 We have a great program here for you this afternoon. Thanks also to everyone who is watching online via the webcast. Before we get started, I want to give a thank you to Catherine Strifle and Emily Fakie on my team for their great work helping to pull this event together. Also a thank you to Travis Hopkins for his assistance today. We are delighted to have Dr. Chris Murray here to discuss the Institute for Health and Metrics and Evaluations New Finance and Global Health 2014 report. I'm sure that Dr. Murray needs no introduction, but very briefly. He is a professor of global health at the University of Washington and director of IHME. He is one of the founders of the global burden of disease approach. And his work has helped transform how governments and decision makers measure and evaluate public health interventions. Dr. Murray will kick things off by presenting the new report in his online tool. I will then ask Dr. Howard Buckner, editor-in-chief of the Journal of the American Medical Association and Dr. Jen Keats, vice president and director of global health and HIV policy the Kaiser Family Foundation to join Chris and me on stage for a panel discussion. So please join me in welcoming Dr. Murray to the stage. And let me start first by recognizing that I'm here along with Joe Dielman in the front here is the lead author on the study. And we're very appreciative for this opportunity to talk about the findings. We're also very appreciative to Jama and Howard Buckner who's here for publishing the main findings and then in addition there's the more detailed supplementary tables and graphs that go along in the report. But the main messages are there in the piece that was published last week in Jama. And I'm going to show you some of the key findings in this research using the online data visualization that's available there now. And I think some of the visuals you'll recognize from the Jama paper and from the report are similar and probably easier to follow in the online version. Before going through the sort of main empirical findings just a what is this type reflection on the work on tracking spend? So at the Institute for Health Metrics and Evaluation we do many things. One of them is the global burden of disease which is our attempt to systematize the world's evidence on what's happening to human health by population over time by country. And then in parallel we have this body of work trying to track where resources go. And the focus here is on tracking what we call development assistance for health and those are resources that originate essentially in northern countries that go towards health or with the primary intent of improving health in low and middle income countries. And our definition of development assistance for health includes monies that come from the World Bank, regional development banks from private philanthropy and from private donations which is a broader construct than for example overseas development assistance. So that's what we call DAH, Development Assistance for Health. And what we try to do is take all the financial statements of various organizations and work through the challenges of double counting and figure out what the totals are and where do they start. And for the very first time we've been able this year to connect both the source of the funds, the institutional channel by which they flow and also the health focus area as well as the country and region where the funds go. So we've in the past been able to track pieces of that story and now I think what's really interesting is we've actually been able to weave it all together to give you that view from source to channel to final health focus area. And I'm sure in the Q&A part we can explore what this means and I'm just going to sort of give you a tour of the main findings from this effort at pulling together the information on the dollar flows. I'm not going to talk about one the other part of financial flows which is what governments themselves spend on health which is a larger sum of money globally than what comes from development assistance. And just as a reminder that even in Sub-Saharan Africa where development assistance is large and many countries are low income it on average development assistance is still only 40%. So 60% on average is coming from governments themselves. So bear that in mind as we think and reflect on the development assistance for health component. So here's a signature graph that shows in constant dollars updated to 2014 US dollars from 1990 through to 2014 what is the total development assistance for health and you can see the sort of three phases and it's broken down by country of origin. So the bar for the United States is not just the US government that's all sources based in the US. The bar I mean this is actually channel sorry that is US bilateral. When I show you source it'll be all sources for the US. So on this diagram you can see that we started off at about six and a half billion dollars in 1990 and we're up to around about 35, 36 billion dollars in the most recent four or five years and there's clearly three phases of the growth of spend and there's a slow growth period from 1990 to about 2000 a rapid growth of about 11% per year to around 2010 or 11 and then a period of sort of flatline with some variation year to year from 2010 onwards and on the right hand side you can see absolute change in spend by different channel the big growth for example and this is from 2000 to 2010 during the period of rapid increase the big growth of the global fund, the growth of NGOs, the growth of the Gates Foundation in absolute terms and then the huge growth of US expenditure if we change that to percents you can see Gavi that was essentially zero in percent terms looks very large if we go back to absolutes you can see the absolute change now if I change this period of growth from 2010 to from 2010 to 14 sort of flatline period you see a somewhat different story about growth in the period US flat from that period UK continuing to grow continued expansion of money flowing through the UN through Gavi through the global fund and through direct programs of the Gates Foundation now if we back up to source you get a different picture the US is quite dominant in terms of a source with the UK coming next and then the Bill and Melinda Gates Foundation is the third largest source of development assistance at the global scale and you can see some of the evolution by source over time and I'll show you that in different way in a moment and then finally if we look at health focus area you there's some important findings I think in the more recent time period which is the development assistance for HIV has been pretty flatline there is being continued growth 2010 to 14 you can see it over here for child and newborn health maternal health in the last year the rejection of money into Ebola as you can see it at the global level and you've seen declines in some areas some of the other categories as well as other infectious diseases so flatline HIV continued shift towards more spending on newborn child and maternal health now what we've done as I mentioned I think which is new here and the major sort of contribution of this work in the recent time period has been to connect all up those different static views of or slices of the world which is from source to channel to focus area so this is a nice sort of signature diagram for just reminding us just how complicated global health is because you have over here on the left the actual originating source of dollars private philanthropy we pull out the Gates Foundation because it's so important other governments and then the big governments contributing Australia UK France US Canada and Germany and this is for 2014 I'm going to go back now and do a little bit of history and give you these flows at the macro level in 1990 and not only was the total smaller six and a bit billion but the makeup of the flows looks rather different and for example France was an important donor back in 1990 proportions go and the UK in terms of contributions to health was much smaller go to the beginning of the of the sort of golden era for golden health in terms of dollar growth you have a picture where the development banks were now quite a bit more important and they were before quite a bit more pluralism in terms of sources the rise of new mechanisms like the Gates Foundation and if we go forward again to 2010 at the sort of peak of growth or the end of the peak of growth you can see what's happened is the US has become a major source its funds throwing through bilateral channels but also through various multilateral mechanisms for example through foundations the global fund in this flow money's going to the UN in that flow and finally if we come on to 2014 what you'll see is the sort of state that I was showing where the US is a dominant funder but followed by the UK and the Bill and Melinda Gates Foundation for channels you have the rise of the global fund and the rise of Gavi down here now in this tool we can start to drill in on this so if we take for example the global fund and say well let's just focus on that there's the sources for the global fund which contributors in terms of their resources in each year in 2014 of disbursement back calculated and then what it goes to for HIV, malaria, TB and then for some health system investments if we go back now we can do the same sort of analysis around Gavi and you can see the sort of diversity of funding for Gavi the UK, the Gates Foundation a mixture of other governments in the US so the rise of these new mechanisms that are quite quantitatively large in terms of dollars and their diverse funding now another way to look at the results here is to ask what do countries spend on so we go through the top three donors here's the US you know a very dominant component from the US overall as a source is US government in pink and then I mean US flows to USAID in pink and then to funds to the global fund channeled through NGOs, UN agencies and here by focus area you can see the enormous contribution to HIV from the US maternal health malaria it's a dominant funder for child health as an example contrast that to the UK and you see much less for HIV a much larger fraction going to child health and to maternal health and a larger fraction going to health systems and swap type investments but like the US not quite as impressive a substantial flow through bilateral channels and then the last of the sources that I want to highlight in this sort of review of main findings is the Gates Foundation which has become number three in terms of this list of key sources and the direct giving of the Gates Foundation is a big component but not all they give to the global fund through NGOs, GAVI and monies to the UN as many of you may now know for example the Gates Foundation is the number two funder of WHO and that gets reflected as you see here alright so that's a view from the source end one of the observations I think by linking these up is that there are some health focus areas with dominant funders and then there are some health focus areas where you can see with all the colored lines here have a much broader base of source funding so first HIV, if we look at it from that perspective you can see you where the monies are going to HIV programs PEPFAR and the US programs the most important global fund and then a variety of other mechanisms but a huge important role in this for the US if we do that same analysis for malaria bigger role for the global fund but the US and the global fund together account for most of malaria so another example of if there's major changes in those sources then that's likely to have a pretty dominant effect in the future on flows for malaria and then if you look at the two areas where there's been the most growth in the last four years in the period of flat line, child health you can see just how much more diverse funding streams are for child health but a very prominent role as you'd expect for GAVI but nowhere near that sort of prominence that global fund has for malaria or US PEPFAR has for HIV same type of analysis on maternal and that's probably the last of these I'll show where you can and you know you can all play with this tool online yourselves if you want to sort of you know explore or the findings but here like child health support for maternal health comes from quite a diverse set of organizations and because they're not in the GAVI or global fund framework there's no dominant source from one of the big public-private partnerships to date on maternal health now I know there's some people out in the hall should we try to let them in somehow or okay I just noticed them sort of milling out there and let me just close this sort of framing of the discussion with just the geographic pattern that's there and I won't go into great detail but of course there is a geographic pattern this is showing development assistance in 2012 because it's a bit more of a lag of being able to trace it to the geographic areas than there is for some of the other components that we track but this is showing development assistance per dally no sorry per population let's switch to dally's in 2012 and just to show the places and you can just sort of get rid of some of the smaller areas the places that have sort of more than twenty dollars per dally you get you can see the prominent role in that respect if you think of dally's is a metric of need for the PEPFAR corridor as well as a number of select other countries where one prominent donor for example the Inter-American Development Bank and the World Bank of investments in Argentina which is the reason it lights up like that and you can find similar stories for some of the other countries like Mongolia so that's a flavor of the findings and what insights that have come now from being able to link all the way through from source to health focus area and also there's been a lot of work that's gone on and trying to tease out a much more rich set of health focus areas than has been possible in the past you know I'm sure it's going to come up in Q&A because of the division there between newborn and child health and maternal health and because if you think about it compared to dally's one of the things that's in the JAMA paper that we highlight is that maternal health in terms of spend per dally is about the same level as HIV and then everything else is dramatically lower per dally so there's maternal and HIV but the maternal numbers I think we have to interpret taking into account that maternal interventions may also affect newborn you know more early neonatal mortality and that's not reflected in that dally denominator in these analyses so you might make an argument that if you take that into account eventually the spend per maternal and early neonatal dally is lower than in the case of HIV so just that further reflection to what's in the paper and in the report so I'll stop there and hopefully that was a good sort of intro to some of the material that's in the paper and in the longer version in the report so thank you very much or fall down as the happen to pop the wall all right well at least I think we're popping the wall well while we're waiting for that to happen Howard why don't we turn to you to start with a few minutes of comments you know Jama receives thousands of submissions every year for publication what made you choose this article yeah so Jama the Journal of the American Medical Association gets about 5,000 papers each year we send out for review about 1600 and then ultimately we accept about 240 and the process is rigorous I know Joe's in the audience he knows how rigorous it is because I tortured him for three months over every single word in the paper but the peer reviewers thought that this had been the single best analysis that they had ever read about the flow of dollars over 15 year period in global health so we go from five or six billion dollars a year that moves from rich countries to poorer countries to about 30 or 35 billion where does it originate what does it flow through and where does it go and the peer reviewers felt that this was the best analysis they had ever seen why why was that important to Jama well one it's unique and it's innovative the analysis so we're always interested in papers that tell a story that people haven't really seen or heard before the second are the data true so are the results valid and I think if you read the whole report particularly the supplement you'll see the care that IHMP took to make sure that their analysis of the data were accurate they could be off a little bit and they acknowledge that in the limitations but generally they've given an incredibly wonderful picture of this flow of dollars and I think the last reason it was of great interest to Jama is if you think of the eras of global health globalism which is in the newspaper every day it's on every medical school campus every academic medical center is now interested in globalism there's a great greater shift of dollars than ever before I think we've come to the end of the first chapter which was the investment so that begins in the late 1980s and it seems to have peaked it may increase again if the economy gets better but you've seen a great increase in investment it may grow a bit more depending upon what happens with the Gates Foundation and the Buffett dollars and how much of that eventually goes to global health but now there's the next question to be asked are we spending $35 billion well which is an incredibly important question so what Chris didn't show you is the other data that he also generates which is under 5 mortality and the world has come down substantially over the last decade the crisis in HIV AIDS is very different now than it once was is that a result of the way the dollars have been spent in order to move to the second generation of global health we need to understand the flow of resources and I think this is a landmark paper because it will start the discussion about how we move from just giving away dollars to understanding whether or not we're giving away those dollars in a way that provides value both for patients and for countries the last comment I would make is we know that the future is non-communicable diseases and infrastructure and what was tremendously disappointing in the data was this very small investment both in infrastructure and non-communicable diseases now the struggle is when you face a global epidemic that's affecting an entire continent like Ebola how do you acquire new dollars to invest to stop that epidemic we are much more effective at the approach to emergencies with respect to infectious diseases than we are in building infrastructure and so I think the next part of global health will be to understand how to use those dollars to build an infrastructure that can also respond to epidemics Jen I'll turn to you for a few comments Thanks Talia and CSIS for inviting me to be part of this and to Chris and IH Amina's team and Joe this is the most comprehensive research on financing in the world we all use it, we all look to it and it tells the most complete picture for us to understand implications for policy, for practice so thank you again for doing this so I was trying to take a step back and say what does this all mean for policy and the implications for the future and there are four points I want to make the first has to do with the MDG agenda and success of it the second about the flattening of the resources the third about the US role and the fourth about the risk of backsliding so on the first I think it's pretty clear from the data that the MDG agenda has been a success and I'm putting that in quotation marks and I'll come back to that but if you look at the data whether it's literally the goals themselves or just the galvanizing around those goals the response, the leadership, political will, finances and frankly I think a confluence of factors and historically that we probably will never see again or may never see again it's sort of an unprecedented story that we see in the data and that's very significant and then which leads me to the second point about the flattening there is a flattening in the funding the resources have flattened and really this is across the board and where you look and so should we be concerned I think the question is we should it is one of the fundamental outstanding issues is how is that 35 billion being spent but the other question is that agenda is unfinished the MDG agenda we haven't finished it WHO just came out with a report saying that there are 400 million people that lack at least one essential health service and if you look at how they define essential health services it's all MDG agenda related services so we clearly and you can look at many measures of that we clearly have not finished that agenda particularly in sub-Saharan Africa so the flattening raises that concern coupled with now we're in the post 2015 agenda and the sustainable development goals and if you look at that proposed set of 17 goals and more than 160 targets it's a much more expansive agenda it's a much more comprehensive agenda and so that has pros and cons health is one piece of a much bigger agenda a much more crowded space today that is going to compete for policymakers attention for resources and frankly for finishing the job and I think that just the appetite may not be there we see it not just in the financing but the appetite may not be there in terms of political will to finish the agenda and take on all the new challenges or challenges that have been under-recognized that we've had in the past the third point is the role of the U.S. and as we saw from these data the U.S. is about a third of all global development assistance for health and if you look just at donors the U.S. is more than half so it has an outsized role if the U.S. goes up that makes a difference if the U.S. goes down if the U.S. remains flat and you can actually we can answer some of what's happening with the U.S. because we know what happened in 2015 and we know what's likely to happen in 2016 which is essentially flat and if you look at specific areas within that some might not do as well but the U.S. is not going to increase and I think that's an important piece to remember and I think the point that Chris made about domestic government resources is a critical one but they're not necessarily going to be able to pick up any gap that remains in the near term and the last point on the risk of backsliding there is a risk I think if we agree that there's an unfinished agenda maybe some don't agree with that especially for infectious diseases there is a risk to not finishing that and we can see what could happen with Ebola we can see what happens with HIV in the United States in places where there might have been less awareness that HIV could be an issue and so I just think it should give us all pause it should give policymakers pause but we know that the fiscal environment and the crowded sort of attention field of attention for policymakers on not just global health but development for all very important causes and issues is going to pose a challenge for that going forward so maybe that's a little bit of a doom and gloom but I don't mean it to be I think it's a realistic sense of where we are and some concerns about the future great thank you well you are a great launching point for what I wanted to start in on last year Chris and you were here we were talking about a 4% growth in funding we were talking about donor resolve we were feeling relatively optimistic this year we're seeing a slight decline a 1.6% decline but that's in a light of an Ebola crisis that galvanized the world attention around global health it's in light of a very successful Gavi replenishment we just saw this week I think Finland announced it's going to be cutting its foreign aid budget by 40% is the where do we see this going what are your thoughts looking at the data is this trend as troubling as it could be interpreted to be I think if you looked at those percent changes by source it's sort of by chance that it's flatline because you've had some declines you've had the U.S. stagnating and then you've had increases through Gavi somewhat through the Gates Foundation so there's no particular reason why things couldn't converge that they actually go down or you don't hear a lot of discussion right now about people likely to increase spend at least I haven't you know there's some places that that might happen but it seems likely it will be either flat or there is this risk of actually declines in a world where the SDG position of health is even a little bit worse than I think you're describing it's a crowded and then you have signature things like the progress on child mortality and although there's a target about ending preventable child death there's no indicator we somehow lost child mortality at least in the negotiations so far and I think it's less the goals and more the indicators and the sort of drive at least my interpretation around MDGs and all that constant attention about progress so I think the indicators matter and you have so many people on this health list that it may be hard to maintain the focus one of the concerns I have is I I don't know if science is going to be the great contributor in the future as it was in the last 15 years the NIH budget is about 30 or 31 billion dollars it's unchanged essentially in five years against inflation it's decreased but some of the great gains that you've seen in global health is because of the investment in science both in the United States and around the world so when you have a pneumococcal vaccine or an H flu vaccine that literally eliminates millions of deaths around the world that's an extraordinary gain I'm not quite sure we're going to see those gains coming out of the basic science engine both in the United States and around the world as we've seen in the past there's some novel developments broadly neutralizing antibodies could give you vaccines that are more widely adaptable but I don't think I'm telling anyone here we've struggled with malaria vaccination HIV vaccination there could be some gains from science but they may not be as great as they were in the last decade so as we move into the SDG phase one of the key pieces when we're talking about the rise of non-communicable diseases and we're talking about a push towards universal health coverage which is a major theme across a lot of the developing world particularly as countries are moving into middle income status it's a very different supporting UHC is very different than the siloed approach that we've seen across individual diseases and I think it makes contributing to health how those flows of money are going might need to adjust the channels that you just described for us to what extent to achieve universal health coverage and support that piece of the SDGs are donors going to really need to rethink the channels that they use to direct their funding and are there ways in which they can impact health system strengthening and some of the necessary infrastructure investments that we know we're going to need Good question I think both the new financing facility that's going to be housed at the bank I think the health system windows through GAVI and other organizations provide some mechanism whether anybody has an appetite for another channel for that I'm not convinced other than the ones that are there and so that's on one reflection that the other reflection about the universal health coverage that thing that's interesting about that at least in middle income countries is that you can broaden the audience domestically of who's interested in financing beyond those whose primary interest is in health because the financial risk protection element the protection from catastrophic spend if you look at a place like Mexico they were pretty effective at getting the ministry of finance interested in that as an outcome and that can in some places has worked to raise domestic spend I think that's one of the hopes there on the universal health universal coverage agenda low income countries it's a very different story where external finance is going to be part of that and just to pick up on that in low income countries I think the challenge there since it is going to be external finance related is convincing capitals that this is donor capitals that this is the way that money should be channeled in the future and so if we agree or believe that the future funding coming from donors at least is at best flat maybe some increases at the margins here or there maybe some decreases if more funding is going to a different channel or different area of health different focus it's going to come from something already so that is the risk that I was alluding to earlier so it's not that it's clear from the data that health system strengthening that basic infrastructure has not been a focus it's certainly gotten funding and bolstering through some of the health areas itself and it's hard to sort of paint that picture but it's not been a focus and to the extent that it becomes more of a focus which it obviously needs to be strengthened it can come at the risk of some of the other things and you're very familiar with the U.S. context and how these decisions are made on Capitol Hill have any predictions on how you see this playing out I think the challenge in the U.S. context is it seems that there's a real weariness on the Hill for global health has enjoyed tremendous bipartisan support and attention in very difficult times and we're still seeing that this year but you're starting to hear more weariness I think around the edges of how much do we need every year it's global health, global health, global health and it's gotten, I think among some there's a sense of global health has really gotten a lot and it's true there's still a gap so that is one discussion or occurrence the undercurrent that is on the Hill and then I think while there's been a really good effort to raise awareness about what health infrastructure means and why you have to bolster it to have successes in child health and have successes in family planning, have successes in HIV it's much harder to translate that at least in the U.S. congressional sense translate that into a line item on a budget or a bill as you know and so I think that's really a challenge just in the basic structures of how our congress works and how things are funded so it's an uphill battle I would say more of a recognition today of why that's important but no closer to a solution of how to do it I would add there's competition for dollars just as there may be awareness about global health investment now there's increasing concern about investment in biomedical research in the United States so it's clear that the U.S. used to spend about 54 percent of the world's investment in biomedical research about 50 or 54 percent now it's about 40 or 45 percent that's of tremendous concern to other parties on Capitol Hill so there are competition for these limited dollars the pool of resources isn't going to get much larger and so there may be shifting and so the attention may shift away from global health to biomedical research investment in the U.S. On the opposite of the doom and gloom side there is a big pot of money that exists for which it may be increasingly possible to make the case that health should have a larger share not smaller and that's IDA so you think the bank's mechanism around IDA a lot of the money flowing in is payments of old IDA loans and so even if the donors aren't replenishing at the same rate there's still a lot of money in IDA and traditionally IDA has gone quite a lot to infrastructure but you now have other actors on the infrastructure front like the new bank in Asia and so there is this question in Margaret as countries graduate out of IDA there's still a big pot of IDA money what does it go for and the case is there to be made and I know people are trying to that education and health should be prominent in that I mean that's not next year but that's something that I think can grow in the time frame and the other you know there's a short term discussion that we tend to focus on and then this sort of venue which is what's going to have a next year or the year after and then if you go out 5 or 10 years you might actually have a very different situation if there's continued economic growth in a number of places that are currently development assistance recipients they may not need very much development assistance and if donors even flat line at their current level that pool may be able to go farther for the remaining low income countries so there are I think it's a different story if you're asking what 10 years outlooks versus you know the next 5 Chris if you had looked at the investment for example in Pakistan or India in 1990 versus 2015 would it have shifted very dramatically over that 15 year period I think in dollar terms there's never been a big issue in Pakistan just in terms of the percent because there's such large populations can I add something absolutely Chris was talking about what might happen in the next 5 plus years which I think is really critical in addition to how the money is being used and should it be used better is this issue of countries graduating and that's going to happen I think every donor should or is looking at that what does that mean and it's going to be so critical to get that right and to work with those countries and donors work across with each other to do it responsibly because if that is the case and several countries if a country for example is going to graduate in terms of eligibility for assistance from more than one donor mechanism at a time that could have a real lopsided effect on their health spend and their spend on other areas that need attention so it's going to be really critical for those countries to get that right and to really make an effort to manage that transition as carefully, slowly and in a coordinated way as possible so that at the end you do get a situation where there's additional funds that could be used where they're still needed versus a situation where there's been resurgence of challenges because it wasn't handled in the best way possible Well and that gets at the PC you didn't go over in your presentation but domestic spending for health those trend lines seem to be going up in a pretty promising way but I think there is still a lot of concern about graduation and whether or not countries are going to be able to support the health advances that have been made with the help of assistance so maybe you could talk a little bit about that piece of the data that you didn't get a chance to talk about earlier Sure, I mean as you say I mean the main reflection there is domestic spending is growing there's less of a relationship than I think we thought in the past of sort of that the share of GDP inexorably goes up as income goes up that relationship is weakened and part of it is the DAH part that's sort of broken that but certainly the share of GDP doesn't go down it probably drifts up over time and may even go up as income goes up as a driver and so we're seeing that play out as long as the economy is growing further to spend just a quick reflection on the graduation issue I think the bottom line there is cliff models are high-risk you get all this money and then tomorrow suddenly you fall off the cliff and there's obviously there's lots of discussion now about alternatives to cliff models that make that a softer landing than abrupt changes and flows So not to say I'm kind of doing the gloom side of things but UNICEF released a report today called progress for children that notes that millions of children are being left behind despite progress towards the MDG goals and that trend length continue and accounting for population growth 68 million children will die from mostly preventable causes by 2030 They note that in the effort to reach the MDGs folks may have focused on the easy to reach children and left behind the harder to reach and the more vulnerable populations and that when you look at data that goes across nations or across continents or across regions that it can mask the underlying problems with those last 20% or the last groups that aren't being reached So I'm interested in your reflections on the limitations of the data or how the data can be parsed down to make sure that policymakers are who we're missing even when we're looking across aggregate numbers I think the on the epidemiological side child mortality, malaria there's been big progress lately of producing super fine grained analyses so something like the malaria atlas project has now produced a time series by 5 km pixels of malaria and that shows you progress in some places and other places where there's not progress same thing now is starting to be produced for child mortality, super fine assessments of where child deaths occur and I think eventually we're going to want to know where money goes within countries to get at this question because if you could line up the sort of outcome side you can see a few years into the future we're going to have available that sort of mapped result for lots of outcomes and if you could track financial flows then you would start to get at what UNICEF is talking about who's actually being left out and where are you dollars really not making progress or the dollars just aren't going that requires a total change in the way the financial flows are recorded so in the health side, on the mapping side sort of getting access and geotagging data but it doesn't even exist in the way most financial books are kept so even a donor who's interested in this doesn't actually able to say how much goes to sort of remote rural areas of their resources and how much does not doesn't mean it's impossible but I think that's the frame shift that you need to be able to sort of say the national tracking is fantastic we can now do this, we can trace it couldn't do it before but the next step is to look in at least urban rural some sort of notion of you know the people who most need is that where the money is actually going and is that next for you is that your well I think you know we we can't do it unless the people who are putting the resources in decide that they want to track where there was where geographically where resources go it's not sort of like you know if you put a little extra effort late at night the way it's sort of a fundamental change in saying this is important we really care about inequalities within countries and therefore we should care where the money goes and let's start trying to track those that information you know here I'm more optimistic that science will help so here big data you know that term big data may actually help you know the world's populated with cell phones you know you will be able to record deaths in very small areas you'll then have to map the resources to those areas and you'll have to know cause of death but if you're talking about under 5 mortality versus morbidity which are very different discussions I think big data and science can help hone the discussion about very focused areas geographic areas where intensive services are necessary also I think you know the data better than I under 5 mortality is focused in a very limited number of countries you're not talking about a large number of countries so the focus could be honed even further focus in geographic areas in specific countries and I do think technology and big data may be able to help frame at least part of the discussion. I'm going to open it up to the audience for questions now we will take probably 3 questions at a time bundle them all together and then turn it over to the panel I've got a couple folks who are going to have microphones in a second when a microphone comes to you if you could say your name where you're from into the microphone for the purposes of the webcast and keep your question relatively short that would be great and let's start with this gentleman right here with his hand up straight down for me thank you very much fascinating presentations my name is Carl Hen from the American International Health Alliance here in Washington a couple things that were surprising I didn't see a category for what used to be an important area of development assistance which was family planning and reproductive health wondering what happened there also didn't see nutrition and was wondering if that was incorporated under maternal and child health or something else and the third question was spending in emergencies I just saw a report that we have the largest number of refugees and something like 2 decades 60 million people and is emergency spending broken down by health as well there's two hands in the back row in the center and then we'll come back up I am Jacques van de Gaak Brookings Institution I'm happy to join the panel by congratulating Chris and his team for this report that has become the standard that we all have to live with I guess my question is a little different about two or three years ago in the same report there was some analytical work in the annex that if I remember correctly we showed or estimated that for every dollar that gets into every development dollar for health that gets into a particular country the country substitutes about 50 cents of its own resources I had hoped that that report which I believe is very true would have resulted in a very lively discussion on how we can do things smarter because before we start we seem to lose about 18 billion dollars of the 36 that we pump in there what happened to that report is there new information are there smarter ideas on how to pump that money into the countries and then if you want to hand the microphone right next to you Hi, Evelyn Cherau Global Partners United two weeks ago the United Nations had their annual conference of state parties on the convention on the rights of people with disabilities and that treaty has been human rights focused in recent years after promulgation but at this year's meeting the most critical piece was healthcare access and that leads to education access 90 percent of children are not included in schools and their health and rehab access is non-existent so I'm not surprised to hear about the UNICEF report that came out today so in that context last year and this year the big emphasis from the 154 countries who are ratifying for the treaty is on gathering disability statistics which hasn't seemed to happen at all in the maternal newborn and child health context if you speak to any of the large programs in that area there are hardly any that have tried to gather anything that has evolved from saving children's lives so the World Health Organization the World Bank estimate 1 billion people with disability and we know that there is growing due to the aging of the world's population and the life-saving efforts at birth that we know in developed countries has led to increase disability the autism epidemic is one of those so I'm hoping that when you look at your next report you might consider and those who are developing the indicators are considering how will we have disability counted it's in a few of the indicators but it is not in the health indicator thank you so we'll turn back to the panel with those I guess Chris starting with you there were a number of questions there that got at categories of data where is family planning, where is nutrition are there statistics on disabilities and numbers about spending in emergencies both humanitarian emergencies so we have conflicts in parts of the world that are disrupting in major ways health systems in Syria and Yemen and Ukraine how is that data integrated into what you're seeing and then also the question about what happened on the diversion of domestic resources in light of development assistance on the sort of categorical definition I'm going to ask Joe to stand up to answer those shout Joe stand up for Joe here Emily is right here thanks so regarding categorical definitions in the report we do break out child health and maternal health a little bit more granularly and I think just for space it didn't make it into the jam article so if you are interested in family planning estimates those are not currently on the interactive visualization but they are in the back of the appendices tables in the actual reports so that includes family planning and also nutrition which falls within our child health bucket and then questions regarding disability currently as far as the development assistance for health that's not something we're currently capturing and I think the limitations on how we break out these health focus areas are the data that we utilize as our inputs and in some cases funding for HIV is very well coded very pretty clear on how those resources are being spent some of the other categories where there is likely less resources going to the coding is is also harder to kind of pick out and grab those pieces so that's not something we've currently broken out so so on the other on substitution so great question and the paper you're referring to is actually there was a paper in the Lancet just on the results about substitution and it's been interesting because you know it's this sort of classic thing there's two camps one camp the sort of development economists who think substitution is great because it empowers ministries of finance to do what they want to do and then there's the health focus people that say substitution is really bad and because the donors and people are putting their money where they want it to go and that's what they would like to have marginal impact with that so there's not as if everybody thinks it's a bad thing so that's part of the landscape and on the other hand where there are sort of commitments to not to have additionality it's been difficult politically I think to say we're going to sort of enforce that or even how to track it so there hasn't been a lot of to actually deal with this issue head on and you know I think there's also probably the more we look at this there's pretty different behaviors out there in some cases where resource levels are now so low there's not a lot of scope for squeezing the sort of government you know funding of their own you know what we call GTS sort of government as source funding you really can't squeeze it much smaller so you run up the point where it's no longer much of an issue whereas in a bunch of other places it is the other thing that's likely true is there's an asymmetry unfortunately which is money comes in there's a little bit of moving money by the Ministry of Finance somewhere else when the donor resources reduce they don't give the money back and so there's also that asymmetry there which could actually create all sorts of things as we think through the future of less development assistance in some settings just last reflection on disability statistics you know there's a wealth of resource to be used which I think is being underused in the quantification of congenital anomalies of disabilities related to neonatal disorders disabilities following meningitis disabilities following cerebral malaria etc and it's all sitting there in the details around the global burden of disease where June 8th I think the Lancet put out our results for disease incidents and prevalence enormous detail and I think there's a tremendous resource to be used it hasn't perhaps been aggregated up in the way that the disability community thinks but there's a lot of descriptive epi there that could be leveraged I was going to make a comment about the question around emergency assistance and crises etc it's a really good point because in this analysis and really all analyses that we all do of development assistance for health it's not included and that's not because of we don't understand that it's of course important and you can't separate out what happens in a conflict or what happens in an emergency whether it's natural or war etc from health I mean that's literally the definition of health being impacted in those situations historically and I don't really see this changing the way that institutions approach those that issue conflicts and crises is in a fundamentally different way different line items of budgets different organizational approaches different authorities to allow things to happen and those two worlds don't meet very easily for those who are interested and we put out a report last year looking at this question from a US perspective particularly saying these two worlds don't meet maybe they should and what are some ideas for trying to bring them closer together I don't it's a conversation that happens but I think it's really hard to impact so they're not in the data but that's just because that's just not how the world right now is organized to approach health well it cuts both ways right because in addition to emergency funding coming from different sources and being ramped up in emergencies you also have disruption of underlying health programs so you may have health programs moving out and emergency funding coming in if the data isn't tracking them then it gets a very infused picture of what's actually going on on the ground I mean the sad comment is that Tom Frieden from the Centers for Disease Control has been asking for additional dollars to set up sentinel centers around the world to understand when epidemics are developing we never received those funds and following the Ebola crisis and epidemic he has now received those funds so it's a sad comment because I think if Tom were here he would have said had there been an investment in over a 5 or 10 year period to develop these local sentinel labs that could do appropriate testing quickly that the Ebola epidemic may never had increased so dramatically as it did so now he's received the funding and we'll see if over the next 4 or 5 years if it's helpful. Well let's come up to the front and just do the 3 in this row here and then we'll cluster sample. Just real quickly on the trend that Jen was talking about it is really concerning that we're seeing a flatlining because I think sometimes the assumption is well these things don't really affect us or the assumption maybe the phenomenon that we're addressing the global health problems are not changing but they are changing because of drug resistance to one example if you look at drug resistant tuberculosis something actually even more dangerous for us than Ebola in many ways and I think actually you'll have access to actually even more recent data given the fact that some of the most populous countries it's only in the last 2 years that we're finally getting access to data that actually show the real burden of disease of TB in those most populous countries so that I think will actually change the statistics rather dramatically but the question I had is child mortality there's no indicator for child mortality in the negotiations going on in the SDGs this seems kind of crazy can anyone on the panel enlighten us on this? Thank you Anthony Dutton from Handicap International normally I'm the one asking the disability question so it's great for Evie to have brought that up so I'm going to ask a more general question the data was fascinating to look at and as I saw the different streams of sources of funding it struck me whether there's anything in the report any analysis or there's a data available about how complimentary they are to one another are we duplicating I know we touched a little bit on how well is that 36 billion being used but it sort of struck me does the right hand coordinate with the left hand or are we sort of really stuck in a cycle of even sort of risking offsetting one effort against another effort and on that note is the data to look into where universal health coverage defines different types of health approaches how much goes into preventative versus curative approaches and so on Thank you Jerome with UNAID and I also had a similar question about efficiencies in terms of how the entire financing architecture weaves together given the complexity of the funding streams I also wanted to solicit your comment on end user specifically corruption and exactly what this money is doing I mean you might not have gone that far in your analysis but do you think that this has the potential or looking at these factors might have the potential of either freeing up more resources for global health or you know in the face of competing priorities even if the budget or the funding remains static could there be potential there for complementary funding Thank you So back to you I think a number of these questions touched on now that you have the channels in your analysis that seems to open up a lot of opportunities for discussion on some of these questions coordination, complementarity efficiencies, whether or not the corruption issue you might be able to get at eventually interesting to think about what the channel allows you to do on these points and then also the question about what happened to it goodness I'll start Howard and Jen try to sum up some of those on the coordination front let's start with simple one, corruption we haven't done anything in our analysis on corruption and I'm not sure we would be able with the types of data that exists I don't think we're in a position to track that I think that needs some other type of sort of function to get at that the general issue around efficiency I think is the huge issue and it's most it's come to prominence in the area of ART programs but likely true in other program areas that you know there's now a wide array of studies out trying to quantify the variability and costs per you know year of effective delivery it's showing huge variation probably tenfold variation across programs so that suggests there's a huge opportunity to learn from programs that are more efficient and as a more general reflection in work that we've done so I know it sort of personally or directly but others have done as well there's probably still considerably I mean the level of technical efficiency in most facilities in low income countries is still pretty low even benchmarking against within each country so forget about international benchmarking just within and that does also suggest there are these opportunities to you know get more health for the available resources in addition to the continued struggle to maintain the resources that are there so I think that's a big topic it'll come more and more prominent over time if you comment about drug resistance you know I think this is particularly lately there's been a lot of interest in antimicrobial resistance and I think there's been a lot of prominent discussion UK government example and so I think there's some optimism there that there'll be some new resources around antimicrobial resistance not enormous but still some so I think in the next few years there'll be something in that space both in the surveillance side and maybe the understandings about it for the child mortality there's probably other people maybe more can tell us the inside story on how on earth we ended up without child mortality as an indicator but my world's a little different than the world of my two colleagues I don't focus just on global health John was a general medical journal so I would I saw your question about corruption I thought it was going to be a somewhat different question we didn't publish a paper about the effect of violence on the delivery of health systems and vaccination programs without going into the details it would have been a very controversial paper and we ended up not publishing it we also have received a number of opinion pieces on corruption and global health dollars and we didn't have the expertise nor could we find the expertise to review them it's a very difficult area and a sensitive issue because you name countries that becomes problematic most times people don't want to name specific countries so it becomes more difficult the issue about drug resistance has come and gone from the medical literature you know it was very prominent in the medical literature to the mid 90s late 90s since my early research on antibiotic resistance and then it disappeared but it's emerged again just in the last three to five years and both federal agencies governments and major foundations have really begun to reemphasize it the Pew Foundation interestingly enough has put a huge amount of resources in trying to understand antibiotic resistance and I think they're acutely aware of it in the United States but they're also acutely aware of the concerns about tuberculosis particularly in countries that represented the old Soviet Union and some countries in Southeast Asia so I'm encouraged that the solution there may come from the more traditional medical groups that are interested in it or the countries that are more traditionally interested in it because it's going to affect them directly it will be a threat to the health of people living in the United States and in other countries that are resource rich that science may progress to help in that particular area I was going to make a comment about corruption because it clearly is something that comes up all the time when you're doing global health development work it comes up on the hill, it comes up with the constituents, it comes up in the media we do polling of the American public and we ask questions about what the public thinks in terms of the levels of corruption in U.S. dollars spent on global health and it's a huge percentage that people think is being lost to corruption and when you stop to go well what's the reality nobody actually knows the answer I think those of us who work in global health think it's not what the public thinks it's there is some corruption that's the price of doing business in every program every program is publicly funded and probably privately funded but what it is is very hard to measure it needs to be measured we're so interested in this question experts who look at corruption in health and development to talk about it and we put out a report, a summary of that discussion and it was a really interesting discussion to talk about how you can get at it, what the auditing function could be other ways to look at it it's not that easy to measure, it clearly has to be measured and so if that is of interest there's some information and growing interest in this question I would just add global health doesn't live in the isolation of other trends in the United States and what influences both citizens and politicians, all of us so for example, we spend 2.7, 2.8, 2.9 trillion dollars on health it's 17, 18, 19 percent of the gross domestic product you've heard the numbers, they're relentless the suggestion is that anywhere between 7 or 8 or 10 and 20 percent of that is wasted dollars and whether or not you could refocus those on high value care those same issues now are going to emerge in the global health and the spend of the 35 billion dollars and I would argue that the global health community cannot avoid that discussion because it's occurring in every donor country and because it's occurring in every donor country it is going to eventually affect the flow of dollars where people are going to begin to say, tell me if you're spending those dollars wisely I just can't imagine that that discussion wouldn't emerge over the next 5 or 7 years and if you think that the 30 or 35 billion dollars is flat and not going to increase dramatically then you would really like to understand the efficiency of the way those dollars are being spent so that they could be spent more wisely or shifted to areas of higher yield so the same discussions that are occurring in the United States and around the world around efficiency will come to the global health community dollars I think an important follow up to what I was saying that you just alluded to is important here people use the term corruption it's really much more complex than that you can have to unpack it maybe not spending things in the right ways in the right places maybe not understanding we had a target money how to have the systems to get the products out to the field that are needed at the right time that's not corruption people use corruption to capture a whole range of things so it's really unpacking that term and understanding where it's about efficiencies because this is literally corruption which is taking money that's supposed to be used for health and using it in the wrong purpose just flat out using it incorrectly that's a much smaller share of what we're talking about but it is something that stops Congress when you look at needing to support systems or needing to support countries themselves there's a lot of hesitance in our government to do that because no one trusts that the money is going in the right direction that's impactful I've got a handful right here and then I promise we'll come over to the side of the room thank you very much my name is Michael as I fall I've looked at the figure 7 which presents these flows from multi sources and the question that comes to mind is do you take the U.S., France Germany, Britain and so on their priorities are not always the same their perception of the healthcare system are not always the same and then you think of receiving countries they also have priorities which are not necessarily the same I think some further work is needed to look at what happens and how can we improve the way that multi funding gets to the countries and how it is used even when it comes from a U.N. agency the U.N. agencies all employ people who come with knowledge of the healthcare systems in their own countries and therefore the agendas that are not necessarily in consonance with the first of all the problems of the countries and the needs of the countries one area I can cite very clearly is over the last 50 years we have neglected the question of health, personnel training, deployment and maintenance and this is why a lot of the funds that I've gone in have really not provided indicators that in other words it is great and these global statements become more wishful thinking than empirical evidence we can quantify and say we've made progress here, thank you very much. Thank you, if you could hand the microphone in front of you. Hi, Jason Saridhar from USAID I just want to thank all of you and my question kind of pertains to the same figure seven the permutations that were brought up in the slides I noticed going through that was that with the exception of Great Britain there is very little investment in health systems support and health system strengthening I just kind of wanted to see if you guys had any ideas as to why that might be given that between health systems and NCDs those are two of the big things we need to figure into our collective agenda going forward so is the lack of health systems focused kind of based on the verticalization of donors is that poor M&E is that disruption what kind of attributes to that Hand right in front of you I'm Heidi Ross with Malaria no more and my question actually tags on what Jason was saying and that is that I'd like to hear a little bit more how you categorize the health system strengthening money because I think a lot of us would argue that various programs do support health system strengthening malaria, PMI, Trains Health Community Health Workers we know that the impact of Ebola was lessened in Nigeria in terms that were put in place as part of TEPFAR and as part of GAVI so I'd like to hear a little bit more about the health system strengthening and how that was done in this report and then on top of that hear a little bit more about how we can get better data surrounding health system strengthening because I think that it gets a bad rap on Capitol Hill because we don't have a lot of tangible things that we can point to and that health system strengthening is going to be a key component of the future of global health and so how do we tell that story better and what are some of the questions there on health systems kind of what does it mean how do we sell it, how do we get the data I would add to that in addition to the bilateral programs the support health systems, what about the multilaterals GAVI Global Fund and then also the question about differing priorities which I think gets towards country-driven processes which is one of the goals of the sustainable development goals that these be country-led priorities but is that how is that going to play out so on the health systems front first on the definitions that what gets labeled as health systems are projects where that's the primary focus primary stated aim so it's certainly possible and likely that investments and other things can have spillover effects on health systems but those aren't captured in that bundle to the question of why there's less investment in health systems I mean so there's a lot of rhetoric about health systems there always has been this is not a new topic I mean you go back 20 years there was always the same discussion that this is a weak point so there is actually resistance to investing in health systems despite what anybody may say because the policy discussion is always the same and there hasn't been a big shift in the dollars and I think part of that is about accountability for donors to report back to their legislatures and with clear metrics around accountability to say your dollars or our dollars did X and led to Y and that's just been a harder thing to do and then there's been waves in the health systems world as I'm sure you know of people being more or less pessimistic about whether the investments that have been made have done much there was a pretty well famous internal review at the World Bank in the late 90s that basically said look if you compare the vertical investments to the health system ones the vertical ones that just did a lot better and so that there is also this sort of undercurrent that it's harder to know if you've got the right investments so it's more difficult to show accountability and it's a little bit of a sort of poor value proposition in many regards doesn't mean that all apply to that and that's sort of a little bit of a a victim of the way things were done in the past or what types of investments were made on the metric side I actually just a comment I am that last point as a physician a pediatrician certainly I agree that everyone should should have access and should have universal health care but one should not imagine that the relationship between universal health care and non-communicable diseases is very strong and there's many countries that have universal health care that are really struggling with non-communicable diseases and so sometimes people equate an investment or universal health care with the ability to reduce non-communicable diseases I would say that relationship from an evidence base is tenuous and I would argue we should have universal health care but we should not link it necessarily to then having an impact on non-communicable diseases one could have a substantial impact on non-communicable diseases without universal health care and you know so now back in 2000 we published with colleagues at WHO the World Health Report 2000 about performance evaluation of health systems some of you may remember that and we ranked the world's health systems and we had some outcome metrics back then the data wasn't like it is today and so lots of uncertainty around that but in the debates that followed that from 2000 to 2003 I think the thing that emerged to me was that if you really want to track health systems it's not enough to count infrastructure headcount of human resources or availability the real metric and it sort of comes to Howard's comment of having a high performance health system is that you are delivering the things to people that they need and that's the notion of intervention coverage with quality embedded and we call it effective coverage and that construct we put out didn't have much traction at the time it's sort of come back in the universal health universal coverage agenda so now people start talking about effective coverage and but now what's interesting is it's sort of much more measurable than it was the data the methods are so much better that you actually could do a reasonably decent job of saying what fraction of things people need are they getting and that would encompass the NCDs the closest that anyone's got to this was in Mexico where Julio Frank and Rafael Lozano and others tracked this at the state level super fascinating coverage for maternal and child health package pretty high coverage for NCDs pretty short list of things that they were tracking so I think that would be the direction of having sort of a more serious effort at tracking coverage and ideas interest in that's there because of universal health coverage how you do that for the NCDs is pretty tricky because the routine dependence that we all have on MIX and DHS to tell us about what's happening in a health system from a population perspective is so MCH focused or that it's a little bit hard to stretch into some of these other areas that health systems are essential for but it's doable any comments on the the country led process and the different priorities perhaps between the donors that you profiled and no original comments on that given what's been said the only reflection on that is that I think transparency about where dollars go whether they're government dollars or development partner dollars is a huge contributor to that because when it's not clear then it's much harder for a clear set of priorities from a country to emerge so I actually think just the task of documenting where monies go but whether government or donor helps in that regard so running short on time there were a couple hands that I have been ignoring do we still have a couple questions over here let's take these two and then we will wrap up right here thank you very much Erin Emma from the American Academy of Pediatrics I'll unite two of these strands about non-communicable diseases in maternal and child health with another perplexing thing in the SDGs is that the indicators suggested for non-communicable diseases 3.4 don't actually address children and so that raises the larger issue of do you see in development assistance going forward more integration across siloed approaches such as NCDs and MCH or others or do you see a continuation of the type of disease specific or population specific approaches that we've seen in the past thank you and then let's come up right to the front corner here hi thank you very much I'm Lily Koch from USAID I had a question about the way you've lumped newborn health and child health together which actually these days it's not very helpful because I think newborn health has become a field in its own right and we really need to track the funding for newborn health even though the newborn is a little child the interventions are quite different so it really doesn't tell the true story so I quickly went through your document and might have missed it but I didn't see any breakdown between the two and I would really love to see that analysis otherwise it's not very helpful for people who are focusing on newborn health the other one I just wanted to respond to the issue of the SDG target understand the discussions are still going on there's a very strong advocacy group trying to get the target in there for child health but it is stated as there's no number there but it is stated as ending preventable child mortality and ending newborn mortality and a lot of analysis as you know has already gone into actually specifying what the target is in order to end it what should it be so we do have the two numbers it's 20 by 2035 for under 5 mortality and it's 10 for neonatal mortality by 2035 so we do have targets but they're not in the SDG document itself which is I think I agree would be very important to have it there so the question about integration across silos which we've talked about a little bit but maybe we can delve in a little bit more the question about newborn versus child health and then I will just add for kind of closing comments feel free to give whatever closing comments you feel is appropriate but if you could kind of wave your magic wand and create the next set that you could analyze what would it be just one yes let's prioritize so just should I go first of a rapid fire on that aspiration or forecast integration would be good forecast I don't think it's going to happen but hopefully I'll be wrong the newborn versus child that should be on our to-do list because I think as we in another initiative with Ray Chambers and UN Special Envoy we've been looking at a life-safe scorecard and you know trying to say the dollars have gone in how many lives have been saved and sort of can you infer that and that's it merges really clearly there because if when you look at the maternal side if you don't take into account the connection to newborn you would get a very different picture so I think that should be on our to-do list I don't know the technical feasibility in terms of how much project description there is from donors but certainly something that we should look at last comment on the child mortality so the targets there without a number but the indicators not as you know and I think that what I take from the MDGs is having the targets good but you've got to have the sort of drumbeat of measurement and to keep people accountable and if you just have a target the history of targets without indicators is not being great so you know I'm sure half the room knows the whole politics and you know that at this juncture it's looking sort of grim that there'll be new indicators but who knows maybe the Greek debt crisis can be solved maybe this the SDG lack of child mortality can be solved I agree with Chris on the integration question yes good thing to work toward probably not going to happen and I was just going to add on my wish for the next data set to look at one of so the fact that you can now look at source to channel to health focus is pretty incredible I would love to be able to see health focus broken down even further who is the ultimate recipient even if you could do it proof of concept for a couple of donors we've tried to do it for the U.S. others have tried to do it for many it's really hard to trace that first input down the line to who is the ultimate recipient and that's not unique to anyone funder it's a real challenge so that's my wish list I'd love to see that really cool graphic going all the way down to people well what would JAMA publish next it's a little there we go question I started by saying you know I thought this was part one of what needs to become increasingly detailed analysis of what's happening with thirty five or forty billion dollars a year so I think you know the next focus really needs to try to understand where the dollars are working well and where the dollars aren't working well and then to generate from that try to understand why is it work well in one place and not in another place because my sense is that the golden age of growth in the dollars is likely to be over as I said the one great unknown is the Buffett money that will go to the Gates Foundation which is substantial at his death and how the Gates Foundation will decide to spend those dollars that will potentially represent a very substantial increase in that thirty five billion dollars on a yearly basis but that aside I don't see donor countries really emerging with new funds Chris I'll give you the last word what's your wish list I have too long a wish list I would like in the financing space I sort of like I would like to trace dollars down to the geography where they're actually being spent because that would address a little bit of how much is going elsewhere along the way not corruption but in terms of overhead and other processes but if you could actually trace it down to where the spend is I think you can start to put that together with the increasingly rich sort of stuff that comes out of the the burden of disease at fine grain level and start to do some really interesting issues that Howard was alluding to which is you know where's it working and where's it not so that's the wish list well many thanks to our panel thank you all for coming today and we hope to see you at our next event thanks