GAO-23-105579, COVID-19: Usaid Plans to Share Lessons Learned from Efforts to Meet Global Vaccination Goal

Report — GAO-23-105579, COVID-19: Usaid Plans to Share Lessons Learned from Efforts to Meet Global Vaccination Goal, dated 2023-07-05, issued by Government Accountability Office.

Full text

COVID-19
USAID Plans to Share
Lessons Learned from
Efforts to Meet Global
Vaccination Goal

Report to Congressional Addressees
September 2023

GAO-23-105579

United States Government Accountability Office

 United States Government Accountability Office

Highlights of GAO-23-105579, a report to
congressional addressees

September 2023
COVID-19
USAID Plans to Share Lessons Learned from Efforts
to Meet Global Vaccination Goal
What GAO Found
The U.S. Agency for International Development (USAID) supports COVID-19
vaccine country readiness and delivery abroad by assisting a country’s capacity
to receive and administer vaccines. As of March 2023, USAID obligated an
estimated $904 million to support its COVID-19 country readiness and delivery
efforts in 125 countries. USAID’s obligations for these efforts covered eight areas
of technical assistance, including promoting demand for vaccination and
supporting supply chain logistics.
USAID, together with other U.S. agencies, host governments and other entities,
helped vaccinate an average of 45 percent of the population across assisted
countries as of July 2023. This average was in comparison to the global goal of
70 percent vaccination in each country. Close to two-thirds of the assisted
countries had vaccination rates below 50 percent, and most of those rates have
leveled off. Regional vaccination rates for countries that received USAID
assistance ranged from an average of 28 to 63 percent (see figure). USAID
stated that it could not measure its direct contribution to countries’ vaccination
progress because, among other things, the agency is only one of many entities
involved in these efforts.
Average Fully Vaccinated Rate by Region for Countries Assisted by the U.S. Agency for
International Development (USAID) as of July 5, 2023

Note: Vaccination rates reflect the efforts of USAID and other entities in assisted countries. USAID
officials, citing World Health Organization guidance, defined “fully vaccinated” as a complete primary
series, which may be one or two doses depending on the vaccine manufacturer. USAID assisted 125
countries; no vaccination data existed for two small USAID-assisted countries in Asia. The most
recent vaccination rate data for most countries are prior to July 2023.
USAID faced demand, supply, and other challenges in providing COVID-19
vaccine country readiness and delivery assistance. U.S. agency officials in
assisted countries reported that demand issues have overtaken supply issues as
the greatest challenge to these efforts. Demand issues included, for example,
vaccine hesitancy and barriers associated with people getting to vaccine sites.
As vaccine demand diminished, USAID and other partners shifted priorities to
vaccinating vulnerable groups and incorporating activities into countries’ primary
healthcare systems on the way to reaching the global 70 percent vaccination
goal. USAID initiated several efforts to learn from these challenges, and has
plans to disseminate the lessons learned, in accordance with agency guidance.
View GAO-23-105579. For more information,
contact Latesha Love-Grayer at (202) 512-
4409 or LoveGrayerL@gao.gov.
Why GAO Did This Study
To attain high population immunity
from COVID-19 during the pandemic,
the U.S. pledged to substantially
contribute toward a 70 percent
vaccination goal of the world’s
population, initially by the end of 2022.
USAID has partnered with other U.S.
agencies, multilateral organizations,
and donor countries on country
readiness and delivery efforts to
significantly increase assistance to
countries around the world to meet the
vaccination goal.
The CARES Act includes a provision
for GAO to monitor the federal
government’s response to the COVID-
19 pandemic. This report examines (1)
the assistance USAID has provided to
support COVID-19 vaccine country
readiness and delivery abroad, (2)
progress USAID has made in its efforts
to support COVID-19 vaccine country
readiness and delivery abroad, and (3)
any challenges USAID has faced and
how it has addressed them.
GAO reviewed laws, funding, and
guidance documents from USAID, the
Department of State, the Centers for
Disease Control and Prevention, and
the World Health Organization. GAO
analyzed publicly available data to
obtain global vaccination rates. GAO
also interviewed USAID officials in
Washington, D.C., and USAID officials
and other local stakeholders in three
countries: Guatemala, Malawi, and
South Africa. GAO selected these
countries based on factors such as the
amount of estimated country readiness
and delivery assistance USAID
obligated for each country.

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
Letter

1
Background
4
USAID Provided More Than $900 Million for CRD Efforts in 125
Countries
6
USAID Contributed to Vaccination Assistance That Fell Short of
the Global Goal, and the Agency Faced Difficulties Measuring
Its Progress
11
USAID Shifted Its Priorities in Response to CRD Challenges, and
Plans to Disseminate Its Lessons Learned
20
Agency Comments
25
Appendix I
Objectives, Scope, and Methodology
30

Appendix II
Countries Receiving U.S. Agency for International Development COVID-
19 Vaccine Country Readiness and Delivery Assistance
35

Appendix III
Comments from the U.S. Agency for International Development
37

Appendix IV
GAO Contact and Staff Acknowledgments
44

Table
Table 1: List of Countries Receiving USAID Assistance for
COVID-19 Global Country Readiness and Delivery, by
Region, 2023
35

Figures
Figure 1: U.S. Agency for International Development (USAID)
Total COVID-19 Allocations and Obligations and
Estimated Obligations for Global COVID-19 Vaccine
Country Readiness and Delivery (CRD) Efforts, as of
March 2023
7
Figure 2: U.S. Agency for International Development (USAID)
Estimated Obligations for COVID-19 Vaccine Country
Readiness and Delivery by Region, as of March 2023
8
Contents

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
Figure 3: U.S. Agency for International Development (USAID)
Areas for COVID-19 Vaccine Country Readiness and
Delivery Technical Assistance
9
Figure 4: Percentage of Population Fully Vaccinated in Countries
Assisted by the U.S. Agency for International
Development (USAID) as of July 5, 2023
12
Figure 5: Average Fully Vaccinated Rate by Region for Countries
Assisted by the U.S. Agency for International
Development (USAID) as of July 5, 2023
13
Figure 6: Percentage of Population Fully Vaccinated in Global
VAX Surge Countries Assisted by the U.S. Agency for
International Development (USAID), May 2021–June
2023
14

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad

Abbreviations

CDC

Centers for Disease Control and Prevention
COVAX
COVID-19 Vaccines Global Access
CRD

country readiness and delivery

DEC

Development Experience Clearinghouse
Global VAX
Initiative for Global Vaccine Access
UNICEF
United Nations International Children’s Emergency Fund
USAID
United States Agency for International Development
WHO
World Health Organization
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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
441 G St. N.W.
Washington, DC 20548
September 27, 2023
Congressional Addressees
COVID-19 has adversely affected the health of populations around the
world. The pandemic has also killed millions of people both at home and
abroad. The U.S. government has prioritized mitigating the public health
impacts of COVID-19, slowing the transmission of the virus, deterring the
emergence of new virus variants, and saving lives through vaccination. At
the height of the COVID-19 pandemic in 2021, the United States pledged
to substantially contribute toward a global goal of vaccinating 70 percent
of the population of each country by the end of 2022.
To stop the spread of the virus and attain high population immunity, the
United States, led by the U.S. Agency for International Development
(USAID), moved to the forefront of the pandemic global response. This
response included building and strengthening countries’ readiness for and
delivery of vaccines (country readiness and delivery, or CRD).1 To
achieve the global goal of vaccinating 70 percent of the population of
each country against COVID-19, the U.S. established the Global
Response and Recovery Framework (the Framework) in July 2021. The
Framework established a set of objectives to end the pandemic, mitigate
its harms, support the global recovery, and strengthen pandemic threat
readiness.2 The first objective of the Framework was to accelerate
widespread and equitable access to and delivery of safe and effective
COVID-19 vaccinations. In December 2021, the USAID Administrator
announced a new, whole-of-government response, guided by the
Framework, called the Initiative for Global Vaccine Access (Global VAX).
Global VAX combined the capabilities of USAID and a number of other
U.S. government agencies to respond to the evolving COVID-19 crisis in
an effort to significantly enhance assistance to many countries, especially

1USAID defines CRD as the support needed to ensure that the infrastructure is in place
and the technical assistance is available to make certain COVID-19 vaccines can be
safely delivered to all those who need them. According to USAID guidance, this
assistance involves financial support, training, and technical assistance provided by
USAID-funded implementing partners.
2White House, “U.S. COVID-19 Global Response and Recovery Framework,” July 1,
2021. See https://www.whitehouse.gov/wp-content/uploads/2021/07/U.S.-COVID-19-
Global-Response-and-Recovery-Framework.pdf.
Letter

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
low-income ones, which remained under-vaccinated and unprepared for a
new variant or a surge in infections.3
The CARES Act includes a provision for GAO to report on ongoing
monitoring and oversight efforts related to the receipt, disbursement, and
use of funds made available to prepare for, respond to, and recover from
the COVID-19 pandemic.4 This report examines the (1) assistance USAID
has provided to support COVID-19 vaccine CRD abroad, (2) progress
USAID has made in its efforts to support COVID-19 vaccine CRD abroad,
and (3) any challenges USAID has faced in its efforts to support COVID-
19 vaccine CRD abroad and how it has addressed them.
To respond to these three objectives, we reviewed relevant federal laws,
regulations, and USAID planning, funding, and guidance documents. We
also conducted interviews with officials from USAID, the Department of
Health and Human Services’ Centers for Disease Control and Prevention
(CDC), the Department of State, and other U.S. government officials in
Washington, D.C. In addition, we selected three countries, Guatemala,
Malawi, and South Africa, for a series of interviews with multiple
stakeholders. These stakeholders included officials from USAID, CDC,
State, other interagency partners and multilateral organizations, as well
as from host government health offices and local organizations. We
selected these countries based on several factors, including their
receiving greater amounts of estimated CRD obligations and, in order to
understand vaccination challenges, their having lower COVID-19
vaccination rates.
To identify the types of assistance provided for COVID-19 vaccine CRD
abroad, we obtained data on all USAID CRD assistance funded from
appropriations to prevent, prepare for, and respond to COVID-19 and
other appropriations obligated to address COVID-19. We obtained and
analyzed additional CRD funding data from CDC and State officials. We
interviewed relevant agency officials with knowledge of global vaccine
CRD obligations and types of assistance and reviewed agency responses
to our questions about the data. We reviewed related documentation and

3The other agencies included, among others, the Department of Health and Human
Services’ Centers for Disease Control and Prevention, the Department of State, the Office
of the Global AIDS Coordinator, the Department of Defense, the Peace Corps, the
Development Finance Corporation, and the Department of the Treasury.
4Pub. L. No. 116-136 § 19010(b), 134 Stat. 281, 580 (2020). The American Rescue Plan
Act of 2021 also includes a provision for GAO to conduct oversight of the COVID-19
response. Pub. L. No. 117-2, § 4002, 135 Stat. 4, 78. All of GAO’s reports related to the
COVID-19 pandemic are available on GAO’s website at https://www.gao.gov/coronavirus.

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
performed data reliability checks, and determined that the data were
sufficiently reliable for estimating obligation amounts.
To describe the progress USAID made in meeting global COVID-19
vaccination goals and to identify factors that affected the measurement of
this progress, we reviewed relevant USAID documents and interviewed
officials as described above. To determine the overall vaccination
progress in USAID-supported countries—reflecting the efforts of USAID,
the host government, and other donors and entities—we reviewed
COVID-19 vaccination and other data from the Our World in Data COVID-
19 vaccination dataset.5 This dataset draws on data from the World
Health Organization (WHO), United Nations World Population Prospects,
direct reports from country governments, and other sources. To assess
the reliability of this dataset we conducted testing to identify any missing
data or logical errors. We determined that the data were sufficiently
reliable for the purposes of measuring overall vaccination progress.
Finally, to identify any challenges USAID has faced in its efforts to
support COVID-19 vaccine CRD abroad and how the agency addressed
them, we analyzed agency documents, including surveys of U.S.
overseas staff, mitigation strategies, and plans for monitoring, evaluating,
and assessing lessons learned. In addition, we interviewed officials from
USAID, CDC, State, WHO, United Nations International Children’s
Emergency Fund (UNICEF), other international partners and multilateral
organizations, and host government health offices and local
organizations. We asked about the challenges in CRD assistance and
mitigation strategies. We also asked USAID officials about plans for
developing and disseminating lessons learned from USAID’s CRD efforts.
We assessed USAID’s efforts against its Program Cycle Operational
Policy.6 See appendix I for a full description of our scope and
methodology.
We conducted this performance audit from January 2022 to September
2023 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe

5Our World in Data is an open access and open source non-profit organization that vets
the source data for accuracy and consistency. It provides data on multiple variables,
including people fully vaccinated (total and per capita data for people who received all
doses prescribed by the initial vaccination protocol), COVID-19 cases, confirmed deaths,
and numerous other COVID-19-related and broader socio-economic variables.
6USAID Automated Directives System 201 Program Cycle Operational Policy.

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.

In response to the spread of COVID-19 globally, the WHO declared
COVID-19 a public health emergency of international concern in March
2020. Since then, COVID-19 has killed millions of people, infected
hundreds of millions more, and adversely affected the health of
populations around the world. Providing safe and effective vaccines to
protect people from COVID-19 was crucial to mitigating the public health
and economic impacts of the virus and to ending the pandemic as a
public health emergency. In addition to limiting severe illness and death,
slowing transmission of COVID-19 through vaccination—particularly of
high-risk populations—was critical to deterring the emergence of new
virus variants.
The United States and global partners have assisted countries around the
world to access vaccine supply and receive and administer vaccine
doses. These efforts were conducted in collaboration with international
partners, such as COVID-19 Vaccines Global Access (COVAX), a WHO-
backed effort initiated in April 2020 to rapidly develop and provide
equitable access to vaccines.7 In October 2021, COVAX partners
anticipated that once vaccine supply constraints were alleviated, other
factors, such as countries’ abilities to absorb and administer vaccines, as
well as waning vaccination demand and vaccine hesitancy, could
significantly affect vaccination efforts. In May 2023, WHO declared an
end to the public health emergency phase of the COVID-19 pandemic but
also stated the disease remains an ongoing global health issue. As the
COVID-19 pandemic enters a new phase, ensuring equitable access to
and administration of COVID-19 vaccines continues to be essential to
protect vulnerable populations and to prevent surges of new variants.
Since the early stages of the pandemic response, the U.S. government,
through USAID, State, CDC, and others, has supported global COVID-19
vaccination efforts. These efforts first helped to improve the equitable
allocation, access, and distribution of COVID-19 vaccines across the
globe and subsequently provided technical assistance in priority areas to
support CRD. In March 2021, USAID established a COVID-19 Program
and Operations Strategy Task Force to advance and to coordinate the
administration’s COVID-19 response and recovery efforts. The objectives

7In addition to WHO, other COVAX partners included the Coalition for Epidemic
Preparedness Innovations; GAVI, the Vaccine Alliance; and UNICEF.
Background
The COVID-19 Pandemic
and Global Vaccination
Efforts
U.S. Efforts to Support
COVID-19 Vaccinations
Abroad

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
were to coordinate USAID’s development and humanitarian assistance
response to COVID-19 as well as existing efforts to support global
workforce well-being, safety, security, and continuity of operations amid
the pandemic. The Task Force’s Vaccine Access and Delivery Initiative
was established to advance equitable access to and delivery of COVID-
19 vaccinations globally.
Following the establishment of the task force, the White House published
the U.S. government’s COVID-19 Framework in July 2021. USAID, CDC,
and State led the interagency development of the Framework, which
provides objectives and lines of effort to guide the United States in a
coordinated, strategic response to the global COVID-19 pandemic. The
first objective was to accelerate widespread and equitable access to and
delivery of safe and effective COVID-19 vaccinations. It had a target of
substantially contributing to help achieve the global goal of vaccinating 70
percent of the population of each country, initially by the end of 2022.8
Updated in September 2022, the Framework now places greater
emphasis on vaccinating and boosting high-risk and hard-to-reach
populations and integrating COVID-19 vaccines into routine primary
healthcare. USAID’s November 2022 Technical Priorities Update for
USAID’s COVID-19 Response reinforced the 70 percent global
vaccination goal but did not specify a timeframe. This update also
focused on fully vaccinating priority populations, including healthcare
workers and older adults, and recognizing vaccination targets set by
countries.
Following the establishment of the Framework, USAID and CDC began to
jointly plan COVID-19 vaccine CRD efforts once it became clear that
vaccines would become available and significant resources would be
needed to distribute them at scale. With USAID’s announcement of the
Global VAX initiative in December 2021, the U.S. government sought to
boost international coordination for vaccination assistance, such as
identifying and rapidly overcoming barriers to vaccine access and
demand. Global VAX encompassed efforts to increase uptake of COVID-
19 vaccines in 125 countries. These efforts complemented the expansion
of the global vaccine supply, but focused on ensuring that partner
countries were ready to deliver and administer the donated vaccines.

8This report focuses on activities and results associated with the Framework’s first line of
effort—specifically, USAID’s efforts to support COVID-19 vaccine CRD. Other Framework
objectives included reducing disease and death from COVID-19; addressing acute needs
driven by COVID-19 to build resilience; bolstering economies and other critical systems
affected by COVID-19; and strengthening the international health security architecture to
prevent, detect, and respond to pandemic threats.

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
CDC worked in close coordination with USAID on CRD efforts. CDC also
provided technical support and assistance to national governments to
support implementation of their vaccination plans.9 State supported CRD
efforts through interagency coordination of dose deliveries, engaging with
host governments, and promoting messaging in support of vaccination.10
Other interagency partners involved in CRD assistance included the
Department of Defense, the Department of the Treasury, the Peace
Corps, and the White House, among others. In addition, U.S. government
agencies worked with implementing partners, including non-governmental
organizations, local civil society organizations, and public international
organizations, such as WHO and UNICEF.

As of March 2023, USAID had obligated an estimated $904 million in
awards to support CRD efforts in 125 countries.11 USAID allocated a total
of $13.6 billion for COVID-19 mitigation efforts, of which it obligated $8.7
billion in awards and $4 billion for a contribution to Gavi, the Vaccine

9CDC allocated an estimated $296 million for CRD assistance from fiscal year 2020 to
January 2023, according to CDC officials. Of this amount, CDC allocated about $118
million to specific countries and $178 million for cross-cutting mechanisms that supported
multiple countries, according to CDC officials.
10State also allocated $850 million for the Bureau of Population, Refugees, and Migration,
the agency office focused on humanitarian efforts, to respond to COVID-19, but could not
specify how much supported CRD efforts. State also noted that it provided $280 million in
funds appropriated by the American Rescue Plan Act of 2021 to WHO, a portion of which
supported vaccine-related pharmacovigilance and demand generation; $170 million to
UNICEF, of which $125 million was intended to support operational costs of vaccine
delivery; and $75 million to the Pan-American Health Organization to help implement and
monitor COVID-19 vaccinations. Additionally, State transferred about $14 million for CRD
assistance to USAID, CDC, and other agencies involved in the global COVID-19 response
as of February 2023, according to State officials.
11USAID officials said they were unable to isolate a specific subset of obligations for CRD
activities from funding for broader COVID-19 efforts because its financial management
system is not designed to track spending at this level of detail and many activities
involving CRD also included non-CRD assistance. Instead, officials provided estimates of
the agency’s CRD obligations by analyzing regional bureaus’ program records and
country missions’ implementation plans.
USAID Provided
More Than $900
Million for CRD
Efforts in 125
Countries
USAID Obligated about
$904 Million in CRD
Awards to 125 Countries

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
Alliance, for vaccine procurement and delivery.12 The $904 million in
estimated CRD obligations represents about 10 percent of funds USAID
obligated for COVID-19 efforts. Figure 1 shows USAID allocations to
address COVID-19, its total COVID-19 obligations, and estimated
obligations for CRD efforts.
Figure 1: U.S. Agency for International Development (USAID) Total COVID-19
Allocations and Obligations and Estimated Obligations for Global COVID-19
Vaccine Country Readiness and Delivery (CRD) Efforts, as of March 2023

Note: The circles in the figure are not proportional. The $13.6 billion includes $4 billion in
appropriations for vaccine procurement that, pursuant to direction contained in the Consolidated
Appropriations Act, 2021, USAID contributed to Gavi, the Vaccine Alliance, a multilateral body that
increases equitable and sustainable use of vaccines. Amounts that USAID did not obligate for awards
to address COVID-19 or for a contribution to Gavi went to operating expenses, international disaster
assistance, and other efforts.
USAID funded CRD activities in 125 countries around the world. The
amount of estimated CRD obligations varied by country, from a high of
about $75 million to a low of $100,000. Geographically, the vast majority
of USAID’s CRD funding supported countries in Africa (see fig. 2).

12Gavi, the Vaccine Alliance, is a multilateral body that increases equitable and
sustainable use of vaccines. USAID made the $4 billion contribution to Gavi pursuant to
direction contained in the Consolidated Appropriations Act, 2021. Pub. L. No. 116-260,
134 Stat. 1182, 1821 (2020). Amounts that USAID did not obligate for awards to address
COVID-19 directly or for a contribution to Gavi went to operating expenses in support of
COVID-19 response efforts, international disaster assistance programs to mitigate the
impact of the pandemic on ongoing humanitarian crises, and other efforts to prevent
development backsliding due to the pandemic.

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
Figure 2: U.S. Agency for International Development (USAID) Estimated Obligations
for COVID-19 Vaccine Country Readiness and Delivery by Region, as of March 2023

Note: Dollars do not sum to $904 million and percentages do not sum to 100 due to rounding.
To optimize CRD assistance, the Global VAX initiative, led by USAID in
close partnership with CDC, invested more of its COVID-19 vaccination
financial, technical, and diplomatic efforts in a subset of 11 countries with
significant need and the potential for rapid vaccination progress.13 An
estimated $379 million, or 42 percent, of USAID’s CRD obligations
supported these 11 Global VAX “surge” countries. All 11 countries are
located in sub-Saharan Africa. Ten of them are classified as either low or
lower-middle income by the World Bank, while one, South Africa, is
classified as upper-middle income.
USAID has provided CRD assistance for eight identified areas of
technical assistance to facilitate the delivery of COVID-19 vaccines.14 The

13USAID, COVID-19 Fact Sheet, Global VAX: An ‘Initiative for Global Vaccine Access’ To
Turn Vaccines In Vials Into Vaccinations In Arms Around the World, May 12, 2022. USAID
previously referred to Global VAX surge countries as Tier One countries, and had
identified six other countries—which the agency had designated Global VAX Tier Two
countries—for intensified focus. According to USAID’s COVID-19 Global VAX Field Guide,
these six countries demonstrated high needs, regional or strategic importance to overall
vaccine progress, and political or security complications that would first require diplomatic
engagement followed by intensified investments.
14USAID officials said they were unable to break out the amount of funds obligated to
each of these areas of technical assistance because its financial management system is
not designed to track spending at this level of detail.
USAID Supported Various
Forms of CRD Assistance

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
agency grouped these technical assistance areas into three categories:
planning, implementing, and monitoring (see fig. 3).
Figure 3: U.S. Agency for International Development (USAID) Areas for COVID-19
Vaccine Country Readiness and Delivery Technical Assistance

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
To conduct CRD assistance, USAID awarded funding to implementing
partners and has coordinated closely with CDC and other U.S.
government agencies to support these efforts.15 USAID and these
partners align technical assistance with the countries’ National
Deployment and Vaccination Plans, a framework established by WHO
and UNICEF to help countries plan their vaccination strategies.16
USAID mission staff, implementing partners, host government health
ministry officials, and other stakeholders we interviewed in three countries
identified various examples of USAID-supported CRD assistance at the
country level. Some of those examples are listed below.
•
Demand and community engagement: In Guatemala, the USAID-
supported Pan-American Social Marketing Organization encouraged
demand and community engagement by using “micro-influencers”
(such as well-known athletes and musicians in particular regions) to
generate demand over social media for the COVID-19 vaccine among
vaccination-hesitant youth.

15USAID provided assistance primarily through agreements with awardees—including
nongovernmental organizations and universities—that it refers to as implementing
partners. International organizations such as UNICEF may also act as implementing
partners for USAID.
16A National Deployment and Vaccination Plan constitutes a country’s overall plan to
deploy vaccines and deliver vaccination to identified target populations. A country can use
the plan with the World Bank and other donors. Completion of a National Deployment and
Vaccination Plan is a requirement to receive vaccine donations from COVAX.
Encouraging Demand and Community
Engagement in Malawi by Vaccinating a
Community Leader Against COVID-19
U.S. Agency for International Development
(USAID) implementing partners promoted
demand for vaccinations by meeting with
traditional leaders and by vaccinating them
and other influential community members.

Source: USAID implementing partner Right to Care. | GAO-
23-105579

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad

•
Service delivery: In Malawi, UNICEF, acting as a USAID
implementing partner, supported service delivery through
Vaccinate My Village, a project that trained healthcare workers to
report vaccination data by text message and provided mobile
vaccination units to reach isolated communities.
•
Evaluation and health information systems: In South Africa,
USAID implementing partner Right to Care supported health
information systems by developing a data registry for the National
Department of Health to track vaccination progress by geography
and demographics. Right to Care also created “Find My Jab,” an
app which shows users the closest vaccination centers and what
brands of vaccines they offer.

As of July 5, 2023, USAID, together with host governments, multilateral
organizations, and other donors, had contributed to fully vaccinating an
average of about 45 percent of the population across 123 assisted
Supporting Service Delivery in Guatemala
by Vaccinating Indigenous Communities
Against COVID-19
Guatemalan COVID-19 vaccination brigades
supported by the U.S. Agency for International
Development (USAID) visited indigenous
communities in rural areas to vaccinate the
population.

Source: USAID implementing partner Breakthrough Action. |
GAO-23-105579
USAID Contributed to
Vaccination
Assistance That Fell
Short of the Global
Goal, and the Agency
Faced Difficulties
Measuring Its
Progress
USAID Contributed to
Vaccinating 45 Percent of
the Population in Assisted
Countries, Short of the 70
Percent Goal

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
countries,17 falling short of the global 70 percent goal.18 Seventy-six
(close to two-thirds) of these countries had vaccination rates below 50
percent (see fig. 4).
Figure 4: Percentage of Population Fully Vaccinated in Countries Assisted by the
U.S. Agency for International Development (USAID) as of July 5, 2023

Note: These vaccination rates reflect the efforts of USAID, host governments, and other entities in
assisted countries. USAID officials, citing World Health Organization (WHO) guidance, defined “fully
vaccinated” as a complete primary series, which may be one or two doses depending on the vaccine
manufacturer. While WHO updated its guidance in July 2022 to recommend booster doses in addition

17No vaccination data exist for two USAID-assisted countries: the Marshall Islands and
Micronesia. USAID officials noted that one implementing partner may have multiple CRD
activities in one country or similar activities implemented across multiple countries, and
that implementing partners may not be currently assisting all 125 countries. For example,
partners in some countries may have already completed activities. According to Our World
in Data, just under 65 percent of the world’s total population was fully vaccinated as of
July 11, 2023.
18USAID officials, citing WHO guidance, defined “fully vaccinated” as a complete primary
series, which may be one or two doses depending on the vaccine manufacturer. While
WHO updated its guidance in July 2022 to recommend booster doses in addition to the
primary vaccine series, we are using the term “fully vaccinated” to mean the primary
series only, in part because the protocol for booster doses continues to evolve. USAID
issued updated guidance in November 2022 (Technical Priorities Update for USAID’s
COVID-19 Response, last updated November 30, 2022) that was grounded in WHO’s
Global COVID-19 Vaccination Strategy in a Changing World: July 2022 Update. The
updated WHO strategy reinforced the goal of fully vaccinating 70 percent of the total
population of each country, with a focus on fully vaccinating 100 percent of priority
populations, including healthcare workers and older adults, and increasingly recognized
vaccination targets set by countries.

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
to the primary vaccine series, we are using the term “fully vaccinated” to mean the primary series
only, in part because the protocol for booster doses continues to evolve. USAID assisted 125
countries, but Our World in Data lacked vaccination data for two USAID-assisted countries: the
Marshall Islands and Micronesia. The most recent vaccination rate data for most countries are prior to
July 2023.
Vaccination rates varied by region. Figure 5 shows average fully
vaccinated rates across all USAID-assisted countries in each of five
regions as of July 5, 2023. Asia had the highest average rate (63
percent), while the Middle East and North Africa had the lowest (28
percent).
Figure 5: Average Fully Vaccinated Rate by Region for Countries Assisted by the
U.S. Agency for International Development (USAID) as of July 5, 2023

Note: These vaccination rates reflect the efforts of USAID, host governments, and other entities in
assisted countries. USAID officials, citing World Health Organization (WHO) guidance, defined “fully
vaccinated” as a complete primary series, which may be one or two doses depending on the vaccine
manufacturer. While WHO updated its guidance in July 2022 to recommend booster doses in addition
to the primary vaccine series, we are using the term “fully vaccinated” to mean the primary series
only, in part because the protocol for booster doses continues to evolve. USAID assisted 125
countries, but Our World in Data lacked vaccination data for two USAID-assisted countries in Asia:
the Marshall Islands and Micronesia. The most recent vaccination rate data for most countries are
prior to July 2023.
As of July 5, 2023, the fully vaccinated rates for the 11 Global VAX surge
countries averaged 34 percent—well below the 70 percent goal—and
progress had slowed in most countries. None of these countries had a
vaccination rate above 50 percent as of July 5, 2023, despite the
countries being the focus of roughly half (42 percent) of USAID’s CRD
assistance. The rates for most of the surge countries began to plateau in
2022 or early 2023. Some showed a sharp increase in their respective
rates between May 2021 and December 2022, and one remained
relatively flat, with a rate of less than 10 percent (see fig. 6).

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
Figure 6: Percentage of Population Fully Vaccinated in Global VAX Surge Countries Assisted by the U.S. Agency for
International Development (USAID), May 2021–June 2023

Note: Global VAX surge countries are 11 African countries USAID identified as having significant
need and the potential for rapid acceleration of vaccine uptake. These vaccination rates reflect the
efforts of USAID, host governments, and other entities in assisted countries. USAID officials, citing
World Health Organization (WHO) guidance, defined “fully vaccinated” as a complete primary series,
which may be one or two doses depending on the vaccine manufacturer. While WHO updated its
guidance in July 2022 to recommend booster doses in addition to the primary vaccine series, we are
using the term “fully vaccinated” to mean the primary series only, in part because the protocol for
booster doses continues to evolve. The most recent vaccination rate data for most countries are prior
to July 2023.

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
According to USAID officials, various factors contributed to the
vaccination rate trends in these countries. For example:
•
Tanzania: USAID officials stated that vaccination efforts in Tanzania
had a slow start because at the time vaccines became available,
political leadership had cast doubt on the safety of vaccines and
prohibited them from entering the country. This trend changed when a
new president was sworn into office in March 2021 and the country
received its first tranche of over one million U.S. government-donated
vaccine doses.19 The officials said a series of USAID-supported music
events in five regions from late July through August 2022 drove
demand for more than 40,000 vaccinations in 5 weeks. According to
an article in The Lancet, the Tanzanian government began an
intensive campaign to vaccinate all eligible adults older than 18 years
of age in September 2021.20
•
Lesotho: USAID officials said that anticipated regional travel
regulations in Lesotho restricting border crossings for the
unvaccinated may have contributed to an increase in the country’s
vaccination rate in late 2021. The officials said vaccination coverage
leveled off in mid-2022, due in large part to the government’s lifting of
all COVID-19 restrictions, including masking and proof of vaccination
for traveling, prior to the fall elections. As a result of these changes,
officials said that people no longer perceived COVID-19 as a threat.
According to the officials, the country’s national COVID-19
coordinating body also disbanded in mid-2022, leaving its work to the
health ministry, which has many other responsibilities.
•
Senegal: USAID officials attributed the relatively low, flat vaccination
rate in Senegal to a change in the way the government managed
COVID-19 vaccination efforts. The officials said resources committed
to these efforts declined when those resources were moved from an
emergency operations center—which coordinated activities across all
relevant ministries and with local leaders—to the country’s national
vaccination program, which lacked this level of coordination. Low
demand and data backlogs also contributed to the country’s stagnant

19Tanzania has a population of 65 million people, according to Our World in Data, which
sources its population data from United Nations World Population Prospects.
20The Tanzanian government’s campaign to vaccinate all eligible adults focused on
combatting vaccine hesitancy, especially among healthcare workers, and included one-
on-one engagements with stakeholders to address concerns, surge staffing to maximize
the effect of vaccination drives, and U.S. government agencies’ leveraging of existing HIV,
tuberculosis, and other service delivery infrastructure to provide vaccinations nationwide.
See Tanzania’s COVID-19 vaccination strategy: lessons, learning, and execution, The
Lancet, Vol 401, May 20, 2023, p.1649.

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
vaccination rate, according to USAID officials. For example, they said
perceptions among people that COVID-19 posed minimal risk, due in
part to low case rates, depressed demand. They also said strikes
among healthcare workers reduced the reporting of COVID-19
vaccination data, and thus the reported vaccination rate.
USAID officials also provided detailed information on factors affecting
vaccination progress in two non-Global VAX surge countries. For
example:
•
Malawi: USAID officials in Malawi credited policy changes and
vaccine campaigns for the country’s improved vaccination rate, which
rose from 6.4 percent of the targeted population in March 2022 to
almost 20 percent in the fall of that year.21 The USAID officials noted
that policy changes allowed individuals who received a first dose from
one vaccine manufacturer to receive a second dose from another
manufacturer and lowered eligibility for the Pfizer vaccine from 18 to
12 years of age. The vaccine campaigns included a shift from
administering vaccines at fixed vaccination sites to door-to-door
campaigns and mobile clinics that brought the vaccine to individuals
where they live.
•
Haiti: Persistent political instability, high levels of gang violence, and
fuel shortages contributed to Haiti’s lack of vaccination progress by
creating a difficult operating environment for providers, according to
USAID officials. The officials said the August 2021 earthquake and
tropical storm, followed by a late 2022 cholera outbreak, posed
additional challenges and redirected scarce resources away from
COVID-19 vaccination. They noted that low demand due to
widespread misinformation and disinformation also slowed Haiti’s
vaccination rate, which remained below 4 percent as of July 5, 2023.
More broadly, USAID officials attributed variation in vaccination rate
trends across countries to a variety of factors, including the strength of
their underlying healthcare systems; physical environment, such as
transportation infrastructure, electricity grid, geography, and natural
disasters; and demographic characteristics, such as population mobility,

21Malawi’s national vaccine task force, on which USAID, its implementing partners, and
other donors serve, facilitated these policy changes. The targeted population consisted of
groups at high risk of contracting COVID-19 and experiencing hospitalization and death
from the disease, such as healthcare workers, social workers, and individuals with
underlying medical conditions that put them at increased risk of severe disease from
COVID-19, and those 60 years of age and older. According to Our World in Data, Malawi’s
fully vaccinated rate as a percentage of the country’s total population rose from just under
5 percent in March 2022 to about 15 percent in the fall of that year and to just over 20
percent in July 2023.

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
median age, density, and displacement. Officials added that conflict and
instability can depress vaccinations and outbreaks of other diseases can
shift priorities and redirect resources. They also noted that political
leadership is an important factor, as it can lend credibility to vaccination
drives by marshaling resources to support them, or undermine them by
helping to spread misinformation.
USAID faced difficulties measuring its direct contribution to vaccination
progress. According to USAID, as of September 30, 2021, at least 7.7
million people had received a first recommended dose of an approved
COVID-19 vaccine and at least 2.9 million had received a last
recommended dose22 with USAID direct support (those injections that
would not have occurred without USAID).23 By December 31, 2022, the
number of people receiving these two types of doses with the agency’s
direct support rose to at least 158 million and 167 million respectively.24
USAID faced several difficulties measuring its contribution, some of which
it had anticipated before it began providing support. The anticipated
issues included:

22The initial COVID-19 vaccine protocol requires two doses for most vaccines and does
not include booster doses. USAID implementing partners report to USAID on the number
of people who received a first recommended dose and the number of people who received
a last recommended dose with USAID direct support. According to USAID, its
implementing partners use a variety of systems to record vaccinations at different sites,
and many countries have deployed vaccination cards similar to those used in the United
States. USAID officials noted, however, that these cards may not be consistently used,
retained, or tracked.
23USAID’s COVID-19 Saving Lives Now & Global Vaccine Access Initiative Indicators: a
Compendium of Indicator Reference Sheets for COVID-19 Reporting by USG Projects,
updated in February 2023, defines “USAID direct support” as operational support to
vaccine delivery sites, provided in part or in full by a U.S. government-funded
implementing partner, to strengthen service delivery approaches required to reach target
populations equitably and rapidly. The Compendium states that without U.S. government
support, the site would not be able to operate. It further states that this support may
include but is not limited to the establishment and operation of alternative vaccination
sites; provision of items such as syringes, personal protective equipment, and masks;
rental costs; and monetary or non-monetary support for personnel. It does not include
indirect support for vaccine service delivery, such as guidance and technical assistance,
planning, training, and supervision.
24According to USAID, the number of last doses reported exceeded the number of first
doses reported because individuals may have received their last dose at a USAID-
supported site, where doses administered were captured in USAID implementing partner
reporting. However, these individuals may have received their first dose in a government-
run or other setting not directly supported by USAID, where doses administered were not
included in implementing partner reporting. In addition, a number of implementing partners
reported the single-dose Johnson & Johnson vaccine as a last dose only, contributing to
the higher number of recorded last doses.
USAID Faced Difficulties
Measuring Its Contribution
to Vaccination Progress

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
•
The unprecedented nature of COVID-19. USAID had to establish a
new set of indicators for its COVID-19 support that could provide
detail but also evolve over time, according to USAID officials.
•
Attribution. According to USAID’s Annual Evaluation Plan for Fiscal
Year 2022, it would be difficult for USAID to precisely quantify or
attribute the impact of its support because of the complexity of the
pandemic and the international response, as well as challenges to
establishing valid baseline information. For example, USAID officials
in Malawi noted that the pandemic created an emergency situation in
which it was difficult for donors and others engaged in CRD activities
to measure the progress of vaccination campaigns because they were
focused on vaccinating people as quickly as possible, rather than
distinguishing implementer efforts, ascertaining baselines, and setting
targets.
According to USAID, the agency also faced other difficulties measuring
vaccination progress once it began providing CRD support. These issues
included:
•
Incomplete vaccination information. Implementing partners were
unable to determine, with full accuracy, the number of individuals who
received all recommended doses of an approved COVID-19 vaccine
with USAID direct support, according to USAID officials. The officials
said that with few exceptions, USAID implementing partners did not
have the information needed to determine if the people they
supported in receiving a last dose also received a first dose with
USAID direct support. For example, implementing partners generally
do not collect the personally identifiable information used to track the
people that they helped the country’s government vaccinate because
doing so is expensive and therefore not sustainable.
•
Voluntary reporting. One of the reasons USAID was unable to
determine how many people received vaccine doses with its direct
support was because it made COVID-19 vaccination reporting by
implementing partners voluntary. This approach meant that reporting
was therefore limited.25 USAID opted to keep reporting voluntary
because of the high estimated cost and technical difficulties of
producing mandatory, high-frequency reporting and a determination

25According to USAID, the agency’s vaccination progress data “significantly undercount”
the number of people who received first or last doses with USAID direct support because
reporting by implementing partners is voluntary. In addition, doses administered by public
international organizations, such as UNICEF, are not generally included in the totals—
even when they are acting as a USAID implementing partner—because public
international organizations are not required to report this information, according to agency
officials.

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
that doing so would have yielded marginal results.26 However,
according to USAID, reporting rates were low. To address the gap in
data, USAID transitioned to mandatory reporting in April 2023 for a
subset of large awards in Global VAX surge countries and seven
additional countries. The seven countries—Ethiopia, Haiti, Liberia,
Madagascar, Malawi, Mozambique, and the Philippines—received the
highest estimated CRD obligations of non-Global VAX surge countries
in fiscal year 2022.
•
Multiple entities supporting CRD efforts. USAID was unable to
isolate its contribution to a country’s vaccination rate and to measure
its progress independent of other actors because it is one of many
entities involved in CRD activities. These entities included the host
government, other bilateral donors, and multilateral, private-sector,
and nongovernmental organizations.
•
Difficulties determining vaccination results from indirect
support. According to USAID, the agency cannot link certain CRD
activities to specific vaccination results. For example, USAID reported
progress for CRD activities that might indirectly contribute to people
getting vaccinated, such as those designed to generate demand for
vaccination or to provide training in COVID-19 vaccine-related
topics.27 However, agency officials said they were unable to measure
how many people actually received vaccinations as a result of these
activities. For instance, it was not possible for USAID to determine
how many people were motivated to get vaccinated by USAID-
supported radio messages. The officials also said USAID faced
difficulties quantifying how its technical assistance for policy and
training contributed to an increase in vaccination.

26USAID’s Automated Directives System 201.3.5.1 allows for exceptions to otherwise
applicable monitoring requirements. USAID documented the voluntary reporting decision
in an October 25, 2021, Action Memo approved by the Executive Director of the agency’s
COVID Task Force. USAID officials said that, according to an agency assessment, the
largest implementing partners with the greatest volume of programming typically submit
progress reports on CRD indicators.
27According to USAID, the number of people reached through USAID-supported mass
media and social media with COVID-19 vaccine-related messaging increased from 37
million in September 2021 to almost 178 million in November 2021. Similarly, the number
of people trained in COVID-19 vaccine-related topics with USAID support increased from
about 33,000 healthcare workers and other staff in October 2021 to more than 127,000 in
November 2021.

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad

According to multiple stakeholders,28 USAID, together with other U.S.
government partners, host governments, multilateral organizations, and
other donors, faced a variety of challenges in providing COVID-19
vaccine CRD assistance. These challenges varied by country and
evolved over time. For example, initially, supply issues were the largest
challenge. However, by mid-2022, U.S. agency officials in assisted
countries reported that demand issues had overtaken supply issues as
the greatest challenge to CRD efforts. A July 2022 survey of U.S.
overseas staff found that the most frequently cited challenge was a
decrease in vaccine demand caused by vaccine hesitancy and a
perceived low risk of COVID-19 transmission. An earlier survey in
January 2022 had found that supply chain logistics such as cold chain
storage were the most frequently cited challenges, which hindered
delivery to vaccination sites. Ultra-cold chain storage (for the Pfizer
vaccine, which must be kept at a very low temperature) in some countries
was limited at the national level and in others at the local level. Even
when such storage was available, challenges existed with staff expertise
and reliable electricity or backup power.
The various types of challenges USAID and other entities faced included
the following:
•
Demand challenges hampered the demand and community
engagement area of CRD technical assistance. These challenges
included:
•
misinformation and disinformation
•
mistrust of government efforts

28These included USAID, CDC, and State officials; USAID implementing partners; host
government officials; and other bilateral donors in the three countries we selected, as well
as headquarters-based USAID, CDC, WHO, and UNICEF officials.
USAID Shifted Its
Priorities in Response
to CRD Challenges,
and Plans to
Disseminate Its
Lessons Learned
USAID Faced CRD
Challenges Related to
Countries’ Vaccine
Demand, Supply, and
Other Issues

Page 21
GAO-23-105579  COVID-19 Vaccine Delivery Abroad
•
“COVID fatigue” (vaccine hesitancy and apathy because of a
perceived low risk of infection or severe disease and the lifting of
COVID-19 prevention policies by some governments)
•
refusal of some healthcare workers to be vaccinated
•
initial exclusion from vaccination planning of trusted local,
religious, and traditional leaders in certain communities
•
confusion over evolving vaccine protocols and changing COVID-
19 messages
•
dissemination of outdated information
•
lack of information in local languages
•
travel costs and lost income associated with getting to vaccination
sites
• Supply challenges constrained the human resources for health,
service delivery, and cold chain and supply chain logistics areas of
CRD technical assistance. These challenges included shortages of
trained healthcare workers, expiration of vaccine doses, difficulties
storing vaccines at required temperatures because of unreliable power
grids, and limited tracking of vaccine doses as they moved through the
supply chain, according to stakeholders we interviewed in the three
selected countries and documents we reviewed. In addition, we found
that in Malawi healthcare workers were stretched thin due to
competing outbreaks of cholera and polio.
• Other challenges affected the policy planning and coordination and
the evaluation and health information systems areas of CRD technical
assistance. These challenges included host country laws and
regulations, data backlogs, and weak information management
systems, according to multiple stakeholders. In Guatemala, for
example, USAID and implementing partner officials said laws and
regulations made it difficult for the government to obtain WHO-
approved vaccines in a timely manner, lowering trust in the
government’s provision of vaccine doses that were not approved by
WHO. By the time some vaccines were received, they were near
expiration, which further lowered public trust and demand. In addition,
multiple stakeholders in Guatemala stated that, in some cases, laws
holding vaccine suppliers—from national procurement officials to local
healthcare workers—liable for expired doses reduced the willingness
of these suppliers to obtain new doses, thereby decreasing the supply
of doses at both the national and local levels.
Meeting Supply Challenges in Malawi by
Storing COVID-19 Vaccines at Required
Temperatures
The National Vaccine Storage Facility in
Malawi contains ultra-cold chain equipment
needed to store COVID-19 vaccines at
required temperatures. Such equipment was
provided with assistance from the U.S.
Agency for International Development
(USAID).

Source: USAID. | GAO-23-105579

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
In late 2022, as vaccine demand diminished and worldwide vaccination
rates began to plateau, USAID shifted its global COVID-19 CRD priorities
in line with WHO guidelines.29 These priorities included vaccinating
vulnerable populations and incorporating COVID-19 vaccination activities
into countries’ primary healthcare systems, on the way to reaching the
global 70 percent vaccination goal. To support this shift in priorities,
USAID adjusted its approach to its areas of CRD technical assistance
and modified indicators for some of them.

Consistent with WHO guidelines, USAID is working with assisted
countries to incorporate the new COVID-19 priorities of vaccinating
vulnerable populations and integrating CRD activities into countries’
healthcare systems.30 USAID is prioritizing vaccination of healthcare
workers, older adults, and other groups most at risk for severe disease
from COVID-19, in part to mitigate demand challenges related to low
perceived risk of infection or severe disease among the general
population. It has also begun incorporating COVID-19 vaccinations into
routine immunization and primary healthcare systems to mitigate service
delivery challenges, such as healthcare worker shortages. As the
pandemic has drawn personnel and other resources away from countries’
immunization and healthcare systems, USAID is seeking to make those
systems more efficient and sustainable over the long term, as discussed
below. Officials have stated that these efforts will benefit both the current
COVID-19 response and future pandemic responses.31
USAID adjusted its approach to CRD assistance as a result. In November
2022, to reflect updates to the Framework in response to the pandemic’s
changing nature and evolving global needs, USAID identified four
technical approaches that focus on increasing vaccination coverage
among vulnerable populations and integrating vaccination activities into
countries’ primary healthcare systems.32 According to USAID, these

29WHO, Global COVID-19 Vaccination Strategy in a Changing World: July 2022 Update.
30See WHO, Global COVID-19 Vaccination Strategy in a Changing World: July 2022
Update, and USAID, Technical Priorities Update for USAID’s COVID-19 Response, Last
Updated November 30, 2022.
31UNICEF officials stated that a significant number of countries are now redirecting efforts
away from the pandemic response toward addressing systemic issues, such as reversing
the rollback of routine immunization coverage, which was significantly affected by the
impact of the pandemic on healthcare systems.
32USAID, Technical Priorities Update for USAID’s COVID-19 Response, Last Updated
November 30, 2022.
USAID Shifted Its
Priorities and Adjusted Its
Approaches in Response
to CRD Challenges
Vaccinating Vulnerable Populations by
Administering COVID-19 Vaccine to an
Elderly Man in Malawi
The U.S Agency for International
Development (USAID) supported vaccination
of elderly and other vulnerable populations.

Source: USAID implementing partner Right to Care.  | GAO-
23-105579

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
approaches are meant to prioritize remaining resources to help countries
achieve their vaccination goals and do not eliminate or replace any of the
eight priority areas of technical assistance. The four approaches are as
follows:
• Advocacy to counter low risk perception from COVID-19 among host
government officials, encourage sustained support for COVID-19
vaccination, support updating national vaccine policies to include all
vulnerable groups, and prioritize the vaccination of these groups.
• Demand generation, risk communication, and community
engagement to address challenges like disinformation and perceived
low risk of infection or of severe disease. For example, generating
demand is critical to reaching vulnerable elderly and other populations
now being prioritized for vaccination, according to USAID officials.
USAID documented that it can be more difficult to reach these groups,
who may require more tailored messaging because they might live in
isolated rural areas and be less able to access fixed vaccination sites,
and less able or inclined to use social media.
• Ensuring the integration of gender equity into COVID-19
vaccination activities to address challenges like gender-specific
misinformation campaigns and difficulties accessing vaccination sites.
For example, USAID reported that targeted misinformation campaigns,
such as false claims about COVID-19 causing infertility or sterility, have
contributed to vaccine hesitancy, and gender-specific issues have
added to difficulties for both men and women using fixed vaccination
sites.33

33Specifically, USAID reported that women often work in the informal market, or are the
primary caretakers of their families, which makes it hard for them to take time off for travel
to fixed sites. Similarly, USAID reported that in some countries men work extended or odd
hours, which makes it difficult for them to get to fixed sites during the hours of operation.
Generating Demand for COVID-19
Vaccination in Johannesburg, South Africa
The U.S. Agency for International
Development (USAID) supported events in
urban and rural communities to promote
demand for COVID-19 vaccination.

Source: USAID. | GAO-23-105579
Addressing Difficulties with Fixed
Vaccination Sites Faced by Both Men and
Women by Using a Mobile Clinic in Malawi
The U.S. Agency for International
Development (USAID) supported mobile
clinics that use vans to bring vaccines to
isolated communities.

Source: USAID implementing partner Right to Care. | GAO-
23-105579

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
• Strengthening data access, management, and utilization to
address challenges like identifying and reaching priority populations,
integrating COVID-19 vaccination data into countries’ existing health
information systems, and eliminating data backlogs.34
In addition, USAID modified indicators for some CRD areas of technical
assistance and did not create indicators for others. USAID officials said
the agency did not create indicators to collect information for three areas
of technical assistance: policy, planning and coordination;
communications and advocacy; and evaluation and health information
systems. The officials said USAID made this decision because indicators
for these areas would provide no useful data and increase the reporting
burden on implementing partners. Officials stated that they have modified
indicators since their introduction in fiscal year 2021 to align with changes
in the pandemic and the COVID-19 response, such as the introduction of
booster doses, or simply to improve indicator quality. These changes
have included, among others, adding an indicator to capture the number
of people who have received a booster dose with USAID direct support,
and revising an indicator that tracked the number of vaccine sites
established with USAID support to one that tracked sites operating with
ongoing USAID support.
USAID has developed plans to learn from its CRD challenges, including
plans to document and disseminate some lessons learned. USAID
guidance states that lessons learned should be incorporated at several
stages of agency project activities, including strategy development,
implementation, and close-out.35 The guidance also requires these
lessons and related information be posted to the Development
Experience Clearinghouse (DEC), an agency repository of development
assistance information.36 USAID maintains this clearinghouse as its
primary institutional resource to provide staff and development partners

34According to UNICEF, there is limited population and coverage data for priority groups,
which makes it difficult to locate and track vaccination progress for elderly and other
vulnerable individuals. UNICEF also flagged countries’ weak health information systems
and their struggle to manage large data backlogs that accumulated during the pandemic.
35See USAID Automated Directives System 201.3.2.9; 201.3.2.18.B; and 201.3.4.12.
36USAID Automated Directives System 540.3.2.3.b. This information includes, for
example, reports that describe progress and accomplishments or document significant
evaluation findings, lessons learned, development results, performance measures, or
evaluative information and observations. See
https://dec.usaid.gov/dec/home/Default.aspx.
USAID Has Taken Some
Actions to Identify Lessons
Learned and Plans to
Disseminate Them

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
with accurate, comprehensive, and timely information to support strategic
planning.
Given this agency guidance, we asked USAID for information about
lessons learned. In response, USAID officials outlined several underway
or completed efforts to learn from its provision of CRD assistance and to
answer the following questions:
•
What factors have affected widespread access to safe and effective
COVID-19 vaccinations?
•
How has USAID contributed to equitable vaccine distribution and
delivery?
•
What approaches have been successful in combating disinformation
and misinformation and in promoting vaccine uptake within and
across diverse population segments?
USAID officials said in May 2023 that they plan to deliver the results of
these efforts in reports, slide decks, data sets, a blog post, and a draft
paper for submission to a peer-reviewed publication, among others.
USAID officials also stated that the agency plans to make the results of
these efforts available on the DEC once they are completed.37
Given the challenges U.S. agencies and others have identified in
implementing CRD assistance, USAID’s plans to use the DEC to
disseminate lessons learned are an important step in making this
information readily available in a centralized, designated place where
agency staff and other stakeholders know how to access it. For example,
UNICEF officials said they would welcome the opportunity to review key
lessons learned with USAID to identify recommendations that can help
improve routine immunization, primary healthcare measurement
indicators, and public health emergency preparedness and response.
Using the DEC as planned to disseminate lessons learned will help
USAID’s headquarters staff, mission management, and global partners
ensure they are better able to apply these lessons when responding to a
future global health emergency.
We provided a draft of this product to USAID, CDC, and State for review
and comment. We received written comments from USAID (reproduced in

37USAID has posted one completed, publicly available study to the DEC—a report that
assessed the efficacy of different interventions used to encourage vaccinations in South
Africa. We verified that this report is on the DEC. We found the report by typing into the
DEC’s search bar the exact title that USAID provided. Since stakeholders may be aware
of the report but may not recall the exact title, we also used keywords like “South Africa”
and “COVID-19” to try to locate it but were unable to do so.
Agency Comments

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
appendix III) in which the agency highlighted its efforts to help countries
vaccinate vulnerable groups and countries’ eligible populations. In
addition, we received technical comments from USAID and CDC, which
we incorporated as appropriate. State did not submit any comments.
In its comments, USAID stated that it and other U.S. government partners
initially aligned vaccination targets with WHO’s goal to vaccinate 70
percent of the total population in each country. USAID added that as the
virus and pandemic evolved, WHO released an updated global COVID-19
vaccination strategy that reduced focus on the 70 percent target and
prioritized vaccinating healthcare workers and high-risk populations. We
note in our report USAID’s efforts to vaccinate these populations, but also
that USAID reinforced the 70 percent goal in its November 2022
Technical Priorities Update. We therefore compared country vaccination
rates to the 70 percent goal.
USAID also provided new information regarding vaccination rates for
healthcare workers, older adults, and eligible populations in the 11 Global
VAX surge countries. We did not use USAID’s information for two
reasons. First, these rates relied on information provided by USAID
country teams, which was not independently verifiable by GAO. Second,
as we note in appendix I, age cutoffs for vaccinating eligible populations
may vary by country and over time as COVID-19 vaccine protocols
change, making it difficult to arrive at comparable vaccination rates for
eligible populations across countries. We therefore used the total
population data compiled by Our World in Data, which allowed us to
calculate comparable vaccination rates across countries.
In addition, USAID described the impact of its support for countries’
vaccination targets. We note, however, that agency officials said it is not
possible to isolate, attribute, or measure USAID’s direct contribution to
countries’ COVID-19 vaccination progress for a variety of reasons,
including that the agency is one of multiple entities involved in these
efforts.
We are sending copies of this report to the appropriate congressional
committees, the USAID Administrator, the Secretary of Health and
Human Services, the Acting Director of CDC, the Secretary of State, and
other interested parties. In addition, the report is available at no charge on
the GAO website at https://www.gao.gov.

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad

If you or your staff have any questions about this report, please contact
me at (202) 512-4409 or LoveGrayerL@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to this
report are listed in appendix IV.

Latesha Love-Grayer
Director, International Affairs and Trade

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
List of Addressees
The Honorable Patty Murray
Chair
The Honorable Susan Collins
Vice Chair
Committee on Appropriations
United States Senate

The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate

The Honorable Bernard Sanders
Chair
The Honorable Bill Cassidy
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate

The Honorable Gary C. Peters
Chairman
The Honorable Rand Paul, M.D.
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate

The Honorable Kay Granger
Chair
The Honorable Rosa L. DeLauro
Ranking Member
Committee on Appropriations
House of Representatives

The Honorable Cathy McMorris Rodgers
Chair
The Honorable Frank Pallone, Jr.
Ranking Member
Committee on Energy and Commerce
House of Representatives

Page 29
GAO-23-105579  COVID-19 Vaccine Delivery Abroad
The Honorable Michael McCaul
Chairman
Committee on Foreign Affairs
House of Representatives

The Honorable Mark E. Green, M.D.
Chairman
The Honorable Bennie G. Thompson
Ranking Member
Committee on Homeland Security
House of Representatives

The Honorable James Comer
Chairman
The Honorable Jamie Raskin
Ranking Member
Committee on Oversight and Accountability
House of Representatives

The Honorable Jason Smith
Chairman
The Honorable Richard Neal
Ranking Member
Committee on Ways and Means
House of Representatives
The Honorable Robert Menendez
United States Senate

Appendix I: Objectives, Scope, and
Methodology

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GAO-23-105579  COVID-19 Vaccine Delivery Abroad
The CARES Act includes a provision for GAO to report on ongoing
monitoring and oversight efforts related to the receipt, disbursement, and
use of funds made available to prepare for, respond to, and recover from
the COVID-19 pandemic.1 This report examines the (1) assistance the
U.S. Agency for International Development (USAID) has provided to
support COVID-19 vaccine country readiness and delivery (CRD) abroad;
(2) progress USAID has made in its efforts to support COVID-19 vaccine
CRD abroad; and (3) any challenges USAID has faced in its efforts to
support COVID-19 vaccine CRD abroad and how it has addressed them.2
To respond to these three objectives, we reviewed relevant federal laws
and regulations, and planning, funding, and guidance documents from
USAID, the Department of Health and Human Services’ Centers for
Disease Control and Prevention (CDC), and the Department of State. We
also conducted interviews with officials from USAID, CDC, State, and
other U.S. government officials in Washington, D.C., to examine the
extent of their global COVID-19 CRD efforts. In addition, we interviewed
multiple stakeholders in three countries USAID supports with COVID-19
CRD assistance. These stakeholders included USAID, CDC, State, and
other U.S. government officials, and officials from USAID implementing
partners, beneficiaries, host governments, multilateral organizations, and
other bilateral and private-sector donors. We also reviewed written
responses to our questions from World Health Organization (WHO)
officials in Geneva and United Nations International Children’s
Emergency Fund (UNICEF) officials in New York.
For all three objectives, we selected for in-depth analysis a non-
generalizable sample of three case study countries that had received
CRD assistance: Guatemala, Malawi, and South Africa. In selecting these
countries, we primarily considered the following factors: (1) those with
greater amounts of estimated CRD funds obligated by USAID through the
first half of fiscal year 2022; (2) those with lower COVID-19 fully

1Pub. L. No. 116-136 § 19010(b), 134 Stat. 281, 580 (2020). The American Rescue Plan
Act of 2021 also includes a provision for GAO to conduct oversight of the COVID-19
response. Pub. L. No. 117-2, § 4002, 135 Stat. 4, 78. All of GAO’s reports related to the
COVID-19 pandemic are available on GAO’s website at https://www.gao.gov/coronavirus.
2USAID defines CRD as the support needed to ensure that the infrastructure is in place
and the technical assistance is available to make certain COVID-19 vaccines can be
safely delivered to all those who need them. According to USAID guidance, this
assistance involves financial support, training, and technical assistance provided by
USAID-funded implementing partners.
Appendix I: Objectives, Scope, and
Methodology

Appendix I: Objectives, Scope, and
Methodology

Page 31
GAO-23-105579  COVID-19 Vaccine Delivery Abroad
vaccinated rates, based on publicly available data sources;3 (3) countries
that represented regional diversity; (4) demographic features, such as
population and socio-economic status; (5) severity of the COVID-19
pandemic in each country, as expressed through total cases and deaths
per population; and (6) countries recommended as case studies by
USAID, CDC, and State officials, as well as other stakeholders with
relevant expertise. We determined, based on these considerations, that
the three countries we selected were reasonable for the purposes of our
reporting objectives. Following our country selection, we conducted audit
work for all three objectives in Washington, D.C., and virtually, through
video-conferencing, in Guatemala, Malawi, and South Africa.
To identify the types of assistance provided for COVID-19 vaccine CRD
abroad, we obtained data on all USAID CRD assistance funded from
appropriations to prevent, prepare for, and respond to COVID-19 and
other appropriations obligated to address COVID-19 as of March 2023.
We obtained and analyzed additional CRD funding data from CDC and
State officials. We worked with the agencies to identify their estimated
CRD-related obligations. To describe the types of CRD assistance USAID
provided, we examined USAID policy and guidance documents, and
agency presentations on global COVID-19 vaccination progress. We also
interviewed agency officials to clarify information about this assistance.
To assess the reliability of USAID, CDC, and State funding data, we
reviewed agency responses to our questions about data reliability, noting
the specific labeling required for COVID-19 vaccination funding. We also
reviewed related documentation and performed data reliability checks
(such as examining the data for missing values and checking values
against other documentation). We interviewed relevant agency officials
with knowledge of global CRD assistance from each agency’s
appropriations, obligations, and types of assistance supported by the
obligations. We also interviewed these officials to corroborate our
interpretation of the data. From these steps, we determined that the data
were sufficiently reliable for the purposes of this reporting objective.

3We chose countries that received larger amounts of estimated CRD funds. To ensure we
chose countries that were experiencing vaccination challenges, we eliminated countries
with more than a 50 percent vaccination rate. USAID officials, citing WHO guidance,
defined “fully vaccinated” as a complete primary series, which may be one or two doses
depending on the vaccine manufacturer. While WHO updated its guidance in July 2022 to
recommend booster doses in addition to the primary vaccine series, we are using the term
“fully vaccinated” to mean the primary series only, in part because the protocol for booster
doses continues to evolve.

Appendix I: Objectives, Scope, and
Methodology

Page 32
GAO-23-105579  COVID-19 Vaccine Delivery Abroad
To describe the progress USAID made in meeting its global COVID-19
vaccination goals, and to identify factors that affected the measurement of
this progress, we reviewed relevant USAID policies, procedures, reports,
and guidance documents. We also interviewed USAID officials in
Washington, D.C., and our three case study countries, as well as other
stakeholders in these countries. Through the documentation and
interviews, we were able to identify (1) USAID’s global vaccination goals;
(2) how USAID defines “fully vaccinated”; (3) the indicators it uses to
assess progress for the types of CRD assistance it provides and
difficulties measuring progress against them; (4) how it defines “directly
supported by USAID”; and (5) factors affecting the measurement of
USAID’s progress.
To determine the overall COVID-19 vaccination progress in USAID-
supported countries—reflecting the efforts of USAID, host governments,
and other donors and entities—we obtained and analyzed publicly
available data. First, we obtained and analyzed COVID-19 vaccination
and other data from WHO’s COVID-19 Dashboard. The Dashboard
provides information about cumulative total vaccines administered and
vaccine mix by country.4 Second, we obtained and analyzed COVID-19
vaccination data from the Our World in Data COVID-19 vaccination
dataset.5 We ultimately decided to use the Our World in Data dataset
because it is a more comprehensive source, drawing on data from WHO,
United Nations World Population Prospects, direct reports from country
governments, and other sources.
We reviewed the reliability of both the WHO Coronavirus Dashboard and
the Our World in Data dataset and determined that both are sufficiently
reliable for the purposes of this reporting objective. Specifically, we cross
checked the relevant fields in both sources and found no discrepancies.
We also conducted manual and electronic testing to identify logical errors
such as outliers and higher vaccination rates followed by lower rates—
since the percentage of people vaccinated cannot decrease but only
increase or stay the same over time—and found none. Using the Our
World in Data website, we reviewed detailed information regarding
sources, vetting, accuracy, completeness, consistency, and limitations.

4WHO pools data from numerous sources, including direct reports from member states
and other publicly available official data collated by third-party sites.
5Our World in Data is an open access and open source non-profit organization that vets
the source data for accuracy and consistency. It provides data on multiple variables,
including people fully vaccinated (total and per capita data for people who received all
doses prescribed by the initial vaccination protocol), COVID-19 cases, confirmed deaths,
and numerous other COVID-19-related and broader socio-economic variables.

Appendix I: Objectives, Scope, and
Methodology

Page 33
GAO-23-105579  COVID-19 Vaccine Delivery Abroad
We also reviewed USAID documents that use Our World in Data as a
source for country COVID-19 vaccination rates,6 as well as scientific
studies on COVID-19 vaccination that use Our World in Data.
We used data showing fully vaccinated rates per capita from Our World in
Data for each country that received USAID CRD assistance7 to (1)
determine the number of countries falling within certain vaccination rate
ranges, (2) arrive at average vaccination rates for these countries by
region, and (3) produce vaccination trend lines for 11 countries identified
by USAID as Global VAX surge countries.8 Finally, we interviewed USAID
officials to corroborate our interpretation of the data presented from this
source.
To identify any challenges USAID has faced in its efforts to support
COVID-19 vaccine CRD abroad and how the agency addressed them, we
reviewed policy and guidance documentation from USAID and WHO. We
also reviewed other documentation from USAID and its implementing
partners, surveys of U.S. overseas staff compiled jointly by State, USAID,
and CDC,9 and written responses to our questions from WHO and
UNICEF. In addition, we interviewed USAID officials in Washington, D.C.,
and in our three case study countries, as well as CDC and State officials,
USAID implementing partners, host government officials, other bilateral
donor officials, representatives from private sector donors and local
organizations, and other stakeholders in these countries. We derived the
information on foreign law in this report from interviews and not from our
original analysis.
We reviewed these documents and interviews using content analysis to
identify demand, supply, and other challenges, along with more specific

6These rates reflect the COVID-19 vaccination efforts of all entities in a given country,
including the host government, USAID, other donors, and other entities.
7Our World in Data has vaccination data for 123 of the 125 USAID-assisted countries.
There are no data for the Marshall Islands or Micronesia.
8Countries have been vaccinating their populations over a certain age, according to
COVID-19 vaccine protocols and their own guidelines. However, age cutoffs for eligible
populations may vary by country and over time as protocols change. Our World in Data’s
total population data, drawn from United Nations World Population Prospects, and its
country vaccination data, drawn from host governments, WHO, and other sources,
allowed us to arrive at comparable vaccination rates across countries.
9We reviewed the results of two surveys, one based on responses received as of January
24, 2022, and the other, based on responses received as of July 30, 2022. The earlier
survey was administered to officials in 111 countries and officials in 80 countries
responded. The later survey was administered to officials in 63 countries and officials in
51 countries responded.

Appendix I: Objectives, Scope, and
Methodology

Page 34
GAO-23-105579  COVID-19 Vaccine Delivery Abroad
challenges within each of these categories. To conduct the content
analysis, two analysts independently identified examples of the
challenges in the documents and interviews, and a third checked their
findings.10 In addition, we reviewed USAID’s mitigation strategies,
including its plans for monitoring, evaluating, and lessons learned. We
compared USAID’s efforts to its internal guidance, which states that
lessons learned should be incorporated at several stages of agency
project activities, including strategy development, implementation, and
close-out,11 and requires that these lessons and related information be
posted to the Development Experience Clearinghouse, an agency
repository of development assistance information.12 We assessed
USAID’s efforts to systematically document and disseminate lessons
learned against this guidance.
We conducted this performance audit from January 2022 to September
2023 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.

10Specifically, we conducted a content analysis of our interviews with multiple
stakeholders in our three fieldwork countries and written responses from headquarters
officials at USAID, CDC, WHO, and UNICEF. We did so to identify challenges in
implementing COVID-19 vaccination country readiness and delivery activities in the three
countries (and worldwide, in the case of responses from headquarters officials). We
iteratively identified patterns to develop a set of three broad challenges—demand, supply,
and other challenges—and more specific challenges within each broad category. Two
analysts coded the interviews and responses to group the challenges within each broad
category and in more specific themes within each category. A third analyst independently
reviewed and verified this organization of the challenges into these broad categories and
subcategories.
11See USAID Automated Directives System 201.3.2.9; 201.3.2.18.B; and 201.3.4.12.
12USAID Automated Directives System 540.3.2.3.b. This information includes, for
example, reports that describe progress and accomplishments or document significant
evaluation findings, lessons learned, development results, performance measures, or
evaluative information and observations.

Appendix II: Countries Receiving U.S. Agency
for International Development COVID-19
Vaccine Country Readiness and Delivery
Assistance

Page 35
GAO-23-105579  COVID-19 Vaccine Delivery Abroad
The U.S. Agency for International Development (USAID) provided
COVID-19 vaccine country readiness and delivery (CRD) assistance to
125 countries in five regions.1 Table 1 shows the countries receiving
USAID’s CRD assistance for COVID-19 by region.
Table 1: List of Countries Receiving USAID Assistance for COVID-19 Global Country Readiness and Delivery, by Region, 2023
USAID-
assisted
regions
Countries
Africa (47)
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central
African
Republic
Chad
Comoros

Cote
d’Ivoire
Democratic
Republic of
the Congo
Djibouti
Eswatini
Ethiopia

Gabon
Gambia
Ghana
Guinea
Guinea-
Bissau

Kenya
Lesotho
Liberia
Madagascar
Malawi

Mali
Mauritania
Mauritius
Mozambique
Namibia

Niger
Nigeria
Republic
of the
Congo
Rwanda
Sao
Tome
and
Principe

Senegal
Seychelles
Sierra
Leone
Somalia
South
Africa

South
Sudan
Sudan
Tanzania
Togo
Uganda

Zambia
Zimbabwe
Asia (31)
Afghanistan
Bangladesh
Cambodia
Federated
States of
Micronesia
Fiji

India
Indonesia
Kazakhstan
Kiribati
Kyrgyzstan

Laos
Malaysia
Maldives
Marshall
Islands
Mongolia

Myanmar
Nauru
Nepal
Pakistan
Papua
New
Guinea
Philippines
Sri Lanka
Solomon
Islands
Tajikistan
Thailand

Timor-Leste
Tonga
Tuvalu
Uzbekistan
Vanuatu

Vietnam

Latin
America
and the
Caribbean
(25)
Antigua and
Barbuda
Bahamas
Barbados
Bolivia
Brazil

Colombia
Costa Rica
Dominica
Dominican
Republic
Ecuador

El Salvador
Grenada
Guatemala
Guyana
Haiti

Honduras
Jamaica
Nicaragua
Paraguay
Peru

Saint Kitts
and Nevis
Saint Lucia
Saint Vincent
and the
Grenadines
Suriname
Trinidad and
Tobago

1USAID defines CRD as the support needed to ensure that the infrastructure is in place
and the technical assistance is available to make sure COVID-19 vaccines can be safely
delivered to all those who need them. According to USAID guidance, this assistance
involves financial support, training, and technical assistance provided by USAID-funded
implementing partners.
Appendix II: Countries Receiving U.S.
Agency for International Development
COVID-19 Vaccine Country Readiness and
Delivery Assistance

Appendix II: Countries Receiving U.S. Agency
for International Development COVID-19
Vaccine Country Readiness and Delivery
Assistance

Page 36
GAO-23-105579  COVID-19 Vaccine Delivery Abroad
Europe
and
Eurasia
(12)
Albania
Armenia
Bosnia and
Herzegovina
Bulgaria
Georgia

Kosovo
Moldova
Montenegro
North
Macedonia
Romania

Serbia
Ukraine

Middle-
East and
North
Africa (10)
Algeria
Egypt
Iraq
Jordan
Lebanon

Libya
Morocco
Syria
West Bank
and Gazaa
Yemen

Source: GAO analysis of US Agency for International Development (USAID) information. | GAO-23-105579
aThe West Bank and Gaza are territories not recognized by the U.S. as independent states.

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

Page 37
GAO-23-105579  COVID-19 Vaccine Delivery Abroad

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

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

Page 38
GAO-23-105579  COVID-19 Vaccine Delivery Abroad

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

Page 39
GAO-23-105579  COVID-19 Vaccine Delivery Abroad

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

Page 40
GAO-23-105579  COVID-19 Vaccine Delivery Abroad

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

Page 41
GAO-23-105579  COVID-19 Vaccine Delivery Abroad

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

Page 42
GAO-23-105579  COVID-19 Vaccine Delivery Abroad

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

Page 43
GAO-23-105579  COVID-19 Vaccine Delivery Abroad

Appendix IV: GAO Contact and Staff
Acknowledgments

Page 44
GAO-23-105579  COVID-19 Vaccine Delivery Abroad
Latesha Love-Grayer at (202) 512-4409 or LoveGrayerL@gao.gov
In addition to the contact named above, Joyee Dasgupta (Assistant
Director), Carolina Morgan (Analyst in Charge), Eli Dile, Kay Halpern,
Kathleen Monahan, Jason Bair, Gergana Danailova-Trainor, Mark
Dowling, Justin Fisher, Christopher Keblitis, Danny Lee, Amanda Miller,
and Aldo Salerno made key contributions to this report.

Appendix IV: GAO Contact and Staff
Acknowledgments
GAO Contact
Staff
Acknowledgments

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