 Good morning. Welcome. I'm Jen Cates with the Kaiser Family Foundation, and I'm so pleased that so many of you could join us today and hi to those watching online. We'll have this up later today as well. We are here to talk about the state of global health financing, and just we didn't plan it exactly this way, but it is World Malaria Day, and there will be some new data coming out on malaria resources, so we're excited that that will be here. This event has become one of our signature events, done with our key long-term partners, CSIS, and Steve Morrison and his wonderful team, thank you, Steve, and CSIS, and also IHME, always timed with the release of their annual report and related research, which is the cutting edge in this area, and I want to thank Chris Murray and Joe Dielman in particular for joining with us each year and allowing us to preview and show your amazing data that many of us use. I also want to thank my KFF colleagues for all their help here, particularly there's many of them, but I just want to single out Tiffany Fordfield, Stephanie Ohman, Craig Palowski, as you know, you can't make these events happen without the team. So going to the event, this event gives all of us in DC in particular an opportunity to take stock of where we are in financing and read the tea leaves a little bit from a policy perspective. For today's event though, we have a special guest who doesn't always, we don't always get to hear from him in DC, Dr. Tedros, the WHO Director General, and there are many firsts with Dr. Tedros, including that he is the first person from the WHO African region to serve in this capacity as WHO's Chief Technical and Administrative Officer. He has implemented incredible reforms and brought new vision to WHO and to the global community on health, including on UHC, and someone as we know with a long and proven history of making change in global health, and we're thrilled that he will be providing some remarks to us today. Before that, I want to set the stage with some new data that we just released. It's new polling data of the public's views about the U.S. role in global health, something we've been tracking for a decade. And I'm just going to have a few highlights. We have the data are all up now on our website. After I do that, we'll hear from Joe, who will present the new IHME data, and then Dr. Tedros, and then we'll go to our panel. And of course, your questions. So to start, if you live in Washington or you follow developments here, you know that the current administration has taken a different approach to international engagement, including on global health, and has signaled in many ways wanting to pull back from that engagement. This is important because the U.S. is not just the main funder of global financing. It's also been the value setter and helping to steer a global ship in many cases. So what the U.S., the direction that the U.S. goes matters. What we find in our latest survey, at least looking at the U.S. public, is a bit of a tension about this new direction. The administration's stance is somewhat at odds with where the public thinks we should be, but also there's a growing partisan divide. So first, for example, we find that most see that there should be a major role for the U.S. in improving health in developing countries. This is more true for Democrats, of course, but in general, overall, people want the U.S. to play a leading or major role. Second, we were curious to see what people want in terms of how the U.S. should work in the world. And we asked, do you believe that the U.S. should participate in joint international efforts or operate on its own? And interestingly, two-thirds, as you can see here, say the U.S. should work in joint international efforts. This is a cross-party. Of course, there's more Democrats and independents are more likely to believe this, but even a majority of Republicans say the same thing. And just so you know how we asked this question, we said, do you think the U.S. should participate in international efforts so other countries will do their fair share and efforts will be better coordinated or should the U.S. operate on its own so it has more control over how the money is spent and gets more credit and influence in the country receiving aid? So there was a clear preference for the first one. And this is important in the era of global fund replenishment, Gaby replenishment, and just thinking about how the U.S. should be going forward. Not shown here is trends on this. We actually have seen this trend getting more pronounced over time. People are more likely to say this now. And we also asked how the public sees global health as a priority for the Trump administration compared to others. And most say it's a lower priority for the administration and nearly four in 10 want it to be a higher priority. However, at the same time, we do see a widening partisan gap in this area. Over time, Republicans have gotten more negative about spending, saying that the U.S. is spending too much. Certainly it's not the dominant view, but it's more the view that's coming out on the Republicans, whereas Democrats have stayed the same. So this is a widening divide. It's not unique to global health, although global health has been more insulated, I think, than other areas. But it is something to think about this tension and what it means for going forward. And then lastly, I'll just leave you, before we get to the financing part of this, our own tracking specifically on the U.S. side of things and funding for global health. As everybody who works in this area knows, it's leveled over the past several years. The bump that you see is really the Ebola money, but it's pretty much been leveled. And the last bar is the president's current request, which as those following know is a couple billion plus more of a cut from where the funding is, not likely to happen. But I put it up here just as a reminder of the difference really in the value and the sort of message that is coming out between the administration and actually Congress and to a good share of the public. So moving from that, I'm going to now turn to Joe from IHME, who's an assistant professor at the University of Washington. He leads the resource tracking team at IHME and is responsible for this masterpiece. And I've learned a lot from him. He's a prolific researcher and also someone who is driven by wanting to help others and improve health outcomes around the world. Thank you, Joe. Great. Thanks so much, Jen, for the warm introduction. I have a bunch of slides, so I'm going to dive right in, but I don't want to miss the opportunity to thank four different groups of individuals. So first, thanks to Jen and also to Steve at CSIS. This event and partnership has been fantastic over the years and I really appreciate the opportunity to continue to connect and disseminate this research in this manner. Also, I want to be sure to thank the Bill Melinda Gates Foundation who have funded this research and then in addition, really thank the IHME team that has made this possible. Today, I'm going to be presenting research that has been put together and published in a 200-page report, as well as four papers, most of which are peer reviewed. To do all of that takes a large team of people making figures and doing research and collating statistics. And without this group, it certainly wouldn't be possible. In addition, I want to thank the Global Burden of Disease Health Financing Collaborator Network. That is an active research community that participates and helps lead this research. Again, for more information on that, I have a URL there and we're always looking for more people to join and participate. Like I mentioned, this is a new report that's coming out today. There's hard copies in the back if you didn't get one. And it's important to reflect on the fact that this is the 10th year of this report coming out. In the past, especially the early years of this report, it really focused almost exclusively on development assistance for health. And I think in many ways became a leader in this space as far as collating and putting together statistics on development assistance for health. More recently, we've added to that tracking of domestic spending and particular focus on tracking disease focus or disease-specific spending. And I'll present on that today. I want to mention the four papers that are coming out today. Two of them are already published. And again, hard copies, I believe, are available in the back. The first one is our capstone that has a summary of total spending on health across 195 countries. And it looks backwards and it looks to the future with some projections on what we expect past trends and relationships to say about the future. Additionally, we have a viewpoint that summarizes some of this research published today in JAMA. And then later this afternoon, two papers are coming out, each with a specific disease focus. So one will come out in Lancet HIV, focused, of course, on spending on HIV, as well as a paper in Lancet Infectious Disease that's focused on spending on malaria. The last thing I want to draw your attention to is our interactive visualization. I won't be using it much in this presentation, but it certainly lines up with IHME's mission and vision of making data and estimates publicly available for policymakers, students, advocates, and whatnot. And all of the data that I'm presenting on today are publicly available both for download but also in an interactive way on this website. So with a very few minutes, I'm going to focus on four key themes. First, I'll look at total health spending. Then we'll dive deeper and look at development assistance for health. And then disease-specific financing, specifically for HIV and malaria. And then I'll end today by talking about how this connects, in my mind, to universal health coverage. So here's a map. This is an updated version of a map that many of you may have seen before. It's looking at total health spending per person by country across the globe. And I simply want to draw your attention to the red countries, which is where health spending, measured in US dollars, is less than $100 per person per year. And those red countries collectively make up 2.8 billion people, or about 37% of the world. And then, of course, the blue countries in juxtaposition is spending where the spending oftentimes is about 100 times more per person per year and, of course, makes up high-income countries. Another way to split this apart is by looking at the global population and the total amount of health spending across the globe. And you can see that 81% of the $8 trillion spent on health in 2016 was in high-income countries. Of course, about half of that was in this country alone. And that spending represents about 17% of the global population. And in green, you see less than 1% of the total health spending, which is low-income countries. And that makes up about 10% of the global population. So one question is, of course, how does this happen? We know there's a very strong association between economic development and health spending. This figure shows that positive relationship using data from 1995. So each dot is a country. And the x-axis here is economic development, measured with gross domestic product. And the y-axis is total health spending per person. And you can see that as countries become more economically developed, as they have larger GDP, there is more health spending. And I think one thing that's really interesting and important is you really see this bar shift. You see that kind of uptick right around the $10,000 or $20,000 mark, that it tends to be relatively flat before that. So essentially low-income and lower-middle-income countries are at a very low level relative to the high-income countries. We can start to overlay this with more recent data. So now the blue dots are the same set of countries, but for 2016. And I think the really important thing to reflect on is that the major increase in spending is almost exclusively in high-income countries, the countries that are beyond $50,000 per year GDP. And if we start to look at our forecast, 2030 is important because it marks the end of the sustainable development goals, and 2050 is the furthest set of projections. And again, what you see is this ongoing increase in health spending in the highest countries, the highest income countries, but relatively low progress in the low-income countries. Another way simply to look at this is across time. The bottom part of these whisker plots is the low-income country health spending per capita. And you can see it's relatively flat. It is actually going up a little bit, whereas the top bar is the per capita spending in high-income countries. And you see, again, that's where the real growth is over time. And this is looking at the income groups as a whole. For me, this highlights one reason why it's important to continue to study development assistance for health. So this figure simply shows the total amount of development assistance for health provided by major development agencies to low- and middle-income countries to maintain and improve health. And you can see that in 2018, we hit $38.9 billion of total disbursements that year. One set of trends that we've commented on before is the fact that this period can really be broken up into three different epics. The first is the 1990s and first few years of the millennium, shows about 5% annual growth, whereas the next year, really the golden age, is we see major increase at about 12% a year. And then following, we see the most recent years of stagnation, where we see growth less than 1% per year. This can, of course, be split up in lots of different ways. This figure shows how it's split by the source of funds. This includes administrative costs. And we see that the United States government is the largest donor at about $13.2 billion. And I also call attention here to China, only because it is the first time we've been able to include China in our estimates. And we see that in 2018, we estimate about $645 million of development assistance provided by China as a middle income country. This can also be split up by health focus area. And we see that the trends over time for each health focus area are quite distinct. The bottom part of this stacked bar chart, the green, is spending on HIV AIDS, which we see at about $9.5 billion in 2018. But we've seen year over year reductions since about 2011, whereas to juxtapose that, we see child health is up at about $7.8 billion, but has continued to see gains since 2011. Quickly switching over and looking at disease-specific spending, this compares disease-specific spending on HIV with disease-specific spending on malaria. Now it's important to realize that these aren't the exact same set of countries. For our malaria study, we focused on 106 endemic countries where malaria is present or at least was present post 2000, whereas for the HIV analysis, we're really focusing on low and middle income countries. So not a perfect comparison, but still a pretty good comparison. Couple of really important things to point out. The first is just simply that the Y-axis, which here is billions of US dollars spent, is totally different between the two figures. So we see about $20 billion of spending on HIV in 2016, whereas we see just over $4 billion spent on malaria. They have similar trends, though. We see major growth in the first decade of the millennium, and then we tend to see some flatlining henceforth. The other thing that's worth pointing out is that malaria actually has more reliance than HIV on out-of-pocket spending and development assistance for health. Real quickly, focusing on HIV, one of the new things we are able to do this year is take the HIV spending, and particularly the domestic HIV spending, and break it out and look at where the money was being spent. So this breaks apart care and treatment, which is where we see a lot of domestic spending on HIV is going, but also looks at prevention and other spending. This figure highlights aid dependency in the HIV space, and again, I wanna draw your attention to the red countries, which are countries where we see that development assistance in particular is making up the lion's share of the financing. So this highlights aid dependency. The last part of HIV that I just wanna draw your attention to, and of course, more details are available in the actual paper, is our measurement of additional potential spending from the government, the domestic government, on HIV. So this graph looks at potential increases specifically for 15 countries. These are 15 countries that receive the majority, or at least a large part, of the development assistance for health that is for HIV. And it highlights in the green bar, where more domestic resources could be spent according to our econometric analysis. On the malaria side, I think one interesting thing is to start to break the 106 countries that we studied up into their elimination status. And so the green bar here highlights that the majority of health spending on malaria is occurring in countries that are controlling malaria, but rather than really a concrete path towards elimination. And another way to think about that is really asking the question where malaria money is coming from, depending on the incidence. And so this figure here has an x-axis that looks at the incidence rate of malaria. And so the countries that are on your far right are countries that are controlling malaria. They have a relatively high incidence rate. And as countries move left across the x-axis, they're essentially lowering the incidence of malaria. And what you can see across our analysis of these 106 countries, that as countries move more towards malaria elimination, they're relying more on domestic financing and particular government spending for those programs. So my last two slides are just to ask the question of how does this connect back to universal health coverage? The first thing I wanna draw your attention to is actually a slide that I showed earlier, but highlight one spot that is showing up here with a red box. And that is essentially the health spending per capita in low-income countries projected in 2030, the end of the sustainable development goals. And highlight the fact that that, the amount of resources that we're estimating there is right around $50 per capita for low-income countries, measured in inflation-adjusted US dollars. And so what that suggests to me is that there's a major constraint on the amount of resources that will be available to reach that goal. Second part of universal health coverage that I'd like to connect with is thinking about where resources are coming from. We know that a major part, or major goal of universal health coverage is to minimize, or I should say, maximize financial risk protection and minimize out-of-pocket spending and catastrophic health expenditure. This figure highlights the 3.2 billion people that live in countries in 2016 that had the majority of their health financing come from development assistance or out-of-pocket, which we know essentially minimizes financial risk pretension or at least sustainable long-term financing for that. So that I'll close and turn it over to Dr. Tadros to continue looking at universal health coverage. So slight change. Dr. Tadros is running a few minutes late, probably according to our original schedule, but Joe is available to take a few questions on the data that he presented before we get into the broader discussion and the panel. So please take this opportunity to, I'm gonna let you come back up and do that. Great. For those who are watching, so if you could just wait one minute, we'll be able to capture here that comes. Thanks. Thank you very much, Michelle Forsley. Since there's a strong association between economic development and health spending, I wonder if you have looked at the amount of spending on economic development in comparison to health spending to see if we can't design a proposal to our funders to parallel their spending in a way that supports both. Should we take a couple questions or should I answer that right away? Good morning and thank you. My name's Felice Aptor. I was really interested in the analysis you did on potential financing available from governments and it would be really helpful if you might share just a few top line ideas about how you did that analysis. Yeah, of course. Thank you. Good morning, my name is Jacob Hughes. I'm with Management Sciences for Health. You presented a slide about the potential for additional HIV spending and I wonder if you can clarify, is that additional funding for health overall or is that within the health envelope how funds could be moved from other priority areas over to HIV? And I have a second question about the survey findings that were presented at the beginning. Very interesting survey findings. Thank you for those as well as thank you for your presentation. Were there any questions directed at public perceptions of USAID's new policy orientation around self-reliance and sustainability? That would be interesting to hear as well. Great, so I'll try to address all three of those questions. So we have not looked specifically at development assistance for broader economic development. I think within the economic development community and just the development assistance community in general, there's more and more conversations about how to take resources that are maybe earmarked for a specific sector and think about how they interact together. And so I was having interesting conversations recently about thinking about how health funding, development assistance for health, lines up with climate change funding. Again, a very pertinent and important topic. Thinking about how health can be a catalyst for economic development is critical. And something that IHME has done a lot of work in specifically looking at how human capital connects back to economic development as an input. The idea that essentially you need a healthy workforce to be educated and to then work in order to lead to more economic development. So that's one way that we've thought about it. And then for the two questions about potential additional spending from governments on HIV, I think this is new novel work for us. We're very excited about it. We chose in this analysis to take the perspective of the Ministry of Health. And that's important because we kind of assumed then that the health budget for these countries is fixed. You could take a different perspective in this analysis and think about maybe a ministers of finance perspective where the minister of finance might be able to allocate more resources towards the health sector. But in our case, we really focused on thinking about if what is this constrained budget could more resources be spent? And you asked for some more top line kind of takeaways from that, I point you to the paper as well. But for me, I think one of the most important takeaways is that where we found additional resources were available was mostly in middle income countries. And the amount of additional resources available in low income countries was quite constrained. And again, it connects back with this kind of concept about where is development assistance going in the future? And is there a role for development assistance, particular in this case in funding HIV prevention and care? And I think certainly our potential spend analysis would suggest that for HIV, there certainly is a need for ongoing support. I ask on that question, but it's a good one. And we have a whole list of ones we'd like to ask. Thank you. Other questions for Joe? Let's take a couple more right back there, up here, and then we'll get one more. Good morning, Patricia Wu with C&M International. You have on the Lancet piece here a really beautiful chart that shows a composition of health spending by source. I think it's over time. And I see here that prepaid private spending was kind of a smuss liver, but seems to be growing a bit more. And I'm wondering if you can comment a little bit about the nature of that and also kind of implications for the future. Hi, Ted Pacone from the World Justice Project. On your slide comparing spending for malaria and HIV, have you done a breakdown on a per capita spending, in other words, a number of people who are actually affected by the disease and also mapping it geographically and by income? Hi, Trish Moser. Also, is there any way that you're able to look at this in terms of efficiency or value for money, something like that? Yeah, great questions. So I'll try to take them in order. The first one, it was about the composition figure and about prepaid, thank you. So prepaid financing is an interesting bucket. Everyone understands government health spending. That's pretty clear. Development assistance out of pocket. Those are our three categories that most audiences immediately connect with. Prepaid private is essentially private insurance and we do see it growing in some places. It remains a pretty small sliver in most countries, including many high income countries and that's partly the way that it is defined is if private insurance is mandated, it is considered by our taxonomy which evolves from the national health accounts and others, it's actually considered government spending. And so there's just kind of an interesting nuance there and that's why it remains a pretty small piece because it's really only considering spending that is voluntary contributions to private insurance. And so yes, it's growing, but I think we don't expect it to necessarily take off as a major financing mechanism. Regarding the comparisons on malaria and HIV, we cut this up all different ways. And I think really right now there's two separate papers and I think we're really just at the tip of the iceberg of putting the two together and saying what can we learn about malaria by looking at HIV financing and vice versa. Because there are some really important similarities. There's also really important differences and I think learning from the two is important. You raised the question of per capita and I think that is something we've talked a lot about. We can look at it by per capita. It can also connect to the global burden of disease research and be analyzed per incident case or per prevalent case. And it really begs the question, which way should it be looked at? If you're interested in a malaria elimination, you probably don't wanna look at it per incident case because the numbers get really crazy as a country gets close to eliminating malaria. If you look at it per capita, it assumes that everyone is susceptible or potential candidate for the disease and that's not always true as well. So there's really lots of interesting conversations to have about what's the appropriate denominator for those statistics. And the last question was over here and if someone could remind. Efficiency, yeah. We are very interested in looking at efficiency. Our analysis, and I don't have materials on it today, but we've done analyses that connects pooled financing. You see that video? He's right. It connects the pooled financing to universal health coverage or health access and quality. And there you can actually see how spending leads to improvements in those spaces and also the inefficiency can grow or shrink and I think that's really exciting ongoing work. So it is now my pleasure to introduce Dr. Tedros who's joining us from Geneva to share his thoughts on where we are, where we're going, where we could go. We're honored that he's here joining us. We thank him for doing so. Before I turn to him, I really just wanna say one thing, in addition to what I said about you earlier, but a bigger issue I think that we're all, we should all acknowledge the most recent or one of the most recent tragic killings of one of WHO's frontline Ebola workers. We send our condolences to WHO, to healthcare workers everywhere who are on the frontline. And it's just a really stark and sad reminder of the complex times we live in. Our thoughts are with you and the WHO family. So thank you very much for being here. Yeah, thank you. Thank you so much. I'm really glad you started with that tragic event over the weekend. It's really sad. He was a very young epidemiologist and, you know, he was only saving lives. He, it's his commitment and so on to people's lives actually that made people so sad when he was killed. And thank you so much for your kind words. But that attack on him is affecting the program now. Many of our colleagues are very much shocked and our field operation has actually been significantly affected. And I will be traveling to Butembo tomorrow to stabilize our staff, to show solidarity, but also to discuss with Monusco on improving, beefing up the protection. But still, I think this attack should strengthen our resolve and should even be a message for all of us to fight even harder because that's how we can even respect the friend or colleague we just lost over the weekend. So thank you so much for starting with Richard. And we will remember him and really strengthen our resolve in order to finish Ebola in DRC. Chris, my friends, Chris Mary, Joe Dilman, Lloyd Space, Chris Collins, and Jennifer Cates and all participants, I would like to start by saying good morning. And it's such a great honor to be invited to take part in this important event. I'm really sorry I cannot be with you in person. As you know, we're witnessing a profound and positive transformation in global health financing. In February this year, WHO launched a report, Public Spending on Health, a closer look at global trends that shows total health spending around the world is growing faster on average than the rest of the global economy, accounting for 10% of global gross domestic product. In low and middle income countries, health spending is growing fastest with average growth of 6% every year, compared with 4% in high income countries. Even more importantly, an increasing proportion of health spending, an average of 51% is coming from domestic public resources while a decreasing proportion is coming out of people's own pockets. That's reason to celebrate, because it means fewer people are at risk of being pushed into poverty by out-of-pocket health spending. As you probably know by now, universal health coverage is one of my and WHO's top priorities at the heart of our strategic plan is for one billion more people to benefit from universal health coverage by 2030. Ladies and gentlemen, universal health coverage is not a luxury that only rich countries can afford. All countries can make progress with the resources they have. WHO estimates that 85% of the costs of meeting the Sustainable Development Goal, health targets in low and middle income countries can be met with domestic resources. That means universal health coverage is not an economic choice. It's a political choice. And it's a choice that many countries are making. Just in the past year, Kenya, India, the Philippines, South Africa, and other countries have made significant strides towards universal health coverage. In each case, political leadership at the highest levels was essential. These examples prove that with political commitment, all countries can make progress and they can do so by committing their resources, progressively expanding access to services and taking other steps to reduce out-of-pocket spending. Primary health care services must play an essential role in ensuring everyone has access to the health services they need. Primary health care is a good value for investment. When countries have quality primary health care available, they can save money and improve efficiency by reducing expensive hospital admissions, as we all know. At the same time, however, WHO's report on health spending shows that increased domestic health spending does not always translate into increased access to health services. This is where countries need our support and guidance to make the best investments and get the biggest bang for their health backs. More money for health is good, but more health for the money spent is even better. Sustainable financing for universal health coverage is not just about spending more. It's about spending smarter and using innovative ways to raise funds. For example, by taxing tobacco, alcohol, and other harmful products. Progress toward the universal health coverage is a complex process, and we all know this. WHO does not endorse one specific approach to health for all. We know that country ownership is essential to sustainable progress toward the universal health coverage. Every country has a different profile, and there is no one-size-fits-all approach. We have a lot of evidence that shows that all countries can reach universal health coverage. While each country will take a slightly different path, there are clear principles that have emerged from our experience over the past 30 years working with countries at all income levels. First, countries need to move towards reliance on public funding sources by strengthening domestic tax systems and ensuring health as a priority in resource allocation. This requires political will and insight into the steps that will make a country stronger across the board, above and beyond specific health indicators. Within a well-designed national health financing strategy, private health insurance can play an important complementary role. But domestic public financing is the bedrock of universal health coverage. No country has ever achieved UHC by relying mainly on voluntary private funding. Second, fiscal policy actions such as increased taxes on tobacco, alcohol, and sugar, as well as carbon emissions are proven ways to raise funds and improve health at the same time. This also require political will along with an enlightened social consensus. Third, funds should be pulled to reduce inefficiencies created by duplicative approaches such as silos created by these specific programs. To put it another way, pulling off funds empowers countries to take a holistic approach to providing access to health care, an approach that's aligned with the course of each person's life. Fourth, countries need strong institutions, excellent people, information systems, and decision-making processes, so that resources are allocated based on provider performance and the health needs of the people they serve. Weak institutions breed weak access to health care, external aid accounts for less than 1% of health, total health spending, and recent numbers show it's declining overall. However, it remains important for low-income countries where it represents about one set of health expenditures on average. It's essential that these countries receive more streamlined and comprehensive external support to strengthen their national health financing institutions. At the same time, these countries need to develop their domestic financing systems to make more effective use of resources both external and from within. The Global Action Plan for Healthy Lives and Well-Being is supporting country action on building sustainable financing. Partners, including the World Bank, the Global Fund, GAVI, GFF, and others are working with the WHO Hosted Health Financing Collaborative to set harmonized approaches, instruments, and methods of work across agencies. These global public goods are integral to the broad UHC 2030 partnership. Health spending is not a cost, it's an investment. Health is a driver of economic growth and a platform for sustainable development. Health creates jobs, it drives productivity, it stimulates inclusive growth, it protects economies from impacts of outbreaks and other emergencies. Investments in health in recent decades have already generated a huge payoff in terms of human capital. Between 2000 and 2016, global life expectancy increased by 5.5 years. We have prevented millions of cases of and diseases from HIV, malaria, and TB. There are millions of women alive today who 20 years ago would not have survived childbirth. There are millions of children alive today who 20 years ago would not have survived to their first fifth birthday. Thanks to improvements in access to health services, particularly vaccinations against deadly diseases like measles and diphtheria. Countries that invest in building resilient health systems based on strong primary health care are making investments that will pay rich dividends for decades to come. Governments have a key role to play in ensuring everyone, no matter who they are or where they live, has access to health services. We must not leave anyone behind. As we work together to support countries on their journey toward this inverse health coverage, we're not just working for a healthier world. We're also working for a safer, fairer, and more prosperous world for everyone, everywhere. And thank you so much for inviting me. And I thank, especially Steve Morrison for his invitation and for making my participation happen. Thank you to all colleagues and friends. Thank you. Thank you so much. This is Jen Cates. You might not be able to see me, but we really, really appreciate you taking the time to share your thoughts. It's such an important, not just a compliment, but the data are one thing, but really hearing about what we have to do, how we act on this information is what we all need to be thinking about. As you know, we've invited you to stay on and listen in or participate, but we understand that you have a very busy schedule. So we will say goodbye, and thank you again for being here. Please join me in thanking Dr. Tedros one more time. Thank you, thank you so much. Thank you. Thank you. And now we will move to our panel. So I'll ask our panelists to come up and take a seat, and we'll get started. Remember to turn on your mics. Fortunately, Dr. Tedros is quite a presence. So the fact that he was small on the screen does not matter because he shared his vision and ideas with us and his bigger hero than his little picture, so great. So now I'm turning to the panel, and this is always a great part of this event because this is where we get into, and we've seen the data, we've heard sort of the vision, now we can get into the issues, and we've put together a group of people that I think are the best to talk about these issues, and then of course we get to you all to ask questions. So I'm just gonna briefly say who's here and then get into our conversation. They're full bios, you have them, but just very briefly, Dr. Chris Murray, who's the founder and brainchild and leader of IHME, one of the world's, he's one of the world's most foremost experts on developing the Bank of Evidence and Analysis needed to understand health trends and issues, and it's pioneering work that we really rely on as the standard out there. Also, Chris Collins, who's president at Friends of the Global Fight Against AIDS, tuberculosis and malaria, where he leads Friends' effort to educate and engage U.S. decision makers on the work of the global funds. He's also been at UN AIDS, AMFAR, AVAC, and other amazing places, and is the smartest advocate strategist out there. Then we have Lois Pace, who's the Global Health Council's president and executive director, who's also held many leadership positions, including the Livestrong Foundation, the American Cancer Society, among others, and she has worked to elevate the voices of global health organizations in D.C. at WHO and around the world and brought new energy to the community. And then finally, Steve Morrison, who's a senior vice president at CSIS and director of its Global Health Policy Center. He's the main partner for us, and I was thinking about it, Steve. I think we've been working together on these issues for almost two decades, dare I say, and this is one example that we look forward to every year. So now I'm gonna go to our palace and we'll start with Chris, because one of the things, for those of you who've been at this panel in the past, know is that Chris will always listen to all of this and then tell us the big story here from the data picture and also maybe give us a little preview about what's next, because we always get a sense of where's IHM gonna go, and if just even maybe five years ago or six years ago, this issue of looking at domestic spend and really getting more granular was an idea. And the fact that it's here, not just on general domestic health spending, but on HIV enamel area is quite a leap forward. So I'd love to hear from you what you see, what your big takeaways are and where we might be going. Great, thanks, Jen. And it's working out. Great to be here. This is always a great event. I would like to combine what Joe was showing on the trends in spend with work that we published last fall on various future health scenarios, because I think looking at the two together sort of points out to some real issues that we may be facing. So first reflection is we're spending more, but we're also seeing steady improvement in health and that's great. There's been real progress and I think there's a pretty direct connection. You see it for HIV, for malaria, but I think we can see it for child health, maternal health between spending and that progress. In the forecasting as we go forward, that progress is statistically likely to continue as is the growth in spend, but we produce a range of scenarios and there's scenarios where like we've seen the spending on DH, stagnate, we can well see progress in health slow down or stagnate, probably not reverse. The overwhelming thing to me though is both in where the money gets spent and the future trajectory for health is that we're gonna have lots of inequality still in the world even in 25, 30 years and that's really quite extraordinary if you think about it that despite all the technical advances, all the sort of global dialogue about focusing on the worst off, we will still have really marked inequalities if trends continue. So in other words to not be in that situation, something really has to be quite different than what we've been doing in the past. And I think when we see the thing that comes out of the financing research that's the most alarming in some sense is not the flat line on development assistance. That's obviously a great concern and we should be lobbying to try to change that trajectory, but it's the really slow growth in spend in most of the developing world, particularly the low income countries where we're not seeing the percent increase in spend that would need to be there to really create the amount of spending to deal with this sort of resilient inequalities issue that we see in the various scenarios. And I think if you think about the vehicle by which we might have fewer inequalities in the future, it's all, it would require us to tackle some of the sort of classic risks associated with poverty, scale up primary healthcare and UHC. But when we look at the relationship between spend and UHC, UHC as it currently exists, as it currently measured, is pretty expensive. If you take the frontier of that relationship to spend our way into complete UHC is extraordinarily costly. And what the financing research says is that's just not gonna happen out of domestic spend. And so some middle income countries, even some lower middle income countries can, but for the worst off and most of the lower middle income, I don't think that's gonna occur. And so we really have to, where that drives me is, what's the innovations that we're gonna do that get us to somewhere where we can have a prospect of getting closer to the SDGs? And sadly, when we look back over time, there's very little evidence on average that the efficiency of the world's health systems is getting better. There's change, some countries get more efficient, some countries get less, but there's not much net progress on efficiency. And so that whole area of how do we make systems more efficient, we're not succeeding on that front. And so where we'd like to go on the work that we do on data and on forecasting at IHB is continue this trend of more granular analysis because I think it gives you these much more tangible insights on the disease specific areas. And wire up our forecasting work more directly between what gets spent domestically on health and on UHC and on disease specific programs to the different scenarios that we produce. So we produce these reference better worst scenarios, they implicitly have assumptions about spend, we wanna make those explicit so that decision makers or different groups can sort of turn the knobs and say, well, what would be different from malaria if we spend more on malaria? What would be different if we spend more on UHC? So those are some of the directions we'd like to see. And sort of, I think we have this sort of yawning gap between aspiration, desire of us all collectively and where the money is. One follow up. One of the potential applications of this work that I think we began last year when the HIV spend data was available, but now malaria as well is to, if donors and others are interested to really do a better job targeting where they're focusing their resources. If we have a better idea of the places where there is more room for more fiscal space for growth, of course, there's a lot of complex factors to look at. Have you seen, has that conversation happened yet to your knowledge, or do you see a way to kind of push on that a little bit? I know it's risky, there's many reasons why a country that might on its face look like it has fiscal space to spend more might not be able to do so, but. So I think this whole issue of targeting effort and the whole construct around precision, public health, if you will, is something that we're trying to contribute to by doing lots of an increasing array of highly spatially resolved analyses for different outcomes, for coverage of vaccination that just came out as an example, and we'll see more and more of those from us and from others. So there's gonna be more data tools available that tell us where disease and gaps in coverage are. Likewise, I think if we can get to that sort of disaggregated spend information, even within countries, that would be incredibly powerful to sort of put those two together. But here's the part that I also think we really need to think through carefully as a community, which is some things we should target. Bed nets should go to those who have malaria transmission or in need, and some things are universal as in universal health coverage. And we probably don't really think we should be targeting access to general primary health care. And getting that nuanced understanding of where targeting is the right thing to do versus where universality is the right strategy, both because it's gonna create buy-in in societies for health systems, and because there isn't a great utility in targeting. That's the part that I think we're not that advanced on. To your question, are people starting to think this way? Sure, I was just in Indonesia at Bapinas rolling out their health sector review where they're using, not hyper granular, but provincial level burden of disease data to say, look, we should focus some strategies more in different provinces than in others. And so I think that's starting to happen in some countries, but it would be great for us to sort of have a clearer sense of where that's the right way to go and where we should be investing on the universality. Thanks. Okay, so I'm gonna turn to the other Chris, Chris Collins, to talk about the Global Fund in particular. And for a lot of reasons, I mean, the Global Fund, if we think about it, is the largest financing vehicle in global health right now, so, Chris. Great, well, thank you, Jen and Steve for including me in this fascinating discussion. You know, I think when we're talking about the challenge of getting to UHC, but then also the great challenge of defeating the three biggest epidemic killers in the world, we just need to continue to understand and appreciate how those efforts do reinforce each other right now and how they need to reinforce each other even more so in the future and design systems that are able to do that. You know, it's obvious that we're not gonna end the epidemics of AIDS, TB, and malaria without there being stronger health systems that can serve the needs of folks that are affected by those diseases, the diversity of needs that they have. By the same token, any good health system has to be able to help people who are confronting those infectious diseases. They need, health systems need to be able to address those three infectious diseases. So, I think that we need to look at how do we get the financing right, as you're saying, to be doing both these very focused things but also growing primary healthcare. In the case of the Global Fund, this is a perfect example because, you know, it's very much focused on ending the epidemics of AIDS, TB, and malaria, but to do that job and to produce results in those areas every year, you've gotta be making health systems investments all the time and human resources for health and data and laboratory and all sorts of other areas. In fact, the Global Fund is the biggest financial of health systems strengthening in the world. They put in about a billion dollars or the four billion they spend every year out in countries around health systems. And it's also important to understand how vertical efforts have been foundational for leading to stronger health systems in general. Japan is an example with when they scaled up their response to tuberculosis in Japan, really used that as a way to build out a broader health system. The president of Kenya has said that he thinks Kenya's effort to eliminate malaria in that country is gonna be foundational in terms of them pursuing universal health coverage. We also know that there are other benefits when we invest in fighting disease through the Global Fund and other platforms. There's just a study that came out of Georgetown University, the O'Neill Senator, that found that in countries that are big recipients of Global Fund financing, you see really distinct improvements in governance across a whole range of measures of that. And there's reasons for that because there's a lot of things built into what the Global Fund does in terms of stakeholder engagement, broad engagement, and decision making, civil society, attention to human rights. But we are actually seeing now the evidence that these investments in health are leading to better governance. So just need to understand how the efforts right now are really connected, both on a disease level and a broader level, and think about how to make even better use of that going forward. I do think that as we're talking about as a community, both in the United States and the U.S. donor role, but also globally about how to think more broadly about building primary health care, that we don't lose the values that have been so effective in the vertical programs in many ways. And frankly, I come out of the AIDS movement, I would say also similar values that are in the AIDS movement, which include really demanding results, demanding sufficient financing, demanding services that are provided in a way that respects human rights, and addressing the needs of key populations. So as we think more about funding universal health coverage, both domestically and as donors, and the connections to that with vertical programs, let's not lose those good values of results orientation and those other things that we've seen come out of the vertical programs. The stakes are super high right now, you know that. We are under-investing in ending the three diseases to the tune of about $10 billion a year. We're under-investing in what we need to be doing to end AIDS TB and malaria. It's global fund replenishment year, so it's really a great year actually for all of us to be standing up and talking to elected officials about the opportunity and the need to invest. And you know, just to put that $10 billion in context, we are, as we saw, we're kind of stuck in this flat line world of donor financing for health, and it needn't be that way. It's just kind of nuts to be honest with you that with $10 billion we could get on track as a world to end the three biggest infectious disease killers. I just looked up on my cell phone about an hour ago, found a study from Congressional Budget Office from a year ago. They say that if we did a financial transaction tax in the United States at about 0.1% of financial transactions, it would generate nearly $800 billion over 10 years. That's about $80 billion a year just by doing that. So, and that's just for the United States. The world can come up with another $10 billion to end AIDS TB and malaria by 2030. We just have to keep challenging ourselves to do that. I would also say, we're in a presidential cycle. This is a great opportunity for candidates to start, for us to get candidates to start articulating what they're gonna do to end these pandemics, the pandemics of today and prevent the pandemics of the future. I think also in Congress, there's a hunger for new ideas about global health. There's a lot of pride, rightly so, in Congress in what the United States has done in terms of leadership on global health. And I think there are a lot of new people there, but there's also people there that have been with our champions for a long time that are ready to hear new ideas about how we advance global health, continue to make the measurable progress, but also address a broader range of issues, continue to show results and continue to engender greater domestic investment. So, I really think we have the potential there if we seize it. Thanks. I have more questions for you, but I wanna go to Lois because you talked about sort of the ideas and the success elements of the HIV movement. And one of them I would say is the, sort of from the outset, the civil society driving that movement and the role of community and civil society. And so one of the things I know Lois has done and also has been just in general an issue that's been out there is how do you further engage the voice of civil society generally on global health? So it's not just where HIV's been quite successful, but beyond that, but then also not just in the US context, but at WHA on the global stage and how you see that as playing a role in the financing and UHC side of the equation. Yeah, no, well first again, thank you. Thanks to you, Jen and Steve for having me here. And obviously thanks to IH and me for always delivering such robust data for us as advocates because we really do see it as a great tool in the work that we do. And first and foremost, I see it as confirmation. I think we all saw this coming. I mean, we knew that the trend line was sort of moving in the wrong direction and it's sort of not surprising to see that born out here with the data. We know that sort of the ask is sort of outpacing the reality of funding and the resources. And it's a gap we've been trying to close in our advocacy for example with the recent high level meetings on TB and NCDs. And now with UHC, I think we as a community have constantly been asking, well, what about the financing? Because it's a question that a lot of those conversations and debates have largely avoided and it's been quite frustrating. So we definitely wanna bring that to the fore. And I think that, I guess I see it as sort of two options. One is as Chris was saying, we can really dig in our heels and amplify the advocacy that we have been doing along these vertical lines and that's still critically important, particularly in replenishment years and as we think about reaching the finish line and infectious diseases in particular and in the big three, right? And so that's absolutely something we wanna keep doing. But I think the other Chris was saying, well, but do we keep trying to do the same thing? I do think that what's required now is a game changer and we talk about that in terms of policy and programs. We don't always talk about that in terms of our advocacy. And there is interest in our community and there are conversations in our community around how we can begin to or better mobilize around a common cause, whether that's UHC or some other banner initiative. I mean, we saw the beginnings of that with the SDG process and that agenda. But I would argue that that joint advocacy hasn't yet taken off. And I think that is what's required if we're going to as the IHME sort of reports are saying really spur prioritization in how to ensure that as countries climb the economic development ladder, they truly are making these holistic health investments. And that's, you know, again, I think we can carry two glasses of water at once and people in this room and on the webcast have heard me talk about sort of defense and offensive strategies. So the defense is still, let's get that line up if not maintain it where it is, but it's also looking offensively at how we can create new ideas and new action that can really move the needle because it's not happening now. And I think that that's something that concerns us, but it's something that we see piloted by, say, GFF. You know, you have global financing facility coming in and saying, okay, well, how can we get civil society to support countries and their packaged plans and how can we collectively promote a broader or collective health agenda? And it's building on the great work of, say, the Global Fund in Gavi. You have these existing networks in countries, surely, who have effectively argued again for very specific programs and dollars and the people on the ground are more than willing to wear multiple hats and to fight for immunization and HIV and malaria and TB and cancer. I mean, we meet these people on the ground all the time. And so coming back to what it looks like in country and the reality, I mean, not only is this, I would argue, a necessity and I think Tedros was getting at that as well, but we can do this. We just have to start it. And there's been fear and debate around how it gets done, but I think it's more natural than we realize and it doesn't have to be an either or. It can be a both and. Great. Steve, I'm gonna go to you to give us your great insight on the outlook or what you see. And I know you tend to be a realist, maybe pessimist in this regard, but maybe not, maybe you'll surprise us and give us a really rosy picture of where we're going, but I would love to hear from you about the current political environment for considering everything we've heard so far. What should we be thinking about, worrying about being optimistic? You asked me to talk a bit about US leadership and what does this mean and I'll concentrate most of my remarks on that. And in my closing remarks, I'll come back to sort of the stark contrast between the hope that came across in Dr. Tadriel's vision of UHC and the sort of stark realism that comes across in the IHME presentations. Those two are not fitted together in any clear, complimentary way. It's, we build this as hope and reality and we got it. The, I'm also encouraged that Dr. Tadriel has drew attention to what's happening in DRC and I think that needs to be registered. Dr. Mazzocco's deliberate, the deliberate murder of Dr. Mazzocco is part of a broader trend of targeted violence against the health sector there and it is at a crisis point. And that operation, we've now crossed, I think 1400 cases over 800 fatalities and it's hanging by a thread. And so I do think that is something that deserves very high attention, much higher than what we've seen in the security challenges that he enumerated and pointing to the UN peacekeeping operations as probably the only option that we have at the moment. In terms of US leadership, I think we're at an odd and paradoxical moment. I mean, the gains, the different epics that were laid out, the high growth phase, the 5%, the 11 point something percent and then the stagnation period. US leadership across all three of those has been very fundamental and that leadership has started and remained at the White House, backed by strong congressional bipartisan support and backed by strong support from other Western donors along with key partners at the leadership level in Africa and elsewhere. And I would, I think today the picture is very ambiguous. The US leadership is no longer, the US is no longer a visible and active leader in this domain. But on the other hand, as we saw in the data, we're still at one third, we're 13.2 billion. So our leadership in sustaining the stagnation period, which I think you can argue that if there hadn't been US leadership since 2011, the picture would be much worse than what it is today. So we have this paradox where the active and visible leadership is no longer there. The money is still there. Global health hasn't entered the firing line as trade or alliances or Iran sanctions as a top line priority. And the bipartisanship has been preserved although it's very frayed. It's getting much more frayed. I think the things that have changed that we need to point to as vulnerabilities and places of concern at looking at what the future would bring would be, first of all, what is the corrosive impact of having three years running of assaults upon budgets? And when you look at the most recent budget submission, it's not just that it's three billion below current levels. It's calling for changing the equation for the global fund, dropping a billion, changing from a two to one match to three to one. Beneath that is an assumption that we as a country should no longer be in the same leadership position that we have been in. And there's an implicit recognition that we're in a deep predicament about sustaining funding and the US should begin thinking about getting out of being in that leadership position. That's how I read that. Let's not own this problem to the same degree. Let's move back from owning this problem. A second dimension is the news national security strategy which posits that our greatest concerns are a confrontation with China and Russia, with others in the mix, Iran and North Korea. Global health is no longer tied in any explicit fashion to US national security strategy as it has been in the past. That is no longer the case. And if you look at the response from this White House to the Ebola crisis in DRC, it spells itself out very clearly that this does not merit the same level of leadership and attention. And in fact, the health security director at the White House has been dismantled and scattered. So it's another very important step. And in terms of our allies that we've relied on so much, you know, we're in a phase of populist nationalism and it's not just here, it's in Europe. And migration is the dominant, the dominant dimension. And it is something that is really eating away at the notion of an enduring normative and institutional approach, a liberal Western international approach, which global health is dependent upon that vision in order to be sustained. And yet that vision is eroding fairly quickly. And I would say also that our alliances with South Africa has one very important instance of a country that we rely on, have relied on as a partnership in terms of reminding people of the huge investment we've made and the huge need to stay that investment. That itself is in a quandary and a very difficult position at this moment. So what does this mean? I think that what this means is our leadership role will limp along, I don't see it as a risk of precipitous collapse, but I think that there's higher and higher uncertainty surrounding it. And we have to ask ourselves what will be the damage over time, incrementally and corrosively of this. And when we look at what's happening in the data that Jen cited in terms of the divergence of opinion among Republicans and Democrats, are we at risk of this becoming like climate change where it begins to divide along party lines in terms of the support and the like? When we get to what's next here, I think it's important to say that we really do need new thinking of a much different type. We're not gonna go back to the status quo. Anti, we do not see clear security threats tied or national security strategy and we're not gonna go back. And this question, it seems to me, is really very fundamental and very much up in the air in terms of where we go as a country in our global health strategies. And the election cycle that we're entering is, I agree with the other speakers have said, the election cycle is a choice moment for beginning to try and do some of that new thinking. But I don't think that falling back on the language and logic that we've used up to this moment is necessarily gonna be what pulls things forward. Thank you. Thanks. I wanna know if anyone on the panel wants to respond or add to that. Because I think that's really the fundamental question, I think, for all of us working in this space. I don't know. I can be more specific and say that Steve talked about wondering if this partisanship or global health becoming more partisan potentially among some. It's certainly in the White House view is that way. Is do you see that in your work? You're on the hill all the time. You're talking to the community. And do you see that bearing out as well? Or do you still feel like there's a preservation of something different? And other Chris too, if you... And I have a couple of questions for you about the IHME analysis before we go to your questions. Yeah. I'm seeing the bipartisan support for global health quite firm. I mean, I don't see that slipping. I actually get the sense that members wanna hold on to that as one of the unique places where they can find the collaboration. I've seen no slippage over the last, during the life of this administration. Maybe even stronger, really, because the leadership and appropriations, for example, I think the work they've done in terms of global health leadership is a badge of honor for them and it should be. I don't think they wanna give that up. They certainly haven't shown that they want to in their appropriations bills. I think this year is no different. It's tough with the funding pressures overall on the state foreign operations bill. We absolutely need a cap steel this year to loosen up additional resources for that appropriations subcommittee bill. But I think the strong support is maintained. But again, I would agree with everyone. It's time for a fresh idea, not at all abandoning the good things we've done before. We need to finish the job with ATB and malaria. But we also need to think about how do we rally the world to join us in a stepped up effort that can more broadly help countries address primary health care needs in general. And the conversation I think we need to have is how do we do that? I mean, how do we do that in a way that it's effective for people but also politically sustainable? How does that effort maintain the real results orientation? And one reason that the funding keeps flowing from the United States is our bilateral programs on the global fund can say, this is how many lives we saved this year. This is how many bed nets we got over kids in Africa this year. Those sorts of metrics and specifics about impact are absolutely essential not to lose just to maintain the political support. So we can't lose that and we can't lose a lot of the really prudent management pieces that are brought by, for example, our bilateral programs in the United States. So, and again, we have the presidential race. So I think it is a time for all of us to find ways to come together. Lois has brought people together around these issues. We need to be having these conversations now because it is a time where I think on the Hill and in the public, I think your polling data is just a whole another example. There's an interest there. There's an understanding of the great things we've done as leaders in global health. I think there's a hunger for a new idea. Well, and Chris kind of covered, I love when my members do our job for us because it means our work is working. But I want to connect these two thoughts, right? Because while, yes, the bipartisanship has been maintained to some degree, we have seen, even if it's not a sense of partisanship, we haven't been able to fill the pipeline of champions, I guess. Considering all the new blood that has come to the Hill, there isn't a ton of, I guess, automatic interest in these issues in the way that there has been throughout the Golden Age. And so what we at GHC are trying to do with our members is use this new idea to inspire that participation and that engagement. Because that, it's our sense that that's what's required. I mean, think about everything that's in the narrative right now, right? Whether it's Green New Deal or Medicare for All, what's our equivalent in global health? And if somebody were to ask me, which they have in these rooms, well, forget eight billion or 10 billion, if you got 20 billion, what would you do with it? We don't have an answer to that. At least a consensus response to that as a community. And that's a problem. And because again, we've been so focused on how we have been doing business to date versus really how we can change the game for tomorrow. And so that's, I really want to drive home this big idea conversation because it's the time is now for us to do it. And I would add, we are seeing this administration come up with their own ideas. Whether or not everyone's comfortable with some of those proposals is another conversation, right? But whether it's a journey to self-reliance or some of the other policy proposals that have been put forth, again, our community has to match that innovation with our own proposals and with our own ideas. And so that's something that we collectively are really trying to do with the community. And I think that that's the call to action. We want to leave with people here today and just continue to drive home. And part of, I think, doing that, too, is let's find new ways to talk about the power of these investments in health. And first, one thing I want to say is we did a sign-on letter for members of the House to call for a bigger US pledge to the Global Fund this year. I was really glad that Congresswoman Ocasio-Cortez was one of those signers. And a lot of other new members in the House were signers of that letter. So I think there is, for some people, a recognition that from out of the starting gate, they want to be engaged in some way here. But again, we haven't articulated exactly what that looks like. But I do think for a lot of new people in Congress, we need to be talking more about, like, this governance study that came out, health investment is a way to advance governance. Health investment is a way to advance equality for women and girls. Health is a way to push civil society strength so that people can participate in a whole variety of ways in their decisions or their governments and fight for their rights. So I think we were on, for the first couple years of this administration, we were on real defensive mode. We were all trying to survive. But I think now it is time to pull ourselves out of that and say, what are the new ways of talking, in real ways, of talking about these investments? My question for you, Chris, and is kind of picking up on that. I was already thinking this, to what extent, it's like a technical question, but to what extent have you all, or could you use the rich data that you have on the financing side with the burden side to really look at the correlation between investments, certain donor investments, or certain country investments, and outcomes? Because I think that level of showing where it's working, where it's not working, that relationship could be helpful. I don't know. But we might not always see what we want to see, but it's what the data will tell us, hopefully. And I know it's hard to do that. Yeah, we're looking at that. And in fact, we planned something for the summer that's trying to look at what have we bought with this money and how much does that vary by location, using typical econometric investigations of these. And so I think we'll try to contribute that. I think the bottom line there that we have is a story of success, but it's less rosy than some of the PR that we put out there. And so it's sort of half full, half empty type discussion. But again, to Steve's point, it's a dose of realism. It costs a lot of money to save a woman's life from maternal mortality. You have to build health systems. You have to have an emergency obstetric care. It's not a simple product delivered at a one-shot moment. But there's real progress, so you get real benefits. There's another topic. I think there's a tension here in the discussion between the immediate, which is super important. What's the funding cycle, the replenishment, and some of the issues that Steve's raising, which is what's the new narrative that sustains the energy around improving health? And we've been looking, I do with this with some trepidation because this is not going to be popular, but we've been looking at long-term forecasts, both economic forecasting, population growth, and health, and the interconnections here. And there is just a totally obvious issue if you go from the immediate to the 10 or 20-year view, which is sort of an economic security argument around this, which is probably one of the biggest issues that the world's going to be facing is, and China is facing now, is declining numbers of workers. So China hit the peak, and they're now declining at about 1 and 1 half percent per year. The State Council there is totally aware of this. And so low fertility in China is like an alarm issue for them. And how have we avoided this issue in the US? Well, we've had generally liberal immigration. And we have sustained our workforce through liberal immigration. And this low fertility issue, which is not an issue for Sub-Saharan Africa, but it's for everybody else. Even India will hit this in about 20 years, means that we should have a, and the only solution is migration. Actually, it turns out if you look at the demographic numbers, means we should care really heavily about the health and the human capital, the people that all these other economies are going to need to sustain themselves in 20 or 30 years. Because so far, nobody has got a solution to below replacement fertility. And not popular, I know. But boy, is this the issue for the next generation. I mean, it's just we see it in the numbers. And nobody wants to really address this. There's books. There's some discussion of it. But it does connect all the bits in a way that means that even from the base notion of even geopolitical reality in terms of the size of GDP, size of armies, these are highly connected. And I don't know if there's a way to have a different narrative that is effective even in the shorter term about that. So just throw that out there. Thank you. That's not so funny. Don't worry. So I just want to say, I truncated purposefully the question part because we had some earlier, and I wanted to get this out. If you'll bear with us, I know some may need to leave in a few minutes. But let's take three questions, get a few answers. We can stay a little longer. I know Steve has some closing thoughts. But thank you for being patient on that. So we'll start with three questions. Say who you are and your question. Hi. This is Mickey Chopra from the World Bank. Thanks, a really rich discussion. Chris, one of the new findings both Chris is actually is the one on the HIV AIDS paper, which is the one about the additional financing. And if India and South Africa in particular, you posit, could actually get more value for money and therefore spare up all the global fund and other resources to go to poorer countries. And this resonates with the new leadership of the World Bank as well, that we shouldn't be investing so much in the China as in India as in more in the Sub-Saharan Africa. But as you said, it's premised on efficiency gains. And as the other Chris said, actually the DAH may well be a key catalyst for efficiencies in these countries by helping them to more target, to be more focused on the problem. So do you want to just reflect? Because the key message coming from the paper is that there are ways in which we can get more resources to where it's needed the most if some of these middle income countries were doing better. And therefore, we should withdraw those resources. But there is a tension there between the need for external engagement to get those efficiency gains in the first place. I'll say two more. We have a break. Hi, David Guili from American International Health Alliance. Wonderful panel as it is every year. So this is really addressed to anyone on the panel. But Steve, you talked about the lack of leadership from this administration in supporting health and the factors contributing in Europe and other developed countries for their reluctance. But I wonder if you can make the connection of the corrosive nature of this administration and its impact on other countries that are providing assistance, how much it emboldens them to walk away from commitments statements, like when Trump appears in front of the United Nations and says, American first, and we only give to our friends, not to our enemy. So what's the relationship? And maybe there's some data, Chris, on that as well. One last question. Anybody? Anybody who hasn't asked the question yet? If not, you can please go ahead. Oh, there is somebody. Thank you very much. Shirin Yasin from Metronik. Quick question. So I know we've been talking a lot about infectious diseases. But what about NCDs, noncommunicable diseases, as we see the global burden of cardiac disease, diabetes, cancer increasing. So just to get a sense of what's being done when it comes to NCDs. And then second quick question is, what do you see the role of the private sector when it comes to helping and supporting to achieve UHC? Thank you very much. So I think on the first one from World Bank about, we'll start with this, Chris, if you want to. Sure. I think Mickey brought up a really interesting, much more subtle question, which is a little bit harder to empirically test, which is how much above and beyond the sort of spend efficiency type analyses, which are easier to do, and we can do more and more of them as the data's gotten better. Is there a sort of, is there crowding in or crowding out? Let's put it that way. And both from a ministry of finance, budget point of view, and a sort of more political point of view, is there social buy-in because there is external buy-in? The crowding in and crowding out one, we've done studies in the past. There tends to be crowding out. I don't know, I don't think we've redone them lately, so we're worth revisiting that. But I don't think that quite gets to the issue of the sort of political buy-in and that sort of broader notion of believing that global health is a priority because there's that donor input. And that's really hard to assess, could be super important, it's one of those intangibles that I think we don't really have a great way to get insight into that. And I really appreciated that paper too. I mean, I think it's really helpful to have these analyses that look at where is there a fiscal space where you can expect and ask countries to be doing more and where's the greatest need on donor aid. A couple of things I would just say about that though. First of all, this is not a zero-sum game, as we're all saying, right? We need more money in healthcare for people to be healthy. So it's not as if, for me, I would never say, well, one country can do a little bit more based on its GMP, so let's pull out donor aid. A lot of them still need the donor aid. And let's also remember what external donors have done that doesn't happen domestically a lot, which we've got to change, which is think about the most marginalized people in those societies. When the United States and other donors pull out of some countries, there are a lot fewer people at the table to make sure that civil society is engaged in decision-making, that we address the needs of people like gay men and other men who have sex with men and sex workers and people who inject drugs and trans people. These people are, as you know, horribly marginalized in so many countries. When the donors pull out, they have just a whole lot less protection in terms of them being able to get health services. So we can't, as we talk about the evolution of global health financing, have, even though it is tough to think about how do you motivate donors around middle-income country finance, we cannot abandon the most marginalized people. And others on the panel on, yeah, Steve. Well, the one question around US leadership and other opinions in Europe or elsewhere. There was a Pew study that came out in February, I think it was timed for the Munich Security Conference in mid-February, which showed a precipitous transformation of opinion of the United States from being seen as a leader committed on these norms and values to being a threat. And that was a pretty dramatic and profound change in a very short period of time. And it cut across, it cut across an entire spectrum of states. That's just one point. The mood, certainly at the Munich Security Conference was one where the US had been sort of relegated into being a, not a source of ideas and direction, but a problem to be managed at that context. And certainly that was the way that Vice President Pence's presentation was received, which was also a startling change of tone and atmosphere from just a year before. The last thing I'd say is that populist nationalism is not confined to the United States. It is rooted in a number of factors, and not the least of which is migration and fear. And our European allies are every bit as affected by this in their own domestic politics, and it does have dramatic impacts on foreign aid budgets and priorities and the actions of parliament, parliaments and the like. Can I respond to this as well as the last question? So I, yes, and I do think we should acknowledge that there's been a, the opposite response, meaning, you know, you've seen other governments step in and say, okay, we're gonna really amplify our voices around these issues, where there's been a vacuum left by the US, and in reality, no one country can really fill this vacuum, and that's a big part of the problem. But there's, how do I say this? You know, it's interesting that there's now an opportunity for leadership by other donor countries that we haven't seen or maybe they haven't felt previously, and I do think that this, you know, what's happening here politically is also very much building the case for domestic mutual mobilization, and you have recipient countries themselves really amplifying their own voices and really upping their own commitments around this, because the writing's on the wall in many ways, and sure, I'd love for the rubber band to snap back, but I agree with Steve, I don't think we're going to return to that normal, I think we're currently in a bit of a new normal, and we might've been a little bit behind the curve in preparing for this moment, but now people are, and I do think that, you know, I think we've all heard on the ground, you know, countries are actually a bit anxious for there to be new leadership, and you know, we see in the polling here in the US with these calls for partnership, that's not necessarily a bad idea. The administration is continuing to come back to us and say, okay, well who else is at the table, and I do think so we can avoid this kind of situation in the future, we shouldn't be hanging our hat on any one source of funding anyway, so to the extent we as advocates and in a broader community can sort of drive towards that, I guess, more collective approach, it's a different kind of approach, one of the things that I'm stuck on that's kind of unpopular is, we're still expecting sort of this transition of the current model, which is a pretty tough model to maintain. We have, there's a global health architecture that's massive and not arguably not sustainable, right, and so to the extent we can really start to think about how that gets transitioned responsibly, of course, in retaining what's been working, maintaining these results and kind of all of the benefits of the architecture, but then really being critical about kind of if this gets passed on how we can do so in a way that countries can sustain and manage, that's really the conversation we need to be having, and it's a scary conversation, but I think it's unavoidable, and the longer we wait to have that, the more we're gonna continue to have this sort of back and forth around what we do and this hand-wringing. Quickly, sorry, on the cancer, NCD question, as well as the private sector, obviously you heard in my bio, I worked in that space for a long time, so it's critically important to me and to GHC that those issues are included in these conversations and all the more reason why we really are pushing for health systems approaches. We really need to meet people where they are, and all around the world, people are dealing with these issues of chronic diseases of NCDs in addition to everything else we're used to talking about in the global health community. I think everyone gets that now, but there's still this huge gap in terms of resource mobilization in that space, and we're doing a disservice to people on the ground by ignoring that. I think in the same way we do a disservice by not being inclusive in our partnerships, and so yes, you hear Dr. Tedra's talk about this, you hear us talk about this, we need to have industry at the table, and I think that's not just kind of the usual suspects, but whether it's innovative in the innovative financing space, thinking about new investors, thinking about other industries who can be brought in responsibly, of course, but meaningfully, that's the only way we're going to truly be able to solve this problem, whether it's more funding or new ideas around how we do business differently and effectively. Thanks, so you've indulged us to go on. I'm gonna turn it over to Steve to close us out since we partnered with CSAS on this. He was gonna offer his closing thoughts. Sorry, we can't take more questions, but I think most of us can stay up here and continue for those who want to. Steve, please. Thank you. Special thanks to you, Jen, and your colleagues at Kaiser and to IHME, Joe and Chris, and everyone else for this opportunity. This is terrific. We look forward to doing this again next year. You know, the main takeaway from this is the stark contrast in visions from what we heard from Dr. Tadros and versus what we heard from Joe and Chris. And the big question that comes from that is, who's correct, right? I mean, on the one hand, it's quite inspiring to hear Dr. Tadros talk about the change of outlook that he observes and the need to see health in the way that he's seen it and that this is a matter of political will in pointing to four or five countries where he sees the opportunities move ahead. And those countries track with the same countries that you identified as ones that have the ability to dig deeper. And the fact that he put such a strong focus on political will translating into taxation and translating into taxation in his words around alcohol, tobacco, sugar, which is gonna be a big contest if that happens. If that's the formula for getting there, it's a politically risky and a big contest to break through in order to find those resources that are required. And then on the IHME side, the, what we heard, which is a widening gap projected inequalities, greater ghettoization of low income countries and a $50 per cap budget at 2030 in low income countries for health. So those are two quite different pictures of where we're heading. It's also the one issue that we haven't really focused much on here is where's the United States in this debate? Where's the United States in the debate on UHC? It was interesting that Dr. Tadros did not really have much of a direct message to us, to a Washington audience, which he doesn't often address an audience like us in a public way and what was the takeaway message for to us in terms of where the US should be in that debate about UHC? I'm not so sure what that is. I take the view that we are a bit more vulnerable than we realize. We're a bit more vulnerable at this moment than we are comfortable admitting. We don't have a budget deal. We have a historically polarized and confrontational situation emerging very rapidly. We have a certain complacency around HIV globally that is problematic in getting people to focus on the need to take the HIV global programs to the next stage. And we've got a very crowded and noisy environment right now and so I just think we need to be very cautious and mindful of the fact that this is in my mind, this is a vulnerable moment. Thank you. Thanks. All right, well please join me in thanking all of you for being here. Thanks to you. Great, thanks for staying a little extra.