 I'm Jeff Sachs, President of the United Nations Sustainable Development Solutions Network, and I was very fortunate and honored to chair the Lancet COVID-19 Commission. The Lancet Commission issued its report on lessons for the future from the COVID-19 pandemic on September 14, 2022, at the time of the opening of the UN General Assembly. During that launch, we have initiated a series of three webinars to discuss key implications of the Commission report for follow-up, and today we have the webinar on global health finance and governance. We're joined by many, many important leaders in public health and leadership of the World Health Organization, so I'm absolutely grateful. Let me briefly review the main conclusions of the Lancet Commission with regard to today's subject of global health finance and governance. I think that the report deposes a number of challenges for the international system, and that will be the topic of our discussion. I'm going to share my screen, and if you can see that, I will talk about the main findings and the questions that I think are posed by these findings. Let me start by making an obvious point. The pandemic has been a horrific experience for the world, and many of the horrors continue until today. The loss of life, the disease burden, the long COVID, the continuing anxieties, the disruptions of global supply chains, the loss of confidence in public institutions, the difficulties of global cooperation, all have been part of this monumentally disruptive experience since the beginning of 2020. We're not out of the woods yet, unfortunately, but we finished our report for the purpose of trying to draw some lessons, even though the pandemic itself isn't over. It was, we thought, possible to draw some lessons that would be helpful, not only to take further steps to bring this pandemic to an end, but also to respond effectively in the upgrading of institutions following this pandemic. Let me remind everybody that best estimates are that if one counts the unreported as well as the reported deaths from COVID, we are around 18 million dead. This is truly an astounding burden and an astounding calamity. So we're talking about something of profound significance where we need to draw lessons. There's a lot of text on my screen right now, but I'm just going to read basically the first line, which is that countries should strengthen national health systems on the foundation of public health and universal health coverage. Our first point is that the response to a pandemic like this requires a health system. This may seem pretty obvious, but the truth of the matter is that around the world, we found even in rich countries parts of the health system, for example, the public health side, not the curative health side, but the public health side were seriously wanting. A national health system includes both curative health, clinical health, and public health. And countries did not have effective public health systems to respond to this pandemic. The biggest shortfalls not surprisingly were in the poorest countries. As part of that strengthening of national health systems, each country should determine and expand national pandemic preparedness plans. So this is a point that's been made by several groups reviewing the pandemic, which is that countries were not ready by and large for a new emerging disease, especially one so easily transmissible. And the countries that were the most ready were those in the Asia Pacific that had grappled with the SARS outbreak in 2003, 2004. Those historical memories were also embedded in specific preparedness plans in the readiness of the public to abide by public health mandates and recommendations. For example, on physical distancing or face mask wearing and so forth. And in much of the Asia Pacific, the result was a much lower burden of disease and death from the pandemic, even before the question of vaccines became operational in 2021. The rest of the world was not ready. This was a pretty steep learning curve in real time, not in a drill, but in a real pandemic for countries around the world on what is pandemic response. And obviously next time through, we need to be ready in ways that simply were not the case this time. We recommend importantly funding as a centerpiece of the global response funding for the low income countries and the lower middle income countries in particular. And specifically, we call for the creation of a unified global health fund closely aligned with WHO based in Geneva and drawing together a number of existing funds as well as the new pandemic preparedness funding. So there is in Geneva currently, of course, the Global Alliance for Vaccines and Immunizations. There is COVAX, which was the instrument created to do the best possible to get vaccine coverage for COVID to the developing world. There is the Global Fund to Fight AIDS, TB and Malaria. And there is now a new WHO led financial intermediary fund for pandemic preparedness and response, though based in Washington at the World Bank with the trusteeship of the World Bank. Our recommendation, which is not the way things are moving right now, but our recommendation is that these be combined into a global health fund. And again, really essentially next door to WHO as our lead international institution for global health, because we face a massive financing challenge for global health and for building health systems and for the health systems for pandemic preparedness that requires, in our recommendation, a coherent approach that actually pulls together the strengths of the existing institutions and bolsters them with new financing for primary health system strengthening, which does not have an obvious financing source right now in the international milieu. We say more generally that the UN member states, especially with the responsibility of the G20, should adopt a new financial architecture to scale up the financing for low and middle and lower middle income countries to meet the challenges, not only of pandemics, but also climate and the SDGs. And the last two weeks has been an ongoing fight actually both at COP 27 and at the G20 in Bali this past week for reforming the global financial architecture so that more funding is available, more fiscal space is available to the poorer countries to take on these big challenges. Let me just conclude in this very brief opening remarks by pointing out that WHO and the World Bank together have produced an excellent report on this question of universal health coverage and all of the work in monitoring UHC, which is target 3.8 of the SDGs, SDG3 is health for all, and target 3.8 is universal health coverage and that according to our panel's recommendations, our commission's recommendations is central for effective response. But what we know from the monitoring is UHC, universal health coverage does not yet exist. And not surprisingly, it falls, the shortfall is most dire in the poorest parts of the world and notably in tropical Africa as you can see on the map. When we look at the correlation between the universal health coverage index score prepared by WHO and the World Bank and compare it with the income levels of countries, it's almost a perfect relationship. Poor countries have low health coverage, rich countries have much higher health coverage. We have a problem of poverty here. We have a problem that poor countries cannot afford SDG3 unless there is additional financing available. There is some good news, which is from 2000 to 2019. There was improvement in this index of health coverage, more access. I've been lucky to be part of this and witnessing this since 2000 when I chaired a commission for WHO on macroeconomics and health. Financing did rise. What we learned about the increased financing, for example, the financing going through the Global Fundified Aids to be in malaria or the U.S. programs, PEPFAR, and the President's Malaria Initiative is that money works. If you put in more financing, you get better health outcomes. You get more health coverage. In other words, there's nothing that prevents us moving the resources to achieve UHC. But poverty remains the biggest killer, in effect, whether it's inability to respond to a pandemic or more generally, the toll of poverty on life conditions and the shortfalls of the health system itself. The gap in life expectancy is shown here in this map between the longest-lived countries, Japan, for example, with a life expectancy of 85, and the lowest life expectancy countries in Africa is 30 years difference between the mid-50s and the mid-80s in life expectancy on one planet that we aim to be a civilized place. And this tracks also health expenditures, which vary also by two orders of magnitude. It may be $50 to $100 per capita in the poor countries per year versus $5,000 to $10,000 per person per year in the rich countries. And this showed up, of course, we know in the challenge to get vaccine coverage, every map looks the same, basically. Poor countries lag way behind rich countries in every dimension, whether it was the health coverage, whether it is life expectancy, whether it is vaccine coverage, this is a matter of basic economics. And this excellent report by WHO and the World Bank demonstrates this, that low-income countries lack coverage because income, because low-income blocks the access. The core of WHO's recommendations for decades, the correct core, is the need for a primary health care system. And what WHO calls its primary health care theory of change, which is outlined in this report. And we endorse this in the Lancet COVID-19 Commission. Now, the final point I want to make before turning it to our esteemed speakers is that we have, in 2023, upcoming a global summit on universal health coverage in September 2023 at the UN General Assembly. I would like to see a global health fund announced at the time next year. We need a fundamental breakthrough of funding. Let me note that in the adoption this past week at the G20 of the Financial Intermediary Fund for Pandemic Preparedness and Response, which is a first instance of financial response to this, this is as often the case with our donor countries very, very narrowly conceived. And I believe from the press releases that the commitment so far for this preparedness fund remains under $2 billion total. I may be out of date, but what we need clearly is tens of billions of dollars per year. This is a complete difference of perception of the donor countries, which want a narrowly focused marginal financing of specific pandemic preparedness versus the Lancet Commission, which wants health systems to function according to the vision of WHO. And for that, I can say as an economist, we need a different order of magnitude of financing to make that work. And we want to support WHO and the global health community in trying to make clear what is the real financing needed in order to learn properly from this pandemic disaster that we have been through. So those are the main points from the commission side. I'm going to pass the microphone to Julie Bartels at SDSN and the Secretariat of the Commission, and she will take us through the program now. So thank you very, very much. Thanks to everybody for being here. Thank you very much, Professor Sacks. Next, I'd like to introduce Dr. Mike Ryan, who is the Executive Director of the WHO Health Emergencies Program. Dr. Ryan, please give us your remarks. Thank you. Okay. Can you hear me? Yes. Okay, good. Great. You're a hard act to follow, Jeff. So I will try not to do too much repetition. First of all, thank you to the commission. WHO obviously believes that the core recommendations of the commission are really hitting the right areas, hitting the right spot in terms of governance, the financing, the systems, the tools, the workforce that we need. You mentioned this in terms of clinical care and safe, scalable clinical care is still an essential part of the health system, but it's an essential part of pandemic or emergency response as well. But community protection is what takes the pressure off the health system and being able to do the same at community level is something that's been terribly under-invested in. And you mentioned that the last mile of health delivery primary healthcare is the first mile of health security. But they're not essentially, they're not the same thing. I think we sometimes get these conflates. It's interesting in the SDGs when we set targets for UHC and for health delivery, we didn't set targets for epidemics and pandemics. It's target 3.D. It didn't even justify a specific target. And again, that shows the schism in people's minds that focuses on health delivery. That's great. Again, I will contend that health systems delivery purely delivered as that will not stop a pandemic or an epidemic. What you need is to deliver both. You need to be able to deliver essential healthcare and essential public health functions at the same time through a primary healthcare-led system, where both parts of that system are fully integrated, interoperable, able to manage and cope different ways with different stresses at different times. And that's a very sophisticated approach. But the system won't work. It's not a ying or yang jeff. It's not going to work to say we'll all just run down this road and then we'll all run down the next road after it. And we tend to pendulum swing on these things. So we swing away from investing in health systems to invest in public health functions. And then we swing back the next time we see the TV data or we see the HIV data. So I think there's a need to focus on a collective, integrated approach for strengthening national health systems. And I think the Commission has really nailed it very close to how WHO would see the world. In our world, we mentioned the safe, scalable care, the community protection, collaborative surveillance, access to countermeasures and coordination. They're the five essential functions in terms of health emergency preparedness and response. Those functions don't work unless you have a skilled, protected, paid workforce. They don't work unless you have core financing to the health system and to the public health system. And they don't work unless that's governed at all levels. And I mean governed by communities in communities, governed nationally and governed regionally and globally. So the recommendation has been made by the Commission in just purely avoiding a systems approach and focusing in on the financial solutions that are needed and the governance solutions. Governance and financing solutions don't guarantee success. I know you did say there that money talks, money makes a difference. It does. Financing put into an effective system that is efficient and able to deliver works. Exploring money at a poorly designed system, at a poorly governed system, drives corruption, it drives inefficiency, it drives frustration, and it drives non-delivery. The real trick is, and I see one part of us getting ready to speak as well, is how do we align the design of a system at all levels? How do we align that with the financing needed to drive it? And how is that governed? And I mean governed as in who is accountable? Because governance is often seen as a kind of a distant concept. We set up committees to oversee the overseen, and then everyone oversees them. But governance is actually around accountability. Governance means we take responsibility. The government of a country has the sovereign responsibility to protect the lives and health of its citizens. That's governance. You're in government in order to meet that accountability. You're elected to do that and be the same at regional or at global level. So I hope we don't just say governance for the sake of setting up new mechanisms. Governance means absorbing accountability at whatever level you govern, whether you're a member of a community health committee, all the way to sitting on a global health board or an executive board of the World Health Organization. So within all of that, the proposals around funding, I think you're right, I think a fifth is a step forward. No one set a ceiling on fifth. Fifth is at the two billion because that's what the donors have put in. It's very clear in the documents underpitting that from the G20, the Finance and Health Minister's Working Group, and Manpal will probably speak more to that. It's very clear. It's exactly what you said. The gap is seen as north of 10 billion a year. That's the gap that's seen. And therefore, the current fifth does not meet that. Equally, a preparedness fund needs to be much bigger. Whether member states and those who govern us decide to integrate those into larger instruments. That's a governance decision. That's a decision that's way beyond my pay grade. What I want to see at the very minimum is coordination and multilateral funding mechanisms so that they're able to do what they say on the tin. How far you go from coordination to integration depends on what the appetite for that is. That's a political decision as much as it is a practical decision. But there are other funding things needed. We've set up to really focus on preparedness, but it doesn't address at-risk funding for access to countermeasures. You may not need an actual fund for that. You may need some kind of a commitment fund. It doesn't have to money in it, but when somebody presses the red button in five years' time, is there 30 billion immediately? So it might be a commitment to fund, not actual money. Similarly, the commitment to scale up response in countries at the beginning of a pandemic doesn't necessarily need to be money, but it could be commitments to deliver that money. And the sometimes much criticized mechanism, the PES mechanism, the World Bank, I think had a lot of merit in actually deciding on having upfront money available through an insurance and a cash mechanism. It may not have been the perfect mechanism or the perfect vehicle, but the idea that there would be funding, triggerable funding, not necessarily sitting in an account, but triggerable funding to get to scale, both in upstream development to countermeasures and downstream delivery of response. That's where we struggle most. In fact, we actually access money for upstream. The hardest funding to access during this pandemic was funding to support downstream countermeasures, oxygen delivery, expansion of workforce, delivery of goods and services. That's where we struggle. That's where we really struggled. And then there are obviously other mechanisms. We have our own contingency fund in WHO. It's a hundred million dollars. It's smaller scale funding. It allows us to respond in minutes and hours. So linking different, whether we need one global health fund, Jeffrey, or whether we need a series of financial instruments that are managed as a set of tools. It really is. I'll leave that to Juan Pablo and people much more smarter than me and Jeffrey Yu and others to decide. Sometimes putting everything into one basket creates conformity, but it also can create calcification and inefficiency. Efficient agile mechanisms, well coordinated, can also work equally as well. So I won't speak to, you know, again, these are political and financial decisions. I'm not a financial expert, but the idea of aligned, coordinated health funding, especially when we talk about moving through, I don't know, Juan Pablo and the World Bank have just launched IDA 20. There's a lot of funding out there too in the multilateral development system. There's a lot of funding out there in the international financing institutions. Part of the problem in the past has been multiple institutions investing in national preparedness through their own plans. Everyone going, I remember one point years ago, the Minister of Health in Nigeria said to me that he had 80 different health representations in Abuja. So who's disintegrating the system? It's the outsiders who are. We need one national action plan for public health security integrated into a national health systems plan. That plan needs many supporters and many donors. What we don't need is hundreds of plans funded vertically by different institutions who all think they know better. This is creating tremendous fracturing of effort. It's confusing our member states. It's driving corruption, quite frankly, and we need to bring that back together. So the idea of strong national action plans, where governments own that, you see the UHPR process now, the universal health preparedness review process, allowing governments to come to a much more accountable vision for what they want to commit to. There are many instruments to measure and deliver on those national action plans. What we lack is a clear financing mechanism to fund those plans and hold everyone accountable for that delivery. And beyond that, finally, in terms of government governance, we are making progress with the intergovernmental negotiating body at a treaty, we believe a global accord to underpin much of the governance and financing and systems and tools approaches over the coming years. We very much appreciate and warmly welcome the work we've had with the World Bank on this. I think WHO and the World Bank have taken a tremendous step forward, not only in bringing this fund together with the G20, but actually in bringing our organizations together in a much more functional way. And we need to do that. I think financing institutions and health institutions need to come together in a much more systematic way in order to deliver exactly what you said. There's lots more I could speak to. We're currently in the process of reviewing the international health regulations with a working group of member states, obviously the member states working on the international negotiating body. So we're really in a phase now where the member states of the organization are in deep, deep consultation about the future rules of the game. Similarly, I think on the World Bank side, deep consultation through the G20 Finance and Health Ministers on exactly what you said, Jeffrey, what are the rules of the game going to be for financing health with large in future? And how are we going to drive those investments? Not as a cost in the system, but as an investment in the future, as a protection of our civilization and our economy and our way of life, not as an insidious cost in the system that is seen as that. It's seen as a liability. Health is seen as a libelous cost in the delivery of governance. We need to change that. We need to change that narrative and show that health protection is an investment and you can measure the benefit of that. You counted the bodies earlier, which is tragic. We need to be able to demonstrate that doing things a different way results in a different outcome. Thank you. Mike, thank you very much, really wonderful. And I think just a couple of points I know then we'll turn to Juan Pablo and who will give us some very important perspective. But I think it's clear that there are two kinds of funding that we're talking about and we should be clear about that. One is ongoing funding for health systems year in, year out. And there are problems everywhere, but a fundamental problem is just poverty. We have to face up to the fact that there is a significant part of the world in which government budgets cannot cover what should be regarded and what is regarded as a basic human right. And that is access to a functioning health system. And that's almost an iron law of poverty. And we've never really faced up to that. But we have the in bits and pieces like the specialized funds. Then there is the question of the emergency response when disasters occur like the outbreak of this pandemic. And there will be others in the future. And they're your point that it's not even necessarily money in the bank that counts. It is the ability to have a wholly elastic supply of financing to face the emergency. What's interesting there, I think clearly is that when the pandemic hit, the rich countries for their own response had a very elastic response of trillions and trillions of dollars. The United States incrementally spent five or six trillion dollars more than had been envisaged in the budget in the first two years of the pandemic. But when it came to financing COVAX, the facility for vaccine coverage, it was going cup in hand, desperately trying to find a few billion dollars here and there. And it turned out to be impossible to do. By the time the money was actually raised, the pharmaceutical companies had made their contracts with those who could pay upfront. And we know how difficult it was therefore to operationalize universal vaccine coverage, much less other downstream countermeasures as you described them. We just didn't have the contingency financing in place. So I think these two have to work hand in hand. I want to be absolutely clear as well that I always regard money as allowing you to build the pipes to have the governance. So I don't see it as a contradiction or an either or and it's not throwing money at problems. It's building the solutions in my view, but absolutely we need functionality to be able to deliver just so people know what fifths are, because that's not everybody's vocabulary normally. They are financial intermediary funds. They're kind of trustee funds that the World Bank manages for special purposes. And this fifth is a fifth for pandemic preparedness and response. So it's a particular financial intermediary fund. And I think if I might, Julie, probably on the program we were going to turn next to Juan Pablo who is of lead responsibility at the World Bank and partner with WHO on this. So we're very eager to hear the perspective from our lead development finance institution on how you see this question of the scaling up of financing. So Juan Pablo over to you. Jeffrey, thanks so much. And to you, to Julie and everybody in the team, and congratulations for leading the Lansing Commission in the report. Excellent recommendations. I'm very happy also to talk after Mike makes my life easier. He has an incredible capacity to explain the correct things in the correct way. And by the way, Mike 100% in agreement. It's also very important for us to see that we do have that alignment with all the very important messages that you just shared with us. I want to comment briefly and thinking about our time for the discussion on three of the recommendations that the Lansing Commission report brings forward that are close to the World Bank's work. There are many, by the way, correctly focused on strengthening WHO. And I want just to highlight that those recommendations are also on the table and are extremely important for the global health agenda. But that said, I want to stop briefly, of course, on this fifth now called the pandemic fund. I will also stop a little bit on the national pandemic preparedness plans. And for last, I want to talk briefly about the health system strengthening recommendation Jeffrey that you started with. So quickly on the first recommendation, I know that the idea of a global health fund that you just, by the way, illustrated is much wider and stronger than an intermediary fund in the bank. But I do want to say that 12 months ago we didn't have this additional instrument for pandemic preparedness prevention and response. Now we have it. 12 months ago, many people were skeptical that we would be able to develop this instrument. Now we have it. As you said, it has so far mobilized Jeffrey $1.5 billion. But it's confronted with immense, tremendous needs and expectations that are many times bigger than those resources so far. But the good thing is that, again, it exists. It has bring together many, many different institutions, governments, civil society. And it has an open horizon in front of it to strengthen its governance with inclusivity, to decide on key next steps, and hopefully to bring additionality in a sustained way to a much underinvested area as is pandemic preparedness prevention in our countries. And I'm speaking of all countries, but in particular middle and low income countries, where this area within health systems has been further underinvested than any of the other areas. So I think this is an important development. And again, it's one that needs to be crafted as we work together. We've been able to do this working hand in hand with WHO. I want to praise here, Mike and WHO and Scott Pendergast and Digitatoros for all their work. By the way, Mike is going to be leading the technical advisory panel. And all these important technical aspects of pandemic preparedness and prevention will be brought into the advisory capacity of that panel in guiding the proper investments from the pandemic fund. And I think that's going to be extremely important. There are other important decisions in the coming weeks or months. The most important one for me is the results framework that will be guiding the medium and longer term of the pandemic fund. It's going to be very important that there's convergence around that results framework and what it is expected for this additional instrument. But also in the coming weeks, we will know more about the first call for proposals, how it's going to be focused, how it's going to be reaching countries that really need additionality in their efforts to mobilize resources around pandemic preparedness and response. And most of what we're listening, I don't want to anticipate a decision from the board of the fund is that it's going to be focused on integrated decision surveillance, which has a lot of those core functions that Mike referred to, which are deeply needed, again, within our health systems, as core public health functions connected to better response to future challenges like we just had with COVID-19. Maybe let me stop very quickly into comments on the fund, which I think are going to be very important for that discussion. One, and it's that it's not exclusively for what we call either countries or low-income countries, it is also a fund that will be looking at IBRD countries, middle-income countries. And this is very important. Listening from friends who know a lot about pandemics themselves, we know that probably the next pandemic may happen in a middle-income country, in big cities where a lot of public health functions are basically still extremely weak. So it's not just focusing on low-income countries, but also bringing in middle-income countries in terms of preventing future pandemics. And the second comment has to do with regional initiatives. Jeff, one of the things that we learned from COVID in a very harsh way, I would say, is that countries also need to break down political frontiers and work together regionally when it comes to pandemics. I could talk about my region, Latin America, but we saw a great example in Africa coming together around our regional CDC, coming together around mechanisms for procurement of vaccines, building a network of surveillance, and even coming together in West, in East Africa, in a national, regional network of public labs. Those are all excellent examples, and I think other regional CDC initiatives are taking care, are taking place right now, and this pandemic fund and other resources should work with them, making, again, regional capacity and important element of future pandemic preparedness. Quickly, let me move now, leaving the pandemic fund aside, and I'm sure there may be questions and discussions around it. Let me move into the national pandemic preparedness plans that the commission also highlighted as much needed. I was thinking of my own experience in a middle-income country like Colombia, Jeffrey, and by the way, I saw my predecessor Alejandro in the commission's team. He's now with another responsibility facing a different public challenge, also very important, but of course we have national pandemic preparedness plans, but we need to further strengthen them, and we need to really invest in the capacities behind those plans. So this is a much-welcome recommendation. The bank working closely with WOHO in many of these countries is helping prepare these national preparedness plans. We have roughly 20 of them done in complete detail led by countries, and of course it's just a baseline. We need to continue on that, and my hope is that to a great extent the proposals funded through the pandemic fund will build a national pandemic preparedness plans at the country level. That's what's logical, and that would make things much better, effective, and organized in terms of the needed investments. We're also using there, for those pandemic preparedness plans, other resources that the bank has, like the HEPR trust fund, or like the I.20 resources that might refer to, which have explicit commitments in this round of resources on pandemic preparedness and prevention. So it's important that IDA is explicitly focusing on the homework that needs to be done at the country level in terms of preparedness and prevention. There are also ongoing discussions, and maybe Professor Matsukato will mention this, and the relation that the International Monetary Fund, the IMF, has with these important areas of global public goods, and in particular the Resilience and Sustainability Trust, and how it may look into the existence of these, let's say, assessments and preparedness plans for their own relations with the countries in terms of the macro and fiscal way forward. I'm not an expert on that, but it's important to basically acknowledge that these discussions are happening, and I do believe they are also going in the correct way. And let me conclude now by moving to the third recommendation, and again for me the most interesting one, which is strengthening health systems. The bank currently has in health, to a great extent, increased by the COVID response, but also being sustained by very strong demand from the countries, a portfolio of $34 billion in health system strengthening projects. Most of these projects, almost all of them, are focused on primary health care and universal health coverage. They're country-owned, they're country-led. They try to integrate the responses around the country leadership. We try to follow Mike's advice of not being one more divisive voice. We try to align platforms and instruments behind the country leadership, with all what that implies in terms of opportunities and difficulties, etc. But we do believe that this has to be bottom-up country-driven, and that's the only way health systems are really constructed to face their communities. It has a lot of public health functions embedded in it. These functions, as Mike said, are different from many of the essential services delivery functions, but they're closely and intimately intertwined. It's very difficult to disentangle them at the end of the day. It's the same nurse, the same general physician. By the way, it's the same community, and many times the same systems and facilities, etc., that are doing both public health functions and essential services delivered to mothers and infants, just to give an example. So we need to be conscious of assessing the functionalities precise, but also that the overall system is strengthened. We have two concerns here. I would say three concerns that I want to highlight for that discussion. One, you mentioned the universal health coverage report. We're working together with WHO and the 2023 and what we could anticipate is an important back step in terms of progress to universal health coverage. Second concern has to do with the health workforce. As Mike properly said, without people properly trained and also properly sustained, we won't have health systems delivering public health or essential services, and in particular community health workforces. So we're looking very carefully into that aspect. And the third one has to do with the sustainability of recurring costs. It's our estimate that at least 75 or 80 percent of the costs associated with pandemic preparedness, prevention, and response are recurring costs. Systems need to have them in place year after year after year in their budget and in their institutions. So this is very difficult in the current and projected fiscal scenario. Let me conclude by acknowledging that pandemic preparedness and prevention are unfortunately long-term endeavors. Nobody will be able to buy out of the shelf a short-term solution for our countries. They are part of health systems which are created through decades of continuous and sustained investment. And that's what we need to do. Of course, we need to start now, hopefully, yesterday, but we need to maintain the effort, Jeffrey, in the long term. And for that, political decision and leadership is a must. For that, confronting the determinants of health and in particular poverty, inequity, and discrimination is also a must. And just to conclude, also Mike said it, we will need a lot of institutional capacity with sound governance to again sustain a long-term effort that will have that world better prepared for future health challenges. Juan Pablo, thank you very much and really excellent report and very encouraging. Let me make a couple of points, if I could, things that I've been worrying about for 25 years on this. First, I think this strong link of WHO and the World Bank is really superb because WHO is a normative institution and it doesn't have the bucks there and the World Bank is our financing institution. One thing that would be tremendously helpful and I know it's part of the planning, but I think it really needs strengthening is to bring WHO together with the World Bank and the regional development banks in a coherent operational way because a lot of the financing will come through regional development banks in your region, the Inter-American Development Bank or in Africa, the African Development Bank and so forth. And I think a teamwork that links the normative institution with the development banks generally is the right strategy. It could even supplant a global health fund, it could essentially be the governance of a global health fund. But we need that team very clearly in place. But then something that I think is really fundamental and it has been a fundamental mindset barrier that is crippling is this question of recurrent costs. We need development finance to cover recurrent costs. There was long for 50 years of mantra that development finance could cover capital costs but not recurrent costs. This is completely mistaken, fundamentally wrong and the reason is very simple. Think of it even not the poorest not the poorest country but a poor country World Bank member that has a per capita GDP of a thousand dollars, which is typical in Sub-Saharan Africa. If you look that country probably raises between 15 and 20 percent of GDP in government revenues and maybe it's able to manage four percent of GDP in health outlays. But four percent of GDP for a thousand dollars per capita means 40 dollars per person for health. And so even without any more research we know well that's not a health system. You cannot run a health system at 40 dollars per person. In the United States it's 10,000 we're not going to get there but we're not going to do it at 40 no matter how efficient. A health system needs a few hundred dollars per capita. It cannot be found in the national budget period. So the question is where is it going to be found and and what is most of that is salaries. Most of that is recurrent costs most of that is the health workforce. It's got to come from outside for the next 20 years. 20 years on these countries will be much richer. They will be developed and then they'll be able to fund this. But if we want to have functioning health systems for two or three billion people living in countries that are too poor to do with themselves we must from the outside help to finance recurrent costs period. It's simple arithmetic. It runs against all the mantras of development that I've been experiencing in 40 years of work in this area because people need to do arithmetic which they don't do our governments. You're member governing institutions. If in your 2023 universal health coverage report you can lay out the basic arithmetic how much does a health system cost even a rudimentary one. What can a national budget finance what is a fundamental gap. How can that fundamental gap be covered. This will I will be very happy to help on that. This will be a huge advance of understanding. Now one more point that is counterintuitive even if you're covering recurrent costs from outside it can be by debt by the way it doesn't have to be grants as long as the terms of the debt are reasonable. If their IDA terms 40 years at concessional interest rates great even if they're IVRD terms so-called non-concessional they're certainly concessional relative to what the country can do by itself. And you could borrow for 30 or 40 years at 4% interest to fund the health system and 30 or 40 years from now a country of $1,000 per capita might be at $6,000 per capita $8,000 per capita. It could service the debts and have had a health system during those 30 years onward. So we have to help the U.S. Congress the U.S. Treasury others to understand that recurrent cost does not mean national budgets and because it's impossible absolutely impossible. It has to come from development finance doesn't have to be grants it could be loans but it can't be five-year euro bond loans at 12% interest it has to be development finance institution loans basically on IVRD or IDA terms. So just my little pitch which I've been giving for 30 years but it's arithmetic that we need financing for recurrent costs for salaries for people reliable and it's no sense in telling the governments be serious raise your spending they can't do it on their own until they get richer. So this I think is just a basic point and if you bring the rest of the development banks along you'll have more money in the kitty for this and the last point I want to mention is my work at the UN in the coming year is to help raise more money for you for the World Bank for the regional development banks because my argument is we need five to ten times more development finance than we have right now we run at maybe 120 to 150 billion a year development finance but it should be 500 billion or even a trillion a year and that's my job is to help you get more money and your job is to help explain why that money will really develop what we need to develop so I just want to concur 100% but I want us to get past this mantra of recurrent costs they are recurrent but for poverty stricken countries they need help to meet them that's that's the basic arithmetic that we need to emphasize. Thank you very much Jeff. Julie over to you. Thank you so much. Thank you Jeff and thank you to Dr. Ribé for your excellent comments especially about health system strengthening. So next I want to introduce Dr. Miss Joy Fumafi from the who's the new co-chair of the Global Preparedness Monitoring Board and she was also the principal local government auditor for the people of Botswana and served in the parliament of the Botswana so thank you Miss Fumafi is joining by phone. Basically I was agreeing with all the comments that were being made but making the important point that in addition to what you are saying about just the basic primary health care services being financed is a big challenge because you cannot finance primary health care systems at 40 years per person. I think what is equally important is that when we talk about the systems that need to be financed and that needs to be structured coordinated and for which we need to hold our government and other stakeholders of course private sectors of society and communities accountable it goes beyond health systems you know there's the one health interface there's the health systems there's the research and development innovation development and access to medical countermeasures that needs to be covered because that's part of the system that needs to be financed socio-economic preparedness that is social protection education you know mental health and psychosocial health that has become so evident now with COVID-19 this needs to be effectively financed as well the multicultural preparedness in terms of the trade systems you know travel transportation supply chains which really hampered our response during this pandemic we need to look at the human development aspects of it including the health workforce training and the other related factors so it's a huge systems area so the what we feel at the global preparedness monitoring board is that in order to have this whole systems approach you really do need to have a coordinating mechanism that will link all the global players link all the national and regional players together so that we can actually we can actually be prepared to respond to the next next pandemic so the governance component is extremely important it's not just about financing but it's about what is it about financing we are currently preparing a global preparedness and monitoring framework which are around these you know type of dimensions which we will use to monitor the state of the world's preparedness and we will be relying of course on the current work that has been done on on a result framework we will be relying on you know the type of guidance that you that this commission that your commission has just produced but I think what is really more important is that what is it that we are going to be financing which is really the the message that I want to put forward yes the financing is not enough we need to we need to address the current financing as well as the long-term financing in a more sustainable manner and in a more deliberately structured manner but what will we be financing how are we going to ensure that we have mechanisms in place that will that that will channel the resources to where they are needed and which will prioritize the right areas and for me that is equally as equally important as the actual design of the of the financing mechanism so you know our message from GP and B is that let us create a more coherent global multicultural response with proper coordination and led of course by WHO and and the World Bank and the other U.M. processes but incorporating the the the private sector the the all the global players and regional and national players in global health because if we don't do it that way if we don't adopt a more structured approach and they we are going to continue to have the huge gaps in investment in important areas of preparedness and overall incoherent approach that has actually led us to where we are now where we have a total disarray in terms of our emergency ecosystem so we are hoping that people can can appreciate that financing on its own is not a standalone that systems is not a standalone that a multi-sectoral universal response is required so that a mechanism for coordination action across sectors across government is actually necessary in order to get us to where we need to be so that really is our concern at the moment and and I'm encouraged that this report is taking us in the right direction but I think I want us to appreciate that we have to to think a little bit broader than this and we have to bring in more stakeholders and unfortunately we do have to be as ambitious as we possibly can in order to be able to to sufficiently respond to the next pandemic but also to recover effectively from this one and in order for us to adequately strengthen accountability for preparedness so I'll stop there thank you. Joy thank you very much and very with a very clear message about what is the content of preparedness and again I would also emphasize I think completely consistently with you that it's not preparedness only for a new emerging disease it's our current context where many countries have ongoing multiple epidemic diseases and other causes of premature mortality that lead to that outcome of life expectancy dozens of years less than they should be basically and if I might just I wanted to share one thought again I know I'm a broken record on this but I think it's important if countries actually if national governments actually feel that there will be financing available for well-thought-out plans they will think out plans in much more detail than if they don't feel that there's actual financing we're a little bit in that situation again with the climate change countries are told make bold plans and then they say okay but where's the money so they're making plans but they're not getting the financing my microcosm of this enjoy your of course one of the world leaders in this when funding actually started for AIDS treatment for example in the early 2000s suddenly plans came that were nowhere to be found beforehand because governments knew if we get our act together the global fund or PEPFAR or others will actually fund us so it's really worth pursuing it presidents leaned on their health ministers why don't we have the money our neighbor has the money why don't we have the money well we need to put in a plan well put in a plan and so I think if we combine the idea of this comprehensive effective systems approach with actual financing potentially available for good plans we really can leverage a big response and there I would again emphasize Mike and Juan Pablo and other of the development finance institutions if the package can be really there one other instrument that was very useful in the global fund that I I was surprised at how well it worked was the country coordination mechanism basically if you want funding you have to get the main stakeholders within the country together just as you were saying joy don't come with the ministry of health plan by itself come with a ministry of health plan that has incorporated the key stakeholders and our technical review board which Mike is going to lead in this case for the fifth will respond to such a program but if you come only ministry of health alone you're not coming in a in a credible way it comes back to my mind to have the clear incentive do your homework you will actually get funded at an adequate scale to do it we don't have the money in the bank to be able to make that promise now but if we combine not only the specific new fund but the the the backing of the development finance institutions more generally and we build up their portfolios so that they can be lending a lot more money on favorable terms then I think it's possible to have that joint vision that you joy Mike and Juan Pablo have all expressed credibly put forward to governments do your homework you will be supported and that will generate a lot of homework a lot of good planning and therefore a lot of systems building that we know can take place so that that would be my my reaction to your very wise comments um thank you very much thank you I could not agree more um because I think you know our our vulnerability of countries at the moment is that we rely on donations and development assistance and this development assistance is very limited and it provides only a section of what is needed so you are absolutely right that um we need a system that is more reliable more robust that we can have more confidence in and that that at the same time build our own capacities to to to finance ourselves more reliably long term so um I mean I I'm just agreeing with what you are saying I mean you have actually keeps the nail on the head wonderful I think those of us that are trying to make our systems work can begin to see that they're you know we are together these systems that that need to be functioning and scaled up and I think that the lessons of the pandemic give us this opportunity to really press home this case very strongly and as we go into 2023 perhaps we'll have that breakthrough moment that where we can get the political leadership on board to to take that systems approach so that it's not cup in hand every time but actually a full-fledged system uh that is that is working uh in place and Julie back to you uh thank you so much so next we'll have um professor Mariana Mazzucato she's joining by a video video recording she couldn't be with us today but I'm going to share her recording hello um I am Mariana Mazzucato I am a professor at University College London where I direct the Institute for Innovation and Public Purpose and I'm really speaking to you today as the chair of the World Health Organization Council on the Economics of Health for All and it's really this combination actually of these two words I've just mentioned public purpose and health for all what does that look like so first of all of course we know that just like with climate change the cost of inaction in terms of not investing in global health systems is so much greater than the cost of action by not investing in global health systems for example the economic cost of the COVID-19 pandemic was so much greater than it had to be and there's different studies that have you know shown why we should be investing in health and seeing it as an investment and not a cost why it's positive for our economy of course it also enables all the people in our economies to uh to be nourished to be nurtured and also eventually also to work better in terms of actually adding to economic growth but that's not enough we must also remember the other side and this is really the side that the council focuses on which is that health for all matters it matters for human rights reasons it matters for reasons related to our sustainable development goals so what we try to do in the council is we start with the idea of health for all being the goal and then we backtrack and ask what does it mean for how we design the economy to deliver on that and the more we can do that also by innovating and investing yes it would also lead to economic growth but really asking what does health for all mean whether it's for a vaccine so actually vaccinating the entire world and then backtracking and asking what it means for the design of all the different areas whether it's intellectual property rights whether it's the collaborations between public and private actors whether it's how we do budgeting so outcomes oriented budgeting and the council which is made of all women economists from around the globe from the five continents has been looking at this over the last two years and our work streams have been divided into four the first on value how do we actually value health for all the second on how do we innovate how do we invest and innovate for health for all with common good metrics at the design of the collaboration the third on financing finance isn't neutral right so how do we actually finance health for all with issues around access universe universality and really paying attention to the quality of the finance not just the quantity of the finance and lastly public sector capacity without capacity on the ground we actually won't end up with the ability of countries globally actually to invest and be able to innovate in their local health systems which again we found was absolutely crucial during this last pandemic so maybe I'll just say something quickly about those four streams which I think are very important for your conference today first on value you know my own work for a long time has been trying to unpick this very siloed way that we think about value in economics as though it's just created in the private sector and somehow the public sector is there just to fix market failures or to regulate or to redistribute that value what we actually know about value in the economy is it's collectively created of course we need private companies so in the healthcare area of course we have you know small biotech companies large pharmaceutical companies and so on but there's also been continues to be and will always be a very important role for the public sector not only in terms of creating healthcare systems but also investing in the drugs and the therapeutics and the remedies themselves and this really requires then to really focus on what does it mean to collectively create value what does it mean to share the rewards of that value creation but also in terms of investing within healthcare systems really seeing the people who work within our healthcare infrastructure both the soft and the hard infrastructure as value creators we've done quite a bit of work on this we've looked at what it means for how we value care and often it is women who are in those areas of of the economy we have undervalued care workers we call the essential workers important during coven we even clap them but we haven't actually been resourcing those infrastructures and also their their pay they're often under paid and again coming back to the role of public investment you know in places like even the united states where you have over 40 billion a year of healthcare sorry health investment spending by the national institutes of health we haven't included that investment in drug innovation and how we then price the innovations so value value based pricing doesn't actually include the value that has been co-created by the public institutions and if we did there would be very different ways to think about for example the prices of the drugs that are coming out so we don't need the taxpayer to pay two or three different times first for the innovation itself where the high risk capital intensive phase is often publicly financed and then again to subsidize the very high prices which are set by the pharmaceutical industry by the state bringing those prices down through subsidies to the healthcare system there's more efficient and more just ways to think about the pricing if we actually value the different investments that are made by different actors not just in the private sector second innovation this is obviously related to what I just said if we care about the end result and not just the innovation there's all sorts of questions that come about for example related to intellectual property rights so I mentioned the vaccine we have about eight different vaccines but that's not the mission the mission was and should be to vaccinate the entire world and that would have ramifications for how we actually structure intellectual property rights and develop patent pools and and share the knowledge so these kinds of issues really need to be thought about x anti not x post I would call it a pre-distributive way to think about how to collaborate between public and private actors in the innovation space patents in general tend to be too wide just used for strategic reasons too strong hard to license and often too upstream so the tools for research are being privatized and patented and so this isn't about pro or or against patents but how do we actually structure and govern an innovation system for the common good precisely in areas that actually include so much public funding and again it's quite interesting here if we look at the different vaccines the AstraZeneca one I think you know really represented a very different type of deal between public and private so the Oxford University researchers insisted that the costs and the prices remain low and the knowledge be shared very different from one that happened later in the case of the Pfizer vaccine so we should go beyond just thinking about public and private and actually get our hands dirty with the granular of how do we learn from those types of collaborations that are more just and have access at the center and represent a more symbiotic deal between public and private and those that we should really be scaling down and learning from the problems that are embedded in the design of those collaborations third finance you know we sometimes forget that money is not just the medium of exchange but how we structure finance matters it's not neutral so if you look at for example the biotechnology sector the fact that there was so much exit driven venture capital which wanted to exit through an initial public offering or a buyout actually rushed the science and biotech and myself and others have written about this bill is on it calls it plipos it's produced many productless IPOs by rushing the scientific the scientific research in order to develop areas that could be then quickly bought up that doesn't help the the science which can often take a very long time but also the death valley phase for companies can often take longer than say three to seven years so the requirement of actually needing patient long-term finance not just quick exit driven finance this is one insight but also if we look at global financial organizations and funds coming out of say the IMF and the World Bank most recently with the financial intermediary fund which is meant to be helping us for pandemic preparedness what really matters is to learn the lessons from the past in terms of actually embodying within these funds the right conditions so as we know IMF loans and World Bank loans to the developing world have often been conditional on reducing the fiscal space by you know just focusing on deficits how can we actually make sure that these funds are increasing the global fiscal space for developing countries to invest in their own requirements in terms of on-the-ground preparedness but also how can we make sure that the funds themselves are governed in a transparent way and an inclusive way and basically a universal way so that we can actually make sure that the benefits are truly as widespread as possible and fourth our work on capacity and this is again related to something I've just said which is that one of the effects of a lot of the austerity that many countries have experienced has been this outsourcing of public sector capacity we see this in different fronts but in terms of this points of making right now it's in terms of the healthcare system so it's not enough to think that we could just kind of have helicopter money on the back of a COVID pandemic for a recovery scheme we really need to better analyze how it could be that we have undermined and under-resourced those very systems also from a capacity point of view so what does it mean to invest in the ability to use for example outcomes oriented procurement policy which during COVID came back it's something that we use during oriented procurement procurement is the interface between public and private actors and by being very clear on what the goal is then that can help affect the whole supply chain it can help affect that public-private collaboration that I've been talking about throughout these four different points but that's about having a creative bureaucracy a creative civil service and not outsourcing that capacity whether it's to Deloitte as we did in the UK where the test and trace system was carried out by a consulting company that had very little experience on that front but really investing within our local administrations that will be able to govern the systems that we need of course alongside different actors whether it's in the philanthropy space whether it's in the private space but we need to admit what we've seen which is the lack of investment over the last decades in public administrations which then make our system so much weaker anyway so thank you so much these four areas about value innovation finance and capacity are absolutely central if we want to deliver on clear moon shots around health for all thank you very much thank you everyone so now we can proceed to discussion part of this webinar and everybody who's an attendee we invite you to submit your questions in the q&a and we'll moderate them and ask them in the discussion so thank you very much and Jeff you would like to leave the discussion yeah thank you and I'd ask anyone that is on our panel first Mike and Juan Pablo to make any comments at this point and we'll also look for questions coming in and I see some are coming in but please jump in at this moment if you'd like and yeah please Juan Pablo very very very briefly Jeff I wanted to highlight Professor Masucato message about investment in health for a long time and still in many discussions it's seen as a recurrent cost by the way so I do believe that that's a very important element and she brought many other interesting comments that I'm sure you're going to be reflecting upon I also wanted to briefly say that there's already a baseline of country coordinated mechanisms out there I'm the director of the global financing facility gf that works for women children's and adolescents health and it works through coordinating mechanisms at the country level in a recent study I think that roughly 40% of countries had coordinated mechanisms now the question is is to have really one and a solid one sometimes these methodologies are in a way copy paste and we can even have several coordinated mechanisms existing at the same time so again back to Mike Ryan's recommendation of integration at the country level fundamental and again the country coordinated mechanisms can be the right approach and just to conclude on the pandemic fund something that Joy brought in as a very important need which is a multi-sector approach to pandemics it's also being closely followed in fact the one health dimension is critical here we talk a lot about it but when we go to practical operational developments at the country level we have less cases but still there are important examples of successful one health projects and I think we will need to build on those for future pandemic preparedness over thank you very much you know one one way to overcome the fragmentation and splintering is if WHO together with the financing institutions would create a a basic template this is what a this is what a an integrated framework should look like you prepare it once under WHO auspices together with the finance partners and the individual bilateral donors in a way are just pushed into using that shared framework I think it needs to come from the top the top being WHO and the financing partners or the financing institutions but it won't emerge from the bottom up of saying well that's a nice plan this one's not a nice plan or country access has done this 50 times for different agencies but rather have a template and again maybe you can use 2023 as leverage for this if you aim you know at the time of this summit for all the deliverables that we've been talking about I think that you could clear a lot of the underbrush away and and really facilitate facilitate a common approach to my mind it's crucial that WHO lead and create a framework that has the buy-in of the world's health ministers and our central normative institution and that it be done in conjunction with whatever general financing framework we have and if it's a global fund or as I say as a footnote to that a virtual global fund that has a coordination mechanism among a number of funders but it's one template not 50 templates that are agreed by these institutions that would be really a very big help the ministries of health are so overtaxed to begin with that they can't do this 50 times they need to do it once in this exercise and I do think that the you know that the international system could basically put that put that to work as here's what we're going to do and the UN as one backs that up and the the MDBs back that up and you you make something that is actually much more functional as a result of that rather than going with getting 50 countries each one to make a sector-wide approach you just make it and here's the handbook here's the guidelines maybe it is the GFF mechanism basically but now adding in all of these other components but I think all of us basically feel that we need that kind of more efficient framework and linked to the actual financing Julie I see lots of questions excellent I have sent some to you would you like me to ask them out loud yeah um okay so we have a question from uh Lobore Popula who says uh from Jeff's presentation and available facts the worst hit countries in health coverage are the poorest countries Mike emphasizes this by his reference to the need for an efficient health system how do we reconcile these realities with migration of health workers from four countries to countries with better health systems so they're not usually deliberate action to stem the trend good question I'll ask Mike or or uh Juan Pablo for any reflections on that no the reality is there is no work without a workforce and and the brain drain from many developing countries who to some extent have become feeders of health capacity into the north through people using medical education nursing education health education in general as a means to move their families forward choose to they don't often choose who wants to leave your home but there are many ways for us to choose to leave because the prospects of higher wages more security um is higher elsewhere and again this comes back I think it's not just the amount of money that's paid to a health worker in the setting of a developing country setting it's it's it's also the continuity of those funds I've been in many situations in epidemic response and humanitarian response in fragile states particularly for health workers before the epidemic started hadn't been paid for months sometimes years of course so it's not just the amount of remuneration it is about security it's about continuity it's about it's about career prospects it's about promotion on the basis of merit not on the basis of who you know there are so many drivers that push workers health workers out of a country it is not just wage releases there's so much more and I think we have to look at that as a workforce and what are the incentives to stay and the disincentives to stay versus the incentives to leave and migration is going to be workers going abroad coming from my own country a small country on the edge of Europe historically we gain most of our high level medical expertise by good doctors and nurses going abroad getting experience and bringing that back home that's not a negative thing uh migration and health workers can be a very very positive experience for everyone the question is is it managed is it functional does it result in a whole unfillable hole in the system providing workers what are the incentives to bring people back to to apply the learning they've had in another system uh so it's a real we need a systems way of thinking about this because again it's not just an issue of regulating this to say you can't go or punishing states or others who take workers in from other it becomes zero sum game we need a much more sophisticated mechanism to incentivize people to stay in their home systems and the only way we can do that is to give people a living wage that they can rely on in which they have a career path and and if workers do go to the north from these countries there must be a mechanism to compensate those countries who train and invest in those workers i i agree i'm going to be a broken record just to say that uh if you have a country that is at a thousand dollars per capita and it's competing with countries at forty or fifty thousand dollars per capita and we yet have a standard that there should be health for all uh we need a financing mechanism to make that work and for as long as i've been in this business which is 40 years uh somehow it's expected that uh poor countries and tiny salaries and tiny budgets make that work which doesn't happen and we should do the arithmetic you have to pay as you said a decent salary that is it doesn't have to be the same as in a high income country because people would like to stay in their home country but not at a ratio that's 100 to 1 and unreliable and inconsistent but i guarantee you this is what is going to continue in low income countries until recurrent costs are paid internationally in some way and that's what we need to help explain again and again uh maybe they know i don't know whether they know or not but uh there needs to be a decent salary it's the same by the way in the education sector it's uh but health is especially uh dramatic in this regard because not only do people migrate but the rich countries come in shopping for nurses and doctors very aggressively and so this is also part of a game which is absolutely uh not tolerable the way that it's played right now Juan Pablo I see you had your hand up well very quickly i wanted to underscore that this has been a chronic problem only that uh covid made it uh more acute because of the burnout but we have for many years we have been missing the proper response to stop this brain drain which makes things even more difficult and the weaker systems um i also would just add that there may be also um harmonization of regulatory frameworks around this that should also be carefully looked especially for regional initiatives that could help in a way reduce the the burden of this migration but again it's an unanswered problem and it's a really really current one traveling through countries it's incredible how this is hurting systems as they try to get back in their fit thanks i don't know if you can hear me can you hear me yeah yes joy yeah i think i think the other issue related to um health workers is really um the availability of um you know the the conditions of service but not not the finance i mean absolutely i agree with all the comments that i made but you find that health workers get into a facility there are no medicines for treating they don't have um you know they don't have anything to test people they don't have any laboratory support next to the support sensors are not there they cannot access patients even if they access them they're not able to help them so that that that can be really um cause a lot of um you know pressure on on on the on the health workers so some health workers migrate not just because they are underpaid but they actually cannot save lives but it's business decision where they cannot save lives so i think all of these things are interconnected we cannot just address you know the health worker issue without addressing access to commodities the strengthening of the other you know essential components of a robust health system so i think you know we we need to identify what are the global common goods for preparedness that needs to be in place and what is the best way of financing them that you say we cannot isolate one because everything is interconnected so it doesn't matter what it is whether it is intellectual property issues that someone referred to earlier on but everything is interconnected and and we have a narrow set like you have said powerful actors that have proposed solutions for these global problems but they are not working not for us in lower and lower middle income countries so we need to create a system with more responses based on global public goods which are common goods which are for preparedness properly financed and that can that can be easily accessible to all these countries including the financing of of health workers but it cannot be limited to that so that's that's the comment I wanted to make wonderful thank you thank you so much very very clear and maybe we'll take one more question Julie excellent um so we have a question from Ritu Sadana who's leading the WHO secretariat supporting the council on the economics of health for all that's chaired by professor mazucato um who just spoke and she asks uh austerity managers often require cutting of health and education programs and she says this needs to be turned around how can we turn around this practice given the different voices and aims of the global global financing institution maybe i'll take a starting crack at that um i've been asked by uh secretary general guteras and deputy secretary general aminamohamed to help think through a better approach to sdg financing in general and in september secretary general guteras called for an sdg stimulus as a general framework for increasing the fiscal space for the sustainable development goals and we have our eye on as i've been emphasizing the multilateral development banks as the primary instrument for this expanded development finance uh of course private finance will play a role direct investment will play a role domestic saving will play a role but the development finance institutions the world bank the regional development banks uh some other important national development banks that also have a global finance role are crucial and the key is to mobilize those institutions so that uh poorer countries don't have to move to austerity when capital market conditions tighten as they are right now if we go in this immediate crisis in the normal way we will have dozens of developing countries facing budget crises in the next year because they're being hit hard by rising interest rates by the sharp increase of energy and food and fertilizer prices by the existing debts that they carry by the tightening of financial conditions and so on but if you look at their situation more generally from a development point of view these are countries that need a lot more finance and investment and not only in health but in other areas as well and we need therefore that when these countries have their interface with the development finance institutions the outcome is more financing not less financing and that requires that the development finance institutions have the wherewithal to provide that which they don't quite have right now but as i've emphasized these institutions starting with the world bank and the regional development banks need to expand their portfolios and can do so many times if they are backed by the world's governments which profess to have a commitment to all of this our our treasury secretary in the united states Janet Yellen gave an important speech in the spring where she said we have to move from billions to trillions in development finance getting that through the US congress and so forth is not the easiest call in the world but this is actually what we're talking about and the health finance is a piece of a more general puzzle we need to expand development finance now and yet we're in a kind of cyclical moment with tightening credit markets where normally there would be more budget cutting rather than fiscal space and so this is why this coming year is actually so important i've been asked specifically work with a number of governments in the real-time negotiations with the fund and the bank and others to make sure that we go in the expansionary not contractionary direction to my mind that makes sense because good development finance looks at this from a 40-year perspective not a one-year budget cycle perspective and in a 40-year perspective these countries should take on more debt actually as long as it's good long-term ibrd or ida terms that give them a long-term scenario for turning the increased debt finance into increased investments increased growth better health better education all of the objectives that we have so i think that the question is right to the point right now because we're in that tightening cycle which is quite dangerous something like it was 40 years ago in our previous stagflation but we need not to follow the same route that we did 40 years ago which was a generalized debt crisis actually of developing countries we need an expansionary stimulus for sdg accomplishment including the health systems building that we're talking about on on this webinar right now and on which i think there's radical agreement among the panelists on what really needs to be done and the point i would add as a macroeconomist is the poorer countries have tremendous capacity to achieve economic development if they are financed to do so and so what looks like a lot of debt right now is actually quite manageable if you take a 30 or 40 year perspective because that would be a growth perspective and a big amount of debt now is not a big amount of debt in a context of rapid economic growth and that's what we have to help everybody to see it's worth making the investment and it actually reminds me of one point i wanted to follow up with Juan Pablo our national accounts data really are not helpful because we count health spending and education spending as consumption rather than as saving an investment it's analytically wrong if it were done the other way we'd have much more clarity that when we fund finance these areas even in our national accounts we're boosting investment and boosting growth and that's not just a nice thing to say because it sounds good it's actually literally how you achieve economic development and so if we reclassified our national accounts as we should to put health and education spending into the investment category we'd have a much greater clarity of why more financing is feasible not only desirable but actually sustainable from a long term budgetary point of view so i this is how i'd like to change the national accounts it was just a mistake in our sna handbooks written 60 years ago to put education as a as a not only as a cost but as a consumption item rather than an investment items and same with same with health so i'm going to let Juan Pablo and Mike have the last words and then we're going to wrap up yeah thanks so much and listening to you i was thinking that it would have been great having you by my side when i was confronting my colleague the minister of finance looking at those accounts but it's a little bit too late as always happens with experience but i wanted to quickly react to also on what this upcoming discussion will mean for for the world bank of course as you said a big pressure to step up the capital and lending capacity of the bank and other multilateral so i think that's going to be a great discussion and hopefully a positive one in terms of results the second dimension has to do with the operational models in which the banks work and here again i want to insist in the importance of moving from national interventions to also regional and global interventions yes why because we're talking about global public goods and the two best examples of course are climate change as we signed this past weeks and uh pandemics like we've been filling during the last three years and lastly and it's meaningful because it touches something that um mariana said and it has to do with the purpose this also has to be reflected and embedded in the mission and vision of our institutions we need to think that our purpose has a global public good in it it is extremely important we're not 50 years ago looking at countries and frontiers i think we're a much bigger community that interacts permanently and therefore collective endeavors and trust among all of us globally is going to be fundamental so i just wanted to end highlighting those three direct implications for my institution and also for many other institutions and it's think globally and let's act collectively perfect perfect wonderful and we'll do it and mike over to you for the final words no i just wanted to draw together two things that you all would say the joy was also saying as well the reality is that 74 countries have completed national action plans for public health security which are country-owned multi-year plans based on one health and all hazards whole of government approach they exist our problem is none of them are funded the problem is the countries know what they want to do and they've done that analysis and if you look at that map that you the three maps you showed jeff where we saw the gaps in equity and the gaps in financing and the gaps in health workers and all of that if you look at that map the countries who have done those those national action plans are in those countries it is exactly in the gap countries that these national action plans have been done we need one plan many donors many supporters many champions not many plans and i think we have got to get back to that idea of a nationally-owned sovereign plan now governments need to engage non-governmental organizations and civil society it can't be seen purely as an inside the government effort so i think there's a huge benefit in thinking about how can we focus in on that the ihr calls for that it's it's legislating international law i hope the future treaty enshrines that principle uh i think organizations like ourselves and the world bank are beginning i think to show the kind of discipline and commitment to doing things together to support countries rather than you know in effect acting as title agents in country because the title for the tectonic forces that a ministry of health or ministry of finance feel are huge and sometimes we add to that we actually create instability in that process last thing i would say is and i'd say this in a message of hope i actually think with climate with health and others i think the world is waking up our young people are waking up to a world that they want to see that's fairer that's more just that's more equitable um i think we have never in the history of our civilization ever being in a better position to protect and restore health it's not that we have to develop the technologies to do it we have them so the issue for me is to keep that hope and that perseverance and that dogged desire to deliver and when the obstacles are governmental and legislative let's take them out of the way when the government the obstacles are financial let's remove that and let's unlock the potential of our health systems let's unlock the potential of our societies uh the mechanics of how we do that are in our grasp if we can put egos and organizational and other sort of ideologies aside for a few moments we actually have a massive opportunity so at a moment of historic risk we actually have an unprecedented opportunity and i don't see that coming again for a very long time i don't think if we don't take this chance now if we don't take this opportunity now i've been at this for 30 years i've seen it come and go and you've been around maybe a year or two longer Jeffrey but i've been through the Ebola's of the 90s i've been through the massive meningitis outbreaks in Africa i've been through the cholera spread in east and southern Africa i've been through the yellow fever epidemics i've been through the the SARS i've been through H5N1 i've been through H1N1 in 2009 the West Africa Ebola uh you know it's it's high time we learnt those lessons and did something about the essential underlying issues and just final word most people who died in the pandemic didn't actually die from the virus they died because of 20 30 40 years of unmanaged underlying conditions unmanaged hypertension unmanaged diabetes so many of our population were so vulnerable before this pandemic has and then we couldn't deliver the we couldn't deliver the the rescue we put people in a leaky boat and then we were late to the rescue and that i think we have to look at both sides of that in the future so over to you wonderful final words closing words thanks to everybody for a fantastic session we will post this we'll have the summaries of the presentations as well um and uh we have a tremendous opportunity in the coming months and uh i i think a clear path ahead of working together to realize all that we have been discussing together so thanks to everybody for your leadership and for your participation today thanks to all who have joined the webinar and uh we will be posting this uh online at the Lancet COVID-19 Commission website an SDSN website and uh to everybody stay well stay healthy uh and uh we'll be back soon thanks a lot bye bye