 A sea change is underway among emerging economies to strengthen health systems to expand coverage to the underserved, to provide protection for those vulnerable to financial catastrophe, to improve the health of societies as a path to greater social stability, economic prosperity, and equity. It is a matter of justice, stability, good public health, and equity. It is also very complex, expensive, uncertain, and risky. As we will hear, we have to proceed smartly in the future in making the key decisions in the coming years, and the coming years are going to be critically important as we'll hear. As we've discovered in putting this conference together, there are many talented experts from diverse corners around the world busy puzzling over how to build upon this moment, this emerging social movement to get the best results. From the lower and middle income countries themselves, which are the central driver of change, from businesses in the faith sector, which account for so much of current health and which will remain integral to future expanded solutions, from international organizations that have taken up the charge, the World Bank, the World Health Organization, PAHO, from the Rockefeller Foundation, which has been an intellectual leader for several decades from experts at universities, consultancies like R4D, fellow think tanks like the Council on Foreign Relations, and of course the United States, and other advanced economies which wrestle with many of these same issues. And in our case, we wrestle with this a lot in the mud, as you've seen in the last few months. We are in this here at CSIS in terms of universal health coverage for the long run. We will follow today's events with further activities over the course of 2014 and welcome your thoughts and suggestions. We have a very full day. I want to offer special thanks to my colleagues, Nellie Bristol and Matt Fisher, who Nellie authored the paper that you have, the Longer Study on Universal Health Coverage, which is the main document we're putting out today. That was indefatigable in coordinating and designing and putting in all the different pieces. And many other CSIS staff came to the table to help us, Carolyn Schroet, my colleagues at the Global Health Policy Center, Alicia Lindsay, Claire Brie, and our support staff in putting these together, Annie Anderson, Ryan Sickles, Ian Gottesman, thank you so much. I also want to offer special thanks to Pharma and its support for this project, especially Jennifer Young, Fumi Griego, and Jennifer Ossica. They have been terrific partners throughout this process. We will open with a short video, three minute video, and I want to acknowledge Beverly Kirk and Paul Frantz who put that together. This is a tool, we're opening this in order to show you, this is a tool we have developed for the social media universe in order to reach a diverse, non-technical audience that may not know much, but which is curious to know more. These are tools that we're developing to stir more interest, to create a quick baseline understanding and to motivate people to delve more deeply in finding other sources from many of your organizations that will explain this in greater depth. It is paired with this longer primer that Nellie has authored, the Global Action Towards Universal Health Coverage, which you have in hard copy and is available online. We will also be translating Nellie's paper into several languages. We will also issue a synopsis from this event in March. So let me, if I could ask Beverly and Paul to quickly tee up the video and then I'll move to the introduction of our keynote speaker, Dr. Kim. Thank you. The demand for affordable healthcare is growing worldwide as emerging countries become wealthier and citizens increasingly press for better social services. Universal health coverage, or basic and affordable healthcare for everyone, is a goal for many nations. An estimated 150 million people annually face financial catastrophe and fall deeper into poverty when a family member gets seriously ill. Services are unavailable, too expensive, or delivered too late to be affected. Emerging economies now confront these realities, acknowledging that affordable quality healthcare is essential for long-term economic growth, equity and social stability. Universal health coverage is the most powerful concept that public health has to offer. An ensuring equality in health has to again start here at home. Governments should take a strong lead in strengthening national health systems. But success won't be easy or quick. Health systems lack resources. Many need personnel, better infrastructure and supplies. Containing costs can be challenging and controversial. Finding a successful formula for cooperation and engagement frequently leads to division. Leaders have to forge a political consensus and build public confidence that governments can make systemic changes. The WHO estimates low-income developing countries need to invest about $60 annually per person to provide a minimum level of health care. In 2010, they spent only $32. Rich countries spend considerably more, but still struggle to contain expenses and maintain efficiency. Working toward universal coverage requires more reliable tax systems, an increase in public health spending and effective incorporation of the private sector. Despite the complex challenges, many countries are determined to make progress. China, India and South Africa started ambitious programs that target inequities. Over a few decades, Thailand and Brazil developed impressive forms of universal health coverage, something Japan established as a key piece of its post-war recovery. Each country approaches the task in its own way, influenced by existing coverage, history, culture and politics. We can expect very divergent outcomes. It will require time to see whether it's feasible to provide quality, affordable care to the millions in need. Thank you all. We're very honored today to have as our keynote speaker Dr. Jim Yong Kim. He is a visionary, a leader. The demand for affordable. A person who is drawn naturally to radical concepts of how the world might work differently and better. This is reflected, this core aspect of Jim is reflected throughout his more than two decades of work dedicated to development and health to improve the lives of the underserved. I first met him when he had founded Partners in Health and we were both participating in a congressional hearing in the Senate. And he was remarkably bold, confident in advocating to that audience skeptical at the time of the feasibility of expanding antiretroviral treatment to poor populations in weak institutional settings. And in arguing that you could tackle tuberculosis, including resistant forms in very tough settings. And I saw how the perceptions began to change in that period. And he of course carried this passion and this drive forward at WHO where he headed the HIV AIDS Department and led the three by five initiative which was met initially with a wave of skepticism but a short while later by 2007 that goal of putting 3 million people on antiretroviral treatment had been met and as of today we've now hit 10 million. Now 18 months at the helm of the World Bank, Dr. Kim is moving the bank swiftly into the center of the debate around universal health coverage. So please join me in welcoming him here this morning. Thank you. Thanks, thanks Steve and thanks everyone for being here. It's a great honor for me to be here and addressing this really wonderful and distinguished group of people. I just want to recognize a few people before we start. In building up to universal health coverage with so many people, it feels like we've been working up to this for a long time. Ariel Pobles Mendez from USAID. We worked together on tuberculosis issues and now Ariel told me many years ago that we should think bigger than tuberculosis and now of course we are. Is Jono quick here? You know Jono I know is going to be here for management sciences for health. There he is. For those of you who don't know Jono was the absolute hero and took a lot of what's the right word criticism for his efforts to make essential drugs available and his help to us both around the TB issue and around HIV was critical. And I also want to recognize Tim Evans, my longtime friend and colleague. Tim is the mastermind behind these targets that we have now for universal health coverage and we hope that it spurs us on to action. And finally I just want to thank Sally Stansfield. Sally is here. Sally gave us what at that time was the largest grant in the history of tuberculosis control to tackle this crazy issue of multi-drug resistant tuberculosis. So we have so many great people here and I want to thank CSIS for taking on this really ambitious topic of universal health care. Their strong evidence that investments in people like health, education, social protection are not just good for individuals who directly benefit, they're also good for their country's growth and political stability. Likewise, I believe that not providing health, education and social protection is not only fundamentally unjust, it's also bad economic and political strategy. But many people say that our agenda for universal health coverage is too ambitious, too complex and too costly for high income countries, let alone for emerging economies. We've heard that argument many times before. My first year of medical school was when we first understood the devastation of the AIDS virus. Now people forget, but there was absolute devastation in 1981 when we began to understand what that virus was all about. And then in an extremely short period of time, about 15 years, we had so-called highly active antiretroviral therapy. And it's difficult to understand how extraordinary that accomplishment was. And it was the HIV activists who started tackling every link of the value chain and getting from nowhere to drugs that actually treated the disease. We have to understand that that was one of the, I think, one of the most extraordinary accomplishments in recent history and perhaps in the history of health care. But when we thought about bringing those treatments to the poorest people around the world, the conventional wisdom was that treating people with AIDS in places like Africa was too expensive, too difficult, and offered slim prospects for success. In fact, some of the most important leaders in public health angrily opposed and even ridiculed our efforts and talked about focusing on the next generation through an emphasis on prevention. Yet others were compelled to act or to act up. They had aspirations as high as the people living with HIV everywhere in the world. Indeed, some of them, some of these activists, were living with HIV AIDS themselves. As a result, millions were treated, millions of lives were spared, and incalculable human and economic costs were avoided. In fact, it's hard for me to imagine that we would have seen over 5% growth rates in Africa over the last five years if no one was tested. Why would you get tested if no treatment was available? And people from the ages of 19 to 55 were dying unpredictably all over the continent. Who would have invested in African infrastructure and African industry if that was the case? So what's the lesson for us here today? As we hear the same negative arguments about universal health care, we saw that with AIDS, concrete action often only happened when there was a powerful political and social movement behind it. And just as the AIDS activists drove the movement for treatment and brought along the scientists, policymakers, the donors and businesses, today around the world we're seeing a large and growing movement to achieve universal health coverage. Universal health coverage will deliver better health outcomes. But like other investments in people, investing in health is also imperative for economic growth and poverty reduction. Nobel Prize-winning economist Michael Spence, chair of the Growth Commission, noted that health dramatically improves income and welfare. The Growth Commission report concluded that investing in good health and nutrition in young children improves the productivity and earning of individuals and households with quote, strong implications for economic growth and the aggregate over the longer term to help break the cycle of poverty. And the new report of the Lancet Commission on investing in health estimates that about 24% of growth in full income in developing countries from 2000 to 2011 resulted from health improvements. Full income is defined as the sum of the income growth measured in the national income accounts plus the value of the change in mortality or life expectancy in that period. Projecting forward to 2035, the Commission reports that the Commission reports, excuse me, says that better investments in health could yield a nine to 20-fold return in full income. That is an extremely good return. Health care is the right for everyone. In every country, rich or poor. As with AIDS, to make universal health coverage a reality, we have to be committed to take on the conventional wisdom and the vested interests. And we should expect to be called some names, but as an experienced activist and as a parent, I found that that gets easier over time. For us at the World Bank Group, achieving universal health coverage and equity and health are central to reaching the global goals to end extreme poverty by 2030 and to boost shared prosperity. Our aims are clear. First, everyone should have access to affordable quality health services. Our commitment is universal, but during the next 721 days, until the Millennium Development Gold deadline in December 2015, we're putting a special focus on expanding access to vital services for poor women and children. Second, no one should be forced into poverty or be kept in poverty to pay for the health care that they need. Every year, an estimated 100 million people, that's more than a quarter of a million people every day, are forced into poverty as a result of out-of-pocket health care costs. That's a little smaller number than the number you heard, which is catastrophic health care costs. 100 million people are actually forced into poverty. So we have to pay special attention to affordability for the poorest 40% of the population in every developing country. Third, all countries must harness investments in other sectors beyond health that provide the essential foundations for a healthy society. Achieving universal health coverage requires solutions beyond the health sector, including investments in people like education and social protection, but also things like roads, water and sanitation and information technology. For example, policy interventions to curb tobacco use or improve air quality, diet and road safety can all play a critical role in addressing the alarming increase in chronic conditions and injuries in so many emerging economies. Helping countries advance universal health coverage is a strategic priority across the World Bank Group. Through our bank loans and technical assistance, we're partnering with middle-income countries to design and implement tough health sector reforms and contain costs, while at the same time expanding and sustaining coverage. Through IDA, our fund for the poorest countries, we're supporting the next generation of countries to lay the foundations for universal health coverage. The strong commitments made by the United States and other donors for the recently completed IDA 17 replenishment round will enable us to scale up our efforts over the next three years. And through the International Finance Corporation, or IFC, our private sector arm, we're helping both middle and low-income countries harness the resources and innovation of the private sector, while promoting greater collaboration between private and public sector health institutions. Now, while there's no single pathway for countries to achieve universal health coverage, all countries can learn from each other's experiences as they chart and calibrate their own paths. Why, for example, are some countries able to achieve better maternal and child health outcomes than others with the same level of resources? How have some countries managed a rapid expansion and coverage? These are the best ways for governments to engage the private sector partners while ensuring equity and quality. All of us who are committed to improving global health need to document, evaluate, and share these lessons across countries. This will help save lives, reduce spiraling health care costs, and demonstrate value for money. That's why at the World Bank Group, we are placing a priority in what we're calling the science of delivery, which for us means a more rigorous and systematic focus on outcomes and how to achieve them. We need to understand why development approaches succeed in one country or context and fail in another. This search for global knowledge to solve local problems will be an integral part of our everyday work. Our knowledge must be accessible, usable, and relevant to government policy makers and development practitioners, telling them how to drive decision-making by policy makers, solve political problems, and change behaviors. The ultimate test is whether our science of delivery actually delivers results for the poor. And we're learning a great deal about how countries have achieved universal coverage. Last year, we produced 27 case studies on universal health coverage experiences from low and middle income countries. These countries are geographically, culturally, and economically diverse, but all demonstrate how these programs can improve the health and welfare of their citizens and promote inclusive and sustainable economic growth. Here are five fundamental lessons from the country experiences with universal coverage. First, strong national and political leadership and long-term commitment, excuse me, a little bit of water, strong political leadership and long-term commitment are required to achieve and sustain universal health coverage. You know, we always say this, and I remember that one of the great contributions of the DOT strategy was that we started off with political commitment. And the difficulty for us is to try to get across to the people who make the money decisions, heads of state, finance ministers, that this kind of long-term commitment is precisely what's needed. We're beginning to make the transition from thinking of healthcare as just an expense to a fundamental and critical investment, but we're not there yet. The second point, short-term wins are critical to secure public support for reforms. For example, in Turkey, hospitals were outlawed from retaining patients unable to pay for care. There was a noticeable public difference. Third, economic growth by itself is insufficient to ensure equitable coverage. Countries must enact policies that redistribute resources and reduce disparities in access to affordable quality care. A strengthening quality and availability of health services depends not only on highly skilled professionals, but also on community and mid-level workers who constitute the backbone of primary healthcare. And finally, countries need to invest in a resilient primary healthcare system to improve access and manage healthcare costs. Not surprisingly, all of the 27 case studies also demonstrate that as countries move toward universal coverage, they will inevitably confront competing demands and continuing tradeoffs. Countries face choices that can either enhance or erode coverage. Countries of all income levels, which have been most successful in expanding coverage, have been in a mode of continuous learning. They continuously observe what's happening both inside and outside their borders and have adapted their approaches based on the best available knowledge and evidence. This is a clear example of countries without calling it that, really utilizing, in their own way, their own science of delivery. Let's take a closer look at a couple of examples. In 2003, Turkey's infant and maternal mortality rates were among the highest in the region while life expectancy was 10 years below the OECD average. Despite fiscal difficulties and double-digit inflation, Turkey decided that to become more economically competitive it had to reform its healthcare system. Today, formal health insurance covers more than 95% of the Turkish population. Infant mortality has dropped over 40% since 2003, and three-quarters of the Turkish people say that they're satisfied with their health services. Thailand focused on strengthening its health workforce, a network of rural doctors leading the push for reforms. The government increased the number of doctors and nurses, raised basic salaries, and introduced incentives to attract and retain health workers. As a result of this and other factors, catastrophic health expenditures are declining. In the poorest rural northeast region of Thailand, the number of impoverished households dropped by nearly two-thirds, and as my friend, Dr. Suet, always reminds me, Thailand did this against the very loud objections of the World Bank Group. When Ethiopia launched its free universal primary care program in 2003 at its center was a network of health extension workers. These 35,000 women, 10th grade high school graduates recruited from their communities, were trained for one year and redeployed back into their communities. The latest survey data showed that child mortality fell by over a quarter, as did child stunted. For women, anemia rates fell, and contraceptive use nearly doubled, helping to reduce the total fertility rate. Our case studies show that all countries face challenges implementing complex health reforms to achieve universal health coverage. That's why we need global mechanisms such as a joint learning network through which countries can gain access to the latest experiential knowledge. The World Bank Group is now moving toward a global practice for health, nutrition, and population as a platform for supporting countries in achieving these goals. Our ambition for universal health coverage is very high, as are the ambitions of many nations. But no goal is real unless measured against an actual time-bound target. All countries need to make their universal health coverage policies and programs accountable and measurable so they can track progress and adjust as they go. In order for countries to continue learning from one another and to benchmark progress, the world needs a measurement framework that can provide a common and comparable set of metrics. That's why the World Bank and the WHO have released a joint framework for monitoring progress toward universal health coverage with two targets, one for financial protection and one for service delivery. For financial protection, the proposed target is by 2020 to reduce by half the number of people who are impoverished due to out-of-pocket health care expenses. By 2030, no one should fall into poverty because of out-of-pocket health care expenses. Snow small feet. This would mean moving from 100 million people impoverished every year now to 50 million by 2020 and then to zero by 2030. For service delivery, the proposed target is just as ambitious. Today, just 40% of the poor in developing countries have access to basic health services, such as delivering babies in a safe environment and vaccinating children. We propose that by 2030, we'll double that proportion to 80% coverage. In addition, by 2030, 80% of the poor will also have access to many other essential services, such as treatment for high blood pressure, diabetes, mental health, and injuries. This is really, really important. As an AIDS activist, we've always said that the increased investment in HIV-AIDS would lead to an improvement in health services overall, and the fact that we're now able to set targets on chronic diseases, chronic non-infectious diseases is personally very important to me, and we really need to be serious about those targets as well. We're now consulting with a wide variety of partners to work out the details for tracking these targets. The targets are very bold, but we need bold targets to close the gap on universal health coverage. Simply put, targets drive action. Without the ambitious 3x5 target for HIV, the target set by PEPFAR, I don't believe that today we'd have 10 million people in counting on antiretroviral treatment. I know all of us in this room will help nations who seek the path to universal health coverage. And while the road won't be easy, the lessons and experiences we're sharing today show that it's possible for all countries to realize this goal. Because it's possible for all nations to achieve it, let's make that an explicit goal as well. The goal of universal health coverage should be firmly embedded in the emerging post-2015 global development agenda. It's been 20 years since the landmark 1993 World Development Report on Investing in Health, which led to a generation of investments that produced dramatic achievements in global health. It's time to finish the job in this generation. But as we seek a brighter future, let's not forget the lessons of the past. Today, some say achieving universal health coverage is impossible. What I learned from the HIV AIDS fight is that individuals must stand up and advocate for doing the right thing, despite the difficulty. Ultimately, it's the duty of each of us, all of us here today, to persevere through the doubts and indifference, to educate our friends and colleagues, and to work tirelessly to find evidence-based solutions. With our moral compass as a guide and aid by dogged determination, we can provide quality health care to millions and literally billions of people. We can help them lift themselves from poverty so that they may lead healthy, productive lives, lives with dignity, equity, and opportunity. Thank you very much. Thank you very much. Dr. Kim, while we're in this transition, I also want to thank the many friends from the World Bank who've helped us with this. Tim Evans is joining us on a panel. Melanie Mayhew and Carolyn Reynolds were very helpful in putting the program together for this morning. And John Donnelly, a long-standing friend, has been very helpful. So thanks to all of you. I'd like to follow up and ask the first question around the targets that you've put out. You've put a stake in the ground. You're forcing a debate around these targets in particular. And when you went to Tokyo and did that, it was, I think, a very important moment in laying down some concrete goals. So the question, I guess, for you is, what do these mean, do you think, in practical terms? Are they aspirational or aspirational goals that are meant to catalyze? Are they ones that you then use to rally around and build an emerging consensus? How do you see those functioning in your overall plan? You know, the lessons go back to the great Jim Grant, who was the executive director of UNICEF years ago. The lesson for me was, when we began talking about a target for HIV treatment, the reason that we got it through, because my friend J.W. Lee, who was the director general of the World Health Organization, is not by nature a gambling kind of guy. But he happened to be the head of vaccines when Jim Grant was running the child survival campaign. And what he said was, before Jim Grant set the target of going from about 20 percent immunization to over 80 percent, people were fighting each other. There were all kinds of arguments. But once there was that goal, everything changed. And he said that, finally, we were the ones who were most excited. We were going into work early. We were leaving late. We had a target, and we were going for something that was concrete. And at the first meeting, when we were talking about the three-by-five target, J.W. said to the HIV team, and he was very blunt about this. And he said, I had experience with the child survival campaign. And before it was everyone hated everyone else. And so you guys in HIV, I know what's going on. Before it's these three hate those five, and those five hate those three. And now you have three-by-five. So get about the business, figure out what it would take to get there, and do all the things intervening. And J.W. was there. We had to do things like, how can we ensure that the developing countries would get access to low-cost drugs? And part of what we had to do was to put together what we called a pre-qualification process. Is that what it was, Jono? And it gave signals about Indian and Chinese drug manufacturers who are manufacturing antiretrovirals that were of good quality. So what it did was it said, if this is the goal, now we've got to go back and think about all the steps that we need to do to put it in place. And we've got to think about where we need to be at which particular time. So it just transformed a sense of urgency we had, certainly in the HIV department at WHO. But it also created a huge negative reaction. So the donors were saying, wait a minute, you didn't ask us. And then I'd always ask them, well, if we had asked you, what would you have said? And they said, oh, we were told you not to do it without question. And then at first, the ministers of health of the countries were also really angry at us. I mean, they were saying, how can you give us a target like that? This is crazy. We don't have any money. We don't have any infrastructure. This is unfair. But then what we started seeing was the simple act of every six months measuring and then publicizing to the entire world how people were doing. It just created a different kind of sense of urgency both in the countries and among all of us who are working in global health. And I think it did have an impact. And then soon, you know, three by five was first. But soon after, PEPFAR set a target, 2, 7, 10, I think it was. And there's no question that President Bush's commitment to PEPFAR was, I think, among the most if not the most important thing to happen in the struggle against HIV-AIDS. But the fact that the Global Fund was there also that we had targets, it was a different sense. And people forget that when we launched three by five, there was tremendous, what's the right word? There was tremendous controversy still about wanting to scale up at all. I mean, there was still people saying, wait a minute, this is crazy. The pendulum has shifted too far in the other direction at a time when not a single person was on treatment, right? There was this intensity of it. And when I say angrily and even ridicule, that's what it was, right? People were angry that we were talking about treating people living with HIV-AIDS. And that's a hard lesson because lots of folks have become newly converted. But that was very real at that time. And there are people in this audience, Paul Davis is sitting right there, we went through this together. It was as if people were saying, if it were possible to do, we would have done it. So why on earth are you telling us now that this can be done? And I think the lesson here is that sitting a really bold target with a clear end date, even in the face of people saying you can't do it, is precisely what communities like ours need in order to then put the whole program together. So if we're going to be at 50 million by 2020, what do we need to do? What are all the things we need to do urgently this year to get there? Thank you. I apologize to those on this side who's visioned to on so long. I'm sorry about that. That wasn't our plan, my apologies. Just following up on what you said about the experience with 3x5. So where do you expect to see the greatest resistance in controversy? And where do you expect to see the quickest gains? Well, I think there are all kinds of different forces in global health. And what I think we really have to do is bring all of the different communities, whether it's the priority diseases, the maternal and child health, I think we have to bring everyone together to say, look, there is a way for us to move forward that will allow us to deliver across all the priorities and then really work hard at finding that. I mean, one of the approaches that I've always found very powerful and we kind of forgot about it, but the great Sidney Kark wrote about community-based primary care in the 40s and 50s in South Africa. And I think we need to go back to thinking about what are the models that will work. And unfortunately, just the opposite is happening in a lot of middle-income countries. I mean, I visit so many of them and the heads of state ministers of finance ask me all the time about health care and here's the dual problem that they face. On the one hand, they see rapidly rising costs in the big cities. And at the same time, they're unable to get health care to all of the poorest. You know, it's one of the most helpful things for a politician to do to have a beautiful, shiny hospital built in their district or their state. And so that's been happening. There's been an epidemic of hospital building going on. And so when we talk about universal health coverage, what we're talking about is globally speaking, focusing on building those kinds of systems that can ensure that we reduce maternal mortality rates, that we reduce the infant mortality rates, that we provide basic primary health care. And when I was speaking with Ali Babajan, the minister of finance and deputy prime minister of Turkey, he told me that we knew we were doing the right thing in our health care reforms when the patients liked it and the doctors hated it. Now, you know, as a doctor, I have to tell you that that's the issue. I mean, that was in one large, very large middle income country. And they were telling me about how many billions of dollars they'd spent in their capital city on pet scanners and MRIs and CT scanners. He was very proud of this. And I said, you know, there's a big problem with putting all that machinery in place. And he said, well, what's that? He couldn't imagine. I said, doctors will use it. And indeed, the finance minister said, you know, my health care costs are going up so quickly. And yet I know that in the outer regions, I'm not getting health care there. So I think that the universal health care movement could potentially shift the conversation around health care to asking much more fundamental questions. We need healthy people to have growing economies. You know, incentivizing countries to build more hospitals is completely different from incentivizing countries to do everything they can to keep their people healthier. So what's the relative impact of tackling tobacco consumption versus building more fancy hospitals? I think there's no question that in many, many countries, the overall benefit of tackling tobacco consumption is going to be much more cost effective. So I think that's the conversation we have to have. We have to have it in an urgent way, as opposed to the arguments we've been having over the years, which is I'm an AIDS person. I'm a TB person. We need more money for this. We need more money for that. And what you see in many developing countries is you see the actual outcome when you have that kind of discussion. There's one infrastructure for TB and another infrastructure. I have been to villages where there's one funder that supports preventing mother-to-child transmission. They have a building in a village, another that supports testing, and they have a building in a village, another that supports treatment, and they have a village, and then the TB program has another building in the village. This is crazy. Absolutely crazy. A waste of money. And if we could have that tough conversation, the vested interests are many of us. I want to have that conversation. I think it's time to have that conversation. I think all the donor dollars that are going into global health will welcome that conversation, and the donor dollars may even increase if they feel like, oh my goodness, they're actually solving the problem. And in the end of the day, we may even bring sanity to some first world healthcare systems that are also, I think, going in the wrong direction. Man, just to ask you, you've talked about the science of delivery. You've talked about helping set targets with WHO and others and track those targets. Looking forward in the coming years, what is the bank's role going to evolve into in terms of making this work in partnership with the countries that come to you and say, yes, we are on this path and we want the bank as this technical partner? What is that going to mean in terms of your, the way the bank operates, the capacities it creates, the sort of new things that it needs to take on? Well, we do a lot of lending for health-related programs. Tim, what's the number? So we did two and a half billion a year in lending. And what we've talked about up till now was health system strengthening, right? But I don't think that our health system strengthening work was connected, for example, enough to the AIDS work, to the TV work. I think we really have been thinking about these interventions as a war between maternal and child health and priority diseases. I hope that what we can do is, because of our focus on system strengthening, that we can be part of and maybe even help to convene that discussion that says, what are the systems that we'll deliver across the priorities? Now, the reason I have such a bias in this direction is because of partners in health, those are precise systems we've been building for the past 25 years. And what we have found is that for a very low cost, utilizing community health workers and nurses intensively, and then doctors for the things that only doctors can do, that we've been able to provide very high quality, comprehensive health care at low cost. So that's the discussion we have to have, but it's hard to get people who've been advocates for their disease for so many years to, I think, be part of that discussion, but that's simply what must happen, so I hope we can help. And also with financing. Let's take two or three quick questions. Dr. Kim's gonna need to leave in about three or four minutes, so we'll gather together a couple of questions. I apologize in advance. Paul, you had your hand up, and please be very succinct, identify yourself, and we'll bundle these comments and questions together and then come back to Dr. Kim to close. So Paul. Paul Davis from HealthGap. We have microphones. There's a mic right there, please use the mic, and then we'll come over here to this gentleman. It's Paul Davis from HealthGap. Thanks to the center and to Steve for hosting this very timely event. I think that Dr. Kim, you'd know more than any that achieving these ambitious goals around universal healthcare requires a great deal of civil society mobilization. And just by way of example of AIDS groups, as we are from, they have been very active in terms of even universal healthcare. In Kenya, a few years back, PEPBAR Civil Society Groups and the National AIDS Control Council developed a really ambitious proposal to expand the National Hospital Insurance Fund, and HAF, to cover outpatient prescription services, all kinds of things, and a great deal to cover many, many more people in the informal economy. There was a lot of momentum, but it was ultimately derailed by endless court battles from the private insurers, and actually there was not a whole lot of faith on the part of workers and unions that the government had the ability to deliver, very understandable, but probably incorrect in this case. So, I guess my question is, will the World Bank Explorer program to increase support for civil society front line patient advocacy to help demand universal healthcare, to demand and win universal healthcare, how will we get the right to health without civil society? Thank you. Over here. Yes, Fernando Zacarias, Global Health International Advisors. Dr. Kim, I was the head of the AIDS program for 20 years for the Pan American Health Organization, and I was really impressed by the mention you made to HIV AIDS. I have one question for you. In the case of AIDS, we started with prevention, and then we moved to several other strategies, ending up in 96 with initiative of three by five. My question is, when you attack poverty, we know very well the link between health and poverty. Are you going to start with primary prevention of poverty? What are the causes of poverty, secondary prevention and tertiary prevention? The reason I'm asking you is because of the ambitious goals of by 2020 and 2030. And are you going to start with the people on the brink of poverty, or are you going to start from the bottom? What is going to be the strategy? Thank you. Thank you. I apologize to those who have questions. We're running out of time. I probably have like five to six more minutes. So should I take these and then take one? We'll take one more set. Okay, look. Yes, all right. So you want to take these and we'll come back. So Paul, thanks, thanks. You know, the involvement of civil society will be critical, right? I hope that civil society gets just as active around universal health coverage. It's harder because it's not as directly focused on a single problem or a single disease, but it's important. Now for the World Bank Group, we have traditionally never provided funds for advocacy for civil society organizations until two years ago in which we started the Global Program in Social Accountability. Now, you know, we are governed by member states, 188 member states. And these member countries have extremely varying views of the importance of civil society, right? And so in that context, to be able to get this program started, I think was a great victory. And this was really Bob Zelik that did that. So now that we have the GPSA, it's starting. The things that we are doing for our own work is that we move from a very low percentage of our projects that have direct beneficiary feedback, civil society feedback, to a target of 100% feedback. So that in itself is very important and a step forward. And the GPSA we think is a good step forward, right? Poverty prevention. So we actually know a lot about how people were lifted out of poverty since 1991. It's been the most rapid eradication movement in poverty for years. And we actually know pretty much how it happened. Two thirds were based on economic growth and about a third on redistributive properties. So it is still critically important for us to find paths toward inclusive growth. And what that means, I mean, for the first time in history, we are measuring inequality. Some say indirectly, but we're measuring the income growth of the bottom 40% of the population. It's the first time that we have done this explicitly. And it's also one of our targets. So economic growth is critical. But what we know is that if you ignore the bottom 40%, you are likely building instability into your society. We've seen this all over the world. I mean, where did they have relatively high growth rates with very little inclusion? This was the Arab Spring. I mean, this was one of the reasons the Arab Spring happened. And I think leaders all over the world understand that you really gotta pay attention to ensuring that the poorest participate in growth. So that's one part of it. Another part of it is just job creation. The best way to lift a person out of poverty is jobs. 95%, 90 to 95% of all jobs are created in the private sector. So we have very important, for us, extremely important efforts to make sure that both public and private investments are focused in a way that it will have a development impact. The reason we have a private sector arm because the private sector is so important in ending poverty. For us, it's not a question of whether you embrace or not embrace the private sector. The question is what your aspirations are for poor people. Infrastructure needs in the BRICS countries alone are about four and a half trillion dollars over the next five years. All of official development assistance is about 130 billion. And you add on private foundations and the like, it's another 25 to 30%. There is no way that aid is going to solve the problem of poverty in the world. So we've got to find great strategies to bring public and private monies together to create the jobs that will lift people out of poverty. That's how it works. Now, we're involved in all of those schemes. And so, for example, in Africa, Nigeria, fast growing country, Jim O'Neill has made them one of the mints, Mexico, Indonesia, Nigeria, and Turkey. Fast growing economies. But they only have 20% of the energy they need for their population. How are you gonna grow if you only have 20% of the energy? So we work on energy. In the Great Lakes region, we're gonna work on energy. There are things that you have to do to set the foundations for that two thirds. But then the one third is investments in people, health, education, social protection programs. And of course, we're very involved in all of those areas. And in healthcare, we think that there is so much money on the table. I mean, for Tim and Arielle and I, 15 years ago, to imagine that there would be billions, 18 billion just for HIV, total, we never would have imagined that we'd have that kind of money. And so I think it's imperative for us to say, okay, thank you so much. We're gonna now get busy to make sure that every single dollar is spent in the most effective way and that we'll have spillover effects for people suffering from the widest variety of medical problems. Okay, let's take two more questions. There's a woman in the back here and then in the front. Yes, please take the microphone. Please identify yourself and be succinct. Jill Gay, what works for association? My question is how your renewed focus on primary healthcare is gonna impact access to emergency obstetric care. Thank you. Rick Burzon with the NIH, although I'm not asking this on behalf of the NIH, thank you very much for your talk. We've met at AIDS meetings before. The question really has to do with the next controversy in healthcare which is likely to be the issue of drug pricing. With the understanding that Big Pharma is funding this meeting and I worked for the pharmaceutical industry for a dozen years myself, I wanna better understand your thoughts and the bank's thoughts on as we move, as we transition from infectious diseases to chronic diseases and so many more drugs will be needed in developing countries. If the bank has given this some thought and what programs you might have that you were thinking of moving forward. Okay, great. So a couple of quick things. First of all, I think that access to emergency obstetric care is a critical part of the objectives. I mean, maternal mortality is something that I think the world has embraced in thankfully and finally we see the rates of maternal mortality going down more recently. You know, at Partners in Health, we've always thought of emergency obstetric care as part of what we need to offer in primary healthcare. Now how that discussion goes, I'm not sure but one of the things we know is that reducing maternal mortality is as much a question of logistics as it is about healthcare. So my own personal view is that I think that with the commitment to maternal mortality that's completely understandable and something that I embrace that we've gotta figure out ways of ensuring that emergency obstetric care is part of the formula. And in terms of drug prices, you know, this is, I both have a lot of bruises from battles with various industries and players but I've also been the huge beneficiary of the generosity of the research-based pharmaceutical industry and so I think if you look at the history of all donations to good causes, you know, the research-based pharmaceutical industry is way up there in terms of how much they have contributed to these efforts. Now, you know, it didn't start off that easily but let me just tell you, we would never have been able to scale up our approach to drug resistant tuberculosis without the help of Lillian Company. I mean, Lillian Company invested over $100 million themselves in helping us get these drugs made. And, you know, despite the controversies at first, many of the research-based industry that are making antiretrovirals have come around into a partnership that I think has worked. And so I, you know, these are always difficult discussions and I think you can expect the patent holders to always take a tough line. But what I have witnessed in, you know, 20-some years of working on this, is that over time, despite difficulties, we've come to a place where we have reached agreement and we've been able to dramatically improve the outcomes of people living with these diseases. And I just have to say, you know, we had a lot of very, what's the right word, you know, there were a lot of hopes that a non-private sector-based approach to developing new drugs for the so-called orphan diseases would work. But, you know, I'm an MDRTB guy and so far, it's been going pretty slowly. And in malaria, again, it's going pretty slowly. And look at the number of antiretrovirals we have. It's related to the fact that there are about 2.5 million people living with HIV in wealthy countries. So, market mechanisms are really important in getting new drugs made. The industry is a critically important part of the solutions we want to find. And I think the important thing is just engage intensively, engage early, and try to move as we have in a direction where drugs are available for the poorest. Thank you so much. Please join me in thanking Dr. Kim. We're going to transition right away into our first panel. It'll take just a minute or two to swap out some equipment and get a few chairs up and I'd invite the panelists, Ariel, Johnno, Tim, Gina to come forward, please.