Hey Tessa. Hey. Did they know you came to meet with them? No one does. I, um, put it lightly. I guess I'm hopefully grasping for it actually was not you that did that to Cornwood. Telling a bit of a lie, aren't you? I mean, I'm not really involved in it. You don't really need to say anything. Well, for the sake of everyone, I hope it's not true. I guess so. You know if it's going to go on the docket or am I going to get accosted at my home again? I'll push for it to be the, uh, the first of those two. I would appreciate that. Take care of yourself. Hey Big C. Howdy. So I've seen you to put as many details as you can in your statement that you could recall. After that point, I'm going to subpoena her phone records to see if she was in contact with Hubcap Jones. Cause I believe that they conspired to set up an alibi saying that she would have been at his concert, which was transpiring about 30 to 30 minutes to an hour before you were stabbed on the beach. And that's it. So I already interviewed a neutral party and I interviewed Hubcap and I interviewed Tessa. And I, there's a, the neutral party claims that Tessa was at this concert for five to 10 minutes, both Tessa Lam and Hubcap claim that she was there for about an hour. Okay. So you get, there's a large stretch of time unaccounted for it, which helps us place her at that sea potentially. Regardless, your testimony is the most important part. Oh yeah.  Well, there you go. Yeah.  Okay. Yeah, hell, I'm fine now.  So yeah, she did it. But, uh, yeah, there's a hell of a lot more to it. I'm sure, but yeah, I mean, that's, that's what I remember. All right. Yeah, just right in there and then I will be able to continue. All right. Sorry. Declan was yelling at me or not yelling at me. He was just telling me what was going on. Speedy recovery friends, you out there. All right. Yeah. Do you want to, do you want to pair this? I had it with suspension. This is going. Oh, I sent this thing all the way up. Oh, so I said Max. I just did it because I thought it looked funny. I actually love driving it with this suspension. Like you get the chance to talk to Lenny and Crane. Barely.   Liam, do you know Tessa Lamb? Maybe briefly in passing. Yeah. So she used to be a park ranger and she was the, she was a game warden. Right. And I think she actually became game warden after I left. I think he was in charge of Rangers while I was around. Apparently went crazy.    You should have Lenny talk to Jordan receptionist about your stabbing because she knew why they did it. Oh really? Yeah. She said she was upset about the dolphin that I said, you know, you know, this dolphin was a rescue and I brought it in as a gift to the, to the mayor. As a winner said, Hey, we're going to put a dolphin in the pool. She was upset about the dolphin because the dolphin apparently didn't.  I mean, He was fine. Actually, he was swimming around for a while. I don't know what happened after. And you're saying he died after. I don't know. This is not a good luck. Well, there's no maritime laws. There's like animal cruelty law soon. Yeah. I mean, it's a fish. What if I'm fishing? There's no fishing license. I mean, I wouldn't quite say about fish. Dolphins are protected creatures. Aren't they not? Any person physically harvests an animal weather through reckless negligence or direct malice when not in the act of legally permitted hunting? I mean, I wasn't hunting. When not in the act of legally permitted hunting. Can we, can we talk about how Tesla lamb tried to stab me in the throat? Kill me instead of making a dolphin. I'm not, I'm not saying that. Was it like a saltwater pool? Was a freshwater pool?  I don't know.  Well, you know who was with me? Who? Multiple other officers. Wait, who was it? So I can tell you. Yeah. The only language I'm going to speak with Tesla from now on is this one. Okay. I'm letting you know.  I tell Tesla. And then if, if they get the same thing. I guarantee you this is a former, listen, this is a former park ranger.    If you tell on me, I guarantee you.  And whoever else helped me do this thing. I don't know if I'm right or wrong, but I know this.  Someone who I consider a friend I was always good with.  Uh-uh.  No shot. No Surrey. So here's what we do. Okay. When was the mayor married? The 29th. So I'll let y'all know on the 30th. I don't remember what happened until the 30th.  I think so. But I'll let y'all know on the 30th what happened. Oh, okay. All right.  I mean, being the former park ranger and park warden, you know, Game Warden, whatever you call it. Oh, and yeah. And you can see why I'm going to tell you on the 30th, right? Being a former lawyer. I get it. I get it. I understand. I'm just saying, like, hey, I think you know what you did. Yeah. I got stabbed in the throat after getting kidnapped. Yeah. There you go.  You're in a full statement. The other corner of everything you remember. Can't remember. I'm on a lot of mess. What? You can't remember what happened. You can't remember if you did the statement or not. Oh, both. All right. Well, would you feel that way? What do you have in mind? Oh, I do not recall. Okay.  That's what you want permission to leave chief before he incriminates himself. No time being. Look, look at that statement written up in the next few days to a week though. Oh, so here's the thing. If you are not going to be able to stand up on trial. If you just say like two words and then at the pause for like 30 seconds. Well, I'm thinking, I'm thinking, I'm thinking about this. I'm thinking about this. I'm thinking about this. I'm thinking about this. I'm thinking about this. Well, I'm thinking, I'm thinking, I'm thinking about this. Why can't I just say she did it? You can. But I think it's you. You're articulating that more than just saying she did it. It's probably pretty important. I mean, Mark Furman right now. Yeah. But I mean, look at Lenny's Lenny statement is to a T. I saw her turn around 15 seconds later. Cornrows on the ground and she is no longer there. And then they catch her and she says she says she don't know what happened. And then I say, yeah, she did it. Nobody else is there. I mean, it's pretty much, you know, that's clear as day to me. No, no, no, no, no, it's not as clear as you think it is because you're going to there's going to be a whole question of motive and why did she do it and what happened during that? And there's going to be this whole line of questioning.  You can't even give it evidence of the statement of yourself.  Only the defendant doesn't have the right to plead with them. Yeah. But no, no, no, no, it's all self-incrimination. I mean, this could lead into a different thing. Furman did wasn't on trial for O.J. And he was pleading the fifth on stand. That's what I'm saying. I'm saying Cletus can plead the fifth without his statement being revoked. Yeah, but you'd have to be able to question it. If you plead in fifth, I don't know how much of that's going to be able to stick. Here's what I'm saying.  She takes that and then she pushes it forward and then oh, Cletus Cornwood shouldn't have his job because he committed a felony. Okay. So can I just, can I just play this off for you guys in court real quick? Can I do this? All right. Here's how it's going to go. As the prosecution, yes, Cletus. Cletus, you were present for the incident that happened. What happened to you? She stabbed me. I was kidnapped and I stabbed by a slyam. Okay. Okay. Where did she stab you? In the throat. I'm not going to prove that. Yes. Okay. Don't answer any questions. Now they can't expand on the scope.  They call them as a witness. Okay. So they recall him as a witness. Okay. So they get him up there and they say, Cletus, where were you on the 29th of February? All right. Objection, your honor. Relevance. Hello. What does the 29th of February have to do with anything? The fact is, is it doesn't matter. If they want to establish a motive for why Tessa hurt Cornwood, that doesn't help their case. Even if she did it because he committed a felony. I got one. I got one. You don't get to commit a felony. You don't get to put pressure on him. She's willing to go down for the cause. What if she's willing to be a martyr? She'll get up on the stand and she'll say why she did it. That's fine. That's perfectly fine. And if somebody picks it up because of that, that's their choice. I mean, that's the burden. The fact is they can't get to him. They can't get to him to make him answer anything about it. And if he did manage to get the scope open that wide or actually question him on the stand directly about that without the objections being handled and essentially sustained, then at that point he just invokes the fifth. He has every right to do so. It doesn't eliminate the rest of his testimony. Yeah. So I understand where you're coming from and I'm not saying it's a good book. Don't get me wrong. I'm just saying there shouldn't be a very easy way for them to get that. Tessa can go on the stand and give her side of the story about why she did it. But that just affirms that she did it. It doesn't somehow indict Cornwood because she saw that on the 29th. Did she go make a police report about it? Did she go do X, Y or Z about it? I guess this is a prosecutorial case. Then you're getting him first and then they recall him and then it's the defense thing. So I think if you start off by pleading the fifth, doesn't that make you kind of, you can't really answer anything at that point? No, that's only if you're a defendant. Only defendants can have the right to plead the fifth. No, he's saying I don't have to answer. That's what you're saying, Mac? I'm saying because you're getting called after. Recall. They'd have to recall. They'd have to bring you up on recall. Yeah, and I don't have to say anything. I'd just be like, no. Well, you do have to answer their questions. Yes, you do. Oh, OK. When you answer their questions, if it's an incriminating question, you can invoke the fifth. And if it's not incriminating question, and it's something like, why were you on February 29th?  I mean, it's very easy to prove. I get it. I mean, why would the defense do it? I get it. I'm just saying if she gives you a motive, she sets you up for her. We could have plenty of people testify that I wasn't being cruel to the animal at all. If it did even get to that point. Well, it did. First of all, is anybody going to testify that they saw you go grab that dolphin? You were in possession of the dog, but that doesn't inherently mean that you were the one that caught it. Listen, whoever ends up prosecuting this case, it's up to them. But all that I ask is that you guys do the right thing. Yeah. Shoot Tessa. All that I ask. It's true. No, I'm playing. I'm not going to shoot Tessa. Unless I have to. Legally.  I can't believe you stopped. What?  How many people were there? Oh, like the whole city was there. Oh, my God.  Yeah, but you know, it was great. Everybody loved it, except for Tessa. So that dolphin, it was a rescue. It was going to die anyway. I raised it from birth. I don't know how it got into the Alamos, but it did. That's what I said at the thing. And his name is Finney. He had a bad fin. So, you know, I was bringing Finney to the party. And yeah, it was a saltwater pool. Would your dolphins live in saltwater? Actually, they live in both saltwater and freshwater to be fair. As far as I know.  I don't think that was animal cruelty. I took good care of him. Would it only be animal cruelty if there was proof of the harm? Yeah, there's no proof.  Well, here's the thing. What if Tessa took photos of everything and she tries to make me look real bad? Because there's no, you know what I mean? There's no proof of me not harming it. You can drop the charges, but then, I mean, you're letting her get away with what she did. I mean, that's why we just wait until my statute of limitations is up on the third. Why that? Oh, you better count your days, my man.  You got to stay under the radar until then. Yeah, you see what I'm saying? We're going to do push charges after the 30th on Tessa. Yeah. That's two weeks from today. Because I can't let her retaliate with an animal cruelty charge on me. Because what if she does find somebody to prosecute? If you're going to fell on anything. Also, I don't want to incriminate nobody else. That's another thing.  You can't say, you can't... Oh, she was an old game warden. She knows the law, man. Yeah, that's what I'm saying.  You ever heard of the phrase victim blaming? I get it. I get that she's a lunatic and she stabbed it for this. But it's just like the idea of the why if that comes out, which I'm sure will be asked. I feel like most sane people in this city would hear Cornwood went and grabbed a dolphin and put it in the pool at the mayor's wedding for everybody to play with. They'll hear that and they'll say, based. That's it.  All right. I mean, I'm not trying to grill you or nothing. I'm just trying to, you know, we got to consider all angles. This is all I'm saying. You got to be careful that this could be a real thing to turn its head. And you just got to be ready for it. I cover all my bases, my man. I'm just throwing that there. I'm helping you out more than anything. Yeah, actually, I mean, I think I'm fine. You'd rather the pressure for someone that's on your side. I think I'm fine.


Anyone that's wanting to teach should definitely come down to the Career Fair. I went to the Rural Career Fair as well and I know a lot of people recognised me from that career fair and I think that really helped me today.


onstruction now in Northampton. And I could provide photos of some of those units, including the kitchen area. It might help you visualize what's in the kitchen, what it would look like, things like that. You've read my mind, I was, you know, you read my mind. One of the things I was apt to ask about is if you've managed similar properties with the similar income groups. And if there was any way you could show us some of the, some pictures from some of that. So that would be very, very helpful. And also your kind of your history with very low income, very low income people and how you've managed that property. And I think we'd like to hear more about that in subsequent meetings. Okay. All right. We've got, we're almost at nine o'clock. I don't think it, in my determination, it doesn't make sense to begin the public comment with just eight minutes where we just get one comment. So I think we'll hold off public comments until next week when we have the next meeting. Let's see, what else do we have to do? That's it. So what I'd like to do is move that we continue this public hearing on this matter to 630, not six, but 630 next Thursday, July 2nd. And we continue the public hearing. Do I have a second? Second. Is there any discussion on the motion to continue this matter of this public hearing till Thursday, July 2nd? Nope. All right. All in favor. Oh, it's gotta be a roll call. I'm sorry. I gotta get used to this. It's always a roll call with Zoom. So I vote aye. Mr. Langsdale. Aye. Ms. O'Mara. Aye. Ms. Parks. Aye. Mr. Maxfield. Aye. Motion passes five to nothing. So the last item on the agenda on the agenda for this meeting is the opportunity for public comment on any matter that is not the subject of this public hearing. So anything before the ZBA that's not a subject of this public hearing. And we always make that public comment available at our meetings. So Maureen, could you help me see if there's anybody in the attendees that wish to speak on something that's not about this particular application? Yes. So if anyone from the public has any comments about items that are, as the chairman said, items that have not been discussed tonight, you would have to click on the button to raise your hand to indicate that you have something to say. I am not seeing any hands being raised. I am not seeing any hands. Okay. So the, with our meeting next on July 2nd, I anticipate that there will mostly be public comment. We will take, we will update the board members with the material that you provide that the applicant provides to us. Make sure that we all have that. I mean, there'll be some short discussion about that, but July 2nd meeting will be principally public comment and we will meet at that point. So with that, unless there's any further discussion, I move that we had, we've continued the hearing. So I move that we adjourn this meeting for tonight and that we meet again in next Thursday. Do I have a second? All right. All, I agree. I vote aye. I really want to do these voice votes. It's so hard. Mr. Langsdale, how do you vote? Aye. Ms. O'Meara, how do you vote? Aye. Ms. Parks, how do you vote? Aye. Mr. Maxfield, how do you vote? Aye. Aye. The motion passes five to nothing. We're done. Thank you everybody for all your work. Thank you to the applicants for your presentation. Thank you for your time. And thank you to the public for participating. Thank you. Thanks everyone. Thank you all. Talk to you next week.


Thank you so much for joining us this morning for this discussion on enhancing U.S. engagement on maternal and child health. My name is Talia Dubovie, and I am the Deputy Director of the Global Health Policy Center at CSIS. It's my pleasure to welcome you here this morning. Before we get started, I want to thank Senator Warren and Ashley Colom on her staff for hosting us here this morning. Special thank you as well to my colleague, Catherine Strifle, for all her good work pulling this event together, as well as Jesse Swanson, Chris Millard, and Ariane Malexade for their help. For those of you who may be unfamiliar with our work, the Global Health Policy Center works to provide strategic, long-term, and actionable recommendations to U.S. policymakers in order to make U.S. global health efforts efficient, effective, and sustainable. Formed in 2008, the Center grew out of an earlier HIV-AIDS task force that was chaired by then Senators Kerry and Frist and played a role in the Congressional Authorization of PEPFAR. The Center engages across a spectrum of global health issues, including infectious disease, women and children's health, and global health security. An important part of our work involves traveling to see U.S. health programs in action. And in many cases, we organize delegations to provide a broader set of perspectives to inform our reports and recommendations. Today's event is a result of one of those delegation trips. In February of this year, we took a delegation to Tanzania to look at U.S. engagement on maternal, neonatal, and child health. Our goal was to better understand the ways in which the U.S. supports the Tanzan government in its efforts to reduce maternal mortality and improve child survival rates, as well as have the U.S. engages with multilateral partners, most notably Gavi the Vaccine Alliance. The delegation was led by Katherine Bliss, Senior Associate with the Global Health Policy Center, and Katherine Streifel, Program Manager and Research Associate. In addition to myself, the other delegates were Ashley Cologne with Senator Warren's office, Dana Derrider from the Bill and Melinda Gates Foundation, Michael Gerson with the One Campaign and the Washington Post, Sarah Hank from Rabin Martin, and Barbara Riley with Congressman Crenshaw's office. Each member of this group who collectively represent experience in Congress, multiple administrations, advocacy organizations, foundations, and the private sector made significant contributions to the trip, as well as to the report that we are releasing today, which it was available as you walked in and hope you all grabbed a copy of. We chose Tanzania for a number of reasons. Tanzania has made strong progress in extending vaccine coverage throughout the country and is on track to meet its MDG target of reducing under five mortality. At the same time, the country has been less successful in reducing its maternal mortality rate and newborns still represent 40% of deaths among the under five. The one major goal of the trip was to better understand the reasons behind this divergent progress. In addition, the US has a long-standing and comprehensive relationship with Tanzania on health issues. The Tanzanian government has recently rolled out major initiatives aimed at reducing maternal mortality and improving neonatal survival. A second aim of the trip was to see how the US is working to support the Tanzanian government in those efforts. Over the course of the six day trip, we met with US and Tanzanian officials, as well as NGO and civil society representatives, and we conducted site visits to health facilities in both Dar es Salaam, Tanzania's largest city and economic hub, and Mwanza, a rural region bordering Lake Victoria that has lagged behind on almost all health indicators. Throughout the trip, we received exceptional support from both US and Tanzanian governments, as well as a wide range of international and local implementers, health workers, mothers, fathers, caretakers, and at one site in particular, children, all of whom went out of their way to ensure that we had a productive trip. So a big thank you to everybody who was involved in that work. In a moment, I will turn things over to Catherine and the panel who will discuss the major observations and recommendations that we make in this report. Before I do that, we are very excited this morning to unveil a new product that we have developed to share what we saw in Tanzania. An honorary member of our delegation was Salah Lewis, an extraordinarily talented photographer who lives in Dar es Salaam and who traveled with the group and captured what we were seeing. We have created a dedicated website that combines the main points of the report with her images, as well as some other graphics and visuals. Our goal is to create a more visually engaging product that might reach a broader audience. So that's what you're seeing above me on the screen and we're just gonna run through a couple features of the site. You can find this, the website is maternaltz.csis.org. And when you go into it, this is your front page. Before we scroll down, there's a little menu at the top where you can also, there's a number of footnotes throughout if you want to see our sources. You can also download the full PDF report that we have been handing out this morning. So if you wanna get that way, you can access it there. And then if you start scrolling down, what you'll see is a reduced and slightly restructured text that is mixed in with some of the spectacular images that Sala was able to capture from the trip. And we've also added in some maps and some graphs and some data points that hopefully will allow some of the information that we include in the report to become a little bit more accessible and more usable. You can open any of the various graphs as Paul is doing now, get bigger pictures of it. And there are slideshows throughout, so you can click through some of the images. There's places where, there's some places where you can expand if you want more details. You can skip that if you want, but if you want the more details, they're there. And then we conclude at the bottom with our recommendations. And if you want to print this particular site as a PDF, sorry, it's long, you can do that at the bottom. And then you get all the pictures as well. So we hope that this will be useful to all of you as we please share this widely. Again, the site is maternalTZ, Tanzania.csis.org. Please give us any feedback. This is one of the first times that we're doing this particular model, and so we're very interested in hearing what you think, whether it's useful, any feedback that you have, please let us know. This site was created and designed by Paul Frans and Allison Bores of CSIS, who went above and beyond to put this together and get it up in time for this morning's event. So a big thank you to them for all their work. With that, I will now turn things over to Catherine, who will get the conversation started. Thanks again for joining us. Talia, thank you very much, and welcome to all of you here this morning. It's my pleasure to be able to open a conversation here with our panelists and with you, the audience this morning, about the future of United States engagement on maternal, neonatal, and child health today. Now, the occasion of today's event is the launch of the delegation report and the web microsite that Talia has just described, but I really hope that we can use the observations and recommendations in the report as a platform for a much broader discussion about challenges and opportunities in the areas of global maternal, neonatal, and child health issues. Talia has already spent a bit of time describing our February, the delegation's goals and agenda in February. So let me just take a few minutes to share some of the observations and recommendations from the delegation report before we move into the discussion. So basically you'll see, I think when you came in, you were able to receive a copy of the hard copy of the report. You could see this on the website as well. We essentially had four overarching observations after our eight days, a very brief trip really, but we were able to cover a lot of ground, both I think topically as well as geographically, but basically four observations. One, the government of Tanzania has launched two high-profile initiatives, the Sharpen One Plan and Big Results Now, which are intended to improve maternal, neonatal, and child health outcomes in the country, but there are funding gaps in the health sector overall and for maternal, neonatal, and child health too. As the country moves from being a low-income economy to a lower-middle-income economy, and this is actually a goal of one of those efforts, the Big Results Now effort, but as it begins to transition from eligibility with some multilateral and bilateral funding partnerships, there may be greater gaps, funding gaps in the years to come. Tanzania has strong bilateral and multilateral partnerships that offer external support, but as the country moves as the United States, and we found that the United States is investing critical resources, important resources, and critical training programs, mentorships, and supply chain reform to help improve maternal, neonatal, and child health, but the needs in Tanzania, particularly at the community level, remain great. Programs to expand coverage, this is number three, programs to expand vaccine coverage have been highly successful, thanks in large part to the support provided to the government of Tanzania by Gavi, the Vaccine Alliance, and other partners, but reaching the most remote populations remains a challenge. And a fourth observation was that, although not always explicitly framed as maternal, neonatal, and child health initiatives, kind of broadly speaking, PEPFAR-supported programs are nevertheless helping to link women and children to a much larger array of maternal, neonatal, and child health services, but there are limits to the extent to which PEPFAR's program can address the broader populations, maternal, neonatal, and child health needs. So the four recommendations which you can see in greater detail in the report are these. One, focus health systems strengthening support, including training and commodities and supply chain reform for maternal, neonatal, and child health on activities at the community level. We heard time and again that in Tanzania, the population is largely rural based, and so getting those services out to the communities where people are based and needing to seek them is critically important. Second, use the successful vaccine partnerships that have been developed as a model for other services and programs. We suggest that it may be helpful or useful to consider how to better integrate the provision of immunizations and voluntary family planning services, as well as there may be lessons that can be learned from the extension of immunizations into some of the remote areas for other kinds of services as well. Third, consolidate and protect the maternal, neonatal, and child health gains realized through PEPFAR, but recognize that they are not sufficient to fulfill the human resource, commodity, and financial needs required for further reductions in maternal and child mortality. And finally, strengthen the dialogue, continue to build on and strengthen bilateral and multilateral dialogue around domestic resource mobilization for maternal, neonatal, and child health to begin to plan well into the future for increasing domestic funding for such important activities. So what I propose to do this morning is to use these observations and recommendations to launch a conversation about broader challenges and future directions related to maternal and child health in the Sub-Saharan African region, particularly but more broadly in general. Here to help us answer some of these questions are four experts in the fields of policy and programming around maternal and child health and health financing. To my immediate right, I have Koki Agarwal, director of USAID's maternal and child survival program based at Jepaygo. To my far right, Natasha Bilimoria, director for United States Strategy at Gavi, the Vaccine Alliance and based in the D.C. office here. To my left, Aliala Nandakumar, USAID's chief economist for global health and also a professor at Brandeis University. And to my left here, Heather Watts, coordinator for maternal and child health within the office of the United States global AIDS coordinator based in Washington, D.C. So I'd like to start by posing a question to Koki. You know, on our trip to Tanzania, we learned the delegation, learned that the country has made considerable progress in reducing child mortality, thanks in large part to both immunizations as well as vitamin A supplementation and an increase in malaria prevention and treatment activities, among others. But we heard both in Dar es Salaam and in Wanzan in many of the different sites that we visited that reductions in maternal mortality have been more difficult to achieve and newborn deaths still account for about 40% of deaths of among children under the age of five. So Tanzania is not unique in experiencing these successes in child health on the one hand and challenges around maternal and neonatal health on the other. So I'd like to ask you to kind of kick off our discussion and share your perspective of, you know, what do you see as the most important obstacles to success when it comes to the maternal and newborn health piece, particularly in sub-Saharan Africa? Can you tell us a bit about what USAID's maternal and child survival program? What steps that the program will be taking over the next few years to accelerate progress in this area in the priority countries? And, you know, if you could give us a sense of how you see things evolving over the next five to 10 years. Thank you. Thanks, Kathleen. It's really an honor for me to be here and share some perspectives with you based on our working as a USAID's flagship program in several countries. And I think that you, the report itself and what you mentioned as your perspectives and observations from your recent trip to Tanzania really outline and lay out what maybe many countries in sub-Saharan Africa are experiencing as well, that they might have been able to have gains in reducing child mortality, but they haven't seen the similar gains in maternal and newborn mortality. And I think part of the reason for this is that maternal effecting and impacting maternal mortality in newborn health is really a health systems issue. And it needs for us to look at the household to hospital continuum of care and what needs to be done. Many years ago, we had experts who had mentioned the three delays relating to addressing maternal mortality. The first being the fact that women don't seek care and the decision to seek care is the first delay. The second delay may be getting to a facility. And the third delay is the kind of care that you receive at the facility. And we know that for addressing maternal newborn health, we need to address all of these. As the report and other statistics from Africa highlight, more than 40 to 50% of the births are still happening in the house with unskilled unskilled attendance or just a household member. And so we need to make sure that those women who are delivering in the house are, if they're not reaching a service that will provide a skilled attendant, which is going to be the safest outcome, that they have some opportunities to prevent complications like postpartum hemorrhage or for the newborn health, they have opportunities to have essential newborn care at the household level. And those are the challenges that countries are finding it difficult to address. I think making the decision to reach a facility is also another big challenge. Many communities don't have referral systems in place or transport systems in place. And then under the previous project that USAID had funded, we had done a quality of care assessment in almost seven countries in Sub-Saharan Africa. And many of these countries, while we did direct observation of what the skilled attendants were able to provide. And even if you have a trained skilled attendant, which may not be the case in many countries because of the human resource shortages, we see that they are unable to provide the standard-based care that is needed for managing the main complications because there may be lack of commodities, there may be lack of equipment, or they just may not have adequate training that they received as part of their pre-service education. So I think that there's things that we need to address at all levels and we need to have a dual approach to addressing this in countries where we work, including working at the community, improving referral, using innovative strategies of using mHealth approaches, and then making sure that the facilities are ready to receive women as we create an opportunity for them to deliver with a skilled attendant. I also just came back from Tanzania and I have to share, one of the regions that USAID's project is working in is Kagera, very close to Moansa, which is one of the hard-to-reach areas with very poor indicators, and the largest maternity that we visited had only five or six beds with at least 20 women, many of them lying on mattresses, three to a mattress, and there was no separate newborn ward. So there are really strong challenges that exist at the health center hospital level, and many women will not come in because they feel like they're not going to get the services that they should get when they go into a facility. So even if the government is really trying hard, which I know Tanzania has many initiatives in place, including what Kathleen mentioned, like the big results now, a sharpened one plan, they're working to develop a new RMNCH plan, which is going to address a continued focus on addressing maternal newborn mortality. Well, we need to make sure that we also address the challenges that exist at the health center level and equip these facilities so that we are not shifting the deaths that happen at home to a facility level. So I think that just laying out, those are the main challenges I see, and then at the facility level, we know that there are human resource shortages, which is a big issue in some of the sub-Saharan African countries. We need to make sure that we are working with professional association, faith-based group, private sector to see how we can utilize every resource possible to have human resources, shortages addressed at these facilities, and use a task-shifting approach, making sure that if physicians are not there, nurses and midwives are able to provide services. I think another aspect of challenges for maternal newborn health is an integrated focus on family planning side by side as we assure that we are providing maternal health services. We know that family planning can reduce maternal mortality and newborn mortality by almost 30%. And we need to make sure that when we are working in these facilities to provide essential maternal care, we also provide postpartum family planning so that women who have an unmet need for family planning leave with a method of their choice or are able to access a method of their choice as they move forward. Koki, can I interrupt for just one second? We've just received a notice that there is an unclaimed bag at the front of the building. So I just want to ask everyone to check for their bags because if the bag is not claimed, then they will take steps to enhance the security of the building and perhaps evacuate. So if you are missing a bag, please go claim it at your earliest opportunity. Sorry about that, please. No, not at all. So I was just going to move into what the maternal and child survival program is focusing on. And our vision is to see that every country that we work in is self-reliant and equipped with tools and approaches and effective systems so that they are able to end preventable child and maternal mortality. And we are working in about 20 of the 24 priority countries that USAID has narrowed down based on the burden of disease and the problems that these countries are facing for maternal newborn and child health. And our approach is to really enhance country ownership, making sure that we work to support the health system and try and focus more so now on the district level and making sure that we are strengthening the district health systems to not only manage the issues and problems, but also prioritize and have resources that are needed for supporting the health systems to enhance the numbers of deliveries and essential newborn care that might be needed at the facility level. So we are really trying to work with the health system and looking at all of the different players that might exist in that district, whether it's the faith-based hospital or whether it's the private sector or individual providers who can all contribute in a unified, comprehensive manner to support the maternal mothers and the newborns. I think that the other aspect I wanted to highlight was looking forward in terms of where I see things might go. I feel that this is a really great time to support maternal newborn health initiatives. There's a really strong global commitment, country-level commitment as we are reaching the MDG, end of the MDG era and starting a new initiative on the sustainable development goals while the maternal health, the MDGs have really driven some countries into sharpening their focus on these issues. We want to make sure that this continues under the sustainable development goals and there are initiatives like the Every Newborn Action Plan and Ending Preventable Maternal Mortality that multiple partners, WHO, UNICEF, USAID and multiple partners have worked on together that can provide the impetus to these countries. In addition to other things that we will hear about the Global Financing Facility and the ability for these countries to get health systems strengthening grants from the Global Fund. So I'm really hopeful and I'm a born optimist, I think. I'm really hopeful that these countries are going to really benefit from this environment at this point and take the challenge and continue to strive to work towards Ending Preventable Maternal and Newborn Mortality. Well, thank you very much. Natasha, I want to turn to you because we've heard a bit about the maternal and neonatal challenges when our delegation was in Tanzania. We also heard quite a bit about the really extraordinary partnership between the government of Tanzania and Gavi, the vaccine alliance and the many different partners that worked to support that partnership. We understood that in a relatively short period since the inception of Gavi really, the government has been able to scale up and make remarkable progress and expanding immunization coverage, introduce a number of new and underutilized vaccines and engage in a very successful co-financing arrangement as well. So I just wanted to ask you if you could reflect a bit on some of the factors that have made extending immunization coverage in Tanzania so successful. What lessons from Tanzania and expanding coverage and co-financing do you think can be shared with other countries in the region? And one of the goals of the Big Results Now program is for Tanzania to reach that lower middle income economy status. And so as that happens and its eligibility for Gavi and other kinds of support changes, how is Gavi thinking about working with countries in that kind of situation to plan for graduation and others? Thanks, Catherine, and thanks. Thanks to CSIS and Senator Warren for putting this together and congratulations on the report and the microsite. It's really great to see all of it come together after I know a lot of work went into the trip and all of it. So Tanzania really has been a great story and has really shown how a country can succeed in particular ways when the right factors really converge. And as Catherine said, Tanzania became a Gavi partner country in 2001. And we've had very strong collaboration with the government, other development partners that are part of the Alliance UNICEF, WHO, as well as NGOs. And because of all of that, Tanzania has really made some significant progress in reducing preventable child deaths. The routine immunization rate at the time Gavi came in in 2001 was at 76% and in 2013 we're now at 92%. And what's great about these numbers is that it's actually equally distributed among wealth quintiles, but also between rural and urban divide. So again, by all intents and purposes, successful. And I think there were probably three key issues in my mind that really led to this. The first was an incredibly high level of political commitment. I think that commitment on the highest level all the way down really provides a solid basis for the support countries need to implement any kind of health program and obviously including immunization. And it really helps work to overcome challenges that can arise. And in Tanzania, we've really seen that at all levels. And in particular, President Kikwete, I think has been a huge champion for global health and immunization in particular. He actually attended our replenishment conference in January and really spoke to donors directly, really acknowledging all of their support and really meeting Gavi's replenishment goals and how much that would lead to better health for children in his country, but also all over the world. The second factor I think that has played an important part is really having a strong and competent EPI manager. EPI is the expanded immunization program. Technically speaking, but also managerially speaking. And I think all of us here know how important, just like in any job, how important management is to the success of a program. And the EPI manager in Tanzania who oversees this program, it's comprised of a lot of different priorities from costing and financing, cold chain logistics, surveillance and reporting. And I think the strong leadership has really been critical to ensuring all of these programs run well and are run in coordination with each other. And then finally, I think a third factor is really around a well resourced EPI team. And that really has been the case in Tanzania. And also again, strong local support from other partners in the Alliance have really created a partnership that has allowed Tanzania to really benefit and improve their immunization systems. As far as lessons learned, I think obviously these three key factors are critical. And I think the more we see that in other countries, I think we see similar kinds of impact. But I also think that another important lesson with Tanzania has been really the strong interaction that they've had with civil society organizations on the ground. I know many of us who are in global health really understand how critical CSOs and NGOs are to the success of global health programs because they really bridge the gap between communities and governments and other global health actors like Gavi on the ground. So as an example in Tanzania, Lions Club International, who is partnered with Gavi, really helped raise awareness with Tanzanian health workers in the community, and particularly about the dangers about measles and rubella, which is the particular issue Lions Club is interested in. And this work was really pivotal to the success of a campaign that Tanzania led last October and it targeted 21 million children with the goal of achieving 95% coverage during that time. And so this type of CSO support has really been essential to strengthening the vaccine programs as well as the health systems. And in Tanzania in particular, given that NGOs, CSOs provide 43% of all the medical services in the country, these partners are really able to help ensure strong health outcomes. And I think another area that can be learned from is it's really important to have functioning delivery infrastructure and good health systems. I think these have been words that have been talked about a lot over time, and especially in the recent past with Ebola, but the bottom line is as public health gains of vaccines or any other health intervention can really only be fully realized when you've got a system that's strong enough to support the specific intervention. And one thing I just want to point out is while the US has been a huge partner, contributor and champion of GAVI since the beginning, the funding that the US provides goes solely to the purchase of vaccines, but GAVI also provides health systems strengthening support with other funding. And I think the flexibility in our health systems support really allows countries as they're looking at introducing new vaccines to identify and target the barriers within their health systems that stand in the way of increased access to immunization as well as other child and maternal health issues. And in particular, our health system strengthening support to Tanzania has really helped strengthen the capacities at the district and the local level through training of healthcare workers, improving data management, really engaging the community and civil society in those communities, importantly improving cold chain systems and ensuring the transport of vaccines to rural or underserved communities. I mean, as we heard, this has been a difficult thing for immunization and we're obviously working to continue to improve that with the country. But I think overall these investments have really are targeted really at building up the immunization system, but at the same time can really be leveraged to provide a platform for which other key maternal and child health interventions can actually be delivered. And then finally on graduation, again, this is something that I think we're all talking about. Long-term sustainability of any program, immunization or otherwise is critical. That's why we're all doing this work and obviously in the end, that's really our goal. And with Gavi, our vaccine support is really done through country demand. So countries ask for support for the vaccines that they wanna introduce, but at the same time, we also require all countries regardless of income level to actually pay something for their new vaccines. So this co-financing contribution is based on a country's ability to pay and countries in the Gavi world are really divided into three areas, low income, intermediate and then graduating groups. And currently Tanzania is classified as a low income country. And so that means it's co-financing share for each vaccine is 20 cents per dose. And there's no annual increase to that again because they are considered a low income country. But to date Tanzania has contributed almost $15 million to the cost of the Gavi supported vaccines. So they have very much been a part of supporting these vaccine programs with domestic resources. And Tanzania is still a bit distant from the graduation threshold for Gavi. But as Catherine said, I mean, supporting a successful transition for countries as Gavi's support ends is really a cornerstone to our catalytic model. And there have been a lot of discussions going on and the board will be discussing more in about a month approaches on how to even more successfully support these transitions of Gavi countries building on the existing policies we have to bolster the sustainability of national immunization programs as Gavi support starts to decrease. But like many other African countries, long-term sustainability is going to be difficult. And Tanzania's programs have faced some challenges in sustaining or it could face some challenges, excuse me, in sustaining that high level of immunization coverage. And I think particularly in expanding the vaccinations to the hardest to reach places. And that's really the part of the program where in our next strategic cycle, Gavi overall will be focusing a lot on the issues of coverage and equity and making sure that the most vulnerable populations are reached in this next period. I think some of the key challenges on this really have been a shortage of human resources and a lot of turnover of healthcare workers. That was Koki, you mentioned that. And I think again, the access to getting to remote areas. I think that has also been a challenge for the country. But these are also challenges that are faced by many countries in Africa. And again, through our health system service, health system strengthening grants, we're really working with countries to target these bottlenecks or barriers within the healthcare system as a way to increase access of immunization and other MNCH services in the country. But I think if we really hope to see that continued success, overall we are going to have to see enhanced efforts to strengthen the capacity of health systems in the country to provide immunization and other health services. And so at Gavi, we're looking forward to continuing that strong partnership in Tanzania, as well as with the United States to really ensure that these programs, the immunization programs can continue to be successful and really sustain themselves in the long term. Natasha, thank you. And I should have mentioned at the beginning that we were fortunate our first day of the delegations, actually our first full day of meetings to have Stefano Lazari from the Gavi secretariat in Geneva join us for some of the discussions. He works with the Anglophone country team there. And so we really thank Gavi for their support on our trip as well. Heather, let me turn to you. In Tanzania, when the delegation was there, we learned a great deal at essentially every site that we visited about the important ways in which PEPFAR supported activities for maternal and child health, such as prevention of mother-to-child transmission, early infant diagnosis of HIV, and other programs, are really serving as platforms for the introduction and access to other maternal, neonatal, and child health services. And obviously Tanzania is not the only country where the PEPFAR platform has really contributed to a broader strengthening of the health system and uptake of health services overall. And so I just wanted to ask you if you could explain a bit about how PEPFAR programs can contribute to broader maternal, neonatal, and child health outcomes. And then one thing that we heard quite a bit about was the refocus that is going on as PEPFAR programs are kind of refocused on the highest burden areas in the 3.0 plan or 3.0. What measures will be taken to kind of ensure that the gains realized as a result, the maternal and child health gains, realized as a result of PEPFAR support can be maintained even as the overarching program kind of moves to focus on the highest burden areas. So please. Great. Is this on? Yeah. It should be. Okay. Thank you so much. I appreciate the opportunity to be here. I thank CSIS and Senator Warren's office. Sorry. So let me just review, obviously PEPFAR started a little over a decade ago and has provided an incredible platform for strengthening health systems and contributing to maternal newborn and child health. Obviously human resources for health, both pre-service training, the NEPI and MEPI programs, in-service training, and trying to integrate PMTCT into the maternal child health setting and providing dual training for a lot of healthcare workers. There's been a lot invested in supply chain management, obviously directed initially at HIV rapid test kits and antiretroviral drugs, but that can be tapped into, we try to work with national systems to improve those. Blood safety is another focus of PEPFAR, which has allowed safe transfusion services for management of obstetric hemorrhage. We've helped develop strategic information systems to try to allow monitoring of implementation and the results. Demand creation for antinatal care, which allows HIV testing and obviously provision of care and treatment for HIV positive pregnant women. Screening for their infants. Integration of screening for tuberculosis, which is a major cause of morbidity and mortality, especially in HIV positive women, but also in women in general in the reproductive ages. And improved screening and obviously provision of antiretrovirals for women living with HIV to prevent transmission in the current pregnancy, but also maintain maternal health. As you know, the maternal mortality in women who are living with HIV can be up to eight times higher than in the background population. Some of that's tuberculosis, some of it's sepsis, there are a whole host of reasons, but we're hoping as rolling out B plus and lifetime treatment for pregnant women that will improve maternal health and reduce the HIV related component of maternal mortality. We've also included enhanced counseling and nutritional support for breastfeeding among women living with HIV to provide the best start for their infants. So there's been a huge investment in health systems strengthening that has provided a platform for MNCH. Obviously a lot of you have probably heard about PEPFAR 3.0 or the pivot as it's called. And I think first of all, to give you the background on that, we're really at a crucial juncture with the HIV epidemic. We know we have treatment available now. We know by identifying infected people and getting them on treatment that it not only improves their health but almost eliminates their risk of transmission to their partners. So it's very crucial. And if you look at, we sort of have to either intensify and really double down on our efforts in the high burden areas and reduce transmission now or we're gonna have a huge burgeoning of the epidemic, especially as we see the youth of all of Africa and young women entering into the peak time for HIV infection. So that's the idea behind the pivot. So the idea is that we can focus on the highest burden areas. PEPFAR started as an emergency plan. We were rolling it out everywhere because that's what seemed to need to be done. We now have data to show us that in some areas we've been testing HIV positive, or we've been testing pregnant women for years and we haven't identified any positives. There are as many as 60% of sites in some countries where we've never identified a positive pregnant woman. Now why would we put our limited resources into continuing to test and roll out treatment and training and all where it's not doing any good? So the idea with the pivot is we're gonna focus on those areas with the highest burden and we're going to intensify our services. And I think that this will obviously provide better care for pregnant women in those areas who are identified as HIV positive. We're gonna tap into community health workers and civil society organizations to try to improve access to care, to improve services, to improve identification, and to get women on to treatment and to keep them on treatment. We know if we look at PMTCT rates, two thirds of our transmissions are now occurring after delivery. So we're doing a fairly good job with getting women identified during pregnancy and getting them on to ARVs. But then we're not doing a great job of keeping them on care necessarily during breastfeeding. So we need to intensify our efforts. So the whole idea of the pivot is you can take the services and deliver them in the areas with the high burden and really intensify services to identify. We're working in general to get 90% of people to aware of their status, 90% of those on treatment, 90% suppressed. In pregnant women, we really wanna make sure we're getting at least 95% of the pregnant women tested and 95% of those on treatment. So in the areas with high burden, our intensified services should lead to better outcomes for the mothers and the infants and we'll also generalize to, again, increase demand creation for antinatal care, increased support for antinatal care in general, increased support for followup of the infants for immunizations for early infant diagnosis. It can also lead to improved efficiency in the areas where we're just not identifying pregnant women. So instead of spending a lot of time trying to test lots of pregnant women who are not gonna have HIV, we can spend more time on other things in antinatal care, family planning, education, syphilis screening, immunizations, whatever. The other thing that I should say, everybody looks at the pivot and they hear about the geographic refocusing, which is what I'm talking about with the high burden areas. And also the core, non-core, near-core activities so that some of the activities that PEPFAR has done may be transitioned. But I wanna emphasize that another key component is still the health system strengthening component of PEPFAR. So even though we're doing geographic refocusing, we're still providing a large amount of money to health system strengthening to again continue to support human resources for health with training, improve commodity and supply chain, blood safety. The idea with a lot of this health system strengthening now is to look at transitioning to sustainability so that as we're strengthening supply chain, the idea is that we're improving it for the country to allow eventually transfer to country ownership and sustainability. Blood safety, there's been accreditation processes developed, we're working to help the countries get their blood banks accredited and be able to maintain those. There'll be continued support for the health management information systems. PEPFAR now is all about data so we're not gonna abandon our pursuit of better data. And TB will remain a major effort so enhancing TB screening in general. So again, I wanna re-emphasize we're still supporting the health system strengthening activities to a great extent and we're gonna be providing better services to the areas with the highest burden to really turn the corner on the epidemic. Heather, thank you very much. Let me turn to Dr. Nanda Kumar. Nanda, to tell us just if you could, in Tanzania the delegation learned about these very high profile commitments to maternal and child health sharp in one plan and big results now. But challenges at the same time when it comes to mobilizing domestic resources for maternal and child health and health activities in general. We learned that the government is putting together plans to extend health coverage but at present the populations out of pocket spending on health for all kinds of services remains quite high. I know that you and others have been carrying out research in the region to understand more about domestic and external resources for health. I wanna ask you to share a little bit about what you are learning about resource mobilization for health in general and what you can about maternal and child health. Say a bit about how the United States can help countries prioritize and finance health programs. And so if you could share some of that with us that would be helpful, thank you. I wanna begin by thanking Senator Warren's office and CSIS for inviting me to be here. I'm glad to be invited as an economist because we have a very peculiar way of looking at the world which I'd like to share with you. Let me start by saying that economic transition especially in Africa is real, right? If you go back to 2000, domestic revenues of the Sub-Saharan African countries accounted for $100 billion. In 2010, they accounted for $500 billion, okay? Now if you take Tanzania, in 2000 it's per capita income in PPP terms purchasing power parity terms was around 1200. By 2020 it will be 3700, okay? If you take Kenya, Kenya will grow from $1,800 to $4,400. Nigeria will grow from $2,300 to $7,800. And South Africa will go from $7,900 to $15,000. So economic growth and economic transition is real, right? So it does create the fiscal space for countries to invest more in health. But we should always learn from history and I want to acknowledge a colleague of mine, Caroline Lee who's sitting there. Caroline and I have done a lot of this analysis together. So we looked at what was where the trends in health spending between 1995 and 2011 in the 24 countries that are of interest to USAID for ending preventable maternal child deaths. So in 1995, for countries that remained low income between 1995 and 2011, donor spending accounted for 13% of total health spending. In 2011 it accounted for 39% of total health spending. In 1995, there were three countries out of the 24 where donor spending on health exceeded government spending on health. In 2011 there were 11 countries where donor spending on health exceeded government spending on health. There are some other interesting observations. When countries migrate to being low middle income, donor spending very rapidly declines from 39% to 9.5% of total health spending. And there is really no glide path. When this happens, governments are not stepping in and making up the gap. So what you're seeing is really an uptick in the burden of auto pocket spending. As incomes grow, people spend more on health. That's a reality. Countries spend more on health. That rule applies, and this is called the first rule of health economics. So where does that money come from? It's really coming from an increase in auto pocket spending. In the presence of donor spending, governments have invested away from health. That again is a reality. And it is true for all of our 24 countries, but it is also equally true for Tanzania. In 2000, donor spending was 27% of total health spending and government spending was at 25%. In 2011, donor spending was at 48% and government spending was at 21%. And the share of the government budget going to health in almost every single country has declined over time, okay? This is a very important thing to keep in mind. We talk about domestic resource mobilization, but it's important not to ignore history. The other interesting thing is, as incomes of countries increase, where governments put their money in healthcare is not in primary healthcare. They are increasingly investing away from primary healthcare into hospitals, more sophisticated technology and tertiary care. So there are countries I know where 65% of government health spending is going for secondary and tertiary care. So while we have economic transition creates a tremendous opportunity, one cannot afford to sit back and relax. What we need is a very strategic and proactive engagement and a new way of doing business that will incent governments to put more money into health to begin with and within health into HIV, AIDS, RMN, ACH, and other services that are of interest to us and the global community. So this is, I think we should keep this in mind. And if you just look at the funding gap for maternal child health, currently it is at $27 billion, okay? In Tanzania, I mean I saw your report, your report is suggesting it's somewhere around $170 million. And in Tanzania, that gap is projected to increase to about $350 million by 2020. Where is this money going to come from, okay? So it has to come from domestic resources even as the donor community supports it. So as USCID, we have been implementing a very interesting initiative for Ambassador Bucks. And this is around domestic resource mobilization for health with a sub-focus on ensuring sustainable financing for HIV, AIDS. And what are the big takeaways we are getting from it? And I think people have spoken to it. I think the first thing is you need very strong evidence-based advocacy around domestic resource mobilization. National health accounts go a long way, but one thing to keep in mind is what we are, we have to talk to ministries of finance and not just ministries of health. And ministries of finance speak a very different language, okay? So what you have to go to them with is an economic argument that makes sense. For example, if you would not invest in these services, what does it do to direct foreign investment? What does it do to interest rates at which you can borrow? What does it do to economic growth? How does it affect various sectors? How does it affect agriculture versus mining, versus other sectors? So an economic argument of the economic cost of inaction is something that they understand. So advocacy becomes a big part of the question. The second thing, and it has come out in what the other speakers have said, is you have to lead with an efficiency argument before you make a sufficiency request, okay? So, and what ministries of health, or many of us who are health professionals mean by efficiency is very different than what ministries of finance view as efficiency, right? We view technical efficiency, and we need to get things done better at the facility level. And their point is, what is your optimization paradigm? How are you prioritizing against competing demands? How do you ensure that more of the dollar you spend reaches point of service? So they are looking at efficiencies, and in many countries you will notice that budget execution is never at 100%. So how, before if you're not executing at 100%, why are you coming and asking for more money, right? So I think the dialogue advocacy with evidence is critical, efficiency is critical. The third thing we absolutely need to do is you cannot ignore the private sector in this mix, okay? The private sector in many of these countries accounts for 70 to 80% of our patient visits. So you have to explicitly bring them in to the mix through innovative financing or through other methods. The good news is with increased fiscal space, you have the ability, we have an arsenal of health financing tools that you can apply to the problem. Whether it's a problem of insufficient domestic resources, you have tax policy and tax administration, you can have bonds, now people are talking about development impact bonds. So you have more things. If it's a question of providers lacking incentives to treat the poor, you have financial instruments that you can bring to bear. If it is a lack of working capital, you have for supply chain strengthening, there are financial instruments one can bear. If it is delayed payments to health workers, there is technology one can use. If there is a limited ability to pay, there is insurance, there are vouchers, there are various things one can bring. So we have an arsenal of health financing instruments that we can bring to bear, but one has to be strategic and understand that you have to align these instruments to achieve objectives of domestic resource mobilization. So domestic resource mobilization is the way to go. There is no other solution. I mean, I think we need to understand that and accept that as the reality of the world we're gonna live in. And once we accept it, all of us at the global community need to align in our messaging. The solution cannot be if the US government withdraws some of its money, we'll go to the global fund. That is not the solution. So we all have to come together and align and make sure that we give the kind of support that is needed, engage in the kind of dialogue that is needed to ensure more domestic resource go to health and within health to these things. I couldn't agree more that health system strengthening is important and we have to focus on it. Bringing services closer to the poor, to the community and the poor is another tremendous way of improving outcomes because in many cases, a big thing is distance to facility and the lack of ability to access services. And the third one is integration of services. So these are system improvements that I think we should all focus on. I'll stop here and I can answer more Tanzania specific questions if we come up in discussions. Thank you. Well, thank you very much. Before we turn to some comments and questions from the audience, I wanna ask our panelists, if anyone wants, if you wish to respond to a comment that another one has made. Koki, please. I have a quick comment based on Dr. Nandkumar's point about advocacy for domestic resource mobilization and making the case for the Ministry of Finance of the economic cost of inaction. I think one of the challenges that we know and are facing in sub-Saharan Africa is that more and more the decision-making has shifted to for funding has shifted to the region, to the districts or to the county level. And the challenge is that how do we make that case at those levels rather than at the national level? The data doesn't exist and it's very hard to make that case. So I think that's one aspect. If there's some way that we could create that information at the regional level so we can utilize that data to make the case for more domestic resource mobilization and set priorities for the health systems at that regional, at the district or the county level would be great. I think this is a terrific, this is an excellent point, Koki. And we ran into this in Kenya as one of the priority countries for Ambassador Berks' initiative. So let me, in one minute, I'll tell you what happened in Kenya. So Kenya decentralized its entire system to the 47 counties. So what they did was they took block grants and gave each of the counties block grants and said, you can invest it in whichever sector you want. But 60% of those block grants when they were transferred actually came from health at the national level. When it went to the counties, two things happened. Three things happened. Only 37% of the block grants, on average, were spent on health with a low of 7%, okay? The second thing that happened was at the national budget, $20 million was set aside for ARVs, TB drugs, malaria drugs. When they went as block grants, the national government zeroed out their budget line item and not a single one of the counties put a budget line item, not one, okay? And the third thing was that when counties were making decisions and what they were going to put their money into, they were more interested in buying equipment and vehicles and building facilities. To us, when we were doing this work for Ambassador Berks, this crisis was an opportunity. So what did we do? So we decided to work with 10 of the counties on moving them from line item budgeting to program-based budgeting, okay? So that's the first thing we did. So we'd said, so program-based budgeting forces you to look at what your outcome objectives are and then look at what are your inputs you need to do. And we didn't do it just for HIV-AIDS. We said, let's do this for health. And within that context, we will look at the maternal child health program, the HIV-AIDS program. So that's the first thing we did. The second thing, so to your question, I think that's a huge opportunity that one can leverage as this decision-making gets decentralized. And then we are doing subnational health accounts at the county level. So we are understanding where the money is coming from, what it is being spent on. So in addition to just having data on the sources and the uses of funds at the national level, we are doing it at the county level. But also what we are combining that with is benefit incidence analysis because there's also a huge equity element to this. So if you do these three things we're trying to do this and we're trying to work with the Council of Governors there to get some support behind these initiatives. Thank you, Heather. Okay, well, thank you all. I wanna turn to seek some comments and questions from the audience. We've got a mobile microphone that I'd like to first see if I could turn to one of our delegation members who has kindly joined us from New York this morning, Sarah Hank, Vice President, Raybin Martin, the global health strategy firm. And I'd just like to invite Sarah to offer some comments or pose the first question just to get us started. And as we move toward the questions, I've already introduced Sarah, but if when you get the microphone, if you could just say your name and affiliation just so that many of us in the room here know each other, but we've got a large web audience as well so that they can hear that as well. So Sarah, please. Thank you. That was a fantastic panel. Thank you so much. I really enjoyed that. Hello, a very full room that I just noticed how full was. Hi, I wanna just make four really quick points to give a little color from the delegation's experience. We were there, like Catherine said, for just a week, but I think these four anecdotes or points or observations that we had really highlight the themes that have come out in this panel in a more specific way. I think first, the thing that I heard from several panelists was the, and what we really experienced there was when we were in Dar, hearing of the really impressive plans at the central level. Some of the most impressive plans I've ever heard for strengthening maternal and child health services and thinking really creatively about how to involve performance-based financing, how to address human resources for health, how to address health systems strengthening in a really innovative way. And then we were struck when we go to the field by how challenging it is to implement these really impressive plans at the central level, at the district and really local level and really remote areas. And so the points that have been discussed here about evidence-based advocacy at the district level and strengthening human resources and management skills at the local level really rung true for us during that week. The second point that was made about the value of bringing in the private sector, I think, as coming from Raven Martin, a global health consulting firm that does a lot of work with the global private sector, but also with the local private health sector and understanding how to bring those together. It was really powerful to me. We had a lovely evening with a lot of folks working with the local private health sector, which is small in Tanzania, but growing. And it was powerful for me to see just how much that sector needs to be brought in to these plans and brought into the fold in order to really make sure everyone is focusing on the same objectives. The third point that was raised about the ministries of finance and ministries of health speaking a different language and operating in silos that don't often connect was very much came to life for us while we were there. We had a number of meetings with Ministry of Health and then had a joint meeting with the Ministry of Health and Ministry of Finance, which I will never forget. The dynamics between the two were really interesting to observe and it was very clear who held the decision-making power. And I don't have to make that clear to this room, who held that power, but seeing those dynamics and seeing just how siloed their discussions had been and just how clearly it would benefit for the two to be at the same table in these planning discussions more and more became very, very true for us in that week. And then I think the fourth point about the GAVI approach to domestic resource mobilization or progressive purchasing in and participating in the financing of the GAVI program was really something that we all came away as really impressed by and wondered if there are ways to examine that model outside of vaccine programs. So I don't have a question, but because you had fantastic presentation. So thank you very much. I look forward to everyone else's. Sarah, thank you for sharing your thoughts. Let's take an initial round of questions. Maybe we'll take three questions. So if we could, let's see, start back here. I think there was someone in the third row in the blue dress, can't quite tell. Let's start there. Hi, thank you. Excellent presentations and discussion. And I'm Laura Shemp. I work with John Snow Incorporated on the MCSP USAID funded project and also on a GAVI grant as well. And we've been supporting the new vaccine introduction and activities in Tanzania since 2011. And I just want to build on the more recent points, particularly the last point about domestic resources because one of the issues that we've been seeing the government commitment is there as was mentioned and very good interagency coordination in terms of finance mobilization and coordination as well as technical coordination. But one of the biggest challenges they're facing is data use for better decision making, in which case they're doing, Tanzania actually has a very strong e-health strategy, which I think should also be mentioned, very much led by the Ministry of Health and their ICT unit. And they're working on an integrated logistics management information system to have better transparency across all of their commodities, vaccines included, as well as all health commodities, as well as trying to link in data through the administrative reporting system to have better quality in terms of their use of data. But with that, one of the things we found, and this was the point I wanted to raise with the financing, even though there is that strong commitment, we're just adding more things to that line item. And they have a dedicated line item for vaccines, which is highly valued and they have not defaulted on their payments. However, that is tied to GNP and therefore it only goes up so much, but yet we've added several new vaccines into the mix. So the problems that they're facing is they're paying more now for additional vaccines and less to be able to fund the recurrent operational costs that are required to deliver those vaccines. So the fuel for the vehicles and outreach sites, the ability to get per diems for staff to go 50 kilometers or more to find those children to vaccinate them or provide other integrated services. So I'm curious your impressions, and I'd love to talk to you about Kenya. One of my headaches these days, because it is, in Tanzania there is the commitment, but one of the things we're looking at is through their CCHPs, their council health plans to try and mobilize those domestic resources and get them focused around preventive health, because there is a tendency to go for curative over preventive, because curative is more of a revenue generator. So I'm curious how you work at the national level to get that on the agenda, but then also at the domestic and subnational levels to really make sure that that preventive public health focus is maintained as a priority. Thanks. Okay, thank you. Let's take another couple of questions. Let's see, yeah, right there, please. Hi, Jill Gay, what works association? My question is for Dr. Watts. How do you see incorporating into PMTCT, PEPFAR's new gender strategy, and also how do you see collaboration between the PMTCT work you're doing and the DREAMS work? Okay, thanks, and one more question. I guess we'll just stay on this side then we can come over to this side. How about that? Hi, Karen Lane, Office of HIV AIDS, USAID. I think my question might be for Dr. Nandakumar, but I'm not sure. It's about domestic resource mobilization, and we've talked a little bit about infrastructure problems and access to healthcare, but where my concern lands is on the healthcare workforce, and having worked in these clinics in Kenya for four and a half years, I would still choose to deliver at home. And we talk about task shifting, but right now I just see asking the same five nurses to go from doing 12 things to 20 things, and I'm curious, was there any conversation in Tanzania with their government about how do we grow the healthcare workforce, get people interested in being in nurses, but the payment issue is the other thing. And was there discussion about domestic resource mobilization around salaries for nurses? You mentioned the technology piece, that's one. Even if they could get paid on time, that'd be great, but there's lack of interest as well because it's such a low-paying position. And when Kenyatta announced that he'd offer free delivery services in maternal child healthcare, I nearly lost my mind. I'm like, there's no healthcare staff to take care of the women. So something about human resources and what you feel came out of those discussions. So we have three questions here. One is broadly about data for logistics and supply chain management. And I should add that when the delegation was in Tanzania, we actually visited the medical stores department at the national level and the zonal level with JSI to learn about some of that interesting work that is going on. A question about PMTCT programs and then also a question about domestic resource mobilization. And Nanda, I might ask you also if you could say a little bit about the global finance facility, which we heard about when we were there as well. Oh, I can go first and then you have two questions, I guess, okay. So the question about the gender strategy and then also how PMTCT interacts with dreams. And thanks for giving me the opportunity to mention the dreams initiative, which is a focus in 10 countries, but the idea of being implemented actually in all the countries as they're developing their country operational plans for prevention of HIV infection in young women. And obviously that's the ultimate, it's prong one of the global plan is prevention in young women. And that's the ultimate way to eliminate transmission to infants, obviously, is to prevent the women from being infected in the first place. So I think the ANC platform and PMTCT programs offer us a great opportunity to try to educate women about the new gender strategy and about empowerment and things like that. But then also we're encouraging all of our dreams programs to link with their PMTCT programs. One of the biggest ways to reach out of school, adolescent girls and young women is actually through these PMTCT programs because many of these women, young girls and women present during pregnancy. So testing during pregnancy, education to remain negative and even including them, linking them into some of the other dreams programs to try to maintain their negative status. Also to encourage partner testing, I just saw something this morning about women who serial convert during pregnancy who get their HIV infection during pregnancy represent about 2.7% of pregnant women but they represent 25% of the cases of transmission to infants. And obviously those are missed opportunities where when the woman was negative early in pregnancy, if we are not able to access their partners and find out their partners are positive and get those partners on treatment, we're not gonna be able to prevent those infections. So I think that's obviously a key thing that we need to focus on. So kind of cover what you were getting at. Okay. Cookie, do you wanna address some of the questions around human resources that came up? Yes, I can jump in there. I think that it's a really valid point. I feel, I really feel for the provider who's sitting there seeing 50 women line up for anti-needle care and she's a single midwife trying to see all of them. And then we blame her for not providing adequate quality of care. I really do think it's a challenge for many of these facilities and countries. But I think that there are opportunities for us to build some elements of the care that women need to support the women themselves to recognize what they can do for themselves as well as work through community health workers to be able to target some delivery of certain interventions that they can do recognizing that everyone is not going to make it to the facility as these countries transition towards more facility-based births. So I think that the program that we had worked on in several countries was looking at providing mesoprostil for preventing postpartum hemorrhage through a community health worker program directly to the women themselves at the eighth month so that she could take it as soon as delivery was done and make sure that if she didn't make it to the facility, she would be supported for not having postpartum hemorrhage. So I think we need to continue to look for broadening our horizons and looking at who can provide those services, including strengthening the ability for women to take care of issues and recognizing symptoms themselves. Thank you, and Nanda on the resources. Yeah, sure. I think it should be on. Yeah, it's on. So two observations, I think this human resources for health is a problem, not just in Tanzania but also in the United States, seriously, I mean, but I think one of the things that we have to look at is whether we can be agnostic to ownership. Okay, I mean, we cannot talk about leveraging the power of the private sector if all we talk about is a publicly financed, publicly delivered system, okay? So I think, especially if someone mentioned Kenya, I mean, Kenya, there is a vibrant private market out there, so how can you leverage this, right? That's the first thing we have to look at. Can we go from being agnostic and being smart about who are we going to get these services from? The second thing is there are very interesting experiments globally. I mean, I can point to the Corona Trust experiment in India where basically the management of public primary healthcare facilities have been handed off to a non-profit NGO and they get 85% of the budget, okay, to provide the services and they manage about 80 primary healthcare centers in hard to reach areas. And they're doing interesting things. They're using drones to deliver drugs. No, seriously, I mean, but they ensure that it is staffed, drugs are available and they're able to do it for about 85 or 90% of the budget that would have normally been spent. So my submission is that one has to look at, how do you use some of these newer ways of looking at the human resources problem, right? The global financing facility, I think it's a very interesting concept and idea and to address the financing shortage, but not just address the financing shortage. I think, to me, there are many other things that make it more attractive. So what is the underlying premise of the global financing facility? If you look at the RM and ACH world, this world gets a disproportionately low proportion of funding compared to the burden. I mean, there is, when you can take Tanzania and someone, I mean, one of the reports that came out said that maternal child health, this burden is about 53% of the total burden of disease in the country and gets about 15% of the funds. Okay, so there is a funding gap that has to be done, but, and therefore the grand convergence to 2035 that was discussed is not going to be feasible without doing two things. One, bridging the funding gap, but using the monies smartly to invest in high-impact interventions, but simultaneously promote long-term financial sustainability. I think, to me, those are the, that's what makes it exciting. The other thing is the IDA leverage, right? So there is the ability to leverage IDA, correct? Which means that IDA goes to countries, but if the requirement is that if there's a country trust fund to which the IDA flows, then you will use it for maternal child health. It is dedicated, so you are bounding, right? You're protecting funds going to RMNACH. I think the Global Financing Facility and the country-level trust funds can achieve that. I mean, I think this is still new, it's still being worked out, but I think it holds a lot of potential. Well, thank you. We've come to the end of our time here and we have this room, we've been able to enjoy this room for just a very brief period this morning, so I wanna give each of the panelists an opportunity to make some final remarks, if you, maybe 30 seconds or so, if you would like to just offer some final thoughts or remarks on some of these issues and then we'll offer some things. Well, I would just like to say that I think that there's a really great environment now for these countries to make changes and invest in the right high-impact interventions that will reach the most in need and make a difference. And I think that as long as all of the donors and partners are working to support them together so that there's more efforts to recognize that there's a bigger market out there without not just the public sector that they can make a difference in their countries. Thank you. Heather? Yeah, I guess one thing that I didn't mention when I was talking about the PEPFAR pivot is that obviously we're not transitioning out of these sites overnight and that this is an ongoing dialogue between the host country governments and the PEPFAR programs and obviously we'll be done hopefully in a very thoughtful manner to make sure that we try to maintain these systems because obviously we do wanna see maintenance of the systems that have been built up over time. Great, thanks. I just wanted to echo Koki's observations that I think we are at an incredibly exciting time in terms of the global health financing architecture. Domestic resource mobilization is possible. It is the way to go, but I think what we need to do is to change how we engage and how we work with countries to achieve it. All right, well, I wanna take this opportunity to reiterate thanks to Senator Warren's office and delegation member Ashley Coulomb in particular for hosting this event and facilitating our presence in this beautiful space here today. I wanna thank Barbara Riley from Representative Crenshaw's office for her advice and support in planning this session. I wanna thank CSIS Global Health Policy Center staff, particularly my colleague, Catherine Strifle, who was here, but I think she may have stepped out for a second to both help plan and lead the trip and also co-authored the report and the website as well. Also to Talia Dubovie who worked considerably on the website, to Paul Frantz and Allison Boers of the CSIS iLab in External Relations for their effort, advice and considerable patience as we worked on developing this to Jesse Swanson and Ariane Malekzadeh for their help in managing this today, but the webcast and the smooth running of this event. Let me thank you for joining us here this morning and please join me in thanking our panelists. Thank you. Thank you for joining. Thank you, that was... Hi. Sure. Hi. Yeah. Yeah.