 I think we'll go ahead and get started. I know it's a lovely afternoon, so it's really great to see everyone down here for a discussion this afternoon. My name is Catherine Bliss, and I am a senior fellow and a deputy director with the CSIS Global Health Policy Center, and it's really a pleasure to see all of you. The topic of today's session is social franchising and health. And specifically, we will be looking at the emerging challenge of non-communicable diseases in the developing world, and the role that the private sector in general and social franchises in particular may be able to play in addressing them. Now the role of the private sector in providing health care is certainly well known. We spend a lot of time talking about the role of the government in providing health care, but in some world regions over 50% of household expenditures on health go to private sector entities, such as clinics, hospitals, pharmacies, or NGOs. According to a 2007 WHO report, in many Asian and Latin American countries, the private sector provides more than 50% of all contraceptives, and in sub-Saharan Africa around 30% of family planning methods are procured from private sector suppliers. And this trend is not limited to reproductive health. Nearly half of the most impoverished quintile of the population in sub-Saharan Africa who sought remedies for childhood diarrhea did so from a private sector institution, according to one survey. So social franchising, we're gonna hear a lot more about it in our discussion in a few minutes, but has been defined as a business model that involves building a network of outlets, or franchisees, that are locally owned, but act in a coordinated manner with the guidance of a central headquarters, or the franchisor. And so in this setting, the franchisor maintains quality standards, provides training, and conducts centralized purchasing and promotes a common brand. In a business or commercial franchise, that relationship between the franchisor and the franchisee may be contractual, and involve the franchisee buying into the franchise and paying fees, and it's generally a profit motive. In a social franchise situation, the franchisor is more often an NGO, or a nonprofit, providing access to commodities or supplies at lower costs. The franchisee may pay fees and ensure a standard quality of care to clients, and they may report data and service statistics to the franchisor, but in that arrangement, the motive is improving social well-being rather than profit-oriented per se. Now, evidence from developing countries suggest that social franchising as a concept has worked well in terms of improving quality of care, access, and affordability for the most vulnerable populations, particularly with respect to reproductive health care and tuberculosis treatment. So the overarching question we wanted to tackle this afternoon is whether the concept can be applied to the non-communicable disease challenge. If so, what would that look like? Under what conditions might it work best? What might be some of the challenges or drawbacks? And to discuss some cases where this has already been tried and to discuss some lessons learned. And of course these are relevant questions, as we look ahead to the high-level UN meeting on non-communicable diseases to be held in New York this coming September. Now, fortunately, we have with us today an expert panel to provide some background information and to help begin a discussion and to explore these questions. I am pleased to welcome Nikki Charman, Rebecca Firestone, and Gina Lago-Marcina here to speak with us this afternoon. And you should have received a copy of their full bios at your place or when you came in. So I won't repeat all of the information you have there, but let me tell you a little bit about each of them. Nikki Charman works with Population Services International, or PSI, as the Global Services Marketing Manager, and leads PSI's social franchising initiatives worldwide. She's based in Nairobi. I think that's right, yes. Rebecca Firestone is a researcher at PSI, specializing in sexual and reproductive health and non-communicable disease. A social epidemiologist, she is based here in Washington, D.C. And Gina Lago-Marcina focuses her work on health systems design and financing as a managing director at Results for Development. She has a background in business administration and previously served as Senior Health Policy Advisor to Mayor Anthony Williams here in Washington, D.C. So Rebecca will start us off with a discussion and an overview of the NCD challenge in developing countries. And she'll be followed by Nikki and Gina with a discussion of social franchising and its potential applicability to NCD issues. And then from there we'll open for discussion and questions. So let me turn the table over please to Rebecca. Thank you, Catherine, and good afternoon to everyone. Thank you all for coming. We're hoping to stimulate a lively discussion about some of the intersections between social franchising and NCDs. So I'm going to start out with the epidemiology and some of the policy context about why we're talking about NCDs. And there's three things that I'm hoping to come across in the next 15 to 20 minutes. And one is that non-communicable diseases are a major health challenge for low and middle income countries now. It's projected to get worse into the future. There are effective and cost-effective approaches to address, to both prevent and treat, many non-communicable diseases in developing country and low resource settings. And we need to start thinking about opportunities and strategies for integrating that into the existing platforms that we have within the global health community to address the current diseases, which are a major focus. So as long as this works, what are we talking about when we see non-communicable diseases and why are we talking about it? The primary impetus right now for conversation on non-communicable diseases is the upcoming UN high-level meeting in September, as Catherine suggested. And this is, in a way, similar to the 2001 summit on HIV AIDS held at the UN. The non-communicable diseases themselves are a somewhat broad term. And just to focus it down and get us all on the same platform, usually we're talking about cardiovascular disease, cancers, chronic obstructive pulmonary disease, and diabetes as the major non-communicable disease as a focus. And those are likely to be the diseases that policy and strategy will focus on at the UN meeting. The UN meeting does follow on several other major policy initiatives that have occurred around the world of non-communicable diseases. Most notably in 2003, the Framework Convention on Tobacco Control was introduced, and this is the world's only public health convention or sort of treaty in the world. And that was a major impetus focusing on tobacco. But right now, if we actually look at the priority within the global health community that is given to non-communicable diseases, if we just look at overall development assistance for health as kind of a measure for priority setting, in 2007 less than 3% of all development assistance for health was dedicated to non-communicable disease. So that was less than $1 per disability adjusted life year, dedicated to non-communicable diseases compared to about $24 per disability adjusted life year to HIV, to B, TB, and malaria. So there has been discussion around non-communicable diseases, but it has not yet led to much in the way of action. So why the focus? I'm going to go through and show a little bit of the epidemiology based on estimates from the World Health Organization. And non-communicable diseases are leading causes of death now and likely well into the future. NCDs account for 60% of all deaths globally, and 80% of those diseases occur in low and middle income countries. So this figure here shows mortality rates across different regions of the world. I'll see if I can get my neck to stretch back and forth here. So the blue are communicable diseases. Red is non-communicable diseases. And green are injuries. And these are categories that the WHO has set up to organize causes of mortality and morbidity. And the blue category, communicable diseases, maternal and perinatal and nutritional deficiencies stand out. But what I really want to show you on this slide is basically that the red, which are non-communicable diseases, are a large proportion of overall mortality rates across regions of the world. And that red proportion is just going to get bigger projected to 2030. And this is despite the fact that in some regions of the world, overall mortality rates are projected to decline between 2004 and 230. The proportion attributed to NCDs is expected to increase. So 2004 is the last date for which we have, the last year for which we have comparable data across countries. And I wanted to go through and look at what the actual causes of death in 2004 were. So can I get any guesses from the audience about what the leading causes of death were? OK, cardiovascular? Traffic accidents? Others? OK, yeah, chronic obstructive pulmonary disease. OK. Here's the actual rankings. Top five. So we got some of them. Ischemic heart disease? Cerebrovascular, so stroke. Lower respiratory infections, chronic obstructive pulmonary disease, and diarrheal diseases. So two, I'm sorry, three out of the five main causes of death in 2004 were non-communicable. And besides just looking at mortality, NCDs are also a major cause of disability in 2004 and projected to 2030. So this is because there is a chronic element, or sort of a long-term element, to many of the non-communicable diseases that we're looking at, that they are likely not just to be causes of death, but to be causes of illness prior to death for an extended period of time. Then going into sort of what's causing some of this, there are a handful of modifiable risk factors, about six, which are attributable to, for most of the non-communicable deaths in the world. And these are starting over on your left. High blood pressure, tobacco, high blood glucose, physical inactivity, and overweight and obesity. And I've also added a few other major causes of disability here, so unsafe sex, alcohol use, underweight, unsafe water, sanitation, and hygiene. And you can see that high blood pressure is really the big one across regions of the globe that the majority of, this is the leading risk factor for non-communicable diseases. Tobacco itself accounts for one in six of all NCD deaths, and three of those risk factors are actually related to diet. So blood pressure, blood glucose, overweight, and obesity, these are all associated with nutrition. So we can look at a handful of modifiable risk factors and think there's something that we can focus on. If we focus on diet, physical activity, if we focus on tobacco, those are things that we can get a handle on. But there's actually some underlying causes that are at play that are contributing to why we see a rise in those modifiable risk factors in developing countries. And those are things like, for one, population aging. As the population just gets older, the chronic diseases are likely to become more prevalent. But other factors like rapid urbanization, agriculture subsidies of tobacco, corn, and soy, and the role of multinational corporations looking for expanding markets in developing countries are all factors that are contributing to sort of underlying what we see as the growth in modifiable risk factors. So although some people might say a frequently term non-communicable diseases as lifestyle diseases, there's actually and suggest that there's a matter of individual choice involved. If you actually look at some of these contextual processes, it's not just about individual choice. So I've tried to lay out some of the epidemiology and why there is an existing burden. The question is, why has there been so little action to date based on the evidence? And I'm going to reference Julio Frank, who's a major global health leader who's been speaking about non-communicable diseases recently. And he suggests that there's a set of misconceptions in the conversation in the global health community, which are likely focusing on why we haven't really focused on NCDs too much to date. And this is in some ways somewhat similar to the conversation we were having around HIV back 10 years ago. And that's one is that it's not a problem or that NCDs are not a problem for developing countries because these are diseases of affluence or individual lifestyle choices. So I've tried to present some data to suggest that that's not the case. We can discuss this more. Even if we accept that NCDs are a problem for poorer countries, we might think that it's not that important or that it's too complicated to do something around NCDs. These are chronic diseases. It's going to involve real investment over the long haul to deal with these diseases. So what can we do? So we'll address that. And then even if we felt like there was something that we could do about NCDs in low resource settings, it's going to be too expensive. So I'm going to go through and try to address some of those statements. And I'm going to start with some data from Southeast Asia, which is a region of the world that I know best. And I think it's also interesting because Southeast Asia encompasses countries from the lowest income in the world to the highest income in the world. So it's a good kind of microcosm of what's going on. And if we look over here on your left, I have non-communicable mortality rates mapped against gross national income down here on the x-axis. And over here is NCD deaths as a proportion of overall mortality within those countries. And then on the right, we have NCD death rates themselves. And so on the left, you can see that as a proportion of overall deaths, NCDs decline. I'm sorry, they increase by income. So there's more NCD deaths proportionately in Singapore than in Laos. But if you actually look at the absolute mortality rates, the NCD mortality rates in Laos are higher than they are in Singapore. So that suggests that this is not just diseases that affect only wealthy countries. If we break it down even further, we can look at risk factors for non-communicable disease deaths in the same set of countries and see that if you disaggregate by socioeconomic status, for some risk factors, it's very clear that the poor are actually disadvantaged. And that's clearest for tobacco. Again, let me see if I can go over here. We've got Malaysia, Philippines, Vietnam, Laos, and Myanmar are the columns here. And at the top, we have wealth quintiles from the poorest in blue to the wealthiest in the light purple. And you can see that there's a gradient where tobacco consumption is highest amongst the poorest quintiles across all of these countries in Southeast Asia and lowest in the wealthiest quintiles. The pattern is less clear for insufficient fruit and vegetable consumption, but there's some evidence of a gradient where the poor are actually consuming less of a healthy diet than the rich. And the pattern may be somewhat reversed for insufficient physical activity. But what I just wanted to indicate here is that across many different Southeast Asian countries at different levels of economic development, some risk factors are disproportionately disadvantaging the poor. So we have evidence that poor countries are affected by noncommunicable diseases, and we have evidence that poor populations are disadvantaged within those countries in noncommunicable diseases. Some further evidence as to why NCDs are a development issue is the link to poverty. So chronic illnesses themselves are a major cause of catastrophic expenditures within households because of the chronic illness, the chronic nature of it, that there's just going to be an expenditure over time. And if you're paying out of pocket, it's going to be an increased burden on the poor. Poor people are likely to have worse access to health services to begin with. And so that's evidence at the household level of the likelihood of NCDs becoming involving people in poverty traps. On the macroeconomic level, there's some evidence to suggest that NCDs and the burden of having to treat these noncommunicable diseases over time are associated with reductions in economic productivity. I would say that there is a need for better research on the economic burden of NCDs. There's some initial evidence out there, but it's spotty, but the evidence to date suggests it's not a good picture. So that's to suggest that we need to do something, particularly if we're concerned about the health of the poor and the most vulnerable to focus on NCDs. And this slide is to indicate that there are a handful of effective and cost-effective interventions have been identified and costed. The costing here was for 23 of the highest burdened countries in the developing world, and these included countries like India and China, but also Brazil, Nigeria, South Africa, and several others. And this suggests that these interventions for risk factors of tobacco, dietary salt, unhealthy diet and physical activity, alcohol intake, and then treatment of cardiovascular disease are likely to be of a minimal cost. So for tobacco, we're talking about ensuring implementation of the Framework Convention on Tobacco Control, which includes efforts such as tobacco taxes and much more careful regulation of tobacco marketing. Those are some of the items, and that is projected to avert 5.5 million deaths over 10 years. For salt, we're talking about reducing salt consumption on a population level through things like voluntary reformulation of processed foods, just to take the salt out of the cans of fruit or vegetables or bread, as well as media campaigns on salt reduction. And that has been estimated to avert about 8.5 million deaths in some of these over 10 years in the highest burdened countries. For obesity, we're talking again about regulation and taxation strategies, same for tobacco. Risk reduction for cardiovascular disease. Some work has been done to look at a very low cost regimen of a statin, aspirin, and a couple of hypertensive drugs that could be introduced at a primary care level for about a dollar and eight cents per person per year. And if you did opportunistic screening of people for risk of cardiovascular disease and provided this type of low cost regimen, it could potentially avert about 18 million deaths over 10 years. So these are potentially really big wins if we think about how to implement them. PSI itself is an organization, and I'm going to say that there are several PSIers in the room who can chime in on some of this work as well. PSI has been thinking about how to approach the noncommunicable disease burden through a few different types of interventions around tobacco control and obesity, and then social franchising. I'm going to leave that to Nikki to talk about. She's going to mention a little bit of the work there. So I just want to leave us with, I think, in terms of stimulating a conversation into the future in this panel, is to think about noncommunicable diseases, not just from the epidemiology or the policy level, but how are we going to respond on a health systems level. And from there, I think we need to really be focusing on the fact that a continuum of care is required to follow through the full life cycle of disease from prevention all the way through to palliation is going to be necessary. We have to prevent the coming increase in the burden of disease, but there is an existing population of people who are in need of treatment right now, and are in need of palliation and sort of pain relief for human rights purposes. I think there's two things that we need to be thinking about, getting our heads around for that. And one is on the prevention side, we need to be thinking about extending beyond the health sector, that some of the most effective population-wide prevention strategies are going to require engagement with people in ministries of finance, in ministries of trade, and urban planning. And we need to think about how, as people who are accustomed to working within the health community, we're going to start to make those conversations and coordination happen. Within the health system, we need to be thinking about stronger health systems for noncommunicable disease, because that chronic element of non-communicable diseases is critical, that if we're doing our jobs right, we'll be able to ensure that some people are having, have access to care over the long term, because many of these diseases are eminently manageable, even if you have them. And the opportunity there is that through integrating approaches to NCDs into existing health systems, that it's likely that we can end up with stronger health systems that will benefit other diseases as well.