 Host Ambassador Jimmy Coker as our, as our luncheon keynote speaker. Ambassador Coker is the Assistant Secretary for Global Affairs at the U.S. Department of Health and Human Services. He came into that post in 2014 and prior to that served as the Deputy Assistant Secretary in that office for three years. He's a career diplomat with a very distinguished path he served as Ambassador to Burkina Faso 1999 to 02 and then in Uganda 02 and 05, which is a really pivotal moment in U.S. global health engagement with the launch of PEPFAR and subsequently with the President's Malaria Initiative. And I think as Jimmy can describe this had a transformative impact on him personally in terms of getting his full attention and energy focused upon the response on HIV within Uganda that then grew into service as the Deputy in the Office of the Global AIDS Coordinator back here in Washington after serving in Uganda. And then at five years stint at UNICEF as the Division, the Section Chief on HIV and AIDS in New York. So a very, a really remarkable trajectory professionally from diplomacy into deep global health diplomacy. The office that he heads up has become really a dynamic focused, focal center of expertise and policy engagement within the U.S. government. That was not always the case and we can trace it back as predecessor Niels Delaire and prior to that, Bill Stager both worked very assiduously to build up the capacities in the last several years. It's really a blossomed, attractive multitude of talented individuals and its influence and expertise is really deep. And so Jimmy, thank you so much for joining us. Ambassador Coker is going to speak for about 15 minutes and then we're going to move very rapidly to hear from you. So please think about your questions and interventions and I'll moderate that and then we'll close at 1 p.m. So thank you. Thanks so much, Steve and it's really a treat to be here. Thanks to Nellie and CSIS for continuing to highlight questions of universal health coverage and it's humbling for me to be in a room with so many people who know so much about that topic and about global health as well as many of you who have devoted your lives to bringing us to some of the advances we've made both domestically and internationally on universal health coverage and I hope I can at least scratch the surface of some of the work that you all have done and they're still doing in that topic. My task is to talk about the approach that the United States is taking toward realizing and sustaining universal health coverage and it's a good time to do that because what we're doing domestically on health reform and expanding access to health insurance coverage is the highest administration priority and it's very significant and I will talk about that later in my talk but I did want to start with some of the international and multilateral aspects of universal health coverage which have been your theme this morning. Margaret Chan, Director General of the World Health Organization says universal health coverage is the single most powerful concept that public health has to offer. It's inclusive, unifies services and delivers them in a comprehensive and integrated way based on primary health care. But for years the United States resisted or amended or footnoted any language that talked about universal health coverage and the UN or WHO and there were two main reasons for that. One of them has happily been overcome very dramatically with the passage in 2010 of the Patient Protection and Affordable Care Act. We're now proud cosponsors of these resolutions and decisions promoting universal coverage. These advocating that position is now consistent with and not an implicit challenge to US law and US government policy. But there was always a second reason for caution and just hearing the discussion right before lunch is a good reminder of why some of that caution is still something the US advocates in terms of international language about health coverage. Health systems and health financing are recognized as national decisions and national responsibilities. Even that within the European Union the subordination provisions put health into the national round much more than into the community's decision making responsibilities. And some advocates of universal health coverage have in mind a particular means of achieving the coverage via the single payer system of Mutual or government provided national insurance scheme or as Jeanette Vega raised in the discussion just before and with some good examples because they're so vivid in South America right now a right to health concept in which denial of even very expensive or experimental care can be contested in court. And the US is still opposed to this judicable right to health but this debate is quite active both in our hemisphere and globally and it's certainly something that I know you've been addressing in different national contexts. But needless to say the United States has not adopted and is not likely to embrace in the very near future any of those concepts of a single payer system government provided insurance scheme for everyone or a constitutional right to health. And universal health coverage therefore remains a broad concept to be achieved and we would say in order to account for the slow progress we're making the United States progressively achieved according to national circumstances. That said I have yet to be in a meeting with Secretary Sylvia Burwell or before her Secretary Sebelius with foreign ministers of health that in which the delivery financing and cost of health services was not on the agenda. Every country faces challenges in rising costs, determining who accesses which services, reaching those who are non-adherent or hard to reach, measuring value for money and how to integrate, regulate and leverage private and public provision of services and pay for them. We can no longer talk about universal health coverage just as a supply side issue is health care available. It's not just this coverage exists, every country and every community is worried about the quality of care, is worried about improved efficiency and about cost. So in this context the United States strongly supports a dedicated health goal for the post-2015 development agenda and all through the negotiations we've consistently supported inclusion of goals and targets relating to universal health coverage although indeed this is controversial and sometimes hard to measure. Through the open working group on the sustainable development goals will continue through the summer and the report of these proposed goals of course will be released in July. Many people have questioned whether universal health coverage is the right fit for development goals but we think it is. Most of you are surely aware of the rise of emerging economies like Brazil, China and India means that the majority of the world's poor people, vast majority now live in middle income countries and most traditional development assistance donors limit or prohibit assistance available to middle income countries. So when we started to look at sustainable development goals we quickly realized that either these would have to focus on a small and diminishing slice of the world's population, in other words the low income countries or that we needed to think about goals beyond the context of development assistance which apply not just to middle income countries but in fact to the United States as well. We're also aware that looking at trends in global health and ever growing share of the burden of disease will come from non-communicable diseases. This is true in both developed and developing countries and almost two thirds of global mortality today across the spectrum is due to non-communicable diseases. We'll therefore not be able to meet these new health goals, especially goals about greater longevity and diminished premature mortality without the promotion of universal health coverage throughout the world. So the SDGs do have relevance for every country but this new focus also means that while the original millennium development goals were primarily valuable in helping focus development assistance and low income country achievements, the new goals will have to have a broader focus. They'll be not as dependent on foreign assistance but will increasingly be a way to focus priorities for the use of domestic resources. In that context the dynamic, the sort of paradigm of donor recipient countries and of development assistance where the U.S. government for instance would pay for an international NGO for whom many of you work to provide primary care services in developing countries seems already very last century. Countries certainly developed in middle income countries but even those who are the poorest are looking more for technical partnerships than they are for a donor recipient relation. The question we get is how do you do this in the United States? What lessons can we learn from what you're doing there that could help our country? And as we heard in the last session, the U.S. should be asking this question more often than we sometimes do but we certainly are asking the question as well of other countries in particular in terms of coverage, quality and cost of health care. But within those technical partnerships coming from the Department of Health and Human Services it's a sweet spot for us because centers for disease control and prevention, national institutions of health, food and drug administration, health resources and services administration, even the substance abuse and mental health services administration, all these large operating divisions within HHS actually have a cutting edge role in this. They have a comparative advantage in looking at how can we use our capacity and what we know about health care in the United States, about its organization but also about using the latest data and evidence to achieve the best policies. How can those, that capacity and that knowledge be applied to meet challenges that are global challenges or challenges in another country? So we can't lose sight of the need to promote healthy lives through accelerating and sustaining progress on the unfinished business of the Millennium Development Goals but we really do need to use this 2015 opportunity to look at both domestic financing and the quality of the partnership that the United States we hope can provide to countries large and small in terms of how do we jointly solve the challenges and problems that confront us in the health area. This grand convergence is perhaps the most important of health outcomes. We certainly continue our commitment to ending the HIV and AIDS epidemic, creating an AIDS-free generation, ending preventable maternal and child deaths and the statistics on these again are converging and that's something in which we can all rejoice and I think the MDGs have a role in that. But there are other priorities that remain universal challenges, sexual and reproductive health and rights, preventing and treating communicable diseases including malaria and tuberculosis, addressing the challenge of non-communicable diseases, certainly the behavioral causes of non-communicable diseases, ensuring adequate nutrition, access to safe water, sanitation and hygiene, reducing indoor and outdoor air pollution. And the promotion of universal health coverage will become an increasingly important way for countries to prioritize and deliver on their own health goals and build sustainability of their health achievements rather than universal health coverage as an end in itself. So what does that universal health coverage goal in 2015 look like? It needs to be accompanied by clear targets supported by evidence-based interventions. It should focus on continuing achievement of current health-related MDGs. Certainly shouldn't ignore the further efforts urgently needed for an AIDS-free generation and preventing child and maternal deaths. And it must be universal in the sense that it ensures that all people, especially the most vulnerable, have access to health coverage. So put simply, 2015 should provide globally measurable goals that would be appropriately applied at local and national levels. National responsibility implies that countries take action in ways that reflect but also improve their domestic conditions. U.S. is eager to engage with all partner countries and partners, non-government partners as well as they define packages of essential services. The role of what the U.N. system calls non-state actors of private sector of interest organizations, advocacy groups, academic institutions have grown enormously in importance and one of the challenges to WHO that we're working on and will be a main subject of the World Health Assembly in May is how does an organization like WHO amass the best minds, the best evidence, the best practice in order to set norms and standards in a way in which there are inevitably conflicts of interest. People have agendas and people are going to promote those agendas. But how do we make sure that that best evidence, whether it comes from private profit-making organizations which do have interests or advocacy groups which do have interests, how can that evidence be judged in a way that does not represent a conflict of interest but in fact will result in the best norms and standards and the best partnerships we can achieve to provide those goals. So we're eager to engage in defining those packages of essential services. We hope that we can help to assure that countries prioritize reaching key populations with priority services, such as those from maternal and child health, HIV and AIDS and non-communical disease prevention and management. We are in a situation where the data and evidence about some of the marginalized populations, for instance, lay, lesbian, gay, lesbian, transgender and intersex populations, we don't know. There's certainly anecdotal evidence that their access to health, their results from the health system are deficient. But we tried at WHO to get simply authority for WHO to collect evidence on this and we're not successful. Fortunately, PAHO is now, Pan American Health Organization, is collecting evidence on LGBT access to and results from interaction with the health system. But the violence as a health issue is another one where the evidence is very weak. Violence against health workers and the role of health workers in responding to crises and emergencies is an area where the evidence is very weak. So we need to be sure that as we're looking towards sustainable development goals and universal health coverage, that some of these vulnerable groups for whom we don't have adequate evidence also are brought into this sense of gathering what data we need to know in order to be sure that our results are improved. We also link to sustainable development goals because healthcare costs are one of the primary reasons people are driven into poverty. Development and efficient health financing arrangement supports the government's ability to keep people out of poverty. And universal health coverage is a key to help countries find ways to pool economic resources and risk so people don't have to choose between health and impoverishment. And of course there are many ways for countries to promote pooled resources which have to include private sector systems in most circumstances. So there's a lot of attention and I say from our side a lot of enthusiasm around universal health coverage and the many issues that it brings up. There's much to be done. There's no easy path and there's no better example of that than the United States. But also our example I hope shows that even in tough circumstances with lots of political obstacles that it's not an impossible road and that our experience will make that easier for other countries around the world as well. As I'm sure you know the US spends more per capita on healthcare than almost any other nation. Yet we don't have the broadest coverage and we don't have the best indicators or results. Part of our problem was uneven access to care especially preventive services. Wellness is the great equalizer and our health system needs and needed to reform to deal better with this vital issue of prevention and wellness. Thanks to the Affordable Care Act the US has taken some decisive steps toward universal health coverage. Healthcare is becoming more accessible and affordable for millions of Americans. Because of the new law, today's statistic and the government is not keeping these. We're trying to let independent folks calculate but I saw a statistic this morning that 11 million more Americans now have affordable coverage and reliable access to preventive services, treatment and care because of the Obamacare, the Affordable Care Act. Before it was passed in 2010 there were about 50 million Americans who did not have health insurance at all. Best estimates are that this number is now well below 40 million. Still much too high but a huge step in the right direction. Our efforts in the US were and continued to be influenced by lessons learned from other countries. Like any historic and transformative change there are bumps in the road and we've learned from how other countries have navigated those. The good news is that the reality we now see and end result which is more clearly in focus are worth it. The quality affordable coverage is within the reach of the United States and we're really pleased that we think we're on the right path and that that path is showing some demonstrable results in all of the areas of access of cost and of quality. In 2012 the Obama administration for the first time allowed the United States co-sponsor resolution at the UN General Assembly on promoting universal health coverage and it emphasized social protection and sustainable financing as two key components. There are still huge challenges of course in those areas and in a number of others as I'm sure you touched on in the talks this morning about what does universal health coverage mean for various things that are perhaps in the penumbra of it. First, do we have evidence that universal health coverage does produce the ultimate outcome of healthier lives? Is this, it's been considered an end in itself but we have to be sure that universal health coverage is a means to an end and that the outcome is reflected in results in people's longevity and their ability to live healthy lives throughout the life course. And we need to be sure that universal health coverage is especially sensitive to persistent disparities. This lack of data on things like violence and LGBT but also questions of persistent disparities within countries in which the difference between countries is often less pronounced than the differences and differences both in results and in coverage, access to health and prevention within countries. And we realize of course that the universal health coverage shines its light on huge deficiencies which were caused by lack of universal coverage and are gonna be solved by instituting it but the development of the health workforce applying it to the highest priority needs, geographic distribution, reimbursement, incentives for serving underserved populations. We've certainly been reminded about this in the Ebola outbreak where health workers for very rational reasons abandoned their posts rather than increased the number of people working in the most affected areas because the incentive structure was on its head and the sense of protecting and valuing the health workforce itself were not at the fundamental part of the health systems that were responding. Pan American Health Organization was the first regional body of WHO to develop a strategy to promote universal health coverage. Member States adopted resolution and strategy called universal access to health and universal health coverage at the 2014 Directing Council. And that title is worth talking about because to many people universal access to health, the term access to health has a very important meaning and the US for the first time did agree to that title, universal access to health and universal health coverage. And universal health coverage implies access to health but again this question of judiciable right to health is something that is one of the huge questions I think that faces us as advocates for universal health coverage in days to come. We also need to look at some progress that's been made but clearly not enough on health technology assessments. How can a provider, both an individual provider, a government, a payer, a patient or a patient's family look at the technology available and decide what's appropriate for whom when they're very expensive courses of care when there are options that, consequences of which may not be immediately available to the obvious to the patient or the provider. And the question of health governance, who makes those decisions? Who can reallocate resources? Who makes a man of life decisions about care based on those technology assessments? These are issues our government has not addressed head on. We have a confusing collection of laws. Medicare in particular does not use these sorts of assessments as a basis for reimbursement of providers and we need to be looking at that and look at how the social determinants and the results should be affecting our decision-making. They're also within the multilateral context some definitional questions. There's a resolution this year which we're supporting and it seems obvious, but that surgical and anesthetics, surgical care and anesthetics be part of primary coverage and part of universal health care. That's true but it's not actually covered in all systems. The role of mental health is now also recognized as something that needs to be covered by universal health coverage but isn't treated equally by many systems. Dementia and Alzheimer's are a huge issue now. The UK has been leading a G7 effort on dementia. Again, the coverage for the sufferers, people with diseases that especially affect elderly people, question of abuse of elders are issues which we haven't as a global or national community adequately addressed. And the same unpalliative care. What does end of life care mean? What sorts of drugs are appropriate for people who have terminal conditions and how do we make that process of dealing with chronic conditions one that's both humane, medically sound and financially put in the proper perspective. So in conclusion, universal health coverage is not just a matter of having the government or a third party pay for services. It's a goal to be, we would say, progressively achieved unique teach society that's aimed at better, more equitable health outcomes across all strata of society. It's both a technical agenda and a social justice agenda and one that we as the United States are ready to embrace. So thanks very much for your interest and leadership on the topic. Thank you very much. I'm gonna just move this back so that we're not blocking people's sight lines. What I'd like to do is turn to you. I'd like to offer Jeanette a vague of the opportunity to kick things off if you care to. It'd be great also to hear from some of our other guests from Calypso, Akika, Akika, Tessa, Sebastian, Janzon, some of the other experts that have come. Jeanette, if you could get things rolling, I appreciate that. Thank you very much for your very interesting talk and really I think that the international community has been able to see the change in the position of the US government. We all know how difficult it has been and all the discussions about the Affordable Care Act. However, we do believe that it's quite essential to have the endorsement of the US government. All of us that we had been in the global arena for a long time, we have dealt with the issue of the very strong opposition of the US for several years. So it's good to see that change. It's a hopeful change. Now, with regards to your specific talk, I'd like to ask you about, what do you think is the take off of the US policy makers and decision makers and basically advancing towards a more social insurance type of protection? I realize that it's a huge change, but there is a fundamental issue that is still remaining. The way that you organize your coverage is still much more on an individual basis as opposed to a population basis. And given that you spend 19% of your product in health with, I would say, not very good results in terms of health indicators, I was wondering, how does your government see this and if there is any sort of plan or ideas on how to sort of change the situation? Sure, then there are people in the room who are surely more expert than I, but the question about social protection, social insurance, how does that relate to, especially in the health sector, the way in which the Affordable Care Act was structured is that lots of things are permitted and there are some financial incentives to create, for instance, accountable care organizations in which people would get together and the providers would be paid by a result that they would achieve for a population or a group together that's a kind of social protection, social insurance that we haven't had in our system before. And many of those systems, a lot of them having to do with incentives for paying for results rather than paying for interventions or tests or particular treatments, have in fact now had a track record which is very promising. The question which I heard discussed and I think we all have is how do you then scale up best practices on a national basis or even on a basis beyond that motivated group that originated them? And I have to say that we don't in the Affordable Care Act have a clear answer to that question. But we hope that by the fact that this is a transparent process and that these things now are blossoming in many places, that these will be recognized and rewarded and that as we have the ability to reimburse providers under various schemes, and Sylvia Burwell I know has talked a lot about this, that we are definitely looking at the way to move over two or three or five years to be sure that we are giving reimbursements based on results not based on the tests provided or the individual intervention. So I think that frame of mind is taking hold but you're right, we don't have a social insurance scheme in the US and the basic social safety net is of course not stronger now than it has been in past years and I think that's a worry to many people. So just let me just follow up on that because I think that you made a point that is extremely useful and we haven't got into that which is the point of that in addition to defining the benefit package, one critical issue or critical factor of success is to change the purchasing function. I mean, because even if you define an excellent benefit package but if you continue purchasing using fee per service or ineffective ways of purchasing not purchasing based on results but purchasing based on activities, you won't achieve effectiveness in terms of using the resources to guarantee outcomes. And of course that could be another probably seminar or a thing but I just wanted to flag that because that's extremely, extremely critical the reform of the purchasing mechanisms. Thank you. Some of our others for Yanzong. David, I hope David Granger will join in, jump in if you have something, Yanzong. Okay. Well, thank you Ambassador actually. I'm pleased to hear that the United States is supporting UHC and of course also delighted that the United States is finally joining this UHC global momentum but I'm curious besides endorsing UHC, I expect that it's gonna happen at the September UN assembly meeting. What, any substantial substantive steps the US can be taking to support other countries especially those poor countries to obtain universal health coverage. Do you envision the US to contribute to a contingency fund, a health system strengthening in general and UHC in particular or launch a pet file like initiative to support other countries to build UHC? The answer is yes, but the yes is clearly those of you who know Ariel Publis Mendis who Jeanette succeeded at Rockefeller but has now been my counterpart at USAID for quite a while know that he is passionate about this and that USAID has indeed set up a special office responsible for health system strengthening that this is to be part of our health development aid in those countries where USAID does its health work. Likewise, CDC is seen health system strengthening as one of its core functions within the PEPFAR program and beyond the global health security agenda which the president met with 44 countries on September 26th and is now has a huge new head of steam because of not only seeing Ebola as the failure of the health security infrastructure surveillance detection and response but the money that was in the emergency appropriations bill that can go directly toward US government and we certainly want partners to be joining in on that. US government help to countries to set up what are now 12 action packages for global health security that include basic lab services, basic detection, emergency operation centers, surveillance capacity, many things that we think would help prevent outbreaks in all hazards, security threats but are also crucial to standard primary care kinds of responses that countries have. So we have both through USAID and CDC now more dedicated responses to health systems. That said, and to be fair, the PEPFAR program is having to concentrate, we had opened lots of doors to health system strengthening as the Global Fund did. Global Fund had a separate window for some of the rounds for health system strengthening. Those windows are not opening more widely and in many cases are closing because the funds are capped and because turns out the AIDS epidemic and in case the Global Fund TV and malaria are not in fact on the dramatic downward course that we hope they could be. And so just the money to maintain treatment and maintain existing programs in AIDS, TV and malaria are gonna suck up a higher percentage of money than that could otherwise in the ideal world have been available for health system strengthening. And my impression is I can't speak for others and I know there's some in the audience but that most European donors are actually in the same circumstance that the money for health systems is not only not expanding but in many cases contracting. So there are people like Gavi, people like Global Fund, UN AIDS, all of us have health systems on our periscope and I think are trying to address things that would advance it but the sense that there's gonna be a PEPFAR for health system strengthening or that the world is uniting in a way that's gonna make this a priority as it hasn't been before. I don't see us moving in that direction at all and that's, I know, disappointing to some people. Why don't we take three or four interventions here and then come back to you to respond to those and then we can close Calypso. Any of our other special guests, Tessa or Sebastian, Yacht, David, will come to David after Calypso, yes? Thank you, thanks for a very encouraging talk. I wanted to check with you what the situation is with defining a benefits package in the US. I understand there was an IOM attempt, perhaps a couple of years back, for the exchanges to set sort of a benefits package but that was mostly ended up being about principles as opposed to substance. Are you thinking about it? I think I missed the key word in what you're asking about packages. The benefits package, the benefits package, attempt to design a package and I think there was an IOM effort and it wasn't there a few years back. Thank you. David? Thank you. A comment as much as a question but the US continues to be one of the major drivers and contributors of R&D for new technologies in healthcare and at the same time, the system often gets criticized for the use of high-cost technologies to the detriment of other things but I think what you've got starting to occur now are some opportunities to experiment and perhaps find some leading ways that can be useful for other countries and the example that comes to mind is a study that was completed last year from the United Healthcare looking at payment options in oncology and doing a study that compared two groups of oncologists, one paid on the traditional fee-for-service basis, the other paid under an incentive basis for adhering to quality guidelines, et cetera. What was really interesting about the study was that in the experimental group, the total costs came down but the expenditure on innovative oncology drugs went up and so it was an illustration that it's not always necessarily about the costs of technologies, it's about getting the incentives right and getting the sort of quality aspect working across the system. So I think that's one of the things that the US can contribute to is how do you manage those things well in an environment that is rich with technological innovation. Thank you, let's take two more, Keith Martin and Paul. Yes, Keith? Thank you, Steven. Thank you, Ambassador Kolker and Officer Ford. The tremendous work you've all done to make the ACA a reality. Tomorrow, universal healthcare is adopted by all countries in the world. Then what? I think there's a part of the picture we're missing in a great opportunity. In order to operationalize, I think, the public health, primary care, surgical capabilities to address the social determinants of health, not only do they need to have an effective ministry of health, but of course we need to have a ministry of finance, public works, and importantly, a justice department that works. So corruption, conflict, and a lack of capacity is not going to undermine any of those programs we're all talking about here that are going to improve people's well-being. So I'm really interested, Ambassador, and if you can give us some guidance as to what's occurring to sustain, retain, and build the professional capabilities in public services in low-income countries. Thank you. Paul, last question. I'm a retired USAID employee. I just had a question on the financing side. I think you've pointed out very correctly that we're all lucky in the public health community that there's been so much additional financing over the last 10 years that's come from traditional donors, Global Fund, Gabby, all these different sources. What we're now seeing though in countries, and we've heard today, I think, from a number of the successful countries, there's a whole bunch of other countries out there that aren't the Chileans and the Thailand's and the Mexicos and the China's of the world that need to mobilize their own domestic resources. I wonder if you have any insights about how we as a donor or we as a partner in the global community can help, whether it's put pressure on or whatever is such a way to help countries realize that they have to mobilize their own resources, invest their own resources for their own health systems because, as you've just correctly pointed out, we maybe aren't gonna have a Global Fund for Health Systems and the money's gotta come from somewhere. Thank you. Great. The first question I'm gonna clear my ignorance, I'm sure there are people in the room who know more about defined benefit packages than I do. My impression is that it's one of these things that can be piloted, that the Affordable Care Act is permissive in letting this happen, but to my knowledge, I have not seen any reports on results of whether that's been successful. Is there anybody here who knows more than I do about that? We'll shelve that one. Yeah, well, sorry, good question. And there are many models that should work and it's one of those things that as, if there are countries that are doing this well, I think there's a real appetite within HHS for finding that out and trying to incorporate that as to something that at least would be permitted under the Affordable Care Act if there are people who wanna replicate that. But it's, so in Mexico, the windows of health that you have with all your consulates in the US has been a huge interest to us. And as we've tried to look at what responsibility do foreign embassies have here as employers under the Affordable Care Act, which it turns out they do, what responsibilities do foreign companies that may have their own benefit packages based in their home countries, turns out that they can get those approved under the Affordable Care Act, but also to foreign people who are here on our soil and people who are dual nationals but maybe under some other system. It's a very complicated issue and Mexico has been our first partner in trying to adjudicate some of these issues and figure out who's covered and who's not. So I appreciate that. R&D and the, as you know, NIH set up a couple of years ago, a new institute, their only new institute under this administration has been on translational science. And the sense of how do we use what we know and apply it, I was talking to the master from Costa Rica, that diplomats, and I'm now a diplomat in the medical and scientific world, and that many scientists, if they publish a peer reviewed article, will that problem solved? And if you're a diplomat, that's just the beginning of the solution. How do you use that data and evidence to change policy, to change practices, to get our priorities or what we think might be a better option onto other people's agendas? And the complementary roles of science, because diplomats sometimes do that without evidence. Having the evidence is a big advantage. On the other hand, just having the evidence is rarely enough. Even, you know, once the FDA approves a drug for use in the U.S., this goes to some of the mobilizing domestic resources parts too, but once the FDA approves drug in the U.S., typically it takes seven or eight years before a developing country will be able to market that same drug. And so, some of the questions about how are we using our research advances, and the question you raised about the cost of drugs going up, but the actual cost of the care going down, one of the things we're trying also in our universal health coverage emphasis within HHS and multilaterally, bilaterally, is to look at access to medicines not as a zero-sum game. There are certainly people, the intellectual property and the needs of poor people for access to medicines are often in conflict, but those aren't the only, or we think even the major reasons that access to medicine is limited, the national approval processes, supply chain, corruption, as somebody else mentioned, a huge number of obstacles that could be addressed, almost all of the essential medicines recommended by WHO are in fact off-patent. We just had the debate about epilepsy at the last executive board meeting. The epilepsy advocacy organizations were saying that the epilepsy medications, which have been around for decades, cost about $5 per person per year, but two-thirds of the people who need those medications are not getting them. So clearly this isn't the cost of drugs question, it's a question of what do we mean by access to medicines and how do we look at this holistically and figure out yes, the cost of drugs is certainly a factor, but what are the other factors and maybe some that we can address collectively or that the US can help countries address in looking at getting the approval process, using science, eliminating counterfeits or we don't even like the word counterfeits as you pointed out, some people use that word perhaps incorrectly, but falsified drugs or mislabeled drugs and in being sure that our goal is access to medicines and people who need them and using the research for best patient results, not simply putting the drug on the market or publishing the article about it. What to do after universal health coverage is achieved with the role of ministries of finance, of the multi-sectoral needs for health, global health security agenda is addressing some of that and realizing that there are a lot of stakeholders in having a health system that works, including people who are worried about bioterrorism and people who are worried about demography of the workforce and so on. One of the again areas where I think we need to rethink as part of universal health coverage is that health is an investment, almost every ministry of finance sees health exclusively as an outlay, this is an expense for the government and how do we minimize that expense. I think in looking at it as an investment, certainly in prevention, behavioral prevention for non-communicable diseases, early detection, better surveillance, better lab, better diagnostics and lab work, that all of these actually are cost effective interventions and that paying for them should be something ministries of finance would embrace and would want to encourage, but we almost never have that dialogue. I give Jim Kim a lot of credit for having a health finance dialogue every year at the World Bank meetings that are coming up next month and I think this is gonna get even more intense as we're looking at that question, health as an investment, retain, build, public sector facilities. One of the problems in the Ebola response, again, it's a little free association here, but one of the problems in the Ebola response was that government's initial reactions were for their health ministries to see this as an outbreak which the public sector was going to respond to and WHO, for better or worse, enabled that response by being embedded in the health system and talking about a public sector response. In fact, in the countries where it hit, it was non-government organizations, especially Doctors Without Borders, but also some other missionary and NGO groups who provided the bulk of the care, bringing in experts like CDC very early on to look at an incident management, a multi-sectoral kind of response, anthropology, behavior, how do you deal with burials, how do you deal with isolation of patients and family responsibilities? All of those were largely ignored because it was seen as something that could be done in a health clinic. And I think as we broaden our view, again, health as an investment, but also that there are a number of things that contribute to better health that aren't necessarily done in clinics or under the authority of the Ministry of Health and we need to build those in. And that, I think, fits right into the mobilizing of domestic resources. As I mentioned, we think, and I'm not sure how many countries have realized this, but that this ambitious sustainable development goals with 17 goals and 170 maybe more targets is essentially gonna be the responsibility of each government. This is not going to mobilize a huge, or a quantum jump of additional development assistance for achieving all of these. It's good to highlight so many things, but governments themselves are gonna have to prioritize. The good news is that in the global health sphere, the biggest increase over the last three, four years has been in national contributions, including in the poorest countries. That's for the AIDS response, it's certainly been true. But across the board, governments are looking at, the Buja Declaration are looking at their own demographics and health challenges and some of the attention that's being paid to global health and we hope leveraging by our own resources has had many governments take another look at health and PEPFAR is certainly, Kenya for instance, has systematically increased the amount of public sector coverage, the middle income countries, Botswana, Namibia, South Africa, Swaziland, Lesotho, are paying for their own antiretroviral drugs. They're not coming from U.S. or global fund anymore. So there's a lot of good news on that front, but there's no question that that's gonna be the biggest challenge of the next 15 years is how are we gonna mobilize those domestic resources? Thank you very much. We're at the end of a very rich day and we owe many people thanks. Nellie, Bristol, thank you so much for all of your leadership and intellectual input and organizational savvy in pulling all of this together. Sahil Angelo, partner with Nellie in pulling this all together. Addison Smith, Katie Peck, thank you both for helping us here and to all of the speakers. Ambassador Coker and all of the panelists and moderators, thank you so much for coming to make this happen. We're really very reliant on our friends for being able to have this sort of rich and dynamic conversation, set of conversations. And I hope we can reciprocate in some fashion down the road to all of you. So please join me in thanking all of these folks. Thank you.