 Welcome to CSIS. I'm Steve Morrison. I'm senior vice president here and director of the Global Health Policy Center. Welcome to CSIS. We have a great program this afternoon. I'll introduce our keynote speaker and in our keynote discussant momentarily. I just want to offer some thanks to people who put in an enormous amount of effort to pull this together and also welcome those who are with us online. There's over a hundred people online here today as we gather to to hear about the financing Global Health 2013 report. Lindsay Hammergren, Catherine Stryphill were particularly integral to pulling this together. Thank you so much. Alicia Kramer, Breonna Bacchus, Chris Melard, Travis Hopkins, Annie Anderson, Joe Jordan, Carole Schroed, Jesse Swanson. Thank you all. From the Institute for Health Metrics and Evaluation University of Washington, we were very happy to work with Catherine Leach. Come on throughout the organization and thank you very much Catherine for all of your help. And there's a number of other staff from IHME here today and thank you for joining us. We were very honored to be able to to have Chris come here today to talk about this new very important piece of work and as we'll hear it's an optimistic argument. It's a case of resilience in the face of austerity. It's trying to unpack what that means and describe what it all is about. And we're here today really to talk about to hear that presentation and have a conversation around what the policy implications are. Particularly in this environment here in Washington DC where budgetary issues remain a very serious matter of concern and this is about money. And when I told Chris that you know the overwhelming response over 300 RSVPs and 150 online and that he must be approaching rock star status to be coming in that. He said well maybe but it may be that the fact of the report is about money and people come when we're talking about money. But it's a very important piece of work and it blends together the kind of innovation and analysis that IHME has has become known for and famous for under Chris's leadership and that is trying to blend together ever better metrics around around financing and in this case match it up against the data from the global burden of disease and to ask a bunch of hard questions around where are the trend lines in the financing and how do those match up against what we think of as the as the requirements and demands that the actual burdens of disease present. Chris Murray is the professor of global health at the University of Washington. He's the Institute Director and Founder of the Institute of Health Metrics and Evaluations, an institution that before it was founded we were really left with far fewer options in this kind of in this kind of analytic data and so he has driven forward both the global burden of disease approach but also the approach around dallas and really had landmark impacts in these in these areas and we're very pleased to have him here today. He has you have his biography here. He has a very distinguished history of working at WHO and working at Harvard and and now out in Seattle. He's both a physician and a public health expert. As a as the lead off discussant for this session Chris is going to come up do the presentation for about 20 minutes and then we're going to sit and have a conversation and we'll turn to Ariel Pablos Mendez to kick that off and Ariel is familiar to to many if not all of you here. He's the assistant administrator for global health at USAID been there for two and a half years. We're very fortunate that the Obama administration was successful at recruiting him into that position. He came to us and from a very distinguished set of accomplishments pioneering work at the Rockefeller Foundation particularly around the transformation of health systems an area that requires that sort of energy and creativity and intellectuals and dynamism that Ariel has brought to the task here and infused AID with that. He's a board certified internist and until recently was a practicing physician at Columbia and as a graduate of the University of Guadalajara School of Medicine and an MPH from Columbia University. So please join me in welcoming Chris Murray for the opening part of this. We'll cut to the audience fairly rapidly after we've had an initial round and please jump forward and offer your comments and questions. So thank you Chris. Thank you very much. Thank you very much Steve for those overly generous introductory remarks not for Ariel but for me and it's my pleasure to speak about our work at IHME on Financing Global Health. You all have the report. It should be clear right up front that my role here is a sort of talking puppet. The real work was done by Joe Diehlman our faculty lead on health financing and the team that works with them and we heard also already about Katie Leachkeman who played a key role. So two slides on definition and then I'm going to switch over to what I think of as a more modern way to present which is with one of our live tools online which you can all access on your smart phones and when you go back home. So we use some terminology that we should all be clear about because it'll always it'll come up in Q&A. We are trying to track money flowing essentially from north to south that's for health. Our definition is different than overseas development assistance because we also look at private flows about NGOs foundations private contributions. We also try to avoid double counting which is what makes this task rather time consuming and not hugely fun to do because we need to go through the financial statements of all sorts of organizations to trace flows because we're all familiar with money going from USAID to Gavi to back to UNICEF and back over to somewhere else and so we have this huge set of cross flows that we try to disentangle. We use terminology around source and channel which I'll speak about in a moment that will also well it's here on this slide which is to help us with the double counting and help people think through USA US government role as a direct bilateral donor versus its funding that goes through the global fund as an example. We talk about the channel of assistance which is the last or the penultimate holder of the dollar before it goes to a activity dedicated to health in the developing world and then the underlying source. So we'll show you both types of information and that's an important thing to understand. We also are looking at the recipients which are the implementing institutions and sometimes the same institution will show up in these different bundles because somebody may be a source of channel and an implementer and that also complicates some of the analysis. This is our fifth of these reports and I think with each cycle the methods get better. The data has gotten richer. We've been able to add much more detail about the analysis of NGOs this time round and so I think the value of this has grown but it also means that we go back each time and recompute the time series. We also update into real dollars that are current. So that's why each report is stands on its own and provides a coherent time series. Okay, so let's see if this is going to work. We're going to go to our browser. This is live so available for all of you to use and I'm going to walk through the main results using our new financing global health online visualization. So I'm going to start with channel. And the thing to be aware of is that when we look at channel the data goes right through 2013. We make using budgets and historical budget execution data. We make estimates right through 2013. When I'm going to show you source it's only through 2011 because we need to have the fully audited financial statements published before we can do that sort of analysis. Bottom line story is that assistance for development assistance for health has gone up from around 6 billion in real dollars in 1990 went through a slow period of growth to around about 2001. The decade of rapid expansion all the way up to 2010. And then we've had this period of sort of bouncing around and slow growth back in the 1990s rate of growth since 2010. So the global financial crisis where I think some people expected this curve to sort of drop off a cliff didn't occur. And we've actually seen the resources continue to grow. Now here's the allocation. Remember this is by channel. This is US bilateral huge big role. And I think you can see the shift in the composition of funding if our tool work. There we go. I'm shifting to a percentage view just to make some points on the change in the makeup of funders. So the bank and the regional banks both IDA and IVRD windows are in the gray colors. And the bank as a percentage was much more important in the 90s and early 2000s. And although they've grown in absolute terms they're a much smaller player in this bigger 30 plus billion world that we live in. The expansion of global fund and Gavi is very clear as a new channel. The decreased importance is a fraction of resources from the early 90s of the UN system. Increased growth in absolute terms but dramatically smaller share of total resources. And then the expanded role particularly in the last 10 years of US bilateral sources clear in there. Now I think there's a lot of interest in recent trends since the crisis and that's on the right hand panel. And with this slider here we can actually move first back to the whole 23 year time series. And you can see where the absolute expansion in different funders is being. Notice that France in the 23 years is actually down and all the other funders are up over that time period. And if we then focus in the most recent time period you can see that we're getting by channel global funding has maintained its volume and gone up slightly because of big increases in flows through Gavi and global fund decreases through the US bilateral window and increases through UK bilateral and then also the capacity of NGOs which is both US government money but money they've raised themselves. Now you can see that distinction if we go to source. Let's go back to the seeing the numbers. I'm sorry. There we go. So again only through 2011 where we can break this down. Here you can see the full US contribution 11 billion in 2011 as opposed to the 8 billion in 2011 that was through the bilateral channel. You can also see the evolution of both US expansion. And if I shift the ranges here on this diagram so we can see the percentages over the time period you can see counting all flows the expansion of global health very strongly linked to the expansion of the US in absolute terms but also important contributions from the Bill and Melinda Gates Foundation over that period from Canada from Germany and of course the UK. When you see this in percentage terms I think probably no surprises. Not sure why am I but there's one thing that you would miss in the absolute numbers that I think is worth drawing attention to and that is the shifting role of some of the bilaterals. So here as source goes if you look on the role of Japan 3% now and back in the 90s it was a much bigger player is actually as much as 8 or 9% of the total role. So Japan's role in bilateral funding for global health is also being shifting over time percentage terms. Okay going to the regional view on this tool we can also look at the patterns that we see. I'm not sure if it's the internet there we go. So here we break down where we can the allocation of funds by region. So here's Sub-Saharan Africa South Asia East Asian Pacific and then you can see Europe Central America etc. And you can see the big expansion of funding into Sub-Saharan Africa over the longer period. And if we focus in on the more recent time period post the last three years for example you can see big expansions in Sub-Saharan Africa have continued. Now I think probably some of the more interesting findings from our point of view is when we look at the health focus area. And so a few caveats on the health focus area. When we look at health focus area we're using searches of project descriptions to try to identify what the funds are going for. So it's an imperfect science although it's pretty details in orientation. And what you can see here is the expansion of HIV and pretty leveling off of growth around about 2011. We don't have the 12-13 figures because we need the fully audited books to be able to get this right. The big expansion that's occurring is maternal and newborn child health over this time period. So if I focus in on the 2006 to 2011 range you can see that there's been greater growth in funding for maternal newborn and child health than there has been for HIV AIDS. So the period from 2010 to 2010 which was really driven by HIV expansion has now been replaced more recently by continued expansion around maternal and child health, smaller expansion around HIV AIDS and you can see these comparatively different figures for TB and malaria. Now we can also in this tool do some comparisons that are in the report. And I'm going to explore the relationship here between development assistance and disability adjusted life years from the global burden of disease 2010 study which gives us a time trend of burden from 1990 to 2010. Just a little advertising the GBD 2013 will be coming out beginning next month and rolling through June and July and so there'll be a new update right through to 2013 soon. But this is based on our analysis published a year and a half ago of the GBD 2010. And one way to look at this is to look at development assistance for health compared to Dali's and we're looking in 2011 and I'm going to use the slider on this map to start and focus in on those countries that get the most development assistance for health per Dali which we think is probably the easiest or the most appropriate thing for thinking about DAH and neat. And as we move down the slider here you start to see the countries that have more and more of the funding and they're on the scatter plot which is Dali's versus money they're on the top part of the curve. They're on the upper part in other words getting more money per Dali than countries that are down here. And you know around about this threshold you can see the PEPFAR corridor where money relate to HIV. You can see per Dali that bank loans from the Inter-American Development Bank the World Bank largely and a little bit of bilateral aid in Latin America and the Caribbean is actually large per unit of need. And you can see a patchwork of other countries such as Laos, Cambodia, Afghanistan that show up as having substantial development assistance per Dali whereas West Africa and Central Africa historically Francophone Africa getting much much less per unit of need and you have to go quite far down that scale to see where it's going. Now another aspect of our study is tracking government health expenditure and there's been quite a steady growth of government health expenditure even post crisis. One way to look at development assistance in the light of government health expenditure of their own resources. So this is what we call government health expenditure as source that's from the tax revenue is to compare DAH to government health expenditure. And we can go up to the places where they're equal or above. So for every dollar of government health expenditure from their own revenue sources these countries shown in red get one or more dollars from development assistance. So greater than 50 percent coming or greater than that one to one ratio coming from development assistance. You can see countries in East Africa but also DRC. You can see Liberia, Sierra Leone, Guinea Bissau, Afghanistan and Cambodia in that category. If we lower it down to the one to three ratio you get that pattern. So there's a few other countries where development assistance is really quite an important component vis-a-vis what the government's able to spend of their own resources come down to the ratio of 15 cents to every government dollar and you throw in a few more countries. Some of them you know that you can look at the map and make sense of why either geopolitically or need-wise their major recipients of development assistance. So those are some of the key findings that you can explore. We can also do this type of analysis for example from eternal and newborn child health and we can see where that relative to government spending is actually very prominent and perhaps even on the disease specific basis more relevant is to go to the disability adjusted life year comparison to see where relative to need where are the countries on the MNCH front that are getting the most dollars compared to need. Remembering we include in our definition of development assistance for health the transfers through the regional banks Ida and Ibrdi and that explains what we're seeing over here in Latin America. So the pattern here for MNCH is really quite different than the pattern that we see where resources go vis-a-vis need compared to HIV A's or again just to zoom in on where the contributions are the greatest. Per unit need you get some unusual recipients on the HIV front and I think there's other ways that I'm sure you have seen that try to quantify that. That yes the volume of money as we saw earlier per dally is going in the PEPFAR corridor but if you think of dollars per HIV dally there's some places that get quite a lot compared to need. So let me actually end there on this presentation. I think what we're hope is that this tool is both giving you enough information to get Ariel going with some comments and also that this tool is online now and hopefully a resource for everybody to use. Hopefully as engaging as the well-written report but maybe more fun to play with than flipping through the report. So thank you very much. Thank you Chris. A very intriguing tool. In the report you know your your main proposition is that we've seen a surprising resilience. We've seen almost 4% growth last year bringing things over 31 billion. You try to identify on multiple transitions that sort of drive this process forward. Donor resolve the force of MDGs. You track pretty well that there's a stalwart core of donors that are that are there right. The USG, UK, Bill and Melinda Gates Foundation that sort of offset the weakening of others. You bring forward that the Global Fund and Gavi Alliance are showing surprising strength and ever greater strength with the support of their major funders so that in this sort of decade after the decade of explosive growth the multilateral instruments these instruments are sort of hitting their stride and even after having some serious bumps and becoming it's becoming a more multilateral world as part of this. And you make some surprising points about the NGO contributions that okay the Bill and Melinda Gates Foundation's at 2.2 billion but that the in the rear of your report you enumerate the big muscular American and non-American NGOs are bringing in non-official dollars that total of 1.7 billion and you add in another half a billion of corporate contributions. Very interesting and then perhaps most important that the surge of funding into the maternal and child health channels that it now is higher than HIV. The HIV is planing off but a really remarkable shift that has happened. Now unpacking this and understanding what the policy implications are when is really what we're here to try and talk to and Ariel could you lead us off with some thoughts about what does this all mean. Well thank you Steve thanks to CSIS for bringing us together on an important topic and it's really a great great report thanks Chris for your leadership all along the intellectual leadership you were saying I'm just a puppet of the guys who do the work but actually they've been doing the work that you designed over several years and put together very carefully so that we can all really fantastic tool also that you have now as you have shown here so thank you and congratulations it's particularly good to see that you have been able to normally develop a systems to get the data through all of those channels and complexities but also fully utilizing the national health account in which you also play an intellectual role and where USAID the bank that we show now gates have been playing important role getting these things rights is almost as important as the epidemiology or the health systems dimensions measurement of which Chris has made a name in and is of course paramount and it has been a signature of the field of global health compared to other areas I think we do particularly well in terms of getting data and the data is never perfect but we've been able to to to get better at it starting from the population service fertility service of the 60s and 70s and then demographic service and national health accounts and so many beats of that that give us an advantage in defining problems solutions and progress as we have seen here I think that I was particularly interested in your last bit on on the distribution of assistance given burden of disease which are two pieces you understand very very well I was stricken I was asking why is there so much MCHDH in Argentina so we we put nothing there but it's like the one thing that crosses all your your lines in your system a there are many challenges it's just technically which you mind issues of inflation issues of sometimes we contribute in for example in Western Africa more to regional mechanisms in part because some small countries may not have a full office and so on and also as you exclude humanitarian efforts that sometimes also include health nonetheless some of the countries in conflict or failstays where we do more health through humanitarian means than to the ones that you cover it may give you maybe there's a way for in the future account for some some of that and I see Wade or my deputy who oversees every year we are trying to always align our investments indeed with the greatest burden of disease in go to this exercise regularly so again this is very very useful but back to the piece your methods that Steve has made I think this is indeed fantastic numbers for for global health despite the recent recession in around the world no cleaves as Chris noted and I think that some people will claim that during eras of austerity investing in people investing in systems is even more important than that when you are thriving and so we really appreciate the fact that the US government in with strong bipartisan support has continued continued to support our work in in global health particularly both for the global fund for history malaria which we have really revamped our investments through the global fund as well as in the area material shall help where the overall global community and USAID and the president has really stepped out the plate in terms of making a priority and if you add malaria which has also grown very much in this area to the mch pool malaria is mostly about saving young children's life so I think we are in good shape for that for that new area of importance and on the whole I think the optimistic picture that you you convey here in terms of these numbers is also a a marker for times we are in a great time for global health both in terms of the resources that we continue to to get there all of you working of course in this area the results we have been I mean 10 years ago we could not have imagined neither these resources nor the results we were just everything was learned by AIDS in states have come a long way and that's invite us all to imagine even bolder possibilities like an age regeneration or any preventable child maternal death which as the last commission reporting December invites a possibility of a grand convergence in life expectancy between rich and poor nations I grew up in Mexico where life expectancy 1950 was 44 and the US was already 20 20 years higher 20 years higher and the US has grown another 15 years of life expectancy in this half a century so some of the 35 years gap in life expectancy from one corner to the other of this period between Mexico the United States if you erase AIDS from the world life expectancy will probably increase by two or three years so 35 years when Mexico has gone to that grand convergence and it's now only two or three years behind the United States so certainly these bold possibilities are already taking place we don't need to imagine them they are taking place and of course we have a lot of work to do still in areas where this is not the case uh and an important thing is this is the policy still is that as we are succeeding in Latin America and parts of Asia and Europe even if our budgets may seem to be flat we are actually bringing down resources from the missions we are winding down which have been like 25 missions around the world and actually increasing the resources even during the last five years in countries priority countries for our agendas in Africa and South Asia so even during this time our missions are enjoying an increase in the resources for the countries where the need is greatest uh a but also I'm very happy that the report has a chapter if you get to read through it on governments local governments investing in their own health and part of the narrative in this period at us ad is that of an economic transition of health where success in economic development also unprecedented in our history is leading to growth in health spending shows locally and the report captures that's that very well and is very good in the concept of crowding back in some areas we crowded out governments maybe in some of the darker countries of investments versus government or the or burden of disease we crowded out some of the local investments and we are now seeing some crowding back in by local governments which is essential for country ownership for successful stewardship and for long-term sustainability but something that we also know from many other analysis is that as countries do move from law to middle income a DAH withdraws or gets diluted and that's natural is to be expected and we should also expect the governments to fill the vacuum left by the age and that does not seem to happen when countries move from law to middle income countries and you see a filling in with our pocket expenditure later on as countries move to the upper middle income status the public financing for health begins to increase again but we have this ditch which is predictable in the financing which is dysfunctional in the financing of health in countries so as we are succeeding with development of we are succeeding with countries being able to have more local resources making sure that the public financing and the organization of those resources away from the out of pocket dysfunctional and inefficient and regressive ways of financing and that requires a different mindset than the disease by disease focus that we often take in this area so there's been a great conversation now taking place globally on mobilizing domestic resources for health and I think that that's going to gain more and more momentum as we discuss with many of our partners even the way we some of our partners intermediaries work in this new financing landscape means new sources of financing will become available to them as your business models evolve and this will be particularly important as many countries in the developing world are increasingly having bold goals of moving towards universal health coverage and that can only happen with increased mobilization of domestic resources this economy transition of health is also important because some of the of those countries like bricks are still not spending enough in in development assistance compared to the proportion of the economy in the world they already represent and so they are now beginning to move we certainly want to nudge more of that in the future as an a new fresh opportunity here but also because of this growth it means that most of the poor patients that were in low income countries are now finding themselves in middle income countries so local resources in those middle income countries become more important to still achieve the goals that we will have for for global health but it is the case that in many poor countries particularly in Saharan Africa even in the next 10 to 20 years those economists may not be able to afford the basic package of health services and even in Africa where maybe 20 countries in this decade are reaching middle income status that means the other half will not and will not even into next decade and that means in those places it will remain a challenge so the need for us to continue to invest in global health particularly in those countries remains very strong but also the need to make sure that since many of them will not have enough to buy the basic services that the health systems are there to provide maximum efficiency in the delivery of resources they do have even if they are insufficient on the one hand and second that we all continue to invest in innovation to make sure that those packages are cheaper and simpler to implement in the future otherwise it will not be an easy task for many of the poorest countries in Africa so we do see optimism because even in Africa excluding so Saharan Africa growth has been like 6 percent a year the fastest growing region in the world so there are many possibilities here for a future that will be different than where we were 10 years ago so I remember your optimistic Steve about the overall enterprise of global health and about the support that the USU will continue to have for global health thank you Chris would you like to offer any thoughts what Ariel said I mean no I think I largely agree with Ariel said I think you know we've had just back on the first comments about what's in the envelope what do we describe as development assistance for health we've had a lot of debates over the years about do you or do you not count humanitarian assistance and I think the point that there's sometimes development assistance for health that goes through those vehicles is a good one it's sometimes hard for us to sort of be able to disentangle what's just straight you know crisis intervention versus actually about health I also think that there's a theme about central Africa and West Africa that will remain with us for a while because when we look at outcomes that's where the biggest laggards are in any vision of radical progress in the future which is if you take current time trends and say who's the most at risk of still having high child mortality or high maternal mortality it's really central Africa and West Africa a few other fragile states and so I think there is a message here about money and a vision about grand convergence for example that might need a strategic rethink about how much the world spends in these very poor places that have not been receiving as much as others Chris, I was trying to enumerate what the most powerful impressions were from your analysis and I just wanted to quickly just summarize those and ask your thoughts and Ariel's one thing that jumps out is that in a period of austerity summits and replenishment processes really matter even more than they did before I mean when you look at the surge on maternal and child health there's the London summit you look at the Abu Dhabi gathering on vaccines you look at the global fund replenishment we're now in the midst of the early stage up to Gaviolats these become very important tools in sustaining this growth and second is you make the point that U.S. leadership remains very essential in partnership with others that $11 billion number that's put out there is a powerful number as a portion of $31 billion total you also make the case that it's very concentrated increasingly concentrated on Africa and the other big powerful another big powerful impression is that the NCDs remain the big exception they had a summit it didn't work they had WHO aspire to do more than it faded Bloomberg took on the tobacco agenda then began to scale back it's not grabbed in in a way the gap between what happens in that sphere and other spheres by your sort of between the lines in your analysis that gap seems to be growing which gets me the last point which is the your point about trying to look at dollars against dallas and the burden of disease is that there is some some serious misalignment that may look at may look irrational in a way but but requires some political consideration NCDs the fact that the lower and middle income countries have such an ever greater share of the poor and those with the burdens of disease but don't remain the major clients for our programs the systems work which remains a paltry investment along with the NCDs and as you point out areas like west africa central africa which are screaming out for more attention but which are which are not given the same level of prioritization as the as you point out this sort of pep far corridor can you just talk a bit about okay when you look at that picture it's a mixed set of impressions what do you make of that in terms of the message that you we would want your audience to take away on policy I mean how does that add up to a so what question okay you painted this picture now what are we supposed to do I think when you paint a picture part of what we're trying to do is to reflect back the totality of where people know well bits of that picture sometimes they miss the total picture and I think there's a value in a lot of what we try to do of just saying this is what the evidence says about money about disease burden and you know it's for sometimes it's for people to sort of say well that's different than what I thought and so often you have that reaction that when you paint the total picture it's it's not what in a particular area people had as the base for their dialogue and so I think there's a value in that stepping back if you look at the where development assistance of health goes or any development assistance there's lots of factors that go into that there's political factors there's you know prioritization for the poorest there is areas where you think you can make the most difference you know I always resist a little bit the temptation that people have to say take you know the dollars per valley for HIV for TB for malaria for MNCH and for NCDAs and say they should be equal of course they shouldn't be equal because we can be more effective at some of those programs they're harder to fund nationally and success breeds success you know we should we've got to remember that the success of ART rollout and PMTCT has been part of the fuel for a whole global health expansion so that's sort of why I think you have to think of all those other factors when you look at those but it's also useful to put up the empirical fact that there's a lot of growing and CD burden in low and lower middle income countries and their governments in those countries are yet to fund action in a way that seems commensurate with the problems that are emerging is that going to change well it doesn't look like it currently and I think that gets back to how hard it is to convince the public and broader groups that special attention from the north is required to deal with those issues in the south are there any thoughts particularly on the NCDI? On the NCDIs we have been having a lot of discussions as you can imagine we all see the data and we all agree that this is an issue that we claim or sure have more attention and support and USAID has a lighthouse strategy making sure that our measurements for example in DHSs we'll have a model for NCDIs so that we can at least begin to support the the description of the problem and so on has always been an important part of our strategy we do a lot of things including some immunization programs that also tackle NCDIs, cancers and so on and our health systems work is systemic and so we believe that some of those investments will help countries deal with the patients will come with also things to the door I do think that given that we had a summit as you pointed out and that I'm impressed how far because of the data the leadership has come in making that agenda visible and at the same time is paradoxical in the calculus of the policy of budget Steve that the economic freeze that we had a few years ago in a way I thought actually was an opportunity for sombre thinking and it did it has triggered sombre thinking in our agendas in how we work how the global fund works so it has been healthy in that sense to get it right some form here tightening it up on the other hand such environment makes it hard for a new agenda to break through with a large significant programming without taking away from the other things that we still are halfway so that's made it a challenge a policy wise and I I would I would think that countries themselves will probably invest more in proportion in the NCDs we measure that than the the age in that balance in that until the economy is improved in the donor's countries we may not have the opportunity for a big, big program I I also think that you're right about health systems being buried in the power of graphs here but it's actually been growing in the last five years and it's grown fast just like the NCDs have grown fast but for a small from a small base and with health systems investment I have to add now that I understand a bit how money flows to our system at least a lot of investment has been made that it's accounted under PFR for example on health systems strengthening from the first five years of a vertical delivery emergency to the second five years where PFR built a lot of efforts with governments in local capacity in many of the countries who were so there's a lot of that health systems that may be harder to disentangle in the way we currently report that may give us a bit more optimistic sense of where we're going thank you I'm gonna I'm gonna ask one question around the optimism and then I'd like to turn to our audience for some comments and questions my question around the optimism is throughout the document you you lead the reader to believe that we're on a we're on a very promising trajectory that the bank that global fund is going to rebound and continue to rebound that the fundamentals that you've identified which are driving this resilience will stay in place just to be play the devil's advocate here sequestration is not over we still have a a major looming problem that's going to put continued pressure on the U.S. the global fund when it was able to when it had its replenishment in December the 12 billion that it that it achieved was significant and promising but it was really the sort of minimum necessary to preserve credibility and it was far less than what people had hoped for and the the the the the problems that other donors are having and coming forward is now constraining the U.S. ability to bring forward the full amount right and Gavi you know as you point out Gavi benefited from at the summit a major infusion coming from the Islamic Development Bank that may be a one-off sort of thing it may not be but I when you look at these and unpack them you could make the case that there's still a lot of good reason to be quite cautious about the fragility of all of this and so I wanted to throw this back and ask you you know is the optimism that's so fundamental to this is it a little mis overstated do you think so if you go back to the financial crisis you know what happened in 2008 well you know people who hadn't looked at previous crises said oh you know we're gonna fall off a cliff and of course the IMF correctly pointed out that the peak fiscal impact of a crisis is you know four to five years later so you know they confidently and I one of our I'm one of our advisory groups was somebody from the IMF and they said you know wait and see and so you had these two different stories you had the global health people in panic saying you know the funding will dry up and I think in when we saw a peak in a sort of small downturn you know I think people thought that that was the the early signs but if the IMF's right 2013 should have been the year of the worst effects of the financial crisis given past history and so in my mind the fact that we we through you know complex mechanisms shift to multilateral funding and the role of the UK the fact that we didn't see that downturn I think it's a good sign I mean our is it can the world shift away from development assistance in general from development assistance for health surely so I think it's a constant issue and one shouldn't take it for granted what's happened in AusAid you know is a is a cautionary tale that you know you can pretty abruptly see major changes in funding so all right yeah well thanks it is a very fair point both in the US and in the rest of the global Donald's landscape with the global fund which has turned around I mean there was almost a coincidence of where things were with the fund and this management and the possibilities there's been a turn around no doubt in and yet and yet the fully matching of the two to one matches pected by the US Congress is still something we need to work is not is not a given and so we need to work and make sure others also come through the global fund in this area and on the US side here on the hill itself is still not there we it's still a dance as you say we still have to make the case we have to I mean the Congress has been given the circumstances quite generous and the president has to be has been trying to be careful of course because of the the whole situation is not totally we're not out of the woods yet and so I think that and that's a case in point with 2014 budgets where the Congress actually gave us more than we asked and and in a way of 2015 was based on the 2013 and so it's it's an interesting dance for us to try to be sensible given the situation in and yet at the same time the results the case that's been made continues to engage the Congress I certainly hope we'll do the same in 2015 thank you I'd like to invite some comments and questions from the audience why don't we we'll start over here we're going to bundle things together you start down in front Carl and Deborah and and then we'll come back here please identify yourself and and your organization and please be brief thanks Steve Carl Hoffman President of Population Services International PSI been a rich conversation already thanks very much I don't think there's any organization that's been more influenced by the work of IHME and Chris than my own because we absolutely use dallas as I think many of you know to to track our progress and to they are our retained earnings in a sense we are trying to optimize and maximize dallas it's a it's a line that runs through a conversation every day at PSI so we thank you for that the companion piece I think that you alluded to at the start of the conversation the global burden of disease data is also you know profoundly important I think to this conversation and I think the mismatch between resources which I agree are robust and about which we should be optimistic and happy the mismatch between the resource picture and the burden of disease picture is still significant and growing and I guess I would build on on Steve's comment really to say I tend to be a glass half full sort of guy but this optimistic resource picture is in a way a little bit fragile I think both Ariel and I I think we're probably at the breakfast around the global fund replenishment that took place up on the hill and there was a there was a parade of members of congress who came up to speak at the lectern about how proud they were to have been associated with the fight against HIV one after the other in the back in the 1990s talking about great moments of leadership around HIV from the 1990s well that's been great to mobilize the U.S. political commitment to development assistance for health but it's still sort of doesn't respond to that burden of disease that much more complex burden of disease picture and I think it's a real challenge for us all to do the educating necessary to shift the resource flows more toward what we know is killing and sickening people I guess a comment then thank you about your reactions Debra hi I'm Deb Derrick I'm president of friends of the global fight so I work on global fund issues and my question is in looking at the charts that you put together Chris and the allocations given to various diseases there was an increasing proportion given to unallocatable section or other so I'm curious to know what and it was a substantial growth over time so I'm curious to know what's that comprised of but it was up to about 18 percent there was a hand in the middle here hi I'm Naina I'm a graduate student at Georgetown law my question was regarding your opinion on the participation of funds like the global health investment fund which essentially functions much like private equity fund when it gets private contributors and goes ahead and makes sustainable investments into green field projects possibly to finance medical trials development of drugs global health infrastructure etc what role do you think going forward structures like those can play in financing global health could you just hand that over here please and we'll come back we'll make that our first round we'll move over in this part of the of the room momentarily yes please hi I'm Joanne I'm the president of the Center for Global Health and Diplomacy my question was to Chris following up on Deb's question of resources you cannot track we have private sector donors that are donating now over half a million dollars and it's not recorded and it's very much under the books I mean how do you track some of that it's you know affecting the global fund the global fund received I think two million dollars over the past year from Middle East private donors so I think that's a big sort of variable that needs to be tracked at some point thanks okay Chris you want to so I hope the IRS was listening to that but let me take the last one first joking aside we do capture a lot of private contribution I think Steve alluded to the fact that NGOs are able to raise in addition to government money substantial resources from private donors and so as long as they're in 990 tax returns we'll find them and so you know it's more about the universe of the entities that we include so there's probably some academic centers or policy centers that may not be on the list that we are trying to track and each year we try to you know incorporate so this year for example we're able to capture some of the international based NGOs whereas in the past we trust track US NGOs so we're getting better at that but where we can we get from the tax returns because you know people do have to report their taxes now and you know anything that's going through a channel like the global fund we're picking up and that's going into those the source and the channel numbers I do think there are these other groups out there that we can increasingly improve and add as we go forward on the unallocable the dollar amounts are going up but the percentage is actually going down so we're actually pretty pleased with the fact that over time data is getting better we're getting better reports from some donors that in historically didn't give you much detail and so I think transparency and accountability is improving and our capacity to shrink the percent unallocable is going down we'd love it to be zero but it sort of reflects the state of data I mean there's some groups they're super transparent about how they spend their funds you know DFID online database for all their projects and then there are other donors that it's really quite difficult so I think it's also a bit of a demand from the users in the community that seems to be pushing in the right direction that that percentage is moving down to the question about alignment between burden and dallas you know I think it's a really interesting one but the thing to me that that's the probably the most could be one of the more important turning points is what happens post 2015 like where is the role for health in the post 2015 agenda and is the post 2015 goal for health if there is one we all hope is it framed in a way that simultaneously has a broad view but also is you know aspirational and motivational so that people are excited about it and I think there's their real tension there because if you want it to be reduce the burden or you know prevent death and disability yes that's the right thing to do but it's hard to get hearts and minds that way and continue resources flowing so I think how the world navigates that really key moment I will have a big influence on the trajectory for funding did you have anything to say on the private equity oh yeah I mean we've actually been trying to talk to various groups about the whole general movement about social investment funds and you know there's a number of active groups interesting you know some of the bigger banks have got some interesting advisory work on that so we're starting to try to get our hands around the whole area around social investment funds so not much say yet but something that we're it's on our radar are you on your staff yes on the on the distribution resources per dalis I think that as I said we are very mindful of that and looking at at it and I I do take the point on central Western Africa where we've been discussing a lot again and how we progressively achieve resources there technically it's important to know that again some of them maybe the poorest or frail states as a humanitarian issue we have sometimes regional approaches to the budgeting and it's hard to maybe it's in the unallocated part that actually goes to those countries predominantly and we could check on that likewise in some other countries it is a dance between the ODA and the local expenditure so the total expenditure may not necessarily be suffering because ODA is there so maybe there's a healthy engagement of domestic resources where you will suggest that maybe we are under investing so these are all those issues and and then in there's the regional politics and it's less so about geopolitical alignment of budgets it's really more about champions there's the people who work in in Latin America and the Hill and they want to make sure that they're not looking at dalis they they simply are saying we still have people that in here we have ill people here I mean they they see their problems and so they're not looking at dalis they're not looking about geopolitical rational they're simply saying don't don't take all the money away from Latin America don't take all the way the money away from Central Europe and and then of course when sparse happen as we have seen recently then people say well there's also that rational that perhaps is indeed a healthy thing so the dalis will never be perfectly aligned even if they were perfectly technically measured but we should continue to do more I think that Western and Central Africa is an area where we we can do more if we're not doing it through the regional mechanism and all global investment funds and private sector I think the private sector will be more and more important in some of those resources may be harder to account because many multinationals may be providing now investment direct investments they provide services that may or may not be captured may not be accounted clearly as the age and yet these are predominance of the resources will be flowing in that way we we don't have enough of a handle on direct investment in health and it's an area that probably will grow in the future it's not been traditionally big but it's important and when we look at pharmaceuticals the area that perhaps is the most familiar within this in this sense we look at the markets growing in Africa where today maybe all of the the age on commodities pharmaceutical commodities may be it will be good to measure it but I think we have a sense to be four or five billion dollars and yet the market there might be closer to 20 billion already and likely to double by 2030 so the private resources and shaping those markets that will seek efficiencies but we can help shape them for equity for quality building institutional capacities regional classrooms so it offers a new sort of opportunities for our DAH because it will be required to shape those markets but with greater leverage and I think market shaping is emerging as a great opportunity for our work thank you there was a very flattering piece in the New York Times today about AID and an excellent shot around these changes that are underway yes market shaping is great credit guarantees is working to leverage a lot of resources so that it brings its moods the planning and prevents stock house and so on or you might decrease the price of many commodities in implantable contraceptives or in the case of the New York Times piece today how GE can contribute with some credit guarantees and equipment for the Nelson Mandela Hospital in South Africa for example let's take another round here behind the women in the green green jacket there please and then there's two other gentlemen right in front yes please we'll do another round and then come back yes men hello my name is Mohga Kamaliani I work for Oxfam and I just want to thank you because it's a series now and we wait for your report every year so basically we're chasing here or we're tracing rather the quant sorry got hearing aid and it's just sorry so we're tracing the quantity of aid what we also worry about is the quality of aid still quite a lot of aid is short term so therefore as I'm looking from the other side you know not the donors recipients being one of a citizen of one of those countries so basically short term so our government cannot invest in long term solutions like you know strengthening health system which we all talk about this is not like saying we vaccinated five children which we can hit the media and be not to say that vaccination is not it's not important of course it is so that's the first thing the second thing it's still tie date it's not perhaps tied in sense that American money buys American cars or UK money buys UK whatever dangerous I would say this tie date in terms of the ideas of how you're going to spend this money we released a report yesterday on how the World Bank advised the government of Lusuto on building a new hospital in the in a very I mean you know Lusuto very poor country 80 percent of the population are rural they helped them to build this big hospital the agreement was it's at no extra cost to the government you know more cost than the old hospital what happened is this hospital is eating 51 percent of the national health budget so you know it's just bad advice and my last point is about accountability so you want us our governments to be accountable to who well to donors really but we don't have the donors accountable to us so you know that the IFC of the World Bank is not accountable to the people of Lusuto about the bad advice and measure on that take on that you know other donors we need mutual accountability and we we need to take into account what are the ideas that we have what are the things that we have in our countries so a public private partnership in a hospital is just not working in this country thank you there's right here down in front right here and then across the way there thank you for being here and sharing today I'm Dr. Sam Hancock of Emerald Planet Emerald Planet TV and in a sense following up on this conversation looking at the other side of this of delivery what what is the tracking mechanism to see how that the resources are actually being delivered within country and looking at all levels of government the local area the regional governments and at the national level so that that builds in transparency and also at the same time allow people that have real needs are actually getting the service that donor nations are paying for thank you very much for being here just across the way there please thank you very much my name is Hernan Rosenberg with Global International Health Advisors and previously with WHO and the Global Fund as a matter of fact couple of questions one is I think what you're doing is fantastic in terms of following financial flows however not all resources are financial so I wonder if you have any guess, estimate or idea of what is like you know like the University of Miami flying surgeons to Haiti to take care of people there I'm not sure that that shows up in any statistic anywhere so I wonder about that that's number one and the other question that I wanted to formulate is to what extent the alternative channels becomes complements or supplements in other words to what extent you're doing what at the expense of the other because this is one effect that we had when when we started with the with the Global Fund is that indeed you increase the amount that came from the Global Fund at the expense of something else because you already had the Global Fund so I wonder about that thank you very much let's take one other gentleman right here buddy I'm Thomas Ward I'm an economist I was at the World Bank and other places and I deal a lot with PPPs because I look at sustainability so I'm thinking about the sustainable funds in other places and year after year there's also talk about the growth of global population so the question I have is not only the funds going out but at what's the sustainability and the impact if we are having kids living longer are we going to create a problem down the road Chris okay that's a those are some important questions so on the quality of aid and let me tie that to the last or one of the later questions about crowding out I mean more generally what's the effect of aid and I think and is there you know is multilateral aid or bilateral aid different is disease specific aid versus system strengthening different these are a series of really important questions for which you know we actually have comparatively weak information which shouldn't be the case right these are actually pretty central to what we know Joe Dilman who's sitting in the front here who's our faculty lead on health financing has actually been doing some interesting things on trying to see what we know does happen which is ministries of finance are intelligent very rational decision makers and they see big influxes of money coming for a particular topic they put their resources usually somewhere else and that's quantifiable and seems to be generally occurring I think the really interesting question is the one that that Ariel talked about which is what happens when the aid goes away do they put the money back and they do and they don't they put it back but they probably don't put as much back as they took out and so you know I think there's some very complex dynamics I don't think we really have a great handle on that but I think it's a really important issue to think about the mid to long term and that's sort of you know back and forth and how ministries of finance play actually turns out to be a very compelling argument that aid flows that bounce around actually make things worse and that if they're steady you actually end up with more counterpart funding or government funding in the mid to long term so there's a there I wouldn't say we have clear answers I think the things we know is there's a lot of aid I think you can make a very strong case that that aids had impact in a bunch of areas and I think the evidence is accumulating about impact whether it's maternal or child or MDG-6 but I think the behavior of governments in the mid to long term effects on systems are pretty poorly understood so I totally agree we need to understand more about quality and behavior I think everybody benefits on transparency whether it's in country or from donors and I think the more that there's general calls from everybody in the community whether they're in local communities or in the international arena for you know financial transparency whether it's government or donors everybody benefits both just because that's probably good practice and also it allows different groups to analyze the information feed that into a more informed broad public dialogue and so we're strong advocates for more transparency on the financial side the last one of flows in kind no we don't capture the surgeons from Florida we haven't figured out a way we'd like to in principle but we haven't figured out a way to capture that they don't get reported anywhere and it's extra pretty hard but we're always open to good ideas on how to try to pick up flows in kind we get technical flows in kind so we're capturing the technical assistance from you know the bank or WHO or others of their salaries that go into providing technical assistance so those are captured last on population you know that's a the population story with many people in the room who will probably know more about it is is pretty interesting because if you go out a few years on forecasts populations a big issue in terms of its increasing demand for services increasing numbers of people who need care particularly in some parts of sub-Saharan Africa I think in many other parts of the world we're at the point where you know fertility rates are converging pretty dramatically I mean Iran's fertility rate is lower than ours and yet you go back 20 years they had a TFR five and a half so you know the fertility transition is is incredibly fast once it starts and and we might as much as we pay attention to accelerating or providing population services in sub-Saharan Africa or helping that happen we should also be thinking a little bit out to what are the population consequences of a world where fertility rates are conceivably below replacement in most countries Ariel are you accountable well I had to to answer to that question and the first if I can also add to your point about the crowding out part is not only in terms of who finance but also what do you finance and I think the question was raised earlier about building a tertiary care hospital in the capital city and consuming 50 percent of the budget that has been in many places is not usually the donors somehow their local politics that play out that way in uh and it's not a good thing because it does crowd out all their expenditures that will be for more basics and I think the movement towards universal coverage the progressive passengers of course always call to ensure all all people will get access to the basics because by virtue of doing that there's no money for the tertiary hospital right away and so commitment to that and then building from there as your economy allows is always always a wiser thing we have been moving increasingly all of the the for us the accountability of course there's there is the accountability for us to the Congress and that's organizational accountability but we all work in this area because for us in the end is to see the world be a better place and be a healthier place and when we see that happening in many countries where we are slowly withdrawing as I said before because of success to us that's the ultimate accountability when countries themselves as President Kennedy Kennedy said 50 years ago can stand on their own and take care of their own needs of their own people and I think we are seeing that success around the world in a historically unprecedented way so for me that's the most important accountability USAID has joined the international health partnership to be able to better coordinate with other donors and with the governments and there's been a greater movement now also coming from PEPR on increasing sense of country ownership in USAID we have built that all along in part because in MCH the an area where we predominate in funding we account the USG account for 15 or 20% of the total whereas in HVAs we account for almost 70% including the the money goes to the global fund so we are moving increasingly to that country ownership working with the governments to find the right the right way and on the point of sustainability I agree with Chris that half the world lives in countries where we are now under replacement that's incredible so how the world is actually shrinking and so just from that pure statistical sense if I can as it you need to save those kids certainly but in addition even in countries where you are worried that there will be too many of them that will get old that will get chronic diseases will that be a headache well it's been made clear and I think the the last commission also made a clear case that investing in saving those lives and the value that the life itself and the value that the lives the person generates to the economy is one of the best possible investments there are today anywhere in the public and the private sector or in any sector thank you let's take another round of comments there's one back here and over two over here yes please thank you very much use the microphone please okay my name is Rick Burzon I'm with the NIH and thank you Chris for yet another fine report I have a question for you about the whole area of evaluation uh resources over time are sure to be more limited if not better targeted to bring together the relationship between DAH and disability adjusted life years which is in itself as an outcome tool you know some people use it and some people don't don't and I think that the the that outcome is only as good as the data that goes into it if we had had the kinds of data that you're presenting we probably could have been done a better job when selecting the initial 15 PEPFAR PEPFAR countries that received funding and then over time those kinds of decisions became increasingly political if not at the start so as as you do your work and as your group moves along I think increasingly many of us in government and outside of government want to do as good a job as we can evaluating the programs to which we put money I know there's there's been a constant back and forth within PEPFAR within OGAC of of doing this and there's always differences of opinion and different methods and so forth can you suggest or is this an area that your group is looking into in terms of recommending perhaps some of the most appropriate and optimal ways of evaluating the programs that are funded by outside sources so that we can all get a bigger and more efficient bang for our buck thank you one person right here Brie Brie there's a gentleman here we'll come up to next yes please and then behind you yes yeah my name is Tia Emmerling from the European Union Delegation and I have a question on chart 37 now that that chart shows that after the Paris Declaration on aid effectiveness more and more donors especially European donors shift their funds towards health system strengthening and if you look at that chart so you see it's mostly Europe but it's also Australia, Canada it's also the European Commission but the major donor on health which is the US Bilateral it is disappearing so in fact it gave none in 2011 for health system strengthening I would be interested in the reasons for that decrease of the US government on health system strengthening and now a zero obviously thank you if you could just hand back yes please my name is Jennifer Leopold I'm with RTI International and my question is about the title actually of the document I was looking back at last year's report and it was entitled the end of the golden age with a question mark and then for this one to be the end of the era or transitioning in the age of austerity I just I feel some very heavy eye-rolling from my colleagues in development that don't work in health and then to see the continuing increasing in trends with funding that I'm just kind of wondering what you're thinking was behind the title of this one sir my name is Dr. Latiri I am the Vice President of GIA which stands for global health international advisors a think tank specializing global health with your permission I would like to give a message to Dr. Murray just coming from Lebanon Dr. Karam Karam the former Minister of Health heard that you are coming to Washington he asked me to say hello and to thank you for your help to his country Lebanon Chris and I worked together when he was the ADG in Geneva of the WHO and I was the WHO representative in Lebanon we had so many activities burn the disease health expenditures in fact the government of Lebanon said that don't forget them because what you have done is a true investment now we go to the question we talk about global health today it's it's the universal health health care coverage we think locally and we act globally my question is why you have selected the West and Central Africa and not much about the other regions example South South America the Asia and other areas could you please answer that thank you very much thank you let's take one one other if there are any other comments or questions right here sir please be brief yes thank you Chris for vision, creativity and usefulness more than anything and Ariel for your leadership okay I have a question regarding North Africa and the Middle East there was a decrease of 20 percent between 2010 and 2011 in figure seven what happened there what is the impact of the a political situation and the war in in those countries and that's my my main question and then have you thought in the part of an analysis and interpretation to use for example neglected diseases as a tracer of economic development social economic development and health thank you thank you so I have a question around why the U.S. is disappearing in terms of health systems why the title why West End Central Africa and then why on the North Africa so there's a lot of geographic questions here and an interesting one around the transition title would you like to start on sure and let me just make a couple comments on the evaluation question you know evaluations are really big topic there's I think of it as evaluation capital E where you really are trying to ask a causal question you know what caused change I mean if you think about formally that you there's a counterfactual and you're comparing reality to some alternative state that's hard and people debate and just argue about the methods and you know do you need randomization etc etc I think there's there is something that's incredibly useful in the policy sphere that is well short of capital E evaluation and that's just credible accounting of change so you look at for example the various replenishment exercises that are go on and you know they're always there's a preamble to it which says you should replenish X whether it's IDA or Global Fund or something else because the money was well spent and has achieved the tremendous outcome and if you actually go through some of those you know it's pretty credible but if you go through some others there's just a tremendous amount of disconnect between the statement that are made and the reality in certain countries so you have the paradox that in some case I won't name names that you know there's a claim that this institution has led to a huge increase in X but the trend in X was down in that country and I think just we would be so far ahead in in understanding not of the causal you know academic sense but just in a you know rational accounting of the world as we know it if we had a sort of more universal approach to saying here's the money going into various places from government from people's out of pocket from donors here's the actual real trend and what's a reasonable way to assign that change to each of those actors and you can get better over that I think of that as sort of development accounts and I think we're that's where we need to go and and I'm a huge fan of you know the sort of high end evaluation research we do some of it ourselves but I think the value in the policy sphere just getting the accounting right of where there isn't double counting of improvement would be pretty pretty large to the title you know I am the last person involved in titles to be honest because I have really bad aesthetic sense and I also I'm really bad at naming things so I really you know as long as the title seemed reasonable to me I went with it so I would have to do you know defer to others on the choice of of title the geographic questions you know despite having great fondness for certain regions of the world where my ancestors are from I you know you can't not look at the data and say that there's something huge burden very low rates of progress in Central Africa and West Africa and that's why I keep thinking back to that that there's you know there's there's poor people who are have bad health all over the world and in different places and that's part of the the inequalities agenda whether it's in China or the U.S. or or in Mexico but I think yet the macro level I get drawn to the Central West African case largely because of rates of change that there isn't there's much less progress compared to many other places and so then if you're thinking ahead and you have aspirational visions from people like Ariel that are that are being set as the goalpost then who do we need to help the most to get there and that's where the the focus on those regions but not to underplay the needs in pretty much every country where there's disadvantaged people do you have any comment on the the drop in U.S. support on health systems well I'll make a a definition statement and then I'm sure Ariel will have a comment which is that was health sector support which is a particular mode of sort of you know unrestricted funding going for health sector support so I think there's a distinction there to be made and the other problem there is teasing out you know how much of disease specific programs are for health systems strengthening and I think there's a distinction to be made there as we said health systems actually growing in USAID has established an office dedicated to health systems and to try to advance more explicitly the word that is being done across many of the disease based programs that nonetheless also support health systems but your question is sector is support there are specified support to the sector through the Ministry of Finance in or health and I think there are many many points as to why we don't do a lot of that traditionally or recently first I like some other donors who may not have missions on the ground where when you have that you have an opportunity to really invest in specific areas more so than if you are not present in the country where it's easier than to just support the sector as a whole is just a fact second I think PEPFAR was something new PEPFAR is big it's almost to third of what we do and it was new there was no the sector did not have that infrastructure a decade ago so PEPFAR came in big time not through a system that existed to be to be just invested upon but needed to build first a parallel system but more recently increasingly working with the systems third part of the one of the approaches was the sector-wide approaches that were popularized five years ago 10 years ago I think there have been many lessons as to the virtues of those approaches and even the UK a big champion has now trimmed back some of the approach going forward as I said before we have joined the IHP plus which allow us to be really around the table with the government and with the other donors in at least jointly deciding how we go and although we have actually many examples of pool financing which is not quite swap but we do have many examples of that and increasingly one of the directions we have in our programs is G2G I mean USAID one of the big moves is trying to get more local solutions more local investments including with the local government direct to government investments and we are in a process of doing that there's a lot of preparation that goes to to make sure that it will be done right but philosophically we actually at USAID very much agree to do a bit more G2G the administrator believes we need to do more G2G and we are trying to learn how to do this right for PEPFAR is even more new but with the now country health partnerships approach there's increasingly openness to do more G2G We're getting towards the end of the hour here I'd like to ask Chris to close with just a few thoughts about what is the message or the one or two top-line messages in your mind that should be carried from this report to policy makers in the executive in congress I think that the you know obviously the the sort of high level story there is that the world has been resilient in terms of finding global health I'd like to believe that's be linked in some ways to the successes that have occurred and we you know the evidence is there's always a lag in evidence and so the evidence I think starts to accumulate more and more about accelerations since the big scale up of funding that's not in this report I think it's coming but I think you know the the more we can link where this huge injection of funds has gone and then trace that to what impact it's had the better it is for both you know accountability and learning and what works but also for sustaining that sort of growth through future times great please join me in thanking both Chris and Ariel congratulations on a really high quality report and we look forward to the next the next round in May so we're adjourned thank you all thanks Steve thank you Steve sure thank you