 Good afternoon everyone. It's nice to see so many friends of CSIS and friends of UNICEF together with us today and I hope you've all enjoyed a meal and this is meant to be a very informal and open conversation so as we get started please feel free to go back and forth and grab some dessert, grab some tea and coffee as you need it. It's really a great honor for us to have with us today Dr. Anthony Lake who as you all know assumed his position as the sixth executive director of UNICEF last May. I believe this is Dr. Lake your first visit to Washington in your new capacity and we're really quite honored that you're with us. Close to your first visit if it's not actually your first visit. Okay so in your official new capacity it's your first your first visit but we're very honored that you've chosen to join us here at CSIS today to talk about your vision moving moving forward. I bring you greetings from from John Henry our president and CEO who unfortunately is in Japan or else he would be here with us as well to welcome you. You know I think there's no doubt that the multilateral institutions are playing an increasingly central role in managing some of the great global challenges of our of our time and that's a set of issues that here at CSIS we're looking at all the more carefully within our Global Health Policy Center we have a stream of work now we're developing on looking at the different multilaterals that work in the health area thinking about how the US can best maximize its engagement with those organizations. Other parts of our institution are going down a similar path we've had a series in conjunction with the University of Miami over the last year or so looking at the great global challenges of our time with a particular focus on the MDGs and what's going to be required to make greater progress there and it's an area of our work we're hoping to expand we're bringing some additional expertise into CSIS Mark Korderman from the Secretary General's office has recently joined us and we look forward to working with him on these on these issues as well. There's certainly been a time of great challenge for UNICEF and for anyone that cares about child health in the time since you've been in office Dr. Lake you've not only been responding to the continuing challenges of rebuilding in Haiti but also the emergency response to the floods in Pakistan and I think most fundamentally the opportunities to look at last month's MDG summit and think about how do we really leverage that event and all the activity and energy around it to ensure a greater deeper and more successful focus on the MDG goals so it's really very timely that you're here with us today to speak about UNICEF's new vision which challenges the conventional wisdom by suggesting that an equity approach approach which focuses on the poorest the most disadvantaged and the hardest to reach children will in fact be the most cost effective and practical means of achieving progress on the MDGs by 2015. The report which is entitled narrowing gaps to meet the goals as well as its companion piece achieving the MDGs with equity is all at your your places for you to look at as we chat a bit this afternoon. I think probably everyone in this room would agree that there's great energy and momentum and excitement around the new levels of political commitment that are being directed to maternal and child health. I mean we've seen this through the work of the G8, the Muskoka initiative, the secretary general's new initiative on maternal child health commitments that are being made by bilateral donors certainly the MCH agenda is a very important part of the US global health initiative. Norway continues its strong leadership but there are also some very fundamental challenges and I certainly sense a concern that we're really going to be able to capitalize on all the political energy and make sure that that really does work result in some concrete achievements this time around and that we tackle in a more meaningful way some of the really deeply ingrained challenges that have prevented progress in the past you know particularly issues around health systems issues around neonatal mortality issues around building a greater base of community health workers who can actually help address some of the real needs within families. So we're very much looking forward to hearing more about UNICEF strategy and how UNICEF intends to tackle those critical problems moving ahead. So thank you very much for joining us. Oh before I give the floor to Dr. Lake let me just introduce for a second also other two senior UNICEF staff members who are here with us on the podium this afternoon Dr. Mickey Chokra who is the chief of health and associate director of programs before joining UNICEF in 2009 Dr. Chokra was with the South African Medical Research Council and he's going to do a short presentation following Dr. Lake's remarks and Dr. Rudy Nippenberg who is the principal global health advisor on health systems strategies and policies and who's been with UNICEF in a variety of positions for more than 20 years. So welcome to you both. Please Dr. Lake. Thank you very much Lisa and thank you Steve for hosting this. I'm very very glad to be at CSIS where I've done other projects and just have enormous respect for all you're doing and all you will do on this issue. I know I know that's a commitment you just nodded. Okay. And you were anyway I know. Let me first note that Mickey is a real doctor and I am not. Thank you. Let me just give you a very brief introduction to this more or less historically though it goes back all the five months and begin by emphasizing this is not a new UNICEF strategy. UNICEF has always been fundamentally concerned with issues of equity and most disadvantaged children. But as we thought about this last spring and looked at statistics not only from UNICEF but from save the children and many others. The fact is that as the world has been making progress towards the MDGs mostly by averaging national statistics. We are discovering that in a lot of countries and we'll show you this in more detail while the nations might be making some progress on the UNICEF strategy. So I think that under five child mortality the it's very uneven and within nations and among nations the gaps between the most disadvantaged and the most advantaged are growing. So I arrived at UNICEF to discover that people at UNICEF shared an equal passion for refocusing UNICEF's work for those children. Whether they are children living with disabilities or whatever they are reason enough in principle as they are being left behind to make us angry and make us refocus on them. So from the start we've been talking about a new refocusing of UNICEF's efforts into those areas. And I'm very happy that our executive board and just our national committees and everybody has been very supportive of this strategy. But we also decided to examine another question. And that was, and Mickey will be speaking about this more analytically and at somewhat greater length, but the questions we posed to ourselves was this, isn't it possible that because the needs are greatest in these areas that the same interventions in these areas would produce greater results in terms of children's lives saved than intervening in areas that are easier to reach, but where the results are less because the needs are less. So the analytical question was, yes, the conventional wisdom is that it's more expensive than it is and more difficult to get into these areas. The question is, are the results of concentrating on these areas greater than any additional costs to get there? In other words, is it cost effective to work there? Because if it's cost effective, that means that we can at a time of limited resources around the world move more quickly towards the MDGs, which is a statistical goal and save all of those children's lives, which is the real goal. So we are proceeding on that. Mickey and Rudy began then an exhaustive study which Mickey will describe in which we got a team of our best analysts to work on this question in terms of under five mortality. They studied it for months, very rigorously, brought in experts from the field, had a couple of times they gave me their results. I rejected them on the grounds that they were much too good, admonished them that there's always an inclination to please a new boss, and I didn't want them to do that. I wanted them to bend over backwards to be fair in the study, go where the numbers took them, and they still came up with the results you'll hear. So I brought in a team of experts from the outside, including the editor of the Lancet, various other people who have been critical of work generally like Chris Murray in Seattle, and they all, and plus practitioners like Paul Farmer and Helene Gale and others, and they all said, this is terrific. We had a briefing this morning at the World Bank, which went very well. Editorial in New York Times supporting this. The Lancet has run an editorial supporting it. There's going to be a series of articles in the Lancet on this. In other words, to my huge relief, frankly, it turned out that the numbers support the conclusion that, yes, it is more cost-effective to do the right thing, and how often in life does that happen? I have very seldom. It is more cost effective to do the right thing, which we were going to do in any case, but I think you'll be interested in the results of the study. Let me just emphasize one other point about it, and that is that this is about health, but the same applies to education, protection of children, etc., etc., for a lot of different reasons I won't run through, and we need integrated strategies in these areas if they're going to succeed. It just stands to reason that if you're intervening on health, but you're not coming in with education, especially for education for girls and those living with disabilities, then you're not going to lift communities out of poverty, and you're going to have to keep going back on the health side. So you need integrated strategies, and that means that all of us, not just UNICEF, have to work together, and I've been saying recently I'll be very disappointed if this is thought of as a UNICEF strategy a year or two from now because I think the facts suggest that this should be a more common strategy and all of us working together. So Mickey, if I can turn it over to you. Thank you. So I'm just going to fairly rapidly take you through something that like Mr. Lake said, took us about six months of a lot of data crunching. It seemed like sex it was for. And just give you the hypothesis and the modeling and so forth and then leave enough time for questions and comments and so forth. As Mr. Lake said, one of the startling findings which many of us in the room were also previously aware of, but actually we now have very clear indication that in particularly if you look at the 16, sorry 24 countries which have made the most progress in reduction of under five mortality, 16 of them have actually done it with increasing disparities between the poorest and the richest. And in majority of those countries has actually been a more than 10 percent widening of inequalities in terms of child survival. We can show the same for nutritional status, we can show the same for access to critical services. And it's something which many of us who have been working in the field will know this that and we have data as well, that investing in these in health and nutrition has quite often been captured by the urban elites and the middle classes and the better off in many of these countries. And they have soaked up and had multiple interventions, whereas a sizable proportion of the population are being left further and further behind. So it was a moment of pause to say well if we continue on this path we may statistically in some places and most places probably not even that reach the MDGs, but as Mr. Lake put it it would have been a moral failure because we will be left with the poorest, left further behind in not much better situation than they were when we started this whole endeavor. And how much more difficult will it be to get the momentum and the movement again going on this area. So clear diagnosis there in terms of increasing inequity largely and significantly linked to access of critical interventions. And on the other hand we do have some examples of countries which have improved but also done it in an equitable manner. And so it's not as though this is an inevitable path and price that you pay for progress. So as Mr. Lake put it the challenge was the conventional wisdom was that the reason why countries have gone down this path is that it is much more cheaper and cost effective to reach those who are within reach of the roads, within reach of where health workers want to go and let's at least maximize those returns and then we'll slowly sort of get out and reach those who are more difficult as we as we make the gains, early gains that we can. However not only epidemiologically does that may not make sense because you know as you add more and more interventions to groups who already got the basics you get less and less return for that investment. But also new innovation, new ways of delivering services, work that many of you in this room have really pioneered in terms of you know ranging from from community-based treatment through to newborn care, through to new delivery mechanisms and accountability mechanisms using technology, mobile technology and so forth meant that the cost of delivering critical interventions may have actually been reduced and we now have a reasonably good evidence space for these kinds of interventions. So putting that together it wasn't completely fantasy if you like to think that doing the right thing was also the cost effective way of doing it and the challenge really was well can we empirically with real data show this to be the case and and whether we have now reached that tipping point where it is more cost effective so I just want to give you a quick run-through of how we we we tackle this challenge. One of the first things we did is we looked at the different patterns of inequalities that you see and and once again this is fairly well established and I won't go through a lot of detail but we sort of establish four sort of key patterns if and it's ranging from what we calling typology A which is familiar to many of you especially from Western East Africa and Central Africa where the large majority of the population are actually quite deprived have higher rates of mortality and something which we're calling a coverage deficit which means basically not having access to basic services and on the other hand you have what we call type C countries where sort of mostly middle lower middle income countries where large the majority of the population have made the gains but there are large pockets and sizable populations who have been left behind either because of political racial ethnic or geographical reasons and then you have sort of linear patterns at different levels of coverage so we selected sort of examples of each of these patterns and countries which had robust and good quality data that we could use and we could disaggregate as well one thing I want to make clear is that we then were trying to model different scenarios of how to deliver promote and finance the implementation of a core packages of services so we did not try we did not say what an equity-based approach will have these really cost-effective interventions and a non-equity one will have these really expensive types of interventions you know intensive care units and so forth what we said is that through all these Lancet series we have 25 30 critical interventions ranging from vaccination through to micronutrients and through to treatments simple treatments of the biggest killers of children across the world and so the challenge is not so much now what you know which intervention should we have and which windows we shouldn't have but it's how do we get those to the poorest and that's what we are evaluating here in this study so it really was about how does one package how does one package and deliver and finance and promote these these core interventions and modeling different approaches to do that I'm going to jump straight to the results because I know that's what you're waiting for and I'll go backwards to explain how we got to the results and so just to show you a couple of graphics of some of the key results and they're in your in your short summary reports there as well calling narrowing the gaps but you'll see from here that what we found is that we we basically model two different strategies something called the current strategy and an equity focused one and I'll go into details of what they consist of but just to briefly summarize the current was the base the current dominant equity strategies that we have the countries have in their plans and we assume that they would implement those strategies including for example getting rid of user fees of scaling up training of health workers of getting more clinics built more nurses and doctors and so forth and you can see that if that gets implemented in the way which plans of for countries have said there will be a notable decrease in the five years that we modeled the 2015 in the yellow bars both in the most deprived and least deprived areas by doing this but what we're calling a more equity focused approach will get you an even greater return and it will accelerate further and give you lower rates of mortality in both the most deprived and even in the least deprived areas as well. In other words if we put this in terms of the 15 countries that we modeled in you aggregate them having an even greater focus on equities and focusing on populations with the highest burdens will actually accelerate progress towards the MDGs and across these 15 countries if we carry or if we actually implement the existing current equity strategies we probably won't reach the MDGs. Not only that but our analysis also found that it's much more cost effective in all the settings and it's most cost effective in the poorest settings in particular across Africa so if you look at the top two graphics with the additional million dollars invested in a more focused equity strategy you will save up to 60 70 percent more lives in the poorest countries because you get much better return for those interventions and those ways of delivering. So very promising and very encouraging results and let me just now take you through how we got to those results. So the first task was really to define what a more focused equity strategy should consist of and here we really did an extensive review of the literature. We spoke to colleagues like yourself about what has worked for reaching the poor looked at large-scale implementation of programs that should be evaluated and shown to increase coverage and improve outcomes for the poor in particular and really built on the previous experiences in literature and the principles that we have from the Alma Ata Declaration for example. And to summarize what a more pro-equity focused approach would consist of you can put them into three main domains if you like. One is different ways of delivering those services in particular changing the way and increasing the cost effectiveness of and decreasing the cost of delivering critical services. And the obvious one which we have in examples and large-scale examples now of is the training of community-based workers for diagnosing and treating malaria, pneumonia and diarrhea the biggest killers of children. And so the development of new diagnostic technology as well as simple training algorithms allow us to do that very safely now at the community level. But it's also about innovations of improving providing services for newborn care as well as we've got new evidence of how to retain and better get performance from health workers and peripheral settings. The second domain was around me more innovative around reducing and overcoming financial barriers for the poor and the most obvious one at this moment being the use of conditional cash transfers as we're seeing in India for delivery in health centers. There are a number of other innovations out there which have also shown to improve and get over some of the key barriers of the poor face financial barriers that they face. And so we modeled some of the impacts of that in different settings. And the third area which I think is quite often under stated not in this audience but in many of the more technical and the more medical audiences which is the role and the importance not just of the supply side in terms of health workers and vaccines and so forth but also about empowering communities and women in particular to know when to get services know how and expectation the accountability of services that they should be getting and key behaviors in the home and between the mother and the child in particular which we know can have a huge impact. So we modeled and we gathered the evidence for some critical face-to-face investing in community-based face-to-face education and empowerment strategies women's groups and so forth. So we collected the data on the costing of those kinds of interventions and put those in. Now we also had two other layers of modeling and sophistication if you like. One was the recognition that there is in all settings a unique blend of demand side and supply side barriers that the poor face and that if you put in a strategy for example of getting rid of user fees that will only is only be good enough if a person actually lives within a reasonable distance of a facility to get to use it. So removing user fees will only give you an impact as good as the access physical access that somebody has and similarly if you take that analogy further it will only be as good as whether that physical facility has a trained health worker with drugs. So for each of the 15 countries we disaggregated their national survey data as well as their administrative data and we went through with the countries and with the ministries to actually validate as much of this data as we could but most of the data was using household surveys and national facility surveys. We sort of got these different types of patterns. Here's an example of skilled birth attendants in Bangladesh just to give you a sense of it and you can see that this is for the poorest in Bangladesh the poorest districts in Bangladesh that they face both supply side bottlenecks but even only about half the population have actual physical access to a facility with a skilled worker but even then they also face some critical utilization demand side barriers which further reduce the effectiveness of the intervention of having a skilled birth attendant. So in our modeling we basically had to model in multiple interventions to see well what can increase the supply and what will then increase the demand side as well. The third sort of area and modeling phase if you like was to take into account the different causes and rates of death between the four and rich and you're all familiar with this and just to give you an example here from Nigeria where on the left hand side the Q1 is the poorest and Q5 is the richest that not only you will notice that there's far higher rates of mortality amongst the poorest but I want you to pay particular attention to the causes and as is intuitive but we have now modeling and you have some data to show this across the countries that the poorest families and children die of diseases and illnesses which are the most amenable to our interventions that we have the most cost-effective interventions so in this case you'll notice a malaria pneumonia and diarrhea cause the bulk of the mortality in the poorest quintiles in Nigeria whereas in the richest it's much more newborn congenital rounding road traffic accidents things which require much more sophisticated and more expensive interventions so in modeling we must also take into account the different cause and rates of mortality between the rich and poor and the different numbers of deaths in the rich and poor so it's putting all that together that we came up with this cost-effectiveness it was really linking the strategies and the evidence base we have of new ways of delivering of overcoming demand and supply side barriers putting them into real life data from countries modeling in terms of the different causes and rates of death amongst the poor and the rich and then costing it in terms of the number of lives saved and the extra cost spent and this is how once again I'll bring you back to perhaps one of the key findings around the extra lives saved with the additional funding and a more equity-focused and equity-based strategy I'm not sure how this slide slipped in this is just well maybe it's a good thing it just gives you and there's a look of shock on luckily it's accurate but basically it's trying this is sort of this is our own sort of and we're sort of thinking as we're running as it were and what does this mean in terms of our own priorities I think the first point to make is that it really is and we've had questions in the World Bank for example how is this different from our human rights-based approach and what we've done previously and it's not different but what it is different about it if there is a difference is that it's a much greater focus on data a much greater focus on doing detailed situational assessments of what are the barriers of the poor are facing it's paying much greater attention to the evidence of what has worked and what hasn't worked so it's trying to shift the organization as a whole to be much more rigorous and much more take much more advantage on the huge investments that we make on household surveys on data collection at the country level and then I think it's also focusing us much more on the collaboration and the partnerships aspect to scale up innovations some of which are our own innovations many of them are not our innovations but it really is trying to get the organization as a whole to focus on partnering and particularly at the country level and we've been talking to many of you about how to do that better to really scale up some of these innovations that we know have worked and are working and taking them to new places and learning by doing so this is part and you know big reason why we're here today really is about how to make this not just our agenda but your agenda partner with you as well on this thank you if I could emphasize or make just three points one is that the actual modeling of taking the two strategies which I would emphasize were models not actual strategies that we'll be pursuing I'll come back to that but in taking the two model strategies and running them through the four typologies and Mickey and Rudy are remarkably sane for having worked on this there were over 180,000 different data points that they had to take account of as they ran the and this was a massive modeling effort again in consultation with some of the world's leading methodologists on all of this and I just want to emphasize one of the points on the MBB analyses of looking at bottlenecks as you notice the supply side it were doing better than the demand side and just as I hope that this study helps us adjust our thinking a little bit on the conventional wisdom that is too expensive to do this because it turns out to be more cost effective to do it another is that certainly for me to the degree I've been a part of the development community and certainly now my conventional wisdom has been that aid is all about supply more vaccines more bed nets more of this more of that but what this shows and it's a very important conclusion is that we have to focus a lot more on the demand side of helping the poor have access to this lowering fees changing behaviors and things as simple as hand washing or convincing mothers if you provide waiting houses for example to go so that they can take advantage of clinics that are closer to it to their villages and that it has implications for how we think about developing health systems because the tradition has been correct me if I'm wrong Mickey I'm a political scientist Dr. that the tradition has been that you start with the hospitals in the city we're not coincidentally the the daughters and sons of ministers can get their kids to government ministers can get their kids to a hospital and then out to the higher tech clinics and then to the lower tech clinics and then finally out into the communities and what this suggests is that it is more cost effective to concentrate on the communities and also build back in your health care systems to the higher tech coming out I would emphasize here we are not calling for stopping what we're doing now in building health care systems you will not find me going to some country and saying tear down that hospital Mr. Gorbachev but we are saying on all of this that as we go forward in our marginal work going forward for the next five years and beyond we need to put more resources into this and less into the traditional approaches and finally for since we have the what does it mean for UNICEF I'm going to emphasize that what we're doing right now is every one of our country offices around the world under the direction of our regional offices are reexamining their programs to look at them through the prism of equity so that we don't stop everything that we're doing now but we are shifting our resources over the coming year or two more into these strategies so that we're building the UNICEF strategy from the bottom up as an amalgamation of all the different country strategies because they're all as we all know different rather than a dictate from New York saying here is the new religion and you will follow it in a certain detail this is going to take a little while and that is why we were working on it so urgently because it is a going to take a while to shift and be then take a while to get the results and all of this I would emphasize all of it is about results this is not about theory it is about what actually happens in the lives of the children and of women and of everybody around the world we would welcome questions and even better comments from which we can learn let me thank you both for the the great presentations and let me say when I was reading through this document which is really quite a phenomenal document if people haven't had the chance to look at it yet I was also struck by the 180,000 data point figure last night and it was giving me quite a headache actually trying to even get my mind around what that might mean in terms of the type of analysis that you're doing but a couple of different streams that I might just try to bring together in one initial question to get us started is I was struck by a couple of things you both said the first is that you don't just want this to be UNICEF's approach you really want this to become a common platform that more globally the community adopts the second is the focus on shifting the demand side of the equation which clearly has been a stumbling walk for quite a while but the third point I come back to is a speaker we had here not too long ago and I think a number of folks in the room with us today were here last month and we had the Afghan minister of health Saraya DeLeo with us who I believe is a former UNICEF staff member herself and she's clearly a woman of great vision and purpose but has an enormously difficult job and you know she laid out some of the progress that's been made particularly on the child health agenda maternal health still seems to be quite stubborn but you know as I was thinking about your presentation just now I was thinking what what does this type of approach practically mean to her and Afghanistan of course is an extreme case and I know you don't even have it included in your data summaries because there isn't enough data to be able to do that but when you look at the countries where the inequities are the greatest places that very often are conflicted countries how is it do you think you can go about moving this approach forward and what are you going to need from others what are you going to need from the other multilateral partners bilateral partners development partners host governments in order to be able to actually make this make this work sure and I think your first comment in many ways also started to address the second one in terms of what we're what we think and we and as you saw from the last slide it's helping us to really focus our our country officers in our own organization and in the way in which we give support to governments and civil society in these countries to really ask the hard questions as to who are being left out where are they and then also try and interrogate as much of the data which and sometimes it also means in addition not sometimes what always means in addition talking to the people who work and live out in these areas about what are the critical barriers in terms of supply and demand but then also bringing to bear on that problem the latest innovation and examples we have of success and even the country like Afghanistan as the minister I'm sure shared with you have some real innovations in terms of their contracting out of critical services of you know even even I mean the polio program there has reached 99% of children even in a country like that so to show that even in the in some of the most desperate circumstances there are examples of where we have succeeded in reaching the poorest and so it really is about working from the ground up taking the perspective of the poorest child and saying okay what is the barriers that she is facing in getting you know survival interventions and then education and development interventions and how can we bring the best evidence that we have and the experience we have globally but also locally onto that problem if I could add into this obviously the hardest place to do this is in countries in conflict or fragile states on either side but we can't let that deter us we have to think hard about how to do it and one question is advocacy here with governments and we hope because in the end it's governments no matter how well we do NGOs do and others it's governments that can take things to scale and that can make the decisions on school fees on health systems health fees etc and we hope that this report will help us be advocates with governments pointing out to them including finance ministries who are the key barrier in most of this they speak this language and if we can speak the language of cost effectiveness and working for results then we're speaking the language that can get to can help our friends in these governments in the health ministries etc make the case with the more political leadership and with the finance ministries and others and we can be better advocates the more we are all doing it together rather than UNICEF obviously alone and I was very encouraged by our conversations with the World Bank this morning where we found a lot of areas that we can now work together going forward the second point is something we haven't touched on at all of how do you operate in Afghanistan or Somalia or elsewhere and let me simply share a concern that I have that I know Sam I believe Sam shares you can disagree and I will go into shock and that is well I began when I was at a polio event in anti-polio event in Geneva and at the airport I was waiting of course for United Airlines whoever it was and had a chance to have a long talk with one of the workers on polio in Afghanistan asking how do you do it in Taliban areas and by the way I think the last holdout on this tremendously important campaign against polio will be along the Pakistan Afghanistan Tajikistan et cetera borders but how do you do it and he was saying well we can work in these areas because while UNICEF may not be popular the Taliban in those areas know that the communities want to see these interventions whether it's against polio or in other areas and the Taliban doesn't want to be unpopular so they're letting us do it or I could use the example of a water treatment plant south of Mogadishu which we had begun in a town south of Mogadishu before the Taliban and before the Shabaab came in and the Shabaab tried to shut it down and the people there said no we want our water so they're allowing us to continue to do it the problem is that we can do this to the degree that we and NGOs and others are perceived to be not neutral but non political and the danger is that in conflict situations there is an impulse to because we are popular as I was just saying to use our popularity for political purposes and to integrate missions in ways that make everything that we are doing a part of the political and military effort in these countries and we are resisting this in every way reasonably that we can I know that the Sam the NGO community is very concerned about this and very usefully concerned about it as well and I simply wanted to mention that because we are in I believe Washington DC where some of those impulses may reside so I just think it's tremendously important that we keep all this in those areas as non political as possible or we are not going to be able to help those children and women and others who are most in need Let's take some questions from our guests and what we'll do is we'll do them maybe groups of three and just please identify yourself when I call on you so Anne please Hi Anne Richard International Rescue Committee I think what's really great about the presentation is this Could we stop right there? Is that it is showing you know quantitatively the impact this can have this approach can have and the time in Washington could not be better for that because you know in every meeting we have with the new USAID Administrator he really is focused on metrics and benchmarks and measurable approaches and I suspect that if it's going to get tougher and tougher making the case for aid to Congress in the months ahead as is predicted this type of evidence will be the thing that gets the most traction so I think your timing could not be better at the same time we're hearing more coming out of the administration about investing aid in a way and what they're really saying is so that it's not wasted which means you know trying to do it in a way that avoids risk and goes to best performing countries the way the Millennium Challenge Corporation does and rewards you know good performing countries and they speak and the terminology about this tends to be very bilaterally focused and also working in places where you get a good investment they're also saying where you get the greatest impact so that potentially leaves the door open to getting to countries where perhaps they have lousy governments but the people really need the aid so have you all given some reflection to how this fits into the new administration's development policy that is as I've described it or the pieces that I'm picking up on Hi Tim Shriver with Special Infix I echo the comments I think this is such an extraordinarily exciting direction and I guess I just have a couple of sort of loosely strung together questions and comes from our experience in trying to provide healthcare in addition to recreation and educational opportunities for people with intellectual disabilities the thing we see the most frequently in this subpopulation this small subpopulation the most frequent barrier to effective delivery of any kind of healthcare service is stigma it's social, cultural interpersonal stigma, bias devaluation and it plays out in many many ways it plays out in the under training of healthcare professionals to treat specific syndromes or specific disabilities it plays out in the devaluation of parents who have children with special needs which leads them to be less likely to bring their children out in public or access services or even admit to having a child at all in certain situations and it leads to sort of this large-scale kind of elephant in the room if you will that's not really about supply if you in a way Tony or even about demand it's about the interaction between the two it's about the relationship between supply and demand and it's not a good one the demand is there the supply is there but they don't talk the same language so it's a long way of saying the idea of community empowerment community engagement I think is right dead on and the question I guess I have is as you begin to think about that are you thinking that there are potential significant paradigm shifts in the way in which you do your work the kind of work you're going to have to do the kind of partners I mean one of the challenges we face you know we do 100,000 health screenings a year and there's not hardly any development organization that will give us a dime to do them that's mostly our fault we haven't told the story properly but part of it is just the sort of sense in which you're a non-traditional partner you don't really have a lot of MDs on your letterhead you don't really do this do you so and I'm not looking for support I guess I'm just trying to flag the complexity of attacking the biases inherent in cultures whether that's on disability or ethnicity or race or gender and the need for dedicated strategies to attack that piece of the barrier if we're going to get to really the hardest to reach because the hardest to reach in our experience aren't just the poorest they're the people that have been most socially marginalized and often quite deliberately so let's take one more question Seth at the same table there the lady with them thanks very much Rachel Nugent Center for Global Development and congratulations on the new post and the very exciting report this seems like it could be quite a watershed and so I want to ask you go back up to New York and shift the focus there and ask you about the relationships with your UN brethren and sister in or whatever and how this fits into the delivering as one UN and in particular because I think there's a nice opportunity given that you have of course a new partner in Michelle Bachelet and the development of UN women and what that will become and you will soon have a new partner at UNFPA I don't ask this as an idle question I have to confess we are doing an expert working group project right now on leadership transition at UNFPA and thinking very in a very focused way about what that agency needs to do and it's next incarnation so I really appreciate what you're bringing to the table for our thinking about that but what's your thinking about delivering as one let me the really interesting questions all of them questions and challenges that we are in fact wrestling with first the administration approach we're taking the road show we've been at the World Bank this morning we're here now we're going to the White House next and we'll be meeting with Don Steinberg from AID various others from around the administration and we're grateful the White House is hosting this and we hope to infect them with this as we are hoping to infect you and I believe we infected the World Bank some more this morning and again let me emphasize this UNICEF didn't discover this we did this study we are going to be focusing on it but this is we are taking advantage of a lot of accumulated work by a lot of people including in this room as we go forward so we'll be working this the question of the how does this relate to the MCC and the best performers and all of that and a related question is does this relate to middle income countries and the answer is twofold one there is a great danger and it's the path we're on now in which with the MDGs we are looking for progress through averaging of countries and theoretically we could make a lot of progress towards the MDGs in a lot of areas simply through China and large parts of India and leaving behind most of Sub-Saharan Africa other parts of India other great swatches of the world and that's A, not cost effective as we're hoping to show as we are showing I think and B, it's just plain wrong so one of our arguments on this has been to use maps from that I've been across my desk and I used it with our executive board maps from Brazil that are Brazilian maps and the Brazilians have been very happy that we're using it showing that if you look at Brazil on under five mortality and progress towards MDG4 it's a beautiful green blob and then if you flip the map and look at it at the state level suddenly there are big patches of red in the semi-arid regions and elsewhere and then if you break it down by municipalities it's a leopard with areas of red throughout the whole country which the Brazilian government is very aware of and is working on my point being that we can't do this for averaging and the millennium I mean the best performers tend to be average best performers but even in those areas like Brazil or the others in Latin America as a whole 14 of the 20 most inequitable societies are in Latin America so there's a lot of work to do in middle income countries as well but the bottom line is the if you remember from the charts in the first two models from Africa if we leave them behind then shame on all of us and we're not being cost effective at the same time secondly on stigma yeah I think it is though mostly a demand side and it is where the demand then comes together with the supply but stigmatizing is a huge barrier to this but it's one of the kinds of social patterns that we have to be addressing and there are as Mickey mentioned more effective ways of addressing them and this is not only although it's very important as I mentioned for a children and others living with disabilities which gets stigmatized but also in the whole approach to HIV and AIDS and PMTCT prevention of mother to child transmission which we are very focused on we're working with UNAIDS and others to for the virtual elimination of PMTCT if possible and I think it is possible by 2015 which means to get it under 5% transmission and their stigmatizing is a tremendous issue as well and let me just describe one very and we are concerned about this running throughout it and let me just describe one specific example which is that in a week I'll be going to I'll be in Kenyon we'll be going out to Kasumu to introduce something that we've been testing in I think four different countries now and they're going to take to scale it's called mother baby packs where we have got a a pack of all the medicines that a mother needs before during and after childbirth to prevent transmission color coded very easy to understand and the mother when she comes to the clinic hopefully before birth then she gets this pack and then she can with the checkups from a community worker administer to herself what would have taken going repeatedly to a clinic that she probably can't reach the problem is that how does she take the pack because she's tested positive without being stigmatized so we are finding I think they're pales now that we're going to use in which every mother gets a pale that she can use for clean water and in some of them the mother baby pack goes into the pale so when she walks away then if she's doesn't have the courage to talk about it she's not stigmatized when she leaves so it's a very practical issue that we're running through a lot of different things with our sister agencies and I'm glad you who was it sorry yeah there you are back there and I'm glad you use the word sister because I am proud to say that Thiraya who runs UNFPA Margaret Chan at WHO etc as it happened in the H4 I guess it was all of them before I arrived were women and they were all calling themselves the sisters and Margaret I thought rather offensively said to me so what do we call ourselves now is it the sisters and the boy and I I said no that gender abuse can go in each direction and I but that I would be honored if they would call me their honorary sister so Margaret and Thiraya and all of them now call me sister which I'm quite proud of it leads to some occasional questioning looks when they do it in public occasions and they don't explain why they're calling me their sister but anyway I've been very pleased at how this notion is getting some traction with the others so for example we've been talking to UNDP now in various ways about how we can integrate it into the through resident coordinators into again a more integrated approach from all of the agencies but I think it's not good enough for it to be simply among within the UN reform system but we need it with NGOs with bilateral aid programs and especially then with governments so so far so good it's been just a couple of months the MDG summit was very useful in spreading this I'm trying to resist again becoming like a religious zealot and going out in the street and grabbing people by the lapels and say have you thought about equity it's cost effective etc but since it is a practical message I think we are making progress for them and I'm I'm pleased with it so far but that is the strategic objective let's take a few if you want to sorry let's take a few other questions David please David ute I had a health and nutrition that saved the children that in I think as you know we're very committed to this issue and in fact very pleased to see this not new in a way but renewed commitment on the part of UNICEF to addressing the issue of equity and if I could intervene we were certainly drawing on Save the Children's work and I wanted to make the point I was just making about playing well with others as we move forward on this mission so we announced this joint press conferences in London and in New York with Save the Children and thank you and we were very appreciative of that what I wanted to say however is that I think this analysis is a very useful contribution it's going to be enormously helpful to us and others I think in helping to make the case that we need to focus more attention on this issue the challenge that we've faced over the years even though we've had relatively good not as good as this documentation of what's working well or not so well is translating that into action so practical guidance and tools that can actually be used by our organization and our counterparts to first of all develop strategies and plans that in fact do more systematically take this into effect but interesting enough develop and use the metrics so that we actually know what kind of progress we're making whether or not we're achieving those results it's surprising and we had Dave Guatkin come and spend some time with us a few months ago and he embarrassed us all by demonstrating that we really didn't have a lot of data to actually document how well or not so well we were doing in this regard so that's really important from our perspective and there are some draft tools and guidance that I just mentioned to Mickey earlier are in the process of being developed the second is that I very much agree about the importance of the demand side it's often ignored or given much less attention but I actually don't want us to forget about the supply side both in terms of having trained and skilled staff in place where they need to be community level first level facilities and with the drugs they need to do the job and I'm this is top of mind right now because right this minute in Mali we have a large scale program in what's called community case management of malaria pneumonia and diarrhea that can't be implemented because those drugs are in fact not available so we do need to continue to work on both ends of this let's take two more brief questions if we can please Sam Hi, excuse me Sam Worthington from Interaction and I appreciate your comments and I think you're just your broader statement that the in conflict environments that the space to improve human well-being that is not politicized is shrinking and that is a challenge that we face and our ability to do our work I think is a whole community more broadly the ability to engage at the community level create demand link that up with supply try to overcome stigma link those front line capacities of governments of communities is a space to some extent the NGO community has filled it's a space that UNICEF has engaged with the challenge we face is how does this relate to the broader concept of of country ownership and the accusations that we sometimes get because of you've been able to reduce these significantly change indicators and performance and so forth but they're not sustainable because they have bypassed the state and there tends to be the implication that the state has to be down from the top and the building the systems that way rather than this in essence what I see is a broader definition of country ownership that involves demand from the community and I don't know if you could address that because I think it it will play into broader dialogues in this town on a reform and one more question the gentleman in the back here hi I'm John Fawcett with results this is really exciting because as you mentioned it's sort of nice when your values match up with cost effectiveness data which certainly isn't always the case in our field of work so I imagine that you will or have already found a paradox where the study talks about a current approach and a equity approach being distinct things and probably when you talk about this with people they say oh we're already doing that so I guess my question is can you talk and I saw a little bit of it but is it you know is it geographical is it in the types of interventions is it the way you do them maybe as specifically as possible just in a couple of examples how would an equity approach differ from what's currently sort of standard operating procedure that's all all that matters is action and that's why we're emphasized in working at the country level rather than at the more theoretical levels and how to proceed here to turn it into action is of course a big managerial issue it involves very hard work sometimes not dramatic or romantic work every day but that's what we're going to do because the goal here is so important and one of the ways we're going to do it is by forming teams that can go to our regional and country offices who can help especially in the 60 countries from which we got this data that Mickey and Rudy are going to be forming that can go then to the country level and say here's the data we've already got here's the analysis we did in the process of doing this report here's how it can help you now program with a greater attention to equity and Mickey will in a minute address this the paradox when people including our own country offices say but we're already doing it and of course in many ways we are doing it but it's a in essence it's the same interventions in a different mix and with different priorities and both in terms of geography and in the kinds of interventions or the the emphasis on certain interventions rather than others but let me come back to the point first of all on results how do we get the metrics to examine the results so that we can make the case and this is very hard in truth it begins I just met with all of our not all of them but with dozens of our folks from around the world who are doing monitoring and evaluation planning and what I was emphasizing is that and I learned a lot by the way from them and I don't mean to be implying here that I am a world authority on all of this because I've been here in the job five months and I'm still learning but some things pop out at me and one is that there's a great danger there are a couple of great dangers here I think one is that our folks can look on results based planning and therefore the ability to including metrics to the degree possible and then of the monitoring and the evaluation as a laborious box is to fill out for headquarters and we need to emphasize this is a way of thinking that if we are passionate about this mission then it's all that matters as results therefore let us plan for results and then set up the metrics there's a danger here however and that is that because these are hard financial times and because our donors need to make the case to legislatures and to finance ministries etc that this is achieving results there's a great temptation to cheat or to get twisted by this you can get twisted by it because then you're going to start looking for simple programs that have simple results so that we can show the donors to give us more money and so you can get twisted towards simplicity and what are inherently complex questions and secondly you can cheat by well let me back up there's a real paradox here in which we are under a lot of pressure as we should be for UN reform for working well together for all of us integrated approaches we're all working together on the one hand and from donors saying so what specific results did you UNICEF achieve from the money we gave you and we could cheat by saying everything that's been achieved in this community is because UNICEF was a part of it even if we had very little to do with it I don't want to overstate this point but I think most of us will recognize in this room and I think we need at least from our point of view at UNICEF to stop in any way doing this in implying that we have sole credit for these results because if you totaled in my view all the results that are claimed by all of the bilateral aid programs and all of the NGOs and all of the UN agencies we have saved by my just instant calculation something like 140 billion children over the last year so we need to go back to the donors and say let's be realistic about this that not all the results we can achieve are quantitative some of them are qualitative especially as we do more and more advocacy it could be that the government has made a decision to remove school fees yes because we advocated but maybe because it was good policy maybe because the education minister was more powerful etc etc so we need to get the donors to be more realistic also and point out to them that by the way and their bilateral aid programs maybe they can't trace these things exactly perfectly either while working as hard as we can to do this and to come back to the point about humanitarian space and how does that relate to governments well your point is a very I think a wise one which is that if you define government as including more local officials etc with whom we have to work we are doing that but I think the other point and I want to be careful in how I make this point is that we need to show both governments and their the governments who support them whether it's in Afghanistan or Pakistan or Somalia or wherever that these issues Sudan where I predict it's going to get a whole lot more difficult over the coming months and we need to be planning for that parenthetically that in fact by allowing the non-political folks to be working in these areas it's good for those governments because everybody is getting some credit for this progress and the progress itself is important for those governments so paradoxically when governments try to politicize what they are doing they are damaging themselves even if the political impact is not immediate because then these areas are going to get worse and worse and because even if the association is not direct what we are doing is good for their standing in a more general way and the reason I wanted to be careful in how I phrase that is we must never though say that the reason we are doing this is in order to make those governments look good because it's not the reason we are doing it is for the results for the children and the women and the populations in those areas you see what I am saying and I think they are being a bit short-sighted when they want immediate political credit and therefore reducing our ability to do the things that in a much larger sense are good for everybody Micky did you want to just to answer the final question around what was the difference between what we call in current and the more equity focused and really can chip in as well here just to make one point first that the current we didn't want to have a straw man of having a set of policies and interventions which were so regressive that almost anything would get better results so what we call in current did have a lot of progressive components and were based on what national governments progressive national governments have got on their books and plans and so forth so it included abolishment of user fees it included scaling up quite radically training of nurses and midwives and doctors it included building new facilities in the periphery so we did try and model in within reasonable limits of how if things went well and the resources were there how the present progressive strategies would be implemented and as I made in my presentation the critical difference and the different way of working in the equity focused one was really to have those three key shifts if you like one was to focus much more on this changing the service delivery mode the production function if you like of the way in which we deliver services so having much more focus on building from the outside from the periphery inwards in terms of starting with community-based workers and strengthening retention of existing primary care workers and improving their training and so forth working much more innovatively on the financing getting over financial barriers use of conditional cash transfers the use of pooled schemes to compensate people for getting to for drug costs and so forth and then perhaps most importantly was we put many more resources into the communication social mobilization overcoming the stigma side of things so we you know there is some evidence based on what works whether it's in in Vietnam using ethnic people just to be translators in the clinic for example as well as other innovations that we know have worked in improving access to the most marginalized to some of these services so we did try and do it do it as fairly as we could just to make the point that we can still improve on what we have and be much more just on this issue of kind of country ownership just very briefly the other point and on top of what Mr. Lakers said is that we are now having large countries like Ethiopia Malawi India Nepal Bangladesh even Pakistan where they are governments themselves of recognized and are investing in community-based workers health extension workers so this is not just a you know an NGO or UNICEF sort of passion anymore it is governments themselves are realizing this is a wise investment and you know where it's happening they're seeing impressive results already as you know so I think we can start to we have you know and as we are doing to say this is not just a crazy idea from from a group of outside of this is something which countries themselves are and when they have done and they're having really fantastic results some closing thoughts I'm glad you were use the word passion because as I hope you can tell at least in my own reserve New Englandish way this is passionate but a rational passion and I hope that all of you to the degree you agree with all of this will be yourselves infected with some of the rational passion on this issue and help just spread it because again it is not only right it is practical and if we're going to do all the things we can do and we have a responsibility to do that then I hope all of you will help us spread the word as we have to go do now at the or have the opportunity to do at the White House and again I want to thank you very much for giving us this opportunity so I'm sure you'll all join me in thanking Dr. Lake and let let me say wishing you the best on making this vision a reality and recognizing that you're at the start of the process I think this is an audience that's really interested in this issue and you know we'd love to have you back in the future as the initiative unfolds to tell us more and solicit more input and support so thanks again for joining us today