 I am proud to introduce Arnab Acharya. Please welcome. He is currently a professor of public policy in Jindal School of Public Policy in Jindal Global University, India. He just flew in last night. And he have worked with health issues in three continents, at least. Mr. Tzulfi Kar-Tzulfi Botta. Where are you, Tzulfi? Here you go, applause. Who won several awards and medals for his work? Please have a seat. He's a specialist in newborn and child survival. He is also the funding director of the Center of Excellence of Women and Child Health at Aga Khan University. And he made his PhD here in Stockholm at Karolinska. Please also welcome Mr. P.B. Anand, a reader in environmental, economics, and public policy and head of the Center of Bradford Center for International Development, University of Bradford. That's long. Welcome. We will talk about effectiveness in the health sector. And first, Anab, what are the actual needs? The health systems in developing countries do not respond to the needs of the poor. I mean, it's a blunt statement, but probably it's correct. Facilities are not operational. Drugs and supplies aren't always there. Skill shortages are actually quite apparent. And development assistance for health may remedy some of these solutions that may provide some solutions. You say may. We have some evidence. As always, as Professor Dr. Tarp said, we don't want to be too indulgent in saying they always do. But there are some evidence that they may. And we'll see that. So where does the aid actually go when it comes to the health sector? Well, OK. Let's look at this where and what. Where is the age as being channeled? We should see this in terms of per capita basis, not as absolute terms, absolute value. Sub-Sahara countries do receive the high per capita development assistance when we take countries that are larger than a million population. And I'm glad to say that DAH, Development Assistance for Health, goes to the poorest countries. Development assistance in health can go to governments, NGOs, and direct projects. So we need to talk a little bit about that. I'll talk about that a little later. It's difficult to discern what the government expenditure from revenue is. So we don't exactly know how governments respond. But we have some evidence, and I'll go to that. OK, please. To tell you what the time trend is, this is the time trend. Basically, what you see is that Development Assistance for Health has been growing rapidly from years in 1995 to if you look at 2010, it's growing rapidly. And a lot of it is going to sub-Saharan Africa. And that's actually a very, very encouraging sign, because it is the poorest region. And what is it going for? Large amount of it is going for HIV-AIDS, which probably is declining right now, because these are figures from 2007. And I haven't been able to get this type of division, this sort of categorization. But HIV-AIDS actually is seen to be stabilizing, so there is some decline in funding for that in terms of percentages of development assistance for health. But what you do see that I would like to point out is very little money for health systems. And that may be something we need to talk about. And why is that, do you think? Well, I think actually, again, we'll pick it up as was talked about, Miguel mentioned, a lot of it is going for project AIDS. And projects tend to actually fund individual disease problems rather than health systems. And we'll probably have a nice discussion with Zulfi here. And I'll bring that up a little later. But one question that you would naturally ask is, does it work? Yeah, does it work? Well, I think some of it has already been said by Dr. Tarp. And I don't want to say much about it. But look at that development assistance for health may be effective in reducing infant mortality rate. And this is a very nice paper, very, very well done. I urge you to read it from a place no less than the World Bank and IMF, which tends to be AIDS skeptic. And they actually do show that AIDS is effective. And does it work? Well, what's the government response? In some of these papers, they also show that government does indeed respond well in that they tend to actually provide higher aid. But what we cannot know from the data alone is that what exactly the government is spending. So there is a lot more research to be done on this area is exactly showing how governments do respond to foreign aid and to the channels they actually, how do they respond to different channels? We'll pick that up a little later, I hope. So public health spending is neglected in South Asia. I have to say, regretfully, I live in South Asia. And where the per capita aid is the lowest, for example, to India among all the largest poor countries, the per capita development assistance in health is the lowest in India. And you see that India actually hasn't been responsive in spending much on health. Although Bangladesh and Pakistan also haven't been very responsive. So there is something to be said about how aid might actually work in getting countries to spend money on development assistance, sorry, on health. What concerns you the most about this? Well, I think it's actually we need to talk about how actually countries may be pressurized and also the research money that may actually show how to actually spend public expenditure. We need a lot of research. And one of the ways in a large country like India, where aid can be effective, is through research, to doing effective research. And I think actually research is very poor in India to tell you how poor it might be. India just opened up public health research facilities and countrywide in 2007, I believe, from an initiative from the World Bank, Gates Foundation, and the Bush Administration. Before that, there was hardly any good public health research. And there still isn't very good public health research. So I think actually to make countries aware of how to spend money, we need a lot more knowledge. It's, of course, self-serving, because I am one of those people who produces knowledge. But I do agree, do want to say that knowledge is important. And how do you spread that word? Well, how do you make that happen? Forums like this? Forums like this. It could be one of them? Yes. And actually, I also want to say that one of the ways that aid has been effective or ineffective is in the way that we actually are providing, our channeling aid that was said by Miguel. How do we do that? We need a lot more, I mean, this is the area of knowledge that is really, really pertinent. And we need to go forward with it. And as you can see, the Paris Declaration provided a solution, recommended improving aid coordination, promoting donor alignment with countries' strategies and cutting the compliance burden. I don't, we can talk about compliance burden a little later or in the discussion. But this was in 2005. So we need to move ahead and see how this is working, how this can be implemented. So this is one way of actually making aid effective. And these are the things that actually Miguel said. So I don't want to point out. I don't want to go through them again. But as you can see, that Project Aid actually is a large way of giving aid. And we need to discuss that. Some solutions there. Yes. I'd like to say something about this, how we actually can move ahead. Three ways, I think key step is to coordinate aid. And as I said, that's one of the major problems we find now. Donors must coordinate among themselves and work with countries to determine need. I think countries have a big role. And health ministries and education ministries should not be neglected. And they are neglected in many countries. Targeting key sectors or areas like maternal health would reduce coordination problem. And improvement in the health system, I think is actually crucial. And that's something actually would help coordinate aid. And I think we can move. And that's something that we need to look at. And I think it's actually, in some ways, involves the country more than if we actually find an individual illness and diseases. And that's probably all I have to say on this. Thank you very much. Sulfika, do you have any reactions on what's been said before we talk about your? So I have a number of reactions. But let me start off by saying how delighted I am to be here. I came here largely to learn. And this has been a fascinating start. So I have a prepared presentation, which I'm going to dump, because I think there is such richness in the arguments that have been put forward. So I want to start off with just a few comments. And then maybe we can have a Q&A or a discussion around this. So in my own field, in maternal and child health nutrition, if you look back at the last several decades, it's principally a situation of glass half full, half empty, depending upon how you look at it. Yes, there's been progress. But if only the Paris Declaration had come a decade earlier, we might have seen greater sustainability of some of those efforts and a greater focusing on areas of neglect. So if you look at what has happened in terms of child survival globally, yes, we are in a much better, happier place than we were a decade ago. There have been 2 and 1 half million fewer deaths that have come down, largely because of reductions in the simpler things. Childhood diarrhea, pneumonia, some of the measles-related mortality. But the hard core around newborn survival, which constitutes about 41% of the total burden of under five deaths globally, hasn't changed. If anything, that proportion's gone up in many places. And therefore, one asks the question, how come there hasn't been a major focus globally in the last decade, decade and a half of putting interventions in place to address newborn survival? Well, one answer to that is you needed to therefore focus on maternal care, emergency obstetric care, and some of the more difficult things that relate to maternal empowerment, things like family planning that nobody wanted to talk about in the last decade. So there is a huge issue in terms of how we target and put the evidence base for financing. And the second issue that's been raised, both by Miguel and my preceding speaker, is that we are, by necessity as donors, seeing sometimes a focus on projects, because people want to result space financing, and they want accountability at the end of the day for the dollars that they send. But if you ask governments and ministries of planning and development, these project-related funding streams hardly ever strengthen capacity beyond those projects. You hire people specific for the projects themselves. You set up data monitoring systems which are specific to those projects. Projects finish, and nothing's left on the ground. So just like the example of India as to how public health and primary care funding oversight research came much later, you just have to look at the Polio program to see how such a phenomenally powerful, well-funded, global initiative with probably the best surveillance system that you can find in the world down to a sub-district unit level cannot give you data on routine immunization coverage, cannot give you data on any of the predisposing factors to Polio, such as water sanitation and hygiene, because of the narrowness of the program. So I want to stop at this stage by saying there is a whole lot of learning in the last few decades that we could probably put on the table in terms of going forward. But not all of it is bad. There has been progress. We will keep that question in the air. And before we answer it, I would like to ask Anand, who's a specialist on water and sanitation project, actually. How does this connect water and sanitation? Why is it important? Again, if I may echo what Zulfkar said, I'm absolutely delighted to be here. And thank you for this opportunity. Again, I have a presentation, but I don't have to refer to it. It may sound strange. Just now, we have sent Curiosity rover to Mars, and we are looking for water there. And if there were people in Mars and unbeknownst to us, if they had sent a Curiosity to Earth, they would find it surprising that on the blue planet, there are 750 million people who are supposed to not have access to improved water or sanitation. So I think there is a fundamental paradox. The technology with regard to providing access to water and sanitation, if we can have iPads and all these wireless miracles, that technology comparatively looks pretty simple. So we know the technology. And I think we have looked at the issue in terms of whether water itself is distributed. Is that the problem? And we found that that is not the case. So in most cases, where people lack access to improved sources of water and sanitation, it is predominantly, we can say, the responsibility lies at the institutions that we have created to distribute that access to water and to make sure that sanitation is provided. So that's where I think we have to do some soul searching. And of course, the pictures like this, we always see. We always want to be reminded how important it is to provide drinking water or access to drinking water. It's part of what we think of as development. I have hardly been to a development conference where there is not at least one picture of a girl or someone drinking water. So obviously, we understand how important it is and how crucial it is to our vision or our way of thinking about development. But then why we have not been able to achieve, especially if we think of the 2 and 1 half billion people lacking access to sanitation. And it sounds really why we can't do it. So there are a number of things, I think, which have come into light. Aid, I think, plays an important role, but we must remind ourselves also that aid is a very small part of overall picture. And if we ask who actually does the most important job in improving access to water or who contributes the most, it is the people themselves. And we find that time and again. Governments do spend some. And there is quite a lot of private sector investment also going into water and sanitation sector. So over the last, in the graphs that Miguel had shown before, we can see water and sanitation within the social sectors is the poor cousin. You can see it's lingering at the bottom. I have no qualms. I think health is absolutely important. So I have no flags to raise there. But I think we can understand that it is part of this bigger picture. We cannot achieve health-related MDGs and various other developmental goals unless we overcome these very important and very simple issues related to water and sanitation. And I think the way to think about it is not in terms of the physical infrastructure. So I'm really glad that water and sanitation is included in thinking about social sectors. I think that's very important. And in the way that we have learned from Amartya Sen's capability approach and things like that, I think we can see that lack of access to water is not in itself, again, maybe intrinsic. But I think it is instrumental to many of the other freedoms that we think of when we think of development as expanding people's choices or people's well-being in terms of freedoms. So it is in that context, I think we have to ask the question, has aid worked in the case of water and sanitation? If it has not, why not? Or if it can, what can it do? I think that's how I will phrase it. So before I let Sulfi in, he was waving, if it has not, how can it do then? Well, because you said it has not. No, I haven't said it. They're better on the moon than we are here. No, I said it's not about aid itself. It's about, as a human society, I think we have a lot to answer to the Martians, perhaps. Like what? How come that on a blue planet we have 750 million people without access to basic water? So what can be done then? Yeah, I think we have learned a lot. And again, in general, aid has gone to projects, and that is very similar in the case of water and sanitation sector as well. We'll see that more than 80% of aid has gone to investment, project aid. It is understandable. I would like to call this as the masculinity paradigm. Within the water sector, there is a masculinity paradigm. There are some things which require hard infrastructure. And I would like to call that as the masculinity paradigm. So if you give a choice, you want to improve water access to water and sanitation. There are a number of things, and that can be a spectrum. There are some things which are softer infrastructure, which is like empowering people, building the capacity of institutions to engage, to ask questions, to ask for accountability. Those are all softer infrastructure. And there are harder infrastructure, digging, constructing, building, and pipes, et cetera. So when you have 80% of aid going to project investments, obviously, it will go towards this hard infrastructure, which is the kind of a masculinity paradigm. And on the other hand, also, as donors, we are asking more questions about accountability. And again, accountability is much easier in case of this hard infrastructure. Where is the money? Where have you spent it? Here it is 1.5 kilometers of pipelines, easy to show. Whereas if I say that I have tried to build the capacity of the local people or their ability to ask questions or monitor programs, it's a lot more difficult to measure and to demonstrate. So in a way, by asking Paris Declaration, et cetera, donors asking questions about accountability may also be contributing to this increased masculinity paradigm. So I think that is part of the issue. Sylvie. I actually want to pick on this, because this is a great segue to talk about something as fundamental as what sanitation hygiene that you would imagine is a cornerstone of health, but it isn't. So exactly a month from today, we'll release our global daire action plan for daire and pneumonia. And you would say, why do we need an action plan? Because it's common sense. The point is, we needed an action plan, because there's still 2 million deaths every year due to daire and pneumonia in children. And we feel very strongly that they're not going to reduce by the same trajectory as before, because you're now hitting the hardest to reach people. Water sanitation hygiene is an integral part of prevention and management of both, particularly daire. Yet, if you look back at structures, they generally don't exist within health. So one of the big problems that we have is not only within the health sectors, there isn't integration between some of these important determinants and how you implement them, but they're not only there in governments, they're also in UN agencies. So one big agency that we work with, UNICEF, for example, has one of the best possible capacities and programs on water sanitation hygiene, but they don't intercalate with people who do health. So it's also a fundamental issue of how we structure this. Now, I believe that societies, illiterate, poor, as may be, are not stupid. So I want to narrate you a story, and there is some learning in this. So some six, seven years ago in Pakistan, there was devolution of health. Devolution of health meant that the districts became empowered in terms of determining with the money that they had, where they invested, what priorities they made, and how they allocated their budgets. And it was a roaring success because it empowered people. During that process, I met the deputy director, general of primary care and health one day, who's a friend of mine and will remain unnamed, and he was rather morose. So I asked him, why are you morose? And he said, I've been charged by the director general of health to go to Baluchistan to speak to three district nozzems, the governors. Why? Because they haven't put a single penny in this year's budget for health, in their district budgets. So I'm there to make an advocacy with them as to how important it is for them to have a health budget. So I listened and that was it. And I forgot about it. So several months later, I met him by chance and asked, what happened? And he started laughing and then he told me the story. So he went there, he called all of these nozzems, the eight or nine of them, gave them big song and dance and advocacy speech on how the importance of health to human capital development, et cetera. And they listened to him for 20 minutes and then they smiled. And they asked, why are you here? And he said, I'm here because I want you to make a case that you haven't put in anything in your health budget. So he said, why do you think we haven't put anything in our health budget? We have put the money to dig in three deep tube wells for our population because getting clean water, we believe is most important for our health than to have all of these drugs, et cetera, in the primary care system. He smiled and he said he left because they were absolutely right. And the point that I'm trying to make is that societies are not stupid. And therefore, if we have an integrated framework of investments in things that impact social determinants, including environment health, I think we would make much greater progress. But sadly, this isn't the way how aid structures flow within programs or projects into countries. They are still very narrowly focused on things that can be delivered within health. Thank you. Arnaud, when we talk about projects, being so much focused on projects, all of you, I would like to know, is there a way to change that? And why are projects so good for donors then since they decided to invest in projects? What do you think? Okay, I think donors find it easy for accountability purposes to fund through projects because you do something, you tell some people to do it and you actually get something and that's easy to do. The other thing I think is actually quite a problem, especially from where I actually studied and grew up, the US, because they're determined that much of the aid actually comes back to their own country and many countries actually do want that. So to the private sector in some ways. So what happens is that individual companies, individual, mostly companies actually coordinate aid and also due to US laws, they're actually not, one group cannot have the monopoly of it. There is some small private sector actually dominates that market and there actually, as you can see, there'll be a lot of lack of coordination. That's another possibility. And then there is the project aid actually and donor countries don't trust the developing countries. Well, there are some good reasons to do that. I mean, where I live in India right now, there is a big concern about all kinds of corruption and understandably so, but there actually what happens is most of the time there's sort of a, we don't really care how we actually coordinate with the countries and we just leave this problem to them. And another issue is that many countries tend to actually fund one country. I mean, a single country gets a lot of funding whereas some other country may not get a lot of funding. So what happens in those situations is that countries don't really want to coordinate and they duplicate projects. That's another. And they compete as well. They compete for favors within the, and they try to get the best person inside the country through their own project. And what happens is that many of the administrative units actually don't really, administrations within the country really don't have their good people. They're all in working for donors who again are working in very small areas. Not, they never really have the big picture. So I think those are some of the reasons why I would actually disfavor projects. And, but the solution has to be how do we actually coordinate the country's own best interest and how do we actually sort of look at larger issues like health systems and how do we actually basically make all the PhDs actually operational. That's not something that anybody talks about. Anand, and then Sulfi, yeah. And then if you have, does anyone have a, I just wanna see if anyone has a question or a short comment, please raise your hand so I know, okay, okay, enough to that. Please. I think we don't need to be too much exercised about the aid being focused on projects itself. It's partly semantic. I think what we need to be aware of is what we put in the definition of projects. So as long as we don't become overly obsessed with physical things or certain kinds of things as projects. Like what? What do you mean? Like if we think of, I don't know, in the case of water and sanitation, if you think of projects as specific construction activities or large systems or some things like that, that is problem. As long as you call something a project, that's not a problem for me. If it is the stakeholder participation work, if you're doing that as part of a project, that's not a problem. So I think part of it is to unpack the semantics and be careful as to, so it is not about that 80% goes to project aid, that is not the problem. That more than 56% of aid that goes into water actually goes to large systems. So large systems meaning we want to build for the whole town. We can understand that that is the better way, longer term solution. We completely understand that. But I think we need some thinking about that. So projects itself I think is not the problem by itself. Second, I think history and life is run by events. In the sense, we remember when we reflect on the year we graduated or our wedding anniversary, birthdays, et cetera. So history is kind of constructed through these events. So projects can be thought of as those events. So it's easy to monitor, easy to measure, and for accountability purposes. So all those advantages are there. So we don't have to completely throw all the things away in that sense. I think this debate about project aid versus generalized aid is slightly different in the sense if you really want to trust governments and if you want them to deliver development, then why have individual isolated projects and the transaction costs of having so many different projects. I think that is the broader argument. So if we can somehow manage that, of course the issues of systemic corruption is a much deeper issue. And it takes much longer to be able to help institutions to develop in a way that we can have, if you like, participatory monitoring mechanisms to overcome the corruption possibilities. I think it will take much longer. So we cannot say that we will then hold aid until all the systems are improved. In the meantime, we have much more urgent challenges. So that is where I think is the reality. So in the meantime, I think we have to do something and what is the best way to do that? Maybe projects is not the perfect solution, but at least it can fit in that context of reality. We can reasonably control and reasonably monitor and hopefully keep corruption to the lowest possibility. I think that's why projects work. But I think we have to take a very pragmatic approach to that. Sulfikar. So just speaking on this, I mean I agree and this is one of the reasons why I said it's a glass half full. The debate isn't project versus budgetary support. If you ask me, I would never put money in budgetary support alone because accountability for this and control is almost impossible. But at the same time, as Anand said, projects don't have to be very narrowly defined or very classically managed. I mean projects can have by design and by their various implementation processes, a level of engagement whereby the boundaries are not as absolute as one sees. And thereby it allows you to include many things within the project development and implementation framework which also helps sustainability. Give an example, what do you mean? So Sulfikar, let me step away from water sanitation for a minute and maybe talk a little bit about newborn health because it's an agenda, it's an issue, it's unfinished business and many of us are very concerned that particularly with the post-2015 discussions having not achieved a target, having not got there, that we risk losing it still. So as I mentioned, the figures and the trends. So we've not been able to dent newborn survival globally over the last decade, even though child survival has gone down and we will not with business as usual. Why has that not happened and what will change it? Firstly, just going in with a very narrow spectrum of newborn interventions, be those improving resuscitation for asphyxiated babies or managing preterm babies is not the solution. What you really need is an integrated framework which brings in not only maternal health into the picture but actually preconception care, the health of adolescent girls stopping children having children. I mean, there is a significant proportion of girls who are delivering their first baby while they are still adolescents in our geography. So you'll have a discussion this afternoon on nutrition but I just wanted to make the case that here is an example of how you can only impact on outcomes by being broader and not narrower. It also brings in the issue of human resources. You cannot do anything about new-bound care without tackling the whole issue of capacities, skilled attendants, both at birth and postnatally and that's one component that has just not been addressed. And lastly, remember that this is one area on which we have almost no data in countries. So unless you have monitoring and evaluation systems in place, we're going to be talking the same thing in 10, 15 years and depending upon regression models for really what has happened to not only newborn survival, what is the desegregation between early versus late. So strengthening capacities for monitoring and evaluation, implementation framework for issues that go way beyond your own narrow interest and then ensuring that as you do this in countries that people have the political will and the ownership to go beyond the funding cycle. The success of many of the EPI programs, the vaccination programs is, that although they started off with donor funding as a catalyst, but they were owned by the countries and there was an agreement up front that donor funding would dry up or GAVI support will dry up after a while and you would have to support it ourselves, yourselves and that's been one of the reasons why success has been achieved and they've also got very strong monitoring and evaluation systems. They can be criticized, but they're done site better than what we have for anything outside of immunizations. But it sounds like a very big operation to change. I mean, you are talking about changing a whole structure of how we look at these issues and motivation by the own governments and how you educate and how you talk about children having children and you have to address a lot of issues. What does it take to change this? Well, particularly around women in child health and newborn health. If there was a simple solution, we would have implemented it. Right. I mean, there can be 20 simple solutions. They would all be wrong. So I think the important thing in here is if you're going to touch an area like this which you should, which we should, then it's important to have an organizational framework which is correct, which is true even though difficult. And people can then pick bits and pieces on it for strengthening. I mean, nobody is forced to go into a country for development assistance around the entire repertoire of what you need to do. But people can pick up monitoring and evaluation systems. People can pick up human resources. People can pick up the whole issue of adolescent health and nutrition. And you would be addressing pieces of the puzzle and not maybe necessarily the whole spectrum. But to do it piecemeal alone without that organizational framework and without that realization that you would have to negotiate that with governments and donors right up front, I think is very narrow-minded. Thank you, Arnab. And then comment or questions from the floor if we have the microphones. Right. Polio eradicate or elimination. And I think it was a very concerted effort and perhaps now polio is eliminated from South Asia, at least India actually shows that it is eliminated but Pakistan still may have some problems. Now, what that project didn't do was it focused completely on polio. The monitoring evaluation, monitoring process was very, very good for polio. But it didn't extend to other issues because the way it was administered, the way of through WHO, the way it was internationally sort of pushed through NGOs, it was compartmentalized. And we didn't really see a concerted effort about how we can actually help health. There is a recent report by, just a slightly different issue. There's a recent report by the World Bank on their own projects on governance and participatory democracy. And what they found was frequently, it wasn't a participatory framework they used, they used single projects. The World Bank evaluated itself and came up with the conclusion that they didn't do much. When they actually helped and at one time, five years down the road, they were not operational because they weren't funded. Someone actually had moved to something else. So the concerted effort of actually not doing projects but sort of looking, doing overarching activities wasn't there. And that was the major reason they attribute failure of participatory democracy, of the World Bank projects, at least. Some would also argue, Tulfe, I'll ask you before letting her in, that this is also a gender question. I mean, vaccination concerns everyone. Child and maternal health concerns women. Is that true? I don't think you can take gender or the whole issue of equity out of anything to do with health, particularly around reproductive maternal child health. So I firmly believe that for health, you've got to put issues of gender, women's empowerment, access, equity, right in the center of the debate from the very beginning. And if you don't do it, you will end up a situation where you would have to do it towards the end. But just picking up on polio, just to make one point. Fantastic success, at least in terms of achievements. Uneven in South Asia because I'm struggling with polio in my own geography right now in the end game. But one question that one has to ask is, could we have done this differently in terms of leaving things in countries for capacities, surveillance, monitoring and evaluation? That would go beyond the project life cycle. And the answer is that we haven't quite done it that way. Some of those capacities have evaporated already. I mean, I'm going to a part of North Africa next week because those capacities were just never inculcated within the local monitoring and evaluation and health systems. And as a result, we are now facing a massive, massive pushback in many places because polio was just so narrow that its integration with not only immunizations, with the health and lives of women and children is not apparent to people. So the real lessons in there. Thank you. Yes, please. Hi. I have a question that actually after thinking about it, you partly responded to it, but it was a bit about the criticism or about project support aid and the problem with it. And then you came into the alternative would be budget support, which also has a lot of problems in terms of accountability. And so I would rephrase my question. There is a problem with budget support because donors, they wouldn't feel they could have a lot of these recipient countries accountable. But do you see an alternative between project aid traditionally and budget support in order to run initiatives like this but to include the recipient countries' government so that it will be included in the national scheme? We're interested to hear your ideas on that. New models. Let's take those three questions, answer, and then remember who want to ask more, okay? Please, short questions. Roger Williamson, Institute of Development Studies, University of Sussex. Could I ask about how these issues are different in rural and urban contexts? Thank you. Anders Nordstrom from the Foreign Minister here in Stockholm. I'd like to push you a little bit in terms of the question in terms of what do we know in terms of when aid is working for health and what do we know in terms of concrete figures? I mean, in some of the background material you said that an increase of 25 US dollars leads to 1.3 years of increase of life expectancy. What do we know more in terms of when? And I fully recognize that aid is just a small part of the bigger picture, but what can we say? When does it work and what figures or evidence do we have that it works and when? I know some of the studies you've done in the past from RECOM in terms of showing the relationship in between aid, macroeconomics development, and you showed there that health and infrastructure were the two sectors where we could actually have evidence for this. But what do we know in terms of aid and health more in figures? Okay, three quite big questions. Let's try them out. Who wants to start? So I'll take the first one and then my colleague can take the second and third. So alternative model, I wish I had an answer that was based on evidence, experience, and case studies. I don't and I agree that putting money into a basket budgetary support is like losing it, particularly in dysfunctional circumstances. At the same time, we do know from experience that project related financing has its own limitations. So what can an ideal situation look like? So I think a hybrid model has potential, but it has not as yet been successfully implemented in circumstances where we could say that development assistance played a major role in this. But there are some interesting examples. They've almost always had three or four factors. One of those factors is very strong national leadership and accountability with good governance. Those things have been there. So if countries have achieved and made massive gains with a limited amount of development assistance, they've always had a champion at the other end who knew how to utilize that money. Secondly, it has also been the case that development agencies have got together. So instead of this fragmentation and this whole disparate negotiation with governments, people have forced development partners to sit together and say, here are what our needs are, this bigger organizational framework. What components are you going to pick and where? So in terms of clubbing or having this strong oversight by development agencies, sitting together with governments has been one thing that has worked in certain geographies. Do you give an example of? I think in countries, for example, I think it was in Mexico that that's happened in the earlier tenure of Julio Frank and Julio's written about it. This whole health financing and implementation in Mexico took place with a very strong focus by the Ministry of Health of saying, we're going to bring the development aid partners together and say, how do they fit and fill this mosaic so that they're not tackling and talking to different departments separately, but going through a central mechanism. There are also examples, potentially, that this has happened in countries like smaller countries. Malawi is not Mexico, but it's happened there. And it's happened to a certain extent. I see this happening in one of the most difficult countries to work with. I mean, I'm currently working with the government of Afghanistan and a couple of things. I see this happening there. So there is something to be said about this organizational framework. The last thing I would very strongly say to you that strengthening national capacities as part of the project around accountability is absolutely critical to ensuring not only that the project funding that one has around ODA is successful, but also they would go beyond the time span and duration of the projects to create national accountability. At the end of the day, people are not going to go away. If you have civic society engaged, local academics engaged in ensuring that you hold people's feet to the fire, then yes, today it may be in relation to a certain basket of funding. Tomorrow it will be around your own internal resources and their allocations. So in South Asia, as my friend said, if you are dealing with countries spending less than 1% of their GDP on health, that at some stage you've got to ask that question internally and not to the donors as to why is it less than 1% and why hasn't it changed over the last three decades? So there is an opportunity of the development community also to work with civic societies and local academics to create the partnerships that will put that accountability framework in place. Thank you. Unfortunately, I cannot take the question on rural and urban context. I mean, there's some guesses I can do, but maybe sanitation is something that you can talk about, but I can't do that. Well, about aid and health, I have to say that I am actually very optimistic in spite of all the things I have said. One thing that neonatal mortality rate has dropped in many parts of the world and as far as I can see through the statistics that I see and I trust the statistics done by Prachi Mishra and Newhouse from World Bank and IMF that we do see an effect of development assistance on health. I also think that HIV-AIDS is somewhat of a success story and that was a concerted effort and I don't have really data for this and I would like to know what kind of research we can do to say that, but I do believe that HIV-AIDS, first of all, it may have been that the HIV-AIDS case were overblown in some countries and we're finding out that the data that is actually much, well, not as bad as we had thought, but it was still a very bad situation. We seem to be at a place where we can say that we achieved some sort of success in HIV-AIDS. The other thing I would like to point out is what research institutes like ICDDRB have done and in fact, what ICDDRB has done actually may have saved about 50 million lives and it was through concerted effort by Nailen and Richard Cash, who's my teacher, and it was a very sound way of looking at how we can community research and working with the communities to actually deliver healthcare. So I actually am very sanguine that we can do something with health, but I also think that we need a mindset change about working within a country and doing more health systems, system-wide research. Thank you, Anu. If I may respond very briefly to all three questions, but first to Roger's question on the rural urban, I think it is a very important issue, especially in the case of water and sanitation and that's why I was previously mentioning that there is a problem that if most of the aid is going towards kind of project aid, but within that also large systems, so you can see here, much of the aid is going towards large systems and very little is going towards developing the capacity of institutions, et cetera. So the large systems is kind of urban approach, whereas in very small communities in distributed, you know, over large space, in rural water supply, rural sanitation, I think we need a completely different approach. And we also know from studies that actually $1 of aid works much further in rural context, actually, if we can get it to the rural context. So I think there is a very interesting picture there and quite a lot of the people who don't have access to water and sanitation, predominantly, they are in the rural communities. So I think it's a very important challenge. With regard to the aid in, though the question the gentleman asked was about health, I was just thinking of this slide, $1 million, if you want to correlate it with how many people have access to water, there is so much variation and from $1 million will have resulted in only 184 people getting access to water in Armenia. But it's weird. Yeah, but versus, of course, here we have to be careful because this is just correlation. Yeah. You know, it's looking at how much aid has been given to water and sanitation and how many people actually gained access between 1995 and 2010. So we have to do next step actually to unpick where the aid has gone, but there is a lot of variation. Similarly, if you look at the IMR, whether aid in water and sanitation, how does it correlate with the fall in infant mortality? Again, there's a huge, there's hardly any impact in case of India or China or Vietnam, but in case of a place like Oman or Saudi Arabia, there's a huge impact. So I think there's something going on so which we need to understand. Finally, about the budget support question, I think part of the problem may lie with, the finger may point towards the aid architecture, if you like, in the sense that people can criticize saying that, oh, you are in such a rush, you want to see the results. So you are always picking the winners. If you really want to have developing countries to achieve what is intended of the aid, that is to develop and have their own systems and fully capable of running, then you must be patient. And since we don't have the patients, maybe we are always picking the winners and because we want to see the results. And in the process, we may be actually weakening the development of internal monitoring mechanisms, accountability, et cetera in the very institutions which are essential for development to take place. So there is a bit of a paradox there. I'll stop with that. And there we have to reflect a lot on what we are doing. I mean, to have some real reflections on that, how important is this accountability, this fast track towards what does it help? Does it help in the long run? Is it sustainable? I'm Professor Murenzi, I'm the Executive Director of the Academy of Science for the Developing World. And I was former Minister of Education for Rwanda from one to six and Minister of Science from one to nine. So building partnership between development partners and the government is very important for head coordination. And I think that budget support is a key. Budget support is a key? Is a key. That will build around that. And I could give you an example for the decade. When I was appointed Minister of Education in 2001, as a new minister, the World Bank will come, African Development Bank will come. So the head of the CIDA country office will come, the head of DFID will come, the head of the French Corporation will come. Everybody wanted to build primary schools, some will want to build roofs, some will want to do sanitation, some will want to do water. So finally what I decided was, I tried to understand how to put these people together. And then I realized that as one of the speakers said, very strong leadership, good governance, development to partner to sit together was very important. So I asked, why don't we just meet together in the same room to build all the development partners, civil society, academics. We created what you call the JRES, JRES, the joint education review, the joint review of the educational sector. It started in 2003. And at this date, every year they meet around April. So some of the people from CIDA I'm sure have gone there. So we decide in 2003, we wrote the education strategic plan. The Rwanda education strategic plan. And that one actually was very important. And every year, all the donors will come, the civil society, the church, and everybody. Then they will give to the ministry the targets. And that became very important. And all the donors decided to put the money in the basket. And every year, every donor will be bringing money in the basket. So this became the sector-wide approach to education. It's a sector-wide approach to the sector. Then later on, it was adopted by the Ministry of Health, if you read the policies in Rwanda around the subject that were discussed here, a sector-wide approach. And that also adopted in other sectors such as water and even ICT. So sector-wide approach is very, very important. Putting the money in the basket is very, very important. Because then you have a coordination, you have accountability. But if the monies go to the project, the money goes here and there, and you don't know, actually, what they have achieved. But Mr. Marenzi, you will also talk in the afternoon session. We're welcome. And I have a question. What change did it make? The major change was that after the genocide, Rwanda, for example, had 950,000 children in primary school. By the end of the decade, there were 2.3 million. This means double, actually, 2.5 million. Secondary education, 50,000 enrollment in secondary education at the beginning of the end of the genocide, like the 1945. Now half a million children now are enrolled in secondary school. And same with higher education. From 2000 at the end of the genocide to more than 60,000 enrolled. And that is a major, major room. And what was very, very good was every day, every year they will come and say, Mr. Minister, how did you use the money? Good. Yeah. And then you know in Rwanda, they don't play with that. Some minister will even go to jail, somewhere. So they will come. How did you use the money? How was the accountability? And I will do a presentation, sit with the guys and say, this is how the money was used. This is how many primary school were built. This is how the teacher was trained. This is, and that became a very comprehensive strategy that was shared by the Donio community and the government. Thank you very much. And now, we have one microphone there. I think we have three short questions. If you can ask, well, to ask professors to answer short is maybe a challenge, but we'll try, please. Thank you. My name is Astrid Perman. I work as a senior health advisor in Danida. And I find the discussion has been very much on vertical versus program, but it has not been so much, although it has been mentioned sort of indirectly, so much on service delivery versus support to, or focus on service delivery versus giving the support at the central level. The experience that we have in our programs is that in the countries where there is focus on service delivery via funds going directly to the de-central level, be it province or district, with equitable key that they would have a lot of results. Thank you. Thank you. You can just talk. James Thurlow from UNU Wider. I think, I mean, a lot of what the panel has said is that we need more of this and more of that. And I was wondering, I mean, in the world in which aid is finite, do we have information where we need less money spent? So Dr. Butte mentioned that we need more monitoring and evaluation. Would you take that extra dollar away from maternal health? And if you think maternal health, would you take it away from water and sanitation? Is there some tension within the sector? One last question. Short. Okay, I'm Anaribi from Sweetcare. I have a question, maybe a little bit outside the topic, but do you see a role for private sector in health service delivery? Thank you. So we have like five minutes for all of these three. Let's pick. Staccato answers. Private sector, absolutely. I don't think in circumstances where you've got less than 20% going through the public sector, you have an option. And to bring them in also opens the door to innovation and to success. There's a question on where would you take the money from? I would take it from existing projects. And I feel very strongly having now done this for 30 years that currently are allocations to monitoring and evaluation and sound impact assessment within projects is miniscule. There is hardly anything in there to look at impact assessments, better quality surveillance, monitoring and evaluation. So I think doing those projects in terms of imagining that they would achieve their gains in terms of implementation without taking resources from those projects or allocations within those projects for impact assessment, monitoring and evaluation is a mistake. So I think those monies exist. They're just not being allocated. They are going to consultancies. They're going to very high level oversight and overheads and they're not going to where money is needed. And finally, in terms of the question that was placed on service delivery, absolutely. I mean, that's what I meant by the human resource question around, for example, newborn health. The focus has to be on implementation and service delivery. And it does make it easier to have in devolved health systems a greater focus on exactly how much is being reached and at scale. So monitoring in access, coverage and across equity bands. And that does mean that you have to change the flow of funds and allocation of resources with much less for management and much more for implementation. Anand, short and then Anand. Short. Okay, where do we take the money away from? I agree completely with Zulfi. In fact, I'll go out on the limb and say, a lot of people are talking about taking money, not giving a foreign aid to India. I think it's a very wrong idea. I think almost all of it should be actually spent on monitoring and evaluation in India, coordinating with the government. And that may actually be a way to reduce corruption. So I'm going to go very out on the limb. I think actually, even in countries like Tanzania and other countries, I think it actually uses your money much better. You can take away some money from HIV-AIDS or something like that. And I actually believe that HIV-AIDS actually program might even benefit from that. Yes, I absolutely agree with about private sector. Insurance is one of the ways in which you can engage the private sector. We should think about that in much clearer way. And yes, the regional funding and that's absolutely necessary. Thank you. Yeah. I think if I begin with the private sector question, at the moment, already private sector does quite a lot of things in water and sanitation, but it is usually seen as a problem rather than as part of the solution. So I think there is a need for change in thinking about private sector. And also there is another issue. Most of the aid is perhaps quite rightly going towards more difficult projects which are more social and distributive projects because the other projects which are commercially viable are usually very attractive for private sector investment. So there is, but what private sector cannot do, private sector can do efficient delivery, what private sector cannot do is to take care of the social provision, especially access for the poor. And that is where the most difficult challenge is there. So in that case, I think it is essential to bring in innovations from the private sector. I think Gates Foundation's work is very interesting in terms of how that can be done. And the final point I would say, I think we have to take an example from Judo. Anything which, if we see it as an opponent, instead of turn that into a friend or as our best strength, I think it's much easier to make progress. So in case of water sanitation, there are many things which at the moment we treat as problems and we are trying to solve them, rather if we treat them not as problems, but as how I can use it innovatively. I think aid has to play that kind of a catalytic role, rather in changing the mindset or changing the institutions, rather than actually going and putting money into this building of pipes. So I think that's where we can be much more effective. Let's stop with that. Thank you very much for enlightening us on this. Thank you, all three of you. A big applause.