USAID Supported Activities Overseas but Could Improve Funds Tracking and Response Planning

Comments from the U.S. Agency for International Development

David B. Gootnick
U.S. Government Accountability Office
441 G Street, N.W.
Washington, D.C. 20226

Re: EMERGENCY ASSISTANCE FOR ZIKA: USAID Supported Activities Overseas but Could Improve Funds Tracking and Response Planning (GAO-19-356)

Dear Mr. Gootnick:

I am pleased to provide the formal response from the U.S. Agency for International Development (USAID) to the draft report produced by the U.S. Government Accountability Office (GAO) titled, "EMERGENCY ASSISTANCE FOR ZIKA: USAID Supported Activities Overseas but Could Improve Funds Tracking and Response Planning," (GAO-19-356). The International Health Regulations (2005) (IHRs) define a "Public Health Emergency of International Concern" (PHEIC) as "an extraordina1y event which is determined ... to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response." The DirectorGeneral of the World Health Organization (WHO) has only declared four PHEICs since the IHRs entered into force on June 15, 2007: H1N1 Influenza, in 2009; Poliomyelitis, in 2014; Ebola, in 2014; and Zika Virus, in 2016. USAID has gained extraordinary knowledge as a result of the unprecedented battle to contain Ebola and Zika, and is committed to strengthening the aspects of reporting and coordination highlighted by the GAO, pa1iicularly the Agency's policies and practices to prepare for, respond to, and learn from public health crises around the globe, including PHEICs.

USAID must point out, however, that some challenges identified by the GAO in the draft report depend on international actions beyond the Agency's control. Responding to a PHEIC is not the purview of USAID or the U.S. Government alone, but is a shared global responsibility. USAID is committed to strengthening our emergency-response coordination by institutionalizing the Agency's logistical support for tempora1y Task Forces through the creation of a new Task-Force Readiness Unit (TFRU) within the Bureau for Management (M), as outlined in the Congressional Notification for the M Bureau under our Transformation. We hope for Congress's support in establishing this new Unit to respond even more efficiently to emergencies across the world.

I am transmitting this letter and the enclosed USAID comments for incorporation as an appendix to the GAO's final report. Thank you for the opportunity to respond to the draft report, and for the courtesies extended by your staff while conducting this engagement. We appreciate the opportunity to participate in the complete and thorough review of our programs. As an Agency, we believe the GAO's engagements provide a valuable opportunity to assess and improve upon our policies, procedures, and programs.

Sincerely,

Angelique M. Crumbly
Acting Assistant Administrator
Bureau for Management

Enclosure: a/s

COMMENTS BY THE U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT ON THE DRAFT REPORT PRODUCED BY THE U.S. GOVERNMENT ACCOUNTABILITY OFFICE (GAO) TITLED: "EMERGENCY ASSISTANCE FOR ZIKA: USAID Supported Activities Overseas but Could Improve Funds Tracking and Response Planning" (GAO-19-356)

The U.S. Agency for International Development (USAID) would like to thank the GAO for the opportunity to respond to this draft report. We appreciate the extensive work of the GAO engagement team and the specific findings that will help USAID achieve greater effectiveness in future public health emergencies.

USAID worked closely with partners across the U.S. Government to implement a collective response to the outbreak of Zika outbreak that aimed to minimize the number of pregnancies affected by the virus. Together, U.S. Government Departments and Agencies undertook surveillance efforts to identify the progression of Zika, diagnose infections when they occurred, provide care and support for pregnant women identified as having contracted the Zika virus and their affected babies, and take effo1ts to prevent further infections.

The base of scientific knowledge regarding the Zika vims was evolving as USAID partners were implementing their programs. For example, when the Director-General of the World Health Organization (WHO) declared Zika a Public Health Emergency of International Concern (PHEIC) in 2016, the scientific community was unaware of the relative risk of sexual transmission of the vims. As that knowledge emerged, USAID worked with our implementers to adjust programs to target efforts toward both pregnant women and their partners. USAID has a long history of funding health programs in countries in Latin America and the Caribbean, which allowed the Agency to provide technical assistance to Ministries of Health and health providers to ensure they could respond to changing circumstances when Zika arrived in this Hemisphere. We know that in many of these countries, social, demographic, and geographic inequities exist, and infectious-disease outbreaks, economic shocks, or political crises can easily damage hard-wrought gains.

USAID's response to Zika sought to support and strengthen local institutions, including those responsible for ensuring pregnant women have access to high-quality prenatal care. We ensured that our short-term focus on minimizing the negative pregnancy outcomes associated with Zika infection strengthened, rather than undermined, training, curricula, and the delivery of broader health care. The Agency improved the quality of Zika-related prevention and care through both public- and private-sector delivery channels, and also by engaging vulnerable communities to reduce the risk of Zika infection in pregnant women. USAID's response focused on four interconnected lines of effort: Innovation; Vector-Control; Social and Behavior-Change Communication; and Service-Delivery related to voluntary family planning, antenatal and postnatal care, and early-childhood development and care for families with infants affected by Zika.

USAID designed its Zika program to implement it strategically through regional programs managed from Washington. This was both expedient, because it allowed for the rapid mobilization of funds across all the key lines of technical effort, and provided the necessary operational and programmatic flexibility needed to address a rapidly expanding outbreak across multiple countries in Latin America and the Caribbean.

To design the response to Zika, USAID adapted lessons learned in mobilizing and managing resources for the outbreak of Ebola in West Africa in 2013 and 2014. However, detailed, country-level financial data from previous outbreaks have limited utility in planning for future responses to future outbreaks, as each will have distinct scale, spread, and engagement from other donors. For example, in a subsequent outbreak of the same disease in the same country, such as sequential Ebola outbreaks in the Democratic Republic of Congo (DRC), each outbreak has its own pa1ticularities that influence investment priorities and plans. While USAID did not require its implementers to provide as much country-level funding detail as the GAO would have preferred, the rapid placement of country and regional Zika advisors facilitated incountry knowledge and accountability, and the coordination of the programs with local stakeholders. The Zika advisors helped adapt the programs to local contexts and priorities, in line with Ministries of Health and community strategies.

By responding effectively to the spread of Zika throughout Latin America and the Caribbean, USAID helped reduce the outbreak's impact on at-risk countries, and prevented its potential spread to the United States. The Agency's investments focused on protecting individuals, particularly pregnant women, from Zika by controlling the spread of the virus, increasing awareness of how the virus is transmitted and how to prevent infection, improving disease-detection and the surveillance of transmission and supporting affected people. In addition, USAID catalyzed the development of innovative tools to combat mosquito-borne diseases like Zika so the world is better prepared for the next outbreak. USAID's efforts support the ability of governments and civil-society to respond to Zika, as well as to future disease threats, because we know that strength abroad means safety at home.

USAID concurs with both recommendations made in the GAO's repo1t. Please find below our responses and mitigation plan.

Recommendation 1: The USAID Administrator should ensure that, in responding to future Public Health Emergencies of International Concern, the Agency is able to compile funding information broken down by country.

Section 203 of the Zika Response and Preparedness Appropriations Act, 2016, states that the Depa1tment of State and USAID, "Shall submit a consolidated report to the Committees on Appropriations on the anticipated uses of such funds on a country and project basis." Consistent with the Act, USAID's initial report on the anticipated uses of Zika supplemental funds included information on the types of activities the Agency would undertake in priority countries. The subsequent Zika report updates identified changes to assumptions and estimates in the original report, as appropriate. Further, USAID's Zika financial-management practices met the policies and requirements of the 600 series of Chapters (Financial-Management Principles and Standards) of USAID's Automated Directives System.

• USAID will ensure that in responding to future PHEICs, the Agency will compile and report on funding obligated and disbursed to implementers by count1y. The Agency will incorporate this requirement into the programming process prior to the obligation of funds, and into the terms of awards.

Recommendation 2: The USAID Administrator should improve the Agency's infectious-disease response planning to address the challenge of initiating response activities in a timely manner in countries without bilateral USAID health programs.

USAID recognizes that the experiences with Ebola in West Africa and the DRC and Zika throughout the Western Hemisphere demonstrate that the United States must be prepared to respond quickly to infectious-disease outbreaks that could pose a global danger, in some cases before an official PHEIC declaration by the WHO. USAID and the rest of the U.S. Government gained extraordinary knowledge as a result of the unprecedented, multi-sectoral battle to contain Ebola in West Africa, which now is influencing the response to the virus in DRC, and is committed to the continual strengthening of the Agency's policies, practices, structures, and systems to prepare for, respond to, and learn from global infectious-disease outbreaks.

On July 31, 2018, USAID issued an internal Agency Notice titled, "USAID Response to Global Infectious Disease Outbreaks," which included three outbreak-response scenarios that clarified the level of operational and programmatic response by the Agency. USAID updated the Agency Notice for Fiscal Year (FY) 2019 to include four outbreak-response scenarios, and reissued it on October 31, 2018. The Agency Notice outlines the roles and responsibilities of USAID staff when preparing for, and responding to, outbreaks of infectious-diseases, instructs USAID Missions and overseas offices to be vigilant for local outbreaks, and a requirement to notify outbreak@usaid.gov when an outbreak occurs that could require international or additional assistance. The Agency Notice also asks Missions and overseas offices to be prepared to participate in coordination meetings with host governments and other donors related to such outbreaks.

USAID's broad-based and multisectoral approach allows the Agency to collaborate across the U.S. Government to leverage our technical expertise to strengthen local capacity around the world to prevent, detect, and respond to infectious diseases. USAID has established partnerships with the U.S. Departments of Agriculture, Defense, Health and Human Services, and State, and with relevant international, non-governmental, and other organizations, to strengthen preparedness for, and response to, potential disease outbreaks that could require an international emergency response.

• By June 30, 2019, USAID will develop and provide specific guidance for USAID Desk Officers in Washington and Program Officers in countries without bilateral USAID health programs to ensure they are aware of the Agency's process and resources to respond to outbreaks of infectious disease and remind them of the outbreak@usaid.gov email address. This guidance will also request that Desk Officers reach out to their Mission counterparts and regularly engage with counterparts in Ministries of Health, as well as remind them that USAID can provide support and funding in an outbreak, in coordination with the WHO and other U.S. Government partners, including the Centers for Disease Control (CDC) within HHS.
• By September 30, 2019, USAID Missions without bilateral health programs will develop lists of country-level point-of-contacts with their respective Ministries of Health, and will provide the information to the USAID Desk Officers; the Bureau for Global Health (GH); and the Office of U.S. Foreign Disaster Assistance (OFDA) within the Bureau for Democracy, Conflict, and Humanitarian Assistance (DCHA). The Agency will update the information annually.
• By December 30, 2019, GH will pilot the development of a roster off former USAID Foreign Service Nationals and third-country nationals with expertise in global health for rapid, temporary surge support during an infectious-disease outbreak. The surge support will complement USAID/Washington personnel from GH, DCHA/OFDA, and other Bureaus and Independent Offices that might have to work with the affected Missions to support the international response. USAID will continually assess and establish, as needed, internal coordination structures that bring together relevant Agency Bureaus, Independent Offices, and Missions, and other U.S. Government Departments and Agencies, to coordinate response-related efforts and investments.