 Crystal, I'm a senior fellow in the Global Health Policy Center at CSIF, and I am privileged and honored to have this great panel of some of the world's experts on this issue. We have David Granger on the far left, on my far left. He is the senior director of Global Public Policy for Eli Lillian Company. David supports the company's policy positions related to health technology assessment and works with governments and others on universal health coverage issues. Calypso Chakadu is founding director of Nice International, the international arm of the UK's well-regarded health policy body, the National Institute for Health and Nationalist Super Health and Care Expo and Brecht. Calypso helps governments build technical and institutional capacity for using evidence to inform health policy. Akiko Maida is lead health specialist at the World Bank. She has more than 20 years' experience in international health and social development programs, providing policy advice to senior government officials in health policy reform. And last but not least, we have Tessa Tentoris-Ediger, coordinator of the Unit of Costs, Effectiveness, Efficiency and Priority Setting at the World Health Organization. She's managed this unit for the last 10 years and works producing technical guidance for countries. So we have a great wealth of experience and expertise here and I'm sure that we're all going to learn a lot and I'd like to start with Tessa. Good morning everybody. I'm very happy to be here with you. And I think this is one of the rare times where I'm not speaking with my peripheral brain on the screen. So I have my peripheral brain in the old fashioned way with notes. We, when we talk about making smart choices in universal health care, I would wish to refer you back to one of the slides of Jeanette, which was on what we call the UHC box. So the question about smart choices when you're talking about UHC, it's not just about the what, what do you provide, what do you cover. But equally about the other questions on who should be covered and at what level of financial protection. I think this is where it takes it beyond the traditional cost effectiveness analysis and health technology assessment is the incorporation of these types of issues. And all of these choices of what, for whom and at what level of financial protection are essentially trade off against each other. I will tell you about our country. Our country is one of those where we've decided to cover the very, very poor, the first 20% using government tax monies because our government has an explicit policy to actually improve the condition of the poor. And then we have the employed sector, both private and government. So we have the problem, which I again refer to Jeanette, the missing me, though. At the same time, this particular package of services we have, we cover, we provide renal dialysis, kidney transplantation. We also offer cataracts. Now, why would that be? Did it just happen that our Minister of Health used to be a transplant surgeon or that one of the board members of the Philippine Health Insurance Corporation is an eye surgeon? So these are just facts. I'm not implying anything. I asked the Philippine Health Insurance Corporation, how do you make decisions? They have a committee. They have a process. That's what they say. But then we have this very patchy and sometimes I would call it unusual set of services being provided. But the question then is, should you continue expanding this set of services? We're adding cancers already. Or should we think about really the middle poor or the informal sector, the missing middle, because it's a trade-off. What we can spend for providing more services, we can also spend for providing across the board maybe a smaller set of services but covering everybody. How do we answer those questions? Who answers those questions? I think that's a very important thing when we're thinking about universal health coverage. And so where do we get guidance? The global health community says, or the global community says, well, let's look at the sustainable development goals for post-2015 where every president of the member states of the United Nations will sign up in September 2015. We're done with the Millennium Development Goals. We're thinking about the new set of goals and what is it that will be in the SDGs? It's going to be, this is the proposal. Let me, this is why I need my notes. The health goal proposed is ensure healthy lives and promote well-being at all ages. Sounds like health for all, no? Anyway, the explicit target is to increase life expectancy by six years in developing countries and two years in developed countries. You know, if you get six years in developed countries, you might get too old. So two years in developed countries, including a 40% reduction in deaths before the age of 70. The indicators are life expectancy at birth and number of deaths under 70. There is an explicit for the very first time, we learned from the MDGs, there is an explicit equity aspect to this, which is reduce the gap between the poorest and the whole population. And the target is to reduce the mortality figure, the mortality before age 70 by 50% among the poorest compared to the overall. So there are these goals, but how do you actually flesh out? How will I decrease premature mortality before the age of 70? How will I increase the life expectancy? We have eight sub-goals. We have goals on the usual suspects, HIV, TB malaria, non-communicable disease is now present, mental health is now present, injuries is now present, suicide is now present, alcoholism is also there, and neglected tropical disease, the whole caboodle is there. The problem now is, how will we select? Among the many interventions that are implied in order to reach these goals, we cannot afford all of them. And I think this is where we say, we still need to set priorities. This sustainable development goals, this health goals, this eight sub-goals, they need to be prioritized. And the last sub-goal is the sub-goal of universal health coverage, where it says access to an essential set of services and 100% financial protection. Now what will be the set of essential services? There is a core set of indicator services, but each country will decide what is that set. And what can we now say to these countries, how do you decide which set this is? I think from WHO what we offer may need two things. We offer a set of cost-effectiveness analysis, which we call the choice program. This is choosing interventions that are cost-effective, which now looks at the main interventions against all of these conditions, using a standardized method. So it allows you to legitimately compare the cost-effectiveness ratios. So this is one set. The other set is the other tool is actually a tool about process. We assembled a consultative group of ethicists, economists, and country people, and we asked them what is the right process? How do you make the trade-offs? And so there is a guidance which is called making fair choices on the path of universal health coverage. So one of the very few statements from WHO which basically says what the SDG sub-goal of UHC now says, which is really the first thing you need to do is get a set of services for everybody. Eliminate this problem of the missing middle. It's about equity. So, but there are other things. And so I would basically say please refer to these two tools. It's among many in WHO. But it will be very helpful because it addresses both the content and the process. And then finally, I think what we, I want to ask each of you here is by 2030, how old will you be? How old will I be? That's when we finish the sustainable development goals. And what do we want to see for global health? What do we want to see for universal health coverage? And how will I and you contribute to that goal? We can't let this opportunity pass. So please, we will see each other maybe 2030 and if we want it to be a celebration. Thank you. Thank you. Thank you. It's a great privilege and honor to be here and it's great to see my colleagues, Tessa and Calypso, with whom I have worked for many years. And on this issue of how do we make the health systems work better? And so today, rather than I was going to have my usual talk and I said I threw it all out. Because, you know, the last 20 years, I think the work that Tessa, because everyone has been doing is valuable, but somehow it is not enough, right? Somehow we have been missing some critical components. So I wanted to throw to you a few thoughts, suggestions of where we might need to do some transformative thinking and how we seek solutions. And then I'd like to give just a couple of examples from my own country, Japan, since you also spoke about Philippines. Why do we need a transformative thinking? I see that at the 20 years of my experience, I look back and see that I have been looking at health systems and the traditional mechanical engineering solutions. We have various inputs, components, how do we get evidence? The challenge is first getting the evidence. We've come a long ways. And yet somehow it is not sufficient because healthcare is not a simple mechanical box. It is a complex system, an organic system with complex relationships stakeholders. And to understand and model it, we have to go beyond the engineering solution to a much more of a systems analysis, complex systems approach. And I know that many of you have been thinking, but we haven't quite figured out how to translate that into practical policy solutions. And so here are three areas that I think we really need to be much more aggressive in doing evidence-based thinking, analytical thinking, and policy thinking. One is, as been already discussed, is to take the political economy aspect much more explicitly, not as a marginal residual, but as a central piece. If we want to achieve universal health coverage as a 2030 goal, then it's not just the technical solution that we need to look at. We really have to understand the political economy and the dynamics, the relationships among the different stakeholders. Because universal health coverage is about equity and necessarily it is about redistribution. I know some people in this country don't like this term, but it is about redistribution and trade-offs and negotiations. So how do we bring that much more into the arena for evidence gathering? And this will require, and to some extent, HTA is bringing that issue through clear governance and process that brings ethics as well as economic and other evidence together. I think it goes partway, but we need to go further. In developing an understanding, it's essentially a social engineering of the governance structure that will allow these trade-offs to become much more of a constructive way. The first session, the Chile's experience is actually very valuable, showing how the political process contributed to creating that space, creating the trust. How do we not just leave it to happenstance? How can we provide a governance structure, an engineering system that will likely create that kind of a structure going forward? So that number one is political economy. Number two, how do we bring more of the behavioral sciences, psychological sciences, which is just exploding right now into the field? How do we bring that into this issue that I just mentioned, social engineering? How do we bring that behavior economics knowledge into how we design the governance structure, the HTA governing steering committee? How do we engineer that? I think that there's a huge scope and opportunity that offers potential solutions. And number three, this explosion of information technology or big data, social media, this gives us again another fantastic tool as well as risks in how we can gather evidence data and use it in a way that will contribute towards a more fair, transparent and open system that brings stakeholders together in a constructive way. It sounds very challenging, so I wanted to turn to some examples from Japan because Japan has taken a very different approach to this prioritization from I think the rest of Europe and the US and America because we have come from a very different social cultural perspective. We don't like to take a legal regulatory approach in making decisions. We like consensus. We like to do it through a process of constant dialogue within our own political social arena. And so I wanted to give you the example of our national fee schedule as a way that we achieve this compromise redistribution system. It is not just a fee, we have a national fee schedule that determines more than 90% of how the healthcare services are reimbursed. I'd like to emphasize that Japan is mostly private on the provider side. We're 99% private on the ambulatory side and 75% private on the hospital side. So it is a highly private sector driven system and yet we have all come together to agree on a national fee schedule that gets updated every two years through a very intensive horse trading that goes on behind the scenes which then becomes part of the policy making and decision downline. Every two years we get together and agree on the reimbursement schedule for all the items, the huge number of items that is in the benefits package. So the fee schedule is not just the fee schedule. It defines the benefits package in the sense that this is the service for which you'll be reimbursed. It also provides conditions for reimbursement. It's not adequate but it does give some quality conditions. So it is that aspect. But also it determines the price not in a bureaucratic way or not in a pure market way but it's a combination of using market data with the policy data and then pure politics of interest groups fighting each other out. How does it manage to maintain a positive structure? One, yes, we've been fortunate we have a peaceful system for many years. It's a stable system but a key element of that is that the government provides certain amount of subsidies and it tells all the other stakeholders. Every year the stakeholders include the consumer groups, the municipalities, the insurance groups, the pharmaceutical industry, the medical associations. They all come together with all their stakes because the reimbursement affects them in different ways. It says, listen, in the coming two years our subsidy level, our fiscal space will allow us, let's say, 1% increase over the current spend. That's the subsidy that we have to work with and figure out what the reimbursement rates are because if anyone group, let's say a pharmaceutical group or some pediatrician, whatever, gets a very favorable reimbursement rate and then they make in the next two years a lot of money, it will be at the expense of the other groups because there's a certain amount that's set for the subsidy and somehow we have to work around that. So it becomes, so if you take advantage and know that you'll stick out of the thumb in two years' time, your peers, all the other interest groups will beat on you so everyone becomes more cautious in a way that they approach. So the trade-off and give and take does become a long-term relationship. Now I know this is not an easy place to achieve but in some ways the fee schedule has been socially engineered to get the trade-offs amongst interest groups to be more responsible towards the public goods as it were and at the same time there's enough flexibility to allow groups to make the case. Why, for example, we have declining populations. So what do we do with the pediatricians with smaller number of clients? The discussion is should we allow the reimbursement rate for them to go up so they can maintain an income so that we have a certain number of pediatricians coming in knowing they will have a reasonable income. I mean these are the kinds of discussions that this form allows us to happen and it is not, as I said, it is not an easy one but I think that in coming through with some governance structure we have to find the social engineering that allows this kind of trade-off to take place in a consistent way. I just wanted to take one other example of what is happening now. You know that we're in deficit and so the fiscal issue is huge. So one of the ways that the Ministry of Health and the Ministry of Finance realizes that we really need to move towards a community-based healthcare system. And part of that is that the Ministry of Health has very timidly put forward new legislation, I'll explain why it's timidly, saying they wanna give greater role for public health nurses to play a coordinated role in managing, helping to manage care between the clinical and the long-term care and social services. Because we want the elderly to be healthy, to stay at home as long as possible which means we don't wanna maximize on the clinical use. So the role of the public health nurses who are not clinical are going to be greater. Now this is getting a huge pushback, predictably, from the medical association. It was, ooh, we don't wanna be put under, who do they know, do they know? You can imagine the kind of dialogue they're having. But this is where, again, combination of understanding the transformative shift that needs to take place on the education of health workers and the role of the health workers is just as important as the reimbursement rates which would then go to support that. And so how do we socially engineer a kind of movement in that direction? I feel there is a potential now for us to utilize this big data, social media, and a governance structure that allows these interest groups to come together in a very constructive way. But we also, by sharing this kind of information, we know that many countries face similar political challenges. The medical associations, the deans of medical schools are very powerful. How can we bring them on board as part of the solution and not make them fear that somehow they're threatened that the trade union effect doesn't undermine the greater goal of achieving universal health coverage? It is not an easy thing because interest groups, politics, are very entrenched in how we behave, us against them. It is part of our human behavior. And so we need to find a social engineering approach that recognize this and designs this into the way we develop the governance, the regulatory, the dialogue structure. And I think we have a huge agenda ahead of us and I look forward to contributing to that discussion. Thank you. Thank you, thanks very much. So let me use a few slides, I apologize. I'm only gonna use a few of them. Most people who have come before have said all the things I would like to have said. So perhaps there'll be a little bit of repetition. So I guess one of the questions could be what the problem is, why are we here? What are we talking about? And people have discussed the problem, certainly Jeanette gave very clear examples from Chile as well as global. But just to reiterate some of the issues we do know that there's things out there that are high value or not using and things that are low value are using and are using on a scale. And this has implications on equity and on outcomes. And this applies to all of us, not just the poor countries or the middle income countries, it applies to rich countries too, it applies to the US, it applies to the UK. I work for an organization called NICE, part of the Public Sector Advising National Health Service. Every day we feature in the public media, the press, and this is from yesterday on sort of on my way here, talk on the plane, I was very pleased to be able to log on using the United Wi-Fi. But so I downloaded this and it's exactly what Jeanette said when she started about the opportunity cost. So this is a long piece worth looking up if you're interested, most of the different challenges in a pre-election period right now in the UK, we've got elections coming up in May. Basically what it is, it's about what NICE does and this idea that if we say yes to something, however important that something may be, we may be well-saying no to other things. And this idea of making trade-offs and choices, making them explicitly will anger people, will sadden people, but providing a drug, a technology to one person means that someone else is denied the care they need. And we're having this debate very publicly right now in the UK and I think that's a really important thing. So to me, priority settings are a number of things and people have mentioned some of them. It's about countries' own institutions and processes. It's not about lists that we develop in Seattle, in Boston, in Geneva, in London. It's not about global lists, it's about local lists, it's about local decisions and the political process. It's about setting our ground rules and I could mention that it's about engineering a governance structure which could well tackle issues like corruption and make people who spend people's mother people's money accountable and that's really important. It's about quality improvement and I know Sebastian will talk about quality later. Making quality improvement choices is about making priorities. Quality costs money, it doesn't come costlessly and that's a big problem with health technology assessment that has ignored the idea of quality, inequality quality that has tended to ignore costs but it will go together. So priority setting is about transitioning to a new model of development assistance and I want to talk a little bit about that because as countries become richer, GDPs per capita grow but still the world's poorest people live in relatively rich countries now. How do we reach these people? And it's through healthcare to an extent that acts as an equalizer. Benefits packages are accessible to everybody. It's about public-public partnerships and I'm very proud of our work together with the Thai colleagues and Yacht is here and we'll talk about Hicap and I believe partnering up with the public sector across the world, rich and poor countries, there's huge potential in making things happen. It's about making donors accountable. It's about measuring as well and I wonder whether we could have a discussion at some point about sustainable development goals. I appreciate we want to measure things we can measure but perhaps we're missing things we can't measure like processes and institutions and these things matter too. And finally it's about making promises one can keep. So we're very granular packages and making entitlements explicit. We need to be able to keep these promises. I'll give you a couple of examples and I'll stop. One is about institutions. We've been working with the government of India for a number of years in their latest draft health plan. They talk about an institutional approach to selecting technologies. Very proud to mention that's why I put this quote up there with the only non-Indian institution mentioned in this policy. But what I want to highlight is the fact that they talk about values, social values, they talk about participatory processes and I think that's as important if not more important on the evidence of the technocratic solutions and quick fixes that love the time the global health community has edged the words. So it's about procedural fairness, it's about inclusiveness, about transparency, it's about independence. I think implementing these things on the ground and what Tessa mentioned about convening people, bringing people together it's really super important and I think hasn't really been emphasised enough in the debate recently. A couple of words on aid. I can tell you, DFID, we've got 0.7% of our GDP earmarked for global development assistance in the UK. This is enshrining legislation but it's huge, huge emphasis on how we can ensure this aid meets two conditions, additional and sustainability. So what happens as countries become richer, as countries graduate from the Gavi and the Global Fund press holds? How do you reach these countries? How do you reach the poor within these countries as inequity also grows as countries become richer? But whilst doing all that, we need to ensure aid adds on, doesn't displace on country spending and it's sustainable. So when we talk about demand for priority setting support for institutions in middle-income countries, yes, that comes from governments who have more money we can spend. But what happens in really poor countries? Well, you've got organisations still like the Global Fund and Gavi and though the role of these organisations is not as important perhaps as in the past, even the very poorest countries spend more of their own money on health, we know that only a very few handful of countries depend on more than 50% of their health budget on foreign aid. However, a lot of that money that the countries spend, very poor countries spend goes to salaries, fixed costs, so when it comes to money they can spend on technology and services. There's really groups like the Global Fund and Gavi who still have a very important role to play. So what is the responsibility of those groups and those who fund them to boost priority setting within countries and own institutions? And I talked about public-public partnerships. This is a consortium of partners who work together working with partners in other countries and have circled nice and high enough because as two government organisations, I think this public-public partnership working together with ministries of health in Philippines, Vietnam, China is really powerful and builds trust and really you see fellow policy makers in other countries really wanting to work with us and I think that's really important. So I'll just finish. I mentioned earlier about sustainable development goals. I don't know much about them. Tessa kindly read out the list and it looks daunting and important. And again, I want to come back to my earlier point about whether we sort of end up looking for our keys under the light just because that's where the light is. I think it's really important to think about, consider whether we should be reporting on other things in addition to percentages and however granular these are and broken down across socioeconomic groups. So do we care about institutions? Do we care about countries' governance? And if we do, how do we measure that? So I'll leave you with this. This was published a few years back in The Guardian. It was a question The Guardian posed, The Guardian magazine on Saturday. What is the most difficult ethical dilemma facing science? And this was a dialogue between Sir Richard Tembero and Richard Dawkins. And they were referring to a debate, again, involving nice and a cancer drug, a bowel cancer drug, which was very expensive and I said we can't afford it. So this was the top dilemma as per this debate at least. How far do you go to preserve individual human life? Because as Jeanette said, in the end of the day, it is about individuals, it is about people. However much you want to care about our populations as a whole. So how do you make this decision? And I don't have an answer for that, but this is what priority setting is about. Thank you. Thank you, Nellie. And Steven, great privilege to be here with you this morning. And not an easy task to be the end of such an illustrious panel with some really good discussion already. And one of the panelists earlier mentioned that there's a need for transformative thinking. And I think that is something that is starting to happen in the pharmaceutical industry as well in terms of how it thinks about and engages with countries that we're talking about here, in terms of low and middle income countries on the journey towards universal coverage. And by that I mean that historically, the industry has dealt with a lot of those countries or seen a lot of those countries in the sense of being able to sell some products to a segment of the population that could pay for them. And then on the other hand, engage in aid and other types of programs, donor programs, which would deliver product to those who could. It was a fairly simplistic sort of view, I think, of things. As universal coverage spreads and gains, now we see this in sometimes very ambitious political commitments to the extent of movement towards universal coverage, often not matched with a financial capacity to really deliver on those things. That is what it is, that's the reality. And clearly the consequence of that is that you've really got to have some form of evidence-based priority setting that's going to guide health systems, particularly during that initial period of shift on universal coverage. So I think the pharmaceutical industry is not concerned about the concepts of evidence-based priority setting. We're very used to the notion of generating evidence. We have endless discussions about how to meta-generate evidence, particularly for modern HDA requirements and systems. But the notion that systems are going to rely more on evidence-based priority setting is obviously a sensible one. And it's a far better alternative, I think, than having decision-making that is far less clear in terms of how it's made, it's opaque, it's difficult to understand. So in that sense, we're very comfortable in sort of moving forward with that sort of concept and engagement. What we're seeing at the same time as this expansion of discussion about universal coverage is a number of international agencies from WHO and the World Health Forum Declaration last year and a number of others advocating health technology assessment as one of the key tools to achieve that sort of evidence-based priority setting. And Calypso's organization knows that the forefront of being able to be quite nimble and available to help in a lot of parts of the world. One of the things that we've thought about a great deal from the industry point of view is how that happens and how HDA systems and processes get installed into these health systems in the stage of evolution and transformation. And I really like one of the charts from Jeanette around the approach in Chile because it's a good example of what I think we ourselves are starting to talk about as macro-HDA. So we take a much more holistic view of health system needs, disease burden, health system capacity and infrastructure, and you sort of work systematically through that to determine not only what you need but what's going to be achievable and feasible given all of those constraints that you've got as well. Financial constraints obviously being a very large one of those. And so there is some literature now around the concept of sort of macro-MISO and micro-HDA with macro being that fairly broad holistic health system approach. Some people use the term MISO, HDA, to think more about clinical pathways and clinical guidelines, which of course is something that NICE in England does extremely well by linking its technology guidance to clinical guidelines and pathways. Very, very practical. And so we see that as being very, very important in a number of these situations as well. And then below that you have what we would call micro-HDA, which is the way that a lot of people have thought about it historically, which is product A versus product B in terms of comparative clinical effectiveness and not in all parts of the world, in many parts of the world comparative cost effectiveness. And so I think what our consideration at the moment is that it's quite challenging to sort of move straight to that micro level of HDA in situations where you don't necessarily have the capacity to do that in terms of human resources over the appropriate skill levels. And most importantly data. This is very data driven sort of work. But some combination of those elements can become a very viable and feasible way of doing that. An industry is very keen to have some sort of seat at the table as those sort of processes get worked through and thought about and installed because we think we can partner effectively in that sort of environment. And clearly, when you look across disease burdens and disease needs and health system needs, as other speakers have said, it's not a one size fits all sort of solution. And so we do see situations where more specific micro HDA is being used to solve one particular problem. For example, I'm aware that the Philippines has worked effectively with HITAP on an HDA approach to HPV vaccine. So dealing with a specific technology that is specific time to say we really need to get that sorted for our country. But in the meantime, you know, you have a lot of other things to do. We're also interested in how do you, if you take that sort of macro HDA approach and think back to the slide that you now described that, how do you work that through down to the day to day formary decisions, which we're from our point of view, from a pharmaceutical industry point of view where the rubber meets the road in terms of how you make decisions about what goes on formaries and what prices, et cetera. So it's getting that sort of process to flow through, I think. Cliff so mentioned about public-public partnerships and clearly there's a lot going on in that space that is connecting people and sharing enormous amounts of information. For those of you who were at dinner last night, I spoke a little bit about public-private partnerships and the way in which some of those are evolving and maturing and doing some new and different things, particularly in NCDs. And I think there are some learnings from some of those about how you get this intersection working between the sort of the more macro considerations and the practical delivery of technologies on the ground. So I think we're not a long way apart in terms of thinking about this in similar ways. And if the systems and processes that have been talked about create a situation where you can be part of the discussion, you can understand the processes and the thought processes and be able to respond constructively in negotiations that result in formal decisions, then I think we've got a more continuous sort of process in place. And I want to finish really with just a quote from Calypso because I read everything that Calypso writes. And this comes from a paper I think it was from last year on affordable cancer care. And cancer is a particularly challenging one, I think, for many of these countries. There's a lot of things that one can do with low cost generics for many conditions. But at some point for some diseases, you've got to start to think about other technologies, slightly more innovative technologies and how you start to integrate them into the system. And those are big challenges. So in this particular discussion about affordable cancer care, which Calypso, as I say, was one of several authors, I thought there was a good statement. It says that structural organization and cultural issues are equally important factors, if not more so in the delivery of effective cancer treatment than expenditure alone. I hope it talks a lot about a lot of other things as well. But the point that I wanted to make is that it's this consideration of structural organization and cultural issues, which good HTA should do is a really big part of it. And I think what industry is concerned about is that in some situations where you've got this intense affordability issue because the financial capacity is not keeping pace with the universal coverage expansion, then HTA can become a cost containment mechanism that is there to sort of be a barrier to adoption of more costly things. Done well, it obviously is not like that and doesn't have to be like that. And it's trying to find this balance that does have a broader set of considerations about clearly affordability as a key part of it. Well, I'm gonna ask a couple of questions and then we can turn it over. Is this on? So obviously all of you were talking about the social and political implications and that are very country specific. But I'm wondering at least on some of the more technical aspects of it, which are need some combination of these. Is there, can a regional approach, it seems resource intensive and it's data intensive and it's technically intensive. Is there some way, is there any room for countries to do this sort of collectively at a regional level? I think you're right. And I think already countries are doing this and I think with the internet in particular, people look up what organizations like WHO publish, but also most importantly what other countries do. So, you know, they would look at what NICE does or what HITEUP does, there's certain language barriers as well for reports that are put up in English. I think there's a lot of cross checking and there's networks like, I don't know if you'll refer to it, HDA Asia link, which is very much a network of organizations across Asia which facilitates the sharing of information. So I think there's a lot of potential for sharing. I think the processes need to be local. I think it's important that people own the processes and have buy into the processes. And I think there's also technical barriers regarding costs and resource use and all that affordability issues, different countries, different budgets, different social values. So all these things have to be taken into account. But I think already there's a lot of work happening across country. I wanted to raise this issue of the health workforce because what is related to this is because as you know, health labor market is globalizing, regionalizing. You have within the EU the movement, ASEAN is coming up with that. The implication of this is after all healthcare is provided by the health workers. So if they come from different medical backgrounds and so forth and their preferences and they play an important role in determining what services are provided, then the regional globalization offers both opportunity risks and how these information knowledge about the clinical standards practices are propagated enough. So I think there are tremendous opportunities and it is already happening through the movements. Also regionalization of medical schools, nursing schools and others and sharing of standards, examinations and certification across borders is part of that. So the question is then how will this link with also the knowledge about clinical practices and so forth, some of which the scientific facts may be global because of the similarities of biology. But what aspects then need to be local? What needs to be a sovereign decision because of the democratic accountability? Again, this gets down to the governance and how we define that will become increasingly important. I think regionalization all this is happening but I think it's happening in that really nearly many ways and having a better understanding of it would be very beneficial. I think picking up from what Akiko said, the knowledge is global. However, the decisions have to be made locally and these are very political decisions and they must be able to defend it. So I think what you would ask this international agencies who publish this evaluations would be to make it a little bit more detailed, to make it a little bit more transparent in terms of how they made the evaluation to provide the background data so that if I do decide in my country not to do my own analysis but to look at somebody else's, I would want to be able to say, yeah, I agree with this. Well, they have a difference in the price. I'm going to put in my own price and I can rerun some of the analysis. But I think this is something which you would hope that people would have the same agreements but definitely not every country needs to do some form of review. But many of us here who work in international agencies will be able to facilitate this by being more open in terms of the data that we provide which were the basis for our recommendations. So I think we, you can't take out that local process. It's very political. And especially if there are trade-offs and there are winners and losers and there are voices here and voices there, then you really have to make sure as, as Chenette said, you can stay in the newspapers and keep your head. I think the, as has been said, the broad skills are definitely transferable and there is a great deal to gain from doing that. It is dangerous, potentially dangerous, in transferring one technology assessment decision from one place to another. But people have said it needs to take into account the local context. I also agree with the point that at the end of the day it's the way in which that process is integrated into the decision making in a country like Chenette made that point really well. In terms of the end of the day it's a political decision and so the playing out of that, or application of that HTA in each health system needs to be done locally in the context of what the problems of the day are. And so a lot's been made, and this is the biggest issue in the US as well, about preventive care and behavior change as you talked about. And this seems like it's a really difficult thing to capture in some of these processes. How do you capture the cost-effectiveness of behavior change? Is that part of any of these methodologies? Is that feasible? Yes, it is, and it's about who sets the agenda, who asks the question, how the question is structured. Certainly global donors fund a lot of behavioral change interventions in the HIV world, for example. So there is an evidence base, now whether that's consistent with them funding these things, it's a different story. But there's evidence and there's ways of capturing. I know in Thailand, HITEUP has done a lot of work in a much broader sense of HTA, looking at things from policy interventions to behavioral change interventions, prevention. We have a whole program doing prevention in the UK, looking at the cost-effectiveness of prevention. So it's technically possible, there are data, but again it depends on the structure of the system and who asks the questions, and who pays in the end for the recommendation of HACTS and the recommendation of good money. Just the two points, I think the use of availability of big data and social media expanded our ability to understand behavioral responses. For example, a study on obesity has shown that it's not so much your genetics or biology, but who you know, your peers. So that, in fact, obesity propagates almost like infectious disease in the way your network, your connections impact on that. And that kind of data would not have been possible if you didn't have this kind of big data available. And so we're increasing having the ability to do it. I think we're still in the early stages, but as a result, for example, in Japan, I mentioned again, for healthcare, we're seeing more and more the importance of social connectivity, so that it's not just about clinical, but also to make sure Ministry of Finance is interested in preserving fiscal space. So they're very much also pushing towards interventions that show lower cost to having healthy lifestyles, and they have collected data on these. And that is why they're promoting and pushing for more home-based care, community-based interventions that includes psychosocial connectivity that improves your immune system and your ability to fight infections. In the future, I think the data will be collected whether it affects cancer and so forth down the line. But I would add that some of that thinking about behavioral change and so on is not only relevant to prevention, but there are a number of particularly chronic conditions where adherence to treatment is such an important issue. And there is a lot that can be said and done about matching the availability of the treatment with efforts to ensure that both health professionals and patients have the right understanding about how that treatment should be used to actually get the optimal result. So it's not something to be ignored on the treatment delivery side either. Well, one last question. Oh, sorry. Just to see that I think from the prevention part is actually where you start thinking about more intersectoral actions in terms of policies. So if you look at the sustainable development goals, it says to decrease the mortality from road traffic accidents by 50%. I'm not going to really tackle that in my small essential package of services. I would probably tackle that through policies and talking with the Department of Transportation in the same way that obesity and all of this other non-communicable disease, you would basically be thinking really about the very strong impact of behavior modification by certain policy changes like taxing cigarettes or alcohol or putting in incentives for manufacturers to decrease sugar, et cetera, et cetera. I think all of this is still for me part of health but more intersectoral. And really this is where we can probably have the most gains for many of these conditions. We will not be able to achieve it within health alone. Our usual definition of health. Well, and sort of on the flip side of that, how in these processes do you preserve space for innovative interventions that are obviously could potentially be costly initially? How do you create space for that? I think we didn't prearrange this. I think it's, again, it's a cross-sectoral thing. I think it wouldn't be fair to ask the health budget alone to support innovation and R&D. There should be money for certain development because you want the innovations to enter the system on an uncertain evidence base to be evaluated because otherwise you don't know whether they're killing people or saving lives. We want to have a good industrial policy that supports wherever it is you're standing and what level of development you are, homegrown industries, overseas industries. We want to have a strong regular system that attracts foreign direct investment. So I think my answer would be that we need not to ask too much of the health budget. Certainly in the current time of recession the major concern right now is to cover as many people as we can with things we know work and cut waste. And beyond that, I think there's lots of different budgets in government, different ways from patents to an IP rights to, as I mentioned, industrial policies to help encourage innovation. I would agree, obviously, with that at a broader policy level. You mentioned the regulatory side of things and there are countries where the lack of a well operating regulatory sector is as much a barrier to access to some of these innovative medicines as Emily knows. But I think in practical terms about how one can start to integrate some of them into an evolving health system. There is a lot to be discussed, I think, about the concepts around appropriate use. In other words, making something available does not mean to say that everybody should get it. And there is a lot of expertise developed in some health systems around different quote, appropriate use strategies which can mean that you're targeting the availability of that treatment to the patient group where it's likely to be most effective and most cost effective. And that can be done through various ways. Brazil, for example, has got quite an established system now of using expert clinical groups to develop clinical guidelines and the only way that one gains reimbursed access to a number of higher cost specialized treatments is by adherence to that set of guidelines which has been developed through a clinical consensus. So there's a whole range of tools that can be used in those ways so the appropriate use concept is useful. I would like to pose this issue with transforming medical education. I was originally trained as a biochemist that always struck me how different medical students were from those who were doing scientific research, a different culture and healthcare industry has often been more conservative in adopting different types of technologies. That's a huge area because I see that there is a tsunami of innovations already in the pipeline that's coming. In Japan it's the robotics, the material sciences which is way outside of the traditional clinical science field and that's gonna transform the way healthcare at large is going to be provided and I'm sure that through nanotechnology there'll be a huge amount of new things that'll be coming up. The challenge for us is how can we, and they tend to, at the moment, increase the cost but how can we incentivize the industry, the researchers to come for low cost solutions which are possible like what happened in IT that's not happening often enough. For universal health coverage, we've got to innovate for low cost solutions and I think that should also be possible but I think we need to find ways to really incentivize the groups to find these kinds of solutions. I don't have an answer for that but that's something we need to challenge ourselves. I like innovation. I mean it's wonderful. I was in a, I thought a boring meeting with logisticians yesterday and we were talking about how to get the commodities to everywhere, geographic access and so we were looking at what would we need and they were talking about, you know, from simple things like boats to get to this but then they were talking about drones and et cetera. So I think they think about the next 15 years. It's going to be the most exciting 15 years and I'm happy we'll be here in those 15 years. It will be very challenging but I think this wave of potential innovations from the smallest genetic based medicine to drones and robotic surgery, it's not going to be there for everybody but we have to try to make it at least to the extent maximum available for everybody. I mean it's, let us not increase the inequity in this world. In the next 15 years, we should really be looking at this. All right, so questions from the audience. We'll collect a couple of them. Can you identify yourself please and keep it short? Sure. Claudia Morrissey Conlin with USAID Maternal and Child Health. I want to thank Dr. Vega and the panelists for really a very stimulating conversation particularly around the issues of prioritization. And my question to the panel and to Dr. Vega, she wants to take this, is I don't hear a lot about instances where we say yes in order to be able to say more yeses. It's always we say yes to something we're going to put on our essential service package so but we have to say no. And it seems to me the discussion of the epidemiologic ecology, if you will, is very stable and very static here. And that I believe all of us want to reach universal health coverage not only because it's the right thing to do but also because it then rationalizes our use of resources so we can say yes to more things. So I'd like more discussion about this policy box being more malleable and what in the next 15 years can we garner by saying yes now? Hi, I'm Daniel Cotter from the World Bank. And this is mostly to do with a point Calipso mentioned in one of the slides. There's a lot of technologies that are great and have not been taken to scale. So in the bank we were trying to, we were doing a comparison of 24 countries. And one of the things we wanted to know was let's identify 10 things that are great but have not been taken to scale. And let's understand in each of these 24 countries what's the problem with them. So we were looking for 10 great things that have not been taken to scale. And we couldn't find that list. Maybe we checked in the wrong place. Is there such a list? And I wanted to combine this with a surprise, perhaps, that came out of the work done by the Commission of Investing in Health. They have this estimation of what it would cost to achieve convergence. And they do that estimation based on some technologies that they've identified and have not been taken to scale. But all those technologies are referred to communicable disease and maternal and child care. So perhaps my question is many of the countries that are doing universal health coverage are expanding beyond that basket. Are there 10 things that you would say people around the world have reached a consensus are great, are cost-effective, but have not been taken to scale? Thanks. Why don't we take these two questions because they're complicated. Cool, so do you want to turn that? I'll start with Daniel's question since he was addressed. I think it's a really good question. And I apologize if the impression I gave was that one could devise a list of things that applies globally of things that are underused and everybody should use. And I do have my own reservations about the lists in the Investing in Health Commission papers about how these lists were derived, what data were used and how this data could possibly have been applicable to all these different countries in the world simultaneously. So I think I can think of things however at the country level and in order to identify those things you do need to have a process. So for example, I can tell you that in secondary prevention for instance for cardiovascular episodes, MIs, strokes is certainly not done enough in countries like China, for instance, so you have a stroke. You have a stroke really early in your life so that's a primary prevention gap. But then you go home and there's no system to ensure you're on, put on the chip, anti-hypertensive, anti-platelet, I'm less contraindicated, et cetera. So you go on to have a second stroke and then that's it, you either die or you're out of the workforce. There's issues, there's gaps still in vaccination. We're looking with colleagues in Colombia, for instance, there's regions in Colombia that still have less than 50% of the basic vaccine coverage and Colombia pays for a vast number of indications that are even licensed in this country. So talking about diabetes in India where the poorest of the poor there's no means of raising awareness or monitoring people so they go on to have an amputation, lose their sight, end stage renal disease, which has catastrophic costs and cost implications of the family. So I think there are things countries could be doing, should be doing the same applies in the UK. We know that for the type one diabetes care is only 30% of people get the recommended care based on guidelines, clinically and cost-effective care in the UK. So that's usually problematic. Mental health is another major area. So I think there are cases, but I don't believe in global lists. I don't believe you can have a list and say, look, these are the 10 things everybody should do and they're cost-effective. I don't believe in that because I think it's technically tricky because it's about resources and I don't believe in it because procedurally it doesn't make sense. If you want people to do things, pay their own money, they need to go through a process that they've built, that they run, they've bought into, have a conversation and then they decide to spend their money. How would the United States fill WHO set here's the list of 10 things and you should do them? Would you, would the government say, okay, well WHO sets all do these 10 things? It doesn't work like that. Countries need to decide themselves. So the best they can do are things work together to exchange experiences around the processes, but not to share a list. So I think, you know, I agree with you. I couldn't come up with the list of 10 things that everybody should do and everybody's not doing. Sorry. Maybe I'll go. We'll go. We'll come in. Second? Second. First question that maybe I'll respond. First question about how is it that, always saying yes more and more and more, of course there is a pressure as we said, if you look at the behavioral sciences, people want more as an individual, you want to have access to all, but how do we get that trade off? So I think the discussion here was at the public level, at the collective level, how do we get that trade off decisions done? Because yes, maybe you're saying yes on paper, but de facto the countries that we work in, in fact, people are not getting services implicitly or explicitly, a lot of times implicitly, the budget's not there even if it's supposed to be there. If the drug is not there, the drug runs out halfway through the month and so de facto those who comment later, these rationings are actually happening everywhere. What we're hoping for through HD is at least to make it more transparent, so it's not implicit and somehow covered up, because then the poor, the underserved, the marginalized groups are the ones who suffer the most from this. How can we make it more transparent? And again, there's no easy answer, but how can we get a country, a community to have a more transparent discussion, to have a fair understanding of the trade-offs? There's not gonna be easy, and it's always gonna be a negotiated approach, but I think that's one of the biggest challenges that we all face. David? Just a couple of comments related to that question. So within HTA circles of people who get together to talk about HTA, there is also the notion of disinvestment. So the idea that there are going to be various technologies that are no longer regarded as useful or seedly effective or cost effective, and active disinvestment is something you'd now start to see in some systems. Sort of related to that, but a different concept is that of concept of headroom for innovation. And so this is probably something that's applicable in health systems and the more developed end, but maybe not. There are a number of situations where even generics, prices are higher than they perhaps should be for all sorts of reasons related to supply chains, markups, taxes, all manner of things. And there are some examples now where industry in a broad sense has worked with governments to figure out how do we readjust some of that structure so that there is in fact more headroom for innovation so that yes can be said more without necessarily discerning the whole ecosystem. I think to respond also to the first question in order to deliver this, to really guarantee the package, I think it takes a lot of things to do. It will take a lot of things in order to deliver it to make sure that it's guaranteed and everybody gets it. But the idea I think as well is it's a progressive realization is the term use where you start with a basic set, you ensure that you deliver it well with the quality that will give you the health benefits and then you gradually expand with many of these countries with HR problems, with logistics problems. You really have to make sure that what you promise is actually what you deliver and you make the government accountable for that. I think the key thing is really it's to say we're starting but it will become bigger but we want to make sure that everybody gets it, it's very important that you, and this is why I believe that some countries who go with negative lists, you're not going to get there. You really have to make it an explicit list because then you can focus the efforts of the government in terms of governance and then at the same time you can have accountability and you can have the ability of everybody to be able to claim it. If you don't make it explicit, you cannot claim anything. Nobody can go up to the health center and say I want to deliver and I don't need to pay. You have to be able to say that to a mother, to a pregnant mother. You can deliver anywhere and you don't have to pay anything. That's very powerful to our audience and I think this is what we want to make sure. You make it explicit, you have to people know about their rights, what their claims are and you make sure that the providers know it and deliver it well and you start with that and then we grow it. Well, unfortunately, we have run out of time. Can I get a quick one? Yes, this is a very, this is an extremely interesting question because what happened is that, and there are two examples that I think of and it's not in the process of defining the benefit packages in the process of updating it and moving forward. What happens, for example, is that as a general principle, it's good to move forward thinking and going more towards prevention and because when you do that, basically the money is spent more efficiently. So for example, we are moving now and it could appear to be very, very unimportant. We are in a process of implementing throughout the country peritoneal dialysis, instead of the usual dialysis. Why is that? Because basically it's much less expensive and then you can provide more. It has much better outcomes. Therefore, you basically can decrease the complications and therefore you can decrease the money that you are spending in providing the classic dialysis for, right, so that's one. The other example that I can think of is the issue related to drugs. Sometimes you provide more in terms of more expensive drugs but those drugs that are more expensive can in fact be much better in terms of complications. The example that comes to my mind is biological drugs for rheumatoid arthritis, which is an example. So that's the thing that you have to be dealing permanently with new knowledge, with cost effectiveness and at the same time with the population health approach which is moving toward more prevention and promotion. Thank you very much. So we have 10 minutes and we're gonna hold you to it for a quick break and we'll set up our second panel here. Help yourself to copy and we'll be right back.