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. 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 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. 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.) 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). 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. 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. At least 35 U.S. PVOs and 22 other U.S. NGOs participated in USAID’s child survival programs during that year as primary grantees. 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. For-profit firms ($35.1 million) Host country government agencies ($32.7 million) 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. 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. 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. 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 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. 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. 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. 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. 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. 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. 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 (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). 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. 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. 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. Since 1992, the USAID mission in Egypt has designated as child survival about $6.5 million for water and wastewater infrastructure development.Egypt’s sewerage projects include the design, construction, and operation 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. 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’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 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. 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. 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 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. 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 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. 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. 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). 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, USAID stated that the agency’s population and health programs would concentrate on countries that contribute the most to global population and health problems and have population and health conditions that impede sustainable development. 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, maternal mortality rate at or above 200 deaths per 100,000 live births, and 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. 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, acute respiratory infection, vitamin A, breastfeeding promotion, growth monitoring and weaning foods, micronutrients, and 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. 1994 Under-5 population (in millions) (continued) 1994 Under-5 population (in millions) (continued) 1994 Under-5 population (in millions) (continued) 1994 Under-5 population (in millions) (Table notes on next page) 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. The following is GAO’s comment on USAID’s letter dated July 23, 1996. 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. Richard Seldin The first copy of each GAO report and testimony is free. Additional copies are $2 each. Orders should be sent to the following address, accompanied by a check or money order made out to the Superintendent of Documents, when necessary. VISA and MasterCard credit cards are accepted, also. Orders for 100 or more copies to be mailed to a single address are discounted 25 percent. U.S. General Accounting Office P.O. Box 6015 Gaithersburg, MD 20884-6015 Room 1100 700 4th St. NW (corner of 4th and G Sts. NW) U.S. General Accounting Office Washington, DC Orders may also be placed by calling (202) 512-6000 or by using fax number (301) 258-4066, or TDD (301) 413-0006. 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Summary: Pursuant to a congressional request, GAO reviewed the U.S. Agency for International Development's (AID) child survival activities and accomplishments, focusing on how child survival funds are being used to support AID objectives. GAO found that: (1) since 1985, AID has classified obligations totalling 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 AID'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; (2) between 1985 and 1995, AID 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; (3) AID 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; (4) during GAO's field visits, it 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; (5) AID said the projects in Mozambique were critical for reducing child mortality because they supported access to water, food, and health services; (6) AID and other donors have made important contributions toward improving child mortality rates in many countries; (7) in 9 of the 10 countries receiving the most AID mission-level child survival assistance since 1985, mortality rates for children age 5 and under have dropped; (8) 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; (9) both AID 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; (10) in fiscal year 1995, AID'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; (11) AID 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; (12) on the other hand, many countries that were far from achieving the goal, did not receive assistance for child survival; and (13) according to AID, most of these countries did not receive assistance because AID 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.