 Hello, everyone. Welcome to those of you who have just arrived. I'm Amy Sutter. I'm the deputy director of the Simon Chair political economy here at CSIS. Before I get started, just a huge thank you to Steve and Katie, who have put this wonderful thing together, and thank you for involving me as well. It's incredibly interesting. I have to say that I'm part of what Steve described as the very interested but non-technical audience. So perhaps I'm one of the people you're trying to convince. But I am already convinced after the wonderful panel just now. We talked about financing quite a bit in the last panel. But I hope that what this panel will do is really get into the numbers. The money is what matters in political economy. So we're going to talk about that. The financial landscape from malaria financing has changed, as Steve and others mentioned in the last panel. Until 2008, there were huge increases in financing. And then in 2008, financing for everything just dried up, including think tanks, but other things too, including malaria financing. And so it's plateaued. There have been increases, but it's plateaued over the last few years, which I think leaves us with three questions. Assuming the financial landscape in the world isn't going to improve, which I don't think it is. Most economists would agree with me. So we're left with three questions for malaria financing. Are there untapped sources of funding? Are there efficiency gains to be made, and how the money that we do have for financing malaria elimination is spent? And if not, do we need to change the strategy to better suit the financing that we have and that we know we will have? We've got a really fantastic panel here to address these issues. Dr. Jen Keith is going to kick us off with a presentation. She's the Vice President and Director of Global Health and HIV Policy at the Kaiser Family Foundation. She's especially focused on the US government's role, so I'm going to push her a little bit on that in the Q&A. We then have Dr. Mead Over, who's at the Center for Global Development. He really looks into how you increase the efficiency and what the economics of efficiency are. So I'm going to push you on that too. And then we have from CSIS, Todd Summers, who's a senior advisor with the CS Global Health Policy Center here. And he is also President of the US Fund for the Global Fund and Chair of the Strategy, Investment, and Impact Committee at the Global Fund. So I'm going to push him on that too. And with that, I'll hand over to Dr. Keith. Thanks, Amy. And good morning to everyone. It's great to be here. I want to in particular thank Steve Morrison and CSAS for inviting us to contribute to this important conference. I also want to recognize my colleague Adam Wexler, who really conducted much of the analysis I'll be presenting today. So thank you, Adam. And I also want to thank specifically the WHO and policy cures, both of whom are releasing new reports tomorrow. And we're very generous in providing us with some advanced data that we were able to incorporate into our report for this conference. So they really deserve a lot of praise for that. So what I'm going to do is present some top-line findings from an analysis we did to try to inform today's discussion of financing for malaria control and elimination and R&D. What we were looking to do really was to answer this question. This was the question that Steve asked me when we talked about this. Is there enough funding to meet the targets that have been out there? So what we decided to do was to look at what we know. What is the current funding landscape for both malaria control and elimination and R&D? We looked at data from donor governments, from multilateral organizations, from malaria-affected countries, and from the private sector. We analyzed funding over time and looked at a current snapshot, which in the world of looking at what's available is 2013. So there's a little bit of a lag. And we compared to estimated need for funding based on targets. We also tried to project funding a little bit into the future. Where are we going? Where are the increases? If there are any likely to come from? And will the resources meet this estimated need? So briefly on the methods, we used the GMAP 2008 estimate for funding needs. That was our basis for the analysis, the 5.1 billion annually on average, estimated to be needed between 2011 and 2020 to reach malaria elimination, control elimination targets. And we also used their R&D estimate. To look at estimated resources available, we directly collected data from the US government and the Global Fund. We analyzed OECD data for all the other donors and those who report to the DAC. And we received data from the WHO. We also received data from policy cures to analyze R&D funding. And then we projected funding based on what we do know from the two largest donors, the Global Fund and the US government. So what did we find? Looking first at funding for malaria control and elimination, as you can see here, and this is a little bit what we heard, funding increased dramatically. No surprise for anyone who's working in this field. You can see the corresponding increases. And if we went back even a little earlier, it's largely due to the Global Fund and to the President's Malaria Initiative of the United States. And that drove an incredible amount of increase. Although in recent years, as you can see, it's been stabilizing. So the overall increase was a more than three-fold increase. But the last period has been much slower. And actually, 2.6 billion, which is the 2013 amount, is not that different from 2010. Looking specifically at the 2013 breakdown, just so we can see who the major players are here, 2.6 billion total. And approximately 2 thirds of that is from just two donors, the Global Fund and the US government, primarily through the PMI. The next largest source of funding is domestic resources provided by malaria-affected countries, which account for about a fifth of funding. Next is UK and then the World Bank. But this is the chart I want to focus on for a couple of minutes, and I'll pull out some of the data. And our report has a chart with all of the specific data in it. So this changes over time by these different sectors. Most of the growth since 2005 can be attributed, as I mentioned, to the Global Fund and the US government. Domestic funding from malaria-affected countries increased over that whole period, which is important rising from about 436 million to 527 million. But it has declined in recent years, and its peak was 2011. So that resource, a sector that I think all of us are looking at as an important one for the future, has actually gone down. Funding from the United Kingdom rose slightly, and funding from the World Bank, which did grow from just about 15 million in 2005, reached its peak in 2009 and has since declined. So that's the general picture. Funding from all other sources, so lumping together, all other sources, which is all other donor governments, primarily, and a couple other multilaterals, has fluctuated and really doesn't account for more than a few parts of the share. So that's the malaria control story. Looking at R&D, you see kind of a more mixed story. In 2013, funding from malaria R&D was estimated at 549 million, which is a decrease, and it's the second year in a row of decreases. So current funding is now at 2010 levels for R&D. And we know that malaria control and malaria R&D are intimately connected. We need new technologies. We need to get things to the field. It's not just the current control and elimination strategy. So these go hand in hand. Looking though, again, at the 2013 snapshot for R&D, we see that the NIH, the US NIH, is the largest share of the pie, about 25%, followed closely by the Gates Foundation. The third largest source being the pharmaceutical and biotech industry, and then smaller shares from DFID and the Wellcome Trust. Separately, I just want to highlight the Bill and Melinda Gates Foundation. Separately from the data I just presented on R&D, we actually collected data. We'll talk to the Gates Foundation to try to get a better sense of their funding, both for R&D and malaria control and elimination since the inception of the Foundation, since malaria has been such a priority. And I think it's really important what you see here is that since 2001, almost 2 billion for malaria efforts combined, not including contributions to the Global Fund, has been provided by the Gates Foundation. And in 2013, that was almost 200 million, which makes it one of the largest donors to malaria. And we all know that there's been this recent announcement that the Foundation was going to increase its malaria spending by 30%. So the story is one, as we've already heard in the earlier panel, it's the Global Fund, the US government and the Gates Foundation that are the main players in terms of the funding. We wanted to try to look ahead a little bit and say, well, what can we say about the future here? What do we know? And we're a little conservative when we make these projections at the Foundation, so we were aired on the side of just looking at what we knew. And what we did know, and what we do know is that the Global Fund already has planned allocations for malaria for 2014, 2015, and 2016. We also know the United States is, 2014 funding is done, that the budget is already, we know it, we know that's a slight increase, and we know what's been requested for 2015. So we knew those two things. We also, having looked at all the other sources of funding, know that they're really fluctuating and not really increasing. This is from malaria control and elimination. So we felt pretty comfortable that if we projected forward those two donors, which again represent two-thirds of funding, we would get a good sense of where we might end up. And what we found is that the funding projecting those forward would reach about three billion from malaria control and elimination, which as we know is still about 2.1 billion below estimated need. So even with those increasing, there's a gap. And R&D, we didn't have the same data to project forward, but just as we pointed out, with two years of consecutive declines, it means the gap is growing. This is the story that three billion from 2014 to 2016, it goes up slightly, but it's essentially flat. And again, this is if the Global Fund planned allocations, which are planned allocations by the fund, they may be dispersed at different rates. Countries that receive Global Fund money may make different choices, but this is what the Global Fund projects, it's money that's there and the U.S. government with some slight increases, again falling short. So in our scenario, as I mentioned, we projected there would still be more than a $2 billion gap, as estimated by the GMAP. Tomorrow's report that's being released by the WHO also has two scenarios in it. What they did, and I want to point them out because I think it's very important to just show in a sense what would be some very optimistic stories here if we really could look ahead and see what the world could do. Their first scenario looks at projected malaria funding. If malaria funding were to increase at the same rate as overall government expenditures are projected to increase from all sources, that got the story to 3.8 billion. And then their second scenario says on top of that, what if all donors met the 0.7 target? That gets to 4.3 billion. I mean, you can decide if you think that those are realistic. I think this was an important point to say, even with some very, very optimistic and probably unlikely scenarios, we're still short of the current estimated need of 5.1. So just to sum up a couple of points before we get into discussion on this. First, we saw that funding has increased significantly, although it's recently slowed, and that funding from malaria-affected countries has actually declined, from domestic resources are going down slightly. And despite the increases, there's a significant gap and a shortfall. There's a real concentration of funding among the Global Fund, as we said, and the USG. And I think this raises questions about dependency and also issues of their future trajectory. So if everything keeps the planning that we saw happens, we know where we'll be in a couple of years, but beyond that, what happens with the US government and the Global Fund will really determine the future of this effort. And it's, I think, really unclear where any additional resources could come from, which makes this discussion about more efficiency and also where those resources are being spent so critical, because even if all of the other funding sources, besides the US government and the Global Fund, were to more than double their resources combined, we would just barely meet the need. So I'm gonna end there. Hopefully we'll have some more optimistic takes from the panel, and I look forward to your questions. Thank you. Great, thanks, Jen. We'll now hand over to me. It's always a pleasure to be able to comment on something that Jen has written, because she is always so clear and she's got her facts in order, and it's also a bit daunting, I have to say, as well. But this is a welcome report, and I'm pleased to be invited by Steve to be able to comment on the report. Let's see, do I have a couple of slides here? It should, if you press the next button. There it is, right there. So first I wanted to talk a little bit about this idea of a public good. For talking about the financing of malaria, we have to recognize that malaria control, that vector control, is a public good. What do economists mean by public good? Well, for example, health is not considered a public good. Health is a private good. If I have a headache, you don't feel it. If you have a headache, I don't feel it. Curing a headache is delivering a private benefit to me. But controlling a vector like malaria vector is in fact a public good, because people who don't contribute financially to that control also benefit. It's a good, we say that the benefits of a public good are not excludable. And this is a problem when you're trying to finance it. A global public good is something that's not where the benefits spill over from one country to another, not just from one individual to another. And what we see in this picture, where the need is so much greater, 60% greater than what Ken has said that is going to be available, is an example of the problems that we have generally in financing public goods. The problem is called the free rider effect. Countries that in fact benefit greatly from the investment of the international community in vector control do not really have an incentive to step up to the plate and pay for that benefit because they receive much of that benefit even if they don't pay. So the question is, how can we solve that problem? Well, of course the problem is not unique to malaria. This is a slide, this is my only other slide. This is a slide from the recent UNAIDS report that was released in connection with World AIDS Day. And it too shows in red, the far left bar in each of these three pictures shows the amount that's currently being spent. And what you can see is the projection that UNAIDS is making for what is needed. And what they project in fact is that a total of $18.5 billion will be needed. So I just wanna make a few numerical comparisons here between malaria and HIV. As we heard from Jan, I believe you said this, but it's certainly in your report. There are about 260 million cases of malaria a year. That's in comparison to 35 million people who are living with HIV. There are about 0.6 million deaths of malaria a year. And that's in comparison to about two million deaths from HIV. The funding, if we take that three billion number that Jen presents for 2013 and projects forward, that three billion number is also about 30% of the money that's currently flowing to HIV in the low income countries and in the lower middle income countries. So we have to ask now, is the world community likely to act together to fund this public good to the extent that the communities of HIV and malaria believe is required? That means taking malaria from three billion to five billion, about a 60% increase, really remarkable as Jen suggested. In the case of HIV, it means going to that peak that you see in the blue dots, going up to that number, which is about 18.5 billion, that would be more than doubling the total amount that's being spent on HIV. So I just want to end with a note of some pessimism. I actually don't think this is gonna happen. And if this doesn't happen, if that's plan A to take us up by this extraordinary amount of money, if that's plan A, then I think we need to ask the question, what is plan B? Plan B has to have to do with the word that Amy mentioned a minute ago, and that is efficiency. And what I have not yet seen from any of the disease advocacy agencies is, first of all, a clear case, and I think it was Patrick Connick in your session, Steven, that mentioned that malaria has not been making a good enough case based on results. It's been tracking input spending, but has not been doing a good enough job of tracking the results from its spending. And I think the same can be true for HIV. So in this plan B world, where we're gonna have to have a limited budget and live within that, I think the problem that we face as a health community, international community, is understanding how to spend that money most efficiently. I think the panelists that Steven hosted a minute ago made a compelling case for a malaria exceptionalism based on the possibility of eradication. But I want you to note that that case is also being made by UNAIDS. When they see a peak in funding out in the year 2020 and then a decline, it's exactly because they're arguing that they can get to what they call zero by the year 2030. So this argument is gonna be made not only by malaria, it's gonna be made by HIV, and I'm not sure if there are TB people in the room who can also make this argument from malaria. So I think there might be, we might be setting up what I would view as potentially a healthy competition that hopefully the international funders will be most willing to fund those programs which can demonstrate results, not just track inputs, which can demonstrate cost effectiveness with respect to turning the corner the way UNAIDS projects, perhaps the GMAP report tomorrow will make similar projections from malaria and can do that and present that evidence of that success in a timely manner in order to persuade the funders to come forward with money. Wonderful, thank you, Todd. Thanks. Just to clarify, I'm the former chair of the Global Fund Board Strategy Committee. I gave it that responsibility a few months back, so I can now look back and make a lot of criticisms. I couldn't just a few months ago. Excellent, you look forward to them. So I'm gonna follow on your pessimism line and then try to swoop up and be a little bit optimistic towards the end. As Jen's report notes, the Global Fund is the single largest conduit for malaria support from donors. It's a big part of the overall malaria picture and actually in some aspects, like the purchase of bed nets, it's virtually the market. So it is quite an important player in here. I've been involved in the last couple of years in updating the Global Fund's funding mechanism, moving away from a competitive rounds-based system to more of this allocation-based approach. And before that, I worked on the five-year strategy that actually guides the Global Fund's money. And the key element I wanna note in that strategy is an emphasis on focusing the resources on countries with the highest disease burden and the least ability to pay for their own response, which in their language is measured in GNI per capita. And as you can imagine, that works in some cases to support the malaria elimination strategy, but in other cases, it actually conflicts with the malaria elimination strategy. So I wanted to kind of focus on that a little bit. Overall, malaria, just like TB and HIV, is a concentrated epidemic. 15 countries represent about three-quarters of the disease burden. And in Global Fund allocations, they're only getting about half the money. So already, you're seeing, I would expect, more movement towards lower-income countries in the band. And we've even seen so far, and we've already heard squeaks and moans around the pain that some of those upper-income countries are feeling because of the change in the Global Fund's emphasis. The second thing I wanna note is the Global Fund is inadequately funded. The last three-year funding cycle, they went out trying to get $15 billion, and they got about 11 and a half. They're probably in the end gonna even get less than that. There's a bit of a catch here. The Global Fund contribution from the U.S. is limited by law to no more than one-third of the total. So as other donors start to pull back, the U.S. has to pull back. And that is really a challenge because the U.S., as we heard already, has been a stalwart supporter of malaria efforts. That is not the case with most of the other donors at the table, with the exception maybe of the U.K., which is increased modestly at support. The other thing is that most of these other donors came to the Global Fund table with money from their development pots. And they come, therefore, with an expectation that that money is focused on the poorest people in the world, and for years, that has always meant low-income countries, the World Bank classification. When you explain to them now that most poor people live in middle-income countries, it's a bit of a tone-deaf response. Most of those donors do not pay attention as much to global disease strategies, either for malaria, TB, or HIV. They focus on things from a development lens. So when I've said the Global Fund table and you look around the room, the U.S., the private foundations, private sector, and to some degree the U.K., are the only folks on the donor table that are really keeping their eye on disease strategies. Everybody else on the donor table is trying to figure out how do you evacuate as quickly as possible from middle-income countries and keep the money that's going focused on low-income countries. And that's a real problem for supporting the upper-middle-income countries that are essential to disease elimination. So moving a little bit more in the optimistic category, the Global Fund made, I think, a really smart move, although maybe smarter than it even knew at the time, about putting $100 million into the MECON to support a malaria elimination of drug-resistant malaria. It was a $100 million commitment without much purpose, and thankfully a lot of smart people have gotten around to figure out how to make best use of that money. I think what it's translated to is actually a malaria elimination grant for the MECON in a key region. I think that's an opportunity that we can build on. That money is gonna need to be renewed, but I actually think that we could work to expand the amount of money that's being focused in that region. So I want to focus on three events that are coming forward as real opportunities for the malaria community. One is that next April, the Global Fund will receive the second round of proposals for regional initiatives. As I mentioned, there's already one in the MECON for our domestic-resistant malaria. There is an opportunity to put forward more proposals. Expectations are somewhere around $120 million will have available for that round. So April is a real great time to start putting together maybe some additional regional efforts that would address malaria elimination efforts outside of the MECON. The second is that the work on the next five-year strategy is gonna start this year, and actually the Global Fund is hoping that by November of this year, they will have the framework for their next five-year strategy agreed by the board. That's an ambitious schedule, and this is where the malaria folks are gonna need to figure out where they want the Global Fund to go over the next five years, where course corrections might be needed. And the third, of course, is the next three-year funding cycle, which is gonna start really at the end of this year when the replenishment, the next three-year replenishment begins. After that, we're gonna figure out how much money we have, and the Global Fund will start right away working on the allocations. If we're in the same situation we were before, which is we asked for 15 and we get 11 and a half, we're gonna have some very tough choices, and I think Mead made a really good point. Malaria is one of several voices at the Global Fund table. The TB folks are making a very compelling case around the need to ramp up efforts around TB and drug-resistant TB. The HIV folks have got a compelling argument around the opportunity to use the preventive benefits of treatment to expand access to treatment. All three of those arguments were mating in an era of declining resources. And then we've also seen reports around global burden of disease showing that a lot of countries are now seeing escalating rates of non-communical diseases. And there is gonna be a growing voice, including in those countries, the people that have power, saying they want some of their own governments to put more money into those kinds of health issues, competing again for malaria and TB. So I think that we have a bit of work to do to figure out how to make this go forward. My last plea is kind of picking up on some of the comments made in the first panel. One is I think we have tremendous capacity outside of government, both in businesses and in non-governmental organizations. And they're often not very well thought through in terms of global strategies. In many countries, 60, 70, 80% of care is delivered outside of the public sector. And they really need to be active participants in the plan, not trying to take over their capacity but really trying to build on their capacity. I think that's something we've done very poorly. The Global Fund puts about 40% of its money through non-governmental organizations but has no strategy for what it's gonna do with the capacity once the Global Fund moves out. And as we know, governments tend to not like to fund outside of their own remit. So we have some work to do to figure out how do we take that huge capacity that's been built over the last few years and use that going forward. Second, I think that we need to do a much better job of articulating what actual interventions are needed in low morbidity countries. It isn't clear from a non-technical perspective that we have a good handle on what's the minimum essential package of interventions needed to control and finally eliminate. And we do not have the luxury of just throwing everything at it. So we have to be much smarter about how do we take the resources we have now and the ones that are coming and use those with maximum efficiency. And then lastly, around political support. Again, the first panel, someone mentioned that progress has been measurable and that measurable progress has been helpful for politics. Politicians at least here in the United States like to see good statistics. They've been very happy with aid statistics. They see money going out and they see lives being saved, people on treatment, they've seen really good response on malaria. But as you start to get into that last mile and you start spending more per case in order to get to those last 30% or you start actually seeing a declining morbidity and mortality in these diseases, you begin to lose focus, political focus. So I think we have to figure out as we prosecute elimination in low burden countries, how do we measure that in a way that is politically attractive and is compelling for folks who have to decide how to allocate scarce resources. Wonderful, thank you. Jen, I actually wanted to push you on this political will point. Do you see political will diminishing in the US or is it? Good question. I think we're at a really tough time right now with the budget and I think what we've seen on the one hand with the global health budget writ large in a general way, amazing support given the tough times that we've had. I mean, the budget has for the most programs not been cut in the end by Congress. Some programs have seen some minimal increases. So on the one hand, it's one area of the budget where we still see a bipartisan consensus to some extent. On the other hand, it's not completely immune to the situation and I think what we don't know is when push comes to shove will the political will that exists and we're talking about political will among a very few number of people in Congress. Will that be able to withstand the larger budget pressures? Unclear, we'll maybe know a little bit more today because some spending package is coming out but even so, even with the incredible contributions by the USG to the effort, the increases we're talking about now are a few million each year. We're not seeing anything like where we were. So it's really, I think, stepping back and going, what's the role of the US in this context and it's very much connected to some of the things Todd mentioned. I should also say in interest of full disclosure I'm the alternate board member on the Global Fund for the private foundations constituency so I have seen firsthand as well the way the Global Fund has been working to make such huge difference in malaria but the Global Fund was never set up to be the implementer, the technical expert on the ground. It has become the largest force and funder. That is wonderful on the one hand but creates this challenge on the other and that's where I think the USG continues to play a pretty fundamental role with the on the ground technical expertise so it's political will and it's funding but it's also maintaining that role which the Global Fund in a sense can't succeed without it. It's not just the USG but that's really been what the US has been but pushing. Very interesting. So as an Asianist, Todd, I'm interested in, as someone who's kind of worked on the Global Fund trying to get countries to commit, I'm very interested to know why there's so little Asian funding. I mean Japan is one of the biggest economies in the world. China is one of the biggest economies in the world and it's rapidly trying to increase its soft power and part through development aid and infrastructure building. Why isn't health a part of that? And then one of the other, I'm a Brussels person by training now but one of the other things I'm surprised by is the fact that the EU isn't present up there and the EU has a huge aid but it can give long-term aid and it's not there. Well, so it is there but it's buried a little bit. I mean Japan has been a pretty stalwart contributor to the Global Fund as has the European Commission but I wanna pick up on something Jen said which is that as many donors have stepped up their support for the Global Fund you've seen a dilution of their own bilateral programs both in terms of the quantity of financing but maybe as importantly their technical capacity. So I think we've seen a lot of donors who have evacuated some of the very countries that were supporting because the Global Fund is there so we can leave now and that's a real problem because the idea was to be additive, to be complementary both to other donors as well as to domestic funding and I think as Meaded pointed out we've had in many cases the opposite effect. We've seen the Global Fund serve as an unhealthy crutch that's allowed governments to not contribute the kind of resources they should be contributing to their own efforts and it's allowed other donors to kind of peek out the back door or sneak out the back door while the Global Fund's been going up and so the overall amount of funding and the overall amount of technical capacity that's supposed to make the Global Fund work is really diminishing and I think that's a real challenge for all of us. China like many of the emerging economies one stepped away, it was actually pushed out the door from the Global Fund kind of unceremoniously but it was ready to go. That was 200 something million dollars a year that the Global Fund is no longer paying to China that's actually in its own quite a good thing. India really ought to be speeding out the door that's 850 million dollars over three years. Their amount of funding needs to be reduced. Nigeria is the single largest recipient of Global Fund resources. They lose four to six billion dollars a year in oil revenue. It's just hard to tell donors that they actually keep scraping from their pie to put into countries that really are not doing very much for themselves so I think we have a lot of work to do in that area. The challenge is that bilaterals are often not as engaged as we would like to be with the exception really of the US. Very interesting. So may I ask Todd, does he want to use that term free rider? No. I think it's a, you know, the circumstances of countries require, you know, as Alan said, you have to get into the weeds and understand the details. There are many times when we're engaging with health departments. Many of you are part of those and work with those. They're often our best friends in this effort. They're not politically powerful institutions in most countries. So the Global Fund and many of us are engaging with ministers of health who have very little control over their own budgets and they have people in the finance department who see streams of money coming in from outside donors and they're like, well, great, that means we have to put less into that department. So I think the challenge for the Global Fund is to find how it's gonna use the partners around it to enjoin countries in the political dialogue to help them put more money on the table. I mean, I think there was a lot of criticism of giving money to China, for example, and if you know China and you know, particularly HIV and TB, they've made transformative efforts in their own work, partly because they had outside money and the outside money was actually less important than the imprimatur that the outside funding gave them to do the right thing in their countries. So I think the Global Fund deserves a lot of credit for being in some of those countries, but it deserves criticism for staying there too long. Interesting. Now, I mean, given the pessimistic picture we've heard, I read a paper by CGD that actually said that the efficiency gains in the current strategy, there aren't many to be made. Maybe I read it incorrectly, but that seems to be the general gist. So are you suggesting that there needs to be a shift in strategy altogether if our resources are gonna diminish? So I did not write the CGD paper to which you're referring, so I can't speak specifically on that point. I have done a small amount of work on the efficiency of malaria, specifically on the Solomon Islands. And one of the things that I found in the Solomon Islands that was a recipe for efficiency, which I believe the malaria community has taken on board globally, is that you can't say one intervention is more efficient and therefore you should not do the others. In the results of our study, we estimated a production function for incidents decline and the most efficient strategy was to use indoor residual spraying supplemented by bed nets and treatment and even marbicide. So I think the efficiency story varies by the epidemiology of the country and I think there are people in this room that understand that better than I. But I think that the message that I do want to emphasize is that the management of these programs need better data and we heard that in the previous session. We have geographic information systems now that is something that's actually quite important that did not exist in the 1950s. And we need to have better data on the reduction that's generated by the concerted application of these interventions. And until we have that, I think the donors are going to be increasingly uneasy about pumping money into buying the inputs to attempt to do malaria control and even elimination when the evidence is not sufficient to actually fine tune those programs in the specific countries and actually get the job done. And the same can be said, exactly what I just said is also true of HIV. We're at the point now where we need to do greatly improved and basically measurement of incidents. We need to be using assays that can measure incidents and not just prevalence. We need to be doing repeated prevalence surveys so that one can take the difference in prevalence at two points in time, factor in the increase in treatment between those two points in time and back out in incidence estimate. Until we have incidence estimates on HIV, we can't do an efficient job of controlling it. So I think data, data, data is gonna have to be the secret to improving the efficiency. It'd be interesting if folks in the audience can comment on this because there are quite some experts here, but from an outside view, it looks like being able to squeeze more efficiency out of the commodities is quite limited. And so where is the room for efficiency? It either has to be in delivering fewer services, sort of the minimum package I mentioned or some other stuff, because it's hard to imagine you're gonna get bed nets much cheaper than they are or ACTs or diagnostics much cheaper than they are. In fact, the research paper that's out on the table, there points to a number of technologies that are coming at us that I expect are actually gonna be, at least initially, more expensive. So the challenge is where do you squeeze that you're actually gonna continue and expand your effectiveness of your program? Just wanna add to that bit. As I mentioned in our analysis, we looked at the current GMAP funding needs estimates, but as was mentioned earlier, there's gonna be new estimates coming out next year and the preliminary ones I've seen are higher. That makes sense. We haven't been anywhere near where the old ones were, so there's been a cumulative growing need and potentially for some of these other reasons. So the need is going up. Great, thank you. With that, we'll open up to questions. Could I just make one small point? I just want to say that on the fairness issue, the distribution of the burden of payment, UNAIDS did present the breakdown by low income, lower middle and upper middle and that was one slide that I would have liked to see in Jen's presentation. Because the issues that Todd has raised about the fairness of the distribution and who's paying what and how shouldn't the money be focused on the lower income or what is the story? We can't really tell that without that breakdown. Great, thank you. So questions from the floor, please introduce yourself. There are microphones coming to you. There are two there that we can take together. Just over here. Through women over there. Hi, Larry Barrett, President's Malaria Initiative. One response and one question. In response, I think to the question of where can we squeeze efficiencies? I think issues like integration of services, actually pushing services out into the community through lower level functionaries that actually prevent people from getting hospitalized, reducing the cost from thousands of dollars for a treatment of severe malaria to a dollar or so to treat a case of non-severe malaria. And certainly looking at the private sector is certainly a part of trying to build those efficiencies, particularly if we can develop self-sustaining systems. My question is actually on your point about, and you're absolutely right, when I was at the World Bank, they told me the Minister of Finance sits on that in the table and the Minister of Health sits with the Ministry of Sport and Women at the other end of the table. So the question is, what are our, then the intervention has to be at the point of the Ministry of Finance? And what can groups like the World Bank and what other platforms do we have to actually impact that or to have an effect on mobilizing those resources? Yes, Prima. Thank you. I was asked to make a comment on specifically on the eliminating countries, so just to ask people to introduce themselves. Sorry, Rima Shradder from UCSF, the Global Health Group. As we've seen, the lovely graph that Jen presented in terms of the donor financing for Malaria Control and Elimination, just to show you, to highlight that actually, while we've seen an increase in funding for Malaria Control and Elimination since the 2000, the last decade, actually from 2007 onwards, that funding for the eliminating countries themselves has actually decreased by almost over 80%. And on a speak of the eliminating countries, I'm thinking about the 34 countries that have elimination in their national strategic plans or have stated that they're moving towards elimination. So that's a huge cut. Of those funds, many of them actually are already spending about 80% of their domestic resources or rather 80% of that funding for Malaria Elimination comes from domestic finances. So we did a quick cost of what it would cost those 34 countries to eliminate and we came up with a number of about $8.5 billion that would cost over the 2030 time range. So if you look at the funding that's already going in from domestic finances and look at the OECD funding, increases, we can't really expect too much of an increase in domestic finances and even if we do, we still see a gap similar to what you presented in terms of the control and elimination scenario. But one thing that I do want to highlight that in terms and Todd's heard this before but as countries are moving up and get better with their Malaria Control, they're moving up in that World Bank income bracket which means then they're no longer eligible but then to also highlight, well 70% of the world's poorer than in these middle income countries so how can we address the issue of equity in resource allocations and perhaps donors need to be a bit more strategic in that equation for allocation bringing that into account. I don't know how best to do it and happy to do some mathematical modeling to see how we can take that into account. The other issue I want to bring up again from the Elimination standpoint is that often when we talk about investments for Malaria Control we think about the cost of commodities and as you very rightly said, we're not going to bring that down very much further but as we move closer to elimination it's not the commodities. The need for commodities is going to go less when we don't need as many treatments. Hopefully we'll get better with targeting. So those kinds of investments are really investments in systems, investments in management, investments in operations, continued HR surveillance, continued training for a disease that is no longer visible. So how do we then make a compelling case for investment in these systems where the disease is not visible? We're facing an out-of-sight, out-of-mind paradox in many countries and apart from the big ones, HIV and TB at a country level, take Sri Lanka for example, they have a huge case of dengue. So we're having to work with the Ministry of Finance and Ministry of Health to see that malaria funding continues and they're not taking that funding away from malaria and investing in things like dengue. The other issue I want to bring, we always bring about vaccines and we say we should continue to invest in malaria that we do the same way that we do in vaccines, which is true, the US doesn't have the vaccine preventable diseases and yet we continue to spend millions of dollars on childhood vaccines. But having said that, I agree with that but also with just a point of caution that vaccines are again a commodity whereas that's not where we're going to be spending our investments in malaria elimination. So just to going forward, I think there will still be a need for OECD financing. We'll still need domestic financing but we're going to have to look beyond that, particularly in the next 10 years because there'll still be a need for increased investments in the next 10 years. And here's the role of innovative financing and bringing in the new donors, Australia's already investing in the Asia Pacific, looking at not just innovative financing for resource mobilization but for resource deployment we brought up the private sector earlier, how can we actually utilize the private sector to make more efficient investments in malaria elimination in particular. And then again, efficiencies and integration, target of interventions, Thailand doesn't need universal coverage of bed nets nor do some of the other countries. How can we target our intervention a lot better? And then bringing up the point of research and development. So we have R&D for new tools but I want to make a plug for operational research in terms of R&D and operational research for examining the most efficient mixes of interventions from an epidemiological but also an epidemiologic and economic standpoint and the role of regional initiatives. So let me try to plug in a little bit in response and Larry I'll try to pick up some of your comments as well. One of the challenges is you start to articulate more and more needs in an R&D portfolio that's under-invested, a care and control portfolio is under-invested but you just heard a presentation that showed that we've already stalled in terms of financing and we're probably in a downward trend. So somehow or another we got a square of that circle. There's not enough efficiency to be gaining products. To me the only one that we're really gonna get to step up as countries investing more in their own needs. I don't think that businesses are gonna be able to carry much more of their responsibility and this is all deja vu all over again for HIV. So those of you who are here who have done HIV over again, oh we need to look to the private sector, oh we need to find these new donors, oh the Middle East is washing money, they'll finance this, never happens. So I think that we have to be a little bit reality based in all of this. In terms of who can help? So the political discussions as you mentioned the health folks are generally off with others in the side room if not even in the main room when the budgets are being discussed. The World Bank is with ministers of finance. The World Bank sits down with ministers of finance and often negotiates the medium term budget frameworks that guide where countries invest. And I think the Global Fund has done a very poor job of linking up strategically, methodically with the World Bank as they try to help countries make the case for greater investments in health and then within that health expenditure they do much more around disease control. I think that the donors at the table or the Global Fund, the last thing that they can do if they're not gonna provide bilateral technical support is at least politically engaged. The US ambassador, the UK ambassador, other ambassadors ought to be meeting with Prime Minister Modi in India and saying it's unacceptable for us to keep giving you two or 300 million dollars a year. We need to work together on an exit strategy. Same thing with Good Luck Jonathan in Nigeria. We need political pressure from the big donors because the Global Fund has no political apparatus on its own. Can I push you a little bit on this domestic financing piece? When you have a country that's faced with dengue fever, I had dengue fever, it was miserable. I'm really glad that someone cured me. When you have a country that's faced with dengue fever how can you or Ebola or whatever the crisis of the day is how can you put pressure on them reasonably to say you've gotta keep financing this long-term initiative when they're faced with a short-term crisis? The answer to me is that there are overall investments in health for almost every country is under what they've even committed to themselves. So you're trading one disease program for another in an area of overall under-investment. So I think the trick is to get the overall investment in health up as a percentage of government spend rather than making dengue compete with HIV, compete with malaria, compete with TB. We're continuing to support that kind of discussion as opposed to saying the investment in India on health, for example, is just a fraction. It's 1% where it should be three, four, five, six percent. So I think we can allow in some ways for them to sort of keep trading off because in the end it means these diseases just continue on in perpetuity. So I actually wanna tell a story. When I was doing my epidemiological work on the Solomon Islands, I came down with malaria, but I'm sorry, I did not come. I came down with larium. How many of you know what that is? Okay. I was taking larium and I had weird dreams, et cetera, but I was helped by the malaria ologist who is a WHO guy there stationed there. I was there on a World Bank mission and I heard a story as I was recovering and this was not a dream, I assure you. There was a, Solomon Islands is an archipelago with many, many islands and there was an island in the Solomon Islands that had every six months hosted a cruise ship that would come and visit. The people would get off the cruise ship, they would buy the products of the people and they would spend a lot of money. It was a major event in the island's economy and it's hopes for advancement. But one year, not too many years before I had been there, before I visited the island, the Solomon Islands, a person on the cruise ship got malaria and the cruise ship called up the governor of the island and said, I'm sorry, we can't come back anymore because we had this malaria case on board and we simply can't face the reputation risk. So an interesting thing happened. There was a very strong malaria program in the Solomon Islands supported by WHO, really unusual program but divided into 40 malaria districts with a good data collection on case reporting but also on the inputs, excellent data which we were able to use in our statistical analysis. But despite that excellent program, they still had ongoing endemic malaria on many of the islands. The leaders of the island came to the capital, the capital of Solomon Islands. Oh, don't ask me. I need geography boss. That's it, thank you. And they asked the people at WHO and the government people who were running the malaria program to help them. They said, please come and help us. So they went back and they told them all the same things that they'd told them before. You must use the bed nets. You have to accept IRS into the home. You must do a prompt treatment and you must do larvasciting, no stagnant water. So they did that for a period of six months and no more malaria cases were reported. They were able to resume the visits of the ocean liner. And I use that story in order to emphasize that an economic incentive can sometimes help especially in this case because it's a public good, it's not the private sector that's not gonna solve this problem by itself without intervention and subsidy. But sometimes the government can create a situation which might sort of simulate the economic benefits to that country from controlling malaria. So I'm suggesting that as in response to Rima's point about operations research, we need to understand more about the human behavior part of HIV and malaria, I would argue, because that's where the efficiencies lie, not in purchasing the commodities. And did you have anything to say? I just, so I like Mead's cruise ship strategy for the future of making the case. I was just putting together a couple of things that Todd and Mead both said and some of the points brought up in the questions. You mentioned this idea of maybe a healthy competition. If we think of this as a public good and we think of we need more investments, what's the healthy competition between programs and strategies? I think that's a good question to ask. I worry though that that becomes what's the healthy competition between diseases? And that will just, would not result in the intended outcome that we want. So we're at that juncture, I think, and we have, oh, we have that. I mean, the competition's been there. And so it's going forward, it's, I don't have an answer, maybe partially this economic argument, but I think it's gonna be a heavy left. Okay, thanks, so one here. One point and one question. All three diseases, I'm Regina Rabin of the Harvard School of Public Health. All three diseases are faced with resistance. And their response to resistance may be a change in strategy, but usually it's a new product. New products cost more until you get efficiencies of scale. So at introduction, you're trading off a failed strategy, a failed product for something that's gonna cost more and that will impact on the budget. But you have no option. Okay, you have no option. And particularly with malaria, what you will see, unless there's a replacement of failed products, you will rapidly see an escalation of deaths. Take that one to the political center that you're trying to make a case. And unfortunately, that will have to happen several times before it gets the kind of attention that it needs. My question, and so the efficiency may end up being avoidance of resistance or time to elimination. Because if you can do it faster, the program overall will have increased costs, but may overall end up being more efficient, a different way of thinking about efficiency. My question for you is because we're all looking for buckets of money that are unutilized. And I don't know about this, so I'm asking those of you that think about where to get money from. The Lancet 2035 Commission laid out a very ambitious agenda for 2035 on what would happen with health. And whether you agree or disagree with that, one part of that report said, well, that's gonna cost $70 billion a year. And they said, and this is where you can go get it. So that's the part I'd love to get your feedback on. They said you can go get tobacco and other products that taxing on those kinds of commodities can bring income back into the countries and can be spent, just like it has happened in the United States. And so I'd just love to hear has there been an enough exploration of that as a strategy in terms of funding for global health? Thank you. Great, thanks. We'll take a couple more questions. It's the last round. Okay, there's two here. Are there any over there? No, I'm all right. One here to the front and then we'll go back to you. Thank you. Martin Akabeta, I'm a researcher from Benin, West Africa. There is a lot of money for malaria elimination. But this is some researchers say about the distribution of the parts reserved for research. The majority of the fund is kept by the big institution working in Europe and America. We know we need basic studies but we need also to think to African researchers involved in applied studies on the field. The question is, is there a mechanism to allow the African researchers to have directly access to these funds? Thank you. So thanks, Michael McDonald with the IVCC. I'm an entomologist so I have a very naive economic question. And to follow up with Larry and Rima, we're saying about the Minister of Finance. Earlier, Bernard Nalen said that in the private sector the corporate sector they've seen a very positive return for investment. Anglico de Chanti, Levo Sugar, et cetera. Have we missed an opportunity in Sri Lanka, Zanzibar, Southern Zambia to show the positive return for investment for malaria control in terms of economic growth, school attendance, et cetera? I think there was a natural experiment happening there and I think we missed it. Great, thank you. And then there's a question at the back. Thank you. Keith Carter, Pachel, Pan-American Health Organization, World Health Organization. Really very exciting and interesting conversation today in terms of the future vision and financing. And I'd just like to bridge the two presentations or the two panel discussions. And one is that we focused on elimination initially and now we're speaking of financing. And I'd just like to posit that in the Americas where we have seen financing limited to USAID on between 2001 and now, together with some financing from the Global Fund to some countries which were eligible for financing, we have seen great progress in the region. 64% reduction in cases and almost 80% reduction in mortality, which means that there has been progress. So there is the possibility of elimination and the Global Fund has taken that up by supporting, as we heard earlier on, efforts in Central America. And then the Gates Foundation is also looking at supporting, as we heard from Patrick early this morning, the Hamek, the Haitian Malaria Elimination Court Consortium to eliminate the disease from the island of Hispaniola. And then we heard from Todd earlier on of $100 million from the Global Fund for eliminating artemisinin resistance from the Mekong area. Now, we have had some scare about the potential emergence of artemisinin resistance in the Amazon Basin, where we've only got some financing from USAID over the years. Our position would be to us, Mead, to use his efforts to support us to mobilize financing to eliminate malaria and specifically falciparum malaria from the Amazon Basin, where we haven't yet identified resistance by the parasite to artemisinin. So that would then preempt movement of elimination of falciparum for a start from the Amazon Basin and the rest of the Americas. And then subsequently, we can try to eliminate vivax malaria. So that would be our call for support from this group to the region of the Americas. Thank you. Sorry, I know there are a lot more questions, but we've run out of time. If you could take any of those questions that you like, but also use this as your last chance to wrap up as well. Jen, why don't we start with you? Great questions. I'm not going to be able to answer all of them, but I just, I wanted to pick up something Regina said about the Lancet 2035 Commission, because I think that did present almost some new or not all new, but ideas that we really should be pursuing. What is the potential out there? I'm not sure if that conversation has happened as much in the malaria context, but I think the overall global health discussion around where are more resources likely to come from, how much of this taxation of commodities might have a negative effect on health? Can we move in that direction? I think it was great that the commission put that out there. It's probably also a challenge, but I think that has direct application to what we're talking about here. There are other innovative options out there from work that we've done and others have done. I think those can help at the margins. I'm not sure that they will get us over the hurdle that we need to get, but part of the strategy is going to be piecing this together. It's not going to be from one source or another, so it is a puzzle that we have to approach that way. On Friday, I was on a panel at the United Nations in New York, a panel convened by ECOSOC to look at the economic impact and strategies around the Ebola epidemic. And the reason I was there is because I was part of a World Bank team that wrote the report on the economic impact of Ebola. The remarkable thing about studying the economic impact of Ebola is that really 90% of the economic impact of a disease like Ebola or H1N1 or SARS is not either what we call the direct cost, the cost of treatment and prevention, or what we call the indirect cost, which is the foregone labor. It's what we call aversion behavior, basically fear-driven behavior, both domestic fear and international fear. So why do I raise that point? I raise it because the lady who was standing at the mic a few minutes ago talked about the fact that TB, HIV and malaria all have in common the threat of drug resistance. And I want to suggest that if we have an outbreak of fulminant MDR-TB or if malaria, if cerebral malaria begins to spread and it's artemiscent and resistant, the nature of the economic impact and the fear that's gonna be generated internationally by such outbreaks will in fact begin to resemble more an epidemic like Ebola or H1N1 or H5N1. And those, and what I wanna point out is that that epidemic really made the world, the Ebola epidemic really made the world sit up and take notice. So I think the international community, there may not be much more money right now on the table for HIV, TB and malaria, but there is a lot of money available for Ebola. Seven billion dollars was authorized by the United States I think recently and about half of that is for the United States, the other half for the Ebola affected countries. The thing that is going to be on the table increasingly I think in the international community is that global disease surveillance is in fact a global public good and all countries need to step up to the table because they're all threatened. This point was hard to make a year ago but I think it's much easier to make today. So what does disease surveillance mean for us? Well it certainly means doing surveillance for MDR-TB, for artemiscent and resistant malaria and for various resistant strains of HIV. Beyond that, I think the point that was made by the gentleman from PAHO, I think it will become increasingly possible to make the case to public financing authorities in rich countries that the world is a single spaceship traveling through space, they were all in this together and that Ebola is an example of what can happen with these other diseases if multiple drug resistant strains of these diseases break out. So that'll be my optimistic point that I'm making. Yeah, good luck with that. You know, I just have never seen logical strategies draw much political attention, honestly. So you can make the case that we have... But fear works. Fear over the long term is a poor behavior modification tool. I think a couple of things. One, Gina, you pointed out to sources of revenue. Taxes are one, Thailand I think has done a really good job with some taxes around tobacco and alcohol that have been put into its health. Of course, there's an immediate desire to put those monies into anti-tobacco efforts as opposed to broader health issues. And then in some countries, the tobacco industry is the government, China comes to mind. So you have a little problem, for example, taxing something that's heavily subsidized by the government itself. There have been social insurance schemes and that is really an area of promise where people band together and try to cover their own health costs. So by domestic spend, I think we can expand beyond funding from governments in these affected countries to other things that they may subsidize in some way, but could be coming out more thoughtful out-of-pocket spending. Around the support for African researchers and around operational research, the Global Fund, for example, allows operational research to be an eligible use for its grants. Honestly, it becomes a problem because countries don't want to take money out of their budgets to fund research when they're short of the resources needed to fund direct care. So it becomes kind of a competition thing and a political problem for them to actually divert money that they need to buy drugs and to buy bed nets and to buy insecticides and put that into research. So the only way to make that work is to earmark the fund and make it only available for that purpose, which is a possibility. Around the economic case, we have some business folks in the room. I think there have been amazing stories, the Chante Gold and Ghana's one ExxonMobil, Chevron, their Anglo-Americans done a tremendous round in HIV and malaria and TB, and they have been leaders in their fields, but the overall impact is limited really to employees and sometimes families of employees. It's not gonna get the kind of log change that I think we're seeing is needed. And the last I'd say is that we still have to make a good compelling case, maybe not so much fear-based as opportunity-based, that if we don't act now, we have drug resistance, we have other things which are gonna escalate substantially the cost of achieving elimination of malaria. So we act now and save, I think has some compelling arguments. And the other bit is malaria is tremendously responsive to infusions of money. You see the benefit really quickly and likewise you see immediately what happens when even a bed net purchase misses the rainy season. And that kind of responsiveness is actually really attracted to politicians because you can say you put your money in and you will see benefit within six months as opposed to some of the other things. And that does have political attraction I think we've undervalued. Wonderful, thank you. Everyone please join me in thanking this great panel. For an early lunch served out on the terrace, please join us and have some lunch. We'll be regrouping back here in this room at noon to begin the program. So we have about 35 minutes for lunch. Please do not bring your lunch back into this room. Please eat out on the terrace. Thank you.