Health and the university and also not in the way of a great conversation so im delighted to introduce our moderator well known to all of you im sure. Michael is the chair of the department of Health Policy and management. [applause] eye in the chair of the department of Health Policy and management and i want to welcome you to the book launch. My job as the moderator is to let them come up to ask questions while i have a back and forth and then i get up towards the end and say now it is time to go to the reception and have some wine, so that is my main job. Three quick things about this terrific book. This book contains four case studies of leading Global Health organizations around the world. Its to the literature and thats number one. Number two, in an interesting way and pretty unique it is and always case studies. It looks at how the organizations are governed and what the rules of the government are, how they are financed, how transparent they are and takes a look at all these issues and tries to use that to figure out how impactful and influential those organizations are to correlate the governance and finance and transparency. Again that is unusual. Unique and important. The last thing i want to say about the book is in addition to the specific case studies, the book also examines and considers big important questions in the world of Global Health and Public Health more generally. For example, to give one example, i think as the authors point out, theres a long history in Public Health more generally the disease driven initiatives. At the same time it is argued by many that the Health Systems approaches are or a better wayo truly propel and one of the things the books does it says how this changing the trends and the organizations in Global Health, how are they dealing with these issues of vertical disease and Health Systems, really big picture questions come important questions an,impk the reflections we often have to add to the knowledge about this. Thats all im going to say. I want to introduce the author and let them come up. First, debbie got off the plane a few hours ago joining us from edinburg is the professor and chair of global Public Health at the medical school at the university of edinburg. It is a translation of the research but she does. Also a commentator on bbc and other Media Outlets she received her doctorate in her masters from oxford. I recently learned actually come and this is an interesting fact i learned that when debbie was the team, she became the oldest scholar in history. It was quite an accomplishment. Not that long ago the world didnt actually have the global fund or lobby, and one of the questions we used to frame what we attempt to answer throughout the book are what are the differences between the kind of old institutions and the more traditional multilateral institutions. Its known as the publicprivate partnerships and the funds. What does the institution do is the first question that helps to eliminate some of the key differences between the older and newer. We have rather broad and ambitious mandates. They have all people with the highest possible Public Health and i think sometimes one of the kind of challenges in the world is that because it is the World Health Organization we tend to think that it should be able to do all things for all people. They sound very different than the problems in the scenario where the mission that the founders established. The funds attract and disperse Additional Resources to fight and increase access. I think the difference very much is evident on the page itself. The second big difference comes into the franchise of the institution, who gets to help cure rate the agenda and strategies that they employ to achieve those agendas and how they hold themselves accountable and who they partner with or dont. I know these may look a little silly that when i go to the next slide, you will understand the World Health Organization from the world health assembly, kind of the ultimate governing body as well as the executive board known as the entities that sort of oversee the work on a daily basis, 100 of each are Member States. The same is true of the world bank. But what is different and much more colorful is the censorship of the governing bodies and the global fund are much more diverse and comprised of the National Government as well as private companies and ngos. So, we think kind of although this slide may seem a bit absurd when it is standalone, the position is fairly illuminating and this form of governance and the enfranchisement isnt something the world has only begun to experiment with since the new millennium. Thank you all for welcoming me here. The third question that we look at is who paid for the institutions and follow the money to get to what happens in the policy so if we first look as the agency for the director of health work, its skyrocketed about 80 of its increased over time and what that means is that basically its earmarked by specific donors for specific causes, 20 of what the general can say what its for services for example norway and sweden saying we are going to give you 10 million for this or the foundation saying we will give you 15 million for this so if you are the director general running the organization how much is 80 of the budget is coming from the earmarked sources. You can see that it comes from the foundation, the uk and several others. We already see there are two that have a large influence, so its just a state but if you pay for it its not just government. Ideally its part of how the bank finances its health work and overtime its grown and this goes to the poor countries and is financed as education and other social sector issues and you can see again the growth over time. It pays overtime for the replenishment and you can see vast japan, germany france and if we look at one year again at the replenishment you can see 16 am a 15 and so on and so forth so its kind of notable in terms of financing the banks. I will come back to this at the end of the financing section of a lot of it that goes for both systems. The vertical initiatives in problembased initiatives that are discussed the world bank is notable in that it does spend a considerable amount on the Health System so it goes against the trend on focusing on diseases. Theres also the trust funds because many people dont realize that this makes up a lot of the money but what are trust fund . It is funds donors can set up so to give an example, norway can partner with the u. S. And they come together and pool the money and then they can run it through the bank and the bank holds at the financing and the government are separate so they are trust funds that are separate. How important are these . It is hard to get the details on the trust funds but if we just look at the world bank and the degree of the trust fund, we can see that its the biggest. Its a lot of money going into these and it is similar to the earmarked funding the different reality. If we look at the global fund, its the u. S. , france, the uk. 95 comes from the bilateral partnerships and private sector philanthropies and a broad sector but most of it is bilateral donors and. 75 of project read that some of you might have heard of but a certain percentage goes. And they were playing an important influence financing 25 as it started in the uk and the u. S. So what comes out here to summarize the financing is that a large part of the growth in the financing and i think its estimated about two thirds came from the u. S. , the uk and the Gates Foundation we think of Global Health as this activity with more initiatives and partnerships but actually the financing base is narrowed down to three and that makes an interesting and difficult position for the director general or the head of the institutions when you depend on a few donors for the financing so i will turn it back to chelsea. One of the areas that weve gotten increasingly interested in is how much they are curious about any of these institutions that we focus on. How much can pay themselves discover, how transparent is the world think and what it chooses to financing how transparent is who to the department, how transparent is the global fund in what it chooses to provide financing for or not, how transparent in who it chooses to work with on the new vaccines or not, and the answer varies significantly across these institutions is not only with respect to the public but some of the partners and constituents that make up the governing bodies of institutions themselves . This is important not only because of the increasing norm and expectations that all of us share that we should be able to know how our tax dollars are being spent and invested because they can ultimately the bilateral donations that the United States makes or the uk makes are financed from the respective treasuries, but also we may not want to work with those institutions or partner with those institutions or for those of you that are interested in academic careers how easy would it be for you to do research on those institutions or not so as you see in the populated graph on the screen, all of the organizations have open information policies and what that means in practice varies but the global fund is often cited as real leaders in being transparent, open and acceptable by the International Transparency index and by publishing what you find in the watchdog organizations and get the world Bank Organizations that we engage with, the most scrutinized has made significant strides to be more transparent about what it finds and where it funds its contracting and who is partners with and who it doesnt. But who provides very little visibility into what it chooses to fund in a granular level and how it makes decisions and we call that out here because we think that its important to know the institution most expected to set kind of the Global Health agenda and kind of the only institution that had the ability on the screen to establish the norms and Global Health and the only institution that had the ability to engage in hard power and to have the treaty obligations enforcing whether we are thinking about kind of the Tobacco Control conviction or kind of other works that we think who should engage in. It is the least transparent to hold accountable or to be able to persuade to engage in moving the world towards Greater Health for all. So this is something we spend a lot of time on in the buck. But, we will now admittedly pass data back for some concluding thoughts and then open up for your question. The last issue that we look at is doing something that youre not happy with that the Member States were sitting on the board. How easy can you redirect the secretary to do something that you think is better . I wont go into detail now because you have to read the book but i will focus onthe who to give you an example it did get a lot of heat after the crisis for fumbling the ball and not being quick enough to declare emergency not being able to generate enough attention and resources to the problem and there was a commitment made we are going to change certain things. We have to get the Emergency Preparedness right and there have been efforts made but its difficult to reform. Those of us that follow the reform every five years its been going on since the 80s and it comes back into these issues that we were discussing in accountability and trust that its notable that we had a crisis in over 10,000 people died but nobody lost their jobs anywhere in the organizations and it comes back to the issue of accountability and monitoring one of the things that will be interesting to see from the director general and the assembly is whether or not that person can reestablish the bonds of trust with the donors and also recognizing its not only to member the Member States but its also increasingly policies that need to believe that who can and should be establishing the norms and leveraging all of it, soft and hard power tools lead to protection and promotion for more people. She wouldnt have had resources to leverage and deploy on the Human Capital resources. It is a bit of a classic chicken and egg challenge and i wish i could think of a more compelling healthbased metaphor. Well but who have to try to prove itself and hopefully if the latter is the case, hopefully we will not have another ebola or seek another institution to deal with Emergency Preparedness and response. We can be more prepared than we have been in recent history. That is an important point out. You are basically financing so restricted you try to recruit funding from a set number of donors. Its based on all of the evidence. They want to align them with their own objectives to this mandate giving the tight funding. They want to create syntax for importance where you can punish and reward the financing. They want to closely monitor what the agencies are doing and they want transparency. You have to read the book to get that answer of what you think. This would be used for everything, should we have a global fund for the mcd, or for the Childrens Health more broadly, these are all the questions people think of and one of the things is it only works if you have the specific missions. You yalonda foundations and others and that would give the responsibility to give money along with and trust. You have the agencies according to these criteria. The answer is pretty simple. One that has gotten a lot of attention recently is partly because bill gates has spoken about it. From 2000 to 2015. It 6 million per annum and that is extraordinary. You lose a million children on the date of their birth and a million more in the first week of their life. So if you just think about theres been a 40 decline its been extraordinary. We conclude our book with the buck with the lessons of the Global Polio Eradication Initiative that started in 1988, the coordinated efforts catalyzed but in partnership with a number of other institutions both the founders and kind of underground partners at this moment in time i think it is easy to focus on the fact. Another 30 years of concerted effort over the 30 years more than 3 billion children have been vaccinated against polio. More than 20 million volunteers have been mobilized and the work has taken place in more than 130 countries. So that is fairly extraordinary. Succumbing yes, we have work to do. But we think the moral imperative is so strong because we have proof in what can happen when we do mobilize appropriately. So we are so grateful again to linda and michael and everyone here. And before we open up for questions, i want to thank one of the tremendous research assistants, she made working on this project a lot of fun and all of the grass she did, so please give her a round of applause. [applause] and we would welcome any questions that you may want to ask about in the substance of the book although we wont give it all away after heard from. If you have questions about the writing process or other research we are engaged in, we would welcome anything that you may be interested in discussing. Dont all raise your hands at once. [laughter] yes, in the pink. [inaudible] what is the imperative in that commitment . Debbie lives and works in edinburg. Just to repeat the question so that you can hear why when the resources are so constrained given the challenges that they are facing in the National Health service that provides Health Coverage across the country would the money be spent overseas i guess when you look at the proportion that goes to the Global Health its very similar o the states and the focus on what goes abroad and and it is tiny compared to what goes into the National Health service and the Healthcare System so it is a tiny fraction in terms of money. They are looking at billions, 60, 70 billion quite casually. Here we are talking about Global Health getting about 20 so i think there are differences. The second thing is i think there is a commitment in the uk and they call it american strategy on the front, Global Health and National Health. We live in an interconnected world and it really reinforces and even launched a Major Program called the global challenges Reimbursement Fund that whatever is happening anywhere around the world it affects these uk. There is also the articles coming out saying why are we spending so much that it could be a small amount of money in the big scheme of things and its well worth it for everyone. In their best interest wherever you are sitting. The same question is often asked here in the United States. The Kaiser Family foundation does a survey annually where they ask people what percentage of the u. S. Budget do you think goes to foreign aid. Last year was 25 or 26 with an average response the lowest its been as 11 . If you just carve out that we spend on Global Health assistance, it is significantly less than 1 of the total budget. And so, although the majority of the funds that the United States invest around the world more than one in five probably seems like a big number but compared to the 4 trillion, its not a big number so i think we dont have the luxury of choosing only one priority when we do live in the interconnected and independent world where the United States has the prerogative and more security responsibility to leverage the hard and soft power and that is what youre seeing here in the United States is such a robust defense from across the political spectrum and the u. S. Development assistance because there is a broadbased understanding that not only do we not have the luxury to have the offending that we could invest in whether it is here at home and not be willing to still create, foster and support Greater Health agencies and Health Outcomes around the world. Yes. [inaudible] i would like to request how active the other areas are and in the last five years what happened is that the broad coalitions. We moved from not only the single vertical issue in the broad connection of the Life Campaign like the 13 Country Campaign but our focus was on the transparency of the u. S. And other National Taxpayers input into their respective countries and how the pricing structure sort of hit that cost and resume about all of the cost in developing this was borne by the companies themselves. As you may know, its been pushing its work kind of further upstream to be able to have more transparency in the whole ecosystem around development and for the live stream from his reflections were there are more broad coalitions across the sector that are kind of tackling the issues collaboratively for their transparency and pharmaceutical pricing or other areas. I think that we will see more of this partly because the sustainable goals are structured to encourage that and so if you look at the svg it is kind of an explicit multidimensionality and the fact that they are looking to encourage partnerships between the groups that are focused on the Sustainable Development and Environmental Protection and the kind of resilient societies with the Health Systems planning and looking to kind of preempt and ameliorate the health risk factors, we are going to see more and more of that. I love the view coauthored the book. [inaudible] it was more fun than my doctoral work and to kind of collaborative and balance ideas off of. To be sitting by myself and laboring in my own head and sometimes my supervisor. Its a far better work more than i would have done if id been working by myself. I am so grateful to have a coauthor and even more grateful to work with debbie. It was fun. [inaudible] its good to have someone always there. Its a constant positive support [inaudible] other countries dont exchange. [laughter] but i think that yes i would just encourage that for everyone find someone that you like [inaudible] and the kids between the two of us. [laughter] now how about in the blue and white. [inaudible] one of the things in answering that question, i first became obsessed with the global fund before there even was a global fund. I wrote my first masters thesis on the global fund in 2003. And so, i cant remember what first surprised me when i first started engaging in a more critical scholarly way with these types of questions and looking at these institutions. One of the things that did surprise me if i did think that we would get more reform in the aftermath giving the just overwhelming chorus across the Global Health landscape even from the review that it commissioned one of the things we had to argue for and the others had advocated that i do think we were going to get something done if only so that. Two things that i will pull out and it surprised me. They are very vocal about health but i was surprised by how dominant they are in financing the governance and if you want to have a strong strategy to engage in the institutions and governments outside of it is the institutions where they are very active and there is a Clear Strategy and clever strategy if you want to analyze the global objectives for what you are hoping to achieve. I know we dont realize the extent of the foundations and the other thing is the passion for the global fund for my doctor on the world bank and the next book we do is on the world bank hopefully. It is one of the unique funders and healthsystems. We talk about this neglect so it does seem to go against that trend giving interesting the trend giving interesting things like universal Health Coverage and the vertical flows to do more for those awful things. They are doing very interesting things. I was just kind of add to that point about the world bank. To converge the vertical and horizontal funding but even to align the conversations in the horizontal funding so often it is about the Health Systems strengthening here or in primary healthcare or Health Workforce development. And then overhear their conversations about the universal Health Coverage, which is the decoupling just seems so illogical when i would argue that seems pretty selfevident when we look at the Health Systems across the developed world and when you have better alignment across the continuum, you tend to get better Health Outcomes. So, the world bank is trying to not only exist in the vanguard of encourage other funders to think along the same line, and this is important because of what debbie said in the foundation at least as far. He made it clear he is not interested in the kind of financing of the march toward universal Health Care Coverage or the kind of Resilient Systems across. I dont think that invested a billion dollars a year. It is in isnt a commitment to Global Health. Health System Training or universal Health Care Coverage. In the Health System strengthening and try him to marry them together in an impactful way. We have time for one more question. [inaudible] i was wondering to what extent and i was curious that categorization. And second, [inaudible] its hard to see where. So to what extent do you see that right now . That is an important question. Im going to answer the second question and then ask debbie to answer the first. Im going to abbreviate it and the second question was how do we foresee or not a shift in the Global Health landscape to the current developing countries and so forth so that it includes the agencies and not just a rhetoric they are attempts to do that in part having the global fund through having but coordinating mechanisms. They are developing a membership and they have to have the country private sector and Civil Society membership to facilitate at the country level kind of on whatever issue and priority the grant is looking to tackle. And yet as you read every minute of every global fund board, which i have done [laughter] and you read all of the various committees, it is clear that while i think the board member countries in particular have more ability to influence the agenda, the United States provides a third of the global funds budget and probably still continues to have more ability to influence the agenda not only through what occurred in the meetings themselves, but the United States actually publishes its view the board meetings after the conclusions. You can go to that website and see how they feel about the meetings over the last i think now nine years because deborah, the u. S. Global aids ambassador, the head of pep far is the head from the United States. I think theyve gotten further through that kind of goal, but in perfectly. And yet, if you ask the question of who finances Global Health, it is defined by what happens in regards to peoples health. Its often how Global Health is treated so in many Public Schools if you take a class in Public Health you will learn a lot about what happens in other countries that were in your question but less about how what it fails to positively influence in Public Health for all of us whether it is the preparedness or tbacco control. The answerowho finances in the developing world really are the countries themselves. So i think the question will be Going Forward particularly if there is an absent but im hopeful at some point there will be institutional efforts to invest in the Health Systems alongside the universal Health Coverage. I think that is when we will see the pivot that you talk about. I will quickly answer the first question. I will highlight two of them right now. The whole reason that it was created if they would realize they have to put together the differences and use all this with Health Systems and capacity they were neglected for a number of years and all of a sudden one of the things people dont realize is that the click three months to detect that this was ebola because there was the capacity becuse me of them were interested and they were going after the shortterm priority. So, you kind of lost the body that was a little bit removed from the yearly political cycle type of what should be the priority. So there was a major efficiency loss loss that we havent established across the world. Also as well, there are normative switch are at the right the priority is for people around the world are said by three. Is this correct should people decide to vote third party. What you want your priorities set by priority is said by some kind of institution far outside but you dont have access to these resources and you will be cut in half because the taxpayers dont want to pay that anymore. Can you imagine in the state, like what is this. I guess the way to move towards it is trying to build taxation systems and to build a stronger domestic base in financing and you are less reliant are less reliant on these external flows. Also some outofpocket expenditure and then the outofpocket aside from the government. That is the kind of way that you will move away from it. Its hard to break away because the accountability to the taxpayers and if in the next year we dont want to pay that and they pull back because they responded to the media and public pressure and so, that is hope for the future but it is something. We wanted to highlight a 3 dominates not just financing but a mere year the other way is how it is dictated in Global Health cause then the way people think of it. I know we are tight on time. I want to thank everybody here. [applause] its a perfect book as they said, youve got to buy it. If you want to buy it, it is available at the reception that we are having in the room upstairs. I want to invite everybody. You can exit through the top door and then you are practically their. They will be joining for the reception and again i want to thank james freed, mark, chaunceys husband who is with us today, everybody for coming and we will see you at the reception. Thank you very much. [applause] [inaudible conversations] [inaudible conversations] booktv is on twitter and facebook and we want to hear from you. Twitter. Com mac booktv or post a comment on the facebook page, facebook. Com booktv. [inaudible conversations] welcome to the regulator bookshop in North Carolina. I am a professor of history at the university of North Carolina chapel hill, and we are happy to have cspan here to cover this talk for booktv
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