>> and finally, when we think about where veterans live relative to va on the slide i showed earlier, what about where veterans live relative to other providers in our community. this slide shows veterans who live far from the va. more than 40 miles from the va. among those who live far from the va facility. 80% live within 40 meals of a primary care provider in the community. when we look at specialized needs and mental health care, less than half, this is 49%, lived within 40 miles of a private sector mental health provider. and even fewer lived within 40 miles of a private sector neurologist or endocrinologist. this is for health care overall and not particular to the va. for veterans who live far from the veterans facility, in the community cares, those providers may not exist in their communities either. so looking at this overall, it really does suggest that private sector care should complement va care, that va provides care in most cases with high quality in a timely manner and the private sector should come in and complement not substitute for care. it's important since we know very little about the quality of care for veterans that's provided in the community and timeliness of care for veterans that's provided in the community, to really develop a mechanism for monitoring that care to ensure that both in the va and care in the community that va is paying for is high quality and timely for veterans. >> thank you, carrie. music v. [applause] >> before we turn to our final speaker from lifepoint health. i'd like everybody in the room and in c-span, you can participate in the conversation, there are three ways, submit on twitter #rheter veteranshealth care, and you have a green card, you can ask your questions there. john? >> thank you, marilyn and thank you for being here today. before i get started i would like to recognize david krichlow our vice-president of government relations here with me today and available to answer any questions. i'm going to go through a few slides, start just by identifying lifepoint and who we are. it will frame any comments that i make from a small, nonurban sole community provider perspective, walk through some of the volume indicators of the veterans that we're seeing in lifepoint and then talk a little about what we see as opportunities to expand the provider base within this program. >> so a little about lifepoint health. 72 hospital campuses in 22 states. as i mentioned, we are a nonurban, so community provider. there's a bullet point that says leading health care provider in our communities. we're typically the sole health care provider or at least acute care provider within our communities. we operate in areas that the closest acute care facility is over 100 miles away. i found interesting with carrie's comments with availab availability. these are the markets that we see. we're not urban, there is not a va hospital and there's not acute care near us. our ability to serve these veterans in our community is very important to us. avid supporter of the accountability act. this has been a very emotional issue for our leadership team. our leadership and our facilities are veterans themselves. they know the communities and they live there. this has been very important for them and emotional for them and they have embraced this entirely. and we were proud with some of the work they had done, in particular with veterans choice. to reach out to the community and to a certain extent be a resource for veterans to identify whether or not they were eligible for it, but i've embraced it significantly. >> so just some volume statistics of the care that we have provided in 2015. we have provided care for over 15,000 veterans throughout lifepoint facilities. of those 15,000, 1200 for inpatient admissions and 4600 through our emergency rooms, 1600 outpatient services were performed and more than 7100 outpatient procedures and test ins 2015 it's up from 14 and continues to grow which we're very proud of. >> so where can we improve? some staff is here and i'll talk a little and comparing it back to the lifepoint. all of our payers when we look at days to pay. when do we get paid for services compared to when we discharge a patient. for all payers on lifepoint. that's 54 days and we are typically paid, within our group and it says veterans choice, but it's the program at veterans choice. it typically takes 113 days on average in our 22 states to get paid. so, here is why that's so important. for lifepoint, we have very strong balance sheet. we have the resources to basically finance this care. you know, our costs that we're paid at medicare rates almost by defacto costs, we have the ability to bridge that gap between paying for the cost of care we provided and then being paid 113 days later. if you look at the staff for a critical access hospital, their days cash on hand are 69 days, but typical hospitals if you put them altogether, it's over 200, but for the small community, independent hospitals, in particular the rural hospitals, they're fairly fragile financially and we only have 69 days on hand so it's difficult for them when you provide care and you're waiting to get paid at cost, where you then become almost the financing arm for these patients. so, i think by reducing that, a lot of our sister, independent rural hospitals don't participate just because of the cost issue. and so, that's an area that we have looked at. a lot within lifepoint. what we've seen, some of it is provider self-inflicted, but i think there are some ways to maybe mirror medicare, our medicare to pay less than 21 days. so what we would welcome in this is the opportunity to work collaboratively and get those days from 113 down to maybe something closer to medicare because we believe in the hospitals that we work with. that would be very attractive to them to get into some of the programs in these small communities. a lot of these simply can't afford to do that. so i-- last slide going forward again, strengthening guidelines. it does provide on the provider side. there are things that we do wrong and that we can improve on, but i think coming together and figuring out a way to get through some of the prompt pay issues that we deal with, we believe, would bring especially some small providers into this network in this important program. program. [applause] >> okay. thank you. so we've now turned-- we're going to turn to the q & a portion of our program and i'd like to throw out the first question. we've talked a lot about care within the va system and the private sector. i would love for one or more of our panelists to take us back to square one for a moment and talk about the choice program that was-- that came about in 2014 and help us to understand. who is eligible for this program? how are veterans using it? and to what extent are they use it go? do we have just about everybody using it and what kinds of services are they getting? what is the experience like so far? >> sure, why don't i take that one? so the choice program came about approximately two years ago or so. and it's a temporary program so i think this is very important because it actually is set to expire august 7th of next year. so we're less than 12 months before this program expires. this is a huge issue because we actually see kind of the train is coming and we have served more than a million veterans in this program. so a million veterans have touched the community through this. so this is one of the things that va is very concerned about, because there are a lot of folks that are receiving care through the program and kind of what happens next. so, that's one important point. the second is, this program serves a very specific-- has a very specific set of eligibility criteria and as i was mentioning before, we have seven or eight different ways of purchasing care, this is one of them, and their criteria are very targeted. they really can fall into three types of buckets, one is distance, and so it's 40 miles right now from a primary care provider and so if you live more than 40 miles from a primary care position in the va you're eligible for a choice program. if you cannot get care within the wait time goals of the department and third is, they're called unusual and accepted. if there's a mountain range or a lake or stream or severe weather, there's exception. those are the three types that are eligible. as you can imagine, the geographic criteria for the most part are the stable type of population. and so, an individual may be taking-- may be receiving care in the va for one condition that may be we can't provide timely so they would go out on an episode of care in the community and they would still get the rest of the care there. so, that requires a lot of care coordination, so those are really the three types of criteria. now, when we talk about the type of services that we're purchasing in the community, they're pretty common, one of the-- probably when i think of the top five and top ten, we send out a lot of folks getting eyeglasses and we do send out some orthopedic surgery, we send out a ton of laboratory testing and maybe someone is getting an mri, closer to home than coming to the va and lab tests, laboratory tests so it tends to be a little bit of the-- more locally available specialties, although now, as dave was mentioning, we are able to get a more robust network where we can refer to some of the complicated procedures, whether they're ct surgeries or neurosurgery and that's a little bit of the neck. >> what you're seeing on the experienced side on our end is then about 15% of the population is 40 miles in terms of who is utilizing this, about 50% are those that are near a va medical center and the va medical center or community to base outpatient clinic doesn't have the service needed and 35%. the remaining 35% is those that couldn't be scene within 30 days and choose to access their rights. if i could just, for those that are staff members, the expiring in august of the program, it's very unusual for congress to authorize and appropriate at the same time. in fact, it usually doesn't happen outside of black box issues or other types of very rare occurrences. the federal budget rules had to be suspended, in order to get this through and that's what set the trigger for august 7th, but at the same time without action, a whole program goes away. and that's what he's talking about and the notion that it needs to transfer to something else or in its current form it needs to be reauthorized from a bugetary perspective and an authorization perspective. >> okay. thank you. so let's turn to the audience now, we have a question. if you could please identify yourself. >> my name is regina leonard, i am a doctoral opportunity in health policy and nurse administration. i have a question, with veterans needing more access to care, it would seem possible that the va hospital would allow advanced practice for nurses, m p's and clinical specialists and have full practice authority. hr-1247, the veterans access to quality care bill would help the va hospital accomplish its goals. how do you see utilizing m p's in the future? >> that's a very great question and also controversial as va is working on the nursing handbook. we leverage a lot of nurse practitioners and physician assistant provider extenders so i'm not exactly the right person to be able to address this specifically, but what i will say in general is we do have veterans that live in every corner, as i mentioned, in the united states and as we were-- as a colleague was demonstrating. in some areas they are not physicians or there's a derth of those providers so we might need to leverage more of our nursing-- nurse practitioners colleagues and providers and make sure that we take care of veterans. >> i had a ' like to comment to your question as well. aside from care to veterans, the small communities we're in, physician assistants and nurse practitioners are very important in these communities. we use them effectively and they provide great care in the small communities and it's an important part of the network in these communities. >> and i want to jump in, one of the recommendations in the independent assessment is indeed that nurses, nurses practice to the full scope of their license and that the evidence, the research really shows that there's not a difference in quality of care between nurse providers. >> okay. question here. >> i'm dr. carolyn poplin, a primary care physician. i have a question for dr. yehia. a quick question for john. the question for the doctor, i worked for the active duty military for 12 years, seven yea years, and five years at what was then bethesda naval hospital. the military all of that time were working to make their electronic medical record interoperable with the va, they spend millions of dollars and my understanding is they've given up. they couldn't make it happen. how are you planning to make these interoperable-- obviously can't be the way that we tried integrate because that didn't work. >> thank you, an excellent question. i don't think they've given up quite yet, but the point that you're describing is american medicine issue which is there are health systems across the country and market out there for electronic health records, everyone has different records so we have to think of it differently than before. we're doing a couple of things to show promise. community health exchanges we are 80 across the country and a lot of these are individual communities that get together, the hospital systems in that area say we're going to share information. there's a standard template of what data they get, so we share records, we have veterans that quoted more than half a million participating in different exchanges. number two, knowing that not everyone is going to have the same record, how can you share information between the records and what we've been able to do with our military treatment facility, dod partners and now transferring that knowledge to the community is having something that is a viewer of the records. we can actually get a view only read of the record and not able to kind of alter it 'cause that belongs in your health care system so we have something called the joint legacy viewer. and we have a read only view. it's not like we look at the dod record and when we look at community viewer it's integrated record and we are-- we now have these all over the country and taking that knowledge, and doing that and testing it out in a couple locations with community providers and we're now testing in the state of new york, new york and washington working with specific community partners and give access to read-only view of the va record, that way they can as a practicing doctor if i want today look at the mri and ekg i can look at it through the web-base portal. i'm viewing those, rather than trying to get everyone on the same system, i don't ng it practical in the short-term. >> my question for john-- several questions about the use of other tools such as telemedicine and how the va is using telemedicine or other tools like home and community-based services to provide access to care and how can congress help to encourage this. >> why don't i start and comment. va is really at the tip of the spear when it comes to telehealth. we have a number of telehealth clubs that have been doing, various versions for a long time, and it's exactly for that, marilyn, we want to make sure that we can provide access and reach certain areas that we may not be able to have a brick and mortar building, so we're leverages more and more telehealth in all kind of specialties by the way not only in primary care, but mental health care and looking at other fields that traditionally have not been done through telehealth that we can do so we're doing that, there are a couple of things that could really help va with being able to share information and especially with community providers, whether they're doing telehealth or not. and that there's a couple of statutes that prevent va from sharing medical records. and these were developed decades ago and above and beyond the hipaa requirements. the va is not allowed to share records with someone identified as having hiv, sickle cell or a mental health or substance abuse condition so you're taking a big chunk of our patient population and have one of those conditions and in my mind, almost as a st stigmatizization that we have to have them sign more than the hipaa and send it to the doctor in their community. that's an ability to coordinate care whether it's there the telehealth venue or in person venue. that's one thing not providing-- it's outlined in our plan to consolidate care. one thing i think they can do. >> i would completely concur with what dr. yehia said in terms of taking down the barriers. when we were doing dod at the height of the wars, we actually placed in facilities in colorado springs, inpatient of-- inpatient patients for mental health because the military hospital there did not have an inpatient unit and we actually forced grand rounds that were joint. so we required the sharing and the sharing of that information is really, really important to making sure that the patient encounter is proper and that you plug the gaps that might exist. starting next week we will be standing up a series of pilots that will roll out in two markets and expand from there. that will put us behind the tip of the spear, which is the va, but we will do telemental health and start with medication management in a particular market to help give them more supply and then it will also do psychotherapy on that same backbone that will allow us to test out in both urban and rural areas how we jointly want to make sure that people are taken care of and leveraged supply in the private sector when it's not available in the va. and i would just say that making sure that providers are understanding of who a veteran is. and then we select carefully who we place people with is really, really important. and so we've put a million dollars into a nonprofit that's actually constructing the teaching information that will be made available to providers all over this country as it relates to understanding a veteran and evidence training that va and dod have specialized in, and actually make that available from a distance perspective with a coaching apparatus on the back end that we designed in concert with va and dod and that information will be available free of charge to providers all over this country that want to step forward and be helpful. >> i agree that telemedicine and home-based health care is great for small supplier, it i cannily the area of mental health. i've seen many veterans who have troubles who benefit from it, and there are issues that have ton worked out and somebody from san diego might want their same provider and not mesh well in another area. i want to caution, it's not a panacea. i think the optimum health care is person to person. in so many instances, hearing nurses talk about, for example, decubitus ulcer. you can see it on the screen, but it's not the same as appreciating how bad it is when you're there and seeing it in person and happy to see my doctor once a year when i do my annual exams in person. there's something that doesn't want to loose, but don't want to see it as end all-be all care, but for opening care to veterans who need, you know, services. >> great, we have a question at the mic? >> hi, thank you all for being here today, dr. taylor winkleman. it would seem as scary as the 2017 deadline, august 7th deadline is, it provides us with an opportunity to introduce changes to the program and as a veteran who remembers what it was like living 98 miles away from a facility before veterans choice came in, i can certainly related to the benefits and challenges that we face. and mr. gillums i recommend you would extend something to extend title 38. but what would your ask be for improving this ap better more cohesive vision put together. >> but. >> we have to actually have to have changes. this program as was describing came very rapidly and was in it implemented rapidly with congress could change the law for times already which is great and we have other ideas to let the programs work better bed number one is primary-care issue and in some circumstances we have to rely on other health insurance so what does that mean? were have to pay the coach pay and deductibles and premiums and no other program works that way. so it is exposing them to some financial conflict they never had before and a lot of them more upset about that not knowing they have to pay the specific portion. number two we need to be able to work better with community partners especially in the rural areas. right now the choice law limits the v.a. that medicare so now that makes sense to some locales but not others so we have to pass that flexibility to partner with providers at a higher rate because a lot of times but definitely have issues sometimes it isn't that is the flow but it is too low without flexibility of pavement and then i mention the other things to coordinate care better to share information that we have to leave of the program we have invested a lot of infrastructure and we have learned lot. behalf to revolve it should not be completely scrapped as it will go through the same growing pains of a few years ago. but it is how we continue to take what is there for what makes sense for our veterans and community partners. >> i imagine some other panelist imagine what needs to happen with the program put. >> the issue of the primary-care facility that they will not qualify if there was not to the v.a. center within 40 miles. with a veteran that is 3 miles away from the facilities to work through those issues it is those negotiations with the veterans of ministrations but that has been issued and that there is close facilities with that care of need but they cannot utilize >> just to comment on that piece, it is one of the things we have to be aware of. talk about 40 miles from the primary-care doctor or 40 miles from others and a lot of people look at that model definitely would have a very large financial impact. apart from that and with that referral patterns with the service connected to veterans if we cannot provide wraparound services because a lot of those are deferred samara else outside the system then becomes hard to gain competency to recruit doctors in the area. so figuring out flexibility for those veterans that need to be seen. sometimes it is too long but i do raise some concerns about completely because what that will do is contract for those that want to use it because you must not be able to build up the wraparound service if you don't have that volume more expertise to do that. >> i concur so open access is not the right place to open up investing a lot of infrastructure and to make that stronger to make sure it has sufficient supply is important but for the last 15 years we employ people from every set coded this country and has spent very different from many of their conflict. and they don't have to displace where they are they may take a year or two off the have a right to do that with the benefit they have earned. and we all agree that it makes sense but how do we draw the parameters? said from that perspective congress needs to decide how does it want to deal with the responsibility and there is a lot of money that is paid in travel and the lot of money paid when someone doesn't get what they need of a timely basis. because when they are really sick is more expensive. for those things you want to be and the v-8 facility absolutely a top-notch academic is a witty could regard this of where you live in the state that they're great could get the orthopedic service across the state and i think you will sort through those. and when reflects properly to make that work. >> and some ways there is the bigger conversation about what is the obligation and if the decision is and has an annual budget every time there is an increase of demand beyond what was expected rejected there will be access problems and this will be true for community care as well. particularly if you increase the eligibility. so in the bigger picture what is our responsibility to veterans or our commitment and how to be paid for that? >> we have had several questioners want to know how to get claims paid faster? what is the answer? >> this is one of the things that i spend a big chunk of my day on one of the partners delivers care and what we are realizing there is the number of the root cause issues to major to pay providers. one gives back to the eligibility peace six source seven or eight different programs with criteria that if you don't match the but exactly right and you are providing care for a veteran that lurk ... 40 miles then we don't have the authority and that is unfortunate because uh criteria is so many of them that a veteran receives care that we don't have the ability. so how do we get to that eligibility criteria that is clear for the patients and providers that there isn't any ambiguity? medicare is pretty simple. u-turn a certain age you have a card and you are good to go. and to get to that love all of clarity it will be hard for providers to know that. to make adjustments to the allies the biggest area right get complaints about provider payments relates to the emergency room care. er care is a plan to consolidate is very fragmented. in some circumstances it is the primary pair of those conditions and in other circumstances it is hell last resort. by a lot and statute we pay 70 percent of the medicare rate fell with doctors with the er it is considered payment in full but they have to carry a chunk of that of their accounts receivable and then they cannot pay us until we get the law changed. that is around the unauthorized care we have to figure out that the services connected or not. so we could pay the bill to get this more in line with a progressive industry does. does require some investment and if we can get the good criteria in the king said of the system and then we can leverage the community partners. when you actually go to the medical records and then the emergency room you cannot do that by the computer. and with that knee injury service. way to complicated it takes a long time. to get to a system where to the kennedy adopters to know what they are able to deliver. end however we need help in we cannot meet the standard that we want to meet from the legal and congressional colleagues. >> now responsible for paying 322 million appointments i will tell you what we don't collect. if you go back to their try care 20 years ago about three months in it was obvious it never paid claims properly. now walking into a scenario he did not create. of that dates back the long time that the v.a. was paying claims by market by market by market. that is not a very effective way to do with. it is hard to get to core competency. and now to consolidate what that looks like was a very needed change. en to have that one direction on the government side. in the institution and to file properly. did to be in a place where the claims are denied. and then to send the next that is not in anybody's interest anywhere. and with a provider perspective at us start and then get a ride across the system to make it the fastest in the most accurate from those types of programs , you also have to pay one way. right now those from the community they pay one way and file one way if it is through choice it goes down the different ways so of mansion trying to figure out how does this work as a consolidated pipe. we had a project in arlington and texas the members of congress from the area because to have a community-based outpatient clinic. the son of the hospitals have a 50% denial rate. they did not know how to file accurately. within five weeks together we drop dead at 10%. that makes their historical pattern of pavement changes dramatically. it is part of the responsibility starting with the provider fighting accurately than it does to us to make sure reprocesses the work and then to do inconsistently and that it cycle's back. as an actor that's spent time 20 years ago and those in the provider community so from my perspective and then they are riding my side and there is no separation was what they try to accomplish. and then the va pays as. and then to figure out what those pieces are that needs to be changed but there is another pragmatic component to get this work right at the end of the day. we will test that then take what we learned to apply to the rest of the enterprise. >> i would expand on the comments as a provider leered used with the intricate rules medicare is the great example very tight around the medicare recipients but as providers we know what those rules are to incorporate into those processes we know what a medicare recipient comes in for a test what the diagnosis has to be if you can imagine the fear of had their own rules we could develop the systems and process. one pipeline nor one set of rules. and that is very beneficial. >> one or two more questions. please fill up the blue evaluation for before you leave us today. >> the commission on care reports. with the advisory board and one is to eliminate the requirements that are possibly in constitutional but hypothetically what would bidi impact of either of those changes. >> double comment on the of latter. and with the response and to those recommendations. just like mom and apple pie those that our most controversial. that people leave and then to, but that eligibility criteria when myself as a doctor but getting to that same goal way to do referrals with the hide networks to create a partnership of that utilization and an that wrapped around customer service says it was laid out in the consolidation plan and also the way we need to do that. the specific legislative changes and also the budget. and that is a point we hope to get to. >> to all those veterans looking at the numbers 9 million are enrolled in a v.a. 6 million use v.a. health care. most have other waitresses medicare or private insurance through blair and they choose whether to use v.a. or other sources based on a number of factors that is cause and access. if you opened up what you will see is a gigantic increase the demand. and then the va will pay for it and because the v.a. benefits don't have the co-pay. and go through your private insurance or deductibles and and just uh number that is one thing to consider. the other thing to consider is do we maintain uh va health care system are transition to a private sector model? you cannot have both with open access. the reason is that people choose to use private sector v.a. care. and you felicia understand the quality of care decreases there is the tipping point and is not reasonable and as they close and from my perspective needs to be thought out it isn't just uh death spiral. is moving into the private sector. said nike's said that so eloquently. but as a clinician what is missing is coordinations was the thinking about the way the program works it is the reimbursement system you handle your own care and the government pays the bill but what went missing from my relationship perspective is how do helpful the american health care system to make sure their needs are met? the greatest extent that people do it on their own while there is a small segment of the population for many it doesn't work. and if you look at the critical perspective, do we want to have a coordinated system floor by themselves? >> you can have the last question. >> my eighth question is what is going on in technology those seven giving patients the opportunity so has it considered partnering with apple or other technology companies to have their own medical data they can have a dialogue greg. >> we have spent doing that for a while. is the very easy way to download the version of your health record to share with their community providers so we have an entire digital services team to leverage that are thinking of creative ways to exchange information. >> i was pleasantly surprised. and with your medical records so if you follow a claim for certain benefits benefits, it works wonderfully. >> we have reached a the end of our time. please fill out your evaluation form. thanks to our supporters and to our panelists for informed conversation and to all of you. [applause] [inaudible conversations] and. >> will air going to get started been. i hold the cheer - - the chair here referring to a refugee crisis the highest number of refugees since world war ii and whenever meetings that respond to the enormity of the task and has been with us for decades were the folks that are refugees and they are lasting longer that is so cool . of what is happening with many conflicts that to be kept under wraps with the end of the cold war but the good news there is a whole series of countries better dealing with the ranks that our fragile and full verbal. for those that are in the countries but they have to think more and harder about refugees it is one of the major challenges we have to face of a variety of institutions and we will hear about that today so we have mw three very thoughtful speakers. with the u.s. ambassador but that is the concept with the distinguished career on the national security council and then i knew fred mastercard global product development and humanitarian solutions branch of maybe from the perspective of the of rolled bank. debbie will never hear about so how the world bank is thinking about the refugee crisis. >> please just call me back. when they call the doctor i think there will ask me about their elbow. [laughter] but to pick up on what you were saying of perspective as mentioned there is a number of things over the last 30 years also from a world bank board development perspective has included a real decrease solana that is driven by the liberalization of china. with the rise of low incomes but the power. >> we're having technical difficulty. >> i will turn this off. the only point of which to see real shift in the problems we looked at now. with those that we have to focus so in the conflicts day and in a particular environment where we see a particular set of solutions brought to bear. and those types the solutions to get more focused. and this goes to my colleagues to think about solving those challenges the in partnering is different railways. select the world food program related to humanitarian issues the brill bank is a separate set pet these are emerging then the big player on the scene in our conversation is the private sector with trillions of dollars of capital sitting on the sidelines. and then had to turn this humanitarian crisis into an opportunity? but what i would say is a way to think about this and to have extraordinary talents and they're trained as engineers but there's a lot of people with the influx into another country that can be an opportunity. and then to how they think about this look at the fortune 500 companies in the united states, 40 percent founded by immigrants can end the core strength of our economy is the ability to absorber people coming from other places. did they see the great potato famine? but you do have the influx with an opportunity. the another way we think about that is the refugee crisis is not a short-term challenge they will stay nine or 12 for 15 years over the decades you cannot approach this crisis businesspeople tend to stay in the communities for a long time so thinking longer-term what are those institutions could act to build infrastructure strengthening a health care system or any number of other things that is what the world bank in a place to make a difference. the wade they think about this is how recreate the regulatory environment that will allow encourage incentivize those private sector actors because that is what unlocks economic growth over time. so to think about that traditional system rule of law and labor market reforms to shift those dynamics or those who are there will grow or expand economic activity. >> what is the world food program doing in response? >> we are supporting 6.6 million refugees around the world of 32 different countries we have been involved in supporting refugees but what is interesting in this context. >> your microphone is working actually. the global refugee crisis has changed there is a different context from the past. remember those refugees and domain this crass but they were over there. with that humanitarian community that did its job out of sight and out of mind how those host countries were supported as well. and now we have a context where millions of refugees is across from europe not uneducated people they are middle-class they're educated as the same aspirations that we have and we have large numbers of refugees that anymore middle income context. so as the presence summit pointed out, the current response committee structure has been overwhelmed and it is incapable and the current structure. water redoing? there is a humanitarian lovell that has to function better. the new refugee paradigm they're not encamps but urban settings. sodium idea you will gather together to handle resources along their works that is a private sector partners like mastercard was the teacher for the when community to learn the electronic negative card and the debt it card that we can give to refugees and displaced people to those beneficiaries of the local population as in lebanon to go to local markets, by what they need and what they want to buy. and we could not do that if you years ago. but some on aspects are moved to the other refugees situation as well. it is unjust and efficiency that the humanitarian activity because it is madonna as an example -- led the non as an example for hundred 50 commercial shops of commercial traders and a half seen the infusion of $720 million over last three years that is the economic stimulus that the programs can point in there because of mastercard to share with the community. that is very important. at the second level we all recognize countries like lebanon taking in 20 percent of their population they just don't have the infrastructure to support this level of additional people. you have school children children, hospitals and then issues like jobs. with that same response capacity. to enable the host government to create the environment and just to play in the context of the refugees of a benign and jordan those of ours educated as we are to have the same aspirations and expect them to stay there you want them to have opportunities so it is incumbent upon the community it is a global response ability to address these issues. so much of the refugees situation is created by conflict. then there has to be a political solution. >> why is mastercard involved in the refugee crisis? put it that way. >> using the words with that ever structure to give aid to people really quickly. of that what has then made available and then use those to give water vouchers it is close to the heart. and with those communities for a better tomorrow. for those in need to be included financially. and then to keep that straight and that dignity it comes down to trace and that one refugee said i don't have a choice about anything. i don't have a choice where i sleep tonight. i don't have a choice of what my children wear as what i was given a only have a choice of this card to go into a shop to decide what to buy if i die before relied for my child in case they become ill. and the speed with the private-sector. >> so just talk more about that trip when you were there. >> in was usually in stifle. >> who brought you put. >> thank you very much. knowing myself well enough to prepare emotionally for some of the stories and then when you your mom talks your son in syria and have to make that decision as to expect better you prepare for but it is what you are not prepared for that you hear fat when they say that has become the world's capital and it has never crossed my mind. but they no longer know where they are. there is a bigger crisis here to be addressing. to meet with the family had no idea. there was of a group of us and then telling us about the journey. and the baby was born in days said but then keep moving. as they were crossing into greece then the baby came out of the hospital went to the refugee camp that she could not stomach the fuji was weak and frail yeah their children reinvent we made peace with the fact we were going to die every had the discussion and that is where we were. but then they gave me the mastercard prepaid card it saved my life. when you hear somebody say that what does this mean? i have the ability to baby beef -- to buy before rely and food that we could stomach then you realize how much dignity the option of choice can bring people. in to meet with of brigadier-general. and those personalities but i was expecting a military type of person and a compassionate man talk about how to understand these are the people. but how do we do that? it is even like having salt and pepper for their food. and that this is the crisis right now. and so how do we correct that? how do we integrate that? how do we cross the language barrier? or to speak greek but digest gives a very different view. >> above you to respond but also talk about what the world bank is doing with this very dramatic picture. >> what i want to pick up on is the point about the people incorporating of line of the things it is very hard to be successful to support refugees so while those discussions go to the people across the border right spent time 80% is living in the towns and how you support those host communities he will not have success for the refugees. the other piece is the notion the sooner that will let people be too comfortable that they will stay here forever. they're helping people in their economic paths. the bank for the first time -- >> has created ability for middle income companies to borrow from the bank to help the refugees come into the countries and help the countries as well. we created a facility called the global concessional finance facility that allows middle income country piston borrow from -- countries to borrow from us on in interest basis. if your were middle income country you should be able to pay market rate in this inthe jordanians and lebanese government said why should we keep piling up debt. whether win doing something is a broader global public good important that we do are doing whether we want to or not. we said that's actually makes a lot of sense could we created a facility which will support them and bring our expertise and help enemy design programs that will help to absorb refugees. from atlanta we realized that is very good but there are many more refugees in africa than middle east, and a number of countries in that region are members of what is called ida, our operating unit that lends and gives grants to the poorest countries to in the world. so we're proposing and hoping to get funded through a lee plenishment that happens with all of the shareholders of the world bank in the next couple of months2. billion extra which goes for ida countries who are absorbing refugees. and the thing to keep in mind the olders and largest refugee camp in the world is in kenya and people don't talk about that so much. and the refugees throughout the great lakes region, africa has been dealing with any number of these issues a little bit more of the spotlight burn thing is we have to shine the spotlight and help the countries as they absorb refugees. i would just say in closing this is part of an effort to think innovatively how hour capital can be impactful. we think of ourselves as having bold capital, and bob reuben used to say capital is a coward and normally in fragile situations investorred don't want to go. the bank walks into this situations hopefully with an instrument that is helpful and we have been trying to become that that more broadly, not just the refugee situation but also in thinkings about pandemics. we created an insurance product that countries can buy so we would get money very quickly on -- so instead of waiting and adding up the costs and then paying a country, after a certain number of casualties, after a certain size earthquake, country gets the money right away. the point in the pandemic is that keeps the pack dem mick from take -- pandemic from taking off. so we're thinking about new ways we can innovatively use capital to address these broader transnational challenges and that's a long-winded way of answering the question what we're trying to help countryies helping refugeesed. >> there's a -- the short hand in washington is ida 17 or ida 18. so you talked about this international development association act but in addition to the specific moneys, isn't there also some additional agreement or focus there's going to be this special low-interest loans that the international community collects from countries very generous countries like the university of germany or japan or canada and the moneys will be used to target specific countries and specific facilities or intervention you talked about? >> we're going to make it available. we have in mind certain countries are more likely to come forward and ask for it but the key with the two billion i mentioned we're hoping to raise from the shareholders is that it is money that these countries can access separate from what they were normally going to access for whateverles they wanted to the do circumstance spate and above. >> the idea is if you're a country very poor and you're weighing, do we borrow in objector to an serb the hundreds of -- absorb the how much thousands of people who have come across our border or for to are build roads or deepen a port. the idea is we don't want people to choose. we want people to do what they were going to do plus to borrow to deal with the refugee situation. the thing i would say about this that's really important. you're here in washington. this is really core to the u.s. needs to come with a very good contribution. people need to understand how important this is for our leadership in the world but also for the bank, for its ability to go forward and do what wants in conjunction with all the things we're doing bilaterally, and as an example i would say at the bank, at the board, we're pushing a lot of countries to come in for the first time. so pakistan, which is not an extraordinarily wealthy country, for the first time is pledging they'll contribute to ida. and that's the thing we hope to foster and see and the kind of thing we need to keep in mind as the largest donor to ida over the bank's 70 years we need to keep push ago countries and make shower we do the statement and maintain that leadership and continue to show significant support for these efforts. >> so john, would you please explain a little bit about what -- how-what are the gaps you see in terms of the response to the refugee crisis? the first question. and the second one is, i think we can all agree in this room that the challenge that we're talking about here is going to be with us for the next eight to ten years. the next administration is going to have -- win of the things in the in box. so if you were on the national security council staff, john, or having been on the national security council staff 0 senior adviser to the aid administrator or policy adviser to secretary of state or you were an adviser to the next -- in the under world bank -- the re-upped world bank president. what would you be want the southeastern leadership to think about. >> it's always nice to be able to use the president's words rather than my own. >> you're very diplomatic. >> when he said we need resources. his call was for the global community to step up and realize even in the most fundamental sense that the humanitarian level we're not even might those needs. >> let's double-check on that. there have been -- there are acts by organizations like the -- we need $100 worth of goods and money and cash. don't think you're getting your 100 percent of your act. is that correct? the pledges and what you're actually getting in the door aren't the same number. is that correct? >> for the refugee programs that we're managing right now, just to get to the end of the year we're $300 million short. >> are we in arrears in. >> the u.s. is never in arrears. >> that's a good answer. >> it's just it could step forward more but never in arrears. >> but i think it's -- the president said we need more resources from more donors, from the private sector from everybody needs to step skull realize this is a global issue. number one. i think one of the things, if i do just use your question, there's a tremendous amount of knowledge going on and world food program works with the bank on social safety nets, just as an example, and if there were -- if we were able to expand investments in social safety nets where we give the host government the capacity to take care of first their own people, with the basic needs, which we all take for granted, then by default those government's have the ability and systems in police to tate care of refugee of i they came in so we wouldn't ha to good and build things. there are certain longer term things we could do as a global community to encourage countries to give them technical capacity to build their own social safety net systems in their own model, but that would become a resource for all of us as we move forward. so it's a very big thing, and collaboration between the private sector and the bank and -- how -- >> what is -- gee the international food policy research institute here in washington. one of the biggs think tanks on food security. but in any event these are the kinds of gaps we need to fill globally. if you were talking pandemic if we have basic healthcare systems in countries you have a much better forecasting ability on when some disease might start popping up. and the sooner you know, the sooner you can act. so all of these things -- again, the united states takes for granted can actually be put in place at some level in every country in the world. and if you build off of that foundation i think we'll see real improvement over time. >> i want to just come back to matt here and i want you to -- if you were in front of a congressional committee could you just make the argument for why should the united states participate in the world bank, a., and, b., why should -- what is the argument for supporting ida 18? i can give all the reasons why i think we should but yao it would be important for you to give those. >> fundamentally it's about global leadership who america wants to be in the world and historically we have been so central to the creation of the post world war ii bier national financial architecture. we were one of the core founders of the world bank and imf and central to thinking about any number of other multilateral institutions and making sure they bring more and more countries into a global rules based order that really is the benefit not only of-under our country and so many other citizen is in the world and the wonk bander and other like-minded institutions have been a core piece in helping see the reductions in poverty. so one issue is who are we as a country, what values do we want to lead with and it's important we continue to stand strong on that. the otherring this that when we think about the stability of the regions of the world, we have to think about the economic health. the bank is full of economizes and experts across a wide range of field which are working closely riff foreign governments who -- with foreign governments who call the world bank when we need advise how to to think about climate change and having a more sustainable economy. oh due think about the pandemic which is two countries away. so the final thing i'll say and this is quote, a woman at the eu, former corporate secretary at the bank and wrote an article i realen videos called "trouble travels." and the other more self-interested thing to keep in mind if we don't address these fundamental issues where they's, trouble travels and we'll deal witness itch one way or. no man issues that air political issue we laugh do come up with and other instances there are development and economic enter generalizations to make and it's important if we want the world to operate in a way we think works most successfully that we are supporting the institutions and the u.s. continues to be strong and the rest of to the world can see it. >> nina, can you talk about your have some interesting corporate partnerships and you talked about doing good and doing well. just talk more about some of the organizations you're working with, a., and then, b., talk a little bit about what does mastercard's -- when you partner with an organization like the world bank or some part of theun system what are some of the thinks you want that organization to understand about what mastercard's capabilities are? i sometimes am sure they often times say, great, just write us a check. that would be great. but the conversation you were just describing, the picture you described, at the technology is a lot more powerful than just writing another check. so i'm curious about that. >> most of our relationshippers are not about the check. i think a lot of it goes about the education because people go to mastercard? that's a credit card or you give credit to people who don't have money so a lot of it is about educating people from a financially institution perspective but also why are we doing this? we also look at financial inclusion which a lot of this -- a broader perspective saying the six billion people not connected in the the today, what is the actual impact and look to -- when people are not connected, all they're connected to power, are they connected to electricity, do they have water? what does that look like and how can we hope all those ecosystems. all about building a better tomorrow and with partnerships we can do this. in africa we speak -- there's an excellent -- we speak about if you wash don't go fast go on your own. if you want to good far, go together and go in a group. and that's what we are doing here. getting the right partners in a group and the right-minded people together to say how do we could tis? where it's facebook, world bank, wfp, we are all trying to make the world a better place and we can do it more efficiently when we're doing it together and leverage it. master card as an astro nominal footprint from a global perspective. if you actually think about the world we have got it in the net already. with have the connectivity points. we can reach people quickly. we manage to move quickly. we can move whether it be financial, commodities. we have a network to support that. we are present in over 200 countries. so, all of that makes a huge impact on what we bring to the party and we have the data and we can flurries what is needed there and we can help and we're prepared to bring that. we can -- are doing it from sustainability perspective. sure we have the mastercard foundation which does -- the mastercard center, which looks it's are at it from a disperspective and then the commercial side of the business where we -- things need to be sustain april. you've due things for free they're not sustainable. however you do not have to charge premium prices and if everybody can still make and do things more efficiently it works and it becomes sustainable and become repetitive. >> john, we are having a conversation at lunch about the merging of development and humanitarian response. can you talk about how that is happening and what does this mean for the world food program and other organizations and i'd like matt to comment on that from the world bank perspective. >> i think the big change is nat that in the past organizations were happy to -- just do their job. if the delivered their food or delivered the suppliesed 0 whatever, job well done. and now there's really a recognition that it's -- life is much more dynamic than that, and we have power in the resources we provide and we need to use them fully. so is a used just the example, with the right tools, the card, instead of handing out food and just doing nothing to stimulate anything beyond giving people a resource, the card gives the resource gives choice, gives dignity so it's already tripled its value, and then it stimulates the market. it is dish would argue that when the market is happy, and the community is therefore happy there's more stability, you don't have as much resentsment of people taking over things or replacing systems. so, the humanitarian community has to be much more focused on development, and even in wps fundamental work with food assistance we have to really understand markets. not just who needs assistance but loud they need assistance, how that assistance can add value to the market structure to transportation systems. to everything. so, then can it contribute to technical assistance sniff we're doing a school feeding program in a country and we're not helping the government learn how to take the system over, then we'll be there forever. if we teach them how to run their own program, they can take it over and, pour importantly, if we can integrate local agriculture into the program it becomes something the community values. the kids go to school, the farmers are selling goods, the government is getting recognition for providing a service to a community. so, these are broader things way beyond just the humanitarian action. they have developmental impact and we all need to continue to look at how we can use our resources in a much more dynamic way. >> how is this impact the world bank group? >> first some of the thinks mentioned earlier, the financial innovations moving to us think about how we deploy our capital more creatively. that's one piece. the other thing i would say is deachening into different sorts of partnerships like those that john and nina talked about. that's another piece. and think the third is just thinking about what are we learning and seeing out there that ought to shape the way we do things. two quick examples that perhaps people wouldn't think of when they think of the world bank. firsting picking up on the-of basic nutrition and feeding people. we have come to realize through tons of research, not just the bank's but james heckman in chicago and other places, the importance of early childhood nutrition on basic cognitive development and how important it is that children against the right nutrient when they're very young. it matters because from a development perspective, an awful lot of countries have 40, 45, 50% of their children who are stunted, meaning have low height and weight, which ties very closely into cognitive development. it's hard to see an economy really thrives if 45 to 50% of your children are stunted. what we have seen through our program. s in latin america, reductions by half of stunting over the course of ten years. so, in peru, building on a program called -- which i believe you were part of getting together way back when with the brazilians we have been able to reduce stunting in peru from 28% to 14. that it remarkable and then tying it into how that fits with strengthening institutions more broadly. that's the other piece i would touch on. that's we know how to do well and have done so for many years so the question is how do we strengthen the rest of the educational system so it's more connect to 0 where at the world economy is going on and so on, and on example is how da we utilize new technologies. i think mastercard is a great payment platform. penal thing officer as a credit card company but they do payments and transfers of money. so the kauai who is does that matter from a development perspective? the roenis some countries -- anyway as an example -- there are an awful lot of benefits going out in deathsal mode which reduces leakage or the possibility that i ends up in hands of someone else to the ewan of baseballs of dollars. a country with poor people that want to change that county now you the billions of dollars to come week in bank and say what's the next project you think might have be biggest impact and get in that discussion. >> host: that money more effectively somewhere else. so the point is that there are all sorts of inknow vacations taking place as we understand the linkages between mere humanitarian fields and more traditionally private sector activities to overall economic health and growth, the more effect enough advising countries and promote val united states we think here in the u.s. can make a difference around the world. >> great, this has been a very patient audience. thank you for being here. i want to -- i see a lot of thought. people in the room. want to call hundred enough friend, andrea koppel from mercy corps who is here. please give my friend the microphone. thank you for being here. >> so much, dan. i guess my question is for matt. also in ida 18, there's a two-1/2 billion dollar carveout for the private sector. could you elaborate on how that is going to work and how the bank is going to ensure that -- because the money will be going into this fragile countries, where often there aren't functioning institutions and whatnot but how you'll make sure that the money is going where it's supposed to go. thank you. >> i want to take advantage of that and ask -- john i want you answer the question how do you work with ngo's like mercy corps on responding to emergencies and then, nina, i'd like you to answer how you work if the ngos and porter in with them. you talk with how you partner with multilateral institutions and i'd wonder thank you you partner with in ngos. >> thinks for the question. after yao i have to be real year the u.s. congress has appropriated the money for ida yet so these are up proposals the bank is coming forward with. we're in the midst of discussions and quite hopeful these things we realized and i would mention again we're about one of the countried. white we're the largest contributor i'd da, any number of other countried, dozens are contributing as well. so this is a longer and more involved process and i don't want people to leave here think this is flocked and done. there's real two, come. in terms of the private sector window, as it's called. about a third of the bank's lending and investment goes directly to the private sector, the other two-thirds go to governments where they're middle income or the lower income countries. that is through something called the ifc this, international finance corporation. so that's business that we have been doing, and when you think about -- and what goings to are companies that are doing things which increase economic development in any number of the countries where we work. we operate in 120 countries. so, that's something we have already been doing. as you might expect, and to your pointer where you tend to have stronger institutions, more creditworthy banks and more reliable regulatory environments tend to be in slightly wealthier countries, ifc has not done as much poorer countries over time. this is an effort to set aside modify specifically to push harder on the front. and one of the things i would cite is there's a book recently called "rich people, poor countries" that talks about how you reallyow the economies of very poor countries several had some fascinating statistics showing that about 30 to 50% of exports in many developing countriesed come from the five largest companies in the countries. the point of which is if you can identify the local entrepreneurs who are really growing rapidly and support them you can see huge hiring and job growth over time, and so that's part of what ifc is hoping to do howl to identify those companies and help them to expand, and then importantly, how do we also show again being the more bold capital, show other investors the ifc is in there we've made good money and other people may be into ited to come in as well. the final thing i'll say is in the course of that, is we don't just go in and lend money for project fbs or to investment in a healthcare company. it always goes with advice. so we always say we have financial capital and intellectual capital and bring them both together. so, for example, if it's very hard to start banger -- start a business, hard to expert because of customs regulations, those are discussions we are having in parallel with the investment to improve the investment climate business climate and we have substance report which gets attention which ranks countries on a number of indicators like energy provision, how regular it is, how long it takes to start a business, whether or not you can declare bankruptcy, whether or not one has an easy time in resolving disputes. always the other things and that's the tool we have to point the light at different countries and say, here's some things you ought to be working on to improve over time. so it's part of a much more comprehensive effort but one that we think is quite timely and we're hopeful all the shareholders come in and really allow ifthrough do even more in those poorest countries because it's so important for our overall mission. >> so john, could you talk about how to work with the network of partners. there's a whole user of nonprofit -- a whole universe of nonprofit organizations and you must work with them to do your work at the world food program. >> we do, and people way say the ngos are the last mile implementers for wsp and whale tight true in one context, there's so much more, and i think it's -- when we talk about innovation, a lot of the times the ngos are the incubate years to some of outhears creative info vacations and transfers and debit card the ngo communities began investigating that and test it early on but wfp can do with the ngo community other partners is take the things to scale. we have the are symbiotic relationship. one wouldn't work well without thes could also implementing firster ins so we needs them for in men cases the last mile, but it's just one facet of the need partner. the nogs we need partner with, the private sector. our partnership with unhcr and refugee response is almost where -- we're practically married because they set the standards for targeting, but we have a lot of in the impress tools so we have to work back and forth with them all the time, and it wouldn't work without them. so, don't ever think of it as a simple relationship. it's very dynamic relationship and one that we're going to rely on for a long time. >> talk about how you work with nonprofit organizations as part of what you're doing in the con tsk of refugees, nina. >> sure. every crisis is different. every country is different. every need is different and that's how we approach it. we have not gone with a one product or one solution fits all. so, therefore, we understand what are they trying to do, what they need to do it what are they trying to solve, and we go in and help solve the problem. whether it be something where it's out in the middle of know where and there's no connectivity. we have specific products for that. how do they get the echo system -- ecosystem to work or whether it be in mainstream cow country and they want too toe get peopled money but they need access to cash. we literally go in and look at it and i wouldn't say customize but we understand the need and we build accordingly and we have a system to get another throughout are out there. it costing the ngos to get that stuff out there. if the difference whether it cost five dollars oar one dollar, difference between it's going to take two weeks to get something out 0 or we can do it in 24 hours, a difference whether they need 50 people to get it out there or whether they northeast one person to get it out there. those are the thing wes look at. the efficiency, the insight we can bring to to them through data, system build, partnership, what else we need to bring in many cases a market organizer, bringing the right people together to make sure it works. >> great. thank you. other questions and comments from the thoughtful audience? yes, please. this woman here. >> thank you very much. i'm with the united nations development program here in washington. great pleasure. wish we had met before in person. i'm inspired by your experiences. there's two questions perhaps i'd like to raise. one is local authorities. a lot of our experience is that is the burden and the onus of responding, not only to the host community grievances but also to the income communities in jordan or in turkey, and lebanon, local communities, how are we working together with the local communities that one area that i'd like to ask. ... >> >> it is also a matter if you move of the money directly into demon hands that is part of why we think about design along those lines. you are exactly right when we were in jordan, certainly we make sure to meet with the appropriateness tears but it is the mayors to do what they want and then you ask the questions would is useful to you this goes back to why it is so important to strengthen those host communities there were about those core constituents. there also drawing on decades of experience of absorbing refugees 40 or 50 years with the palestinian immigrants. you appear what is the most beneficial and this helps to shape the overall design. this is part of what they have learned over the many years how we have the greatest impact. >> to land directly to national governments? >> made do a lot of work there is a gray area with those recommendations in our cases it is something we have to navigate to which we can do that but one of the things i would say is that in many cases the municipalities is today have the capacity to absorber this many are there ways to help build those entities overtime they will be stronger? it is a case by case. >> how do you work with the local government on a national level? >> we have a very intense engagement at all levels and also with the banking sector with the local government employees to teach them how to attract the refugee data that they can report what is going on and we're asking the community to help identify the weirdest providing assistance to the syrian refugees. so not only constantly assess but also food the vulnerable are in no local community so everybody has a better understanding so would then say huge amount as well. then working with the universities in the area to help us understand what is happening in the community. because we don't claim to know we need locals to help us understand what is happening. but there is of bias to do capital engagement. we paid a very stark picture . what is the ability that you have to get a permission slip? i am not sure what the arrangement is if it is very difficult if you of an agreement with the national government. >> that we have the blanket agreement depending on the country to be more controlled. >> i am making this up if the national government is the red sox and then the city government laugh laugh benzines there are many developing countries of these opposition party is controlled and then controlled by the other even then terrible emergencies. so you had the ability idol what you talking to that mayor? you have the ability to say no. >> is complicated. [laughter] i wish there was a simple answer but then they have to work. there is a sense of the aid fit there is a heavy bias toward capital. yes there are examples of government financing five under the belief to have a permission slip to work with these governments with the changes of urbanization with the red sox and yankees example. >> but they wouldn't say we need to speak to an official pet meet with those to give us the information to get the job done but the national government would want. >> we all presume and we hope. >> tuesday we need to get into this area and it is presumed we talk to the local officials to get that information but sometimes it doesn't go the way you want. >> part of that goes to reputation if this fair and honest they often have more latitude than on a bilateral basis. because they do tend to have a different credibility with an awful lot of places we can say we just did this of 200 million people this is so large country so to take that here is what worked and he did read any news stories about us then people will start to not their head then you go to the next one. also with the brand and the reputation. >> >> usaid. my question is more about corruption to what extent that builds into your free mark? >> what about corruption quick. >> also financing of development b.c.-- today consistently to make us more accountable as we should. how do you build that into your system? >> we will do this world bank style and gather a couple of questions. >> what role d.c. more traditional aid programs like food or airdrops? had you plan on integrating them like the monetizing markets credit cards or prepaid cards? >> correction is said great question with all three institutions especially in the emergency response that is something i know the role banc suspend the lot of time but also the issue to reduce corruption. >> part of this goes to the challenges the, corruption but we have the series of a group of safeguards upon those conditions that protect us by ensuring the certain valuation by doing due diligence or any number of things that we try to institute the likelihood of the world bank project. isn't perfect with the system is in place with a new set of safeguards that will hopefully straighten that to minimize the number of times of those corruption challenges. to utilize the knowledge network to explain what they're drag corruption is on their economy by showing when you eliminate use see many more benefits so part of that is going back to the resources of the intellectual capital but those ways that our problematic the final thing that we haven't place where someone sees corruption they can come to the independent body than hopefully over time people realize you have a strong set of rules. hist. >> we will do with the question first. you worked in some really tough places heidi major nobody doesn't take an extra food to give it to the militia complex had denature they're not taking commodities then selling them on the market? >> we do think about it everyday is very hard none of the organization's have a report that they are involved. and then segue over to the new activities not only do we have the biometrics to ensure giving cards to the right people and not giving them to them twice to have visions going fiver six times. >> but the biometrics are really taking care of that. miso 15 or 20%. >> to eliminate duplication

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