tv Chelsea Clinton and Devi Sridhar Discuss Governing Global Health CSPAN March 26, 2017 11:00am-12:02pm EDT
>> good afternoon, one of the exciting things for the day and exciting moment and i have the honor of serving as the dean of school of public health, for all of you that are here for this exciting afternoon, i'm thrilled, welcome you. and also thrilled not to stand in the way of a great conversation, and so, i'm delighted to introduce our moderator, well-known to all of you, i'm sure, michael, the chair of the department of health policy and management. michael. >> great. [applause]
>> i'm michael and my job as moderator/host today is basically to introduce chelsea and devi talk 20, 25 minutes and let you guys ask question and i sit and have a whole back and forth with them and i say now it's time to go to reception and have some wine and that's my main job. before i do my main job, i just want to say a couple of quick things, three quick things about this terrific book. first thing i want to say, as you'll hear, i'm sure, this book contains four case studies of leading global health organizations around the world and uses those to provide extraordinary insights into where the world of global
health is and where it's going. and in that sense, it really adds tremendously to the literature and what we know on this topic, that's number one. number two, the book also, in a really interesting way, and unusual way and i think in a pretty unique way, in those case studies, it looks at how those organizations are governed, what their rules around governance are, how they are financed, how transparent they are. it takes a look at all of the issues and tries to use that as a lens and find out how impactful and influential those organizations are and trying to correlate the governance, finance and transparency and i think that's unusual, unique and important. last thing i want to say about this okay, in addition to specific case studies, the book also really examines and considers important, big important questions in the world of global health and the
world of public health generally. for example, just to give one example, i think, you know, as the authors point out, there's a long history in global health and public health more generally of vertical disease-driven initiative. at the same time, it's argued by many that horizontal, you know, health systems approaches are really, perhaps, a better way to truly improve health. and one of the things the book does, how will the changing trends in global health and the new kinds of organizations that are coming into global health, how are they dealing with these issues of vertical versus diseases and versus health systems. they're big and important questions and i think the reflections that the authors have really add so much to our knowledge about this. that's all i'm going to say, now, i want to introduce the authors and let them come up.
first, devi sridhar, i gather just got off the plane a few hours ago, from edinburgh is the professor and chair of global public health at medical school at the university of edinburgh. edinburgh, right? she directs the global health governance program there. she works closely, and i think this is really important, with ministries of health in both low and middle income countries around the world, really in an effort to sort of help translate the kind of research that she does into action and in places that really could use her advice and use her guidance. she also is a regular commentator on bbc and numerous other media outlets. she received bother her doctorate and masters from oxford. i recently learned, actually and i think this is one
interesting fact. i learned that when devi was 18 she became the youngest rhodes scholar in history, which is quite, quite an accomplishment. so we're really, really grateful and fortunate that she's here and that she's co-authoring, co-author of this book with chelsea. devi's co-author in this book is chelsea clinton, who we kind of feel just sort of one of us, is one of us here at columbia. chelsea is the vice chair of the clinton foundation. she focuses in particular on the various health initiatives that the foundation has and work that the foundation engages in around the world. she has her doctorate, also, from oxford. she has her masters from a school called the mailman cool of public health, health policy and management. and she is also a professor, an assistant professor here in the department here of health policy management.
in fact, i would bet there are some people here in about two weeks are going to be sitting in on class number one of chelsea's class, global health governance and she's been pretty busy writing books recently. last thing i'd say about chelsea, she has another book you may or may not know, came out in hard cover, called "it's your world, get informed, get inspired" "get going", something like this, came out in paper back and she'll be beginning a book tour on that, we're incredibly greatful to have chelsea and devi with us today and i want to turn it over to them and formally welcome chelsea and devi. >> thank you. >> thank you. [applaus [applause] >> michael, thank you so much
for that introduction. linda, thank you and to everyone here at the mailman school for hosting us today, i also want to thank sarah russo and everyone from oup, our publisher. i also see we have a very young member of the audience here, we both have very young children so please don't worry about if she feels the need to make her voice heard as well. actually, while we were talking before coming out today, devi and i realized while working on this book, we had three children between the two of us. so, this book grew out of our research that we each had conducted independently on the world bank, on the world health organization, the global fund, and then a series of conversations we'd had with colleagues and each other, gaps we'd observed in the scholarly literature around global health governance and we couldn't find a resource that examined the questions that michael talked
about in his incredibly generous introduction. looking at the four big institutions in global health as judged by resources commanded in order, the global fund, the world bank, the world health organization, and davi, we wanted a resource that we could reference as well as use in the classes that we teach on either side of the atlantic, that examined these institutions in a comparative critical way on their governance, their financing, their transparency, their accountability. since we couldn't find it, we decided to write it. so, indeed a couple of years and three kids later, here we are with two parts of the world and why. and we thought we'd share a little of what we discuss in the book and really would welcome your questions and we particularly hope that students ask questions.
i know that there are indeed some students here that will be taking my class later this term and i also recognize some of the students i've had the privilege of teaching before. so we just are so excited to have our first book event for our, maybe fifth child between the two of us, if books are also sort of like children. here at a school that has meant and continues to mean so much to me. so, a few reflections from the book and then we hope that we can have a conversation. so, the four big institutions, we always find, it's surprising to our students that the world bank, for example, funds more global health work around the world than the who does every year. and we also find our students surprised to find not long ago the world actually didn't have the global fund.
and one of the questions we kind of use to frame much of what we query and at least attempt to answer throughout the book are what are the differences between the old institutions or the more traditional multi-lateral institutions, who and the world bank, versus the newer institutions or what are more known. >> and what are the key differences between the older and newer global health entities. the older institutions seem to have rather broad and ambitious mandates. whore, the attainment by all people of the highest possible level of health. sometimes i think one of who's kind of challenges in the world
is because it's called the world health organization, we tend to think it should be able to kind of do all things for all people to ensure that we each have the chance to live the healthiest lives possible. the world banks alleviate world poverty and improve quality of life. those sound very different than the more kind of problem-focused and kind of narrower mission that the founders of the global fund and g gavi, and they fight aids, tuberculosis and malaria, and to increase access in poor countries. i think the difference very much is evidenced kind of on the major itself. the second big difference from the sort of who enfranchises the institutions, who gets to help curerate the agendas and
strategies that they employ to achieve those agendas, how they hold themselves accountable or not, who they partner with, or don't, i know these may look a little silly, but when i go to the next slide you'll understand. the world health organization from the world health assembly, kind of the ultimate governing body of the who as well as the executive board kind of the entity that oversees the work of the w.h.o. on a day-to-day basis, the membership of these bodies are member states, national governments and their representatives. the same is true of the world bank. that looks very different than these slides that are much more colorful because the membership of the governing bodies of the global fund and gavi are much more diverse, compromised of
national governments, as well as private companies and ngo's. so, we think although this slide may seem kind of a bit absurd when it's stand alone, the juxtaposition is fairly illuminating, and this form of government and the enfranchisement of nonstate actors is something really the world has only begun a grand experiment with since the new millennium. >> thank you for all for welcoming me to the mailman school, i'm glad to be here. the first question we look at who pays for the institution. if you follow the heart of the money you look at the policies. we first looked at the w.h.o., the organization we look at chief coordinator of health
work. the budget has skyrocketed 80%, but increased over time. and what it means 80% of your budget is earmarked by specific donors for specific causes. 20% is what the director general actually can say what it's for. this is, for example, norway and sweden saying we're going to give you $10 million for this or, the gates foundation saying we'll give you $50 million for this. if you're director general and trying to run the organization or have a board, how much do they say over the priority if 80% of your budget is coming from earmarked sources? and actually owl of these contributors as they're now called. so if we just take one year, very illuminating, you can see a huge chunk comes from the gates foundation, the u.s., u.k., and several others and you can see there's a few key donors that pay a large influence to the institution. earlier with chelsea, the governance of the state, but look at who pays for it it's
not just governments. this is ida, which is part of how the bank finances its health work. one of the arms. and over time, ida money has grown and goes to the poorest country and largely finances global health and social sector whose. and again, growth over time. and who pays over time for the ida replenishment. and a similar list of donors, u.s., japan, germany, united kingdom and france and if we look at one year again, we pulled out 2012 to 2014 at the replenishment, you can see the u.s., 15% the u.k. at 15%, so on, so forth. notable that the u.s. is the leading institution in terms of financing the bank's ida. and where is the money going? i'll come back to this at the end of the financing section. a lot goes for health systems, the blue. and it's global based and
problem based initiatives as chelsea discussed with gavi, the world bank spends on hell systems and goes against the kind of trend of focusing on diseases. and trust funds, many people don't realize this makes up a lot of money shown in the next slide. what are trust funds? these are that donors can set up for specific countries or projects. give an example again, norway can partner with the u.s. and say we want to do something in maternal healthen they pool the money and set up the governance and can run it through the bank. the bank holds it, but actually the financing and governance is separate. they're called trust funds, they're separate to the ida, kind of what i call the back source of the bang bank in a way. >> it's hard to look at the trust funds if we plot it and the green is trust funds, you can see it's the biggest lines, it's a lot of money going into
these and i want today draw attention to those. in a way similar to the earmarked funds, just a different modality. if we look at global funds, what are its donors, it actually is the u.s., france, the u.k., 95% comes from bilateral donors and hopes for partnership, they would attract new monies from private sector, from philanthropies, from a broader sectors, versus the financing base, but most of it's bilateral, and 4%. the gates foundation and rondelling red you might have heard of, private company and is percentage goes. and gavi, and gates playing an important influence, 25% since it started and then the u.k. here and then the u.s. so, what comes out here, just to kind of summarize, what does the financing sector tell us? a lot of the growth in
financing, i think it's estimated about two-thirds since 2000, that's come from three donors, the u.s., the u.k. and the gates foundation. so while we think of global health as this global activity, more and more initiatives and partnerships, actually the core financing base has narrowed down to three and that's made interesting and difficult positions for the director general or the head of the institutions to be in when you're depending on a few donors for large part of financing, i'll turn back to chelsea. >> one of the areas that our students have gotten increasingly interested in is how much can they know if they're curious about the work of any of these four institutions that we focused on. how much can they themselves discover? how transparent is the world bank in what it chooses to finance? how transparent is w.h.o. in who it chooses to partner with? how transparent is the global
fund in what it chooses to provide financing for or not? how transparent is gavi in who it choose toss work with on new vaccines or not? and the answer varyies fairly significantly across these institutions. and the answers vary not only with respect to the public, but even with respect to some of the partners and the constituents that make up the governing bodies of institutions themselves. this is important not only because of an increasing norman expectation that all of us think share that we should be able to know kind of how our tax dollars are being spent and invested because ultimately the bilateral donations that the united states makes or the u.k. makes are financed from our respective treasures, bies, but
whether we may want to work with those institutions or partner with those institutions. for those of you interested in academic careers, how easy would it be to do research on those institutions or not. and so, as you kind of see in the kind of slightly populated graphs on the screen, all of the four organizations, but for the w.h.o., have open information policiesment you know, what those mean in practice varies, but the global fund and gavi are often cited as real leaders in being transparent and open and acceptable by the national transparency index, by publish what you fund and kind of the watchdog organizations and yet, the world bank, which has been probably of all of the
institutions that we engage with, the most scrutinized for being the hardest to actually scrutinize, has made significant strides in the last six years in being more transparent about what it funds, where it funds, its contracting and of who it partners with and who it doesn't. the who provides very little visibilities into what it chooses to fund at a granular level and how it makes decisions and we call that out here because we think it's important to note that kind of the institution most expected to set kind of the global health agenda, the nugs institution that has the ability on this screen to establish real norms in global health, the only institution that has the ability to engage in hard power, treaty
obligations, it would have those enforced, if we're thinking about the tobacco control convention or other work we think that w.h.o. should engage with, it is the least transparent and the hardest, arguably, to then hold accountable or to hope to be able to persuade it to engage in moving the world toward greater health for all. and so this is something we actually spent a lot of time on in the book, but will now admittedly pass back to devi for some concluding thoughts and then open it up for your questions. >> so the last big issue that we look at is how easy is it to reform the institution. if it's doing something you're not happy with as member states or sitting on the board, how easily can you direct the secretariat to something that
you think is better. it's different across the floor, and you'll have to read the book. to focus on w.h.o., it got a lot of eat after the ebola crisis, for dropping the ball, not being quick enough and generate enough resources to the problem. there was a commitment made, we're going to reform the institution, change some things and we have to get outbreak and emergency preparedness right and there have been efforts made, but it's difficult to reform the w.h.o. that's with those of us who follow reform. every five generations, there are reforms and going on since the '80s. and going back to transparent and accountability and trust. i think it's notable with w.h.o. that, you know, we have an ebola crisis, over 10,000 people died yet, nobody lost their jobs anywhere in the organization.
and it just comes back to the you shall an of accountability and responsibility and making sure people are responsible. and the agency should deliver on those objectives. >> and i would quickly, to jump in, one of the things i think will be interesting to see with the new director general, whom ever emerges from the election in may at the world health assembly, is whether or not that person can reestablish bonds of trust, excuse me, with donors, but also recognizing it's not only donors and member states, it's increasingly the global and public policies that needs to believe w.h.o. can and should be establishing norms and leveraging all of it, soft and hard power tools to ensure that those lead to protection for more people.
and required kind of a commensurate from donors. the fact that the secretary-general has only discretion over 20%. even if she had responded more quickly to ebola, she wouldn't have had resources, either human capital resources or resources to send to west africa. it's a classic kind of chicken and egg challenge and i wish i could think of a more compelling metaphor. but as devi articulated, will w.h.o. have to prove itself more fit for purpose and hopefully if the latter is the case, we won't have another ebola or zika in the interim
until the w.h.o. deals with, emergency preparedness, endemic response, health systems robustness and resilience, hopefully we won't have another ebola to tell us once again why it's so important that the world be more prepared than historically we have been, even in rather recent history. >> yeah, i think that's an important point. now, i guess, as chelsea alluded to in may the new director general of the w.h.o. will be appointed and some have called it the hardest job in the world for exactly this, because you're basically, your financing is so restricted and recruit funding from a set number of donor and at the same time you need to stand up for the world's health and most disadvantaged in the world. it's a difficult job to have to balance that. okay, so just to tie up. so why does the global health system look the way it does? that's our kind of concluding chapter, reflect on why things
look the way they do based on the kind of evidence provided before. the shifts argue into the key donors, one, they want to align the okay tiffs with our own agency and why they want to create incentives to performance, you can punish or easily reward through financing and the global fund in gavi, they want to more closely monitor what global agencies are doing, so they want transparency, not only for the public, but themselves and if they want to check on what's happening. they want to check on board levels, this is important for the nonstate actors who are increasingly important. our conclusion, who runs the world and why? we've hinted at it, again, you'll have to read the book, the exact answer, what we think. looking forward, two of the questions that we often get, are the global fund and gavi
models, should they be the models for everything. for child health more broadly. what people think when they think of models. it only works if you have results based missions and state where it went and it's difficult to do that. foo inly, what should we do with the world bank and w.h.o., what roles? the key thing is trust in agencies and you want countries and agencies and bodies to delegate and give responsibility with that and trust, but to do that you really have to, you know, set certain benchmarks and meet those and the u.k. government is doing this when you have evaluation of agencies with this criteria. yeah, i'll turn it to chelsea to end. >> another question we often get asked is this really the best of times to be living in
from a global health perspective and we think the answer to that is pretty simple. it depends on where you living. and one that has gotten attention recently partly because bill gates has spoke been it and tweeted about it, is that you know, from 2000 to 2015 annual child deaths declined from 10 million per amum to 6 million. that's extraordinary. you lose a million on the day of their birth and a million more in the first of their life. when you think a 40 decline isn't that extraordinary, yes, but as mothers of two small children, are i don't want to be on the other side of that statistic and we don't think anyone should be. so, while we still have enormous work to do, we also do
recognize that the world has made real progress. so to end on a slightly more optimistic note, we conclude our book with the lesson of the global polio eradication initiative, it started in 1988, a real coordinated effort catalyzed by the w.h.o.le and in partnership with funders on the ground partners. it is, i think, at this moment in time easy to focus on the fact that we still have polio cases in the world despite almost 30 years of concerted effort, but over those 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. so, yes, we have work to do,
but we think the moral imperative is so strong because we have proof what can happen when we do focus and mobilize appropriately. so, we're so grateful, again, to linda and michael and everyone here at malman and i want to thank one of our tremendous research assistants and she made working on the project so fun and the prettiest graphs she did. so please give her a round of applause. [applaus [applause] >> and we would welcome any questions that you may want to ask us about the substance of the book, although we won't give it all away as you heard. devi because we certainly hope you'll read it in its entirety, or questions about the writing process, or kind of other research that we're each
engaged in, we would really kind of welcome anything that you may be interested in, in discussing. don't all raise your hands at once. and, yes, ma'am, in the pink. the national fund service-- [inaudible question] >> devi lives and works in edinboro, i'll let her have the first jab at that question. >> to repeat the question, for those of you who couldn't hear, why in the u.k. when resources are so constrained and the
national health service provides health coverage across the country would money be spent overseas. i guess i-- so much i guess that's two reflections, one you look at the proportion that actually goes to global health meaning out of the country and similar to the states. we focused a lot on foreign aid and what goes abroad. it's tiny compared to what's going into the national health service there and what's going into the health care system here so it's really a tiny fraction in terms of money. in terms of nhs they're looking in terms of billion, 60 and 70 billion quite casually. here, you're talking about all of global health from all donors getting around 20. i think the proportion differences. the second thing is i think there's a real commitment in the u.k. and i think they had white papers there, strategy on this last year, global health is national health and we all live in an interconnected world and ebola really reinforced
this and they've even launched a major program called global challenges research fund that reinforce that is whatever is happening anywhere in the world will quickly affect the u.k. so for a safer and prosperous world. and they look at the money is well worth it for everyone's best interest wherever you're sitting. >> the same question is often asked here in the united states, you know, the keiser family foundation does a survey annually where they ask people what percentage of the u.s. budget do you think goes to foreign aid. and last year was 25 or 26%, i think, was the average response. the lowest it's ever been is 11%. we actually spend less than 1% and that's including, actually, foreign military assistance.
and so, if you just carve out what we spend on global health assistance, it's significantly less than one-tenth of our budget. if we look at the majority of the funds that united states invests in global health around the world. and i realize 5 billion seems like a big number, but compared to a budget more than 4 trillion dollars, it's not a big number. so, i don't think we have the luxury of choosing only one priority when we do live in an interconnected and interdependent world where if the united states had a prerogative, but also a moral and a security responsibility to leverage both our hard and soft power in a thoughtful way, i think that's partly what
you're seeing here in the united states such a robust defense from across the political spectrum of pet-far and u.s. development assistance because i think there's a broad-based understanding that not only do we not have the luxury to have kind of the thinking that we can only invest whether it's in health here at home, or kind of only investiga invest here at home or not createsoftware and support and better health agencies and outcomes around the world. [inaudible question] . >> some of the things you've garnered and activists in hiv
and other areas. in the last five years, what's happened is that water and water coalitions organizations have come together specifical specifically-- what's most interesting to me and reflective in your book is to weigh that, you've moved from sort of not only vertical single issue to more broad connect connected. the latest campaign was seven continent like 13-country campaign with breast cancer activists, hepatitis, tuberculosis activists and the
focus was the transparency of u.s. and other national western taxpayers input into their respective countries. national health and how the pricing structure and the pharmaceutical companies sort hid that cost and presumed that a all-- all of the costs in developing unique medicines were born by the companies themselves. >> well, as you may know publish what you find has been kind of pushing its work further upstream to be able to have more transparency. the whole eco system around development, and for livestream, you know, his reflections were partly now
broader coalitions across the global health spectrum tackle the issues collaborative and around transparency in pharmaceutical pricing or other areas. i think that we will see more of this, partly because the sustainable development goals are structured to encourage that. so if you look at seg's versus mg's the explicit multi-dimensionality of them and donors are looking to encourage partnerships now between kind of groups that are focused on kind of sustainable development as it's more conventionally understood and kind of environmental protection and kind of resilient societies with health systems planning and kind of resilient health systems and looking to kind of preempt and ameliorate health risk factors,
i think we're going to see just more and more of that. >> yes. >> i have a question regarding the process. i like to hear how people collaborate with each other and that you co-authored book. [laughter], what was the sort of joy and process of writing this book. >> such a nice question. so her question was what was our process like, and what was it like to co-author a book. it was so much more fun than my doctoral work was. so much more fun to have a co-author, someone to kind of collaborate with, bounce ideas off of, just talk to, kind of problem solve together than to kind of just be sitting by
myself kind of laboring in my own head, kind of in a relationship only with my computer. and sometimes my supervisor. i just had so much fun throughout this process bus it was so collaborative although we each took the lead in various areas and we produced, i don't think it's far too presumptuous, i think a far better book than i would have done if i'd only been working by myself because it was constantly analytic and the conception of it, engaging in the drafting, redrafting, re-redrafting and so grateful to have had a co-author, but even more great v to have been able to work with devi. >> yeah and i would reinforce that as well. it was really fun and i use the word fun because usually you think writing a book was a lot
of work. it wasn't solitary. >> we exchanged drafts daily and she's an expert on the global fund. knows more about it than anyone i've met. and she could say this is right or not right or she could look at graphs immediately and say this is off. now, it's really good to have someone always there and in academia we try to do peer review, send your articles away and hope it doesn't come back ripped to bits by an anonymous person in the universe, this is positive supportive peer review and nice to do it with chelsea and we both have young kids, flexibility, i can't see you today, my kid is sick and your kid is sick. luckily we didn't live in the same country and didn't spread the germs. i would encourage find someone you really like, you really want to kind of have your
intellectual soulmate and think similarly, don't have too many differences you'll never get the book down, come together and produce something. it's taken years. >> back to the three kids between the two of us. >> oh, gosh, now so many hands, how about in the blue and white. >> so in your individual work in global health and then research for this book, have you guys mostly found things that you intuitively find to be true or research and-- >> the question was, you know, throughout writing this book or in our own research if we found things that have surprised us. i think one of the challenges in answering that question is i first became obsessed with the global fund before there was a global fund. i wrote my first master's thesis on the global fund in
2003 and so, i can't remember what first surprised me when i kind of first started engaging in a more critical scholarly way with these types of questions in looking at these institutions. but i will say one of the things that did surprise me, is i really did think we'd get more reform of the w.h.o. in the aftermath of ebola. the events, the just overwhelming chorus across the global health landscape. you know, even from the review that w.h.o. itself commissioned. so, that surprised me. i mean, i didn't think we were going to get all of the reforms that devi and i, for example, had to argue for advocated, but i did think we would get something done if only so that
w.h.o. and the director general, margaret chan, could even point to and say, look, we did get something done. we have heard these concerns, we have responded to this alarm. that surprised me. >> yeah, i think just maybe two things i'll pull out and it surprised me in the book. one, i knew that the gates foundation was important, work in global health and fund a lot of things, they're very vocal about global health. i was surprised dominant financing-wise. if you want a strong strategy for governance taking on outside research institutions, to have a very clear strategy and clever strategy, if you want to start aligning global objectives to what you're hoping to achieve. i knew the u.s. and the u.k., but i didn't realize the extent of the gates influence. the other thing is the burning
passion for the global fund, i guess mine is for the world bank, kind of my pet institution. did my doctoral on the world bank and maybe the next book we do is on the world bank, hopefully. [laughter] >> and one thing that surprised me about the world bank, it's one of the unique funders doing health systems. we do talk about neglect and forming new partnerships, but it does seem to go go ens that trend in the universal health concerns, vertical ways to do more horizontal things, ministry of finance, how do you raise revenue for a health system and people connect to services. and the world bank, they're interested, we don't think of them in global health we think of them as a bank and doing interesting things--
>> i would add to devi's point as the world bank. the world bank is the only institution trying not only to converge conversations around vertical and horizontal funding, but even to align conversations within horizontal funding. so, often the conversations about health system strengthening here or invest in more primary health care here or force development over here. over here there are conversations about universal health coverage, which that decoupling seems so illogical to us. when i would argue, it seems pretty self-evident when we look at health systems across the developed world, that when you have better alignment across that continuum, you tend to get better health. so the world bank is really trying to not only kind of
exist in the vanguard, but encourage other funders to think along the same lines and this is particularly important because of what devi said about the gates foundation. at least thus far, bill gates has made it clear, he's not interested in a financing the march towards universal health care coverage or kind of resilient health systems across the world. now, i don't think he deserves censure for that, they invest about a billion dollars a here in health priorities, but it's not as if he's retrenching his commitment to global health, but the contours of his commitment don't include, at least not yet, health system strengthening or universal health care coverage. and so it will be kind of interesting to see whether or not a new institution can play the game role as the gates institution did in the advent
of davi, either in kind of health system strengthsening or uhc or ideally in trying to kind of marry the two together in a thoughtful and deliberate and hopefully ultimately impactful way. >> i think we have time for one more question. >> in the red. >> thank you so much. [inaudible question] i wondered if you can talk that in a limited landscape impact-- i'm curious-- two countries and one
organization how does that influence the work that we're doi doing. the second to what extent-- [inaudible] it's hard to see where countri countries, where are they, other than these sort of random organizations, to what extent do you see that shift and empowerment of the countries and communities who tend to, i think, have less of a voice obviously in the u.s., u.k. >> i think that's a really important question. i am going to answer the second question and then ask devi to answer the first.
the second question, tif i miss something, shout out. the second question, how do we forsee or not a shift in the global health landscape to put developing countries themselves more at the center of decision making and with kind of that being a real meaningful senatoring, that it concludes an agency and not sort of a per func functory. davi has global fund through country coordinating mechanisms and country coordinating mechanisms have to have countries membership and also the developing country private sector and civil society
membership. so, kind of truly intend today facilitate greater coordination at the country level. kind of on whatever issue or priority, the grant is looking to tackle. and yet, if you read every minute of every global fund board leading minutes, which i've done, and continue to do, and you read all the various committee minutes which i've done and continue to do, it is clear that while i think the board member countries in particular have more ability to influence the agenda, the united states, which provides a third of the global fund budget till continues to have more ability to influence the agenda, not only through what
occurs in the board meetings themselves, but the united states actually publishing its view on the board meetings after the board meetings conclusion. so you can go to the website and see how the united states feels about every global fund board meeting over the last, i think, now nine years because debra burkes who is the u.s. global ambassador head of pet-far is the member of the global fund board from the united states. and so, i think that the global fund and gdavi has gotten to that goal, but imperfectly. if you ask the question who finances global health, if global health is defined by kind of what happens in regard to people's health, live in places not like the united states. and that is not our definition
of global health, but that's often how global health is treated so in many schools of public health, if you take a glass in global health you're going to learn a lot about what happens in rwanda, ethiopia and other countries that were in your question, but less so about how what the w.h.o. actually influences or fails to positively influence public health for all of us, whether prepar preparedness or tobacco control. and who finances global health in developing words, really developing countries themselves overwhelmingly. i think the question will be going forward, particularly, if there is an advent and there is no sign there will be, but i'm hopeful, but at some point there will be, but institutional effort to invest in health systems alongside
universal health coverage. i think that is when we will really see the pivot that you talk about. >> great, so, i'll quickly answer the first question and the question was, what are the consequences of having three donors basically dominate the funding lines landscape. so, we highlight-- i'll highlight two right now the major issues and there is an efficiency, so the whole reason the w.h.o. was created and kind of written there, was that nations would realize they have to put aside their short-term differences for the benefits of long-term collaboration and you saw this with health systems and they were neglected for a number of years and ebola hit and people don't realize, it took them three months to detect it's ebola, there it wasn't the
infrastructure and surveillance and this is the global health is moving towards, building capacities. because none of the donors were interested, they were focused on hiv-aids and short-term priorities, what the administration was interested in and going for. you kind of lost the body removed from the yearly political cycle what would be our priorities and a major efficiency loss that we haven't strengthened those across the world. i think you've highlightled this as well, there is a normative agenda here, is it right that actually the priorities for people, a billion people around the world are set by three donors. is this actually correct in the sense normatively? i often tell my students in edinboro would you want your priorities set by some kind of institution far outside, that says you have access to these services and not these services and next year they will be cut
in half because the taxpayers don't want to pay for that. in the united states you'd say this is our health service. and the world is playing a part in development, taxation system, revenue generations and trying to build a stronger domestic basis and finance base and you're less reliant on the external flows. you're less reliant on out of pocket, the two min thanks, external flows and then the out of pocket from the government, so i think that's the way you're going to move away from it. a dependency model, accountability of the u.k. to the taxpayers, if they don't want that, they'll pull back because the government responds to the media and public pressure. this is why we found this and want today highlight that three donors dominate not only in financing, but a myriad of ways
that dick date global health. that how people think of it and people across the world think of it. i know we're tight on time. >> first of all, i want to thank everyone here and thank chelsea and devi. [applause] i want to-- it's a terrific book, you've got it buy it to really get it and if you want to buy it it's actually available at the reception that we're having in room 401 upstairs. so, i want to invite everybody, actually, if you can exit out of that top door, you're practically there, chelsea and devi will be joining us there for the reception and i really want to thank mark, who is her here-- thing everybody for coming and see you at the reception. thank you very much.
enable a reproductive system and help with the brain size. she's interviewed by gina kolata, medical reporter for the "new york times." >> host: i really like reading your book. it was so much fun and fascinating because i think everybody has questions about why do some people get fat and others not get fat. and what can really, why don't people understand this? it seems like it's been a problem for so long. why is it still a problem? one of the things i like about your book was about you have a lot of personal stories. yourself, scientists, people were struggling with their weight. i was drawn into the book on page one. i think almost everybody would relate to it. i thought maybe people like to hear what your book sounds like size wonder if you could start re