 Good morning. My name is Brian Gallagher. I'm the CEO of United Way Worldwide. We'll be doing this session in English, not because our panelists can't speak French. Each one of them can. Sadly, your moderator cannot. So I apologize for that. We'll be doing this session in English. We will keep our comments brief and then have a discussion among the panelists. And then also, hopefully, take questions from you. And I will not do the formal introductions. Each speaker has their opportunity to speak. I'll say a bit about their background contextually, but you can read their bios. You know, the title of this session, the Status of Healthcare in Africa, Challenges and Opportunities, seems pretty apropos, given the fact that there are clearly significant challenges and significant opportunities. There's been real progress made in health care across the continent. In the last 15, 20 years, life expectancy is increased. Childhood health outcomes are better. Death from communicable diseases is down. But clearly, that progress has been uneven, and we still have many challenges across the continent. Africans endure 17% of all the disease in the world, and yet are 11% of the population. 50% of all expenditure for health care across Africa is out of pocket. Only 1% of health care expenditures worldwide is in sub-Saharan Africa. And in fact, I learned just getting ready for this session, there's a $1.7 trillion US dollar fraudulent drug issue across the continent of Africa, a couple of that with infrastructure, poverty, violence in some places, the shortage of trained professionals. Clearly, we have challenges as well as opportunities. So as we think about in asking the panelists their thoughts on opportunities and challenges in the future, whether it's inpatient care, outpatient, preventative care, diagnostic services, is maybe to think about the way that President Kagami last night described. He was asked the question, did you look at the Singapore experience when you designed the governance model for Rwanda? And his answer paraphrasing was, we looked at everything. He wanted to create a Rwandan system. And what I would suggest is that there is an opportunity given the evolution of health care across Africa to create an African system. Not a US system, not a French system, not an Asian system, but an African system. And that's what I've asked our panelists to think about. So to think about challenges, opportunities, and then the path forward. First, let me ask Nardos Beckelay-Thomas, who's the resident coordinator of the United Nations in South Africa, but has been stationed in many countries throughout Africa, was also interestingly stationed in the Secretary General's office to manage affairs there. So it has a broad experience from a UN perspective as well as in country. And Nardos, I wonder if you share your perspective on regional challenges, opportunities national and overall. Thank you very much. I think you now start by contextualizing everything with the latest development that happened at the General Assembly just three weeks ago. And there was a high level meeting conference on universal health care. And there were, I think, seven points which I have gathered from that meeting. The first one is really for universal health care to happen in any of this world. You need political leadership. Political leadership at all levels. And political leadership that makes sure that there is a coordination between governments, vertical and horizontal linkages. Because a health minister is not the political leader. It's all the ministers that have to deliver on that. The second point is we have to uphold the leave no one behind. This is something that the SDGs have been promoting, and there should be equity. We cannot subject the marginalized people, the poor people, to only mediocre health services. They have to be eligible to a full-fledged, good health service, integrated health service. The third one is quality. Quality is very critical because the MDGs, you writes, Brian, we have delivered on that in Africa. There are primary health care centers all over Africa. But the quality is wanting. And Africans need quality health services. And the government has to make sure that that is delivered. The fourth thing is regulate and legislate. You have to make sure that health services and medical professionals are really clearly regulated. And that is also not only just from the services point of view, also we just talk this morning from the management perspective also. Management of hospitals, management of stock of medicines and all this. And that would take us to the training aspect of it. So we need to have trained, skilled professionals to deliver health services. The fifth one, which is critical and very important, is we need to invest and invest better than what we did before. The 15% pledge that we gave in Africa is not all fulfilled except with very few countries. So we need to invest. And we need to move together. To deliver health services, we need to have our research institutions, our technology institutions, our academic institutions to all deliver on the promises that the government has given. I give the example of South Africa. In South Africa, people think that South Africa is a sophisticated country. Yes, it is a sophisticated country. But there are two countries in one country. The country that has high tech health care system, which caters for 10% to 15% of the population. And the country that has really mediocre, like least developed country where there are basic health services, free by the government, but which caters to the 80% of the population. And the 5% there and there, we can put it as the middle class being part of the 10% that get high health services. We have 153 medical schemes. Each organization is obliged to have a medical scheme. The government gives free for all primary care, too, as long as they go to a public health services. And therefore, the public sector is really stretched, underfunded, and really does not have all what it takes to cater for the poor. Understanding this, the government has taken two important measures. The first one is to introduce the National Health Insurance Scheme, because the private sector is monopolized. There are three companies that deliver good services, high tech services to the population. And the prices are, of course, so high that the poor cannot afford it. So the National Health Insurance Scheme, one, M-Saturing, the cost of health care at all levels, two, make sure that each and every citizen of South Africa gets the health care services integrated that it requires. Three, it makes sure that there is a management of information and data in the house of the people, so that they have the liberty, the freedom to choose wherever they want to do. Information about themselves, but information about the mapping of whole health service facilities in the country. So this is what they are trying to do. It's a very, very tough thing to do. The government spends $717 billion, has pledged actually this year, at the State of the Nations address, the president said that he is going to put in place $717 billion runs per year for health care. $717 billion runs translated into dollars is $71.7 billion. As you know, South Africa is a heavy HIV burden country, with the exception of, you know, USAID, the paid part program in the global fund, the government funds totally. So, you know, government is really very, very keen in that. But unfortunately, corruption takes 22 billion runs per year from the $717. And the recent investigation by the government reveals that, and there is an action now taken to curtail corruption at all levels. So we'll probably come back to this issue of corruption and transparency and governance. But using South Africa as an example of two countries, and one in the complexity of the issues, I think is a good one. We'll also hear from Pierre about Nigeria and using a very large complex country example. Let me next turn to Dr. Julia Tuakli, who's the medical director and founder of Family Child and Associates in Ghana, a public health expert, a women and children health expert and practitioner and an academic. And so a very nice overview, Nardo's of the issue. Juliette, from a practitioner's point of view, what are the challenges and opportunities? And I think specifically, you're going to talk a little bit about technology and the role of technology in care going forward. Ghana's, most of you must know Ghana, I'm sure. But Ghana is in a rather unique position insofar as it is one of the countries that is hailed as doing very well with its national health service, with its capacity to try to raise the level, the standard of care for most of its citizens, which is all true. I think Ghana didn't fall into the trap of providing free care at the national health service level, because I think, and I was certainly in agreement, getting anything for free in any population probably is not a good idea. And health is no exception, even if what you pay is minuscule. And so the government in its wisdom has charged a very, very, very modest amount to those citizens who are eligible for national health service and have rolled out a pretty impressive program. The problem with Ghana is that it is in the middle of the West African hub. And some of our larger neighbors, such as Nigeria, where I'm from, I'm not saying this to be negative, do use services, as do many of the other countries. Liberia is another case in point. Certainly in my practice, we see people from all of the West African countries, especially Nigeria and Liberia, where the services really are much poorer than they are in Ghana. And certainly, they do have a deficit at the public health level. But even within Ghana, even within the national health service, which has been designed to provide to the best of its ability, a broad coverage to a relatively large population, there are gaps, which I consider to be quite important. Yesterday, listening to Paul Kagame, I was reminded of this, because within the national health service, there's no special area for women to seek care. And traditionally, women will not seek care until their children, their family, have been taken care of. And it does show up when we look at the statistics of the services that are provided, number one. And if you look specifically at the health status of women who are enrolled and registered with the national health service, so I think there needs to be a little bit of tweaking so we can empower and advocate access, more access, if you will, for women specifically. We have done a good job with lowering child mortality and morbidity, actually. But we have beautiful, shiny new roads courtesy of China and other large countries. And the rate of road traffic accidents is beginning to negate some of the gains that we have made regarding some of our mortality and morbidity. It's an ironic situation. Many of us in the public health sector had been monitoring the rise of non-communicable diseases. Obesity is particularly important. Diabetes is another. Hypertension is almost epidemic. But certainly, when one looks at the specific numbers, one will see that road traffic accidents trump all. And it's definitely been increasing with the number of roads, that number of highways. Public health issues were not taken into account by and large when some of these roads were implemented, i.e. crossovers for pedestrians to use, side roads for school children to use, even roads for bicyclists to use. We have a large number of people who do cycle when they can't afford motor vehicles. And so they are fair game, unfortunately, along with the goats and the cows and other things that sort of find their way onto the highways. And I really think we need to, within the National Health Service, also look at road safety education for the children at the school level, primary school level, perhaps even further up, because it's becoming a major problem. Absolutely major. And a lot of the accidents certainly could be avoided. And this has got nothing to do with drunk driving. This is just a child who tries to cross the road, doesn't regulate the speed of the oncoming vehicle, and gets knocked over. And it's happening far too frequently, particularly amongst the younger population. So that is a bit worrying, I have to say. And then the other reason Ghana has a little bit of a strain on its system is because we're at the hub for the counterfeit drug system. And as Brian had mentioned, it is a huge business. 1.7 trillion US dollar business per annum. It is not small. There are several major countries involved, both in Africa and outside of the continent, who are pushing these medicines. There is some pushback coming on board, where we have some technological firms developing scratch cards, the system of the scratch card method, that a purchaser can scratch the silver foil on the medication and use their app on their phone to see whether it is a legitimate drug or not. And a company called Sproxel is now working in Nigeria, in Ghana, in Tanzania, and I think even in Senegal. And certainly, I think it's a fabulous program because it involves the government at a very high level as well as the drug manufacturers. But most importantly, one doesn't have to be literate to use it. I think that many of the programs that we do have often presume a level of literacy that is not always present. What I like about this particular program and why I pray that it will be successful is that everybody, I mean, 80% of our population have mobile phones, and 80% of them are used to refilling their services using the scratch card method. So I think it's a very, very, very important intervention that needs also to be promoted and supported. Nardo spoke about leadership. Leadership really is essential. At the current time, we have a president's wife who is very supportive of many of the health interventions that are coming on board. The president himself eloquently discusses them, but it's actually been his wife, I've noticed, who has been much more involved in trying to make sure these advances are sustained and implemented. I think also the last but not least point is the issue of geographic access, which is why I think technology is so important. We have some very remote areas in Ghana where you don't have as much telephony as you have elsewhere. And so you'll find that access is limited. And of course, this is often where outbreaks occur. People aren't aware of it until it becomes a community epidemic, and one is then scrambling to try to contain preventable outbreaks. But I do think, as I discussed earlier, that technology might provide us with a bridge to leapfrog over some of our infrastructural deficits. And certainly with the sproxel example I gave you regarding the counterfeit drugs, I think that's an excellent application of technology. I can speak more to this a bit later, but I'll stop there. It's a, you know, the roads and the accidents on roads just remind me that the two common threads are this transition that countries in Africa are between emerging economies and developed. And that not always plan for the Passover. The road's issue is a perfect one. So Robert Siegel, the question is, why would we invite the CEO of the American Hospital in Paris to a conversation on healthcare in Africa? And Robert's a business leader, ran the GE health business in France before taking on the CEO role and has a very interesting perspective on healthcare generally, but also healthcare in Africa, if you would please. Yes, thank you, Brian. First of all, I would like to thank the organizer and certainly Thierry de Montbriand for organizing this session. Who can imagine that we will aim at a better world without having better health? It's impossible. So healthcare is certainly a founding block of better healthcare. So providing healthcare, if you want to deliver healthcare, whether in France, in the United States, or in Africa, you need basically three things. Basic infrastructure, water, electricity. Then you need healthcare infrastructure, buildings, equipment. And finally, you need human infrastructure, nurses, technicians, and of course physicians. When you look at Africa today, 47 countries, the situation is of course very diverse. If you look at Magreb, for instance, there is infrastructure. There is basic infrastructure, and certainly there is healthcare infrastructure. If you look at data regarding the physicians, for instance, and you look at how many physicians you have by 10,000 population. In Magreb, in Nigeria, you have 18 doctors. Morocco, seven. If you look at South Africa, you are at nine. But now, if you look in between, the situation is not the same. You would be below five, and it can go as low as 0.5 physician per 10,000 people in Nigeria. So there is clearly a problem, a quantitative problem. These progress, however, are there. And yesterday we heard Prime Minister Koulibali, who mentioned that the middle class is going to be 800 million people in 10 years. And this middle class is looking for healthcare, and in general, again, who can imagine that in all these countries, solid growth and social justice will occur without solid healthcare. And so in this mood of making progress, I would like to point to two specific domain. The need for quality is number one, and the need for accountability is number two. Need for quality, let me go back to the problem of physicians. Even if you say that in a country, you have eight, 10 doctors per 10,000. By the way, for France, we are at 30 for 10,000. In the United States, it's 26. But so you need to have the good doctors. You need to have specialists. It's not only, there are certain countries in Western Africa where you have three gastroenterologists for the whole country. So you need to train all those specialists. The second point I would like to stress on regarding quality is hospital and healthcare managers. It's not an issue only for Africa. Believe me, it's an issue wherever you are in the world in France as in any other country. You need good hospital managers. And this point points to my second point which is accountability. There is no shortage or there are financing and financiers around the world. It can be public. It can be the WHO. It can be the Gates Foundation. So there are money. But all these people are asking the same question. And it can be, of course, private sector, of course. But they're all asking the same question. If I invest one euro or one dollar whenever, what is a return on investment? Who is accountable for this money? I am ready to put a lot of money, but I want to be sure that there is a return on investment or a value for money. Call it whatever you want. So I think that for these two challenges, quality and accountability, technology is an answer. Not the only answer, but it's a very important answer. And let me be a little bit more specific. Number one, technology, of course, is completely linked to modern medicine in any hospital, in any clinic. You need now modern imaging, MR, CT. You need an operating room with tools that can deliver on the needs. So this is one. Now I would like to point to information technology. Information technology is transforming our world, maybe at the cost of the carbon, as was said before, but it's transforming the world. And it can be used in several ways. One of them is simply organizing digital education. I spoke about the need to enforce and enhance the education of physicians. We are organizing in our hospital every year what we call the gastro-training, where we train gastroenterologists of Africa, insight, and at the same time, we have a digital link with several countries in Africa where people can watch, participate to this. And there are a myriad of initiatives for this digital education. Now another point with digital is continuum of care, and this is very important. Today, what I see and what we're discussing in my hospital, we get a lot of patients coming from Africa, but in many cases, sorry, it's too late, as simple as that. We cannot do a good service for these people. So having tele-radiology, tele-medical conferences is a tool that able to triage the good patients and to avoid to get patients for which you cannot do anything. And once you've treated the patient, you have to follow up on this patient because you can imagine that you need to follow with the local doctors and the local infrastructures, so this is digital information. But you can even think forward, leapfrog. Let me just say something concrete about artificial intelligence. We are using today in our hospital artificial intelligence with mammograms to detect women's which are at risk for breast cancer. It's used with genetics and it's used with mammography. So today in the Western world, artificial intelligence is a help for the radiologist. But you can imagine that tomorrow in Africa, you have a mobile unit with MAMO, no need for a radiologist, and the MAMO is sent to the cloud a artificial intelligence program and is able to detect as simple as that and to point to women which are at risk for developing a cancer. So this is becoming real now, it's not just a dream, it's becoming real. And finally, the last point about technology, I come back to accountability, it's data. If you are digital, you have more and more data, you're accumulating data, and we know today that in the real world, in the Western world, accountability now is simply data. It's the fact that you're not just speaking with explaining nice things, you show to control the ship data. So if we put and develop those digital infrastructure, the accountability and the capacity and the will of the payers to sustain the effort will increase. I will just finish with this point. In my previous life, industrial life, it was an American company, and the company understood at some point that it was not what was good in America was good for other continents. And there was a lot of efforts which were done in China, for China, in Asia, in India for India. We can exactly imagine the same for Africa, in Africa, for Africa. And yesterday, we had President Kagami, which was there, everybody knows the IT success of Rwanda. You can perfectly imagine that some solution, local solution, are invented in Africa, and because we are close to the market, to the needs, we are cost-effective, and they are good for Africa. But tomorrow, and this was what happened for in China, for China, and in India, for India, those products, which has a beginning where only good for those markets became good for the entire world. So maybe step one is maybe in Africa, for Africa, but step two is why not everywhere in the future? So I am optimistic for Africa. Thank you, Robert. Let me let Pierre jump in here and then we'll go to all four. Pierre-Mé, Pille. So it's mercy ships, mercy hospital ships, but you're a HIV advocate, you're a former WHO representative. You're the fourth. So that's either great position or horrible position. Your perspective on what you've heard so far. Merci beaucoup. Sorry, thank you very much. Brian, I wish to, first of all, recognize that the Africa continent, over the 20 years, the past 20 years, has made significant progress in improving the health of the people. Despite, of course, the disparities between the regions, disparities between the countries, and also within the countries. The Africa continent carries 25% of the global burden of disease. Home of almost 20% of the world's population and only 2% of the world's doctors. So many challenges. But there is hope somewhere. In some countries, like Cabo Verde in West Africa, Rwanda in Central Africa, Botswana in the southern part of Africa, and Ethiopia in East Africa. And I would like to highlight what happened in Ethiopia because it's a true success story in health sector strengthening. Because of the political leadership and commitment for change. Change for health, leadership for actions. And Ethiopia, over the past 20 years, has made impressive progress in improving the health of the Ethiopian people. Ethiopia, just in 2015, concluded health sector development programs from 1997 to 2015. Composed of four series of five years. And this amazing work because Ethiopia achieved almost all related millennium development goals in 2015. And this health sector development program was based on a very bold strategy. The health extension program putting for 5,000 people a health post managed by two nurses, all women. So in a country where you have 100 million people, it's about 18,000 health posts. That is amazing. And of course. All the way down to the local level. And they do promotion, health promotion, prevention. And they use the new technologies, the smart phone because of the national phone coverage network. It's used to monitor. Are they networked through digital technology, the 18,000? To monitor the pregnancy, to monitor the child immunization. So it's about promotion, it's about prevention, it's about care. You can do the HIV testing in the health post. You can monitor the TB. That is a package of key essential health services at low level. And at least two nurses in each post. Two nurses are two women. That is very important to see the place of the women to, you know, a change happening in Ethiopia. And within the community, you also have, it depends on the largest of the, what they call the village. So that is 25 to 45 women leaders within the community, so-called women development army. I was telling the prime minister of Ethiopia, oh, you have maybe the most powerful army in Africa. And he said, ah, no. I said yes, but it's not about the militaries. It's about the women development army embedded in the community, being the link between the two nurses and the community. So let me ask you a question about that and ask everybody to come in on this question. So you've all talked about infrastructure at some level, whether it's human infrastructure or technology or, you know, resources, natural resources. What's the infrastructure requirements that you've seen in going to grounds, you know, versus being centralized at the top of going to ground? And I wonder if all four of you would think about, does the infrastructure have to be thought about nationally only? I mean, should we be thinking about these approaches regionally and even regionally outside of Africa? So, Robert, do you think about an axis from Paris to African countries that are focused on patients that then have to have infrastructure all along? How do you think about infrastructure in this case and how, as you think about scaling innovation, how should we think about organizing infrastructure going forward? Why does it only have to be national or should it be beyond that? Of course, maybe Robert will say more. But I don't think that the infrastructure or health facilities must make a difference. Of course, we need, at all levels, at low level, at district level, at regional level, and at national level. But I don't think it's the people. The human resources are key to make a difference, to improve the health of the people. You can have a beautiful hospital, what we call in French Elefant Blanc, big with everything. But if you don't have the right person, the right doctor, the right nurse, the right midwife, the right training for you. The right place. The health of the people will not be improved. That is my understanding of what we should do in Africa, making sure that we have the people to do the job. Others? I would go along and say one of the things that we haven't mentioned, which I think is very important, is that 85% of most of our patients at any level have usually consulted a traditional healer before coming into the health system itself. So if we're going to devise a system, as you described here, which is excellent, you have people there by who actually understand this, at least potentially, and perhaps can incorporate their knowledge of that, as well as the traditional healers themselves at some level, where it's regulated, of course, and genuine, into the mainstream medical system, because I find that oftentimes we speak as medical people, as though those people, i.e. the traditional leaders, are messing up what we're trying to do. And in fact, that's not entirely true. There are some cases, there are some illnesses, there are some conditions where it's really important to work hand in hand with the traditional healers. And I think where you have a national program that takes into account the relevance of traditional healers in the family life, and then you have women who are part of the community who, of course, assume that this involvement has taken place, I think that makes for a more effective practice of medicine. That's fascinating. Nardo-sen and Robert. I think from my perspective, I think by keeping on saying the ecosystem, we need to have an ecosystem. What do we mean by ecosystem? If a country knows the disease burden, for example, it has to produce the skills that are necessary for that. It has to produce all the infrastructure that you require for that. And this infrastructure should not be a standard one. It should be a differentiated one. And we change this over time. So that's one thing. In South Africa, for example, we have supported the CSIR, which is a Council for Science Innovation and Research, and working with the Cape Town University, we have turned the biomedical engineering students to be designing the medical equipment that the country requires. So we have come out with an asthma equipment by one of the students, which is really something that you can squeeze. Easy squeeze, asthma thing. We have come out with information technologies like mom connect, HIV connect, and all this, where people subscribe and they share information. But we have the most important thing, is the envy flow, where a device, where people can go and be detected. Like you said, the mammogram and all these mobile portable things. So these are students. We have got the young generation whose DNA is technology. Our children come out and they're soft-skated. So we just have to empower them and make sure that the environment is compatible with the needs of the society. So linking them to is very critical. The other thing when you talked about subregional, when I was in Kenya and we developed this cross-border initiative, there is no need for countries where the borders are there to have one hospital in Kenya, another hospital just 100 meters in Ethiopia. It doesn't make sense. They call themselves scale. So what you do is you have the primary centers there and taking advantage of the reference hospital there. So we have to be very strategic in the way we invest. And we should think, this is a global world. It's borderless when it comes to problems. When it comes to solutions, we have to make it also borderless and enjoy the economic system. Flexible and dynamic infrastructure design, Robert. And then we're going to take a couple of questions from the audience and wrap it up. So regarding infrastructure, think global, act local. So this is what Paul Kagame told us yesterday. He benchmarked essentially with other good practices. So there is no one good solution. You have to think global and act local. Now regarding the actors, it's difficult to think that you will deliver good healthcare in a failed state. The state shall continue to play a key role. There is no doubt about that. But to me, the key answer is pragmatism. You can have the state, you can have academic, you can have private sector, you can have donors. It should be pragmatic, but this is my last thing, is the gain accountability. So deliver. Be sure that whatever the plan, you follow up on execution and that at the end of the day, you've got execution, local execution. This is really key. And from the beginning to build a plan where you go from the vision to the plan and then to follow up on execution. Because there are too many stories that we heard about this Elefant-Blanc, nice hospital, nobody's inside. And so this of course is discouraging for the actors. Yeah, it's a line of sight into the operation. And then as data becomes more accessible, how do you manage the data? Right here is Jean-Claude and the woman down here and then right here. This is three and then see where we are. Well, congratulations for a great discussion. A very short question for you, Brian. Why as the CEO of United Way, you care about health in Africa? Because Robert does. I'll answer that. Yes, to the woman, lady down here. And then the man in front and then we'll... Thank you. I want first to join the Mr. Siegel in commending the World Policy Conference for dedicating a special panel on health care in Africa and asking for attention for that. Because I consider that health care in Africa is the single most important challenge African states are facing. So there are a lot of problems. You spoke about it globally, about culture, training, and you know that. There's not one single head of state, African head of state, who believes it can be treated in Africa. They all go abroad because they know their hospitals are broken and they sort of a wasteland they don't care about. I mean, they are of course progress and you spoke about some good examples. But I think of Central Africa, basically. And there's something I just don't understand. I understand lack of training, I understand lack of infrastructure, all the problems you listed. But I don't understand the lack of compassion. I mean, there is so much abuse, again the patients there, that you know, people are sort of tortured. They are being ripped off. I mean, we wanted to open a website on the model of MeToo. Tell about the abuse you are having there. How would you put that into a question? Yes, that's a question. How do you tackle that? It's not technology, it's not infrastructure. The lack of human compassion. That's it. Where do you put it into? Good. And then final question here and then we'll see where we are. Right here, please. It's on infrastructure and how to make some of the white elephants less so. And Juliet knows this that yes, decades ago, there was a policy in Ghana to build a hospital in each district. At that time, I don't know how many districts there and 110 districts, and hospitals were built. And in that particular case, it came along with the equipment. But I don't think the energy to run these hospitals were touched through, because at that time, if in many, and most of these districts are rural districts, of course there are some in the urban center, if renewable energy, just solar panels had been used to provide energy, most of the equipment would probably still be functioning by now. But they were put on the national grid, which Ghana is sort of reliable, but the power cuts still happen. And so you find that within a year or two, very sophisticated equipment put across these hospitals. So you're saying there needs to be an integration of the energy strategy with healthcare strategy. Especially as we were just talking about climate change and energy. That's very good. I'm sorry? Okay, one more, and then we have four minutes left, and we're going to give each one of you an opportunity to react to the questions you've heard. Thank you. Thank you. Thank you. As you're all in Europe, you see, I've done a lot of that in Europe, I've done the prescription. So I took the opportunity to take a tour of Paris, I did the radiography, I brought him the hydrhythmic, you see, it's clear he was happy. I was unhappy. Because films are imported, kept under the heat, and when you use them, it's all gone. So the question is, second point, it's the medicine and the traditional medicine. We have neglected and killed them, whereas in all the faculties, in the medicine, in the pharmacies, and in the laboratories, the medical materials, the most numerous and the most effective are the tropics. There are many in the tropics, and we are the most effective because we are sometimes fighting by pharmaceutical laboratories for traditional medicines that can be valued. I'm not going to say more, more the fake medicine. The fake medicine. No, the fake medicine is on the other side of the world. But no state can fight against it alone. So it's a big problem and the French president, Jacques Chirac, came here to help you. So you have to write it in the conclusion of our work. So I would take that, and I'm sorry, we have to close with those. I would take that last comment as there are lots of resources in Africa and the world. We're sub-optimizing those resources. We're not taking advantage of medical conditions and so forth. But also, the idea of integration of energy policy and healthcare policy and the different cabinet ministry level in government. And then finally this idea of human compassion that shouldn't it just be part of our DNA that healthcare and how we treat each other should be priority one. So any of that or however you'd like to take 35 seconds to make your final point and we'll come this way. I'd like to address the issue of compassion because it was one of the first problems, if you will, that I had to deal with in setting up a practice in Ghana. I had been at Harvard and taught there and set up practices in Boston and the very first thing that hit me was the seeming lack of compassion and yes, in many ways it was a lack of compassion. And I think that in the conditions under which many of the doctors work, I bring it back to the issue of leadership and poor management. The management of the resources within the medical facilities does not support those physicians who put themselves out to really do what they're supposed to do. And I think it's almost like systematic trauma that they are incurring. They're training. They abuse, if you will, starts there. They're expected to work much longer hours than they do in the west and I do mean much longer hours. Nobody can work for three, four days with barely a satisfactory meal and then see a patient and be compassionate. I am not trying to exonerate our healthcare workers. I can assure you I'm not because it is a major, major problem and even hiring old workers for the practice that I run. That's one of the first things I look for because I will not exonerate it. But I do have a better sense of having practiced for 15 years in Ghana seeing some of the conditions under which they're being taught. That's why I don't teach at the hospital there because I cannot teach in that environment. I simply cannot and offer quality medicine. It's impossible. But I bring it back from the actual physicians themselves who don't know any better at that time to the leadership. We don't have our leaders trained in medical management. The people who run the hospitals are usually physicians themselves that have been plucked because somebody liked the way they looked and put them in charge of the hospital. That's not adequate. It's not enough. It's not good enough. There really is an issue of leadership and I can be sure that if I were to go to a Rwandan hospital I haven't been there in a while but even when I went there decades ago you could see that people were selecting people based on qualification not because of some arbitrary interpersonal relationship that they might have with the person. And once you have somebody who understands what quality medicine is and how to get it out of a doctor trained they will not allow they will not permit some of the conditions under which those physicians have to work. We lose our doctors annually because they just give up and move out or into NGOs and other organizations but it's a dreadful situation. Thank you Juliet. So leadership and quality came out of that Robert briefly. In 1950s the life expectancy was around 45 years old. Now today we are at 60 so it's still the lowest in the world but it has tremendously progress and there are all reasons to think that it will continue to progress so it's of course science it's of course financing it's of course humanity but it's of course leadership and I think the question again in this conference the question of leadership is absolutely key because you have some force which have to be empowered and drive this effort. Excellent. Here. Again and again. The problem is not to respond to each of the challenges we will not settle all the problems. I think what we need in Africa leadership commitment for action to change the life of a people. I talk about Ethiopia. They are not rich. I talk about Rwanda. 20 years back they had a genocide. I talk about Kapoverdi. It's not a rich country. I talk about Botswana. They have Daimon but we have so many rich country in Africa. The health sector is failed. They are not able to provide the minimum package of essential health services to people. I think the problem in Africa we need leaders involvement to change the life, the situation of the people. Very good. I'll start with the compassion but I would expand it a little bit. In the entire world, it's not Africa values and standards have really gone down completely down and therefore the world has to think on how to really bring back societal values family values, professional values into the forefront. Truly. I think this should be a discussion, a universal global discussion and not really specific to Africa. Yes, the compassion and passion is associated with the environment and again and again what I said first comes when we plan in a silo we will never get anywhere. So we have to start adopting an integrated planning, an integrated budgeting and develop ecosystems and therefore when we talk about you know what my big brother Robert Osus just said when we talk about healthcare system we shouldn't look at it from just one aspect of it which is a treatment. We should look at it from the preventive side to the treatment the whole integrated system and looking at all environment. When you plan you have to really know the business burdens and how many medical doctors in what fields we should train them and then the institution should respond to that you know academic institution produce them. So you know we have to really look at research institutions like I said you know the biomedical engineering you know they do engineering they go out of course they run out of job because it's not relevant to the socio-economic development we do everything outside the socio-economic development needs of the country and that's where we run into problem. Just one thing I think also for Africa we need to really move out from thinking of and talking about just all the time what we don't have and really highlight on what we have and on how to scale it up there are many best practices everywhere. There are many best institutions everywhere each country cannot afford to have research institutions but it can piggyback on an institution that exists CSIR in South Africa is not an institution innovation centers African governments and leaders come there they don't even visit that research institution. So we have to really know on how to share our resources and on how to talk about you know highlights about prosperity what are the areas of excellence that we can share with others. Thank you so much you know this is one of those examples yeah please that we could take a great deal more time but that's what lunch is for that's what hallway conversation is for let me finish with this one thought United Way is the largest privately supported NGO in the world we generate about five billion dollars US per year and one of the things we've learned and you heard here is that no longer is innovation and scaling going to come from the top down or the center out it's going to come from the out in and the bottom up and whether it's individuals, patients countries we're growing very quickly in India, Mexico China now starting in Africa because we're coming bottom up. Scaling health care will as I think you heard be about leadership quality transparency but engagement of individuals patients driving their their own care in our institutions responding to that that's why we care about health care in Africa. Bon appetit have a great lunch.