 So thank you all. This is a panel that is examining the issues around health system strengthening, and with special reference to the impact of the Ebola crisis and now the process of recovery, and planning in that that is underway right now, and very much involves the two agencies represented here, USAID and CDC. I'm Steve Morrison, Senior Vice President here at CSIS. It's great to be here and to pull people together. Congratulations to colleagues, Connor Savoy and Dan Rundy and their staff for pulling this together. This is the first effort of this kind to have a development-centered forum over the course of the day that pulls on many of the different parts of CSIS. Chevron's been a big part of this over the past five years in promoting the development work that's undertaken here. And Johanna Nasseth and Steve Green deserve special thanks for their support. My colleague, Sahil Angelo, has been very integral in pulling us together for this. He's the captain of this event. So if you address him as captain, he will actually do things. Sahil, thank you. We have a terrific lineup of speakers here today. To my right is Maureen Barty. And I want to correct the title in the printed version. We had a previous title. And her correct title is Team Leader for Global Health Security Implementation. And she'll explain what that means in terms of the Global Health Security Agenda underway and particularly how this is coming into play in West Africa. And that is part of the Division of Global Health Protection in the Center for Global Health at CDC. She served recently as a two-year stent as a liaison, CDC liaison at DOD. Three years at the Institute for Preventative Medicine in Paris and a number of assignments as a CDC officer. And she comes to this work of the Masters in Public Health in the University of California, Berkeley. To my left is Karen Kavanaugh from USAID, who's the director of the Office of Health Systems, which in the era of Ariel Pablos-Menz as leadership of the Bureau of the Health Bureau at USAID has become a much more integral and dynamic force within the agency and beyond, as we'll hear. She served in the Latin American Bureau and in the Global Health Bureau's in various positions since 1997. She's been a lead on results-based financing, GAVI and the GAVI Health System Strengthening Team and a number of other roles. She served at the World Bank. She trained at Georgetown School of Foreign Service and at the Bloomberg School. Our third speaker today is a very close friend and colleague, Jennifer Cook, who directs the Africa program, has directed that for the last six years. And we served together for many years prior to that in the Africa program. That program here has been extremely active under her leadership on a number of issues of great relevance to this particular topic. She's done a lot on energy and expanded energy as a key sector now, particularly in West Africa. She's directed a very ambitious election program on Nigeria, a forum on the Nigerian elections over the last year and a half, done a lot on governance issues and sustainability issues which are going to be a topic for our discussion here today. Last week, just a couple of quick words. Last week, the IMF World Bank had their spring meetings here in Washington. And you had the three heads of state, Guinea, Sierra Leone, and Liberia here. You had the three finance ministers. You had the three health ministers here. It was a big moment in terms of presenting the national recovery plans for those three countries. And each concluded, and we'll hear in some detail, each included fairly detailed plans for the recovery and rebuilding and reconstitution of the health systems in those three countries. So it's a big moment. It was also a big moment in terms of bringing forward some new additional important facilities. The World Bank announced 650 million addition to its facilities on top of about 950 million of existing Africa development. The bank came forward with 300 million in additional commitments. The British pledged 50 million pounds towards the recovery in Sierra Leone instance. As we'll hear, this moment elevated health systems strengthening into a completely different context. It tied it to the security crises that Ebola, the absence of effective systems as a root cause, a root factor in the crises that emerged. It gave it a new legitimacy, a new prioritization, and it brought forward the questions of what are we talking about? And that's what we're gonna hear more from Karen and from Maureen. So these three countries have gone to varying degrees, gone through a very accelerated exercise in formulating their recovery plans, costing them out over multiple years, and revealing to what degree they are prepared to change the way business has gone in the health sector and change the way they finance and the levels of commitments to financing these. So putting a close eye on what's in those plans, which is part of what we're going to do today, just scarcely five or six days after those plans were disclosed, it's very good timing here, very fortuitous for us. We'll hear a lot about the collapse of confidence of societies in their governments in these Ebola states, collapse of confidence in the health system. We'll hear a lot about donors and what is gonna keep donors in the game and keep their interest levels up. Liberia made a very pointed argument at the bank meeting last Friday that it's determined to unlock emergency funding. And it made a very pointed argument that over $5 billion in emergency funding has come into the region. And it's very important that a significant share in the Liberian argument be brought forward into longer term recovery. That $5 billion came forward in dramatic fashion. There were two big trigger moments when you look at the funding patterns. One was in early August when the Secretary General, WHO, announced the global emergency. Funding started to come up. It was late, but it started to come up. But the most dramatic trigger for funding was the president's announcement, September 16th, at CDC of the deployment of up to 3,000 troops and the major expanded commitment. By the end of the year, by the end of the calendar year, the U.S. emergency funding had reached over a billion dollars. The commitments on the military support were up to somewhere on the order of reprogrammed 750 million. We don't have the full accounting. On that U.S. leadership in this period, in the emergency crisis moment, was absolutely pivotal to breaking the arc of the outbreak and getting us into 2015, where it became possible to countenance the recovery phase. As we'll hear, managing an emergency response is in some ways easier than managing a recovery response. In emergency response, there's a fairly militarized, military-style unified command and control. We're now in a period where there is substantial, there are substantial resources available for recovery, but it's in a more fragmented system with where we don't have exactly those kinds of controls. We're also in a period where countries themselves, to varying degrees, are continuing to struggle with the objective of getting to zero new infections. And lurking right behind that, I mean, you had 37 infections in last week. But lurking behind that is the broader scientific and public health question of whether this region is going to live indefinitely with an endemic Ebola that will result in periodic continued outbreaks. And the scientific evidence that's come up recently suggests that in fact, if you go back and re-examine the collection of antibodies, there's proof of Ebola presence in the region going back 30 years. So there's a big debate going on, but the recovery goes against a very abnormal and very unusual public health, continued low-grade public health emergency that has yet to resolve itself and may be with us. We have, of course, the other big dimension of the US response, second to the president's announcement in September was the passage, December 16th in Congress of the $5.4 billion emergency supplemental, the emergency funding. And that was unusual in that it brought forward money for domestic strengthening of Ebola response as well as international. It was $1.7 billion for the domestic, the balance for international. It charged USAID with $2.5 billion with both the emergency, completing the emergency response, but also beginning the recovery phase. It charged CDC with $1.2 billion, half of that, to finish the business of getting to zero. The other half towards creating health security capacities in the three Ebola states and 11 neighboring countries. This was a big slug of cash coming in for the next two years and it raises the question of what next, how fast can these objectives of recovery be achieved so that as we get to the end of this funding stream, Congress can come back. We are now in the game in a substantial way on recovery and on creation of health security capacities in these countries, but it's not a permanent dimension of US foreign policy. It's not a permanent dimension of our global health approaches. It grew out of this unusual moment, but it offers the opportunity, if we're successful, it offers the opportunity for building health security and health systems into a completely different place in our global health approaches and our foreign policy. The next big step, these national plans will go through some period of refinement. We'll hear more from Karen and Maureen about that process. In July, the UN Secretary General will pull the parties together, the three states and donors together for a pledging conference. So between now and July, I assume there's further refinement of the plans and further consultation. I think in a way, when we look at what's in these plans, there's a level of sobriety and realism to them. They're also innovating in order to answer, as Karen will explain and Maureen will explain, the special demands and challenges that grew out of Ebola and the things that were revealed that we don't normally think about in terms of health systems. So with that long-winded introduction, I'm going to turn to Karen to kick us off and then we'll turn to Maureen. They each have some very, very interesting and useful slides to guide their presentations. I'll ask Jennifer to come in in the third spot to speak to some of the bigger governance and sustainability issues. Then we'll have a little bit of an interaction among ourselves, but we wanna get to you as quickly as we can for your comments and questions. So Karen, thank you so much for being with us. Floors yours. Thank you very much and listening to you, I was reflecting on working with other partners on health systems recovery and health systems strengthening in the Ebola affected countries. And we began talking about this last September in earnest among the donor community. We had a meeting at the sidelines of the global health systems research symposium in Cape Town and we had to be very cautious because people were saying there are people dying of Ebola. We can't be talking about strengthening the health system. And so I think we've gotten to a point now where we're not declaring victory. In fact, the meeting that Steve mentioned last week included four topics, getting to zero, restarting essential services, rebuilding health systems and then integrated regional disease surveillance. But there was a recognition and I think this is a common one now that all of these things are related to one another, that it's important to focus on all of them, not to work on strengthening health systems at the expense of getting to zero by any means, but to work on things in parallel and as waves of work. So I'd like to start with one graph which I think is a very powerful illustration of why it's important to focus on the underlying strength of the health system. So this is data that comes from the Liberian government's national health information system and you can see that the provinces or the counties are divided into counties that have been most affected by Ebola and counties that have been least affected by Ebola and then it charts the change in coverage of assisted deliveries over time and what's very striking is that the drops in coverage in the more affected counties are much more dramatic than in the less affected counties. So it begins to show us the sort of interconnectedness of all aspects of health service delivery. So it's not simply a matter of dealing with the Ebola problem but also all the other health challenges that the health system works on. And similarly you can find evidence of this with measles. Liberia has recently been dealing with the measles epidemic because the vaccination coverage declined particularly in heavily affected counties. So let me go back and start with my first point. Really only have three main points to share with you today. One is that I think that Ebola is really a watershed in health system strengthening. And another, the second point is that the planning that is being done for the recovery is a very interesting consultative process that the countries have been involved in with many of their partners and it's a process that demonstrates that things are not going back to the way they used to be. That people have changed the expectation, we have new expectations of the health system. And finally something that Steve already raised which is that the US government and particularly USAID are committed to helping the Ebola affected countries and partnering with them for the long term to improve the situation. So here we see what I call health system strengthening before Ebola and health system strengthening after Ebola. So before Ebola, we thought of the health system strengthening field, our frameworks largely, were following those that were developed by the World Health Organization. They had as the outcome, we want these health outcomes and to get them we wanna improve health system performance and to do that we need to strengthen the way these six functions work. So the functions of governance and financing, human resources, information, medicine and service delivery. And the framework was pretty widely used though it's still, there are many things that we continue to refine. But the notion was really let's work on these functions, that will make the system work and that will achieve these health outcomes. Also health system strengthening before Ebola, there was to some extent, it was considered sort of a back office function like the exciting things are saving lives and vaccinations and new discoveries of micronutrients and other technologies. And then we've got this health system strengthening stuff in the background. And that sometimes went so far as to think, well the health system strengthening work seems to be back office and also seems to be competing with my vaccination program or my assisted delivery program. And so that was, it's a great generalization but there was somewhat of that way of thinking. What Ebola has changed, I think, two fundamental changes. One is that there's a tremendously increased recognition that the health system needs to work, that the health system strengthening is very important for everything. So that I think is much more widely shared sense than it was before Ebola. The other really is something that we're still coming to terms with and that is that the countries that experienced Ebola, when they began to make their plans for strengthening their health systems, they were speaking in terms that are not typically part of our framework. So some of the terms, and I think I have another slide that has that, yeah. So this I know, you always hear, I'm sorry you can't read this, but I figured it's on the slide. If you're distributing slides, everyone will have access to it. The plans from the three countries looked at things that really we had not been talking about. So for example, in financing, something that was an innovation I thought was the recognition of the need to provide free care and support to survivors. The other thing, because the country plans are proposing much higher levels of financing is a recognition that in the short run, they're not going to be financially sustainable with domestic resources. So they are implicitly designing these plans with the understanding of support from the global community. Also they have a broader vision of who constitutes human resources for health. So we're not just talking about the healthcare workers who deliver services necessarily, but also a much stronger focus in human resources for health on the community health workforce. And making that community health workforce really unified national workforce in the case of Liberia, that's part of the plan. And also making sure that they have compensation and that they're linked to the official health system. We've always had information as part of the health system, one of the health system functions, but really the Ebola affected countries are talking about information in a different way. I think a qualitatively different way. And that is talking about information for accountability and open information to have basically one of the countries referred to it, I think as ruthless reporting of results. So a recognition that it's important to share information. The other thing is in terms of you see the six functions of the health system, but then you see all of these other dimensions that come out in the plans. Very strong focus on the community, of something that we generally take for granted in health system strengthening, which is trust. So the trust has been broken between citizens and their government. When we talked about that last week with the in the presence of the ministers of health, we found two major elements that people recognize as being important for rebuilding trust. One is performance. You have to be able to deliver something that people see is working. That's a very fundamental part of trust. And then long-term relationships. And the concept was relationships at all levels. So relationships globally to relationships at the community level. Then something we often do not focus on in health system strengthening as a discipline is the basic infrastructure. Is there running water? Is there electricity? What about sanitation? Things like laundry and waste disposal have not been prominent in this field, but clearly are very important in this context. Safe facilities for workers. When we talk about health workforce, we really talk about ensuring that their workplaces are safe environments for them and for their patients. So that I think is taking on increasing attention. And then the areas of preparedness and infection prevention and control, which we must recognize that these have to be more prominent in our work to strengthen health systems. And just a few aspects, I think that you may have access to information about the plans, but you can see at the very top, the size of the plans that the governments are contemplating. So as Steve mentioned, they are reasonable. They're certainly not doable with domestic resources. So they do imply global support. And I'd like to show one other slide. Let me get back, where is that? Okay, so this, when we talk about not turning back to the way things used to be, this I think if you look at the numbers, you can see that the countries are not talking about things that just take them back to where they were before Ebola. It's not a matter of simply retraining people to fill the positions of people who died and going back to business as usual. They're talking about much higher levels of per capita spending. So you can see in Guinea, Guinea has a current spending of $8.8, including domestic resources and foreign assistance. They're talking about going as high as nearly $42 per capita. So this is a huge change in the way they're running their health system. Similarly, Liberia right now is spending about $20 per capita. They're talking about going up to nearly $50 per capita. So they're building systems, rebuilding systems that are not gonna be the same as the ones that we had before Sierra Leone, which currently has per capita spending of under $7 is going to $21 per capita. So I think if you have the opportunity to see the plans you'll see that they're not simply marginal incremental changes in the systems of before. They talk about radically improving infrastructure, major increases in the availability of human resources. So using this as an opportunity for lessons. And maybe one other thing that I didn't mention in talking about the change in the concept of health system strengthening is that the concept is no longer the health system has to be well performing to produce a certain set of health outcomes. We're talking more about the health system being able to be resilient to shocks because Ebola may be endemic or may not become endemic but they may have some other problem. So some people point out that we're fortunate that Ebola was not airborne. There may be some new problem. We don't want a health system that is capable of delivering essential services and Ebola. We want a health system that's resilient that can deal with the variety of challenges that it may face. Then the final point that I'd like to make is that the United States is in this for the long run. And this is a message that the president has made clearly. He sees this as a point in time where we can help these countries to build long term capacity and to make their health systems work. So Steve mentioned the Ebola supplemental. This is just the part of that law that pertains to USAID. You can see here that actually when I started typing this I had to remind myself, yes it is billions. So the IDA, the International Disaster Assistance 1.4 billion most of that, well all of that really was for the emergency response. And then we have 312 million for global health programs. That is for both the Ebola affected countries and other countries that are nearby and face risks of the same problem. Operating expenses are the money that we use to staff these programs. And then it's quite interesting to see the level of resources that are going to the inspector general. So you can see that there's a very strong desire to be highly accountable. In fact the law that provided this funding calls for reports to Congress every 30 days which I think is unique at least in my experience of managing aid programs. And you can see that the ESF funding and the operating expense funding have to be fully expended by September 2016. So you can imagine that that is a very fast timeline. So with that I'll just thank you and look forward to discussion. Thank you Steve. Thanks very much Karen. That's really great presentation. Maureen. Great. Well thank you Steve and thank you to CSIS for having me here. It's a pleasure and I already learned quite a bit in the plenary session this morning. One thing that Dr. Hamry said in the plenary session was that CSIS has been known as a defense agency or been equated with a defense program for many years. But now the development angle is becoming more prominent and that's a change for people to be when they think about CSIS. And I think for CDC we also have been thought of primarily as a domestic agency. And so I thought I would take the opportunity not only to talk about how Ebola has really made us think about not only health systems strengthening in terms of healthcare delivery but also public health systems strengthening and how both need to be improved in order to really help countries and help the world from having to deal with a crisis like the current Ebola crisis again. So I'm going to start with just a little bit of background on CDC and to take a look about why CDC is involved in global public health systems strengthening. Talk a little bit about CDC's current involvement in the Ebola outbreak and then what's next? What are we thinking about with this large increase in funding for global health security? What are the plans going forward? So I think when I come up to Washington a lot of people wonder well why is CDC in Atlanta and not in Washington DC? And this is not just a fact for your next trivia game but it really is an interesting fact and leads to why, sorry, it's okay, why CDC has evolved the way it has. So originally CDC was started it evolved from the agency Malaria Control in War Areas and Malaria was endemic in the south and that is why it started in Atlanta. After Malaria was under control, Joseph Mountain who was the CDC director at the time but there's other communicable diseases that need to be looked at and so why don't we expand our mission and it became the communicable disease center and opened in 1946. This shows that CDC's origins were focused on an epidemic threat and building public health systems to address this threat. The original mission was simple but challenging prevent malaria from spreading across the nation but as the responsibilities extended to other communicable diseases, CDC started working with states and other partners in order to build health surveillance systems, prevent disease outbreaks and implement disease prevention strategies along with maintaining health statistics for the nation. So over the past 50 years, CDC has become increasingly involved in global health work. We built on the work that CDC has done domestically with our state partners and this really means providing technical assistance and expertise to our international partners to address a variety of health threats over the past 50 years. 40 years ago, we were improving health security by eradicating smallpox using immunizations and surveillance and more recently we've been involved in tracking and controlling outbreaks of novel influenza, SARS and other infectious diseases that could become major threats. So a little bit about CDC's budget. This is a little bit deceiving the numbers because we do receive quite a bit of transferred funds, this is just our direct appropriation which is approximately $440 million or sorry, it's 416 here. I don't show you this for the actual numbers but to look at the last line which is about $55 million and that is how much we have to spend on the broad more horizontal programming. So not in disease specific areas and this is what Karen was talking about before where it's sexier to spend money on HIV or malaria or things where you can really tie it to a specific outcome but there is a need to also invest in the broader health systems and public health systems strengthening but up until now the amount we received for that has been a relatively small part of our overall budget. Steve mentioned the emergency funding request and CDC's portion of this emergency funding request was about $1.8 billion. $600 million was for domestic Ebola preparedness, about $600 million for internationally Ebola and about $600 million for global health security. The global health security portion is what I'm mostly focused on, not the response but what are we going to do following this crisis and this emergency response and how do we build systems that hope mitigate this from happening again in the future. So with the new funds, 600 million of that is forgetting to zero. Really trying to focus on preventing further transmission, rapidly detecting any new cases that occur and responding quickly and decisively when cases occur. But I want you to see what an impact this outbreak has had on our agency. The number of staff who are currently deployed in Guinea-Liberia and Sierra Leone is 182. In general, we have about 350 full-time staff who are posted in overseas locations. So to have 182 in these three countries is a significant portion of our workforce. We've had almost 1,000 people who've completed deployments and that does not include the ones who are currently over there as well. So it's over 1,000 individuals who have deployed to the three countries. And I think most significantly, the number of staff who've been involved in some way has been about one third of CDC's total workforce. So this has been a significant investment and activity for CDC since actually last April before the outbreak was actually officially declared. What we're doing in West Africa can be summed up in three areas. Refine the cases, stop the spread of the disease, and prevent new cases from happening. But after Ebola, what's next? And I think one overarching lesson that we've learned from the Ebola response is the need to strengthen national capacities to prevent, detect, and respond to health threats. All countries must be prepared. It's critical that we minimize the chance of another outbreak of this magnitude from happening again. So the good news is that political commitments have been made across the world toward this aim. 10 years ago in response to the exponential increase in international travel and trade and emergence and reemergence of international disease threats, 196 countries across the globe agreed to implement the international health regulations. This binding instrument of international law was entered into force in 2007. The stated purpose and scope of the IHR are to prevent, protect against, control, and provide a public health response to the international spread of disease. Unfortunately, progress on the IHR hasn't happened as quickly or as consistently as was expected. Only 16% of countries reported being fully prepared to detect and respond to pandemics in 2012. Which is why in 2014, President Obama gathered 44 countries from around the world to commit to the global health security agenda. And as President Obama noted, we will continue to strengthen our own security while we strengthen public health systems. That's the ultimate goal. The impetus for global health security is not new, but we've lacked the resources and political resolve for the efforts, the kind of efforts that we're making today. And what's the difference? It's Ebola. But it can't just be about Ebola. Ebola's going to go away. And we have an unprecedented opportunity here to go beyond Ebola and to prevent anything like the Ebola epidemic from happening again. The global health security agenda has three main goals. Well, the overall goal of global health security agenda is to accelerate progress toward a world safe and secure from infectious disease threats by preventing avoidable catastrophes, detecting threats early, and responding rapidly and effectively. The US government has committed to working with at least 30 partner countries that contain at least 4 billion people to achieve this goal over the next five years. The three areas of prevent, detect, and respond are divided into 11 target areas. These areas involve critical areas of expertise within the prevent, detect, and respond framework. And the targets include the building blocks of strong public health systems, including surveillance, laboratory networks, emergency management, and workforce development. This map represents the 44 countries that have committed to the global health security agenda. It represents different types of commitments. Some are financial commitments. Some are political commitments to try and strengthen a piece of the expertise areas under the prevent, detect, respond framework. And others are countries that have committed to providing their technical expertise to assist others. For the US government, with the funds that USAID and CDC received, as well as partnering with other parts of the US government who already have funding to achieve these objectives, we're focused on 17 initial countries in 2015. There are three different categories for the countries that CDC is working in. The global health security countries are listed in green. The Ebola affected countries are listed in red. And the at risk countries, which include at risk for Ebola and where we want to do some global health security work are in blue. I just wanted to end with a reminder of what we're aiming for. A healthier world by equipping our partners to effectively prevent, detect, and respond to health threats. I think the photo is important because it reminds us that people are counting on us and they want to be equipped to better handle their future emergencies. Think this is a unique moment for public health to establish the global capacity to more rapidly and effectively protect, detect, and respond to these disease threats and increase the impact of our global health work going forward. Think building stronger health delivery and public health systems will allow countries to improve health and emergencies and be better able to address their everyday health challenges. Thank you very much. Thank you very much. Jennifer Cook. Sure, great. Thanks and thanks for the really interesting presentation. Just to say, I mean, this has been a very heartening response from the US, from the World Bank Group, from the international community mobilizing to assist the three effective countries with response and recovery and building resilience against future crises. But this is an enormous undertaking even though these are three small countries and it will be an extremely long-term endeavor. This is very much like countries coming out of war and it wasn't actually that long ago that Sierra Leone and Liberia were in long, protracted, crippling civil wars. Where there are so many priorities, everything is a priority and there's a whole lot of urgency around them and that is very challenging and the record is mixed on how post-conflict recovery is gone. Unlike a civil war, in this case, there was kind of a common enemy and a threat and that, I think, is an opportunity for governments to mobilize a genuinely national response in recovery and in mitigating future crises but maintaining that unified national response the government level, community level, regional and private sector, I think that's gonna be one of the big, big challenges and avoiding politicization has to be, that national response has to be preserved and I think that could be a challenge in some of these countries where leadership is going to change, heading into election cycles and so forth and the urgency of the immediate crisis will eventually fade. A couple of big challenges that I see is kind of not coming from the health security side and issues that I think are gonna be, need careful balancing in the response. First of all is the absorptive capacity of these countries. These are, Liberia has a GDP of 1.9, Sierra Leone 4.3, I think Guinea 5 or 6 so these are small economies. You're also talking about personnel, institutions and capacities that are already very stretched with other competing demands from the post-conflict period. The tendency at the government level is for international donors to rely on a very few kind of motivated technocrats or leaders to get things done and that makes it very hard for them to respond to all the competing demands on them. And at the community level too, working with communities and groups who probably themselves are dealing with recovery and livelihoods and so forth. So the absorptive capacity is a huge problem to my mind and health facilities as well. I think that underscores the need again for genuinely national plans, responses to be strategic, to be finding as much as possible efficiencies whether in tasks shifting or dual purpose personnel. Can you engage the military for example in kind of health related activities and getting the sequence right? It also means that there absolutely has to be coordination among the many donors that are coming in, both in health and in other sectors that there's not overlap, that there's not redundancies. And it means that I think for the US we need to be strategic yes and have that strategic plan but also a lot of flexibility in our response because it's very likely that we're gonna run up against bottlenecks in some areas that will see opportunities that, maybe opportunity to push forward in one area and moving across budget lines and so forth. I think that's gonna be extremely important. So being nimble when there are times to accelerate process and then frankly the situation is still so fluid and unpredictable at this point. We're not yet at zero. We don't know kind of what the broader region impacts might look like. Related to this is the question of transparency and accountability and data collection. These are countries that have very mixed records even with kind of the most willing leadership on accountability for funds on corruption and fund diversion. Now you'll have a massive inflow of funding. You'll have an urgency to get this money spent. That means that the opportunities and the incentives and the possibilities of waste and corruption go up exponentially. I think that's something that could very quickly turn the stomach of US taxpayers if there is not accountability around these funds. We need to know early and adjust early if things are not working, if there is seepage or waste and that means transparency by donors and what they're doing and giving by governments and by NGOs. So this idea of kind of collecting transparency, collecting data, accountability is crucially important but the flip side of that is that you don't wanna overburden NGOs, facilities and governments with reporting requirements as there are multiple donors who each have a form that you have to fill out. You wanna collect data but then there's like 18 categories that you've gotta check on gender and age and this and that and it makes it at least in the HIV AIDS response, that's been a huge frustration by facilities and others that feel their primary job is delivering health services rather than data collection. So getting that balance between a lot of that is coordination again among donors to kind of streamline the reporting and transparency requirements. A third is the balance of intervention. The rapid spread in these countries was the result of weak health infrastructures but the weak health infrastructures were the result of generally underdeveloped and fragile states. This is such a big opportunity to get US and policy makers behind health system strengthening and we don't wanna lose that because that's important but we don't wanna kind of again be lopsided in focusing on the health side of things without also looking at the things that make a health system work and you alluded to some of them. You need water, you need power. A clinic without roads and transportation is not, it's not going to work and you need ultimately the income generation that is gonna be able to pay the massively burgeoning public health expenditures if these countries are promising. $50 per capita sounds very ambitious and the international community is not gonna want to fund the paid doctor salaries into the future. So how are these governments kind of planning for that sustainability of over time? So food security is gonna be the big one infrastructure, power, as I said, education without sufficient investment in these I think you get diminishing marginal returns as you spend in the health sector. So are we getting the mixed rate is something to ask? Are we finding synergies across the various sectors? Education and health for example. And are these, are we responding to genuinely country led strategies? Countries are gonna have a hard time turning down a big spending in health that comes to them but they may feel they have other priorities and are we getting that balance of interventions right? And our governments putting their money with their mouth is and that's something I think we have to emphasize if it's a priority for them they need to be funding it as well and I think a kind of a matching funding type model not matching proportional funding maybe something we need to think about. Fourth is the political context. The question of rebuilding trust between communities and government. Many of these, well, and I think of Guinea in particular deeply polarized in 2013 you had high levels of communal violence and killing you have a government that's heading in in October to very highly contested elections. A lot of allegations which kind of got wrapped up in the Ebola crisis as well ethnic and regional divisions. Guinea for example has been very wary of external assistance in any regard. Liberia has a very good relationship with the United States. The UK has a very good relationship with Sierra Leone as does the United States but Guinea which in that pattern would look to the French does not have a very good relationship with the French and it's been generally insulated and suspicious of external players coming in altogether. And I think the secrecy around the data early on and the lack of reporting I think that was an indication of that. But even in Sierra Leone and Liberia they have elections coming up in 2017. You're gonna have a new leader in Liberia certainly and the election politics can kind of tear apart that national response I think that we're all trying to aim for. On the sharing of data as well and this rebuilding of trust of the governments within their countries there's also the question of the international response and I think the openness with data on outbreaks for example it'd be very difficult for governments in an electoral cycle to announce well we actually had 50 more cases last week. We're not beating the epidemic. I think there could be a tendency to kind of obscure the figures or setbacks. Same with the international community. We saw the international response shut our borders, close it down. Investment pulled out rapidly. How can we reassure that being open with data and setbacks is important and won't result in the catastrophic kind of withdrawal and isolation that we saw in the last year, in the last go round. And then that just raises a final point about kind of to my mind what the US response and I'm not talking about the US government response totally but the general US response said about how Americans look at Africa and how that there's still a huge education that has to happen there. And the idea that this became politicized here in the United States and we're asking those countries not to politicize it. Shut down the border. Schools in Mississippi or New Hampshire or wherever, kind of the stigma around the health workers, the stigma about people who have been traveling to Zambia or Kenya. And I think we want to, the idea that there is a security link is really important in galvanizing and mobilizing assistance but we don't want to portray Africa as this and kind of these Ebola-struck countries as national security threats to the United States and kind of creating a wall of suspicion and feeding into some of the narratives I think that Americans I think who may have about a continent they don't know that well. So there's a big challenge there I think. I'll stop there, Steve. Thank you. Thank you very much. We have 15 minutes. For discussion. There's a couple of key questions that I would like to pursue but I think we should turn to you now and hear from you. You've been very patient. Thank you so much. So why don't we grab like four or five quick comments? Please, there's right here and we'll just put your hand up. We'll do a round of quick comments, be very succinct, one question, not three or two, one question, identify yourself, be real fast and we'll bundle things together. Yes, please. Hi, I'm Ann Claire Hervey. I'm with the Association of Public and Land Grant Universities and thank you for a really fascinating discussion. I wanted to hear what's happening with capacity building of universities with this long-term plan to build local capacity in public health. Universities play a very important role and I didn't hear any mention of universities in this. Thank you. And there's an opportunity here to transform them in doing this. I'd like to hear about that as well. Thank you. Yes, right here. We'll go on this side and then we'll move the second round. We'll come over to this side. Yes, please. Thank you, Paul Ophini from Cardinal. Question for Ms. Kavanaugh or Dr. Kavanaugh, I'm not sure. Having to do with how USAID is going to respond in the field, you have new operating expenses, will you be enhancing your health or other staff in the three concerned countries? Thank you. Right behind you. Hello, my name's Keanna Brooks. I'm actually a student of public health at the University of Pennsylvania. My question was concerning the, sorry, the global security partnerships. You saw the map where you highlighted the countries that had agreed to partnerships and I noticed on that map a lot of the developing countries, particularly in sub-Saharan Africa, were the ones that had not agreed. And I was wondering how you would be able, since those countries might, you know, likely have things that need to be addressed, how you, you know, could work with them if they have not agreed at this point. Thank you. Over here, just pass to your neighbor there. Hello, my name is Kari Lajnass. I'm a AAAS fellow in the office of Congressman Jeff Fortenberry. I had a question for all of you, I guess, about what we're doing as far as detection and surveillance and reporting deeply, deeply into the communities, especially up in remote rural areas where these diseases come from and have some sort of an operational system for doing that and I would love to see it tie into the land-grant universities on that. Thank you, thank you. There's someone up front here who wanted to, are there any other comments or remarks? Why don't we, Krista here? Front, and then we'll come back, that'll be five. Further to the question, oh sorry, I'm Krista Ridley. I'm a consultant. I was in the Ebola area of Liberia last year. I had a question further to the question about universities, about brain drain and we heard about how many doctors per capita, how many nurses per capita and what really are we doing in our strategies to help with that. Thank you, thank you. On the brain drain issue, I think it's important to remind people there were over 850 Ebola cases among health workers and over 500 fatalities and that was an extremely big setback. In the Guinea case that wiped out over 50% of the health workforce, the trained health workforce. So we're starting from systems that were weak before Ebola and now this human resource dimension is front and center in how do you build back and to what degree will there be a need in the near to medium term for the inclusion of external expertise in moving ahead and we know that it's been very hard to recruit and retain staff who have very good opportunities in Britain or US or Europe or elsewhere. The situation has become more challenging now, particularly if Ebola's endemic. So this whole health workforce question is very, very large. Some of the questions were directed specifically to Maureen and to Karen. Why don't we start Karen? Why don't you share which of those you care to answer? So the question about capacity building of universities, universities will play an important role in rebuilding the health workforce. In fact, HRSA now has funding to work directly with the three countries and so they I think will be engaging US universities as will other partners, though I don't have any specific information to share with you about. Is that the 50 million that came through PEPFAR funding? Yeah. About staffing up in the field, USID is currently going through our bidding process and only the Ebola affected countries are on the bidding list. So it's, I mean, a special bidding opportunity we are staffing up. In the short run, we've been secunding people and bringing back retired Foreign Service officers and so we've been able to use those but in the future we're gonna be staffing up because obviously the offices were not set up to deal with Ebola but now I think as you pointed out, I mean, pretty much everyone in global health has a new job description since Ebola. It's become a huge undertaking for everyone. Brain drain, so very interesting because Liberia has been through a civil war before Ebola and so we have the opportunity to ask ourselves what happened to the health workforce during that war? What I've seen is that the physicians left because they were professionally mobile. They were able to leave, they speak English, they have training, they can work anywhere but the nurse practitioners, sorry, not nurse practitioners, nurse midwives and nurses did not leave and so that really helps us to better understand in the future how to move forward training the health workforce. We need to focus on the cadres that are partly faster to train and partly more likely to stay in country so I think that has to be part of the strategy. You mentioned the tremendous toll this has taken on the workforce. I was listening to a presentation by a woman from Sierra Leone, she had a slide up, she had a picture of a woman who was crying that this is the last living member of Sierra Leone's Lhasa fever team of 20 people. Everyone else died so I mean Lhasa fever is not something you learn in a couple weeks so this is a huge challenge now. Maureen. So first to the question about the countries and commitments, the commitments that were made were not necessarily about providing financial resources but committing to being part of this international initiative and I think in some of the Sub-Saharan African countries we as a USG and also some of our partner nations that are promoting this effort currently Finland is the chair of the steering group didn't necessarily reach out in advance of the White House meeting last September very personally to describe what we were really talking about with the commitments and now that we've gone and had further discussions with the governments on the ground more and more are making commitments to be part of the global security agenda. So I think part of it was a confusion of if this was we're making a commitment are we committing to providing financial resources that we don't have and that wasn't necessarily the case so we are seeing as we're having more and more interactions that they feel like this is something they see the Ebola crisis and don't want that to happen in their country and really feel like building these basic public health building blocks are gonna be the way that they can avoid that in the future. I think for the workforce question in universities one way CDC has worked on keeping public health workforce epidemiologists and public health practitioners in their home countries is through the field epidemiology training program and we're expanding that in a number of countries now and rethinking how we do it. Now we have a pyramidal model where not only do we train the workforce at the highest levels of government but also at the peripheral levels and so there's a basic training program for individuals who may be nurses, they may be health workers in a district health location that don't necessarily have a medical background but training on data collection, data analysis, how to use data for decision making and then an intermediate stage where they get a little bit more training and understanding of maybe higher level analysis of these data and then we're having discussions also with universities about outside of the United States and a few other countries for a public health workforce it's mostly been people who are already medical practitioners who then do something in public health but in the United States we have professional degrees that are public health that are non-medically trained individuals and so thinking about how do we do that in additional countries as well and thinking about the opportunities there. Do you want to say something about the question of remote surveillance? Did you want to add anything about data remote the question that was posed? Sorry, I... There was a question about... How do we do surveillance in remote settings? So in the three affected countries we are working with individuals at the community level to collect data and then to analyze that and then send that up through the national system. So there's an actual system that community health workers go out, find information, bring it back to a hub at the community level, it goes up to a district level and then up to the national level. Okay. Just on the personnel, I mean this is where I think task shifting and kind of the linkages between community health workers, clinics, facilities and technology can have a lot to do with it even just cell phones in a number of places in Nigeria and in maternal health, that's being very important. Although it's sometimes controversial when doctors want to preserve kind of their domain but they're, I mean, it's a necessity I think in these three countries. The other thing is kind of the regional, I wonder about systematizing regional responses. Look, Uganda came very quickly and mobilized. African Union is setting up an African CDC. I mean, there may be opportunities to build a kind of a continent wide cadre of responders, trainers and so forth that might be worthwhile. And the third thing, and this has come up on HIV A's as well, is there a way to tap into the diaspora community? There are lots of Liberian doctors, Sierra Leonean doctors as well here in the States, are there kind of ways that they can be without too much disruption to their lives posted back for six months and receive some kind of stipender reimbursement taking advantage of that as well? Thank you. We have time for one more round. I wanna put two quick questions out for you to think about. One is for the two of you, Maureen and Karen from the US agencies, the response during the crisis was exceptionally good in terms of interagency cooperation and many people have commented on that. In this period going forward, the context has changed. Both of your agencies are engaged in very ambitious complimentary efforts right now with substantial pressures, substantial money, short timelines and the like. If you could both say a word when we come back around how are you integrating your efforts and coordinating your efforts without slowing yourselves down too much because that is a, you've got a very difficult dilemma in front of you right now it seems to me. The other question is I'm less, I'm more skeptical than Karen that the US government is in this in the long term. I think there's a, come September 16, there's gonna be a lot of questions around whether Congress is willing to make this a permanent feature of US budgets. So the question is really how are we going to ensure there's continuity? What is, what between now and the fall of 16 is gonna happen that's gonna make the case to the Hill that this is a long-term permanent feature of US global health approaches? We had a number of hands over here. Can we start with Larry and then? Larry Knowles with the Hewlett Foundation. Start along the lines of your question, Steve. I was gonna ask about resources more broadly for the health, the global health security agenda. Big ambitions well beyond Ebola and at least what I'm told is the size of the Ebola emergency funding will help the next year or two of the global security, global health security agenda. But along the same lines, I was a little surprised not to see some additional resources requested for FY16. During a crisis you can catalyze public support, congressional support, take advantage of that, build up a pipeline where you can see this through for multiple years. Are you concerned about the fact that you, while you may have adequate resources now that come 2018 or something like this, the commitment may be less so, it'll be off the headlines hopefully and a new administration and their own priorities. And the threat we'll have subsided. Yes, right? Okay, over right there, please. Thanks, Alicia Bonner-Nass, I'm the editor of the New Global Citizen. I know the focus of this conversation is on health systems strengthening, but there are other very serious setbacks that have happened in these three countries, specifically the economic decimation and you alluded to this, Ms. Cook, has been really severe, specifically in Sierra Leone, the closing of a number of mining companies, which are major revenue resources for the company. So you talked about how international assistance will be needed to make these plans possible. Also, the domestic resources that these three countries previously had have been significantly reduced, which also begs the question, what's going to be done to reinforce the economic stability of these countries to ensure that health systems strengthening actually works? That's an excellent question. At the IMF World Bank meetings, IMF released data projections for Sierra Leone estimating a 23% negative growth. A reversal, an erosion by 23% this year in Sierra Leone as a function of the collapse of the two main mining operations in the softening of global marketplace. And if you add that to what happened last year, it's a reversal of 36 percentage points in less than two years. Are there other hands? Hi. Hi, I'm Jeannie Hammond and I'm from Management Sciences for Health, MSH, and just because we have so many partners here today, I just wanted to announce that MSH is in the process of launching an international campaign No More Epidemics Campaign. And the goal of this campaign is to prevent future epidemics of emerging infectious diseases. And the pillars of the campaign focus on a lot of the priorities that we've talked about today. Advocacy to make preparedness a top priority, innovative, helps with strengthening projects and fostering accountability and monitoring and reporting. So I just wanted to share that and hope to be able to talk with some of you more about that. Thank you. Yes, thank you. Could we have a final question? I just wanted to clarify that my question about universities was not about the engagement of US universities, but building the capacity of local universities for this long-term plan of building national capacity, thanks. Okay, so why don't we start at this end? Okay. We can come back at this direction. So Maureen. I'll start with the budget question. I know for CDC's budget, we did request a modest amount in FY16 for global health protection, which would be global health security, global disease detection, and some of our broad global health programming. We plan to ask for a piece in that area in each subsequent year to build on the investments that we're putting in with this large amount of funding through the emergency funding request. And the question about how CDC and USAID are working together, I think you're right, our work together on the Ebola response has been great. We have really achieved a lot, I think, because of our complementary effort. And so going forward, I know in the countries where we're planning to do global health security work, we are working hand in hand with the USAID missions on the ground. So looking at all of those factors that you talked about that are so important in addition to health system strengthening, but the economic issues, all the other pieces that USAID focuses on, and making sure that we have that information and that we're working together in Mali, for example, I was speaking with the USAID mission there, and they launched a program on resilience. And that includes their economic growth office, their health office, and the number. And so the global health security agenda work is being integrated under that program of resilience so that we're all working together and understanding all the different aspects that are important in not only health, but in the recovery of the country. You wanna say anything in regard to ensuring there's continuity? Like what, when you think strategically about what you have to deliver in the next 18 months, in order to not have a cliff in funding for this work, what is it that in the next 18 months, Tom Frieden's telling you, you better deliver on these two or three things because otherwise we're going off a cliff? Yeah, I think what we're focused on are the basic building blocks of the public health system. So for example, in 2013, we did a pilot project on global security in Uganda, and we focused on building the laboratory system. And how does a sample from a remote corner of the country get transported to the central level and the result get back to the person who took that test within 24 hours. So something like that where we can... You have real metrics. Real metrics and show that these investments are actually achieving... And are local universities figuring in your plans? So at the country level, there are discussions with local universities, I don't know exactly what the plans are right now for each of those countries, but I know that those discussions are happening. And it's alongside our USAID colleagues because they've had some programs already with local universities that we're building off of. Okay, Jennifer? Well, just on the bigger economic picture, I mean again, I think we do need to focus on that. Power is an essential one in the infrastructure as well. We may not be the ones to build the infrastructure, but through Power Africa, for example, we could be working with Sierra Leone on kind of the power sector more generally. Reassuring, this is a huge priority for all three of the presidents. Reassuring the private sector that it's safe to come back and precautions will be taken. The World Bank has again has pledged, and these are fairly broad economic recovery plans that are going forward there. I've just lost my train of thought, but I think absolutely, as we look at the countries, we need to make sure that that balance is struck right as well. May I add a comment to that? I think it's fair to project that these countries, to varying degrees, are gonna be wards of the donor community because their economic recovery is gonna come very, very slowly if it comes in the Sierra Leone case. And the World Bank, IMF, made some exceptional commitments, unprecedented Africa Development Bank, EU, all chipped in in terms of subsidies to the workforce, to keep the public sector workforce in place during this crisis and avoid urban rioting to put in force subsidies to the FISC as the revenue collection collapsed. Those commitments, which up until the end of the year totaled about 1.4 billion and are now well over 2 billion, were absolutely essential at keeping a basic floor to the state in these three countries and avoiding a destabilizing seizure of the state. And I think it's pretty likely you're gonna continue to see something. Jim Kim jumping forward as he did was extremely important and we're gonna see much more discussion around this issue of at the G7 in Germany in July, led by Jim Kim around creating new facilities for encouraging these countries to invest in their preparedness and to give contingency funds, much higher contingency funds for these things. Yes, Jim? My point just came back to me is the Asia Africa Summit is next week and one thing is as we do some of the software, can we look and can we call and can the country leadership call on partners, China, India, and some of the other Asian partners that are engaged to help in that regard as well. And we'll see what comes out of the summit next week. Karen, could you offer us your responses on some of the issues that were raised and then we're gonna adjourn? Sure, thank you. So the question that you raised, how do we ensure continuity? I don't think it's an easy question to answer because there are a lot of unknowns, but I would say that one of the big things that we need to do is have very good information systems with constant updates on what's been achieved and those need to be shared with the governments and the donors and convince the investors that this actually is leading to positive things. I think also we need to see that the human resources for health actually are better prepared to deal with infection prevention and control, that to me is a fundamental thing that should be evidenced pretty quickly. In terms of the economic decimation, it's interesting that you asked that because I guess since we're talking about health system strengthening, it looks like all that money is going to health system strengthening, but in fact the economic support funds are going to mitigating second order impacts. And so there is a lot of focus on how do you rebuild economies? So that's not the topic of this discussion, but there is a lot of emphasis on that. And as you mentioned the global community, particularly with the IMF, the World Bank, and also I would say USAID all working on that, that's a very positive sign. In terms of how we coordinate and integrate within the US government, I think that we need to build mechanisms that allow for that. And part of that is the information flow. We also have the White House playing an active role with the National Security Council. I've heard that it happens. Yeah, so I'll leave you with that. Great, thank you so much. I wanna, before we close, I wanna offer special thanks to Sahil Angelo, Travis Hopkins, Addison Smith for your help. Arianne, I'm not sure where Arianne is. You've really contributed a lot to make this event happen. These have been exceptionally good presentations and discussions. And Maureen, Karen, Jennifer, you all put a lot into your preparations. And we really, they're very rich and very provocative. And thank you so much. This is a huge moment.