 Good afternoon. I'm Steve Morrison from CSIS, and welcome to this very nice event here this afternoon. Happy holiday to everyone, and I'm sure you're happy to be back at work. We're thrilled today and honored to be able to host Dr. Ariel Pablos-Mendes from USAID, the Assistant Administrator for the Global Health Bureau at the U.S. Agency for International Development. He's come here today several months now into that post. The President nominated him back in March. He took up his duties in August, and he's been very busy since then. And from the early days when Ariel began, we had hoped we could get him here to CSIS at the right moment to speak to this audience here and beyond to the thinking and the direction that thinking has been moving within USAID on the global health key of global health issues before the Bureau as it refines and strengthens its own capacities and its own leadership role in moving forward U.S. interests in global health. And that's what Ariel's agreed to do here today, and we're really honored and thrilled that you've done that, Ariel, and thank you so much, and we're very pleased at the staff support that we've received from AID in pulling this event together. Ariel comes from a very distinguished career of almost 13 years at the Rockefeller Foundation, where he really became the dominant personality and leader there across a broad range of issues around research, public-private partnerships and research in diseases of poverty, very instrumental, very integral in defining the Foundation's approaches on AIDS care in Africa. And, of course, the Foundation became a global leader in taking on the health workforce issues, the Joint Learning Initiative on Human Resources for Health. He is an internist, a professor, has been a professor for many years at Columbia University, a professor of clinical medicine and epidemiology. And I think that there's a point that many people have made upon his arrival at AID. We did, the Obama administration did very well in succeeding and enlisting Ariel to come and take on this job at this particular moment in time, and we're all very fortunate. So please join me in welcoming Ariel Pablos Mendes. Thank you. Thank you all. And it's great to see so many friends and all colleagues and new colleagues who allow me to be standing here before you. I'm very pleased to be here to share my perspective in global health in the context of USAID's emerging strategic framework. I want to start by thanking CSIS and Steve pointed out we've been trying to find a time to do this and this is a good time for hosting this forum, and I want to thank you all for joining in as well. Earlier this month USAID celebrated its 50th anniversary. We were just sharing that it's also CSIS 50th anniversary, so happy birthday Steve. President Kennedy founded the United States Agency for International Development on the belief that all people deserve a decent way of life and that peace can be fostered through development. Over the past 50 years the world indeed has experienced a peaceful revolution of hope and human progress. This process has also contributed to our own nation's peace and prosperity. Dozens of new democracies came into existence. The Green Revolution saved billions from hunger. Global poverty rates fell and global literacy grew by 60%. The rates of child mortality have declined by nearly 70%, with more than 50 million lives saved in the last 20 years alone, children who otherwise would have died. And the hopelessness brought on by the AIDS epidemic has greatly diminished, particularly in a continent where there was an implosion of hope. Future generations will look back at this period as a turning point in the history of public health, and one could say in the history of civilization. USAID's contribution to this success has enjoyed bipartisan political support, the engagement of multiple US government agencies, and the participation of civil society and the private sector. The American people and their partners can and should feel very proud of the part they played in achieving these extraordinary accomplishments. Nevertheless, preventable disease and premature death continue to plague much of the developing world, particularly affecting poor women and children. Of the 7.5 million children under five years of age that died last year, two-thirds of the deaths were easily preventable. One of every three children in the developing world suffers from stunting due to chronic malnutrition, which often results in needless deaths. For those who do not perish, malnutrition cripples opportunities and condemns young lives to learn and to earn much less than otherwise. Women in developing countries are more than a hundred times more likely to die from pregnancy-related complications than women in the developed world. More than 215 million women have an unmet need for voluntary family planning. HIV and AIDS-related diseases continue to kill more people in Africa than any other disease, and neglected tropical diseases affect over one billion people worldwide. Our job is far from done, and our bodies are indeed not growing. But for those of you who may doubt that we will see change on a revolutionary scale in our lifetimes, I challenge your wisdom. I believe there are indications that we are closer than ever before to narrowing the gap between our ideals and the reality of our time. Today, I will introduce USAID's strategic framework for global health. The next chapter of USAID's efforts in global health will build on the strong foundation of prior success. The blueprint will ensure we are better able to adapt to changing realities and challenges which are sure to present themselves in the years ahead. Our strategic framework itself is not new. It is driven by the vision of President Obama's Global Health Initiative, the direction articulated by Administrator Shah in his Barms Lectures to the NIH Scientific Community early this year, and reflects our agency reforms efforts called USAID Forward. The actual document is being circulated among U.S. government agencies at the moment. I hope to share with you some of the highlights and engage your views actively. I will begin my presentation by touching on the U.S. government context in which this strategy has been developed over the last two years. We are guided by a dynamic and complex set of national policies, directives, initiatives, and other factors that influence USAID operations into a cohesive approach that will guide a more strategic global health response. Secondly, I will outline how our strategy fits with the ever-changing global health landscape. The world is changing. We must have an improved understanding of the forces that directly and indirectly influence our ability to fulfill our mission, our shared mission. And thirdly, I will discuss our priorities and the way forward. With a solid foundation of success, we are poised to make significant impacts on maternal health and child survival. We will march with conviction on what has been a long road towards an eighth-free generation, while maintaining progress against a host of other infectious diseases. To do so, we need to challenge the world and ourselves, and we will need to adjust the way we work. U.S. efforts in global health are heavily influenced by our international commitments and consensus around the Millennium Development Goals, the Paris Declaration, and the Accra Gender for Action, and more being discussed today in Busan. The structure of U.S. assistance is also guided by a number of national policies, presidential initiatives, principles, and guidelines. In May 2010, President Obama issued a national security strategy that recognized development as a central pillar of our national security capacity. In September of last year, through the first ever Presidential Policy Directive on Global Development, the President outlined high-level principles and called for a new approach to international development. Further, and it's almost its first anniversary, Secretary of State Hillary Clinton issued a quadrennial diplomacy and development review, an unprecedented joint review of the mandates and capabilities of the Department of State and USAID to ensure that these core elements of American civilian power work in tandem. USAID's strategic vision is inspired and aligned with the principles and goals of President Obama's Global Health Initiative and the recently released USAID's Policy Framework 2011-2015, which is making operational USAID forward reforms in our agency. As Administrator Shah has remarked, USAID is aggressively doing its part to usher in a new era. Through procurement reform, talent management, better policy capacity, and a focus on innovation and results, USAID is undergoing an ambitious transformation of the way we do business, something recognized this year by an independent OECD peer review. USAID's strategic vision is guided by the principles and goals outlined in the GHI. Since the launch of the GHI in May 2009, significant progress has been made towards a more comprehensive global health strategy for America. After some initial bumps on the road, GHI is now fostering greater interagency coordination, country ownership, and smart service integration while aligning previous health initiatives for greater efficiency, namely the President's Malaria Initiative and the President's Emergency Plan for AIDS Relief. Portfolio reviews across each of our global priorities have opened up our thinking to external participation, while 42 GHI country strategies are either completed or in development and integrating USG programs across health for improved collaboration and efficiencies. The GHI's principles, which really bring to life the GHI, are now being operationalized and after some consultations will be systematically implemented by US government teams on the ground. On to the changing landscape. Many things are changing in our global health space, far beyond the Beltway and our national borders. The rapidly evolving nature of our sector and its context will require a large degree of flexibility, innovation, and even greater collaboration in the global health community in the years ahead. USAID is prepared for those changes and is engaging proactively to meet those challenges. The epidemiologic transition by product of our success to date in child survival and family planning is manifesting itself with a pandemic of chronic noncommunicable diseases like cancer, diabetes, and cardiopulmonary disease and concerns over road safety are bound to grow. These strengths will require attention and progressive adjustments in our work, even if we cannot launch a whole new platform today. But there are other more contextual developments and we all know that context is paramount to better health. I would like to take this opportunity to emphasize what I call the economic transition of health. Despite the economic slowdown in OECD countries, developing countries are in the midst of an unprecedented economic expansion driven by better governance, globalization of trade and technology, and the demographic dividend. The demographic dividend itself is brought about by family planning and child survival success in combination with rising girls' education. For families and nations, fewer children per woman translate to significant savings while the demographic pyramid gets an expansion of its working age segment further strengthened by empowered women during the workforce. This demographic dividend adds one to two percentage points to the GDP growth of a country for a period of 30 years or more. We have seen this scenario unfolding in Latin America. And more recently, Asia. It is just beginning in Africa and elsewhere. Today, the world's economy is 500% larger than it was when USAID started. Persistent inequality is notwithstanding. That's more than twice the growth of the population. So GDP per capita in the world has been growing at a presidential rate historically. Countries that were once aid recipients are now amongst our major trading partners, as well as participants in a new emerging aid scape. For many countries, from India to Nigeria to Philippines and Uzbekistan, the $50 per capita cost of a basic healthcare package represents 10% or less of the additional per capita income growth projected between 2009 and 2012. How do these developments affect health in those countries? How should we adjust to these shifting patterns of economic growth? If experience elsewhere holds truth, these countries will invest proceeds from growth disproportionately in health. There's a very tight correlation between total health expenditure and GDP of countries. By the end of this decade, domestic health spending may double in many of USAID partner countries. Yet, the default of this growth in the health sector tends to be an expansion of unregulated private provision and out-of-pocket payments, which now accounts for 50 to 80% of the total health expenditure in Africa and in Asia according to the national health accounts. Such default leads to inequitable access and catastrophic expenditures across all health conditions, old and new, as noted in last year's World Health Report, every year 100 million people are pushed back into poverty defeating development by health bills, because they like prepaid risk pool schemes. This cannot be the future of health, especially when growing economies should afford better health for all without families going bankrupt. How do we turn this challenge into an opportunity? At USAID, we are exploring how we can support health financing reform to extend coverage and decrease out-of-pocket expenditure. It's their own money. It can be spent better. We're feasible. We will discuss how we can crowd in local investments of governments and even private sector. Unlike others, we are in discussions with BRIC countries and other emerging economic powerhouses as strategic partners and donors. This brings me to my final point. Our five-year success will be measured by our contributions to saving lives among the poor and vulnerable, particularly mothers and children, strengthening health systems and technological innovation, and by inclusive leadership in global health and international development. The global health portfolio at USAID spans many crucial areas for the health of poor people, from family planning to tuberculosis control. A core belief of the Global Health Initiative reflected in the strategic framework is that improving the health of mothers and children and realizing an ACE-free generation are areas that have a great potential for impact. Earlier this month, Secretary Clinton outlined a vision to accelerate the decline of HIV infections by maximizing preventive interventions like PMTCT, voluntary medical circumcision, and treatment as prevention, as supported by new scientific studies. As the number of new HIV infections falls below the number of deaths from HIV, the AIDS epidemic will enter a period of self-reforcing decline. Since our programs account for most of PEPFAR's work in countries, USAID will contribute to this ambitious yet achievable goal working with CDC and many other agencies and partners. The current budget environment will require us to do work with even greater efficiency and lower cost, while engaging new partnerships and fostering country ownership for sustainability. As I've said before, we cannot solve the challenges of our time unless we solve them together. This challenge for collective action goes beyond combating a single disease. Child survival is a paramount priority for the U.S. government. It is at the heart of USAID's work and cuts across many of our elements, from nutrition to PMTCT to malaria control and immunization, to the growing challenge around birth itself. For those of you who are mothers and fathers, I know at times you have put yourself in the shoes of the people we were to help. As Vice President Biden put it at USAID 15th anniversary celebration, imagine what it feels like to be stripped of your dignity because you can look your child in the eye and know that you will be able to provide for that child's needs. The world agrees that no child should die when it can be avoided. The very idea of a child dying from an easily preventable cause is today a foreign concept for most American families. I believe it is our duty to bring this reality home to every American, both the great achievements to date and the remaining challenges. It is to such an understanding that we will be able to maintain strong support for the work we all do. GSI's emphasis on collaboration, innovation and integration will greatly facilitate our efforts to accelerate the decline of under five mortality. Dreaming of the day when differences between rich and poor countries will disappear and it's not far, the experiences that we have in Europe a hundred years ago have been pretty much replicated in the last 20 years around the world. We are close. A ministeria, a champion of this vision will share more of it at an upcoming CSIS forum and immunizations on December 9th. Beyond specific diseases or age groups, GSI also challenges the world and ourselves to work in new ways. USAID's mission in global health, aligned with GSI's principles and USAID policy framework, focuses on the following, providing technical leadership in responding to global health challenges, partnering strategically with a wide range of actors, accelerating the development and introduction of innovative technologies, scaling up evidence-based and locally adapted health solutions, strengthening local health systems, promoting gender equality and working efficiently as effective stewards of public trust. Many of you are familiar with the Preston curve, those who are in public health, that plots the health outcomes against gross domestic product for all countries over several decades. That graph shows the richer countries do better than poorer ones. But also the recent decades have delivered better health outcomes for the same level of income. This actually has been attributed to knowledge, science, technology, local capacity. While development moves the curves along the GDP line, our work ratchets those curves up. As others have put it, it's not only about more money for health, but more health for the money. To support our mission, we are harnessing the technical excellence of our staff in implementation science. How do we adapt, scale and sustain solutions? We are also strengthening our country's support, monitoring and evaluation and communications functions. And we are strengthening our work in health systems as well as in technology and innovation. USAID has a long tradition of supporting technology for development, and Administrator Shah has endorsed a new platform for science, technology and innovation. Efficiency will be more important than ever to continue to deliver on health equity. Public prior partnerships supported by USAID are yielding novel vaccines and short treatments for tuberculosis. In the last decade alone, USAID has formed more than 900 alliances for greater health impact. And we will continue to test innovative models such as crowdsourcing and impact investments to better deliver on our mission. We are also leveraging the potential of ICT, information technology for global health. From 2006 to 2011, the number of mobile phone subscriptions in the developing world soared from 1.6 billion to 4.6 billion. The growth in Africa has been particularly dramatic. What this will mean for global health is only now starting to come into focus. USAID is committed to leveraging the power of the mobile revolution to improve the lives of women and their families. The agency will also harness the economic transition of health, referred to earlier. This new paradigm calls for greater capacity for national stewardship of mixed public-private health systems, as well as modernizing health financing for greater efficiency and equity. For this purpose, we will strengthen our health systems platforms in the agency. We are fostering greater country support through a dedicated office, geared to operationalize the principles of the Global Health Initiative on the ground, including greater integration, country ownership, accountability, and sustainability. Where economic development and our programs are successful, we will also work towards a progressive transition to independence from foreign aid, as we have done recently in several missions to Latin America and Eastern Europe. USAID has left about 30 countries in its history, so we are not meant to be there forever. To conclude, investment in global health are a pillar of American leadership, advancing our national interests, making other countries more stable, and the U.S. more secure. They are a fundamental expression of our values. We have an impressive brain trust in our global health community, and I am proud of the talent and the dedication of our diverse USAID staff, as are we of the collaboration with countless partners in the U.S. and abroad. We have made incredible progress in international development and global health in recent decades, and a crop of recent demographic health service results give pose for optimism. We can now imagine near-zero deaths among children and mothers, as well as an AIDS-free generation. The budget environment notwithstanding the President's policy directive, the QDDR, and USAID Forward and the Global Health Initiative position us to maintain momentum and move forward with game-changing innovations and better health systems as countries write this economic transition of health. President Kennedy once said, the conquest of poverty is as difficult if not more difficult than the conquest of outer space. His vision to reach the moon took a decade to be realized. Beyond the technological feat, that achievement crystallized a sense that humans are all together in this universe. I have to believe that if we can develop technologies capable of sending men into orbit, we can find ways to deliver better health right here on Earth. The fact is we only have this small planet, and collectively we share the responsibility to ensure that every man, woman, and child is provided with an opportunity to live and to succeed. Given the trajectory of recent decades, I'm optimistic we can realize the founding vision of President Kennedy and complete in our lifetime a peaceful revolution of human progress and health for all. Thank you all very much. Thank you very much, Ariel, for that eloquent presentation. We'll turn to our audience in a few minutes and request some quick comments and questions for Ariel. We also have received a number of questions from folks online, and we're joined by a few hundred people who are able to watch this, and I'll turn to those. Some of those questions, there's quite a bit of commonality across some of the submissions. Let me turn to some of the sort of tougher issues that are out there today for all agencies that are involved in contributing to development and global health. Obviously, the budget uncertainty is acute, and last week we saw the outcome of the Global Fund Accra board meeting, the admission that a $2.2 billion shortfall and pledged contributions, fully a third of the funds that had been pledged, and an inability really to make new commitments for the next two years and hopefully reorder some of those resources to keep sort of the emergency and immediate life sustaining commitments alive in their core countries. For us as a country here in terms of our bilateral budgets, clearly we're living still in the midst of considerable uncertainty and angst about what will happen in this period, but it's fair to say that the resource base, the foundational resource base is going to at best be flat and more likely than not be dropping in this next phase, how badly is to be determined. In your view, as you look at this uncertainty, and we know that development and global health have been the subject of a lot of speechmaking lately around the value and the achievements and the need to preserve those, but I think also the pressures are going to build inevitably upon all of the agencies like yourselves to pick your spots and to protect your vital interest and pick your spots in this next period, which makes for uncomfortable kind of decision making, but it's one that the global fund was forced into doing just most recently in saying, okay, these are the things we can and cannot do, these are the things that are most vital in moving forward. Given the span of things that you talked about just a moment ago in terms of the core agenda of AID, how do you begin to prioritize and communicate to an American public about what the core vital pieces of those are that as we head into the tough headwinds of declining budgets, how do you respond to that challenge, which I think is inevitable and going to be with us for this next period? Thank you, Steve. It is the case that the economy has not been what we would like it to be, and budgets are being reviewed, and we are working with our colleagues in Congress, with our colleagues in the administration. I think in general these scenario people would like to protect, but also we are sensitive to the fact that cuts are being discussed as we speak. So how do we go about making choices? I think what I have stated here and has been studied by the U.S. Administration to the Global Health Initiative is we are focusing on saving lives of mothers and children. There are many specific areas that can accomplish that, and we are looking at which combinations can achieve the best value for the money. We are committed to our work on AIDS, and that remains, and there has been a lot of success and a lot of efficiency gains, as you all know, and we want to carry on that while maximizing prevention. We believe key for the future is to ensure prevention is maximized. Treatment as prevention is part of that equation, but PMTCT and circumcision among others are paramount. So those are the areas, but as the GHI itself also guides, we need to change the way we work. And for us, that means not only a greater emphasis on technology and innovation, but also a greater emphasis on health systems strengthening and working different with partners in the private sector, but also with the governments that we serve. Those are the areas in which we are putting our emphasis. The Global Fund is a pivotal entity, and we all share concerns over recent developments at the Global Fund. The rounds strategy approach to funding is evolving into a more flexible way to respond to country needs, and so the idea of having a round to specify this may not be anymore. General Manager has been added to the equation to make sure that all of the recommendations of the Board and recent reviews will be implemented. And we are working, of course, with PEPFAR and others to maintain our commitments to the fund. The fund is very important to align our work with and to leverage three-to-one other governments and other donors into the causes that we spouse. It was about a year ago that the Quadrennial Development and Diplomacy Review, the QDDR, was completed, and the decision taken to call upon AID to take a larger role as a leader and a convening leader, but also a technical and managerial leader in respect to global health programs and to prove its value and its ability to do more in those areas looking forward. Can you talk a little bit about where we are in that process? Because there were some general benchmarks established. There were groups created to try and refine the indicators, but most importantly was really to begin to substantiate and prove the case that AID was moving forward in this respect and demonstrating its proven capacity and leadership and taking on more and more responsibility. Can you talk a bit about what has happened and what lies ahead in this? Because I think that's very fundamental to the future, the outcome of that process of deliberation. It's very fundamental to the future of the Bureau and of the agency's ability to carry forward on the mothers and children and the AIDS-free generation and the other pieces that you talk about. Thanks, Steve. Well, it is indeed a very important issue. It's almost a year, and USAID has been moving all along. I want to recognize Amy Batson, who is our senior deputy, who has indeed been driving a lot of the work in this benchmarking process over the last 12 months or so. Basically, a lot of progress has been made, a lot of well-documented exercises from the interagency portfolio reviews to the integrated country strategies to better communications. All of those pieces are actually coming along very well. It just happens to be the case that Luis Cuam joined us, Executive Director of the GHI, only this year. And there were many things to pay attention to from the strategy, getting us all aligned in the same direction and so on. And the State Department is only now moving on really validating the process that we have put in place early this year. And there's a consultant that is working with the State Department with the Operations Committee. And we expect to have an interim report to the Secretary this January so that although the timeline that was specified by the QDDR is September of 2012, we hope to have significant progress reports for the Secretary whose decision will be made, will be to decide when and how the GHI will transition. Thank you. Of the questions that came in from our folks online, there were at least four different questions that approached the issue of nutrition. And there was another two that raised the question around water, sanitation, and hygiene. And I think what prompted those questions is the realization that of course USAID plays a very important role in those other areas. And as you lay out your health framework and your strategy, the question that's coming forward is can you explain how that will involve AID's linkages and contributions in the nutrition, water, and sanitation areas as well? Thanks. As you know, nutrition has always been a very important pillar of the work of USAID. And when it comes to child survival, we know it cuts across almost all of the conditions that end up making kids vulnerable to the diseases that kill them. And for that reason, we are very much devoted to, and this has been a great partnership process in the last year or so on nutrition and the scaling up nutrition. And our work on nutrition, which has a lot to do with supplements and micronutrients and so on, is very much aligned with the President's Feed the Future initiative that is also hosted in USAID. So there's a lot more there on the food security, on the production and supply side, but working quite closely with us. The intention is to make sure that all kids in the first 1,000 years of life from up to the second birthday will have appropriate nutrition for the reasons we said before. Some others will actually add that feeding, providing food security and good nutrition in those first 1,000-year days of life will then also help preempt an adult risk of obesity and related conditions. So we believe it's a very important area for our work. Water and sanitation, hygiene has always been also a key point of action for USAID and like nutrition, it builds on the work that is done across the rest of the agency. There's a lot of heavier lifting on the provision of water and sanitation access to communities. We are focused being more on hygiene and drinking water and again, those are essential for the child survival goals that we have noted earlier. Thank you. I want to invite some comments and questions from the audience. Please, what we'll do is we'll bring some microphones over. We'll start here. What we'll do is take three or four quick comments and questions. Please identify yourself. There are three hands up here. Matt, if you could, and we'll, and if you could identify yourself and offer a quick comment or question, I apologize that the podium here blocks your view a bit. Please. Yes, I'll stand up. My name is Michelle Forsley. I'm a professor of global health law at Widener School of Law in Wilmington, Delaware, and work in the field of health sector reform, anti-corruption, pharmaceutical supply, medicines access, et cetera. One of my observations over the last 15 years has been in this field coming from a field of just practicing law to a field of combining my role as a lawyer with that of public health in the global arena is that lawyers are not active participants in the work that you do. They're certainly in the corporate offices of USAID and the World Bank and in the World Health Organization and in other development organizations, but they don't seem to be in the field. And from my observation and experience, there are many times when the interventions that USAID and others try to implement are limited by the lack of analysis and understanding of the wider legal infrastructure that may have relevance to your desired outcome. I mentor students and I run an externship program in global health and the law, and I have to ask myself sometimes, where are these young bright minds going to go? Whether they're U.S. students or foreign students, they come from all over the world. And I'd like to invite you, sir, to consider having the presentation we did last week at the World Bank on law justice and development where we demonstrated the variety of ways in which lawyers and law have been highly relevant to the outcomes. And that includes the World Justice Project, the Rule of Law Index, very much connected to economic outcomes. If Rule of Law is important to economic outcomes, then therefore it's important to health. I'd like to hear your thoughts on that and how we might bring in this extra army. Thank you. And the row right behind, Matt. Please identify yourself and offer a quick comment. Thank you. Juan Manuel Sotelo, PAHO WHO. Congratulations, Ariel. Excellent presentation. Two things I would like from you. You made a comment on partnerships, and we are talking about global health. I would like your comments on how do you see a multilateral approach, for instance. How is WHO and PAHO in this region of the world participating in the strategy? And my second matter is related to how does Latin America and the Caribbean show in the global map of USAID in your strategy? I'm Bob Hershey. I'm a consultant. You had mentioned the Internet and your work, and I wonder how it might be used to get together the communities you're working with and gather private funding and get transparency on some of these projects. Thank you. Do we have any other folks who'd like to join in? There's a woman right here. Seth, right here. Thank you. Nula Moore with American Thoracic Society. I wonder if you can address USAID's goals for tuberculosis control, particularly the need to scale up addressing multi-drug-resistant TB. Thanks. Thank you. So why don't we come back to Arielle? We've got these four questions on the table, and those of you who would like to join in for the next round, please do. Thank you, Arielle. Thank you. To Michelle, as a public health person, I remember beginning to learn from business people and lawyers and economists, we need to engage all of those disciplines and communities in our work. We have done a lot of that over the years, and USAID has been leading in so many ways. Our work in the agency beyond our Bureau on Democracy and Governance is paramount, as you all know. And I've also made a solution to the fact that reform will be important, and the law is crucial to provide clarity and guidance to governments and society. Nigeria, for example, with clear legislation, allowed the private sector to emerge with almost 40 HMOs in Nigeria that are providing services and respooling and so on. Again, so the legislation will be important in health systems going forward. It's not just the community work, but especially those countries mature. The way for us to imprint a sustainable and equitable future will have to involve legislation. So health system reform is the space where I will see some of that. On WTO partnerships and multilaterals, of course we are committed, as you know, the US government in so many ways to the multilateral space, especially in leveraging many of the strengths that technical agencies like WTO have in providing normative guidance, technical assistance, and so on, and working always in tandem with ourselves. We were very closely with WTO, as you know, in terms of making sure we agree and we support the development of guidelines for countries and then we help align the implementation. Latin America and the Caribbean is indeed a place where an icon originally from Mexico where the economic transition has been taking place. And so whether it's Brazil or Mexico or Argentina or Chile, you have to imagine that the world is changing there and that's our role in terms of assistance has also evolved. We still are committed to, of course, the region and Haiti is one such an example more recently of our commitment to the region. The internet, well, we don't need to say much. The internet is out there, everybody's using it. So whether it is for sharing ideas, forming groups, getting resources, the number of possibilities are huge. E-learning and increasingly we are also leveraging through cell phones for many other areas, whether it's electronic records, making sure pregnancies are followed closely or early childhood immunizations also. The IT space is just all over us and in USAID is doing a lot just on mobile health. We have over 70 projects out of a global portfolio in headquarters plus those that our countries are engaging. And we are now developing a strategy for eHealth to bring a cohesive intelligence as to what we do in a very important new space for health and development. Tuberculosis, as some of you may know, I come from the tuberculosis community. That was my original work in MDRTB. So I care a lot for this space. I think that we have witnessed a very successful period in the last 20 years globally and MDRTB remains a great concern and so we know that in addition to the taking and treating MDRTB we must ensure good dose programs are in place to prevent, which is a lot cheaper, MDRTB. So this is a very important area. We work a lot with WHO in supporting the dose programs at WHO, but it's an area that is vulnerable, no doubt, in terms of our priorities on child survival that we have stated before. Yet through MDRTB and through the HIV interactions we are trying to remain supportive of our work in tuberculosis. Thank you. We have a hand up right here and two down in front. Yes, please. Hi, doc. Mendez, thank you for your extra presentation. Please speak up a bit. My name is Nana Sangbende and I am with the UN Foundation. I work a lot on maternal and newborn health and when I realize, if you look at the UN MDGs, four and five, which suppose to focus on child health and maternal health, they bypass what is supposed to be the critical issue or how to achieve this, to address this issue. And what you said with your presentation, what stuck with me was that USID works to save children and mothers. So I wonder what kind of program do you have that actually address family planning and reproductive health, to help to achieve this objective? Thank you. Good afternoon, I'm Mi-Lan Huynh. I'm the director of the Air Force International Health Specialist Program. And as you know, when we work with partner nation militaries, we've had partnered with USAID in the past in areas like pandemic influenza preparedness and HIV prevention. And you mentioned health system in your presentation and our experience with working with other nations is that in their health system, there's really no barriers between the military health system and the civilian health sector. And as we go forth in terms of partners, I wonder what you see would be sort of the military medical role in assisting USID. Hi, my name is Paul Emer. I was a career Foreign Service Officer with AID for many, many years, a health officer. And I'm now working with a group based in the U.K. called HLSP, which has done a lot of work with health systems. I just have a question. I'm very supportive of your comments about kind of going back again toward a focus on maternal and child health. I will point out though that in the mid-80s, AID focused on a very important child survival program as well, which then kind of dissolved out. And I'm just wondering now, given the importance of the health system stuff that you've talked about and moving back toward a focus on child survival and maternal health, how are you going to make this transition between a disease-oriented approach which has been relatively successful with PEPFAR and PMI into a more horizontal, kind of broader health systems approach focused on child survival and maternal health? Thank you, Paul. There's a hand right back here. Yes. Just one second, we'll get a microphone over to you, ma'am. Hello. Barbara Seligman with DAI. My question is, in view of your attention on focusing on capturing or harnessing the economic transition for health, does that change the priorities of countries in which the GHI will be working or how it will look at allocation of resources across countries? And secondly, with regard to health systems strengthening and some of the things that you suggested you might be doing differently, could you please maybe describe a few of the things you might see doing a little bit differently in that area than has been done before? Thank you. Thank you. Hello, and thank you for those great remarks. My name is Adora Iris Lee, and I am with International Relief and Development, IRD. You spoke a lot, doctor, about the relationship between poverty and health, and we all know that quite well. And I'm wondering if you could share your vision, since you are still relatively new here in Washington, but your vision of how the Global Health Initiative will incorporate economic strengthening and women's economic empowerment measures into your global health programs. Thank you. Thank you. Ariel, why don't we come back to you now? We've got five different angles. Thank you. Thank you very much. Onala, yes. MDGs four and five, the role of family planning. Just like nutrition is central to child survival, family planning is also central. About 20% of maternal deaths from unwanted pregnancies could be prevented. So family planning is important for that. It's important also for women's empowerment, which is a core principle of the GHI. And it's also important because it actually helps with the demographic dividend or economic success, although that's not the reason why we actually drive it. The military has been so important in so many ways. We work closely with the OE, not only in emergency response, but across the scope of our works. And your relationships with other militaries are also very important. And I can think of Senegal where the military were so important in helping prevent HIV taking off in that country. So we look forward to continue that relationship. There are so many dimensions to the collaboration. It's hard for me to pin it down, but clearly a referral assistance might be an area where the availability of hospital services where they are not existent in relief and other situations might be an opportunity. Paul, thanks for your work all along in this space. Yes, in the 1980s we had an emphasis on the child survival revolution. Many of you here were part of that. And the issue was sustainability. And so how do we make sure that this time all of the efforts we are making can achieve that sustainability so that indeed as ways come and go we don't have to go back. My sense is we have reached a new level in many countries now around the world, and it is in that transition where we still need to be committed to many of those vertical programs, but also countries are requiring a greater level of integration. So we are still built in a way vertically. We are still accountable to the American people through specific areas and we will probably not change that immediately. But the Global Health Initiative already has opened the door for us to talk more about country ownership. And that usually means country ownership means they are looking at all of their needs, their own priorities and so on. Health system strengthening, sustainability, all of these requires attention. So the question that was asked by Barbara, so what exactly do we do with health system strengthening? There's plenty there from gathering better evidence because it's been a field that has not had the same degree of science than other areas to communicating better. The American people need to understand exactly what it does. How expanding coverage in Ghana leads to not only safer pregnancies, but lower infant mortality. And that sort of evidence will become important because it will then support the priorities that we have again as construed vertically but by supporting countries in a more integrated fashion. So we will do a lot of technical assistance will be important. We will do a lot of technical assistance like the demographic health service have been hugely important flagship programs of UCID that allow us to understand not only ourselves but the rest of the world and the countries where things are, where things are going. So that type of evidence data capacity for stewardship of mixed systems. Many governments are still thinking that the private sector is another deal, it will go away. It's actually two thirds of the sector and how to engage constructively the private sector is very important going forward. And then finally on poverty and health well yes we have noted that I mean global health is one of the largest segments in UCID but UCID is devoted very much to development as a whole. So there are many other groups in UCID working to foster development and across the agency, across our foreign portfolio women empowerment is crucial. It's crucial for all sort of reasons but the most important because the payoff is huge, education and empowerment are huge both in terms of economic development and also in terms of health, the health of families. Thank you. I think we have time for another round. I'm going to ask one question which and then we'll turn to some of you here. We've had the chance recently to visit Ethiopia and South Africa and Zambia and there's a couple of themes that came through quite powerfully that from that trip, from those visits that one in particular that I wanted to ask you to comment on RAO and that is that enormous upsurge of pressure from the partner governments upon AID CDC, OGAC leadership to reduce the number of implementing partners that are non-governmental implementing partners, reduce them and streamline and consolidate them and move them towards away from direct service delivery and towards technical support to government organizations and move towards a greater direct funding by USAID and others of partner government institutions and from the standpoint of the government of Ethiopia or the government of South Africa this is what they understand as country ownership is higher efficiencies fewer implementing partners not saying that implementing partners don't remain very valuable but it seems to be a core right now in a court managerial challenge because you have many many many different contracts out there with implementing partners they can't just be ended overnight it's a managerial challenge it's a political challenge in terms of whether you take a huge risk of accountability if you begin direct funding of government agencies and of course there's a lot of resistance from implementing partners in terms of being basically asked to phase out their work in some of these countries I was struck by just how much turmoil and how much drama and debate is centering around that very issue and how much it really lies at AID's door as one of its key challenges if you could talk about that for a bit thank you very much in South Africa the change is more complex South Africa is sort of in the upper of that economic transition ladder and so indeed and now that the government is so committed to their own HIV AIDS programming it is allowing to change really where the priorities go so there is a change in South Africa in terms of our commitments as well as both one and other countries where success and country engagement and economic development allow us to do so but your point is a bigger point about the way in which we engage in what we call in USAID procurement and procurement reform is indeed one of the key elements of USAID forward as we look at the way in which USAID operates both the global enterprises and the country-based enterprises often there is an emergency of the two through integrated vehicles allow us to provide standardized services scale and the discounts that we get because of that integration of multiple components one very specific successful platform is our supply change management platforms for example and so there is an issue how can we change the way we do our business we also want to foster country ownership which will then mean that we should be willing to support governments that qualify in terms of transparency and capacity and so on but also local NGOs and this is not an easy transition and it's not an overnight transition but if the intention is to get more of that capacity locally so that indeed our success stick in the long term there is a change the change will not be as dramatic I mean the feasibility itself but also the concern that you may be speaking to may not be as big because I mean today maybe only 10 or 15% of our funding ends up being local and so even if we can go to 25 or 30% as part of this reform the majority of our funding will still be in a similar way but the other growth of that small part will be quite significant in many of those countries to allow local NGOs and local capacity and better governments in this space and so whether it is in the case of South Africa or Latin America when there is some transition in programs what you see is indeed our funding moves from the direct service provision and into providing technical assistance, regional coordination and that's just the reasonable path during transitions Thank you we have time for one more round of questions we had a gentleman here in the front row we have two hands here we'll take as many as we can here so please be patient Yes sir. Thank you nice talk Ariel, nice to see you just to Marcos Espinal from PAHO just to ask you and I don't know if you probably will be able to answer this question but one of the issues we're seeing is the challenges of the international community in Haiti you mentioned Haiti as a priority and there's two questions at the beginning about water and sanitation when we see all these problems about cholera about earthquake and some I mean and some NGOs going into to vaccinate you know with limited numbers these are good initiatives but I'm not going to solve the problem Haiti has probably a lot of population without lack of access to water is there any discussion going on or anything that the global health initiative of global health bureau or your role is doing with your counterpart in USAID because it's about development to improve access to water in Haiti and work with the new government Thank you Seth there are two women right there please Thank you Joan Holloway with IAPAC and I'm mentioning this because I know this is an area where you've had a lot of experience Ariel it's human resources for health and I am concerned that with the broader rubric of health system strengthening the area of human resources for health is getting lost now the private sector is taking up a real I think leadership in this with the frontline health worker coalition the goal of a million new community health workers government has to take a bigger role too and I would just like to hear what your thoughts are and how USAID can really expand and foster this Yes Kay Halpern government accountability office earlier you mentioned the austere budget environment and you gave an example as an example actually I think the moderator did the global fund and how they've had to cut back on the future grant rounds and you spoke about procurement reform and I'd like to know how the global health initiative could work with the other large donor out there the multilateral donor the global fund to leverage resources Thank you Thank you there was a hand back here a moment ago Yes right there Hi I'm Grace Chi from apt associates you had mentioned health system strengthening many times and it is identified as a key part of the global health initiative but we haven't seen a lot of very specific guidance of vision out of USAID so I was wondering if you could speak a little bit to that McEwen Hardy development finance international can you elaborate on USAID's strategy to address non-communicable diseases around the world Thank you Thank you great questions Marcus in clearly what an invitation is paramount as it's also housing and many other priorities in Haiti I mean is there's been an incredible community from the US government and the state department has been coordinating a lot of the efforts it's not as easy of course being the ground where the government was weak to begin with and half of it was almost destroyed during the pandemic very quick as you know very well but indeed what an invitation is a priority and availability at least to ensure that water may be accessible USAID has been working very much so in the last year in particular to ensure that that is the case on cholera and having many small scale vaccine and well it is an issue I mean the vaccine exceeds the supply is limited and if you're going to do it you have to do it and I know it's an area where PAHO and CDC ourselves are quite involved in and but I agree that it's probably better to have water and sanitation for the long haul and that is indeed the priority. Joey was worried about health systems swallowing human resources well human resources are the health system and from line workers to the professional service providers to I would say the policy makers in the health space there they have been also relatively neglected and they are very important. It was through the HR window that I began to understand health systems and the reason why is that the economics of the HR only makes sense when you understand the larger economics of the health sector and so what is appropriate in a poor country may not be appropriate as those countries are moving and while we all like to have a very good professional providing services in a poor setting it's a lot more efficient and I think the HR community has done a lot with PAHO and others in the touch shifting to make sure you have community-based workers in those poor areas and so on. So it is paramount and the USAID as you also know has been probably been a lead to the capacity project capacity plus in leading this space over the last almost 10 years Kenya but just how do we leverage others well that's what we try to do every day and we believe that the time is right in OECD countries you know how the situation is in Europe and although the bridge are quite courageous and coming along the Global Fund is a platform for liberation that's why it's important for us to remain to keep the Global Fund as a viable platform for engagement as well as many others the private sector many of you work in private corporations but more and more importantly will be how do we crowd back in local public and private financing for the needs of people in countries where the economics are not beginning to allow it Grace well you know health systems 2020 and so next year is up for renewal and so that will be an opportunity for a redesign of our work in health systems and there will be guidance for that coming up in NCDs again we do not have an office for NCDs NCDs is important and we are doing a few things one is we already have a lot of platforms for measurement demographic health service that are allowing us to understand the prevalence and trends of smoking of obesity so it's very little or no cost we are trying to get the dimensions demographic health services have been so important in building the stories and monitoring the intervention of success so that's a very important platform for us going forward second we are we know that in order to achieve our MDG sometimes you have to do things like advising a pregnant woman to quit smoking and that's another thing that we are doing third integrated community platforms quite often is healthy lifestyles and USAID has a lot of experience in behavioral modification or in mass communications on the whole for healthy lifestyles exercise nutrition and diet all of that lends itself already quite quite well where we are present to make a dent I mentioned nutrition the first 1000 days of life as being probably a way to pre-empt adult obesity and associated risk factors and so all of these are the pieces we are doing today we invest I mean America invest almost all of the NIH colleagues 30 billion is almost all in NCDs and the 50 or 60 billion in R&D that US pharma does is almost all NCDs and quite often food industries and other industries will be on the table for many of these conversations so NCD is going to be very important in our foreign affairs in the future and we are preparing for that future so jumping until we make sure our priorities are addressed in our current government environment thank you let me just close with one last question for you Ariel which has to do looking forward to next year we'll have the international AIDS conference the biannual global meeting will be here in Washington in July third week of July next year will be the first time in 22 years that this conference has been back on US soil the Obama administration lifted the immigrant ban the migrant and visitor ban on persons living in HIV and became possible to do this 20 to 25,000 people will be here for a full week can you talk a little bit about how you see the impact and the value of all of this for an American public that hasn't witnessed this directly on their soil for over two decades and it's going to be coming in the middle of some budgetary tough times in a very heated presidential and congressional set of races so getting the messages right will be very important and there's been a lot of deliberations about how to get the very best outcomes from this very important historic moment if you could offer us your closing thoughts on that please thank you as I noted before next year in particular we are coming out with the priorities that I stressed before for the global health initiative saving mothers saving children and AIDS free generation and each of those three will have opportunities next year you're asking about the particular one of the AIDS conference a major opportunity visibility I have to say that the US communities working in HIV all along have been very strong participants in this country and abroad so that it's not that it hadn't happened because the conference hadn't taken place here I mean I see Shelly and others who have been so involved in the work that we have done in AIDS in the last few years and so I think it's an important opportunity nonetheless because it will bring attention a lot of voices and case stories all of that will matter and at the end the work that we do is the work that the people, the American people ask us to do and to the extent they are compelled whether it's on AIDS or saving mothers and children's lives that should help the work that we do so the AIDS conference an opportunity stay tuned for the others as well Thank you very much Before we close just a reminder December 9th at the Willard Hotel from 9 a.m. to 2 p.m. we'll be staging a major conference on the strategic power of vaccines we'll have an all-star cast there the administrator of AID Rod Shaw will be delivering an address Tony Fauci will be delivering an address and we have three very high level panels I won't go into all the details but please join us either in person or online on that occasion I want to thank Barbara Bennett and her staff from AID for helping make this event happen and from our staff many people worked very hard to pull this together Suzanne Brundage, Julia Nagel Matt Fisher, Carolyn Schroht great thanks to all of you Arielle, it's been great to have you here I hope we'll have you back soon and I wish you the best of fortune in moving this very ambitious agenda forward please join me in thanking Arielle