[Transcribed from an audio recording]

JENNIFER KATES: Good morning, everyone. I'm Jen Kates and on behalf of the Kaiser Family Foundation I want to welcome you here today and thank you for joining us to what promises to be a lively, engaging, and very timely forward-looking conversation. As you know, today's forum is focused on a very critical topic at a critical time; child survival. What will be the ambitious launch this June by the governments of the United States, India, and Ethiopia working with UNICEF of the Child Survival Call to Action. What is being described as an effort that will “galvanize the political will to get the job done.”

What does that mean? How will we, the global community get there? What specifically is the U.S. government's role in getting there? How does this fit in to the larger both response to global health by our government as well as the global community's MDG goals, etcetera? We also are going to hear about the launch of something else by the U.S. government in the lead up to the Call to Action, which is the Fifth Birthday Campaign, which went live just a little while ago, and we'll learn more about it today.

I first want to note one change in our schedule. Right now President Obama is delivering remarks at the Holocaust Museum. He had asked Administrator Shah to be there with him.

Administrator Shah who is coming was going to be here now, but is at the Holocaust Museum and is coming here from there. What we're going to do is flip the order a little bit. We're very happy that Amie Batson from USAID will be able to bring us up to speed on what the Call to Action is about, the new campaign being launched today. As everyone knows, she's the Deputy Assistant Administrator for Global Health at USAID. She's also the USAID Deputy on the GHI and one of the government's point people on the steering committee for the Call to Action. She'll be able to set the stage there. Then we'll go to our panel. Instead of having our panel react to what Administrator Shah says, they'll react a little bit to what Amie says. We're going to count on them to get us all primed and ready for when we are able to hear from the administrator. He will speak and take your questions. We'll get questions in both to the panel and to him.

Without further ado I want to turn it over to Amie, thank her for standing in and getting us started. She'll come up and launch our program.

AMIE BATSON: Good morning. First I'd like to thank Kaiser for setting up this great event, and all the partners that have been working so hard on child survival and on all of the data collection that's going on right now as we really rethink what we're doing.

The world has made tremendous progress in child survival. With a 70-percent decline in mortality over the last 50 years and a drop from 12 million child deaths to 7.6 million deaths between 1990 and 2010. Hidden in that good news is a stark reality. Every year 7.6 million mothers and fathers go through the unfathomable grief of burying a child. As a mother in the U.S. I've had extraordinary good fortune. I had access to nutritious foods and supplements, to antenatal care. I had a safe delivery at Georgetown Hospital where my newborns got state of the art support. They are fully nourished, fully immunized, and protected from killers like malaria and pneumonia. I have two very healthy girls who have both celebrated their fifth birthday to show for it.

For everyone in this room I think we agree. Every child, not just mine or yours, deserves a fifth birthday. What will it take to end preventable child death? We all know the commitment of leaders is essential. That's why we're launching this campaign of Every Child Deserves a Fifth Birthday leading to a call to action on June 14th and 15th that will bring together leaders from all communities. That's to do a lot more than just talk for two days. It's to launch a way forward that builds on the knowledge that we have in our community.

What will it take? It takes a clear target that we all share. We need a common child survival target that brings together the governments, donors, civil society, faith community, academia, and others, that brings together the malaria and HIV/AIDS communities, the immunization newborn care, maternal care, and family planning communities, the clean water and sanitation and pneumonia and diarrhea communities. The people assembled in this room are a perfect example of what we need to start doing globally.

We need a global roadmap that articulates what we will do differently to reach this target, a roadmap that highlights the priorities and the gaps that require attention, the countries and the populations that are the largest reservoirs of child deaths, the mix of interventions that will make the biggest difference in these places because the world is not homogenous and what is killing kids is not homogenous either. Most importantly the how. The new strategies to scale up our proven cost effective interventions to assure that these great tools and technologies are reaching every child, are reaching the mother, and are reaching the family.

Countries are pioneering the way forward. We're working with them to gather their learning, their successes, and their failures to ensure that that knowledge is being shared with all of their peers with all of the world so that everyone learns from them.

Accountability is of course critical; both who is accountable and for what. The call to action is bringing together these leaders from across the world. I recently heard a quote from Nelson Mandela. That quote: “There is no clearer revelation of a country's soul than how they treat their children.” Everyone is accountable for the survival of the world's children and we need the indicators and the improved monitoring to hold them to it.

Countries are working to develop more effective and visible scorecards that show not only national progress, but more importantly within the country, the region, the state, highlighting the disparities and the areas that need more attention. That includes ensuring countries address the policies that are limiting the flow and trade of health commodities, that we have distribution systems for simple interventions like ORS and Zinc to ensure that they are reaching the children.

As we've seen with vaccines and bed nets, it's only when you put the power of these commodities into the hands of everyone that you can begin to save the lives of almost every child. That's why innovation and the power of science and technology are so crucial. We need to take advantage of mobile health technologies in far more creative ways. With the right applications just one smartphone or tablet can help turn a village health center or a frontline volunteer into a sophisticated point of care. We need to encourage and invest in these kinds of innovations.

In addition to commodities and technological barriers financing as ever will remain a challenge. At a time when fiscal austerity in developed countries is leading to either flat or cuts in health assistance every dollar must have impact. Every year the U.S. spends well over two billion on programs that impact child survival. We invite feedback from partners on how we can increase the efficiencies and the impact of that investment. Whether it's something as simple as buying used instead of new or as complicated as working out the economics of a commodity market, we need to squeeze more out of every dollar. Saving money means saving children's lives.

Our funds and that of other bilaterals is just a very small amount compared to the funds that come from the countries themselves. As economies around the world grow, and many of them are, countries need to devote more to their children.

Let me stop here with this very brief introduction. I am looking forward to hearing the comments of the panel both on these topics, these issues that I've raised and others, as well as Administrator Shah's remarks. To kick us off we also wanted to play a very short video on ending preventable child deaths. Thank you.

[VIDEO PLAYED]

JENNIFER KATES: Thanks, Amie. That's the video that is launching the Fifth Birthday Campaign which we'll I think hear more about from some of our panelists and definitely from the administrator when he arrives. Now we're going to turn to our panel who I will briefly introduce. As I said, we will rely on them to get us primed and ready to think about these difficult issues and then ask questions of the administrator later. I also know they're not a shy group, nor are you. I'm hoping that in addition to them raising some good issues you will as well of them and we'll get into a good conversation and be ready to go.

Let me briefly tell you who we have here today. I want to thank them for being here. We have Caryl Stern who's the President and CEO of the U.S. Fund for UNICEF; Ariel Pablos-Mendez who's the Assistant Administrator for Global Health at USAID; Amanda Glassman, the Director of Global Health Policy and a Research Fellow at the Center for Global Development; and Mike McCurry, Partner at Public Strategies, and among other things, formerly Press Secretary to Bill Clinton.

I'm going to start by asking each of them a few questions and we'll engage in a dialog and then we'll go to you pretty soon after that. I'm going to start with Caryl. One of the tenets or ideas behind this new campaign that's launching

in June is that it's going to finish the job. It's really going back into history and saying we started the Child Survival Revolution in 1982. UNICEF launched that 30 years ago. Where are we going with this? What does it mean to finish the job?

I thought it would be helpful if Caryl could provide us a little bit of history and bring us forward. What happened and where are we going and why is this sort of a new era? CARYL STERN: In two minutes.

JENNIFER KATES: In two minutes. I know you can do it.

CARYL STERN: [Missing Audio 00:12:54 – 00:13:13] People kind of looked at him and kind of smiled. They called him the Mad American for quite a long time. He led this amazingly bold effort. He ultimately saved the lives of 25 million children with partners like USAID and others. He pulled together this amazing coalition. He brought together some experts to really look at what's it going to take. That number was so large just like the number we saw on the screen today. It's impossible to get your arms around a number like that.

His analogy was to say, imagine if 120 jumbo jets all crashed today. That's how many children died today. When you think about what happens when one jumbo jet goes down in the U.S. and the amount of attention being paid to it. 120 died the day Jim declared war. 120 jets crashed and yet people called him the Mad American. I would imagine there will be those who will be equally skeptical this time and will say you can't get it done, but we can get it done, and I think Jim proved that.

He brought together experts and they said it'll take four really quick things. It'll take growth monitoring. We can do that. To make sure that malnutrition isn't happening it will take oral rehydration therapy so children dying because they're dehydrated from diarrhea no longer have to. We can do that. He said it will take breast feeding promotion; something so simple. We can do that. It will take immunization; something that our partners here represented in the front know all too well. We can do that.

He brought together this amazing coalition that was the captains and the kings and the people in the classroom. It was government. It was military generals. It was religious leaders. It was teachers. It was students. It was parents. It was people like us. The massive immunization campaign alone took people in 1980 where 20-percent of the world's children were being immunized to 10 years later where 80-percent of the world's children were being immunized.

Thirty years ago 36,000 children dying every single day. Today 21,000 children dying every single day. On the one hand the population has tripled in that time period. It's an amazing success. If one of those children were your child you'd completely understand that one. The death of one child we could prevent is already too many. That's why the U.S. Fund, our campaign, and we ask you to join us this year is, to believe in zero because anything less than zero is unacceptable.

JENNIFER KATES: Thanks. Just a reminder to turn on and off your mics. I want to move on to Ariel and pick up a little bit from there. One of the things also that's being talked about is the post-MDG agenda for child survival. I want to mention one other recent U.S. government announcement that I think relates, or I'd like to hear what you think how it relates to this, which is the announcements last year by Secretary Clinton and President Obama of an AIDS-free generation; sort of a game changer in the way we talk about tackling the HIV epidemic. We all know that that announcement was predicated on new science largely but also on bringing together new science with what we know works and actually for the first time imagining that possibility.

I'm wondering, with this announcement that's planned for June and with today's launch, what is the game changer here? How does it really relate to the AIDS-free generation concept? Does it? What's different now going forward than we've been doing all along? Or is it more of the same just let's give a new emphasis?

ARIEL PABLOS-MENDEZ: Thank you, Jen. Indeed. I think that the science as you know in the last decade in particular has gotten pumped up. The progress in R&D are now in an unprecedented state from where Jim Grant was launching the campaigns with very basic interventions. We're going to have more and more new interventions from vaccines against malaria, new vaccines introduced, the ramping up of efforts is just beginning, neonatal interventions that are just coming up, mobile interventions. Clearly the technology landscape is changing and is going to be offering new opportunities.

Also as importantly in what is likely a post-MDG vision and a post-Busan vision the world is changing itself. Worried about the grand historical economic recession in OECD countries including the United States we have also perhaps not been paying attention enough to the great success that we already are in the midst of in this roadmap to zero. Equally importantly, the fact that the big enabler is going to be the countries themselves. There's been an economic transition even through these periods of recessions. The developing countries themselves are growing at 6 to 8-percent. Total expenditure by the countries themselves is now doubling or tripling as we speak.

That opens new opportunities, but it also calls for a different way of work. That's what the Global Health Initiative invited us to do. Both in how we engage the countries themselves in a different way so that we can build through country ownership sustainable health systems a dream that can only reach 80-percent, but make sure we go beyond and keep it at the high levels going forward. I think that a combination of the success story that we are not appreciating the enabling technology that is coming about as we speak and the change in the economics of health in countries offered totally a new way of framing the world with doing global health. Particularly as we said before, the GHI advised also to do more integration of the work itself. That's what the child survival story is about. It's not about a disease. It's about the person; in this case the child.

JENNIFER KATES: Thank you. Actually that brings me to two questions I have for Amanda to pick up from that. Sorry to put you on the spot. One of the points that we just heard was that one thing that is different now is the role of developing countries and their role in responding or at least recognized role. Is that really one of the game changers here that you see? Can you talk a little bit about middle income countries, rising economies in other countries? Is that what is going to make the crucial difference? I'm going to ask you the second one after you answer that one.

AMANDA GLASSMAN: Okay. Half of child deaths are occurring actually in five countries, DRC, Nigeria, India, Pakistan, and China. Of those most of them are middle income countries. They're lower middle income countries. They're countries that are theoretically able to afford the very simple interventions that are required to meet this goal. Yet historically they haven't done so well at funding them themselves or providing them in an equitable manner.

The other issue is that the United States, per se does not have a huge amount of leverage in these countries as well because U.S. aid or assistance or even aid in general does not represent a very large proportion of these country's spending on health. A big question for me is how will the U.S. and its partners work differently in these countries to put some of these accountability mechanisms in place that we're talking about. I'll end there. I could say more on it, but I'll let you ask the second question.

JENNIFER KATES: We will have you say more for sure on that. My second question pivots back a little bit to the U.S. framework but it's picking up on the GHI discussion that we also heard. I'm going to quote you in something that just came out in CQ and I want you to speak to it. This is a quote from, Amanda, an article that just came out on this topic on this launch today. “The GHI hasn't been particularly compelling in its marketing. It's hard to do that, especially on the Hill, describe how it's value-added.” I'm curious. I think I understand what you meant by that. Is this attempt do you think today to sort of find a way to talk about it that's resonates more with policymakers and others? Where do you see the challenges there?

Also I think it raises the other question that a lot of us may have is how does this relate to the GHI. We heard that it's part of the GHI. What does that really mean?

AMANDA GLASSMAN: The Global Health Initiative, for those who don't know, is the U.S. government's effort to harmonize its own health aid and to be more aligned with country priorities. It's a means to an end. It's a way of working rather than the goal that we're trying to achieve. I think reframing the GHI and its efforts towards a specific goal, either the AIDS-fee generation or ending preventable child deaths in a generation, is a really good strategy, especially for our own lawmakers. The question though is can we translate that public vertical framing of issues to the broad action agenda, the integrated action agenda that the GHI brought to us. That's a question that I hope we talk about later.

The other issue is that our funding structures don't really help us to align behind goals because we still have very earmarked budgets and we depend a lot on the good will of ambassadors in the country and the goodwill of the agencies that are involved to put together their different pieces to achieve this goal. That's something I think will be important to continue to look at going forward.

JENNIFER KATES: I think that's a really good point. We find in our public opinion surveys that when we ask the U.S. public about development or global health broadly it's hard for them to grasp on to what that means, but when we start getting specific they get it. There's a lot more understanding. Child survival, vaccinations, HIV interventions; it resonates in a much clearer way. I think that it raises this ultimate question of how does that support or not the integration agenda.

I'm going to come back to both Caryl and Mike on this issue of reaching the public or different audience. First back to Caryl on what the U.S. Fund does in that regard because I think that's a big part of what you're trying to do; to mobilize the U.S. public to some degree around this concept of child survival and some of the challenges. Then we'll hear from Mike about that more broadly.

CARYL STERN: Obviously it's going to take a certain amount of dollars and coordination, but it is going to take political will or it's not going to happen. People have to be on their feet. Whenever you think about a movement the thing that I always think of is Calvin Butts from Abyssinian Church when he was helping to organize the Civil Rights Movement. He had a quote about, “You can't have a movement til you have a lot of angry people in the church basement.” I think that's step one. We don't have the angry people yet. We need America on her feet. We have to put this problem in front of everyone and we have to make it loud. That means telling a story.

If everyone in this room says, to celebrate the fifth birthday I'm going to do five things to tell that story, five for five. I'm going to tell five people. I'm going to take five actions. That will be the ripple effect that will get it there because we have to make that number real. We have to make it something that people feel. It isn't going to happen when you talk about 21,000. It's going to happen when you talk about one child.

I'm smiling because my predecessor is sitting here in the audience, Chip Lyons. I remember when I asked him when I took the job when would it feel real for me. He said, “The first time you actually get to see a child's life saved the whole thing is going to feel different for you.” Having borne witness to both a baby who died from a cause that $0.70 would have saved, but having also borne witness to a child whose life was saved it forever changes who you are.

I think those of us in this room; we know that but we need to say that loudly and we need to start to engage America in advertising. We need to engage it in our schools. Global competence should be a mandated part of education. We need to do it in our houses of worship. We need to do it in our newspapers, on our televisions. We need to make this issue the issue that it should be.

JENNIFER KATES: Thanks. Mike, do you agree? Think about it this way. I turn on the TV this morning and what I heard was gas prices, the election, the primaries. Is this the kind of thing that would really resonate in this current climate? Who are we talking about that we're going to get angry around this?

MICHAEL MCCURRY: This is a hard issue to elevate to the kind of importance that most in the room would like to see it have, particularly in the presidential campaign year. I think there are a couple of lessons that you can learn from seeing some of the things that are working. Picking up on what Caryl just said on the faith community, I'm here not so much because I used to have a little vaudeville act at the White House called the Daily Press Briefing. My more recent experience has been working on the Global Health Initiative at the United Methodist Church. We became one of the original partners in Nothing But Nets, the very successful effort to stimulate awareness about malaria and do something about it.

I want to talk about it for a second because I think that giving people a reason to invest in these causes beyond just the good that we're doing is a key part of what the equation has to be. We got into this as a denomination because we saw what it was doing to our young people, our youth groups that were getting excited about raising money, buying a net, saving a life; just the whole ethos of being part of something that was larger had a stimulating effect across the church and has been something that has helped revitalize a denomination that like most liberal Protestant denominations has been in decline.

The learning from that for us was that we really had to commit as a denomination to something bigger because, as everyone in this room knows, the delivery of insecticide-treated bed nets is one and only one aspect of the infrastructure for public health delivery that has to be part of everything that we do if we're going to be successful in attacking all the killer diseases of poverty that we care about. We've committed now as a denomination with support from the Gates Foundation and the United Nations Foundation to raise 75 million dollars to support the church's network that it has across so many countries in Africa, but also to support the work of the Global Fund.

One thing that we have learned, and this kind of ties in some of what we've heard from everybody here, is that country by country we are using our Methodist bishops and people that we have on the ground, people who are in clinics to develop country by country plans with control boards in each country that assures that there is efficacy in the delivery of the resources that we help provide. We have to go to our church and say, no this is not money down a rat hole, which you hear all the time from people who object to foreign aid or the spending of money for development assistance. We have got a mechanism in place and we are investing in mechanisms that will make sure that the money is spent wisely and effectively and that will get the job done. That's a big part of the messaging that we have to get out there.

The second part is hope. The good thing about church people; we're in the hope business. We can tell that story very effectively. We are making so much progress. I think many here are familiar with the little clock that we have used to talk about malaria, a child dying; in recent times it was every 30 seconds and then it was every 45 seconds. Now we're talking about a death from malaria only happening every 60 seconds, which is good news, but the bad news is it's still every 60 seconds. That is a way in which you kind of begin to engage audiences.

Taking off my Methodist hat and putting on my hat as the co-chair of the Commission on Presidential Debates. I'm with Frank Fahrenkopf chairing the effort that will structure the debates this fall between presumably President Obama, Governor Romney, and anybody else who shows up with 15-percent support by October. This is not an issue that's going to be raised in those debates by the moderators unless we've got angry people in the church basement who were talking about it. I'll stop now.

I talk too long, but I'd like to talk a little bit on this panel about how do we really effectively communicate in a way that gets people drawn into these issues because that is something that I know of from the White House perspective. What does it take to get a president engaged and thinking and debating these issues? Right now we don't have that. Right now I would say to every one in the room there's not a chance in hell that we're going to have these issues raised as part of our debate this fall between the leading candidates for president unless everyone here collectively does something and gets more organized and structured in the way in which we communicate. Maybe we should spend some time talking about that.

JENNIFER KATES: We're actually going to go to folks in this room who I think probably have a lot to say about these. I wanted to bring back, Ariel, to the goals of what you're launching today. I think it's interesting USAID is launching a campaign to reach who? Is it the public? I think it's getting at these issues, but really what's the hope there? Who will that engage? What do you want them to do?

ARIEL PABLOS-MENDEZ: The Fifth Birthday Campaign is really the beginning of a process to sensitize those people that indeed are the voices that we need to engage. It's a very open and broad campaign right now. We are indeed working to link and build on that campaign that was a call to action specifically in June. We're in coordination with many partners because the call to action is not only a USG drive, although USG has been leading an effort. UNICEF has been a partner from the beginning. The countries themselves had to be part of the story.

It's a complex conversation but it's one that is based on very solid evidence and modeling. We are trying to sensitize the interest of the American people on this call to action so that we can put forward all the specifics that Amie has already put on the table and Raj will also speak, but that we also will be crystallizing with each of you, each of the communities that will make this possible going forward.

JENNIFER KATES: I have one more question. Amanda, please jump in.

AMANDA GLASSMAN: I'm just reflecting on what you're saying. I think one of the issues is that we have three big events going on this summer around global health. If it's the case that we want to arrive at the presidential debate is it necessary to have maybe just one goal? Just putting that out there for our conversation.

JENNIFER KATES: Will you state for everybody what those three are?

AMANDA GLASSMAN: There's the AIDS-free generation. There's the family planning summit. There's also the child survival call. All of that will happen in June. It's a big month. I was sitting next to Robert Clay who dubbed it the Triple Crown.

JENNIFER KATES: Does anyone else want to say anything about that specifically?

MICHAEL MCCURRY: Three is too many. You need one. One of our learnings; my own experience when the Methodist church galvanized around malaria we had a very strong and robust HIV/AIDS program and they said, “What about us? Why are you leaving us out?” There was a reason for that. The African bishops that we work with said start with malaria because we can't protect them from HIV/AIDS if they're dead by five. That's where we want you, the western church, to focus. We had a good reason to do that.

I think it's how do you draw everyone in and use all the things that we're doing to get a larger conversation about what this is all about. Because this community, we use the word community when we talk about all of us in this room, is not very communal sometimes. There's a lot of jockeying for who's going to get resources for this or that. There's a lot of competition. Bringing people together to agree, maybe we are going to have to settle on one goal for right now, but that is a gateway that gets people engaged and moves them into a conversation that they can be a part of, and we can branch out from there. You've got to grab them however you can get them to get them engaged and involved before you can then move them up the ladder and they see the larger picture.

ARIEL PABLOS-MENDEZ: Indeed. In the context of the GHI, the AIDS-free generation, saving the lives of mothers and children and engaging the world in a different way had been clearly the way to go. Last year we were discussing whether to focus on immunization or malaria and indeed the call to action on the child's survival represents a vision of integration of all of these efforts and to put again the child at the center stage of the effort so that we can all benefit from that joint mobilization, but it addresses many of the communities as was reflected in the clip that we saw today.

This is already an example of that; bringing it all together with a single banner and a powerful one. The AIDS-free generation was already put forward last year. It's an important one; the resources, the targets are in place for that to occur. This is really bringing crystal clear focus on the child survival call to action.

JENNIFER KATES: I have one more question for them, and then we want to hear from you, which is around resources. Bringing this back a little bit to the U.S. government role, we all know that the budget situation, the economy, we're in dire straits in some regards. The budget for global health, while it's faired relatively well up to now, is seeing proposed decreases for the first time in many areas, including maternal and child health, HIV, a lot of the areas that we would say can be used to address these challenges. How does that reconcile with the push forward? Does anyone want to comment on that?

CARYL STERN: I think what Michael said is very real. If everyone in this room doesn't make this the primary issue then that is the road we're going to end up down. We're going to see cuts. We are seeing cuts. I'm struggling to remember the name of the book where the story starts with you're down to your last x dollars and you've been out of work forever and they tell you, go to this job interview on Monday and you will get the job but you have to show up and look your best, so you take your last x dollars, you buy your best suit, you put on your best shoes, and you go. On your way there you see a child drowning. You have a choice. If I jump in and save the child I ruin everything I've just spent. I won't get to the interview. I'll stay in poverty forever, but if I don't the child will die. There's probably no one in this room who won't jump in and save the child and consider that more important. If we'll do that with our last few hundred why won't we do that with our first few?

There has to be a change of sensibility. That is the same change of sensibility that has to take place in our request to the government right now. This is about children. It's 100-percent of our future. These are not areas that can be cut, but until we get angry that's not going to change.

ARIEL PABLOS-MENDEZ: I would only add that under President Obama the global health budgets have continued to grow despite the economic hardships that the country has faced. It's getting hard. I just join my voice to what Caryl has just stated, that we need to all come together with a single voice to make the case. Of course that is the beauty of democracy. Things are going to be debated, discussed, and all of the voices will be heard so that the right decisions are made. I'm certainly looking to my colleagues on OMB and others and the Hill for that voice to come strong and give us their support going forward.

MICHAEL MCCURRY: I get to be impolitic in my old age now. I'll say two things. One is that the work that the private sector is doing; obviously I'm talking about the faith-based community, but there are other private sector efforts that are out there. Those should be visible so that people see that this is a partnership that doesn't always require government spending, even though we all know it does require the spending by governments to address so many of these problems in an effective way.

The second thing I'll say is more controversial which takes off on a column that David Brooks wrote some time ago in the New York Times. Unless we all together collectively get behind sanity in fiscal matters, and unless we raise our voices and say in support of two good friends of mine, Alan Simpson and Erskine Bowles, that we have got to get some rational approaches to the way in which we organize our FISC, our federal spending, then all of our efforts are going to be for naught.

I do a lot of work in the U.S. Domestic Hunger Relief area. I give the same message to them that I would give to you that everyone here has to use your resources and your networks to support cutting government spending for entitlement programs that send money to people who probably don't need it as much as the kids that we're talking about this morning. We need to raise taxes on people who can afford to sacrifice and spend more so that we can support the kind of worthy programs we're talking about. Unless you all join efforts to make that part of your own individual agendas too we probably are not going to get the kind of political outcome that we want. We're not going to hear it from the President. We're not going to hear it from his opponent during the campaign because they avoid these issues.

We have to raise these issues and we have to begin to change the political culture in this country so that we have sanity when it comes to fiscal policies. There. I made probably a lot of people unhappy, but I thought I should say that.

AMANDA GLASSMAN: I think sanity sounds good. I just wanted to say that in spite of funding decreases there was evidence that there could be efficiencies in expenditure. Unifying behind a single goal that uses all the different communities' comparative advantages could actually work in favor of the goal. You have to be accountable for what happens as a result. I think increased efficiency plus accountability could be the way out of this budget conundrum.

The other issue of course is that the budget reality is the budget is there, the large budget increases are there, because of activism from a community that hasn't necessarily championed child survival as the main goal. How do you put these two things together?

JENNIFER KATES: We're right on schedule. We expect the administrator to arrive very, very shortly. We have time for questions now, comments ideally to what we've heard. Then we'll hear from him and there'll be time again for more questions. Anybody want to start? Please identify who you are.

KATHARINE KREIS: Sure. Good morning. Thank you so much. I'm Katharine Kreis. I'm the Director of Policy and Advocacy for the Global Alliance for Improved Nutrition. I guess I just have a comment and maybe a question for our panelists. I think you're absolutely right that we do need one shared goal. The voice that has gotten the biggest share of that recently has been HIV. You've had a very engaged community. People recognized early on that advocacy was so important for that. They've done an amazing job. I look at them as the gold standard for how I would want to get a movement on an agenda. They've done it really well.

It's missing I think the broader point of child survival. I'm wondering what ideas you would have for really engaging the global community at a very senior level to come together and decide on what that goal is and have not just USAID doing child survival or the Gates Foundation doing family planning or GFATM doing HIV, but really trying to think from a very, very high perspective what's that one goal and how do we get the global community. I'm really talking about donors and the donor community because that's what's driving the money; to get that on the agenda.

The second question I have for you is advocacy is rarely part of the donor community as a single commitment. You see the Gates Foundation doing it. I spent 10 years at the Gates Foundation. It was only really within since 2008 where the Gates Foundation really made a commitment to really strong advocacy and being out there. Prior to that they didn't. What you saw I think with that was a tremendous increase in reaching out to a variety of stakeholders and constituencies; the public sector, the private sector, individuals, the faith-based community. They did it through a variety of campaigns. Nothing But Nets comes to mind, the HIV ones come to mind. Now it's family planning.

There really was a commitment to that. I don't see the commitment to that particularly from USAID. I don't mean that as a criticism. I think there are lots of politics that are involved in it. It'd be really helpful to know how we could do a better job as a community putting resources behind that advocacy agenda. Thank you.

JENNIFER KATES: Thanks. There are two questions. I am going to urge everyone to be a little shorter in your questions so we can get more in.

ARIEL PABLOS-MENDEZ: If I may take it first. I think that Amanda was also speaking about how do we leverage the world. It is clear that in the economic transition that we are in the midst of that means that the importance of diplomacy and advocacy will become paramount. Even in our larger programs where we account for 20 to 30-percent of the total health expenditure of a country, mostly in Africa. That is changing. In many countries in many of the missions we account for 1-percent or less of the total health expenditure. Clearly the leverage of the ODA dollars themselves changed. It's changing for good because the countries are growing.

Really engaging the machinery of our diplomatic channels is going to be part of the campaign and the effort that we are driving as well as indeed supporting advocacy. Not only the global advocacy for the global dollars, but increasingly within the countries themselves. India three years ago was spending 16 dollars per capita in health. That was less than half of what was required to buy basic services including the child survival interventions. India is now spending 60 or 70 dollars per capita. That is already above the inflation adjusted package that we conceived 10 years ago, and it's going to 100 per capita expenditure in the next three years.

India is changing. How India gets engaged, even though it's the most important contributor to the overall number of kids dying the world, becomes very important. It is the global advocacy. It is also the country advocacy. USAID is very committed to see the child survival go as the central strategy for our work under GHI. Clearly we are going to be working with you and other groups in the advocacy side as well.

AMANDA GLASSMAN: The big lesson of advocacy is to have a single issue. Now that you stood up I'm remembering the thousand days goals as well. That's part of the Feed the Future and food security activities that will be highlighted at the G8 perhaps. I think the administration should choose one and take it to the max. I think that child survival is a good one. I don't want to take sides. I think it should just be one whatever it is and that will deliver for the administration as well.

MICHAEL MCCURRY: I know that food security has been focused on in the prelims for the G8 this summer in Chicago. I think our collective voices, if we used it, could drive child survival a little bit higher on that agenda and move that into the equation that the leaders will address there. I think that's the way in which you engage the donor countries at a high level; you put it on the agenda of the national leaderships that attend the G8.

JENNIFER KATES: Next question. I'm curious to see what people think about this discussion related to messaging in congress. I think it's a different—

DAVID BERK: Hello. I'm David Berk, World Bank retiree. Two things; one is the U.S. public seems to believe that foreign aid is 10-percent of the total federal spending. I wonder if there's some scope for saying no, it's really only 1-percent and look at the good results we're getting with so little. There shouldn't be a prime target for cutting that everybody imagines is out there just waiting to be cut. Second is, the World Bank is getting a new president who's a health expert with a good reputation, coming onboard in July. Can you make some more use of the World Bank and its resources in this campaign?

CARYL STERN: Thank you for the 10-percent, 1-percent because while I agree there can always be increased efficiency I think in terms of a return on investment and the statistical success that we've seen in the area of child development, and boy that's a company I would have liked to have invested in.

MICHAEL MCCURRY: I would just say on that that's the ONE campaign, as many of you probably are aware of or a part of, have tried to drive that issue really hard, another Gates Foundation supported effort along with DATA and Bono and others. One of the things I feel from that collective effort is that the numbers are abstract when you talk about percentages spent on things like foreign aid. What is more effective is to talk about specific things that you're doing with the money that produce specific outcomes. I think one of the reasons why Nothing But Nets took off is because there's something tangible about a net that you can see and that you can learn the story and you can follow a net and know where it goes and know that it goes to this village.

Our narrative and our storytelling around so much of this have to be focused on that. The Gates Foundation, many of you know, developed a campaign called Living Proof that really was, I thought, a very effective way to talk specifically about why this money is being spent and why it's effective. That's the way, you have to kind of build underneath the argument why it's important that we spend this before you get to what percentage of the federal budget should it be. Should it be 0.1-percent or 0.5-percent? It's not 10-percent and correct the record on that.

I think it kind of goes to the heart of some of what we've been talking about on this panel that it's our storytelling ability and our communication strategies that have to be at the heart of how we advance the case.

ANN STARRS: Thanks. I'm Ann Starrs from Family Care International. I wanted to probe perhaps a little bit with Ariel and Amanda around this suggestion that child survival should be the central goal for USAID moving forward and whether you're thinking about this primarily in terms of an advocacy goal or a programmatic, an outcome goal as well. We do have the family planning summit coming up. There's been a significant effort around HIV, around maternal mortality, and a range of other issues. It would be, I think, important to think about nuancing that in terms of how some of these other communities and issues might react to that particular focus.

AMANDA GLASSMAN: I think it's a good idea. I wouldn't say just USAID. I'd like to see the U.S. government commit to a single global health goal for a year. I think that would be a good idea. Maybe next year it could be something different. Maybe in this key electoral year when you want to get candidates talking about the issues and the public domain it might make sense to just choose one.

ARIEL PABLOS-MENDEZ: Of course we agree with that. Not only the government but all of us in the community and we invite you to this. For us the work on the child survival includes of course PMTCT and includes the work of family planning as contributors to the child survival success story. Just to answer also, it should not only be advocacy but programmatic. Indeed the work that is feeding the call to action, a lot of the modeling exercises, the best modeling around the world going on, so that indeed our program of work country by country will be adjusted according to the best evidence, the best possibilities will lead us to the most impactful success going forward.

JENNIFER KATES: I know others of you had questions and I promise we'll get back to more questions, but Administrator Shah is here. It gives me great honor to be able to introduce him, to welcome him to this forum this morning. We know that you came from another very important meeting. Thank you for joining us. As everyone knows, he's the 16th administrator of USAID and is actually one of the key people in the U.S. government pushing the child survival call to action and will talk to us about the launch of the Fifth Birthday Campaign. If you haven't seen his picture on that you will any moment. I encourage you to go look at some other people who are up there. It's fun.

Without further ado I'm going to call you up. Thank you again. I'm going to move this so you won't be extra tall.

RAJIV SHAH: Good morning. Can you hear me? Excellent. It's nice to see you. I appreciate the chance to be here. I heard that you have had some excellent discussion including with the co-chair of the presidential debates explaining how the first official question of each presidential debate will focus exactly on child survival. It's a brave and courageous statement for the co-chair to make. We look forward to holding him to account. I want to thank the Kaiser Family Foundation for hosting us today. As I look around a room of people who are passionately committed to global health and to child survival, I'll just take a moment to say thank you for all that you do and for the discussion that you just had.

This is my daughter Amna with her stunning graduation from a play group. I feel like we celebrate milestones a little more frequently in the modern era than maybe we used to. Next year in August, the following year, she will turn five. Like most children born in America, she's going to have a birthday party. We're big into celebrating birthday parties. We'll invite her friends. We'll have the cake and balloons, and she'll of course get presents.

Now like many children who turn five she will at some point go to kindergarten. Since she won't read this speech I can let you in on a little surprise that one of her presents will be a backpack for school. I have a backpack here that I want to talk to you about. This is our backpack. This isn't the kind she'll get. She'll get one that has a picture of Dora or whatever is the latest and greatest Nickelodeon creation that we spend all our money on.

The fact remains that almost seven million children, most of them in Sub-Saharan Africa and South Asia will die before they reach their fifth birthday. They won't attend kindergarten and they won't get backpacks or any other presents.

Let's not be naïve. We know that preventable child death has always been a fact of life in human history. What is unique and what gives me pause both as the USAID Administrator and as a father is that for the first time in history we really do have the tools and know-how necessary to change this brutal fact of life. Many of them can in fact fit in the backpack. To demonstrate that to you I will show you some of my favorite ones.

Amie, you want to help me here for a second? This is an orange flesh sweet potato which helps provide nutrition. That's not part of a cost estimate we worked up when we created the backpack. I know you've been talking about some of these and I'm quite familiar with these. This is a nutritional supplement but it just represents the advances in science over say the last five to ten years about the role of nutrition in the first thousand days. Nevirapine are more advanced regimens for PMTCT, which we have to rename since that's difficult to articulate. The idea that no child has to be born with HIV/AIDS anymore; we have a very simple, almost costless strategy to do that. Zinc, which we now know helps prevent diarrhea and saves a large number of lives. New vaccines; this is the syringe. The vaccines are in there somewhere for pneumococcus and rotavirus and the traditional vaccines that we know together can save hundreds of thousands of lives. Oral rehydration solution.

We've added to this backpack a couple of larger items. This is a bed net. Everyone's familiar with that. This is my new favorite addition, the low cost bag mask that helps save children's lives from birth asphyxia. The point that we'd make is that all of this stuff together costs about 30 dollars. We now know that with enough application of science and these strategies that they together can lead to a massive reduction in preventable child death in developing countries and all around the world. Together they can be used to help a child born anywhere get a healthy start to life and reach their fifth birthday.

I realize in this community I'm sensitive to the fact that this is a simplistic portrayal. I realize that not every solution is contained within this backpack, and in fact the challenge is getting this package of interventions in any kind of backpack or bag to kids in very vulnerable places. The point is very simple and I find very compelling that we have the tools available to us now to dramatically cut the rate of child death worldwide. And yet, as I've said and as you've heard this morning, more than seven million children will die this year before reaching the age of five. Six million of those children will die in developing countries, representing a massive inequity between rich and poor societies. At current rates of decline this inequity would persist until well into the next century.

I don't want to understate the progress that we've all made together. In 1990 12 million children were dying a year and the rate is down considerably from that high level. With the knowledge we now have, especially in the last few years, with the technologies we've created and with the rapid progress we're seeing in places like Bangladesh, Ethiopia, and Rwanda we know that we can do more to accelerate the global rate of reduction in child mortality dramatically.

Right now in developing countries the rate of decline in under five mortality is about 3.9-percent. To hit the millennium development goal target of cutting the rate of child death by two-thirds by 2015 we'd have to instantly accelerate that rate to 7.1-percent. That will be a tremendous challenge.

As progress is being made, the share of child death is either staying flat or increasing in certain regions. Sub-Saharan Africa's share of global child death increased from 31-percent in 1990 to 49-percent today. South Asia's share has been stuck at 33-percent over the last five years. As vaccines and bed nets have spread throughout developing regions harder to prevent neonatal deaths are also making up an increasing percentage of the total; up in the last few years from 37 to 40-percent and still rising.

As we'd unfortunately expect, inequality remains a major factor driving these outcomes. Children born to the poorest people in a country are almost twice as likely to die as those born to the richest across the world. Rural children are 1.7 times as likely to die as urban kids. Children born to uneducated mothers are nearly three times more likely to die before the age of five than children born to mothers with a basic education.

For all our talk about these simple interventions, this low cost, and the last mile the truth is the world still struggles to reach people who need help the most. Why is there such a large gap? There are four institutions that have been modeling the rates, probably many more than four, but we've benefited from the insights of UNICEF, the Johns Hopkins School of Public Health, the World Health Organization, and the Institute for Health Metrics in Seattle. After studying their more recent modeling we find that each essentially puts forward a pretty consistent picture. It's not easy to understand, but it's a consistent picture. We've seen the largest rates of decline through the expansion of key high impact interventions like the expanded use of measles vaccines, rapid rollout of key malaria interventions such as the bed net you saw, and the improved treatment of diarrhea over the past quarter century, most notably oral rehydration.

Malaria still continues its millennia long assault on the world's children. Neonatal ailments remain far more difficult to overcome than ailments affecting children in the years after birth. Looking at these numbers just sorted by cause is exactly the mistake we've been making for years and years and years. It is what divides this room today into so many different communities. It is what has led to a health system in the field that confuses diseases for patients. A state of affairs President Obama's Global Health Initiative has been fighting to address.

Instead we have to consider child survival as the common goal that unites us and confront the most sobering fact about the world's progress. The countries that have the largest aggregate number of children dying each year, what essentially are the largest reservoirs of child death, are amongst the same countries that have some of the slowest rates of child mortality reduction. This is especially true if you look at the sub-national data. In fact, half of all child deaths occur in just five countries; India, Nigeria, the DRC, Pakistan, and Ethiopia. Over the last 20 years the rate of child mortality reduction in Nigeria, DRC, and Pakistan were each 2-percent annually or lower compared with a global median of 3.3-percent. Despite rapid progress in some areas, many of the poorest and most populous states in India saw reductions well-below that level as well.

Compare that to progress with Ethiopia. Last year, in fact just two weeks ago the country's demographic health survey showed Ethiopia had made so much progress in reducing child mortality that they'd experienced in a four year period a 23-percent reduction in under five child mortality. Ethiopia's success remains too unique. We see country after country choosing to spend marginal health dollars on hospital or tertiary services and cities or other efforts to improve needed access for middle class and wealthier quintile populations in their countries.

We see a global community that rightly works where we can get the best results but hasn't really figured out how to work together to drive an acceleration in child mortality reduction in places where it's been a big problem and a persistent problem over decades. We rely heavily on the individual health commodities in the bag here. Aside from vaccines and bed nets, we're not always overcoming the core barriers that prevent us from ensuring that supply chains leave enough product and commodity out there for people to access in both the private and public sector in country after country and community after community. To say it simply we just aren't being as strategic against the overall goal as we could be.

I know in the discussion you heard about Jim Grant and an era of our time together when perhaps we were more strategic or more uniformly focused on what would be possible if we all came together and made this the absolute top priority. In that spirit we'd like to propose a few things we can do to accelerate our effort and to help eliminate preventable child death.

First we need to articulate and build consensus around a clear, measurable, and ambitious goal for ending preventable child death. We need to identify the areas and regions where progress will be the most critical to achieve that goal and identify the partners who need to lead the effort to drive success in those places. We have to recognize in that spirit that partner country buy-in at the federal, at the state and local level is often more critical than the specific actions we might take in an international development or health community. That's why we're incredibly encouraged that our June meeting, the Child Survival Call to Action, is being co-convened by the governments of India and Ethiopia in close collaboration with the United States and UNICEF in order to display in fact that commitment. Those countries are not focused on simply sharing their own lessons learned or lessons of success. They're making a bold, global statement that they will put child survival at the absolute top of their political and health agendas.

Identifying the locations of the largest sources of child death and securing that kind of support is not going to be enough. In each country and as a global community we need a crystal clear roadmap for action that will highlight proven strategies for success, identify tools and mechanisms to reach the most vulnerable, low income communities, and highlight the regional and sub-regional differences that need to be accounted for as we pursue aggressive strategies to end preventable child death. These roadmaps absolutely require country ownership and the partnership of the private sector, civil society, corporate leaders, and the donor community working together with a renewed sense of purpose.

What they absolutely need to do is address some of the areas where change or success has been more difficult to come by like neonatal mortality. The good news is even there we're seeing big breakthroughs in just the last few years. New data from Bangladesh shows that this can be effective by linking community health workers to stronger, more technologically advanced community health systems. By using frontline workers to provide antenatal care, monitor pregnant mothers, and refer them to clinics, Bangladesh was able to double the number of hospital deliveries in rural areas while cutting homebirths in slums by nearly 70-percent. In some of those cases a token to take the bus or coordination to get a taxi or other form of transport is the technological equivalent of the breakthroughs that are in the backpack.

Finally we need to ensure this roadmap for action has clear metrics for success and child survival scorecards that track progress at the country level and globally so we can hold ourselves as donors and partners to account in an easily understood manner. Agreeing on a goal, developing a strategy, and developing ways to measure and report on success are not revolutionary insights, but they are critical to getting off of the current path we're on and doubling or more the rate of global reduction in child mortality.

We should also be honest about some of the other barriers we currently face. Even in countries that have seen rapid reductions in child mortality, core bottlenecks exist that prevent commodities from reaching those in most need. In India for example, oral rehydration therapy has an incredibly low utilization in northeastern states; this despite it being cheap, nonperishable, and incredibly effective. In fact, in the five countries with the highest burden of child mortality fewer than 5-percent of children are receiving access to recommended treatments like oral rehydration solutions and zinc together.

We need partner governments and the private sector to come together and address policy solutions and programmatic solutions that can improve the flow of these critical health commodities. We've seen that with polio vaccines and bed nets and vaccination more broadly, when you come together and take these commodity challenges seriously we cannot only alleviate the bottlenecks but we can usher in a new era of improved versions of those types of products, improved versions that can save even more lives over time.

That's why innovation and the power of science and technology will only be more important in this effort going forward. We need to take better advantage of mobile health technologies that are proving so useful in parts of Bangladesh but remain completely underdeployed against this task in many of the donor programs and many of the coordinated health systems efforts that we're making together. With the right applications a smartphone or tablet can help turn a previously disconnected village health facility into an integrated part of a modern, if low resource, health system. We need to encourage the development of those technologies and accelerate their deployment in country programs and in strategies around the world.

In addition to commodity and technological barriers financing as ever will remain a real challenge. At a time when fiscal austerity in North America and Europe and elsewhere around the world is putting extraordinary pressure on budgets we need to tackle this directly. Every year the United States spends more than 2.5 billion dollars on child survival. We need to invite feedback from partners on how we can eliminate inefficiencies and get more value for that investment. Whether it's something as simple as buying used vehicles instead of new ones, cutting down the size of home office costs and operations and integrating more closely with local health systems and with local health providers, efforts in this field that save money save children's lives.

We should also remember that this field is increasingly being financed by partner governments and private sector players. We're seeing positive trends in developing countries in terms of the use of new insurance structures and expanding access to private-based health care. We need to learn from and expand those efforts. We need to renew globally the donor commitment. The United States share of global health spending has been going up over the last few years. We need to address that with our partners and directly as a nation do as much as we possibly can.

It's easy to recognize that the incredible moral power of the commitment to fight child death is at the forefront of this effort and of the motivation that brings so many of us to this room and to this cause. The ethical force behind this effort and for many of you that I know have sat in villages with mothers who have both lost children and those whom your efforts have helped to prevent that loss, I understand that you feel the power of that very forcefully. Sometimes because of the moral strength of this argument we don't do as much as we should to make the case in broader economic and political terms.

That's why it's so important that we communicate to leaders here in the United States and around the world that saving children's lives is not just about our moral imperative, although it is absolutely about that as well. It is also an economic strategy and a core part of our national security strategy. Although developing countries are growing economically in many cases at admirable rates; the Sub-Saharan Africa growth rate is two, two and a half, some years three times the global average. We know that if you have more children survive, more effective family planning that reduces the overall birth cohort, coupled with education for women and girls that those things come together and produce an economic growth dividend, a dividend that's been experienced in places as diverse as Chile and Thailand, Malaysia, and the Philippines. Where because of the change in demographics as described in some of the visuals here, you actually see countries experiencing a 1, 2, or 3-percent increase in their annual growth rate for a decade when they can move from some of the charts you see on the top to the ones you see in the bottom row for east Asia and for Latin America.

That kind of growth rate is something that all political leaders everywhere around the world, including here at home, aspire to add to their record of successful governance and stewardship of their economies. We also know that this is a national security imperative. We know the fact that Afghanistan has seen huge improvements in women who survive child birth, in children who survive child birth, and to the age of five and who are now going to school. We know that that lays the groundwork for decades of stability and success. It creates a pathway where over time in an accelerated fashion our troops can come home safely.

You cannot have security, as Secretary Clinton likes to say, without the stability of mothers surviving and of children surviving. It simply cannot happen. That's why we are so excited about the upcoming Child Survival Call to Action in June. There are a lot of promises we have to make real and a lot of support we have to recruit from all forms of American society and around the world. On a topic so complex as child survival we need to do as much as we can to communicate in simple terms the knowledge that those of you in this room have to help save children's lives.

Because at the end of the day the mission is very simple. We believe every child deserves this: a fifth birthday. That one event is such a powerful milestone in our lives. It's one of the first instances where we feel part of a strong community where our links to friends and family are etched in our minds and where the concerns of the world disappear for a day and we all get to be and celebrate children. The power of that one day is why we've developed a new awareness campaign that every child deserves a fifth birthday.

We're asking everyone to upload an image—oh, my goodness. I didn't see that before. I will say when you grow up as the son of Indian immigrants you generally don't spend your time celebrating your fashion choices as a little kid. You generally try to move away from that. Sorry, mom. Sorry, dad. We're asking everyone to upload an image of themselves. If I can do that wearing a shirt like that you can do the same I assure you. Tell your loved ones. Tell your family members. Tell your kids. Get their school groups involved. This is something that we need to do for everybody.

I just had a group of 120 tenth grade girls from a New York school in the office the other day. They had heard about malaria bed nets. They had heard about polio. They had heard about a few of the Nutriset. They had heard about Plumpy'nut. They hadn't heard about some of the other things that were in the bag, but they were very, very, very committed and very eager. We are the most generous, most committed, most volunteer-oriented country on the planet. If we can get everyone to participate in this campaign, if we can raise awareness about both the tragedy that exists and the clear goal and the clear strategy for success we believe we can achieve the ultimate ambition which is the end of preventable child death.

Thank you. I look forward to your questions and to learn from you. Thanks very much. [Applause].

JENNIFER KATES: Thanks. I know that a lot of people have questions. I neglected to actually thank our panel when I quickly ushered them off. Please join me and just thank them very much. [Applause]. We're going to take questions. I encourage the panelists to ask questions as well if they want to.

RAJIV SHAH: Or answer them.

JENNIFER KATES: Or answer them. I'm going to actually start with the first one which is about the U.S. budget piece. Actually I want to clarify one thing because the number 2.5 billion has been put out. To avoid all of you contacting me later about this, what that is I believe is the combination of programs at USAID in child survival that include the maternal and child health, family planning, reproductive health, HIV, malaria, all of which play a role in child survival. I assume that that's what you're talking about.

RAJIV SHAH: Correct.

JENNIFER KATES: On the budget, because it came up earlier and I'm sure there are people here who have questions about it. We all know that this is an era of fiscal austerity. There are a lot of challenges on the budget side. The fiscal year '13 request was a marked change from what we've seen up to that point. It would actually I think represent the lowest amount for the GHI collectively since it was first announced as a program.

Given that the key accounts we're talking about actually are lower in the request how does that reconcile with the ambitious goals for June?

RAJIV SHAH: The President's FY13 budget request was 7.9 billion dollars for global health spending. We believe that that is a request that allows us to achieve the goals that have been laid out, starting with putting us on a path to end HIV/AIDS as President Obama laid out, as Secretary Clinton laid out in the fall and winter. It includes the efficiencies that we believe we've gained, especially on core commodity prices like antiretrovirals and others. It is cognizant of the political realities we face.

I'd point out that at that level we are actually going up, not down, as a share of total global health spending by donor partners around the world and that we remain by a long shot the world's largest partner for global health and will continue to be there. I personally believe that over time the United States has the capacity to continue to invest in global health at ever higher levels if we can honestly demonstrate that we're driving value for money, that we're getting better results, that we're reporting on those results, and that others are also doing their share.

I stand by our budget obviously. We will continue to put forth and fight for the largest global health budgets ever, continuing on a bipartisan legacy in that space. We recognize that it's an incredibly, incredibly difficult fiscal environment overall.

JENNIFER KATES: Time for questions. Alex, I know you had one earlier and I cut you off. Can you wait for the microphone?

ALEX PALACIOS: Hi. Alex Palacios with GAVI Alliance. Just be interested in knowing a little more about some of the leaders that you anticipate coming. I know that there's a lot of interest. There's a lot of discussion with a lot of donors in other governments interested in knowing basically who's coming.

RAJIV SHAH: I'm probably not the right person to answer that question. I do know this. We certainly want to have very strong, high level, and committed participation from countries that, as I described, tend to be the larger reservoirs of child mortality. I personally believe as you look at what we've accomplished over the last decade or 15 years, it's clear to me that those countries for a variety of reasons some of them are not big donor recipient countries.

Some operate in different contexts. We don't all have the same capacities in those places as we might elsewhere.

One of the big strategic challenges we hope this will rectify is to put in place a system that seriously engages, builds momentum and political will and establishes clear roadmaps and accountability mechanisms for countries that are large reservoirs of child mortality that are also stepping up and saying we want to be on the front end of the solution.

That's been a priority and I think we'll have very strong attendance there. We want a strong public, private partnership in mix. We're thrilled that the Millennium Development Alliance has come together to be supportive, and through that I believe there'll be a very strong private sector representation and commitment. I fully expect that if we continue to work at pace that for that meeting we'd like to be able to put forth some solutions for some of these commodity challenges and bottlenecks that may exist that hopefully are creative and effective solutions. We've invited the commission that the Prime Minister Jens Stoltenberg chairs from Norway to present some of its findings on child-related commodities in this setting, so others could speak to attendants more broadly. I certainly would love to see everybody here there and your institutions, your boards, your leadership really represented.

I'll come back to this point that I made that I do think going forward if we're to be back in a context where we can mobilize greater investments against these goals. We do have to come together around a bigger vision as opposed to the disease-specific storyline that I think worked incredibly effectively through the last decade, but probably won't for the next.

JENNIFER KATES: More questions? Put your hands up so we can see where you are.

FEMALE SPEAKER: Hi. My name is Susanna [?]. I'm from Querl [?] U.K.-based investor backed by the Hedge Fund Industry. Thank you for a really inspiring presentation. I'm interested to know what you think is the role of the private sector, particularly in diarrhea control. I was very pleased to see you bring our [inaudible 01:25:25] zinc out of your backpack. Particularly thinking about how the private sector can interact with the public sector and create a separate value-added supply chain rather than something that's competing with a public sector supply chain.

RAJIV SHAH: I think you're leading the answer there. Certainly public private partnerships like the Global Alliance for Vaccines and others in other commodity areas have proven to be very valuable in effectively addressing those supply chain issues. I'm not really expert enough to be able to suggest that one particular solution is the right solution. In general I know we also want to bring things together so we have more integrated supply chains that are country owned and managed, but at the end of the day having good strong public private partnerships that can actually say what does it take to get enough zinc out there so that it's available in both formal health systems and local kiosks in rural villages for people to purchase and use because that's often the main form of distribution. We hope to see some of the solutions emerge over the next few months.

JENNIFER KATES: You have a question over here?

DAVID BRYDEN: Hi. David Bryden with RESULTS on behalf of the Stop TB Partnership. I wanted just to ask about TB as it affects children. As many as half a million children are falling ill with tuberculosis every year. The reservoir of future disease is huge as a result of children acquiring latent tuberculosis and developing it in later life. I'm wondering what more USAID can do to be an engine for innovation particularly for better diagnosis of tuberculosis in children. When will we have a TB diagnostic that will fit in that backpack at the point of care to rapidly diagnose TB in children?

RAJIV SHAH: That's a great question. I don't know the answer but I know it's the right question. Moving away from the discussion of every disease as its own independent task to be handled and thinking about how could we integrate whether it's in this backpack or in some other form the sets of solutions so that we can most effectively deploy what is at the end of the day usually a community health worker or some kind of frontline health worker who hopefully is increasingly tied to a health system.

I think those are the kinds of questions we should be asking. I know that our team is moving aggressively to accelerate the deployment of Gene Xpert. That's not something that fits in a backpack is my understanding. It fits in a laboratory. There's a whole second wave of solutions behind that that we're also accelerating investment in.

We've also launched at USAID a Center for Innovation in our global health bureau to focus energy and resources precisely on that translational space where we think new breakthroughs can be tested more aggressively in the programs and platforms we are able to support around the world.

JENNIFER KATES: More questions? Upfront here? Put your hand up so we can see where you are for after.

NORA O'CONNELL: Hi. I'm Nora O'Connell with Save the Children. I first just have to say, I think this really has potential to be a real turning point in the well-being not just of children but really of nations globally. This is really exciting. Building on sort of the private sector question many of us in the room do have partners in local civil society around the world. I think the emphasis on change at the national level is really key. What role do you see civil society playing? In particular how we can help reach out to our partners and counterparts around the world to help build momentum moving this forward.

RAJIV SHAH: Civil society obviously has a tremendous role to play. When you just look at these numbers where the rates tend to be lowest, the rates of reduction of child mortality tend to be lowest, are lower quintile income populations, urban slums, rural communities, sub-national pockets of countries that are politically and economically less advantaged than others. It seems to me that that's precisely where civil society plays an ever important role to hold leadership to account, to give those types of communities more voice and capacity, and where I know Save has so many strong local -- very, very local partnerships in village communities that I've had a chance to visit -- activating those local civil society partners against this task and vision I think would be a big step in the right direction and hopefully will help then change the way the numbers look a few years out.

KATE DODSON: Good morning. Hi. Kate Dodson from the UN Foundation. Thank you for your leadership on this. I think it's fantastic to see the U.S. government partnered with the Indian government and the Ethiopian government on this initiative. The question about how persuasively you've talked about integration and specifically we spoke before you arrived about the fact that 2012 has so many different moments with child survival, with family planning, with the AIDS conference. Especially on family planning and child survival, if you can speak to how the U.S. government will be using its voice to encourage national governments to integrate programming where appropriate and also to make sure that family planning is not lost as a key intervention in preventing child deaths.

RAJIV SHAH: Great. I would just add to your opening comment, and thank you for that, that UNICEF and the UN system has been an incredibly central partner in this effort. In fact, this is very much a manifestation of the Secretary General's Every Woman, Every Child concept. This actually grew out of that original event announcement and some of the discussions around that. I think that's both important to recognize and a part of the answer to your question is that we do need all of the institutions that are involved to be integrated and going after the same goal.

On family planning specifically we're very excited to partner with the Bill and Melinda Gate Foundation and the United Kingdom this summer to try to reinvigorate that space.

We recognize that the United States is far and away the largest supporter of family planning efforts around the world. That our commodity management programs that we've often transitioned to local country ownership in country after country after country, especially in Latin America, can actually serve as a model for how those transitions happen and will only happen if there is in fact kind of a strong and consistent voice.

That's why part of what we need to do is use the U.S. government voice, but part of what we need here is a strategy that brings these things together, a scorecard or some kind of accountability measure that illustrates how these work together. How many of you have seen the Hans Rosling video with the Ikea boxes? Have you seen that one? Good. I hope my team has because I keep emailing it around. He just talks about if you just look at the pattern of history country after country it has started with a reduction in preventable child death. When that hits a certain level you see, doing his circles moving across the chart, but you see those circles move across on the total fertility rate as that goes down because family planning efforts are more effective when people believe that the children they have are going to survive and they invest in those children's welfare.

Then that core investment in their welfare, particularly girls' education, those three things come together and pay massive social dividends. I think we need a story and a narrative and a scorecard and a measurement system to bring them together and say are we delivering this result. Because if we're delivering this result we are in fact carrying out our moral imperative, but we're going beyond that and we're creating stable and prosperous and economically active countries even in the most resource poor parts of those countries. That I think is ultimately a very important political argument.

JENNIFER KATES: I think we have time from a couple of other questions from certain people who haven't asked a question first. One back there.

JIM COHICK: My name is Jim Cohick. I'm with CURE International. I want to say that I very much embrace the survival for children effort. I don't see it as an either/or as you talked about looking at specific diseases or other lines like that, but a both and because even though we're small in particular I'm very focused and very interested in the treatment of hydrocephalus I see that we could be very integral and involved with the larger picture and hopefully bring awareness to that conditions as TB needs its champions and its efforts as well. Because not everything can fit in your backpack, but innovative things can lead to other innovative things that might be in the OR or help with training to increase the capacity for those that can address such things.

RAJIV SHAH: I just want to say thank you. I appreciate that point. Let me just say a thing about the backpack because I have in multiple different roles sometimes been accused of being too simplistic about the solution set. I think of PEPFAR very much as a model. There's some percentage of PEPFAR investment that goes directly into antiretroviral therapy, but more than 50-percent of its investment actually goes to a range of other things that are important other things to deliver the outcome and the result of a responsible health system that reaches key populations and that saves millions of lives.

That said, the political narrative is very much driven by the number of people treated. I think we should, as people who care about these issues, be comfortable with the dichotomy between needing a narrative for our work that is easily understood, that is accurate, and that can be demonstrated as core results. Then understanding that underneath that lives a much more complex reality. I grew up in suburban Detroit and have always been fascinated by cars in particular. A friend of mine pointed out to me recently that you don't have to talk about the specifications of the carburetor on every model that you're talking about. You can describe a few salient features and we know that the whole thing sort of works together to make it work.

I think we ought to adopt a little bit more of that mindset. Maybe it's the backpack. Maybe it's something else. We ought to have a clear description of where we're going, a very clear, easy to understand goal of what's achievable, and an understanding that because of the expertise of so many people in this room there is of course going to be more complexity underneath that. We all ladder up into a common vision of success.

JENNIFER KATES: that was a great note to end on but we still have a question I see back there. We have a little bit more time so we'll take maybe one more.

RAJIV SHAH: Sure.

KAREN LEBAN: Hi. I'm Karen LeBan with the CORE Group. I wanted to thank you for the backpack analogy. I think it's extremely helpful to show integration in a very tangible way and that the child survival agenda is a maternal newborn child's health agenda as well. I guess I would just add that when you would do it again if you could put in the contraceptives and the antibiotics and maybe iodine or something. Where we can look at water and sanitation it becomes really helpful.

I guess the question I had was on communication. A lot of the issues around child survival are getting to the hardly reached, the chronically missed children, children with disabilities. You start getting into equity issues. How do you suggest we communicate those more difficult problems that don't have a commodity associated with them?

RAJIV SHAH: That's a very thoughtful question. To some extent I would disaggregate a little bit the part of that that is about more complex disability and those items from the point about economic quintiles and equity. If you look at the equity piece I think you'd find that the core challenge will map out sort of geographically in countries that you can create data systems that will track performance in different areas. It's just country after country you see that the rates of reduction, with the exception of what Ethiopia did in the last few years and with the exception of what Bangladesh did in the last few years, but in general rates of reduction in lower quintile populations are lower than otherwise.

This is a finding that actually comes a little bit out of the UNICEF equity report, which I think is a very profound report. That report showed that some interventions like bed nets for malaria broke through what they called the equity barrier. Many interventions that we pursue that we believe deeply in and have fought for, for decades, don't necessarily break through. I would argue that we have an opportunity here to take the backpack and figure out how do we get this backpack to break through that equity barrier because that's where the numbers are. That's where success resides. It's not going to be driven by donors. It's going to be driven by countries and political leaders and interesting and creative private sector partners. I'm convinced based on seeing case after case after case where they're starting to do it that it's possible and it's possible to do with more than just bed nets so that we can drive more substantial reductions in all-cause child mortality.

On issues like disability I think that's very important and I'd put it a little bit in the category of the previous question that we need to understand that our commitment here is a broad commitment that's inclusive.

JENNIFER KATES: Thank you. I'm actually seeing an image of you with the backpack breaking through an equity barriers as the next video. Thank you. I think that will end our program. I want to thank Administrator Shah for not only—

RAJIV SHAH: Could I just say one other thing? I'm sorry. I don't mean to go on. One point I would just urge, because we've thought a lot about this and we'd welcome your feedback. We're hoping that this is not a June event. We're hoping that this goes on year after year after year. If there's one thing, and I look around and I see people like Chip who know what Jim Grant achieved in a very personal way. There's something about consistency of focus for a long enough period of time that we can deliver the results. I would just ask you to think about how you generate and maintain that consistency of focus well after June 14th. Thank you. Thanks for the chance to be here.

JENNIFER KATES: Thank you. Please join me in thanking him. [Applause].