 This last panel, which we will attempt to expedite in an hour, is focused on optimizing resources. And we've got three terrific thinkers coming from different angles or different outlooks to help us get the conversation going. And I hope you all will jump in at the right moment soon in this conversation with your own comments and questions. Let me quickly introduce the three speakers and then we'll come back to them for some quick opening remarks. Ken Thorpe in the middle here, a professor and chair of the Department of Health Policy and Management at the Rollins School of Public Health at Emory University, a terrific program, terrific university. He's chairman of the partnership to fight chronic disease, very important coalitional effort, and his opening remarks will concentrate on chronic disease prevention and private sector contributions and efforts along those lines. He's also co-chair of the partnership for the future of Medicare. He's a PhD in MA and he brings to this conversation today extensive experience on domestic health reform, going back to the Clinton administration in that historic early phase of effort at reforming our national health system. To his right is Murray Aitken, a BA from New Zealand, an MBA from Harvard. Someone who's also the editor of Health IQ is with the IMS Institute for Healthcare Informatics. Someone who really his entire career has been around bringing a close analytic outlook to complex healthcare issues, including the issue that we've asked him to offer some quick opening remarks, which is about how the private sector, private companies can be most enabling in opening access to medicines and technologies. He had 14 years of experience with the McKinsey group before moving to the IMS Institute. And our third speaker today is Jesse Bump, who's an assistant professor in the international health department at Georgetown. He is a PhD out of Johns Hopkins history of medicine program, which we had a chance to talk about earlier today. That is a small community of folks who've left their marks in many different places. And so I was delighted to meet Jesse and that he could come and join us. Jeff Sturcio comes out of that same program at Penn and is familiar to many of you. He's also an MPH out of Harvard and worked at the World Bank on the River Blindness project. So quite an interesting mix of a historical and operational and an analytic outlook. And we've asked him to talk about the role of rationing in making tough choices in the case of universal health coverage. So let's go ahead and just kick things off, Ken, if you could open with a few minutes. And then we'll go to Murray and Jesse and then we'll let things roll. Thank you. Okay, well thanks. Thanks for inviting me. Welcome to the heavily coveted 3 a.m. or 3 p.m. session, depending on where you're coming from. So this was actually our first choice. I'm going to talk a little bit, just introductory comments about NCDs and chronic disease, because obviously we know the huge burden that it plays in terms of morbidity and mortality. Internationally it accounts for about 60% of overall deaths that's expected to grow at well over 70% by 2020. But another role that it plays, and it's germane to the discussion about universal coverage, it is a key driver of rising international and domestic health care expenditures. So in this country, since the mid-1980s, the rising prevalence of chronic diseases in the United States accounts for about 80% of the growth in Medicare spending. And if you think of the framing of the discussion in this country about entitlement reform, that's really not a piece of the discussion. The statistics are growing in similar in other parts of the country as well. And I think it has enormous implications for the design of systems because traditionally most of the systems that we've looked at internationally and including the Medicare program here are budgeted systems. The way for controlling health care costs is largely by simply managing expenditures by silos of expenditures, the drug budget or the hospital budget and so on. And it's really ignored the major underlying drivers of why spending in those different sources and uses have been rising. So I think that just making the case about the critical role that the rise in prevalence of chronic disease is playing not only in terms of health outcomes but in terms of cost really does have some enormous implications in how you really design health systems but also how you design health insurance. So if you think of the Medicare program, a single payer program of sorts has Medicare Advantage programs in it as well, but that's a program that's really not designed very effectively to prevent the growth in chronic disease and certainly does very, very little in managing chronic disease. So it's not just an insurance discussion, it's really a discussion about how do we actually design effective health programs that not only fund things but also do a better job of managing and preventing chronic disease. So just really quickly then I'll move on to my friends here who are flanking me. When I think about health reform in terms of the real key components, yes, moving towards expanded coverage has got to be a centerpiece of it because you have to have a mechanism to fund and pay for things and have access to care. But if you think about the issues that I just talked about that the growth in chronic disease is a major driver, virtually all the spending is associated with chronically ill patients. In this country, well over 80% of spending is linked to chronically ill patients. I think health reform discussion really needs to focus on three elements. How do we do a better job of averting disease in the first place? How do we slow the growth and progression of chronic disease? How do we increase disease detection? In this country, we leave 25% of diabetics undiagnosed. In India, well over 60 million total diabetics are only diagnosing about half of those. So how can we improve our detection systems and how do we do a better job of engaging patients and managing them to keep them healthier and keep them from inappropriately using very scarce resources? To me that's sort of the core of a health reform agenda and I think as we go on and have a discussion about it, we spend a lot of time at the partnership to fight chronic disease identifying best practice interventions that we know that work. And I think the challenge is two parts there. Identify those programs and figure out how we can scale them and replicate them and really focus on programs that we know that work. They're out there, how do we identify them and how do we engage both the public and private sector to make sure that those interventions are more widely used and maybe as we go along in the discussion throughout the panel we can identify some of those best practice programs that we found that are particularly effective. One trillion dollars. That's a number we haven't heard today yet. I'm surprised because it's already three o'clock. But that's the amount that will be spent this year on drugs globally. That's our estimate of the total expenditure on pharmaceuticals of all types. High priced, low priced, generic branded, high quality, low quality. When you sum it all up it's about a trillion dollars in total expenditure. So when we talk about optimizing resources it strikes us that optimizing that trillion dollar spend would be maybe a good place to start. And in the context of a discussion around universal health coverage there's a broader issue about how we do think about optimizing the total expenditure that's involved in providing coverage for all globally. So of that trillion dollars in global spending about 250 billion give or take is being spent in countries with GDP less than 25,000 dollars per capita. And that amount is growing at about a 10 to 13 percent clip and will continue at that rate at least for the next five years or beyond. So one of the things that we've looked at is how would you know if in fact that money is being spent wisely. And we did some work on a global basis trying to come at that issue by starting by asking the question when medicines are available and when they even are affordable are they being used in such a way that they bring the greatest value to the healthcare system. And part of this is around perhaps a notion of value leakage. What's the difference between the theoretical maximum value that that trillion dollars could deliver to health systems and what is actually being delivered and what are the causes of that difference. And in our research we found a pretty substantial gap, value leakage gap coming from the way in which medicines are actually being used or misused or inappropriately used. We refer to the responsible use of medicines where that responsibility is associated with the way in which patients use medicines and the way in which medicines are used by healthcare professionals. So what we found was in 2012 we estimated that around $500 billion was spent across healthcare systems as a result of medicines that were available and were being used but were being used in a suboptimal way. And to that extent we would say it's a major issue in terms of suboptimal use of the resources that are available. A big part of that relates to patient non-adherence. When drugs are being made available and are accessible to patients, are they actually using them as they should? We know that that's a big deal in this country and indeed in other developed countries. It's also a big issue for perhaps different reasons in low and middle income countries. We looked at whether drugs are being used at the right time in a patient's treatment and we looked specifically in the case of diabetes but also hepatitis B, hepatitis C where we know that the longer you wait to initiate treatment with medicines the poorer the outcomes for the patient and the higher overall cost for that patient. We looked at medication errors that get made really across the various healthcare professionals who get involved with prescription drugs, prescribers, those transcribing prescriptions, administering prescriptions and so on. We looked at antibiotic use and overuse, misuse of antibiotics which not only has the effect that that money is really being wasted but also triggers additional costs in the healthcare system because of antimicrobial resistance. We looked at the suboptimal use of low cost, safe generics that are available in markets where instead higher cost branded drugs get used and put a quantification of the amount of resource that we would say is suboptimized in that area. We also looked at the issue of unmanaged polypharmacy, a growing issue given the prevalence of chronic diseases and the situation where patients are taking five or more medicines concurrently for different conditions and no one person is actually looking at that totality of care for the patient which in some cases triggers other consequences in terms of that patient care. So in this case I were able to identify again a pretty substantial economic impact on health systems from available medicines not being used responsibly. Clearly there's also a health consequence which is certainly important although in the context of talking about resources sometimes keeping the focus on the dollars and cents is a useful thing because it is the Minister of Finance that has as much to do with universal health coverage as the Minister of Health. So we can talk about other things that we've thought about in terms of what you can do to improve the optimization of resource allocation but certainly in terms of that trillion dollars and in the context of a discussion around universal health coverage and where that's going to lead us in terms of medicine use. Putting a clear focus on the way in which the available resources are being used is just as important if not more important than making sure that patients have access to the services and that those services are affordable. Thank you and thanks for inviting me. I want to start by saying that universal health coverage has this sort of intrinsic appeal and as a brand name that's why Ariel chose it over other competitors. It sounds good and I want to submit to you that what it actually means is rationing a word that nobody actually likes and that's because when you're talking about the demand for health services, it's unlimited. There is no limit to how many health services people want and resources are finite. So that sets up an inescapable rationing problem. The way we tend to think of rationing in the States is like you go up to this window and then someone denies you a service and actually that's not the way most rationing happens. So when you're thinking about universal coverage I want you to think of rationing and the mechanisms that are usually used to make it happen. I'll just tell you what those are. Before I do, let me take a guess. Your favorite rationing mechanism is time. Rationing by time would mean you guys get all the prizes because you wait around for the three o'clock panel, the much-voted three o'clock panel. And rationing by time is that's what Americans think of when we talk about the Canadian health care system or the UK system. It's like they make you wait for services and that's one way of rationing. We here in the States usually ration by price. We don't usually talk about it, but price is the underlying mechanism that decides who gets what. Distance or geography is another rationing mechanism. I just think about a hospital in downtown Washington. That sounds like a great idea to me and most people. It's not that meaningful by the time you get out toward Reston and when you're in West Virginia it might as well be irrelevant. So where you put facilities determines who can get there easily and who can get what. That's distance or geography. We also ration by income. So think of this as Medicaid. You meet a certain income threshold, you get it, you don't, and you can buy yourself. We ration by age. So think of programs for children or the elderly. S-Chip for instance or Medicare. We also ration by type of service or intervention or disease, meaning like we have treatments for this and those are covered but we don't have treatments for X or Y. Or that we'll provide these services or not those services. Those are the sort of traditional things that you think of when you think of rationing because you can get this, you can't get that. We also ration and this is historically true and unfortunately still true by a lot of ugly categories. So think of race, religion, prestige. We ration by things that don't make sense in a moral framework. These are all dimensions of rationing and when you look at a health system it uses all of them. It's not possible to escape them. So the question becomes how do you manage these things in the best way? I'm not going to answer that. I'll leave it up to your questions. Thank you. Okay. I'm going to put a question out to our panelists and I'd like to encourage all of you who are interested to come up with comments and questions while I do this. Earlier this morning in that vivid session with Jim Kim, there was a question that a gentleman from the NIH put forward which was a sensitive issue around prices for drugs and it was with reference to the HIV AIDS debates over access on antiretrovirals and I thought Jim Kim's response was extremely nuanced and balanced argument for dialogue and engagement and for bringing in the private sector into the dialogue and building upon its stakes and interests in trying to find solutions that satisfy the questions around access, affordability and quality which seem to be the big themes that keep coming forward. That was one I think very encouraging moment from today against a backdrop of I think a sort of tension and contestation around the private sector's role as you look at universal health coverage expansion. I mean earlier this year Margaret Chan at a meeting in June or May delivered a very caustic sort of categorical critique of industry with respect to food, beverage and pharmaceuticals and did some equation of that with tobacco industry which was a very stark and dramatic statement and it set off quite a flurry of conversations and the backdrop for that was I believe that the rise of NCDs and the expansion of universal health coverage is expanding the stake for all with respect to this and if there is latent mistrust or latent tensions or there are conflicts of interest of a variety of kinds between public and private interests in our health systems as you go through a period of expansion in this period where so much is at stake you're going to see some sharpening of those expressions of tension at the same time that you're going to see the expressions like we saw with Jim Kim here today. So my question for our speakers is looking ahead for the next three to five years what are the kinds of steps that are going to be most constructive in light of these enduring tensions and clashes of interest between public and private sectors, multiplicity of private sector entities. What are the measures or principles that are going to allow for the best outcomes in terms of dialogues and constructive integration of public and private? Ken, could you offer some thoughts? Sure, thanks for that softball. Well, obviously we've got to figure it out because if you look at the data and statistics we've just been talking about, the way that we're going to prevent and manage chronic disease is through good primary care, the use of healthcare teams and appropriate medication management and use. So we're going to have to figure it out and it's going to take both the government and the private sector collaborating to do this. I think one of the frameworks that I think is more important is making this transition from looking at just how much do we spend on drugs or how much do we spend on hospitals to total spending. So for example, if you look at the profile of a typical patient, this is more of a U.S. example, just driving all the costs in the system. It's an overweight, hypertensive diabetic with bad cholesterol, asthma, back problems, pulmonary disease and is depressed. So there are multiple medications and nobody's really in charge of managing it but we know if you had appropriate medication use the total hospitalization rates are going to go down. So I worry that we focus too much on unit prices rather than worry about how do we redesign the system to get more efficiency out of it. I think in the 1950s and 1960s having this silo-based way of thinking about it made sense because most of the spending was to treat episodic acutely old patients. Well, that's not the deal anymore. That's not where the money is going. So I think to the extent that we can develop good dialogues between the public and private sector, we're going to have to do that. And I think that if we're going to be effective at really transforming our delivery system and really building a prevention system out there that's effective, we're going to have to do a better job of collaborating and perhaps a little bit less finger point. Thank you, Murray. Yes, so I would add to Ken's comments that when it comes to chronic diseases in the developed world in the last few years we've actually seen the cost of treating those diseases with drugs decline. In the U.S. pretty significantly the declines in the Medicare Part D drug costs are quite striking. Now that's partly because of patent expires and a lack of next generation innovation in those disease areas. But I think it makes the case, however, that the good news is that as we think about universal health coverage globally and we think about chronic diseases, the good news is that the vast majority of patients are going to be treated very well by very inexpensive medicines. There are no patents any longer in most of the chronic disease areas. Now there are still some patients who won't respond and will need the more recent generation versions of medicines and there needs to be some allowance for that. But the vast majority of care is going to be provided as it is today by relatively low cost generic drugs. I think also the issue of the private sector, I think the last panel sort of picked up on this point, but I would sort of emphasize again that there is no one private sector. And sometimes I think people are talking about 20 multinational drug companies representing the private sector when in fact we know that there are many parts to the private sector. But most importantly the delivery end of things around the world, which is often very much based on the private sector and certainly in the case of medicines, it's the private pharmacies that tend to be a big factor in determining how drugs are used and dispensed and also to some extent what they cost at the end of the day. So I think we've got to be careful about using the term private sector and being clear about which part of the private sector we may be critiquing or commenting on. I would also just say to Ken's point also that the siloed budgets really don't help. I mean part of our advice to health ministers is actually get rid of the drug budget because once you have one, it really does prevent you from thinking horizontally from a disease area and perhaps it's better for there not to be any drug budgets particularly in low and middle income countries. Jesse. Yeah and I added once you have a drug budget it's going to grow. They always do and they're out of control. So I agree we shouldn't start them. But I'd like to add to the point that the private sector is heterogeneous. We as health people tend to look partly as scants at the private sector and I don't think that's appropriate. It's not like all private industry is like the tobacco industry. The tobacco industry is one with which the World Health Organization will not cooperate. They won't cooperate with the small arms industry but they'll cooperate with almost anyone else. And I think that's the right model. The voluntary agreements in consumer product companies, food companies, beverage companies just to reduce sodium even by a few milligrams per serving makes an enormous difference. So I see tremendous possible progress through cooperation with industry. And I think it's also worth noticing that if you want to deliver some intervention at scale it is going to involve the private sector. The market reaches everywhere and ultimately the market responds to what people actually want. So if you can convince the public to want something else then industry will follow. You can come around the other side and try to get industry to supply something else too. So I see on both sides there's a lot of opportunity for collaboration and there's relatively little need for the oppositional thinking that characterizes most of our approaches. I think that is appropriate with tobacco but there are not very many industries like that. Thanks. Why don't we open the floor for comments and questions. We have one hand here. We have one over here. We'll bundle comments and questions together. Thank you very much. Anna Melter. I'm a graduate from GW Global Health Program and recently has been working in Georgia, Republic of Georgia for two years and came back with my husband. I have a question about emerging employee-based wellness programs which is very popular in the US and how these programs can be, I'm sure you can point it to the most successful programs exist now, how it can be taken as a model for developing market in developing countries or middle income countries. Thank you. We have a hand over here. There Rosenberg from PSI. We've touched on a bit today about the client's role in the systems that are being created and each of you touched on it a bit more. I was wondering if you go into more about how clients need to be engaged in the system in terms of their own desires. Clients often want the biggest and the best products available, the biggest and best services. How do you manage those expectations? Clients that don't have resources, how do you manage those as well? Excuse me, as well as making sure that they have a voice in the system and that they're able to speak to their own needs. Thank you. Do we have any other comments or questions? Okay, why don't we come back? Jesse, you want to start? Sure. Was your question about employers' programs for their workers? Motion like prevention in regards of the chronic disease. I mean, this is the biggest issue now in the US is the emerging of chronic disease and some employees, like I was reading about Johnson & Johnson, one of the programs like Walmart and other insensitives. I mean, the employee base, employee is a finance and health insurance in the US and they're very interested to create a healthier workforce and they're doing different insensitives, like trying to give them free memberships to the gym, to do insensitives for healthier eating like removing junk food from the workplace, etc. Right, okay, I know what you're talking about. So, I mean, the first part of the answer for me is historical. In the US, jobs and healthcare are connected because of wage caps in World War II. Companies couldn't pay their workers more so they started adding benefits. Healthcare was one of them. I don't think that's a really good link. It's not a good link because it leaves out people who don't work for companies that are either large enough to do it or care enough to do it or whatever. You can't cover everyone if you have job-based insurance. So, I'm going to dispute the premise as a first step, but in the second step, once you have a population that you're caring for, whether you're a business or a health system, I think it makes tremendous sense to incentivize them to do what's right for them. Most of the ads you see on television for food and beverages, they encourage you to do things that ultimately are unhealthful for you and it's no surprise that people go out and do them. I think turning the tables on that is a great idea and the model that private industry has shown, incentives, benefit plans, lots of carrots, very few sticks, it seems to work fantastically. I think it's a great idea. Ken, you've done a lot of work on this. Yeah, I think it's like anything, how you put it together and design it's what really matters. There are good programs and there are really lousy programs and I think that we have enough information on what the good programs look like and they are heavily incentive-based. You're identifying health risks. You're really working with people to do a health risk assessment and health appraisal. You're setting goals. You're making it easy for them to meet those goals, whether it's during lunch or having access to a nurse practitioner there at the work site to help you monitor blood pressure, blood sugar levels and so on. They can be very effective. I think we do have to be careful in designing them to make sure that everybody has the ability to participate in some way in setting goals so that we're not just self-selecting and focusing on healthier populations. But it certainly makes sense and it behooves employers to do it because for every buck that we spend on medical care class through an employer they're losing four bucks on chronically ill patients in terms of productivity. So they have a huge economics incentive to really try to design it appropriately. Murray, can you speak to the client question that was put forward? That's because clients say I want antibiotics even though they might have a virus or something that's not going to help them. So they have these conditions of what they want out of the healthcare system and that might not be what's in the best interest of the healthcare system. Right, so certainly in the case of antibiotics, that's a very big issue. And I think this, I mean the countries or programs that have actually tackled that issue have come at it from a sort of community-based education, public health awareness kind of program to build awareness specifically around antimicrobial resistance about what diseases antibiotics are useful for and what conditions they're not very useful for. So I think part of this and again if we put it into the context of universal health coverage and expansion of access, there's an important patient education element to all of this that has to be undertaken by public health programs or community-based initiatives or even employer-based initiatives to link to the previous question to build that awareness and understanding in the minds of patients so that the healthcare professionals are more effective in the way in which they dispense their advice to the patients and don't get the pushback from the patient that, no, no, they want something that the healthcare professional doesn't think is necessary or useful for that patient. So I think this is where as health systems evolve the evolution of patient education and awareness is just as important as building the infrastructure and the capabilities on the healthcare professional side. I wanted to respond to that too because I started talking about rationing mechanisms and of course what you're asking about is a rationing question. So from a system design perspective you want to avoid the case where the person presents knowing what they need because then they'll always say I need it and I need more of it and I want the expensive one. That's like personal behavior so think of when you go to the doctor's office and he says, well, you could have a brand name or I could give you this generic and you're like, well, brand name might be better. I'll take that one. Somebody else will pay. That's not a good rationing mechanism. So the rationing questions that I was offering and this one that you present these are really ethical questions and probably the most straightforward way to answer it is you get people together who are in that system that's going to rations. You say all the people in the room and they make a decision on what the outcome will be before they know their position in the game. That's called John Rawls's veil of ignorance and it's a way of maintaining fairness through these really tricky questions so that before you know the outcome, that is you know whether you're sick or not sick, you know what the fair thing will be to do for whatever that condition is. Thanks. We've had a very long day and we've covered many, many subjects. We have one hand in the back here. Yes. Last question. Emmanuel Pepper from the National Institutes of Health. Thank you gentlemen. Just one question. I believe that Murray you had alluded to when you're talking to ministers of health. You tell them to really disregard the budget as in the drug budget but in low to middle income settings that might not necessarily be the case so could you elaborate a little bit more on that point? Just disregarding the drug budget if you have a set aside per se so what would be another way to sort of work around that in a place where you have a limited amount of resources and you're trying to improve the health of that population per se. So the point that we would make is that if you look at the component elements of health care in sort of vertical silos then while you may think you're optimizing for one particular vertical you may be sub-optimizing from the patient perspective or from the entire healthcare perspective and that's certainly true in the case of most chronic diseases where there are very low cost effective treatments or even preventions that are possible that will help to avoid more significant costs due to complications and disease progression down the line. So the issue on drug budgets is that if the goal of someone in the government is to minimize the drug budget or minimize the growth in the drug budget that may or may not lead to the optimal allocation of resources across the healthcare system and you may end up underspending on drugs and paying the price in other parts of the health system. So I stated to say you shouldn't have a drug budget. The real point is to be able to understand from a disease state perspective what it's costing the health system to manage that particular disease and the patients with those diseases. So let's take diabetes. Every country should know what does diabetes cost the health system this year. What's the diabetes cost? Most countries including this one will struggle to answer that question. But if you ask them how much do you spend on drugs they'll give you a pretty precise answer. So you should flip that so that there's a clear understanding of the cost of diabetes and a less clear sense as to what the drug cost was. Let me just follow up on that a little bit. I think about it this way too. We know that given the projections we'll stay on our diabetes theme here. We know that under current trends there's going to be a continued enormous increase so worldwide in the United States and so on and certainly one of the ways to effectively manage diabetes is the use of appropriate medications to control blood sugar levels. So if I had a very interesting discussion about four years ago I went to Romania. I dealt with the guy who dealt with the drug budget. He didn't have any idea on anything else but what was being spent anywhere else in the system. He had the drug budget. His goal in his mind was to keep the drug budget growth slow. Small. And despite the fact that they have an enormous underlying chronic disease pressures that are increasing the demand for medications to manage high blood pressure, diabetes, cholesterol and so on. They just raised the question on it's probably appropriate and desirable to see a 10-15% increase in the drug spend over the next couple of years. Because you're going to see offsets elsewhere in the system because the real question is not so much the component the real question is what did the resource take out of GDP on healthcare. And to get them to broaden that question to think about total spending is the way to go because you're going to see as populations change, as they age as chronic disease prevalence shifts, you're going to see as you have innovation and technology you're going to see big shifts in the component parts as we have in the United States. I mean in 1985 1980 we spent about 40% of our healthcare spending was on inpatient hospital care and that's 20% now. And it's largely because of technology and changes in the underlying clinical characteristics of patients. So I think that that silo-based approach to thinking about that is dangerous and inevitably could lead to really counterproductive outcomes. Yes. This is the second or third time that I break my promise not to ask questions. But the question to the panelists is what is the role of women in all this discussion that we are having about universal coverage. If you look at the audience it's mostly women in some countries most of the physicians if not all are women. And we have seen that change again at home the health providers for the elderly, for people who are chronically sick, for children are women. So I wonder what would be your approach to accept this reality because when we talk about health providers we forget the providers who are women and who work at home and work outside home. And if that is also part of the discussion or should be part of the discussion. Thank you. I think to that issue you got to be careful here. So of course I mean most of the long-term care services provided in this country are provided off the books so to speak through informal caregiving. And it's largely by moms and daughters and granddaughters and so on. So it's an essential part of us effectively running our healthcare system. If we didn't have that we wouldn't have a long-term healthcare system at all. It's not paid for formally but it's really sort of the major component that holds together long-term care services for sure. On the provider side we have the United States seeing a somewhat of a shift in terms of more women coming into certainly on the physician side but then again if you look at who's doing all the caregiving in terms of nurses, nurse practitioners it's largely women. We focus a lot on physicians and that's appropriate. Physicians diagnose and they provide treatment options but the types of patients that we're talking about here for the 362 days of the year that they're not in a physician's office the type of care that's being provided is being provided by nurses, nurse practitioners social workers, mental health workers pharmacists and so on who are more likely to be women than men. Thank you. What we're going to do is ask our three speakers to close with thoughts around what are we going to be debating what are we going to be most interested in talking about five years out and particularly with reference to the private sector but not exclusive to that. We have the benefit of a historian being on this panel so Jesse I'm going to ask you to sort of lead off because you were saying earlier and I think this is very valid that the historical outlook does lead you in certain directions but we've also got Ken and Murray who have been analytically engaged in this tracking of the trend lines now for 30 years if you could also think critically around where do you think given what we've heard over the course of the day where do you think this leads us logically in expecting when we convene in five years time and take account of where we are and what are the most prominent issues with special reference to private sector what's that debate going to look like? Jesse? So as a historian and an employee of Georgetown I think I would have to go back to the time of Jesus to answer this No, just kidding. Look for the last 400 years and now I'm serious the way the rich world relates to places that are now poor has been evolving in a long secular trend that's the East India companies back in the age of domination it's been evolving so that there's more power in what we call client or recipient countries than ever before think of the proliferation in the number of aid agencies there used to be one the mutual security agency that became USAID there's more now almost every country and its dog has an aid agency and they compete with each other to give client countries something over the years there has been this increase toward what you could call buyer power if this is a marketplace it's not clear exactly what the donors are competing for but they are falling over themselves to do business to give money to give services in many of the lower income countries businesses are at the same time trying to penetrate new markets there's nothing new about these forces they're just reaching new proportions so I think in five years we're going to want to talk more about the rules of the game right now there is no regulation in the way rich countries operate in poor countries they have different styles they have different objectives they have different outcomes they operate in different ways businesses are increasingly responsible or at least linked to health outcomes so think food, alcohol, tobacco, pharma major industries are playing an increasingly large role in the health of an enormous share of the world's population so these two things both point at regulation I think in five years we're going to want to talk more about that about what international authority or international governance or international something can oversee this space you've seen it evolve in currency and in trade with the WTO we haven't seen it evolve in health the framework convention on tobacco control it's a partial step in that direction but I think that frontier has really yet to be explored thank you Ken well what I would hope for is if five years down the road sort of a major marker for me would be is how differences this healthcare system look like how good of a job have we done building a comprehensive prevention detection in care coordination management system and to do that is going to take two things one is going to take partnerships and coalitions there's a thousand organizations out there we need to find ways to leverage the talent so that everybody sort of contribute what they can contribute to focus on really implementing more comprehensive strategies using this country as an example but it's really probably not that much different from what I've seen internationally as well I think we have to have a change in focus from doing pilot projects to actually implementing things at work we have thousands of pilot projects we have 20 years of accumulated data on things at work I can tell you right now that internationally we are not one pilot project away from a miracle so we need to I think to the extent that we can do targeted pilot projects to fill in the gaps of knowledge we don't have fine but I hope in five years that working both with government and with the private sector that we have identified really effective ways to do vaccinations, tobacco cessation lifestyle change we have programs and interventions from randomized trials internationally on all of those that we know that work I think we just need the leadership focus to develop these coalitions and really change the mindset away from piloting to actually implementing broad systematic change including health insurance coverage obviously but it really is the types of things that we're talking about here are much more public health, population health the delivery of services, how we pay for them in addition to simply doing the insurance expansions so I think in five years we'll be asking the question are we getting our money's worth from the expansion of funding for universal health coverage I think that's a great question to be asked and I'm optimistic that actually there'll be some answers as to whether in fact we think we're getting our money's worth answers framed in terms of outcomes answers framed in terms of quantitative measures of progress so I think that that's one important topic five years from now a second topic that I would hope we're talking about in a positive way in five years which really has not come up today is how well have we used technology to accelerate the goals of universal health care coverage for universal health the use of smart phones and so on we know what the curves are like in terms of penetration of those devices we know again there's a growing number of pilots about how effective they can be in improving quality and access around the world but I think the question is to what extent have those been a central part of the expansion of of health care coverage and I would say it should be a more significant part of the dialogue than has been the case today and then I think the third point I hope we can discuss is the ways in which the domestic private sector particularly in low and middle income countries has really evolved to become a critical and respected part of the health care system that is delivering value that is competitive that's regulated and which is delivering high quality service but where we've had a sort of a generational shift if you like or advancement in terms of the quality and impact that the domestic private sector is playing particularly in the low and middle income countries thank you very much please join me in thanking our panelists Nellie and I would like to say a few words just in closing I want to first of all particularly thank the people that are still here on CSIS staff who have given the entire day to make this happen Francis thank you so much for being the photographer for the day that's been invaluable Alicia Matt Matt who was very much the lead engineer Alicia Kramer there are many people here who gave a lot of time and effort to pull all this together and I want to make a special thanks to you Nellie was the visionary and the intellectual leader in this Nellie Bristol and even after getting thrown off her horse and got back up and carried us to this day and Nellie we're all very indebted to you for having brought us to this point so please join me in thanking all of the folks from CSIS who did this I don't know that I mentioned Joe Jordan who's our newest senior staff person who's been with us here today and Joe thank you I'd like to invite Nellie thanks to those who came a long distance and some a short distance that gave us a lot of time and effort and thought as speakers as contributors as moderators here so Nellie the floor is yours well that's just what I wanted to say to the speakers thank you so much some of you came from a long way this exceeded my expectations and it was a great day and I'm glad I stayed for the 3 o'clock panel and I would have made you all the first panel if I could have made you a pharma for funding the project for the paper and the conference and I hope we hope to do a lot more in this area and look forward to working with you thanks so much so we're adjourned thank you