 Hello everyone and thank you for being with us yesterday at the the United Nations Friends of Vision group, mainly launched the Vision Atlas and this Landsat Global Health Commission on Global Eye Health. This webinar targeting a global Eastern time zone will give more detailed reports of the work of the Commission. And on behalf of Professor Matthew Biden and I and the multidisciplinary group of 73 commissioners representing experiences across all regions, I welcome you all to this webinar. All who participated in the launching and the new participants, including the regional UN offices and its agencies, especially the WHO offices, the media, regional and local in print broadcast on the internet, the national government representatives, especially stakeholders in development, as we reframe eye health within development. Agencies focused on children, the elderly, are vulnerable populations living no one behind. The general health and eye health fraternity who have been and will continue to be part of this journey, donors small and large who have supported global and local eye health over the decades. And in this fast moving innovation phase tackling head on the global challenges of the pandemic and climate change, I welcome industry technology and pharmaceutical companies and in fact the entire population. It will be such a unique opportunity to share with change to discuss. And I thank everyone for attending, for participating, for later listening to the recordings, doing the advocacy and the continuing ownership, even after this webinar, we have the UN decade of action to make it happen. Thank you. Thank you, Hannah. It's lovely to be with you today. My name is Zoe Mullen. I'm the editor-in-chief of the Lancet Global Health. And it gives me great pleasure to introduce this session today on what I've certainly learned over the past two years is crucially important cross cutting issue for health and in fact development. So before we hear from the commissioners in more detail, I just wanted to give you a brief overview of what a commission is as the Lancet journals define them. So commissions are scientific reviews and inquiries into what could be an important and neglected issue. They are science-led and I can vouch for the amount of science that's gone into this report. It's international as we've heard from Hannah. It involved 25 countries amongst the commissioners. It's multidisciplinary and they tend to be focused on policy and particularly policy change and we'll be hearing about that from the speakers shortly. Practically speaking, commissions are 20,000 word reports and you can get your hands on a printed copy of those at some point in the future but at the moment it's available to all open access online at the Lancet Global Health website. And if you don't want to read all 20,000 words, there is a short executive summary of 1,000 words which is also available as an audio file. Commissions are usually commissioned by the editors but they can also be proposed by the authors themselves and that's what happened in this instance and all this has taken around two years from initial inception to what we're seeing today. So it's been a long journey for this very dedicated group of researchers and I heartily congratulate them on this inspiring and I hope impactful work. So I really hope you enjoy the presentations to come. Thank you very much. We're now going to show you a short animated video to give you a flavour of what the commission is about. Thanks. Healthy vision and eyes are something we take for granted but nearly all of us will experience poor eye health during our lives. Today, 1.1 billion people around the world are living with vision impairment that has not been addressed and there are hundreds of millions more who need ongoing eye care throughout their lives. 2.8 out of 10 people in need of eye care and middle income countries and many of those with vision loss cannot access the eye health services they need. Vision impairment has a huge economic impact. The estimated annual productivity loss is equivalent to 411 billion US dollars that's nearly twice the GDP of New Zealand. Poor eye health can compete learning, working, caring for others, reduce overall health and well-being and can lead to lower life expectancy. These challenges have far-reaching effects on the world's development and as more of us live longer the problem is only going to get bigger. Fortunately, solutions exist. In fact, up to 90% of vision impairment could be prevented or treated with existing highly cost-effective interventions. Yet services are under resourced and least accessible to those that need them most. We need to work together to increase investment in eye care. Governments need to include eye care within their health systems, plans and policies, providing comprehensive services that put people and communities at the center of care through health promotion, prevention, treatment and rehabilitation and by reducing the impact of vision loss by creating inclusive and accessible environments. Collectively, we can help to deliver better eye health for all while benefiting individuals and nations economically and advancing sustainable development. Now is the time for action to unlock the power of eye health for all. It is a great pleasure to welcome His Excellency Ambassador Walton Webson who is the permanent representative to the United Nations for Antigua and Babuda. Ambassador Webson is the co-chair of the United Nations Friends of Vision and has kindly agreed to formally open this webinar with a keynote address. Thank you Ambassador Webson. Thank you very much Matthew. Thank you Hannah, Zoe, colleagues, friends all around the world. It's an extreme honor for me to have been invited to be a commissioner with this very distinguished team of professionals and across all disciplines. Because the team is a multidisciplinary team, it helped to amplify the need for us to move eye health from the silo of simply locking it into a health challenge to recognize that eye health is a broader development challenge. This commissioner's report shows the evidence and shows us the urgency that we must take to address the problem of eye health and if we are going to achieve the sustainable development goals. Because I was given this honor as a commissioner, I was able to work with my colleagues and the Friends of Vision group that we founded only three years ago to be able to bring to the attention of the diplomatic community, the politicians, and the health leaders around the world. To bring to their attention the urgency for eye health to be inclusive in universal health, but also to be inclusive in the development agenda if we are going to attain the objectives of leaving no one behind. We know that poor eye health services, poor eye health conditions and individuals is a major factor in inequality. To that end then, we are working with colleagues from across the spectrum to show that the discipline, all disciplines, must come together in addressing the problems from all countries. This report shows the statistics, you will hear more about it. It addresses the urgency, you will read more about that, and it shows us the need for us to address eye health as a multidisciplinary approach towards meeting the SDGs, the sustainable development goals, and towards beating back the challenges and problems of inequality. I want to thank Matthew and the team, every member, every commissioner for the outstanding job done, and for the work that lies ahead, because when we put something like this out, people are looking for solutions, and together we all will work with governments across all ministries in addressing the problem and beating the challenge that is before us. I thank you. Hello, my name is Matthew Burton. I am based at the International Center for Eye Health in London, and with HANA file I co-chaired the commission. I would like to add my welcome to those of HANA, Zoe, and Aubrey to this webinar to mark the launch of the commission, and to thank you for joining us. Today we would like to outline some of the findings from the commission, which we hope will be useful in advancing understanding and catalyzing action on eye health. The commission report is the work of an interdisciplinary group of 73 academics, national program leaders, and practitioners from 25 countries. A further 75 people have contributed to many original reviews, which are being published as subsidiary papers. In addition to the main report and appendices, the commission's subsidiary publications, case studies, and other resources can be accessed through the commission website. You can also access the reports and related materials through the main Lancet commission hub website. The report is structured in six sections. Today we're going to have a series of 14 rapid fire talks by commissioners on a range of topics. Because this is being delivered over several different time zones, these have been pre-recorded. Our key message can be found on the front cover of the report. Investing in universal eye health is a realistic, cost-effective way of unlocking human potential by improving health and well-being, education, work, and the economy. It is essential to achieving the sustainable development goals. The commission seeks to reframe eye health as not only a health matter, but also an enabling cross-cutting issue within the sustainable development framework. We believe the evidence in favor of urgent global action on eye health is compelling. I will now briefly outline who will be speaking today. First, Rupert Borne will talk about the global magnitude of vision impairment. Nathan Condon will talk about eye health and the SDGs. Bonnie Sweener will talk about the relationship between eye health and quality of life, and quality of life, general health, and mortality. Patricia Marquez will talk about the economics of eye health. Nuiro Wangi will talk about the last 20 years of eye research, and Esmil Habtamu will talk about the grand challenges in global eye health project. We will then have a series of talks on different aspects of delivering high-quality eye care for all. I will talk on integrated people-centered eye care, Samarana Yasmin on human resources, Andrew Bastoros on technology, Ian Jones on health financing, Ian McCormack on measuring progress, Tulsi Ravala on quality of care, Jackie Ramkey on equity. Hanifah will round things up with a call to action. Finally, Zoe Mullen will moderate a question and answer session. Just to add that you will be able to access these talks and other resources and publications from the commission website. I will now hand over to Rupert Borne, who will talk about the latest data on vision impairment. Thank you. Thank you for the opportunity to talk about the magnitude of eye disease section of the Lancik Global Commission. I coordinate the Vision Loss Expert Group, which is a group of more than 100 ophthalmic epidemiologists worldwide, which for the last 14 years has gathered together data from population-based studies of eye disease into the global vision database. Every five years we model the data to provide global estimates the prevalence of vision impairment and blindness, for example, the 2015 estimates that we use for the WHO's first report on vision. Working closely with the GBD, we have published the 2020 estimates in Lancik Global Health a few weeks ago and a summary of this data is reproduced in the Lancik Global Commission. None of this would be possible without the generous support of our funders listed here who are funding our current five-year cycle. To give you a feel of how eye disease fits within the overall burden of disease, here are three countries, each with a box into which you can fit all things that ale and kill people in terms of dailies. The orange-red colours represent the disease burden caused by infectious child and maternal health conditions, while the blue colours are non-communicable diseases. There are countries such as Nigeria on the left, whereas much as 70% of the disease burden is caused by infectious child and maternal health conditions with a relatively smaller portion due to non-communicable diseases. As countries undergo what's called the epidemiological transition, where the average age of the population increases and more people live into adulthood, the disease burden shifts to non-communicable diseases and disabilities. For example, Germany here on the right, where 95% of the burden is through NCDs. Most causes of eye disease are non-communicable diseases. Therefore, this epidemiological transition is particularly relevant for vision impairment and blindness, as you'll see in the next slides. This graph shows the strong association of vision impairment and blindness with age. The lowest of the curves is for blindness, and you can see how globally the prevalence of blindness begins to increase in the late 60s. The central curve is for mild vision impairment, and the uppermost curves are for moderate and severe vision impairment. You can see that there's an exponential increase with increasing age from the age of 50 years with 10 to 20% of the world's population in their 70s affected. The prevalence is higher in women. Starting with mild vision impairment, we estimate 257 million people have had mild vision impairment in 2020. That's a 62% increase in cases since 1990. If you age standardize the prevalence data, essentially removing the change caused by changing age structure over that time, then you can see a decline in the prevalence of mild vision impairment over 30 years. For moderate and severe vision impairment, we estimated 295 million people affected, and for blindness, 43 million people, a more modest increase in cases, but a much more dramatic reduction in age standardized prevalence over this time. For blindness and vision impairment at distance, there's been a reduction in prevalence of blindness, which is a really important message to which our blindness intervention efforts will have contributed, but we have a large pool of people still with lesser but still moderate or severe vision impairment. For all of these, we'd expect there'll be an approximate doubling of people affected over the next 30 years, given the population projections. The age standardized prevalence of blindness has fallen over 30 years, and we see that illustrated in purple for cataract, the leading cause of blindness, glaucoma, age-related macular generation, and uncorrective refractive error, the leading cause of vision impairment, where rates of blindness due to these diseases have fallen by about 30%. However, blindness due to diabetic retinopathy is notable in that it is increased. These are certainly striking figures for vision loss, yet under the surface, there's a much greater need for eye care services. In the commission, we presented this need in terms of three groups, people with manifestal corrective vision impairment who need ongoing care, those with early stage disease where they may manifest a vision impairment later in life, and those with symptomatic conditions that typically don't cause vision impairment but do require services. So why collect data unless you can use it effectively and make it available to as many people who may benefit from it? In the words of Bill Gates, whose foundation has supported some of BLEG's work, along with other funders listed here, the focus has been on not just publishing this data, but making it actionable data. That's why the Vision Loss Expert Group partnered with the IAPB to create the Vision Atlas, where vision impairment and blindness data from the VLEG GBD model can be visualized by any internet user. Thank you. It gives me great pleasure to introduce the brilliant new version of Vision Atlas, which is today being launched. I encourage you to disseminate it as widely as you can to make this data truly actionable. Thank you. Welcome to the Vision Atlas, a panoramic view on all things eye health, produced by the International Agency for the Prevention of Blindness, IAPB, the overarching alliance for the global eye health sector at IAPB. We know that improving the world's eye health has far reached and benefits for health. Well-being, education, work, and ultimately the global economy. The Vision Atlas sets out a wealth of data in easy-to-understand formats that illustrate the inequalities of who is affected by vision loss and the inequity of access to eye care services across the world. The Vision Atlas is powered by the latest evidence from the Vision Loss Expert Group, the Lancet Global Commission on Eye Health, and relevant national bodies. It has been kindly supported by Allagan and Aviv company, Bayer, CVN, Saver Foundation, Sitesabers and the Fedholos Foundation. Today, 1.1 billion people are living with vision loss, limiting their education opportunities, income, and their increasing risk of early death by up to 2.6 times. The Vision Atlas highlights the inequality of vision loss across the world, showing that 90% of people with vision loss live in low and middle income countries, that 55% are women or girls, and 73% are over the age of 50. Vision loss costs the global economy $411 billion per year in productivity losses. But it doesn't need to be this way. For 9 out of 10 people with vision loss, the vision loss could have been prevented or could be treated now, meaning many people's lives could be so much easier if only they could reach the basic help they need. The Vision Atlas brings this data into the light so that the world can do something about it. Improving eye health is a practical, cost-effective way of unlocking human potential and achieving many of the United Nations' sustainable development goals. The Vision Atlas enables the eye sector to speak with one voice to governments and policy makers. The simple interactive tools on the Vision Atlas allow you to search and interrogate the database by age, gender, causes of vision loss, country and region over the last 30 years. Understanding the causes of vision loss in your region enables us to work together on the appropriate eye care services to match the needs of the patients on the ground. The Vision Atlas shows quite simply that the burden of vision loss falls on women and girls. This is an invaluable tool to advocate for access to eye care for everyone. The Vision Atlas is accessible, easy to use, and provides simple downloadable content, making it easy to present key data to the right audiences. The data contained in the Vision Atlas is great for adding much needed evidence to media stories and to explain to a wider audience the importance and impact we should be making around the world. We encourage you to explore the Vision Atlas online where you can download relevant and specific resources for your needs. My name is Nathan Condon and I work with Queen's University Belfast, Orbis Internation, and the Dromoshan Athletic Center in Guangzhou, China. I'd like to speak to you today about the various ways in which promoting eye health can help us to achieve the sustainable development goals. The sustainable development goals serve as a roadmap for the global community, guiding us to reach a healthier, safer, and more equitable world by 2030. That path is signposted with specific and achievable targets. We've been working over the last year on the Lancet Global Eye Health Commission. You can read more about our work at the website of Lancet Global Health. Dr. Justine Zhang has spearheaded specific work looking at eye health in the SDGs, and this has shown that promoting eye health offers an effective, fast lane on the path to achieving many of the SDGs. At the heart of the sustainable development goals lie poverty reduction and decent work. Safe, inexpensive, and effective eye care such as glasses and cataract surgery has been shown by high quality studies to increase productivity on the job and stimulate economic activity not only among beneficiaries but also their families in direct service of SDGs 1 and 8. The SDGs recognize the importance of education in the life of a child. It's been shown that providing glasses to children in school improves academic importance, and in fact it has a greater proven impact on parental education, family income, and any other school-based health interventions in achieving this important sustainable development goal. A cornerstone of good health is freedom from injury, and that's recognized in SDG 3 reduced injuries and SDG 11 safe cities. Good vision has been shown to reduce the risk of traffic-related injuries which are the world's leading cause of death between the ages of 5 and 29. Good vision also reduces falls among the elderly, a major factor in the loss of independence and even death. Equity is of bedrock importance to the sustainable development goals, and in fact equity of gender equity between men and women is recognized as its own independent SDG number 5. Vision screening outreach in schools and communities has been shown to reduce gender inequalities and access to spectacles, cataract surgery, and care for glaucoma and diabetic eye disease in direct service of this important gender equity sustainable development goal. Finally, the sustainable development goals really couldn't get off the ground without working together, and in fact partnerships between stakeholders and across borders and disciplines really act as the glue that holds the SDGs together. Importantly, the global eye health community has collaborated in dozens of countries to tackle some of the world's most challenging health care problems, including glaucoma and river blindness, or oncocytosis. I invite you to visit the website of the Lancet Global Health Journal in order to find out more for yourself about the various ways in which investment in eye health can bring the SDGs into focus. Next, I'd like to introduce my colleague on the Global Eye Health Commission, Dr. Bonnie Lynn Swenor of Johns Hopkins University School of Medicine, who will speak to us about the importance of eye health in promoting various aspects of systemic health. Thank you very much for your attention. I'm Bonnie Lynn Swenor, Associate Professor at the Johns Hopkins Wilmer Institute and Director of the Johns Hopkins Disability Health Research Center. Today I'm presenting the summary of the general health well-being and mortality sections of the Lancet Global Health Commission on Global Eye Health. Vision loss and eye disease can impact far more than just vision and have implications on health over the life course. The Commission conducted reviews of the literature examining the connections between vision and health and the data revealed that although this connection is complex, two main pathways emerged which are shown on the slide. First, there are downstream consequences of vision loss, which include reductions in social interaction, restrictions of physical activity, and barriers to health care that can lead to negative health outcomes such as depression, dementia, cardiovascular disease, and cancer. Second, common factors such as smoking, diet, UV light exposure, and changes that come with advanced age can simultaneously lead to vision loss and negative health outcomes, including mortality. While vision loss does not directly lead to death, the mortality risk is elevated among people with vision impairment. The Commission conducted a meta-analysis of 28 studies representing 30 cohorts from Africa, Asia, Australia, Europe, and North America. This slide is showing a forest plot of these results, which found that the risk of mortality was higher among people with visual acuity worse than 6 over 12 as well as those with acuity worse than 6 over 18 when compared to people with better vision. For people with visual acuity worse than 6 over 60, more severe vision loss, mortality risk was elevated when compared to people with visual acuity of 6 over 18 or better. However, a significant association between vision loss and mortality was not found when comparing those with acuity worse than 6 over 60 to those with acuity of 6 over 60 or better. This is likely because the comparison group in that last set of analyses includes people with substantial vision loss. While the reasons for this increased risk of mortality remain unclear, these results reinforce the connection between vision and overall health and add emphasis on the public health importance of vision loss. In addition to the impact on health and mortality, vision loss influences quality of life. Assessments of quality of life can provide insight on how vision loss impacts well-being from a person-centered perspective and how the experience of vision loss can be affected by personal, social, and environmental factors. The commission undertook an umbrella review or review of systematic reviews related to vision and quality of life. Out of 69 systematic reviews identified, 60 of these studies examined the relationship between alphalamic interventions and quality of life, which are shown as the outer ranks of the circle figure on this slide. Of those studies, 75% showed that these alphalamic interventions, which included cataract surgery in anti-vascular endothelial growth factor or anti-vegeth treatment, had a positive impact on quality of life, and that's indicated by the darker shades in the inner ring of the circle figure. These results underscore the close relationship between vision loss and quality of life and call for an increased investment in eye health, as well as a deeper understanding into the factors that reduce quality of life for people with vision loss. Hi, I'm Patricia, and on behalf of the commission, I'm here today to talk about Section 4 of the Commission Report. In Section 4, we summarized the findings of the systematic review on economic sufficient impairment. We present a new axiomative global productivity losses and an analysis of cost-effectiveness ratios for cataract and refractive error services. First, we undertook a systematic review to identify and summarize the costs associated with vision impairments. To do this, we searched the literature from 2000 onwards with no geographic or language restriction, and we identified 138 studies that meet our inclusion criteria. 38 of these studies reported costs for vision impairment and our blindness, and 100 reported data for one of the seven major causes of vision impairment globally. Studies were very concentrated in high-income countries, and we also found large variation in methodological approach, cost measurement, and management of uncertainty, which made it impossible to combine studies to generate an estimate of the costs of vision impairment globally. We generated regional and global estimates of final productivity losses using the most recent prevalence, demographic, and economic data. The vision loss expert group provided us data from their latest model that estimated that in 2020, there were 161 million people in the working-age population who were either blind or had moderate or severe vision impairments. Our literature review identified data on the employment of people with vision loss from 15 countries, and we determined that globally, the relative reduction in employment of people with vision loss was 30%. We calculated productivity losses as the product of the number of people with blindness and moderate to severe vision impairment of working-age, the population employment rate, the relative reduction in employment for people with vision loss, and finally, the per capita gross domestic product. We estimated that the annual cost of potential productivity losses in 2018 to be 411 billion US dollars per chasing power parity, which represents 0.3% of the combined global gross domestic product, as much as Ireland's GDP in the same year. Half of all productivity losses were concentrated in three regions, East Asia, South Asia, and high income North America. In East Asia and South Asia, this was primarily due to their large number of people with vision loss in the working-age population. While in North America, this was driven by the high GDP per capita and a higher relative reduction of employment. Finally, we looked at cost effectiveness of eye health interventions. We focus on cataract and refractive error, hence these accounts for more than three quarters of blindness and moderate to severe vision impairment globally. From our systematic review, we looked for studies reporting health benefits, using disability-adjusted life years, dollies, or quality-adjusted life years, qualities, and what we identified in 11 publications providing 58 cost-effectiveness ratio for estimates for cataracts, and three publications providing 17 cost-effectiveness ratios estimates for refractive error services. Most cost ratios were less than 1,000 per dollar adverted or quality gain, indicating that cataract surgery and refractive error services are cost-effective in many settings. This information combined with a well-structured and context-specific decision-making process should encourage countries to prioritize eye care delivery services. We believe that decision-making on eye care financing and provision of services will benefit from improved economic evaluation studies. To address the substantial data gaps we identified in our analysis, we will need to increase the use of standardized methodological approaches following international guidelines for health economic evaluations, collect more data from diverse settings periodically and in standardized ways, gain a better understanding of the impact of vision impairment on employment status, on absenteeism, on presenteeism, to improve productivity losses estimates, perform more comprehensive economic analysis, including cost-effectiveness studies and cost-effectiveness analysis. Thank you very much for listening. As part of the commission, we explored the extent of eye health research in the two decades leading to 2020. We identified 150,000 published primary research studies. 40% of them were on one of the five leading courses of visual impairment. There was a 50% increase in research output between the two decades and 4% of the studies were trials. Countries such as the United States, the United Kingdom and China had high research output whereas the Caribbean, Latin America, Africa and Southeast Asia had low research output. It is notable that high income countries have 15% of the world's population but contributes 75% of the research output. We also looked at the trials conducted in sub-Saharan Africa during this period and found that half of them had been conducted in only four countries, that is Nigeria, Ghana, South Africa and Ethiopia. These trials focused mainly on trochoma, on cossaciasis and also glaucoma. Regarding the authorship of the 150,000 studies, we found that one third of all authors are female whereas a quarter of the senior or last authors are female. There was an increase in female authorship from 28% to that 7% during this period. Consuming the trials from Africa, 8% of all authors were females from the country of study. Another 43% were males from the country of study. Authors from high income countries contributed half of all the authors. The gaps we find are that there is more distribution regarding where research is done, more distribution regarding the choice of research questions and the composition of research themes. Based on these findings and the findings of other studies on the commission, the commission recommends that we increase solution-focused research, especially on the five leading causes of visual impairment. This needs to be well-designed research studies, which in turn requires capacity building for research, especially in low and middle income countries. This can be done through effective and equitable partnerships between North-South or South-South partners. We will also need to monitor diversity in teams consistently, as well as emphasize on translating the research evidence into policy and practice. I will now ask Esbel to talk about the proud challenges. Hello, I'm Ismail Haftamu. I'll talk about the IHELS Grand Challenges that were conducted as part of the commission work. Wonder took a grand challenge in global IHELS prioritization exercise to identify the key challenges that need to be addressed to improve IHELS in the context of a growing and aging population. We defined the grand challenge as a specific barrier that if removed would help to solve an important health problem, and that its intervention would have a high likelihood of feasibility for scale-up and impact. A several-round modified Delfi was employed to nominate and rank challenges. In the first round, parts nominated up to five grand challenges. Ends and rounds of prioritization led to a final list. Ranked based on perceived importance, as well as likelihood of reducing disease burden and inequality, immediacy and feasibility. Standard 36 people from 118 countries completed all three rounds, among these 48 percent were women and around 31 percent were from South Saharan Africa. These participants included decision makers, researchers, advocates, program implementers, clinicians, and the patient groups. We have identified 60 priority grand challenges summarized under four categories. People were condition-specific, five were on health systems strengthening, three were around access and security, two were on building demand resource capacity. I really encourage you to look at the commission report for details, but here I would summarize the top five grand challenges identified at the global limit. The first ranked grand challenge was creating demand and ensuring access to accurate affordable and good quality refraction services and spectacles. The second most ranked was identifying and implementing strategies to improve cataract services, particularly in terms of quality, productivity, equity, and access. The third most ranked was improving child health so integrated, evidence-based, primary, and secondary care services, as well as the school I have the programs. The fourth most ranked was developing and implementing services that cloudized marginalized communities or groups such as women for communities, indigenous people, ethnic minorities, people with disabilities, and so on. The fifth most ranked was developing and implementing strategies that can reduce out-of-pocket costs for those unable to afford full-cost services such as subsidy, child pricing, and the health infrastructure scale. Universal health coverage will not be realized without universal eye health, and universal eye health will not be realized without eye health research and the youth of the evidence it generates. We believe the findings from these grand challenges exercise provide a starting point for immediate action by helping to guide eye health researchers to prioritize and frame their research questions, guide vendors to frame research advertisements, divide care service providers a clearer and more focused purpose and goal, and facilitate collaboration across various stakeholders to answer the biggest questions. And also this exercise can help for other priority-setting exercises. As next steps, context-specific implementation and health system research is needed. To address most of the grand challenges and particularly to guide effective delivery of services on the leading cause of vision impairment. Health research in low-end medical countries primarily needs to focus on how to effectively expand and scale up coverage, improve quality, and ensure sustainability. Innovative research for specific areas that are without efficacious interventions such as glaucoma remains critical. I will hand back to Matthew who will talk in more detail about eye health within universal health coverage. Thank you. Thank you Esmail. In the 2019 world report on vision, WHO's leading recommendations were firstly making eye care integral to universal health coverage and secondly implementing integrated people-centered eye care. In responding to this call, the commission has sought to unpack these issues in detail and summarize the evidence base. Universal health coverage is central to delivering SDG3, good health and well-being. The commission argues that UHC is not universal, without affordable, accessible, high quality eye care. Throughout section six, we explore turning this aspiration into a reality. We illustrate this with a focus on cataract and refractive error services in particular. We have carried out several new reviews and analyses which I encourage you to read about. To help conceptualize eye health within UHC, we have adapted the well-known cube diagram to show the proportion of the population covered, essential eye services provided, direct costs covered by pooled funds and effective quality. The world report on vision has placed renewed and very welcome emphasis on people-centered approaches to eye care delivery. Effective services need to be easily accessible to the population with easy navigation through the system in cases for which more specialized services are required. The commission examined how eye care can be integrated into different aspects of the health system and other sectors. We developed a framework to illustrate the different connections and components. Integration of eye health with other services within the health system and beyond can take many forms. However, there are a number of key foundations. Firstly, there needs to be policy integration, not only in the health sector, but also in education, employment and finance. A second foundation is integration of eye health into national health financing mechanisms. Ian Jones will talk about this shortly. There also needs to be health workforce integration with thoughtful workforce planning to meet population eye health needs and the inclusion of eye health training for generalists. Samarana Yasmin will talk more about this in a moment. There are many ways in which eye health service provision and delivery can be embedded throughout the health system as a whole. In the commission, we provide multiple examples and case studies. Connections need to be made at all levels of the system, integrating eye health into community level activities, as well as primary, secondary and tertiary health care. A crucial component of delivering eye health within UHC is primary eye care. This is needed in all resource settings. The commission takes a broad view of primary eye care encompassing activities and interventions within community settings, as well as primary health facilities, such as health education in the community, schools and workplace, screening for vision impairment, for example in school programs, protective eyewear to prevent injuries, community-based interventions such as vitamin A distribution, basic diagnostic and treatment services, diabetic retinopathy screening in NCD clinics and child eye health programs. There is an increasing need for refractive error services and access in primary care settings is crucial. In many regions, these services are largely provided in the private sector and represents a major opportunity to bring services closer to the communities. More consideration needs to be given to developing the right regulatory and market conditions to promote high quality, affordable and equitable services. Public-private partnerships are promising ways to increase spectacle coverage while ensuring a safety net for those who are unable to afford commercial prices. Weak connections between primary care and specialist services are common. Considerable action is needed in many settings to strengthen referral decisions and pathways. Delivering integrated people-centered eye care is a complex process. It will require breaking down traditional barriers within healthcare. Major investment in training, sharing of tasks and development of enabling environments. I will now hand over to Samarana Yasmin who will talk to us about the commission section on human resources for eye health. Thank you. Good morning everyone. The commission reflected on the key issues relating to human resources for eye health and made a number of recommendations to enable countries to realize universal health coverage. As we all know, a critical issue is the shortage of eye health workforce experienced by many countries across all levels of care, especially when it comes to projected eye care needs in coming years. Using available data on ophthalmologist and optometrist, we examine the density per million population across world region and share the results of ophthalmologist here. We can see massive differences across regions and also a pattern of higher rates of vision impairment and blindness in regions with low density of ophthalmologist. Beyond the number of personnel, their distribution within the countries is also an issue with much higher density in urban compared to ruler areas. So what can we do to change this? In the commission, we discussed several strategies for countries to realize a competent and well-resourced eye health workforce in place that is integrated into health system and accessible for people in need. To maximize the capacity of eye health workforce, we need to start with strengthening a competency-based model within the training programs. We also need to explore that how we can engage and train journal health workers in eye health and encourage task sharing with them. Developing enabling environment including appropriate equipment, supportive supervision and mentoring is equally important if we want to increase access to eye care. At the same time, we also need to make sure that career development pathways are in place because that's the only way we'll be able to increase motivation and address the issue of low productivity. We know that we cannot achieve success unless we engage with other stakeholders within the sector and outside of the sector. We also cannot underestimate the role of private sector. So if we want to maximize the impact, if we want to increase access, we need to make sure that we engage with private sector. And most importantly, all of this needs to be supported within the local context if we want to ensure integration and continuum of care. As part of the commission, we also assembled some great case studies, including a number which speaks to challenges and innovation in eye health workforce development in settings, including Pakistan, India and Pacific Islands. I encourage you to look at these in annex material of the commission. And at the end, I would also like to include that if you want to change the landscape of eye care in coming years, we need to make sure that we join our hands and work together. Thank you. And now I will hand over to Andrew Vestores, who will speak about technology in eye health. Thanks. Technology has transformed the way we live and has advanced healthcare globally. However, the benefits of these advancements have not been equitably received. In this talk, we will look at three specific aspects of technology in eye health. First, we will look at teleophthalmology. Teleophthalmology has been used for more than 20 years, with ophthalmology lending itself to image-based diagnosis and analysis. Asynchronous teleophthalmology is the practice of acquiring ophthalmic imaging, typically retinal photos, saving them and then sharing them for review at a later date by a specialist or grader. This has been widely used for diabetic retinography screening and more recently for retinography of prematurity. Advantages include reduced travel for patients and more economic human resources for image acquisition, increasing the service coverage, synchronous live consultation, aids in decision making, immediate initiation of treatment whilst reducing the burden of patients travelling. This has increased in importance during the global pandemic. AI or artificial intelligence has a lot of interest in terms of eye care, particularly deep learning. This interest is primarily driven from high income settings, facing challenges related to managing high volume chronic conditions such as DR, AMD and glaucoma. Deep learning is well suited because their diagnosis and management is largely dependent on retinal images. AI has many potential uses in eye health, including point of care diagnostics, surgical decision making, patient management and treatment, all enhancing service delivery and optimizing health systems. Most immediate benefits in public eye health will likely be in diabetic retinography and ROP screening programs. Coupled with teleophthalmology, it enables synchronous image grading and decision support. In 2018, IDXDR was the first AI screening product for DR to obtain FDA approval. To assess the extent of translation ready AI, this commission conducted a scope and review of publications on AI and eye health between 2015 and 2020. Over 1200 primary data reports were identified, most 60% focused on retinal imaging and only 12% of reports addressed conditions that affect the front of the eye. Arguably the greatest potential for AI to contribute to advancing eye health would be to assist in case identification and health system efficiency, helping people with uncorrected refractive error and cataract access services, neither of which are currently well represented in the AI development platforms. A further global review of datasets reviewed huge underrepresentation from LMIC populations which return health data poverty. The scarcity of representative datasets limits the extent to which populations can benefit from digital health solutions and AI systems. We recommend visibility, accessibility and use of existing public datasets as improved and the investment is made in developing new public datasets to support research, innovation and validation in regions with insufficient health data. And finally we look at mHealth. According to the GSMA there are more than 5 billion people today who have a mobile device, that is two thirds of all people on the planet. Its applications in healthcare have led to huge growth in mHealth including within eye health, although few applications have been tested, validated or achieved widespread uptake. Several vision testing applications have been validated and shown good performance compared with conventional tests in rural settings including visual acuity in Kenya and contrast sensitivity in Ethiopia. By linking smartphone applications to a wider system the effectiveness efficiency and knowledge gains can be considerable. For example a cluster randomized control trial for school vision screening in Kenya found that teachers can reliably identify pupils with vision impairment initiating an automated referral and nudging for full assessment. This method more than doubled the uptake of secondary eye care services. In conclusion in this section we define that technological developments offer the potential to revolutionize eye health care, however caution is needed to ensure all populations benefit. Thank you and I'd like to hand over to Ian Jones who will outline the commission's reflections on eye health financing. Hello everyone, the commission includes a call to action for more and better funding of eye care particularly in low and middle income countries where the need is greatest. The amount, the source and the allocation of resources determines the scale, scope and depth of coverage of eye care but it also influences the quality of services and care provided, the sustainability of those services and the equity of eye health programs. As part of the commission we looked at a number of national eye health system assessments, analyzed aid data and considered other sources of eye health funding. Estimating global eye health funding is challenging national health plans and budgets in many countries often don't include eye care. Estimating external support to eye care is problematic and out-of-pocket payments for eye health are widespread but difficult to estimate. But what we did conclude is that eye health is underfunded, the commission calls for more funding for faster progress to universal eye health as part of the wider efforts to deliver UHC. Without a significant step change in funding from all sources we will be neglecting an important component of UHC and we won't deliver on our promise to leave no behind. But as equally important the funds are used wisely supporting the right interventions in the right place, in the right way to maximize impact and tackle inequity. This requires more evidence to inform these decisions and careful design and evaluation of insurance schemes and alternative financing mechanisms so we learn, adapt and evolve these tools as eye health needs change. Hand in hand with more and better funding for eye health we need to increase our data and evidence around eye health. More evidence is needed on costs, cost-effectiveness, efficiency of different delivery models, affordability for governments and individuals. And the financial barriers to accessing services, this would support evidence informed decision makers on faster progress to UHC. Everyone in their population will require eye care at some time in their lives. Yet they are often directed and indirect costs to individuals preventing them from accessing essential eye health services. I hope governments and partners will respond to this call for action for more and better eye health funding. With eye health included in national financing of UHC and efforts to improve access for the whole population to the eye care that they need. I will now hand over to Ian who is going to speak about the commitment work on indicators for eye health. Thank you. Hello, I'm Ian McCormick. I work at the International Centre for Eye Health and I'm going to introduce some of our work on eye health indicators. One of the commission's key messages is that reliable data from both surveys and facilities are key to progress in eye health and that a balanced set of indicators are needed to measure progress and drive change. As part of the commission, we undertook a study to help address this need. We aim to develop an indicators menu aligned with the dimensions of universal health coverage, access, quality, financial risk protection and equity and gathered a global perspective on eye health indicators by recruiting an expert panel to a prioritization exercise. The panel was made up of 72 experts from 39 countries with representation from all global burden of disease super regions. From an initial long list of 200 indicators, we arrived at a final menu representing 22 priority eye health concepts. We identified seven as core indicators, measures which, if collected by all countries, could allow governments and super national organizations to monitor universal access to quality, affordable eye care services. The menu is prefaced with an equity statement. This is intended to be cross cutting and applied to all relevant metrics. Without appropriate disaggregation of indicators, we won't know we're making positive change in the population's most at risk of per eye health. The core indicators include to effective service coverage indicators, effective cataract surgical coverage, ECSC and effective refractive error coverage, EREC. ECSC and EREC have been identified as candidate WHO universal health coverage service coverage indicators and in the near future, we hope to see these two eye health indicators integrated into broader universal health coverage monitoring frameworks. To examine effective cataract surgical coverage in more depth, we reanalyze all available rapid assessment of avoidable blindness survey data from the past 20 years. We investigated regional trends in ECSC and differences by gender. The figure on the left shows some interregional variation although data are limited in certain regions. The figure on the right shows that the regional median ECSC was lower among women than men in every region except for Latin America and Caribbean. The indicator menu developed as part of the commission will now be put forward to help inform development of WHO's indicators for integrated people-centered eye care. While the ECSC analysis will contribute to WHO baseline estimates for monitoring progress towards new national targets for 2030. However, the existence of an indicator framework is insufficient in isolation. Work is needed to strengthen national health information systems and eye health's place within them and to engage with the private sector to support data collection and reporting. I will now hand over to Tulsi Raveela who will outline the commission's reflections of quality of care in eye health. Thank you Ian. Hello, I am Tulsi Raj Ravilla from Aravind Eye Care System in India. I'm going to talk a little about the work that the Lancet Commission on global eye health has done on the delivery of high quality eye care. While everyone appreciates the importance of quality, there is a growing recognition of its central role in sustaining and enhancing eye care. Unfortunately, high quality services are far from being universal. In the commission, we examined the question of quality of eye care from a holistic perspective. We sought to look beyond the narrow confines of outcomes of clinical interventions. Quality is not limited to what we do. It is equally influenced by what we don't do. We use the quality framework favored by WHO, which considers seven components, effectiveness, safety, people-centeredness, timeliness, equity, integration, and efficiency. For the purpose of the commission and to align with the SDGs, we also added planetary health. We have particularly applied this framework to the delivery of cataract surgical services. This is a very busy slide. We systematically reviewed literature for research on intervention approaches that improves quality of delivery in one or more of these components. We found multiple studies that show how quality across these dimensions can be improved. I encourage you to read this section to find more details in the report, appendix, and related papers. As Yen has already touched on, a key indicator to eye health service delivery is effective cataract surgical coverage or ECSC. This combines information on both coverage of services in the population defined as people with cataract vision impairment or operable cataract, and also the outcome in terms of visual equity. Both the threshold of vision impairment defining the population need and the benchmark are for a good outcome can greatly influence the effective cataract surgical rate. The commission has examined this using data from RAB, surveys from Vietnam, the country with the most longitudinal population based survey data. We call for raising the bar for good outcome to be 612 or better, up from the current 618. In addition, we also encourage a similar change and alignment in the threshold for a cataract to be considered operable to 612. You can see from the Vietnam data that these two thresholds changes can have big impact on countries reported effective cataract surgical coverage. We believe that these changes will be drivers for improvement in both quality and coverage of services in the coming years. The commission also examined the potential impact of how we deliver eye care services on the health of the planet. Globally, healthcare contributes 5% of greenhouse gas emissions. Eye care is a high volume, so will be a significant contributor. We have conducted a systematic review of the environmental impact of eye health services. We found only eight reports. This clearly is an area that needs urgent attention. However, we think there will be ways that we can make big improvements. For example, on the left, you see refuse from 32 cataract operations conducted in India. On the right, the refuse from one identical operation conducted in UK, which produced 20 times carbon dioxide per procedure than the Indian Centre. To increase the quality of eye care services, the commission calls for four key actions. One, govern for quality. Two, redesign services to maximize quality. Three, transform the workforce and the environment. Four, ignite demand for quality in the population. I will now hand over to Jackie Ramke, who is going to summarize the commission's work on equity in eye health. Hi, everyone. I'm Jackie Ramke and I'm very pleased to be talking with you about equity in eye health, which underpinned all aspects of the commission in which we've heard several examples of throughout the webinar. One example is that nine out of every 10 people with vision loss live in low or middle income countries with a persistent disparity in the prevalence of blindness and vision impairment, with high income regions having rates less than half of those in regions such as South Asia, Southeast Asia, and Western Sub-Saharan Africa. The commission also highlighted inequity within regions. This figure shows that in all regions there are more women than men with blindness shown on the X-axis, as well as with moderate or severe vision impairment shown on the Y-axis. This highlights that in all regions, for services to be equitable, women should be greater than 50% of service users. Gender is the social axis for which we have most data. In order to understand more about other inequalities, as Ian already mentioned, the core indicators developed as part of the commission have an overarching equity statement, the cause for expanding beyond gender, to also consider other axes of potential inequity wherever possible, including place of residence, socioeconomic position, and disability status. The commission also looked for evidence on what we might do to address inequity in several ways and I will share just a couple of these. The first reflection is that we have not focused research efforts sufficiently on generating good quality evidence on strategies to reduce inequity. For example, we conducted an overview of systematic reviews on gender and eye health. Of the 58 reviews we identified, the vast majority quantified the prevalence of vision impairment or eye conditions. A much smaller number synthesized evidence on access to Kedarex services and only one review synthesized evidence on how to reduce inequity. We began to fill this evidence gap by conducting a Delphi process, drawing on more than 180 stakeholders from all world regions who first nominated and then prioritized strategies to improve access to Kedarex services in population groups who can be targeted with these strategies. We collated the results globally and for all world regions and believe these results serve as a starting point for the systematic development of evidence to overcome the pervasive inequity in access to Kedarex services in all countries. The commission also calls for more equity, diversity and inclusion in global eye health leadership, recognizing that organizations with more diverse leadership are more likely to promote equity focused agenda. New Era already showed the extent to which women were included in authorship teams and those findings were mirrored when we looked at the inclusion of women in leadership structures of members of the professional and scientific bodies. Across each of these, women held between one in three and one in four of all board membership positions. This reduced when we focused on chairpersons or editors-in-chief and reduced further when we were able to assess opportunities for women with intersectional identities such as identifying with an ethnic minority. We hope these baseline findings can propel change across the sector and we'll be aiming to contribute to this as part of the active afterlife of the commission. These and other reflections on equity and access, including the challenges in high income countries, can be found in the commission, its annexes and subsidiary papers. I invite you all to explore these and I thank you for your interest in the commission. I'll now hand back to Hannah. I'd like to thank everyone who attended the seminar yesterday and stayed on throughout this seminar. Yesterday, the UN Friends of Vision group and the ambassadors, the UNICEF, ILO, recognized the need and urgency and advocated passionately for high health within development for the people of the planet. WHO presented the integrated present-centered approach, the vision atlas and ongoing user-friendly tool. This Landsat commission has provided evidence emphasizing the central role of evidence going forward and my wish now is to make a call to action because we are now at the crucial points and the call to action is really for development actors, global development actors, national governments, health and especially non-health actors, non-governmental organizations, research institutions and industry. In line with the SDGs, the first call to action is for a development imperative and development actors. Now, using vision and eye health to unlock the human potential throughout the life course of each individual and with all populations is an enabling cross-cutting issue within sustainable development framework. And I think the new definition suggested by this commission should be considered that we place eye health across the life course to provide maximized vision of each individual, a high quality of life and a maximal functional ability at every stage of vision whether sighted or disabled. The next slide is inclusion and two aspects of inclusion. Inclusion is an essential part of all aspects of the universal health coverage and thus this has been emphasized by the work of the commission. A high quality of service with epiti, geographical and population coverage, inclusion in essential services even in the period of pandemics, emergencies and disasters during and after. And most of all the financial inclusion looking at risk pulling innovative financing and community-based insurance schemes to cover the rural and neglected populations. The second aspect of inclusion is the inclusive eye health. With personalized attention to disabled persons and the changes that society itself has to make to include the hitherto and excluded neglected populations and the disabled. The third call to action is on investments. It needs to be renewed, increased and diversified pulling in from both the public and the private sectors. And our call to action is really to urge countries to commit and include vision and eye health in their national strategic development and health policies and plans in the planning of the workforce not just health but the development as well and the direct and indirect health financing commitments. Secondly, innovations in service delivery, training and partnerships, innovations in technology and health as already been mentioned in the commission and beginning to explore the relationship between eye health and planetary health and its action. All of these need investment of resources. The Lancet Commission has shown the importance and the benefits of an evidenced approach. The current status, the gaps and the challenges. And so this fourth call to action is to the research constituency as advocates for health and for equity. That the research is responsive to the development paradigm in the questions that are asked, the designs and the fields in which we do the research, the connections between eye health and SDGs going forward. The commission highlighted a number of areas pointed to that we could go into for research and increased commitment and diversification of resources. And our last call to action is on collaborations, multi-sectoral and inclusive. We need to believe in and act on the power of collaborations, drawing in and embracing the new actors and partners of some of whom are shown on this slide. The stars have come together. Together we have an opportunity to shape and prioritize the global eye health agenda and in so doing unlock human potential for sustainable development of all the people of the planet. It's my role now to thank everyone and to take for granted the commitment to eye health within the development paradigm. Thank you very much. Thank you Hannah for that rousing call. So that was a lot of information there, very, very rich presentations. I hope you learned a lot from that. I certainly did. You've been a little quiet on the Q&A. There are a couple so and we have five minutes left in a little more leeway if anybody did have any more questions that they wanted to type into the Q&A button at the bottom there. So but we do have a few. I'm wondering if I can ask you this question that's been posed to us by Aftab who says that he is a consultant optometrist but in his region in Pakistan. You know there are actually very few facilities and the human resources are lacking. This is obviously a very frustrating situation to be in. Do you have any thoughts on that? Thanks Zoe and thanks Aftab. I completely agree with your comment. The location where you are in and providing services. It's one of the most remote location when it comes to Pakistan and I applaud that you are there and making sure that your community have access to these services. As part of Pakistan's national and provincial integrated people-centered iHealth plans for 2020 and 2025. There is a significant focus to make sure that iHealth workforce for primary, secondary and tertiary level is developed and then deployed to address the issue which Aftab raised in terms of the distribution of iHealth workforce. It's still a long way to go but I just want to communicate that this is something which is in works and the government is committed to that and we as an organization is also playing our role to make sure that people in those remote locations have access but this is something which is not unique to Pakistan. I must say it's a global issue. Thank you very much indeed and there's another question from Sannel related I think in terms of financing. He wants to know are there any advocacy initiatives plans towards increasing funding for iCare in general and for research in iCare in particular? Something like the Queen's Diamond Jubilee Fund. Who would like to answer that question? Anybody want to raise their hand and offer the okay Matthew over to you? Thank you. I guess Sannel the way I'd approach this is the aim of the commission and the other work around at the moment is to try and move iHealth funding into government main funding mainstream rather than always looking for an external big donation program like the one you referred to. So the argument that's being made in the commission is really around the much broader impact of iHealth on many aspects of life and health and well-being but other sustainable development goals to try and win the argument in the ministries of finance and elsewhere that it is worth investing resources financial resources into this area. So I think that's the primary long-term aspiration is to try and move this into mainstream financing. There are a number of initiatives that I'm one I'm aware of is called the Vision Capitalist Fund which is only really just getting going which which hopefully will be a big international supporter but really the focus is on trying to engage governments to really really build this into their budgets in going forward. Thank you. Thanks Matthew. So while we wait for any more questions to just pop in I wonder whether I could be so bold as to ask some of my own. Jackie you mentioned about you know the fact that women are more affected than men. Can you explain a little bit more about why that might be and maybe how we can you know I think a lot of this is to do with access to care you were saying so how how can we change that how can we get more women to be able to access the care that they need. Thanks thanks sorry. I think part of it is from the service side making services more available more closer to so they're easier for women to reach but also I think working with communities and yes coming to the people-centeredness side of it making families also understand the benefits of supporting women to access care to the same level perhaps that that men may be currently having that support from their families. Thank you thank you very much and and Tulsi you you presented some very interesting data on the sort of planetary health elements and all that waste that goes into cataracts surgeries in places like the UK. Can you talk a little bit more about the balance between you know getting a quality service but without all that that waste. Thank you. Yeah actually once we dig into all that contributes to the carbon footprint I think some of it would be in the realm of surgical supplies and the protocols around it but I think there's a quite a lot around how we design services know so transportation of staff of patients you know how long how many visits a patient makes to get a cataract surgery you know in in in some settings it takes five visits six visits you know just to get the surgery done I'm not talking of post-op so I think there's quite a lot that can be done in designing the services which can really be a win-win in the sense it can bring down costs for the patient it can bring down the cost for the provider and then it can bring down the cost for the overall operational support required. So I think it requires I think two things one imagination and second I think a level of conviction from the leadership to start thinking about this and I think I think there is a tremendous win-win opportunity in this space. Fantastic thank you. While you're all a little bit quiet still maybe we've all just blown you away with what's been presented there oh there's one more question has just popped in Jackie is there a difference in care provided to women in the high-income countries as well as the low-income? Thank you. One of the interesting things the Delphi process we did as part of the commission looking at for suggestions from different regions in terms of prioritising groups that needed I guess to be targeted in terms of improving access and there was a lot of variation between regions and I think it is less of a problem but it's women with the intersectional identity so like from an ethnic minority who don't speak you know if it's in an English if English is the dominant language so I think it's not women as a blanket statement perhaps not but I think within if there is a group of people who are experiencing access issues then there is a chance that it is still women who are sort of overrepresented in that group. Thank you that makes thank you. Okay so I think that was our last question thank you very much everybody for for joining in I will now hand over to Matthew who will just say a few final words in closing thank you everyone. Thank you Zoe and thank you all of the people who are participating this webinar both in terms of presenters and and and you online joining us today thank you very much for your participation. Just as we close I just want to draw your attention to a couple of resources two websites where you can access more information about the commission the first one is the commission's own website which is global iHealthcommission.org you can see it there and that has not only the commission reports and the annexes but also all the subsidiary papers that we're publishing will be posted there some I think a dozen already posted already there's some other additional resources that you might find useful and then the lance also hosts a hub web page for the commission alongside its other commissions and there's lots of additional information there as well other papers that are related to the commission and also a podcast that Hannah Zoe and I did a week or so ago. So finally just to say thank you thank you very much for joining us but also we'd like to just thank the people that have supported the work of the commission as you can see there on the screen a range of donors have helped fund the work and in particular IPB today have helped with the coordination of this event. Thank you for listening and goodbye.