 A number of us went to Myanmar recently with CSIS. Steve and I, Emeril Collison, Lindsey, Murray Hebert, and we were really trying to take a look at how the broader recommendations of CSIS on the lower Mekong Initiative and its relationship to health bore on the particular issues relative to Myanmar. So I hope in the next section we're going to be able to talk a little bit more specifically around some of the challenges that exist in Myanmar and maybe some of the ways that the recommendations that came out in the earlier sessions could take hold there. My name is Todd Summers. I work at CSIS. I also spend a lot of time with the Global Fund, a chair, a commission, or committee of the board that focuses on strategy. The Global Fund is a major investor in the region, and as has been said before, we've just announced a hundred million dollar regional initiative to address Artemis and Resistant Malaria. We also have several hundred million dollars invested in Myanmar, so it is an institution that is providing a substantial amount of resources to the area. Our panel today, we have a great panel. We've asked them to be very sharp and quick so we can get quickly to questions. I know this is the time where the post-lunch narcolepsy kicks in, so we're going to try to be a little bit fast paced here and edgy. Hope that works. Mukesh from the World Bank. The World Bank has a relatively light presence in Myanmar, but is looking at a very substantial increase. They've just finished some studies to look at where the money is on health, so maybe he can give us some late-breaking news on that analysis, but we're really going to understand what the World Bank is going to do with the billion dollars or so that it's talking about with Myanmar in terms of IDA capacity. Katie from USAID. AID has got a small but important presence on health in the region. That's an amazing group of people that are extremely impressive. We were all warmed by the quality of the people there and their commitment, but also daunted by the tasks that's ahead of them and the country. We have Patricia, obviously from CDC, spoke at earlier panel. CDC's in the region and now has some people in country and is complimenting what USAID is doing on health. And then Miat, who's here, I have to say, in his personal capacity, even though in other days he happens to work for the U.S. government with the National Institutes of Health. But he is here on his own, on a vacation day officially. So Mukesh, let's start with you. The World Bank, we've been very excited that Dr. Jim Kim came in, a long history of work on health, a famous HIV AIDS doctor, waiting a little bit for some of the money to move on health. You're looking at Myanmar, I think you've said in the past, maybe a billion dollars of AIDA credit coming to them. Health could be a key part of that. What's the World Bank's view on Myanmar? What are you thinking about going forward? Thank you, thank you, Todd. So a few months back when we were in Myanmar, we had a conversation with the Minister of Health and we asked him, we said, what do you think, Mr. Minister, what do you think is the one big problem of health in Myanmar? And he thought for a little bit, looked up at the ceiling and he said that people in Myanmar die 18 years earlier than people in Japan. I want you to figure out a scheme for us, a mechanism for us so that we can live 18 years more. So that was the vision. Now, that's how we all started doing the work in Myanmar. And then we found out that, okay, maybe Japan is too far away, Singapore is too far away, neighboring Thailand. There are 29,200 deaths annually in Myanmar, which occur due to preventable causes, which would not have occurred or which would not occur if they had health system outcomes the way that they have them in Thailand. There's 29,200 deaths, or 29,200 lives can be saved annually. So that was the inspiration of the work that when we started to see, okay, how much is the money, where is the money going, who's spending the money, who's consuming it, who's using it. And some of the results that we found were absolutely startling. So I'll just throw out some numbers here for your consumption. First, Myanmar today spends a total of $1.2 billion on health. Assuming the population is 60 million, give or take, that is $20 per person per year, that's the amount of money that they spend on health. Second, most of the money, 65% or so is in the private sector, is out of pocket payment. Government spending is about 30%, 5% comes from external sources. Third, in the last three years, to be very precise, between 2011-12 and 2012-13, government spending in Myanmar on health increased four times. In the last year, 2012-13, 2013-14, it increased one and a half times. In the last five years, it has increased nine times. The government is really very serious and pumping in a great deal of money in health. Most of this money is going into medicines. Medicines were not free a few years back, and people had to pay for it. Now, they're coming up with a policy, not fully developed there, but coming up with a policy to give medicines free to everybody. And a great deal of money is going into health infrastructure, into equipment, into buildings, into supplies. Where does this leave us? If there is any one country in that region that has a tremendous amount of potential to leapfrog and to play catch up compared to where they were two, three years back, four years back, it is Myanmar. It's a tremendous opportunity. See, 60 million people, $20 per person per year on health. Jeffrey Sachs would put the ideal number at closer to $40. So that is 2.4 billion. So they are still pretty much short at this point of time. They still need much, much, much more. But if they were to somehow magically discover the money to take care of their capital infrastructure of their equipment. If they were to magically discover the right policies for distribution of drugs, for distribution of healthcare, for delivery mechanisms, for the right kind of technology, for the right kind of people at the right kind of time, then this is one country that to go back to what the minister had said to us when we started, can very rapidly close that gap. Life expectancy today is 65 years, Singapore, Japan is 83 years, it's 18 years. That's where they have to reach. And I think that goal is definitely attainable, very aspirational. Lots and lots and lots of challenges. But to me, in the realm of possibility. Great, Katie, we met a great team over there, Bill Slater, head of the health team, Tuvan, really a very impressive, now there's a CDC person who showed up right after we left. But the challenges are really almost overwhelming. So they took us to visit one of the local health clinics to see a program right in the capital. We had to step over six inches of fetid water to get to into the clinic where there was no power, no electricity. The bed sheets looked like they hadn't been changed in quite a while. There was no IV tubes. We walked through a ward that turned out afterwards to be the MDRTB ward. There was no protection for anybody in the ward. So how are you looking at your engagement with me and Maher and how does it fit within a lot of the dialogue around the grand scheme of LMI and your broader engagement with me and Maher? What is USAID doing on health? So from the beginning of this reopening in Myanmar, we've really been focused on recognizing that we're not coming in with this huge new mission and kind of taking over the donor landscape. So it's been really a big priority for us to work collaboratively with the other donors who are there and to listen to the Ministry of Health and what their priorities are to figure out what our strategic advantage can be. One of the biggest things that's been a priority for us and been really well received is that we're preparing to conduct the first ever DHS for Myanmar. And that will give us a lot of this data to figure out, where do we direct programs to save those 29,000 lives? And what are the disparities? How are health outcomes in the rural areas? We can assume they're much worse than even these urban clinics that you're going to. But the DHS will really give us that data so that we can know where we are at. And then we're also really prioritizing from the health systems perspective on working on the supply chain and helping the government of Myanmar to be able to manage their own supply chain. We're launching the supply chain management systems activity. And we want to help get the right policies and mechanisms in place for them to be able to get the equipment, the medicines out to where they need to go. And also looking at the private sector, there's a huge amount of care in the private sector and we don't quite know what it, what does care look like when it's filtered in the private sector? How are the health outcomes different in the private sector versus the public sector and we want to help answer those questions. Great, thank you. Patty, CDC obviously, we've talked a lot today about the Artemis and resistant malaria. We have drug resets in TB in the area. We have a lot of HIV in the area. We have the potential for some of the other viruses that have been discussed, moving in and out of the country. And we have a huge amount of people on the borders that are in very volatile situations and very mobile situations. So where is CDC seeing its role here? You have obviously a firmly established base in Bangkok. How are you looking to expand your role in Myanmar? Thank you. So I think that there's a lot of issues with the public health system that's been brought up today in a number of ways. And that one of the biggest problems is that we don't have the information that's needed and that the government doesn't have the information that's needed for decision making. So I think that's an important role to help with surveillance and other data needs in the country. There's also public health security challenges that we talked about earlier that are important. We've just started our engagement there. We've worked in small ways for a number of years. But just recently, as you mentioned, we placed our first assignee there with the USAID health team there. And we're starting with our PEPFAR work. And we have been working on an ongoing basis with PMI and with USAID there as well and the malaria resistance issues and the issues on the border. We have a lot of requests for technical assistance. In fact, any engagement we have either at scientific meetings or TDYs in the country that they're even more than financial assistance, which I'm sure that financial assistance is needed, but is really for direct technical assistance. And this is the way that we've worked in a number of countries and it's been a successful model for us working side by side, having full access to the technical expertise that CDC with our partners in country. So we hope to do that more. The challenges, it's currently in Burma, we haven't been doing direct funding for the government and we haven't had a, what we usually do is have a cooperative agreement, an agreement for working cooperatively on public health projects with some funding in the country. So thinking about the transition of the government taking on more of the direct role in the country and also thinking about the leadership that they will take with all of everybody who's trying to work there and how that's going to be coordinated is really important moving forward. So Mia, you're looking at this a little bit from afar, although you obviously have a deep connection to the country. I called Mia and I said, oh, we're going to Myanmar, Steve and Tom and I and Murray and Lindsay and I said, one of the things we want to talk about is mill to mill cooperation and suddenly the phone got very quiet on the other side. And I said, so this is going to be a sensitive discussion, huh? What's clearly obvious is you have great leadership at the top of the Ministry of Health but you don't have to go too far down to find some big holes within the system in terms of capacity. The military obviously has got a much more substantial presence in the country. They command something like a third of the overall national budget. So how do you see the civilian side as this new piece has come forward emerging as a strong leader in health and how do you see the interrelationship between the civilian and the military in addressing some of these urgent health challenges? Thank you, Todd. That's a kind of tough question. You're putting it on the spot. I told you I was going to put you on the spot. I think the military will always play an important role in Burma, whether we like it or not. I wanted to be in the military as a medical personnel because that's how all the decisions are made by military when I was growing up in Burma. And so why do I have to just be a regular medical doctor when I cannot make decisions which will be imposed by military leaders? Why don't I be a military leader? Unfortunately, or fortunately, I was not allowed to be in the military. At the same time, trust of the military and civilian are severely, I kind of like, you know the situation because in 1988 I was a young doctor. A military shot and killed thousands of people on the street. And then I do have friends in military. I would like to walk with them, but at that time there's no way we could do it. So now, taking a look at back 25 years, military is getting stronger. People, especially in ethnic regions, have more concerns about the military because a lot of abuses mention. But one thing I would like to mention is military, you cannot put a big stroke of brush. It's military. Not all military are the same because in military there are some rank and files who are suffering the same as the civilians. Their top leaders may be gaining a lot of wealth and benefits. And so how do we really take a look at military? And I have been listening to a lot of military issues and military also needs to help. Are U.S. military also need to help? How the Burmese military is helping its own personnel? In the border area we saw some of the sex walkers from military families. And so we cannot put military as everyone is the same. Getting back to now the leadership in the civilian military, it's a long history. And so confidence building is crucial. How do we build confidence? Military needs to talk with the civilians not as a top down. And so if the U.S. military can help, Thai military, Cambodian, Vietnamese, if they can just really engage with the Burmese military, how Burmese military can be a part of a change and they need to reform themselves for people to be confident in them, they need to show that they deserve people's confidence and trust. If we can reach that part, we can move forward. I'm just talking about broader part because help is also an essential issue. When we were growing up, we did not have defense service medical school. Now they established. And they have very kind of a good structure, whereas other medical schools are suffering. And so if U.S. military is to engage with Burmese military in medical facility development issues, you also need to work together with the U.S. government in terms of how do we really push forward? Human resources will help. Health system strengthening, medical education, nursing education, lab management, everything that you are doing in military here. And you can help them back. But I would like to just get back to other questions because I have a lot to say. Great. So we're going to open it up in a sec. I just want to ask and catch one more question, which is a number of speakers today, including our guests from Vietnam and Cambodia, have spoken about the importance of health system strengthening. When you talk to the folks at USAID, they understand that there's a lot of money flowing into the country and health. But it's pet farm money, it's global fund money, it's GAVI money. Those are all pretty focused vertical sources of resources. The actual budget they have to deal with the stagnant water around the health facility is pretty small. So as an institution, World Bank has set forth a goal of working in health system strengthening. What do you see in terms of the future relationship and how does it bear on some of these broader system challenges? And some of your work in neighboring countries is a way for the World Bank to help broker some of the shared expertise that sits next to me in Myanmar and bring it in. Excellent question, Todd. Working in health system strengthening is always a struggle because there is the short term objective that the government has, that the ministry has, where they want to see a result immediately. Health system strengthening is not something that will give you an immediate result tomorrow. It is something that gives you a sustainable result day after tomorrow. So that always is a big, big challenge to try and make sure that you have the right elements in place. As Todd pointed out, we in the World Bank have been focusing on health system strengthening. We have a bunch of people in the bank who are trained economists, particularly in health financing and health systems. And we work very closely with a large number of donors like USAID, like DFID, like AusAid, and so on, like Global Fund in countries like Myanmar, taking their vertical programs in some instances, trying to influence them and their budgets and their allocations to make sure that a certain amount of money, maybe 5%, 10%, 12%, gets allocated to health system strengthening, and then working from within those vertical programs. Because if you get out of that vertical program and start doing something fancy, that's not going to work. It has to be something that shows a result as well. In Myanmar, we see three things that are extremely important. One, human resources. We have a huge shortage of doctors, huge shortage of nurses. There are a very large number of townships. We have 330 townships in Myanmar. 110 townships we don't know much about in terms of human resource distribution. 220 townships we have a slightly better sense. 68,000 villages, we have a good sense of about 35,000 of those villages. But a huge problem in terms of human resources and essential element in any health system strengthening exercise. Infrastructure. We are not talking here about hospital buildings. We are not talking here about primary healthcare centers. We are talking about equipment and machinery and consumables and supplies that keep the thing running. Todd spoke about his experience where he went to this, we went to a primary healthcare center very close to Bagan which is a beautiful drive from Napital to Bagan. And we went to a very fancy healthcare center which was shown to us by the government. And we went there, state of the art equipment, state of the art machinery, very nice cold storage for vaccines, for medicines. Everything was completely empty. There was nothing there. Then there was a double lock system through which they opened their own medical supplies cabinet. So there were two persons who had to sign and open that big, heavy steel door. So we thought we'll find something fancy behind that. And it was a site that made us cry. We saw one bottle of Paracetamol. Paracetamol is like acetaminophen, an equivalent of that in most countries in Asia. One bottle of Paracetamol, 60 pills for the entire catchment area of 85,000 people. Lying there. That was the total annual supply of Paracetamol which is a fever-reducing medicine for that entire catchment area. There's no doctor there on duty. There was no nurse even. There was one person who was kind of sort of trained and he rightly said that I dare not even distribute this. I don't know who to give it to. If I give it to one person, others would lynch me. My answer is I don't have anything at all. You guys go and buy from outside. Then this thing expires. Somebody will come and help me dispose it off. That is what we mean by that we need to get that kind of medical infrastructure in place. I'm actually very happy to say that we've been working very closely with the donors and all of them are extremely cognizant of this. We are working very closely with the 3MDG fund that has set aside 11% of their allocation of 230 million U.S. dollars which is earmarked entirely to health system strengthening effort. Global fund has a huge chunk that is set aside. Gavi, huge chunk that is set aside. With USAID, we've been working very closely with Bill and others in trying to figure out what are the right mechanisms of health system strengthening that we can bring into place. The third element of health system strengthening was financing. Now, we believe or at least I believe there is no shortage of money. I just told you that they quadrupled and increase the money sixfold. But we still don't know what to do with that money. We still don't have a formula. We don't have a mechanism or a thought process of how to take that thing around. And we believe that that is where the answer lies. And it is in Myanmar, there's a tremendous amount of cooperation amongst all the donors and an interest in the government to get something going which is why I said that I'm actually very optimistic. Thank you. May I just add I was thinking about this. I think there's similar things in the public health system that there's an opportunity to not just invest in HIV or TB or whatever, but to really think about the surveillance and the laboratory capacities. If we could think about that upfront strategically as the US government and invest in that in a smart way, it could really help build a system that could serve many diseases, not just the individual diseases that have funding right now. So I was gonna get to a challenge that faces both CDC and AID and it actually faces Global Fund and some of the others which is the ability to invest in the government of Myanmar. And Admiral Chin mentioned it in the last session which is when do we know? When do we know when this is actually gonna take hold and we can actually start investing in the government? How do we convince the political people who are appropriately reticent about jumping the gun when it's time for us to turn the tide and try to invest in the government? The Global Fund money goes through Save the Children UK and through UNOPS. Gavi's money goes through intermediaries. Most of it goes through UNICEF to buy vaccines and distribute it. So the actual capacity building money, the ability to invest in the government systems to start to build that up, when do we know that it's time to start doing that? Miat. Right. Time is now. And then it has been, time has been a long time ago. And when we talk about health systems strengthening, what I take a look at it is in five areas. Because status of Burma, Myanmar's health system right now is if I have to say a few words, it's struggling, challenging and promising. It's struggling because they have a major limitation in investment for decades. And the demands and the need for health, the kind of challenges are huge. So the system is struggling. It has been struggling for a long time. It's challenging because now everyone that gets talking about investment is coming in and a lot of countries are coming over. But when we talk about increase of the budget, if I may say so, is although they increase the budget in charts, this is Burma's currency, the previously three years ago exchange rate was about 10 jets per dollar. And then now it is 800 jets per dollar. So although they increase the absolute number of budget, the purchasing power, especially for the one, this is if I understand it correctly, you're a bank, you know better than I do. And I studied economics too, but this is the one that I was told by the minister. And although budget has increased, I cannot purchase as much as I want more. And then so this is one area of challenge that we need to take a look at it is how do we go through this. But promising as all of you put in your book, people are extremely excited. And I was not able to go back for many years. And last five years when I got back, and especially last two, and excitement is palpable in the street. And then so people are so kind of like interested in walking with everyone outside, as well as inside, so it's promising. But we tend to forget that what are the key areas, the people, we strengthen systems to serve people. And then so people of Burma is, as you all know, very diverse, geographically, ethnically, language. And so how do we really provide services? When we talk about services, we talk services about curative treatment and care. Preventive services, rehabilitative services, promotive services, these are the services that they need to move forward. And so for these services, who are going to provide? And providers come in, number three, providers. Traditional providers, nutritional providers. As some of you have mentioned, especially with malaria, in Burma, when I was growing up, there's koinazae, there's kind of beetles in the shop. That's where you can buy medicine. You don't need to do anything, so I thought it was gone. But when I got back here to Burma two years ago, and just in July also, and one of my friends told me that you can just go and get an ass for mixer. Some people got sick and they cannot afford to go to a doctor, they will go to a little kind of shop and ask, oh, I have a headache, I have a fever. Can you give me something? They'll mix things up. And so this kind of provider, we need to just be aware of it. And the traditional providers, such as doctors, nurses, the other ones, and together with other military. Military can serve some of the services too. So these are the providers. But whatever they do, they need to have a structure. The structure, as you mentioned, about financing, regulation, and that we don't know what drugs are coming from. And it's when I was, you know, just a young doctor, and I would like to just, you know, kind of make sure that all the, you know, I was at the teaching hospital teaching. I mean, kind of a giving provider treatment. But medicine that we got, as you mentioned, as you mentioned, it has to be in the kind of like covered, but they are always locked for very important persons. So the point for that is, when we have to just get medicine from China, Thailand, other places, we don't know the quality of it. So these are the areas we need to just change. But now it's support, support coming from, not only just from international, national, local. Right now, people, Burmese people are addressing themselves. Some people pulling their own money, and I had a chance to travel a lot of places where my friends are, and they are pulling their own money with the community money and having free clinic services, but all the good things that they are doing is just, you know, tiny, compared to the needs. And so if we want to just really rehabilitate Burmese health system, and with the people inside, especially in ethnic areas, walking together with them, and also international agencies, coordination, coordination, coordination, and how do we do that? If we can do that well, together with the regional partners, and I think we will see from it that the way that we can help. So a place of huge opportunity and a place of huge challenge. So I wanna open it up for questions. I know if you're sitting there and you're looking at this from the FDA or Michael from the WHO, if you turn around and you look north, you see India and China. Two manufacturers of a lot of the good drugs and two manufacturers of a lot of the bad drugs. So how do you deal with the challenges that Myanmar faces with three billion people sitting on its border that are potentially offering things that are helpful and not helpful in a very challenging environment? Alan, when you're talking about addressing Artemis and resistant malaria, it's certainly the epicenter in some ways has been always identified as Cambodia, but Cambodia is on top of it. Myanmar is still quite behind. So what are we gonna do specifically with a very weak health system and a military that's still using and producing monotherapy, Artemis and what is it we're gonna do that's gonna get on top of this with the kind of urgency that was discussed this morning? So I would love for people to probe and poke at this a little bit. There are some microphones out there. Hands over here and then Admiral Cullison gets a chance. Lumizel, Department of State. I spent a couple of days in Glen Eagles Hospital in Singapore and I would estimate about a third of the nursing staff were Burmese. So I guess the question is, how do you prevent this loss of health professionals to countries such as Singapore and perhaps as well to the Middle East where a lot of nurses go as well? Let me re-ask the question we were asking in the last session. That has to do with the parts of Myanmar that are controlled by other than the government where there's been ceasefires in Sean State and Kachin which have their own health system there. If the US says the time is now and supports the Myanmar military or the Myanmar government, is that a risk of alienating the people who recently signed a ceasefire with that government? Want to take those? There's one more over here. Yeah, I want to find out what you're going to write about when the US actually starts to fund and Colin Chen pulls the lever and more money flows to help in the mill and mill conversation about health. I'll send you the link. So you can tell us what your article's going to say. Again, I'm Feng Tran with the UN Crisis Newswire. We're independent of the Yen, but we're founded by them. My question's for Katie and just in general about donors re-engaging, is your timetable for a project approval and disbursements any different than any other country? I just spoke to Jaika there and they're giving out 912 million by the end of the year. The person in charge of health and social services says she's literally up at night trying to figure out how to spend down her money. She said that her project approval process has been condensed from a year to six months and so I asked her what about donor accountability? She also talked about the problems of finding partners to implement because of the human resource issues. I'm wondering how you will address those challenges. Great, those are three great questions. Let's go. Katie, how are they? I'll answer that, the last question first. And unfortunately, no, we don't have a special allowance for a truncated timetable environment. However, we have had existing programs there. We've actually been working in the country since 2003 in the health sector and we have existing mechanisms that we're able to put money into rather than having these full open procurements that take a long time. We hear a lot about how long we take to program funding. So for right now, we're in good shape and we're able to move somewhat quickly and also we're putting money into the 3MDG fund which is going on there and that gets us leveraging work with other donors in the country too. Going forward, we're getting ready to look what is the next phase of our portfolio there and we're starting early to plan out years of funding so that we hopefully don't have any gaps in our programming or end up with backup pipeline like you're saying. And the mill, mill engagement. We continue to talk about this within the agency and I think the rest of the USG, we realize the power that the military has in Burma, certainly we're not there yet and I think it'll take a lot of action on the hill before we can get there. But we also would be foolish not to be thinking about what power they have within the Ministry of Health and within the states. Fortunately, we have been able to engage with our supply chain strengthening activity. We are engaging with governments in all of the states. So we had senior MIH officials from every state at the launch of the activity, over 120 officials there. So we are engaging across the country. Thanks, Mukesh. An issue you've addressed in many countries, the flow of healthcare workers. That's a difficult one. We don't have a good handle at this point of time on how many trained, trained medical, trained and skilled medical staff have crossed the border and are working elsewhere. We do know that salaries in Myanmar, at least two years back were extremely low in the public sector and the government has taken a deliberate measure to start increasing the salaries. So a great deal of that increase of the budget, not a great deal, but a good proportion of that actually went to fund increased salaries. In the last year again, they have pledged a further increase of salaries of 23% in the entire public sector across the board. But even then, the total wage bill in Myanmar in the health sector remains very, very low. You'll be surprised, 22%. That is it that goes to salaries. Overall in the public sector across the entire government for the entire government spending, the amount of money that goes to salaries, 11%. So it is still extremely depressed. So until such time as the salaries don't rise, some of this movement subject to all sorts of other conditions of movement will continue in any free market environment. I don't know what the answer is. We don't have a good handle on the salience, but we do believe that once the economy starts picking up and there is a deliberate increase in public sector salaries, private sector just now which is concentrated in three big towns starts expanding and grows out of the not-for-profit sector. We think that things will change a lot. And we have seen that in many other countries around the region. I don't think that Myanmar will be any exception. But you're right, at this point it's a concern. If I may address that question, it is kind of why people are outside. It's kind of every developing country is facing the challenge in Africa, in the other Asian country as well. And so it is push and pull. And so it is, salary is very important. And then also more important than salary is recognition and security and career development. And so when a young woman who is posted to a remote country area and who doesn't have the security for her personal security, she will not be able to go. At the same time, when she has a chance to move to another place, she would. And then also another thing is training. That's why when we're talking about health and strength and human resources for health, it's quantity, quality and retention. And so once you really feel that you are recognized, you are appreciated and you are supported. And then when I am in a hospital and if I don't have the medicine that I'm supposed to be providing, if I don't have the instruments I need to be operating, why do I have to stay? And so that question is a very loaded question and extremely important. And I hope that international communities, all of you are walking through the different systems can really provide some form of assistance. On top of it, and the medical professional will like to be linked with international community. And the research, evidence-based interventions, when they are engaged in that, although they may not have a lot of financial rewards, they may want to stay. Just quickly about one other thing about salary. I would like to just mention about the physicians. My friends who would train in England, get that FRCP, MRCP and then go back home. And they had to walk very long hours at the hospital, they have to teach. And they are doing their practice until one or two in the morning because their consultation fees is 3,000 to 5,000 juts, which is $5 per person. And then expenses are getting larger because they have kids, they would like to send abroad. So they have to see about 100 patients a day to make the ends meet. And so when that kind of a situation is there, it is very difficult for them. And so I'm not saying that this is to defend them or anything like that. This is the situation. We need to look at the situation as it is and we need to address as radically as possible rather than theoretical and academic exercise. So we have a question over here. And while the microphone's getting over there, Patty, as Mukesh said, the money shows that a significant part of health is delivered outside of the public system. We don't exactly know what's going on with the military. Most of it's serving members and their families and maybe some civilians. But one of the challenges a lot of your interactions are government to government while significant capacity exists outside the government. So how do you engage in your capacity building when a lot of the current capacity sits outside the public sector? Very carefully. So I think one thing I wanted to mention is that we're working with the PMI to sponsor two physicians from Myanmar to the Thailand FETP, Philadelphia Energy Training Program. And what we know from those, our experience in other countries is that the things that were mentioned earlier that you need people to stay in the, if they're gonna stay in the public health system, they need to have a career track, they need to be valued. So this is a very first step and a very small baby step, but something that we hope will help build that capacity. The other thing is that in other countries that have a lot of challenges with direct funding, we just start small and we provide a lot of technical assistance, not just in the technical areas, but also in the management of the actual agreement and how you do reports and that sort of thing. So I think starting small and building up that capacity over time is the only way I'd have to go forward. Great. I don't know where the microphones are. There was somebody over here with the heads up. There you go. Hi, I'm Anupama Tantri with the Global Network for Neglected Tropical Diseases. I actually just returned from a trip to Myanmar where we were looking at some of the challenges as well as the progress that the national program to address lymphatic fillary isis and other neglected tropical diseases is having and I was having some discussions with many of the partners. And one of the things that I know is coming up is the issue of decentralization across the government. And I just had two quick questions. One is what does that mean for priorities for public health and the health system? And as a country is looking to decentralize, I know that the 3MDG fund focuses on township level and what does that mean for how the capacity is gonna be built across all levels of government. And then my second question was specifically related to ASEAN and with Myanmar taking on the chairmanship of ASEAN in 2014, what does that mean for both regional priorities and the opportunities that are there to strengthen some of those issues like malaria and other issues both within Myanmar as being the chair and being the leader in some of these health issues across the region? Mukesh, help us a little bit with ASEAN and Mia, you wanna come in and maybe while you're at the tail end of that, you can tell us a little bit about where Asia Development Bank's going. I know there's an affiliation and not a direct connection but somebody mentioned earlier today that ADB is looking to get more into health and Myanmar is one of the starting places so if you could help us with that. So ASEAN, as is typical and this we see across the world all of these kinds of forums when a country takes on the presidency of these kinds of bodies, clearly there is this great desire to demonstrate and to show something and to show some big achievement. So in Myanmar, there was the IMF Article IV mission which happened a few months back and in those discussions, the government very categorically stated that the focus that they have in the year to come is on preventive care. I think that was the point which was mentioned by Mia. At this point of time, they spend only around about 9% of total amount of money on preventive care. So they want to spend on preventive care on maternal child health and they want to strengthen primary care. So the amount of money that they're spending on building new hospitals or rehabilitating old hospitals is going to be dramatically reduced and bulk of this money is going into maternal child health because that is one MDG including that of infant mortality which they will not be able to meet by 2015 for sure. And that is something that is preoccupying their thinking at this point of time. Will this get affected by any talk of decentralization? We don't believe so. We don't believe that decentralization is going to change any of the priorities. We don't even believe that it is going to change the ownership and management of health functions at least for a few more years to come. We believe that it will continue to stay within the purview. I mean, after all keep in mind that the public sector in the public domain of the Ministry of Health controls only a small part of the entire machinery of health. So it will continue to stay within that domain at least for some more time to come in the foreseeable future. Yeah, you want to come in? Burma has, you know, neglect tropical diseases, there are plenty of them. And then so they're a lot to address. And so I would be happy to talk with you later about that. But more importantly, that is, other non-communicable diseases, road traffic injuries are huge. And this address has been very limited. Tobacco use and cardiovascular diseases, diabetes is increasing and they're not well prepared to address it. And also the other one is gender. And they're kind of like a woman's health issue. And it's when we talk about neglectic areas, so much Burma needs to address. And that that's why we can assist in many ways. Quickly just want to mention to Admiral's question for it's like if you engage with the Burmese military, would it offend the ethnic minority areas? It depends. Because ethnic minority areas, although I mean there are ceasefires has been kind of like established and there are some paramilitary in those areas and the Shahn, the Shenz and they're still walking on that. And then so you will need to just walk together with civilian arms of those ethnic groups. And then again it's confidence building will be important to establish. So it can be done with mill to mill, but at the same time a country like Thailand and Vietnam can really help you in assisting and talking with ethnic group because a lot of ethnic group leaders have reached out to different health approaches, including another training of their own people. And I have trained many of them when I was in the type of border area. And so I think everything has had to be very cautiously caught in the like Betty mentioned, cautiously approached. But I think it should not stop you from reaching out to ethnic groups and then but you need to get concurrence from the Burmese military. So Katie, one of the things that you've been doing since 2003 is actually working with some of the ethnic groups. There's some discussion although a little disjointed around a federated model depends who you question and what that looks like. But one of the capacities that does exist is that some of these independent or volatile areas has built its own health capacity in some cases looking to build their own departments and ministries of health. So how do you continue to support and build and leverage that capacity while working in Navidad and Yangon with the Myanmar government? How do you work at sort of at both levels? Well, I think this gets back to the importance of really working in a collaborative way with the other donors in the country and with the government and whether it's the national government or the state or township governments because certainly we can't be everywhere. We have two full-time USG staff, so. And with a decentralized model that changes things also. And so really, once we have a unified health strategy which we still don't have and having this dialogue, we can figure out what approaches are needed most where and how we can best work together. Great, last round of questions. One over here in the back with a microphone, sorry. Hold on, we already got a microphone. Hi, excuse me, Dan McBrayer, NIH National Cancer Institute. We've already heard one of the distinguished panelists bring up the importance of tackling NCDs in Burma. And I'm curious as to what the prospects are for engaging Burma on NCDs in the near future, especially considering those which overlap with infectious disease. For example, cervical cancer and HPV. Great, there was a question over here. Hi, I'm Elana Yuretsky. I'm from GW, from the Department of Global Health. I'm an anthropologist of China, so I think about this from the Chinese side. It's clear that China feels as if we have enacted some sort of containment policy since we've increased our engagement with Burma. And so I'm wondering, as you think about mill-to-mill engagement, how do you start to negotiate that with our relationship with China? And even beyond that, if you think about the health concerns, the really serious health concerns in the ethnic states, like the Kachin state, how do we start to approach that? Because then you're getting closer to China. So that's one part of the question. And the other part of the question is how concerned is the Burmese government about these things? Well, Admiral Chin's in the back of the room. You should have given him that question in the last one. Maybe if he wants to take the microphone since he noted that his top priority is spending time in China. If you wouldn't mind giving us a quick answer, how do you deal with that when you're engaging with the Chinese and they're looking south across their border and they're clearly dealing with one of the troubled ethnic states? How are you managing this dialogue, both directly with China and also through your emerging context with Myanmar? Yeah, I'm gonna answer that a couple of ways. If you take it from the Chinese perspective, if they look at a map and you flip that map over and then you see where the US has bases and stuff from their perspective, they're containing them. Admiral LaClaire's perspective, and he's the US Pacific Command Commander, is that, and many of us, US is an Asia-Pacific nation. We've always been an Asia-Pacific nation. And the center of gravity for the world is shifting towards the Asia, towards Asia in terms of population, in terms of economics. And so, as the President has said, we're a Pacific nation so therefore we will be engaged in the Asia-Pacific region. And US military is doing as the President said, because it's not just the DOD thing, this is, again, the entire United States policy is to come to the Pacific. So, from my perspective, as we engage with China, again, I focus on the health related issues. We're working, as I mentioned, on disaster relief, humanitarian assistance. My vision for that, because we have, so the Chinese have a hospital ship, it's called the Peace Ark, we have the Mercy and the Comfort. We have done photo ops on both ships. My predecessor was in Brunei and visited the ship. We have taken their Surgeon General to our ship. But China has been invited to the largest naval exercise in the world which is called RIMPAC in 2014. And they're gonna be actual players and not just observers. And they're planning to bring, we're hearing that they're thinking about bringing the Peace Ark to RIMPAC. So, I think that's a wonderful opportunity for us to take the next step in terms of health engagement with China, is to have our doctors, our nurses, get a team on board their ship, likewise they can come to our ships. And then we work, it's all about, it's a disaster relief exercise that we work together. And figure out how we can work together. So, the next typhoon, the next tsunami, that's gonna, as I mentioned, that's gonna occur if both hospital ships arrive that we, both US and China, we work together. I think that'd be a huge stabilizing optic for that region because most of these nations do not wanna put you sides. They would like to see the US and China working together. So, that's my perspective and that's my vision that I wanna see our engagements and with China for that goal. Thank you, Admiral. It is important to note that China has in the past been very focused on helping. So, I know the Global Fund provided China with money in 2010 to help deal with Artemis and resistance along the border area. Thailand has also stepped forward and some of the other countries have stepped forward here. China is also the manufacturer of the active ingredient in the ACTs. So, they have a very strong and important drug manufacturing industry. So, they're, at least in some places, interested in trying to address the manufacturers of the substandard drugs which are also coming from China and from India. So, like a lot of places, the situation is complex. Quick comments, lightning comments from the panel because we're out of time but it would be great to get a final bit. How do we know that we've succeeded and how long do you think it's gonna take before this stabilizes? There's a lot of discussions around 2015 but one of the points that we made in our paper is that there's still a lot of turbulence ahead. So, what do we expect in the near term and the medium term? Let's go down, Mukesh. How will we know that we have succeeded? President Jim Kim has thrown a big challenge to all of us which is to eradicate poverty and to ensure that everything that we do leads to shared prosperity. 26% of people in Myanmar live in extreme poverty. 60% of them seek care when they are ill compared to 96% of the people who are rich who seek care when they are ill. As far as we are concerned, if we can increase that number of people who seek care from 60% to 96%, then we will know that we have succeeded. Will we get there? We think so, yes. It won't be easy and it won't happen tomorrow. There are a very large number of challenges. There are challenges within the health system. There are challenges within the government system. There are challenges within the society. There are challenges within the country. There are all sorts of political challenges. There are border area challenges. There are challenges across different townships. It's not going to happen tomorrow, but we are extremely optimistic that I think Mia made this point that if you go to Myanmar just now, we have been there maybe four or five times. Between the first time, which was last year and the fourth time, which was this year, you see a palpable difference. You see a hope. You see the excitement. You see that dynamism. And we believe it is that dynamism of the people that is going to make this whole program succeed. Governments are fantastic in enabling things, but it is the people who have to make things happen. And we are seeing that change already. So we are very optimistic. I won't be able to put a timeline to it, but definitely very, very soon. I would say that you would see a very big difference in the next five years. And then, of course, there will be newer challenges which will come forward. I want to very quickly respond to the question from there about NCDs. Is there any appetite in the government to address and think about NCDs? Of course, yes. Can you engage with them? Of course, yes. Can they do anything about it? Perhaps not, because the scope and the control that they have at this point of time is quite minimal. The global burden of disease study that came out a few years back rates, one out of five of the top killers is NCDs. So the four of them still are in the domain of communicable diseases. And that is something that preoccupies the government. Not to say that they shouldn't be doing NCDs, but just to say that the preoccupation at this point of time is elsewhere. Thank you. We've seen a lot of changes in the past couple of years. Our access to facilities to see our sites where our project work is being done has increased incredibly as has our engagement with the Ministry of Health. We are looking at 2015, and we are cautiously optimistic that there will be good, fair elections. And that national reconciliation process is really key to Burma's overall development, but also health outcomes, because you need the people to have trust in the government and the healthcare that the government is going to provide and to feel engaged in their communities. It's hard to say what is success. Like the World Bank, we have a goal of ending extreme poverty within a generation and ending preventable maternal child deaths in a generation, so very ambitious global goals. I think Burma will move fast along that. There are even access to mobile technologies that's going fast. Information is gonna be in people's hands quicker and more accurately than ever before. So I don't know what success will look like in five or 10 years, but I think we'll see definite progress. We'll have one DHS next year and I think we'll see huge improvements when there's another one in five years. And I think one big benchmark of success will be seen, those management of the Global Fund grants transition away from UNObs and save the children back to the Ministry of Health. And that'll be a huge marker of success. Patty. So success isn't a yes or no answer, so it's a, I think. We don't have time for subtleties. I would just say we're just really getting started in that in other situations where we've had a long way to go, like this one, you start out with little baby steps and you don't really think that you're getting very far, but then in no time you look back and see you've actually come a long way. So we look forward to doing that. Great, Mia, I know you've got a lot to say, but give us a short answer. One of the indicators of success is when we don't have to have a meeting like this. Yeah. And so that we can just learn from the success and share it, that will be success. And then what we need to keep on doing is we need to just put our organizations, countries, missions, head aside and look at the people inside. What do we need to help them out? What do they want? Not that what we want them to do. It is what they want us to be helping them. Help them, crystallize it, clear it and work together with them. Country ownership is the sustainability. Country ownership, without country ownership we cannot move forward. At the same time, country with 135 language and different ethnic groups, it will be a challenge. And for me, it'll be my lifetime and I don't think I will see the country that I wanted to see till I die because it is a continuing process, ongoing process. If we think that we can stop, it is wrong. We need to keep walking on it. Great, so to be continued, let's thank the panelists. Professor Morrison, final words. This has been really quite an extraordinary day. I want to do two things. One is thank a few of the folks who really put an enormous amount of effort to make this happen. And then I want to just summarize in one minute what I think I heard. First of all, Lindsay Hammergren, kudos for really an extraordinary effort. Many junior staff and interns put in many hours for this, Amy Shippow, Shwin Zhu, Mary Muller, Anna Anderson, Jessica Alpert. Carolyn Schroed, of course, the mayor of CSIS remains very engaged in helping pull everything together here and our partner Murray Hebert from the Southeast Asia program, a close friend and ally and great guide for this. I come away with a couple of very strong impressions. There seems to be a deep consensus across all of these speakers that health is very fundamental to the stability and the security and the growth of this region, of Mekong, looking forward into the future. There seems to have been a sea change attitudinally across different sectors and across different agencies and governments, those within the region, those like ourselves. There's an enormous amount of energy and hope and optimism and there's a very deep commitment, I think, to finding new forms of engagement. There seems to be this notion that US government agencies, there's a widening array of interest among US agencies. FDA, DOD, as partners that might normally not be on a program like this, along with those stalwart agencies that have such a deep footprint within the region like CDC and USAID and others in NIH. There's a lot of regional capacity. There's a lot of humility that I heard also, particularly from some of the US agency folks in terms of admitting that our role is a supportive and a technical support role in many cases, but we have to be there, we have to be there at the table and figure out how we are going to restructure our relationships in the most productive way soon. There is this strong ethic, I think, that is guiding this. There's an ethic that comes across many of these. Dr. Hien, Dr. Orr, you've made a very extraordinary effort to be with us today. We're very honored and grateful and I hope we can remain, I know we will remain in close touch, so please join me in thanking them and all of you for coming today. Thank you.