 Hello everybody, I think we're gonna start right away without any further ado. People will come back in and they'll catch up. Good morning everyone, my name is Robert Hecht. I'm a managing partner at Results for Development Institute. I've been asked to chair this Auguste panel. And the topic here is building this universal coverage system. I think we have, I'm not exaggerating when I say, I think we have the ideal panel for this task because I have next to me master electricians, plumbers, sculptors and painters. And so building this universal coverage system, we have all the right tradespersons here to tell you how it's to be done. We have a very good division of labor too within this panel because David Evans from WHO can talk to you about the financing aside of the universal system. Srinath Reddy from the Public Health Foundation of India knows so much about the service delivery building pieces about the importance of getting essential services that really make a difference out to people who need them. And Margaret Kruck to my right from Columbia University will talk about the importance of enhancing quality and how that can be done. And I believe Tim Evans mentioned the quality issue in the previous panel. So I think Margaret can pick up on that. And then Yang Zhong here from the Council on Foreign Relations, a fellow knows so much about the Chinese health reform and many other things, but he's gonna focus on this issue that came up again in the previous panel around how to go the last mile, how to reach the marginalized populations in China in particular where so much has been done but there's still our gaps in the system. So I think we have just the right people to take up this topic around what can be done to build a stronger universal system. So without further ado, I'm gonna hand over first to David Evans to speak about the financing building block in this universal coverage edifice. And what David has learned from vast experience working at country level and working across the world, among other things as the director and lead author of the World Health Report on Universal Coverage, which has been so instrumental in bringing us to where we are here today. So David, over to you first. Thanks a lot, Rob. Can you hear me okay? Is that loud enough? Thanks. Usually when someone says you've got vast experience, it means you're getting old. So thanks, Rob, for saying I've got vast experience. Let me start with a few propositions. Moving closer to universal health coverage is not just about health financing. Rob's emphasized that. But if the health workers are not there, if they're in the wrong places, if they're badly motivated, you won't get there. If the medicines are not there, if they're in the wrong places or they're poor quality, you won't get there. If the health services that people need to use are not there in the wrong places or a poor quality, we can't move closer to universal health coverage. And some of the other panelists will talk about that. So let me move on to the second proposition. Health financing for universal health coverage is not just about raising more money. It is a little bit, but it's not just about raising more money. And if I use English rather than jargon, health financing requires a lot of interrelated decisions. And if you get it wrong in one of these decisions, again, it can be very hard to get closer to universal health coverage. And the decisions are who should pay, how much each should pay, when they should pay, what happens to the funds that are then collected in the sense of what services are available, and then who benefits from those services. Each one of those decisions is part of this thing that we call health financing, and each one of them is complex. My third proposition is that every country can do a little bit more in that mix of decisions. There's something that every country, no matter how rich or how poor, can do. As Jim Kim said, countries will have their own individual solutions depending upon their problems, their capacities, but global learning can tell us some experiences that each country would want to take into account when making those decisions. So let me quickly go through those questions and just say, what do we know? Who should pay and how much? Well, obviously the white economists call the principles of progressivity apply. People should pay according to their needs, sorry, according to their abilities. Now that's broad, everyone can agree with that, but that also means that some people won't be able to pay. Some people won't be able to contribute in all societies, and they are subsidized. That means a role for public funding for the people that can't afford to pay. Second question, when should they pay? Well, you know the story about prepayment and pooling. That people should pay largely before they need to use the services rather than when they need to use the services, paying at the time that people need to use the services stops people from getting the services and is the major cause of this 100 million people being pushed into poverty each year. So prepayment and pooling is important. Okay, we've got the pool funds. What should happen to them? Let me turn to who should benefit. Well again, the principles are there and people talked about it in the questions about vulnerability's last session, that people should benefit according to their needs. What needs do people have? That's what they should get. Now that's gonna be, as we say, progressive realization. It's not gonna be available immediately. It's gonna be progressive realization. I was asked to say something about benefits packages as well. Before I do that, in terms of deciding what services are available and what should be provided, we've heard a lot about value for money and I think it is important that the benefits package question is only one part of the question of how to use the funds that are available. There are other ways of improving efficiency and equity in the use of resources. In the World Health Report, we estimated that between 20 and 40% of health resources in many countries are wasted because of various forms of inefficiency. There's a lot that we can do to improve efficiency even before we turn to the question of the benefits package. Let me turn to that now, the benefits package. As you will recall, the 1993 World Development Report talked a lot about essential package of services and Jose Luis Bobadier at the time spent quite some years going around countries trying to work with them to develop a benefits package. In WHO, we had a lot of pushback from countries on that. Partly perhaps because they weren't making the financing changes necessary but many countries said we don't want you outsiders helping us to develop a benefits package. It's got to be a homegrown benefits package. And so in WHO, we focused much more on trying to say here's some tools that you could use to decide what interventions should and shouldn't be available. We produced something that you might have seen called the choice-who-choice project which now has something like eight or 900 interventions in it. We've done it for 14 sub-regions of the world and we have a country contextualization tool that countries can use to say, well, what would be a cost-effective set of interventions for our setting? There hasn't been good uptake of this tool. And I've been trying to reflect why and I think the paradigm that we have used for cost-effectiveness and health technology assessment comes from developed countries. The problem is that the nice, the National Institute of Clinical Excellence in the UK, for example, it asks a question and new medicine becomes available should we pay for it. It has the system that's sort of working and it has to just say, do we pay for a new medicine? That's not the question that many of the countries that we work with are asking us. They're saying, well, and sorry, let me just step back a little bit. And in those countries, they have a fundamental problem that when a patient presents at a primary healthcare level and when a patient presents at an outpatient even at a secondary hospital, you can't say, what's your diagnosis? They won't know. You can't look up your book and say, is it in my package? Oh, if you don't have the disease that's in my package of essential services, go away. You have to do something for the people that turn up at primary level. And so what the countries are asking us is, okay, what's the set of things that we should do at the community level, primary level, secondary level, tertiary level? And they don't ask that in terms of interventions. They say, what are the people that we need to have with what skills at the different levels? What are the medicines that we need to have there? What's the diagnostics that we need to have there? And when do we push people up the system? Or when do we have community-based interventions? What's the set of prevention promotion interventions that we need at the same time? And so I think that the way that we've been asking this question about packages and trying to answer it with cost-effectiveness type analysis is not the way that countries are asking the question. And we need to do a lot more on that to try and answer the questions that the countries are asking. What's the set of people with the skills that are needed in the community at the primary level, first level of care, secondary tertiary level of care? What's the set of medicines, diagnostics, et cetera? What's the mix of prevention and promotion that will back that up? And palliation as well is something that's becoming much more important now everywhere. So I'm still against trying to set packages from externally. I'm still against trying to say, here's a set of interventions that every country should do. Now that being said, obviously that's an extreme version. Most of the interventions that are currently in the MDGs, you would expect that most countries would want to provide. Some of the basic interventions for non-communicable diseases, for prevention, promotion, treatment of non-communicable diseases are something that we would want to see in almost every setting. But that being said, where, at what level of care should they be provided? There's a lot of work that we just haven't done there. And I think that that's something that we need to keep working on. Now let me just turn to the question. David, if I could stop you there, because I think this would be a good place to hand over to Srinath, we can come back to you again. But you've talked about packages of services, you've talked about guaranteed benefits. Is there enough to give everything to everybody in these universal systems, or how do hard choices get made? Let me hand over to Srinath, because as president of the Public Health Foundation and also the chair of a very important commission last year or two years ago that produced a landmark report for the Indian government on how to move toward universal coverage. Srinath, you've been thinking a lot about this question of benefits and priority setting and how to get especially primary care services of one kind or another to 1.2 billion people, not a small task, especially given the burden of infectious disease and maternal and newborn child issues, but also the growing wave of non-communicable diseases in India. So your thoughts on this building block around services and how that can be created as part of these universal systems. Thank you, Rob. Good morning. I hope I'm audible. When we are really looking at some of the problems we still continue to grapple with, even after the submission of our report. When we talk about services and the essential benefits package, firstly, what is the range of services to be included? What is the outreach of those services? And what is the quality of those services? And all of them ultimately add up to effectiveness, which will improve health outcomes. Now, in terms of range of services, universal health coverage basically has to look at health promotion, that's promoter services, preventive services, diagnostic services, therapeutic services, palliative services and rehabilitative services. So it's not merely immediate acute clinical care that we are talking about, we are talking about a wide range of services. And we need to ensure that they have adequate quality. Now, which are the conditions that need to be really addressed? While the MDGs were very useful in focusing attention on maternal child health, for example, HIV, TB, malaria, among infectious diseases, they segmented life into different areas, missing out some important link areas like adolescence, for example. They also fragmented the health system by having extremely siloed vertical programs. There have been some advantages, but there have also been some disadvantages. So really when we are looking at universal health coverage as the unifying platform, we are really looking at a life course perspective, which provides a range of needed health services to everybody across the course of their life, but that also requires prioritization. And prioritization in this case is firstly, primary health care to everybody in rural and urban areas. And that includes a wide range of preventive, promotive, as well as some basic clinical services. At the same time, we are really looking at combining maternal and child health, the new priorities of non-communicable diseases, mental health, essential surgery. Usually some of the necessary surgical procedures are not always available in primary health care. They have to strengthen district hospitals for providing those services, or even emergency obstric care, which is referred to. So we are not really saying, we'll first cover primary health care, then only we'll take a step up. We are saying let's do primary health care, but we also need to accommodate sub-elements of secondary and tertiary care, which are higher levels of care. Then we are also looking at where are these services going to be provided? Is there adequate infrastructure, right from the sub-central level in the primary health care system to the district hospital and then the medical college hospital or whatever? Who will provide these services? Are the human resources adequate in numbers, skills, motivation? Are they appropriately distributed or is there a huge urban aggregation like in India, where about 70% of the doctors are in urban areas which have 30% population? So how do we deal with some of these issues? Then is there a multi-layered health workforce? Are there enough nurses? Are there enough community health workers? Are there enough allied health professionals? Very frequently we think of a doctor-centric medical system, but we now need to think of a multi-skill, multi-layered health workforce where many of the functions performed by specialist doctors can be transferred to non-specialist doctors from doctors to specialist nurses and to allied health professionals, the so-called task shifting. Then how can non-physician healthcare providers be enabled with modern technologies so that their skills can be substantially enhanced to undertake these kind of functions, especially in primary healthcare? Is the health system being adequately managed? Is there public health expertise? Is there managerial expertise? Those questions come in. Is it having proper governance? Does it have regulatory systems? Is the country adequately empowered with drug regulation and regulation of human resources and so on? What is the extent of community participation and ownership? These are all questions that come in in universal health coverage and need to be accommodated. And we are dealing mainly with mixed health systems here in many of the countries and especially in India. So we are talking about public-private sectors and we frequently hear of public-private partnerships, sometimes being distorted because the lack of appropriate regulation of constant quality. And the cynics will say, this is partnership for private profit. That's what PPP is. On the other hand, PPP should be partnership for public purpose, define the public purpose, define the deliverables that each one has to give and define the terms of accountability. So the private sector can be both a provider and even the non-health sector, private sector can bring in a huge amount of managerial expertise like supply chain management, et cetera. The civil society is important, both in demand generation of services, in participating in community-led service delivery, as well as in monitoring and serving as a watchdog. So all of these elements need to be brought in. Now, how is India fairing in this? We started off with the National Rural Health Mission with a major focus on primary healthcare, but with maternal and child health. So the other areas have been somewhat neglected. We have seen benefits in terms of reduced maternal mortality and accelerated decline of infant mortality, but we now need to extend to other areas as well. Then we are looking at a separate scheme for financial protection, the Rashtriya Swasti Bhima Yojana or the National Health Insurance, which has been looking at secondary hospitalized care and some of the state insurance programs which have been looking at hospitalized tertiary care, now there's been no link up here between the primary care and secondary care and tertiary care and one can frequently defeat objectives with other. So the challenge before us now is, how do we combine all of these so that we can have all the necessary services provided from primary to tertiary care as needed with a continuum of care, particularly with people having care and tertiary level and secondary level, returning back to primary care where they can be appropriately followed up so that unnecessary escalation of healthcare costs need not occur. So how can they be connected? Can there be financial sustainability? Are the poor adequately covered or are there entitlements linked to some sort of a civic identity number and some of the poor may not have it? Are they in any sense being distanced from it? All of these issues we need to answer. However, I believe that universal health coverage at least has opened up these questions for discussion and I'm sure with careful thought we can find answers especially by comparing international experiences and then adapting them to our local context. Thank you very much, Srinath. That's fantastic. When you describe all the things that need to be done in India, it feels daunting and practically disempowering to me so it'll be good when we get into the discussion to hear about where you think things should start and where the priorities have to be set. And also, you talked, I think, about the role of government both in investing on the supply side in a stronger health delivery system but also through public insurance and other demand side mechanisms trying to motivate the right kinds of performance. It'll be interesting to hear about how you see the balance between those two given that the Indian government has a lot of resources and wants to devote more to health but in the end those budgets are still limited. Your vision of how that pie should be divided between these investments on the supply and then the stimulation of these insurance arrangements to protect people on the financing. Let me turn to Margaret. People keep talking about quality and quality as being essential if that's not an ingredient or an element in universal coverage, this is all gonna fail if we just think about quantity and not quality. So what are the key lessons and the secrets there to enhancing quality within these universal systems? Thanks very much. Oh, can you hear me? It is on, I need to maybe hold it. Is this better, no? It is on, no. Let's go with that. Okay, great. Okay, so that's better, even I can hear me. Thanks very much, Rob, and thanks to CSIS for convening this conversation. I'm going to be a bit of a gadfly. I want to start with some figures for you. Actually, one figure, 40%. In 2012 in the coast region of Tanzania, 40% of women living within walking distance to free healthcare bypassed that facility to deliver at the hospital, public or private. These weren't just rich women, poor women were almost as likely as rich women to do this. Women living near a weak facility were much more likely to bypass. In 2011, out-of-pocket payments constituted 40% of the overall healthcare spend in Chile, a country that has achieved universal health coverage and has a coexisting private health system. By contrast, out-of-pocket payments were 9% in the UK, another country with UHC and a private health system alongside. What's the link between these statistics? I would suggest it's quality. By quality, we certainly mean competent doctors, the kinds of things that Dr. Reddy has talked about, and available medicines, yes, but also attentive and respectful treatment and responsiveness to people, to patients as people. This is the factor that we heard loud and clear. Drives Tanzanian women to seek higher cost facilities and spend much more to get there. And it also drives Chileans to private providers for second opinions and for more and better technology. Quality also includes meeting the needs of the population, the needs and expectations. We know from survey research that people value health hugely from the Lancet Commission, from various polls. Health is one of the top priorities globally whenever you ask people about what matters. And because of that, I think, and because of the globalized world we live in, people are increasingly sophisticated healthcare consumers and very explicit about what they want. We ignore this at our peril, and we ignore it at our peril not just in this country where we're beginning to focus on it. I was in an emergency department with my daughter a couple of weeks ago and got the customer satisfaction survey within 24 hours, but we're also focusing on it and need to focus on it in poor countries as Tanzanian women have shown us, who are bypassing primary care there. The success of UHC, I would suggest, and agree with Rob, hinges hugely on quality, on delivering on quality, and this is for three reasons. First, we know from extensive research now that quality drives utilization. We need to have quality facilities to get people into them to achieve the convergence agenda, to get maternal mortality figures down and improve outcomes in NCDs. Further, to get health out of that healthcare visit, we actually need quality to be there when people get to the facility. And so the new service utilization that we're hoping to get with universal health coverage will only improve outcomes if we can convert that into good services that reach a specific outcome. And actually, Tim and others have already pointed this out and the notion of effective coverage really captures this very well. And thirdly, to keep out of pockets spending down and keep it from burdening families, we need to protect families from using unnecessary services, getting unnecessary second opinions, seeking higher level facilities and higher level providers to get the care they feel they need and deserve. How do we get there? Well, I would suggest the starting point in terms of quality in the UHC discussion is just to talk about it and be more explicit about it. Right now, it's sort of an adjective that gets added on to the coverage agenda. Quality health services, we should have everyone get to those. But I think we have to be much more serious and explicit about what we mean by quality. Countries won't be able to afford, as Shrinna just pointed out, everything that people need and want, not for countries that are spending $30 per capita, $60 per capita, $1,000 per capita or more. And so countries do need to expand the package available at that first level of care from a bare bones package to something much more comprehensive. I think Mexico and other countries have shown us the way to do that by starting with 30 or 40 interventions and going up to 200 conditions that are covered. And I think equally as important is communicating that path to people. It's not just to say we're gonna do it from a policy perspective, but really making clear that that's what's going on and that's the intent. The second thing is the aggressive, an explicit and aggressive focus on quality. Work from by John Peabody and others from the Philippines shows, for example, that performance-based financing combined with communicating quality results to providers can improve outcomes and not for a large investment. We have an experiment right now in Tanzania to see how we can learn from HIV experiences with improving quality in very resource constrained settings to improve healthcare rapidly across the system. And quality is not a perk for the rich. I really want to emphasize this. I think sometimes we think of it that way. The poor should just be grateful for the services that they get. It is not a perk for the rich. The rich will always find a way to get good quality healthcare, UAC or not. In fact, quality, high quality services are a bedrock promise to the poor and protect that poor in terms of health but also financial consequences. I think if we're serious about quality, I would challenge us to come up with some quality targets that go into the set of targets, for example, that complement the targets, that are excellent targets, I think that WHO and World Bank have proposed if we're serious about the issues of not just access but actually outcomes and responsiveness. The audacity of universal coverage, and I do think it's an audacious goal and this has been emphasized all morning, has to be matched by commitment to quality. I think without it we risk a paper edifice, Rob, and not something substantial. Thanks. Thank you. Is that working still? Still online? Okay, good. Thank you, Margaret. That was great and we'll come back to the question of what needs to be done. What can governments do? What can some of the international agencies, what can Tim Evans do about quality? What can Arielle and USAID do about quality? So we'll come back to that in the question period. Let me turn now to Yang Zheng Wang. And this whole issue of really closing the loop entirely, reaching those who in some ways have historically been the most deprived and discriminated against, is coming up in a very real and pressing way in China right now. So tell us about universal coverage getting the last few percent inside the program and the challenges and the opportunities for a country like China. Thanks. Thank you, Robert. Can you hear me? Okay, great. Thank you, Steve and Nelly for inviting me over. Oh, it's great to be back. And I'm going to talk about the China's experience in extending health coverage to especially the vulnerable population in the country. We all know that before China kicked off the so-called new healthcare reform in 2009 that there's a large percentage of the population not covered by any health insurance. We have the data in 2003, for example, nearly 80% of the rural population was not covered by any health insurance. And access is also a problem because 80% of the health insurance, I'm sorry, 80% of the health resources essentially is concentrated in the urban areas, especially the large urban health centers. So it's very difficult for the rural residents to have access to healthcare as well. But the new healthcare reform with central aim to addressing these issues of access and affordability, they have invested tremendously to fill the gap. Actually over the past four years, between 2009 and 2013, the government has invested a total 371 billion US dollars in the healthcare sector, including more than $100 billion from the central government. And progress has been made in strengthening the grassroots healthcare centers, the township health institutions, for example, and also the equalization of the public healthcare. And another shining spot is in the maternal and child healthcare. The government over the past years have invested tremendously in this sector, reducing the child mortality rate from 2.47% in 1996 to 093% in 2008. In fact, the percentage of female delivery in the hospitals, the female delivery rate actually increased from 50% in 1988 to 100% today. And just a couple of months ago, there's this announcement from UNICEF, I believe, that between 1990 and 2012, there is essentially the 50% drop in the child mortality rate. Actually, China contributed 26% of that decline. So that was quite achievement, especially given the huge population in China. We talk about nearly 1.4 billion people, right? But that being said, well, you know what I'm going to say, the picture is actually not that rosy if we look at the recent government data and also the survey data that was most recently released in October, 2013. We found that access and affordability remain two major problems in China. Access, 81% of respondents say it is difficult to see a doctor. Actually, more than 57% said it actually becomes even more difficult than four years before to see a doctor, compared to 20% who said there was improvement. Affordability, 95% of respondents agreed that it is expensive of seeking care in China. 87% agreed that the cost is actually higher than four years ago, four years before. And only 3.5% say it is becoming less costly. In fact, that you probably read that, they heard that this report last October, there was this farmer in Hubei province self-amputated his leg, simply because he couldn't afford hospital bills. Well, this disappointing outcome of healthcare reform can also be reflected in official data access. Again, we found that daily visits each doctor received increased from 6.7 in 2009 to 7.3 in 2011. That means the workload for a doctor increased by 9% and for inpatient services, the workload for each doctor increased by 23% during the same period. Affordability, during 2007 and 2011, we found that healthcare costs in China continued to increase at the annual rate of 10%, much higher, not much higher than China's GDP growth rate. That probably explained why that conflict between healthcare providers and patients continued to be a problem, actually becoming even worse in China. According to a survey conducted by China Hospital Association, between 2008 and 2012, the proportion of Chinese hospitals reporting violent conflicts between patients and healthcare providers increased from 48% to 64%. While the average number of violent attacks directed at healthcare workers in each hospital covered by the study increased by nearly 30% from 21 to 27. There are also other problems. Low benefit level is certainly still continue to be a challenge. The so-called universal health coverage actually only cover the basic healthcare services. Other services like dental care, mental health, non-communicable diseases actually essentially still not covered. According to a New England Journal of Medicine, the research conducted by the study found that 60% of Chinese diabetes patients are not aware of their conditions because despite the nearly universal health coverage in China, screening and outpatient services for diabetes are not yet covered, medical benefit in many parts of the country. So as a result, a large number of the patients do not seek care until they have developed symptoms or worse in the later stages of diabetes. In the meantime, if you look at the migrant population, 200 million migrant population, even though they are nominally covered, but because that insurance, so-called new cooperative health insurance, are not portable, so large percentage of them actually are not covered. So to, before I wrap up, I want to point it out that despite the tremendous progress China has achieved in pursuing universal health coverage, including actually the significantly large the size of the pool, it still has a long way to go before they could fundamentally solve the problem of access and affordability. Thank you. Great, thank you very much, Yang Zheng. And I'm so glad that China's being included in this discussion because it seems to me that some of the other moves toward universal coverage, Mexico has been well documented, Thailand is very well known, the Thais are very good at telling their story. But I think the Chinese reform is very, very significant and in some ways is the stealth reform of the last decade. So I would urge everyone to read your work and Professor Schaus and some of the other key authors. And I think you point out that despite the enormous changes and a lot of the gains, there are still some very severe problems of access and effective coverage and also cost control issues, which I think you mentioned as well. So the lesson there is as you push on one part of the system, other things tend to bulge out, new problems emerge and reform is a continuous process. It never goes away. All the problems are not solved at one fell swoop and there's always more to address as a country progresses. Let me turn back to each of the panelists and ask an easy question or two just to get the discussion started and then we'll open it up. I think we're doing pretty well on the time so we're getting back on track. David, I didn't wanna come back to where, I apologize for cutting you off, but you were talking about your misgivings around how benefits are defined and prioritized within countries. You mentioned that some of the earlier work around cost effectiveness and some of the things that grew out of the World Development Report in 1993, which was one of the culprits and conspirators on, that this is not the way that countries should be going. I think there's another process here that you are calling for, that you feel is more appropriate or is working better in some of the countries in 2014. Maybe you could just say a little bit more about what you think are some of the principles and good practices in countries wrestling with these difficult choices and trying to come up with a consensus around where to set priorities and what should be featured and what should potentially be de-prioritized or even excluded from some of the guaranteed benefits. I think Srinath, in India, picked up that point a little bit, that because someone coming in, presenting at the primary level, you can't turn away, you have to do something. You have to then make your decisions not necessarily based on interventions but based on the mix of inputs that you need at that level. So you need to have a philosophical viewpoint of, well, what are we gonna do at the community level? What are the primary, the first level, what are the second level, what are the tertiary level? And then what's the mix of people, medicines, diagnostics that are available? Now, obviously that has to take into account the mix of diseases and problems that are in that community. But also, question of where do you want people treated? So the push to have people, women delivering in facilities is a specific recommendation that people don't deliver at home. And these types of questions, where would screening for diabetes take place? Where would treatment for hypertension take place? What is the level of care that you would need? And I think that's the question. I mean, Chris Murray has been doing a little bit of work recently with Josh Salomon from Harvard on trying to redefine at the level of care, what is that mix of interventions and the implications for people and medicines and drugs that need to be put there? Now, that all needs to be put in the context of the availability of funds. And as you said earlier on, the funds are not there for most countries to get to even a very minimum level of universal health coverage. So what do you do? The video suggested $60 per capita. Die McIntyre from Cape Town University has just tried to redo that, bringing it up to 2012 prices rather than 2009 prices. She gets $86, but it's still there or thereabouts and most of the developing countries are not there yet. They won't be there for the next five, 10, 15 years. So external assistance is required at the moment for the poorer countries. And so let me raise a philosophical question. We're all committed to universal health coverage, but when does our commitment for global solidarity in helping countries get their phase out? I'm uncomfortable with saying that once a country becomes a middle income country or a low middle income country, we forget about them, they're on their own. This is an ethical question as well. Everyone's, we had a very interesting discussion at Chatham House recently about when do people think in health the global solidarity should phase out? If someone, a country has 60 years life expectancy, but they're a middle income country, do we say you're on your own? We believe in the principles, but we don't need to contribute. And I think we'll all come up with different philosophies about that. And it's a little bit like giving charity. I probably don't give charity to my next-door neighbor because he's got a car and he earns less than me, but he's got a car, so he's on his own. I only give charity to the Salvation Army because I believe that they're actually looking after people that are much, much worse off than me. Do we do the same thing in health? When is the gap between what they have and what we have sufficient for us to say we don't engage in global solidarity? Thanks, David. Well, let's come back to this question of the role of the international community and the organizations. In fact, Srinath, let me turn to you on that one because Tim earlier said that there is a role for the international organizations on universal coverage. He said it's not around massive financial transfers, it's in these other four areas that he articulated. When you think about India, huge country, a lot of its own financial resources, and also a lot of very well-trained people, a lot of good policy makers and technicians, where do you see key roles for the international community in supporting India on its universal coverage quest? Certainly, despite some slowdown in the growth rates in recent years, I think India's economic position at the moment does not require massive financial assistance. On the other hand, it will still benefit from technical assistance. An international organization should be able to bring in the technical assistance. Particularly when you are at the very beginning of designing a universal health coverage program, there are likely to be mistakes made, which if not corrected in design or at a nary stage, can cost us very dear as we move along. So it is very important to have the international experience and critique also come in, apart from technical assistance coming in for training special categories of people, health workers as well as health system managers and so on. The other area which I believe and where both Tim and President Jim Kim mentioned is to bring in the other sectors to support the health goals. Now Jonathan Quick mentioned three-legged stool. I don't know whether this is the fourth leg of the stool or not, the whole area of multi-sectoral collaboration or whether it fits into the three stools. But the question is, if the policies and programs in other sectors are not sensitive and responsive to public health concerns, then we will continue to face a rising tide of disease which could have been easily averted. But how do we actually bring in joint ownership of the goals and shared accountability across ministries? This is where institutions like the World Bank should be able to do it because they engage with multiple ministries, multiple agencies. So how do they actually bring them on our convening platform? So these are the kind of questions that we should be asking of international agencies beyond the money they bring in. Thank you, Shridat. Yang Zheng, let me turn to you and then I'll come to Margaret and then we'll open things up. But as part of this sort of rapid-fire round, you highlighted some of these, let's call them unintended negative consequences if I can put it that way, putting it kindly. Some of the things that have emerged that are problematic in the Chinese health system, even as a lot of impressive reforms have taken place, are there any prescriptions or any policy recommendations that you're making or that the government is now trying to undertake to correct and adapt the system to deal with some of the dilemmas and the problems that you've highlighted? Yeah, we saw that, just to say, I'm still optimistic about the prospect of the success of the Chinese health reform in part as actually this is also indicated by Dr. Jim Kham in this morning that there's several important factors, I think, would contribute to the success include the robust economic growth, very strong political leadership, political determination, that are still there. And in fact, recently the Chinese President Xi Jinping actually emphasized this concept of social justice and fairness. And obviously, I think that the UHC will still be a top on the leaders agenda. But I think the UHC, as we all know, is not just about health financing, you could inject all the money into the health sector in a very short period of time, extend the coverage, but that doesn't necessarily mean you can solve all the problems because you need to have a holistic integrated approach in tackling the health care reform. For example, in China, even though in the public hospital reform, even the government admitted that it should be the core of the health care reform agenda, but so far the government has not been very serious about reforming the public hospitals. And also, even though we know that more money should be spent on the demand side, but so far only one-third of the money actually is injected to the demand side. Two-thirds of the money still goes to the supply side. And we know, well, this is the supply side, that David mentioned that 20 to 40% of the money actually is wasted in China, despite over the past four years, billions of dollars that the government has injected to the health care sector and to the demand supply side, still, the percentage of the government, in terms of the composition of the hospital revenues, I mean the government public hospitals, the government shares less than 10% still. So I think it's very important for the policy makers in China to really now focus on some of these most, I think, important things on the health care agenda, and also this issue of access. The one of the problems that exacerbated the access is because of the male distribution of health care resources. So the patients would have to go to see a doctor in the major open health centers that causes all the problems. So why not actually, for example, improve the quality of the doctors who work at the grasslands level in the countryside by significantly improving their salary level, to keep them staying. They are instead of giving them the same incentives of staying in the community level, our centers. Thank you very much. And let me just, Margaret, to go around one time here and then open up, we have 30 minutes left. So I hope you're cooking up some really hard questions because mine are the easy ones. On the quality side, I mean, I see Daniel Kotliar here, he's an economist, and Jesse Bump, so they reduce these things to questions of payment and prices and so on. Some of the economists here might argue that the quality issue is really all about financing, that if these countries were just setting up ways to pay for quality and pay for performance that this quality issue would go away. What's your view on that? Necessary but not sufficient, I think is my answer to that. Absolutely, investing in trained providers. You know, we were here, Ariel, I, a few others, many, some of you perhaps earlier this week were looking at the successes of saving mother's giving life. Our team did an evaluation as a large program to reduce maternal mortality. We found that one of the investments that was particularly effective was actually investing in physicians. I know they're not hot, they're not sort of the topic of the day, we're all talking about task shifting, but in a health system that's extremely constrained with very few practicing doctors, infusing physicians into the system actually raised the quality of care, the expectations for care for all women in that setting. So investments in some incredibly important inputs are absolutely essential, but I think the experience of India, the experience of China and other countries has also taught us that that's not enough. There are many brilliant doctors in India and China. What in Thailand and other places, the other issues are issues of political will, policy design, maldistribution, for example. We know doctors and nurses aren't just led by money. For example, when they decide about where to practice, we have evidence on that. The issue of regulation has been, I think, understressed in this discussion. All of these are policy level decisions that may or may not cost a huge amount of money. Some of them do and some of them don't, so not enough. Great, great, thank you. I don't think there are any hot physicians in here, I don't know about that, but we'll check during the lunch hour. Let me open it up, we still have 25, 30 minutes. Let's take three or four comments and questions. I'll take, moving across the room so as not to discriminate. Please, go ahead right there. Thank you, my name is Narelle Chakraborty from PSI. And I have a question, comment related to the issue of quality. I'm very happy to see it being discussed and the idea of quality-adjusted coverage that Tim Evans mentioned. I'm curious in the context of the countries in which we're talking about low and middle income countries, your ideas for how we go about kind of ensuring quality, because I would suggest that in the U.S. and in other developed countries, quality is assured not necessarily through policies per se, but often through the threat of lawsuits and things of that nature. And so I'm curious to ask what kind of systems, kind of policy interventions, regulations, would you think would need to be created in order to improve quality? Great, thanks. So you're suggesting we export medical malpractice lawyers to other countries? Got it. Okay, well that's taken care of. Let's do one from the middle ventures here. Please, go ahead. My name is Niranjan from Management Sciences for Health. Dr. Srinath mentioned about the whole continuum starting from diagnosis, prevention, therapeutic and so on. Given that and given your point about regulation and given this morning's brief acknowledgement on access to medicines, given all these different pieces here, what I'm realizing is anybody thinking about access to medical devices, access to health technologies? Because I'm sure everybody in this room knows about the tumultuous history of drug pricing and how that plays a big role in the design of universal health coverage. And Ariel earlier mentioned about potential of increasing demand, inflation and so on. If that's the case, given what we know about ineffective or poor regulation of medical devices and the perverse incentives that go into the whole system, is that a blind spot? And what can we do about it? Thank you. Okay, medical devices, medical technology, prices for pharmaceuticals, a lot of issues here. Let's take one from this side. Yes, please, in the middle back there. Hi, my name is Tina Curry, just returned Peace Corps volunteer. And I was wondering from the middle income countries, if there are any examples of pressure that residents from those countries are putting on their respective governments to make change. During my service in Madagascar, my second year there was a strike that happened at the health center. And it was really interesting to watch when people came to the health center, realized it was closed, they didn't seem angry or upset. And just kind of wondering if there's examples from some of the middle income countries where residents are putting pressure on their respective governments to create change in their health system. Okay, thank you. Let's take one or two more. These are really easy questions. So we're still looking for some hard ones. Yes, please. Thanks, Lydia Ogden, Emory University Rollins and also Merck vaccines. Picking back on this question, not only how do we assure quality, but how do we collectively define quality? And is it possible to come to some collective definition? Thank you, and let's take one more and we'll do another round. You've been waiting very patiently. Thanks, but I think you had a chance last round too. So, no, but go ahead, please. Thank you very much, my name's Jinning Nguyen. I would like to ask Dr. Wang and also the India, because both of you, these two big countries has significant amount of populations, 1.3, 1.2 billion. So the question has to do with the Food and Drug Administration Agency is that in the thinking of the government, is there any way that we can suggest that? Because we very much have concern with the toxin and toxic and fake medicines being sent over to Vietnam. And Vietnam has suffered a lot of problems in health from ingesting food and drugs that has toxin in it. And we have wondered if, with the significant economy that China has and the huge amount of money that you invested in the healthcare system, is there a thinking of having a Food and Drug Administration to somehow ensure the quality of food and drugs being ingested by the population? Thank you. Thanks. I see more hands, but let's allow the panel to answer. I think, Margaret, a lot of the questions here relate to quality, so people seem to want to hear more from you. Well, I think the quality actually is a feature that's central to all the presentations, but let me take a first crack around the malpractice question. So I would say, also as a former physician to be completely transparent here, never a fan of the malpractice lawyers, I'm not sure this is the most efficient way to enforce quality. I think that's what we're finding here in the U.S. health system that, in fact, it adds to the healthcare costs with all sorts of defensive medicine and potentially unnecessary services. But there are other successful things that some high-end and many middle-income countries are trying to do now in the sphere of regulation, licensing regulation, and maintenance of certification. It's not just good enough to be licensed the first time, but how do you maintain that licensure? What about private providers entering the system? The idea that you can hang up any shingle outside your office is very disturbing and still very prevalent in many countries. And critically, where are the professional organizations in this? Where are the professional organizations who should be active and decrying poor quality, who should be policing their own members? Those are the sorts of things that could be strengthened and potentially with some support from the global community as well. Then second piece, I think, on ensuring quality is giving, putting this in the hands of the population. We know very well the populations get and appreciate and value high-quality care. Why don't we let them know what the quality of care is like at their nearest health center, at their nearest hospital and let them vote on whether they will go there and get care. And if hospitals are interested in seeing volumes and in seeing flows, again, the financing system has to support this, I think we're gonna see some change. 70% and upwards of the population now in rural areas that I study and work in in sub-Saharan Africa, I have mobile phones. There's no reason that information couldn't get out there, but we have to measure it first. We're not measuring it right now. And maybe just a point about defining quality. So I think I see quality as really being comprised of three elements. One is definitely technical quality of care. I work a lot on respectful and dignified care. I think that's incredibly important, but first and foremost, we should do no harm. We should make people better when they come for services. And that requires competence and it requires the right medicines, not expired and effective. So technical quality has to be a part of that. And people are able to judge aspects of that, by the way, the patient. Secondly is the interpersonal quality of care, which is just as important for some services, not all services necessarily. If you've got a broken leg or an arm, you just wanna maybe dealt with quickly and efficiently and effectively, but we know certainly that in the case, for example, of facility delivery, women value interpersonal quality just as much as they value availability of medicines in that health facility. And finally is this issue of responsiveness or fit. Again, understanding what people want out of that primary health center. And you know, we're proposing more recently that maybe primary care is not the place to deliver women. Maybe you can't give the volumes high enough to give good quality care. Maybe we should reformulate primary care, reconfigure it to provide more of a focus on NCDs. Maybe that should be the right area. So I think we have to challenge our own favorite assumptions and our particular compelling notions and listen to the population. Thanks, Margaret, that's, your last point is very provocative about assisted deliveries in facilities and NCDs. Maybe we can come back to that too. At least during the discussion period in the lunch break. Let me turn to Srinath and to Yang Zhang in particular on this question of food and drug safety devices and other regulatory issues and anything else that's been mentioned by the questioners. Srinath, do you wanna go first? Okay, yep. I think it's very important to have very credible and effective regulatory systems. Unfortunately, medical devices have not been appropriately regulated in India and they need to be regulated. They were mixed up with drug regulation. Drug regulation itself is rather bad and therefore medical devices never got regulated in the proper manner. Now the question, of course, you're asking is the use of medical technologies inappropriately. We are now proposing in the country to set up something like a nice like institution which would actually do an assessment of medical technologies and then provide recommendations. But the whole idea of both regulating devices before their entry and regulating the use of technologies after their licensure is an important element and certainly I recognize otherwise it can really inflate costs. As a cardiologist, I know that all affairs of the heart are expensive, not merely in a poetical sense. But also in terms of the FDA, the same thing applies. Drug regulation was rather poor but now we are strengthening it at the moment. In terms of people's anger, et cetera, all of that is really linked to quality of services. I define quality by four measures. Effectiveness, safety, cost in the sense that cost also should be contained in terms of appropriate use of technologies for incremental benefit, not just for profligate use of technology. And fourth is satisfaction. Satisfaction at the level of the patient, satisfaction at the level of the family and satisfaction even at the level of the providers. So if we can actually capture these elements and do technical audits and social audits, then I think some of the issues that you're referring to can be avoided. And I think that's it. Well, those four dimensions seem measurable, at least potentially measurable, if not actually measurable everywhere. Yang Zhang. Sure, the first of the FDA issue, the vaccine in particular, that we know that China has a very robust biopharmaceutical sector. The country is also, I think it's the second largest pharmaceutical market in the world. That being said, that the quality control remains a problem to say that 10% of the drugs manufacturing in the country are fake. And recently probably you have heard this incident that it is suspected that the hepatitis B vaccine was associated with the death of eight children in China, that the vaccine actually was produced by one of the largest vaccine manufacturers in China. And we also actually, despite the presence of a robust biopharmaceutical sector, that all but actually only one so far, the vaccine has been WHO pre-qualified, that is Japan encephalitis, just happened a couple of weeks ago, I believe. And so many of these vaccines, you found in Africa, Southeast Asia probably, they entered in this country through the government in the form of government grants, and they can't because they're not WHO pre-qualified, they can't get into the public sector. That causes a lot of problems. So certainly China should strengthen the regulation on the quality of the vaccine, but in the meantime, given that the supply chain is now increasingly globalized, I think it is important for the stakeholders, the international actors to work together. I know that Mary Lou is there, that the US FDA is the Chinese government and the African governments, the regulators, they're working together to sort of build a global alliance to improve the supply chain, the quality of the vaccine supply. Thank you, Yang Zhong. David, do you want to comment on this? Because I was going to tell people that the next round of questions should all be... Directly to you. You avoid them having to ask me a question. Let me just sort of comment that, like you anticipated, from an economic perspective, much of the incentives for quality and lack of quality are inherent in the way the system is financed and particularly the way providers are paid. So that if, for example, primary level physicians are not, don't get any recompense for asking about smoking behavior and advising against smoking, they don't do it. If the clinicians are allowed to dispense and sell medicines, they dispense and sell too many medicines for the wrong reasons. If people are paid, hospitals are paid for volume, they keep patients in too long and do too many procedures so that the way providers are paid and the way the financing system levitates more towards or against quality, that being said, it's very obvious what the problem is. Changing it is a really difficult political problem. So there is a link between financing and quality. We're still searching for that, but we're trying to identify it. Let's take... Robert, have we... We haven't addressed the medical devices issue, have we? Well, why don't we come back to that in the last round? Let's take maybe three more, four more questions. Why don't you go first? I know you've been waiting, thank you. Hi, I'm Kate Tolenko from InterHealth and I'm the Director of Capacity Plus, which is USAID's Global Health Workforce Project. I have a question about decentralization and the role it will play in universal health coverage. Will it be helpful because you'll have local forms of financing, local accountability, creativity, or will it be harmful because you'll lose out on that coordination and economies of scale? Great, thank you, terrific question. I think there was somebody way down in the corner, please, yes. Henry Hedger, retired federal government. We've been witnessing a revolution in medical care through the use of the corner drug store where you once were able to get your aspirin, you'll now be able to get medical care. Witness, you know, Walgreens, Rite Aid, and CVS and I wondered about the application of this new concept worldwide. Other nations would be able to provide some medical care at a very low original cost through the drug store. What are your feelings on this? Thank you very much. One or two more? You said you weren't gonna ask any more questions so you've already disqualified yourself. No, Daniel, we'll come to you. Hard one. Oh, you have a hard one, well we'll see, we'll see. Daniel Gottlieb. Daniel Gottlieb from the World Bank. I have two questions. The first is for Margaret on quality. At the bank we've done a number of case studies of how countries are expanding coverage and of 27 programs that we studied worldwide, we found that 22 have a program of accreditation or certification. Now the question is, do these programs work? Every country seems to believe they work. We haven't really encountered much evidence that they do and anecdotally what we hear is that there's a very difficult political economy related to this because there's this new agency that's created in almost every country that's in charge of providing accreditation. They're supposed to credit both public and private sector but when it comes to the public sector, they don't seem to be able to not provide the accreditation. And there's a lot of struggle and a lot of people are spending a lot of time and money on this. So do we know if this works and if we don't, how should we think about researching that question? And the second question is I cannot resist the temptation of having China and India in the panel. It's about decentralization. In these 27 countries we find that there's, we have about 12 that are federal countries and the relationship between the central government and the state governments are very different. In some countries which I won't measure, mention they seem to be completely dysfunctional, the relationship. But one thing we find in particular that's striking is that in some countries there's these central government programs that are then adapted and implemented by each regional country and that seems to be the case of China. Whereas in other countries, of which there's lots, there's a central government program that's implemented everywhere, but then states perhaps dissatisfied with that program create their own programs. Is this a good thing, a bad thing? Can you comment on this? Thanks. Thank you, Daniel. Now we're gonna have to spend an extra hour on that last topic that you just raised. I was hoping nobody would mention it. Thank you. You wanted to ask a question, please. Last one. Go ahead. I'm sorry, when we talk about universal health coverage and this is also related to the quality, you mentioned something about the structure, trained personnel, you'll have to have the facilities and then the process of providing care, but most importantly the outcome, the effectiveness of that. Where do we find other forms of healing? For example, in a community you may have a curandero who is qualified, who has the medication or the means of providing care, and most of all many times heals the patient and their satisfaction and respect. How is that taken into account as part of coverage and quality, thank you. Thank you, I'm gonna close off the questions now and let each of the panelists take two minutes. Steve Morrison says we can go four minutes over, but only four minutes over. So I'm gonna wrap up after the panelists have each had a chance. David, do you wanna go first? I mean, maybe just on two questions. The question of the corner pharmacy. I mean, there are a lot of experiments now in developing countries with what has been called task shifting, but I don't know what the most recent name is, but for lower level people, people with less training doing work that people with training has, and I think that it's essential to start thinking of that, particularly when doctors are in very short supply, they're expensive and they migrate. The downside is that in many developing countries the professional unions have been very opposed to this form of shift and they've been the biggest obstacle, I think. And I have a nice anecdote that I remember, I should be very careful. I remember being with Margaret Chan, a director general with one of the professional unions, the meeting with her, explaining to her why they could take on greater responsibilities that doctors currently do, and that was the first half of the conversation and the second half of the conversation was trying to explain why lower level workers shouldn't do what they do. So they want to take on the role of doctors but no one else should take on what they do. And this professional antagonism to task shifting is something that is a problem, but I think it is important. The question of decentralization, again, you know WHO is decentralized and whether you think decentralized is a good thing depends upon where you sit, but it is very difficult in decentralized systems to have national policies and many of the decentralized systems are now finding the need to try and introduce incentives the way the funding flows from the central government to the sub-national level is now being more and more attached to performance criteria for performance agreements to ensure that some of the things that are critical nationally don't fall by the wayside. Thank you, David. Let me move on to Sreenath. As far as decentralization is concerned, clearly India has a federal constitution in which the responsibility for delivery of services is that of the states, but the design of the national programs is of the center with shared financial costs. And the states can certainly modify some of the programs but it's intended that every national program too is devolved to the district level and it's the district level decentralization if effective can really bring about the local context into play. It's very important for us to recognize that unfortunately this has led to primary care being neglected by the states because the center has been financing primary care mostly through national schemes and we must correct this distortion. But there is also the fact that now the power for some of the expenditure is being devolved down to the village level to the local village panchayat or the village local elected body and there is a recent study which shows that after the introduction of the 33% reservation for women led panchayats, the women led panchayats now actually have been demonstrated to show greater expenditure on water, sanitation and health with improved outcomes. So that's the positive news. Now coming to accreditation of public facilities, certainly the national rural health mission has established Indian public health standards mostly for primary care and but going up to district level. But in addition now through the insurance programs, the public sector facilities and the private sector facilities are having to compete and therefore there is a greater incentive even for the public sector facilities to get that accreditation part of it. And as far as indigenous systems of medicine are concerned, the different indigenous systems of medicine which have formal education are now part of the India's health system, India's public health system and they are positioned in primary health care. So in that sense, they're not excluded. Thank you, Srinath. How do you manage to get so much information on a little piece of paper like that? Learn how you do that. And Marguerite, you have it on a- Yeah, I figure. No, you had it on your screen, on your phone. You guys are way ahead of me. Go ahead. Okay, so I think actually the drugs, the corner care question and the question on what can community workers do are linked. They're both really getting at bringing care closer to people. And I think that is such a timely and relevant agenda when we look at MCDs in particular. We have a lot of evidence now that trained and sometimes peer workers can really support good health outcomes in, for example, non-communicable diseases. We should be spreading that far and wide and that's a cost-effective and I think popular patient support of sort of a service. Similarly with drugstores already, as has been pointed out, drugstores and corner medicine shops in low-income countries, middle-income countries serve as an informal point of care for malaria, for other things. Why not be able to weigh yourself there or check your blood pressure as well as MCDs are spreading? I think the question on accreditation is an excellent question. We did a recent review on this exact topic, scouring the literature for what works on quality. And you know, you won't be surprised to hear that the evidence on accreditation is scant. There are, there's probably one study in Zambia that looked at accreditation efforts supported by USID and others to try to improve hospital quality of care and was able to link accreditation. The methods weren't hugely robust but accreditation to veteran hospital outcomes. Turned out, as you just commented, that that process was so expensive, Zambia disbanded that system. Now Liberia, others are trying to introduce accreditation. I guess when I look at the panoply of options available for improving quality of care, I think of accreditation as defining a floor of care, not the optimal performance. So you shouldn't be in business if you can't meet these basic requirements is sort of how I think about it. I think it's pretty much how it's used in the high income world as well. And I do think we have to find ways to make it cheaper. And finally, Yang Zhong, you get the last word. Okay, well, follow up on this question, decentralization, if you look at China Act, is a very highly decentralized system, not only in terms of the health care funding. We know that in terms of financing, the central government over the past four years only contributed like 25 to 30% of the funding. The rest is 70% actually, it's for the local governments. And also keep in mind, we're not talking about one health care scheme, right? We're talking about several thousand health care schemes in China because each locality has its own program on health care, the coverage, universal health coverage. And that actually contributes to one of the problems of that decentralization is that it actually, it actually reinforced inequality in health care access in China because those regions, the localities that are wealthy, that with higher revenue base, they could have actually offer better health care packages and benefit levels. But the four regions actually can't because of this, again, very highly decentralized system. And that inequality can be exacerbated by the existence of what we call the tax war. You know, the health insurance schemes in China, they have the open employee basic health insurance system and open resident health insurance system and a new cooperative health care system. So that is just an example of the introduction of the universal health coverage does not automatically leads to improve to improve the equality in China. And that's an interesting aspect of the health care. Great, thank you very much. It's very interesting. I noticed that as the lunch approaches, the room starts to fill up again. I'm sure there's no cause and effect there. But anyway, it's good to have everybody back here. I'm gonna wrap up very quickly so we can get to the lunch and there's a lunch speaker coming Nils DeLair who's fantastic. When I do finish, let's make sure we give a lot of applause for the panel. I think you have to admit that they are a prime group of electricians and plumbers and even an architect or two here when it comes to building health systems. Now that you've heard about all the different elements that go into a universal coverage system, Steve, I think that during the lunch break, if you can put poster board out there and pipe cleaners and drying implements, everybody can construct their own image. Now of what a universal health system looks like and we could have a little reporting back this afternoon see how people now imagine the construction of a universal system based on the elements we've just heard about from our panel. So again, thank you very much. Let's give applause to our panel and we have an announcement from Matt. Thanks again to all of our speakers this morning. We have lunch behind you. Please be back in your seats at 12.55. We have tables outside for you to eat at and you can also bring food in and sit at your seats during Nils's keynote address. Thank you very much.