United States Government Accountability Office Report to the Chairman, Committee on Foreign Relations, U.S. Senate USAID June 2023 Management Improvements Needed to Better Meet Global Health Mission GAO-23-105178 June 2023 USAID Management Improvements Needed to Better Meet Global Health Mission Highlights of GAO-23-105178, a report to the Chairman, Committee on Foreign Relations, U.S. Senate Why GAO Did This Study What GAO Found The Bureau supports U.S. efforts to The U.S. Agency for International Development's (USAID) Bureau for Global save lives, protect the people most Health's (Bureau) staffing is not aligned with its mission and priorities. More than vulnerable to disease, and promote the half of the Bureau's workforce consists of contractors who USAID has stability of communities and nations determined cannot perform inherently governmental functions. These functions throughout the world. From fiscal years include overseeing the Bureau's contracts and grants-its primary mechanisms 2019 through 2022, the Bureau had an for implementing its programming. In addition, the distribution of the Bureau's annual budget between $1 billion and staff is inconsistent with its program funding levels. Specifically, the Bureau has $1.4 billion. The COVID-19 pandemic the greatest number of staff working on HIV/AIDS programming, but receives has highlighted the importance of the less funding for this programming compared with its other strategic priorities- Bureau's work to U.S. foreign policy. preventing child and maternal deaths and combating infectious diseases. Despite To respond to disease outbreaks and support existing health programming, these challenges, the Bureau lacks a workforce plan, leaving it with limited ability the Bureau requires a workforce with a to address its current and future staffing needs. variety of skill sets. Its ability to assess Bureau performance assessments have gaps at the Bureau and program levels. its performance is important to its The Bureau does not have indicators for bureau-wide performance that measure preparation for future health crises. progress for each of its strategic priorities, or across them. Communicating the GAO was asked to review the Bureau's Bureau's overall performance is also challenging due to variations in its data. operations. This report examines (1) While the Bureau assesses program level performance for its health program the Bureau's staffing and its workforce areas, its reports to Congress in some of these areas do not always include key plans; (2) its performance information. For example, reports on maternal and child health do not contain assessments; and (3) key factors that results for 18 countries that received more than $200 million between fiscal years affect the Bureau's ability to execute its 2019 and 2021. By assessing its bureau-wide performance, harmonizing its data, mission and priorities, and the steps it and improving its reports, the Bureau can better evaluate and communicate its has taken to address them. GAO results and enhance the quality of the information it is providing to Congress. analyzed USAID staffing data and global health reports. GAO also Examples of Programming Funded by the Bureau for Global Health interviewed USAID officials in Washington, D.C., and at five overseas missions, selected based on factors such as geography, amount of funding, and number of health program areas. What GAO Recommends GAO is making six recommendations, including that USAID ensure the Bureau develops a workforce plan, improves performance assessments and reporting, documents lessons learned from the COVID-19 pandemic, and institutionalizes efforts to address The Bureau has recently faced several challenges to its ability to execute its negative behaviors identified by the mission and priorities. These have included challenges posed by the COVID-19 Bureau as affecting its culture. USAID pandemic, including disruptions to existing health services. The Bureau took concurred with all of GAO's steps to address COVID-related challenges, such as by providing lengthier recommendations. supplies of medications during lockdowns. However, while some USAID missions have documented lessons learned from the pandemic, the Bureau has not. Doing View GAO-23-105178. For more information, so could help the Bureau better respond to future global health emergencies. contact Chelsa Kenney at (202) 512-2964 or kenneyc@gao.gov. Finally, though the Bureau has identified negative behaviors that affect its culture, it has not yet institutionalized its efforts to address them. United States Government Accountability Office Contents Letter 1 Background 3 The GH Bureau's Staffing Is Not Aligned with Its Mission and Priorities and It Lacks a Workforce Plan 12 The GH Bureau's Performance Assessments Have Gaps at the Bureau and Program Levels 28 COVID-19 and Other Challenges Affected the GH Bureau, Some of Which It Has Taken Steps to Address 37 Conclusions 49 Recommendations for Executive Action 51 Agency Comments 52 Appendix I Objectives, Scope, and Methodology 53 Appendix II Comments from the U.S. Agency for International Development 59 Appendix III GAO Contact and Staff Acknowledgments 66 Tables Table 1: U.S. Agency for International Development's (USAID) Bureau for Global Health's Strategic Priorities and Health Program Areas 5 Table 2: U.S. Agency for International Development's (USAID) Bureau for Global Health (GH Bureau) Fiscal Year 2022 Funding for and Examples of Global Health Programming 10 Table 3: Examples of Challenges to USAID Missions' Programming from the COVID-19 Pandemic and Steps Taken to Address Them 38 Table 4: Examples of Operational Challenges to USAID Missions from the COVID-19 Pandemic and Steps Taken to Address Them 40 Page i GAO-23-105178 USAID Bureau for Global Health Figures Figure 1: U.S. Agency for International Development's (USAID) Bureau for Global Health Organizational Chart 3 Figure 2: U.S. Agency for International Development's (USAID) Bureau for Global Health Program Budget Allocations, Fiscal Years (FY) 2016-2022 8 Figure 3: U.S. Agency for International Development's (USAID) Bureau for Global Health Operating Expenses Budget Amounts, Fiscal Years (FY) 2016-2022 9 Figure 4: USAID's Bureau for Global Health Program Funding and Number of Staff by Strategic Priority, Fiscal Year 2021 16 Figure 5: U.S. Agency for International Development (USAID) and Bureau for Global Health (GH Bureau) Demographic Data on Race and Ethnicity, Fiscal Year 2021 21 Figure 6: U.S. Agency for International Development (USAID) and Bureau for Global Health (GH Bureau) Demographic Data on Gender, Fiscal Year 2021 22 Figure 7: U.S. Agency for International Development (USAID) Bureau for Global Health (GH Bureau) Demographic Data on Race and Ethnicity, Fiscal Years (FY) 2019-2021 23 Page ii GAO-23-105178 USAID Bureau for Global Health Abbreviations COR Contracting Officer Representative CS Civil Service DEIA diversity, equity, inclusion, and accessibility FS Foreign Service FSL Foreign Service Limited FY fiscal year GH Bureau, or Bureau Bureau for Global Health GHP Global Health Programs HCTM Office of Human Capital and Talent Management HSS health systems strengthening ISC institutional support contractor NTD neglected tropical diseases OE Operating Expenses PEPFAR President's Emergency Plan for AIDS Relief PMI President's Malaria Initiative PPR Performance Plan and Report PSC personal services contractor TB tuberculosis USAID U.S. Agency for International Development This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page iii GAO-23-105178 USAID Bureau for Global Health Letter 441 G St. N.W. Washington, DC 20548 June 9, 2023 The Honorable Robert Menendez Chairman Committee on Foreign Relations United States Senate Dear Mr. Chairman: The U.S. government's efforts in global health and development abroad have undergone rapid and significant changes in the last few years. While the U.S. government has faced new and emerging health challenges, such as the COVID-19 pandemic, it also maintains an ongoing commitment to improve maternal and child health and nutrition; expand access to health services; achieve control of the HIV/AIDS epidemic; and prevent, detect, and respond to infectious disease threats and other public health emergencies. The U.S. Agency for International Development's (USAID) Bureau for Global Health (GH Bureau, or Bureau), one of the agency's largest bureaus, supports U.S. efforts abroad to save lives, protect the people most vulnerable to disease, and promote the stability of communities and nations throughout the world. From fiscal years 2019 through 2022, the GH Bureau had an annual budget between $1 and $1.4 billion to implement its programming. 1 The COVID-19 pandemic has highlighted the importance of the GH Bureau's activities to support U.S. foreign policy interests, including promoting global health security, which is the capacity to prepare for, detect, and respond to infectious disease threats and to reduce or prevent their spread across borders. The Bureau received a significant increase in global health security funding from $190 million in fiscal year 2021 to $397 million in fiscal year 2022. The COVID-19 pandemic is the latest of several global health crises that the Bureau has responded to in recent years, each of which has required unique responses and a workforce with different skill sets. The Bureau's ability to assess its performance is important to ensuring that it is prepared to respond to future global health crises and continues to make progress on all of its health programming. 1Thisannual budget amount does not include supplemental and emergency funding appropriated in fiscal years 2020 and 2021 to respond to the COVID-19 pandemic. Page 1 GAO-23-105178 USAID Bureau for Global Health You asked us to review the operations of the GH Bureau. This report assesses (1) how the Bureau's staffing is aligned with its mission, priorities, and funding, and the extent to which the Bureau has workforce plans to address current and future staffing needs; (2) the Bureau's assessments of its performance in executing its mission and priorities; and (3) key factors that affect the Bureau's ability to execute its mission and priorities, and the steps the Bureau has taken to address any challenges it faces. To assess how the GH Bureau's staffing is aligned with its mission, priorities, and funding, and the extent to which the Bureau has workforce plans, we analyzed the Bureau's data on its staffing composition from fiscal years 2019 through 2022. We compared its staffing data with the amount of funding for each of its strategic priorities, reviewed USAID documentation on workforce planning, and conducted interviews with USAID officials. To assess the reliability of the data, we reviewed information from USAID on the procedures, checks, and controls in the systems used to generate the data, and interviewed USAID officials. We determined that the data were sufficiently reliable for the purposes of providing an overview of the Bureau's staffing and funding. To examine the Bureau's assessments of its performance, we reviewed reports the Bureau produced between fiscal years 2019 and 2021 of its performance at a bureau-wide level and its reports to Congress on its performance at a global health program area level. To identify factors that affect the Bureau's ability to execute its mission and priorities, we selected a non-generalizable sample of five overseas missions and conducted interviews with officials at those missions, as well as officials at headquarters. We selected these missions based on several factors, including geographic region, amount of global health funding, and number of global health program areas. We also examined what steps, if any, the agency is taking to address any challenges. For more details on our scope and methodology, see appendix I. We conducted this performance audit from May 2021 to June 2023 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. Page 2 GAO-23-105178 USAID Bureau for Global Health Background GH Bureau's Role and The GH Bureau functions as USAID's focal point in providing worldwide Organization leadership and technical expertise in the areas of child and maternal health and nutrition, HIV/AIDS, infectious disease, population, family planning and related reproductive health, and health systems, among others. According to the Bureau, it influences the global health priorities of the U.S. private sector, U.S.-based foundations, other donor organizations, host country governments, and civil society organizations. As shown in figure 1, the GH Bureau consists of nine offices that support the technical and programmatic needs of USAID's global health efforts around the world. Figure 1: U.S. Agency for International Development's (USAID) Bureau for Global Health Organizational Chart • The Office of the Assistant Administrator provides oversight of all the GH Bureau's global health programs, support to the field, research, legislative relations, and external affairs. This office also houses the Center for Innovation and Impact, which supports innovations, applies market-based approaches, and advances efforts in digital health and private sector engagement, among others, to maximize the impact of its global health work. In addition, the COVID- 19 Response Team, which undertook many of the coordination functions of the agency's response to the pandemic, is located in this office. Page 3 GAO-23-105178 USAID Bureau for Global Health • The Office of Country Support provides strategic technical and program assistance for USAID's global health efforts overseas and facilitates communications between field offices and headquarters, including regional bureaus, to ensure a coordinated response to global health priorities across the agency. • The Office of Health Systems works across the GH Bureau's global health programs and provides technical leadership and direction in health systems strengthening to enable countries to address complex health challenges and protect against extreme poverty. • The Office of HIV/AIDS leads USAID's efforts under the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) in controlling the HIV/AIDS epidemic by providing technical leadership, monitoring impact, and ensuring program integrity. • The Office of Infectious Disease leads USAID's efforts to combat infectious diseases and manages prevention, mitigation, and control programs for tuberculosis (TB), neglected tropical diseases (NTD or NTDs), malaria through the U.S. President's Malaria Initiative (PMI), and emerging threats to global health security. • The Office of Maternal and Child Health and Nutrition functions as USAID's technical and policy lead on maternal and child health, newborn health, immunization, nutrition, and water, sanitation, and hygiene, and plays a leading role in the agency's efforts to prevent child and maternal deaths. • The Office of Policy, Programs, and Planning guides the GH Bureau's strategic planning, budgeting, programming, and procurement functions, and is involved in providing leadership in resource allocation as well as performance monitoring and evaluation. • The Office of Population and Reproductive Health provides strategic direction for the GH Bureau and global health sector as well as global technical leadership and support to field programs in population, voluntary family planning, and reproductive health. • The Office of Professional Development and Management Support provides professional staff development to employees as well as personnel, administration, and management functions to maintain the GH Bureau's workforce and operational efficiency. GH Bureau's Strategic The GH Bureau has three strategic priorities: preventing child and Priorities and Health maternal deaths, combating infectious diseases, and controlling the HIV/AIDS epidemic. The Bureau's strategic priorities are aligned with Program Areas eight health program areas. These program areas are: (1) family planning Page 4 GAO-23-105178 USAID Bureau for Global Health and reproductive health, (2) global health security, (3) HIV/AIDS, (4) malaria, (5) maternal and child health, (6) neglected tropical diseases, (7) nutrition, and (8) tuberculosis. 2 Table 1 shows the three strategic priorities and the eight health program areas associated with each of them. Table 1: U.S. Agency for International Development's (USAID) Bureau for Global Health's Strategic Priorities and Health Program Areas Strategic priorities Health program areas Preventing child and maternal deaths Maternal and child health Nutrition Family planning and reproductive health Malariaa Combating infectious diseases Global health security Neglected tropical diseases Tuberculosis Controlling the HIV/AIDS epidemic HIV/AIDS Source: GAO analysis of USAID documents. | GAO-23-105178 a According to Bureau officials, the malaria program area supports both preventing child and maternal deaths and combating infectious diseases. For purposes of its performance results, Bureau officials stated that malaria results support preventing child and maternal deaths. In addition to these eight program areas, the Bureau also has two cross- cutting program areas: health systems strengthening and innovation. Both program areas support the Bureau's efforts to achieve all three of its strategic priorities. Health systems strengthening comprises the strategies, responses, and activities designed to sustainably improve country health system performance. 3 According to USAID, high- performing and resilient health systems are imperative for improving and sustaining health progress and can also mitigate the deleterious health and economic effects of infectious disease outbreaks, such as Ebola, Zika, and COVID-19. USAID defines innovation as the pursuit of novel approaches that lead to substantial improvements in addressing development challenges. According to the Bureau, it innovates through 2According to Bureau officials, in fiscal year 2021 and previous years, the Bureau was involved in an additional program area-social services. Its role in this program area was to manage USAID's Child Blindness Program. Starting with fiscal year 2022 funds, management of the Child Blindness Program was transferred from the GH Bureau to the Bureau for Development, Democracy, and Innovation. 3A health system consists of all people, institutions, resources, and activities whose primary purpose is to promote, restore, and maintain health. Page 5 GAO-23-105178 USAID Bureau for Global Health improving health solutions it already supports, engaging partners in new ways, and enhancing health financing and work structures. The Bureau also developed annual objectives and goals for 2022. According to Bureau officials, these objectives and goals provide a common framework for identifying and operationalizing Bureau priorities. The first objective is to drive lasting impact, with goals such as anticipating and delivering on all priorities to fight COVID-19 and its effects and making the U.S. and the world better prepared to prevent, detect, and respond to the next pandemic or other health emergency. The second objective is to strengthen the Bureau's resources and reputation, with goals such as the Bureau's country partners and external stakeholders considering it a trusted team for leadership, collaboration, and impact on global health. The third objective is to improve its performance in teams, with goals such as measurable improvement in employee engagement and teamwork. Types of Staff Working in The GH Bureau has two primary types of staff working to execute its the GH Bureau mission and priorities: direct hires and non-direct hires. 4 Direct hire staff primarily consist of Civil Service (CS), Foreign Service (FS), and Foreign Service Limited (FSL) staff. 5 Non-direct hire staff primarily consist of personal services contractors (PSCs) and institutional support contractors (ISCs). PSCs are contracted directly with the U.S. government, while ISCs are hired through third-party mechanisms. The Bureau's staffing 4USAID defines direct hire employees as U.S. citizens employed as direct hire (general schedule Civil Service) and excepted service (non-career and Foreign Service) experts, consultants, or advisory committee members serving without compensation. See U.S. Agency for International Development, Automated Directives System Glossary (revised Sept. 2, 2021). According to USAID officials, direct hires are considered career staff that have inherently governmental responsibilities, while non-direct hire staff are considered temporary, term-limited positions. 5Foreign Service staff and most of the GH Bureau's Civil Service staff are considered permanent employees. Foreign Service Limited Staff are considered temporary employees and are appointed for 1 year to 5 years. 22 U.S.C. § 3949. See also U.S. Agency for International Development, Automated Directives System Chapter 414: Foreign Service Appointments (revised May 1, 2020). According to USAID officials, USAID has been granted the authority to extend non-career FSL appointments up to 9 years total, but this authority must be renewed in annual appropriations acts. For the most recent renewal of this authority, see Pub. L. No. 117-103, Div. K, Title VII, § 7065(d), 136 Stat. 49, 678 (2022). Page 6 GAO-23-105178 USAID Bureau for Global Health types also include political appointees and consultants, among others. 6 CS and FS staff are considered permanent staff, while FSLs, PSCs, ISCs, political appointees, and consultants are all considered temporary staff. Global Health Funding for The GH Bureau receives funding for each of its health program areas to Programs and Operating implement its programming. It can also use funds from the program budget to hire non-direct hire staff, such as contractors. 7 Further, the U.S. Expenses Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 allows the agency to use HIV/AIDS program funds to hire direct hire staff to work on HIV/AIDS programming, but according to USAID, this is the only program area in which it has this authority. 8 The Bureau also uses program funding to hire its FSL staff. Figure 2 below illustrates the Bureau's program budget allocations between fiscal years 2016 and 2022, which ranged from about $954 million to about $1.4 billion. 6Politicalappointees are employed as direct hire employees and consultants are primarily hired through non-direct hire contracts, according to USAID. Other staff in the Bureau include those from other agencies hired through an Intergovernmental Personnel Act of 1970 assignment agreement, interagency agreement, detail, or other agreement. 7Program funding and the program budget refer to the GH Bureau's allocations for its health program areas from the Global Health Programs (GHP) appropriation account for USAID. The Bureau receives GHP funding from both USAID and the Department of State for HIV/AIDS programming. 822 U.S.C. § 2151b-2(g). Page 7 GAO-23-105178 USAID Bureau for Global Health Figure 2: U.S. Agency for International Development's (USAID) Bureau for Global Health Program Budget Allocations, Fiscal Years (FY) 2016-2022 The GH Bureau uses the Operating Expenses (OE) budget to hire direct hire staff for all of its health program areas with the exception of some CS staff working on HIV/AIDS and FSLs, for which it uses program funding. 9 Figure 3 below illustrates the Bureau's OE funding between fiscal years 2016 and 2022, which ranged from about $18 million to about $28 million. 9The OE budget refers to the GH Bureau's allocations from the Operating Expenses appropriation account for USAID. HIV/AIDS is the only health program area for which the GH Bureau uses both program and OE funding to hire CS staff. Page 8 GAO-23-105178 USAID Bureau for Global Health Figure 3: U.S. Agency for International Development's (USAID) Bureau for Global Health Operating Expenses Budget Amounts, Fiscal Years (FY) 2016-2022 GH Bureau's Health USAID implements its global health programming in approximately 60 Program Activities countries. 10 Under its three strategic priorities, the GH Bureau implements activities in each of its eight health program areas. 11 Missions develop and implement programming activities in some or all of these areas, depending on country needs. Table 2 shows fiscal year 2022 allocations and examples of activities by health program area. 10These countries are those in which USAID implemented global health programming using funds from the GHP appropriation account in fiscal year 2022. It does not include all countries in which USAID implemented COVID-19 pandemic programming. 11The GH Bureau works with USAID's missions to oversee the implementation of its activities in the family planning, HIV/AIDS, malaria, maternal and child health, nutrition, and tuberculosis program areas. The Bureau centrally manages neglected tropical disease activities, as well as some global health security activities. The Bureau centrally managed all global health security activities prior to fiscal year 2022. Page 9 GAO-23-105178 USAID Bureau for Global Health Table 2: U.S. Agency for International Development's (USAID) Bureau for Global Health (GH Bureau) Fiscal Year 2022 Funding for and Examples of Global Health Programming Fiscal year 2022 allocations Program areas (Dollars in millions) Examples of activities Global health security 397 million • Preventing and detecting zoonotic disease, and strengthening the veterinary laboratory system • Working to contain antimicrobial resistance Maternal and child health 370.7 million • Improving health systems to ensure quality services for mothers and children during pregnancy, delivery, and post-delivery periods to reduce maternal and child mortality • Expanding access to and use of vaccines to prevent child deaths HIV/AIDS 226.9a million • Training healthcare workers to deliver HIV and health services • Testing for HIV and providing anti-retroviral treatments Neglected tropical diseases 102.5 million • Scaling up chemotherapy to control the most prevalent neglected tropical diseases • Distributing medicines to communities at risk of neglected tropical diseases Family planning and reproductive 96.5 million • Expanding access to family planning methods to reduce health unintended pregnancies • Expanding affordable contraceptive options Tuberculosis (TB) 81.9 million • Strengthening laboratory detection and diagnostic capacity of TB in health facilities • Expanding access to quality TB care and treatment services, including medications Malaria 60 million • Improving access to high quality detection and treatment services • Increasing the availability of insecticide-treated bed nets and preventative prophylaxis for children and pregnant women Nutrition 16.5 million • Increasing access to and consumption of nutritious food, particularly for young children • Improving community outreach and access to facility- based nutrition services Source: GAO analysis of USAID documents. | GAO-23-105178 Note: According to GH Bureau officials, in fiscal year 2021 and previous years, the GH Bureau was involved in an additional program area-social services. Its role in this program area was to manage USAID's Child Blindness Program. Starting with fiscal year 2022 funds, management of the Child Blindness Program was transferred from the GH Bureau to the Bureau for Development, Democracy, and Innovation. Because the GH Bureau does not have a role in managing fiscal year 2022 funds for the Child Blindness Program, the social services program area is not included in this table of the GH Bureau's fiscal year 2022 allocations. a HIV/AIDS allocations represent those funds for which USAID has a responsibility for implementation. They include $112.7 million from the Global Health Programs appropriation account managed by USAID, as well as $114.2 million from the Global Health Programs appropriation account that is a transfer from the Department of State to USAID. The funds in this table represent those managed by the GH Bureau only. Page 10 GAO-23-105178 USAID Bureau for Global Health GH Bureau's Response to In response to the spread of COVID-19 in China, the World Health the COVID-19 Pandemic Organization declared COVID-19 a public health emergency of international concern in January 2020. In February 2020, the GH Bureau sent guidance to its overseas missions on programming resources during a declared public health emergency of international concern. Bureau officials reported sending specific technical guidance to missions starting in March 2020. The Bureau provided technical and programmatic guidance on responding to the pandemic and continuing existing global health programming activities during the pandemic. USAID is part of the administration's strategy to provide vaccinations worldwide and support implementation of the U.S. COVID-19 Global Response and Recovery Framework, which was released in July 2021. The framework includes the following objectives: • Accelerate widespread and equitable access to and delivery of safe and effective COVID-19 vaccinations • Reduce morbidity and mortality from COVID-19, mitigate transmission, and strengthen health systems, including to prevent, detect, and respond to pandemic threats • Address acute needs driven by COVID-19, mitigate household shocks, and build resilience • Bolster economies and other critical systems under stress due to COVID-19 to prevent backsliding and enable recovery • Strengthen the international health security architecture to prevent, detect, and respond to pandemic threats To support this framework, the GH Bureau's activities include procuring COVID-19 vaccines and diagnostic test kits, strengthening laboratory and diagnostic capabilities, and training the health workforce to prevent, diagnose, and treat COVID-19. The Bureau has allocated approximately $10.1 billion as of September 2022 to combat COVID-19 using funds from Page 11 GAO-23-105178 USAID Bureau for Global Health the fiscal years 2020, 2021, and prior year appropriations acts. 12 This amount represents about 75 percent of USAID's total COVID-19 allocations from the fiscal year 2020 and 2021 appropriations acts, as well as prior year appropriations acts, as of September 2022. The GH Bureau faces a number of challenges in aligning its staffing with The GH Bureau's its mission and priorities, and it lacks a workforce plan to guide its efforts. Staffing Is Not Aligned The majority of the Bureau's staff are non-direct hires who, according to USAID, do not meet the definition of federal employees who are able to with Its Mission and perform inherently governmental functions. As a result, these non-direct Priorities and It Lacks hires are not permitted to oversee the Bureau's contracts and grants-its primary mechanisms for implementing global health programming. a Workforce Plan Moreover, the distribution of the Bureau's staff across its strategic priorities is inconsistent with the funding levels for those priorities. In addition, the Bureau has had persistent vacancies in Civil Service positions from fiscal years 2020 through 2022. The Bureau also faces some challenges in its demographic diversity, such as underrepresentation of African Americans or Blacks compared with USAID's permanent workforce, according to USAID. Finally, the Bureau does not have a workforce plan, leaving it with a limited ability to align its staffing with its mission, priorities, and funding; to determine the optimal mix of senior leaders to ensure it operates as efficiently as possible; and to accurately project future staffing needs. Most of the GH Bureau's Most of the GH Bureau's workforce consists of non-direct hires. However, Staff Are Non-Direct Hires according to USAID, the vast majority of these staff are not permitted to perform inherently governmental functions, such as oversight of the Who Cannot Oversee Bureau's more than 200 contracts and grants-the agency's primary Contracts and Grants 12The $10.1 billion allocation consists of $435 million from the GHP account and $75.6 million from the Economic Support Fund account appropriated in the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, Pub. L. No. 116- 123, 134 Stat. 146, 152, 153 (2020); $17 million from the OE account appropriated in the CARES Act, Pub. L. No. 116-136, 134 Stat. 281, 590 (2020); $4 billion from the GHP account appropriated in the Consolidated Appropriations Act, 2021, Pub. L. No. 116-260, 134 Stat. 1182, 1702 (2020); $5.5 billion from the Economic Support Fund account and $3.2 million from the OE account appropriated in the American Rescue Plan Act of 2021, Pub. L. No. 117-2, §§ 10002-10003, 135 Stat. 4, 238, 239 (2021); and $99 million in prior year appropriations from the Emergency Reserve Fund. Page 12 GAO-23-105178 USAID Bureau for Global Health mechanisms for implementing global health programming. 13 Between fiscal years 2019 and 2022, the Bureau's total workforce grew from about 500 staff to about 740 staff. 14 Non-direct hire staff (largely ISCs) constituted about 60 percent or more of the workforce during this period. 15 Direct hire staff (largely CS, FS, and FSL) constituted the rest. 16 According to GH Bureau officials, the amount of the agency's OE budget limits the number of CS and FS staff they can hire. 17 OE funding was between 1.9 and 2.4 percent of the Bureau's funding between fiscal years 2019 and 2022, while program funding made up the remainder. 18 In fiscal 13Functions determined to be inherently governmental are based on the Federal Activities Inventory Reform Act of 1998. Pub. L. No. 105-270, 112 Stat. 2382 (1998), codified at 31 U.S.C. § 501 note. The Act mandates that inherently governmental functions are to be performed by federal government employees. USAID policy requires that employees serving as Contracting Officer Representatives and Agreement Officer Representatives, both of which provide oversight of the agency's contracts and grants, have a direct employee-employer relationship with the U.S. government. Such staff include direct hire and PSC staff, as well as employees of other U.S. government agencies. See U.S. Agency for International Development, Automated Directives System Chapter 302: USAID Direct Contracting (revised Mar. 8, 2022) and Automated Directives System Chapter 303: Grants and Cooperative Agreements to Non-Governmental Organizations (revised July 1, 2022). 14The total number of staff consists of CS, FS, FSL, ISCs, PSCs, and Fellows onboard in the GH Bureau as of the end of each fiscal year, according to Bureau officials. For further details on this data, see the subsequent footnotes on non-direct hire and direct hire staff. 15The GH Bureau's non-direct hire staff also include PSCs and Fellows. According to Bureau officials, USAID hires global health Fellows to support the Bureau's work. The Fellows in this data represent only those who are based in Washington, D.C. According to Bureau officials, data for non-direct hire staff in this calculation consist of ISCs, Fellows, and PSCs onboard in the GH Bureau. The PSCs and Fellows represent staff onboard as of the end of the last pay period of the fiscal year for fiscal years 2019 to 2021. For fiscal year 2022, the PSC data is as of September 25, 2022, and the Fellows data is as of September 30, 2022. The ISC data are as of September 30 of the fiscal year. The numbers of ISCs used in the calculation are according to data compiled by GH Bureau officials, which they receive from the ISCs' employers. 16The CS, FS, and FSL data represent staff onboard as of the end of the last pay period of the fiscal year for fiscal years 2019 to 2021. For fiscal year 2022, the CS and FS data represent staff onboard as of September 30, 2022, and the FSL data represent staff onboard as of the last pay period of fiscal year 2022. 17Based on the OE budget amount, USAID's Bureau for Management determines the total number of OE-funded positions that the agency can hire and the agency then determines the number of staff each bureau is allocated. 18Program funding refers to the GH Bureau's allocations for its health program areas from the GHP appropriation account for USAID. The Bureau receives GHP funding from both USAID and the Department of State for HIV/AIDS programming. Page 13 GAO-23-105178 USAID Bureau for Global Health year 2022, the OE budget was about $28 million, while the program budget was about $1.4 billion. The Bureau's OE budget amount is determined by annual appropriations acts, and USAID policy requires that all personnel expenses for full-time employees in permanent positions be funded from this account only, with very limited exceptions. 19 Thus, funding for most of the Bureau's direct hire staff comes from the OE budget. 20 The Bureau can use program funds to hire contractors, along with FSL staff, to work in any of its program areas, according to USAID officials. USAID has determined that it can use HIV/AIDS program funds to hire CS staff, as well, and that such program-funded CS staff can only work on HIV/AIDS in support of PEPFAR. According to GH Bureau officials, the considerably larger amount of program funding and the ability to use it to hire contractors is the reason that non-direct hire staff make up such a significant portion of the Bureau's workforce. In fiscal years 2020 and 2021-the most recent data provided by the Bureau-the GH Bureau had among the largest program budgets in the agency, but also had among the smallest levels of direct hire, full-time employees per dollar managed. For example, Bureau calculations show that it managed $48 million on average per CS and FS employee, compared with an average of $7.2 million for other bureaus in fiscal year 2020. In fiscal year 2021, the GH Bureau managed the agency's largest program budget, but it was second to the Bureau of Humanitarian Assistance in the amount managed per CS and FS employee. Specifically, the GH Bureau managed $91 million on average per CS and FS employee in fiscal year 2021 and the Bureau of Humanitarian Assistance managed $136 million per CS and FS employee that year. 19U.S. Agency for International Development, Automated Directives System Chapter 601: Funding Source Policy (revised Dec. 21, 2011). 20There are some exceptions to only using the OE budget to fund direct hire staff, which the GH Bureau exercises. These exceptions include the authority to use some PEPFAR program funding to hire CS staff, as well as the authority to use program funding to hire FSL staff. Page 14 GAO-23-105178 USAID Bureau for Global Health Other bureaus managed an average of $3.6 million per CS and FS employee in fiscal year 2021. 21 According to Bureau officials, they do not have enough direct hire staff to serve as Contracting Officer Representatives and Agreement Officer Representatives to oversee their contracts and grants. Under USAID policy, only direct hire and PSC staff can serve in these roles. Bureau staff told us that this shortage has led to some direct hire staff overseeing awards in program areas outside their areas of expertise and having a greatly increased workload. For example, one official working on TB became an Agreement Officer Representative for a global health communications award, which was outside this official's area of expertise. Another official working in NTDs became a Contracting Officer Representative (COR) for a $100 million interagency agreement on COVID-19 response activities at the peak of the outbreak in Brazil because the Bureau had no other employee available for the position with the necessary level of COR training. According to this official, the COR duties for the agreement resulted in almost a year spent working outside the field of NTDs, which resulted in a significantly increased workload for this official. The Distribution of GH The distribution of GH Bureau staff does not correspond with the amount Bureau Staff across of funding for its three strategic priorities. Figure 4 below illustrates the GH Bureau's program funding and the number of staff supporting each Strategic Priorities Does strategic priority in fiscal year 2021. Not Correspond with Funding Levels 21As of the end of fiscal year 2020, USAID was undergoing a reorganization, including of its Bureau of Democracy, Conflict, and Humanitarian Assistance. This bureau was split into separate entities, one of which became the Bureau for Humanitarian Assistance. As a result, the fiscal year 2021 calculations compare the GH Bureau to a different set of bureaus than those in fiscal year 2020. Neither the fiscal year 2020 calculation nor the fiscal year 2021 calculation includes USAID's Bureau for Foreign Assistance, as the staff in this office work under the Director of the Office of Foreign Assistance at the Department of State. Page 15 GAO-23-105178 USAID Bureau for Global Health Figure 4: USAID's Bureau for Global Health Program Funding and Number of Staff by Strategic Priority, Fiscal Year 2021 Notes: Data include CS, FS, and PSCs for onboard and vacant positions and FSLs for onboard positions only. Data on CS, FS, and PSC staff are from the U.S. Agency for International Development's (USAID) staffing pattern report as of September 27, 2021, while data on FSLs are according to numbers compiled by Global Health Bureau (GH Bureau) officials as of the end of the pay period of fiscal year 2021. Data do not include any staff from the Offices of Policy, Programs, and Planning; Professional Development and Management Support; Country Support, Health Systems, and the Assistant Administrator, as GH Bureau officials told us that staff in these offices support all three strategic priorities. Program funding data represent fiscal year 2021 Operational Plan amounts for maternal and child health and infectious disease funding and President's Emergency Plan for AIDS Relief Headquarters Operational Plan amounts for HIV/AIDS funding. The maternal and child health strategic priority includes the family planning and reproductive health, nutrition, and social services program areas, in addition to maternal and child health. The infectious disease priority area includes global health security, malaria, neglected tropical diseases, and tuberculosis. According to USAID officials, malaria staff support both infectious disease and maternal and child health. Thirty malaria staff are included under infectious disease in this figure because malaria staff are located in the Office of Infectious Disease. As shown in the figure above, the largest number of the GH Bureau's staff work on HIV/AIDS, but the Bureau receives the smallest amount of funding for that programming of its three strategic priorities. 22 Compared with HIV/AIDS, 52 fewer CS, FS, FSL, and PSC staff work on maternal 22The HIV/AIDS funding in figure 4 represents PEPFAR funds that, according to USAID, only headquarters staff in the GH Bureau are responsible for managing. In fiscal year 2021, USAID received $330 million and State received $5.9 billion for PEPFAR activities. Page 16 GAO-23-105178 USAID Bureau for Global Health and child health, but that programming receives the largest amount of funding of its three strategic priorities. 23 According to GH Bureau data on ISCs by Bureau office, the number of ISCs follows a similar pattern, with a greater number of ISCs working on HIV/AIDS than the number working on maternal and child health and infectious disease combined. 24 Consistent with figure 4 above, HIV/AIDS had the largest total number of staff and the Bureau received the least amount of program funding for it compared with its other strategic priorities in fiscal years 2019 and 2020, as well. According to GH Bureau officials, they have the authority to use both OE and program funding to hire CS staff to work on HIV/AIDS, but they only have the authority to use OE funding to hire CS and FS staff to work on other strategic priorities. As a result, the Bureau has more resources available to hire staff to work on HIV/AIDS compared with its other health program areas. The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, as amended, provides USAID the authority to use up to 7 percent of its HIV/AIDS program funding to hire CS staff to work on HIV/AIDS only. 25 In addition, the number of staff working on COVID-19 response activities does not correspond with the GH Bureau's funding to implement such activities. The Bureau considers COVID-19 activities to be emergency activities that are separate from its strategic priorities, and the Bureau has received a larger amount of funding for COVID-19 response activities in fiscal year 2021 than the total amount for its strategic priorities combined. However, its staffing level for COVID-19 response activities is well below the level of each of its strategic priorities. For example, in fiscal year 2021, the Bureau had an annual budget for its strategic priorities of about $1.1 billion. By comparison, as of September 2022, the Bureau had allocated $5.5 billion of American Rescue Plan Act of 2021 funds from the fiscal year 2021 Economic Support Fund appropriation account to prevent, prepare for, and respond to coronavirus. It had allocated $3.2 23Direct hire staff, including CS, FS, and FSL staff, as well as PSC staff are the only employees who can oversee the Bureau's contracts and grants, according to USAID. 24The number of ISCs comes from data compiled by GH Bureau officials, which they receive from the employers of the ISCs. Additionally, according to Bureau data, there were approximately 32 Fellows in the Bureau in fiscal year 2021 and they were fairly evenly distributed across the three strategic priorities, with the greatest number working on maternal and child health and the lowest number working on infectious disease. 2522 U.S.C. § 2151b-2(g). Page 17 GAO-23-105178 USAID Bureau for Global Health million in OE funding appropriated by this same act as of September 2022. The Bureau was authorized to use this OE funding to hire staff to work on COVID-19 using Schedule A hiring authority. 26 According to Bureau officials, the Bureau had 18 CS positions specifically dedicated for Schedule A staff to work on COVID-19 activities, and it had filled 11 of these positions as of the end of fiscal year 2021. 27 Bureau officials stated that the only fully dedicated staff working on COVID-19 at the end of fiscal year 2021 were these 11 staff hired through Schedule A hiring authority. Bureau officials told us in June 2022 that, in addition to the Schedule A staff, the Bureau has relied on other staff serving in a rotating capacity to guide its COVID-19 programs throughout its COVID-19 response, including 10 direct hire staff. 28 Overall, 21 dedicated and rotating direct hire staff spent significant amounts of time on COVID-19 response activities. The GH Bureau Has The GH Bureau had persistent vacancies in CS positions between fiscal Persistent Vacancies in years 2020 and 2022. As noted previously, the Bureau has determined that it can use program funding to hire CS staff to work on HIV/AIDS only, Civil Service Positions and it uses the OE budget to hire CS staff for all health program areas. According to Bureau officials, the OE budget is insufficient to meet the Bureau's staffing needs. However, over the past 3 fiscal years, the Bureau has been unable to fill all of the OE-funded CS positions that the agency has allocated to it. In fiscal year 2020, the Bureau had 25 vacancies in OE-funded CS staff, with an allocation of 118 staff and 93 onboard at the end of fiscal year 2020. In fiscal year 2021, the Bureau 26On March 20, 2020, OPM authorized the use of Schedule A excepted service appointments under 5 C.F.R. § 213.3102(i)(3) to address the need for hiring additional staff in response to COVID-19. USAID was granted the authority to fill positions on a temporary basis for up to 1 year as needed, with the possibility of extension for an additional year, in response to, or as a result of, COVID-19. USAID told us this authority was extended through March 1, 2023, but previous appointments may be extended beyond this date. 27Thenumber of CS Schedule A COVID-19 OE-funded staff comes from data compiled by GH Bureau officials. 28According to Bureau officials, these rotating staff consisted of both non-direct hire and direct hire staff, with non-direct hires mostly performing 6-week details, while direct hire staff mostly provided longer-term support in a part-time capacity, filling leadership and program positions. Of the 10 direct hire staff, six dedicated significant effort on top of their regular responsibilities to contribute to the Bureau's COVID-19 response activities. Four other direct hire staff dedicated about 80 to 90 percent of their efforts for 3 to 6 months to COVID-19 response activities. Page 18 GAO-23-105178 USAID Bureau for Global Health also had an allocation of 118 positions and had 99 staff onboard, for a total of 19 vacant positions. In fiscal year 2022, the Bureau had 31 vacant OE-funded CS positions, with an allocation of 136 staff and 105 onboard. According to Bureau officials, the OE-funded CS vacancies are due to regular attrition. The Bureau also had vacancies in program-funded positions in the Office of HIV/AIDS and Schedule A positions for COVID-19. According to Bureau data, in fiscal year 2020, the Bureau had 47 program-funded CS vacancies and 13 Schedule A COVID-19 OE-funded vacancies. 29 In fiscal year 2021, the Bureau had 36 program-funded CS vacancies and seven Schedule A COVID-19 OE-funded vacancies. 30 As of the end of fiscal year 2022, the Bureau had 26 program-funded CS vacancies and no Schedule A COVID-19 OE-funded vacancies. 31 Bureau officials noted that the COVID-19 Schedule A positions are difficult to recruit and fill due to their short duration of 1 year. The GH Bureau also had vacancies in FS positions based in Washington, D.C., in fiscal years 2021 and 2022. In fiscal year 2020, the Bureau filled all 24 of its allocated positions, but at the end of fiscal year 2021, it had two vacant FS positions, with 24 allocated and 22 onboard. For fiscal year 2022, the Bureau had 26 FS positions, and as of the end of fiscal year 2022, there were 17 FS staff onboard, for a total of nine vacant FS positions. The GH Bureau was unable to provide vacancy data for fiscal years 2016 through 2019. According to GH Bureau officials, the Bureau did not have protocols in fiscal year 2016 to track vacancy data across its staffing mechanisms and therefore could not provide us with reliable vacancy data for that fiscal year. In January 2017, according to USAID officials, USAID instituted a hiring freeze, which remained in place in 2019. 32 29Thenumber of CS program-funded and Schedule A COVID-19 OE-funded staffing vacancies for fiscal years 2020-2022 comes from data compiled by GH Bureau officials. 30In fiscal year 2021, the Bureau also had one COVID-19 OE-funded PSC position. However, that position was not filled and the Bureau rescinded it in November 2021. 31GH Bureau officials explained that, as of the end of fiscal year 2022, the Bureau was no longer filling Schedule A COVID-19 OE-funded positions when they became vacant. Instead, the Bureau eliminated the positions. As a result, there were no vacancies in such positions. 32USAID's hiring freeze was lifted in 2018. However, its Hiring Reassignment and Review Board, in place since August 2017, continued to vet requests for positions in 2019. Page 19 GAO-23-105178 USAID Bureau for Global Health During this time, the Bureau could not hire CS or FS employees lost to attrition, and the maximum allowable positions changed with staff attrition. As a result, neither the Bureau nor HCTM tracked vacancy data during this time. The Bureau was unable to provide vacancy data for FSL staff and non- direct hire staff, both of which are program-funded staff in the Bureau. Bureau officials explained that vacancies for program-funded positions work differently than those funded from the OE budget. HCTM gives the Bureau its allocations of OE-funded CS and FS positions each fiscal year. In contrast, the Bureau does not need to request approval from HCTM for positions that are program-funded, according to Bureau officials, so there is no set number of allocated positions for such staff each fiscal year. As a result, the concept of a vacancy for program-funded positions differs from that for OE-funded positions. For example, ISCs and PSCs are contractors and are recruited as needed. When the contracts for such positions end, the Bureau may not need to renew them. In cases where the Bureau decides not to renew the positions, the resulting reductions in staff numbers are not considered vacancies. The GH Bureau Faces Both the GH Bureau and USAID face challenges in achieving a diverse Some Challenges in workforce. As we previously reported, USAID has a stated commitment to fostering an inclusive workforce that reflects the diversity of the United Demographic Diversity States. 33 According to USAID's Equal Employment Opportunity Program Status Report for fiscal year 2021, multiple demographic groups were underrepresented in USAID's CS workforce, including Hispanic or Latino males, Native Hawaiian or Other Pacific Islander males and females, and Native American or Native Alaskan males and females, among others. 34 This report also stated that USAID's FS workforce is underrepresented in African American or Black males and females, Asian males, and females of two or more races, among others. 35 As shown in figure 5 below, 33GAO, USAID: Mixed Progress in Increasing Diversity, and Actions Needed to Consistently Meet EEO Requirements, GAO-20-477 (Washington, D.C.: June 23, 2020). 34These demographic groups are underrepresented compared with USAID's total workforce, which includes both permanent and temporary staff. They are also underrepresented compared with the Civilian Labor Force, with the exception of Native Hawaiian or Other Pacific Islander females. 35These demographic groups are underrepresented compared with USAID's total workforce, which includes both permanent and temporary staff. We reported in 2020 on the demographic composition of USAID's workforce, including a comparison of USAID's workforce with the federal workforce and relevant civilian labor force. See GAO-20-477. Page 20 GAO-23-105178 USAID Bureau for Global Health several of these racial or ethnic groups, such as Hispanic or Latino males, African American or Black males and females, and Asian males, are more underrepresented in the GH Bureau compared with USAID as a whole. In addition, the Bureau's permanent CS and FS workforce has a lower percentage of males across all racial and ethnic groups, with the exception of males of two or more races, compared with USAID's permanent workforce. 36 Figure 5 below depicts the Bureau's permanent workforce demographic data by race and ethnicity compared with USAID's permanent workforce data for fiscal year 2021. Figure 5: U.S. Agency for International Development (USAID) and Bureau for Global Health (GH Bureau) Demographic Data on Race and Ethnicity, Fiscal Year 2021 Notes: "Other" includes Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, and employees of two or more races. USAID's permanent workforce data also include data from the GH Bureau. Data in this figure for USAID and the GH Bureau represent their permanent Civil Service and Foreign Service staff only. 36The permanent workforce includes CS and FS employees. It does not include FSL staff, which are considered temporary employees. Nor does it include any non-direct hire employees. Page 21 GAO-23-105178 USAID Bureau for Global Health In addition, employees with self-identified disabilities comprised 2 percent of the GH Bureau's permanent workforce compared with 6 percent of such employees in USAID's permanent workforce. The GH Bureau's permanent workforce has a greater percentage of some demographic groups than USAID's permanent workforce. For example, it has higher percentages of Asian females and White females compared with USAID's permanent workforce. The Bureau's permanent workforce also has a greater percentage of females compared with USAID's permanent workforce, as shown in figure 6 below. Figure 6: U.S. Agency for International Development (USAID) and Bureau for Global Health (GH Bureau) Demographic Data on Gender, Fiscal Year 2021 Notes: USAID's permanent workforce data also include data from the GH Bureau. Data in this figure for USAID and the GH Bureau represent their permanent Civil Service and Foreign Service staff only. Between fiscal years 2019 and 2021, the demographic composition of the GH Bureau's workforce did not vary substantially. The greatest variability was in the percentage of White females, which decreased by about 6 percentage points between fiscal year 2019 and fiscal year 2020. Figure 7 below shows the demographic composition of the Bureau's workforce between fiscal years 2019 and 2021. Page 22 GAO-23-105178 USAID Bureau for Global Health Figure 7: U.S. Agency for International Development (USAID) Bureau for Global Health (GH Bureau) Demographic Data on Race and Ethnicity, Fiscal Years (FY) 2019-2021 Notes: "Other" includes Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, and employees of two or more races. Data in this figure represent the GH Bureau's permanent Civil Service and Foreign Service staff only. In an internal report from January 2022, GH Bureau staff and management reported a number of diversity, equity, inclusion, and accessibility (DEIA) challenges in the Bureau. 37 Some staff noted that the Bureau has a healthy dialogue on DEIA issues, while others noted bullying, disrespectful behavior, and micro-aggressions. The report also states that DEIA efforts seem to be working well, but tend to be focused at the team or office level, and that the Bureau should continue and expand these efforts into a more systematic approach. The GH Bureau has made some efforts to improve DEIA. In July 2020, the Bureau formed the Anti-discrimination, Diversity, and Inclusion Council, which has outlined objectives for furthering DEIA within the Bureau and its programs. In February 2022, the Bureau began recruiting 37The report reflects the views of 99 staff who participated in listening sessions and 39 senior management team members, among others. Page 23 GAO-23-105178 USAID Bureau for Global Health for a DEIA senior advisor to oversee the development and implementation of the Bureau's efforts to improve workplace diversity and inclusion, recruitment and retention, sustainability, and accountability. According to Bureau officials, this position will be located in the Bureau's front office, which is also the location of its leadership team. A Bureau official was serving in this role in an acting capacity until the Bureau hired a permanent official for the role in October 2022. 38 The GH Bureau also formed a team in January 2022 to address the DEIA issues raised in the internal report, and the team merged its membership and efforts with the Anti-discrimination, Diversity, and Inclusion Council. This joint team has held leadership trainings on DEIA, created a Bureau DEIA inbox where employees can raise DEIA issues with the acting Bureau DEIA Senior Advisor, and developed a toolkit for leaders on recognizing unconscious bias, mitigating micro-aggressions, and managing stress, among other actions. As of July 2022, Bureau officials are also reorganizing the Council to, among other things, focus on DEIA within its workforce and are developing a Bureau-wide strategic implementation plan on DEIA. 39 Finally, DEIA is included as one of the Bureau leadership team's objectives and key results, and the Bureau has developed DEIA-specific objectives and key results for the first and second quarters of calendar year 2022. However, some of the Bureau's efforts have not been finalized or vary by office. For example, USAID's DEIA strategic plan was released in August 2022, and Bureau officials have developed DEIA targets for the Bureau for 2023, but they have not been approved as of May 2023. Moreover, each office within the Bureau is a different size, has a different capacity to execute DEIA efforts, and is developing its own DEIA objectives and key results, according to Bureau officials. For example, the Office of Policy, Programs, and Planning has taken two primary actions on DEIA- establishing a DEIA committee and a buddy system for new and current staff. In contrast, the Office of HIV/AIDS has at least 14 ongoing or completed DEIA actions, including bringing in an external anti-racism and DEIA consultant, holding focus groups to gather input on staff experiences pertaining to DEIA, and developing an office-specific DEIA 38InMarch 2022, the Bureau hired a non-direct hire to support the acting DEIA senior advisor and to help coordinate Bureau-wide DEIA efforts. 39The reorganization of the Anti-discrimination, Diversity, and Inclusion Council also includes establishing inclusive development practices to support local organizations in implementing the Bureau's development assistance. Page 24 GAO-23-105178 USAID Bureau for Global Health implementation plan. Bureau officials stated that the Council is working to find a way to ensure that the Bureau's ability to make progress on DEIA issues is not dependent on the size and resources of its individual offices. Lack of a Workforce Plan According to USAID's guidance, one of the objectives of its human capital Complicates the GH framework is that the agency guide its planning by data-driven, results- oriented processes, and document an approach that periodically analyzes Bureau's Efforts to human capital data to assess results or progress toward goal Address Current and achievement. 40 USAID's guidance also states that Bureaus have Future Staffing Needs operational responsibility for position management and must ensure that positions under their control are structured in accordance with sound position management principles. 41 We have previously reported that high- performing organizations identify their current and future human capital needs-including the appropriate number of employees, the key mix of competencies and skills for mission accomplishment, and the appropriate deployment of staff across the organization-and then create strategies for identifying and filling gaps. 42 However, GH Bureau officials could not provide us with a workforce plan for the Bureau or a date on which their last workforce plan had been completed. USAID had an interim workforce plan for the agency as a whole, created in February 2020, which ran through fiscal year 2022. However, this interim workforce plan did not contain anything specific to the Bureau that articulated its future human capital needs or enabled it to create strategies for identifying and filling gaps. It also did not address the Bureau's appropriate mix of direct hire and non-direct hire staff, alignment between staffing levels and funding levels for its strategic priorities, persistent vacancies in CS positions, and underrepresentation of certain racial or ethnic groups in the workforce. As of March 2023, USAID has not completed a new workforce plan. At the same time that it lacks a workforce plan, the GH Bureau has experienced additional difficulties in planning its staffing and aligning its workforce structure with its strategic priorities. For example: 40U.S. Agency for International Development, Automated Directives System Chapter 401: USAID's Human Capital Framework, Section 401.3.2 (revised Oct. 11, 2018). 41U.S. Agency for International Development, Automated Directives System Chapter 102: Agency Organization (revised June 27, 2017). 42GAO, A Model of Strategic Human Capital Management, GAO-02-373SP (Washington, D.C.: Mar. 15, 2002). Page 25 GAO-23-105178 USAID Bureau for Global Health • According to Bureau officials, it is burdensome for GH Bureau management to staff for complex crises, such as a global health emergency, in part because it does not know how long it will need additional staff to respond to a crisis. In addition, USAID's traditional staffing model is for long-term development programs, rather than emergencies. In global health emergencies, the Bureau needs staff with different skill sets and for a different duration than it would for traditional development programs. • USAID requested 70 new global health security staff for its fiscal year 2022 budget. Although the GH Bureau is USAID's lead bureau for global health security programming, Bureau and HCTM officials could not provide any documented analysis of how they had arrived at this number. According to HCTM officials, USAID decided on this number during a discussion with Office of Management and Budget officials. 43 • The structure of the Bureau's workforce does not consistently align with its strategic priorities. For example, malaria staff work in the Office of Infectious Disease, which supports the strategic priority of combating infectious diseases. However, Bureau officials stated that the results of malaria staff's work support a different strategic priority-preventing child and maternal deaths. In addition, as previously discussed, the number of Bureau staff does not correspond with the amount of funding for its three strategic priorities. In the absence of a Bureau workforce plan, the GH Bureau also has not assessed its leadership structure. According to Bureau officials, the leadership structure of the Bureau results in a high level of turnover among its senior leaders. Specifically, the Bureau's senior leadership consists of an Assistant Administrator-a political appointee who leads the Bureau-as well as four Deputy Assistant Administrators, of whom two are political appointees, one is CS, and one is FS. Political appointees and FS officers both serve in their positions for a limited time: political appointees change with each administration, while FS officers typically serve in Washington, D.C.-based positions for 3 years. Thus, four of the Bureau's five senior leadership positions rotate every few 43In the President's budget request to Congress, USAID requested additional funding for 70 staff global health security staff. A House of Representatives report submitted by the Committee on Appropriations to accompany the fiscal year 2022 appropriations act recommended that OE funding above the prior year's level be used to increase USAID personnel in global health security and support for new secure communications in addition to expanding diversity, equity, and inclusion initiatives. H.R. Rept. 117-84 (2021).The fiscal year 2022 appropriations act did not direct USAID on how to allocate the new OE- funded positions. The GH Bureau was notified by USAID that it would receive 18 new position allocations. Page 26 GAO-23-105178 USAID Bureau for Global Health years. According to a Bureau official, political appointees who have served in senior leadership positions in the Bureau are often new to USAID, and FS officers in these positions are often new to the Bureau. As a result, according to Bureau officials, individuals in these leadership positions may be unfamiliar with the Bureau's processes, which, according to one official, can lead Bureau leadership to reinvent processes, rather than taking advantage of existing processes that CS staff are already using. Although USAID's Administrator determines the designation of senior leadership positions as CS, FS, or political, developing a workforce plan would enable the Bureau both to determine its optimal mix of senior leaders and help inform agency decisions about the Bureau's leadership structure. The GH Bureau has made some workforce planning efforts, but they have either ended or remain incomplete. The Bureau's Office of Professional Development and Management Support had a group for workforce planning in place in April 2021, but it discontinued its work. Moreover, according to Bureau officials, because the Bureau lacks the expertise and resources to conduct its own workforce planning, the group's main purpose was limited to ensuring the accuracy of Bureau workforce data. In July 2021, the Bureau created a scope of work for an external consulting firm to conduct a workforce analysis for the Office of HIV/AIDS. In September 2021, the Bureau expanded this scope of work to include the entire bureau. In January 2022, it informed the firm of a delay in the availability of funding to conduct this review. According to Bureau officials, the Bureau received approval to fund the consulting work in May 2022 and the firm began a workforce assessment at the end of that month, which it completed in September 2022. This assessment is of the current state of the Bureau's workforce and includes an analysis of two of the Bureau's offices. Although the Bureau plans for the firm to conduct a second phase of its work to analyze its remaining offices, the firm has not started this work as of January 2023. In addition, the Bureau has to decide how to use the current workforce assessment, as well as the second assessment once it is completed, including for the purposes of developing a workforce plan. Having such a plan would be a key first step for the Bureau to take when addressing its staffing challenges. Without a workforce plan, the Bureau will have limited ability to accurately project future staffing needs, such as the appropriate mix of direct hire and non-direct hire staff; align its staffing with its mission, priorities, and funding; and address persistent vacancies in CS positions, as well as the underrepresentation of certain racial or ethnic groups in its workforce. The Bureau may also be unable to Page 27 GAO-23-105178 USAID Bureau for Global Health determine the optimal mix of the types and numbers of positions in senior leadership to ensure it operates as efficiently as possible. The GH Bureau has gaps in both bureau-level and program-level The GH Bureau's assessments of its performance. Two primary bureau-level gaps exist. Performance First, the Bureau does not have indicators for bureau-wide performance that measure progress for each of its strategic priorities, or across them. Assessments Have Second, communication of the Bureau's overall performance is Gaps at the Bureau challenging due to variations in its data across different health program areas. While the Bureau assesses program level performance according and Program Levels to its health program areas, its reports to Congress in some of these areas do not always include key information. For example, the Bureau's reports to Congress on maternal and child health do not contain results for 18 countries that received a total of more than $200 million in maternal and child health funding between fiscal years 2019 and 2021. Because of such gaps, Congress may not have key information needed to provide oversight over the breadth of the Bureau's programming and performance results. The Bureau Does Not According to USAID's guidance, its operating units, including the GH Assess Its Performance at Bureau, should analyze performance monitoring data to inform judgments about the outputs and outcomes of programs as a basis to improve a Bureau-Wide Level effectiveness and inform decisions about current and future programming. 44 When planning for monitoring, missions and Washington, D.C., operating units have to consider the utility of the information for management at the relevant level of decision-making. 45 To assess performance at the bureau-wide level, the GH Bureau has made efforts to assess performance (1) in each of its strategic priorities and (2) across them. We reviewed both efforts for fiscal years 2019 through 2021 and found gaps in each of them. The Bureau is unable to fully assess its performance in each of its strategic priorities. The Bureau does not have bureau-wide indicators 44U.S. Agency for International Development, Automated Directives System Chapter 201: Program Cycle Operational Policy (revised Sept. 28, 2022). Operating units are responsible for implementing a foreign assistance program and include all U.S. government agencies implementing any funding from foreign assistance accounts. These include USAID Bureaus and missions and independent offices in Washington, D.C., that expend program funds to achieve development objectives. See U.S. Agency for International Development, Automated Directives System Glossary (revised Sept. 2, 2021). 45U.S. Agency for International Development, Automated Directives System Chapter 201: Program Cycle Operational Policy (revised Sept. 28, 2022). Page 28 GAO-23-105178 USAID Bureau for Global Health that would allow it to fully assess its performance in each of its strategic priorities. The GH Bureau assesses its performance on some indicators in its strategic priority areas in two main documents, both of which have gaps that make them insufficient to serve as bureau-wide performance assessments. • The first document is the GH Bureau's annual Performance Plan and Report (PPR), which contains targets and results for some indicators in all three of the Bureau's strategic priority areas. However, according to the Bureau's September 2020 Data and Analytics Report, the PPR is insufficient to meet the Bureau's needs because it does not tell a cohesive story about the Bureau's programming across all of its health areas. In addition, according to the Data and Analytics Report, Bureau programs do not all find the PPR to be valuable, as the reporting on indicators in some program areas is limited. • The second document is State and USAID's annual performance report, which contains targets and results for some indicators in two of the GH Bureau's three strategic priority areas. Specifically, the report includes targets and results for controlling the HIV/AIDS epidemic and preventing maternal and child deaths. However, the report includes limited reporting on combating infectious diseases. While malaria and child infectious diseases are included, the report does not include indicators for several other diseases, such as tuberculosis and NTDs. According to Bureau officials, the health indicators included in the annual performance report are selected based on the goals in USAID and State's Joint Strategic Plan for fiscal years 2018-2022. The health-related performance goals in this plan focus on preventing maternal and child deaths and controlling the HIV/AIDS epidemic, which is why more combating infectious disease indicators are not included. The Bureau and State plan to report on three COVID-19 indicators and one global health security indicator in the fiscal year 2023 performance report. However, this report will not contain any indicators for other infectious diseases, such as tuberculosis and NTDs. In addition to these documents, between March and May 2020, the GH Bureau developed a results framework that contains indicators for each of its strategic priorities, linking them to global health objectives and USAID's mission. However, the results framework does not contain any targets or data on the results of these indicators that the Bureau could use to assess its performance in each of its three strategic priorities. The results framework was also developed under previous leadership. According to Bureau officials, as of December 2022, the current Page 29 GAO-23-105178 USAID Bureau for Global Health leadership is reexamining the results framework to determine whether it is still valid. The Bureau is unable to assess its performance across its strategic priorities. The GH Bureau also lacks a set of high-level indicators or metrics at a bureau-wide level that would help it monitor, measure, and communicate the effect of its programming across its strategic priorities, or across the health sector. According to the Data and Analytics Report, the Bureau could consider the adoption of a core set of bureau-wide, shared indicators. Such indicators would reflect bureau-wide results, track progress over time, and enable the Bureau to communicate the effect of its work. In February 2022, the GH Bureau formed a working group to identify a set of high-level indicators to monitor and communicate the impact of its global health programming. In March 2022, the group proposed two potential indicators: an index of health service coverage and a ratio of preventable mortality. These indicators would enable the Bureau to track progress and trends in USAID-supported countries against these indicators. However, neither of the proposed indicators would enable the Bureau to assess progress at a bureau-wide, or health sector, level on an annual basis. • The first indicator-the health service coverage index calculated by the World Health Organization-captures a dimension of universal health coverage that represents the average coverage of essential services for a country's population under four categories, two of which include reproductive, maternal, newborn and child health and infectious diseases. The index is based on data collection efforts that the GH Bureau already supports and allows it to conduct further analyses of the data. However, the World Health Organization calculates the index every 2 to 3 years, rather than annually, according to the Bureau's working group. The working group also noted that the index does not enable the Bureau to determine the components needed to strengthen a country's health system. • The second indicator-the ratio of preventable mortality-captures the proportion of all deaths in a country among children under 5 years of age and females ages 15 to 49. The data for this indicator are simple to calculate and readily available, according to the GH Bureau's working group. However, officials in the working group acknowledged that these groups of people are not the only beneficiaries of the Bureau's programs. Page 30 GAO-23-105178 USAID Bureau for Global Health In July 2022, GH Bureau leadership approved further exploration of the indicators, but as of December 2022, the Bureau had not yet adopted them. Until the Bureau assesses its bureau-wide performance, it will continue to lack important insight needed to identify any areas of improvement for its programs and inform its decisions about current and future programming. Communication of the The ways in which the Bureau collects performance data, as well as the Bureau's Overall types of data that it collects, vary by health program area, which presents a challenge for communicating the results of its work. Federal internal Performance Is control standards state that management should use quality information Challenging Due to to make informed decisions and evaluate performance in achieving key Variations in Its Data objectives. Quality information is appropriate, current, complete, accurate, across Different Health accessible, and provided on a timely basis. 46 According to a GH Bureau Areas document produced as part of an effort to develop a data strategy for the Bureau, the Bureau has struggled to use information about its programs to monitor and communicate successes, manage performance, and leverage data to identify challenges, opportunities, and gaps. The Bureau's Data and Analytics Report states that the Bureau's program areas have historically organized their data and analytics efforts independently and in ways that reflect their varied objectives. These objectives are shaped by congressional and administration directives, funding levels, and management models. For example, programs with centralized reporting, such as PEPFAR and the President's Malaria Initiative (PMI), have more control over data collected by their implementing partners because of their management structures. Similarly, health programs funded and managed in Washington, D.C., such as NTDs, have more control of their data collection due to the limited role of missions in implementing such programs. Other health programs have less control over their data because they have to coordinate with 20 or 30 missions-and all their implementing partners- to get the data they need, which may be collected in very different ways even when the indicators are the same. As a result, the types of data GH Bureau staff uses varies across programs. For example, the data that each program collects can vary by the level of detail, the number of missions reporting on a particular indicator, and the frequency of data collection. The data the Bureau collects for a particular health program area may be sufficient to meet its reporting requirements, but may be 46GAO, Standards for Internal Control in the Federal Government, GAO-14-704G (Washington, D.C.: Sept. 2014). Page 31 GAO-23-105178 USAID Bureau for Global Health insufficient to tell a more complete story about the Bureau's work in that area. The GH Bureau is developing a 5-year, bureau-wide, data and analytics strategy to help it better leverage data as a strategic asset, make program decisions, and improve global health outcomes. The goal of the strategy is, among other things, for the Bureau's offices to actively collaborate to make data available and accessible to staff to support decision-making- and to communicate health achievements. The strategy includes an objective on improving the availability of data and the interoperability of data systems, as well as establishing a methodology for harmonizing health data from disparate sources. However, a draft of this strategy notes a lack of agreement among Bureau leaders as an obstacle to moving forward with the strategy. As a result, it is unclear what progress the strategy will make in addressing the Bureau's data-related challenges. Without taking steps to harmonize its data across different health program areas, the Bureau will continue to struggle to monitor, evaluate, and communicate the results of its performance in executing its mission and priorities. The GH Bureau Assesses USAID's guidance states that one principle of its monitoring is to be Its Performance at a transparent, and that missions and bureaus should share information widely and report candidly. 47 The GH Bureau primarily reports on its Program Level, but Does performance results at a program level through congressionally required Not Include Key reports and on its website. However, its reports in some program areas Information on Some do not include key information that is either required to be included or that Results we have identified as important for performance assessment, hampering Congress's oversight of the breadth of global health programming. The GH Bureau publicly reports on agency-wide contributions in several of its global health program areas through mandated annual reports to Congress, such as the Acting on the Call report for preventing maternal and child deaths and PMI and tuberculosis reports on progress in combating these diseases. The Bureau also reports annually to Congress on cross-cutting health program areas, such as health systems strengthening (HSS), health-related research and development, and global health innovations. However, the Bureau does not include key 47U.S. Agency for International Development, Automated Directives System Chapter 201: Program Cycle Operational Policy, Section 201.3.5.2 (revised Sept. 28, 2022). Page 32 GAO-23-105178 USAID Bureau for Global Health information in its reporting to Congress on several of these program areas. Specifically, as discussed further below: • The Acting on the Call reports do not contain reporting on all countries receiving maternal and child health funding. 48 • The Bureau's annual reports on malaria do not have targets. 49 • Finally, the Bureau's HSS reports do not contain results from all countries implementing such programming, while its health-related research and development reports do not contain all congressionally- required elements. 50 Acting on the Call reports. The GH Bureau reports on maternal and child health results for 25 priority countries in its annual, congressionally mandated Acting on the Call report. A Senate Committee on Appropriations Report accompanying the fiscal year 2018 appropriations act stated that the USAID Administrator shall submit a report to the Senate Committee on Appropriations detailing results in expanding evidence-based, highest-impact interventions on a country-by-country basis. 51 The current annual reporting requirement for Acting on the Call has existed since 2018. However, the reports for 2020 and 2021 do not contain results for 18 non-priority countries that receive funding for 48According to USAID guidance, the agency must promptly and thoroughly fulfill its reporting obligations to Congress. See U.S. Agency for International Development, Automated Directives System Chapter 556: Reports to Congress (revised Apr. 21, 2017). 49According to USAID guidance, targets must be set for performance indicators. See U.S. Agency for International Development, Automated Directives System Chapter 201: Program Cycle Operational Policy (revised June 16, 2020). 50The USAID Administrator is required in annual appropriations acts to submit a report to Congress on USAID's health-related research and development strategy. See, for example, § 7019(e) of the Department of State, Foreign Operations, and Related Programs Appropriations Act, 2020, which required the USAID Administrator to submit to Congress the reports described in House Report 116-78 and Senate Report 116-126. Pub. L. No. 116-94, § 7019(e), 133 Stat. 2534, 2856 (2019). The reporting requirements include specific health product development goals, including timelines for product development, among others. 51S.Rept. 115-152, accompanying the Department of State, Foreign Operations, and Related Programs Appropriations Act of 2018, Pub. L. No. 115-141, Div. K, 132 Stat. 348, 833 (2018). Section 7019(e) of this Act required the USAID Administrator to submit the reports contained in Senate Report 115-152. Page 33 GAO-23-105178 USAID Bureau for Global Health maternal and child health activities. 52 According to GH Bureau officials, maternal and child health funding for these non-priority countries was $71.3 million in fiscal year 2020 and $80.5 million in fiscal year 2021. The latter amount represents approximately 22 percent of the Bureau's maternal and child health program funding in fiscal year 2021. According to Bureau officials, the Acting on the Call reports only contain reporting on the 25 priority countries, which represent more than two- thirds of all maternal and child deaths and were chosen based on several factors, including the magnitude and severity of maternal and child deaths in those countries. Bureau officials stated that the non-priority countries report results on their maternal and child health programming in their PPRs, but these reports are not publicly available. Malaria reports. The GH Bureau's malaria reports do not contain targets to measure its progress. The Bureau primarily reports on its malaria programming through annual reports to Congress on PMI. 53 The 2019 through 2021 reports describe progress against baseline data but not progress against targets. Although the law does not require reporting on targets, USAID guidance states that comparing actual results achieved against targets is critical in determining the progress that has been made 52Unlike the 2020 Acting on the Call report, the 2021 Acting on the Call report does not contain country-level progress on efforts such as increasing the number of households with improved water sources, antenatal care visits, and first doses of the measles vaccine, among others. According to GH Bureau officials, the 2021 report does not include these data because the COVID-19 pandemic disrupted data availability and reliability across countries. 5322 U.S.C. § 7634(h). For Presidential delegation to USAID for this requirement, see Exec. Order No. 12,163, 44 Fed. Reg. 56,673 (Sept. 29, 1979). USAID is required to report annually to Congress on United States assistance for the prevention, treatment, control, and elimination of malaria, including (A) the countries and activities to which malaria resources have been allocated; (B) the number of people reached through malaria assistance programs, including data on children and pregnant women; (C) research efforts to develop new tools to combat malaria, including drugs and vaccines; (D) the collaboration and coordination of United States antimalarial efforts with the World Health Organization, the Global Fund, the World Bank, other donor governments, major private efforts, and relevant executive agencies; (E) the coordination of United States antimalarial efforts with the national malarial strategies of other donor or partner governments and major private initiatives; (F) the estimated impact of United States assistance on childhood mortality and morbidity from malaria; (G) the coordination of antimalarial efforts with broader health and development programs; (H) the constraints on implementation of programs posed by health workforce shortages or capacities; and (I) the number of personnel trained as health workers and the training levels achieved. Page 34 GAO-23-105178 USAID Bureau for Global Health in achieving the expected results. 54 According to GH Bureau officials, the initial PMI reports to Congress outlined targets for each intervention, but because of the evolving nature of the disease and growing insecticide resistance, global and country-level intervention targets are no longer as useful for tracking progress. PMI reports now focus on impact, such as reductions in malaria mortality and morbidity. However, the reports continue to include country-level information, and the lack of targets makes it difficult to determine progress in PMI countries and, ultimately, whether PMI is meeting its goals. HSS and health-related research and development reports. The GH Bureau's reports to Congress on HSS also have gaps. The Joint Explanatory Statement accompanying the Consolidated Appropriations Act, 2021 requires that the USAID Administrator, in consultation with the United States Global AIDS Coordinator, submit a report to the appropriate congressional committees on the results achieved in the previous fiscal year to build accessible, accountable, and affordable local health systems, among other requirements. 55 In addition, according to USAID guidance, the agency must promptly and thoroughly fulfill its reporting obligations to Congress. 56 While the fiscal year 2020 HSS report to Congress contains examples of results from six countries, only two of these were among the eight countries with the largest HSS programs in fiscal year 2020. In addition, the report states that 20 missions in fiscal year 2020 reported on one or more HSS indicators, but it does not contain any information on these indicators. According to Bureau officials, they did not include results from more countries or reporting on HSS indicators due to a recommended limit of five pages set by USAID's Bureau for Legislative and Public Affairs. 57 While USAID was not required 54U.S. Agency for International Development, Automated Directives System Chapter 201: Program Cycle Operational Policy (revised Sept. 28, 2022). 55Joint Explanatory Statement accompanying the Consolidated Appropriations Act, 2021, Pub. L. No. 116-260, 134 Stat. 1182 (2020). 56U.S. Agency for International Development, Automated Directives System Chapter 556: Reports to Congress (revised Apr. 21, 2017). 57According to GH Bureau officials, USAID's Bureau for Legislative and Public Affairs set an expectation in 2019 for technical reports required by Congress to aim for no more than five pages of text so that the agency can summarize its results and meet its reporting requirements succinctly. Officials noted that the five page limit is a recommended standard with exceptions permitted with justification. Page 35 GAO-23-105178 USAID Bureau for Global Health to report on all countries or include HSS indicators in its reports, USAID guidance states that its congressional reporting should be thorough. 58 Finally, the GH Bureau's reports on USAID's health-related research and development strategy do not contain all required elements. 59 These requirements include specific health product development goals, including timelines for product development. However, the reports for fiscal years 2019 and 2020 do not contain health product development goals or timelines for product development. According to Bureau officials, these goals and timelines are outlined in a strategy document. Bureau officials stated that the health-related research and development reports to Congress provide annual updates on progress under USAID's Global Health Research & Development Strategy for 2017-2022, which outlines the agency's overall global health research and development goals and approaches. Bureau officials stated that the strategy also outlines a broad timeline across the research continuum, including delivering a product to scale. However, these goals and timelines are required elements of the Bureau's annual reports to Congress. Because the Bureau does not include the goals and timelines from the 5-year strategy in its annual reports, Congress may not be able to readily track progress on annual health product development goals and timelines. More comprehensive reporting that addresses all of the Bureau's congressionally mandated requirements and provides additional key information that we have identified would help ensure that Congress has the information needed to provide oversight over the breadth of global health performance results. 58U.S.Agency for International Development, Automated Directives System Chapter 556: Reports to Congress (revised Apr. 21, 2017). 59The USAID Administrator is required in annual appropriations acts to submit a report to Congress on USAID's health-related research and development strategy. See, for example, Pub. L. No. 116-94, § 7019(e) of the Department of State, Foreign Operations, and Related Programs Appropriations Act, 2020, which required the USAID Administrator to submit to Congress the reports described in Senate Report 116-126. Page 36 GAO-23-105178 USAID Bureau for Global Health The GH Bureau has recently faced several challenges to its ability to COVID-19 and Other execute its mission and priorities. These have included the COVID-19 Challenges Affected pandemic, which created challenges to both the Bureau's programming and operations that led to changes to activities and other adaptations. the GH Bureau, Although the Bureau took steps to address these challenges and to better Some of Which It Has position itself to address future global health emergencies, it has not documented any lessons learned from its response to the pandemic. The Taken Steps to Bureau has taken recent steps to address challenges to implementing a Address new congressional committee directive associated with its HSS work. It has also identified negative Bureau leadership behaviors, such as reported instances of bullying, as a challenge. While the Bureau is taking steps to address this issue, our prior work indicates that such efforts to change organizational culture can take significant time and sustained attention. Finally, the Bureau faces a variety of external challenges, such as security concerns, that affect its health programming. USAID Missions Took The GH Bureau's programming experienced challenges and setbacks Steps to Address COVID- during the pandemic that led to changes to global health activities at the country level. Health officials at the mission level reported that Related Challenges to the government lockdowns and public concern about accessing health GH Bureau's services during the pandemic led to disruptions in existing global health Programming programming. Four out of five missions we interviewed reported some negative effects on global health programming as a result of the pandemic. While another mission reported that it was too early to determine if it had seen any erosion of development gains, officials there cited other challenges, including an inability to conduct some community- based programming during lockdowns. To respond to these challenges, missions reported adapting health programming to address disruptions and lockdowns caused by the pandemic. 60 See table 3 below for examples of these challenges, as well as steps taken by USAID missions to address them. 60For additional information on how USAID addressed challenges caused by the COVID- 19 pandemic on family planning and reproductive health assistance, see GAO, International Family Planning Assistance: USAID Has Faced Implementation Challenges Related to U.S. Policy and COVID-19, GAO-22-104228 (Washington, D.C.: May 31, 2022). Page 37 GAO-23-105178 USAID Bureau for Global Health Table 3: Examples of Challenges to USAID Missions' Programming from the COVID-19 Pandemic and Steps Taken to Address Them Challenges Steps taken Childhood vaccination campaigns, including polio and other One mission worked with the local COVID-19 taskforce and routine vaccinations were disrupted, causing significant community groups to administer childhood vaccinations in hard-to- numbers of children to miss routine vaccinations. reach communities, while two other missions developed strategies for reaching unimmunized children and their families. Notifications of tuberculosis (TB) cases declined, resulting in Some missions developed plans to address setbacks in TB case increased numbers of undiagnosed infections. notifications. One mission developed TB/COVID-19 testing guidelines with the national government, and another developed TB/COVID-19 joint intervention activities to improve TB case notifications. HIV patients were unable to access medications due to Missions provided a longer supply of medications so that HIV patients government lockdowns. would not have to access medical facilities as often. People seeking medical services could not travel to medical Missions shifted to community-based service delivery to enable people facilities to seek care due to government restrictions during to access services closer to their homes. For example, one mission the pandemic. The pandemic also affected people's distributed family planning methods throughout the country during willingness to travel to medical facilities for health care. lockdowns. This mission supported health care workers to provide mobile services to ensure antenatal care follow-up for pregnant women. People had difficulty seeking family planning services, and As part of an effort to prevent further setbacks to national family providers were reluctant to go to facilities because protective planning services, one mission developed infection prevention and measures were not in place. control training to ensure continuous family planning services. Source: GAO analysis of USAID documents and interviews. | GAO-23-105178 Note: The five U.S. Agency for International Development (USAID) missions that we interviewed reported starting COVID-19 response activities in their respective countries at different times, ranging from January to June 2020. However, some health programming continues to experience challenges due to the pandemic. For example, a USAID report noted that the pandemic has set back maternal, newborn, and child survival gains by a number of years, if not decades, due to disruptions to health services, such as routine immunizations, antenatal care, breastfeeding counseling, and voluntary family planning. While some initial drops in health visits have somewhat recovered, lower levels of care-seeking persist, according to the report. Officials at one mission stated that there were delays in measles and polio vaccination campaigns of 2 months and 7 months, respectively, due to the pandemic, setting back efforts to counter measles and polio outbreaks in that country. Page 38 GAO-23-105178 USAID Bureau for Global Health The GH Bureau and Both the GH Bureau and mission staff experienced challenges to USAID Missions Took operations as a result of the COVID-19 pandemic. The Bureau and mission officials implementing global health programming had to change Steps to Address their normal ways of operating. For example, according to Bureau Operational Challenges officials, some of them worked every weekend and took no vacation days Due to the COVID-19 for the first year of the pandemic. Some Bureau staff in Washington, D.C., Pandemic also had increased workloads as a result of working on both existing health programming and COVID-19 response activities. According to Bureau officials, such adaptations were ineffective in the long-term because they led to staff burnout and morale issues. GH Bureau officials also adapted in other ways to support the COVID-19 response. Early in the pandemic, Bureau officials established a technical working group and, as noted previously, used rotating staff from the Bureau to support its workforce. The Bureau also used staff who were in between assignments or had been evacuated from overseas missions to the United States to help with its response to COVID-19. Bureau officials also reported amending their existing health programming assistance to include activities to respond to the pandemic. As part of this effort, GH Bureau officials told us they used expedited procedures that enabled the Bureau to more quickly incorporate COVID-19 response activities into the scope of existing health programming. For example, Bureau officials also reported that the Office of HIV/AIDS used these procedures to add pandemic response activities, such as clinical and ventilator technical assistance, into four of its projects. At the mission level, officials identified both operational challenges and adaptations to address them. Table 4 below illustrates operational challenges that mission officials reported facing during the COVID-19 pandemic and the actions they and, at times, headquarters officials took in response. Page 39 GAO-23-105178 USAID Bureau for Global Health Table 4: Examples of Operational Challenges to USAID Missions from the COVID-19 Pandemic and Steps Taken to Address Them Challenges Steps taken Mission staff faced difficulties in accessing facilities to Some missions reported using virtual technologies to perform remote conduct monitoring activities. monitoring activities. Mission staff was limited in its ability to meet with Mission staff used online platforms to meet with implementing partner implementing partner staff. staff. Mission staff reported difficulties in managing both COVID-19 Missions used supplemental staff, including direct hires, consultants, programming and existing programming. and personal services contractors, to support the implementation of both COVID-19 and existing health programming. Two missions reported the hiring of a COVID-19 coordinator to assist with managing COVID-19 programming and to allow other mission staff to focus on managing existing programming. Missions needed to implement COVID-19 response activities Missions reported using a variety of mechanisms, including an quickly. expedited procurement process and crisis modifiers in their grant agreements, to implement COVID-19 response activities more quickly, according to mission officials. Disruptions in the global supply chain affected missions' USAID headquarters provided guidance to missions on local ability to secure personal protective equipment. production of personal protective equipment. Source: GAO analysis of U.S. Agency for International Development (USAID) documents and interviews. | GAO-23-105178. The GH Bureau also provided guidance on adapting mission programming and operations in response to the pandemic. For example, the Bureau provided guidance on programming resources during a declared public health emergency of international concern, carrying out PEPFAR and malaria programming, and using staffing and funding mechanisms or redirection of funds to support response activities. Although the Bureau first issued its guidance to missions on programming resources in response to the pandemic in February 2020, followed by technical guidance in March 2020, officials at one mission stated that they started responding to COVID-19 in January 2020 and created their own strategy for responding to the pandemic, given its urgency. Missions also reported receiving guidance from multiple sources, such as the GH Bureau, regional bureaus, and the COVID-19 Task Force. Some missions indicated that they were satisfied with the guidance provided by the GH Bureau to the field. However, officials at one mission indicated that the guidance was sometimes confusing, incomplete, or contradictory. Another mission official stated that the multiple sources of guidance for the missions were confusing. This official stated that it would have been more helpful to receive clear and concise guidance from one source rather than several. In addition, the GH Bureau provided supplemental staffing support to some missions to address the COVID-19 pandemic. These included Page 40 GAO-23-105178 USAID Bureau for Global Health consultants, PSCs, and Health Foreign Service Officers who take temporary assignments to overseas missions. Of the five missions that we interviewed, four reported using supplemental staffing mechanisms to respond to the pandemic. 61 However, one of these four missions reported that it did not use the supplemental staffing mechanisms between March 2020 and January 2022, because the Bureau did not have available staff for the mission to use. This same mission reported that it wanted to hire a COVID-19 coordinator in late 2021. 62 However, due to differences with the Bureau over the appropriate staffing mechanism to use to hire the COVID-19 coordinator, officials at this mission reported that the position remained without a direct hire staff to fill it until November 2022. According to a mission official, the mission filled the position approximately 1 year after the initial request and with only 3 to 4 months left until the funds were to be expended for most of the activities the position was intended to manage. The GH Bureau Has The GH Bureau has taken some steps to prepare for future global health Taken Some Steps to emergencies. For example, the Bureau is in the process of establishing a rapid response unit to enhance existing capacities and address future Prepare for Future Global global health emergencies. This unit will be integrated into the global Health Emergencies but health security program as part of the program's core objectives to Has Not Documented prevent, detect, and respond to disease outbreaks. Bureau officials Lessons Learned from Its reported that this unit will use new and existing staff with expertise in COVID-19 Response infectious disease and outbreak operations to support missions and partner governments to quickly respond to outbreaks. 63 As of November 2022, Bureau officials stated that they have filled initial positions in the unit for core outbreak response capabilities. They also reported that they 61The fifth mission we interviewed determined that it did not need supplemental staffing to address the pandemic and used existing staff to maintain ongoing programming and COVID-19 pandemic response activities. 62The mission filled the position on a temporary basis through a supplemental staffing mechanism between February and March 2022. 63The GH Bureau has also taken steps to update the agency framework for responding to future disease outbreaks. Specifically, in April 2022, the Bureau, along with the Bureau for Humanitarian Assistance and the regional bureaus, released an updated Framework for USAID Response to Infectious Disease Outbreaks. This framework outlines roles and responsibilities of USAID's operating units and staff for responding to infectious disease outbreaks around the world. Page 41 GAO-23-105178 USAID Bureau for Global Health are recruiting staff for additional positions to expand the unit's capacity to manage multiple public health outbreak responses simultaneously. 64 The GH Bureau also plans to expand the number of countries that will receive global health security funding. Bureau officials told us that the COVID-19 pandemic demonstrated that nearly all countries in which USAID conducts global health programming have weaknesses in global health security. For example, Bureau officials stated that better integration is needed between animal health and human health to improve detection and response to outbreaks that originate in the animal population and spread to the public. More countries also need to build the capacity to monitor their animal health sectors. As a result, the Bureau has expanded the number of global heath security intensive support countries from 16 in fiscal year 2019-that is, prior to the COVID-19 pandemic-to 25 in fiscal year 2022. 65 Officials added that they are finalizing the number of countries that will receive global health security funds in fiscal year 2023 but would like to be able to provide support to about 50. In addition, the GH Bureau plans to modify the funding and programming structure of the global health security program starting with fiscal year 2022 funds from centrally managed to primarily bilateral funding managed by the missions. 66 The Bureau has centrally managed global health security funding since at least 2014, when the Global Health Security Agenda was launched. As part of this transition, Bureau officials stated that they plan to transition 85 to 90 percent of centrally managed funding to bilateral funding, similar to existing global health programs, while continuing to centrally manage a small portion of the funds. The need to broaden global health security programming to more countries and to make it a longer-term program led the Bureau to change how it is managed. Officials we interviewed at one mission reported that providing global health security funding bilaterally through missions would take 64The GH Bureau also activated an Mpox Response Team in late July 2022 in response to the outbreak. The team includes representatives from the agency and, according to the Bureau, it will guide communications, intra-agency and interagency coordination, and USAID assistance to address the outbreak. 65According to a White House report on global health security, intensive support countries receive intensive financial and technical assistance to address capacity gaps related to global health security. 66A central award is managed by a USAID bureau or independent office in Washington, D.C., with activities being carried out in one or more countries. USAID missions manage activities funded by bilateral funding. Page 42 GAO-23-105178 USAID Bureau for Global Health advantage of experts at the mission with relevant country and global health security expertise. With respect to COVID-19 lessons learned, GH Bureau officials noted that some have been documented at the country and project levels. For example, some USAID missions have developed lessons learned by country and shared them with other missions, as well as with the GH Bureau. These lessons learned identified issues such as the impact of responding to the pandemic on mission staff, vaccine hesitancy, risk communication, and access to medical services. Additionally, in July 2021, one of USAID's NTD programs published lessons learned from conducting this programming during the pandemic. 67 Mission officials told us that the Bureau has organized informal discussions to share lessons learned from the missions. The GH Bureau has not documented lessons learned from its own response to the pandemic to help inform its plans and strategies to respond to a future global health emergency. According to USAID guidance, lessons learned should be included in various parts of USAID's project and strategy development, implementation, and close-out. 68 However, the Bureau has not documented which aspects of its internal operations performed well during the pandemic, or which hindered its response efforts or ability to conduct other health programming during the pandemic. Nor has the Bureau documented how it could strengthen any areas of weakness to better position itself to address future outbreaks. Previously, USAID has made efforts to identify lessons learned on how the agency can improve health resilience when there are disruptions, such as the COVID-19 pandemic, to countries' health systems. For example, in June 2021, the agency issued a report examining the pandemic's effects on healthcare delivery and how it can build more resilient health systems. However, the report focuses on improving health resilience to strengthen health systems in the event of future disruptions, 67USAID's Act to End NTDs East program supports ministries of health to quickly adapt and respond to NTDs. 68U.S. Agency for International Development, Automated Directives System Chapter 201: Program Cycle Operational Policy (revised June 16, 2020). In addition, Standards for Internal Control in the Federal Government notes that management can anticipate and plan for significant changes by using a forward looking process to identify change. See GAO-14-704G. Page 43 GAO-23-105178 USAID Bureau for Global Health but does not specifically document the Bureau's own lessons learned on its response to the COVID-19 pandemic. 69 GH Bureau officials stated that they did not have the opportunity to perform such a lessons-learned analysis because they were still responding to the pandemic. As of May 2022, Bureau officials told us that the Bureau is working with USAID's COVID-19 Task Force to document lessons learned regarding the COVID-19 pandemic and the agency's response. They also told us that some of their weekly COVID-19 updates and meeting notes contain lessons learned. However, the examples of this documentation that officials provided to us discuss the spread of COVID-19, trends in vaccination rates, and results and takeaways reported by implementing partners. They do not document how the Bureau responded to the challenges of the pandemic, where its organizational response worked well, and where it fell short. By documenting those kinds of lessons learned from its response to COVID- 19 as well as lessons about its ability to conduct other health programming during the pandemic, the Bureau will be better able to respond to a future global health emergency. The GH Bureau Has USAID conducts HSS to underpin all other health investments and to Taken Steps to Help foster greater resilience and global health security. This work helps USAID reach its goals in its three strategic priorities and is implemented Address Challenges to with funding from other health program areas, as HSS does not have a Meeting a Congressional separate appropriation. Cross-cutting HSS activities, which comprise a Committee Directive on subset of HSS, are funded through two or more health program areas and Health Systems are defined as those that would be expected to affect multiple health Strengthening program areas and have health system-wide implications. The Fiscal Year 2022 House of Representatives Committee on Appropriations report directed the USAID Administrator and Global AIDS Coordinator to ensure that, for operating units implementing more than one Global Health program area, not less than 10 percent of each program line in the ''Global Health Programs'' table, including HIV/AIDS, is spent on cross- cutting health system capacity to ensure these systems are affordable, 69Previous GAO work has identified the use of lessons learned to improve agency operations in response to the pandemic. These include: COVID-19: State Carried Out Historic Repatriation Effort but Should Strengthen Its Preparedness for Future Crises, GAO-22-104354, (Washington, D.C.: Nov. 2, 2021); COVID-19: DOD Has Focused on Strategy and Oversight to Protect Military Service Member Health, GAO-21-321, (Washington, D.C.: June 3, 2021). Page 44 GAO-23-105178 USAID Bureau for Global Health accessible, reliable, and accountable to the people served. 70 The committee report also states that (1) these funds should be in addition to ongoing health system capacity building that supports individual programs, and (2) programs should be jointly funded. 71 According to Bureau officials, HSS activities may be funded by a single health program area, but such activities would not be classified as cross-cutting HSS activities and would not meet the congressional committee directive. USAID has previously identified challenges with cross-cutting HSS activities. For example, USAID's Fiscal Year 2020 Health Systems Strengthening report stated that providing centralized direction to missions to program cross-cutting HSS activities was an ongoing challenge. Bureau officials acknowledged in May 2022 that missions may not understand how to attribute funding to cross-cutting HSS activities because it comes from funds designated for other health programs. Similarly, officials at three missions we spoke with in early 2022 cited challenges related to implementing cross-cutting HSS activities-due, in part, to the fact that funds for them come from other health program areas. Further, while the congressional committee directive only applies to fiscal year 2022 funding, relatively few operating units (10 out of 50) reached the 10 percent threshold using fiscal year 2021 funding, indicating potential difficulties in meeting the fiscal year 2022 directive. 70H.R. Rept. 117-84, at 44 (2021). The program areas identified in the report are: Maternal and Child Health, including maternal and neonatal tetanus, polio, and the GAVI Alliance; Nutrition, including iodine deficiency disorder and micronutrients; Vulnerable Children, including blind children; HIV/AIDS, including microbicides; Family Planning and Reproductive Health; Other Infectious Diseases, including global health security; malaria; tuberculosis; and neglected tropical diseases and other public health threats. It also includes funding directed to the Department of State for HIV/AIDS, including the Global Fund to Fight HIV/AIDS, Malaria, and Tuberculosis and the Joint UN Program on HIV/AIDS. 71USAID has interpreted the committee directive to mean that its operating units, which include USAID missions and the GH Bureau, receiving funding for two or more health programs, such as TB and malaria, are to program and attribute at least 10 percent of their funding amount for each health program area to cross-cutting HSS activities. For example, a mission would need to spend 10 percent of its TB funds and 10 percent of its malaria funds on cross-cutting HSS activities each fiscal year to meet the directive. Regional bureaus that receive multiple program areas of global health funding are also subject to the directive, according to USAID. Page 45 GAO-23-105178 USAID Bureau for Global Health Bureau officials added that they instructed 28 operating units to identify additional investments or improve their reporting. 72 The Bureau has taken recent steps to address these challenges. For example, Bureau officials stated that they explained the congressional committee directive during calls with mission health officials and Bureau office leadership in June and July 2022. Additionally, in August 2022, the Bureau issued guidance, as well as a list of frequently asked questions, on how to meet the directive. However, it is too early to tell if these actions will enable the Bureau to meet the congressional committee directive. Bureau officials stated in November 2022 that they are collecting data to monitor which operating units meet the congressional committee directive and which do not. The officials added that they are committed to meeting the directive and will continue to support operating units' efforts to meet it. They also have committed to share lessons learned from fiscal year 2022 implementation of the directive with key congressional stakeholders. The GH Bureau Has A GH Bureau report identified that negative leadership behaviors in the Identified Negative GH Bureau affect its culture and ability to implement its mission. USAID's Mission, Vision, and Values statement includes fair treatment of Leadership Behaviors as colleagues and valuing all people equally as part of its core values. an Impediment to Its Additionally, federal internal control standards state that management Mission but Has Not Made sets the "tone at the top" by demonstrating the importance of integrity and a Sustained Effort to ethical values through its directives, attitudes, and behaviors. 73 These Address Them standards further state that management should correct behavioral deficiencies in a timely manner. The GH Bureau held listening sessions at the end of 2021 on strengthening its processes and teamwork. The Bureau used the results of these listening sessions, along with interviews of senior management, among other sources, to identify and address key challenges to enhance its ability to accomplish its mission. In January 2022, the Bureau completed a report that presented the results of its analysis. The report 72The Bureau also reported that 11 operating units significantly invested in cross-cutting HSS with fiscal year 2021 funds, but some of their health program areas did not reach the 10 percent threshold. 73GAO-14-704G. Page 46 GAO-23-105178 USAID Bureau for Global Health includes information from staff representing all offices, direct and non- direct hiring mechanisms, and the range of staffing levels in the Bureau. Among the challenges identified in the report was a lack of accountability for negative leadership behaviors. 74 For example, according to the report, some GH Bureau staff stated that "toxic" or "unhealthy" behaviors occur with the perception they are allowed to persist unchecked, although other staff disagreed with that perception. Bureau officials we spoke with also reported instances of bullying within the Bureau, as well as unequal treatment of institutional support contractors, who have little or no recourse to address such behavior. The report also cited the perspective of some staff that the Bureau lacks both accountability for these negative behaviors and a mechanism for staff to provide feedback on them. 75 According to Bureau officials, as the Bureau's mission has grown, no commensurate growth has occurred in the capacity of management and supervisors to address such negative behaviors. In addition, some negative behaviors are consistently tolerated, according to Bureau officials, which affects the Bureau's culture. Following the report, the GH Bureau established a leadership priority team to improve the behaviors of leadership and staff, as well as the Bureau's culture. 76 The team developed a set of behavioral principles and shared them with senior management. 77 It has also identified a need for creating a culture that promotes feedback and resolves conflicts at the lowest possible level, as well as a related accountability system for negative behavior within the Bureau. The team further suggested that it would be helpful to have clear operational direction to support and guide 74Examples of other challenges identified in the report include overwhelming workload, cumbersome processes and bureaucratic inefficiencies, cross-office competition, and developing a more systematic approach to DEIA issues. 75The internal report did not specify how many staff reported instances of bullying behavior and lack of accountability. 76Bureau officials established leadership priority teams to address other challenges raised in the internal report as well. As of July 2022, in addition to the team focusing on behaviors, there were three other teams focusing on workload; flexibility, agility, and speed; and cross-office collaboration. As discussed earlier in this report, the GH Bureau formed a team in January 2022 to address the DEIA issues raised in the internal report, and the team subsequently merged with the Bureau's Anti-discrimination, Diversity, and Inclusion Council. 77The principles developed by the team include statements such as: "I welcome open and direct communications"; "I respect boundaries"; and "I am committed to universal respect in all dealings with colleagues." Page 47 GAO-23-105178 USAID Bureau for Global Health managers who work with institutional contractor staff and Bureau direct hire employees. In addition, the team proposed establishing an ombudsman within the Bureau to help address conflicts. As of July 2022, the senior management team had reviewed the team's activities, and the team identified next steps to implement its behavioral principles and improve accountability. These steps include outlining a process for addressing misconduct and exploring the creation of a feedback system, among others. GH Bureau officials who described these steps emphasized the importance of establishing systems to institutionalize the desired changes and measure their impact, noting that prior efforts to identify negative leadership behaviors within the Bureau were not accompanied by efforts to create systems to address them. The officials noted that, due in part to the lack of success of those prior efforts, some participants in the Bureau's 2021 listening sessions expressed skepticism that action would be taken in response to the concerns they were raising-or, in some cases, raising again. As we have previously reported, it can take years to change organizational culture, and such change requires sustained efforts by senior management to address challenges related to organizational culture. 78 Without a lasting commitment to making and institutionalizing improvements in this area, the Bureau will remain at risk of allowing negative behaviors to persist, adversely affecting its organizational culture and falling short of standards that call for leaders to act with integrity and ethical values. By taking steps to address negative leadership behaviors, such as by developing an accountability system, the Bureau will better position itself to implement its mission, improve its culture, and support USAID's values. External Factors Affect the The GH Bureau faces a variety of difficulties due to the locations and Bureau's Ability to Execute conditions in which it operates. Mission and Bureau officials identified several external factors not related to the COVID-19 pandemic that Its Mission and Priorities affected global health programming in the countries where the Bureau supports global health programming, including the following: • Security concerns, such as violence and political instability, limit the movement of mission staff and their ability to conduct health 78See, for example, GAO, Securities and Exchange Commission: Improving Personnel Management Is Critical for Agency's Effectiveness, GAO-13-621 (Washington, D.C.: July 18, 2013). Page 48 GAO-23-105178 USAID Bureau for Global Health programming activities in some areas of their countries. 79 For example, three missions reported difficulty reaching some areas of their country to conduct and monitor global health programming due to the risks to staff and implementing partners. One of these missions had to delay an evaluation of one of its health programs due to the security situation. Another mission reported that a warehouse for HIV and malaria products and a lab were looted. • Some host country governments have a limited capacity to support global health programming. For example, one mission had to continue providing assistance for some health programming that the government would normally assume responsibility for implementing. Mission staff in that country also reported that the government was unable to make timely decisions on health programming due to capacity challenges. • Bureau officials reported delays in the annual budget cycle, including not receiving a full-year budget at the beginning of the fiscal year. These delays limit the amount of time the Bureau has to obligate funds for global health programming. • Both Bureau officials and officials at one mission cited withdrawal from the World Health Organization as a challenge that caused a delay in coordinating and implementing activities with international partners. Officials at the mission reported that the timing of the withdrawal occurred at a time during the pandemic when the mission would have otherwise coordinated frequently with the World Health Organization. The GH Bureau's role in supporting U.S. foreign policy goals by saving Conclusions lives and promoting the health of communities and nations throughout the world became even more important and complex during the COVID-19 pandemic. As the global health and development landscape continues to evolve, it is important that the Bureau ensures that it has an appropriately-sized workforce with the necessary skills in each of its strategic priority areas to successfully execute its mission and priorities. Conducting workforce planning will help the Bureau strengthen its ability 79The Bureau has a Non Permissive Environment Community of Practice to share experiences of missions operating in such environments. According to USAID guidance, a non-permissive environment is an environment characterized by uncertainty, instability, inaccessibility, or insecurity in which USAID's ability to safely and effectively operate is constrained. See U.S. Agency for International Development, Automated Directives System Chapter 201: Program Cycle Operational Policy (revised Sept. 28, 2022). A senior Bureau official noted that the number of non-permissive environments in which USAID operates has increased in recent years. Page 49 GAO-23-105178 USAID Bureau for Global Health to project future staffing needs and inform associated funding requests. Additionally, developing and implementing a workforce plan will better position the Bureau to carry out its current health programming and combat future global health crises. Comprehensive performance assessments are also a critical part of ensuring that the GH Bureau is successfully executing its mission and priorities. While the Bureau assesses program level performance for its health program areas, it lacks bureau-wide indicators to assess its performance in each of its strategic priorities and across them. In addition, the dissimilar types of data that the Bureau collects across its health program areas make it difficult for it to communicate performance results. Some of the Bureau's health program area reporting is also missing key information on country and disease-specific performance results. By assessing its bureau-wide performance, harmonizing its health program data, and improving the comprehensiveness of its program level reporting, the Bureau can better evaluate and communicate its results and enhance the quality of the information it is providing to Congress. The COVID-19 pandemic caused various disruptions to the GH Bureau's programming. It also affected the operations of the Bureau and USAID's overseas missions. As COVID-19 remains a large challenge to the Bureau, it is important that the Bureau document its lessons learned from responding to the pandemic while simultaneously carrying out its existing health programming. Such lessons learned will help ensure that the Bureau is better prepared for the next global health crisis. Leaders who act with integrity and uphold ethical values are fundamental to creating well-managed organizations. However, negative leadership behaviors have persisted in the Bureau without a system to hold leaders accountable, according to Bureau officials. Such behavior is contrary to USAID's values of fair and equal treatment of colleagues and detrimental to executing the Bureau's mission and priorities. The Bureau has taken some initial steps to address these issues. However, organizational culture change takes time and requires sustained effort by senior management. By institutionalizing efforts to address negative leadership behaviors, the Bureau can help ensure accountability for such behaviors, adherence to USAID's values, and an organizational culture that supports staff in carrying out its mission and priorities. Page 50 GAO-23-105178 USAID Bureau for Global Health We are making the following six recommendations to USAID: Recommendations for Executive Action The USAID Administrator should ensure that the Assistant Administrator for Global Health develops and implements a workforce plan for the Bureau. Such a plan could communicate the Bureau's optimal mix of direct hire and non-direct hire staff, as well as senior leaders; outline key actions to better align its staffing with its mission, priorities, and funding; and identify how it plans to address persistent vacancies in CS positions and the underrepresentation of certain racial or ethnic groups in its workforce. (Recommendation 1) The USAID Administrator should ensure that the Assistant Administrator for Global Health takes steps to assess the Bureau's performance at a bureau-wide level, such as by developing indicators to assess its performance in each of its strategic priorities or across all of its strategic priorities. (Recommendation 2) The USAID Administrator should ensure that the Assistant Administrator for Global Health takes steps to harmonize the Bureau's health program area data, such as by collecting common types of data across its different health program areas, to facilitate reporting of the Bureau's overall performance. (Recommendation 3) The USAID Administrator should ensure that the Assistant Administrator for Global Health takes steps to improve the comprehensiveness of the Bureau's health program area reporting, such as by including results from all countries receiving maternal and child health funds and including all required elements in its health-related research and development reports. (Recommendation 4) The USAID Administrator should ensure that the Assistant Administrator for Global Health documents lessons learned from the Bureau's response to the COVID-19 pandemic. (Recommendation 5) The USAID Administrator should ensure that the Assistant Administrator for Global Health institutionalizes efforts to address negative leadership behaviors identified in the Bureau's January 2022 report on strengthening processes and teamwork, such as by taking steps to (1) establish systems to promote accountability for such behaviors, (2) measure the impact of any changes made to address such behaviors, and (3) ensure senior management support for any such efforts. (Recommendation 6) Page 51 GAO-23-105178 USAID Bureau for Global Health We provided a draft of this product to USAID for review and comment. Agency Comments USAID provided written comments, which we have reproduced in appendix II. In its comments, USAID agreed with all six of our recommendations and highlighted a number of actions it is taking or plans to take to implement the recommendations. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to the appropriate congressional committees, the USAID Administrator, and other interested parties. In addition, the report is available at no charge on the GAO website at https://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-2964 or kenneyc@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 III. Sincerely yours, Chelsa L. Kenney Director, International Affairs and Trade Page 52 GAO-23-105178 USAID Bureau for Global Health Appendix I: Objectives, Scope, and Appendix I: Objectives, Scope, and Methodology Methodology This report examines (1) how the U.S. Agency for International Development (USAID)'s Bureau for Global Health's (GH Bureau, or Bureau) staffing is aligned with its mission, priorities, and funding, and the extent to which the Bureau has workforce plans to address current and future staffing needs; (2) the Bureau's assessments of its performance in executing its mission and priorities; and (3) key factors that affect the Bureau's ability to execute its mission and priorities, and the steps the Bureau has taken to address any challenges that it faces. To examine how the GH Bureau's staffing is aligned with its mission, priorities, and funding, we requested and analyzed its staffing data by the total number of staff for each staffing type (Civil Service, Foreign Service, Foreign Service Limited, personal services contractors, institutional support contractors, and Fellows) onboard as of the end of fiscal years 2019 through 2022. In addition, we analyzed the Bureau's allocations data from the Operating Expenses (OE) appropriation account, which is the account that USAID policy requires the Bureau to use to fund full-time employees in permanent positions. We then compared the Bureau's OE allocations data with the amount of the Bureau's program funding in fiscal years 2019 to 2022 to determine the difference between the Bureau's funding for staff and the funding for health programming that its staff oversee. We also collected and analyzed USAID data on the dollar amount of program funding managed by full-time employees in each USAID bureau to see how the GH Bureau compares with other bureaus. To determine the distribution of the GH Bureau's staff by its strategic priorities, we analyzed USAID's staffing pattern data for fiscal year 2021, which includes the Bureau's Civil Service, Foreign Service, and personal services contractor staff by Bureau office. We also examined data on Foreign Service Limited, institutional support contractors, and Fellows by GH Bureau office in fiscal year 2021. Fiscal year 2021 data were the most recent data available at the time of our analysis. We analyzed data on the Bureau's allocations for its health program areas and grouped them by strategic priority. In addition, we analyzed the Bureau's allocations for COVID-19 programming, as of September 2022, from the Economic Support Fund appropriations account in the American Rescue Plan Act of 2021 and the number of staff assigned to work on COVID-19 activities to determine the extent to which the allocations and staffing data aligned. 1 1Pub. L. No. 117-2, § 10003, 135 Stat. 4, 239 (2021). Page 53 GAO-23-105178 USAID Bureau for Global Health Appendix I: Objectives, Scope, and Methodology To determine the number of vacancies in the GH Bureau as of the end of fiscal years 2016 through 2022, we examined its vacancy data for Civil Service staff that were OE-funded, Schedule A COVID-19 OE funded, and program-funded. We also examined vacancy data for Foreign Service staff. 2 The Bureau was unable to provide vacancy data for fiscal years 2016 through 2019, because it did not have protocols in fiscal year 2016 to track vacancy data across its staffing mechanisms and thus could not provide us with reliable vacancy data for that fiscal year, according to Bureau officials. In January 2017, USAID instituted a hiring freeze, which remained in place in 2019. 3 As a result, neither the Bureau nor USAID's Office of Human Capital and Talent Management (HCTM) tracked vacancy data during this time. We did not report on vacancies for other categories of staff, such as Foreign Service Limited and contractors, as the Bureau does not have a set number of allocated positions for such staff each fiscal year to compare with the number of staff onboard. To examine the demographic composition of the GH Bureau, we analyzed data from USAID's Management Directive 715 (MD-715) reports on both USAID's and the Bureau's permanent workforces and compared the two workforces by gender and racial and ethnic groups in fiscal year 2021, the most recent data available at the time of our analysis. We also compared the Bureau's workforce composition by gender and racial and ethnic groups using these demographic data in fiscal years 2019, 2020, and 2021 to determine any significant changes in those fiscal years. We also reviewed documentation on the Bureau's diversity, equity, inclusion, and accessibility (DEIA) efforts at a bureau and office level to examine the Bureau's actions to address workforce diversity. To examine the extent to which the Bureau has workforce plans to address current and future staffing needs, we reviewed the Bureau's workforce structure and workforce planning efforts. To describe the Bureau's workforce structure, we reviewed its organizational and leadership structure, including by type of staff (Civil Service, Foreign Service, or political appointee). To analyze its workforce planning efforts, we requested and reviewed relevant documents, including the scope of work for an external consultant's assessment of the Bureau's workforce. 2On March 20, 2020, OPM authorized the use of Schedule A excepted service appointments under 5 C.F.R. § 213.3102(i)(3) to address the need for hiring additional staff in response to COVID-19. 3USAID's hiring freeze was lifted in 2018. However, its Hiring Reassignment and Review Board, in place since August 2017, continued to vet requests for positions in 2019. Page 54 GAO-23-105178 USAID Bureau for Global Health Appendix I: Objectives, Scope, and Methodology We used USAID guidance and GAO criteria on strategic human capital management to assess the extent to which the Bureau has a workforce plan. 4 We assessed the reliability of the GH Bureau's staffing and funding data, as well as USAID's demographic data. To assess the reliability of each of these data sets, we requested and reviewed information from USAID on the procedures, checks, and controls in the data systems used to generate the data to ensure its accuracy and reliability. We obtained staffing data from the GH Bureau, as well as HCTM, and compared the data provided by the two. Where we found discrepancies, we asked the relevant officials to review and to resolve them. As a result of these steps, we determined that the data were sufficiently reliable for our purposes of reporting on the Bureau's staffing composition in fiscal years 2019 to 2022 and funding in fiscal years 2016 to 2022, as well as the demographics of its and USAID's permanent workforces in fiscal years 2019 to 2021. To determine the extent to which the Bureau has assessments of its performance in executing its mission and priorities, we reviewed Bureau- level performance documents, including its annual Performance Plans and Reports, and State and USAID's annual performance reports for fiscal years 2019 to 2021. We also examined Bureau documents on proposed bureau-wide indicators and the Bureau's development of a global health data and analytics strategy. We used federal standards for internal control to assess the quality of information the Bureau communicates about its overall performance results at a bureau-wide level. 5 In addition, we analyzed a variety of the Bureau's program-level, congressionally mandated performance reports for fiscal years 2019 through 2021 and compared their contents with congressional requirements and agency guidance to determine the extent to which the Bureau has comprehensive performance information on its health programming at a program level. Reports that we analyzed included the Acting on the Call report for preventing maternal and child deaths, the President's Malaria Initiative reports, tuberculosis reports, health systems 4For USAID guidance, see U.S. Agency for International Development, Automated Directives System Chapter 401: USAID's Human Capital Framework, Section 401.3.2 (revised Oct. 11, 2018), and Automated Directives System Chapter 102: Agency Organization (revised June 27, 2017). For GAO's strategic human capital management criteria, see GAO, A Model of Strategic Human Capital Management, GAO-02-373SP (Washington, D.C.: Mar. 15, 2002). 5GAO-14-704G. Page 55 GAO-23-105178 USAID Bureau for Global Health Appendix I: Objectives, Scope, and Methodology strengthening reports, and health-related research and development reports. To examine the key factors that affect the Bureau's ability to execute its mission and priorities, and the steps it has taken to address any challenges it faces, we reviewed and analyzed a variety of documents on the Bureau's and missions' programming, operational, and external challenges and the steps taken in response to them. To describe challenges to programming as a result of the COVID-19 pandemic and steps taken to address them, we reviewed missions' strategies and plans, as well as health program area reports. We also reviewed programmatic and technical guidance documents to identify operational challenges and steps taken in response. Additionally, we reviewed strategy documents on steps taken to mitigate the effects of the pandemic. To describe external challenges and steps taken in response, we reviewed strategy documents on the factors that affected missions' ability to conduct health programming, guidance on operating in non-permissive environments, and additional Bureau resources provided to the missions to support their operations in such environments. To describe steps taken by the Bureau to prepare for future global health emergencies, we reviewed USAID's updated framework to respond to future global health emergencies and obtained information regarding changes to its global health security programming. To examine the Bureau's lessons learned from its response to the COVID-19 pandemic, we requested and reviewed documents that Bureau officials identified as relevant to COVID-19 lessons learned, such as those from USAID's COVID-19 Task Force and the activities of the COVID-19 Technical Working Group. We also reviewed health program area documents from both the Bureau and its non-governmental organization partners that implemented global health programming during the COVID-19 pandemic. We examined documents developed at the mission level on the lessons that specific missions learned from implementing health programming during the COVID-19 pandemic. Finally, we assessed the Bureau's efforts against USAID guidance on the use of lessons learned in various parts of USAID's project and strategy development, implementation, and close- out. To describe the GH Bureau's efforts to meet a congressional committee directive on cross-cutting health systems strengthening, we reviewed its guidance that explained the new directive's requirements and how health Page 56 GAO-23-105178 USAID Bureau for Global Health Appendix I: Objectives, Scope, and Methodology programming activities could meet them. 6 We also reviewed reports that identified challenges the Bureau has faced in implementing cross-cutting health systems strengthening programming, and examined strategy documents that describe the role of health systems strengthening in implementing USAID's global health goals. To review the Bureau's identification of negative leadership behaviors and efforts to address them, we reviewed documents that described challenges to the Bureau's workplace culture, proposed actions for addressing negative leadership behaviors, and behavioral principles developed in response to this challenge. We also assessed the behaviors described for their consistency with USAID's Mission, Vision, and Values statement on the fair and equal treatment of USAID employees. Finally, we evaluated the Bureau's actions against federal internal control standards on management's role in demonstrating integrity and ethical values, and in addressing behavioral deficiencies in a timely manner. 7 We discussed all of our objectives with officials from the GH Bureau in Washington, D.C., including officials from all its offices, as well as senior Bureau leadership. We discussed agency-wide staffing and workforce planning with officials from HCTM and workforce diversity with officials from USAID's Office of Civil Rights. Specific to the GH Bureau, we spoke with officials from the Office of Professional Development and Management Support on the Bureau's staffing data and workforce planning and the Office of Policy, Programs, and Planning on the Bureau's mission, priorities, and performance assessments. We also spoke with the Bureau's Data Scientist to obtain information on Bureau efforts to improve the use of its performance data. We spoke with officials on the Bureau's COVID-19 Technical Working Group, as well as officials from the Offices of HIV/AIDS, Infectious Diseases, Maternal and Child Health, and Population and Reproductive Health, on challenges related to the COVID-19 pandemic, including the effect of the pandemic on the Bureau's non-COVID health programming and lessons learned. We interviewed officials from the Office of Country 6H.R. Rept. 117-84, at 44 (2021). USAID has interpreted the committee directive to mean that its operating units, which include USAID missions and the GH Bureau, receiving funding for two or more health programs, such as TB and malaria, are to program and attribute at least 10 percent of their funding amount for each health program area to cross- cutting HSS activities. 7GAO-14-704G. Page 57 GAO-23-105178 USAID Bureau for Global Health Appendix I: Objectives, Scope, and Methodology Support on its assistance to overseas missions, including staffing support during the COVID-19 pandemic, as well as an official who coordinates the Bureau's Non-permissive Environment Community of Practice, to obtain information on steps the Bureau is taking to help missions operate in such environments. 8 We also interviewed officials from the Office of Infectious Disease on the management of global health security and neglected tropical diseases programming. In addition, we spoke to knowledgeable officials in the Bureau about the structure of malaria programming and on the structure of health systems strengthening programming. We also interviewed senior officials about the Bureau's efforts to meet a congressional committee health systems strengthening directive. To obtain information on management challenges, we interviewed Bureau officials who were working on teams to address such challenges, including those on DEIA and leadership behaviors. To inform all of our objectives, we selected a non-generalizable sample of USAID missions in five countries. We selected this sample based on several factors, such as geographic diversity; the number of global health program areas for which the country had been designated a priority country; the amount of global health funding, including COVID-19 related supplemental funding, managed by the mission; and the country's status as a priority country for staffing health foreign service officers. Using these criteria, we selected the USAID missions in Bangladesh, Ethiopia, Haiti, India, and Nigeria. We collected information via teleconference and in writing from health officials in all five countries regarding challenges to implementing health programming, including in staffing and performance monitoring, and in responding to the COVID-19 pandemic. 8According to USAID guidance, a non-permissive environment is an environment characterized by uncertainty, instability, inaccessibility, or insecurity in which USAID's ability to safely and effectively operate is constrained. See U.S. Agency for International Development, Automated Directives System Chapter 201: Program Cycle Operational Policy (revised Sept. 28, 2022). Page 58 GAO-23-105178 USAID Bureau for Global Health Appendix II: Comments from the U.S. Appendix II: Comments from the U.S. Agency for International Development Agency for International Development Page 59 GAO-23-105178 USAID Bureau for Global Health Appendix II: Comments from the U.S. Agency for International Development Page 60 GAO-23-105178 USAID Bureau for Global Health Appendix II: Comments from the U.S. Agency for International Development Page 61 GAO-23-105178 USAID Bureau for Global Health Appendix II: Comments from the U.S. Agency for International Development Page 62 GAO-23-105178 USAID Bureau for Global Health Appendix II: Comments from the U.S. Agency for International Development Page 63 GAO-23-105178 USAID Bureau for Global Health Appendix II: Comments from the U.S. Agency for International Development Page 64 GAO-23-105178 USAID Bureau for Global Health Appendix II: Comments from the U.S. Agency for International Development Page 65 GAO-23-105178 USAID Bureau for Global Health Appendix III: GAO Contact and Staff Appendix III: GAO Contact and Staff Acknowledgments Acknowledgments Chelsa L. Kenney, (202) 512-2964 or kenneyc@gao.gov GAO Contact In addition to the contact named above, Joyee Dasgupta (Assistant Staff Director), Rachel Dunsmoor (Analyst in Charge), Bolko Skorupski, Ashley Acknowledgments Alley, Jason Bair, Adriana Derksen, Christopher Keblitis, Terry Richardson, and Aldo Salerno made key contributions to this report. Page 66 GAO-23-105178 USAID Bureau for Global Health The Government Accountability Office, the audit, evaluation, and investigative GAO's Mission arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. 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