 16 million new cancers every year, and 13% of all deaths on the planet. But think about that, a third of them could be prevented. A third of them could be prevented with healthy lifestyle and healthy living environment. So prevention has to be part of the procedure. Now, a third of them could be cured, or at least managed in a chronic disease fashion in a manner where the patient will still survive for many years with a totally acceptable quarantine. So think about that, the number of lives lost and the economic prejudices in combination. In 2011, with the RAT School of Public Health, the public community forum was publishing a report on the economic burden on the cost of non-communicable diseases. And we came to the conclusion that from 2012 to 2030, the cost of cancer will be 8 trillion. Well, that's something that obviously has also a toll on the economic growth of the planet. In that context, now think about mature worlds and emerging economies. Cancer is not a disease of a rich country. I mean, people think it is. We always think that in emerging economies it has to be about a neglected tropical disease or a combating infection, so obviously malaria is already on top of the risk for many. But 80% of the burden is in emerging economies. And sadly enough, this is in a context where 65% of the cases are in emerging economies. So, from what you might wonder, why is that 60% of the burden and 65% of the cases? Well, that's already a bit. Why is that? Because the life expectancy on the survival rates of cancer patients in emerging economies in Africa are about half the ones they are in emerging and in natural economies. Because Finland is not accessible. And we will talk today about maybe the number of oncologists who have trained in these regions. We will talk about possibility of access to radiation to the human structure. So, with no further ado, I will introduce a great panel. And starting at my screen right, Dr. Paul Park, director of noncommunicable diseases, a partner in health, I can also join. A little bit closer to me. Dr. Prébo Barron, medical officer inter-country support team, Eastern South Africa, the New York City. Dr. Julie Torore, Julie, you are deputy CEO for the Union for International Cancer. And, possibly at least, someone I admire immensely was the way she has promoted Rwanda as a role model for health equity on the planet. And I'm talking about Honorable Minister Hanyes Inaugural. So, starting with you, maybe, Dr. Inaugural. You are the strategic plan, as I understood, the strategy 2020 for Rwanda. Health care and health is paramount as part of the strategic plan. And as part of that, obviously, the combat against non-communicable diseases. Can you tell us about the plan, what you were expecting to deliver, how you would do that? So, first of all, thank you for having me. And you have in this room one of the biggest champions of first aid in the fight against those neglected diseases that we can consider the cancer. To promoting access to care and equity for a minister like me, it's not so complicated because the vision of the government is just to implement. And out of that, we have the EDP-RS, the Economic and Humanity Reduction Strategy. And in that strategy, the government has put the fight against non-communicable diseases as a cross-catholic issue. We have 20 rounds of the EDP-RS, meaning for the Ministry of Health, it's not a health issue only. It's easy to go to the minister in charge of environment and talk about the pollution, the cancer, the fighting spirit, deal with the ministry in charge of commerce, because it's a cross-catholic issue. There is no sector that is not concerned by non-communicable diseases. Now, out of this strategy to implement the vision 2020, we have the sectorial strategy, the health sector strategy, Rwanda. And in that strategy, we have a strategy for non-communicable diseases and for cancer. So that means everything is aligned. And for each level to allow better implementation, when time arrives, we change rules and the plan, et cetera. So that's how everything is linked and it's easy to work in an alignment. And of course, we still have to improve. But the government framework is there to make it happen. Very interesting. I was reading somewhere that my number is not correct. You can tell me that we have 98% vaccination for the young group girl in Rwanda. It really comes to HPV. Ninety-three percent. Ninety-three percent. So my number is a little inflated, but it's not as bad as 47% in Texas. So you are, again, a leader in that matter. Can you tell us about that program and what the effect has been that you have measured already? Or is this something that we contribute to the 2020 target? This will definitely contribute to the targets of the country because there will be less young women and mid-aged women suffering from cervical cancer. And it's very costly. I want to recall that cervical cancer killed as much as maternal death. So that means as much as a country fights maternal death around pregnancy and delivery, we absolutely need to do whatever we can to prevent those unnecessary premature deaths leading to cervical cancer. So this is a long story, and the story starts with the champion we have in front of us because our first lady mobilized the pharmaceutical firm that was providing that vaccine. And when the mobilization was done, the minister of health entered in and went concretely in the MOU, and we got the vaccine for free for all our girls aged 12 if we managed to vaccinate 85% of them. And we vaccinated 93% with a good report, and we got it for three years. And after that, because Amanda has showcased that massive vaccination of girls aged 11, 12, can be done, gave it to the world and make it available to the world. We continue this vaccination, but it's school-based, meaning it's not a program of the Ministry of Health. It's a program of the social cluster. We have the local government, we have the Minister of Education that are part of this program because the girls are vaccinated at school. And it's all an organization to vaccinate all girls in four days across the country. And with the catch-up program we have made for girls 15 years, during two years, we have all 93% of girls aged 11 to 20 years now that are vaccinated to protect themselves against the survey. Thank you very much, Minister. My number now of 98% is not going to be wrong for two more days. You mentioned WHO, and I would like to turn over to you, Dr. Barongo. It's still my impression or it's still our impression that cancer in Africa is flying below the radar. And you mentioned that OKC, what is being done in Manda, is this something that you think is sufficiently recognized by international communities? And as WHO, what can you do to bring this issue higher on the agenda? Thank you very much for your question. I won't go over the figures that the data you gave earlier on was a pipe. They are spot on. Cancer in Africa is often misunderstood. There are very few local... I don't know if there's a local number for cancer in Africa. There are very few photos that have local numbers. This concept of it is often a disease that affects Western world. But as is presented earlier on, 70% of the mortality from cancer now in low and medium-income countries is the challenge that Africa is facing with cancer and NCDs in general, is that Africa is undergoing demographic change. So people are getting older. So as you are getting older, the risk factors for cancer are going away. And then there's an epidemiological change as well, as in people's lifestyles are changing. So Baku, which is one of the major cause of cancer, is increasing in Africa. On healthy diet and the other risk factors are going to increase in Africa. So this... In addition, there's another characteristic of cancer in Africa. In the Western world, cancers that are due to infections are coming down. But in Africa, so cervical cancer is one of the cancer that is associated with HIV. And also have liver cancer. So the commonest cancers in Africa will be breast, liver, cervical cancer, prostate, colon, and the hipposystem. So they don't have any due to infections. And so, if you recognize this, another characteristic of cancers in Africa is that most of the time, they come in late. So this is almost impossible to treat. We don't have treatment facilities, but we have a lot of the burden of treatment. So the pleasure I've been interested in, cancer is part of the globalized environment, like we mentioned earlier on. This is a digital part of it. So there's need to have the pages of what the country is to do advocacy. At the regional level, actually I mentioned the BU and the GITS project that is looking at advocacy and awareness of cancer so that everyone has a good case, the point here gives money to scale up in the vaccine. There are guidelines that the bridge has developed as well to support training for screening and treatment for cervical cancer. So these are some of the efforts at the regional level. At the global level, cancer is high on the radar. But as you are aware, nobody can tell your story better than yourself. The others may look at it. So there are a global coordination mechanism for NCDs at the regional level. And what we're trying to do is to get all UN agencies on board. And with that also, there's an entire agency task force for NCDs and there's a focus for cancers. We are actually planning to have to focus on cancer to support one country per region. For Africa, there are only two countries to scale up prevention and control of cancers. And in addition, we also collaborate with the international agency for atomic energy. We do in part missions to assess the readiness and accessibility of cancer control and treatment across the spectrum for countries. We've had it in three countries in the region so far. We were in the Wanda two years ago. And the whole idea is to see where the gaps are in cancer control and see what supports the government of Africa. Thank you very much. I hope you don't know that the issue will be beyond the agenda. And when this is the case, Dr. Tuarade, when this is going to happen, what's the priority intervention should be under-dialized that the international community should implement priorities so that they can be translated into tangible actions in Africa? Well, we do have a global goal that all governments around the world have signed up to to reduce the rate of mortality due to cancer and other NCDs by 25% by the year 2025. We also have targets and indicators that have been signed off. And we have a roadmap of evidence-based and cost-effective interventions that have been agreed. And I think what we need now is to convert that into action at country level. And I think for that to happen, we need a set of urgency. We've talked about the institution of mortality, but let's look at 36 million people living with cancer in this world. And those that are living with cancer where there's poor health systems are really suffering alone. So we do really need strong African leadership, and we're seeing in Rwanda how that's making such a difference already. But we also need creative partnerships. We need to shape implementation for the country needs. And we've learned a lot this last few days here at the World Economic Forum about, for example, how we can translate that into enhanced care solutions. So I think your voices from Africa are really important now. Firstly, at the government level to really drive progress and it's made to see that the policy frameworks and the legal frameworks are starting to be put into place. But we also need strong voices at government to negotiate to get the access to medicines and technologies and really get those carers, the health workers, they're the ones that provide the service, right? Medicine on itself does not solve the problem. You need the people, you need the skills. And I think the second African voice that we will start to see coming through are the patients, the survivors. They are going to be the ones that are going to drive health system improvements. They're going to demand African data, African research to shape the solutions. So let's get some survivors and I think we'll see more progress. An important thing for me today is it's also got cross sector work. It's great to hear that UN agencies are working in the cross sector and it's great to hear the government in Rwanda is really thinking about a holistic solution. But I think the cross sector needs to think about harnessing our energies. We say UICC perhaps was everyone's business and not just healthcare. We've been working very hard in the last few years to look at evidence for the investment case, the economic case for building cancer services. And we released just last year both economic reports on surgery and radiotherapy and it shows very clearly that radiotherapy only saves lives. But also it's a cost-effective intervention which will bring returns in a 10 to 15 year time frame. But I think we have to be clear in poorer countries that the upfront costs are high and there needs to be international support to get that basic infrastructure in place. Thank you very much Julie. And obviously you mentioned publishing and to you Dr Papi, you're living here in Rwanda. You are actively working in publishing in the establishment of the Infrastructure for Cancer Services. I don't know if it covers radiation therapy by the way. I hope you have the means to get some of the Linux in place. In case you don't, you can still tell a few words about what you're doing with the guitar workings maybe on the screenings. Do you think you could open partnerships with private sector international organisations and the Rwanda government? Yeah, thank you very much for that question. So I completely agree that the key is strategic partnering and for our partners in health from our experience we've had the luxury of working very closely with the Rwanda government. We were invited back in 2005 and since then with the initial request that we come in and provide support in rural communities specifically with HIV character literary. That was really the introduction but since that successful interaction with the government we've been able to continue. Based on the needs and requests of the government we've been able to respond and provide the structural support we're needed. I think that one thing that partners in health really believes in in collaborating and establishing strong partnerships is that when we talk about rights such as the rights of healthcare and the rights of education for example those rights are hard to be conferred by the governments. Partners in health as a NGO we do not come to Rwanda planning to deliver rights. We are here to support the government to deliver those rights. So I think that government-led approach is probably the most important component of the successful partnership. And then when we talk specifically about the cancer programs specifically with Ptaro we like to look at it as framed in the accompaniment model. So when I say accompaniment I'm really focusing on two components investment and invasion. So when the Ptaro Cancer Hospital started there really was no hospital at that time. At the time the district was without a true district hospital facility. So together with the government we saw the need to invest in physical infrastructure and then capacity building and providing a strong support staff providing technology, equipment, etc. All within the leadership of the industry. And so once you have investment then comes the innovation which is equally important. So together with the government we've been asked ever since the initial components with the 2005 HIV model but now with cancer and other NCEs what are innovative ways that low income countries can deliver NCE care particularly with cancer which provides a whole landscape of complex challenges such as pathology. Now together with the ministry we have been able to implement very innovative telepathology system that really is leading the charge worldwide showing that complex pathology services are able to be delivered not just in low income settings but rural settings when you have the proper investment and proper innovation. And to that point of your last an isolated facility and it's not. Everything we do because we are functioning within the partnership we know that as Rwanda expands the bills more cancer facilities whether it's in Kigali or other regional referral hospitals we know that the lessons learned the experiences, data because we're doing it in partnership that it's together with the ministry and that those valuable lessons learned will be directly used and we are happy to accompany that process for further scale of replication of the successful experiences. Thank you very much. Very inspiring talking about innovation I would like to also order the minister maybe flag one issue maybe it's not an issue but I see you know we have that cancer new shot session in Davos and we are vice president Biden looking into actually solving cancer and obviously we talk about clinical analytics, big data genomics, we talk about regenerative medicine immunology, gene editing we talk about vaccination for hepatitis C and in the prevention of liver cancer and all of that is cost a lot of money and in the meantime you need to build an infrastructure where you get out by the Japanese information therapy agreement and at the end of the day are we not ending in a situation where some countries in the world maybe not one that some countries in the world or maybe in East Africa end up with the critical solution of the 20th century when in natural economies it's also innovation from the 21st century that's not to be in the fight against cancer it's old even when you see the vaccine like the Mokoko that was really good in Kenya and Kenya wait nine years to have access that for their own children so this is another area where international partnership can bring some ethics and some legal framework and we are all together we can fight for that but we are really willing to be part of research and innovation and we do we do but when the new innovation is on the market most of the time the financial accessibility is so difficult that international advocacy and partnership need to come and make it accessible but the example we had for HPD vaccine the example we had for access to the drugs with Goliath the access to the drugs for hepatitis C when as a government and with some partners we go and advocate for innovation of price at least reduce the benefit of the fund because sometimes also the new innovation that is created let's say value one thousand but because it's an innovation it's sold one hundred thousand so there is some sanity that we can all together come and bring some health for better access to the population but then again the partnership contribution to research the innovation is key another thing is that a lot of research is done not necessarily on the type of cancer we are suffering here in Africa and this is also a partnership in research that we had to create with institution like the National Institute of Health in the US or some European organization so that we can also contribute to advance the science but a portion of science that are in the interest of Africa meaning help Africa to grow, build, educate researchers and also have center like in Qatar to make it a site that is suitable for international research so that we can test together a new treatment that will benefit London and the region so there is a lot of and that's why this forum is important because it brings together the people who have the money who have factories the universities who have the brain to do research and the platform where we can contribute to accelerate those research for the benefit of our people Thank you very much and I'm sensitive to that you have to live in a few minutes as you have an over event but about research and innovation obviously cancer is not one disease it's not a monolithic event and cancer in Africa from time to time very much so from the ones in the material economies but the market being what it is and the market forces being what they are that's in the material economies who invest in cancers not necessarily the ones that are prevailing in the African generation what can you do about it? It's again about partnerships we've practically been forward on what the science is and approach those entities that are doing research to include us and as we go the world is more and more open to that it's also had universities to have partnership among universities from the north and from the south an interest of factories that Africa is doing markets that if they invest here there is a very good promising return in money that sometimes having few people in the north is better to have a lot of people in the south for business purpose so there is a lot of discussion why forum like this are very interesting and so forth but you need always as a government to accompany this with innovation, with policies strategies in access to care like what we do now everyone that is a civil servant or employee official in a classic way can have a check up we have done the same under the community as citizens for 12 cents and in London above 35 years for a woman 40 years for a man can do a check up and if some alert is there can go for a full check up because honey detection is also the most important thing for not coming late like Alcalde from the red show was saying too many people are coming late because of ignorance so we need to proactively promote those check up, annual check up for each and every one Thank you very much and precisely Dr. Laurent the role of the W.H.O in helping accelerate access to care I mean it's possible that one time there is a situation that many African countries if you look at the continent at large what can be done what practical measures can be pushed by the W.H.O to actually accelerate access Yes, thanks to accelerate access it's still collaboration and using local resources the need for partnerships like she mentioned earlier it's very very very important to see like the private sector there is less involvement of the private sector in research and in the distribution of this research for product diseases especially in Africa because of the privacy the good returns from it but with the W.H.O's specialised agency for research in cancer we are strengthening to make a case for cancer so cancer registries we are strengthening countries to develop and strengthen their cancer registries that way you have evidence that yes it's not just cancer is a growing burden so countries are strengthening to develop and strengthen their cancer registries they are also the basic research that are disseminated to countries we are also for cervical cancer screening with the VIA and the W.H.O so that is cost effective local resources yes and that fits probably very much to what you are doing because a lot of what you do is actually working at the community level and a lot can be done at the community level how are you in your community centre strategy with NCD's prevention fit and also from a side note how what do you do for cancer survivors in these those communities thanks for that question absolutely, so partners in health with the W.H.O hospital we are working together with the ministry already based in the world W.H.O is a district hospital but it's in a very rural centre and so immediately in terms of this discussion of access we've already increased access for rural communities showing as a model for many low milling countries where the only access to care is in the capital city we are actually creating a model to show that access to care doesn't have to be confined to just those who happen to live in the capital city and so part of as others have stated is trying to create innovation to provide greater access and to create examples that we have is we have a research implementation research study together with the ministry where we are looking at how to bring access to care not just at the district level but all the way down to the health centre level where we've trained nurses to do clinical breast exams and so that nurses are more aware of breast cancer to the breast cancer community and the cancer we see here in the Wanda thus far and so for these innovative models we can create more access to those who are in the most rural communities if you look at Wanda's numbers for example, 79% of the population lives in the rural community so already right there we have to ask ourselves of that 79% is it really realistic and affordable whether you're talking about Wanda or other low-income countries to ask them to travel every month to see where they came from the capital city and I think partners in health are really trying to work together with the government to be at the forefront of creating that type of accessible If I can add something before we're going what is it just say it's so important that we have created a pyramid of care in Wanda we have the referral at in cities teaching hospital, tertiary and specialised in each district we have a district hospital with doctors and in each of those district hospitals we have trained doctors and nurses for breast cancer parmiation etc and let's say 30% of them now can do in a very safe and replicable manner the 416 sectors in each of them except 15 we have a health centre with nurses there also are doing using the health insurance we have 90% of our Wanda all Wanda insured for health insurance and the package of the annual screening is inside that the benefit of the affiliated to any type of health insurance in Wanda even the community health insurance so we have that at health centre and we propose, we mobilise the population to go for that checkup where they have to receive breast cancer parmiation and advice for quality quality detection so it is a national programme that will allow us to detect value that we are going to go because it's like in the beginning of the epidemic of HIV when people believe always that people infected when people almost die kashectic etc they need to understand that you can have HIV and be healthy you can have a cancer and be healthy and the day you have the first time so we really need to work that I really want to insist on its partnership with people in countries like you with international organisations for good guidance with advocate like you to use Montaigne with our first lady that is always with us in all those innovation and when we have a good deal we just haven't asked the boss who is there for the people of Montaigne and also with people like you to bring a panel like this that will bring awareness to the people so with the AU yes absolutely because with the AU it's also a very big parallel because and it's also Africa has so many emergency to deal with natural resource etc infectious disease now we start to see many cancer because it means that Africa have done some success in management of infectious disease really longer and unfortunately we were so focused on infectious disease that we didn't focus on the other things so it's not only English it was we need to run to run to catch thank you very much to go we have been talking about community and 79% of the population living in rural areas with that said you would find situations where actually the organisation is happening even faster than it happens in Buranda and then addressing cancer in cities is an overbook so I think you have a programme on this initiative where you're planning to launch an initiative in that form yes that's right and I think it's always planning for the future as we've been discussing and globally already 54% of the world's population live in urban areas and this is expected to continue and by 2045 it's anticipated that people living in cities would have increased by 1.5 times so adding 2 billion people to the urban settings and when you think that 60% of the global GDP is generated in cities then urbanisation should be seen as something positive that we need to harness a World Bank really stated last year that they feel increased productivity will stimulate innovation and emergence of new ideas so you know UICC is really thinking about this and I didn't ask the Minister to talk about the period of care but it fits very nicely and that we obviously need to get good cancer centres in these urban settings but it does need to be connected to that period of care and connect the communities and rural settings so UICC is looking to launch a campaign next year and really appealing in this form so that the partners that have helped us shape that program we'd like to reach out to city leaders and send them a challenge to establish these cancer centres and work with us to create creative partnerships to really make this work harness on the good models and innovative ideas we've seen emerging in Africa to really try to progress so that's what we're going to be doing and we're really looking forward to making that a reality in your first talk thank you so thank you very much I think I'm at the end of my question but I also think we still have six or seven minutes and we have a fantastic panel and I think you should enjoy this gaining additional insight by asking yourself a question so if someone could end the mic and if we have anyone that would like to ask a first question to our three panelists Hi, my name is Shukla Hi, my name is Ethan I'm a branch group private equity firm investing in amongst other sectors healthcare and we've just raised a really good fund by finalizing that to invest in providing affordable healthcare in the NCD space in Africa and Asia so my question really is about as the double distance building is hitting and the private sector is starting to think more about how to address NCDs and specifically cancer the challenges we're finding from the private sector perspective is the gap at the primary care level because we need the referral put in and so there is significant capacity building which is necessary at the primary care level the question I have for all of you is how would you advise we think this through because the alternative is we end up building specialist secondary and tertiary care facilities without addressing these another question going to this one first maybe I think that's not a question for one of you it could be a question for each of you so I would like to maybe talk to the private care starting with you I'm happy to start thank you for that question you're absolutely right, it's one of the critical areas of NCD and I would focus on two potential avenues to try to answer that challenge the first one being working together with the government to be able to increase awareness so having these advocacy and awareness campaigns all the way at the community level so if we could learn lessons from the HIV experience where there were literally armies of campaigners going out into the most rural communities so speaking the local language speaking in the context in the context specific manner that makes sense for those who are trying to educate so that type of broad, wide-scale campaigning equal if not greater than that HIV because with the HIV some of the approaches of that campaign were a little bit more simplistic because of the nature of the disease that NCDs, especially cancer, comes in very broad, wide variety of forms so it's going to require a bit more of a dynamic campaigning education approach so I think that's first and foremost one but once you have someone that comes from the community level and are identified and they need to be receiving care at the tertiary level then you have a challenge of pertaining it's a loss to follow-up it's a huge challenge that we have in all conversations and so if you try to combat loss to follow-up it not only depends on the health infrastructure that you have at the tertiary possible are you calling patients are you using mobile phone technology to try to remind them of when their appointments are but even beyond that are you able to create again the incentives and create the community-based incentives where the patient understands their disease so even if they come to the tertiary facility one time in a while when they go back home we've tried we've implemented such ideas like support groups having breast cancer associations at any rate early HIV patients associations so having that community-based presence to really reinforce even when they're not in the same hospital when they're at home to be reminded that cancer is a crime disease that requires a kind of follow-up that requires home-based self-pantry and requires a community level so I think it's a very important point you raised and those are some I think two points for us Thank you very much The MCDs equivalent disease a little came out with what is called best buys these are a set of interventions that any country has and I thought to implement on the line of these there's what we call the pain package of essential end-stage interventions that can be provided at the primary care because we need to appreciate that Rwanda is not just alone here in most of the African countries more people live in the rural area so they need to access care at the lowest level when it can be to access good quality care and knowing that unlike HIV MCDs can't have we can't have a global fund for MCDs the pain package integrates management of MCDs, chronic MCDs with the other system so it's not a parallel system but it's coming back so yeah we are not bringing up a new model it's just that if a patient comes if the woman is between 30 to 49 years old ask a question have you screened for cervical cancer she says no, would you like to be screened and this is the primary healthcare person can't screen and it's linked strengthening the health system as a clear referral system when if she's positive the first healthcare worker knows what to do and where to go to I think that's the way to go but because it's sustainable and with little resources we can do that rather than having we can't afford to have a parallel system for MCDs that's what we're contributing to the care it's a very important thing first thing you need to do is change mindsets I think there's still a lot of people when they think of cancer if they look at a cancer hospital and say you only come out lie down in the coffin you go in there and you die so if you can't change that mindset then you can't really get people to think about early detection or even health promotion and prevention so we need to enter a dialogue in the community and really change those mindsets I think we have some really nice examples coming through the cancer community of managing the flow from primary through district to tertiary hospitals and I think we need to share that those success stories to create a useful model if we look at breast cancer for example you can't just mobilize the population and then expect the tertiary centre to deal with everyone that has a lung in their breast we need to think about how we would triage those concerned cases to make sure that the cancer centre is dealing with those cases and we have models where countries are working on that and I think it's really important to share there are definitely very clear packages of activity that can be built into primary care signs and symptoms information about screening information about what a person can do to reduce their risk if they start early then I think people are more ready to engage with the health system when they do have a concern so I think we need to give people time, we need to educate, we need to change the community dialogue but keep pressuring to really share these models and I think WHO is a great vehicle to share the great cases and support you from that thank you very much very good thank you sorry you had a question yes I have a question, my name is Farid Tazwagli, G Healthcare for Africa and my question you know public private partnership is I think what you touched on including the whole area around access and affordability is big on our agenda I speak for some of the private sector but it's more about you know how do you see an effective collaboration with the private sector the lines of ourselves the lines of the forties that oncology and cancer have been developing interesting solutions going forward but more to make it economically and clinically viable and sustainable I might sure I can start so as a representative of a non-profit organization I can give my thoughts but I definitely don't represent the public or the private sector but you know the advantage of launching cancer programs I think it absolutely requires that upfront investment so I think when there's a private public partnership the commitment for the upfront costs obviously have to be there but then when you look at the long-term plan obviously at some points once you have the upfront investment you get the appropriate revenue but at the same time you have to be my opinion be realistic of what that time comes I think a lot of low-income countries they absolutely are urgently needing greater access to cancer we absolutely love to engage in that type of partnership however the reality is many of the patients that's for example you look at Warren looking back at that 79% number that they or government or some other entity is going to be able to pay the appropriate user fees pay the appropriate cost of care to eventually over time turn around a revenue that's going to take time but the vast majority of patients that need the care urgently really don't have the means to afford it so I absolutely think that this type of partnership has a lot of truth and promise and I encourage it but I think we also have to think of the long time frame when the turnaround time is reducing that example we start using people in this review because we are I'm a lot more optimistic because I'm glad this is exactly what we've all achieved with the city cancer challenge we've all had this experience that you all have had in the private sector where we need to think big partnerships single public private partnerships here and there, policy bring that together and we can be bold and try to move to the market a little bit faster and that's exactly what we want to do and so we've been really open to learning from you and coming up with some great ideas to show you how it works Dr. Maramlo the last one thank you with the WTO the Ruban Coordination Mechanism we have entered into a partnership with the International Federation of Consumer Capital Manufacturing Association of IFPMA and they are doing to prevent them they fear with the private sector there's been conflict of interest with the UN system there's been conflict of interest but having that in mind a lot of times having this partnership like we've done with the IFPMA we are hoping that it's going to open to us from the other private sectors and that's why I'm doing what I'm coming from we're very proud to work with all the global coordination mechanisms working in any way for them to make a second life as we facilitate co-curses in events to come including in China we're working with the WTO on that particular topic and also maybe we do that I need to thank you it was a very good discussion I think we covered a lot of ground I appreciate you came after the event and you learned a lot and you became advocates of the course thank you very much