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.