Responset the [indiscernible] the partnership between these ministries has been fairly typical. Havee Civil Society groups played an Important Role in getting governments to do the right thing. This is very important in the context of a longterm financial agreement. Our own programs are about information and financing an increase [indiscernible] a country that is only raising a percentage of gdp of national revenue. If countries are only spending , what needs tore be done to support better domestic tired visitation of budgeting . They need external resources. Many countries are not putting in the necessary domestic resources to help. Right combination of pressure and controlling dust could drilling. Ng. Cajolihn negotiations that , itmpany large agreements needs to be bolstered. There are initiatives among various countries. Support for National Health financing strategies. Providing additional funds who are making domestic efforts. A better focus on highlevel negotiations. Me stop there for the moment. Thank you. Tell us a little bit about the partnership. What it takes to accomplish and how it will work. All, we need to situate this in a wider context. We have a comprehensive view of how we are going to achieve epidemic control and maintain it over time. This new treasury partnership, we are very excited and it is part of that provider effort. It is not that we did not have contact with the ministry before but this is an opportunity for that. Give structure to drive for this stability. And sustainability. Thiseveloped world, new arrangement allows us to do that. I am reminded of a conversation from early on. Sometimes, we do not talk the same language but we very quickly got to commodity problems. The health side was talking about the commodity in the wasnce ministry side talking about the copper and gas and oil prices. Together by partnering with treasury we can use their unique here relationship that they have an leverage the goodwill that they to get use program talking on the same page. We know from a longterm sustainability standpoint, we need finance. We have seen weaknesses in the Financial System as one of the reasons why this has failed. We also need them for shortterm. Lara, would you like to comment on oca . The office of Technical Assistance has been around for 25 years. Working withd on countries that are interested in reforming their systems. We are invited by the countries to calm rather than be demand driven. Invited, we put together an Assessment Team and we go out and assess the needs of the country. And together with the country design terms of reference that focus on their needs and how we mutually agree to address them. The programs we have put together, we try to be very ,ractical, very targeted focusing on the basics. At the root of it, that they be sustainable. That once we are done, the country can pick up the tools that we have transferred to them. Our advisors, we select them from practitioners. Financeto hire directors, budget directors. People that have actually work in these jobs, been responsible to their executive leadership as well as responsible to the legislative leadership. And can craft Practical Solutions with the counterparts. Once they have been identified, we want to make sure they are a good fit the country. With the country. We want the advisor in the counterpart to have a fair understanding of what is expected on both parts. Within 60 f in 90 days of arrival in the country, the general terms of the terms of reference are expanded into annual work plan where the counterpart and the advisor are mutually responsible for the work getting done. It is not the advisors work program. It is a program to implement a reform in the country. And then the execution of the sittingis the advisor sidebyside with their counterparts on a daytoday basis, working through the problem. 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. We 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 . More resources required in the immediate future. External funding will be in an ideal world, the same, it wont increase. Whats the outlook on this . What are we asking our partner countries to do . Lets give you a couple so what we all know is and so 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 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 at me and said thats fantastic. Tell me what you can do in three years. [indiscernible] [laughter] she is known for her patience. 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 vietnam 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 eventually 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 International Funding goes down. 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 Ministry Finance is going to but beyond that, our since that Ministry Finance tends to think of the social sectors. Which includes Health Education and welfare. We have put it in a broader context. I do think we have to face the issues that have been touched on is that is that outside help not considered an efficient ministry. The efficiency argument becomes essential. I would close by saying that i think this initiative is an important opportunity to move from an Emergency Response to a sustained response. Thank you. 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. Weve 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 in that effort. The 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 were 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 talk more about direct 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 global fund or from others . Nanda, lets just brainstorm. [laughter] 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 of 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 inch kenya, you 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 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 i 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 . Well, theyre facing quite a difficult 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. I think it lays out sustainable parkway. I think pepfar did use the 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. We need expand from about about six Million People on treatment. But we will do what we need to do. So i think well do our best in a difficult climate with the valued help of our partners. So doubling the number of people on there, maybe were all in 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 from other reallocate other uses. We want to raise 25 billion 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 south africa at the moment. And 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. So i think that thats underappreciated that the systems within these countries are very fragile and unable to cope 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 their execution, inventories of drugs 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 dont 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 demands and do they have the 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 colleague of mine points out. 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 about 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] ive 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 i. 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. Second, 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. By 2013, we had at least 11, if not 13 countries where donor spending on health exceeded public spending on health. In 1995, donor spending constituted 13 of total Health Spending for these countries. In 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 about 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 categories where, you know, the 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. I 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 item is a broad 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. Go 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 Financing but also be agnostic and buy 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 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. And 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 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. [indiscernible] 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, work always on the perspective of countries that are partnering with the u. S. Government and other development partners. What makes sense in that context. What are the other demands on their budget . What can we reasonably expect in a certain amount of time . And with that, i think all of our panelists. And thanks to our panelists and thanks a lot to you, the audience. [applause] sunday, on both tvs in depth. We are hosting a discussion on the december 19, 19 41 attack on pearl harbor. On the program, steve twomey, author of countdown to. And craig nelson with his book pearl harbor from infinity to greatness. Followed by an interview with a survivor of pearl harbor. Phone calls, your tweets, and email questions live from noon until 3 00 p. M. Eastern. Good is cspan. Org for the complete weekend schedule. Follow the transition of government on cspan as donald trump becomes the 45th president of the United States and republicans remain control maintain control of the house and senate. We will take you to key events as they happen. Watch it live on seized him, watch ondemand on cspan. Org or listen for free on our cspan radio app. Bags of their leader, on washington journal, we got an update on the fight on isis. Combined joint task force. Before we get to the latest, could you first explain who makes up the combined joint task forces and how many u. S. Service members are part of that mission over there right. Sure. Overcoalition is made up 60 nations. About 19 or 20 troops and contributing nations on the ground or in the air. Facing off against isil. All told, the u. S. Troops on the 8000 and between iraq and the surrounding regions, Coalition Troops number another 3000 or 3000. Host general, we appreciate you working with us with this delay. What are the main way Service Members are participating in the fight . How close are they getting to the front line especially in the fight we see so much about in the News Headlines . With advisershem who accompany their headquarters and commanders on operations at and we provide them enabling capabilities. Some examples include reconnaissance, checking for artillery and things like that. We talk about the battle to retake mosul. Gets tougher to use those things in the battle to retain muzzle. That effort isow going in mosul could you talk about the main u. S. Role. Guest full question is about muzzle. I think the operation in muzzle is going pretty well. In mosul is going pretty well. Two years ago, it was not. They have recovered their footing, reframed their armies, liberated about half of the isocontrol territory in iraq. And they are now liberating muzzle, the largest city held by muzzle, iraq, or anywhere. That city is three or four kilometers from their capital here in baghdad. A pretty remarkable turnaround. Coalition forces are up there doing some of the tasks. Most of the training. We are down to advising capabilities near u. S. Troops in and around muscle with their counterparts. Ousl with the counterparts. Artillery fire, closer to there with iraqi headquarters and commanders. Host in this segment in the washington journal, a special line for iraq veterans if you want to call in and talk to general stephen townsend, commanding general. That is the number four wreck veterans. Iraqat is the number for veterans. Independents as viewers are calling in, general, i want to talk a little bit about those in the front lines going into the city of muzzle. City of mosul. Assets overtest there . Who is proving to be the best in the city . Well, the iraqi city forces or a broad type of force and capability. Army,you have the iraqi with more than nine brigades involved in the operation right now. Various states of training and readiness as you might imagine with any army. Some of the best are up there osul right now. There are iraqi police. The elements are in various states of readiness. Probably parts of them are better than some armies and federal police. Policere local police, forces in the United States like them. Mostly law and order. They are being rest to do some combat duty because of the situation but they are not really trained and equipped for that as much. There are neighborhoods in securing their own volunteers from the neighborhood. There are militia forces that have responded to calls. And, they have a wide range of capabilities. Probably the best Overall Force is the town to terrorism service. Until recently they were part of the armed forces and they are now a separate force. They have had a training relationship with u. S. Special 2011tions forces since they are probably the most all the forces. All of these forces are engaged and taking the fight to the enemy there. That fight happens, i have heard upwards of one million civilians. What are you trying to do to work with our allies to reduce civilian casualties. Guest well, the greatest level of concern comes from the government. They do not want to inflict unnecessary casualties on their own people and damage to their own infrastructure. Behind the government of wreck is the coalition. We are here at the invitation of the government of iraq and we dont want to inflict unnecessary damage. We are probably running, i think we are running the most precise campaign. We go to extraordinary lengths to try to avoid civilian casualties. Are we inc. We have or here may have inflicted reporting through more media or watchdog groups, we investigate each and every report. Some are credible, some are not credible. We investigate and find out how we can fix that and avoided in the future. There is a lot of concern at all levels for civilian casualties and we work very hard to avoid those. Host the lines are open for viewers. We will start with kendrick. En independent. Littleear with us with a bit of a delay as we talk to the general. Go ahead with your question. Drags yes. Insanity ison of doing the same thing over and over and expecting a different result. We trained these soldiers. We have been there over 10 years. Weve trained them and they threw down their weapons and ran. Game . S the end own should fight their battles. We have been fighting them for over 10 years and nothing has changed. They are fighting. They neveron tv, fight. Ende are talking about the game and the concern about doing the same thing over and over again in iraq. Caller yes. Guest thank you kendrick, i would suggest we are overoing the same thing and over again. We were there in 20032011 then we left. We left because the government did the not desire is there any more. They invited us back in 2011 and that is the first thing we are doing differently. Invitation of the the government of iraq. You say if we were not pushing they would not be fighting. That is not the case. Wars here for the previous and during those days, we led the fight and we brought the Security Forces with us. That is not the case here at all. We are not leading the fight. Fighters not coalition leading the way. Who is doing a . Iraqiaqi army, the police. They are not leading in any way in the fight. Given their commanders advice. Enabling capabilities. The iraqis have their own artillery. Their own air force. They are using it. We are just helping. They have their own capability, were just helping. A completely different situation today the it was from Operation Iraqi freedom. Rack warthe line for a veterans, joining us from sun city, florida. Good morning. Caller general, i was in for lucia. Fallujah. We took five cities. George h the doctor when he further. He did not want to destabilize the area so he pulled out. So the people in iraq wanted drillingwith the oil rights. Which was kind of cool, you know 5000 people that is roughly 40,000, you know. In andbush went destabilized everything. Doody hit the fan. After i got out of the service, i got a job on the base as a Civil Servant and i used to work for the admiral. One confided in me. He said the president dismisses all of the generals and admirals and appoints his generals and admirals. Like a response. What is the question, before returning over to the general . Caller we turned over the drilling rights to russia. President that the generals . All of his host got your point. We will turn it over to general townsend. Ok. T thank you. Interesting question. I am not sure what it has to do with the operation but i will give it a shot. First of all, thank you for serving. You mention you were in uniform and a Civil Servant for a while so thank you for your service to our nation. I am not sure about the drilling rights. Im not sure that russians have exclusive drilling rights here. Actually, iraq does. Thedrilling on international market, that is how it works. It is not true that each president fires and rehires all of the generals and admirals. That is not how our system works. Theact we all serve at pleasure of the commanderinchief. The commanderinchief could fire generals and admirals but not. Ally they do if you look over history who is in positions from one administration to the next you will probably see a remarkable line of continuity there. Joe. You for the question, post general, a question for you about the strategy right now. A lot of focus on muzzle. Mosul. Can you tell us what is happening in syria right now . Sul what will happen after mou falls . The strategy for the u. S. Campaign against basil . Isil . Also known as the Islamic State is a threat not only to the region but to the entire world. All you have to do is look at recent events in europe and the United States to know that. Some of the examples are belgium, france, florida, new york, etc. Thes very important that whole world bears down on this problem. Why are we so focused on iraq and syria . If isolate and its franchises are worldwide phenomenon . Thecore of that and manifestation of the socalled caliphate are right here. This is where it started, this is where its leader, baghdadi, declared the official caliphate in the capital of rocca,s syria. Of holdings in the city mosul here in iraq. Is critical. Osul you mentioned, what are we doing in syria. We are with our partners in a march to the city of raqqa. guest what we are going to do is take that city and give it back to the people. Tot this will do is a lot discredit, destroy the narrative of basil. Isil. Mythology has depended upon having this quasistate. When they lose that, it does a lot to sway their narrative. As a terrorist organization. Sul . Happens after mo isont think that isil completely destroyed with the liberation. Isil will persist. Keepartners will have to working to reduce that threat. What we are ultimately working for is reducing the threat of localere and helping the forces handle it on themselves without a lot of help from me coalition. Host you talk about after we kicked them out we will give it back to the rightful owners. Who do you think the rightful owners are right now amid a civil war with several different rubble groups against the Syrian Government . Guest first of all, we are not solved with charged with helping solve the civil war. It is certainly a complicate her for us. How do we figure out who the rightful owners are . We ask them. We asked the locals. Effort here. A lot of time and energy goes into recruiting folks from the local area. Partnerple our local force will go to Great Lengths raqqa and from both syria and they will go to Great Lengths to make sure it is them. Eventually the Liberation Force which much come from all over will move on. But the forces left behind will be folks from raqqa. An example of that, there are other towns and cities in Northern Syria turned back over to local people to govern and secure. Host back to the phones. Barnett is waiting in marshall, north carolina. The line for democrats. Marshall, good morning. Caller good morning. I have one question for the general. Would he tell me how many people are left over from blackwater . Guest thanks, barnett. We dont really have any mercenaries over here. Mercenaries, in my mind, are paid to fight. What we do have our contractors who are performing security duties many of them for the United States or for other countries. They do things like guard the vips. They helped to guard the United States embassy. Free or reduceo the need for military forces to do that. Contractors over here to cook our food and service to us. And they perform a wide range of tasks so we can reduce our uniform footprint here. No mercenaries, but plenty of contractors, some of whom are performing security duties over here. Host kathleen is in new york, republican. Go ahead, kathleen. Caller first, i have a comment that i believe are National Guard should be here protecting our nation, not over in the middle east. Secondly, i really feel that if the people over there in iraq particularly, are handling their defense well, then we just dont belong there. Let those people settle their own problems. Thank you. Host general townsend . Guest ok. Will she made a comment, well, she made a comment, she didnt really ask a question. She made a comment about the role of the National Guard. I dont disagree with her. The National Guard actually does help secure our own country, america, and the states. They help secure our nation there. They are also a part of our armed forces and a part of the normal rotation of the u. S. Armed forces overseas, so National Guard units get mobilized. That is why they exist, not only to protect america at home, but go do, as part of the regular forces, Security Operations and military operations overseas. We have a number of National Guard soldiers today that have immobilized and our own federal duty performing just like the rest of the armed forces. I am very proud to serve alongside them and have them in our formation. When they are done here, they will go back home and resume their duties defending america at home. Then i think, well, i dont remember what her second question was exactly. I got it. She was mentioning that she thought that the local folks could handle their own defense, and they should. And the reason we came here, for a long time, we watched iraq struggle with the threat that is isil. Eventually, the United States and the rest of the World Coalition to determine we should be involved. Isil is not just a threat to iraq, it is a threat to america, and that is why we are here. To fight this threat here rather than on our sure. Host lets go to martin in new jersey. You are on with general townsend. Caller and the fight against isis, i heard to my surprise the general petraeus, sometime this r or part of flash to her, that general trias, much to my surprise [inaudible] , they gave a positive response about favoring the reduction in Collateral Damage in going after isis. Host martin, we are losing you a little bit. We will try to get that line a little bit better. And try to get back to you. Lets go to anthony, a democrat. Good morning. Caller good morning. Thank you, cspan, and general, thank you for your service to america. Eventually, iraq, when their civil war but is any type of political solution . In the horizon . Thank you once again and happy thanksgiving, sir. Host general, go ahead. Guest thanks, anthony, and happy thanksgiving to you. 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. 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, usually go all out, pull out all the stops, to deliver a thanksgiving meal to our soldiers. They may be sitting in the dirt on a side of the mountain, but we will bring them a hot thanksgiving meal with all of the sides. Then i was able to come back to the larger bases and see thanksgiving with all of the trimmings in the chow hall and everything you would expect of a thanksgiving meal back home. We try to reduce our activities on thanksgiving where we can, and that the soldiers enjoy a little time off, maybe watch a little bit of football on the armed forces network. But there are soldiers engaged in a war here, and combat operations, so not everybody got a day off. Certainly the soldiers in the field did not, and even those back at the headquarters had to take turns pulling duty, while others watched the football game. Host in michigan, tim is on the line with the general. Caller thank you, general. How was Technology Working over there . Is it more covert . Thank you for your service. Guest good call, tim. In general, go ahead. Guest thanks, tim. Drone technology, i dont think anyone uses Drone Technology than the United States. We use them all the time. We are constantly watching the enemy with them. It is the first time in the history of our arms armed forces that we face an enemy threat. Even isil is deploying an enemy drone threat. Some of them are offtheshelf drones you could buy at the mall and they are deploying these things against us and are using them to control and direct fire and have use them even to attack our positions by dropping smaller explosive devices and they have landed a trojan horse your Coalition Forces and enticed iraqi forces to go pick it up and bring it into their position to examine it when it exploded. This is a significant threat to us now. We are building a lot of capabilities to protect our soldiers. Host 10 minutes left with general townsend. North carolina, will is waiting on the line for republicans. Go ahead. Caller my question is a question on technology. With our heirs appear youre ready and air power isis remain on the battlefield . Why do why dont we have 10,000 drones in the sky watching every move every second . It seems to me are superiority and suffering technologically it seems to me that our superiority would keep them from coming out of their hole. Can you answer that for me, please . Guest sure, will. Thanks. No army in the history of warfare has been able to be everywhere all the time. So, despite our superiority and technology, wherever we are, we can dominate. And we can have insights. We cannot be everywhere all the time. There are not 10,000 drones. And even 10,000 drones could not watch iraqi aroundtheclock can watch iraq around the clock. It is hard to see through bad weather. We had seen the enemy use creative techniques to include sending oil wells on fire to create giant clouds of black smoke and environmental disasters in an attempt to support an attempt to thwart our eyes in the skies. We cannot see through buildings. So isil and mosul have freedom of movement. They dig tunnels and moves through subterranean passages under cities and moves from building to building through walls. It is very difficult for us to see what isil is doing in cities. In open does it, it is easier, but still challenging with our modern technology to see through visitation through vegetation. If they stay undercover, whether that be an oil cloud or dense visitation or dense vegetation, it is hard to see