than a big part of diarrhea deaths pneumonia deaths also went down and that's because gobby took some vaccines that were being given to middle-income and rich country children who were at very little risk of dying from those diseases still a good thing but actually the kids who had ten times the risk we're not getting the vaccines and it's by buying the vaccines through gobby that now our coverage on rotavirus and pneumococcus is actually quite high and so that's why that acceleration took place so and we're lucky enough to have the director of the Global Fund and Gotha here today I want to start with you Peter – now that we've seen what's possible with investment and with focus and with using the tools that we've learned over the last twenty years what what are the immediate and urgent challenges what what happens if we don't focus on these things well I think the starting point is Bill saying is that the Global Fund of Gary have been to financial innovations for global health that have actually worked extremely well and have delivered a massive difference in terms of lives saved the challenge is going forward well the job's not over and goes you can talk on the vaccination side but suddenly with AIDS TB and malaria we've roughly speaking haft deaths in AIDS and malaria and about 20% reduction in TB but if we really want to achieve the sustainable development goal ambition of ending the epidemics by 2030 we have to step up the fight we have to do more better that's not just about money it's innovation it's collaboration it's better execution better use of data but it also takes more money which is why as bill mentioned our replenishment is this year the way the replenishment works in the global funders it's a three year cycle so we're raising money for the next three years and we're saying we need at least 14 billion dollars and for those of you from the private sector we want at least a billion dollars of that to come the private sector to fund the next three years of the global funds work now why is it so challenging well resistance is a problem across all three diseases most potent lis and obviously with MDR TB multidrug-resistant TB but also with the P host becoming resistant to bed nets we also face the way the epidemics work has changed I mean the the most likely person now to be catching HIV is an adolescent girl and the root causes of the high rates of infection around adolescent girls and young women in southern Eastern Africa and particularly our horrible cocktail of all the gender inequalities you can think of from sexual in a sexual violence to economic disadvantage educational disappointment and we are finding that we are having to work in different ways with different partners to address that challenge malaria tell two areas we got some countries making great progress towards elimination but the highest burden of countries frankly we're doing enough to save lives we're not doing enough yet to break the transmission cycle the numbers of cases are not coming down fast enough and on and on TB well frankly we will all regret it if we don't meet the challenge of MDR TB so it the other issue of course is emerging threats and and though she you know we've had a really remarkable and stark example of what happens when these partnerships work in the case of Ebola in May there was an outbreak of Ebola virus in Equatorial province and a Democratic Republic of Congo and the nonprofit world Gavi the the state governments to the the World Health Organization under dr.
Ted knows and all and Merck and other private companies work together created a ring vaccination stopped it with a small number of deaths and it never left the area later that summer we've now seen a new outbreak in Kiva province where it's in a war-torn regions and some of these partnerships can't get the job done it's just too difficult and we're now at a place where hundreds of people have have either confirmed cases of the disease and 400-plus have died and there's no sign of it alleviating in fact it seems to be accelerating and you talked a little bit about you know given the role that you have played in coordinating all of these stakeholders you know that challenge that's I mean that's the perfect example of when it works versus when a dozen the threat well let me thank you I think Davi is that new modern type of organization that we all want to achieve where you have an alliance that brings together partners you know that can work together in collaboration to tackle a given problem so that Alliance has w-h-o in it does UNICEF it has the World Bank it has farmer from a suti coal company so we have private sector at the table we have civil society and we also have the beneficiary countries around the table so it's a unique partnership where you're coming together and I think that's the modern type of cooperation we need to solve problems these days so when you talk about Ebola dr.
Ted Rose was in the field he took the lead with WH o to go and try and see the problems first and he went with Seth Berkley the CEO of Gavi and I think because we had taken this step of trying to stockpile some of these experimental Ebola vaccines there was something available so when you say it's a failure this I don't quite agree with you I think if we hadn't had that it would have been much worse but I'll leave dr.
Ted Rose to talk about that because he was actually there on the ground so yeah you know so I just want to say that the Alliance I think worked and I'm very proud because it could have been much worse you know when you have conflict that's one of the challenges we face that in reaching people where there's conflict is a and it's one that we are trying to overcome but it's not easy because people's lives are in danger but dr.
Tetris can say more I was a member of Gavi board and I know the Alliance works I saw it when I was hell as minister and now I see it as director general of that nature and as Ngozi said I I was three weeks ago during the New Year actually and it was for me very emotional time to share a meal with my colleagues the fighting Ebola in DRC in the front line you could see to what extent they're putting their life on the line even when we were there on New Year Day one of the Ebola vaccine responders vaccinators we're talking about vaccine was attacked and he sustained head injury and myself and Jeremy were in the field Jeremy the Wellcome Trust director and luckily is a neurologist and he helped the patient to not only stabilize but using the helicopter we had we had to evacuate him and that was really a very humbling moment to what extent you know our colleagues that are facing daily challenges and serious dangerous actually to keep others safe so then coming to the vaccine I told you about the story but Charla's anga the guy because of the vaccination the vaccine because he was vaccinating when he was attacked actually and then the other side is so far we have vaccinated 60,000 and if it wasn't for the vaccine we would have seen more cases we have now around 650 in five months you cannot limit the spread of Ebola in 650 without the vaccines and not only that the [ __ ] colleagues I spoke to in the field told me that in the eyes of the people affected by Ebola we see hope not fear but in 2014 during the West Africa Ebola it was fear everywhere even in everywhere all over the world so we are in a different situation which is which is really important and I think it's very important that we recognize the power of partnership the power of alliance the power of innovation and technology that helped us to be where we are but when I say this I'm not saying it's perfect we're still very very vulnerable to outbreaks including to Ebola and we have to build on the success we have already achieved and so you're seeing in in Pakistan you know a shift and not just obviously there are still the threat of infectious disease but you're seeing non communicable diseases diseases that used to be most prevalent in the West and wealthier countries and now you're starting to see them get you know grow with with you know a frenzy in some cases talk a little bit about how you manage those twin challenges well the shift towards non communicable diseases being the predominant contributors to burden of disease is not just something that's happening in Pakistan it's it's a global trend it's happening all over the world and in terms of financing for global health we have to appreciate that non communicable diseases are not just disruptive in the epidemiological sense of the damage they caused because we all know that they are the biggest contributors to deaths to disease to disability but they're also equally disruptive in terms of the political that you cannot make the societal and health systems responses needed to address the challenge now if you look at country demand for technical assistance and Integra's will bear me out on that and CDs amongst the top three asks from countries and in fact when we were campaigning together two years ago this was the consistent asked from from different from different countries but as opposed to that we know that it is not within the realm of competencies of ministries of health and the existing infectious disease partnerships that we have created to fully respond to the full range of determinants and non communicable diseases so it's quite an imperative to have the new to have a new set of institutional competencies and financing instruments to deal with with non communicable diseases and I fundamentally believe that an appropriate response to non communicable diseases could be revolutionary for Public Health just as the HIV response to hiv/aids was you know more than more than a decade ago in terms of institutionalizing the right space approach to health and catalyzing the access to medicines dialogue in including affected communities in the civil society in the planning process I believe that an appropriate response to n CDs could actually change the rules of game on two fronts firstly this whole aspect of the whole of government approach and the multi sectoral approach to dealing with public health and and secondly the whole piece around engagement with the private sector so so NC DS can be quite transformative in in in these respects well that's a perfect segue to our last speaker who represents the private sector you know vas your unusual for a drug company CEO in a number of ways when you're a physician but – you're also a practitioner of global health care from your earliest days you were at the WH o when you started you've had great experience in that and and thirdly I think you're also a data geek you're you're a guy who really is looking it's sophisticated ways to address these access issues and finding out where you know what drugs can work more effectively can you talk a little bit about you know the tools that we've got to address some of these global health channel challenges from the private sector you know when I reflect and I love the the Steven Pinker charts because I think they put it all in perspective you know we as an industry I probably our greatest contribution is bringing innovations forward and I think that's hopefully obvious everyone here when you look over that period 100 years at least from 1900 to today you have 1500 enemies you have over 20 vaccines that constitute what we talk about on this stage and that was the industry bringing these technologies forward and I think whether it's health care water or energy ultimately as a as the private sector our ability to innovate on these problems but then ultimately give access to the poorest of the poor is the conundrum that we face that's really where we make our greatest contribution we put forward a hundred and seventy billion dollars a year into R&D just in our in our healthcare industry and that Rd ultimate leads to innovations I was recently as reflecting on it and in Ghana and gabble and if you go to a dispensary in those countries and you look at the list of drugs you know those those list of drugs were innovated just 15 20 years ago and now finally they've reached you know the forest reaches of the planet that's the problem I think we now need to be all about which is access to medicines you know Gavi was founded on the premise that Previn are actually are pneumococcal vaccines took too long to get to people and we left that to bill and and Gavi to sort out and I think we as an industry now have to be all about how do we bring our innovations within the first year or two of when we find them to reach all populations on the planet so I think that's actually where we create our greatest contribution know we as an industry I think we give twenty billion dollars into various forms of corporate Giving and donations I asked myself is that well directed is that really having the impact it could I think that's a that's a open question but if you ask me the biggest impact we could have is if all that hundred and seventy billion of R&D to find the next innovation reaches that patient in Kenya or Botswana much faster than we've had the impact of so you brought up a really please I hope you don't mind I watch I can't resist you know because he talked out the pneumococcal vaccine and you know one of the things that Garvey does is we have a mechanism called the advanced market commitment and we're able to negotiate with Pharma you know prices that are affordable to poorer countries and accessible so it does now is about to two dollars 95 compared to about $100 in the in the US so you can see how you know countries can now afford to get these vaccines for their children so that's a huge innovation for in financing and accessibility so I want to come back to this issue of vaccines because you take rotavirus vaccine which eliminated huge amounts of diarrheal disease which is a massive killer of young people in the developing world but it there was as great a success story as that is there was a delay in getting that drug out there because of fear of very rare cases of intussusception a reversible case and and that and so the West ended up removing it from their schedule of vaccinations and delaying that process of getting that drug out there and I wonder bill if if there is sometimes a little bit of a deadly caution or are we are we what's slowing us down I know as fast as we're moving what would you change to make us really even faster well I think we need to keep the industry Hardy to be very high while figuring out how this these tiered pricing approaches makes the access issue a lot faster than it it would be otherwise in the case of vaccines gobby is able to negotiate a very cost oriented price so that for the 73 poorest countries there's not recovery of the Rd or profit that's gonna have to come from the more middle-income and rich countries in in the example you gave the only gold standard regulators are rich country regulators European and US regulators and because the deaths of from diarrhea rotavirus in particular very very low the bar they set for our rotor shield side effects was extremely strict and to keep the reputation of vaccines as being beneficial and not asking refusals that is a challenge even in in rich countries the quality of that regulation you know I no issue with it at all if the world was super rational we would have accepted that there was some side effect because the death rate in Africa and India from rotavirus was high enough but there's really no way to say to those countries so this is not good enough for the u.s.
Because their death rate isn't very high so we moved fairly quickly we got discounted pricing from GSK and Merck over time we brought in an Indian manufacturer to Nieman lower price so it's pretty much a good news story we have about 80 percent coverage that's one of Gabby's focus for its next five year period is going to be taking that coverage where we have parts of Africa Nigeria being one of our particular difficulties in getting in getting that up but right now the the system of regulation the idea of recovering your cost and getting your profit off of the the middle income rich countries that's working pretty well in addition to the regulatory issue though and I would agree with Billa there is a degree of lag which I think we collectively have to address which is the speed at which treatment guidelines get changed all the way through to national level and then have physician practicing describing behavior changes this can be this can take years and how we can work together to get the best new biomedical interventions to patients quicker I think is is a challenge for all of us so which one of you wants to get the hate mail because I'm about to bring up the anti-vaxxer movement but this is I mean this is a real challenge we've seen you know a backsliding of polio cases some fear in Nigeria and go see your your home country where you were the Health Minister twice and Finance finance minister to finance minister and finance minister twice and also the your foreign affairs that were yeah chief diplomat but but so we've seen that we've seen a backslide of measles and and and rubella and in the West and it's kind of scary and this is you know this is one of the that we've talked a lot over the this last couple of days about trust you know fundamental to the global health effort is the the belief that the vaccines and the other you know tools of international health movement are are safe and effective how do you deal with that well address if you want to yeah maybe maybe I can start I mean you know I have to say that when you look at the landscape there's really been a high degree of trust and deliverability in the vaccines we've had in the world actually it's amazing to me and them and you know so we have to stress that but we also have to look at cultural issues at fears you know at false information that comes in and people get afraid so there are all sorts of issues and I think working through the local community has been essential both for the alliance with the Bill and Melinda Gates Foundation bill was talking about Nigeria's also done excellent work on the ground in the case of polio for instance you know to try to break down some of those cultural barriers and have the local Imams you know the community leaders to talk to people we showed them I know there was a time we even had to have that since brought in from Indonesia you know to because you know to make sure that people have trust that it came from an Islamic country and everything was you know alright and so but I don't think we should exaggerate those there's a lot of trust in the system and we should not allow people to undermine funny I know you wanted to jump in on this yes I think the trust issue that you just mentioned is part of a much bigger problem because when you talk about global health and its sustainability and the way forward we have to appreciate that today we are living in a world where you know the value of international institutions and the trust and multilateral system is wavering we are in fact seeing a scenario where many of the cross-cutting agendas such as family planning and reproductive health in sexual health are you know the the value of investment in them has been contested and Peterson's just reiterated the wide-ranging ramifications of that of the of that setback and on the other hand I think paradoxically there has never been such a time where the value of international institutions and the imperative to invest in them has been more imperative I mean I can go on and on with a list of things for instance relevant to the health sector there are three risks that threaten to wipe out the development gains of the last century pandemics antibiotic resistance non communicable diseases Tedros will tell you that universal health coverage is his top priority and the top priority of many countries where and and for very good reasons but but in order to institutionalize universal health coverage you have to play health with a very different stack of guards you have to engage the private sector in many different ways a colleague here will tell you that precision medicine is likely to become the default option very soon because of a number of different transformations and you know there's this whole technology piece and how institutions outside of the healthcare system are taking the lead on providing solutions for universal health coverage these are institution an shal Institute and online retail actors and in order to institutionalize and reap the benefits of all these transformations you new need new standards new rules you need workforce realignment you need stepping up and change in regulatory capacity and you essentially need change in stepping up of capacity and and all that is not going to happen if we will not invest in international institutions in the multilateral system which are consistently under attack yeah so so this whole question about which country is going to take a lead in raising its voice and becoming the world's conscience and which country has the the fiscal strength the fiscal ability the credibility and the spine to raise the voice are becoming hugely important in this discourse not just of around global financing for health but also global development financing and I think these are big ticket things around which there needs to be a dedicated discourse yeah I wanted to pick up on this point on as we evolved into precision medicine and looking at all the advances I mean it's quite striking to me when you think about the conversation here Gavi global from 20 years ago we knew that infectious disease was where we had the biggest potential for a significant impact we set up the Global Fund you know bill set up Gavi we've had tremendous impact and we need to continue to fund those institutions but if you go to a typical West African country even with a well-run healthcare system you look at the burden of hypertension you look at the capacity for basic dialysis and basic medical interventions to manage hypertension or manage any of the consequences of hypertension much less diabetes or obesity I see systems that will soon collapse I mean I think this is gonna be a significant issue and I ask myself do we need a global fund for non communicable disease or do we need some other mechanism because even if we raise the 16 billion for the Global Fund and we tackle AIDS TB and malaria it'll help for the next 10 years but 20 years from now we sit in a very different problem and far we're still very far from bringing things like precision measurement Edinson gene therapies etc to solve it that's a great point I mean bill you know do we need new financing mechanisms beyond the the multilateral groups that we've talked about today you know obviously the Global Fund in Gavi and the Polio Eradication Initiative and the effort for maternal and child health the the financing facility those are critical but for things like dealing with or the challenge of antibiotic resistance or for vaccines for ailments where there isn't a large market should there be another financing mechanism a model that can help do what the what the the market initiative did for vaccines you know think about it in a different way well I'm sure every panel at web wants to find some new magic funding source for their particular laws and if somebody finds that I'm all for it I think realistically the overseas development aid will not be going up very substantially and in fact if we don't bring back the track record of global health and really get that story out there we run the risk with so many distractions including a sort of more turning inward type framework we could have less money and you know we talked you know Global Fund could spend 16 billion and you know Peter and I met and I said hey let's set the goal at 14 billion because I think it'll be a challenge to raise 14 billion if we go beyond that I'll buy him a drink celebrate I will say that I was wrong but it's the the getting this messy job these are issues that are very far away and the slightest mistake that gets made you know some money goes to a training session that never took place and so that's RUP even if it's 1% of the money that gets a headline whereas the 99% saving millions of lives doesn't so we you know we're not in a position to afford very expensive interventions there are some non communicable diseases like cervical cancer you know one cancer you know you can do lots of things to tax the backhoe cut it down hypertension is a great example where the drugs are now cheap enough it's cheap to measure blood pressure those blood pressure medicines have been long off patent you know so we were funding an organization that's now gonna help get some of those interventions out there so we always need to see when something comes down and it's practical but you know the when people talk about precision medicine the US can't afford precision medicine so I dare anybody else to try it there's many definitions of that it but if it means designing drugs for very very small patient groups ie N equals one it's it's not in the cards you know we need to to deal with diabetes and obesity and Alzheimer's in rich countries and then bring those costs down eventually gene therapy I do think will come in to a form that can be delivered in developing countries but first we have to get it into the rich countries and then you know for sickle cell HIV cure and in the upstream area it's it's super exciting but it'll it'll take quite a bit of time talking about financing is important of course we will need resources but we need to ask another question are we really doing the right investments for instance or colic side hypertension and maybe diabetes or cardiovascular you name it the non communicable diseases many of them are linked with risks and thus our central strategy should actually be to address those risks alcohol smoking dietary issues inactivity then obesity comes in all colors and forms so really talking about the investment we are doing whether it's the right one or not is important and that leads me to the right investment that we should do globally and this is primary health care its investment is actually low but it's return is is high and we should go back to the basics and focus on health promotion and is prevention and we need to really invest in that be it for communicable diseases or non communicable disease the response or the vehicle is primary health care and now we are at partnering with Gates Foundation and to give focus on primary health care as part of the inverse Angeles coverage in Versailles coverage as a rights issue and end in itself and also a means to development because no country actually can prosper without healthy society it's a smart investment but within that investment in primary health care can actually be quick many countries have have have done it so the smart and the right investment I think has to be discussed in addition to the finance one reflection I have is you know we've been talking I think in global health about primary health care and primary health care for all for four decades and I think we actually we've made a lot of progress but I also wonder in in the topic about financing how do we finance disruptive ideas how do we finance you know entrepreneurs because one thing I've noted in our own activities is there is a pretty healthy growth of startups that are really trying to tackle these ideas in very disruptive ways and typically we take Oda funds and we channeled them through the traditional paths and Meimei that is the right answer but I wonder how much more we might be able to catalyze if we start to support those those entrepreneurs and there's good examples I mean well known I think things like they'd be well known zip line example in blood transfusion or we are we are supporting a number in Africa but I'm quite struck by the fact that these disruptive ideas to try to get around what seems to be quite significant constraints locally might be something to look at sort of feeding that micro environment along with doing the big top-down push for primary care one of the disruptive I would like to say I would like to answer that question one of the most disruptive is political commitment political intervention is surgical intervention countries who have committed politically and allocated domestic resources and who considered external support as catalytic support can move a long long way so it's not an economic argument actually in many countries it is of course but it's more of a political because there are many countries when when they have even the resources who can't do it and when you see countries who have done it they have started it actually when their economy is in shambles like the UK for instance immediately after the Second World War when Lourdes beverage designed and the NHS started so you know that could be disruptive the political commitment but not only mobilizing domestic resources when there is political commitment to health for all our inverse Angelus coverage it can also have disruptive ideas to involve the private sector to do its share to make it happen and I just I wanted to country say something being a former finance minister about domestic resources not before that I want to let you know that Gavi indeed has a fund which they the Gates Foundation matches and a program called infused where we encourage innovators including local ones to come up with ideas that are disruptive that can really help us tackle some of the central challenges we face such as reaching the children who are hard to reach we've done the easy work now and we are sort of stagnating around 80% in terms of immunized how do we get past that how do we reach that difficult to reach surcharge in remote areas and conflict-affected areas also so we have that program so if you want to do with us the big point i want to make though is really bill said something about about aid is not going to be so much available we want to encourage yes more resources Gavi will be going into its replenishment I don't want to say number year we are still working on it but whatever we will need it however I also want us to focus on domestic resources dr.
Dubrow's mentioned we have an you know our programming Gavi encourages countries every country no matter how poor must contribute to its immunization program so on over time as a countries get more and more well-off they contribute more and more down the line because we want to work ourselves out of a job that's it we want countries to graduate and take over you know so so helping them to mobilize more of their own resources so that we can be sure the sustainability of the fight is also a key so as we work on the eight side we also need to work on raising demand and it's it's it's hard we talk of domestic resource mobilization it's become almost a slogan you know to answer all questions but as a former finance minister who actually tried to do it in my own country whether tax to GDP ratio is very low particularly after we rebase the economy we hadn't done it for twenty four years and we more than doubled our GDP you can imagine what happened to all the ratios then trying to strengthen tax administration you know so you can close loopholes and get the expertise you need to a lot of people not to escape from from paying their taxes you know trying to reset tax policy trying to bring more to the tax net to broaden your base because we have a lot of informality in our economies this is a huge task I know that it's not a health task only you know so in our alliance we've got the World Bank with good you know so we have to also partner with people who are not directly health in order to make some of the financing work but Peter you know and go she just makes a really good point this isn't as aids so much as it is investment investment in one's own country investment in the world Bill & Melinda Gates have often used the expression that you've got that 20 times return on your investment with the money you've invested so far I don't want to quote you if that's wrong but yeah but Peter I mean can you talk a little bit about how you make the investment case to the donors since you're gonna be going out there with the very rich team cup yeah it's it is true that the returns on investment in global health are incredibly high I think we were more conservative in our investment case we've said 1 to 19 so you get 19 back for every you know but you know as a ex-banker I used to think that getting 1.1 1.2 to 1 was a really good return so the idea of getting 19 to 1 is pretty extraordinary now of course the real issue here is that the people who pay the money don't get the 19 and that the the returns are much broader in society but they are so huge that really you can tell a compelling case and also these infectious diseases aren't static there is no kind of middle ground you are either winning against them or they are beating you and the economics of being on the backfoot against AIDS TB and malaria all the diseases that you get hit by backs yeah these are terrible economics the point about disruption I think is a really interesting one and we tend to think about disruption in terms of sort of medical innovations and so on but also I think a thing that is going on and I give others on this panel credit for this is that we're getting a lot of disruption in an innovation in terms of delivery models of different ways of reaching or organizing programs whether it's 0 TB cities or other sorts of program like that but we're also breaking down silos I think through the global action plan there's been a huge amount of often painful discussion between all the multilateral entities about how do we work together better and certainly between Gavi and the Global Fund there is now an intense dialogue on every single aspect of what we do from boring administrative things like our shared cafeteria and building and cybersecurity to share programming in the field and I think breaking down those silos and then and they also occur in the clinical profession I mean we should have much closer integration between HIV treatment and TB treatment but we run into professional silos because these people are in the National TB program and these people are in the National AIDS program and we've got we've got to force these things 1 1 dichotomy that always irritates me is the is people talking about sort of vertical or horizontal as if they're sort of in opposition so in some people's view the Global Fund and indeed Gavi are the archetypal vertical interventions disease focused not caring about the system just focused on the disease or you have horizontal interventions building the healthcare system I mean the reality is you will never get rid of one of these diseases in less you build a system and a system that isn't coping with these diseases isn't really a very effective system so you need to do both and actually a big chunk of global fund programming is actually spent on health systems we spend about a billion dollars a year on health systems which actually makes us the largest multilateral provider of grants for health systems so I think we we need to we need to be prepared a lot of these kind of paradigms of its vertical or horizontal Lloyd's you know these particular silos of activity because that's not what patients care about the banker do you think social impact bonds are gonna lead to a big shift over time in financing I'm afraid to say my many years as a banker have made me actually quite skeptical about a lot of financial innovation financial innovation is brilliant at reassigning risks changing the timing profile or changing incentives it is not a magic money machine it doesn't create some unknown you know pull of resources and if you look at what happened with Gary in the Global Fund what you had was a pooling of resources a way of changing incentives with if him a changing of the timing profile of the money to make it more optimized so you can attract more money because it has greater impact but the fundamental thing that innovative finance does is give you greater impact and so I don't want to sound to dismiss social impact bonds have their role but let's not kid ourselves that there are some sort of wonderful silver bullet e-type things out there that are going to transform the fundamental challenges we've got yeah yeah I just wanted to say a quick word on if him the international finance facility for immunization which is an instrument for raising resources that Peter alluded to I think the key issue we need to think about is what does it do we are about saving lives so if we can find a way of getting resources faster sooner to save more lives that could be that's a very valid objective so what this instrument does is with the securitisation of aid so instead of being given five million or ten million every year you say look we have these resources we know we are coming with us correct Isis and front-load so this instrument we go to the market and we actually raise resources on the capital market to be repaired later what does it allow us to do we can save more lives faster sooner so I think financial innovation where we need a sense of urgency can be very very important and we've raised six point five billion dollars so far including even a saqqaq bond recently sharia-compliant bond so I think there's a there's a very fun play so for some of these instruments yeah we've been using these mechanisms to fund to finance bridges and tunnels so Sonia woody what's being discussed firstly you know this conversation is veering towards the importance of the global funds infectious-disease funds and I think that they're they're not two opinions about it they've been enormous ly how enormously impactful they need to be supported but the reality of the matter is that conversations about graduation and transition are always happening are already happening and they're already and they're also happening at the country level so it is important within that context to ascertain where the financial vulnerabilities are and to be very clear about creating the transition frameworks well ahead of time because even if we're looking at a five year horizon we should be prepared with the transition frameworks we should be prepared with very explicit and predictable co-financing arrangements because these need to be sorted out ahead of time secondly there's this conversation about non communicable diseases I don't think that there is an appetite for a new global fund like initiative for n CDs we all know that but I think when we talk about a new financing instrument and a new architecture for non communicable diseases for which there is ample justification we may be talking about an explicit integration mandate because that exists at several points across the whole spectrum of health systems and global health institutions for a for example at a country level non communicable disease medic medicines should can be included international essential drug lists the several waves of surveys that USAID that the UNICEF and that the World Bank supports at a population-based level could integrate modules for n CDs that that does not necessitate creating vertical structures for instance PEPFAR and the Global Fund for a TB and malaria have done remarkably well in terms of creating primary healthcare systems for chronic care and you layer this up with the online capabilities that retail institutions and the banking systems are creating and there's a perfect justification for including n CDs in that mix so we we do not have to create a global fund worth X billion and with 400 staff in Geneva they the N CDs piece could be addressed number one with an explicit integration mandate and financing instruments around that and of course as Ted was mentioned there is this whole other piece about the whole of government approach around tobacco food systems physical activity alcohol which needs to be mobilized through different instruments which are not in resource intensive paradoxically they can generate resources for prevention activities through earmark Louisa's as we all know and just a 30-second response I cannot resist – what Nkosi you said I think tax can be one of the most important innovative instruments because we talk about debt swaps and we talk about bonds and the rest the rest of it but we have to realize from a country branch point that anti tax evasion efforts anti montiel money laundering efforts and anti-corruption efforts have perfect synergy because because the monies that are whisked away by tax evasion on the one hand are used for money laundering and terrorist financing and on the other hand they take away the the money that is needed to invest in human capital investments – this is my favorite bit of innovative finance basic blocking and tackling to have good tax design and collection I think absolutely right I said a quick point one thing I reflect on is one of the things on the global fund that focused the mine on AIDS TB and malaria and every time I heard the world non communicable diseases I think that's a lot of diseases and I wonder it's hypertension diabetes in COPD or whatever the quoc the University of Washington quality lists would tell us maybe that helps focus the mind because I think right now the it just seems like such an insurmountable task when we say non communicable disease it'd be like if you are the global fund of communicable disease I think you'd have a harder time raising raising money so what what else also focuses the mind is the is the fear of backsliding and Peter you mentioned that a little bit and Bill I know you've mentioned that but where are we most in danger where do you see as the sort of critical places where if we don't move forward we're going to move back and also can we just talk a little bit about the demographics the the very young cohort in Africa and in much of the developing world and and how dangerous that is when you get communicable disease framework well the in economic development in Asia in general has been strong enough that the really the best stories of graduation where they'll be able to maintain the health systems our countries like India Indonesia Vietnam plenty of challenges there but overall those are really good stories Africa's you know challenging in Nigeria is graduating from gobby that's been lengthened out which was a really great move that gobby made that was sort of a quid pro quo to go to the country and say okay we're gonna smooth this thing out over a 10-year period instead of a five-year period if you step up to your part and so you know there's ongoing work to make sure that that that goes very well I do think the consensus around global help is is fragile because you know had some enlightened politicians who believed in these causes you know we had President Bush who started PEPFAR and and got the US and the Global Fund you know we had increases in the UK aid levels the German aid levels but if you if you look at the awareness of what's been achieved here people may be more aware about the criticisms than they are about the success so getting a good news story out is very hard when it's a very far away thing and there's a bunch of acronyms even the disease's you know people you know we assume that they live it like all of us awesome panel do and that can make it less of a story and yet you know if we do it right it is a very strong story but we don't have broad voter awareness that locks in the even the current level of generosity as wanting to add to what we've said I think will be important to invest on alignment of the SDG I mean the global health players we have signed 11 agencies including Global Fund Gavi and and others and we have an SDG action plan now to online accelerate and also account and this will help us to align not only at the global level but as Peter said to online at the country level so that can have better impact actually when we online and based on the country's priorities of course that's one and second we're doing replenishments for global fine for Gavi and so on we need to have a united voice on that what do we need in terms of resources for global health together and then how do we mobilize it with United voice would would helped even to convince the donors and and and so on so this is just what I would like and then I fully agree we have many stories which we don't really tell and we have to tell our stories and we should tell to the taxpayers through you know active media campaign what their money is actually doing in the lives of millions and what has changed as you have shown in the last 20 years thank you Peter you got 20 seconds to make your elevator pitch to the world governments we can and the three biggest infectious disease epidemics in the world if we want it why wouldn't we and with that mm-hmm thank our panelists Peter sands sign an Ishtar y stylus in hand goes you know conscient you the allah change us adenomas get rhesus and bill gates thank you all very much thank you we have a couple people still coming in the doors and welcome to good morning everybody I know we have a couple people still coming good morning everybody I know we have a couple people still coming in the doors and welcome to the World Economic Forum thank you all for coming so early as we kick off this this Davos it's a privilege for me to be here I'm Andrew Ross Sorkin of The New York Times and CNBC we have a remarkable conversation that I hope we're gonna have over the next hour and we're gonna bring you all into this conversation really about the new architecture the new market dynamics with which I think we're all living and trying to grapple with and those things involve everything from the idea of scale the idea that every business every person I imagine involved in business in this room is always thinking about how they can be bigger and what does bigness mean is bigness good Google provides us all sorts of different search search options and video and all sorts of things in Brian Mooar in Hana bank of America i can use my ATM machine and get money in all sorts of ways around the world and well Steve get all over the world so we can we can go all over all over the world with everybody so there are benefits of scale clearly but there are also downsides and we will talk about all of that and we're also going to talk about the global economy and where we are in a world where we keep trying to expand and become more global at a time where maybe that's becoming a little bit more complicated and we will have that conversation here who is with us today we have a remarkable group Brian Moynihan from Bank of America is the CEO of that company Raghu Rajan is here he's the former research director at the IMF former governor of the Reserve Bank of India and now a professor at finance at the Chicago Booth School of Business in Chicago minghao is here he's the chairman of San Oh Cal one of the four largest chemical agricultural companies in China and can speak specifically to the idea of scale given your size Steve Schwarzman is here chairman and CEO co-founder of Blackstone and Ruth Porat you know have many titles but we'll call you SVP & CFO of alphabet better known for many of us as Google thank you all for being here I'm gonna go right over first because I know you have fought a lot about this idea of scale you've written a book that's coming out about competition and where we are in this world and you have actually perhaps a more balanced view of this than people might think in that I think you have thought about the good size of scale but also the other side or scale and I thought you could maybe maybe start this conversation and I'd start with this at a time when there seems to be hand wringing in the United States and Europe maybe less than in China and we'll talk about that is the hand wringing politically on both sides and by the way you get it on every side is it right meaning meaning is that is there too little competition or too much okay well I guess I'm supposed to maintain the balance on this panel that's why I'm not wearing a tie other than Ruth of course look the today we benefit tremendously from scale there are scale economies which are passed through to the customer in many ways there are benefits of efficiency in these global corporations that we see on this panel and that's all to the good I mean Google