Emergency Assistance for Zika: USAID Supported Activities Overseas but Could Improve Funds Tracking and Response Planning

The World Health Organization (WHO) declared the Zika virus a public health emergency of international concern in February 2016. According to WHO, as of March 2017, 79 countries and territories—including 48 in the Western Hemisphere—reported evidence of ongoing Zika transmission. In April 2016, USAID and State repurposed $215 million for Zika from funds appropriated for Ebola. Subsequently, the Zika Response and Preparedness Appropriations Act, 2016, provided over $175 million in supplemental funding to USAID and State to support Zika response efforts overseas. The act also included a provision for GAO to review the status of USAID and State actions to respond to Zika. In March 2019, the Centers for Disease Control and Prevention downgraded its international travel warning for Zika.

This report examines (1) the status of USAID and State funding for U.S. Zika response overseas, (2) activities supported by these funds, and (3) implementation challenges, if any, and responses to any challenges. GAO reviewed information from U.S. agencies and met with U.S. and host country officials in Washington, D.C. GAO also conducted fieldwork in a nongeneralizable sample of countries in Latin America and the Caribbean where agencies implemented key response activities.

The U.S. Agency for International Development (USAID) and the Department of State (State) obligated $385 million of the total $390 million available for international Zika response and disbursed $264 million as of September 2018. USAID obligated 95 percent of the total funding. USAID and State provided some country information to Congress but did not provide, or take steps to track, funding on a country basis. According to USAID officials, tracking funding information by country would be helpful in the future. The ability to compile funding by country when responding to future infectious disease outbreaks would enable USAID to provide additional information to key decision makers to better support spending oversight and inform budgetary and planning decisions.

In response to the Zika outbreak, USAID and State supported a broad range of activities overseas, including mosquito control, research efforts, and medical evacuations. In one activity, USAID implementing partners monitored mosquito populations; in another, they researched methods to reduce Zika virus transmission rates. USAID implementing partners reported various outputs from selected activities. For example, an implementing partner reported that its awareness campaign on Zika prevention reached more than 5 million people.

USAID faced sustainability and timeliness challenges in implementing its Zika response. According to agency and other officials, one-time funding and a short time frame posed a challenge related to sustainability of Zika response activities. In response, USAID worked to align activities with those of host governments and other organizations so they could continue in the long term. However, USAID's emergency response planning did not fully address the challenge of timely implementation of response activities in countries without bilateral USAID health programs. Twenty-two of 26 countries with Zika response activities did not have bilateral USAID health programs when the Zika outbreak began. As a result, response activities took additional time to deploy in some countries where USAID first had to establish relationships with key host country officials. Although USAID developed an infectious disease response plan in 2018, the plan does not provide guidance on how to address the timely implementation challenge in countries without bilateral health programs. By improving its planning, such as by adding such guidance in its 2018 plan, USAID would be better positioned to respond quickly to future disease outbreaks.

USAID should (1) take steps to ensure it is able to compile funding information by country for future infectious disease emergency responses and (2) take steps to improve its infectious disease response planning. USAID concurred with GAO's recommendations.

Zika is a virus that is primarily transmitted through mosquito bites and  causes symptoms that include fever, rash, conjunctivitis, and joint and  muscle pain, though many infected individuals do not have symptoms or  only experience mild symptoms. The Zika infection in pregnant women  has been linked to adverse pregnancy and birth outcomes: The virus can  be passed to the fetus and cause microcephaly and other severe brain  defects and may be associated with miscarriage and stillbirth, according  to the Centers for Disease Control and Prevention (CDC). The Zika virus  is also linked to other problems such as Guillain-Barré syndrome, an  uncommon condition of the nervous system. In the Western Hemisphere,  the first cases of locally transmitted Zika virus disease were confirmed in  Brazil in May 2015. The World Health Organization (WHO) declared the  Zika virus a public health emergency of international concern in February  2016. While WHO declared an end to the public health emergency in  November 2016, it subsequently reported that 48 countries and territories  in the Western Hemisphere reported evidence of ongoing Zika  transmission, as of March 2017.

To address the epidemic, according to U.S. Agency for International  Development (USAID) documentation, $215 million of fiscal year 2015  supplemental Economic Support Fund funding initially appropriated to  respond to the Ebola virus was repurposed for the U.S. Zika response  overseas. The Zika Response and Preparedness Appropriations Act,  2016, also provided over $175 million in supplemental funding to USAID  and the Department of State (State) through the end of fiscal year 2017 to  support the U.S. Zika response efforts overseas. The act required  USAID and State to submit a consolidated report to Congress on the  anticipated uses of the funds appropriated in the act on a country and  project basis and to submit updates every 60 days until September 30,  2017. The act also included a provision for us to review the status of  USAID and State actions to respond to Zika. This report examines (1) the  status of USAID and State funding for the U.S. Zika response overseas,  (2) activities supported by these funds, and (3) challenges, if any, to  implementing Zika response activities and actions taken to address any  challenges.

To examine the status of USAID and State funding for the U.S. Zika  response overseas, we reviewed obligations and disbursements that the  agencies reported as supporting international Zika response activities, as  of September 30, 2018. We also reviewed USAID and State’s  consolidated reports to the Senate and House Committees on  Appropriations mandated by the Zika Response and Preparedness  Appropriations Act, 2016, and interviewed agency officials to discuss the  status of the agencies’ obligations and disbursements for Zika response  activities. We determined that the data we used were sufficiently reliable  for the purposes of determining the status of USAID and State funding for  the U.S. Zika response overseas. We assessed USAID’s tracking of  funding data against federal internal control standards related to using  quality information.

To examine activities that USAID and State implemented in response to  Zika overseas, we conducted fieldwork, analyzed agency documents, and  interviewed officials. We examined the status and progress of Zika  response activities. We conducted fieldwork in a nongeneralizable sample  of countries: Barbados, Colombia, Dominican Republic, Guatemala,  Honduras, Peru, and Trinidad and Tobago. We selected these countries  based on criteria including, among others, geographic diversity to include  the Caribbean, Central America, and South America and the presence of  activities under way that accounted for a significant portion of total USAID  and State Zika funding. During our fieldwork, we interviewed agency  officials, host government officials, implementing partners, health care  workers, community volunteers, and researchers to get their perspectives  on the progress of Zika response activities. We analyzed agency  documents describing the plans and goals of activities. We also analyzed  progress reports of a sample of six activities to provide illustrative  examples of results from these activities as reported by implementing  partners. For this sample, we selected activities that had among the  highest amounts of funding and that together represented a range of  countries, lines of effort, and types of implementing partners. Our sample  is not generalizable to all activities.

To examine challenges, if any, to implementing Zika response activities  and actions taken to address any challenges, we interviewed USAID  officials, USAID implementing partners, and host government officials,  and we analyzed progress reports from selected USAID-funded Zika  response activities. We analyzed the information collected in the  interviews and document reviews to identify the themes, or key  challenges and responses to those challenges. We assessed USAID’s  infectious disease response plan against relevant federal internal control  standards. See appendix I for more information on our objectives, scope,  and methodology.

We conducted this performance audit from December 2017 to May 2019  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.

Zika is spread to people primarily through the bite of an infected mosquito  but can also be transmitted from mother to child during pregnancy or from  person to person through sexual contact or blood transfusion. The  disease can cause symptoms that include fever, rash, conjunctivitis (“pink  eye” where the eyes appear red or pink), and joint and muscle pain.  Although most people with Zika have only mild symptoms or none at all,  Zika in pregnant women has been linked to adverse pregnancy  outcomes, such as miscarriage and stillbirth, and severe birth defects.  Zika can be passed to the fetus and cause a birth defect of the brain  called microcephaly and other severe brain defects, according to CDC.  Zika is also linked to other problems such as Guillain-Barré syndrome, an  uncommon condition of the nervous system. Although at present no  vaccine has been approved by the U.S. Food and Drug Administration to  prevent Zika, several vaccines are in different phases of development.

Zika was first identified in the Zika Forest in Uganda in 1947 and caused  only sporadic human disease until 2007. In 2007, Zika was detected in  Yap State, Federated States of Micronesia, and subsequent outbreaks  occurred in Southeast Asia and the Western Pacific. In 2014, Zika spread  east across the Pacific Ocean to French Polynesia, then to Easter Island.  In May 2015, Brazil documented the first case of locally acquired Zika  transmission in the Americas. See figure 1 for a timeline of the Zika  outbreak and the U.S. Zika response overseas. According to WHO, in  November 2015, Suriname, El Salvador, Guatemala, Mexico, Paraguay,  and Venezuela reported cases of locally acquired Zika, followed by  Panama, Honduras, French Guiana, Martinique, and Puerto Rico in  December 2015. Zika continued to spread throughout the region, and on  February 1, 2016, WHO declared that the recent association of Zika with  clusters of microcephaly and other neurological disorders constituted a  public health emergency of international concern. In November 2016,  WHO declared an end of the public health emergency of international  concern regarding microcephaly, other neurological disorders, and Zika.  However, WHO announced that Zika and the associated health outcomes  remained a significant public health challenge requiring intense action.

Zika spread to multiple countries throughout the globe but primarily  affected countries in Latin America and the Caribbean region. According  to WHO, as of March 2017, transmission of the Zika virus was occurring  in 79 countries or territories, most of which are located in the Western  Hemisphere. According to WHO, from 2015 to 2017, there were  approximately 583,000 suspected and 223,000 confirmed cases of Zika  virus transmission in the Western Hemisphere. See figure 2 for the  cumulative Zika incidence rates in each country in Latin America and the  Caribbean from 2015 to 2017.

In February 2016, the President submitted a request to Congress for  emergency funding to enhance ongoing U.S. efforts to prepare for and  respond to Zika, including a request for funding for USAID and State to  respond to the outbreak overseas. In addition, in April 2016, USAID and  State notified Congress of their intent to repurpose $215 million of fiscal  year 2015 supplemental Economic Support Fund Ebola funding for the  U.S. Zika response overseas, which included $78 million for CDC  international Zika activities. In September 2016, Congress appropriated  about $175.1 million in supplemental funding to USAID and State in the  Zika Response and Preparedness Appropriations Act, 2016, for the U.S.  Zika response overseas. USAID activities initially began in five  countries—Haiti, Honduras, Guatemala, El Salvador, and Dominican  Republic—based on an assessment of their Zika risk and limited host  government capacity to prevent the spread and respond to the impact of  the virus. USAID ultimately supported activities in 26 countries in the Latin  America and Caribbean region.

USAID and State Obligated Almost All Funding Available for the Zika Response but Did Not Report Funding by Country USAID and State Obligated Almost All Funding Available for the Zika Response and Disbursed Approximately Two-Thirds

As of September 30, 2018, USAID and State had obligated about $385  million (99 percent) of the total $390 million available for the U.S. Zika  response overseas and had disbursed approximately $264 million (68  percent). Specifically, USAID had obligated all of its funds available for  the Zika response and disbursed about two-thirds, and State had  obligated and disbursed more than three-quarters of its funding for Zika.  USAID and State had disbursed a higher proportion of the repurposed  Ebola funds than the funds appropriated in the Zika Response and  Preparedness Appropriations Act, 2016. See figure 3 for USAID and  State Zika response funding appropriations, obligations, and  disbursements as of September 30, 2018. Of the $215 million in  repurposed Ebola funds, USAID and State had obligated $215 million  (100 percent) and had disbursed almost $201 million (93 percent) as of  September 30, 2018. Of the approximately $175 million appropriated in  the Zika Response and Preparedness Appropriations Act, 2016, USAID  and State had obligated about $170 million (about 97 percent) and had  disbursed about $63 million (36 percent) as of September 30, 2018.

USAID and State Track Zika Funding by Account and Activity

As of September 30, 2018, USAID had obligated all funds available for  the Zika response and had disbursed about two-thirds, from three  accounts. USAID has two sources of funding for Zika response activities:  $211 million of fiscal year 2015 supplemental Economic Support Fund  Ebola funding repurposed for the Zika response and about $155.5 million  provided in the Zika Response and Preparedness Appropriations Act,  2016—including $145.5 million and $10.0 million through the Global  Health Programs and Operating Expenses accounts, respectively—for a  total of $366.5 million. As of September 30, 2018, USAID had obligated  approximately $366.5 million (100 percent) and had disbursed  approximately $245 million (67 percent), from the Economic Support  Fund, Global Health Programs, and Operating Expenses appropriations  accounts. See figure 4 for USAID Zika response funding obligations and  disbursements by account. USAID obligated all funding for Zika response  activities within a year after it was repurposed or appropriated. As of  September 30, 2018, USAID had disbursed a higher proportion of  repurposed fiscal year 2015 supplemental Economic Support Fund Ebola  funding (93 percent) compared with Global Health Programs and  Operating Expenses funding (28 percent and 72 percent, respectively),  which was appropriated in the Zika Response and Preparedness  Appropriations Act, 2016, in September 2016.

The $211 million in Economic Support Fund obligations supported 56  USAID activities, as well as a $78 million interagency transfer to CDC.  The $145.5 million in Global Health Programs obligations supported 25  activities and program support. Obligations for USAID-supported  activities ranged from $12,000 to $37 million and included support for  activities such as the procurement of insect repellent to assist pregnant  women in avoiding Zika infection and strengthening the ability of civil  society and community networks to disseminate information related to  Zika. CDC supported 25 activities that ranged from $276,000 to $13.6  million, including activities such as collecting and analyzing public health  data, conducting epidemiological studies to better understand the  prevalence of Zika and related risk factors, building laboratory capacity,  and providing training to conduct Zika virus testing.

As of September 30, 2018, State had obligated and disbursed more than  three-quarters of funding available for the Zika response, from two  accounts. State has two sources of funding for Zika response activities:  $4 million from a fiscal year 2015 supplemental Economic Support Fund  appropriation for the Ebola response that was repurposed for the Zika  response and about $19.6 million provided in the Zika Response and  Preparedness Appropriations Act, 2016, the majority of which was  provided through the Diplomatic and Consular Programs account, for a  total of about $23.6 million. As of September 30, 2018, State had  obligated and disbursed about $18.3 million (almost 78 percent) from the  Economic Support Fund and Diplomatic and Consular Programs  accounts. See figure 5 for State Zika response funding obligations and  disbursements by account.

Under the Zika Response and Preparedness Appropriations Act, 2016,  State was provided almost $14.6 million through the Diplomatic and  Consular Programs account, $4 million through the Emergencies in  Diplomatic and Consular Services account, and $1 million through the  Repatriation Loans Program account, for a total of almost $19.6 million. In  September 2017, State notified Congress of its intent to transfer the $4  million from the Emergencies in Diplomatic and Consular Services  account and $870,000 from the Repatriation Loans Program account to  the Diplomatic and Consular Programs account. These transfers resulted  in a total of $19.5 million available under the Diplomatic and Consular  Programs account and $130,000 under the Repatriation Loans Program  account.

The $4 million in Economic Support Fund obligations supported research  and development activities by the International Atomic Energy Agency to  control disease-carrying mosquito populations. The $14.3 million in  Diplomatic and Consular Programs obligations supported activities  including medical evacuations to protect the health of pregnant U.S.  government personnel and eligible family members, mosquito abatement  training and other measures to reduce Zika risk to overseas staff, as well  as public diplomacy efforts to further inform journalists and the public  about the U.S. response to Zika.

Agencies Did Not Track or Report Zika Funding by Country

In their reporting to Congress on the uses of Zika funds, USAID and State  included some country information but did not track or provide information  on funding uses broken down on a country basis. In October 2016,  USAID and State submitted a consolidated report to the appropriations  committees on the anticipated uses of funds made available to USAID  and State by the Zika Response and Preparedness Appropriations Act,  2016, in response to a reporting requirement in Section 203 of the act.  After the initial submission, the act required the agencies to update and  submit the report to the committees on appropriations every 60 days until  September 30, 2017. The initial report described ongoing Zika response  activities in five countries as well as planned activities in additional  countries. Subsequent reports listed specific countries where USAID and  State supported Zika response activities. However, USAID and State did  not provide information to Congress on the uses of funding appropriated  by the Zika Response and Preparedness Appropriations Act, 2016,  broken down by country. The reports also included obligation and  disbursement information for the fiscal year 2015 supplemental Economic  Support Fund Ebola funding that was repurposed for the international  Zika response; however, similar to the information provided regarding the  funds appropriated by the Zika Response and Preparedness  Appropriations Act, 2016, the reports’ information on the use of the  repurposed Ebola funds was also not broken down by country.

USAID officials told us that Zika activities were designed to be  implemented on a regional and multicountry basis. While over 95 percent  of all U.S. government funds available for the Zika response overseas  were obligated by USAID, and the agency had a number of financial  tracking systems in place, the agency did not take steps to record its  funding by country at the outset of Zika response programming.  Specifically, USAID officials noted that the contracts and grants the  agency had signed with its implementing partners did not include  provisions requiring partners to provide information to USAID that broke  down their use of funds by country. Consequently, USAID was unable to  track the uses of Zika funds on a country basis.

Federal internal control standards state that management should use and  communicate the necessary quality information both internally and  externally to achieve the entity’s objectives and address related risks.  According to USAID officials, tracking information on the uses of Zika  response funding broken down by country would be helpful in the future  for mission directors, chiefs of missions, and partner-country ministries of  health, some of whom have requested this information. Moreover, data on  USAID funding to address future infectious disease outbreaks if broken  down by uses in each country could provide additional useful information  to decision makers in assessing risks and planning responses. The ability  to compile funding by country when responding to future infectious  disease outbreaks would enable USAID to provide key decision makers,  including Congress and agency officials, with additional information to  better support spending oversight and inform budgetary and planning  decisions.

USAID and State Supported a Broad Range of Activities in Response to Zika

USAID Supported Mosquito Control, Public Awareness, Capacity Building, and Research Activities

As part of the U.S. Zika response overseas, USAID provided assistance  to several countries in the Caribbean, Central America, and South  America and conducted a variety of activities related to mosquito control,  public awareness, capacity building, and research.

In support of mosquito control, USAID’s Zika AIRS Project (ZAP)  conducted activities that included

Entomological monitoring: collecting and reporting information on  the location and population of mosquitoes;

Larviciding: placing agents that kill mosquito eggs in likely breeding  sites, such as water receptacles;

Source reduction interventions: facilitating the removal or mitigation  of likely breeding sites, such as tires, pots, barrels, or anything that  may allow for standing water; and  Indoor residual spraying: spraying insecticide that has a lasting  effect in houses.

We observed mosquito control activities during our fieldwork. For  example, in Honduras we followed a team as they went house to house to  implement and facilitate mosquito control activities. They collected  information from mosquito egg traps, which serve as indicator of breeding  activity, and recorded it for monitoring purposes. They also examined the  premises for potential mosquito breeding sites, treated susceptible areas  such as wash basins with larvicide, and spoke with residents about  picking up trash and covering outdoor plant pots to reduce potential  breeding sites.

To support raising public awareness of the risk of Zika virus and to  promote behavior change to reduce the spread of the disease, USAID  implementing partners such as the Red Cross and CARE told us that they  collaborated with communities, local government, and schools to  communicate information about Zika. For example, in Trinidad, the Red  Cross conducted educational campaigns at schools to improve students’  awareness. During our fieldwork, we observed a session led by adult  volunteers during which children played games and engaged in  discussions designed to teach Zika prevention and response methods.  Implementing partners told us that the impact of such efforts extends  beyond those reached directly; for example, they said the children who  learned about Zika risks and prevention also conveyed the knowledge to  their families, who in turn may pass it on to friends or others in the  community.

In Peru, CARE worked with schools to develop written education guides  for application in the classroom and conducted communication  campaigns. During our fieldwork, we went to schools and observed  students delivering oral presentations on Zika risks and prevention. In  addition, we witnessed other student activities, such as classroom  discussions and art projects focused on Zika, designed to demonstrate  understanding, raise awareness, and promote behavior change.

To support capacity building, the Applying Science to Strengthen and  Improve Systems (ASSIST) activity, which USAID funding supported,  focused on improving Zika-related health services. Specific efforts  included conducting a baseline assessment of the quality of care,  improving clinical guidelines, training health care providers, and  implementing a quality improvement program. During our fieldwork in  Honduras, we visited a hospital and met with ASSIST-supported health  workers who told us that they applied new guidance in their practice, and  as a result, improved care in areas including counseling, screening,  diagnosis, and follow-up of those affected by Zika. We also visited a  hospital in Dominican Republic, where health care workers stated that  they collaborated with ASSIST in responding to Zika by training staff and  producing guidance materials. These activities raised awareness,  increased prevention efforts, and improved care, according to health care  workers.

USAID supported research, training, and innovation activities through its  “Grand Challenge” program as well as its interagency agreement with  CDC. USAID launched a series of Grand Challenge efforts, providing $30  million in grants to foster innovation on new methods and technologies to  respond to Zika. One grant, for example, supported the World Mosquito  Program’s research into the feasibility and effectiveness of infecting  mosquitoes with bacteria to hinder transmission of the Zika virus. We  visited the program’s operations in Colombia, met with scientists, and  observed the breeding lab.

Program scientists told us that initial efforts have been promising and that  if more tests prove successful, the potential for reducing Zika  transmission could be significant. Another USAID Grand Challenge grant  supports research into the possible use of genetically modified yeast to  prevent mosquito eggs from hatching. We spoke with scientists, lab  technicians, and viewed facilities supported by this grant in Trinidad  during our field work. Scientists stated that yeast attracts mosquitoes and  is inexpensive, commonly available, and environmentally friendly. Testing  is ongoing, but if successful, the approach could help reduce populations  of mosquitoes in critical areas, according to the scientists.

The USAID–CDC interagency agreement identifies a range of activities  that involve technical assistance to help strengthen surveillance,  emergency operations and management, and epidemiological  investigations and research. One CDC activity, for example, focuses on  supporting public health surveillance and epidemiological studies to better  understand the prevalence and risk factors for severe health outcomes  related to Zika. Another activity aims to build laboratory capacity in areas  such as Zika diagnostic test production and distribution. In addition, the  objectives of CDC’s Field Epidemiology Training Program are to train  qualified professionals, build sustainable capacity for detecting and  responding to health threats, and develop in-country expertise so that  disease outbreaks can be detected locally and prevented from spreading.  In Dominican Republic, CDC officials told us that this program delivers 3  months of classroom and field project training, and that as of August  2018, four cohorts of approximately 80 students each had completed the  training. CDC officials told us that in addition to implementing various  activities, CDC’s Central America Regional Office in Guatemala played an  important role in facilitating U.S. government cooperation with Colombia,  which had the second largest outbreak of Zika after Brazil.

Implementing Partners Reported Various Results from Selected Activities

We reviewed status reports for six USAID activities that received among  the highest amounts of funding, and each identified various results.  Below, we describe the activities and examples of reported results. For  more information, see appendix II.

ASSIST: This activity sought to strengthen Zika-related health  services and systems in Latin America and the Caribbean with a focus  on pregnant women, newborns, and women of reproductive age.  ASSIST reported that it conducted virtual and in-person training,  courses, and workshops on Zika prevention, diagnosis, and care.  ASSIST also reported that 8,133 health care workers had been  trained as of March 2017, and that its efforts had supported the  development of Zika care protocols and guidelines with a new  emphasis on clinical care and support for affected infants and  families. ASSIST further reported that through March 2018, 75  percent of children affected by Zika in Dominican Republic received  specialized care at Hospital Infantil Robert Reid Cabral, an ASSIST- supported hospital in the capital, Santo Domingo.

Red Cross: This activity aimed to reduce risks associated with Zika  infection through community involvement, sharing lessons learned,  and improving practices. The Red Cross reported that its  communication efforts reached approximately 3,000 students, 29  communities, and almost 140,000 people via TV, radio, and social  media engagement, providing them with information on risk and  protection methods.

Zika AIRS Project (ZAP): This is a mosquito control activity focused  on reducing Zika transmission in Latin America and the Caribbean.  Specific activities supported by USAID funding included entomological  monitoring, larviciding, source reduction interventions, and indoor  residual spraying. ZAP reported that five countries (El Salvador,  Guatemala, Haiti, Honduras, and Jamaica) implemented  comprehensive mosquito control activities.

Population Services International: The purpose of this activity was  to improve the capacity and raise awareness of people in countries  affected by and at risk of Zika and other vector-borne diseases.  Population Services International reported that through March 2018,  35 health providers in Dominican Republic, El Salvador, and  Guatemala had been trained in raising awareness about Zika  prevention and the use of printed educational materials. In addition,  1,006 pregnant women received counseling on Zika prevention, and  967 received prevention kits containing condoms, mosquito repellent,  and printed educational materials. Additionally, 227 pharmacy  attendants from 195 pharmacies received information on Zika  prevention.

Save the Children’s Community Action on Zika (CAZ): The goal of  this project was to reduce Zika transmission and minimize the risk of  Zika-related microcephaly and other neurological disorders. The  project focused on helping the most vulnerable through community- based prevention strategies in Colombia, Dominican Republic, and  three Central American countries. CAZ reported that it had reached  approximately 65,000 students and trained 3,838 community agents  and volunteers who supported efforts to strengthen the capacity to  prevent Zika in 921 communities.

United Nations Children’s Fund (UNICEF): This activity focused  primarily on four countries: Guatemala, El Salvador, Honduras, and  Dominican Republic. UNICEF worked to promote the adoption of  prevention behaviors among at-risk populations through actions to  raise awareness at multiple levels: individual, interpersonal,  community, institutional, and national policy levels. UNICEF reported  that these efforts reached more than 5.5 million people with key risk- communication messages and more than 150,000 people through  coordinated social mobilization and person-to-person communication.  For example, in Guatemala, UNICEF worked with a local partner to  train young people and adolescents in schools and social groups to  lead prevention activities in their communities. Moreover, around  25,000 pregnant women benefited from counseling sessions on Zika- prevention behaviors.

State Conducted Public Awareness Initiatives and Medical Evacuations

In response to Zika, State conducted public awareness and  communication initiatives, medical evacuations for overseas staff, and  other activities. According to a State official, State conducted Zika-related  public outreach to U.S. citizens abroad through social media and the  Smart Traveler Enrollment Program, a service that provides information  from U.S. embassies about local safety conditions. According to a State  official, State also implemented public diplomacy activities related to Zika  awareness and communication. For example, one activity aimed to raise  awareness of vector-borne diseases such as Zika and collect information  on insect breeding grounds. Another supported the addition of a science  envoy who focused specifically on Zika and mosquito-borne diseases. In  addition, according to a State official, State conducted Zika-related  medical evacuations as part of those normally offered to female staff who  became pregnant while serving abroad. State’s medical services division  also supported overseas posts by purchasing and distributing mosquito  repellent. State officials also told us that they coordinated Zika response  efforts internally and externally. For example, State participated in a U.S.  government interagency group led by CDC to exchange information on  Zika and coordinated with other agencies on the response effort.

USAID Took Steps to Address Sustainability Challenge but Only Partially Mitigated Challenge to Timely Implementation USAID Implementing Partners Aligned Their Activities with Host Governments and Involved Local Communities to Address Sustainability Challenge

Over the course of our fieldwork, USAID and implementing partner  officials identified two key challenges to the implementation of Zika  response activities. The first was the long-term sustainability of Zika  response activities. The second was the timely implementation of Zika  response activities in countries without bilateral USAID health programs.  While USAID took steps to address the challenge related to sustainability,  it only partially mitigated the challenge to timely implementation of Zika  response activities in countries without bilateral USAID health programs.

Agency and implementing partner officials identified the sustainability of  Zika response efforts as a key challenge. While USAID did not intend to  continue U.S. Zika response activities after the one-time emergency  funding, sustainability was a consideration and posed a challenge due to  the short implementation time frame, according to agency and  implementing partner officials. One official further elaborated that Zika  funding efforts occurred during the acute phase of the outbreak, which  made it difficult to focus on long-term needs. For example, an  implementing partner said that Zika-affected children require long-term  care that host country governments may not be able to support after U.S.  assistance ends. In addition, host country government officials, U.S.  government officials, and implementing partners said that some Zika  activities may not be sustainable after U.S. assistance is finished due to a  lack of funds and limited capacity to continue the work.

To address this challenge and support the long-term continuation of Zika  response activities, implementing partners aligned their activities with  those of host country governments and other organizations. Implementing  partners reported working with governments and other organizations to  incorporate Zika activities into their plans and practices so they could  continue over the long term. One implementing partner and the  Dominican Republic’s Ministry of Health, for example, planned mosquito  control efforts together, and a Ministry of Health official said they intend to  continue those control efforts after the end of Zika funding. Implementing  partners in various countries also stated that Zika activities brought  broader benefits to mosquito control, disability services, maternal health  care, surveillance efforts, and emergency preparedness, which facilitated  partners’ efforts to align their Zika response activities. For example, an  implementing partner reported using Zika funding to develop  organizational guidelines for treating Zika-affected children, which will be  used by the health care system in Dominican Republic to treat children  with related disabilities in the long term. According to some implementing  partners in countries we visited, they developed Zika protocols and  guidelines in response to new scientific information, trained government  and other personnel on the protocols, and worked with officials of host  country governments and other organizations to encourage adoption of  Zika activities. For example, according to an agency official, an  implementing partner in Peru developed a curriculum for epidemiologists  and trained them on how to detect and contain mosquito-borne diseases,  such as Zika. The agency official said that the implementing partner  shared the training curriculum and materials with Peru’s Ministry of Health  so it could continue the trainings after the end of Zika funding.

According to implementing partners, they also involved local communities  in activities to increase community ownership and address sustainability.  For example, an implementing partner official said they trained a cadre of  community volunteers in Guatemala and El Salvador on behavior change  practices so that they can continue activities after the end of Zika funding.  In addition, implementing partner officials said that engaging with  communities to learn about needs and resources is important to  continued community interest in activities. For example, an implementing  partner that works with communities on health priorities developed an  approach that includes a toolkit for identifying a community’s specific risks  for Zika and the efforts best suited to helping the community eradicate  mosquito breeding sites. In places affected by violence, some  implementing partners engaged with communities to better understand  how to prioritize community worker and volunteer safety to enable the  continuation of activities. For example, an implementing partner in  Guatemala engaged with local communities to understand areas they  recommended health workers avoid due to safety concerns.

USAID Only Partially Mitigated the Challenge to Timely Implementation in Some Countries Where It Did Not Have Health Programs

Agency and implementing partner officials described timely  implementation of activities in some countries without bilateral USAID  health programs as a second key challenge. Twenty-two out of the 26  countries where USAID implemented its Zika response activities were  countries without bilateral USAID health programs. USAID officials stated  that, as a result, there were no USAID health program officials present in  these countries to build on relationships with host country health officials  and help facilitate the start of implementing partners’ activities during the  Zika response. USAID officials noted two reasons that working with host  country governments took time. First, some U.S. Zika response activities  started after a decline in Zika cases, when some host country  governments were no longer as focused on countering the disease.  Implementing partners responded to this situation by identifying related  health service improvements that could stem from implementing a Zika  response and were of interest to the host country governments. Second,  agency and implementing partner officials said that in some countries  without bilateral USAID health programs it also took time to identify the  appropriate points of contact and establish relationships—preliminary  steps needed to obtain approval from the host country government before  activities could get underway. According to USAID officials, these  relationships are critical to navigating bureaucratic systems and assist in  designing activities that meet the needs of host country governments and  communities, which are needed for timely implementation.

USAID took some steps to address the timely implementation challenge  in countries without bilateral health programs. For example, according to  USAID officials, USAID worked with multilateral partners that had a health  presence in those countries and relied on regional field-based Zika  coordinators to build relationships with in-country points of contact. As  noted above, however, agency officials indicated that Zika response  activities took additional time to deploy in some of the countries without  bilateral USAID health programs. Further, implementing partners reported  it took additional time to start up activities in those countries because of  the time it took to obtain approval for them from the ministries of health.  For example, one implementing partner reported that activity startup was  postponed for nearly 3 months until it received approval from the host  country government. Another implementing partner said it was a  challenge to get information on Zika from the host country government or  establish dialogue until USAID officials became involved. USAID officials  also said that efforts to start and integrate Zika response activities in  countries with ongoing USAID health programs did not face a number of  the obstacles to timely implementation experienced in countries without  bilateral USAID health programs.

According to federal internal control standards, agencies should design  control activities, such as a plan, to achieve their objectives and address  related risks, such as the challenge related to timely implementation. In  an effort to enhance its planning for outbreaks, USAID developed an  infectious disease response plan in July 2018 during the time frame of our  review. However, the plan does not provide specific guidance on how to  address the challenge of initiating emergency response activities in  countries without bilateral USAID health programs, such as by noting  particular practices that implementing partners and other officials can use  to address that challenge. For example, our fieldwork and interviews with  USAID officials indicate that the following may be helpful practices for  infectious disease response:  Immediately establish an in-country working group that includes  implementing partners, host country government officials, and U.S.  government officials to help initiate and coordinate outbreak response.

Communicate a current list of health ministry and other relevant  government officials to implementing partners and other officials so  they can quickly identify the appropriate points of contact.

According to USAID officials, USAID missions maintain regular contact  with host country governments, maintain contact lists, and participate in  coordination meetings. However, in the case of overseas Zika response,  some implementing partner officials in the field told us that they did not  initially know who to contact in the host country government. Likewise, a  host country government official told us that a working group on Zika  outbreak response was not established until after officials recognized that  implementing partner and host country government officials did not have  regular channels of communication. By taking steps to improve planning  for countries without bilateral USAID health programs—such as by adding  specific guidance for initiating emergency response activities in such  countries to its July 2018 plan—USAID would be better positioned to  quickly build relationships with health ministry and other key government  officials in host countries and thus be better able to provide a timely  infectious disease response to future outbreaks.

The Zika virus quickly spread to dozens of countries in 2015 and 2016,  prompting WHO to declare the virus and associated health risks an  international public health emergency. As future infectious disease  outbreaks arise, Congress will be called on to fund overseas response  efforts, as it did with the Zika outbreak, and USAID is likely once again to  play a vital role in those efforts. Because USAID did not provide key  decision makers with information on how Zika funding was distributed  across the various countries where it conducted response activities,  decision makers lack visibility into a key aspect of the overall U.S. Zika  response overseas. The ability to compile this information by country  when responding to future infectious disease outbreaks would enable  USAID to provide key decision makers, including Congress and agency  officials, with additional information to better support spending oversight  and inform budgetary and planning decisions.

Further, while USAID took steps to address the challenge of sustaining  Zika response activities over the long term, it did not fully mitigate the  challenge of timely implementation of activities in countries without  bilateral USAID health programs. As a result, the agency’s response to  Zika took additional time in some countries without bilateral USAID health  programs. Infectious disease response planning that addresses countries  without bilateral USAID health programs would better position USAID to  quickly respond to infectious disease outbreaks, such as Zika, whenever  the need arises.

We are making the following two recommendations to USAID:

The Administrator of USAID should take steps to ensure that, in  responding to future public health emergencies of international  concern, the agency is able to compile funding information broken  down by country. (Recommendation 1)

The Administrator of USAID should take steps to improve its  infectious disease response planning to address the challenge of  initiating response activities in countries without bilateral USAID  health programs in a timely manner. (Recommendation 2)

We provided a draft of this report to USAID, State, and CDC for review  and comment. USAID provided written comments, which we have  reproduced in appendix III. In its comments, USAID agreed with our  findings and recommendations and identified a number of actions it plans  to take in response. Specifically, USAID stated that in responding to  future public health emergencies of international concern, it plans to  compile and report on funding by country. USAID also outlined the steps  it plans to take to develop additional guidance for USAID officials in  countries without bilateral health programs. State and CDC did not  provide formal responses. CDC provided technical comments, which we  incorporated throughout the report, as appropriate.

We are sending copies of this report to the appropriate congressional  committees, the Administrator of USAID, the Secretaries of State and of  Health and Human Services, and to 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 IV.

Appendix I: Objectives, Scope, and Methodology

The Zika Response and Preparedness Appropriations Act, 2016, included  a provision for us to review the status of U.S. Agency for International  Development (USAID) and Department of State (State) actions to  respond to Zika. In this report, we examine (1) the status of USAID and  State funding for the U.S. Zika response overseas, (2) activities  supported by these funds, and (3) challenges, if any, to implementing  Zika response activities and actions taken to address any challenges.

To examine the status of funding for U.S. Zika response overseas, we  reviewed USAID and State’s reports to the Senate and House  Committees on Appropriations mandated by Section 203 of the Zika  Response and Preparedness Appropriations Act, 2016. We reviewed  agency reporting submitted to Congress and discussed the reports with  agency officials. We also reviewed USAID and State’s reports to the  Senate and House Committees on Appropriations mandated by the  Department of State, Foreign Operations, and Related Programs  Appropriations Act, 2015. We obtained additional funding and activity  information from USAID covering a period beyond that included in the  reports to Congress. We reviewed the interagency agreement between  USAID and the Centers for Disease Control and Prevention (CDC),  outlining the CDC’s Zika response activities supported by $78 million in  funds USAID obligated to CDC. We also obtained additional funding data  from CDC and interviewed CDC officials to discuss the status of the  agencies’ obligations and disbursements for Zika response activities. We  analyzed USAID’s and State’s obligations and disbursements that the  agencies reported as supporting the U.S. Zika response overseas, as of  September 30, 2018. We analyzed agency obligations and disbursements across agency bureaus, funding accounts, and activities for the Zika  response.

Additionally, we interviewed officials from USAID and State to discuss the  agencies’ obligations and disbursements for Zika response activities. We  then reviewed the funding data and related documentation and consulted  with USAID and State officials on the accuracy and completeness of the  data. In the small number of instances where we identified potential  issues or inconsistencies in the data, we contacted relevant agency  officials and obtained information from them necessary to resolve the  discrepancies. We assessed USAID’s tracking of funding data against  federal internal control standards related to using quality information. We  also utilized information from data reliability assessments for two recent  GAO reports that utilized funding data from the same USAID and State  systems. 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 activities that USAID and State implemented in response to  Zika overseas, we conducted fieldwork, analyzed agency documents, and  interviewed officials. We examined the status and progress related to Zika  response activities. We conducted a teleconference with officials in Haiti  and El Salvador and conducted fieldwork in Barbados, Colombia,  Dominican Republic, Guatemala, Honduras, Peru, and Trinidad and  Tobago. We selected these countries based on the following criteria: (1)  geographic diversity to include the Caribbean, Central America, and  South America; (2) coverage of the main lines of effort (mosquito control,  public awareness, capacity building, and research); and (3) the presence  of activities under way that accounted for a significant portion of funding.  During our fieldwork, we interviewed agency officials who played a role in  Zika response activities, which included officials from State, USAID, and  CDC. We also interviewed host government officials, implementing  partners, health care workers, community volunteers, and researchers. In  addition, we visited offices, toured facilities, and observed operations. We  also attended a conference in Guatemala that addressed topics including  status, successes, challenges, and lessons learned related to USAID’s  Zika response. We reviewed agency documents describing the plans and  goals of activities. We also analyzed progress reports of six activities to  provide illustrative examples of results. We selected activities from those  with among with the highest amounts of funding and that together  represented approximately 33 percent of all USAID funding for Zika  response and a range of countries, lines of effort, and types of  implementing partners (such as nongovernmental organizations and  international organizations). The sample is not generalizable to all of  USAID’s Zika response activities.

To examine challenges, if any, to implementing Zika response activities  and actions taken to address any challenges, we interviewed U.S.  government officials, USAID implementing partners, and host government  officials, and we analyzed progress reports from selected USAID-funded  Zika response activities. We identified key challenges based on the  nature of the description and the degree to which a diversity of  interviewees and documents made mention of them. We reviewed USAID  policy, USAID’s infectious disease response plan, federal internal  controls, implementing partner progress reports, and interviews with  officials to determine what agencies did to address these challenges. We  assessed USAID’s infectious disease response plan against relevant  federal internal control standards.

We conducted this performance audit from December 2017 to May 2019  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.

Appendix II: Illustrative Examples of Results for Selected Zika Response Activities

To provide illustrative examples of the results of Zika response activities  funded by the U.S. Agency for International Development (USAID), we  analyzed implementing partners’ progress reports for a sample of six  activities. We selected activities from those with among the highest  amounts of funding and that together represented approximately 33  percent of all USAID funding for Zika response and a range of countries,  lines of effort, and types of implementing partners (such as  nongovernmental organizations and international organizations).  Quantitative figures related to individual indicators listed below reflect the  targeted population of the activity. Start dates and funding information  provided below reflect the date of the report to Congress in which the  activity first appeared and the associated funds obligated. The sample is  not generalizable to all USAID’s Zika response activities.

Applying Science to Strengthen and Improve Systems

Table 1 presents the progress on key indicators as of March 2018  reported to USAID by the Applying Science to Strengthen and Improve  Systems activity. The aim of the activity was to strengthen Zika-related  health services and systems in Latin America and the Caribbean with a  focus on pregnant women, newborns, and women of reproductive age.

International Federation of Red Cross and Red Crescent Societies Global Health

Table 2 presents the progress on key indicators as of May 2018 reported  to USAID by the International Federation of Red Cross and Red Crescent  Societies Global Health activity. The activity aimed to reduce risks  associated with Zika infection through promoting community involvement,  sharing lessons learned, and improving practices.

United Nations International Children’s Emergency Fund

Table 3 presents the progress on key indicators as of March 2018  reported to USAID by the United Nations International Children’s  Emergency Fund activity. The activity aimed to promote the adoption of  prevention behaviors among at-risk populations through actions targeting  multiple levels of their environment: individual, interpersonal, community,  institutional, and national policy levels.

Save the Children Community Action on Zika

Table 4 presents the progress on key indicators as of September 2017  reported to USAID by the Save the Children Community Action on Zika  project. The goal of the project was to reduce Zika transmission and  minimize the risk of Zika-related microcephaly and other neurological  disorders among the most vulnerable through community-based  prevention strategies.

Table 5 presents the progress on an illustrative selection of key  indicators, by objective, as of March 2018 reported to USAID by the  Population Services International activity. The purpose of the activity was  to improve the capacity and raise awareness of people in countries  affected by and at risk of Zika and other vector-borne diseases.

Table 6 presents illustrative examples of accomplishments as of March  2018 reported to USAID by the Zika AIRS Project (ZAP). This was a  mosquito control project focused on reducing Zika transmission in Latin  America and the Caribbean. Specific activities included entomological  monitoring, larviciding, source reduction interventions, and indoor residual  spraying.

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

Appendix IV: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Joyee Dasgupta (Assistant  Director), Marc Castellano (Analyst-in-Charge), Diana Blumenfeld, Alana  Miller, Fatima Sharif, David Dayton, Francisco Enriquez, Christopher  Keblitis, Amber Sinclair, and K. Nicole Willems made key contributions to  this report.

The Zika virus appeared in the Western Hemisphere in May 2015 and spread to many countries in less than a year. Zika can have mild or unnoticed symptoms, but it can also cause severe birth defects.

In response, USAID supported a range of activities overseas, including mosquito control, public awareness, and research. However, USAID didn't track Zika funding by country and took longer than desired to get response efforts launched in some countries.

To better position the agency for future outbreaks, we recommended that USAID track funding by country and take steps to improve its infectious disease response planning.