 Thank you all. This panel is a special opportunity to hear directly from three of the primary partners to this initiative. I'm going to introduce the three of them in a moment. And it's an opportunity to hear from them on a couple of things. And we're going to structure our conversation to start out with a very basic question, which is what is it that you do, your agency or firm, what is its role, what is its contribution in this initiative? So we can get that out in terms of the role definition and the special contribution. Then we're going to move rapidly through that into a consideration of phase one. The last 12 to 18 months in Uganda and Zambia, from the outlook of these three partners, what worked and why? And ask them each to comment briefly on that. It's meant to be an interactive round table conversation. After that, we're going to move to consideration of what did not work or what worked less well or less optimally than some of the other things. So we can get a little bit of critical thinking into this discussion. And then we'll close with a quick consideration of the future. And looking out three to five years, what is this partnership, what is this initiative, in their view, what should it look like and how we're going to get there. There are serious questions around bringing to scale what's the model going to be, what are the core services going to be. We know that there's considerations around funding, political will, funding coming from both host governments, donor governments, and other partners in the private sector and elsewhere. So let's get started. Dr. Naveen Rao, for the past three years, has headed up Merck's, Merck for Mothers initiative. He is a medical physician. He practiced for 10 years in New York City and then joined Merck 20 years ago and has been with Merck for that extended period. Extensive period of time, working in the labs and health divisions, I think it was 12 years and then a number of years in India setting up the MSD. India programs there with a variety of different responsibilities and now over the last three years has been the lead personality in the Merck for Mothers. So we have a person here who's had very strong leadership responsibilities, enormously varied expertise and depth of experience within Merck and continuity in leading this effort there. We have next to Naveen, we have Tracy Carson, who's a senior policy advisor at the Office of the Global AIDS Coordinator and she's been in that role now for two years, a little over two years and prior to that was the PEPFAR director in Tanzania for five years and prior to that, over a decade with HHS in the domestic HIV AIDS programs and two years in the Office of the National AIDS Program, the ONAP office. So enormous depth of experience in HIV AIDS programs, both domestically and internationally through the PEPFAR program and has played this key role now as this initiative has been launched as the senior policy advisor at the Office of the Global AIDS Coordinator. And then we're joined by Robert Clay, familiar to many of you also, who's the deputy assistant administrator in the Bureau of Health at USAID. He, too, played a... his career at AID had him heading up the population health and nutrition programs in both India and Zambia over an extended period of time. He directed after that the Office of HIV AIDS at USAID and he's been in this leadership position of the deputy assistant administrator for now three years. So what we have here is quite an assembly of expertise and talent that was brought to the task of getting this initiative up and running. And I think that's testimony to the seriousness of purpose that these agencies, these partners, brought to this task. So let's start just rapidly with a quick snapshot on what is it that you do in contributing to this initiative, like what is your role? And you can offer a little bit of why, too, on that. So Naveen, let's start with you. Thank you and I thank CSIS for hosting us, for giving us this opportunity. As they say, nothing succeeds like success. And it's really a pleasure to be here to see the first year results and repledge and recommit ourselves. So with that out there also, I hope I do justice to all the partners while you were right. We represent very aspects of the partnership with this. I represent behind me every mother counts, project cure, ACOG, NORAD, all those. So I hope I do justice to all of them. And at the end of the day, this is really Uganda and Zambia's success. We were just the vehicles. So I just want to lay all those out there when we start. I think it would be helpful if I couch my comments to say, why we joined what we're doing and how we're doing it. I mean, I think that would help. And I'll very briefly give the perspective. Why we joined is we truly believe that maternal mortality is a multifactorial problem. And like any multifactorial problem, the solution has to be multi-sectorial. It's that golden triangle people talk about with a garment, with civil society and private sector. This problem is too big for any one sector to truly believe that they can tackle it alone. And history has shown that it's not working. So what attracted us, the first thing that attracted us was this was a true golden triangle. That the parties being called to the table represented all parts. And so we were excited. The other reason we were excited is that in the past, everyone has approached it as a rifle shot, a silver bullet approach. Either it be with training or with transport or with family planning. I think each parts of it were tackled independently. This was the first time it almost seemed like instead of a silver bullet, we were going at it with silver buckshot. And so that attracted us that we were going to tackle all three delays and so with multiple partners and with a holistic approach, we truly believe that there was an opportunity. So we jumped on board. It seemed ambitious and audacious enough to excite us. So that's why we raised our hand and I do want to give out a shout to Lois Kwam who represented Secretary Clinton when she invited us to come to the table and we joined as a founding partner as I've said, as are the partners that I'm representing. So that was why we joined. What we do beyond everything else on the scientific and business expertise and the financial dollars, I would like to categorize them in three buckets again. The first bucket has to do with customer focus. I think as a private sector, as a business, we would not survive if we didn't have a customer focus and I think we brought that to this partnership. The customer focus here were two customers. One was the host countries and we wanted to make sure, as Dr. Acheng and Dr. Firi said, that we added wind in their sales and that we didn't set up parallel programs and that we were actually helping the local host countries and to do that we needed to know what the customer wanted so the host countries were one customer and the other customer was the woman. We wanted to know what the mothers wanted and are they happy with what they were getting and as we'll go through the Columbia University report that Dr. Scrook and Gallia put out for us showed that indeed women were able to say that this worked and that they preferred this. The third thing is communication and the report, as you can see, these are the kind of things that a private sector does very well and we were responsible to get out. So it's basically customer focus, data, and then communicating the data. So let me stop there. Those are why we did and what we did and depending on what you ask next, I'll let you know. Thank you. Thank you, Naveen. Tracy, the PEPFAR initiative obviously was what made it possible to begin thinking about such an initiative, right? So it started with people realizing the magnitude and the power of that initiative and how it opened other opportunities. Can you talk about that, please? Sure and thank you very much for the opportunity. I wanted to be here but thank you for being so interested continually in this subject matter and this partnership because I think Naveen has talked about the ability to communicate and get the word out in its forums that you often provide that allow us to do that. So thank you because this is really good news that we can talk about amongst ourselves and we can talk about with our partners but we don't often necessarily have the convening authority and power that these forums allow us. So thank you. I think that our role in the partnership and our interest in the partnership is that from an HIV perspective we know that integration is a powerful part of what this administration has asked us to do especially under the Global Health Initiative and partnership is the way that we can do that integration. Our HIV resources can build platforms, they can invest in health systems and they can definitely impact both HIV positive and HIV negative people and especially women but the expertise of helping that mom when she's delivering that's our maternal health and the maternal health platform and the partnership and the reaching across to make that linkage is the beauty of this partnership for us. And so I think we've brought our expertise around training, we've brought our expertise in blood safety, we have allowed for experiences and I think good platforms with the supply chain system also with just the shared volume of healthcare workers that have been brought in through the HIV system but we need that very strong hand hold with the maternal child health platform to make our work as effective as possible. And so this partnership has created I think conversation and partnering opportunities that we didn't necessarily take a fully advantage of within the U.S. government but more importantly from having talked with our government and counterparts is it allowed them to harness us in a way that hadn't been present in its intentional of a way. And so I think that's what we've done is we've brought our program which was incredibly focused on PMTCT and incredibly focused on delivering on the global plan for the elimination of pediatric and also saving moms. Those are those key drivers for us in the partnership and the second prong of that plan is about saving moms and this really fits in nicely under that plan for us. Thank you, Robert. Obviously we've heard the very eloquent statement from your boss this morning. So we've got that already out there. So we're pushing you to say a little bit more around why you're doing this and maybe we can peer behind the veil a little bit more. But thank you. Well, thank you, Steve. And also thank you for calling us. You asked us what do we do in this partnership? We show up when you ask us to come. So but it is a great convening role that you play. You know, we have been working in global health for over 50 years going back to 1961. So when you look at the areas of maternal and child health, this has been central to what we've been doing at USAID. This initiative, I think, offered us an opportunity to partner with others and to, as the Columbia evaluation talks about, have a big push. And I think if you look back about 25 years ago, we actually started working maternal health at USAID. Actually, Marge Kablinski is here with a lot of the mother care work that we did early on, really establishing, I think, the fundamentals of how we move forward. But I think we always were frustrated that we didn't have a champion or a movement behind this initiative. And I think with former Secretary Clinton and this vision, we saw an opportunity. And so for us, this opportunity really was a way in which we could take our past experience working with other partners and really realizing that vision and achieve results. And I think that's what we've seen here. At USAID, we coordinate, lead the government agencies that work in this area. And it's been, I think, very rewarding to see how both at headquarters and also at country level that our teams, as we heard this morning, are really working well together. And I think that's because we've defined very clear roles for each of the agencies to be able to add value. And I think that as we move forward, we're going to be looking to enhance it as we move into other areas. But to us, this is a critical program for us to achieve, as you heard earlier. Dr. Shaw talking about the ending preventable child and maternal death. And that vision over the next 15, 20 years of really bringing us down to an equitable world where we can achieve rates of maternal mortality and child mortality that don't have the discrepancies that we're seeing today. Thank you. Now we have new data. We have the mailman school analysis. We have the Futures Group budgetary analysis as we've got other insights coming from the government partners and from Merck and others. So we're at this moment in which the first phase is concluding and folks are reflecting retrospectively on this complex and compressed, very compressed set of experiences in a remarkably short period of time. And so unpacking that is very important right now in a very interesting sort of exercise and wading through the reports was quite interesting to sort of see what is it that has happened. And let's start first, as you've digested these reports and been hands-on in putting these programs together. Your observations, what has worked? These partnerships are very complicated. They're managerially intensive. They're ambiguous. They tend, I don't think this one is any different than most other partnerships, they tend to evolve in a kind of sloppy ad hoc way in the early phases and there's nothing to be ashamed of in that being the case in the early phase of any startup. I think that's part of what happens. And then things sort of evolve. They evolve and people learn the role definition and the expectations and the contributions and the like. We heard that the general headline is that this first phase has been a remarkable success with some caveats attached. So what has worked to be able to sit here today and say that this is the headline is that this has been a success and a surprise to many of us? Tracy, do you want to start off? So now I want to maybe divide your question into two parts. I think there is the success that we heard this morning when it was really the on the ground at the country level success. And then I think that your, the question that maybe resonated a little bit more on the sloppy side was, okay, so what is at the big P partnership level? What is that kind of forming and coming together? Because I think there are two very different ways to look at the partnership. At the country level, what I've heard from the folks who have kind of put it all together is what worked was being able to come around to one plan at one point in time that was exactly what the governments were asking for and them being able to look across their different inputs to be able to help coordinate us. And I'm looking at my counterparts because they're in the driver's seat on this. And so having that convening authority of our country governments has been key on delivering the success here. And it was from the Ministry of Health down to the district, down to the health centers. The other piece that has been critical and especially critical in my learning around the maternal health field is this was a package. And it was a package that was brought at a certain level to coverage and to a very intentional way so that it wasn't just one piece that was delivered. The presenters on panel one spoke eloquently about both the impact of that in phase one but also the need for that intentionality as you move into phase two. So to me, those were the probably key pieces around the success in phase one was the convening authority, the pulling together of all the different inputs, whether it was the PEPFAR push on PMTCT, whether it's the maternal child health, the increase in health care workers. And I think one of the interesting kind of success pieces around the partnership in phase one was there were certain pieces that the USG partners could do and take on. So we hired some initial health care workers but the governments have now are in the process of taking those over. So it's almost like a turnkey type approach. And that is, that's a wonderful thing about being able to sit at the table with a lot of different actors to say, how do we do this? And then how does it transition? I think in the Big P partnership, we are looking at how to put together actors who come to the maternal health and the HIV space in very different ways in very effective ways. And so I think we're looking and seeing a lot of opportunity both to learn from the private sector about how to do quick wins, how to fail fast, how to continue to push on innovation but also not be so attached to something for so long that you've missed the opportunity to course correct. I think with Norway, they've got an incredible amount to tell us about their results based financing and how to pull this district model into their work and then how do we support that in the different ways that we fund. And so I think that ACOG has got a wonderful amount of expertise that they're bringing to the table. Every mother's counts brought vouchers and it has a commitment to doing that in the future. Project Cure is helping with the supplies going forward. So we're sorting it out, but it's really exciting. And I would hope that people leave here feeling enthused about having conversations or restarting conversations across disciplines that you maybe haven't had in a while. Thank you, Naveen. These public-private partnerships are always very difficult in practice, right? So what has worked in this period, in your view? So if maternal mortality is a sentinel measure and I was always taught that when a country's maternal mortality ratio is high, it basically reflects the absence of any systems. I'm now flipping that over on the positive side saying what is telling me today is that these successes, these maternal mortality reductions, are telling us now there is an operating room that functions there. It's not just only going to function for cesarean sections. There is an operating room. There are healthcare workers who are trained. They're not just only going to take care of mothers. They are trained healthcare workers. So this system strengthening is a success that I see that all the partners had to play a role in. No one person could have got this. And I really appreciate Tracy's comments and giving a shout out to all the partners. But truly, the unsung heroes in this are the country teams that worked tirelessly, that believed in this, that when the night was dark and long, they believed that they will be tomorrow. And for them to have stayed the course. And yes, public-private partnerships are messy and sloppy to start with. But I must tell you, I've been on a few. This one wasn't sloppy. I've seen sloppy ones. This one was actually effective. Thank you, Robert. What's worked from your standpoint? Well, first I would say, in Washington we always ask, what does the success look like? I mean, that's a common question when you start something. And I would just say that success to me looks like the last panel. Because in that panel you saw displayed countries that were committed, countries that had plans, professionals that are leading this initiative, working well with partners, bringing in resources, having a vision for the future. That's what we want, really, this whole initiative to be. And so to me, that was success. And what we're, I think, the vision for us in this partnership is really to have that repeated in many more countries. And hopefully we have now champions that will be promoting this in Africa and other countries. But I think it's that ownership and that leadership that really is critical to making this work. You know, communications, a good rule of communications is to repeat it over and over. And you're going to hear similar things from all of us, and that's one good because it means that, you know, we're not diverging from each other. But I would say, looking at my experience in global health, which goes back some time, that it's the systems approach that we focused in this initiative that really made the difference. And it's a systems approach in terms of looking at the community. And we heard about, you know, getting traditional leaders, getting mothers aware, putting birth plans together, or huts where people can go, and then at the facility level that you have the equipment, that you have a system to replenish it, it's looking at from bottom to top, making sure that that's there. Another example is training. We often take people, train them, send them back to the environment, and what do they face? They face all kinds of negative incentives of why not to do what we just trained them to do. And in this process, we really went into the system and we had the whole system sort of be trained and revamped. And I think that provided a reinforcing environment so that these skills could actually be reinforced and continued in the long term. So I think, you know, this is the systems approach was very important. I think the other thing that worked, and it's not total success, but I think we're witnessing it today, is that this idea of the big push and then as the Columbia talks about this long tail. And I think it's very important for this area that we had the big push because as I mentioned earlier, there is a lot of doubts whether we could actually do something here. And as we talked last night, there's a lot of people that just assume that, you know, women are going to die. There's sort of a fatal assumption and we had to really change that dynamic. And I think that's hopefully the reason. And that enables us now to really look at how we're going to have the long tail. But I would say we didn't start this as a parallel program. That's very important. We didn't set this up as an emergency program just to reach mothers as quick as possible. We actually use systems, use government systems. We train people so that we actually have now an integrated program. And I think it's very important to look forward with this, with other partners, with their own resources. And I think that's very important. The final thing I would say is that this was a proof of concept. So we did spend a lot on monitoring and evaluation. And I think that was critical both for giving us this feedback that's very important that you see, but also to reinforce that this for those of you in development, I mean, you know that global health and development is not like building a bridge. You don't know everything at the beginning as you start. So you don't have all the answers. You know where you need to venture, where you need to go, but you need to have learning in the process so that you can make changes. And I think that's what we demonstrated with this past year is that we tried new things, but we made changes. And it's that learning approach that I think is going to be critical as we move this out. Not a blueprint. Everything can't be just like what we did in Zambia or Uganda, but we need to adapt it to the countries and learn and use the same methodologies in terms of learning and then adapt it to those countries. And I think that's been very successful in this program. Okay. So, thank you. I'm looking back. Everything, of course, wasn't perfect. There were discoveries along the way of things that didn't work quite as well as you might have hoped. Why don't each of you say, tell us, if you were to, in retrospect, given what you know today, what was the one thing you would have done differently starting out 18 months ago or 12 months ago? Is there one thing, one critical thing in your mind, one lesson that you would have translated into a different approach of some kind? Navin, would you like to start with that? Before I go there, I just had a flashback. I must share this story. I don't know Dr. Chang if you remember, but two years ago, when I first went to Uganda and I went to Dr. Chang's office when we were discussing this program at the end of this, she said, Navin, will you pray with me? I had never been in this situation. I didn't know what to say. She sat me down, she held my hand and we both prayed. We prayed for the benevolence, we prayed for the success of this program and my God, maybe I should do that every time now. No, but I truly believe maybe that's why we are where we are. But if I were to go back and say one thing I would do differently is I would have communicated more. I think what communicated amongst ourselves much more to a certain extent, I think we left the local teams hanging for a long time till we got our act together. In retrospect, that was not fair and I would communicate more and we would have made the tough decisions that we really did make, we would have made it earlier so that we would have supported the local teams better. I think it's hard with the results on the page to say oh my gosh, what do we want in retrospect, what should we change because I'm really proud of what was achieved. I think that someone spoke last night from Zambia and he said they were audacious targets, they became ambitious targets and they're now feeling like realizable results. I have a hard time almost stepping back to say what do we do differently because driving that sense of urgency and putting that big vision out there transformed I think the conversations and the amount of energy that came behind the initiative. I think that you can't take that away from it but you have to also realize going forward that level of energy has to be modulated across a longer period of time. I don't know that there's a lot that I would have done differently at this point but I do think that sense of high intensity sense of high urgency we have to figure out how to take that enthusiasm and really modulate it for a much longer period. You all sound like that excerpt from the Walter Isaacson book on Steve Jobs about how Steve Jobs would take his teams and give them impossible tasks and bend them I think there was a term he used around bending the universe and took a certain pleasure in this and it sounds like you've all gone through you've gone through this universe bending experience and you may still be in it I don't know. Robert what are your thoughts that are very different in retrospect? I think the best way to approach this is to look at over the last year what have we modified because if we're really true to the learning model we've actually learned and modified and therefore those are the things we would have changed and I would just there's lots but I would say and it's represented actually this afternoon we're going to have a leadership council meeting and we're actually going to have here with us to talk about what we're doing and I think what we've learned is that we need to we need to engage our field both our country counterparts but also our US counterparts in country more in the leadership discussions and also have the feedback from them more on the table so that we're actually you know in many ways I've been in the field I can't claim that anymore since I've been in Washington too long but the field can teach the central a lot and I think there's a problem in that Washington is our powerful and we sometimes think that we have all the answers and we do have a very important perspective but also our field offices perspective and particularly on how this is implemented in the constraints and what will work in the social context that we're working in and I think being open to that that's an area that we're really focusing a lot more now and I think that's something if we had done that early on in the program I think we might be further along in that realm. Thank you. We're going to move to the last question and before we do that I would like to just give a little forewarning that when we get to the end of that I'd like to ask Dr. A Chang and Dr. Peary to offer some comments to kick off that segment if I could just give you a shout out on that and hopefully we'll turn to you momentarily it'd be very important to hear your thoughts on any part of this conversation that we've had. So the future this initiative started as a proof of concept as an initiative, as an experiment as you've said this crash course and let's see what we can do let's take this multitude of partners and push ahead we're at the end of that first phase there's outstanding questions around where does this go in terms of financing, political leadership what kind of model there's some three or four key outstanding questions that are going to need to be answered looking forward but it seems to me that even above that is the whole question of what next like what's the vision is this initiative is it a transitional and catalytic initiative that is supposed to lead to something else or in five years time are we going to be convening here again or in two years or three years time and having the same assembly of partners talking about where we are in this with a broader group of countries but the framework will remain pretty much the same so maybe you could tell us even in the midst of the deliberations that are underway and I realized decisions have not been taken to some degree in defining what that vision is and your leadership council is charged with that and certainly higher ups within our government and within the partner governments but just tell us even with those constraints what do you see as the future I mean Navin when you talk to your president and CEO and he or she says where are we going to be in five years with this what's your answer I'll frame it in my vision of where this could go and obviously we need to work towards it but I can see where these early results form a pull model not only for Uganda and Zambia to scale up within country but for other countries that have this problem to realize that if there's a concerted effort and their partners brought in that this can be tackled and we are invited into other countries to work with them to kick start this so that we can have the impact we are having in Uganda and Zambia I have vision I dream that we have more partners that this is a movement and that basically we've all come together and said enough is enough we won't let these mothers die Tracy I think that's like that's applause warranted so I think that my vision also could be divided between okay so what can happen within the partnership but what happens with all of you all and I'm hoping that within the partnership we continue to help bring this to scale in Zambia and Uganda that if there are countries that USAID would like to move into that we can partner with them as that happens and that there's very concrete and specific roles for the other partners within the actual partnership the bigger vision that I have is that this women and mothers eight times more likely to die in pregnancy this is a critical conversation for our work it doesn't matter if it's within saving mothers or just within work within the US government or within any other fund or so this is a critical conversation for the HIV community the maternal health community is our solution whether it's and with the governments in the driver's seat but we have to have that conversation and it has to be brought bringing us more intentionally to the table to solve and bring the resources together and that my bigger vision is that as we look towards the post-2015 environment that we really do look and say that integration is how we solve these problems integration requires partnership that we deviate from what our core mission is but it means we can do it a lot smarter we don't have to duplicate we don't have to overlap and we don't have to make assumptions about gaps that we think another platform is filling that maybe hasn't been ground truth or isn't working as well as it could be and we actually have an intervention that could help influence that and so that's probably the bigger vision Robert within five years are we going to see AID as the lead agency operating at a much different scale in pushing this initiative forward is that likely to be is that one pathway looking forward I mean there is this question around okay where do you go from here what's next well I talked earlier about this opportunity that we have right now because of the results and the ability to demonstrate it's hard to predict how this will play out we're hoping that this will lead to increased funding resources we have many constraints in the US government but that's I think we have the tools that and the data to make that argument much stronger now so I think we're in a stronger position I think the other important role that SMGL is going to play is sort of as a catalyst an incubator of good ideas and we certainly see the incredible important necessity to increase in Zambia and Uganda but we're also looking beyond that Dr. Shaw mentioned a couple more countries but even beyond that USAID has a much broader maternal health platform and we're looking at these programs being able to influence those programs as well when there's learnings and lessons we want to pick them up and be able to disseminate them throughout the work that we're doing because we have this vision of looking at ending preventable maternal mortality we're working with many of our partners to come up with exactly what that means just like on the child survival child side and by 2035 really trying to get the world and I think SMGL is going to be a very important contributor to that it won't do it on its own so we're going to be having to influence other partners and most importantly in this whole equation is country governments because if you look out over the next 15-20 years that's where the majority of the resources are going to be in order to tackle this program so we're certainly focusing a lot of attention on that thank you very much now, Dr. Acheng can you offer a few thoughts and then Dr. Peary if we could ask each of you to just offer some reflections on any piece of this the future what worked, what didn't work well thank you very much what worked, what didn't work first of all the most important thing in there that got us moving was the strength of partnerships as they have very well elaborated and being focused on one common goal and the goal here was to reduce maternal mortality to address preventable maternal death and ensure that the mothers actually stayed alive as well as their babies and everyone was in for that and that is what caused us moving irrespective of the fact that resources were limited so if I was asked that what would you have done differently at this point in time I think everything we did was very good to the best of our ability and everyone was very committed the other important thing was the coordination meetings were held everybody was in there and everybody was doing what we were supposed to do without you know diverting from the original goal so coordination is very important when we set out to do these very ambitious projects you know sometimes you may have other things to do but when you're focused in doing certain things it moves very well of course the other was getting the communities and the countries to own you know to own the whole program because sometimes people feel programs are being imposed on them and they don't you know understand the whole depths of the whole program but getting them to own the program to believe in the program and to know that the program actually gives good results is very important and in this case of course getting the communities to drive the program was very important resources are extremely important we cannot do without the resources and in this case there was the financial resource that you know the partners put in to make this successful we are extremely grateful for that but then there are also other resources that we have to consider and this is the human resource that actually does the work and you know drives the whole program to success and this was also extremely important moving forward in the scale up the most important thing that is going to cause us to move forward is better coordination with all the partners in this initiative of saving mothers giving life there are many partners all over but if they are not brought on board with a common goal it is difficult to drive the initiative and I believe that that is where the strength will lie in better coordination and availability of resources and finally allow me to thank all the partners and to thank Naveen for praying with me I had actually forgotten that part but when he reminded me I also had a flashback and you know I saw him seated in my office and a very humble man you know speaking in a humble way and he didn't say no when I requested him to pray I believe our prayer brought us to where we are today yes and of course all the other partners we are extremely grateful for being very very very you know helpful very humble very understanding in spite of the difficult situations we have in our countries sometimes they are the motivating factor we go ahead and say yes you can do it even when we are saying this is impossible you know they keep on saying let's try you can do it it is possible it can work and I want to thank you wholeheartedly you know from the bottom of my heart thank you Dr. I'll start with what didn't what didn't work or what were the challenges I think the time when SMGA was just starting that's the time when the ministries were being split and we had changed government and the Ministry of Community Development was created with no manpower and no money and they were in charge of the program while the Ministry of Health had the money and the manpower but were not in charge of the program so I think that is a challenge and I think what I really liked is that in such a situation sometimes you find that one partner will go this direction they will do their own things but because of the understanding of the partners and the partnership which was there the coordination went ahead when we finally found our feet we were able to move together we were challenged at first and we were trying to understand the program but I think when we did finally find the program it went ahead and I think the biggest plus was that this program was ingrained in the district health system which never moved at all it still stayed in the same district so the district health management team was existing and they are the ones who are the implementers who carried on with the program so partners go there they work with the district the districts continued coordinating I think that was a very big plus that I noted and I think as I said the coordination between the different partners went on quite well until we got the results and we always were on top of the results finding out what is going on monitoring together and being given feedback and giving advice on how to improve on certain indicators I think that's basically what I think worked and did work thank you we have about five minutes so why don't we field let's say we'll bundle together three comments so we'll three people there's one hand right here and just please identify yourself be very succinct there's a microphone coming around behind you and we'll bundle together three quick comment questions my name is Jane Caps and then we'll come back to our speakers and allow them to pick and choose these and we'll wrap up so yes my name is Jane Caps and I'm a consultant I do quite a few evaluations of health programs Robert has been the recipient of a number of my debriefs in India and Zambia over the years I've been focusing on larger programs the last few years and I want to congratulate you first on all on having data data when you do evaluations you look at the data and as I have looked at the data in the back of this preliminary report the one thing I can say about data is the data will tell you the what but it won't tell you the why sometimes there's very good reasons for both and sometimes what we think led to the findings positive or negative are not what we think they are having said that I would like to bring forward a question from the last session where our colleague identified that in your own report and your own data you've identified a pre-discharge increase in neonatal mortality that doesn't say why it could be there for many many reasons one it could be that sicker babies are being born in the facilities but I would recommend that before this has a wider release or is finalized lest you be bombarded with saving newborn lives and other people who are in neonatal survival that you look at what might have led to that. Thank you. Thank you. We have a hand here and a hand back here so Shwin yes come on Claire yes right here and then we'll come to this gentleman in the back and then we'll come back to our speakers yes please. Thank you I'm Mary Carnell from John Snow Incorporated GSI thank you very much for putting this all on and we're all grateful to the work and we're all grateful for what looks to be success my question is also kind of data driven and I'm really pleased to see the results but knowing how hard it is to measure maternal mortality and over such a short period of time and probably relatively small population of four pilot districts is this only trend data or is there any statistical significance to any of the findings and how many births were there total in the two countries in the four districts over the project period today. Thank you. Thank you. Just behind there Hi I'm Daniel Singer from CDC Malawi the achievements are tremendous but as you said with your reference to Apple it came with tremendous effort and that wasn't just a commitment of resources but time and focus from the government from the partners who were on the ground there there was a lot of energy that went into these districts so as you get ready to scale up how do you how can you assess whether the focus that went into maternal child health which is a great cause for success for those who work in maternal child health wasn't having adverse effects on everything else going on in health do you know what was happening to malaria programs what was happening to immunization and vaccine programs in those districts because the great fear is that you're taking human resources, you're taking material resources and you're putting them on this problem and these are countries that don't have those resources to spare so Dr. Rouse hope that these operating rooms will yield benefits in other cases where surgery is needed that's a hope but what will you be doing to look at that? Thanks very much Dan let's take one more we have a hand here and then we'll turn and ask Robert to kick things off Hi my name is Smita Gudapakam and I work with the Consortium for Affordable Medical Technologies at Massachusetts Hospital Center for Global Health thank you for sharing your lessons learned in the partnership it's very informative for our group as we gear up to launch a wide partnership in India with the generous support of USAID my question is in terms of what do you see the role of technology in the coming technology innovation in the coming years for SMGL and how do you see that achieve some of the goals that you've planned so it would really be helpful to get your comments on that. Thank you so we'll wrap up with closing remarks addressing some variety of those questions and Robert if you could start off. So this issue of the neonatal I think it's we admit I mean this was not really first a big focus of the initiative so I think to assume that we were going to have a major effect wasn't realistic given the way the program was designed in fact we've started the program looking at 24 hours and we expanded it to 48 hours trying to include more of the neonatal period but this is an area that we need to be focusing on and I think this shows the learning process is that we've got this information and we heard earlier in the earlier session that this is going to be a focus of the program more as we move forward so that's what I would say and I think we do have to explore whether it's just better reporting that we're able to find something else going on but you know it's a good it's a good flag and something that we actually will be discussing this afternoon on the MMR and how to measure it it is difficult we put a lot of tremendous funds and resources into this I'm not the expert we have others in the room that we could actually have them deal with that directly and actually there's a report I think that's available that CDC really took the lead on this and so they can address that and then in terms Dan of your comment about the effects of other initiatives I think you're right that this did have a tremendous push to it and a lot of focus and our feeling is as the next phase we're not going to have to have that same level of intensity we have information we have experience that we can actually build on so we're not we're not envisioning monthly trips from Washington to come out and to visit our teams and that was a lot of the intensity that went on at the early phases but the point is also that we need to be monitoring what's happening broader and I think it's both to see the effects but also both the potential negative effects but also the positive effects and I think we need to monitor that we're not presenting the whole programs of Zambia and Uganda here there's lots of other things that were going on in those districts that were happening we didn't report on that so it's a good flag for us to watch as we move this out Tracy so on the the data piece I'm always a great believer in just sending you to the source so for the two or three people who know who they are in the room could you just raise your hand so that if folks want to follow up and stand up Howie, Isabella you guys stand up so that people know really who are our data drivers and if you have very specific questions on these pieces please just come find them because they have an art itching to answer this question I'm I'm she's about to jump and grab the mic so please just follow up with her because she'll do it much more eloquently and much more specifically than you're going to get probably from from this panel in quite in a lot of honesty on the time and focus and any potential adverse effect I hope what we learn over time is that the integration actually goes and reduces that I think what we're hoping is that as you actually integrate your training curriculum and you integrate the trainings themselves you pull fewer and fewer people out for very distinct issues and then take them out the next time for the next one and so I don't know that we can tell you that that actually happened in this first 12 months and I believe that that is what we are trying to achieve it's certainly what I heard from the folks on the panel the first panel was that that is they're part of their in game and on technology I think that I can't let this go by without just turning it straight to Naveen I appreciate that in fact since all the others are taken I'll take the technology and I appreciate the question and thank you right now we have work streams looking at we have work streams looking at supply chain we have work streams looking at helping the community worker perform his or her job to the best and the way to integrate all that would be a technology so if you were to envision and I know our team is working on innovations such as this which would allow us to have a platform that helps the frontline healthcare worker do her job and while she's doing it measure quality take care of supply chains and all of that can be done through technology and it's just a question of time so technology is going to amplify but technology wouldn't have started this project so we needed to show we needed to get the commitment we needed to feel good and now it's the time to bring technology to amplify and accelerate it just one quick thing on technology I think mobile health is going to be tremendous and we've already seen this with many programs in terms of being able to communicate to mothers in very distant villages I was in Bangladesh where we were way up in the mountains and every woman had a cell phone and we were able to text her messages directly in terms of when to go for a prenatal and all kinds of information that you can reach directly so that's going to be a huge huge addition an important tool for us as we move forward Thank you we're at the end of our time so please join me in thanking our presenter sir Our closing our closing address keynote address is by Dr. Thomas Frieden who's kindly joined us here today and is familiar to all of you I'm sure hi Tom welcome he became the head of CDC June of 2009 so four and a half years ago and has brought that remarkable intensity and level of innovation and energy to this task that we saw in other places five years of TB work in India cutting his teeth during the TB crisis in New York City New York City 10 years later New York City Health Commissioner putting in place many of the many of the public health reforms that as Mayor Bloomberg exited just last week after 12 years in office there was all of this retrospective analysis and survey work around what the legacy would be and it was remarkable that the things that the public valued the highest out of that 12 year period were the things that Tom Frieden put in place and with the strong backing of a guy named Mike Bloomberg and so please join me in welcoming Tom Frieden to bring this to a close thanks very much Steve thanks very much Steve and thanks to CSIS for hosting this event this is actually the first time I've been in your new digs they're very impressive congratulations and really thanks for all of the support from CSIS for global health and for the Saving Mothers programs I think what you've heard today and I've tracked it very closely what you've heard today is really impressive for many years I've had the following analogy about maternal mortality you know the old story of a guy who's looking under a lamp post for his keys and somebody else helps and they crawl around on the ground for about an hour looking together and the second guy says are you sure you lost them here and he says no I lost them across the street but it's bright here and I feel like that has been until now our approach to maternal mortality and I really want to thank the public-private partnership that made possible looking and addressing where the problems really are I'll talk a little bit more about the many different partners but I want to thank Rod Shaw for his leadership in USAID and for them taking this on to make sure that we can sustain it and expand it in the future I also really want to recognize Dr. Anjali Atrakar without whom this project would not be where it is she has been steadfast she has been strategic brilliant and also incredibly hard working at getting this project from a conception to where we are today a birth so thank you I also want to thank the frontline staff in the countries that have been working on this because that's where change happens that's where really we're seeing a revolution in how to prevent mothers from dying in childbirth and the reason I used the lamp post analogy is that if you look at what mothers are dying from it's largely hemorrhage and obstruction and infection and those interventions are likely to be only addressed effectively by in many cases surgical interventions but for many years there has been a global consensus that operative interventions to reduce maternal mortality are necessary but not practical they're too expensive they're too difficult to do they require too much of a system so we're going to try a series of other things that we hope might work because we think that this thing that we know works is too hard or too expensive and I think what this project is going to be and I think what this pilot has shown very convincingly is that you can bring operative and comprehensive approaches to scale and that doing so has remarkable results often we are at risk of overstating the results of a pilot I think in this case we have substantially understated the results of a pilot we've shown about a third reduction in maternal mortality in facilities that would be fantastic but we also have a 60% or 30% increase in the number of women coming in to deliver so the actual reduction is undoubtedly larger than that and whether or not the program met its 50% reduction target in one or the other country or in one district or more we don't know yet but the solutions are real and they are dramatic I had one picture I just wanted to show I was privileged to be in Uganda last year I don't know if it's going to project well but basically we're data people at CDC and for those of you interested in data please go on the website we've got lots of data there but what that slide would show is a handwritten chart in the back and it shows that the number of deliveries is from 100 to 1100 and that's the kind of change we saw in Uganda dramatic differences in fact at one of the public hospitals we saw the doctor saying well we used to have floor patients I said well what were floor patients well that was when there were two pregnant women per bed and not enough beds so there were pregnant women on the floor as well and now we don't have any floor patients and at the mission hospital we saw the number of caesareans go from I don't have the numbers at the tip of my tongue but they went from around 40 a year to around 150 to 200 a year and we know that these were caesareans that were all indicated we know we have a problem in this country of too many caesareans particularly on first births but in much of the world there is a caesarean gap and you have to analyze it not just by the country or district level but by the community level to see what's happening because if you have less than a 5% rate in any geographic area bad things are happening women are getting injured fistulas are being created babies are dying women are dying now launching a program of this scale often takes years but in just one year we're seeing real impact of saving mothers on reducing maternal mortality but on strengthening systems and I think this is an area which maybe we haven't looked at enough but once you have someone who can do a caesarean and do anesthesia and replace blood you can also address trauma and trauma is a leading cause of death around the world and often the ways to address it aren't that complicated I think we've had two misconceptions when it comes to surgical interventions in different countries and I credit one of my mentors Dr. Koch McCord for really bringing this data out there and he's continuing to document it the first misconception was that surgical interventions were too difficult to do and what a number of dedicated people around the world showed is that you can train health workers to do a core number of surgeries with a high degree of accuracy very effectively and second that they're too expensive and actually what Dr. McCord and others have shown is that we kind of missed out on something important I guess this is being shown there maybe I can't see it but maybe you can the come down that's okay we kind of missed something in global health there was an ethos that said primary care and prevention good tertiary care problematic but we saw huge proportions of government budgets going to tertiary care facilities that did tiny numbers of patients we forgot that between the numbers one and three there's something, what is it? Secondary care is the district level hospital and district level hospitals can be highly cost effective if they're run effectively, if they're done well so launching this in one year was a tremendous accomplishment and also had tremendous progress for HIV and you've seen the data there but a big increase in HIV counseling testing and initiation of ART now this is not a simple thing, anytime you have someone who tells you you know I can solve this complicated problem with this one simple intervention you've probably gotten over simplification and there is no simple solution to maternal mortality reduction but we know that a comprehensive approach that includes collaborative interventions can make an enormous difference and I think of this Saving Mother's Initiative as basically having had five key components. The first was skilled attendants at birth, doctors and midwives and we know that in too much of the world there is no doctor present, there is no trained midwife present to attend to women so the voucher system addressed the transport of getting people to where they needed to go and that's very impressive and the second were safe facilities and hospitals for delivery the renovations don't have to be expensive, they don't have to be complex they don't have to take a long time by which you know that it wasn't the government that did them right in our country or any country because generally renovations are like you start them, my favorite story on this is when I ran Tuberculosis Control in New York City in the early 90s I got money to renovate our clinics I came back as commissioner ten years later and was able to cut the ribbon on opening them and spend a long time for things to happen but actually within a year because of the real focus and moving quickly they were able to get skilled facilities and that includes very important you know often it's those am I messing something up here often it's the things that are the little details, I can't be trusted with things like computers it's the little details that make a difference and one of the things that we've learned is that you know if you want the nurses and the doctors to be there you have to have a place for them to sleep so putting low-cost hostels in facilities for anesthetist nurses and surgeons makes an enormous difference and allows you to have 24-7 services so safe facilities is the second third are supplies and provision of basic and emergency obstetrical facilities addressing that caesarean gap at the sub-national sub-district level, very important fourth, systems for communication referral and transportation and one of the things that this program addressed that I have not seen well addressed often is the transport issue it's all about location, location, location like real estate right so how do you make sure that a woman who needs urgent care gets to where she needs to be and fifth is quality data surveillance, vital registration by healthcare teams all accessible 24-7 that data is crucial you need to be able to give regular feedback and frankly when I was there there had been an interruption vouchers and there had been a little glitch in the program and because there was data that could be addressed so those five things I think are key it's also important to emphasize that PEPFAR was very important it didn't happen without PEPFAR it couldn't have happened with many of the partners we'll talk about in a minute but it was a totally valid use of PEPFAR dollars because just as this is going to strengthen the health services generally PEPFAR is strengthening health services generally we've documented improvements in immunization rates declines in infant mortality improvements in maternal mortality in PEPFAR assisted facilities and what we've seen is a big increase in uptake of HIV testing treatment just this week actually in another medical journal there was a report from Zimbabwe where they looked at the integration of ART and antinatal care before integration only 57% of women who are HIV positive gone on to ART after integration it went up to 87% so we know that providing good services together really makes the most sense PEPFAR has created a platform a real platform where you can strengthen services by ensuring that you have trained workers, regular supplies good data and regular supervision those are the key components including laboratory services blood transfusion and others and also saving mothers was able to leverage a true partnership the PEPFAR platform the USAID maternal and child health expertise and infrastructure platform and partners the CDC approach to focusing on data and looking at results and outcomes and laboratories the partnerships have been tremendously important saving mothers really demonstrates that many partners have been important the governments of Uganda and Zambia and the government of Norway I would particularly like to thank and to recognize that this was not a US program this was a Ugandan and Zambian program and that's why it had the kind of progress it did the CDC, PEPFAR ourselves at CDC the DOD, the Peace Corps all involved in saying what can we do in the private sector the American College of Obstetricians and Gynecologists, every mother counts and project cure and many many implementing partners in the field it was really impressive to see that at this program as with many effective programs it became a social movement in the field and that's another reason for the progress that you've heard about today we went together with complementary skills to address persistent but preventable tragedies and we're seeing I think very exciting information now that we're not looking under that street lamp we're looking where the key is we're finding the key and with that key we're able to save so many lives I think this year was a proof of principle and now the challenge is really three fold I think because we've instilled hope in women and where I've been recently elsewhere in the world where there's hostility to government services it's often because of the poor quality delivery services delivery is a very common thing and so if you don't get that kind of quality services from the government you're not going to trust the government so we've instilled hope and now we need to do I think three key things as we move forward and I'll stop with this the first is to optimize and expand we know that there are a lot of investment costs that not every dollar that was spent was perfectly spent because we were trying to do a proof of principle it's always better to flood the zone and then cut back to what works rather than do something in a kind of halfway way and then you don't know if it didn't work because you didn't really try it or because it wasn't a good model now we've shown this model works all right now's the time to figure out what are the different ways we can optimize it which vouchers worked how did they work how were they used were the community efforts effective what are the ways that we can get the cost for delivery down how can we scale this up and thinking about costs is not a way to argue for not doing something just the contrary thinking about cost is saying no matter how much money we have there's always going to be there are always going to be tradeoffs and we always need to think of how we can be diligent stewards of the dollars entrusted to us we always need to think of with a set amount of money how can we reach more people how can we save more lives how can we improve health more so the first is to optimize and expand that's the first challenge the second challenge and an area that was partially addressed in this was to make sure that we're fully addressing contraceptive services and I've been in too many countries in Africa where HIV positive and other women have said to me I want to not have more children or more children for the next few years and health workers have said to me we don't have the resources we don't have the commodities to provide to them and we can talk about issues of generating need or other issues but at least we should make sure that every woman who comes forward and says I don't want to have another baby I want contraception we're there to try to provide that because you know in terms of maternal mortality reduction every pregnancy that doesn't happen is a pregnancy that will not result in the death of a woman third to kindle the flame this program is a neonate it needs good parents good family good relatives good foster parents it needs to grow and thrive because like every child born everywhere in the world it can grow up to change the world thank you very much I'd like to invite Janet to do the benediction here thank you there's not much more to say I think we have been extraordinarily honored to have this informed and engaging set of speakers, panelists and all of you who have come to share your insights and information I think that's the kind of model that we're looking for going forward to get high level commitment at the country level in Washington the engagement of the private sector the NGO sector the foundation sector this is a really interesting new approach and I hope we can all stay to come together again to discuss how this moves forward and to see how it can be scaled and sustained so thank you all very much