oversight

International Food Assistance: Improved Targeting Would Help Enable USAID to Reach Vulnerable Groups

Published by the Government Accountability Office on 2012-09-24.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States Government Accountability Office

GAO              Report to the Committee on Foreign
                 Affairs, House of Representatives



September 2012
                 INTERNATIONAL
                 FOOD ASSISTANCE

                 Improved Targeting
                 Would Help Enable
                 USAID to Reach
                 Vulnerable Groups




GAO-12-862
                                             September 2012

                                             INTERNATIONAL FOOD ASSISTANCE
                                             Improved Targeting Would Help Enable USAID to
                                             Reach Vulnerable Groups
Highlights of GAO-12-862, a report to the
Committee on Foreign Affairs, House of
Representatives




Why GAO Did This Study                       What GAO Found
In fiscal year 2011, USAID spent             In-country, the U.S. Agency for International Development (USAID) and its
approximately $1.7 billion on food           implementing partners face a range of factors that, to varying degrees, affect
assistance reaching over 46 million          their ability to target food assistance effectively to vulnerable groups. These
people in 48 countries. USAID targets        factors include (1) the quality of data used to identify and reach recipients, (2)
food assistance so that benefits accrue      host government policies, and (3) sharing of rations among recipients and
selectively to only a portion of the         community members. Targeting effectiveness is reduced when data quality is
overall population, typically the most       poor, host government policies cause distortions in program design and
vulnerable. Effective targeting is           implementation, and sharing prevents food rations from being consumed by the
important to maximize the impact of          intended recipients in the intended amounts. USAID and its implementing
limited resources, especially as USAID       partners try to mitigate such challenges by, for example, employing technology to
begins to use more nutritious but more       improve data quality, coordinating closely with government officials to foster
costly specialized food products to          better relationships, and educating recipients about proper food usage to reduce
address hunger and malnutrition              sharing. In some cases, host governments have facilitated targeting efforts by,
among vulnerable groups. GAO was
                                             for example, establishing national targeting guidelines that set a common
asked to (1) describe in-country factors
                                             standard, or national statistical offices that assist in collecting data. Nevertheless,
that USAID and its implementing
partners face in targeting vulnerable
                                             ensuring that food assistance reaches intended recipients remains difficult.
groups, and (2) examine the extent to        Weaknesses in the design, monitoring, and evaluation phases of USAID’s
which USAID’s targeting process              targeting process hinder targeting effectiveness, although the agency is taking
supports effective targeting. GAO            actions to make improvements. In the design phase of the targeting process,
analyzed program data and                    USAID does not provide sufficient guidance on whether and how to target
documents; interviewed relevant              specialized food products. Specifically, USAID’s guidance on design currently is
officials; convened a roundtable of food     neither up-to-date nor complete, and does not adequately address key benefits
assistance experts and practitioners;
                                             and risks that inform decisions on whether and how to target specialized food
and conducted fieldwork in Ethiopia,
                                             products. In USAID’s monitoring and evaluation phases, weaknesses limit
Guatemala, Sri Lanka, and Zimbabwe.
                                             targeting effectiveness and hinder decision making. USAID currently does not
What GAO Recommends                          require monitoring of key indicators needed to determine the level of targeting
                                             effectiveness. For example, during implementation USAID does not monitor
GAO recommends that the                      actual recipients in its emergency programs. Furthermore, its evaluations do not
Administrator of USAID improve               systematically address targeting effectiveness. Without adequate guidance,
USAID’s targeting of specialized food
                                             monitoring, and evaluations, USAID cannot ensure targeting effectiveness in its
products to vulnerable groups by (1)
                                             food assistance programs. USAID is taking some steps to improve both guidance
issuing, as appropriate, improved
interim guidance to assist                   and monitoring. For example, USAID is updating guidance and plans to track
implementing partners in deciding            indicators such as detailed age breakdowns that are key to better understanding
whether and how to target specialized        targeting effectiveness. However, these steps do not fully address the
food products; and (2) establishing and      weaknesses in USAID’s targeting process.
reporting program-specific indicators
                                             Weaknesses in the Targeting Process         Targeting Effectiveness Unknown
related to targeted vulnerable groups,
to assess effectiveness in reaching
such groups. USAID agreed with the
recommendations and provided
examples of recent efforts to address
them.



View GAO-12-862. For more information,
contact Thomas Melito at (202) 512-9601 or
melitot@gao.gov.

                                                                                       United States Government Accountability Office
Contents


Letter                                                                                              1
                       Background                                                                   4
                       Various In-Country Factors Affect USAID and Implementing
                         Partners’ Ability to Target Food Assistance Effectively to
                         Vulnerable Groups                                                        13
                       Weaknesses in the Design, Monitoring, and Evaluation Phases of
                         USAID’s Targeting Process Hinder Targeting Effectiveness,
                         Although Some Improvements Are Under Way                                 20
                       Conclusions                                                                30
                       Recommendations for Executive Action                                       30
                       Agency Comments and Our Evaluation                                         31

Appendix I             Objectives, Scope, and Methodology                                         33



Appendix II            Organizations That Participated in GAO Roundtable                          36



Appendix III           Cost Differences between Traditional Food Products and Specialized
                       Food Products                                                              37



Appendix IV            USAID New Specialized Food Products Pending Introduction                   40



Appendix V             Comments from the U.S. Agency for International Development                41



Appendix VI            GAO Contact and Staff Acknowledgments                                      45



Related GAO Products                                                                              46




                       Page i                                 GAO-12-862 International Food Assistance
Tables
          Table 1: Illustrative Examples of Cost Per Ration of Different
                   Types of Food Products, for Children 6 Months to 2 Years
                   of Age, Based on 2012 Prices                                      10
          Table 2: New Specialized Food Products Purchased with USAID
                   Funding, Fiscal Years 2010 to 2012                                22
          Table 3: Relative Costs of Traditional and Selected Specialized
                   Food Products (in U.S. dollars)                                   37
          Table 4: Number of Days Grain-Based or Corn Soy Blend Ration
                   Could Be Provided for the Cost of Providing Selected New
                   Specialized Food Products                                         38


Figures
          Figure 1: Prevalence of Stunting as an Indicator of Hunger and
                   Malnutrition among the Countries That Received Title II-
                   Funded Emergency Assistance in Fiscal Year 2011                     7
          Figure 2: Commodity Value of USAID Title II Emergency Program
                   by Product, Fiscal Year 2011                                       9
          Figure 3: Overview of the Food Assistance Targeting Process                12
          Figure 4: Targeting Effectiveness Is Measured by the Magnitude of
                   Targeting Error                                                   27




          Page ii                                GAO-12-862 International Food Assistance
Abbreviations

APS               Annual Program Statement
CSB               corn soy blend
CSB+              corn soy blend plus
CSB++             corn soy blend plus plus
FANTA             Food and Nutrition Technical Assistance
FAO               Food and Agriculture Organization
FAQR              Food Aid Quality Review
FFP               Office of Food for Peace
IFRP              International Food Relief Partnership
LNS               lipid nutritional supplement
MFFAPP            Micronutrient-Fortified Food Aid Products Pilot
NGO               nongovernmental organization
RUSF              ready-to-use supplementary food
RUTF              ready-to-use therapeutic food
SUN               Scaling-Up Nutrition
UN                United Nations
UNDSS             United Nations Department of Safety and Security
UNICEF            United Nations Children’s Fund
USAID             U.S. Agency for International Development
USDA              U.S. Department of Agriculture
WFP               United Nations World Food Program
WSB               wheat soy blend




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Page iii                                         GAO-12-862 International Food Assistance
United States Government Accountability Office
Washington, DC 20548




                                   September 24, 2012

                                   The Honorable Ileana Ros-Lehtinen
                                   Chairman
                                   The Honorable Howard L. Berman
                                   Ranking Member
                                   Committee on Foreign Affairs
                                   House of Representatives

                                   As the largest international food assistance donor, providing about half of
                                   global food assistance, the United States plays an important role in
                                   addressing hunger and malnutrition among vulnerable groups around the
                                   world. 1 Nearly 1 billion people suffer from undernourishment, which
                                   contributes to more than one-third of child deaths globally, according to
                                   United Nations (UN) sources. 2 In fiscal year 2011, with funding authorized
                                   under the Food for Peace Act, 3 the U.S. Agency for International
                                   Development (USAID) reported that it spent approximately $1.7 billion on
                                   food assistance that reached over 46 million people in 48 countries. 4 Of
                                   this total, USAID spent approximately $1.2 billion on emergency
                                   programs to help alleviate hunger and malnutrition in countries affected




                                   1
                                    Vulnerable groups may include pregnant and lactating women; children under 2; and
                                   individuals who are elderly, handicapped, or afflicted with chronic diseases such as
                                   HIV/AIDS.
                                   2
                                    United Nations (UN) Food and Agriculture Organization (FAO), The State of Food
                                   Insecurity in the World (Rome, Italy: 2010); and UN Children’s Fund (UNICEF), Tracking
                                   Progress on Child and Maternal Nutrition: A Survival and Development Priority (New York,
                                   NY: 2009).
                                   3
                                    Section 3001 of Pub. L. No. 110-246, the Food, Conservation, and Energy Act of 2008,
                                   changed the title of the underlying legislation from the Agricultural Trade Development
                                   Assistance Act of 1954, also known as P.L. 480, to the Food for Peace Act. Title II of the
                                   Food for Peace Act, administered by USAID, addresses donation of agricultural
                                   commodities for humanitarian purposes. Other U.S. food assistance programs are
                                   administered through the U.S. Department of Agriculture, including Food for Peace Title I,
                                   Food for Progress, and the McGovern-Dole International Food for Education and Child
                                   Nutrition programs. In this report, we refer to the Food for Peace Act as Title II.
                                   4
                                    Fiscal year 2011 data reported by USAID were preliminary data at the time of this report.




                                   Page 1                                          GAO-12-862 International Food Assistance
by natural or man-made disasters, such as drought or conflict. 5 USAID
programs provide three types of food assistance products: (1) traditional
food products, such as wheat, corn, and sorghum; (2) traditional
specialized food products, such as corn soy blend (CSB), a nutritionally
enhanced commodity; and (3) new specialized food products, such as
ready-to-use supplementary or therapeutic foods. 6 Both traditional and
new specialized food products are intended for vulnerable groups.

USAID’s goal is to focus its food assistance efforts on the reduction of
hunger and malnutrition in vulnerable groups through targeting. As
defined by USAID, targeting is any method by which an intervention is
designed or implemented so that benefits can accrue selectively to only a
portion of the overall population. Targeting may be categorized by
geographic area or eligibility criteria, which are usually defined by
recipients’ characteristics, such as age, gender, income level, asset level,
or nutritional status. For the purposes of this report, we define the
effectiveness of targeting as the degree to which USAID and its
implementing partners are able to (1) accurately assess needs and
identify recipients using appropriate eligibility criteria, and (2) ensure that
the food assistance provided reaches and is consumed by the targeted




5
 USAID spent approximately $426 million on development programs and the remainder
on other related efforts. USAID previously referred to these development programs as
nonemergency programs. Development programs typically include a range of objectives,
such as agricultural development, health and nutrition, or community development.
Emergency programs may have some of these same objectives, but as noted above they
are generally focused on alleviating hunger and malnutrition in countries affected by
disaster. In this report, we focus on both Title II emergency and development in-kind food
assistance programs, particularly those that have nutritional goals and include the use of
specialized food products. We do not focus on other types of food assistance program
activities, such as food-for-work or food-for-assets.
6
 For the purposes of this report, we use the following terms in reference to food products:
(1) traditional food products, which include grain, pulses (dried beans, peas, and lentils),
and vegetable oil; (2) traditional specialized food products, which include fortified and
blended food, such as corn soy blend (CSB) and wheat soy blend (WSB); and (3) new
specialized food products, which include reformulated fortified and blended food, such as
Supercereal and Supercereal+; ready-to-use supplementary food (RUSF), such as
Nutributter and Plumpy’Doz; ready-to-use therapeutic food (RUTF), such as Plumpy’Nut;
and ready-to-use emergency rations, such as A-20. Traditional and new specialized food
products are collectively referred to as specialized food products. Not all of the products
defined in each food product category are currently used in Title II-funded food assistance
programs.




Page 2                                           GAO-12-862 International Food Assistance
recipients as defined by the eligibility criteria. 7 While targeting may never
be perfect, targeting error indicators can be used to assess effectiveness.
These indicators include the percentage of intended recipients that did
not receive food assistance or the percentage of people who were not
eligible for assistance but still received it. 8

Effective targeting is important, particularly in the context of constrained
resources, continuing humanitarian and food emergencies, and
increasing focus on addressing malnutrition in vulnerable populations.
USAID’s food assistance budget has declined from approximately $2.3
billion in appropriations in fiscal year 2009 to less than $2 billion in fiscal
year 2011. The demand for international food assistance remains high as
the threat of drought and famine persists in the Horn of Africa and other
regions. Moreover, USAID has begun to introduce, for limited use, some
new but more costly specialized food products designed to improve
nutritional outcomes for vulnerable groups, such as children under 2
years of age. However, as we previously reported, providing food that is
more nutritious but also more costly, within a fixed budget, would result in
fewer recipients fed. 9

As part of our work on international food assistance, 10 you asked us to (1)
describe in-country factors that USAID and its implementing partners face
in targeting vulnerable groups, and (2) examine the extent to which
USAID’s targeting process supports effective targeting.



7
 For the purposes of this report, we use the term “implementing partners” to refer to the
UN World Food Program (WFP) and nongovernmental organizations (NGOs) that are
awarded U.S. government grants to carry out food assistance programs.
8
 These indicators are known as exclusion errors, which occur when people who are
eligible for assistance do not receive it, and inclusion errors, which occur when people
who are not eligible for assistance receive it. Together, these two measures can be
referred to as targeting errors.
9
 GAO, International Food Assistance: Better Nutrition and Quality Control Can Further
Improve U.S. Food Aid, GAO-11-491 (Washington, D.C.: May 12, 2011).
10
  Our current work on international food assistance includes a recently issued report,
GAO, World Food Program: Stronger Controls Needed in High-Risk Areas, GAO-12-790
(Washington, D.C.: Sept. 13, 2012). In addition, we are conducting a review of the Feed
the Future initiative, the U.S. governmentwide strategy to address global hunger and food
security. The strategy was developed pursuant to a U.S. pledge made at the G-8 Summit
in L’Aquila, Italy, to provide at least $3.5 billion for agricultural development and global
food security over 3 years.




Page 3                                           GAO-12-862 International Food Assistance
                           To address these objectives, we met with officials from USAID and its
                           implementing partners, including the UN World Food Program (WFP) and
                           nongovernmental organizations (NGO). We also met with academics,
                           experts, and practitioners associated with research institutes and
                           universities, as well as officials from the U.S. Departments of Agriculture
                           (USDA) and State (State). In addition, we reviewed USAID’s targeting
                           framework, including guidance, related to the food assistance targeting
                           process. We analyzed data from USAID and WFP to identify trends in
                           food assistance funding, the use of specialized food products, and the
                           costs of these products as compared with traditional food products.
                           Furthermore, we conducted fieldwork in four countries—Ethiopia,
                           Guatemala, Sri Lanka, and Zimbabwe—and met with officials from U.S.
                           missions, implementing partners, and relevant host government agencies.
                           Finally, we convened a roundtable of 10 experts and practitioners—
                           including representatives from academia, research organizations, and
                           implementing partners such as WFP and NGOs—to further delineate, on
                           the basis of our initial work, in-country factors that affect targeting
                           vulnerable groups and the process that USAID and its implementing
                           partners use to target food assistance. Appendix I provides a detailed
                           discussion of our objectives, scope, and methodology.

                           We conducted this performance audit from October 2011 to September
                           2012 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.



Background
The United States Has      Combating world hunger and malnutrition is a stated objective of the Food
Stated Its Commitment to   for Peace Act, which authorizes international food assistance for
Combating World Hunger     developing countries. The United States has also stated its commitment
                           to the Millennium Development Goal to halve world hunger by 2015, and
and Malnutrition           it supports the Scaling-Up Nutrition (SUN) movement to provide
                           assistance to country-led efforts to address maternal and child




                           Page 4                                  GAO-12-862 International Food Assistance
malnutrition. 11 To support SUN, the United States and others initiated the
1,000 Days public-private partnership, which aims to improve nutrition for
pregnant and lactating mothers and children under 2. Adequate nutrition
in this critical period in a child’s life is widely recognized to have the
greatest impact on saving lives, developing a child’s cognitive and
physical capacity, and mitigating the risk of chronic disease. According to
the USAID Policy Framework 2011-2015, USAID plans to ensure that the
quality of U.S. government food aid is improved within 3 years to meet the
nutritional requirements of vulnerable populations overseas, including by
developing new blended products and formulations to support pregnant
and lactating mothers and children under 2.

In fiscal year 2011, USAID provided about $1.2 billion in Title II
emergency funding to deliver about 1 million metric tons of food to 33
countries, as shown in figure 1. Approximately 74 percent of the food
commodities were delivered to 14 countries that received U.S. emergency
food assistance every year from fiscal years 2006 through 2011. 12 Ten
countries—eight of them in Africa—accounted for about 83 percent of
Title II emergency funding. 13 Seven of these 10 countries consistently
received Title II emergency food assistance in the last 6 years. Also,
among these 10 countries, the prevalence of stunting, a standard
indicator for undernourishment in children under 5, ranged from 32 to 59




11
  SUN promotes the implementation of nutrition interventions, proliferation of successful
practices, and integration of nutrition goals into sectors such as public health, social
protection, and agricultural development. The SUN movement currently comprises 27
member countries, as well as civil society groups, donors, businesses, and international
organizations.
12
  We previously reported that, although Title II emergency funding is intended to address
short-term food needs, more than half of the funding in fiscal year 2010 was spent on
multiyear emergency programs. See GAO-11-491. In 2011, the 14 countries that received
U.S. emergency food assistance every year from fiscal years 2006 through 2011 were
Afghanistan, Burundi, Central African Republic, Chad, Colombia, Democratic Republic of
the Congo, Ethiopia, Kenya, Nepal, Rwanda, Somalia, Sudan, Tanzania, and Uganda. In
addition, 23 percent of the emergency food commodities were delivered to 15 countries
that received U.S. food assistance for 3 to 5 years from fiscal years 2006 through 2011.
Three percent was delivered to four countries that received emergency U.S. food aid for 1
to 2 years.
13
 The 10 countries were Afghanistan, Chad, Democratic Republic of the Congo, Ethiopia,
Kenya, Pakistan, Somalia, South Sudan, Sudan, and Zimbabwe.




Page 5                                           GAO-12-862 International Food Assistance
percent. 14 Ethiopia, one of the four countries we visited, received about
$207 million, which accounted for about 17 percent of total Title II
emergency funding. A higher percentage of the total population in
Ethiopia suffers from malnutrition than in most other recipient countries,
with 51 percent of children under 5 suffering from stunting.




14
  As defined by UNICEF, undernourishment includes stunting (being too short for one’s
age), a key indicator of hunger and malnutrition. USAID uses wasting as an indicator of
acute malnutrition in Title II emergency and development programs and stunting as an
indicator of chronic malnutrition in Title II development programs.




Page 6                                          GAO-12-862 International Food Assistance
Figure 1: Prevalence of Stunting as an Indicator of Hunger and Malnutrition among the Countries That Received Title II-
Funded Emergency Assistance in Fiscal Year 2011




                                         a
                                          Stunting data are not available for Ecuador, Libya, and West Bank/Gaza.




                                         Page 7                                               GAO-12-862 International Food Assistance
                              b
                               South Sudan became independent from Sudan in 2011 and first received Title II-funded emergency
                              assistance in fiscal year 2011. Stunting data reported include both Sudan and South Sudan.

                              c
                               The percentage of stunting among children under 5 is based on World Health Organization data for
                              2006-2010, as reported by UNICEF.

                              d
                                  Countries requiring external food assistance as of June 2012, according to FAO.

                              e
                               Countries receiving Title II-funded emergency assistance from fiscal years 2006 through 2011,
                              according to annual U.S. International Food Assistance Reports issued by USAID and USDA for 2006
                              through 2011.

                              f
                               Title II emergency food aid tonnage and funding levels for fiscal year 2011 are preliminary based on
                              the U.S. International Food Assistance Report (draft) for 2011, to be issued by USAID and USDA.



Traditional Food Products     USAID uses traditional food products, such as grain, pulses, and
Account for the Vast          vegetable oil, for the vast majority of its food assistance programs, but
Majority of Food              specialized food products are increasingly being used. For more than 40
                              years, USAID has been using fortified blended foods, such as CSB or
Assistance, with the Use of   WSB, as the primary food product to provide enhanced nutrition during
Specialized Food Products     emergencies. Figure 2 provides a breakdown of USAID Title II emergency
Increasing                    program commodity value by product in fiscal year 2011, with traditional
                              specialized food products accounting for 8 percent. Since fiscal year
                              2010, USAID has been purchasing small quantities of new specialized
                              food products such as ready-to-use emergency rations, making a limited
                              supply available in two of its prepositioning sites where food commodities
                              are stocked for shipment as necessary. 15




                              15
                               In addition, USDA’s Foreign Agriculture Service has a Micronutrient-Fortified Food Aid
                              Products Pilot (MFFAPP) that received $10 million in fiscal year 2010 to support the
                              development and field testing of new ready-to-use foods, fortified blended foods, high-
                              energy foods, and micronutrient powders to address the micronutrient deficiencies of a
                              population or group. The first MFFAPP project was under way in fiscal year 2011, with
                              additional pilot projects continuing in fiscal year 2012.




                              Page 8                                                  GAO-12-862 International Food Assistance
Figure 2: Commodity Value of USAID Title II Emergency Program by Product, Fiscal
Year 2011




Note: Traditional food products include grain, pulses, and vegetable oil. Traditional specialized food
products include CSB and WSB.

In recent years, nutritionists have argued that traditional specialized food
products may not be appropriate for children under 2 to obtain sufficient
nutrients. 16 As a result, USAID and WFP have introduced new specialized
food products, including enhanced versions of some of their traditional
specialized food products, such as CSB+ or Supercereal+, to better meet
the nutritional needs of vulnerable groups. Recently, USAID also has
introduced a range of ready-to-use products, which are designed for
recipients affected by emergencies such as natural disasters or
conflicts. 17 WFP is the largest provider of global food aid and
implementing partner of USAID, accounting for 90 percent of U.S.
emergency food assistance funding. WFP has increased the share of
specialized food products in its procurement by 10 percentage points
across a period of 2 years, reaching over 25 percent in its 2011



16
  GAO-11-491.
17
  According to USAID officials, these ready-to-use products also include products that are
aimed at reducing malnutrition, which can occur even outside of emergencies.




Page 9                                                  GAO-12-862 International Food Assistance
                            procurement. The countries that received the largest amounts of
                            specialized food products from WFP were Ethiopia, Pakistan, Kenya,
                            Niger, and Somalia.

                            Specialized food products are designed to meet specific nutritional needs
                            of vulnerable groups but are more costly than traditional food products.
                            As a result, within a fixed budget, USAID and its implementing partners
                            must decide whether to provide more nutritious but more costly food to
                            fewer people, or less nutritious and less costly food to more people. In
                            other words, they face a quality-quantity trade-off. 18 Table 1 provides
                            illustrative examples of cost per ration for the three different types of food
                            assistance. See appendix III for a more detailed comparison of cost
                            differences between traditional food products and specialized food
                            products.

                            Table 1: Illustrative Examples of Cost Per Ration of Different Types of Food
                            Products, for Children 6 Months to 2 Years of Age, Based on 2012 Prices

                                                                                                               Cost per daily ration
                                                            a
                                Type of food product                               Example of product                       or dose
                                Traditional food product                           Grain                                $0.02-$0.06
                                Traditional specialized food product               CSB                                  $0.09-$0.18
                                New specialized food product                       Ready-to-use                         $0.42-$0.46
                                                                                   therapeutic food (RUTF)
                            Source: GAO analysis based on various studies and USAID and WFP data.

                            a
                             The products listed in this table are used for different purposes. This table does not assess which
                            products are more effective. We note that USAID does not provide RUTF as part of a general food
                            distribution ration.



Targeting Is an Iterative   Targeting in food assistance programs is an iterative process that aims to
Process                     ensure that food reaches and is consumed by people whose
                            characteristics meet certain eligibility criteria, such as age, gender,
                            income level, asset level, or nutritional status. Figure 3 presents a
                            simplified schematic of the overall targeting process and its key phases—
                            design, implementation and monitoring, and evaluation—and steps within



                            18
                              For the purposes of this report, we define the “quality” of a given food product as the
                            degree to which it meets specific nutritional needs of vulnerable groups, not the degree to
                            which it adheres to specifications designed to ensure that it is safe for consumption, which
                            all USAID food products must meet at a minimum.




                            Page 10                                                           GAO-12-862 International Food Assistance
each phase. As key stakeholders in the targeting process, USAID and its
implementing partners, including WFP and NGOs, play an important role,
as do host governments. In the design phase, implementing partners
design food assistance programs and submit proposals to USAID. USAID
reviews the proposals and decides whether to fund the programs. 19
Feedback occurs within and across each of the phases—both in host
countries and at USAID headquarters—and is crucial to maximizing
targeting effectiveness, leading to steps within the process that may not
be strictly sequential. For example, during the design phase, USAID and
its implementing partners may conduct an assessment of needs to
determine the basis for the design of a program; however, as needs may
change or be clarified, they may retarget or make adjustments during the
monitoring phase to address issues that may arise.




19
  According to USAID and WFP officials, this process functions differently for WFP
programs. After WFP submits its program design documents, USAID decides whether to
fund the program in part or in its entirety.




Page 11                                      GAO-12-862 International Food Assistance
Figure 3: Overview of the Food Assistance Targeting Process




                                        a
                                         This figure illustrates a generalized targeting process for both Title II emergency and development in-
                                        kind food assistance programs, particularly those that directly distribute specialized food products to
                                        achieve nutritional goals. It does not necessarily reflect other types of development food assistance
                                        programs, such as those that do not directly distribute food or have any nutritional goals.




                                        Page 12                                                GAO-12-862 International Food Assistance
                                 USAID and its implementing partners face a range of in-country factors
Various In-Country               that, to varying degrees, affect their ability to effectively target food
Factors Affect USAID             assistance to vulnerable groups. These factors include (1) the quality of
                                 data used to identify and reach recipients, (2) host government policies,
and Implementing                 and (3) sharing of rations among recipients and community members.
Partners’ Ability to             Targeting effectiveness is reduced when data quality is poor, host
Target Food                      government policies cause distortions in program design and
                                 implementation, and sharing prevents food rations from being consumed
Assistance Effectively           by the intended recipients in the intended amounts. USAID and its
to Vulnerable Groups             implementing partners take steps to mitigate such challenges by, for
                                 example, employing technology to improve data quality, coordinating
                                 closely with government officials to foster better relationships, and
                                 educating recipients about proper food usage to reduce sharing. In some
                                 cases, host governments have facilitated targeting efforts by, for example,
                                 establishing national targeting guidelines that set a common standard, or
                                 national statistical offices that assist in collecting data. Nevertheless,
                                 ensuring that food assistance reaches intended recipients remains
                                 difficult. 20


Poor Data Quality May
Hinder Implementing
Partners’ Ability to Identify
and Reach Intended
Recipients
Lack of Reliable Population      Poor data quality—lack of timely and accurate information—may affect
and Household Data May           implementing partners’ ability to effectively identify and reach recipients.
Hinder Targeting Effectiveness   For example, in Zimbabwe, USAID and three implementing partners
                                 noted that a lack of current and reliable population data made it difficult to
                                 determine the overall number and geographic distribution of households

                                 that are in need of food assistance. 21 In Guatemala, an implementing
                                 partner told us that because it used inaccurate data on average


                                 20
                                   These in-country factors and mitigating measures apply to both emergency and
                                 development programs.
                                 21
                                   WFP reported that the last census in Zimbabwe was conducted in 2002. Since then,
                                 uncertainties about the volume of emigration due to economic and other reasons and the
                                 mortality rate due to HIV/AIDS have led some UN organizations to raise questions about
                                 official statistics.




                                 Page 13                                        GAO-12-862 International Food Assistance
                                 household size to determine the initial ration size, people who were
                                 initially identified received more food than they would have received if the
                                 data had been accurate. Although the error was later corrected, if the
                                 data had been accurate, resources could have been used more optimally
                                 to reach people in need.

Natural Disasters or Conflicts   USAID and implementing partners we spoke with stated that sudden
May Cause Population             natural disasters or conflicts could raise security concerns for
Movements and Raise Security     implementing partners, hindering their ability to reach the originally
Concerns, Hindering Ability to   targeted recipients. Furthermore, gathering reliable data on transient
Reach Targeted Recipients        populations is challenging. For example, USAID and an implementing
                                 partner in Ethiopia told us that in some areas of the country, it is difficult
                                 to determine the number and location of people in need of food
                                 assistance, particularly pastoralists, who move often as a traditional way
                                 of life and to cope with drought or natural disasters. As a result, it is
                                 difficult for implementing partners to accurately assess the needs in a
                                 particular geographic area and design an appropriate food assistance
                                 program.

                                 In addition, natural disasters or conflicts may raise security concerns,
                                 hindering ability to reach targeted recipients. We recently reported that
                                 security concerns prevented WFP from conducting field monitoring of
                                 food distribution to determine whether the food rations reached the
                                 originally targeted recipients in some high-risk areas of Ethiopia, Kenya,
                                 and Somalia. 22 For example, WFP noted that it has been unable to
                                 access six districts in the Somali region of Ethiopia since May 2011. As a
                                 result, WFP’s ability to collect data to ensure that the intended recipients
                                 received their food assistance in these high-risk areas is limited.




                                 22
                                   See GAO-12-790. In the countries where WFP operates, the United Nations Department
                                 of Safety and Security (UNDSS) assesses the general security environment in specific
                                 geographic areas using five categories of threats: armed conflict, terrorism, crime, civil
                                 unrest, and hazards. UNDSS rates each area at one of six security levels, with level 6
                                 indicating the most dangerous environment. The UN Security Management System uses
                                 these ratings to assess security risks to UN agencies, funds, and programs; on the basis
                                 of these assessments, WFP determines appropriate risk mitigation measures to protect its
                                 staff and operations.




                                 Page 14                                         GAO-12-862 International Food Assistance
USAID and Its Implementing   USAID and implementing partners have taken some measures to improve
Partners Have Taken Some     data quality by building capacity through technology, training, and other
Measures to Address Data     activities. For example, USAID funds the Famine Early Warning Systems
Quality Issues, but They     Network (FEWS NET), which is used to monitor and prepare for changes
Remain a Challenge           in food assistance needs. FEWS NET monitors and analyzes vulnerability
                             information, using multiple sources such as satellite imagery and field
                             observations. Moreover, some countries, such as Ethiopia, have
                             established national statistical offices that can assist in collecting data for
                             targeting food assistance. In addition, a 2011 report on food assistance
                             stated that implementing partners are working on increasing the speed,
                             accuracy, accessibility, and comparability of information. 23 Implementing
                             partners in two countries we visited told us that they are using mobile
                             devices, such as tablets and phones, to collect recipient and distribution
                             data. The use of technology enables the implementing partners to better
                             identify and track recipients throughout the program and identify needs. In
                             the aforementioned example about excess ration size in a Guatemala
                             program, the implementing partner used tablets to collect information on
                             recipient consumption patterns. In this way, the implementing partner
                             ultimately discovered the ration error and corrected the ration size for
                             each household, freeing up resources to reach more recipients as a
                             result. Also, implementing partners in Guatemala and Sri Lanka indicated
                             that they train their staff and community volunteers on data collection, and
                             work with the host governments to improve the governments’ ability to
                             collect data. In addition, some countries, such as Sri Lanka, have
                             conducted repeated assessments of food assistance needs over several
                             years, which can lead to improvements in the precision of the data
                             collected.

                             Even with efforts to improve the data used to identify and reach
                             recipients, data quality remains a challenge in targeting food assistance.
                             A 2011 food assistance report points out that implementing partners often
                             lack disaggregated information, such as household-level data, that would
                             help them design an effective targeted food assistance program. 24
                             Similarly, implementing partners we spoke with stated that the detailed
                             data necessary for effective targeting are often not available, while
                             acknowledging that data quality differs across countries. An implementing


                             23
                              Christopher B. Barrett, Andrea Binder, and Julia Steets, Uniting Food Assistance: The
                                                                  st
                             Case for Transatlantic Cooperation, 1 ed. (Oxford, UK; and New York City: 2011), 55.
                             24
                              Barrett, et al., 67.




                             Page 15                                        GAO-12-862 International Food Assistance
                           partner in Guatemala stated that data need to be improved continuously
                           to measure outcomes and impacts of targeting, particularly for programs
                           with a nutritional objective.


Host Government Policies   Host government policies may lead to distortions, hampering targeting
May Cause Distortions,     effectiveness, but implementing partners have made some efforts to
Limiting Targeting         reduce these adverse effects. We previously reported that one of the key
                           challenges to accurately assessing the needs of vulnerable groups was a
Effectiveness              lack of coordination among key stakeholders—especially with host
                           governments—on assessments of food assistance needs. 25 In addition,
                           some host country governments have been criticized for underestimating
                           actual needs or directing implementing partners to operate only in certain
                           geographic areas, due to political or other reasons. 26 As a result,
                           implementing partners may not be able to reach recipients or locations
                           most in need of food assistance. 27 For example, an implementing partner
                           in Ethiopia reported to USAID that the government of Ethiopia set an
                           artificial quota for the number of people targeted in each household that in
                           some cases did not reflect the actual needs, and severely hampered the
                           partner’s ability to reach vulnerable groups as a result. However, USAID
                           and implementing partner officials in Ethiopia also told us that working
                           with the government’s distorted figures is less challenging now than in the
                           past, due in part to recent efforts of local and regional government
                           officials to improve the validity and documentation of needs assessments
                           as well as better stakeholder coordination.

                           In some instances, however, host government policies may facilitate
                           targeting efforts. For example, the government of Sri Lanka has worked
                           closely with WFP to identify vulnerable groups and has supported efforts
                           to improve both data collection and the analysis of food needs, including
                           by supporting the research organization that partners with WFP in



                           25
                             GAO, Foreign Assistance: Various Challenges Impede the Efficiency and Effectiveness
                           of U.S. Food Aid, GAO-07-560 (Washington, D.C.: Apr. 13, 2007).
                           26
                            GAO-07-560; and Barrett, et al., 65.
                           27
                             For example, a 2001 study found evidence that the government of Ethiopia, which plays
                           an important role in deciding where food assistance programs may operate, has at times
                           transferred food assistance to favored regions. T.S. Jayne, J. Strauss, T. Yamano, and D.
                           Molla, “Targeting of food aid in rural Ethiopia: chronic need or inertia?” World
                           Development, Vol. 29, No. 5, pp. 887-910 (2001).




                           Page 16                                         GAO-12-862 International Food Assistance
conducting assessments of needs for food assistance. 28 In another
example, the government of Ethiopia has published National Targeting
Guidelines that are intended to standardize and improve targeting
efforts. 29 This document helps all food assistance stakeholders in the
country operate under a commonly understood set of targeting policies
and practices.

To address host government policies that cause distortions, implementing
partners undertake efforts to coordinate with stakeholders and verify
information on food assistance needs. Implementing partners we spoke
with told us they work with each other and with host governments in the
initial phase of the targeting process to increase transparency, in an effort
to encourage more accurate government estimates of actual needs. For
example, in Ethiopia, USAID officials told us that to increase
transparency, donors are working with the government to introduce
software tools and technology that facilitate access to information and
increase public awareness and thereby discourage government
authorities from manipulating data on food assistance needs. Moreover,
to help facilitate distribution of food assistance to intended recipients in
Guatemala, implementing partners stated that it is essential to closely
coordinate with government authorities at the beginning of the targeting
process to obtain approval for the use of new products and to set up the
appropriate distribution channels and protocol. In addition, in Sri Lanka,
an implementing partner told us that it plans to use local organizations to
conduct independent verification of the potential recipient list, which is
largely selected by the government. Doing so would help the
implementing partner ensure that only recipients who qualify for food
assistance are included on the list, increasing the likelihood that food
assistance reaches the intended recipients. Despite these efforts,
implementing partners have limited ability to influence host government
policies.




28
  The Hector Kobbekaduwa Agrarian Research and Training Institute (HARTI), an entity
that is funded in part by the government of Sri Lanka, partners with WFP to conduct the
food security assessments.
29
 Federal Democratic Republic of Ethiopia, Ministry of Agriculture, National Guidelines on
Targeting Relief Food Assistance (Addis Ababa, Ethiopia: Aug. 2011).




Page 17                                         GAO-12-862 International Food Assistance
Sharing Reduces Targeting    Sharing within recipient households and among community members
Effectiveness If Food        may result in food rations being consumed by unintended recipients or in
Rations Are Not Consumed     unintended amounts, but implementing partners have taken some
                             measures to reduce sharing. External assessments suggest that sharing
by the Intended Recipients   of food rations is a widespread and established coping mechanism when
in the Intended Amounts      insufficient food is available. The 2011 Food Aid Quality Review (FAQR)
                             report 30 and the 2011 WFP guidance on targeted food assistance
                             programs acknowledge that sharing of specialized food products is a
                             concern, and according to a 2011 USAID assessment of a food
                             assistance program in the Somali region of Ethiopia, sharing of food
                             rations is widespread. In addition, in countries we visited, USAID and its
                             implementing partners told us that both CSB and traditional food products
                             are routinely shared within and among households in some
                             communities—a finding we previously reported in 2011. 31 The 2011
                             USAID assessment also notes that sharing is an established coping
                             mechanism for the recipient community when not everyone in the
                             community receives food rations. When food rations are shared, the
                             intended recipients may not consume the intended food products in the
                             desired amounts, which may reduce targeting effectiveness by limiting
                             nutritional impact, particularly for specialized food products that are
                             intended for vulnerable groups.

                             Implementing partners have made efforts to reduce the likelihood of
                             sharing, especially of specialized food products. Specifically,
                             implementing partners have employed various strategies to teach
                             recipients how to use specialized food products and have monitored
                             recipient food ration consumption. For example, one implementing
                             partner in Guatemala requires pregnant or lactating women to attend
                             education sessions, where they learn about the benefits of the specialized
                             food products and how to properly prepare them, before they can receive
                             rations. Implementing partners in Guatemala also print culturally relevant
                             instructional images on the food packages or the canvas bags given to
                             recipients to carry the rations. The images explain how to prepare the


                             30
                               The 2011 Food Aid Quality Review was a 2-year study conducted by Tufts University
                             that recommended 35 changes to U.S. food aid products and programs to deliver
                             improved nutrition. Food Aid Quality Review: Delivering Improved Nutrition:
                             Recommendations for Changes to U.S. Food Aid Products and Programs (April 2011).
                             31
                               Both USAID and implementing partners recognized that food rations are shared within
                             and among recipient households. For example, 26 of the 30 programs we surveyed in
                             2010 reported at least some sharing of CSB by recipients. See GAO-11-491.




                             Page 18                                       GAO-12-862 International Food Assistance
food products and depict the type of person for whom the products are
intended—such as a pregnant woman or a child under 2 years of age.
One of these implementing partners reported that it had seen an
improvement in recipient participation in these education sessions and
expected that these sessions would reduce sharing.

In addition, implementing partners use community volunteers to monitor
effectiveness or consumption of food products. For example, in
Guatemala, implementing partners train “mother leaders”—mothers who
are also recipients—to provide training to other recipients on how to
prepare food and monitor outcomes by, for example, observing
improvement in a child’s weight or overall health appearance. In Sri
Lanka, another implementing partner uses health volunteers from the
recipient community and coordinates with the host government to ensure
that specialized food products are consumed by the children through
monthly monitoring of their nutritional status at government-run clinics
and weighing stations. The health volunteers also follow up with the
mothers of these children, who are receiving specialized food products, if
they do not bring their children to the monthly checkup. While
implementing partners have taken these and other steps to address
sharing, evidence of the impact of these steps has yet to be determined. 32




32
 GAO-11-491; Food Aid Quality Review (April 2011).




Page 19                                      GAO-12-862 International Food Assistance
                             Weaknesses in the design, monitoring, and evaluation phases of USAID’s
Weaknesses in the            targeting process hinder targeting effectiveness, although the agency is
Design, Monitoring,          taking actions to make improvements. In the design phase of the
                             targeting process, USAID does not provide sufficient guidance on
and Evaluation               whether and how to target specialized food products. Specifically,
Phases of USAID’s            USAID’s guidance on design for both emergency and development
Targeting Process            programs is neither up-to-date nor complete, and does not adequately
                             address key benefits and risks that inform decisions on whether to target
Hinder Targeting             specialized food products. In both USAID’s monitoring and evaluation
Effectiveness,               phases, weaknesses limit targeting effectiveness and hinder decision
                             making. USAID currently does not require monitoring of key indicators
Although Some                needed to determine the level of targeting effectiveness for either
Improvements Are             emergency or development programs. Furthermore, its evaluations do not
                             systematically address targeting effectiveness. 33 Without adequate
Under Way                    guidance, monitoring, and evaluations, USAID cannot ensure targeting
                             effectiveness in its food assistance programs. USAID is taking some
                             steps to improve both guidance and monitoring. For example, USAID has
                             a contract with Tufts University to develop updated guidance, and the
                             agency is taking steps to improve monitoring by planning to track
                             indicators such as detailed age breakdowns that are key to better
                             understanding targeting effectiveness. However, these steps do not fully
                             address the weaknesses in USAID’s targeting process.


USAID Does Not Provide
Sufficient Guidance in the
Design Phase on Whether
and How to Target
Specialized Food Products,
Although the Agency Is
Starting to Make
Improvements



                             33
                               We selected 20 of USAID’s final evaluations for review. Our sample included final
                             evaluations for both emergency and development programs and provided coverage of all
                             years going back to 2009 and all geographic regions to which USAID provides food
                             assistance. For the purposes of this report, we refer to these final evaluations as
                             evaluations.




                             Page 20                                      GAO-12-862 International Food Assistance
USAID’s Guidance for              We found that USAID’s guidance for targeting is neither up-to-date nor
Targeting Is Neither Up-to-Date   complete for both emergency and development programs, which reduces
Nor Complete, Hindering           the ability of implementing partners to make informed decisions in the
Decision Making                   design phase. USAID currently provides its implementing partners with a
                                  range of guidance and tools. Of these, the Commodities Reference
                                  Guide 34 is USAID’s official standard reference for food assistance
                                  programs and is intended to be used by USAID and implementing partner
                                  staff in deciding how to plan, manage, control, evaluate, and use Title II-
                                  funded food products. It is available on USAID’s public website and
                                  provides information on available food products, including nutritional
                                  values, physical properties, and storage and handling guidelines. 35
                                  However, USAID has not updated the Commodities Reference Guide
                                  since 2006 and has not included guidance in the Commodities Reference
                                  Guide on all of the products currently used in USAID food assistance
                                  programs. The 2011 Food Aid Quality Review also noted that the
                                  Commodities Reference Guide and other USAID guidance relevant to
                                  targeting are neither up-to-date nor complete and recommended, for
                                  example, that USAID improve its guidance to enable implementing
                                  partners to better determine whether to use certain products for
                                  programs.

                                  We found that the lack of updated and complete guidance has hindered
                                  implementing partners’ ability to make better-informed targeting
                                  decisions. One participant at our roundtable, for example, told us that his
                                  organization was unable to find all of the products it was using for a
                                  program in the outdated Commodities Reference Guide. As a result, it
                                  was not able to use these products in its program. Furthermore, USAID
                                  has recently deployed some limited quantities of various new specialized
                                  products without providing official standard guidance on how to use them.
                                  We recommended in 2011 that USAID provide clear guidance on whether
                                  and how best to use new specialized food products, including guidance to
                                  its implementing partners on targeting strategies to ensure that the
                                  products reach their intended recipients. 36 USAID concurred with our


                                  34
                                       USAID, Commodities Reference Guide (Washington, D.C.: 2006).
                                  35
                                    USAID also provides other forms of guidance to its implementing partners, including a
                                  commodities price calculator, which is used to estimate the cost of food aid commodities.
                                  According to USAID officials, the calculator is updated quarterly and available on USAID’s
                                  public website.
                                  36
                                       GAO-11-491.




                                  Page 21                                         GAO-12-862 International Food Assistance
recommendation and is taking steps to develop new guidance, but has
deployed new specialized food products in the interim. USAID has
purchased relatively small quantities of new specialized food products
over the past 2 years, including those shown in table 2 below. For
example, USAID purchased just over $6.5 million worth of these products
in 2011, as compared with $502 million of traditional food products and
$42 million of traditional specialized food products purchased through
Title II emergency program funding.

Table 2: New Specialized Food Products Purchased with USAID Funding, Fiscal
                  a
Years 2010 to 2012

    Fiscal      Total cost of                                               Cost of      Metric
    year           purchase            Product type                       purchase        tons
                                                                   b
    2010           $1,965,484          Lipid nutritional supplement     $1,965,484          302
                                                                   b
    2011           $6,565,820          Lipid nutritional supplement     $1,998,920          315
                                       Ready-to-use therapeutic food    $4,566,900          990
                                       (RUTF)
    2012           $5,693,940          Ready-to-eat meal                  $660,000          110
                                       replacements
                                       Ready-to-eat meal                  $715,000          110
                                       replacements
                                       Ready-to-eat meal                  $649,000          110
                                       replacements
                                       Ready-to-use therapeutic food    $2,065,200          500
                                       (RUTF)
                                       CSB+                               $819,040        1,000
                                       CSB+                                $64,800           80
                                       CSB+                               $720,900          890
    Total        $14,225,244                                           $14,225,244        4,407
Source: GAO analysis of USAID documents.

a
As of August 22, 2012.

b
 These purchases were made with funding available through USAID’s International Food Relief
Partnership. This program enables USAID to award grant agreements to U.S. NGOs to produce and
stockpile shelf-stable, prepacked commodities for use in emergency food assistance programs.


In addition, USAID is planning to introduce nine new or reformulated
products in the final part of 2012 and 2013, including new RUTFs and
ready-to-use supplementary foods (RUSFs) (see app. IV). USAID has not
issued fully updated or complete guidance for all of these products.
However, it has issued some guidance on their use. Moreover, USAID
officials told us that they are providing the products only on a limited basis



Page 22                                                    GAO-12-862 International Food Assistance
                                 to organizations such as UNICEF that have experience using them in
                                 controlled environments, such as clinics, and have issued their own
                                 guidance on the use of these products.

USAID’s Guidance                 USAID guidance inadequately addresses key benefits and risks of using
Inadequately Addresses Key       specialized food products, according to USAID and implementing
Benefits and Risks That Inform   partners we spoke with during our field visits and our expert roundtable.
Decisions on Whether to Target   This inadequate guidance hinders decision making on whether to use
Specialized Food Products        these products. As discussed earlier, the benefit of specialized food
                                 products is that, while more costly, they are also more nutritious, or of
                                 higher quality, than traditional food products. However, USAID has not
                                 quantified or clearly defined the degree of benefit that specialized food
                                 products may provide. In 2011, we reported that in recent years,
                                 nutritionists have debated the appropriateness of using fortified and
                                 blended foods to prevent and treat malnutrition in young children 6 to 24
                                 months old, who have smaller stomachs, making it more difficult for them
                                 to eat enough of the product to obtain sufficient nutrients. 37 As a result,
                                 the benefits of some traditional specialized food products are not clear. In
                                 addition, limited information on new specialized products is available. As
                                 we previously reported, USAID and implementing partners do not know
                                 how well new specialized food products perform in promoting nutritional
                                 health indicators, such as weight gain and growth, particularly in a
                                 program setting, or how well they perform in comparison to traditional
                                 food products. 38 The efficacy of new specialized products, or the extent to
                                 which these products promote desired outcomes, is still being studied by
                                 USAID, WFP, nutritionists, and other researchers. As a result, while
                                 USAID is building knowledge about these products, it is not providing
                                 sufficient guidance on the benefits of specialized food products to
                                 implementing partners.

                                 USAID also lacks guidance on how to adequately address risks of using
                                 specialized food products, according to implementing partners we spoke
                                 with during our field visits and our expert roundtable. A key targeting risk
                                 is that various factors implementing partners face in-country may reduce
                                 targeting effectiveness to such a degree that the additional cost of using
                                 specialized food products outweighs the potential benefit. This trade-off
                                 becomes more significant with the higher cost of new specialized food


                                 37
                                      GAO-11-491.
                                 38
                                      GAO-11-491.




                                 Page 23                                  GAO-12-862 International Food Assistance
                             products, for which the cost per ration can be more than triple the cost of
                             traditional food products. Poor data quality, host government policies, and
                             sharing may reduce implementing partners’ ability to identify and reach
                             recipients, but USAID’s existing guidance does not adequately inform
                             decisions on whether the reduction in targeting effectiveness is of such a
                             degree that the use of specialized food products is no longer justified. 39

USAID Is Taking Steps to     USAID is taking some steps to enhance guidance on whether and how to
Improve Targeting Guidance   use new specialized food products, but fully up-to-date and complete
                             guidance will not be completed until at least late 2013. In response to our
                             2011 recommendation on improved targeting guidance, USAID stated in
                             its official agency response in July 2011 that it would work to address our
                             recommendations through the second Food Aid Quality Review study
                             now under way with Tufts University. This work is expected to include
                             cost-effectiveness analyses on new specialized food products, adding
                             information important to help determine whether and how to use them. In
                             addition, according to USAID documents and officials, USAID is updating
                             and improving the Commodities Reference Guide and other guidance
                             related to targeting, including for new specialized food products.
                             However, this work will not be completed until September 2013 at the
                             earliest, according to USAID officials. USAID also plans to introduce other
                             guidance before September 2013, including updated fact sheets for
                             individual products. According to USAID officials, this interim guidance
                             will be released on an as-needed basis, beginning in October 2012. In
                             addition, USAID has existing guidance that helps inform implementing
                             partners’ decision making, including its Annual Program Statement (APS),
                             Food for Peace Information Bulletins, and some Food and Nutrition
                             Technical Assistance (FANTA) guidance.




                             39
                               We previously reported that USAID officials acknowledged that more research is needed
                             to better understand sharing of CSB, so that the agency can provide partners with more
                             guidance on this issue. See GAO-11-491.




                             Page 24                                       GAO-12-862 International Food Assistance
Weaknesses in USAID’s
Monitoring and Evaluation
Efforts Related to
Targeting Could Limit
Targeting Effectiveness
and Hinder Decision
Making, but the Agency Is
Starting to Take Steps to
Improve Monitoring

USAID Does Not Monitor Key         USAID does not require monitoring of key indicators needed to determine
Indicators of Targeting            the level of targeting effectiveness, although it is beginning to make
Effectiveness, but Is Initiating   improvements in this area. 40 Information on indicators that are consistent
Improvements in This Area          with the goals of the program is critical to determining how effectively a
                                   program targets food assistance. 41 Targeting effectiveness can be
                                   measured by the extent to which food assistance reaches correctly


                                   40
                                     In 2009 we reported on the overall monitoring and evaluation efforts of USAID’s Office of
                                   Food for Peace development programs. At that time, we acknowledged that USAID
                                   monitors a wide range of indicators related to assessing the extent to which development
                                   programs are achieving their goals. For example, we noted that USAID has monitored
                                   indicators on height-and-weight for age, maternal and child health practices, and
                                   household food security. We also reported that USAID’s monitoring and evaluation
                                   practices for development programs were consistent, to varying degrees, with good
                                   practices set by the American Evaluation Association. See GAO, International Food
                                   Assistance: USAID Is Taking Actions to Improve Monitoring and Evaluation of
                                   Nonemergency Food Aid, but Weaknesses in Planning Could Impede Efforts, GAO-09-
                                   980 (Washington, D.C.: Sept. 28, 2009).
                                   41
                                     In its efforts to monitor in-kind food assistance, USAID collects data on both recipients
                                   and beneficiaries. Recipients and beneficiaries are related but different, and the
                                   differences between them are important to understanding the extent to which USAID can
                                   measure targeting effectiveness. According to USAID definitions, recipients are individuals
                                   who receive food assistance rations, while beneficiaries are individuals who benefit from
                                   food assistance rations. Specifically, beneficiaries include all recipients and any other
                                   individuals who may benefit from the food assistance. For example, in a food-for-work
                                   program, only one person—the recipient—actually receives targeted food assistance, but
                                   other members of the recipient’s family or community may benefit from that individual’s
                                   participation in the program, making them all beneficiaries. Therefore, while beneficiary
                                   data are useful to USAID in its efforts to monitor overall program effectiveness, they are of
                                   limited use in measuring targeting effectiveness. Recipient data are better suited to that
                                   purpose. As noted above, USAID collects a wide range of beneficiary data that are useful
                                   for many program purposes. For the purposes of this report, we refer to USAID indicators
                                   that are specifically about recipients and are directly related to measuring targeting and
                                   targeting effectiveness, such as the degree of targeting error.




                                   Page 25                                           GAO-12-862 International Food Assistance
targeted recipients—that is, the percentage of intended recipients that
actually receive food assistance in the intended amounts (see fig. 4). 42
Effectively targeted programs reduce the magnitude of these errors.
USAID guidance states that monitoring should be used to measure
progress toward planned program results. 43 Additionally, FANTA
guidance states that monitoring efforts should allow USAID and its
implementing partners to assess the extent to which targeted recipients
received intended food assistance. 44 According to a USAID official,
USAID field staff do consider targeting during their routine monitoring of
food assistance programs. In addition, USAID requires its implementing
partners to collect some data, such as the number of intended recipients
for all food assistance programs, and requires other indicators to be
monitored depending on the type of program—emergency or
development. However, USAID does not currently require sufficient
monitoring of key indicators consistent with program goals that would
allow its implementing partners to report on levels of targeting
effectiveness. For example, it cannot determine the effectiveness of a
program targeting children under 2 because it does not monitor the age of
the actual recipients in either emergency or development programs.

USAID monitoring is inadequate for both emergency and development
programs because it does not monitor key data on recipients that would
allow USAID to measure whether food assistance is actually reaching the
intended recipients. Specifically, for emergency programs, USAID collects
the total number of intended recipients from its implementing partners, but
does not collect the total number of actual recipients or indicators such as
breakdowns of age and gender for intended or actual recipients.
According to USAID, these types of more specific indicators may not be
as important for some emergency programs that focus solely on rapid
lifesaving. However, these indicators are important for emergency
programs that do have specific targeting goals, such as reaching severely



42
  As noted above, for the purposes of this report we define targeting effectiveness as the
degree to which USAID and its implementing partners are able to (1) accurately assess
needs and identify recipients using appropriate eligibility criteria, and (2) ensure that food
assistance provided reaches and is consumed by the targeted recipients as defined by the
eligibility criteria.
43
     USAID Food for Peace Information Bulletin 09-06 (Washington, D.C.: July 2009).
44
 FANTA, Food Security Indicators Framework for Use in the Monitoring and Evaluation of
Food Aid Programs (Washington, D.C.: Jan. 1999).




Page 26                                           GAO-12-862 International Food Assistance
malnourished children. For development programs, USAID collects both
the total number of intended and actual recipients from its implementing
partners, but as with its monitoring of emergency programs, does not
collect data on key indicators such as breakdowns of age and gender.
Without monitoring full sets of data for both intended and actual
recipients, including key indicators consistent with program goals, USAID
has limited ability to learn about the magnitude of targeting errors or the
degree to which its implementing partners are achieving their program
goals.

Figure 4: Targeting Effectiveness Is Measured by the Magnitude of Targeting Error




According to USAID and implementing partner officials, it is particularly
complex to gather monitoring information on indicators related to targeting
effectiveness about actual recipients, due in part to cost and data quality
issues. These challenges are heightened for programs using new
specialized food products, which are designed to provide nutritional
benefits to very specific vulnerable groups, such as malnourished children
or pregnant or lactating women. Identifying and selecting recipients for
such programs requires using indicators that are more complex than
those used for programs designed for the general population. Some of
the indicators, such as nutritional status, are costly to measure and prone
to errors. For example, implementing partners we spoke with during our
fieldwork in Guatemala and Sri Lanka told us that they have difficulty in
collecting data for some indicators in other, non-USAID programs using



Page 27                                     GAO-12-862 International Food Assistance
                                 new specialized food products due to resource constraints, lack of
                                 technical capacity by some local NGO staff, or problems with unreliable
                                 data.

                                 USAID is making improvements in monitoring of some nutrition-focused
                                 development programs, for example, by planning to require implementing
                                 partners to collect data on the age of young children, a common criterion
                                 for new specialized food products. However, as mentioned earlier,
                                 indicators key to measuring targeting effectiveness are not consistently
                                 monitored across all USAID food assistance programs. According to the
                                 Standards of Internal Control in the Federal Government, program
                                 managers need to compare actual performance to planned results and
                                 analyze significant differences. 45 Without reporting targeting
                                 effectiveness, USAID cannot compare actual targeting effectiveness to
                                 planned results. As a result, USAID may not be able to make fully
                                 informed targeting decisions for both ongoing and future food assistance
                                 programs. For example, USAID may not be able to track the performance
                                 of food assistance programs’ targeting over time or across programs and
                                 may therefore miss opportunities to identify improvements to the targeting
                                 effectiveness of these programs.

USAID Evaluations Do Not         USAID’s evaluations of its food assistance programs do not
Systematically Address           systematically discuss targeting effectiveness. As a result, the agency
Targeting Effectiveness, Which   may be missing opportunities to learn important lessons about targeting
May Hinder Decision Making       effectiveness and apply them to current and future programs. 46
                                 Specifically, the 17 development and 3 emergency USAID evaluations
                                 going back to 2009 that we examined did not systematically discuss
                                 targeting in general and targeting effectiveness in particular. These
                                 evaluations addressed targeting effectiveness to varying degrees—
                                 ranging from an entire section on targeting that included a discussion of a
                                 targeting effectiveness indicator, to no mention of targeting at all. The


                                 45
                                  GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1
                                 (Washington, D.C.: Nov. 1999).
                                 46
                                   USAID’s targeting evaluations are not systematic, in part, because they are not routinely
                                 conducted. USAID requires evaluations to be completed for all of its development
                                 programs but does not require them for its emergency programs. Instead, emergency
                                 programs are required to submit Annual Results Reports, which contain many of the same
                                 types of information as evaluations, but for which no baseline assessment is conducted.
                                 According to USAID officials, the difference between these requirements is due to the fact
                                 that emergency programs are by nature typically in places where there may not be the
                                 time or resources available to do a proper baseline assessment.




                                 Page 28                                         GAO-12-862 International Food Assistance
evaluations that discussed targeting effectiveness included information on
the magnitude of inclusion or exclusion errors and the level of community
satisfaction with targeting. For example, USAID’s evaluation of an
emergency program in Zimbabwe discussed inclusion and exclusion
error, a key measure of targeting effectiveness, within a section focused
exclusively on targeting. Similarly, USAID’s evaluation of an emergency
program in Ethiopia mentioned the level of community satisfaction with
targeting: almost 90 percent of the respondents to a survey of community
members were generally satisfied with the fairness of the program’s
targeting. Some evaluations, however, contained only a brief mention of
targeting in general, with no mention of targeting effectiveness. For
example, an evaluation of a development program in Bolivia mentioned
targeting and contained tables showing monitoring indicators for the
baseline compared against the final evaluation, but did not explain how
the recipients were originally targeted or how the final evaluation results
were verified. Other evaluations, such as a 2011 evaluation of a
development program in Guatemala, did not discuss targeting or targeting
effectiveness at all.

USAID policy and guidance call on USAID and its implementing partners
to use evaluations as opportunities to learn about past programs to inform
decision making for new programs. USAID policy calls for evaluations to
“systematically generate knowledge about the magnitude and
determinants of program performance, permitting those who design and
implement programs…to refine designs and introduce improvements to
future efforts.” 47 USAID guidance states that evaluations should assess
the extent to which the program is meeting its stated objectives. 48 For
example, if a program is providing food assistance to a vulnerable
subpopulation, effective targeting is an important program objective.
However, USAID’s evaluations of its food assistance programs do not
systematically address targeting effectiveness, and as a result, the
agency’s ability to assess the extent to which a program is meeting its
stated objectives is hindered, and it may miss opportunities for learning
lessons that could be useful when designing new programs or improving
ongoing ones.




47
     USAID Evaluation Policy (Washington, D.C.: Jan. 2011).
48
     USAID Food for Peace Information Bulletin 09-07 (Washington, D.C.: July 2009).




Page 29                                          GAO-12-862 International Food Assistance
                      The use of specialized food products, especially some of those most
Conclusions           recently introduced, offers the promise of providing better nutrition to the
                      most vulnerable. However, the increased cost of these new specialized
                      products means that their use may likely reduce the overall number of
                      recipients receiving food assistance under a fixed program budget—a
                      quality-quantity trade-off. Choosing more costly specialized food products
                      over less costly traditional food products may be the optimal policy option
                      in certain circumstances, including areas with a high percentage of
                      children suffering from hunger and malnutrition. However, the
                      achievement of this policy goal requires effective targeting of food
                      assistance so that food ultimately reaches the intended recipients. If food
                      assistance is not targeted effectively, the program may fail to achieve its
                      nutritional goals while simultaneously feeding fewer people.

                      USAID recognizes the need to update and broaden its guidance on the
                      use of specialized food products, but this revision will not be completed
                      until late 2013 at the earliest. Issuance of improved interim guidance
                      related to food assistance targeting will help USAID and its implementing
                      partners make better-informed decisions about whether and how to
                      deploy the range of food products that are available, particularly new
                      specialized products. Moreover, the monitoring and reporting of key
                      indicators consistent with program objectives are necessary to ensure
                      that specialized food products are, in fact, reaching intended recipients.
                      Improved targeting—which takes an approach that is appropriate to the
                      circumstances and conditions—would better ensure that valuable food
                      resources are put to their most optimal use and that vulnerable groups
                      receive the most effective assistance available to them.


                      To improve USAID’s targeting of specialized food products to vulnerable
Recommendations for   groups, such as children under 2 and pregnant women, we recommend
Executive Action      that the Administrator of USAID take the following two actions:

                      •   As USAID continues to purchase new specialized food products
                          without updated guidance, it should issue, as appropriate, improved
                          interim guidance to assist implementing partners in deciding whether
                          and how to target specialized food products.

                      •   When USAID chooses to provide specialized food products to
                          targeted vulnerable groups, it should establish and report program-
                          specific indicators related to each targeted group to allow USAID to
                          assess its programs’ effectiveness in reaching these groups.




                      Page 30                                  GAO-12-862 International Food Assistance
                     We provided a draft of this report to USAID, USDA, and State for
Agency Comments      comment. In its written comments, reproduced in appendix V, USAID
and Our Evaluation   concurred with our recommendations. USDA and State provided no
                     written comments. We also provided relevant excerpts of this report to
                     WFP for comment. USAID, USDA, and WFP provided technical
                     comments that were incorporated, as appropriate.

                     USAID strongly agreed with our recommendation on improving interim
                     guidance to help implementing partners decide whether and how to target
                     specialized food products. USAID provided examples of recent and
                     ongoing efforts that are expected to contribute to improved guidance on
                     new specialized food products. For example, USAID expects to publish
                     on its website updated fact sheets on food products provided in its food
                     assistance programs and will prioritize issuing those relating to
                     specialized food products. Although USAID noted that some existing
                     guidance is available for three of the new specialized food products it is
                     introducing, such as CSB+, the agency also acknowledged that it expects
                     to issue its own guidance on all new products and update the
                     Commodities Reference Guide.

                     USAID agreed with our recommendation on establishing and reporting
                     program-specific indicators to allow USAID to assess its programs’
                     effectiveness in reaching targeted groups. USAID agreed with us on the
                     need to develop new, program-specific indicators to assess the nutrition
                     goals of new specialized food products for its Title II emergency programs
                     and indicated that it would engage with partners on demonstrating impact
                     and results. To that end, USAID indicated that it is in the process of
                     recruiting a nutritionist to ensure that products used match their intended
                     purpose and high-value specialized products are properly targeted.


                     We are sending copies of this report to appropriate congressional
                     committees, the Administrator of USAID, the Secretaries of Agriculture
                     and State, and relevant agency heads. The report is also available at no
                     charge on the GAO website at http://www.gao.gov.




                     Page 31                                 GAO-12-862 International Food Assistance
If you or your staff have any questions about this report, please contact
me at (202) 512-9601 or melitot@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 major contributions to this report
are listed in appendix VI.




Thomas Melito
Director, International Affairs and Trade




Page 32                                     GAO-12-862 International Food Assistance
Appendix I: Objectives, Scope, and
              Appendix I: Objectives, Scope, and
              Methodology



Methodology

              Our objectives were to (1) describe in-country factors that the U.S.
              Agency for International Development (USAID) and its implementing
              partners face in targeting vulnerable groups, and (2) examine the extent
              to which USAID’s targeting process supports effective targeting.

              To address these objectives, we met with officials at USAID and its
              implementing partners, including the World Food Program (WFP) and
              nongovernmental organizations (NGOs). In addition, we met with officials
              at the U.S. Department of Agriculture (USDA) and the U.S. Department of
              State. We also spoke with academics, experts, and practitioners
              associated with research institutes, universities, and NGOs. We
              examined USAID program documents, including guidance and tools,
              related to food assistance targeting processes. Furthermore, we
              conducted fieldwork in four countries—Ethiopia, Guatemala, Sri Lanka,
              and Zimbabwe—and met with officials from U.S. missions, implementing
              partners, and relevant host government agencies. We also convened a
              roundtable of 10 practitioners and experts—including representatives
              from implementing partners such as NGOs and WFP, academia, and
              research organizations—to discuss in-country factors that affect the ability
              of USAID and its partners to target vulnerable groups, as well as the
              guidance and monitoring and evaluation tools that USAID and its
              implementing partners use to target food assistance activities (see app. II
              for the list of participating organizations in our roundtable).

              To provide context and background, we analyzed data from USAID and
              WFP to identify trends in U.S. funding for international food assistance
              and procurement data on the use of traditional and specialized food
              products. As these data were for background purposes, we did not
              assess their reliability. In addition, we reviewed data that we reported on
              in 2011 concerning cost information for specialized food products relative
              to traditional food products. We then reviewed similar data to obtain
              updates about the costs and relative length of feeding for these products
              and interviewed USAID, WFP, and Tufts University about the reliability of
              the updated data. We used this information to create an analysis
              comparing the amount of time various commodities could be provided for
              the cost of other commodities. We found that these updated data were
              sufficiently reliable for the purposes of this report, in that they
              demonstrated the order of magnitude of the relative cost of different types
              of food products used in food assistance programs. Although commodity
              prices may fluctuate and suggested feeding lengths may vary by program
              or individual recipient, the data were sufficiently reliable to demonstrate
              that there are large differences in the cost of feeding, depending on the
              products used. In addition, we reviewed various literature on the targeting


              Page 33                                 GAO-12-862 International Food Assistance
Appendix I: Objectives, Scope, and
Methodology




process, as well as USAID guidance and tools to facilitate targeting
decisions.

To describe in-country factors USAID and its implementing partners face
in targeting vulnerable groups, we reviewed literature on targeting and
new specialized food products issued by academics, research institutes,
implementing partners, USAID contractors, UN organizations involved in
humanitarian assistance, and independent international organizations;
spoke with in-country officials such as relevant host government officials
and implementing partners; and obtained the input of our roundtable
participants.

To examine the extent to which USAID’s targeting process supports
effective targeting, we analyzed responses and information from the
general methodologies listed above. To examine the extent to which
USAID provides guidance to its implementing partners on targeting, we
reviewed existing USAID guidance for targeting and USAID’s contract
with Tufts University and spoke with USAID and Tufts University officials
about the scope of work for this contract, including the section on
updating guidance. We reviewed information from USAID about the
product types, costs, and tonnage of new specialized food products
purchased since fiscal year 2010. We interviewed USAID about the
sources of this information and also compared it to data about these
products from other sources of information. These included the requests
for applications that USAID provides to its implementing partners for new
specialized food products, including ready-to-use therapeutic foods and
lipid nutritional supplements; USAID’s commodity price calculator; and
relevant legislation authorizing the use of these products. We found that
the data were sufficiently reliable for the purposes of this report, in that
they showed the magnitude and trends of purchases of new specialized
food products with USAID funding in recent years. To examine the extent
to which USAID monitors and evaluates targeting effectiveness and other
related information, we analyzed monitoring information provided to us by
USAID about numbers of planned recipients and actual beneficiaries for
Title II food assistance programs since 2009. We reviewed current USAID
policies and procedures on monitoring and evaluation. We also reviewed
guidance provided by Food and Nutrition Technical Assistance (FANTA),
under a cooperative agreement with USAID. This guidance covers
aspects of monitoring and evaluation, such as the performance measures
to be used for food assistance programs. Through searches of USAID’s
website and discussions with cognizant officials, we identified a total of 30
final evaluations of USAID programs going back to 2009. Final
evaluations are conducted at the end of a program. However, USAID


Page 34                                  GAO-12-862 International Food Assistance
Appendix I: Objectives, Scope, and
Methodology




could not assure us that it had provided all of the evaluations conducted
for its development programs, and also noted that it does not require
evaluations of its emergency programs. We selected 20 of these final
evaluations for review based on the following criteria: we included all 3
final evaluations for the single-year programs, and selected 17 final
evaluations for the multi-year programs to ensure that we had coverage
by year and geographic region. We reviewed these evaluations to
examine the extent to which they had addressed targeting issues. Finally,
we reviewed evaluations that WFP conducted of those of its programs
that were implemented with USAID funding.

We conducted this performance audit from October 2011 to September
2012 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 35                                GAO-12-862 International Food Assistance
Appendix II: Organizations That Participated
               Appendix II: Organizations That Participated in
               GAO Roundtable



in GAO Roundtable

               The following organizations participated in our roundtable of experts and
               practitioners held in May 2012:

               •   CARE

               •   Catholic Relief Services

               •   Cornell University

               •   FHI 360

               •   International Food Policy Research Institute

               •   Mercy Corps

               •   Save the Children

               •   World Food Program

               •   World Vision




               Page 36                                           GAO-12-862 International Food Assistance
Appendix III: Cost Differences between
                                          Appendix III: Cost Differences between
                                          Traditional Food Products and Specialized
                                          Food Products


Traditional Food Products and Specialized
Food Products
                                          Table 3 provides a comparison of cost differences between traditional and
                                          selected specialized food products, which include both traditional
                                          specialized food products and new specialized food products. For
                                          example, to feed a child 6 to 23 months old, a traditional grain-based
                                          representative ration costs $0.02 to $0.06 per day, a CSB+ ration, $0.10
                                          to $0.21 per day, and a ready-to-use therapeutic food (RUTF) ration,
                                          $0.42 to $0.46 per day.

Table 3: Relative Costs of Traditional and Selected Specialized Food Products (in U.S. dollars)

                                                                                                                                    Overall cost for
                                                                                                              Cost per ration     suggested length
        a                                                                                                                                          b
Product                              Description                                                                    for child                of use
Traditional food product
Grain-based representative ration    Grain, pulse, CSB, and vegetable oil                                          $0.02 - 0.06       90 - 120 days
                                                                                                                                      $2.07 - $7.45
Traditional specialized food product
CSB fortified blended food           Processed cornmeal, soy flour, soybean oil,                                  $0.09 - $0.18       90 - 120 days
                                     vitamins, and minerals                                                                          $8.41 - $22.07
New specialized food products
CSB+ (WFP Supercereal)               WFP formulation for children over 6 months old                               $0.10 - $0.21       90 - 120 days
                                                                                                                                     $9.22 - $25.58
Ready-to-use therapeutic food        Nutritionally dense food for community-based                                 $0.42 - $0.46        42 - 90 days
(RUTF)                               treatment of severe acute malnutrition                                                         $17.77 - $41.40
Lipid nutritional supplement (LNS)   Supplementary complementary food for children 6                               $0.10 - 0.13     180 – 545 days
                                     to 24 months old to prevent stunting                                                           $17.06 - $71.90
Emergency food bars                  Meal replacement used during onset of                                        $0.32 - $0.33          3 - 15 days
(A-28 rice & A-29 wheat)             emergencies                                                                                       $0.97 - $5.00
Emergency food paste (A-20)          Meal replacement used during onset of                                               $0.29           3 - 15 days
                                     emergencies                                                                                       $0.86 - $4.28
                                          Source: GAO analysis based on various studies and USAID and WFP data.


                                          Note: Costs per ration are for a child 6 to 23 months old, in 2012.

                                          a
                                           The products listed in this table are used for different purposes. This table does not assess the
                                          relative effectiveness of each product. We note that USAID does not provide RUTF as part of a
                                          general food distribution ration.

                                          b
                                           The suggested lengths of use in this table are fairly wide ranges of time (for example, 180-545 days)
                                          that reflect uncertainty, in part because limited data from actual application are currently available.
                                          The suggested lengths of use could change as more data become available for more precise
                                          estimates.




                                          Page 37                                                           GAO-12-862 International Food Assistance
                                             Appendix III: Cost Differences between
                                             Traditional Food Products and Specialized
                                             Food Products




                                             The cost per ration is one aspect of the relative cost of food assistance
                                             products; the length of time a product is used in a food assistance
                                             program also affects its overall relative cost. Some experts suggest that,
                                             although an individual daily ration of a new specialized food product may
                                             be relatively expensive, it may ultimately be less costly overall because it
                                             may be fed for a shorter period of time based on its suggested length of
                                             use. However, we found that some new specialized food products with a
                                             relatively shorter suggested length of use may still cost relatively more
                                             overall. For example, as shown in the table, although an RUTF’s
                                             suggested length of use (42 to 90 days) for a child 6 to 23 months old is
                                             shorter than that of a traditional grain-based ration (90 to 120 days), the
                                             RUTF may still cost more overall ($17.77 to $41.40) than the grain-based
                                             ration ($2.07 to $7.45). Despite their higher overall costs, RUTFs may be
                                             the optimal choice in certain circumstances, such as for emergencies in
                                             areas with a high percentage of children suffering from severe acute
                                             malnutrition.

                                             Table 4 illustrates the number of days that traditional food products
                                             (grain-based rations) or traditional specialized food products (CSB) can
                                             be provided for the cost of providing a new specialized food product
                                             based on its suggested length of use. For example, for the cost of
                                             providing a nutritional supplementary paste fortified ration for 180 to 545
                                             days, a grain-based ration could be provided for 741 to 3,121 days and a
                                             CSB ration could be provided for 183 to 769 days.

Table 4: Number of Days Grain-Based or Corn Soy Blend Ration Could Be Provided for the Cost of Providing Selected New
Specialized Food Products

                                                       Suggested length of use                 Number of days a grain-             Number of days a CSB
                                                          of a specialized food                  based ration could be                   ration could be
                                                                        product                 provided for the same              provided for the same
                                  a                                           b                                      c                                  c
New specialized food product                                 (number of days)                                    cost                               cost
Nutritional supplementary paste                                               180 - 545                              741 - 3,121                183 - 769
Ready-to-use therapeutic food (spread)                                           42 - 90                             772 - 1,797                190 - 443
A-20 paste (ready-to-eat meal replacement)                                         3 - 15                               37 - 186                   9 - 46
A-29 wheat bar (ready-to-eat meal replacement)                                     3 - 15                               42 - 211                  10 - 52
A-28 rice bar (ready-to-eat meal replacement)                                       3 -15                               43 - 217                  11 - 53
CSB+ (WFP Supercereal)                                                          90 - 120                             400 - 1,110                 99 - 274
                                             Source: GAO analysis based on various studies and USAID and WFP data.

                                             a
                                              The products listed in this table are used for different purposes. This table does not assess which
                                             products are more effective. We note that USAID does not provide RUTF as part of a general food
                                             distribution ration.




                                             Page 38                                                           GAO-12-862 International Food Assistance
Appendix III: Cost Differences between
Traditional Food Products and Specialized
Food Products




b
 The suggested lengths of use in this table are fairly wide ranges of time (for example, 180-545 days)
that reflect uncertainty, in part because limited data from actual application are currently available.
The suggested lengths of use could change as more data become available for more precise
estimates.
c
Cost of a grain-based ration for a child 6 months old.




Page 39                                                  GAO-12-862 International Food Assistance
Appendix IV: USAID New Specialized Food
             Appendix IV: USAID New Specialized Food
             Products Pending Introduction



Products Pending Introduction

             USAID has thus far deployed a relatively limited quantity of new
             specialized food products but plans to introduce the following products to
             address various needs:

             •   Ready-to-use supplementary food (RUSF) - Nutritionally dense and
                 highly fortified for management of moderate acute malnutrition.

             •   Fortified vegetable oil - Fortified with vitamins A and D.

             •   Fortified milled cereals - Reformulated and standardized to improve
                 general rations.

             •   CSB++ (WFP Supercereal+) - Formulated by WFP for children 6 to 24
                 months of age.

             •   CSB-14 – Reformulated CSB to be prepared with vegetable oil.




             Page 40                                   GAO-12-862 International Food Assistance
Appendix V: Comments from the U.S. Agency
             Appendix V: Comments from the U.S. Agency
             for International Development



for International Development




             Page 41                                     GAO-12-862 International Food Assistance
Appendix V: Comments from the U.S. Agency
for International Development




Page 42                                     GAO-12-862 International Food Assistance
Appendix V: Comments from the U.S. Agency
for International Development




Page 43                                     GAO-12-862 International Food Assistance
Appendix V: Comments from the U.S. Agency
for International Development




Page 44                                     GAO-12-862 International Food Assistance
Appendix VI: GAO Contact and Staff
                       Appendix VI: GAO Contact and Staff
                       Acknowledgments



Acknowledgments

                       Thomas Melito, (202) 512-9601 or melitot@gao.gov
GAO Contact
Staff Acknowledgment   In addition to the person named above, Joy Labez (Assistant Director),
                       Carol Bray, Marc Castellano, Ming Chen, Anna Chung, Debbie Chung,
                       Martin De Alteriis, Mark Dowling, Etana Finkler, David Schneider, and
                       Jeremy Sebest made key contributions to this report. Sada Aksartova,
                       Vida Awumey, Teresa Heger, Erin McLaughlin, Michael Maslowski, Julia
                       Ann Roberts, Barbara Shields, and Phillip Thomas also contributed to this
                       report.




                       Page 45                                GAO-12-862 International Food Assistance
Related GAO Products
             Related GAO Products




             World Food Program: Stronger Controls Needed in High-Risk Areas.
             GAO-12-790. Washington, D.C.: September 13, 2012.

             Farm Bill: Issues to Consider for Reauthorization. GAO-12-338SP.
             Washington, D.C.: April 24, 2012.

             International Food Assistance: Funding Development Projects through
             the Purchase, Shipment, and Sale of U.S. Commodities Is Inefficient and
             Can Cause Adverse Market Impacts. GAO-11-636. Washington, D.C.:
             June 23, 2011.

             International Food Assistance: Better Nutrition and Quality Control Can
             Further Improve U.S. Food Aid. GAO-11-491. Washington, D.C.: May 12,
             2011.

             International School Feeding: USDA’s Oversight of the McGovern-Dole
             Food for Education Program Needs Improvement. GAO-11-544.
             Washington, D.C.: May 19, 2011.

             International Food Assistance: A U.S. Governmentwide Strategy Could
             Accelerate Progress toward Global Food Security. GAO-10-212T.
             Washington, D.C.: October 29, 2009.

             International Food Assistance: Key Issues for Congressional Oversight.
             GAO-09-977SP. Washington, D.C.: September 30, 2009.

             International Food Assistance: USAID Is Taking Actions to Improve
             Monitoring and Evaluation of Nonemergency Food Aid, but Weaknesses
             in Planning Could Impede Efforts. GAO-09-980. Washington, D.C.:
             September 28, 2009.

             International Food Assistance: Local and Regional Procurement Provides
             Opportunities to Enhance U.S. Food Aid, but Challenges May Constrain
             Its Implementation. GAO-09-757T. Washington, D.C.: June 4, 2009.

             International Food Assistance: Local and Regional Procurement Can
             Enhance the Efficiency of U.S. Food Aid, but Challenges May Constrain
             Its Implementation. GAO-09-570. Washington, D.C.: May 29, 2009.

             International Food Security: Insufficient Efforts by Host Governments and
             Donors Threaten Progress to Halve Hunger in Sub-Saharan Africa by
             2015. GAO-08-680. Washington, D.C.: May 29, 2008.



             Page 46                                GAO-12-862 International Food Assistance
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           Somalia: Several Challenges Limit U.S. International Stabilization,
           Humanitarian, and Development Efforts. GAO-08-351. Washington, D.C.:
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           Foreign Assistance: Various Challenges Limit the Efficiency and
           Effectiveness of U.S. Food Aid. GAO-07-905T. Washington, D.C.: May
           24, 2007.

           Foreign Assistance: Various Challenges Impede the Efficiency and
           Effectiveness of U.S. Food Aid. GAO-07-560. Washington, D.C.: April 13,
           2007.

           Foreign Assistance: U.S. Agencies Face Challenges to Improving the
           Efficiency and Effectiveness of Food Aid. GAO-07-616T. Washington,
           D.C.: March 21, 2007.




(320880)
           Page 47                               GAO-12-862 International Food Assistance
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