, and respond to  the Ebola outbreak.

The reimbursement was made from the International  Disaster  Assistance, Economic Support Fund, and Global Health Programs  accounts of the fiscal year 2015 appropriation.

For the 21 reimbursements (totaling over $60 million), USAID did not  reimburse the same appropriation accounts as the accounts from which  USAID originally obligated the funds. Moreover, for 4 of the 21  reimbursements, USAID reimbursed obligations for which it did not  document that it incurred the obligation to prevent, prepare for, or  respond to the Ebola outbreak. Specifically,

USAID did not reimburse the same appropriation account as the  account from which USAID originally obligated the funds. The Bureau  for Global Health; FFP; and the missions in Guinea, Liberia, and  Senegal incurred over $60 million in obligations from the GHP, Title II  of the Food for Peace Act (Title II), and Development Assistance  accounts. Although USAID used funding from the ESF and IDA  accounts of the fiscal year 2015 appropriation to make 21  reimbursements for these obligations, the agency did not reimburse  the GHP, Title II,  and Development Assistance accounts from which  USAID originally obligated the funds, in accordance with the Act (see  table 6). Instead, USAID reimbursed the office, bureau or mission that  originally obligated the funds. These reimbursements were made to  different accounts, with different spending authorities, than those from  which the original obligation was made. For example, FFP obligated  approximately $30 million in Title II account funds for the World Food  Program’s regional program to address the urgent food needs of  populations affected by the Ebola outbreak, but USAID used  approximately $30 million in IDA account funds from the fiscal year  2015 appropriation to reimburse FFP and credited the funds to FFP’s  IDA account.

USAID reimbursed obligations for which it did not document that it  incurred the obligation to prevent, prepare for, and respond to the  Ebola outbreak. USAID made four reimbursements, totaling about  $3.3 million, for which USAID was unable to provide documentation  showing that the original obligations funded activities to prevent,  prepare for, and respond to the Ebola outbreak. For example, USAID  reimbursed approximately $1.3 million for an obligation incurred by  the Bureau for Global Health in September 2014. However, USAID  officials noted that they did not document the amount or purpose of  the obligation at the time the funds were obligated. In July 2016, in  response to our inquiry, USAID prepared a memorandum to attest  that the original obligation was approximately $1.3 million and funded  technical assistance for Ebola preparedness to 13 African countries.  In another instance, USAID reimbursed $500,000 for an obligation  incurred for the preparation of laboratories to detect Middle East  Respiratory Syndrome (MERS) and other acute respiratory infections  in the Africa region. However, USAID was unable to provide us  documentation showing how the obligation funded activities related to  the Ebola outbreak.

Because USAID did not have the legal authority to make the  reimbursements that were not in accordance with the reimbursement  provisions in the Act, these 21 reimbursements represent unauthorized  transfers. Further, the Antideficiency Act prohibits an agency from  obligating or expending more than has been appropriated to it. As of  October 2016, USAID had not determined whether it had the budget  authority to support the obligations against the accounts that were  improperly reimbursed.

See appendix V for a complete list of USAID’s reimbursements for  obligations incurred prior to the fiscal year 2015 appropriation.

section_title: USAID Has Not Developed Written Policies for the Reimbursement Process
paragraphs: The concerns we identified with the 21 reimbursements could partly be  attributed to the fact that USAID has not developed written policies or  procedures to guide staff on appropriate steps to take to make  reimbursements and document them. Internal control standards require  that management design control activities—actions established through  policies and procedures—to achieve objectives and respond to risks and  implement such activities through policies. By developing written  policies and procedures, offices and bureaus would know what steps they  should take to ensure that reimbursements are made in accordance with  an appropriation act and other applicable appropriations laws and are  recorded in a manner that allows documentation to be readily available  for examination. Such written policies and procedures could provide  USAID with reasonable assurance that it is complying with  reimbursement provisions and help mitigate the risk of noncompliance.

Without written policies and procedures, USAID does not have a process  in place for making reimbursements and maintaining documentation to  show that it complied with the reimbursement provisions of the Act. Our  review found that USAID made 21 reimbursements that it did not have the  legal authority to make, possibly resulting in the obligation or expenditure  of funds in excess of appropriations, which would violate the  Antideficiency Act. In addition, because USAID did not have written  policies and procedures for maintaining documentation of the  reimbursements, USAID officials spent several months locating records to  demonstrate to us that USAID had reimbursed 250 obligations in a  manner consistent with the provisions of the Act. USAID officials also  noted that because they did not document the purpose of some  obligations at the time the funds were obligated, USAID officials had to  create a memorandum to explain how two reimbursed obligations funded  USAID activities to prevent, prepare for, and respond to the Ebola  outbreak.

section_title: Conclusions
paragraphs: West Africa has experienced the largest and most complex Ebola  outbreak since the virus was first discovered, resulting in more than  11,000 deaths. The outbreak not only disrupted the already weak health- care systems in Guinea, Liberia, and Sierra Leone but also contributed to  reduced economic activity, job loss, and food insecurity in these  countries. USAID and State have funded a range of activities to control  the outbreak and will continue to fund longer-term efforts to mitigate the  second-order effects and strengthen global health security.

The Department of State, Foreign Operations, and Related Programs  Appropriations Act, 2015, authorized the reimbursement of obligations  incurred prior to enactment to prevent, prepare for, and respond to the  Ebola outbreak. While most of USAID’s reimbursements were made in  accordance with the reimbursement provisions of the Act, roughly 15  percent of the funds that USAID reimbursed were not. In particular,  USAID did not in all cases reimburse the same appropriation accounts  from which it obligated funds as required by the Act, and in several  instances it made reimbursements for obligations for which it did not  document that it incurred the obligation to prevent, prepare for, and  respond to the Ebola outbreak. As a result, USAID may not have the  budget authority to support the obligations against the accounts that were  erroneously reimbursed, which may result in a violation of the  Antideficiency Act. Furthermore, without written policies and procedures,  USAID risks the possibility of noncompliance recurring should USAID be  granted reimbursement authority in the future.

section_title: Recommendations for Executive Action
paragraphs: To ensure that USAID reimburses funds in accordance with section 9002  of the Department of State, Foreign Operations, and Related Programs  Appropriations Act, 2015, we recommend that the Administrator of USAID  take the following three actions:  1.  Reverse reimbursements that were not made to the same  appropriation account as the account from which USAID obligated the  funds.  2.  Reverse reimbursements for which there is no documentary evidence  that the obligation was incurred to prevent, prepare for, and respond  to the Ebola outbreak.  3.  Determine whether reversing any of these reimbursements results in  the obligation of funds in excess of appropriations in violation of the  Antideficiency Act and, if so, report any violations in accordance with  law.

To help ensure that USAID complies with reimbursement provisions that  may arise in future appropriations laws, we recommend that the  Administrator of USAID develop written policies and procedures for the  agency’s reimbursement process.

section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to USAID and State for comment. In its  written comments, reproduced in appendix VI, USAID agreed with our  findings and recommendations. USAID noted that it would reverse  reimbursements that were not made to the same appropriation account  as the account from which USAID originally obligated funds, and that it is  reviewing whether it has violated the Antideficiency Act. State did not  provide formal comments. USAID and State also provided technical  comments, which we incorporated throughout the report, as appropriate.

We are sending copies of this report to the appropriate congressional  committees, the U.S. Agency for International  Development, the  Department of State, and other interested parties. In addition, the report is  available at no charge on the GAO website at http://www.gao.gov  If you or your staff have any questions about this report, please contact  me at (202) 512-3149 or gootnickd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix VII.

section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: The Department of State, Foreign Operations, and Related Programs  Appropriations Act, 2015 (the Act), included a provision for us to conduct  oversight of the U.S. Agency for International  Development’s (USAID)  and the Department of State’s (State) activities to prevent, prepare for,  and respond to the 2014 Ebola outbreak and reimbursements made. We  examined (1) USAID’s and State’s obligations and disbursements for  Ebola activities and (2) the extent to which USAID made reimbursements  in accordance with the requirements of the fiscal year 2015  appropriations act.

To examine USAID’s and State’s obligations and disbursements for Ebola  activities, we analyzed each agency’s allocation, obligation, and  disbursement data for Ebola response and preparedness activities  reported in USAID’s and State’s reports to the Senate and House  Committees on Appropriations mandated by the Act. We analyzed  USAID’s and State’s reported data on allocations, obligations, and  disbursements that USAID and State reported from February 3, 2015, to  July 1, 2016. We obtained and analyzed the data from USAID for the  International  Disaster Assistance; Global Health Programs; Economic  Support Fund; USAID Operating Expenses; Nonproliferation,  Antiterrorism, Demining, and Related Programs; and USAID Office of  Inspector General appropriation accounts. We obtained and analyzed the  data for the Diplomatic & Consular Programs account from State, which  State reported separately. We reviewed each agency’s reports to  congressional committees to determine the activities funded and reasons  for any changes in the agencies’ cost estimates and use of the funds. We  interviewed USAID and State officials in Washington, D.C., from each  bureau and office that administers funding from accounts of the fiscal  year 2015 appropriation to discuss the status of the agencies’ obligations  and disbursements for activities to prevent, prepare for, and respond to  the Ebola outbreak in West Africa, methods for reporting the funding data,  and plans for obligating and disbursing the funds. We also interviewed  officials from each of USAID’s and State’s offices that report on the funds  to obtain information about their budgeting process and terms to  determine the best method for analyzing the data across accounts. We  then reviewed the data and information reported and consulted with  USAID and State officials on the accuracy and completeness of the data  and information. When we found data discrepancies, we contacted  relevant agency officials and obtained information from them necessary to  resolve the discrepancies. To assess the reliability of the data provided,  we requested and reviewed information from agency officials regarding  the underlying financial data systems and the checks and reviews used to  generate the data and ensure its accuracy and reliability. To further  ensure the reliability  of the data, we obtained from USAID officials data  from the financial data system that USAID used to report obligation and  disbursement data and compared them to a sample of the data that we  analyzed. We determined that the data we used were sufficiently reliable  for our purposes of examining USAID’s and State’s obligations and  disbursements of the funds.

To examine the extent to which USAID made reimbursements in  accordance with the Act, we reviewed USAID’s reports to the Senate and  House Committees on Appropriations mandated by the Act to determine  the obligations that the agency incurred prior to enactment and the  reimbursements that USAID made for the obligations. We obtained data  and documentation from each USAID bureau and office that administered  the appropriation accounts for the obligations incurred prior to the fiscal  year 2015 appropriation. To assess the reliability of the data provided, we  requested and reviewed information from USAID officials regarding the  underlying financial data systems and the checks and reviews used to  generate the data and ensure its accuracy and reliability. We determined  that the data we used were sufficiently reliable for our purposes of  examining USAID’s reimbursements. We analyzed these data and  reviewed documents to determine the dates and amounts of the  obligations, the activities that the obligations funded, and the  appropriation accounts used for the obligations. We also analyzed the  data and reviewed documents to determine the amounts of the  reimbursements, the appropriation accounts from the fiscal year 2015  appropriation that USAID used for the reimbursements, and the  appropriation accounts to which USAID reimbursed the funds. We  reviewed USAID’s congressional notifications and award documentation to determine the amounts, purposes, and appropriation accounts for the  obligations that USAID incurred prior to the enactment of the Act as well  as the amounts and appropriation accounts from which USAID  reimbursed the funds. We interviewed USAID and State officials about  the extent to which the agencies incurred obligations prior to the  appropriation and reimbursed the funds. We also interviewed USAID  officials and reviewed USAID’s policies for the management of funds to  determine the extent to which the agency had developed and  implemented written policies or procedures for the reimbursement  process. We assessed the extent to which the obligations and  reimbursements were consistent with the provisions of the Act as well as  the extent to which the procedures USAID used met relevant internal  control standards.

We conducted this performance audit from June 2015 to November 2016  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

section_title: Appendix II: USAID and Department of State Total Obligations and Disbursements, by U.S. Ebola Strategy Pillar
paragraphs: As of July 1, 2016, the U.S. Agency for International  Development  (USAID) and the Department of State (State) had obligated the largest  share of the Department of State, Foreign Operations, and Related  Programs Appropriations Act, 2015 (the Act) Ebola funding for activities to  control the outbreak (Pillar 1). USAID had obligated lesser amounts of  funding for activities to mitigate second-order impacts of Ebola (Pillar 2)  and activities to strengthen global health security (Pillar 4). USAID  obligated a minimal amount of funding for building coherent leadership  and operations (Pillar 3). For all strategy pillars, the largest percentage  increase in obligations occurred between April 1, 2015, and July 1, 2015  (see fig. 9).

section_title: Appendix III: USAID Funding for Ebola Activities, by Country
paragraphs: The U.S. Agency for International  Development (USAID) obligated  funding from the International  Disaster Assistance (IDA) and Economic  Support Fund (ESF) accounts for almost all of its country-specific Ebola  funding. More than 80 percent of the funding that USAID has obligated for  Ebola activities in Guinea, Liberia, and Sierra Leone is from the IDA  account. Since USAID began its reporting to Congress on Ebola funding  in February 2015, IDA obligations for Liberia show the greatest increase  between February 3, 2015, and July 1, 2015, and ESF obligations for  Liberia show the greatest increase between April 1, 2015, and October 1,  2015 (see fig. 10). ESF disbursements do not begin before July 1, 2015.  USAID deobligated and reprogrammed IDA funding for Liberia between  January 1, 2016, and July 1, 2016, as it needed fewer funds to control the  outbreak.

Consistent with Liberia, since USAID began reporting to Congress on its  Ebola funding in February 2015, USAID obligations of IDA funding for  Sierra Leone show the greatest increases between February 3, 2015, and  July 1, 2015. However, USAID made no obligations of ESF funding  before April 1, 2015, and no disbursements of ESF funding until after July  1, 2015 (see fig. 11).

Since USAID began reporting to Congress on its Ebola funding in  February 2015, the greatest increase in obligations from the IDA account  for Guinea occurred between February 3, 2015, and July 1, 2015 (see fig.  12).

section_title: Appendix IV: Total Obligations and Disbursements for Ebola Activities, by Account
paragraphs: The International  Disaster Assistance (IDA) account represents the  majority of funding obligated and disbursed for Ebola activities to control  the outbreak. After the enactment of the Department of State, Foreign  Operations, and Related Programs Appropriations Act, 2015, obligations  and disbursements from the IDA account increased the most between  April 1, 2015, and July 1, 2015 (see fig. 13). The U.S. Agency for  International  Development (USAID) deobligated and reprogrammed IDA  funding between January 1, 2016, and July 1, 2016, as it needed fewer  funds to control the outbreak (see fig. 13). The Office of U.S. Foreign  Disaster Assistance (OFDA) programmed the majority of IDA funding.

The Economic Support Fund (ESF) account represents the majority of  funding obligated and disbursed for activities to mitigate the second-order  impacts of Ebola. USAID increased obligations of ESF significantly  between April 1, 2015, and October 1, 2015, as new cases of Ebola  decreased. Disbursements of ESF funding did not increase significantly  until after July 1, 2015 (see fig. 14). USAID’s Bureau for Global Health  and Global Development Lab programmed the majority of ESF funding.

The Global Health Programs (GHP) account represents the majority of  funding obligated and disbursed for activities to strengthen global health  security. USAID did not obligate any GHP funding between February 3,  2015, and April 1, 2015, and did not report disbursements until August 1,  2015, as USAID intends GHP to fund longer-term activities to respond to  future outbreaks (see fig. 15). The Bureau for Global Health programs  almost all GHP funding.

section_title: Appendix V: USAID’s Reimbursements for Funds Obligated Prior to Enactment of the Fiscal Year 2015 Appropriations Act
paragraphs: The U.S. Agency for International  Development (USAID) made 271  reimbursements for the approximately $401 million total obligations that  USAID’s Bureau for Global Health; Office of Food for Peace (FFP); Office  of U.S. Foreign Disaster Assistance (OFDA); and the missions in Guinea,  Liberia, and Senegal incurred prior to the enactment of the Department of  State, Foreign Operations, and Related Programs Appropriations Act,  2015 (the Act). Of the 271 reimbursements, USAID made 250  reimbursements (totaling about $341 million) in accordance with the  reimbursement provisions of the Act. USAID made these 250  reimbursements for funds that OFDA and FFP obligated prior to  enactment of the Act. However, USAID made 21 reimbursements  (totaling over $60 million) that did not accord with the reimbursement  provisions of the Act. USAID made these 21 reimbursements for funds  that the Bureau for Global Health, FFP, and the missions obligated prior  to enactment of the Act. Tables 7 through 9 provide information about  these 21 reimbursements and the requirements of the Act that each of the  reimbursements did not meet.

section_title: Appendix VI: Comments from the U.S. Agency for International Development

section_title: Appendix VII: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Valérie L. Nowak (Assistant  Director), Bradley Hunt (Analyst-in-Charge), Ashley Alley, Bryan  Bourgault, Debbie Chung, Neil Doherty, Rachel Dunsmoor, Jill Lacey,  Amanda Postiglione, and Matthew Valenta made key contributions to this  report.

Fast facts: West Africa experienced the largest Ebola outbreak in the history of the virus, resulting in more than 11,000 deaths as of June 2016.

In response to the outbreak, the U.S. Agency for International Development began funding a range of activities to control the virus's spread and strengthen global health security. Congress later provided billions of dollars to support and reimburse these efforts, and we found that USAID's management of more than $60 million of the reimbursed funds did not comply with the law.

We recommended ways for USAID to better manage these funds and ensure compliance with the law.

Question-summary annotations: questions: question: To what extent were USAID's reimbursements in accordance with the Act?
answer: Of 271 reimbursements that USAID made for obligations incurred prior to the enactment of the Department of State, Foreign Operations, and Related Programs Appropriations Act, 2015 (the Act), USAID made 21 reimbursements, totaling over $60 million, that were not in accordance with the Act.
child_questions: question: How large were these reimbursements compared to the overall flow of reimbursements?
answer: These 21 reimbursements represent roughly 15 percent of the $401 million that USAID obligated for reimbursements, of the almost $1.5 billion that had been obligated as of July 1, 2016 (see fig.).

question: Why might these reimbursements be cause for concern?
answer: For these 21 reimbursements, USAID did not reimburse the same appropriation accounts as the accounts from which it originally obligated the funds, and therefore it did not have legal authority to make these reimbursements.

question: To what extent were these reimbursements a failure of policy?
answer: In reviewing the reimbursements, GAO found that USAID does not have written policies or procedures for staff to follow in making and documenting reimbursements.
child_questions: question: How does this lack of policy lead to confusion in the reimbursement process?
answer: As a result, USAID does not have a process that could provide reasonable assurance that it complies with reimbursement provisions of applicable appropriations laws, such as the reimbursement provisions in the Act.

questions: question: How widespread was the Ebola outbreak in West Africa?
answer: In March 2014, the World Health Organization reported an Ebola outbreak in West Africa and, as of June 2016, reported that the outbreak had resulted in more than 11,000 deaths in Guinea, Liberia, and Sierra Leone.

question: How did USAID fund Ebola activities?
answer: USAID and State initially funded Ebola activities using funds already appropriated.
child_questions: question: How was USAID's funding increased?
answer: In December 2014, Congress appropriated approximately $2.5 billion to USAID and State, in part, for international efforts to prevent, prepare for, and respond to an Ebola outbreak and mandated that the agencies report periodically on their use of the funds.
child_questions: question: How were these funds involved in reimbursements?
answer: Congress also allowed the agencies to reimburse accounts for obligations incurred for Ebola activities prior to the fiscal year 2015 appropriation.

questions: question: How did the Act ensure the process had oversight and was reviewed?
answer: The Act also included a provision for GAO to conduct oversight of USAID and State activities to prevent, prepare for, and respond to the Ebola outbreak.

question: How did GAO examine the reimbursement process?
answer: This report examines (1) USAID's and State's obligations and disbursements for Ebola activities and (2) the extent to which USAID made reimbursements in accordance with the fiscal year 2015 appropriations act.
child_questions: question: How did GAO obtain specific data about funding?
answer: GAO analyzed USAID and State funding, reviewed documents on Ebola activities, and interviewed agency officials.