 been a big part of. Diarrhea deaths, pneumonia deaths also went down, and that's because Gobi took some vaccines that were being given to middle income and rich country children who were at very little risk of dying from those diseases, still a good thing. But actually the kids who had 10 times the risk were not getting the vaccines. And it's by buying the vaccines through Gobi that now our coverage on rotavirus and pneumococcus is actually quite high. And so that's why that acceleration took place. So we're lucky enough to have the director of the Global Fund and Gobi here today. I want to start with you, Peter, now that we've seen what's possible with investment and with focus and with using the tools that we've learned over the last 20 years, what are the immediate and urgent challenges? What happens if we don't focus on these things? Well, I think the starting point, as Bill said, is that the Global Fund and Gary have been two financial innovations for global health that have actually worked extremely well and have delivered a massive difference in terms of life saved. The challenge is going forward. Well, the job's not over. And Gosi can talk on the vaccination side. But suddenly with AIDS, TB, and malaria, we've roughly speaking halved deaths in AIDS and malaria and about 20% reduction in TB. But if we really want to achieve the sustainable development goal ambition of ending the epidemics by 2030, we have to step up the fight. We have to do more better. That's not just about money. It's innovation. It's collaboration. It's better execution, better use of data. But it also takes more money, which is why, as Bill mentioned, our replenishment is this year. The way the replenishment works in the Global Fund is it's a three-year cycle. So we're raising money for the next three years. And we're saying we need at least $14 billion. And for those of you from the private sector, we want at least $1 billion of that to come from the private sector to fund the next three years of the Global Fund's work. Now, why is it so challenging? Well, resistance is a problem across all three diseases, most potently and obviously with MDR, TB, multidirug-resistant TB, but also with just people becoming resistant to bed nets. We also face the way the epidemics work has changed. I mean, the most likely person now to be catching HIV is an adolescent girl. And the root causes of the high rates of infection around adolescent girls and young women in Southern and Eastern Africa and particularly are a horrible cocktail of all the gender inequalities you can think of, from sexual violence to economic disadvantage, educational disappointment. And we are finding that we are having to work in different ways with different partners to address that challenge. Malaria, tail of two areas. We've got some countries making great progress towards elimination, but the highest burden of countries, frankly, we're doing enough to save lives. We're not doing enough yet to break the transmission cycle. The numbers of cases are not coming down fast enough. And on TB, well, frankly, we will all regret it if we don't meet the challenge of MDR, TB. So the other issue, of course, is emerging threats. And Gosi, we've had a really remarkable and stark example of what happens when these partnerships work, in the case of Ebola. In May, there was an outbreak of the Ebola virus in Equatoria Province in the Democratic Republic of Congo. And the nonprofit world, Gavi, the state governments, the World Health Organization under Dr. Tedros and Merck and other private companies worked together, created a ring vaccination, stopped it with a small number of deaths, and it never left the area. Later that summer, we've now seen a new outbreak in Kivu Province, where it's in a war-torn region, and some of these partnerships can't get the job done. It's just too difficult. And we're now at a place where hundreds of people have either confirmed cases of the disease and 400-plus have died, and there's no sign of it alleviating. In fact, it seems to be accelerating. And you talk a little bit about, given the role that you have played in coordinating all of these stakeholders, that challenge, that's the perfect example of when it works versus when it doesn't, the threat. Well, let me thank you. I think Gavi is that new, modern type of organization that we all want to achieve, where you have an alliance that brings together partners that can work together in collaboration to tackle a given problem. So that alliance has WHO in it, it has UNICEF, it has the World Bank, it has pharma, pharmaceutical companies, so we have private sector at the table, we have civil society, and we also have the beneficiary countries around the table. So it's a unique partnership, where you're coming together. And I think that's the modern type of cooperation we need to solve problems these days. So when you talk about Ebola, Dr. Tedros was in the field. He took the lead with WHO to go and try and see the problems firsthand. He went with Seth Berkeley, the CEO of Gavi. And I think because we had taken this step of trying to stockpile some of these experimental Ebola vaccines, there was something available. So when you say it's a failure, I don't quite agree with you. I think if we hadn't had that, it would have been much worse. But I'll leave Dr. Tedros to talk about that, because he was actually there on the ground. Well, please jump in. So I just want to say that the alliance, I think, worked. And I'm very proud, because it could have been much worse. You know when you have conflict, that's one of the challenges we face, that in reaching people where there's conflict is a problem. And it's one that we are trying to overcome. But it's not easy, because people's lives are in danger. But Dr. Tedros can say more. I was a member of Gavi Board, and I know the alliance works. I saw it when I was Health Minister, and now I see it as Director General of WHO. And as Ngozi said, I was there three weeks ago, during the New Year actually. And it was for me very emotional time to share a meal with my colleagues fighting Ebola in DRC, in the front line. You could see to what extent they're putting their life on the line. Even when we were there on New Year Day, one of the Ebola vaccine responders, vaccinators, we're talking about vaccine, was attacked. And he sustained head injury. And myself and Jeremy were in the field. Jeremy, the welcome trust director. And luckily, he's a neurologist, and he helped the patient to not only stabilize, but using the helicopter we had, we had to evacuate him. And that was really a very humbling moment. To what extent our colleagues that are facing daily challenges and serious dangers, actually, to keep others safe. So then coming to the vaccine, I told you about the story about Charles Mwenga, the guy, because of the vaccination, the vaccine, because he was vaccinating when he was attacked, actually. And then the other side is, so far, we have vaccinated 60,000. And if it wasn't for the vaccine, we would have seen more cases. We have now around 650. In five months, you cannot limit the spread of Ebola in 650 without the vaccines. And not only that, the colleagues I spoke to in the field told me that in the eyes of the people affected by Ebola, we see hope, not fear. But in 2014, during the West Africa Ebola, it was fear everywhere, not only in the Ebola area, even everywhere, all over the world. So we are in a different situation, which is really important. And I think it's very important that we recognize the power of partnership, the power of alliance, the power of innovation and technology that helped us to be where we are. But when I say this, I'm not saying it's perfect. We're still very, very vulnerable to outbreaks, including to Ebola. And we have to build on the success we have already achieved. And, Sonia, you're seeing in Pakistan a shift. And not just, obviously, there are still the threat of infectious disease, but you're seeing non-communicable diseases, diseases that used to be most prevalent in the West and wealthier countries. And now you're starting to see them get, you know, grow with, you know, a frenzy in some cases. Talk a little bit about how you manage those twin challenges. Well, the shift towards non-communicable diseases being the predominant contributors to burden of diseases, not just something that's happening in Pakistan, it's a global trend, it's happening all over the world. And in terms of financing for global health, we have to appreciate that non-communicable diseases are not just disruptive in the epidemiological sense of the damage they cause, because we all know that they are the biggest contributors to deaths, to disease, to disability. But they're also equally disruptive in terms of the political, the economic, the societal and health systems responses to address the challenge. Now, if you look at country demand for technical assistance, and Tedros will bear me out on that, NCDs rank amongst the top three asks from countries. And in fact, when we were campaigning together two years ago, this was the consistent ask from different countries. But as opposed to that, we know that it is not within the realm of competencies of ministries of health and the existing infectious disease partnerships that we've created to fully respond to the full range of determinants of non-communicable diseases. So it's quite an imperative to have a new set of institutional competencies and financing instruments to deal with non-communicable diseases. And I fundamentally believe that an appropriate response to non-communicable diseases could be revolutionary for public health, just as the HIV response to HIV AIDS was more than a decade ago in terms of institutionalizing the right space approach to health and catalyzing the access to medicines dialogue and including affected communities in the civil society in the planning process. I believe that an appropriate response to NCDs could actually change the rules of game on two fronts. Firstly, this whole aspect of the whole of government approach and the multi-sectoral approach to dealing with public health. And secondly, the whole piece around engagement with the private sector. So NCDs can be quite transformative in these respects. Well, that's a perfect segue to our last speaker who represents the private sector. You know, Voss, you're unusual for a drug company CO in a number of ways. One, you're a physician. But two, you're also a practitioner of global health care from your earliest days. You were at the WHO when you started. You've had great experience in that. And thirdly, I think you're also a data geek. You're a guy who really is looking at sophisticated ways to address these access issues and finding out where what drugs can work more effectively. Can you talk a little bit about the tools that we've got to address some of these global health challenges from the private sector? When I reflect, and I love the Steven Pinker charts, because I think they put it all in perspective, we as an industry, probably our greatest contribution is bringing innovations forward. And I think that's hopefully obvious to everyone here. When you look over that period, the 100 years, at least from 1900 to today, you have 1,500 enemies. You have over 20 vaccines that constitute what we talk about on this stage. And that was the industry bringing these technologies forward. And I think whether it's health care, water, energy, ultimately as the private sector, our ability to innovate on these problems, but then ultimately give access to the poorest of the poor is the conundrum that we face. That's really where we make our greatest contribution. We put forward $170 billion a year into R&D just in our health care industry. And that R&D ultimately leads to innovations. I was recently reflecting on it in Ghana and Gabon. If you go to a dispensary in those countries and you look at the list of drugs, those list of drugs were innovated just 15, 20 years ago. And now, finally, they've reached. The forest reaches of the planet. That's the problem I think we now need to be all about, which is access to medicines. Gavi was founded on the premise that Prevnar, actually our pneumococcal vaccines, took too long to get to people. And we left that to Bill and Gavi to sort out. And I think we as an industry now have to be all about, how do we bring our innovations within the first year or two of when we find them to reach all populations on the planet? So I think that's actually where we create our greatest contribution. Now we, as an industry, I think we give $20 billion into various forms of corporate giving and donations. I ask myself, is that well-directed? Is that really having the impact it could? And I think that's an open question. But if you ask me, the biggest impact we could have is if all that $170 billion of R&D to find the next innovation reaches that patient in Kenya or Botswana much faster, then we've had the impact that we would have. So you brought up a really, yeah, please. I just want to say a word, I hope you don't mind. I want you to. I can't resist because you talked of the pneumococcal vaccine. And one of the things that Gavi does is we have a mechanism called the Advanced Market Commitment, and we're able to negotiate with pharma prices that are affordable to poorer countries and accessible. So it does now is about $2.95 compared to about $100 in the US. So you can see how countries can now afford to get these vaccines for their children. So that's a huge innovation in financing and accessibility. So I want to come back to this issue of vaccines because you take Rotavirus vaccine, which eliminated huge amounts of diarrheal disease, which is a massive killer of young people in the developing world. But there was as great a success story as that is, there was a delay in getting that drug out there because of fear of very rare cases of interseception or reversible case. And so the West ended up removing it from their schedule of vaccinations and delaying that process of getting that drug out there. And I wonder, Bill, if there is sometimes a little bit of a deadly caution, or are we, what's slowing us down? I know as fast as we're moving, what would you change to make us go even faster? Well, I think we need to keep the industry, indeed, to be very high while figuring out how these tiered pricing approaches makes the access issue a lot faster than it would be otherwise. In the case of vaccines, Gavi is able to negotiate a very cost-oriented price so that for the 73-force countries there's not recovery of the R&D or profit. That's going to have to come from the more middle-income and rich countries. In the example you gave, the only gold standard regulators are rich country regulators, European and US regulators. And because the deaths from diarrhea, rotavirus in particular, are very, very low, the bar they set for rotoshield side effects was extremely strict. And to keep the reputation of vaccines as being beneficial and not having refusals that is a challenge even in rich countries, the quality of that regulation, I take no issue with it at all. If the world was super rational, we would have accepted that there was some side effect because the death rate in Africa and India from rotavirus was high enough. But there's really no way to say to those countries, so this is not good enough for the US because their death rate isn't very high. So we moved fairly quickly. We got discounted pricing from GSK and Merck. Over time, we brought in an Indian manufacturer at an even lower price. So it's pretty much a good news story. We have about 80% coverage. That's one of Gaby's focus for its next five-year period is going to be taking that coverage where we have parts of Africa and Nigeria being one of our particular difficulties in getting that up. But right now, the system of regulation, the idea of recovering your cost and getting your profit off of the middle-income and rich countries, that's working pretty well. In addition to the regulatory issue, though, I would agree with Bill there, there is a degree of lag, which I think we collectively have to address, which is the speed at which treatment guidelines get changed all the way through to national level, and then how a physician practicing prescribing behavior changes. This can take years. And how we can work together to get the best new biomedical interventions to patients quicker, I think, is a challenge for all of us. So which one of you wants to get the hate mail? Because I'm about to bring up the anti-vaxxer movement. But this is a real challenge. We've seen a backsliding of polio cases, some fear in Nigeria, and it goes to your home country where you were the health minister twice. Finance minister. And finance minister. I would have dared to be a health minister. Two finance minister and I'm sorry. Finance minister twice, and also you're a foreign affairs, so we're a cheap diplomat. So we've seen that. We've seen a backslide of measles and rubella in the West. I mean, it's kind of scary. And this is one of the, we've talked a lot over the last couple of days about trust. Fundamental to the global health effort is the belief that the vaccines and the other tools of the international health movement are safe and effective. How do you deal with that? Well, Tedros, if you want to take two. Maybe I can start. I mean, I have to say that when you look at the landscape, there's really been a high degree of trust and deliverability in the vaccines we've had in the world. Actually, it's amazing to me. And so we have to stress that. But we also have to look at cultural issues, at fears, at false information that comes in and people get afraid. So there are all sorts of issues. And I think working through the local community has been essential, both for the Alliance with the Bill and Melinda Gates Foundation. Bill was talking about Nigeria. He has also done excellent work on the ground, in the case of Polio, for instance, to try to break down some of those cultural barriers and have the local imams, the community leaders, to talk to people and reassure them. I know there was a time we even had to have vaccines brought in from Indonesia, because to make sure that people have trust that it came from an Islamic country and everything was, you know, all right. So, but I don't think we should exaggerate those. There's a lot of trust in the system. And we should not allow people to undermine that. Sanya, I know you wanted to jump in on this. Yes, I think the trust issue that you just mentioned is part of a much bigger problem, because when you talk about global health and its sustainability and the way forward, we have to appreciate that today we are living in a world where, you know, the value of international institutions and the trust and multilateral system is wavering. We are, in fact, seeing a scenario where many of the cross-cutting agendas, such as family planning and reproductive health and sexual health, you know, the value of investment in them is being contested. And Peter Sands just reiterated the wide-ranging ramifications of that setback. And on the other hand, I think paradoxically, there has never been such a time where the value of international institutions and the imperative to invest in them has been more imperative. I mean, I can go on and on with a list of things. For instance, relevant to the health sector, there are three risks that threaten to wipe out the development gains of the last century, pandemics, antibiotic resistance, non-communicable diseases. Tedros will tell you that universal health coverage is his top priority and the top priority of many countries where, and for very good reasons, but in order to institutionalize universal health coverage, you have to play health with a very different stack of guards. You have to engage the private sector in many different ways. A colleague here will tell you that precision medicine is likely to become the default option very soon because of a number of different transformations. And you know, there's this whole technology piece and how institutions outside of the healthcare system are taking the lead on providing solutions for universal health coverage. These are financial institutions and online retail actors. And in order to institutionalize and reap the benefits of all these transformations, you need new standards, new rules, you need workforce re-enlightened, you need stepping up and change in regulatory capacity. And you essentially need changing, stepping up of capacity and all that is not gonna happen if we will not invest in international institutions in the multilateral system, which are consistently under attack. So this whole question about which country is going to take a lead in raising its voice and becoming the world's conscience and which country has the fiscal strength, the fiscal ability, the credibility and the spine to raise the voice are becoming hugely important in this discourse, not just of around global financing for health, but also global development financing. And I think these are big ticket things around which there needs to be a dedicated discourse. Yeah, I wanted to pick up on this point on as we evolve into precision medicine and looking at all the advances. I mean, it's quite striking to me when you think about the conversation here, Gavi Global, from 20 years ago, we knew that infectious disease was where we had the biggest potential for significant impact. We set up the global fund, Bill set up Gavi, we've had tremendous impact and we need to continue to fund those institutions. But if you go to a typical West African country, even with a well run healthcare system, you look at the burden of hypertension. You look at the capacity for basic dialysis and basic medical interventions to manage hypertension or manage any of the consequences of hypertension, much less diabetes or obesity. I see systems that will soon collapse. I mean, I think this is gonna be a significant issue. And I ask myself, do we need a global fund for non-communicable disease or do we need some other mechanism? Because even if we raise the 16 billion for the global fund and we tackle AIDS, TB and malaria, it'll help for the next 10 years. But 20 years from now, we sit in a very different problem and we're still very far from bringing things like precision medicine, gene therapies, et cetera to solve these problems. But that's a great point. I mean, Bill, do we need new financing mechanisms beyond the multilateral groups that we've talked about today? Obviously the Global Fund in Gavi and the Polio Eradication Initiative and the effort for maternal and child health, the financing facility, those are critical. But for things like dealing with or the challenge of antibiotic resistance or for vaccines, for elements where there isn't a large market, should there be another financing mechanism, a model that can help do what the market initiative did for vaccines, think about it in a different way? Well, I'm sure every panel at WEF wants to find some new magic funding source for their particular cause. And if somebody finds that, I'm all for it. I think realistically, the overseas development aid will not be going up very substantially. And in fact, if we don't bring back the track record of global health and really get that story out there, we run the risk with so many distractions including a sort of more turning inward type framework, we could have less money. And we talked, Global Fund could spend 16 billion and Peter and I met and I said, hey, let's set the goal at 14 billion because I think it'll be a challenge to raise 14 billion. If we go beyond that, I'll buy him a drink and we'll celebrate. I will say that I was wrong. But getting this message out, these are issues that are very far away and the slightest mistake that gets made. Some money goes to a training session that never took place and so that's corrupt. Even if it's 1% of the money, that gets a headline whereas the 99% that's saving millions of lives doesn't. So we're not in a position to afford very expensive interventions. There are some non-communicable diseases like cervical cancer, lung cancer. You can do lots of things to tax the back or cut it down. Hypertension is a great example where the drugs are now cheap enough. It's cheap to measure blood pressure. Those blood pressure medicines have been long off patent. So we're funding an organization that's now gonna help get some of those interventions out there. So we always need to see when something comes down and it's practical. But when people talk about precision medicine, the US can't afford precision medicine so I dare anybody else to try. There's many definitions of that but it means designing drugs for very, very small patient groups i.e. N equals one, it's not in the cards. We need to deal with diabetes and obesity and Alzheimer's in rich countries and then bring those costs down. Eventually gene therapy, I do think, will come into a form that can be delivered in developing countries. But first we have to get it into the rich countries and then for sickle cell, HIV cure and in the upstream area, it's super exciting but it'll take quite a bit of time. Yeah. Talking about financing is important. Of course we will need resources but we need to ask another question. Are we really doing the right investments? For instance, our colleagues said hypertension and maybe diabetes or cardiovascular, you name it, the noncommon cable diseases. Many of them are linked with risks and our central strategy should actually be to address those risks. Alcohol, smoking, dietary issues, inactivity, then obesity comes in all colors and forms. So really talking about the investment we're doing whether it's the right one or not is important and that leads me to the right investment that we should do globally and this is primary healthcare. Its investment is actually low but its return is high and we should go back to the basics and focus on health promotion and prevention and we need to really invest in that. Be it for communicable diseases or noncommon cable diseases, the response or the vehicle is primary healthcare and now we are partnering with Gates Foundation and to give focus on primary healthcare as part of the inverse health coverage. Inversal health coverage as a rights issue and ending itself and also a means to development because no country actually can prosper without healthy society. It's a smart investment but within that investment in primary healthcare can actually be quick. Many countries have done it. So the smart and the right investment I think has to be discussed in addition to the financing. One reflection I have is we've been talking I think in global health about primary healthcare and primary healthcare for all for decades and I think actually we've made a lot of progress but I also wonder in the topic about financing how do we finance disruptive ideas? How do we finance entrepreneurs? Because one thing I've noted in our own activities is there is a pretty healthy growth of startups that are really trying to tackle these ideas in very disruptive ways and typically we take ODA funds and we channel them through the traditional paths and maybe that is the right answer but I wonder how much more we might be able to catalyze if we start to support those entrepreneurs and there's good examples, I mean well-known things like the well-known zip line example in blood transfusion or we are supporting a number in Africa but I'm quite struck by the fact that these disruptive ideas to try to get around what seems to be quite significant constraints locally might be something to look at sort of feeding that micro environment along with doing the big top-down push for primary care. One of the disruptive I would like to say I would like to answer that question. One of the most disruptive is political commitment. Political intervention is surgical intervention. Countries who have committed politically and are located domestic resources and who considered external support as catalytic support can move a long, long way. So it's not an economic argument actually in many countries. It is of course but it's more of a political because there are many countries when they have even the resources who can't do it and when you see countries who have done it they have started it actually when their economy is in shambles like the UK for instance immediately after the Second World War when Lord Beverage designed and the NHS started. So that could be disruptive the political commitment but not only mobilizing domestic resources when there is political commitment to health for all or universal health coverage it can also have disruptive ideas to involve the private sector to do its share to make it happen. And does it? Yeah, I just I wanted to say something being a former finance minister about domestic resources. But before that I want to let you know that Gavin Deed has a fund which the Gates Foundation matches and a program called Infuse where we encourage innovators including local ones to come up with ideas that are disruptive that can really help us tackle some of the central challenges we face such as reaching the children who are hard to reach. We've done the easy work now and we are sort of stagnating around 80% in terms of immunization. How do we get past that? How do we reach that difficult to reach child in remote areas and conflict affected areas? And so we have that program. So if you want to do work more with us, check it out. The big point I want to make though is Bill said something about aid is not going to be so much available. We want to encourage yes more resources. Gavin will be going into its replenishment. I don't want to say number here. We're still working on it but whatever we will need it. However, I also want us to focus on domestic resources Dr. Tedros mentioned. We have our program in Gavin encourages countries. Every country no matter how poor must contribute to its immunization program. So and over time as the countries get more and more well off they contribute more and more down the line because we want to work ourselves out of a job. That's it. We want countries to graduate and take over. You know, so helping them to mobilize more of their own resources so that we can be sure of the sustainability of the fund is also key. So as we work on the aid side we also need to work on raising the money and it's hard. We talk of domestic resource mobilization. It's become almost a slogan to answer our questions. But as a former finance minister who actually tried to do it in my own country where the tax to GDP ratio is very low. Particularly after we rebased the economy. We hadn't done it for 24 years. And we more than doubled our GDP. You can imagine what happened to all the ratios. Then trying to strengthen tax administration. You know, so you can close loopholes and get the expertise you need to allow people not to escape from paying their taxes. You know, trying to reset tax policy. Trying to bring more into the tax net to broaden your base because we have a lot of informality in economies. This is a huge task. I know that it's not a health task only. You know, so in our alliance we've got the world bank. We've got, you know, so we have to also partner with people who are not directly health in order to make some of the financing work. But Peter, you know, it goes to just makes a really good point. This isn't as aides so much as it is investment. Investment in one's own country, investment in the world. Bill and Melinda Gates often use the expression that you've gotten a 20 times return on your investment. With the money you've invested so far, I don't wanna quote you if that's wrong. But Peter, I mean, can you talk a little bit about how you make the investment case to the donors since you're gonna be going out there with the very rich tin cup? Yeah, it is true that the returns on investment in global health are incredibly high. I think we were more conservative in our investment case. We said one to 19. So you get 19 back for every, you know, that's, but you know, as a ex banker, I used to think that getting 1.2 to one was a really good return. So the idea of getting 19 to one is pretty extraordinary. Now, of course, the real issue here is that the people who pay the money don't get the 19 and that the returns are much broader in society, but they are so huge that really you can tell a compelling case. And also, these infectious diseases aren't static. There is no kind of middle ground. You are either winning against them or they are beating you. And the economics of being on the back foot against AIDS, TB and malaria or the diseases that you get hit by a vaccine, you know, these are terrible economics. The point about disruption, I think, is a really interesting one. And we tend to think about disruption in terms of sort of medical innovations and so on. But also, I think a thing that is going on and I give others on this panel credit for this is that we're getting a lot of disruption and innovation in terms of delivery models of different ways of reaching or organizing programs, whether it's zero TB cities or other sorts of program like that. But we're also breaking down silos. I think through the global action plan, there's been a huge amount of often painful discussion between all the multilateral entities about how do we work together better? And suddenly between GAVI and the Global Fund, there is now an intense dialogue on every single aspect of what we do from boring administrative things like our shared cafeteria and building and cybersecurity to shared programming in the field. And I think breaking down those silos and they also occur in the clinical profession. I mean, we should have much closer integration between HIV treatment and TB treatment. But we run into professional silos because these people are in the national TB program and these people are in the national AIDS program and we've got to force these things. One dichotomy that always irritates me is people talking about sort of vertical or horizontal as if they're sort of in opposition. So in some people's view, the Global Fund and indeed GAVI are the archetypal vertical interventions, disease-focused, not caring about the system, just focused on the disease, or you have horizontal interventions building the healthcare system. I mean, the reality is you will never get rid of one of these diseases unless you build a system. And a system that isn't coping with these diseases isn't really a very effective system. So you need to do both. And actually, a big chunk of Global Fund programming is actually spent on health systems. We spend about a billion dollars a year on health systems, which actually makes us the largest multilateral provider of grants for health systems. So I think we need to be prepared to challenge a lot of these kind of paradigms of its vertical or horizontal loads, these particular silos of activity because that's not what patients care about. Peter, as a banker, do you think social impact bonds are gonna lead to a big shift over time in financing? I'm afraid to say my many years as a banker have made me actually quite skeptical about a lot of financial innovation. Financial innovation is brilliant at reassigning risks, changing the timing profile, or changing incentives. It is not a magic money machine. It doesn't create some unknown pull of resources. And if you look at what happened with Gary and the Global Fund, what you had was a pooling of resources, a way of changing incentives with IFIM, a changing of the timing profile of the money to make it more optimized. So you can attract more money because it has greater impact, but the fundamental thing that innovative finance does is give you greater impact. I don't want to sound too dismissed. Social impact bonds have their role, but let's not kid ourselves that there are some sort of wonderful, silverability-type things out there that are gonna transform the fundamental challenges we've got. Yeah, I just wanted to say a quick word on IFIM, the International Finance Facility for Immunization, which is an instrument for raising resources that Peter alluded to. I think the key issue we need to think about is what does it do? We are about saving lives. So if we can find a way of getting resources faster sooner to save more lives, that could be, that's a very valid objective. So what this instrument does is with the securitization of aid. So instead of being given five million or 10 million every year, you say, look, we have these resources, we know we are coming, we can securitize this, and front load. So this instrument, we go to the market and we actually raise resources on the capital market to be repaid later. What does it allow us to do? We can save more lives faster sooner. So I think financial innovation, where we need a sense of urgency, can be very, very important. And we've raised $6.5 billion so far, including even a Sukuk bond recently, a Sharia compliant bond. So I think there's a very fun place for some of these instruments. Yeah, we've been using these mechanisms to fund, to finance bridges and tunnels. So, Sonia, what are you... Three quick reflections on what's being discussed. Firstly, this conversation is veering towards the importance of the global funds, infectious disease funds, and I think that there are no two opinions about it. They've been enormously helpful, enormously impactful, they need to be supported. But the reality of the matter is that conversations about graduation and transition are already happening, and they're also happening at the country level. So it is important within that context to ascertain where the financial vulnerabilities are. And to be very clear about creating the transition frameworks well ahead of time, because even if we're looking at a five-year horizon, we should be prepared with the transition frameworks, we should be prepared with very explicit and predictable co-financing arrangements, because these need to be sorted out ahead of time. Secondly, there's this conversation about non-communicable diseases. I don't think that there is an appetite for a new global fund-like initiative for NCDs, we all know that. But I think when we talk about a new financing instrument and a new architecture for non-communicable diseases, for which there is ample justification, we may be talking about an explicit integration mandate, because that exists at several points across the whole spectrum of health systems and global health institutions. For example, at a country level, non-communicable medicines can be included into national essential drug lists. The several waves of surveys that USAID, that UNICEF, and that the World Bank supports at a population-based level could integrate modules for NCDs, that does not necessitate creating vertical structures. For instance, PEPFAR and the Global Funds for ATB and malaria have done remarkably well in terms of creating primary healthcare systems for chronic care. And you layer this up with the online capabilities that retail institutions and the banking systems are creating, and there's a perfect justification for including NCDs in that mix. So we do not have to create a global fund worth X billion and with 400 staff in Geneva, the NCDs piece could be addressed number one with an explicit integration mandate and financing instruments around that. And of course, as Ted was mentioned, there is this whole other piece about the whole of government approach around tobacco, food systems, physical activity, alcohol, which needs to be mobilized through different instruments which are not in resource-intensive. Paradoxically, they can generate resources for prevention activities through e-mark levies, as we all know, and just a 30-second response, I cannot resist to what Nikozi you said. I think tax can be one of the most important innovative instruments because we talk about debt swaps and we talk about bonds and the rest of it, but we have to realize from a country vantage point that anti-taxivation efforts, money laundering efforts and anti-corruption efforts have perfect synergy because the monies that are whisked away by tax evasion, on the one hand, are used for money laundering and terrorist financing and on the other hand, they take away the money that is needed to invest in human capital investments. So I think- This is my favorite bit of innovative finance for her. Basic blocking and tackling to have good tax design and collection. I think, absolutely right. I just had a quick point. I mean, one thing I reflect on is one of the things on the global fund that focused the mind on AIDS, TB and malaria. And every time I hear the word non-communicable diseases, I think that's a lot of diseases. And I wonder, it's hypertension, diabetes and COPD or whatever the University of Washington quality list would tell us. Maybe that helps focus the mind because I think right now it just seems like such an insurmountable task when we say non-communicable disease. It'd be like if you are the global fund of communicable disease, I think you'd have a harder time raising money. So what else also focuses the mind is the fear of backsliding. Peter, you mentioned that a little bit. And Bill, I know you've mentioned that. But where are we most in danger? Where do you see as the sort of critical places where if we don't move forward, we're going to move back? And also, can we just talk a little bit about the demographics, the very young cohort in Africa and much of the developing world and how dangerous that is when you get communicable disease framework? Well, the economic development in Asia in general has been strong enough that the really the best stories of graduation where they'll be able to maintain the health systems are countries like India, Indonesia, Vietnam. Plenty of challenges there, but overall, those are really good stories. Africa's challenging and Nigeria is graduating from Gaby. That's been lengthened out, which was a really great move that Gaby made. That was sort of a quid pro quo to go to the country and say, okay, we're going to smooth this thing out over a 10-year period instead of a five-year period if you step up to your part. And so there's ongoing work to make sure that that goes very well. I do think the consensus around global health is fragile because we've had some enlightened politicians who've believed in these causes. We had President Bush who started PEPFAR and got the US into Global Fund. We had increases in the UK aid levels, the German aid levels, but if you look at the awareness of what's been achieved here, people may be more aware about the criticisms than they are about the success. So getting a good new story out is very hard when it's a very far away thing and there's a bunch of acronyms. Even the diseases, we assume that they live it like all of us on the panel do and that can make it less of a story. And yet, if we do it right, it is a very strong story. But we don't have broad voter awareness that locks in even the current level of generosity. I want to add to what Bill said, I think it would be important to invest on alignment of the SDG, I mean the Global Health Players. We have signed 11 agencies including Global Fund, Gavi and others and we have an SDG action plan now to align, accelerate and also account. And this will help us to align not only at the global level but as Peter said to align at the country level. So that can have better impact actually when we align and based on the country's priorities of course. That's one and second we're doing replenishments for Global Fund, for Gavi and so on. We need to have a united voice on that. What do we need in terms of resources for global health together? And then how do we mobilize it with united voice would really help even to convince the donors and so on. So this is just what I would like. And then I fully agree. We have many stories which we don't really tell and we have to tell our stories. And we should tell to the taxpayers through active media campaign what their money is actually doing in the lives of millions and what has changed as you have shown in the last 20 years, thank you. Peter, you got 20 seconds to make your elevator pitch to the world governments. We can end the three biggest infectious disease epidemics in the world if we want to. Why wouldn't we? And with that, I want to thank our panelists, Peter Sands, Sanya Nishtar, Vaisnau Sinhaan and Josie Alkanja-Iriyala, Tadros Adinom Agabereesis and Bill Gates. Thank you all very much, thank you. We have a couple of people still coming in the doors and welcome to Mr. O'Bennett. Good morning everybody. I know we have a couple of people still coming. Welcome to the World Economic Forum. Thank you all for coming so early as we kick off this Davos. It's a privilege for me to be here. I'm Andrew Ross Orkin of the New York Times and CNBC. We have a remarkable conversation that I hope we're gonna have over the next hour and we're gonna bring you all into this conversation. Really about the world economy, the world economy, the world economy. All into this conversation. Really about the new architecture, the new market dynamics with which I think we're all living and trying to grapple with. And those things involve everything from the idea of scale, the idea that every business, every person I imagine involved in business in this room is always thinking about how they can be bigger. And what does bigness mean? Is bigness good? Google provides us all sorts of different search, search options and video and all sorts of things. And Brian Morinhana, Bank of America, I can use my ATM machine and get money in all sorts of ways around the world. And, well, Steve, all over the world. So we can go all over the world with everybody. So there are benefits of scale, clearly. But there are also downsides and we will talk about all of that. And we're also gonna talk about the global economy and where we are in a world where we keep trying to expand and become more global at a time where maybe that's becoming a little bit more complicated. And we will have that conversation. Here who is with us today, we have a remarkable group. Brian Morinhana from Bank of America is the CEO of that company. Raghu Rajan is here. He is the former research director at the IMF, former governor of the Reserve Bank of India and now a professor of finance at the Chicago Booth School of Business in Chicago. Ningou is here. He's the chairman of Sino-Cam, one of the four largest chemical agriculture companies in China and can speak specifically to the idea of scale given your size. Steve Schwartzman is here, chairman and CEO co-founder of Blackstone and Ruth Porat. You know how many titles, but we'll call you SVP and CFO of Alphabet, better known for many of us as Google. Thank you all for being here. I'm gonna go Raghu for first, because I know you have thought a lot about this idea of scale. You've written a book that's coming out about competition and where we are in this world. And you have actually perhaps a more balanced view of this than people might think in that I think you have thought about the good sides of scale, but also the other side of scale. And I thought you could maybe start this conversation. And I'd start with this. At a time when there seems to be hand-wringing in the United States and Europe, maybe less so in China and we'll talk about that. Is the hand-wringing politically on both sides? And by the way, you get it on every side. Is it right? Meaning, is there too little competition or too much? Okay, well, I guess I'm supposed to maintain the balance on this panel. That's why I'm not wearing a tie, other than Ruth, of course. Look, today we benefit tremendously from scale. There are scale economies which are passed through to the customer in many ways. There are benefits of efficiency in these global corporations that we see on this panel. And that's all to the good. I mean, Google.