 We've worked very closely and very fruitfully in cooperation with that office. We're very grateful to Nils and as well as his Deputy Ambassador Jimmy Coker, his Chief of Staff, Katie Kampf, and others in that very important office. In his role, he is the Senior Representative, the U.S. Representative to the World Health Organization's Executive Board. He's the Principal Liaison with Health Ministries around the world. He is the Senior Most Advisor to Secretary Sebelius on Global Health Issues. And of course, we know she has played an important role in blessing the first global health strategy that was issued in the first Obama administration and in her own travels to Vietnam and Thailand in the summer. Prior to taking on this role, Nils, for 10 years, was the President-CEO of the Global Health Council, and we're happy to see today Christine Sau here, the new Executive Secretary of the Global Health Council, as well as Jono, Man, the Chairman of the Board. Prior to that position, Nils was the Deputy Assistant Secretary in the Bureau of Health in the Clinton administration, and in that role, really elevated USAID's voice and impact there. So please welcome, please join me in welcoming Nils today as our keynote speaker. Thank you. Thank you. Well, thank you. It's nice to be among friends. A lot of very familiar faces here, people I've worked with for, in some cases, decades. So it's a pleasure to be here. I want to talk briefly about universal health coverage as a construct, as a reality in the context of some of the international discussions that are taking place, as well as in the context of our own domestic policies and policy debates. I will frame some things from my vantage point, as someone who spent close to three decades in international development before moving into a domestic health agency. And also try to leave room and space for comments and dialogue at the end of this session. Universal health coverage is, I believe, one of the key public health challenges and opportunities of our time. It's also an area in which there is broad agreement. As many of you know, I frequently travel around the world representing Secretary Sebelius, the Department of Health and Human Services, and the U.S. government in a range of health discussions and negotiations with other ministries of health. And while there are many topics on which health leaders around the world do not agree, and we get to fight about those all the time, there is no question but that universal health coverage is a common goal, a common mission, an area in which when Secretary Sebelius goes to China and they have debates about trade agreements and debates about defense alignments and debates about currency, there is very strong similarity in terms of views about the importance of providing accessible, effective quality healthcare to all of the citizens and looking for ways in which we can share experiences and approaches in a constructive way. So from the global health diplomacy standpoint, universal health coverage is a both an effective and a very meaningful tool for international dialogue. As Dr. Margaret Chan has said repeatedly, universal health coverage is the single most important concept that public health has to offer. It's the best way to cement the health gains made during this previous decade. It's a powerful social equalizer and the ultimate expression of fairness. Now universal health coverage is not just a matter of having someone, government third party insurers pay for services. It is a systemic construct unique to each society that is aimed at better and more equitable health outcomes across all strata of society. It's both a technical agenda and a social justice agenda and maintaining a balance of these two drivers is vitally important to the success, the ultimate success of the universal health coverage movement. We have a counterpoint on that and I have friends here in this room who are well familiar with that counterpoint which was the declaration made 35 and a half years ago in Alma Ata that posited a goal of health for all by the year 2000. Health for all was very largely a social justice construct but it did lack some of the substantive technical underpinnings that would turn it into useful programmatic achievements and because of that while I think it had a very important impact in terms of international mobilization and the echoes of health for all still are heard loud and clear in debates on health care. It was not an agenda that I think any of us can say succeeded in the way that many of us had hoped. You have to have that balance of the technical and the social justice and so when I look at the substantive aspects of universal health coverage I view it through a variety of lenses that have to be in a sense overlaid in order to really get to the end point that I think we all share. The top layer is a layer of coverage and of course we need to make sure that people have access but access by itself doesn't do it in terms of real public health impact in terms of health outcomes. We have to have efficiency because without efficiency we will spend ourselves into bankruptcy as the United States is effectively shown and we also have to have a focus on quality of care because accessible and efficient health services that provide lousy services are not likely to make a meaningful impact on people's lives. And finally in my construct it's not just about those elements but it's also about the active engagement and interface between the health provider and the patient or the client or whatever name you want to give that person for true choice and joint decision making not the top-down medical construct that so often is seen in healthcare systems in which the doctor decides and the patient is expected often unreasonably to simply follow through with that and very often to the detriment of the health care of that person so the issue of meaningful engagement and joint decision making is in my view a very important aspect in the long run of whether universal health coverage is going to really have the impact that we're talking about. Now UHC is especially important now as we look to address the new geography of global poverty and I'm pleased to see my friend Ariel Pueblos-Mendiz here who speaks to this with great expertise and he may already have done so in which case I apologize for repeating something he may have said but I wasn't here this morning. As I said I've spent three decades working on issues of health care and equity in developing countries and like many of us in this room who have done similar work we did so in a world where poor people lived in low-income countries. This is no longer our global reality. Two decades ago nine out of ten of the world's poor, nine out of ten of the world's poor population, lived in low-income countries. Today nearly three out of four of the world's poor live in middle-income countries. Governments are coping with the reality that while average incomes are rising many of their citizens remain impoverished. Access to affordable care is critical if governments are to address this internal economic and frankly social disparity. Pulling people out of poverty requires a system-wide approach to achieve population-wide gains and also importantly an effective safety net to prevent medical impoverishment. Universal health coverage can serve as that unifying element serving as a potential umbrella by which to achieve population-wide health gains. This is why I believe that universal health coverage is a fundamental topic for the post-2015 development agenda discussion. The change in the geography of poverty is resulting in a shift away from the traditional development model of health assistance. When the MDGs, the Millennium Development Goals were created, they were created in the context of a world where the poor were in low-income countries. As the world comes together to create the post-MDG goals, we are in fact looking at a very different picture and are still struggling with how we can best accommodate to the new global realities in a way that remains true to our fundamental commitments to improved health and health equity. Middle-income countries no longer need traditional development agencies to build roads to send healthcare providers or provide medicine. Rather, what we see at HHS in terms of our interactions with our sister health ministries around the world is that countries are increasingly seeking technical collaboration to help them build better systems for themselves to address domestic needs. This is not to say that they no longer need resources. Resources continue to be a big challenge and I know that this is a topic that is very ripe in terms of the discussion of what the role of development assistance is in universal health coverage. But in fact what we see is very often what countries are asking us for is know-how, operational expertise in terms of a wide range of health programs and policies and procedures so that they can have the opportunity to build it themselves in the context that's most appropriate to them. For that reason I think that universal health coverage really will help to define the future of global health in which countries are creating and investing in their own health systems and becoming more self-reliant as social protection structures become more efficient and the challenge I think for traditional development assistance is finding ways in which to provide that assistance in effective leveraging context to help to catalyze that change without building further dependency or distortions into the domestic systems. Now as for the post 2015 goals I don't know whether universal health coverage will be the official overarching goal and the US has not as yet established a firm position on this because there's a lot of discussion and dialogue going on but as disease burden is more and more a key marker of inequity and wellness is the ultimate equalizer universal health coverage may well be the most powerful tool as well as mobilizer that we do have. I do know that as I said that there's considerable debate as to how much of the UHC agenda can be driven and supported by the international community and to what degree it needs to be homegrown and I look forward to comments and discussion about this later on in the session but as I said this is no longer an issue of the poor versus the affluent them versus us we're very much facing the issue of universal health coverage right here in the United States you may have heard of the Affordable Care Act I'll refer you to our website later clearly clearly the US has demonstrated that universal health coverage is in fact a universal issue just as we are a clear example as the United States is a clear example of how putting more and more money into health care does not necessarily result in better health care outcomes or more equitable health care and I'll talk briefly about our domestic situation because it is really a global arena in which we're operating now as I said after spending several decades working in international development I've now spent the last four years in a domestic health agency and therefore by the logic of Washington I am a clear expert on US domestic health care I'd like to talk a little bit about the journey that's taken place here in the US in our country we now spend 2.8 trillion dollars each year on health care which is far more per capita than any other nation this represents nearly one in every five dollars used in our economy a level a proportion nearly twice that of our nearest I hesitate to use the word competitor but as everyone in this room knows this has not made us healthier and in fact it has also not made us more competitive in the international arena it's just helping us to spend more and more in an apparently endless spiral part of our problem has been uneven access to care especially preventive services we live in a country with some of the best clinical specialists in the world and yet many Americans not only do not have access to those specialists once they are sick but they cannot even access basic preventive services to keep them from getting sick as I said wellness is the great equalizer and our health system has generally ignored this final issue in addition we see that the health system as we have constructed it here in this country devotes a an extraordinary level of resources to end of life care it's estimated that 40 percent of health care spending is spent in the last three months of a person's life now in some instances those resources are well spent and make a huge difference for the person and for the family and for the community and if I can say so even for society but in many cases it's driven by medical technology and what is possible to be done rather than what is desirable to be done and when I mentioned earlier the issue of patient choice and patient provider dialogue and interaction one of the things that we've seen is that in circumstances in which uh there is a well articulated interface and dialogue between the provider and the patient and the patient is empowered to make thoughtful choices and given the information that she or he needs in terms of prospects of various outcomes in a very large proportion of cases they choose the less technological heavy and certainly the far less expensive approaches which give them the opportunity to have time with their families to have the dignity of being at home and this makes a huge difference in terms of social outcome even if it doesn't result in greater lifespan and of course has the potential to make a huge difference in terms of healthcare expenditures so these things are issues that we're learning here domestically that we're working on very actively in the context of the Affordable Care Act in trying to rationalize and humanize the healthcare system and those are areas in which I think we have things to offer not as solutions but rather as a dialogue with partner countries who are beginning to face and encounter the same sets of issues there are of course two major obstacles that we always talk about cost or affordability and complexity or accessibility and again I mentioned some of the problems that are well known about the healthcare website which became too complex for people to use even when it was operating right we're simplifying it we're trying to make it more more oriented towards the user rather than towards the developer and the engineer but you look at where we are today compared to five years ago when I joined the Obama administration 50 million Americans were without any healthcare coverage since the passage of the Affordable Care Act and the opening of the marketplaces which allows people to sign up for affordable quality healthcare according to the latest figures nine million more people now have the security and peace of mind of health insurance that's not just people who've signed up through the marketplaces but the expansion of Medicaid the availability of health insurance for young people under their parents policies and other mechanisms in the broader context of universal health coverage the Affordable Care Act is not only about access it's about new rights and protections and that's the social justice side of the equation no one can any longer be denied coverage because of a pre-existing condition such as high blood pressure diabetes asthma pregnancy or prior cancer no woman can be charged more for coverage simply because she is a woman no longer will annual limits be allowed allowing coverage to run out just when people need them the most leading to medical impoverishment and no one will again have to worry about going without health coverage when they lose their jobs one of the benefits that we look towards in the not distant future from this growing flexibility in terms of health coverage will be in fact a more flexible and mobile workforce who are not chained to a job and position that does not suit them simply because they fear the loss of their health coverage and this could in fact result in new entrepreneurship new flexibility within the economy that could demonstrate itself in real hard economic growth terms that's still a conjecture but I think there's a solid reason to believe that it it is on the way so as I said in our international travels secretary Sibelius and I have found that this topic probably more than any other has been a regular feature of discussions with health care leaders from other countries at the World Health Organization and also at the WHO executive board where I've served as the representative in these conversations it's been very clear that there's no one size fits all model there is an infinite variety of of important dynamics that go on within the political economic and social structure of each country there's a huge variety in terms of capacity to meet a range of needs but the overall construct has really become very clear that as a common goal universal health coverage is is well recognized and desirable as I said around the world countries have successfully taken a range of approaches to health care coverage in regards to services to cost sharing financing and organization all of them have their particular advantages and each has unique shortcomings we have a responsibility to share both the advantages and shortcomings in a very honest and transparent way so that we can learn from each other so that we can modify and improve our various systems not with the aim of coming together in a single unified system around the world but rather being able to better tailor the systems that we are each building it but while it is the responsibility of individual governments and their people to decide how each will make health coverage a reality it is in fact our shared burden and shared responsibility to work towards these goals the world health organization also has a critical leadership role to play and one that they have assumed under Margaret Chen's leadership both in advocacy as well as in technical support last year the United States co-sponsored a world health assembly resolution on developing health workforce by promoting workforce education to meet the needs of universal health coverage and next week I'll be in Geneva for the executive board meeting to discuss a new resolution on health intervention and health technology assessment in the context of universal health coverage this resolution in many ways gets to the heart of what we're discussing here today how to design a health system that not only provides access to necessary services and interventions but that does so in a rational sustainable and patient-centered way while there's much enthusiasm around universal health coverage there is a great deal to be done and there's no clear or easy path this is an iterative process but it's certainly far from being an impossible road the progress that we've shown here in the US over the past five years and in countries around the world over the past decade or more make that very clear we're really in a very different context today than we were at the time of the launching of the Millennium Development Goals in the year 2000 President Obama reminds us that access to health care is not some earned privilege it is a right and quoting President Obama at the World Health Assembly has been a real delight because for many years the United States refused to use the word health and right in the same sentence it's very hard to disagree with your president so I'm very pleased to be able to quote him in that context our work means that the generations to come will have the opportunity to live happier and healthier lives and as a son as a husband as a parent and recently as a grandparent that could not please me more thank you very much Joe Gaye what works association how do you see PEPFAR evolving under universal a move toward universal insurance coverage hi Neils Paul Shaper with Merck more broadly than PEPFAR what do you see the change within the development aid for health architecture of the U.S. with a move toward universal health care Jill I'm not sure I can answer your question in terms of the impact of universal health coverage on PEPFAR certainly PEPFAR has been increasingly integrated into conversations that take place across the government and REL can attest to that in terms of maintaining the the legal the legislative focus on care treatment and prevention of people with or at risk of HIV and AIDS but also recognizing the importance of integrating that whole program of services and approaches into a broader health systems context I think that's going to be a significant challenge and I mean that in a positive way for the incoming global global AIDS coordinator Dr. Debbie Burks who's just been nominated by the president and I think what we're all looking for is ways in which PEPFAR will and it's already started this will transition out of an emergency response into a sustained response and that cannot be done without being deeply engaged in health systems and health systems development along the channels that I've been talking about there are a number of countries where PEPFAR is working now to develop agreements with the countries in which greater responsibility and direction and leadership is taken by the by the country at national authorities themselves and I think it's early on in the process but I think the interaction between PEPFAR USAID and parts of my department is probably a useful development we're seeing similar kinds of developments within the global fund to fight AIDS TB and malaria Paul I will take a shot at the the development aid architecture but I will also invite my friend Ariel to comment on that because we we you know we're seeing we're seeing the same elephant but from from different angles in in this context as I said repeatedly today I come to this position from really very much an international development perspective because that's where I've devoted most of my working life and I think that USAID is a vitally important part of the the the global agenda in terms of both health and the broader development context but I am seeing from this new perch a different side of things which is the the very deep interest and respect that host governments and particularly ministries of health have for as they call us their sister agency and there's an enormous interest in working with CDC NIH the Food and Drug Administration even domestic agencies within HHS such as the Health Resources and Services Administration the Substance Abuse and Mental Health Services Administration basically to to to get to get some of that shared experience and expertise and I have to say this has been far from a one-way street the people who I have met at HHS who started out being domestic health people and who got engaged through PEPFAR or other mechanisms in the international arena a lot of them have stumbled we we all know that international development is not simple and you have to have some understanding of the complex dynamics of societies and cultures you can't just apply what we do here in the US but they've learned a great deal and I think they they've become better professionals as a result so I think what we're seeing is a shift not a not a transition but a gradual shift into more and more of that technical collaboration between similar parts of our governments but one in which particularly in the poorest countries where the more traditional development assistance continues to play a very vital role in terms of providing the resources and the the sort of the poverty orientation which is different from the health technical orientation Ariel can you thank you and that's indeed the heart of the matter Paul and that's why it's great the CSIS has convened this conversation it's a more complex conversation it's not a simple issue to get right and it's even less simple to communicate it well in Washington or to the American people and yet I think more and more people will understand that that's what's happening the world is changing very fast and PEPFAR specifically has I think attempted to move from the first five years which were we need to go in and save lives there were not enough resources and you came in with a vertical parallel system but they accomplished the job and in the second five years PEPFAR has been more nuanced indeed more integrated building capacity we and UCAD have been doing a lot of that with the health systems work and the next five years for PEPFAR are going to be more complex and challenging the the approaches will will not work anymore because South Africa now come by all their entrepreneurial pills and what does that mean so as Nils alluded earlier in his presentation what I've been calling the economic transition of health growing domestic resources not in all countries but in most and very fast means that we had to adjust and change precious Obama global health initiative gave us all of the principles to deal with that complexity but the budget realities had not followed not only in amounts but in the qualitative architecture that you are suggesting not only to do the job of development well in this new space but also to plan the seeds for the future I tell Nils and I've told in many other places that as development succeeds and is succeeding widely around the world all I mean all of this growth in economics and better governance and better health has been an incredible success for the last 20 years we certainly hope at UCID President Kennedy we were funded to eventually to the ultimate day in which the countries can stand on their own from development assistance but I tell Nils the future then belongs to HHS and many of you in universities who work as grown-up partners with already countries like Brazil or Mexico or South Korea or Taiwan and so on so forth it's a different dynamic we have not invested in that future very well today PEPFAR has a mandate but there should be some budget for the office that Nils has to have health at the chest in more countries that can orchestrate the relationships with all of the other agencies and entities public and private in this country we have to imagine that future now and begin to tee up an end in the end I've learned in Washington budget talks and so how the architecture of the budgets evolve will become very important but all of us getting it right communicating it right will be important if we're going to be successful because the longer it takes we are missing opportunities for the leadership that the US has played in the previous paradigm and what it still has to play in the upcoming paradigm and let me just add one thing to that which is that the issues themselves that we're dealing with are also shifting in the in the the dialogue globally whereas 30 years ago it was maternal and child health reproductive health infectious diseases what we're seeing and I think everyone here is well aware is a huge surge of non-communicable chronic diseases around the world which of course is the the issue that has driven our health care costs here in the United States when you look at non-communicable diseases they are I call them I actually say that they are they are not non-communicable they are socio-communicable diseases they're driven by markets by global trade by economics by urbanization by the changes that are going on in the world and the response to those kinds of health issues is qualitatively different than child survival or safe motherhood in that very often it's national policies and importantly trade policies that play a vital role in serving as the drivers and so you know in our context my office now has as I think you're well aware one of my deputies really focuses a great deal on the trade issues and the health aspects whether that has to do with tobacco or other related topics that are fact important factors in the emergence of non-communicable diseases I think that's going to be a growing part of the international dialogue on both universal health coverage and better health care thank you one quick observation and then a closing question for Nils the observation is in listening to you talk about the case for universal health coverage and then talk about what's happening here in the United States and then the unresolved question around is what is the U.S. position heading towards the end of 2015 on the post MDGs and it's an unresolved issue it did remind me that when we have in our country and a health reform moving towards universal health coverage that has so deeply cleaved our country and in which we have one party making the opposition to that it's it's top it's top priority heading into the 2014 cycle and perhaps the 2016 cycle and the reverse being the case on the on the Democratic Party versus the Republican Party it it does create an enormous dissonance in trying to talk about what our position is on universal health coverage and on a global level right because by taking that position it's very hard to dissociate or distance the two the two phenomenon you have to somehow walk and chew gum at the same time around what we have as such a deep division around this within our own country and we're trying to forge a consensus as Ariel's pointed out trying to forge a new consensus around what do we mean by universal health coverage globally and so just to close the question would be Nils you sit at that point of you you sit on the edge of that of that tension line right because you're you're the lead personality on the global issues at HHS but you're part of HHS so you are you are deeply embedded within this enterprise this historic enterprise that is underway in the United States how do you foresee dealing with reconciling this dilemma in the next two years when we we have now what 23 months or plus before we get towards the conclusion of this and the U.S. role in the deliberations around the post MDGs is going to be critically important well I'd say there are there are two aspects to that one is the domestic aspect which as you note is very conflictual I think ultimately the domestic side of this debate will will be determined by what happens by the outcomes ultimately the noise and the politics will be drowned out by the reality and it is our very strong belief and expectation and certainly our profound hope that the Affordable Care Act will have sufficient and clear benefits to the American people that they'll say oh yeah this this works and let's get on with things but you know that's fortunately I don't deal with the domestic politics of of that so I am spared that particular bright flame on the international side it's it's very interesting the the you know we I meet as I say regularly with with colleagues and counterparts from around the world and they just don't understand what all the fuss is about they you know they they say you know of course everybody should have coverage why are you still fighting about this and they are very appreciative of the efforts underway here and Secretary Sebelius is a is a absolute rock star internationally wherever she goes they want to hear about her efforts on on the Affordable Care Act so so it really hasn't gotten in the way of our in fact it's been a positive net positive in terms of our international relationships and and on on the part of many of the the countries that I deal with the the basic responses well thank goodness it's about time now we can sit politely in the same room and have the same conversation so that's made it easier as far as the the issues relating to the MDGs I haven't yet seen the domestic battles come into that discussion I'm hopeful that they won't I'm not naive enough to be optimistic but I'm hopeful but you know this is this is an area where we really need I think to to maintain a focus on I think what has been a very strong bipartisan non-partisan effort from the United States on health care improvement around the world and that's certainly been my effort thank you very much we've reached the end of this part of our program so please join me in thanking Assistant Secretary Golaire we're going to move immediately into our next panel