 We have strict instruction that we have to finish this session by three o'clock But let that not stop you from asking questions. We are friendly and small enough So I will try my best to give everyone a chance So when you do get a chance, please be brief if you have more than one question I will try my best to come back to you in the second round So in the first round, I'll try to take three questions and then give the panel a chance And then we will do as many rounds as necessary and possible. Okay So I have two hands three hands here. So first three is three questions. Yeah, please. Hi I'm from University of Gothenburg. I've seen this overall performance Improved in health, but I my question is how much this performance is Only into changing in health behavior because changing her behavior for me is more sustainable Than just external forces to the people. That's my question Hello, I'm from University of Copenhagen and I think my question is mostly for Michael I was just wondering if you had given any thought to The business proposal. So if it's possible to drive investments in health through Making a business proposal for factories, for example That the productivity gain may be large enough for it to actually be a sustainable business investment And if so, how it would be possible to promote this and which fields you think Would this would be particularly interesting in Okay, my name is Dick Durval from University of Gothenburg. My question is really to Yuko You mentioned all the mechanisms that leads from health to wealth and you said took by behavior behavior change And it's obvious that if somebody gets cancer or death sentence that they will not invest in education some but do you have any strong evidence that Improved health actually affects behavior in general maybe among those that just have small risk again getting ill The panelists come back with questions. The others may think about further questions to ask. So Okay So starting from the last question You mentioned that you were asking about the channels from health to wealth and I think There are several channels and you were specifically asking about the investment or Yes, there is there's very rich rich evidence on that and So for each of the channels that I explained the demographic and the investment in education and And each of them they have they are backed by both micro and macro data So for example microeconomic evidence is that are as I mentioned RCTs. So if you give if you take all the Indonesian, I think the Duncan Thomas study was RCT in 700,000 Indonesian productive women and men and they did a randomized Control trial and they gave three iron supplements to one group and nothing to the other Possible to the other and they did find that people who got iron supplements were more productive compared to those who weren't and also there is Evidence there are Micro both micro and economic evidence Education there's it's very rich. So it's almost undisputed that better education leads to better wealth in the economics So Because you expected Oh, so like the investment and yes at the macro level there is data. That's right. There is a huge if I think in the recent years This behavior economics how that plays role in developing economics has really changed and And they think even experimental data. There is evidence on that So it is there is scientific evidence and then the first question I guess the question to Michael. I'm sure that You follow but I think that like there's a lot of evidence in like HIV High prevalence countries like the for example mining countries mining companies. They've really invested in the House of Workers and then therefore improve the the The productivity of the company because I mean if HIV affected 23% of the the productive population There's no way that you don't do anything about that and it makes an economical sense and then the first question on the What how much of it is the behavior? I'm not sure if all that Behavior is what's driven because I mean taking pneumonia and diarrhea the Most of the children under five still die are dying from pneumonia and diarrhea and That and the there's ways to prevent it and there's ways to treat it and it's very cost-effective But still children are dying so I mean How do you explain that? Yeah, I mean go back to that first thing I mean if you immunize a child then you don't get a disease so I think for communicable diseases I think it's a critical issue for non communicable diseases and for HIV AIDS, but So I think it really just depends which disease you're talking about I don't think you can make blanket statements like that And I think that one of the advantages of health is that we do have these technologies like like immunization that are Highly accessible and highly cost-effective. I mean in terms of investment cases I mean, so first of all, that's the new term that everyone is using, you know, so For the new global financing facility for MCH people are developing investment cases for MCH UN AIDS has the investment case for HIV AIDS so that Terminology has now permeated And as you said as Yoko said I think that there has been a lot of interest for large companies say for example for HIV AIDS And also for malaria and for other diseases what I would say that one of the I think broader issues for human development Is that most of the focus is on children? But if you think about it from a human capital standpoint What we should be particularly interested in as adults and that I think that's one of things that came out from the HIV AIDS Epidemic and why some of the South African big companies did invest because they were using losing their labor but I think that we tend to under invest in Adult diseases like for example chronic diseases like diabetes and heart attacks in in Africa and in low-income countries Because that's not part of the Millennium Development Goal hadn't historically been part of the Millennium Development Goals And yet those are critical I think for for economic investments in the country and then just to go back to your question I mean there was a I mean first of all just I mean about ten years ago There was a huge review you know from the macroeconomic commission on health that actually did both the both Reviewed both the macro and micro studies that you were talking about and actually saw I mean causation in both ways But obviously it makes sense that that there would be I mean if you think about malaria for example I mean one of the reasons that you have relatively low agricultural productivity is because a lot of the workers actually are suffering from malaria And actually you see significant improvements in agricultural productivity once you start decreasing malaria Sorry, I'm not talking about productivity That's obvious what I'm asking about is change the change in behavior due to better More expectations of better health, you know you change your investment future investments I mean those studies they show that if you get a you find out that you really not well I mean you might not study as much but other strong effects Yeah, I mean there's strong studies of that already from just the AIDS epidemic in Africa You know with the introduction of treatment. There's been dramatic changes in household behavior, you know because people work Yeah, if you if you get a medicine, but I'm talking in general I mean it's got it that doesn't have a very strong impact on the economy in general I mean the many studies on the impact of health on Growth but economy in general and they don't find a very strong effect I think the main point is that we should not assume that there is a causal relationship in one way or the other and the fact that a certain level of Achievement has taken place might influence the behavioral assumptions I think that is the point, but I'm going to stop there We can continue further discussion during the coffee break. I'm going to invite curry to thank you I think at this only this first question is is my area of expertise about the role of behavior in in diseases and especially in or at least in chronic diseases, of course, health behavior is most important It may be misleading sometimes to give this irritability estimation because somebody may think that It's it's kind of excluding the role of behavior, but this is not the case For example, if you look at these clonkended chains of Obesity, they are all expressed mainly in hypatalamus and it is very likely that actually the mechanism how these chains affect obesity is that they some way modify human eating behavior and that's why they increase the probability to develop obesity. We have actually pretty interesting results about this field just accept it for publication. Other issue is that if you look at the chronic diseases it is also it is maybe it can be misleading to talk too much about this title of nutrition because it's also that is modified by adult behavior. We know that we have epidemiological evidence just so that suggesting that childhood malnutrition is is associated with the higher prevalence of coronary heart disease. However, this is not the situation in all populations. For example, this applies very well in many western populations, but for if you look at for example, Japan, we don't we don't see this kind of association because also Japan was very poor country before the second world war and and we could expect that because of this very rapid economy development in Japanese population, there would be a massive increase in coronary heart disease. This is however not the case. There is coronary heart disease rates at a very low level in the Japanese population and so are also all metabolic diseases. Only exception is a stroke because of the high short consumption in Japanese population and so this is not a deterministic process, but by health behavior it's surely possible to prevent these kind of diseases and health behavior in the population is very strongly modifies both genetic and this childhood environment or risk factors of coronary diseases. We can have another round of questions. Two, three and four. Yeah. Hello, my name is Helis Samuelsen. I'm from University of Copenhagen. I'm not an epidemiologist, not an economist, but I have a question to the last presentation on the BMI and the difference between western countries and Japan. I don't know if you have data on Africa. If you have, what does, would they show or if you don't have, what would you predict? What would the differences in BMI and the different groups of professionals show? Thank you. Thank you all presenters for your interesting presentations. I'm Sato Ulicida from University of Helsinki. I just wanted to find out what your thoughts were in terms of human resources for health and the kind of graphs that you showed for the age in Africa and the kind of very, you know, rapid demographic growth. I mean, how do you see this playing out in the coming decades? Thank you. My name is Abruna E from McLeod University Uganda. My concern has to do with the progress so far made. Yes, we made progress, but I think we would have made more progress if we need more money for health years, but I think we should also look at more health out of the resources we have. I think that can only be realized if we mainstream health in all the policies of the various ministries and not leave it to the Minister of Finance and Minister of Health. It's not a question, just an addition. Thank you. Maybe we'll take responses from the panel and then I'll come back for a final set of questions. So this idea of multi-sectorality I think is critically important. I think it's particularly important for non-communicable diseases like obesity. I would say, going back to more health for the money, I mean, did you say you're from Ghana? Uganda? I think that if you look at the health facilities themselves, they're not particularly efficient. And if you, I mean, for example, there's a study in Uganda showing huge variations in the performance of health facilities. You have a national health service system you pay by input-based budgeting. So I would say that is a critical challenge about improving the efficiency of health service production in Uganda. And I mean, so, although I agree more generally on the broader issue of multi-sectorality, and I have to say Finland is one of the countries that leads sort of international work on this kind of the commission on social determinants and doing, working across ministries. But in the particular case of Uganda, I would say there's real need to change the performance of the health service, not just actually working multi-sectoral, but that there's a critical issue from both the ministries of health and finance to work together to change the way the NHS works in Uganda. The human resource question, do you want to come back? Well, I think generally, I mean, what we would hope for Africa is that they will have this demographic dividend, you know, that you're going to see like the epidemiological transition, you're going to see like, so they currently have a lot of, you know, they have a relatively high population growth rate, it will start to decline, and then they'll have this demographic dividend, you know, that like China, for example, and a lot of other countries have had actually. And so I hope that's what will happen in Africa. I think it obviously, you know, Africa's a very large continent. So, I mean, the countries that were, there's a group of countries with generalized AIDS epidemics where that demographic dividend is more complicated, actually, and they have a critical challenge of how to actually, you know, solve the AIDS epidemic when you have like, you know, 20% of the adult population with AIDS, and that's a very specific case, actually, say, for example, for South Africa. You could do want to add anything on those two questions before I pass on to Kariya. Yes, more health for money, I agree. And also, but I think with all the money that's going into AIDS, I also question, are the AIDS being used going into the right area and supporting the right things? And just looking into this simple analysis that I'm doing with DHS, it's really the basic fundamental public health interventions that's cost-effective that is really associated with reduction in child health. But of course, all the money is going into more sort of flashier, easy to see results, sort of interventions. And we don't really see the benefit of that. So like, I mean, if we don't really have the evidence that these interventions are affecting the under five mortality rates, I mean, where do we go from that? And sectors like water and sanitation, that's like multi-sectorial and hard to see civil registration and vital statistics, for example, that would benefit the population. Like, how do you finance that? And also like breastfeeding practices, like literally no donor has supported that. And it was almost to the contrary, because of this HIV epidemic and HIV experts and their sort of strong advocates. That's probably why the breastfeeding coverage rate has gone down instead of up in the Sub-Saharan Africa countries. So these are questions that I have for the health and development in the next years. And then on the human resources and demographics, I agree with Michael and like just the population and age structure is so drastically different. And I think there's just so many elements that's different about Sub-Saharan Africa and Asia and Latin America that what I do reflect from this conference is that economists, they do really focus on GDP per capita and like this monetary way of measuring things. And when there are just really many fundamental factors that affect the economy and productivity and welfare of the populations like health. And also when we look into historical development, there are many puzzles. I think the development in Latin America and Asia, it's sort of following the U.S. and North America and Europe model where kind of the overall infrastructure and economic development and health are sort of gradually developing, going in the better direction whereas Sub-Saharan Africa, some things have really gone better like the immunization coverage and in reducing child mortality. But then if that wasn't followed up with better nutrition, like what does that imply for the this generation of children? They're surviving, but they're not healthier, they're not stronger. So what is the implication of the productivity of this generation? I have a couple of points to say, but I will see if I get a chance towards the end, I will say that, but I would request Kali to respond to the BMI question and also the others. Yeah, actually unfortunately very little is known about chronic diseases and obesity in African population, but I would expect that this is actually inverse gradient in African population. And there is a slight evidence that for example cardiovascular diseases are more prevalent in upper socioeconomic groups, at least in Kenya, I think there's one study about that. And it is very expected results because these chronic diseases, they're driven by westernized lifestyle, like sedentary behavior and westernized diet. And it's quite likely that this is more typical in upper socioeconomic classes in poor countries. On the other hand, it is not only a question about the affluence, but it's we have some speculated that this may be also because of this volunteer health behavior, because how we explain these results from Japan is that maybe working class persons, they are more conservative in their behavior. And so in Finland, they used to have poor health habits because traditional Finnish diet is not very healthy. But in Japan, working class Japanese men, they follow this healthy Japanese nutrition. And that's why they don't develop obesity. And there is no gradient in these chronic diseases. And the same can seem similar results can be also found in Mediterranean countries where there is no any socioeconomic gradient in cardiovascular diseases. So maybe lower level people in Mediterranean countries, they follow this very healthy Mediterranean diet. And so I would expect that partly because of the poverty, but maybe partly also because volunteer health behavior in lower socioeconomic classes, we can see the inverse gradient in African countries, but surely would be very, very interesting topic for future research. I have a couple of points to say, but I will give preference to you. Okay, one and two. Could you kindly be very brief? We are very short of time. Absolutely. I'm James Thirle from IFPRI. And I was just thinking about this issue of trying to mainstream or to try and speak more directly to the Ministry of Finance. And I think one of the real challenges we have is to do some of these translations of say health interventions or nutrition outcomes into effects on GDP. I don't think we can run away from GDP. That's the language of the Ministry of Finance. And so we have to meet them where they are. And so I know in the climate change literature or in energy, we go to great lengths to try and take the tools that the Ministry uses and augment them and see what does energy investment mean for GDP and poverty. And I think at IFPRI we're trying to get nutrition mainstreamed in those tools that the Ministry uses. The challenge is on the health people to do that rather than to wait for the Ministry of Finance to come to you. Can you please be very brief? Okay. The question is short. Isn't there a better measure than BMI on obesity? I'm just under overweight. I'm tall and slim. But the taller you are, the more biased I think the BMI measures. Another problem is that people are getting stronger. And I'm sure that if you look at manual worker in Sweden, it's much more muscular than a manager. So I think there are two biases. Isn't there a better measure that could correct for this? I think we are almost at the end of time unless my panelists desperately want to respond. Can I summarize? Yeah. I'm sure these are, one is a comment and the other one I think is a question for the research. There are just a couple of points I wanted to add. I think when we are thinking about health in broader human development terms, I think it underpins in terms of freedom to live a long and healthy life. And that is kind of the starting point for human development. So when you mentioned human resource question, I think there is a human resource question related to that is a human capital question. I think much broader is the human development question in terms of health as underpinning human development. And related to that also, Yoko mentioned about the demographic transition associated with that. We also have the so-called epidemiological transition. So as people become more urbanized and more educated in developing countries, you have also non-communicable. There is a group of population where non-communicable diseases are the number one priority. And there is another group of population who are probably in the rural backward areas and who are not benefiting from the development for them still the communicable and infectious diseases are the priority. And then if you have a political economy where health resources are allocated based on power, etc., then there is always a pressure that maybe the urbanization, you know, urban sectors get much more. So you will have a lot more of the health budget going to non-communicable diseases which benefit the urban richer middle classes. And related to that is I think number of people and especially our colleague from Uganda raised, I think it is absolutely correct that in developing countries, the share of GDP going to health is still very small. Of course, within that the private sector share is much bigger. And there is no doubt that overall amount of resources going to health has to increase. Where will those additional resources come from is one question. And then that doesn't mean then we don't address the inefficiencies that are there in existing use of resources. A lot of amount of wastage and wasteful allocation is there. So I think both of those and improving in general the accountability of health expenditures. I think these are big challenges which I am sure Yoko and our fellow researchers will address in the coming decades. So let us express our appreciation to all three of our panelists and we close this session.