If there political solution on the horizon . First thing we have to do and our mission here, the military mission is to defeat isil. I am not here necessarily to facilitate a broader, political solution in iraq. But for a lasting effect, there has to be political reconciliation in iraq. There are a lot of competing interests here, political interests, ethnic interests, religious interests that is the environment we live here in in iraq. As i watch it, i am hopeful that there is a broader political solution that will bring greater stability to in iraq. You could probably argue that it was the lack of that kind of political solution you are talking about that caused the rise of isis after al qaeda and iraq were defeated in 2011. Isil rose in its place. What you are alluding to was lack of a political position here. It is very important and we have achieved some sort of political solution in iraq as well where all of the people in iraq have to look at their government and make sure that it is representative of their interests. Until we get i think that is a requirement to guarantee another threat does not rise in the place of i sold after they are defeated in the place of isil after they are defeated. Host can you give us an idea of what thanksgiving was like for the troops in iraq . Guest sure. I got to see thanksgiving on all ends of the spectrum. We traveled out into the field, very close to mosul, and revisited u. S. Troops on the battlefield the day before thanksgiving. A and revisited some of our will and revisited some of our special operations folks nearby, and some troops from the airborne division. They were out there in the field, but they were getting a full, thanksgiving meal. Our military, regardless of where we are in the world, program has been a and it has been that way since making anwe had anonymous amount of progress. And enormous amount of progress. [indiscernible] we also have to recognize [indiscernible] t to i mean . First [inaudible] 56 are currently you are going to have a growing er of hivinfected a doubling of the hivinfected population every 25 years. The fiscal burden will continue to grow. Fundersxternal [indiscernible] some analysis suggests this is available and inefficient. Also greater domestic funding should give priority. I would like to announce this new partnership to support the finance ministry. You have everyones files. We will start with ambassador burke. We will end with the economic counselor out of the embassy. Counselor of the embassy. Thanks. Slide i slept too many times. What we are going to be talking is very much around accountability, transparency and impact. When we talk about the fiscal , it is that level of transparency and clarity about are those dollars are going. Because it was getting more and more difficult to translate our data, we put all of our data online. Any minister of finance can utilize to see where the program is and the impact it has. That is a partnership between the communities. We felt like we needed to model ministryiors the needed to have. So really around transparency, accountability, and impact. We will be announcing the three Impact Survey that will be in the field this year. We have known for a number of years we have had a tremendous impact. Pediatric new infections are down by 70 over the last decade. We also realize we didnt have the same impact. When we are talking about the minister of finance about a year and a half ago, there in mind what they believed the hiv epidemic lies, was family dying. There was no real visibility to the epidemic. We werent really clear about our numbers. In 2000 you had 8000 new 80,000 new infections. Obviously the programming you need to expand and invest on becomes really critical. There is this real issue between equal versus equity. We work really hard to create equity. The diseases are not equally represented. If you sign them the same essential medicine, in some clinics those will stick. You can see in kenya there is a Geographic Area that has an at expanding has an expanding epidemic. We have been looking at the demographics in subsaharan africa. In the decades since hiv started, there are exactly twice as many 15 to 20yearolds. Cap comes a new issue when you have this data out of south africa. The number of infections in the young age range are particularly high. That dynamic has been ongoing for the last decade. When you start looking at these see in theircan group they dont know their status. 80 of the Adult Population knows their status. Less than half under 25. You have three different epidemics going on. You have the over 30 epidemic where you are approaching an immunity of vaccination. Then you have the 15 through 24yearolds, who have the huge demographic numbers and ongoing transitions. Those are the kinds of discussions we need in the ministry of finance. It is the discussion of gender equity. The discussion is bigger. That is why we are excited about the program. Conclude by saying we believe there is an amazing shortterm opportunity with this new direction we have. We dont always get all the words correct. We bring in the heavy hitters who understand the words and understand that these kinds of stments and really have that dialogue about how you create a Preventive Health system. Or 10 through 25yearolds, no matter where you are in the world they dont interact. It has to be a different kind of interaction. Are aniscussions exciting juncture to recognize the progress that has been made and hone in on the area. We are excited about the new partnership. I would especially like to thank [indiscernible] burke andmbassador all members of our panel for sharing their important insight. I would like to build on ambassador burkes opening. Emarks this was a collaboration launched in may of 2015. To improve the efficiency and hivaids. Ess to fight our remarks will outline the and the partnership, our work to date. Issue. Ss this achieving an aids free debt 83 generation an aids Free Generation the strength the longterm sustainability. You are all aware of the needs for more resources. By some estimates current annual spending will meet the increased by him was 40 . In an environment of resources, partner countries will need to and mobilize more resources. Than ever important to maximize every dollar. The treasury collaboration is motivated by the finance minister having a key role to play. The finance ministry has generally been less involved. Majority because the has been channeled through Health Ministries and other organizations. Given their different expertise they often dont speak the same language or policy. Given the current financing and the key will the finance ministry is playing, it is urgent that these institutions coordinate their counterpart. They will be better print in a better position to promote efficiency. Central to these efforts will be aroundcome challenges how Public Financial Management and sure is that hivaids resources are properly tracked and integrated into the regular institutional process. The requires strengthening financial resources. With an eye toward the budget developing a robust execution system, strengthening Human Capacity and linking bae for Strategic Programming and planning areas. And indeed the broader governmental sector. Governments are taking stacks in this area. Established and oversight work ministry. To help dress these challenges u. S. Treasury department , as well asialogue treasuries and many years of experience. Firmly establishing the sustainable and successful response. Improved engagement a nations. And third effective mobilize a shins. Close collaboration with the film. Since the partnerships launch 18 months ago, regularly incorporating policy dialogue. Most recently at the Imf World Bank in october. Several partner countries that assess and diagnosis. Have also held discussions with our country teams. Global funds and other implementing partners. The partnership is entering its next end most exciting phase. They were unable to partnership and billing foundations. Ugandas ministry of finance and terms ofsury find reference to the partnership it aims to bolster uganda, hivaids and greater coordination and Public Financial Management system. Among the ministry of finance, and the full program. Optimized programming decisions and helped with cap data availability, building an understanding of the support and address other gaps to prevent uganda from maximizing the impact. The treasury resident advisor will be working alongside ugandas ministry of finance. The resident will also help resident advisor will also help develop a methodology to ensure resources are allocated to andimpact communities recommend ways in which incorporate on and off Budget Resources into the government Financial Management. Together we hope this collaboration will support ugandas effort to make the most informed decisions possible about the allocation and use of the countrys hivaids resource. We look forward to collaborating with the finance ministry. And providing Additional Details on the upcoming panel. More broadly we hope this project in uganda is just the beginning of the treasuries. Ollaboration i would like to express my appreciation for the work you are all doing. You know Global Health and hivaids are new frontiers to the u. S. Treasury we are dedicated to complement the work you do in saving lives. We look forward to updating you. Thank you very much. Quirks i would like to thank the u. S. Treasury for inviting me. I would like to thank the u. S. Treasury for inviting me. Doing inistry is i think the ministry put down that isng efficient and productive. Fullytry of finance labor. Ates the health the minister of finance also mmends fiscally impacting the ministry of finance ognizes the importance despite the treasuries efforts it is clear domestic resources other diseases and challenges in the health sector. Finance isr of involved in the implementation in hiv aids when the Government Funds are provided. It has not been acquainted with sharing accountability that are coming into the sector. It used to get up to the levels of coming through the state. There are systems for use Realtime Data on a volution and funding. Working with the usa government, came up with [indiscernible] the group is working on improving data on resources, extending development on financing, and focusing on points of overlaps. And improvehis finance involvement, the government has a Second System to a resident advisor. This advisor will support the oversight with financing and Financial Analysis. The resident advisor will recommend financial policy, ensure our resources to highimpact activities. They also provide capacity we also support we will develop and implement at the four levels of government in a timely manner. We will improve financial response. We will recommend methodologies and incorporate the owner and Budget Resources. We provide advice and supporting development. There may be other areas upon which the ministry of finance advisor expected to be valuable. To ministry of finance is in agreement. He is aligned with the vision. Public financial regimen. Fiscally these are not [indiscernible] thank you minister. We have an invited guest from who willtry of finance join us on video. Why dont we change out our panel while the hear from Mark Fletcher. Are there any questions . Maybe i can ask one question before you go. Youis a lot of the measures are thinking of taking with this partnership are really relevant for the hivaids response. Is it the role of this treasury hivaids . Ook beyond philosophy that needs to be embedded in the overall government and Financial Management, if you look at the terms of reference that have been developed for uganda, basically embedded in a broader look of Financial Management. The most sustainable intervention will be one that is tailored to assessing the inectiveness of employment the hivaids area. But also the sure the system is with maximizing return on public health. I think these interventions will be tailored in greater detail. Often those needs will be the broader context. When you think of one result andwant to see in the year financial sustainability, what would you like to see . That we can look at this partnership and the outcome and impact and whether that investment, whether thats invest investment the Health Facility itself or in the laboratory symptoms that we invest in, has to be linked to outcome and and we can help generate that together, it will ok so much well look out. Do you want to add any . I think the recipient should benefit the most from this plan higher levels. The end user should benefit from this plant. Thats a really excellent issue and it goes to the heart of the issue of efficiency. We dont no how were spending necessarily every dollar, etc. So well look into that. Thank you so much for our first panel. We can get Mark Fletcher on screen and second panel come up. [captions Copyright National cable satellite corp. 2016]] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Isit ncicap. Org] so well start off really respond r panelists to a little bit to what theyve heard on the panel based on their work. D maybe we will start with mike at the end. Maybe we wont start with mike. Lets start with you, laura. Ok. Well start with you, david. All right. Ok. So why dont we start youre to ng at the world bank hear about partnership. Have any thoughts, responses at the world bank . Lets go to mark first. Ok. Because i see you. Mark, can you hear me . Yes. Could you hear me . Yes. Perfect. So do you want to say a few words about this partnership between treasury and pepfar and how the government of south africa is thinking about these issues . Ok, thank you very much. Ood morning. Between the new treasury and pepfar, most of them have been engaged and in our experience at the domestic and planning sustainability is congressional to the financing response. The annual the budget negotiation between the health and other sectors between these two ministries is critical n ensuring budget. Indiscernible] an increasing sustainability has increasingly clear that outside of the context of world Domestic Financing for health care. So that a country that is only raising 10 to 15 of gled of National Revenue and building a spending 6 xation of health care as many countries in africa are. And theyve been working to support better domestic prioritization. While some countries like malawi are [indiscernible] in the domestic resource to help and at special services and indiscernible] that a Large Company has commitment these people from a longer term in the context of national and global commitments u. H. C. Linked to u. H. C. , incentive ased funding, providing better outcomes, several counterpart funding agreement, [indiscernible] and a greater focus in high level associations on the overall of Domestic Health financing. Tell us a little bit about the partnership, how it will work. First of all, i think we need to situate this in a wider sustainability. We really do have a comprehensive view about how we are going to achieve epidemic control and maintain it over time. So this new treasury partner, theyre excited about it. Its a wider effort. What we its not that we didnt have contact interfere, but this is just an opportunity for us to really recognize that and give structure to that engagement in this climate and its part of this drive for sustainability. We off hear in the Development World that you need to to talk the finance department about that and this new arrangement louse us to do that. Allows us to do that. Im reminded of a conversation that i was part of very early on about sometimes we dont talk the same language. But we very quickly good the concern got to the commodity problem. The health side was talking about the finance ministry side was talking about the gas and the oil prices. And just to bring you those together is something that by partnering with we can use their unique relationship what they have and we can leverage the good will of their program get us talking about the and we know from a longterm sustainability standpoint, we need finance. The transition have pointed to weaknesses in Financial Systems as is one of the reasons that it failed but we also need them for he short term as well [indiscernible] with countries that are interested in reforming their systems. What we do is we are invited by the countries to come rather than try and be demand driven rather than supply driven. So when were invited, we put together an Assessment Team and go out and assess the needs of the country and together with the country develop terms of reference that focuses on their needs and how we mutually agree address those needs. The programs that we put together, we try to be very focus l, very targeted on the basics scat the voast it that they be sustainable. Once we are done, the country tools ally pick up the that we transferred to them. Our advisors, we select them from skilled practitioners. We like to hire finance directors. Budget director, people that have actually worked in these jobs, been responsible to their executive leadership as well as be sfobble the legislative leadership and craft Practical Solutions with their counterparts. Once someone is identified, went to make sure that theyre a good fit with the country. So we have handed a missions so both the advisor and the counterparts have a clear understanding of whats expected on both parts. Within 6090 days of arrival in the country, the general terms of the terms of reference are expanded into annual work plans where the counterpart can ask the advisor are mutually responsible for the work getting done. It is not the advisors work program. It is the program to implement a reform in the country. And then the execution of the project is the advisors sitting their side with counterparts on a daytoday basis working through the problems and transferring knowledge with handson working together, some formal training. But a lot of it is peertopeer mentoring that its not separate from their work. They are incorporateing what we are trying to achieve within their work product. E realize its sustainable reform isnt quick. Its what we expect in a year. Often systematic reform is a three to fouryear process and thats treasurys engagement. We are patient. So the counterparts that we have daytoday jobs. And they may not be working in the most efficient manner, but for us to come in and impose changes to their activities takes them away from their work and we ultimately have to shift that work into more efficient models. So treasury does have the patience to do that. Ok, nan da, youre involved with the Sustainable Finance initiative and even if were very successful, the fiscal burden will increase on the most effective countries in the near term. You have any sense of tell us about sustainsable financing and what is the time frame for this . External funding will be in an ideal world, the same, it wont increase. Whats the outlook on this . Solets give you a couple and so all know is what we what we observed was that there is a parts of the economic transition taking place but over time what we have done is donor money has come in and crowded out spending on health which is a rational response from the ministry of finance. But as the countries evolve and grow, don heres pull back very quickly. And they differential is made out by outofpocket increases. It takes some time for Public Financing to make up this gap. And our sense was that in order to leverage the Economic Growth of countries, one had to have a Strategic Engagement that focused on four specific importance. One was mark and others have said that really good data that can be used to go and have a dialogue with he ministry of finance and health. The second was improving Financial Management systems and planning period. The third was we cant ask for money without focusing on efficiency. And the fourth one was how can we leverage the private sector to play a more Important Role . And we did all these analysis and i had the pleasure of representing for ambassador burks all the modeling and all this stuff . I asked him if he could give us the opportunity and she looked me and said thats fantastic. Tell me what you can do in three years. Me and [indiscernible] the result that are sustainable over too long. Vietnam comes to mind where what we found was that h. I. V. Is highly insurable in the vam these context vietnam these context. And the and it is going to lead to major efficiencys and the net value of over 200 now the link of the finance because not what this Economic Cost of investing in h. I. V. , it was what is the Economic Cost of not investing in h. I. V. . This is a very different question to answer and we ran some models and we were able to demonstrate Significant Impact to g. D. P. Growth rate, through labor markets and direct investments and this is the kind of information and data that ministries of finance like to see. So what we are observing is that this concept of shared responsibility is something that countries are in favor of, countries want to do, countries want to take on and what they want is more strategic and more focused assistance or support to help them. And this is where really getting the treasuries involvement is fantastic from a u. S. A. Perspective. Because the credibility that the treasury has and what the ministry of finance is something that is important. And we worked closely with treasury on this and its not about h. I. V. Its about improving systems as a whole and then talking about increased investments going to help but with a clear line of sight to h. I. V. Great. That helps a lot. David, do you want to Say Something about the role of the world bank in all of this effort . Sure. I think i would just say is my mic in . Yes. This is extremely timely and i think because the ultimately challenged if we can get a lot right and the first thing we need to stress is what an extraordinarily successful Emergency Response h. I. V. Has been and how we can be proud of it but we do need to move from an emergency to a longterm developmental approach and i think that is going to be why this initiative is so important. To me, the single greatest challenge is if we compare the share of International Assistance for health in general with h. I. V. Specifically. And in lower to middle Income Countries is about 20 including t. B. It can be as high as 90 for h. I. V. And ultimately, those figures need to converge and we need to help promote that convergence. I think the next important point to stress is one thats been touched on and that is how we can balance things across the International System base and if we can do that right, we can be prepared for some buffers and shocks. And the reality is that upper middle Income Countries needs to be progressing for paying nearly all of their responses and thats happening. Lower middle Income Countries need to stiff change up, not 100 , but probably closer to 50 to 75 and within a relatively compressed time frame and there are a category of countries that are poor for which we have no exit and we need to be frank about that. So what do we need get right . Well first, Economic Growth is going to be important and there will be no surprise to people in the world that our Economic Growth forecast for africa are not as good as they were. The second storm has stormed. And the rest of the africa has downgraded to 4 which looks good until we consider population growth which is approximately 4 . So, clearly, we need to focus on the growth thats not simply commodity driven. The second point we really need to do is focus on improved revenue efficiency and the opportunity we have in africa is kafka is a region collect less and spends more. So this is why the Treasury Initiative can really help. But beyond that, weve also got to ensure that a greater share of resources are al call ited to health. And it might be rational the short term to pull out of health but its very hard to reallocate an entire budget if goes down. Al funding and i think to do that, advocacy has to change because our sense of the world bank is finance ministries are against single issue arguments. Its really hard to find a good argument for focusing on one disease or teaching algebra as opposed to trigonometry. Its not the question that butstry finance is going to beyond that, our since that Ministry Finance tends to think of the social sectors. O audio. We have about half an hour. Maybe i will go through one round with you and well bo the audience to prepare your questions. So, you know, given that we are at the cusp of a new administration and the uncertainty is that involves, i wonder if you could reflect on scenarios for pepfar going further what, you would hope the globe fund would be doing differently Going Forward as a result of any uncertainty that we have, any thoughts about that . Maybe ill start, mike, with you. So i mean, i think from our standpoint, were really in the midst of what david is talking about, this moving from that emergency to sustained response and i think that theres just broad agreement that these are the things that we should be doing. So the work that were doing here with the Treasury Department is part of anybodys package of what we need to do to make that pivot. Indeed, this is just part and parcel of a larger sustainability plan that we have. We talk about financial and programic sustainability for emphasis but theyre part of the same thing that were doing. ve created a sustainsable framework. We chart progress against that with our sustainability index and the dashboard that thats created. Weve taken a further step to look at how we can take whats now is really a plateaued International Dollars of further. Were very much looking at efficiency of spending, Going Forward and hoping that Ministry Finances can be a good partner n that effort. E efficiency drive is really the key to making that going. And locating that within the context of the finance ministry is key. And thats just a pieces of it. Getting us to look at the totality whether its education or in the labor market, we have to pull all of those pieces together. And working with the Health Ministry themself to show that they are a useful place to invest in over time. And so, again, this is much this is part of a much broader set of packages. The pepfar program even though ere h. I. V. Specific, we understand that we need to get to for the long term sustainability and response. And, you know, here at the center for global development, we understand that we talk more ab financial incentives for greater domestic cofinancing. Have you considered that . Whats your role of the global fund in that effort . When we look at the composition of pepfar financing, you know, if we want to leverage a domestic spend on this or greater domestic spend, especially in those lower middle incomes that have some capacity, nots to finance everything but they do have some capacity, what strategies would you see Going Forward . Either from pepfar or from lobal fund or from others . N da, nanda, lets just brainstorm. The fact remains that donor financing is not going to be sufficient. To meet the needs of financing of health and h. I. V. And so that is no option but to work with countries on a shared responsibility agenda. And the bulk of the financing has to come from domestic resources. The other question is how do you make that happen . So its what modality one uses has to be what we have to do is manage for results, and the results have to focus in two areas. One is more money and better use money and measurable impact of what the money invested brings. So i think what we would have to focus on Going Forward whether its pepfar, global fund, u. S. G. Or anyone ills on this three dimensions. And having the data and the evidence really to demonstrate this increasingly. Unless we can demonstrate the value proposition, arguing for more money by itself is not going to get us very far. And i agree that there are significant deficiency gains that can be achieved. And ill give you one example work with the finance ministry and they put in money for the response. The first question they said was can you ensure that the money is properly work with the spent . Then the its to ensure that this money was properly spent and the next year, they put 24 million. So if you can demonstrate success, you are going to see that finance ministry will get more responses. But its going to be the countries that will have to put in 50 , 757 of the responses. Mark, let me ask you, if you can still hear us, what us the size of the fiscal challenge that south africa is facing . And do the new reform strategies that youre thinking of deal with this adequately . What do you see is the outlook in south africa . A well, theyre facing quite ifficult period at the moment. We do have a very low growth scenario. But i think we do have a strong sense of responsibility that this is our problem as a country and that we need to deal with this problem. I think we have a strong sense of ownership. Out sustainable parkway. I think pepfar did use the sniffs. Incentives. They were happy with the way that the partners are performing and thaw felt they want to support intervention for young women and young girls. So that was an incentive. But i think it does recognize other countries that are much poorer than ourselves, for example the g. D. P. Of malawi compared to ourselves. Its clear that changes do need to happen over a lengthy time period. We are on a period of massive expansion. E need expand from about about six Million People on treatment. But we will do what we need to do. Best in k well do our a difficult climate with the valued help of our partners. So doubling the number of ople on there, maybe were being too polite but this is an extraordinary fiscal ask from partner governments and so well look forward to following that. Its a very major challenge to think about what has to be youll have some growth in your health budget, maybe not and youll have to real accumulate om other reallocate other uses. Billion t to raise 25 additional revenue. We have to make 25 billion of tax to achieve repriorization. A lot of that repriorization is in the Higher Education sector. We have a very active fees in outh africa at the moment. We want young people who want to be able to enter into tertiary education. So a combination of different strategies, but we need to try and get all of these to fit together. And i think we do have a fair amount of reassurance to our partners that they will transport us to the best extent they can. Even if they are not able to, well continue to do what we think needs to be done. Excellent. So laura, do you want to comment a little bit about what youre seeing as you partner with ministries of finance and treasury and your partner countries . Theres a lot of talk about efficiency but how does that manifest itself . Theres talk about putting more resources to health and other areas. Part of the problem is they cant execute the budgets they have. Against the global fund recently in uganda, reported that uganda could only execute 46 of the available grant. I think that thats underappreciated that the systems within these countries unable to gile and ope with large flows of funds. So the basic underpinnings need to be supported. And so one level of efficiency is the ability to execute their budgets, thus putting more rain showerses into the effort. If budgets are more timely in heir execution, inventories of rugs dont expire. If the vendors can start moving the money through, paying their vendors with an inappropriate appropriate level of time, then they can get the competition. The vendors that want to participate go for a high premium on their cost. They are just sitting there because they cant get through the system. But, you know, those are some of the underlying issues that i ont think that is fully appreciated. And honestly, some of the risks are getting the right people that can take on the reforms and sustain them without a turnover of staff and also the adequacy of information Management Systems. There are lots of information Management Systems there. Are huge Information Management the s and do they have underpinning systems to generate the data . So theres a lot going on that the term of efficiency kind of masks what the details are beneath it. Yeah, just get the basics right in terms of spending and executing budget, absolutely. So david, last question to you. What do you see as the world banks role in partnering with pepfar and treasury in this effort . I think this is obviously really closely related to everything the bank does, whether were talking about trying to help the economy go better and be more efficient about revenue collection, spend that health share more wisely. The overlaps are immefpblets ill just touch on one dimension. I drew attention that a points out. Mine and that is the game theory lens is pretty helpful to look at this. The u. S. Is at a unique fogs be responsible. The other donors really have the early mover not to increase the involvement and to focus it on the scale and were seeing it. Theyve not been able to match the extent that the u. S. Has been put on. And many precip yet countries have a really clear interest in not paying more as long as it can be internationally financed. Understanding this lens better is important in relation to your question, the one thing the bank does pretty well is often predictability to countries out their either lens, eligibility. And if we could communicate greater predictability about what countries need to do and over what period and if we can hold to it, we would be dover what we can achieve together. Hallelujah. Ok. Lets go to the audience. Please say who you are and then ask your question. Well take three questions and then well come back. Hello. Im lauren [indiscernible] ve got a few things to say. On looking at what how do you precisely at looking at how transition can be done smoothly. Were starting with lower countries in latin america have lower incidents although sometimes the prevalence is quite high. And one of the things that weve zone is weve looked at the range of ways that the transition has been thought about. Were a little concerned about the idea that you can sort of you can go do the ministries of finance and say we need a line item. And that doesnt go well in many countries. But i think what we have done is harness some of the things that mark was talking about and nanda was talking about financing in general, talking about delivery. And this question of efficiency keeps coming up as something we need to do but its a very difficult pieces of all of this. But i think one of the thing that weve seen in terms of maintaining h. I. V. Is integrating it into the chronic care management. And Something Like diabetes is fine for heading on to something that is very similar which i h. I. V. Which is h. I. V. Treatment and following of the patients. Thats no for in the thank you patience but for those on. V. V. s. And this was mentioned by louise on the ministries of health side. That is off the real sticking point. You can talk the ministries of finance. They understand but they cant talk to the ministry of health and its about this issue of efficiency and not really speaking the same language or worrying about the same kinds of things. And that is something that i can be added it. The world bag may be helpful in this. I think trying to bridge that gap, we had a seminar about 10 years ago for eight countries in africa. Ministry of finance, ministry of health and education, oftentimes, theyve never met. So this is an issue. Finally, i just want to mention something thats ongoing which is the Public Expenditure in Financial Analysis initiative that the world bank is carrying out for many donors which is trying to look at some of the exact same things that louis talked about in terms of expenditure, how you deal with that and theyve just started to do this for health. So this may be something that could be harnessed and used as part of the earths here because i think its very complimentary. Could save some time and may be able to bridge some gaps. Thank you for the panel. Great. Thank you. Here in the blue shirt. Go ahead. Sorry, i make you walk around a lot. Thank you. And thank you to all the panelists. My name is jessa holmes. Were conducting an evaluation of the pepfar geographic pivot in uganda right now. Theres been a lot of talk about three years, five years, longterm structural issues, but this is something thats already occurring and has been occurring for years in 2015, funding for h. I. V. Decreased internationally. And my question is will there be a gap between the most optimistic case of Domestic Financing and the reality of pullback from donor countries and what will happen in that time frame . Very good question. Ok. Next. And then ill go to you. Thank you. Sophie from question everyone been asking is what could this mean that the trumppence agenda, imagining probably not a reduction in the pepfar envelope but a realigning of what gets spent on. Would be great to hear some thoughts on that. Ok. So i thought me . Well, lets take these three and then we will go to my colleague. So one question i want to pick out a couple of things that marie had said. One is line item or no line item and what does that mean for a rational Health Financing strategy. Econd, she mentioned the analysis. It is a standard use methodology that the world bank uses. Is that something that would be used in the new initiative . Our colleague from hopkins asks a very, very important question. What happens if our optimistic assumptions about resource allocation dont come through in the context of flat aid. And then sophie, what next. Maybe ill answer that. I dont know. Lets nanda, do you want to Say Something about line items . Ill take the second question. Ok. As i mentioned that analysis showed that we looked at countries from 1995 through 2013. We look at countries that started low income, remained low income, that start as as low income and transitioned to low to middle income and it is really interesting. Data is powerful. In 1995 there, are only three countries in south africa where donor spending on health exceeded Government Spending on health. Y 2013, we had at least 11, if t 13 countries where donor spending on health exceeded public spending on health. In 1995, donor spending constituted 13 of total Health Spending for these spending on health countries. N 2013, the constituted 39 . Ok . Now the other important data point is that when countries transition, donor spending on health accounted for only nine. When they transitioned to lower middle income, for those countries, they accounted for only 9. 5 of total Health Spending. And the pullback was quite dramatic. So there was no glide past to transition. Now youre rich. So what is very important and critical is to consistently map i think the point is very important is to able to understand whether theres a glide part or transition part. And be willing to make close corrections as we make around. It cant be one trajectory and thats where we go. So getting the data to make those connections is going to be extremely important. And we have history behind it. Laura, maybe the question pepfa . As far as the analysis, whatever we do an assessment, we do a lot of research because we werent interested in reinventing the wheel. Its just part of the many tools that we use when were trying to go into a country. On the issue of a line item, i think that the Donor Community could probably be a whole lot more efficient that they are. Everyone comes up with their own the ories where, you know, International System for class of line functions of government and you can drill that down to sub functions and go into programs and sub programs. The line items for economic, the i. M. F. Puts them out in the general financial statistics. Every country is running their budgets according to those to international classifications. They have to. For i. M. F. And other reporting, they must do this. Think that this community should build off of that structure thats already in place. Because again, the information Management Systems are primitive. The capacity people from primitive. If they are constantly doing very specialized reporting for each donor, thats very inefficient and very labor intensive and ministries of finance have had very unskilled employees. So i think there are some efficiencies among ourselves to be gained from some classification structures that already exist. David, do you want to Say Something about this topic . Not this one. The trump question . I can touch on the question. Having worked quite a bit with pepfar in the culture war and the dispute about the relative with a might give us a little bit of confidence is the competition of h. I. V. Funding has changed so much and the big agreement that is something we need to agree to. That treatment really matters. And it is likely to be preserved so that just based on my own interactions over the last 15 years what is i would stress. Makes sense. Other thoughts from the panel . Mike . Well, i just add about the on the treatment point and getting back to the sort of resource issue is that the realities are fine and has been flat for several years, five or six years. As to as the global fund. And weve managed every year to hit increasingly higher treatment targets every year. So we are by definition becoming more efficient and we believe that theres further to go within that, within that space. That only will take you so far and this is where we need to create that Business Case with the finance ministries. We need to talk about the Different Things. We need to start to make those shifts. So we can buy ourselves some time through efficiency, but this is why the importance of starting that dialogue off now and building it over time is so important. Yeah. Lets go to your question now, mead. This has been a really interesting discussion. There are two theres an important word that often comes up in discussions between donors and ministries of finance which i havent heard mentioned. And thats the word effort. The question is whether the poor countries in africa are exerting the tax effort that they should be and many countries, im wondering whether mark would want to weigh in on half of south africa. But many countries are judged by International Experts to not be exerting about that effort and im going to use effort in the h. I. V. Sense. Many countries in the world, partly because of the generous donor financing have not exerted the effort they have on h. I. V. Prevention. And i think what id like to hear from the panel if you can offer some suggestions is what incentives are built into these new cooperative agreements that might enhance tax effort on one hand and h. I. V. Prevention effort on the other . Thanks. Thanks, everyone for your comments. Weve talked a lot, ive heard a lot about results and if were putting more money into this and that needs to be directly linked to results or impact. And im wondering to that end if theres what is that donor financing can incentivize domestic resource levels. Weve touched on this a bit but im wondering if there are specific ways, results based schemes come to mind, token for c. G. D. But would this work for health . Has it been shown a big snuff scale or is it not feasible at this stage . Are there steps to be taken by donors in the next couple of years understanding that what laura said. Theres a lot of donors can learn from. I would love to hear your thoughts on that. Excellent. O ahead. Hi. Anna heard. So sort of in line with jennys comments about results and i think debbie burks comment about needing to see outcomes. There seems to be from the sense of the world a little bit of a hesitancy to spend a lot of money on Impact Evaluations on research to offensive what is working and what is not working. And if we dont know whats working, are we just throwing a lot of money at programs that we hope are having the effectiveness that we want them to have that may or may not be the most costeffective interventions to achieve the goals that were trying to do . We spent a huge amount of money of this treatment as prevention, Clinical Trial with the result basically showing that people are not interested in starting the therapy earlier than they have been current write in the numbers that we really wanted them to take it up. And so due to a lot of Different Things like stigma. So the question is we addressing these ground level issues in a way that is going to allow more greater efficiency and how are we going to know whether we are become more efficient . Well, thats a great suite of questions. Maybe well start with you, david, and just go across the panel to respond. So what are we doing to incentivize fiscal effort and programic effort for intervention if will we see more result based funding . And third, why so little Impact Evaluation seeing that we have a lot of sticky issues in this area . Sure. I will be glad to know that im a big proponent of cash on delivery. I dont think that h. I. V. Prevention is necessarily the best case to use. The bank has done a lot of work on performance based and result based financing. The conclusion suggests that we get a consistent and significant but ultimately incremental, not transformative improvement. It isnt negligible but neither is it transformative. I clearly think we should be doing more on results based financing in general. I like your point about the sent to which we should invest in different evaluations. And my own view is really clear. We dont have the tools we need to end h. I. V. We are going to need vaccine or a cure and that research should continue. N. I. H. Has the Worlds Largest funder. And maintaining thats going to be critical. But i also like the nuance underlying your point is we need to do much more evaluation on Service Delivery models and implementation and efficiency and delivery, which we can do more quickly. We can do it more context and we can get some important answers. So as i think one of the lessons is maybe to do more speedtype delivery studies and i want to underscore that we need to buy a vaccine if we ever were to end h. I. V. Thanks. Excellent. Nanda. I dont want to repeat what he said. And i completely agree with what he said and the need is to focus on effort in the absence of effort, thats why we use the word shared responsibility but shared responsibility has to come with effort on both sides. I think and that point is extremely well taken. And more so probably in the h. I. V. Aids than elsewhere. My sense is that just as we are talking about moving the h. I. V. Resources to geographys most in need, you also have to understand that the h. I. V. Phenomenon is not uniformly distributed across all and its interesting to understand that what we might have done is killed the private markets that can put finance and provide the services for people who are willing to pay. Right if so, one of the questions i think we have to take on clearly is there segments of the population which i believe there are that were willing to selffinance and selfpay spurns or outofpocket payment as look long as they get good quality care provided to them in the private or the public sector. I think Going Forward, we also have to start segmenting populations to increase the greatest effect of public and buyut also be from that sector that gives you the best value for your purchase. So i think that goes back to your question, also, that we have to focus on getting results and therefore by that, i mean be agnostic and look at populations differently. So we go to mark and then ill turn to you. Mark . I think we still have a massive problem with the 6 countries. Thats the countries that are only getting 6 of their domestic budget on health care services. Sometimes to do this analyst circumstances one has to be quite careful in the way you take out the donor. Because if you look at the total Health Spending without taking the donor side of it, you may overestimate the funding. So i think that countries that are persistently not responding to efforts to improve the Overall Health sector financing should face some consequences. There needs to be progress ratchingt up in negotiations, the approach, the friendly approach, the pervasive poach approach but countries that are persistently funding 6 . They should face some consequences from the donor fund being community. Laura and mike . I think one thing is getting countries to budget more. Because ive seen this in other programs. And then they dont execute it. So i think that if youre going to have them, you know, make that an incentive, it cant just be we want to see x percent in your budget. We want to see x percent e constituted out of your executed out of your budget. But the other thing is this domestic rain showers resource mobilization, collecting more revenues, its very difficult. Most countries, the large taxpayers are the Big Industries and youre going to get about 80 of your revenue from those industries. It goes down to middle size industries, let alone small vendors. The level of effort to get that last bit out of the system is very difficult. Nd i dont think that thats well appreciated and especially in these countries that you dont have systems where were all having payroll with withholding from our income by our employers. So the next couple of levels down become harder and harder and harder through effort and greater staffing and to get that compliance. Final word . Final word. So ill just sort of pick up on what laura said. I think that the evidence based on a lot of these innovative financing techniques and whatnot is quite thin. And im much more interested in i think it would be innovative if a country built its own health program, put it in the budget, fund it and execute it but thats really what is going to get a lot more bang for the buck, particularly over the media medium term. And we need to put our time and effort into things that take out from the Decision Making process whether were going to put an x amount into health or whatever that case may be and to be thinking more about Health Financing schemes that will take the bulk of what we have to do and then focus the rest on the disease surveillance, the prevention efforts that really cant be part of an insurance regime. Ok. And sophie, its very hard to answer your question. Obviously, were waiting to know who will be appointed into the new administration at the department of state and elsewhere. And so but on the positive side, i think Global Health is likely to fare, hopefully, fairly well given the bipartisan interest in this area. What ive heard from the panel is that this is what would need to happen no matter what barring an extreme scenario. With the focus on increased programic feasibility, a focus on prevention. Theres some disagreement on how we should get that done. We all agree that its inadequate. But how that will happen, there are lots of different options on the table. You know, i think the other thing to look at is how the u. S. Channels its money now through contractors and guaranties, how that money is spent. What share goes to Service Delivery and what share goes to incentives to invest in prevention and treatment. I think whats clear is that we have to show results no matter what on lives saved and reduction in h. I. V. Incidents. And obviously, what could be reasonably be expected in a short amount of time. With that, i think all of our panelists. I especially want to think who has been instrumental in getting this all together. And thank you to our panelists and their bosses and thank you to do, the audience. [applause]
comparemela.com © 2020. All Rights Reserved.