 Welcome back, just again to thank our audience, in particular to thank our panelists who have excellent presentations on the first panel. Some of you have traveled at great distance. Really great discussion this morning, I thought. My name is Jennifer Cook. I'm director of the Africa program here at CSIS. I'm playing a moderate role here, moderating. If the dinner last night is anything to go by, my timekeeping will be essential. Our panelists have a lot to say and a lot of it extremely interesting. So we're going to talk now about regional interactions and trilateral regional south-south cooperation. We have three distinguished guests with us. We have Priya Balasubramaniam Kakar, who is a senior public health specialist at the Public Health Foundation of India. Her work in India has involved building capacity in the field of evaluation through incorporation of evaluation philosophy and techniques into core public health training. She'll talk a little bit about south-south cooperation from an Indian perspective. We have Jonathan Hale, who is the deputy assistant administrator for Europe and Eurasia at USAID. His responsibilities include management of strategic planning, policy, and implementation for AID's programs spanning 15 countries in Europe and Eurasia. He represents USAID as the interlocutor with the National Security Council, the Department of State, and other U.S. government agencies regarding policy and programming. We have Dr. Marianne Jacobs, who is the dean of the Faculty of Health and Sciences and director of the Global Health Initiative at the University of Cape Town. She is chair of the board at the African Population and Health Research Center. She's president of the African Medical Schools Association. She's on the board of the African Platform for Human Resources and Health. And she's formerly chair of the board of the ICDRB, Bangladesh, chair of the board of CO-RED, former WHO advisory committee on health and research. Really we're delighted to have you here, Dr. Jacobs, and talk a little bit from the South African perspective. Finally we have Dr. Felix Rosenberg, who is director of the Itaborei Forum on Health Policy Science and Culture at Fiocruz, Brazil. Dr. Rosenberg is also the acting executive director of the Union of South America and Nations National Institutes of Health Network. I'm botching this introduction, it is a long name. And the acting coordinator and executive secretary of the community of Portuguese language countries, National Institutes of Health Network. Okay, my job is done now. We've asked the panelists to talk a little bit about the possibilities for health cooperation, South-South cooperation, trilateral cooperation among the BRICS or North-South, South-South and so forth. Getting to how important is the idea of South-South cooperation to these individual countries and their global health outlook. What are the challenges and opportunities presented by horizontal or trilateral cooperation? It always sounds good in the theory. It's sometimes much harder to implement. And what are the advantages, disadvantages to fostering cooperation on health within a regional context? So we're going to begin with Priya, who has PowerPoint. And I'm going to ask, I'm going to give a one-minute warning. We have a full panel with lots to say, so I'm going to try to keep good time so we have time for questions and answers. Thanks, Priya. Thank you, Jennifer, for that very warm introduction. And thank you, Catherine, for inviting me on behalf of CESIS. It's indeed a privilege to be here this afternoon among a sea of experts, especially in the field of policy and diplomacy. I'm going to share a little bit of the work that we at PHFI have been engaged in, in India. And in terms of relating that to what we are talking about today, both in terms of South Dialogues and regional cooperation, it would appear that my answer is already a little biased towards actioning South-South collaborations. What we have been, or rather what I have been involved in the last one year is one of India's largest, I would say, since the Boer and Sochi report of 1946 policy exercises. India has finally decided to go to the root of universal health coverage. And the Public Health Foundation of India was commissioned to be a secretariat to a high-level expert group that looked across seven terms of reference to provide recommendations, guidelines, and a way forward for India to achieve universal health coverage for its 1.2 billion citizens over the next 10 years. India has always been bandied and bracketed as global power, emerging power, bricks, mortar, whatever you may want to call it. I'm not a diplomat. I'm a public health scientist. And I'll speak in that context. The recent Time magazine article says very clearly that with so many of the world's economies and tatters, and the combined might of China and India could spearhead global growth in the coming decades, are they up to the job? So this will allow me to set a little bit of context for universal health coverage. I am a public health specialist, so forgive me. I have to look at health metrics one way or the other. But it might give you some context as to how and why India decided to approach health with the kind of rigorous and almost disciplined agenda that they have come about with as commissioned by the Planning Commission. India is a growing economy. It's a large chaotic democracy. And it has a lot going for it. But despite economic growth, a lot of diplomatic dialogues in India have traditionally focused on trade and investment. Health has often been relegated or often neglected as something that actually takes away resources from the country. But evidence has now pointed very firmly in the direction that health is a key driver to economic growth. And like education, health has to be looked upon as an investment in this country. Not only within a national context, but within how India perceives itself in the global arena. Quickly going through some of the metrics here, we have one of the largest numbers of underweight children in India, 46% under three years, current infant mortality rates of 50 per 1,000 live birds. The maternal mortality ratio presently stands at 212 per 100,000 live birds. All these are challenges to meet the national and MDG goals of 38 per 1,000 and 100 per 100,000 by 2015. We're still lagging. We have a huge rising burden of non-communicable diseases that Julia had talked about a little earlier. But what's very interesting is that we face a dual burden. We face a burden of non-communicable diseases. We also face a burden of infectious diseases. So becoming rich, being empowered, only gives us that much more to deal with. So we deal with the lifestyle diseases of the rich, urban spaces, diabetes, hypertension, tobacco deaths, and then we deal with disease of poverty, malaria, tuberculosis, a couple of incidents of polio which are supposed to have been eradicated. And then infectious diseases, avian influenza, chicken gunia, SARS, the list is endless. What's interesting in India is that the private purchase of health care in India is huge today. About 60% of health care in India is now provided by the private sector. The private purchase of drugs and the purchase of health care services constitute 78% of the country's total health bill. Of this, 72% is due to out-of-pocket expenditures on drugs alone. So if you actually look at this, the combined rural and urban impoverishment due to out-of-pocket payments for health care in India are huge. I mean, it started from about 26 million in the mid-90s and ratcheted up to 40 million in 2004 and 2005. So why is health system reform needed for the country? More, 18% of all episodes in rural areas and 10% in urban areas have no health care at all. 28% of rural and 20% of urban residents have no funds for health care. 40% of hospitalized persons have to borrow money or sell assets to pay for their health care. Over 35% of hospitalized persons fall below the poverty line. And 2.2% of the population may be impoverished simply because of hospital expenses. So this sets a little bit of the policy context for this exercise. A high-level expert group, as I'd mentioned earlier, was convened by the government of India to mandate a framework for universal health. And the Public Health Foundation was appointed as secretariat. The review process for this document was interesting. Rather than view this as just another policy exercise to collect dust in the Planning Commission, we didn't know the future of this report, what would happen to it. What was interesting is that it was complemented with the experience of other countries. It highlighted what worked, what was relevant, what could have been replicated, along with limitations of various approaches. And this is where the context of both South-South dialogues and also interaction with regional level partners and players within the geopolitical context of India comes into play. The report consulted a slew of network of experts from Brazil, China, South Africa, more importantly, our neighbor in Thailand, and others as well. North America, Britain, Europe, the OECD countries, the World Bank, the WHO. And then we look at disparities. I mean, India is geographically a heterodox. Huge diversities, huge population. I mean, just looking at the infant mortality rate, Madhya Pradesh, 72 by 4,000. Uttar Pradesh, 69 per 1,000. Tamil Nadu, drastic reduction, 35, what an aberration. Kerala, even lower, 13. The neonatal mortality rate varies from 11 in Kerala to 53 in Odisha. That's the kind of disparities that the country is looking at. Now, how do we compare with some of the other countries? If you look at infant mortality per 1,000 live birds, we have 50, China 17, Brazil 17, Sri Lanka 13, Thailand 12. Under five mortality per 1,000 live birds, India 66. China 19, Brazil 21, Sri Lanka 16, Thailand 13. Percentage of children who are fully immunized, 66 in India, 95 in China, 99 in Brazil, 99 in Sri Lanka, 98 in Thailand. And our immediate neighbors, Bangladesh has 85% of all children immunized by the age of one. And Nepal, 80% immunized by the age of two. Birth by skilled attendance, similar metrics. And what about public spending on health? India, 33% of total public spending as per GDP. 4.1 total public spending. Public spending on health as per center of GDP, 1.4. But this is an overestimation. It's about 1.2. Sri Lanka, 1.8. China, 2.3. And Thailand, with the achievement of universal health coverage, 3.3%. The same with hospital bed capacity. Where do we stand? Between Sri Lanka, it's 3.1. China, 3.0. USA, 3.1. UK, 3.9. And India, 0.9%. There's a huge disparity here. So where does this all lead to, eventually? I mean, historically, while financial protection was a principal objective of this initiative for universal health coverage, it was also recognized that dealing with universal health coverage spans infrastructure, the health workforce, access to health care services, reforms and management, the participation of communities and civil societies, access to affordable medicines, health care protection and financing. And last but not the least, social determinants of health. This was actually added on. It wasn't part of the original terms of reference. And it was found that social determinants of health have a profound influence, not only on the health of populations, but more importantly, in their ability to access health. And that, and therein, lies one of the main challenges of the health care system in India today. There was additional focus on urban health, gender, the role of public-private partnerships, and information technology-enabled health services. So what was our vision for universal health coverage? It was seen as a universal health entitlement for every citizen to a national health package of essential, primary, secondary and tertiary health services that will be funded by the government. And what does this mean for India in terms of universal health coverage? What was the pulse that we were getting from the government? For once, it seemed to us that to the government of India, the kind of political will that went behind this whole exercise, universal health coverage meant a lot of things. It meant greater equity, a great leveler for a country with huge social and political disparities. It meant improved health outcomes which reduces spending on health. It meant an efficient and accountable and transparent health system free from corruption. It meant reduction of poverty. It meant greater productivity in a country that's crippled by a slew of chronic and non-communicable diseases. And it meant increased jobs. An estimated 24.5 million jobs are estimated if universal health coverage is brought about in the country today. So the provision of health care would mean strengthening of public services, especially primary health care. And for this, we look to our partners in Brazil. We look to our partners in Thailand. We look to our partners as far as Kyrgyzstan and Sri Lanka and looked at how they strengthened and focused on primary health care to bring about greater equity and lower costs in providing universal health care. We have suggested that private providers of health be contracted into the system as per need and availability with defined deliverables. And ultimately integrating primary, secondary, and tertiary care aspects of health through these networks of providers, public, private, and public and private partnerships. And all this would be regulated and monitored for cost and health outcomes. I'm not going to dwell too much on this. I know there's a paucity for time, but I'll give you a few key recommendations. The first one was the government should increase public expenditures on health from the current level of 1.2% of GDP to at least 2.5% by the end of the 12th plan and to at least 3% by 2022. The second quick win that we wanted was the availability of free essential medicines by increasing public spending on drug procurement. I repeatedly heard in the previous session that India has this fantastic pharmaceutical industry, huge manufacturer of generic drugs. They bring down the cost of drugs. But the reality is a lot of these drugs are simply not available for the Indian market. You walk into a public hospital in Chennai or Delhi, you won't find drugs. And that's one of the key deterrents of people going into the public system, using public services, because they simply don't have the medications. They go outside. They buy drugs in the free market. Some of these are spurious. Some of these are about cost. And eventually, that's where the 72% goes of OPs towards drugs. And finally, general taxation as a principal source of health care financing, complemented by additional mandatory deductions from salaried individuals and taxpayers, either as a proportion of taxable income or as a proportion of their salaries. We've also advocated the removal of user fees for national health services. And this applies for even those who have the financial capacity to pay. The reason is because I think the group viewed, the expert group viewed universal health coverage as something that transcends the narrow, often inadequate and sometimes inequitable definition of universal coverage as universal health insurance. What India looks at and what this particular group looked at in terms of universal health coverage was it moved beyond the realm of insurance and went to the realm of assurance where every Indian citizen was assured of basic health care. We recommended a package of financing that was flexible with differential norms that would be proposed to states who are very, very powerful players of health care access and delivery in India and recognizing both physical and socio-cultural diversities of these states. The other quick win that we went for is the 15% allocation of public funding for health to drugs and the state must procure all essential drug list medicines. They should be centralized procurement. Quality generic drug should be insured and warehouses at every district level. We borrowed heavily from the Brazilian model here. These are some of the management reforms that we have suggested, but in the paucity of time, I will not pause here. But let's move on. So what are the immediate outcomes to this whole exercise? It's interesting. We had an interesting conclave on the 27th of November where we invited a slew of international experts to comment. They came from different countries, India itself, local experts, Sri Lanka, Brazil, and experts from multilateral agencies, WHO, the World Bank. They not only gave their comments on the report, but they also evaluated it and shared some of their comments with the Planning Commission when the report was formally presented to the Government of India on the 28th of November. On December 1st, the Deputy Chairman of the Planning Commission, the Planning Commission, by the way, is the money bags of the Indian government. They hold the purse strings and also determine how much spending health would get for the country. Montek Singh Alualia, the Deputy Chairman of the Planning Commission, announced in public, what I perceive is a major coup of this entire exercise, that health care spending in India is to go up by 2.5% in the 12th five-year plan, which actually is being compiled as I speak, and will be released and tabled in Parliament by January of next year, 2012. And that's it. That's the immediate quick win that we achieved, is pressing the government that for any kind of health reform, any kind of health parity, we need the funds to make it, to achieve some of those goals. Here's another headline. Here's how the United Party Alliance, which is the current ruling party of India, can seduce the common man. Universal health care as a game changer that will truly reform India. And finally, a third one. By the times of India, December 5th, that's yesterday, after many wrongs, the Planning Commission has just got it right. Universal health coverage to become a reality in the upcoming five-year plan. And then as we debate the quick wins on generic drugs and the essential drug list, the business standard publishes one on 30th of November, should drug prices be regulated, should it be for hospitals for transparent and more objective price regulation. DG Shah is from the Ministry of Health and Pharmaceuticals, and has instituted a new policy that it looks at drug pricing and competitive bidding in a more transparent manner. So, I think in some ways, by the institution of a policy like this, and the fledgling steps towards universal health coverage, we have charted our own small road to global health policy. I do believe that India has firmly joined the global movement towards universal health coverage and care. Perhaps it could, in its own way, be a leader in the future. And universal health coverage in this context places health in the centre stage of global country agendas. When you look at our fellow countries, Thailand, Sri Lanka, countries in Europe, Spain, and countries in the developed world, Canada, New Zealand, and the UK, these are all countries where universal health coverage has evolved as a movement. And by India firmly, but positively joining this, we have, I think in our own way, positioned ourselves in a global space where the national priorities of health will now start defining our global priorities in health. So why a South-South context? It's interesting because I think Peter in his very beautifully articulated speech had talked about the uneasiness of the bricks and the evolving, shifting dynamics of the various agendas of different countries. We speak for the bricks, except that India has to first look at its own national agenda before determining its space in the global arena. Some similarities in terms of why South-South dialogues would work, a similarity in terms of environment, in terms of political, economic, and historical and geographic agendas in countries, for example Bangladesh, Thailand, Sri Lanka, and some of the ASEAN countries have a very close agenda with India, both in terms of historical, political, and economic context. Living conditions, disease dynamics, non-communicable and chronic disease, affect parallel countries in the region at the same time. Bangladesh has had the tsunami crisis, huge resurgence of infectious diseases. Pakistan had the earthquake, a huge resurgence of infectious diseases there. And health systems, the ability to learn from each other's health systems and put into place mechanisms that can make health systems within the country work better based on proven agendas in other countries. So what are some of the opportunities? Health systems, the ability to collaborate in technology, low-cost technologies in Bangladesh, for example, the use of zinc supplements, has greatly benefited maternal and child health. Telemedicine, in fact, based on the SARC agenda, India, Nepal, and Bhutan have actually put together an agreement where they will use telemedicine to effect changes in maternal and child health integrators. Disease surveillance, I mean, this is a huge area of cooperation with the avian flu influenza, SARS, and other, and more recently, the New Delhi-Metallobacillus virus, the antibiotic-resistant strains of bacteria that are coming into the country. Using regional cooperation to monitor survey diseases and to be prepared for pandemics is a huge area to foster regional cooperation. Affordable medicines, I mean, the use of generic drugs has time and time again been the focus of health agendas in other countries, and it's time that India started interacting with them to talk more about trips, re-evolving India's own generic drug agenda, and also issues regarding manufacturing and distribution of drugs. Primary healthcare, we're all countries who are grappling with unsanitary conditions, lack of safe water and hygiene. Thailand actually has 97% achievement of good drinking water and sanitation, and it's resulted in a huge drop in their infectious disease rates. And lastly, institutional linkages. I mean, I was just talking with Felix and Marion, and we were talking about PHFI reaching out and having some collaborations, both inter-institutional and inter-governmental. Political bill doesn't always have to foster agendas, but we need institutional linkages to begin some of those relationships. So what are some of the challenges? I think one thing that comes up repeatedly is political will and a committed leadership to reach out both in terms of South-South dialogues and regional co-operations. The issue of trust. I mean, once again, this was mentioned in Peter's presentation. India and China view each other with awareness as adversaries, and we have to get over this, this geopolitical suspicion in order to work in common health agendas. More importantly, what we also need is a supporting and enabling international environment and partners. And this is where multilateral co-operation and organizations can come into play, where normally you're talking about disease interventions. Now perhaps aid could be about fostering regional co-operations, both in terms of research, in terms of surveillance, and in terms of building better health systems. There's been a traditional north-oriented mindset with vertical links, HIV-AIDS, malaria, cholera. They're all silos. And perhaps now is the time to break those silos and kind of look at it from a horizontal point of view. A lack of shared history, and my time is up, and a low-level awareness among common problems within countries. And lastly, weak policy frameworks, where countries focus only on national goals and are so preoccupied with them that they lose their sense of position in a larger global arena. But having said that, if we don't create the future, as Toni Morrison says, the present only serves to extend itself. Thank you very much for your time. Thanks very much, Priya. Let's turn to Jonathan. Okay, someone's going to help us with the PowerPoint. Good morning. I am Jonathan Hale. I'm Deputy Assistant Administrator for Europe and Eurasia at USAID. And I'm here to speak about co-operation with Russia on global health and development. And I want to thank CSIS for the opportunity and for the important work that they're doing on the BRICS to start with. Today, USAID is working with Russia as a development partner, while we still also cooperate on remaining challenges in Russia itself. As a G8 member, Russia has expanded its development and global health assistance around the world over the last five years. It has worked and is continuing to work through multilateral organizations like the World Bank, and we heard about this in the first panel. At this point, Russia's total bilateral and multilateral development assistance to other countries is about $500 million every year. Russia is in the process of joining the organization for economic cooperation and development. And at this point, it is not a member of OECD's Development Assistance Committee, but it may be in the future. Finally, Russia is also in the process of setting up its own development agency, which is set to launch this year, and I'll talk a bit more about that later. The U.S. and Russia have a rich legacy of working together on health issues. And thanks to the reset in relations initiated by the Obama administration, the U.S. and Russia have been able to cooperate more closely on a number of global challenges, including those impacting global health and development. Within the health working group of the U.S.-Russia bilateral presidential commission, we're cooperating on scientific research, maternal and child health, healthy lifestyles, and global health issues. And USAID is delighted to be working with the U.S. Department of Health and Human Services on these matters and coordinating closely with the Centers for Disease Control and Prevention. And one of the photos you'll see there, it's timely, is Secretary Sebelius and our health working group meeting. Earlier this year, USAID and the Russian Ministry of Health and Social Development signed a protocol to work together to facilitate polio around the world. And in May, U.S. and Russian teams, working under the auspices of the World Health Organization, conducted joint polio surveillance in Kyrgyzstan and Tajikistan. And the pictures that you'll see as I speak are from that mission in Central Asia with our experts and the Russian experts together. It was very successful. Our teams visited a number of regional health facilities and accompanied local mobilization and immunization teams door-to-door in order to identify strengths and immunization campaigns and to provide suggestions for improvement. U.S. and Russian technical and financial collaboration contributed to rapidly stopping the polio outbreak in the WHO European region that impacted at least four countries. And the work of the U.S. and Russian teams helped secure a determination from WHO's Regional Certification Committee that the region was again polio-free. We continue to actively promote cross-border coordination and planning and are looking at our next steps in the global fight against polio. This fall, I also started a dialogue with the Russian Ministry of Health about possible U.S.-Russian cooperation on malaria. And we're in the process of exploring how and where we might cooperate and whether it will involve training, surveillance, or eradication efforts. And the Russians are already working through the World Bank to train African doctors and to take part in other anti-malaria efforts in Central Asian countries, where USAID is also active. There's also interest in trying to understand the remaining problems with malaria in Central Asian countries, like Tajikistan, and how we might work together to combat them. I just want to mention a few other areas of bilateral cooperation and global health between the United States and Russia. Later this week, the U.S. and Russia will participate in the delivery of 180 wheelchairs which are being donated to Kyrgyzstan. And the U.S. and Russia are also deepening cooperation on international disaster response and emergency medicine. We've held a joint tabletop exercise and are now planning an exercise in a third country. Over the last few years, USAID has also supported the deployment of Russian doctors and health experts to African countries, including Namibia, Botswana, Ethiopia, and Tanzania, to build capacities needed to fight HIV AIDS and other global diseases. And finally, USAID has been in a dialogue to share the various practices as Russia sets up its own development agency. The Russian Ministry of Finance is taking the lead on this agency within the Russian government. USAID recently hosted a study tour to the United States for representatives from Russian universities in Moscow, St. Petersburg, Yaroslavl, and we're looking to introduce them to leading American universities with development assistance curricula. Another goal of the study tour was to expose Russian professors and experience of practitioners in international assistance from the US government, the NGO community, and international organizations. To be sure, US cooperation on development with Russia is relatively new and both sides are trying to work closely together as development partners, but it's had its challenges. For instance, we've had to overcome the language barrier and clashes of institutional cultures between relevant agencies. Funding for any foreign assistance effort today is under strain in the difficult global economic environment. Still, trust is being built on both sides and as our experience in the health sector illustrates by building capacity and working together, we can have a significant impact on major global development challenges. There's great will, good will on both sides and it's very positive. The US and Russia do not always see eye to eye or share common interests. However, engagement in the health sector has been positive and constructive and we look to continue it in the future and build on it. Where we do face common threats from infectious diseases to global poverty, we need to continue to deepen our cooperation for the sake of Americans and Russians and the rest of the world. Thank you. Thanks very much and that begins to get at a question maybe for the question period to our other panelists on what is it that the US can do to kind of encourage the BRICS in that global South-South engagement. Let's turn to Mary Ann. Good afternoon. Good morning. Thank you to CSIS for making it possible for me to be here, but particularly to Caroline and Farah and Matt and Jenny and Catherine. I hope that by the end of my 20 minutes, the 22 hours that it took for me to get here will have proved to be worthwhile. So I have chosen to look at India, Brazil and South Africa and not the whole of BRICS because like Peter, I don't think that the BRICS alliance makes good sense, particularly for global health and global health equity. So if one looks at global health in the 21st century, I think there's a lot to be said for the achievements, the reductions in children's mortality, and technological achievements, but of course this is juxtaposed with an agenda that still has a far way to go in the world in terms of equity across the world. The response of the world has been a number of phases. Peter spoke about it starting with tropical health, moving into international health and more recently in the last 10 or more or 20 years this phenomenon called global health which has unleashed a tsunami of global health initiatives, public-private partnerships, public sector, private sector threatening actually to overwhelm us. So within all these global health initiatives the question is what is the place and contribution of the global south? Can the global south make a contribution to global health equity? And so in this context I believe and I'm going to argue that it is time to revitalize the collaboration. So just a couple of pictures the history of south-south cooperation starting with the Bandung Africa Asian Conference in 1955, moving to the non-aligned movement in 1961, IBSA, the G20, the technical cooperation among developing countries, the UN program and then finally the inclusion of South Africa in the Bricks last year. So in 2009 the UN decided to have a high-level meeting to review progress among these South-South corporations over a period of 30 years. The meeting was held in Nairobi in Kenya and these are the issues that emerged from this 50-year review, that emerging economies play a lead role in South-South cooperation. They address transnational challenges they are both by and multilateral initiatives are relevant the networking, the interest of emergence of triangular cooperation, meaning South-South North, the number of regional and inter-regional initiatives that are possible and the place of South-South in global negotiations and trade finance and investment was made as a clear recommendation. So Busan endorsed the idea of South-South cooperation for development there was several meetings leading up to the Busan meeting, it was held last week and there is even a handbook towards the effect of South-South and triangular cooperation if anybody needs guidance on how to do it. Fairly simple handbook actually, it was a couple of kind of 18-point font guidelines on how to do it. So can India, Brazil and South Africa then be a useful model for looking at South-South cooperation for development? Well, IBSA was established for three main reasons because the three countries share democratic credentials because of their status as emerging economies that a number of people have spoken to and also very importantly because of their potential to engage in the world with other major global players. So there were three main threads to the Brazilian declaration that IBSA would be a political forum it would look at cooperation on projects and very interestingly that each country would donate a million dollars a year to support poverty reduction projects in other parts of their respective regions. But the whole initiative of IBSA and Gears Brick has challenges and this is a paper from the South African Institute for International Affairs by Senona and he asks are these forums neoliberals in disguise or are they truly champions of the South that they put themselves out to be? And the challenges that IBSA faces one of them was raised by a question in the last session each country needs to look at its economic progress in the world against social development and redress for internal inequality and you will know that the Brazil and South Africa's genie coefficients are among the highest in the world so we have that challenge. Should there be regional solidarity or are people in it for global advantage? And for looking for global power. Is this just another political wave or is this truly a global development commitment? And the challenges of IBSA's governance its plans, its resources and accountability in this really loose alliance that doesn't have a constitution when overall plan is challenging. So I believe that there is a place for looking again at how health development can be accelerated through a partnership between the three countries. These are the key elements of the Brazilian declaration that are relevant to health. They talk about social equity, about a focus on a range of social goods and they talk about the value of exchanging experiences in combating poverty, hunger and disease as being useful. I don't have to show you numbers but there are a couple of reasons why I think the partnership between the three countries is relevant. First of all they share a rights framework. The constitution of each of those countries looks at health as a basic human right and that means that in each country there is a possibility of a constitutional challenge if the population believe that that's not being honoured. Priya has spoken about the issues of universal access. Both India, Brazil and South Africa are all engaged in looking at universal access for their populations. Congratulations to India for their achievement. Brazil's been going much longer with the SUS and in 2012 South Africa will roll out national health restrictions. South Africa actually has a challenge under this issue of the right to health. Peter addressed it very shortly but this emerged in the issue of trips and the right to antiretrovirals. The issue of the right to health on the one hand civil society felt the state was obliged to deliver on access to antiretrovirals. On the other hand we had signed the WTO agreement and we were there for obliged to observe the guidelines of trips. In the end the issue was not taken to court. The treatment action campaign challenged the state to deliver on its right to health and the pharmaceutical companies withdrew and I think that it was a very interesting issue of the supremacy of human rights in the constitution against an international agreement. The second one talks about why we need to be together because we can build on the strength of civil society. In social science and medicine a couple of years ago there's a very interesting article on the lessons from building Brazil's national health system the way in which formal channels were created for civil society to engage with us. At Busan they discuss the same consensus on the role of civil society in development and next year is the third people's health assembly, the people's health assembly being a global coalition of constituencies concerned with the right to health but of advertising it's going to be in Cape Town in July and next year a beautiful place to come but more importantly I think an opportunity to continue the dialogue that we're starting here. This is a different kind of metric that's not generally used in discussions like this and I shared it with a meeting in South Africa recently that if we want to look at academic collaborations between our countries the world university rankings are contentious but if you look at South Africa, Brazil and India you will see that in each case the institutions in those countries are the first or highest in the rankings in their respective regions so they have an opportunity to play an academic role if we want to take on that challenge. A second set of metrics looks at what is more traditionally used in science as the outputs in terms of publications and impact in terms of the H index and again you can see there's a huge gap between the US and UK and India, South Africa and Brazil it doesn't count doesn't take population into account and certainly doesn't take into account the resources that are available to do science and to publish. In terms of these two metrics between the three of us our academic institution should be able to make a significant contribution through South-South collaboration. The gentleman on the end was asking about R&D in the case of health biotechnology yes there are a number of collaborations and in fact Cuba is the greatest number of biotech collaborations the challenge though is that most collaborations are linked to licensing arrangements and not to resulting in the joint development of new projects and new products and so there's a need to accelerate innovation and translation and we have the potential we can do it. So those are there. The International Centre for Genetic Engineering and Biotech has a branch in Delhi there's another chapter in South Africa and together with FIOCruz I think those three institutions can really make magic in biotechnology. I was asked to say something about regional collaborations I'm less pessimistic than Peter is I think that even though the state may not be playing a role in Africa there's a whole lot that's going on independent of government. Yes there is a new partnership for advancing for economic development in Africa through which the leaders can pursue cooperation but there are also other platforms like the Africa platform on human resources for health the Equinet Network in Africa H3Africa Africa is not just about Missouri and AIDS H3Africa is human health and heredity looking at building capacity for genetics and genomics and then we've just reestablished the African Medical Schools Association so lots of things going on in which South Africa is playing a facilitating role again with the World Bank Africa Development Bank and Capacity Plus looking at community of practice projects with Sean Naronia on the other side. So I believe that the time for IBSA Health is right the three countries are implementing universal coverage there's a prevailing concern about global health governance a threat of declining ODA and we have a chance to be the gateways to regional solidarity and health development so what then are the next steps for our three countries in contributing to the South-South cooperation for health development the first one is I believe that we need to have an active engagement in health development plans there's the NCD summit the World Conference on Social Determinance COP 17 has just happened in Durban there's a high level forum on aid effectiveness there's a commission on global health governance I believe that we need to get in there and have our voices heard in there because if these different summits are not coordinating their recommendations I think we can perhaps do it through harmonizing if it's from a southern perspective the second one is I think it's actually crucial for us to get a better understanding of the position of the US and other development partners so the Center for Global Health Development published what's on the agenda in Global Health in 2009 there was a subsequent publication from CSIS led by Helena Gale and neither one of those talk about support they talk about supporting countries in the South but not supporting South-South collaborations and when you look at the governance of Global Health the Global Health Initiative in the US from the tip of Africa it's very hard to see how we need to engage with quite a complex arrangement Busan is yet another opportunity whatever comes out of Busan I believe we need to interrogate very actively to see what it is in the minds of our partners that we can actually benefit from the third one is and I have just five steps is the need for us to review the Brazilian conceptual framework as a model for trilateral partnerships and I hope Felix is going to talk a little bit about it this Silia Almeda and Paulo Bus published this in the Lancet but they talk about structural cooperation in health and they have a set of principles and talk about the need for long-term engagements which is based on the need of the countries the need to strengthen whole system capacities and not just bits and pieces like the HIV directorate in the government the opportunity to promote dialogue among actions and also the need to facilitate leadership in the processes most importantly to ensure that the country ownership of the agenda is predominant so we have a couple of things to start with us the fourth one is claiming the place of the global south in the plans for new global health governance so there is a joint action and learning initiative towards the global agreement on national and global responsibilities for health and anyone can join that anyone who has a passion for looking out for what it is that needs to happen to make health development to accelerate health development can join the joint action initiative the new commission on the global governance for health is a lease open structure it's led by the University of Norway with Julia Frank from Harvard and Richard Horton editor of the Lancet and they just started up they've identified about I think they're about 16 commissioners handpicked from different institutions and one looks forward to see what mechanism of engagement they are going to use to take up issues like making sure that the voice of the global south gains greater prominence particularly when the commission is led by northern institution the last step I believe is moving to action so what do we do after we've met here we've come we've come a long way and my hope is that something will happen after today I think that we need a commitment from the IBSA leadership to make a bigger space for health to look at how the IBSA countries can work more closely with one another on a more expanded agenda for health to support the IBSA countries in their quest for supporting regional engagement to truly become champions of the south of the global south and possibly to look at how IBSA needs to interact with the G20 and other fora the challenge is that if one is only going to look at state actors participating in these structures you may not get as far as if we look at the non-state actors like civil society and like academic institutions we are going to need dedicated leadership I think that the IBSA presidents are perhaps have big issues that they having to deal with other than meeting every couple of years they're now also having to go to BRICS meetings and there's a chance that IBSA can be dwarfed by BRICS and their original intention to strengthen participation partnerships may be lost we need a plan, a clear plan that has a goal that has values that has principles and mostly that has clear outcomes and lastly I think we need a monitoring and reporting mechanism that is more than just an occasional report that one picks up off the internet that mechanism needs to track progress with the plan it needs to show impact and it has to have accountability so I'm suggesting that instead of all these high level forums maybe we need a low level forum that can address some of the issues that I've raised here today thank you Dr. Jacobs excellent let's turn to Felix thank you good morning I think it's always a big challenge for us to to speak in very few minutes so huge, large complex matters but the third time being with her I'm trying to learn I want to thank Marian because she presented the Brazilian conceptual framework and this will help a lot all my presentation because everybody will be sort of acquainted with the basis of that I would like to start with I think a very important concept playing behind all what we do or try to do and that's of course I know this is in the mind of everyone but it's not always stated cooperation in global health is a diplomatic tool for international relations so we have to understand this we are speaking of diplomacy we are speaking of a tool and so what lays behind this tool it's extremely complex and varying I have listed some of them which are picked up from most of the papers discussing global health and certainly global disease that is international disease prevention is one of the major issues laying behind global health cooperation of course international health that is getting together to lobby for global policies, health policies is a second drive national strategies, geopolitics I think this is a tremendous important, very important drive national security that is prevention against bioterrorism has been one of the big motors of development of global health in the last years commercial international trade is extremely important and many you will see that many many of the corporations are dealing with either specific health inputs or products not only specific health related products also other commodities which are insured through this diplomatic tool ensuring commodities like oil or food stuff and so on and of course medical products like medical technology and services and then of course there is what I would call the global health market in the last years there is a huge development of global health institutions, institutions private and public who deal with international with global health actions and this creates a big employment sector I mean many many professionals are being employed in global health and traveling and I mean this is not to be not considered and last and I would say unfortunately least also least we have international ideological commitments and that is human rights and global justice is also the drive for many countries or individuals working in global health that it was mentioned Cuba for instance today this is maybe one of the big drives they still have China used to have it until it still has some residues of that sending the barefoot doctors to Africa's countries they are trying to stop it but it used to be and many of our countries they do international cooperation just because or also because of international commitments the strategies I would normally we speak of bilateral and now including eventually trilateral triangular relationships and multilateral which may be regional or international and I would like to add what I'm quoting unilateral cooperation this may sound awkward but I would say that many of the NGOs define corporations are almost unilateral they decide what they're going to offer, donate and to whom and under what circumstances and what is left to the partner to decide it's so little that I think we can call it almost unilateral however all of these both the strategies and the reasons for this international cooperation I would say they're interrelated and they are mixed they are not excluded whenever we do international cooperation we are doing all of them with different values for them but we are dealing with diplomatic relations we are dealing with social justice we are dealing with commercial issues we are dealing with global health market etc and so we cannot say we cannot separate them separate them as excluding reasons I would say from all this mixture of reasons and strategies and increasing global health cooperation actions what are the outcomes and I would say there is certainly a very significant global health market NGOs and consultants and global health related inputs and products that we can see every day if you look at it it's increasing very fast I would say much faster than any of the other outcomes I will affirm that in all other areas there are relatively limited results even in as a diplomatic tool there are some people, some companions of mine they feel that global health cooperation has a tremendous little influence on major diplomatic relations and commitments in international arenas so and that's why G20 doesn't even speak of health commercial issues if we compare it with others it has a very low weight so I would say it has limited results it has had as an outcome a fragmentation of health institutions, programs and systems we work a lot in Africa and in Latin America and I would say that although some of the corporations are very important in general I'm not sure if the balance, the final balance has been so important because it also has caused fragmentation of systems that's created parallel programs, parallel systems some based on the theology we have created in many countries the AIDS ministry the Ministry of AIDS mostly the Ministry of Malaria and also because of the different agencies you have private agencies, NGOs competing with the government programs so you duplicate actions and you lose the power, the possibility of having synergy between all the actors and all the disease oriented corporations I would say also the dubious effect on specialized manpower because although all this cooperation probably has contributed more than anything on producing, creating, developing human manpower in red the capturing the migration policies of robbery as somebody said of high developed resources has really had a tremendous impact on the countries and last I would say the emphasis on the donor agenda has often weakened national commitments with national priorities because the donor agenda that's where the money is, those countries are extremely poor they don't have financial resources so many times they have to deviate from their commitments at least political commitments in order to receive those donations so we have to go through new approaches there is no doubt about that and for the new approaches before going and considering some of the resilient activities I would say we have to consider a dialectical relationship between individual, institutional and government projects individual belongs to an institution an institution belongs to a government and they are all interrelated they are not the same thing but they are not the same thing I want to insist on that and also between the donor and recipient countries and for that to consider the relationships between donors and recipients when I mean dialectical it means they both influence each other and from their influencing each other it means they both influence each other and from their influencing each other you get to a new outcome you produce a new solution it's neither the donor or the recipient it's neither the individual or the institution you get mutual influences and then we have to consider the levels of asymmetry between the donor and the recipient country and this is probably the most important thing to consider if you have a very asymmetrical relationship it's very hard to have trust and commitment in the corporation so what are the emerging practices the requirements from our point of view from Brazilian point of view is first of all as Marilyn put it it has to be structuring cooperation that is you have to help develop and consolidate strong national health systems and health structures and this is a major consideration anything going away from that or anything not going towards that end it's not going it's not solving this big challenge and this means I would say strategic planning comes first in every corporation we have to sit down with the country and discussing our different experiences and knowledges and discuss a strategic plan for the country instead of just point specific actions secondly peer that is horizontal relationships we have to have a joint learning both countries working cooperation learn from each other or from the cooperation it has to be based on mutual commitment and mutual trust principally and I would say something which probably is going to cause a very big debate in here I would say only and this is our view only with governmental or at least governmentally linked institutions the question of who represents civil society is a question which has been put forward today and this is extremely present NGOs is something in Brazil for instance somebody said we almost don't have NGOs what we have is civil society participating in the health commissions at the national level the ministry of health at the state level and at the district level and they are civil society organizations but they participate in finding the policies and strategies of the health system in Brazil the another thing is to work with NGOs isolated from the government so we would put this as a premise we have to work with government or at least government linked civil society organizations what is the emerging strategy what is Brazil putting forward to solve this and to address these issues it's to focus on what we would call affinity nations or affinity nation communities and this is what we do what we have been doing that is either regional communities like Latin America geographically regional communities which are the strongest I may say stronger than any other one we have linguistic cultural communities like the community of countries Portuguese speaking countries CPLP and finally we have economic communities and that is tricks and probably Ipsa we have to try to include bilateral and multilateral international within the affinity nations communities we cannot discuss this is a bilateral project this is a multilateral we have to try to get the synergies so include bilateral relationships between the multilateral ones and whenever possible I think this is the most important breakthrough we have to work with through trilateral that is North-South-South Corporation and we have worked with IAMFID that's the International Association of National Institutes of Public Health although it's international it's north based because Gates found it so it's a north agenda but still working together with South-South Corporation the World Bank has worked with us in a fantastic experience with the Portuguese speaking countries the US CDC has worked with us in a beautiful experience and very learning experience challenging experience in Mozambique we are working with Canada and with European Union now and what we consider the first priority issue in UNASU and that is to develop national laboratory networks institutional networks so our priorities as I say are UNASU and some related countries like we have a strong work with IT and with El Salvador mostly South-American countries with CPLP and with BRICS and from the three the national priority is certainly UNASU and probably extending to Latin America in the future finally to finish some examples from our perspective in UNASU we have been working first of all getting in the health sector with developing a five year strategic plan for UNASU that means that all of the 12 countries sit together and discuss what is their midterm cooperation plan we discuss together the same table the same room what are we going to do together in order to cooperate within among us we have the second thing in order to do that is to develop institutional networks of which the national institutes of public health are very strong addressing the problem of science and technology the problem of teaching the problem of diagnosis the problem of science-based services active actions and then the network of schools of technicians that is high school technicians which for us Africa, Asia and America is still one of the strongest and most important manpower in health for health equity we have been working strengthening I personally the national institutes of public health we have been working particularly with Argentina and Peru trying for them to be then new leaders within this region the idea is whoever has some type of structure to upgrade the structure in order to intervene in mutual cooperation and try not to concentrate cooperation in Brazil for instance this of course may not be shared by others but I think it's important as I say there is a relationship between the individuals institutions and the country in CPLP we have also worked with a four year strategic operation plan we have had worked very much with the networks the three networks I mentioned and we have been working particularly with Mozambique and Guinea-Bissau in order to get original critical mass and now they decided we all decided to eight countries Portugal, Brazil five Africa and East Timor that we have to concentrate in developing new public health institutes in the countries who don't have it and that's the smallest countries that the Santome principle Cape Verde and East Timor they are islands and they are very small countries so when you go to an overall international global health discussion strategic discussion what people would say it's not cost effective because there are too few people and I mean we cannot speak about the country who has a small population it's not cost effective they have the right to have their system and their structures as much as any other country so now we are working together with Portugal in order to try to develop those institutes in those three very small countries it's a challenge to get financing for that but we are going to try to solve it and finally BRICS then BRICS has a completely different perspective from what I can see now it has had its first health meeting in China this year and it seems that health inputs that is drug, vaccines, kits either for production or for development joint development may be the big issue among those countries because they have the basis to do that and to increase accessibility to drugs and vaccines in the world particularly in the south world is there a possibility for joint cooperation within with third south countries I think there is for instance with China to work together CPLP and China for instance in East Timor would be an ideal thing to work in our case with CDC China CDC because they are nearby and they have natural affinities we can work with China and Mozambique with East Timor so the possibility of working and maybe with South Africa it's a very important issue to work with South Africa together with Angola and Mozambique because there we will get together the CPLP linguistic our linguistic with original commitments which are so strong so I'm just finishing by saying this we have to work as Marion already put it in the same table discuss together what really we all need and this is the big difference with traditional donor recipient cooperation great well thanks very much for really thoughtful presentations which came at things from slightly different angles let's open up for a question and answer we have 10 minutes but we may cut a few minutes into Steve Morrison's time if you don't mind just let's take a few questions at a time we'll start with the gentleman in the far back my name is Patrick Day and I work for the voice of America my question is in the programs and all this that you talk about you incorporate using media because again apart from the large board rooms and seminars the final analysis that this information has to get to the lowest common denominator which is the people that are affected and an important part of this equation is how does the information and education permeate down to the lowest level and is this something that you incorporate in your strategies because the voice of America actually broadcasts in 42 languages throughout the world and one of the things that we do is we've partnered with USAID for example the State Department in providing education and training to local journalists who are experts, doctors and whatnot and talk at the lowest level on how to approach some of this pandemic Hello, my name is Vesna Kutlesik and I'm with the UNIS Kennedy Shriver National Institute of Child Health and Human Development here in Bethesda, Maryland and my question is to what extent are children a priority for BRICS countries particularly child health, early intervention education, thank you Jessica Hi, good afternoon Brian Lemie with GBC Health Priya I think opened the session appropriately with some GDP statistics and the importance of health to countries economics and I think that the private sector really recognizes that importance as well and I was nervous that there would be no mention of the private sector in all of these cooperative opportunities and then we did hear Felix allude to the idea of the commodities and those in the pharma business as well as food and oil etc can you speak a bit more just anyone on the panel about engagement strategies for the private sector as they truly represent a big base of their employees for the communities but also have vested interests certainly in these growing markets which may sometimes compete among the BRICS or the IBSA at least competitive interests was there one yes gentlemen Brad Tytel again from Global Health Strategies this I think is kind of an expansion of all these questions which is as the BRICS become more engaged in global health and global health assistance particularly I was wondering what if any role you think the kind of groups that are in this room particularly international NGOs could play to help accelerate and facilitate this process in a way that's respectful of the strategies and approaches of the individual countries but also hopefully helps maximize health impact we take these and we'll go in the order that we spoke and you can pick off whichever you need to answer all the questions but pick off the one that you think or the couple that you think are most you have most to say on sure first question of how you can engage media I can speak from the Indian sub context at least where universal health coverage is concerned I mean our next phase of engagement once the policy unfolds into an implementation plan is advocacy through the media we do have to go down to the lowest common denominator especially for state level engagement what's also interesting is that a lot of the states within the country have their own regional engagements for example Tamil Nadu does borrow heavily from the Sri Lankan model and from a couple of the Asian countries as well so under I think underestimating the media is a far cry if we have to engage regional cooperation within a larger context but as far as the universal coverage movement goes in India we do plan to not only engage regional media but even local media to get the message of health equity across so it is a huge and ongoing part of our advocacy efforts in the next stage I would just say first on the child and maternal issues that's a major priority for Russia. Russia's made quite a bit of progress in infant mortality and they actually just had a conference in early October to highlight what they've done and also to talk about how it can be shared internationally and I think that's an area that will be of great interest to us and working with Russia in third countries and trilateral cooperation in the future and USAID is actually the leader of the child and maternal health subgroup of the health working group of the VPC so I would also just want to highlight that on NGOs of all the work USAID does around the world capacity building and working through NGOs is very important and particularly in this part of the world and in Russia most of our work I would say the majority of our work is through NGOs and working to strengthen the capacity of local NGOs and that's certainly something I think over time as we develop what we do we will want to try to continue with Russia in third countries as well. So on the issue of the media I can only speak from an institutional perspective. The challenge is often to translate all these wonderful documents into formats that are easily accessible for popular access and very often it's hard to get funding for that kind of activity that translational interface between the production of big policy documents and big academic documents for distribution. So in Africa there is an almost an annual basis there is a forum to which journalists and other people from the media are invited to come and learn more about the health sector and also to teach people in the health sector about what it is that they need to do to be more accessible to the media so it's certainly a big issue. On the issue of children I think that again in South Africa there is a national plan of action for children children are given special rights in the constitution and we even have a ministry that deals with children but the ministry has allowed to give children, women and disabled persons and the grown ups always win out against the children so the important thing is to keep to have some kind of watchdog structure and fortunately we are several of those in the country. The question about international NGOs the challenge for us is understanding what it is that you guys can do we don't always know what it is you can do and very often let me withdraw that from time to time the efforts of international NGOs are tied to consultants from the north that come and sit with us for a couple of days and then a couple of months later we get the recommendations from the NGO but I think there is an opportunity for NGOs to meet with institutions from the global south and work out a new code of practice a new set of guidelines and maybe the guidelines that came from the Istanbul discussion from CSOs could help to some extent Well, the questions can open up a new seminar I think the question about children gives me the opportunity to comment on a very I think extremely important issue when Julia presented the data on NCDs we have to be clear that statistics is not necessarily priority you may have 75% or 80% or 60% whatever in nontransmissible diseases but you still have the poorest people in the world carrying children mortality and female mortality because they are not taking care of so we have to be extremely have extreme attention to that certainly if we control transmissible diseases and expectancy of life expectancy increases we will have nontransmissible diseases as a major cause but that doesn't mean that we have solved social justice because the poorest people they still are dying at the rate even in the richest countries or some of the richest countries for the private sector I always say governments are not invited to discuss the strategies commercial and industrial strategies of the private sectors I think both are extremely important a nation cannot develop without the private sector neither with the state but we don't have to mix up both commitments because they are different and they have different interests so of course there is a relationship between health and development and non-extremely direct relationship we have very poor countries with the best health indicators in the world we have some of the richest countries not necessarily with the best indicators but there is a close relationship so private sector will benefit certainly from development of the countries and they have to be they have to support health as a means of economic development but for the governments the social development is more important than the economic development so both private and public have to be partners they cannot just dominate one over the other one and finally about NGOs here with Jonathan we as USAID will have to have a very important discussion because this is a major issue here is where we have different policies and if we want to work and we have to work together in trilateral relationship we have to put on the table this type of issue you see PEPFAR for instance in Mozambique about 80% of their contribution is private is to NGOs and this weakens the governments this may strengthen local NGOs but it does not certainly strengthen the national health system so here this is a major issue we have to discuss and when we discuss in trilateral cooperation we have to put it on the table it's no mean or no way in saying we will not discuss it because we are different no we have to put differences on the table and discuss why we have different strategies and how we can come close together at least on some of the issues I just have a quick comment about the private sector one I think one thing that we are realizing in India is that because health care is provided largely by the private sector and there is little faith in the public sector to have really delivered one of the things one of the strategies that we are incorporating in involving the private sector is to look at innovation for the largest trajectory of India's history since liberalization has been the ability to deal with failures in the public sector through innovations in the private sector so whether that's the ability to provide low cost solutions to health care in terms of secondary care innovations in addressing health care in tier two and three cities innovations in hospital management and integration so one of the strategies we are looking at in engaging with the private sector not only within the drug and pharma industry but also within the realms of innovations within the private sector we are looking at examples not only within the country for which there are quite a few but also looking at other nations and this could involve the BRICS nations as well as other regional nations for innovations that the private sector has delivered on the ground that we could eventually adopt and incorporate for a more equitable health system I'm going to ask our panelists to step down but everyone to remain in their seats. Steve Morrison director of the Global Health Policy Center here at CSIS is going to give some and Catherine Bliss are going to give kind of some concluding wrap up remarks kind of summarizing some of the big themes so why don't we step down and turn over to Steve and Catherine. Thank you to our panelists.