 Welcome. Very glad to have you all here today. My name is Lisa Cardi. I'm the Deputy Director of the Global Health Policy Center here at CSIS. We're very glad that you could join us for what promises to be a very exciting event in our ongoing statesman series of speakers. A particular welcome to Dr. Shah and also to his staff that have joined him today. I'd also like to welcome our several hundred guests who are joining us online. Most importantly, I'd like to bring you all, but particularly Dr. Shah, greetings from John Hamre, CSIS's president, who unfortunately is overseas today and can't join us. The statesman series is CSIS's premier speaker series, generously supported by the Lavrantiatis Group. It's designed to bring global leaders here and to give them a platform to talk about the critical issues of the day. There was a time when a discussion on health and development might not quite have risen to this level, but luckily that time is long gone and that's no doubt in part due to the extraordinary contributions of USAID over many decades that I think have proven beyond any doubt that not only is development the right thing to do, but it's the smart thing to do. CSIS has been enormously fortunate in having many AID administrators come here and speak in the past, but I believe this is actually the first time we've had two administrators here with us. That's at once both a current administrator and a former administrator. So I am really delighted to be able to welcome this afternoon Henrietta Holtzman IV. As many of you know, Ms. IV was AID administrator from 2007 to 2009. Prior to her work with the agency, she was a very successful career in both the public and private sectors. She's a trustee here at CSIS and also a very good friend of CSIS. Most importantly, she's someone who really cares deeply about development and about creating more opportunities in the developing world. So I'd like to invite Ms. IV to come to the podium to introduce Dr. Shah. We'll then have Dr. Shah's remarks and then we'll have some time for Q&A. Thanks for joining us. Thank you very much, Lisa, and it is great to see all of you here today. It means that development is alive and well and strong and that's very important for all of us in the world. I would first like to mention the good work that's being done here at the Center for Strategic and International Studies and Lisa Cardi to you and Steve Morrison. Thank you because it has been seminal work on health but also before this the work on food and other issues. So thank you for leading that. I think it's important that we all talk about and engage in the discussions of what development is and what it can do. As all of you know, the United States Agency for International Development is the premier institution that leads development around the world. And it leads in peace and security, it leads in infrastructure and economic leadership, in ways that help in legal systems and that help with governance and democracy building, humanitarian assistance in education, in health, and of course in disaster assistance in Haiti. Our administrator, 16th Administrator Rajiv Shah, is with us today because he is a remarkable symbol as well as a leader for USAID. There are many experts within USAID but we are delighted that Raj is a doctor. So as a medical doctor it means that he can lead with enormous integrity in the field of health. He has initiatives that have spanned from food to entrepreneurship to health to online activities and ideas that stress innovation and that stress integration. And today he will talk to us about health and about the opportunities of the Global Health Initiative. In a town in which we often do not have bipartisanship, Raj and I have a good relationship and it is with great pleasure and an honor that I am able to introduce Rajiv Shah, the 16th Administrator for USAID. Thank you, thanks very much. Good afternoon. This is a wonderful group that you've assembled, Lisa. It's very impressive. It's great to see so many familiar faces turning up to talk about global health. That's very exciting and I look forward to this conversation and to hearing your thoughts, ideas and questions. Henrietta, thank you for that overly kind introduction and wonderful description of USAID. I'm still learning how to do that so it's helpful for me to take notes as you're doing that. We are in many ways building on some of your important successes, especially in rebuilding the human resources of the agency through the Development Leadership Initiative. Every day we think about the contributions you've made in that regard. And I really do want to commend CSIS and the leadership of Lisa Cardi and Stephen Morrison for really paving the way towards the integrated health approach that we'll hopefully talk about today. It was in fact your global health policy group which replaced I think the earlier AIDS task force and has been really pointing people conceptually and in practice to the concept that the future lies in smart strategic investments in health systems. I'd like to start today just by telling you about two women. Two women with one thing in common. They're both pregnant with their third child. Consider for a moment the dilemma of a woman in Sub-Saharan Africa and even one with the unique access to many of our own U.S.-funded programs. To get the prenatal treatment that is necessary to prevent her from transmitting HIV to her child, she must travel a great distance with an infant on her back and a toddler in hand to a PEPFAR-supported clinic. And to get her two other children immunized against measles or other vaccine-preventable diseases, she has to make another arduous journey to a different clinic at a different point in time. Neither clinic is equipped to provide complicated obstetric care. So this mother, like her mother before her and so many others in her village and her community, will likely decide to take her chances in birth at home because the journey to an adequate facility is too arduous and too difficult. The burden of fear generated by this ordeal weighs on her entire family and, in fact, her entire community. Now consider for a moment a different situation. That of a woman here in Washington. A woman also carrying her third child. A federal employee whose health plan provides convenient, comprehensive care throughout her pregnancy and a healthy head start in life for her first two children. Healthy children we know are more likely to learn, more likely to thrive throughout their lives and as adults. The peace of mind that comes with knowing one's family will be well cared for by competent medical professionals spanning a broad range of potential needs enables this woman, my wife Shevam, was due to deliver our third child in November. And her husband, that would be me, to focus on, in case there was any question, to focus on giving our real utmost effort to our jobs, our family, our community. Medical technology and strong health systems have made maternal death a relative rarity in our world. According to UNICEF, an American woman faces a 1 in 4800 chance of dying during childbirth. But in Sub-Saharan Africa, the story is very different. The chances of dying in childbirth there are 1 in 22. The fact that some women are more likely to be HIV positive and more than 200 times more likely to die during childbirth than a woman in the United States is simply unacceptable. The President's Global Health Initiative is designed to close that gap and to bring about a convergence between the stories I just described. Health is in fact at the heart of human progress and we recognize that the well-being of people around the world is not just an important end in and of itself, but it is strongly linked to the security, prosperity and partnership of our country with our colleagues around the world. And that's why Global Health is a central part of President Obama's and Secretary Clinton's plan for a more peaceful and a more prosperous global community. This administration's initiative is about helping partner countries achieve major advances in health by working smarter, by building on past successes and by making some tough decisions. To achieve these advances, the GHI will invest $63 billion to this end. That's more than double the amount of money we spent on health during the preceding six years and a significant commitment of resources during a very difficult fiscal time. Through integration and efficiency, we will be very focused on getting more value for every dollar we spend in health and ultimately saving millions of additional lives worldwide. GHI builds on remarkable progress in public health that we've all seen. Over the last decade, we've made huge strides through a variety of disease-specific or intervention-specific campaigns. The President's Emergency Plan for AIDS Relief is the largest single effort by any country to combat a single disease. The first phase alone provided anti-retroviral treatment to more than 2 million patients and supported care for more than 10 million people affected by HIV worldwide. By all accounts, PEPFAR was a game changer. And to support its efforts, the administration is increasing funding for PEPFAR consistently and in greater ways than before. Similarly, the President's Malaria Initiative reduced the intolerable burden of malaria, which causes 900,000 deaths each year, most in Africa and most among children, through a package of proven control measures. Since the initiative began in 2005, we've distributed more than 19 million insecticide-treated nets and 40 million lifesaving anti-malarial treatments. These low-cost interventions, coupled with behavior change programs and real outreach and engagement, has resulted in really remarkable results. In Ethiopia, Rwanda, and Zambia, we've seen malaria deaths come down significantly and in some communities come down by half or more. The work of the diverse leaders and advocates behind these breakthroughs leaves a legacy that actually goes even beyond the life-safe, and that's many of you in this room. Your work has helped teach the world that rampant disease imperils global stability and must be addressed. Your work has shown grassroots communities that support for global health is critical and you've triggered an upsurge in attendance in global health courses in colleges around our country, in the faith communities, activity and commitment, and even amongst branch-conscious consumers like myself that own red watches or red t-shirts and wear them with great pride. It has helped expose the weaknesses of health systems in developing countries and forged a bipartisan consensus that we should do more to spend our resources to save lives abroad. So I thank you for that. And yet, in isolation, nearly all of us agree that disease-specific approaches also have some serious deficiencies. Visit any African country and you're likely to find a health system organized around diseases and interventions, not the actual patient. You'll find separate clinics in separate places for AIDS, for children's health, family planning, and advanced obstetric care. Not only is that bad for the patient, but it is strikingly inefficient for taxpayers. And in many cases we have ourselves to blame. Our siloed, single-disease focus means that in many countries the same health system that can prevent the transmission of AIDS to an infant is unable to prevent that same child from dying of diarrheal disease before she turns five. I saw an example of this myself on a recent trip. In May I visited an impressive PEPFAR-supported facility in Kenya. I learned that every government clinic in Kenya once had an area set aside where mothers were counseled about oral rehydration therapy, commonly called the ORT Corner. As many of you know, ORT is cheap, simple, and widely credited with saving millions of lives a year. But when AIDS funding rehabilitated the government clinics in Kenya, the ORT counseling areas were often taken out and replaced by sites for HIV counseling. It is an important lesson, as unintended as it was. Our disease-driven focus can sometimes crowd out other cost-effective, life-saving interventions, even in Kenya, a country that this institution, CSIS, has rightly highlighted as being on the cutting edge of health program integration. By integrating health delivery in countries we can extend the reach of these focus interventions at the clinic and in the community. And that means a woman who enters a maternity clinic can receive the full range of services she would need for herself and her child. The Global Health Initiative is therefore about the patient, not just the disease. The initiative will enable country-led health programs to be smarter, more efficient, and more effective. We'll support community-based health systems that are appropriately staffed and stocked to deliver a broad range of health services and to reach back into more formal health systems when necessary. But let's not confuse ends and means. The ultimate target of the GHI is not to simply build health systems for the sake of building systems. It's to achieve more health outcomes and to sustain those gains over a long period of time. And we do that by rooting our investments in those who are ultimately responsible for seeing them through governments, NGOs, and the local private sector. And it's worth reiterating that effective health systems, as sometimes unsexy as they are, I particularly think a good health system can be quite sexy, saves lives and enables more people to be healthy and productive contributors to society. Just like the disease campaigns that it builds upon, the GHI will use data and clear metrics of success, doubling the number of babies born free of HIV, having the burden of malaria, cutting the under five mortality rate by a third, and reducing maternal mortality, a number that's been moving in recent estimates, by 30%. But unlike previous health initiatives, GHI will focus from the outset on, as President Obama states, creating the conditions that will reduce the need for future aid in the out years. As many people here know, the Child Survival Revolution in the 1980s contributed to rapid progress by mobilizing unprecedented global medical system and political support. That successful movement was driven largely by the force and charisma of one man's leadership, Jim Grant of UNICEF, and of course Bill Fahey of the CDC and Peter McPherson of USAID, and many, many others. But as we later learned, despite the tremendous successes of that movement to raise immunization rates, in many cases to over 80%, and to greatly expand primary care services to people in need and save millions of lives, any movement that rests on the tirelessness of one individual or even a small group of leaders is inherently unsustainable. In the early 1990s, when funding slowly shifted to other areas, immunization coverage and child survival began to slow. In fact, DTP3 immunization rates dropped almost 60% globally, and much more so in many countries where we all spend our time and energy. I mentioned the lack of an ORT corner in the clinic I saw in Kenya. Actually, our DHS surveys documented a more than 20% decline in ORT use in Kenya between 1998 and 2003. Fortunately, our experts recognize this trend and have been working to reverse it. But we as a donor community have an obligation to keep countries off of this seesaw of donor trends. And that is exactly what underpins the GHI vision. And here are some of its defining features. First, we believe in doing more of what works, a simple concept. GHI will expand proven treatment and prevention strategies in TB, HIV, malaria, and a range of neglected tropical diseases. But it also will expand what works in nutrition, in hygiene, in sanitation, in family planning, and in maternal and child health. All of those areas statistically have been under-invested in through the last decade of increased global health investment. GHI is investing in improving measures and methods for monitoring and evaluation in each of these programs. We're learning about better ways to treat diarrhea and pneumonia and children to save lives and prioritizing vaccines like rotavirus or pneumococcus to more effectively prevent disease so they don't have to be treated later. And we're learning, for example, that simply training more doctors and nurses is not sufficient to ensure a health workforce that's capable of providing care to an entire population. Doctors and nurses, and as a doctor I feel this is a safe comment, are wonderful contributors to medicine. But they're often the first to be hired away by other countries who pay a higher wage. And they can be reluctant to work in a rural environment where they might not have access to tertiary care services and the ability to provide those services. So we've learned a lot about the importance of task-shifting and the tremendous value of building a cadre of community health workers trained in primary health care who stay in their communities with the trust and respect of their neighbors. We have more than 10,000 such community health workers in Senegal where I recently visited and the commitment and connection they have to their local communities is just tremendous. And GHI will also create an environment where it's safe to report on things that don't work because that's ultimately the only way that we can experiment and learn. Second, GHI will focus on expanding existing service platforms. Saving more lives means being smarter about getting the maximum impact for every dollar we spend in health. And this means developing new insights and better methods for using our HIV, TB, malaria treatment platforms to provide a broader range of services. The good news is that we have strong platforms from which to build. Under PEPFAR, we built strong HIV aid service delivery systems in many countries. And USAID's work in primary health care has contributed to widespread maternal and child health platforms with doctors, nurses, clinics, hospitals, pharmacies, community linkages, and procurement and product distribution systems. Similarly, the President's Malaria Initiative has its own platforms for providing access to needed interventions. These different platforms are the basic foundation for GHI. We can strengthen these platforms by bringing together all of the capabilities across PEPFAR, USAID, CDC, and a full range of other federal global health partners, including DHHS, the National Institute of Health, the Peace Corps, and the State Department. Expanding these existing platforms and programs will mean providing easier access at a single location for a broader set of medical and health interventions. It means making the shift from diseases to patients. And it means focusing more cleanly on the last mile problem of getting a full package of basic health services out to those people who are most vulnerable because they lack access to any protective care at all. These expanded platforms will do more for HIV-positive patients. And it will do more to prevent an HIV-negative patient from contracting the disease. Because the current reality of two new people on treatment for every five new people contracting the disease, frankly, is not enough. Integration just makes common sense. Third, we will prioritize innovation. Under the GHI, we are identifying, evaluating, and implementing a range of entrepreneurial approaches to public health, such as results-based financing and incentives to encourage better and broader utilization of proven services. We are getting many of our best ideas from small programs that are today small but have the real potential to scale. In Zambia, for example, one clinic wanted to get more mothers to come in for prenatal services to return when it was time to deliver their babies because we all know the 48 hours around childbirth is the period when 70% of maternal deaths occur. So the clinicians promised patients inexpensive mom kits that included soap and a baby blanket and a few other things. And with this small incentive, these clinics experienced a boom in birthing visits. It's not unlike the conditional transfers we've seen in other parts of the world. And we're pioneering entrepreneurial ways to encourage more private sector participation and financing. In Namibia, for example, we conducted a campaign to convince mining companies that it was in their interest to pay for their employees' counseling and treatment and ARVs by showing them that that was cheaper and more effective than to hire and train new workers for those that they had lost to the disease. And we're building on the current experience that's just being created, which is a U.S. initiative called Text for Baby, an effort to actually use SMS text platforms to reach a broader group of people in a more targeted way with more effective health messaging. These types of applications in developing countries could now reach millions of expectant and new mothers with critical healthy behavior messages. Finally, research and innovation are critical to the Global Health Initiative. Game-changing new technologies such as new diagnostics will change the economics of treatment across a range of diseases. Tuberculosis is often cited because we're not that far from new TB diagnostics that are cheap and efficient and can make the distinction between multi-drug, resistant treatment pathways and lower-cost pathways that are less burdensome. By using these types of new breakthroughs, we can save money, treat more people, and save more lives. Fourth, the GHI will focus on country ownership. The GHI recognizes that the United States can simply not do this alone. President Obama, Secretary Clinton, and the American public are deeply committed to saving lives around the world. But the global needs for HIV-AIDS, for maternal and child health, for family planning and immunization, are genuine global responsibilities that require a full global response. Every government, every bilateral donor, every multilateral alliance like GAVI or the Global Fund, and every community from the American taxpayer to a Ugandan village must take greater ownership for this challenge. The GHI meets the Obama Administration's core development principle of working in partnership, not patronage, by supporting real country-owned plans and being willing to redirect and realign our investments against those plans. Rather than building parallel health services that frankly are often not even visible to country ministries and country leadership, we want to strengthen host country systems. Host country, we can do contracting through host country ministries, and we can work more closely with host country implementing partners. We're stepping up our coordination with critical global health partners like the Global Fund, GAVI, the World Bank, and the full range of UN agencies. And in fact, our ability to do this will be critical to our ability to align multiple streams of funding that come into countries and better align them with what countries hope to achieve and sustain themselves over time. I'm sure many of you watched the G8 this weekend. I did from time to time as well. While many consider the MCH commitments there to be modest, the G8 this year made important strides in ending smoke and mirrors when donor countries make commitments. President Obama insists that we ensure accountability, transparency, and accountability when the United States makes a commitment. These principles are particularly critical in current times of fiscal constraint. We owe it to our domestic constituencies and we owe it to ourselves to be clear about our commitments and our commitment to getting more value for money we're spending. Already, we're doing a better job of coordinating U.S. health spending within our own government. Our country teams are coming together to see boundaries and developing a harmonized approach to get more value for money. In fact, we currently have a USAID CDC and PEPFAR team in Ethiopia doing just that. We've also launched new partnerships and that will be a major component of how we improve coordination going forward. For example, we've launched a new partnership to increase coverage of newborn resuscitation with the American Academy of Pediatrics and with Lairdoll, a private manufacturer of resuscitation devices. To support introduction, we developed agreements with UNICEF in Ethiopia and we've worked with the National Institute of Health who will provide an independent evaluation of this approach. The end result is a new program designed to save newborn lives and designed to generate data and knowledge on a set of new strategies that could be applied more broadly and elsewhere. Our final approach is around focusing on women and girls. Women and adolescent girls are particularly vulnerable to ill health because of their reproductive role and because of really pernicious gender discrimination that still exists, gender-based violence and a lack of respectful care and access to such care. Improving the health of women and girls is important as an end in and of itself. But each of us in this room knows that when a woman dies in childbirth, the real welfare of her offspring is fundamentally threatened. We also know that when a woman has access to decent care and basic knowledge about nutrition, safe drinking water, sanitation, improved hygiene, she amplifies those benefits to her family and within her community and across generations. But too often, despite this knowledge, we collectively fail to operationalize this insight. GHI will look at better ways to extend healthcare to more women through simple strategies but real operational requirements such as adjusting clinic hours to be more friendly to when women can make a visit by making certain items like condoms, vitamins, contraceptive pills, and other medications available through a broader variety of commodity distribution channels like local kiosks, pharmacies, and even beauty salons. And it will support systemic changes such as broadening the range of services offered at existing clinics and extending services into homes through primarily female community health workers. Our health programs already address some of the social and behavioral aspects of improving women's health. In Ethiopia, USAID works with youth, teachers, and community leaders to change attitudes around accepted practices with respect to child marriage. Girls advisories committees established in more than 3,700 public schools are succeeding in delaying sexual debut and increasing class attendance. This is a critical health intervention because we know that this is statistically correlated with improving the health and welfare of these girls over the course of their lives and their childbearing age. And it leads to an important lesson. Family planning plays a crucial role in improving the health of women and their children throughout the world, and it will be a major component of the Global Health Initiative. By helping women space births at least three years apart, bear children during their healthiest years, and avoid unplanned pregnancies, experts believe family planning done appropriately could prevent 25% of all maternal deaths. Where family planning and other health services are linked, levels of contraceptive use typically increase. A study in Togo demonstrated the telling mothers about family planning services when they brought their children in for immunizations actually increased their awareness of family planning methods and use by up to 58%. So the GHI is already well underway. The defining features of the initiative that I've laid out before you are being implemented today everywhere we work. In addition, 10 days ago we announced the first set of GHI plus countries. We're starting this year we will focus intensive technical and management resources to get this right. The eight GHI plus countries will accelerate GHI implementation and the learning that goes along with that implementation so that we can share this with other parts of the US government but almost more importantly with the entire global health community that simply has to get this right for our gains to be sustained. Ethiopia is one of those countries. In 2003 the government there made a huge commitment to a new health care approach. They recruited, trained and hired and deployed more than 30,000 female health extension workers. So at that time we had redirected our integrated programming in maternal and child health, family planning malaria and nutrition to support this new health worker based strategy. We assisted local and regional governments in developing their implementation plans and we worked to fill gaps where governments had needs. In 2007 the Ethiopian government asked USA to join them in UNICEF in developing an integrated nationwide computer based drug and commodity management system. We did that and that system is now up and running. The global health initiative draws on examples like this and on expertise across the US government. USAID is a critical part of this effort with I greatly enjoyed getting to meet the nearly 400 health professionals that work here at USAID in the United States in Washington and to meet the incredibly dedicated and talented teams especially the Foreign Service nationals that are often medical doctors or real public health professionals and political leaders that are now part of our expanded team abroad. And I believe greatly in their ability to offer leadership and to implement the program. Yet I realize that USAID must improve how we work and in many ways we're working hard to do that. Many feel that we are too bureaucratic perhaps too wrapped in our own programs and processes and after several months of being there I agree. Over the years our officers in the field have been mired in excessive reporting requirements and Byzantine procurement practices that do not often serve the larger purpose. But I also saw a different story when I experienced our response to the Haiti crisis. I saw our team break free of the rules and I saw our team demonstrate a tremendous amount of entrepreneurial energy and evidence based decision making in trying to simply solve problems in a quantitative and smart way. We're moving forward with a package of major operational reforms designed to help our whole agency operate like our teams did with respect to Haiti. Free from some of the requirements in the red tape that can be reduced and implementing a major package of procurement reforms that will allow us to cut our contract costs, build more internal program capacity, and redouble efforts to support local institutions, invest in local ownership and develop local capabilities. And these reforms will also include a major new approach to monitoring, evaluation and impact assessment. We have a unique opportunity with the GHI to figure something out that's been hard learning for over three decades in global health. And it's how we learn to build real health systems in a targeted health outcomes oriented way and we intend to capture those learnings through strong monitoring systems. So we do need to be stronger and we're on the way to get there. But really no one should underestimate what can be done right now. Our agency is determined to make progress in the stubborn numbers that are all too familiar to you. 11,500 people die each day from HIV AIDS, tuberculosis and malaria. More than 8 million children still die a year before their fifth birthday. I've met with the mothers who've lost those children over the years and in my work in global health. And now as I soon hope to be the father of three children, five and under, I'm both terrified of that and deeply excited. But I can only imagine what it is like anywhere in the world to lose a child under five especially when you know that loss does not have to take place. By being here today each of you demonstrates your commitment to help us get this right and to help demonstrate to the world that we can save these lives in an efficient and sustained way. And I want to thank you for being here. Thanks very much.