 Thank you all so much for coming. It's good to see so many champions of family planning here. And before I begin, let me acknowledge the staff of the Global Health Policy Center who made this event and this whole project possible. To begin with, Alicia Kramer, who has been indispensable in our work on women's health and who is heading off to medical school. So we are going to be losing her and we will miss her deeply. And of course, to Steve Marson, whose leadership and support for this project has made it all possible. And special credit to Jesse Swanson, our videographer, who helped put together the video that you are going to see shortly and whose talent you will be able to observe very quickly. On a recent trip to Ethiopia last October, I was able to meet with the first lady, Mrs. Roman Tespai. Trained as an economist, she explained why family planning is so important for women and girls in Ethiopia and for the country as a whole. She said, to be engaged in the economic sphere, to create income, to contribute to family health and well-being, and to the country's development, we must have family planning services. And that's why Ethiopia has attracted so much global attention for its progress in advancing family planning. Much of this is due to the Innovative Health Extension program and the deployment of some 38,000 health extension workers across the country, almost all of whom are young women. And they have had a real impact. Contraceptive prevalence has increased from 15% in 2005 to 29% in 2011. And new data indicates that it has now risen to 38%. Still far to go, but very impressive improvements. The Ethiopian experience of training and paying community health workers and implementing task shifting for family planning services holds important lessons for other countries and for US policy. So to examine the impact of family planning and its linkages with broader US health and development goals, the CSIS Global Health Policy Center led a delegation to Ethiopia in February 2014 and produced a report that's available outside and the video that you're about to see about family planning in Ethiopia. The CSIS delegation was bipartisan from three congressional offices, representatives of the Bill and Melinda Gates Foundation, and hope through healing hands. Many of the members of the delegation are here today, and we thank them very much for all their participation and input in this project. We went to Ethiopia because of the government's high level commitment to family planning in that country and because of the importance of US health investments. While Ethiopia has made incredible achievements in the health sector, there are also significant challenges. It's the second most populous country in Africa with a population of 90 million projected to double by 2050, still high rates of maternal mortality and extreme poverty and restrictions on human rights. Reaching adolescence and young women remains a major challenge, especially given the continued prevalence of child marriage. And overall, the need to build sustainability of these health programs and family planning programs is critical. And in this country, while support for international family planning has been a key feature of US global health policy, family planning is still seen as a contentious issue by some policy makers and influential actors. One of the aims of this trip was to clarify and illuminate the value of family planning through an on-the-ground study of a dynamic national program. There is a convergence in this country at this point around the family planning agenda. Faith-based groups, foundations, the US government, other governments, UN agencies, NGOs, really a smart and sensible consensus has emerged about the power of family planning and its importance for achieving US health and development goals. In Ethiopia, we can see this at work. We can see what's possible. It shows the impact of national mobilization. And despite the challenges, the determination by the government and by the health sector to push to address the unfinished agenda and to address the unmet need is quite significant. Congress and the Obama administration, faith-based organizations, public health groups, women's health advocates, all of us should be focusing on what this means for US policy and how to translate these lessons to other places of great unmet need. And that's why we're here today, to examine the lessons on family planning in Ethiopia for US policy and for other countries, and for the linkages between family planning and broader US health and development goals. We hope to address the questions of lessons learned from Ethiopia's ambitious health extension program and how this model might be adapted to other countries, how to build effective community-based mechanisms that are reliably financed, competently staffed, and sustainable, and what strategies other funders are pursuing to leverage US investments in family planning. We have a great program today. Our distinguished panelists will discuss the opportunities and challenges in scaling up and sustaining family planning programs from the perspectives of the US government, implementing partners, faith-based organizations, and other donors. Before we turn to our keynote address, I think we should begin in Ethiopia. Let's listen for a moment to the voices of women and girls at Rural Health Post in Ethiopia, as well as health extension workers, representatives of the Ethiopian government, and even the Orthodox Church. We hope that this video will highlight the importance of family planning as a core component of Ethiopia's development and set the stage for our discussions today. I'm very happy to be here today. I got married at the age of 12 when I was grade three, and I had my first child when I was grade eight at the age of 17. When I got married, I never heard of family planning. I didn't even know about marriage. UN estimates that one out of three maternal deaths can be prevented by appropriate family planning methods. That's why the government of Ethiopia has prioritized also family planning. Family planning service now is being delivered through the health extension workers. Ethiopia has attracted global attention for its leadership in advancing family planning. Contraceptive use rose from 15% in 2005 to 29% in 2011, due largely to the government's ambitious health extension program. The United States has been an important partner in these achievements. Yet Ethiopia presents stark challenges with the population projected to double by 2050, high levels of maternal mortality and extreme poverty, and restrictions on human rights. Sustainable commitment to and resources for family planning will be critical for Ethiopia to achieve its health and development goals. I go door to door to meet with husbands and wives to discuss family planning issues. Before, wives who use family planning used to come to us at the health facility secretly. This attitude has considerably changed within the community. The health extension program, which is led by the health extension workers, is unique. It was started in 2003. It is something that Ethiopia designed for itself. So if you go to other parts of the world, you would see voluntary community health workers. And we learned that it is not sustainable. Hiring, recruiting, training more than 38,000 health extension workers and bringing them into the government budget is a political commitment. I learned about family planning from the health extension workers. They create awareness about short-term and long-term family planning contraceptives. These are pictures showing different contraceptives, IUCD, pills, condoms, depopravera, and diaphragms. We use these pictures to explain the contraceptives to the users. I use an implant to space my births, which is very vital for my own health and for the physical, mental, and social well-being of my child. Family planning is beyond hands. It is beyond the gender issue. In Ethiopia, we consider it as a fundamental right issue. It allows women to make choices about their lives. And it empowers women to participate in economic production. We have adolescents there to support them. And there are teenage pregnancies, and it's kind of low-women to finish a school and to avoid unwanted pregnancies. Of course, it is sometimes important to engage traditional leaders as well as religious leaders, prominent persons who are influential in the community, and engage men themselves and to show them the benefit of family planning service and to show its leakage with economy, economics, politics, as well as all social aspects. We work in collaboration with the health extension workers to discuss family planning issues with our followers, who have questions about its use and function in the position of our church. Actually, using family planning is not a sin. Being against child spacing is uninformed. Sin is having too many children beyond one's economic capacity with the result that children suffer from hunger. In the past, women were vulnerable to various difficulties, especially in the areas of reproductive health. Nowadays, all these are changing due to the introduction of family planning. I am delighted to be a part of this change. Ethiopian women will, in a very short period of time, attain the gender equality. I'm very ambitious in this regard. Women do this society. They build the mission. And investing in family planning is investing in the future. It's now my pleasure to introduce the Assistant Secretary of State for Population, Refugees and Migration, Ann Richard. Right on cue. She has been at PRM for the past two years, just had her second year anniversary there. And one of her top priorities has been protecting women and girls, reinforced by her travels to crisis areas and visits to the Central African Republic and to Syrian refugees in Jordan and being a focal point in the administration for these issues. She was instrumental in the formation of Safe from the Start, which builds on the Obama administration's gender and protection policies by dedicating new resources and leadership to better address the needs of women and girls at risk of gender-based violence from the outset of crises and in emergencies. She was also the highest ranking US government official to attend the International Conference on Family Planning, held in Addis in November, 2013. Her closing address to the conference provided a strong message of support from the US government for international family planning. Assistant Secretary Richard has also advocated for improving maternal health and access to reproductive health services as central to the post-2015 development agenda. So without further ado, Assistant Secretary Richard. Hi, good morning, everyone. It's great to be here. It's great to be in the new CSIS facility. It's particularly great to be here on time since it was the close one there. But, you know, we don't like to waste it a lot of time at PRM, so very efficient use of my time this morning. So thank you for organizing the event. Thank you for preparing this video that you all saw. It's inspiring to see how enlightened family planning policies can transform the lives of women like me, Rhett, who was a child bride and young mother, is now proudly helping others to make their own choices about when to bear children. I'd also like to thank CSIS and Janet Fleischman and Alicia Cramer, and my friend Steve Morrison here. But Janet and Alicia, especially for producing this excellent report. The fact that it grew out of a bipartisan trip is very encouraging. So is your student analysis of what Ethiopia is attempting to do in the area of reproductive health? The strategies that have worked, the obstacles to be overcome, and what donors and governments, including our own, can do to help. And finally, I would like to thank many of you in the audience who have dedicated your careers and lives to bringing family planning services to women who so desperately need them. As assistant secretary, I have had the chance to witness firsthand how important this work is and what it means to those who benefit from it. This past fall I attended the Third International Family Conference in Addis if you've just heard. And I didn't just go to the conference, I also was able to spend some time touring and meeting some people doing this work at a local level. And I went to two implementing partners facilities and saw projects run by Pathfinder and Marie Stopes International. I visited the home of a family involved in Pathfinder's model families effort. And in this program, families are encouraged to adopt 16 measures to improve the overall health of the household, such as using family planning, but also vaccinating children, sleeping under mosquito bed nets and building hygienically trains. These families are then celebrated as trend setters for the community so that others will copy their behavior. I also visited Marie Stopes Blue Star Franchise Effort where pharmacists receive special training in the use of long-term contraception in sexual and reproductive health services. They then agree to provide high quality, longer-term family planning methods like implants and IUDs at affordable prices. And they get to use the Blue Star logo on their clinics and pharmacy. This brings customers to them who end up also using their other services. So it's a nifty kind of win-win setup. Ethiopia's enlightened health policies and quest for sustainable development are incredibly important. Not just for Ethiopia, but as an example to other nations grappling with similar problems. Today we share the planet with seven billion people. We added a billion in just the past 12 years. And by 2050, there could be nine or even 10 billion of us. Virtually all of this growth will occur in developing countries. Birth rates elsewhere have plummeted, but in some of the world's poorest nations, they are rising. It would be one thing if women were simply choosing to have large families, but we know that many become pregnant as early and as often as they do because they have no means to prevent it. Globally, surveys indicate that hundreds of millions of women want to avoid getting pregnant, but have no access to modern methods of contraception. The gap between what is needed and what is available is widest in sub-Saharan Africa, where, according to the Guttmacher Institute, 28% of married women aged 15 to 49 lack access to modern and effective forms of birth control. Young girls face the most acute unmet need. Like the young girl in the video, the woman in the video we've seen, many are expected, even compelled to marry and bear children when they are still in their teens. Every year, more than 60 million girls get married before they turn 19. Throughout the developing world, less than one third of married adolescents are using modern contraceptives, although many more want to avoid or delay pregnancy. More than two thirds of the married adolescents in sub-Saharan Africa age 15 and 19 want modern contraception and do not have it. And I find this particularly shocking. Around the world, two million girls aged 10 to 14 give birth every year, and over 90% of them are married. These marriages of girls 10 to 14 years old and pregnancies can have devastating life-long consequences. We see them as a form of gender-based violence and an abuse of these girls' human rights. But adult women who cannot access modern contraceptives or adequate healthcare also can experience life-threatening problems. One in 22 women in sub-Saharan Africa dies during pregnancy or childbirth. That's compared to one in 6,000 in wealthy countries. Babies face hiding risks as well, and mothers have baby space closely together, survival rates fall, and these are very preventable deaths. In addition to saving lives, sexual and reproductive health and reproductive rights can promote human rights, gender equality, health, economic empowerment, and prosperity. Ethiopian government and health officials spoke forcefully and eloquently about this, and we in the U.S. government could not agree more. The evidence is overwhelming. Women's equality, empowerment, and human rights are inexorably tied to their ability to control when they bear children. And empowering women to make these decisions is one of the best ways to fight poverty. Girls who can delay pregnancies can become educated, productive, healthy adults, and raise more educated, productive, healthy children. This virtuous cycle can propel families in whole nations out of poverty. Research has provided compelling, concrete examples of how family planning unleashes economic growth. Falling fertility rates in parts of East Asia and Latin America have raised the share of the population in the workforce, driven up output, and created a so-called demographic dividend. A U.N. study has also documented the opposite. When early pregnancy truncates girls' educations, it derails their careers, reduces their lifelong earnings, and hampers their ability to invest in their children. The researchers estimate that the United States loses 1% of GDP due to adolescent pregnancy. Uganda loses 30%. The countries that pay the steepest price for these early pregnancies are the countries that can least afford it. Finally, I was recently surprised to learn that simply providing family planning services to all women who want them would cut global carbon emissions by between 8% and 15%. So of course the first thing I said is does the Secretary Kerry know this? He's so revved up about fighting climate change. So this is the same reduction I am told. We would achieve by stopping all deforestation or by multiplying the world's use of wind power by 40 fold. More proof that voluntary family planning can fuel sustainable development. Against this backdrop, what Ethiopia's attempting is all the more impressive and urgent. Ethiopia is the second most populous nation in Africa with a high birth rate and 65% of its population is under the age of 30. It faces the same array of challenges that many of its neighbors do. Child, early and forced marriage and maternal mortality are far too prevalent and the vast majority of the population is rural and poor and hard to reach. Yet Ethiopia has placed family planning at the center of its development agenda as pioneering effective health extension program and dedicated funds to pay health extension workers and I was privileged to meet one very impressive health extension worker while I was visiting Ethiopia. This is a potent combination of ingredients for success. In the past decade, Ethiopia has quadrupled the use of modern contraception. Today in Ethiopia, contraceptive prevalence is 28.6% and the government aims to more than double contraceptive prevalence is 66% by 2015. And in a span of five years, Ethiopia has cut the mortality rate for children under five and a half. At the same time, it has nearly doubled literacy rates, approached nearly universal primary school enrollment and strengthened education for women and girls. Together with other measures intended to spur Trump entrepreneurship, which looks better on the page than actually saying it, entrepreneurship and approved fiscal and labor policies, Ethiopia has begun to reap its own demographic dividend. How is Ethiopia succeeding in this regard where others have failed? As your report notes, changing attitudes towards contraception has been key. Engaging traditional religious leaders as allies is good. I commend the government's willingness to invest real resources, including providing contraceptive services for free. And I also credit the government's partnerships with organizations such as those represented in the room today. The question is whether these achievements can be replicated? Will other developing countries that face daunting immediate needs make the same critical investments and choices? We in the US government are committed to doing what we can to help the United States through the US Agency for International Development is the largest bilateral provider of family planning assistance, providing approximately $610 million in fiscal year 2013. As a global leader in support of family planning and sexual and reproductive health for nearly 50 years, US government has provided over $3 billion in family planning assistance and support since 2009. Along with expert colleagues, the Bureau of Population Refugees and Migration also works in international fora to highlight the links between family planning services and development. In planning meetings that will shape the post-2015 development agenda, the United States making the case that sexual and reproductive health and reproductive rights are essential to empowering women, eradicating extreme poverty, and fostering sustainable development. During the recent UN Commission on Population Development, our population team led by Margaret Pollack, who's here today, called on delegates to fulfill the commitments made in Cairo in 1994 under the ICPD program of action, namely universal access to quality, comprehensive, sexual and reproductive health information, education and services. Governments promise to promote and protect reproductive rights, reduce infant child and maternal mortality, and achieve gender equality and the empowerment of women and girls so that all individuals and all nations have the opportunity to realize their full potential. Our delegation pointed out that we are not there yet. We called for an end to the scourge of violence against women and girls and to practices such as child early enforced marriage and female genital mutilation and cutting, and for integrated quality, sexual and reproductive health services. We stated that these should include maternal health care and access to a broad range of safe and effective modern forms of contraception. We also called for services to prevent and treat sexually transmitted infections, including HIV and AIDS, and provide access to safe abortion. We also drew attention to the special needs of the largest ever generation of adolescents and youth. The majority of these young people live in developing countries have limited access to sexual and reproductive health services and crave information. They needed to help them make wise decisions about their health now and in the future. Another priority for us is the plight of people affected by conflicts and crises. Reproductive health needs do not disappear when people are driven from their communities by conflicts or natural disasters. In fact, they can become more acute. Displacement can heighten the need for contraception while raising barriers to access, both for women who cannot care for or protect newborns and adolescents who may be torn away from family and social structures and exposed to sexual violence and coercion. Comprehensive family planning programs should begin as soon as the situation allows. This involves training staff, offering community education, establishing client follow-up, providing a wide range of methods and maintaining a contraceptive supply chain. We will continue to actively support you in population fund, UNFPA, the UN High Commissioner for Refugees or the UN Refugee Agency, UNHCR, and many other development and humanitarian organizations to respond to the challenges of providing predictable access to reproductive health services and crisis settings. We also recognize that we have more to learn about what it is that women want and need from sexual and reproductive health services. To that end, we applaud Family Planning 2020's research going beyond numbers and metrics so collectively we can improve our understanding of why some women stopped using particular types of birth control. These efforts will help us to better provide the range of modern contraceptive methods individual women want, empower them to understand, ask for, and receive specific products that suit their needs. The objective is to enable an additional 120 million women and adolescent girls in the world's poorest countries to get and use voluntary family planning information, contraceptives, and services by 2020. In closing, we know that being able to plan one's family is pivotal. It can spell the difference between life and death, opportunity and helplessness, hope and despair. And as Ethiopia's government has recognized, it is one of the best weapons against poverty. So please keep doing what you're doing. You make the case every day for why it is so important. It's you and your organizations that are in the field who can tell the most compelling stories of people whose lives have been directly affected by our joint initiatives and programs. These stories remind us of why consistent US government support for sexual and reproductive health and reproductive rights are so vital. Your continued support and commitment is essential to fighting for a sustainable future. One that empowers children, my children, your children, children I meet in my travels who really have the greatest needs and perhaps in some ways, the biggest hopes. It helps them to grow up healthy and pursue their dreams and help their communities and nations thrive. Thank you very much. Thank you. Thank you for the question. This is Han. Assistant Secretary Richard said she would take a couple of questions from the audience before she asked the leave. Let me perhaps start out with one. I think they said easy questions. Very easy questions. We in the report identify the importance of US leadership in this issue as a imperative for diplomatic development and security agendas in this country. And we talk about some of the upcoming opportunities to bring family planning into those broader agendas. Can you talk a little bit about what are some of the upcoming events where you see the US being able to elevate the importance of family planning? Oh, the big one for us is the 20th anniversary of the Cairo Conference, I think. That's the one that I'm really focused on. And one of the reasons I focused on it is because then Senator Kerry attended it 20 years ago and his sister was there too. She now is a liaison person for USUN in New York, but she was there too as working with the Planned Parenthood at the time. And so we know that he has a personal connection to this issue, to that event. And so we want to make sure that the celebration of the 20th anniversary really is not sort of a look back on something in dusty history, but a really living sort of progress report on what's happened since and where we're going with people, dynamic people still engaged and still working on these issues. So that for me is the number one. I don't know if my staff wants to mention another place or two, but you know what I'm doing, Janet, which we have talked about and with some folks here, is trying to tie in some of these issues with just my normal travel as part of being the Assistant Secretary dealing with the refugee crisis. Because as we said in the speech, some of the most vulnerable people on earth are caught up in these displacement crises and I do have a habit of showing up in some of these challenging situations and so the more I can add this set of talking points which are so well-developed thanks to smart people like you and then help explain these issues and incorporate them into the discussion of emergency response, I think that that could potentially add something that hadn't been part of the discussion before. Okay, we're gonna open it up to a couple of questions before she has to leave. Please identify yourself, your name and your organization and people will be coming around with microphones. We'll take maybe three and then we'll allow. I'm Melinda Kimball. Hi, I'm Melinda Kimball with the UN Foundation and just skipping through what's going on with the goal-setting process in New York, I think it's critical that we link the execution of things like ensuring sexual reproductive health rights and services for all to governance because the fragility of states is really a critical reason why we fail to deliver services in the past. Can you comment on how we're connecting governance with execution of social goals like sexual and reproductive health and rights? Yeah, well, even though these are clearly very logical steps to take and programs to support, they get very, very controversial. The states who are sort of aligned against some of the things we're trying to do, this odd left-right coalition kind of of passionate opponents. And so it's very frustrating. One of the things that Margaret has impressed me by is her ability to not give up, but just keep going back in and doing battle and keeping very patient and working through these things and sort of being the last one standing at the end of the negotiations. I think, I'm not sure I would have that endurance. I think at some point I would throw up my hands and walk out of the room. So I'm trying to become more diplomatic, persistent, it's not necessarily easy to me, but Margaret shows me that the potential benefits of really hanging in there and outlasting your opponents in negotiation can benefit people all over the world. So it's crazy not to. Other questions from the audience before she has to leave? I just want to add anything more heard about that. Sorry, we have a question over here. Two more questions here. Why don't we bundle them together? I thank you. I'm Kristin Eiffler from JSI and we partner with Pathfinder International on the Ethiopia Integrated Family Health Program. Thank you very much. I just wanted to talk about the, or ask about the health extension program and the sustainable inputs of funding that we're seeing in Ethiopia and what you're seeing in other countries as that example is possibly carried over and how the U.S. government is pushing for those kind of sustainable inputs. Question right here, let's take them both. Yeah, hi, my name is Paul Emer. I'm a retired Foreign Service Officer with USAID, was with the AID for a number of decades and so lived through some of this. Just want to mention that it's interesting being here in Washington because this is obviously a place where politics plays a role and I don't want to put you on the spot in terms of your politics or the politics of the State Department but just wanted you to comment on how you see the crossing the aisle, the Democrat-Republican issue which over the years has been somewhat difficult sometimes in the family planning issue. How you see a way forward with that and of course we see that this event here, CSIS does a great job in presenting the data to people but I wonder how you think that this could be done up on Capitol Hill so we can have some support across the aisle for this important program. Thank you for your service at USAID and I want to say that I don't know of another area where State and USAID work together so well, mesh so well as on working on these reproductive health issues. It's really great. And I thoroughly enjoy it. A lot of our refugee assistance enjoys bipartisan support. Issues like anti-trafficking, enjoy bipartisan support. It's such a wonderful thing. It makes everything possible. It makes everything available. So when you trend into the area that becomes hot-button issues with certain members of Congress, it's a real drag. And what I am hopeful for are some members of Congress who are representing Republican districts but are for family planning. We were talking about Mark Kirk on the way up in the car who's been a supporter for years. That is exactly the kind of voice on that issue that we really need. And that was the case once upon a time. And I think it can be the case again. We need the data. We need maybe a generational shift of people who really get the importance of this as people travel more. They may get this more. This still doesn't mean that rationality will descend on Washington and people will make smart decisions based on data and evidence. But I haven't completely given up, obviously. And on the sustainability of funding, last question. Oh, I don't know. Every time I make a prediction about funding, I'm wrong. We have been very fortunate the last few years because we have strong funding, both for humanitarian efforts and for this bilateral population funding. But I almost hesitate to say that into a microphone because somebody will target us and start. So let's all keep that secret, shall we? So people like Senator Leahy and Senator Graham, who are working together to provide the funding and their staffs, I just want to build a monument to them. The High Commissioner for Records, he's told me, and you should put a new Mount Rushmore in your office here at PRM with Leahy and Graham and Research and Grow for the two top staffers. He said, but it shows you the power of just a handful of individuals to make an enormous difference. So other than taking out life insurance policies on them, I guess we have to develop more allies like that so that should they ever decide to stop doing the wonderful things that they're doing on these issues, we have others who can step in and take their place. Please join me in thanking Assistant Secretary Ritchard. Thank you so much for your job. All right, we're gonna call up our first panel, Jenny Dyer, Robert Clay, and Pernima Mane. So this panel is going to be looking at lessons from family planning in Ethiopia for US policy. And we are delighted to be joined by Pernima Mane, the CEO of Pathfinder International, Robert Clay, the Deputy Assistant Administrator in Global Health for USAID, and Jenny Dyer, the Executive Director of Hope Through Healing Hands. I should note that Jenny was on our delegation, and I see Gretchen Lomis here from Senator Kirk's office was also on our delegation. We were also joined by Sarah Nitz from Congresswoman Bass's office, and Kristin Dini Hernandez from Congressman Dent's office, and Tom Walsh from the Gates Foundation who will be on the second panel. So thank you again to all the participants in our delegation and to our panelists. I won't go through their whole bios because you have them as a handout, but we are delighted to be joined by these very knowledgeable people who will bring us the perspective of an implementing partner, the US government, and outreach to faith-based organizations, all of which are critical pillars, both for family planning on the ground and for understanding the importance of US policy and advancing US policy in this area. So we're gonna start out with short introductory statements from each of them, but then we're gonna have a more interactive discussion after which we will open it up to your questions. So let's begin with Robert from the US government. Good, well thank you Janet, and first just as Ann did, thank you and Elise for the nice report and also for CSIS for bringing us all here today. I just returned from Seattle last week where I was at a family planning 2020 conference for reference group meeting, and it was real very clear that family planning has gotten a lot more energy over the last year, and I think what was real evident in that meeting was the progress that we're seeing in many countries, and so it's great to focus on Ethiopia because it's one of the countries where we are seeing progress and it's important to talk about why and what we learned from that, so thank you very much. Family planning in USAID, as Ann mentioned, we go back 1965, so we have a long history of working in the family planning area, and if you look at our current goals in the global health arena of ending preventable childhood maternal deaths and AIDS-free generation, family planning is critical to achieving those goals, and the Obama administration has recommitted itself to exploring that, and if you just look at the impact, the numbers, if you have timely, well-spaced births, you can reduce maternal mortality by up to 30%, child mortality by up to 25%, so you can have a big impact by having a strong family planning program, so it's very critical to our future and reaching the targets that we have set out for ourselves. I was fortunate to also be at the Addis International Family Planning Conference, and it was very important that it was held in Ethiopia. Ethiopia has made remarkable progress, again, a nine-fold increase in terms of its contraceptive prevalence rates from 1990 to 2011, TFR going from seven to 4.8, those are remarkable findings in a country that is not at the transition period. We see this in other countries, like in Latin America and parts of Asia, but Ethiopia's a very poor country, so I think it's great that we're looking at that, and as we, from our experience, as well as I think was highlighted in the report, I would just say a couple of things about why it was possible in Ethiopia. One was the political support. The government really took this on its own and invited donors to help them, but it was real strong country leadership, and I think that's really what we're fostering and looking for more and more in our countries, but Ethiopia really did exemplify that, and this idea that it was a national program, that it was focusing on hard-to-reach areas, getting access was very, very critical to these changes. It also had a very important partnership component and particularly at the community level. We heard in the tape about the religious leaders, participation, civil society was engaged. It was a very open and flexible way to address gaps and to be able to work together in partnership. I think that was key, and then finally, the health extension worker that outreach to the community and getting it right, and I can talk a little bit more about the history of that, because I think we've learned a lot of lessons about what worked in Ethiopia, but I think that is a real critical core component of the success that we're seeing here. Thank you, Robert. Lots to follow up on in the next part of this, but Pranima, do you wanna come in as an implementing partner on the ground? I should also say that the Pathfinder team in Ethiopia was extremely helpful to us, both in the delegation and in the video, so thank you again to your country director, Mengistu Aznake, and your team in Tigray. Thank you very much, Anit. I did want to refer to Mengistu, so I'm glad you did. Thank you very much, and it's been a pleasure to review the report, and I particularly appreciated the film because it captures the spirit of Ethiopia, the optimism, the lessons learned, and also what needs to be done in some senses in a very encapsulated form. Pathfinder, just to say, we have been in Ethiopia since the early 90s, and one of the things that I think has already been mentioned by you is the fact that the government's leadership has made a huge difference. If we could have that in every country, if that could be replicated, that's what we need because that really gives the momentum that any good implementing partner, any stakeholder wants to see on the ground. I think the strides that Ethiopia has made have been covered quite a bit so far, but in the coverage areas that Pathfinder is working in, we're also seeing other things. For example, the issue of long-acting methods. Our data shows that when we did the early studies, in terms of baseline, we had 1% use, and now we are seeing that was in 2008, and in 2013, you're seeing 6.3% of the clients using long-acting methods. So all of these things are beginning, there's an impact in a variety of ways. What I'd like to focus about is that there are several factors, and I think Robert referred to, that have contributed to this national leadership, of course. There's also donor commitment for considerable period of time from a wide variety of donors, both the US government, but also other donors who are represented here and will be speaking later, but it's not just the money. I think it's the unity and the breadth of the strategy. The government's been in charge. The strategy has been collectively designed, which makes it very different. People aren't working at disparate directions, and I would say there are five elements that are particularly important. We say that end users must have, and this is what all of us who work in this area keep saying, and we see that in Ethiopia. They must have access to contraceptive options which are safe, socially acceptable, high quality. They must have diverse mix of access points, and there needs to be a high level of accountability. If you look at Ethiopia and the way in which Pathfinder is working, you see all of these elements. For example, increasing community participation. All our program activities increase and enhance that, and you can see that exemplified in the community health extension workers. This is something that the government and Pathfinder work very closely on, along with our other partners, as was mentioned by JSI. The second element is taking into consideration age stratification and the needs of different age groups, particularly young people. I can talk about that later. I don't want to take a lot of time on this. The method mix, which I emphasized earlier. Fourthly, I would say the accountability and local stewardship. There is right now a technical advisory committee that not only includes the government and the international NGOs, but also includes local NGOs and donors so that there is this unity, as I said, of working together and the integration. That's a very important lesson we've learned, integrating family services into an array of other health services, whether it's primary health care, HIV, maternal health, because we know how that it works, and therefore it's important. So I would say that the reason for success is that all of these elements are making an impact and that we're all working together collegially, and that makes a huge difference. You pointed out one thing. You did say the work, why we are celebrating successes and learning from the challenges. We do know there's a whole lot yet that needs to be done. What is worthwhile is that there is recognition of that nationally as well, not just internationally, and that recognition gives you a baseline in some ways. It gives you a launching pad to go further and continue this effort. So I'll stop here. Thank you, Pranima. So Jenny Dyer, we were delighted to have you on the delegation and bringing that element of the role of faith-based organizations in advancing family planning. Some of the issues that you saw in Ethiopia, but also that your organization is working on here in this country. Tell us a little bit about that perspective. Sure, so I'm the executive director for Hope Through Healing Hands, which is a Nashville-based global health organization and Senator Dr. Bill Frust is the founder and chair of the organization, and it's about 10 years old. Our flagship program, just to let you know, is really a medical missions program. We send out medical students and nursing students and public health students all around the world to serve in underserved clinics and trained community health workers. But alongside that, recently we've just partnered with the Bill and Melinda Gates Foundation to launch a faith-based coalition for healthy mothers and children worldwide, really galvanizing faith-based leaders to learn more about maternity-born and child health, as well as healthy timing and spacing of pregnancies, as well as advocate for this. We're asking them to help enhance the learning of policy makers around healthy timing and spacing of pregnancies, as well. And we've been working at this for about six months. So Senator Frust and I co-authored a piece in Time a few weeks back, and it was entitled Contraception, is a pro-life cause in developing nations. And we really wanted to throw our weight behind the 222 million women who lack access to contraception around the world and support Melinda and her initiative with this, as well as other partners. Why this issue and not clean water or HIV AIDS, and we have worked in those spaces as well. And we have worked in maternal and child health for the past five or six years in conjunction with Save the Children. And Senator Frust leads their newborn and child health committee there. And we really do feel like maternal and child health and this crux of healthy timing and spacing of pregnancies gets at the core of global health issues, addressing issues like extreme poverty, gender equality, the MDGs, getting at, of course, improving child health and combating maternal mortality. So we really do wanna move in this direction and support these issues in full. And in doing that, we really want to galvanize conservative and faith-based groups around these issues and do the work of education and advocacy for this. All right, thank you. Well, maybe we'll start with you, Jenny, just to follow up on that. What more do you think can be done in this country in terms of raising awareness and encouraging family planning for women and families in Ethiopia in terms of the religious community there and engaging the religious community here in the advancement of family planning? Right, so in Ethiopia, we were able to meet with Ethiopian Orthodox priests largely and I don't know if you know much about religion in Ethiopia but Ethiopian Orthodox, the Orthodox religion comprises about 45% of the population and Muslim population is about 30, 35%. So there has been fantastic work done in the Ethiopian Orthodox Church there. UNFPA has produced with Population Council a nice development Bible, which is being used by priests. So as they go through seminary, they're presented this Bible and this Bible is almost like a daily devotional. It has 365 different lessons with scripture correlating with a piece around development issues, right? Like HIV AIDS or clean water or family planning. So they can use this for their own devotion or use that for their communities. They're using this development Bible with workshops with current priests and so the dissemination of that really is a fantastic education tool to get in remote regions of Ethiopia. So we were encouraged with the interviews we had with the priests as well as some of the seminarians there that there was good work being done in the religious sector to promote awareness and advocacy. Back in the United States, similarly, I think there needs to be a lot of work done in terms of just sheer awareness raising what we're talking about when we talk about family planning getting at the definition of healthy timing and spacing of pregnancies and what that means and just having open and honest dialogue about that with a variety of people who are influential in the faith sector. Thank you, there's also been a lot of talk about engaging with NGOs, with religious sector, with civil society and Pranima, I know that Pathfinder has done a lot of that in Ethiopia and in other countries. Do you wanna reflect a little bit about what are some of the lessons from your program in Ethiopia for outreach to faith-based groups, outreach to groups who are addressing the issues that youth face? What are some of the things that you're doing in Ethiopia that you are translating to other countries? Thanks, Janet. I think one of the principles of the work that Pathfinder has done in many countries, including Ethiopia, is reaching out to community groups of different kinds and faith-based groups have been quite important within that area, but also youth groups, groups that reach out to young people that actually enable young people to speak their mind and their voices and their needs rather than talk at them, as well as women's groups and various other groups. Now that's quite a long list of groups that one would want to associate with, but I think that is absolutely critical in conducting a program. While a lot of the efforts that we make are within the public sector, the public sector and civil society need to be brought closer in order to dialogue with each other, because a lot of times the efforts happen sort of alongside each other rather than with in combination, in concert. And that's one of the things, for example, the Technical Advisory Committee has achieved that purpose to some extent. That's not the only means, but that is a critical means to bring different sectors together to talk to each other. And this is a lesson, I think that this is a methodology that we adopt in almost every group, whether it's Bangladesh, whether it's Niger, and all the other countries that we work with, we adopt this methodology in order to ensure that community voices are respected and brought together rather than having one more important than the other. And Robert, it's interesting that your career started with work in India with community health workers. And now we have these, there's been lots of different examples and models along the way during your career. Could you reflect a little bit about what has changed? What does the Health Extension Worker Program in Ethiopia mean? Is it scalable? Is it sustainable? Why does this work better than other things that have been tried in the past? Where does this fit in the sort of scheme of community health worker model? Sure, but before I do that, I just wanted to make a comment on the faith-based groups because I was fortunate about, I guess four years ago to be in Ethiopia, I was working with the PEPFAR program, working on HIV-AIDS. And I was in the Lullabella and the, I guess it's the Bishop at the time, asked that all the priests come to a church at Lullabella at noontime when it was closed, just to show appreciation to the US government of the work that we've been doing in HIV-AIDS. And it was an incredible gathering of about 30 to 40 different religious leaders. And they all came just to show thanks for the support that we had provided. So I, one, that's a testimony to the importance of the faith-based groups and their outreach. And then, two, how much of a positive diplomatic gesture this is than work that we're doing in the country. So I just wanted to share that. But on the health extension worker, in some ways, this was the in vogue in the late 70s, 80s, everybody was doing community health worker programs. And I was fortunate to be in India evaluating their effort in 1982. And I think, you know, we made progress, but I think we, the field kind of moved on. And I think there was some feeling that community-to-be-ex-workers weren't, didn't have enough maybe professionalism or they didn't have the skills necessary. And so they, we were looking more at different auxiliary type of workers. But we never really, I think, addressed how to reach the community. And so I think we're back at that issue in many countries of saying, how do we really engage communities and make sure that they have a strong referral process into the formal health system. And so this, it's interesting for me because this issue has been throughout my career, one that's been debated. And I think Ethiopia has done some things that were quite innovative. One is they decided volunteers is not the way to go. So they, as we talked about in terms of their political commitment, they committed to increase their budget to bring these on their staff. Their budget went up two times and doubled their health budget in five years. So in part of that doubling was able to support these extension workers. So they're actually paid. They set a level of a fifth grade or a 10th grade, which is their high school level. So they were educated and then they trained them for a year and they provided them with a lot of skills. And I think that that has been very, very important in terms of getting the right people that are going to be staying in the community to be able to address the problems that are there. The other is this referral or the connection with the official health system because they are having much, much more oversight, more supervision than I think some of the earlier programs where you would, the program I evaluated, the selection was rushed through. It was often the Pinchot chairman who selected the individual. So it wasn't community-based. It wasn't community-owned. And then after a couple of years, the person left because they weren't really given the kind of support. So I think that that's what we're seeing, the sustainability of these health extension workers in this program is being addressed by some of these more fundamental issues. Can I just, I just want to comment on the issue and the issue of support to community health workers. I think that is critical throughout whether you have a voluntary community health worker or whether it's paid health worker, this ongoing support and the ongoing training in addition to the monitoring is absolutely critical. That's something that, for example, Pathfinder has done in India with the community health workers as well, which is because they are not part of the staff, the government offers an incentive scheme which has its own pluses and minuses, as you well know. But nonetheless, the kind of support, the ongoing training, the ongoing education that they need, the methods, the provision of the contraceptives, the understanding of because they are community representatives themselves, they influence community norms and attitudes. So working on those elements is something that Pathfinder has done in India because that too needs to happen and it's the same in Ethiopia. That element, if you continue, it also contributes to the success of a program. And certainly the whole task shifting element of the health extension workers has been fundamental for injectable contraceptives, for insertion of implants, and that's something that you really don't see everywhere. Jenny, if I could get back to you for a minute, because you have also past experience in outreach to faith-based groups here in the area of HIV AIDS. And maybe you can talk a little bit about what are some of the lessons for the family planning community from your work in HIV. Right, so in the past, I was the faith outreach director for the Data Foundation, which became the one campaign, I guess some 13 years ago now. And we were somewhat at the forefront of galvanizing faith-based communities, faith-based leaders across the US, and that included pastors and Christian music artists and academics and nonprofit leaders across the faith spectrum and culture to really get behind the issues of HIV AIDS in Africa, which was not an easy time or an easy space to do that, frankly, at that time. It was the Bush administration. At that moment, we worked largely with evangelicals when I was there, though we did work across faiths as well. But it was really important to educate these faith-based leaders and energize them to educate their own constituencies about this, to build a momentum of support so that we could push forward with increased funding, which became PEPFAR, and then Global Fund monies at the time, and then of course to maintain that sustainability of funding over that administration and beyond. So we're in the nascent phases in my, and I'm new to this subject in all honesty, of family planning and galvanizing faith-based communities, but I think I'm very optimistic, I'm very encouraged about moving forward with the faith-based communities as we do the work of education and awareness raising to move towards advocacy and moving policymakers on these issues. I wanna give you all a chance for another round of comments, but maybe you can also talk about what are the next steps? How do you take the lessons of Ethiopia and what does that mean for US policy? What are some of the key things that you wanna see the US address in order to move this agenda forward? And then we'll open it up for some questions. Pranima, do you wanna start off? I think the consistency with which the US has supported the efforts on family planning in Ethiopia are commendable and I hope will continue because there often is a tendency, not in the US government, but in many other donors, to see when things are going well, well, if things are fine, we can move on to another country or another area. This is not the time to quit, this is the time to stay with the government and the community efforts in order to build on the success. It is also a time to share the success. I don't think that many other donors and many other countries recognize the successes that we are making. We focus a lot on what's not working. We don't focus on what is working, where things are going better. We need to find ways, such as your film, for example, and various other means that the US government needs to use in order to highlight the success that Ethiopia has reached in order to build support internally within the country because a lot of people don't know that Ethiopia has made these strides to build support for continued support of Ethiopia. I think that's getting the message out of success, what needs to happen, what we've learned and how we are actually taking these lessons. I know we are, but the fact that the US government is doing the same in terms of other countries is what really needs to get out. And when I say get out, it needs to get out to policy makers, it needs to get out to the Congress, it needs to get out to the media and through the media to the general population that often has a feeling that we are wasting our money on these resources. No, we are not. And that's the message we need to communicate. And clearly there's a strong link, Robert, between the investments in family planning, important in and of themselves for all the reasons we've discussed, but also as a way to achieve broader US health and development goals. Do you wanna talk a little bit about that from the USAID perspective? Yes, well, one of the things that we're really focusing on is getting the message out. And so we have a series of high impact practices that we've put together. And it's a very systematic process of looking at where we've learned really important lessons and putting them up for people to follow in other countries. So this Ethiopia and the health extension workers, one of those high impact practices. And this is going to be part of the Family Planning 2020 portal that they, or their website so that people can also disseminate it through that means. So we're seeing other countries quite interested in Ethiopia. We have study tours that have been going to the country to look at the way that they've been structuring their health system and their outreach workers, so we've supported that. So I think that face to face south to south exchange is very, very important. I would say that instead of just focusing on donor funding, which is important to play a critical role, we should really be also putting a lot of attention on continuing that ownership that Ethiopia showed early on by taking the initiative themselves and we're supporting that. And their line item for contraceptives in their budget, their increase in the health system, all of those things need to be encouraged and fostered in Ethiopia as well as other countries because if you look at where the money is, the money is really in the countries themselves. And we need to harness that and make sure that those resources are being used more effectively as we move forward. So I would put an emphasis on, our relationship is changing of just filling gaps to really looking at how we work with countries as partners and making sure that the resources in countries are being used wisely. So that's how we're going to be achieving our role visions for any preventable child and maternal death in an AIDS-free generation. Jenny, in terms of next steps in terms of the faith-based communities and for engaging the US government more effectively on these issues. Right, so just thinking, I was just thinking in some perhaps just shared stories, I think sharing the stories of the Ethiopian Orthodox Church and the priests there and the faith leaders there back here at home with the faith leaders here who want very much to know what is going on in terms of the church there, how they are supporting, promoting family planning. That's one piece. The other piece is the leadership of nonprofits here in the US who are doing family planning who are faith-based organizations talking about that more, talking about the successes of that and moving forward in that space of advocacy. And then I think also to the extent that we can, pushing policy makers to think about considering the role of religious leaders in these developing countries and how we can engage them to promote awareness, to promote access to contraception and to be leaders in that space. Thank you all very much and I'm sure that there's gonna be a lot of questions. We have about 15 minutes. So please identify yourselves and your organization and we will take around a question. Let's start over here. Margaret, wait for the mic because I should have said that we are joined by over 100 people online who are also watching so we welcome our online audience. So you need to speak into the microphone. Okay, I actually don't have a question. I have a comment on lessons learned. And one of those lessons I think that's really important to bring up with Ethiopia and other countries in Africa is that it didn't start in 2003. It really started before 1993 with Pathfinder hanging in there with the DERG having a footprint in Ethiopia with the Family Guidance Association of Ethiopia, the IPPF affiliate. So family planning and activities have been going on in Ethiopia for a pretty long time. And then 1993 to 2003 when the government became much more integrally involved there was a long, again, USAID was funding Pathfinder and other organizations through Pathfinder to really get family planning started. And there are a lot of exciting stories there. They based their original NGO network on a consortium of NGOs that worked in humanitarian assistance earlier. So it's all been building over time. A lot of policy work with the government, et cetera, even encouraging leadership within the Ministry of Health to include that leader who ended up being the person who really pushed for the Health Extension Worker Program and having some models that were built on volunteer community health workers, CBRHWs who had been already very active at the community level with local faith-based and non-faith-based NGOs. And the faith-based community had been engaged from a very early stage. I think the other thing that Pathfinder did with its partner organizations was develop district level and regional level coordination committees that worked actively across, as Pernima was mentioning, across the sectors. Engaging people in family planning, harmful practices and changing harmful practices, et cetera. So I just wanted to make that note that we have to be, we have to stay in there for the long term that it doesn't start from nothing. It didn't come full force into the Health Extension Worker Program out of nothing. There was a lot that they built on and I have to hand it to the Minister of Health who initiated the Health Extension Worker Program that he recognized that but then felt that a lot more could be done and did a lot more, obviously, and took a very strong leadership role and had the donors running after him in terms of catching up to his vision of what could happen. And fortunately, the donors didn't say, wait, wait, wait, wait, wait, we have to do pilots, et cetera. They said, okay, we're gonna go with you and help you and figure out how to fix it later on if we need to do some fixing. That's unusual, again, for donors and I have to hand it to the donors who are involved that were willing to do that. So that was my comment. I think we have to not assume that this is something from 10 years. This is from 20 plus years of concerted effort at both, at all levels in Ethiopia. Thank you. So we're gonna take one question over here and why don't we bundle a couple for a limited time? So we'll go here and here and then over on the other side. Thank you. I'm Sambedwale, I'm a public health consultant just to follow on what Margaret has said. In the report, you said that there's restriction on private sector and NGOs, but in most African countries, family planning services are delivered by NGOs and faith-based organizations. So I wonder if the lesson that you want us to transfer to other countries is to have banned the NGOs and have the government take the leadership because it looked like they are walking in Ethiopia with the government taking the leadership and banning NGOs. We will go here. Hi, Jill Gay, what works for Women Association? My question is for Dr. Mané as an implementing partner in Ethiopia, which is, we know that, I mean in the report it also states that adolescents are a big challenge. How are you working in country to reach adolescents both married and unmarried? And what are the legal restrictions, if any, for providing contraceptive services through HEWs? Two adolescents are their restrictions. And third, has there been any studies on the, because a lot of the HEWs are adolescent, girl, women, have there been any studies of the impact on them in terms of their own contraceptive views in providing services for others? We're gonna take one more question over here and then we'll do this round and we'll have time for one more. Hi, I'm Rick Berzon with the National Institutes of Health. I wanted to ask a question about perhaps the bundling of services provided by HEWs with clinical officers who provide primary care services in a number of countries in Africa. The concept of providing family care is important in many countries in Africa, but as the world transitions from acute illnesses and circumstances to issues around chronic illness, I'm wondering if it might be more cost effective and efficient to provide healthcare family planning through individuals that are more trained up in the area of primary care, such that countries that are in the process of developing their own infrastructures to provide healthcare services over time have a frontline cadre of practitioners that are well-versed in all kinds of primary care services that can then be, these individuals can be quickly trained up like physician assistants in this country, for example, can be trained up quickly and then put out into rural areas to deliver healthcare services. And if that might be sort of the next step in terms of where to go with helping, developing countries build healthcare infrastructures. Okay, why don't we go through the panelists and address some of these questions. Pranima, do you want to start? Yes, I'll take the question that was raised about adolescents. As far as your second question is concerned, I don't know the answer to that. I don't know if any of my staff know whether there was any study conducted on the impact on the health extension workers themselves, their contraceptive use. I am not aware of it, but if any of my staff know they're welcome to step in, but I will certainly find out and communicate the response to you. Because it is important to have a sense of their attitudes at least and their beliefs if not their practices, because practices matter more, but attitudes and beliefs also permeate in the way in which they provide their services. As for adolescents, I'm glad you asked that question. I didn't have the time to get into it too much, but I will just mention very briefly that in fact it is a very critical part of the program that we are working on with the government and with our other partners. I would say since 2005, almost we've been working on youth, the tools that we have developed to address young people, but also the significant others around them in order to build a much more enabling environment for the adoption of family planning, for delay in marriage, because all of these are related. And I don't need to convince this group of that. So there's a whole range of things that you need to work on and it is inbuilt into the program and in fact we have some brochures that I can provide. I don't want to get into the details of it, but adolescence is a critical part of the programs that we are working on and the government considers it important for a variety of reasons, as was pointed out, the prevalence of child early marriage, the prevalence of early pregnancy, spacing being an issue, maternal mortality, a range of issues and also in general the ability to make decisions about your own body, which is what you're aiming at, a whole new generation of young people that value that. So all of that is inbuilt and there's a variety of tools that Pathfinder has developed, which we are making available to populations and actually scaling up. The government is extremely interested. We work in certain project areas, but the government is really working with us to scale it up to the entire country. So it's a very, very critical period of part of the program. And Robert, do you want to maybe take the question about clinical officers, family care integration? Yeah, first I'd just like to underscore what Margaret said because I think that was a very important comment about how we've been at this for a long time. As I mentioned, at USAID, it's been 50 years plus of our work. And I think one of the things that we're seeing is that as we continue to deal with these issues, we're getting deeper into really what the crux of the matter is. So issues of how do you reach those communities that are the most hardest to reach? How do you get people to change that behavior? It's just not the easy access issues or knowledge issues. But so I think family planning has a lot to say about these more fundamental problems that we're facing in development in general and having some tools. And I think Ethiopia, because of that consistency of our focus there, has a lot of lessons to be said. So thanks, Margaret. In terms of the clinical officers in the bundling of services, actually the health extension officers, they're trained in 16 different areas. So they're not just family planning providers. So the year course, which is probably one of the longest that I've been aware of, they get a lot of different areas of expertise. I don't know, I don't have the details of exactly what it is, but they have a much broader array which helps in integration, which we heard is very important for the success of the program. And it also then links them more back to the formal health system. So back to the health post, the health center, and so forth, though, for referral and for issues of supervision and oversight. So I think it's, that Ethiopia system has that much more defined than others. So Bob, I'm just thinking of the, so a number of countries allow you and is investigating this as well. So I'm just wondering in terms of future plans, if you're just training, and you can't really train people to deliver sophisticated primary care services in a year, although it's a nice thought. It's just not enough time. So you need a year of training in a classroom, and then you need a year of clinical hands-on mentoring and so forth. So you need more time to do this. So in terms of next steps, what I'm thinking is that it might make more sense rather than to replicate this kind of a program in countries that don't have it, but there are countries that are interested in this issue of primary care providers and expanding that quickly. That this is the kind of thing that could be implemented in other countries. That's what I was asking. Sorry, we're short on time. We just wanted to get to this last question, which I can just quickly say. I don't think any, I think what we say in the report is clearly acknowledging the extreme importance of the government's leadership in promoting family planning and raising concern that it be done in a broader, in conjunction with a broader partnership with civil society organizations. So we are not in any way promoting government leadership to the exclusion of engagement with civil society. We are looking for models that can encompass both. And I think we have time maybe for one last question. Let's give Molly a chance to ask a quick question, and then we're gonna have to wrap up and go to the next panel. Hi, my name is Molly Schmalzbeck and I'm from U.S. AIDS Bureau for Global Health. And clearly the health extension program has had dramatic impact on a variety of health outcomes. As Robert mentioned, there are 16 different elements. And I know particularly with reduction in child mortality, a lot of people, including Ethiopia's Minister of Health, have credited the health extension program for Ethiopia's achievement of the Fourth Millennium Development Goal. And so I'm wondering, in comparison to that, it seems like there haven't been as dramatic of gains in reduction of maternal mortality. So I'm wondering if you can comment on why you think that is and what lessons there are for U.S. policy there. Very quickly, anybody wanna take that and then we'll have to wrap up. Well, I would say that where we have seen real dramatic reductions in maternal mortality has been through the Saving Mothers Giving Life initiative in both Uganda and Ethiopia where we've seen 35% and 30% respectively. And what that has involved is a comprehensive approach at a, you know, looking at not just training or not just referral, but the whole package of maternal health interventions with very strong equipment upgrades and community mobilization with government leadership. So I think this program has been focusing more at the community level, which is one component of, but maternal mortality, we really have to have a much stronger clinical base program with good facilities, good training, which involves a lot of time and attention, but when you do it right in a comprehensive manner, you can see important reductions and we're hoping now to expand that to other areas. I wish we had time for more questions, apologies to the audience, but thank you so much for your excellent presentations and for your engagement as the audience. And we will move to the next panel, but please join me in thanking the panel. Thank you. Hey, Joe. And are we free to get started? Well, thank you all. We, I'll introduce our three speakers just in a moment. I'm Steve Morrison from CSIS. This panel involves three organizations with considerable depth of investment and experience in Ethiopia and in family planning and in health writ large. And what we're attempting to do is really spring forward from the experiences that have been gleaned in this last period by each of these three in Ethiopia and elsewhere and look forward into what the future looks like. And I'll say a few words before we skip this off. I'll see a few words about what some of the big issues are. In that, I want to thank the Ethiopian Embassy for its support that we've received. We have with us Mr. Wahid Belay. Thank you for joining us, Wahid. And thank you to Ambassador Guillermo Biero for his support in the course of this and putting this all together. And, you know, in looking back at what CSIS has brought to the table over the last decade, I was really taken by the magnitude, the body of work that's accumulated over this last 10 years on Ethiopia itself, on different dimensions of its health agenda and on the governance issues. We had a mission that went out in 2004, a fairly large mission with a number of different folks from the Hill, from the administration, from the UN, from elsewhere that we did in partnership with Packard, with Pathfinder, with the US government, the US Embassy, and with the government of Ethiopia. And this is what we're doing, what we're releasing today. If you go back and read that 2004 analysis, which was focused upon HIV AIDS and gender issues and other things, it's a very similar set of actors struggling with a very similar set of issues. And we were able to, I think, have the good fortune that we had both through the prodigious efforts of Janet and Alicia in Ethiopia and the advance work and the like, but also for the fact that we've been cooperating and collaborating over well over a decade in looking at these different issues. There was a report on governance that Terrence Lyons published through CSIS 2006. Suzanne Brundage and I were in Ethiopia and in Oromia in 2012 visiting health extension workers, visiting district health centers and the like. We published that report, many of the same issues. A lot of commentary that was issued by myself, by Richard Downey on the passing of former prime minister, Melis Senawi a year and a half ago in August of last year during the Aspen gathering of members of Congress in Addis at which the Ethiopian government was very participating in the US embassy. I had the opportunity to work on the health piece of that and the embassy was very cooperative, the US in bringing forward the AID, the CDC, the PEPFAR personnel to interact and ambassador and minister Tedros very forthcoming and coming to engage with those members of Congress as well with us personally on the preparation for this mission. So I'm very proud of that and I think that what you're seeing today and the work that we're releasing and the discussions that are happening here really builds on the outcomes from that. In terms of where we are and getting to our speakers, this seems to me to be a very big moment. And a nervous moment in a way. The London summit that resulted in family planning 2020 set various bars, set various goals and began to put more precision around accountability and commitment. We're now at that moment where people are beginning to dig in and look carefully at what that all is going to mean over time. We have a new, as we'll hear from Tom Walsh, we have a newly released family planning strategy from the Bill and Melinda Gates Foundation. We have a world bank that is very prominently engaged in terms of universal health coverage, has a newly appointed senior manager, Tim Evans, on the health agenda. This is a very active period and it's one in which people are looking critically at the issues of sustainability of commitments, fulfillment of commitments, and what are the pieces that are going to be in place for success in Ethiopia, looking forward, and beyond in other places. And those you'll hear, I think from our speakers, there's some common categories of factors that people are organizing their thinking around. There's questions around money. There's questions around what are the commitments by the partner governments most importantly by themselves. How do we know what the budgets are and how do we know where the budgetary dollars are going? And we've heard many folks debate, most recently the Minister of Finance from Nigeria at the World Bank meetings, spring meetings, say we have to be very conscious of the fact that dollars that go towards family planning, reproductive health are dollars that are competing against other very worthy objectives, be they water, agriculture, others health sectors. And this is something that is very much at play here. What do we know about the budgets? How do we know where the dollars are moving and how do you navigate a very competitive environment? Capacity, when the London summit was held, there were questions around do the organizations exist to implement these programs on non-governmental side as well as governmental side. Data, there's a lot of discussion around data. What quality and timeliness of data do we need in order to know whether we're achieving success? And then there's a lot of discussion around technological innovation, new interventions in terms of programs, how to shape markets to make the products affordable and accessible when they're needed. And most importantly, the question around ownership. Ownership of this issue of family planning. Within our own government it's controversial and it sometimes gets lost. And within many other governments, sometimes it gets lost or out-competed. And that's an issue really that we live with now as we look out at whether FP 2020 will reach its objectives and be able in a few years to look back and say that that was a really quite dramatic turning point. Now we have three speakers here representing three major institutions that have considerable depth and experience. Yameserich Balena is here. She has been for the last 14 years with the David and Lucille Packard Foundation. Since 2008 she's overseen the grant-making activities in the population and reproductive health program areas. She is a BA from Addis University and an MA from Azusa Pacific University and a management, trained in management, as a trainer of reproductive health and leadership development. Tom Walsh is a senior program officer at the Bill and Melinda Gates Foundation and in the offices here in Washington in the Global Policy and Advocacy Shop. He came to that position after eight-year, very distinguished period of service in the U.S. government within the Office of Global AIDS Coordinator where he served as the Chief of Staff, as a deputy coordinator, as an acting coordinator in a variety of very senior leadership positions over the trajectory of several different leaders, Mark Dible, Eric Goosby. Prior to that served under Senator Grassley at the Senate Committee on Finance and the Special Committee on Aging. Soji Adeyi is here from the bank. He's a doctor, an MBA, a public health doctorate and he's the sector manager for Eastern and Southern Africa in health, nutrition, and population. He was very instrumental in developing at the Global Fund, what's called AMFM, which was the Affordable Medicines Facility from malaria, very innovative, complex facility. He's played senior coordinating roles on population and public health programs at the bank over many years and published very widely. What I'd like to do is ask Yamesorech if she could begin. I neglected to mention one very important thing, which is that at the Third International Family Planning Conference, which was held in Addis at the end of last year, in November, she served as the co-chair of the National Steering Committee and she was really responsible, she was in the Catbird Sea for actually executing the organization of that, which was kind of remarkable. So congratulations on that. Thank you so much for coming the distance to be with us today. Why don't you open with five or six minutes just of reflections around what's come out of this long stretch of Packard's investments in this area in Ethiopia. It's unparalleled, it's unparalleled. There's no other organization with the depth of commitment that Packard has brought to the family planning reproductive agenda in Ethiopia. And so you've got something very special to tell us. So thank you. Okay, thank you very much for the kind introduction and much has been said about the success of family planning in Ethiopia and as most of you were there at the family planning summit conference in November, we celebrated the reproductive health community celebrated these achievements. But I think what we need to talk about is how we were able to achieve this success and much has not been done and I really would like to thank Janet, her team and CSIS for organizing this forum and also for the visits which has really looked into the depths of what happened, what were the roles and responsibilities of different stakeholders in this process. So as I mentioned, the Packard Foundation has been in Ethiopia supporting family planning and reproductive health programs since 1999 and with a budget of close to 90 million US dollars. And what we always say is we just don't bring the dollars to the country but we bring also partnership capacity building and other things that go with the dollar and I think that's where we have really leveraged the presence of the partners and other stakeholders in the country. And I also would like to say that it is very interesting to see that our role through the years have changed a lot. When we started the program in the 1990 and early 2000, we're doing a lot of advocacy, supporting programs, generating evidence so that we can get a lot of ownership from the government and make family planning the center of the overall development initiative. Now our role has changed. The government has taken the leadership and we're providing the supports and the resources needed for that and it is really, really gratifying to see that. Things change through the years. And the reason why the foundation decided to go to Ethiopia in 1999 were very obvious. High maternal death, serious complications with child health, teenage pregnancy, all the factors that we were. And the foundation also saw the unique relationship and interdependence between family planning, environments, and overall development in the country. So Ethiopia was lucky to be considered among the nine or 10 key focus countries for the foundation way back in 1999. And since then, the foundation has continued to provide technical and financial support to the country. And in terms of our approach and our experience, we used a multi-pronged approach. So we support civil society organizations directly. We provide financial and technical services. However, our strategy is we work within the health sector development plan. We have a very strong relationship with the governments. We participate in the policy dialogue, in terms of providing technical capacity or commissioning and helping them in developing appropriate strategies for the country. But our funds are channelled through both local and international civil society organizations. In terms of our relationship with the government, not only do we provide, you know, not only we are working in partnership, but recently we have even started to co-fund projects. For example, currently we're funding data and public health association together with the Ministry of Health, where the ministry is providing around 40% of the resources to train health extension workers in long-acting family planning methods. So, you know, we have come to a place where we negotiate with the government. We identify problems and we establish partnership so that the public-private partnership can also be a reality in the country. In terms of, you know, the relationship that we have with civil society organizations, initially when the program was started, most of our partners were international NGOs, you know, Pathfinder and Gender Health and the others, who came to the country to provide critical services to the people and the women of the country. But through the years, we have also established very good relationship with community-based associations. You know, in the Ethiopian system, in addition to the local NGOs, like the Family Guidance Association, which is the IPPF affiliate, we have strong large-scale community-based organizations. We call them Development Associations, who initially used to do hardware infrastructure development activities, but now they have shifted to do social work, including family planning. And we do provide support to local civil society organizations and community-based associations. Currently, our portfolio consists, about 90, 95% of our portfolio is directly funding local organizations, which has challenges, but at the same time, it is really gratifying and, you know, building to the local capacity. The other experience we had was also in terms of building local leadership and ownership, not only with the government, but, you know, developing champions for family planning. And we have a leadership development program, where we provide trainings and support to, you know, enhance population and reproductive leadership fellows. And in the earlier days, it used to be one of the key strategies for the foundation, where we built in established and emerging leaders who later become champions for the program. And I think that was also one of the experiences that we have in the country. And finally, one of, you know, our key strategy is working with public universities in terms of generating evidence and using professional associations, the OBGY, the nurse midwives, and others, so that they can be part of, you know, the larger moment, the larger national activity and having, you know, multiple voices to support family planning programs in the country. So through, you know, using different approaches, I think, and also partnering with others, other donors, other stakeholders, and leveraging the presence of, you know, USAID, you know, DFID, and the World Bank, and other partners, donors, who have, you know, more resources and also more presence when it comes to making change in the country. So the foundation together with other partners is a member of the Health Population and Nutrition Donors Forum. In Ethiopia, we have a very organized system where donors come together and talk about, prioritize issues in health, nutrition, and population activities, and family planning happens to be one of the key areas of discussion. So, you know, it is not, you know, we cannot achieve success by just having one approach. So we also, as much as possible, because we have also the foundation has also a country presence for the last 15 years. We used all these multiple opportunities that are present in the country. Thank you. Thank you so much. And thank you for the support you've provided to the CSIS delegation when they were there. And they're both their advanced work and when the delegation was all there recently. It was really essential. And Dr. Salu Hale has been just a great friend and supporter over many years. And we're very grateful to all the expertise and support. Tom, could you say a few words? I mean, you kindly joined our delegation. We're very grateful to you for that. And you were able to take your seven-time Jeopardy championship experience to the table there over many dinners, I understand. This is a kind of propitious week in that we're talking about the trip and the meaning of the trip. And it occurs in a week when the new strategy, the foundation's new family planning strategy comes out. So maybe you could say a few words about how does the trip relate to a new strategy that's come forward and for that new strategy, what's driving it? What account for why it's coming forward now? What's new and different about it? It puts a lot of emphasis on certain things like data and advocacy, accountability, many of the themes that run through the discussion of the trip. But if you could tie those two together in a sort of opening way, that would be very helpful. Thank you. Thanks, Steve. So I very much do appreciate CSIS including me in the trip. I'm not a family planning expert by background or an Ethiopia expert. So it's good to be among those who are. But certainly a fascinating country in which to see the challenge of family planning globally, so many of the issues are crystallized there. It's one of the best things about the trip certainly was the bipartisan group of staff that were there. When we think about FB 2020 and the goals, if the US were really to back away from family planning in a big way that would really be a major risk factor. So I do, and we as a foundation really do think rebuilding bipartisan support around healthy timing and spacing of pregnancies is a fundamental need and one that this trip did address. So in terms of the Gates strategy, we call it a strategy refresh. And if you're more of a visual learner, we've posted some of the highlights on our website. It's basically an attempt to take advantage or rather to craft to our programs in a way that reflects the new world that exists since the 2012 London summit when many partners, including Gates, came together with Melinda Gates really playing a leading role to talk about how are we going to achieve these FB 2020 goals of getting access to 120, providing access to 120 million new women. And so for us, part of our involvement in this is simply as a donor. So we increased our commitment from 70 million a year to 140 million as part of that summit. So we are one of those donors who needs to be held accountable for following through on what we said we would do. We're also involved certainly in technical respects with Chris Elias, the president of our global development function being on the FB 2020 task team. But it really was then incumbent on us to say, okay, we've got kind of an existing strategy that fit a $70 million effort and we could either just do more of what we're already doing or we can take a look at what we're doing and see do we need to make some adjustments and indeed we did. With that doubling of the budget though at 140, we're still less than a quarter of what the US is spending per year as you heard earlier. It's about 610 million a year. So we still, I think in all areas, see our role as fundamentally a leveraging role, not as the main answer on any issue, including family planning. So let me just tick off the five main areas that are addressed in this new strategy and relate them briefly to Ethiopia, what's going on there. So the first is accelerating country action on family planning to reduce maternal and newborn mortality. And I'd say the fundamental focus here is countries. And you've already heard today about how the FP 2020 construct is one that really sees the countries, including governments, but also civil society, faith, other sectors, as the leaders and the role of all of us as donors to ask, okay, what can we do to help? So we decided we have certain country, focus countries, I should say, for us. The two biggest are India and Nigeria. These are areas of countries in which we've already been working in a big way. In India, we're considering, actually in Nigeria, we're considering expanding beyond the two states that are currently the main focus for us. In India as well, we're focusing on two states at present but are exploring a third. So those two countries are so fundamental to the success of FP 2020 that they are now fundamental to our strategy because we think we might have some value to add in them. The next tier of five countries are Indonesia, Pakistan, Ethiopia, Kenya and DRC. And again, countries where we, for various reasons, there's a story behind each one but where we think we can add some value. And these are countries that are, again, very large important ones for FP 2020. And then we're also investing in Senegal and Niger as part of a commitment to the Wagadugu partnership that was launched last year at the Addis Summit. And so the idea there is investments in those two countries will then have a ripple effect into the other Francophone countries in West Africa. So as you heard, Ethiopia is now one of the focus countries for us in a way that it wasn't before. On a very simple level, we see the critical role of Ethiopia in achieving the global goal. So that's one. Second element is strengthening policy and advocacy work. I think we see that we do have a role to play in keeping both donors but also developing countries accountable for the commitments they made. There's often a lot of confusion even within the governments that made commitments about what their commitments were. So sometimes it's incumbent on the rest of us to help them remember or sort out what they piece together their statements at different fora by different people into a commitment. For FP 2020, I think one of the interesting numbers is that there were $2.6 billion worth of commitments, new commitments by donors, but two billion of commitments by developing countries themselves. So as you certainly heard from Robert and others, it's really important for us all to maintain a focus on both halves of that. And at Gates, we really clearly have an investing role but also a voice role as we call it with Melinda Gates in particular but also Bill Gates and then others within the organization getting out there and speaking about this in public fora but also in private meetings, in sort of diplomatic type meetings, although we're not a government, with our counterparts in these various countries. So in Ethiopia in particular, there's a need to ensure that the Ethiopian government is making the investments that it said it would but also to help draw to their attention areas where policy issues may be thwarting some of the commitments they made. For example, around the ability of civil society and other non-governmental organizations to make their full contribution to the effort. Sometimes it's helpful to point that out. Third, I'll go a little faster here, monitoring performance and promoting accountability. You know, Gates is a very data oriented organization and so we see an ability to help countries monitor changes in family planning use to track their progress. We're supporting rapid surveys every six to 12 months rather than every three to five year cycle that has existed to date. So because in a sprint to FP 2020, we really need to have faster data and also we're working with other partners to harmonize the resource tracking. One thing we really did hear in the visit was that the Ethiopian government has a tremendous appetite for data and they are very eager to adjust programs based on data, which isn't something I think we could say for every government but it's a real strength and so we're trying to help them with that. Related, our fourth pillar is building evidence to improve service delivery. So this would be more in the operations research kind of arena. Just better identifying, understanding what works in terms of addressing supply and demand barriers. Again, on a very country specific basis. In terms of public private sector collaboration. In which countries does that make sense? In which ways? What's the evidence? And then in disseminating the findings so that the world increasingly has a good grasp on what's happening. And Ethiopia is both a consumer of data but also a major producer of data. I think not only for its own programs but for the world. And then the fifth one is the one that really looks beyond FP 2020. So it's about 20% of our family planning budget that is really oriented. The other 80% really is oriented to these next six years but looking beyond is investing in new contraceptive methods and that's something we've been at for quite a while. We really need methods that address the barriers to use that have been identified and that really keep being identified as progress on them is slow, such as in particular populations like women who've already achieved their desired family size. What are the things that work best for them? Or young women, adolescents as we've heard quite a bit about. And then about populations, women who are concerned about side effects because it's no secret that most other medical interventions there are side effects for family planning methods. So all of these things I think are issues in Ethiopia. Certainly we've heard about all the progress but still there's a very significant task ahead. And so addressing these barriers in the near term but also with new methods going forward. So I'll stop there. Thank you. Thank you, Tom. Now, Soji, you served in Addis, W-4-W-H-O at that time in 1990-91, right at the change of, right at the transition moment, which was poignant and dramatic. You've also been with the bank to see the arc of its investment, which has been extraordinary, really the multi-sectoral commitments that have been made over, stretching over two decades now in the support of the development agenda across multiple sectors, agriculture, education, power, health. It's also been something that the bank has taken great pride in the achievements. It's used its results-based financing methods increasingly in the way that the funds are allocated. It's worked in very close partnership with the government and with others. Maybe you could offer your thoughts from that bank of experience, that rather remarkable perspective. Tell us a bit about how you see the family planning we product. Where does that fit and how do you look forward from this? Thanks. Let me start by thanking CSIS for convening this forum and for the opportunity to share some ideas and learn from fellow panelists and the audience. Ethiopia, the story in Ethiopia is really fascinating and I think it's probably best understood, in my view, if one takes the time to reflect on the narrative of the society itself and the things that are most dear to the government and the people of Ethiopia. For the World Bank, we're approaching health from the perspective of universal health coverage and all people should have access to the essential services that they need and they should not suffer financial hardship in accessing those services. Then, in relation to that is the important concept of sustainability, which has come up from at least one member of the audience today. And that, of course, has several dimensions. I'll just point to three of them, which is the policy dimension. The second one is the social dimension and the third one is the institutional dimension. You notice I didn't mention the financing because that is one that often gets most currencies. So yes, I recognize that, but I deliberately left it to the end. Now, in our relationship as an institution with Ethiopia, what we seek to do is explicitly support the program of the country itself. So in the health sector, that program is the so-called HSDP or the Health System Development Program and we approach this in a way that combines the achievement of outcomes or output, if you like, in the immediate term with concurrent improvements in the system for delivering the services that achieve those outcomes. And so we are increasingly working through the country systems. We use the country systems. We do not operate in a way that creates parallel systems whether for supply chains or service delivery, et cetera. And the rationale for this is twofold. First, intuitively, if you really want something that is going to be effective and to be durable, then it has to be something that is grown within the country's own system itself. It may not be snazzy at the beginning, but it is more likely to last. A second one is one that is very pragmatic and actually more institutional. The government of Ethiopia itself did ask the World Bank, we would like it to come up with an approach to working with us that is less laborious, reduces transaction costs, while making it possible for us to focus on results. And that led, that fueled the development of what we now call the Program for Results instrument, which is, you might think of it as a whole of system, result-based financing. So how does this work? In Ethiopia, the bank is now funding working the health system through the Ethiopia Health MDG Program for Results. We call it P4R. We need to have an acronym for it. You understand that, right? Yeah, it's called the P4R. If it doesn't have an acronym, it doesn't exist. And this is approved in 2013 and it includes $100 million credit from IDA, the concessionary lending arm of the World Bank, and $20 million from the Health Results Trust Fund, Innovation Trust Fund. And the way it works is it disburses against independently verifiable achievements of some results. So there are eight of them there. We call them Disbursement Linked Indicators. And one of them is actually the Contraceptive Prevalence Rate. So the essence of this is that we no longer at the risk of putting it in the Dakotomo's way, we do not obsess over inputs and input controls per se. We are a lot more passionate about the outcomes and the capabilities of the country system. So it's a shift in thinking and it's a shift in practice. So in principle, provided there's a direct-visit agreement on the outcomes, there is independently verifiable mechanism for assessing the performance or the achievement of those outcomes. And the country systems for procurement, for financial management, for monitoring, for example, are sufficiently robust to manage the program, then we do not micromanage things on a day-to-day basis, perish the thought. And the last time I was in Addis, which was just a couple of months ago or so, we got very positive feedback from the ministries of health and ministries of finance. This whole new way of doing business actually reduces the burden on them. So the investment of the World Bank Group in family planning is part of that broader package. Wittner includes a family planning specific indicator, but it's not quote unquote a family planning project. Now all of these need to be seen in a broader context. The World Bank Group supports Ethiopia through multiple sectors. And if one of the principle vehicles for that is the so-called PBS, which is the Promotion of Basic Services, which has been in effect since 2006, it's gone through multiple generations now. And I think the most recent one was approved in 2012 to the tune of $600 million. And it works in education, health, agricultural extension, rural roads, and a few other things, with the aim of improving access to and the quality of basic services. And this has resulted, it supports by the way, both the staffing costs, including the health extension workers, and recurring costs. So it's one of these quietly effective programs. You don't read about it because it's not quite the same thing as supporting a disease-specific program, but it's one of those quietly effective programs that actually propels the system to be effective, including the 30,000 health extension workers that we talked about. So when we put all of this together, what do we see as the following? We see a very compelling convergence of country leadership that has set its own direction in terms of where it wants to go. We see a credible country program. We see broad and growing collaboration among the development agencies and the donors to throw their weight behind that country-led operation and to learn from it. The program for results of which I referred is versus against activities that are approved under the Health MDG Fund. And there are now, I believe, 11 agencies that pull their inputs into that fund, and the World Bank is one of those agencies. Now looking to the future, I think there are tremendous opportunities to learn. Ethiopia has come a long way, but these are still any days in the family planning experience. If you look at it in terms of the trajectory of the society. So what works? What are some of the adjustments that need to be made on the basis of what has worked well in Ethiopia? What are some of the adjustments that a country might wish to make on the basis of things that probably have not worked so well, or how can some of those lessons be piloted into curbing the still high persistent problem of maternal mortality, to which my colleague referred, while linking it up to the most sophisticated clinical services. In that regard, I just wanna share a note of caution. I think there are compelling lessons that have been learned in Ethiopia under the Health Extension Workers Program. Having said that, let's also keep in mind that this was grown in Ethiopia in a way that makes sense in Ethiopia. So we probably need an outbreak of humility, not to say this must now be exported wholesale to other countries. I think the relevant question to ask is, what makes sense in the context of Ghana or Tanzania and how can they learn from some of the experience of Ethiopia in a way that is inherently effective and sustainable in their own countries? Just like we would probably not want to say because something has worked in the state of Maryland, therefore it must be done in the other 49 states of the US. I think that's the same way of looking at it. But the whole, I think that this is a really positive story. I think the future is very bright and the World Bank Group remains committed to and very proud of its collaboration with Ethiopia. Thanks. Thank you, thank you so much. We have about 15 minutes. And so I would like to move quickly to hear from you all comments and questions and bundle things together. So please put your hands up and we'll come around to you. There's a woman right here and over here. Please identify yourself and please be succinct. Yes, thank you. Nancy Peelemyer, Health Systems Consultant and Co-Chair of the USAID Alumni Association. I wanted to just add to Margaret's noises comments and Robert's comments as well to remind ourselves that this program is not done in isolation. That in addition to having had a long history of investment in family planning programs per se by the US government and other partners, that the government of Ethiopia also had a very strong support and interest in health systems and strengthening the system as a whole. And the US government has responded to support those health system programs for at least 15 years. So that again, to remind ourselves that these things don't happen in isolation, that investment in strengthening innovative financing systems like the World Bank is also participating and have been invested in by the US government and by the government of Ethiopia over the long term. That has definite impact on the upon family planning as well as in the health sector in general. Thank you. Right here. Hi, thank you to this panel on the morning, the earlier panel. My name is Mona Bormet and I work at Christian Connections for International Health. And we know in many countries, including Ethiopia, 30% or more of healthcare is provided by faith-based organizations. So I'm just curious as foundations, as donors earlier, I wanted to ask this question also. Our faith-based organizations part of your partnership strategy. Thank you. Other comments or questions? Back here. Yes, my name is Vince Blazer and I work at the Frontline Health Workers Coalition. It's a coalition of 37 NGOs and private organizations, including Pathfinder from the first panel. Thanks to, for the event today and for all the panelists. My question, there's a lot of talk today about the Health Extension Worker Program and the success in Ethiopia and how to adapt and how other countries can take it up in a way that fits for them. I guess my question is over the political, what's needed politically, both from the donor's perspective from the United States and others, that don't have funding specific to health workforce or to health systems and then globally in the post-2015 and some of the other discussions, what do you think is needed to sort of move the needle to address the health workforce issue of which the WHO currently estimates that 7.2 million lacking of doctors, nurses, and midwives and that doesn't even account for community health workers. Okay, yes, right here. Okay, my name is Nagasi. Actually I'm from Ethiopia. I used to work in the medicine demand as coordinator of. So my question is, do you give them training for the leader community and for the leader of religious and church? So I think by video tape, that's my question. I'm sorry, can you? Do you give them training for the leader community and also for the leader of religious depending on supporting by video tape to give less time for the people? Okay, thank you. The speakers from the first panel, Pranima, Robert, Jenny. Do you wanna offer any thoughts? Do you have any thoughts you'd like to jump in? Yeah, Robert? Jen? Yeah, Robert. So just to comment on the faith-based organizations that was raised, when I was in Zambia, we were trying to reach communities, and reach people. And there were two main ways in which we could do that. Through the faith-based, because you had many people going to churches, mosques, whatever, and that once a week, and so there's a great, and the other was the traditional healers, or traditional medical, traditional leaders. And I think those two groups are so influential in society. And when you're looking at changing behavior, you need to have those kinds of role models, you need to have that kind of influence to be able to complement what you're doing on the technical side. So it's clearly a key component of what we're doing within USAID. If Jenny has any thought, you don't need to, but if you wish, otherwise we'll come back to our panel. Jenny? Pardon me, but would you mind just repeating the question one more time? Well, there were four or five, but there was one specific one around the role of faith-based organizations and strategies. And are they being, are religious leaders being trained? Is that a focus for those? Oh, right. So in Ethiopia, in fact, yes, they were being trained. This was a part of their curriculum in the seminaries in the Tigray region where we went. So we did hear from the dean, as well as professors there, that they were implementing coursework around the development Bible that I discussed earlier and really doing work to promote awareness and education for priests that were going through the seminary education. Thank you. If I may jump in on that one. So one of the distinctives about Ethiopia is that relatively less of the service provision is done by faith-based organizations compared to other African countries because the government provides such a large, large-shared healthcare. But that doesn't in any way undermine the importance of faith leaders at the deeper level of norms and behaviors that are very important. So it's an example of how every country, there are commonalities across countries, but everyone is different. And Ethiopia is certainly very distinctive. For example, not having been a colony, perhaps, that may be why there are fewer mission hospitals and things than you find in a lot of other African countries. Am I sorry? Yeah, let me jump, sorry. I think in terms of the work with faith leaders, definitely in Ethiopian context, faith leaders have a very important position. And it's not only enough to provide them training. Yes, training is important, but it is also creating a system where they can be engaged in the dialogue and in the discussion. And for that, today we have talked a lot about the health extension program, which is definitely a very important strategy, but there are also other opportunities, other venues that we need to leverage in the future. And one thing is currently the government is now rolling out a huge women development army, they call it, which is based at the community level and if properly used, which can serve as a very good opportunity to mobilize communities, because service utilization is a big challenge for the community. You may have whatever services available, we have expanded the health process and health centers the last couple of years, but still utilization of services is low. So to do that, we really need to have a strong community mobilization strategy and behavioral communication and change approach. So for that, I think the church, at least the three, all churches, but most importantly, the three big churches, the Ethiopian Orthodox Church, the Muslims, and also the Ethiopian Protestant Church has a great potential of mobilizing and educating communities. So I definitely agree that they have a very important place and we as Packard Foundation work with faith-based organizations and actually that one of the first grant that we gave was to the Ethiopian Orthodox Church to educate communities in HIV AIDS and health family and health pregnancy. So it has a very important role and I just want to mention that Pathfinder has worked with the Ethiopian Muslims Council and actually they came up with the Fatwa which says that the Muslim does not really prohibit people from using family planning services, but rather what is not appropriate and seen is for families to bring in children which they cannot, just like in the film, what has been said by the person from the Ethiopian Church. So I think there is a strong role for the faith-based organizations and I take also the opportunity to address the other question which is regarding the health personnel and it is a challenge and the health extension program came as a result of the problems that we have with health personnel because we didn't have enough and we still don't have enough with my midwives, doctors and nurses to provide family planning and other primary healthcare services in rural community and Ethiopia is at 5% of our population lives in rural places. So it is, the health extension program itself is created out of necessity. So we are still struggling and the government is trying to do more production in terms of mid-level and higher level health personnel but this is going to be a challenge for the coming few years. So I think the lesson for other countries and also for the US policy makers to support government's initiative as they come up with innovative ways of addressing primary healthcare issues by training and, you know, capacitating community workers, people, you know, mothers and also, you know, including young people themselves because young people can also be a very important messengers to other young people both in terms of providing comprehensive sexual information and services. So we really need to become more creative and innovative and use existing resources while we build, you know, the infrastructure for health. That's the answer. Thank you. Thank you. Very patient. Thank you. My pleasure. I would like to reflect a little bit on the question about what is needed to start addressing the health workforce challenge. There's quite a bit of discourse around this and if I, one of the relatively recent pieces of analysis done by a team at the World Bank, looked at this question through the perspective of labor markets, which is not a traditional way in which we have looked at health workers. The traditional way has been you need to produce so many nurses, I need to produce so many doctors because you have this kind of need. And what I found was that a traditional way of looking at this is probably not sufficient or not adequate. So the challenge is also to think about the following. For critical health workers like nurses and midwives and doctors and community health workers, for example, the stark reality is that many of the countries simply don't produce enough. If you have a population of 90 million and you are producing 50 or 75 doctors per year, your problem is not migration of those doctors. Your problem is not that they're going to Europe or North America. You simply are not producing enough to start with. So that's one issue. A second one is the mix of skills. We learned here today, it was Robert who pointed it out somewhat indirectly, that having trained adequately deployed and adequately funded health extension workers to say is great, is very useful. But it only goes so far in relation to something like your maternal mortality ratio because you need a different set of skills to tackle a different set of problems at a different level of the health sector. So what are we doing in terms of production of midwives and nurses? Again, question of numbers, question of deployment. Also critically, location of training. I think people who grew up in urban cities and who are trained in cities are very unlikely to voluntarily go to remote rural areas to live. It is not because they're immoral people, it's just because their mental image of themselves when they go into school of midwifery involves a person who is living in a very distant health post. So it will make sense therefore to recruit and train much closer to where people are actually expected to practice and live. Another one, of course, is that of the incentives in terms of service. For the foreseeable future, many countries are still going to face disparities between the urban areas and the more remote areas. So those countries or health service management teams will be looking at differential remuneration to attract people to those underserved areas. Just like it happens in this country, if you're going to the far distant part of Appalachia or Maryland, some foreign medical graduates are encouraged to serve there because it's a lot easier for them to remain in this country later if they want to. I've seen some banners welcoming some people to remote populations. I was quite impressed by the extent of which they go to attract some of those workers. Then I think a lot also now comes down to the question that we talked about earlier, which is that of sustainability. And this is not only a question for the public system, it's a question for the health system as a whole. So as society and incomes grow, what is the distribution of demand for health services in the society across the public sector and the private sector, for example? Across income quintiles, for example? Across geographic locations, for example? And all of this will affect the extent to which people are drawn into and retained by the service delivery system. It's a somewhat longish response to your question. Perhaps I should have said that by saying there is no easy one, there's no single bullet or magic bullet solution to that question. A lot of it is going to depend on the structure of the labor market in each country or if you like, maybe in a sub-region because some countries are probably too small to really take care of those needs, as well as the structure of the health service delivery system in that country. Thank you. We have gotten to the end of the hour and I think Janet is going to offer... Are you no... Okay. I'm going to close this. So this has been a very rich day and I want to thank our panelists, Tom, Ia Meserec and Soji for coming and being with us and sharing your insights and thank you for the marvelous work that your respective organizations do in this space. I think you leave us with a pre-optimistic picture. I think clearly there's an enormous amount of thinking going on today in how to move to the next phase. There's been an enormous amount of learning. There's been an enormous investment made over many years in Ethiopia and elsewhere that you bring to the table here today in the wisdom and insights around how we're going to move forward towards 2020 and beyond. So please join me in thanking these speakers. And I really want to thank all of you for being with us over the course of this. I want to thank our other panelists, Vanima, Robert, Jenny, and most importantly, Janet and Alicia for really just a sterling amount of work over many months. A very prodigious set of great products. The video, Beverly Kirk and Jesse Swanson put their shoulder to the wheel to get that together, which is a beautiful piece. We're very proud of that. We hope all of you will go out and post it on your websites or take it home and watch it. But thank you all. This has been a very successful day and a very successful body of work thanks to the many contributions you've provided to us. Thank you.