Rachel Glennerster: Welcome everyone, those in the room and also everyone online. I'm Rachel Glennerster. I'm President of the Center for Global Development. Thank you all for coming at this extremely critical time for global health. You know, it's critical, domestic budgets are tight. We've seen big aid cuts fall particularly on health for the most vulnerable countries and people. And that means that global health institutions are going to have to prioritize. So I will be putting these guys on the spot about how they're going to prioritize. The diagnosis is broadly understood. We have fragmented systems. We have parallel systems. We have domestic health budgets that are too low to cope with the needs. And we have concerns that aid has distorted domestic priorities. And as a result, now with the reductions in aid, many countries are facing a domestic health crisis. But I want to focus this panel on solutions and what we're going to do now. These are tough questions that we're facing, but I think if any group of people can have some positive solutions, I think we've got the right group to respond.
I want to briefly mention some of the work that CGD has been doing in this space, partly as a provocateur to challenge you all. The first is looking at the prioritization and decisions that some of the organizations like WHO and Gavi have to make. These are tough times, and they're going to have to make some tough choices. And CGD's recommendations include the WHO focusing on the core global functions, which would mean reducing their in-country programs. And we've got a brief suggesting that Gavi focus more on prioritizing its funding of vaccines and more on the poorest countries. In the medium-term, we are suggesting that we need tight prioritization of health spending at the country level, and CGD has put forward the idea of a New Compact where governments themselves take the lead in deciding what prioritization they need and picking out the most cost-effective interventions that make sense in their context. And that countries themselves focus on the most essential interventions with donors coming in to supplement. In Ethiopia, our modeling suggests that you could increase total health impact by 15% using the same budget if you introduced a kind of prioritization process like that.
Finally, expanding domestic health financing is another area where we've been working, which again is something that we need to do in response to these cuts, particularly focusing on health taxes, on tobacco, alcohol and sugary drinks, both as a method of raising revenue but also combating important health challenges.
So with that background, I'm pleased to now turn to our panel. Hitoshi Hirata, Vice President, Japan International Cooperation Agency. Mamta Murthi, Vice President, People Vice Presidency at the World Bank. Sania Nishtar, Chief Executive Officer of Gavi, the Vaccine Alliance, and John-Arne Rottingen, who is Chief Executive Officer of the Wellcome Trust. So we have bilaterals, multilaterals, and research and funders and private funders.
So let me turn to Mamta. With the cuts in global health aid, countries are likely to be turning to the World Bank more to fill in some of the gaps, but also to domestic revenue resources. How is the bank adjusting what it's doing, or are you adjusting what you're doing, to help support countries to weather these immediate cuts?
Mamta Murthi: Thank you, Rachel, and good morning, everyone. It's always so great to be here at CGD. Let me just say one thing for context setting, and then I want to come to your question. Without a doubt, the cuts in external assistance have had a significant impact, especially in low-income countries. But we should all be aware that low-income countries spend far too little anyway. So broadly-and, you know, take these numbers with a grain of salt-we think for a basic package of health services, countries should be spending around $50 to $60 U.S. dollars per capita per year. Low-income countries currently spend about a third of that, so $20 or less per capita. And in low-income countries, roughly half of this comes from external assistance. So we're already talking about very low levels of spending. And with the cuts and the projections that we're making on what external assistance is likely to be, we don't think that this number can go up significantly above $20 without some serious reprogramming of domestic resources. Now, what are we doing? We know that countries need more resources for health. We have a country-demand-driven model of providing financial assistance, and where countries are asking for more assistance in health, we are providing that. We're also trying to support countries in executing the existing resources that they already have from us, executing that more rapidly. And we're also helping them prioritize. Rachel, you talked about prioritization. It's very important to prioritize the most cost-effective interventions. And I was in Ethiopia just last week, and I think they're aware that there are ways in which they can spend. They already have relatively strong primary health care, but there are ways in which they can optimize even further. That being said, I don't think that's going to be enough, and there are other ways in which all of us are going to have to work to support countries. The first, of course, is expanding tax revenues and engaging in domestic resource mobilization. Hard to do if you're in debt distress, but not every country-not every low-income country is in debt distress. In fact, when we look across low- and middle-income countries, our view is that a large number of them can actually raise domestic resource mobilization through better tax policy and better tax administration. And that includes health taxes. The second thing that they can do, of course, is make health more of a priority within their means, within budgetary resources. And again, our estimate is that of – when you look across low- and low- and middle-income countries, about a third of them can actually allocate more resources for health within the fiscal constraints that they have. And I don't think they should just look at health taxes. There are lots of other things that they spend on which don't deliver a bang for the buck and might actually be harmful for health. Let's think of fossil fuel subsidies. So there's scope there. And then, finally, we're really emphasizing budget execution. For us, it's shocking that on average, about 10 to 15 percent of resources that are allocated for health spending don't get spent. And so there's a budget execution piece here. It’s a cliché, but it's going to take an all-of-government effort around resource mobilization, making sure that health gets prioritized, better execution of health resources, and of course, defining a basic package of services that is cost-effective and delivering that.
Rachel Glennester: Sania, you've been given the cuts. There's these pressures to reform in various agencies, including Gavi. You've been kind of getting out ahead of that. You're talking about the Gavi Leap program. Can you tell us about that? What reforms would it introduce? How would it work?
Sania Nishtar: First of all, thank you for convening us. Thank you for your intellectual contributions at this very critical juncture in the history of international development and global health. So basically, when I came in 18 months ago, it was quite clear to me that we were looking at a very different world from the international development vantage point. This was a world where fragility was the norm with massive aid retrenchment, and we had to position ourselves for that new environment. Today, whichever meeting that you go to, 80% of the discourse there is about reform of the global health architecture, reform of the international development architecture. So the Gavi Leap is basically about positioning Gavi in this new architecture of international development. Because there was an era of the MDGs, it finished. There was an era of the SDGs, it's sunsetting. And now we have to prepare for a post-2030 world. And already we're seeing the beginning of the end of ODA. So through the Gavi Leap, we are preparing for this future. And we are basically preparing for a future where countries have greater ownership, where countries have greater agency, and we are powering them to be more effective in this resource-constrained environment. So when I came in initially, I went to Africa, and I listened to all kinds of stakeholders, from community health workers to heads of states. And the good thing is that they want to have ownership. They don't want aid anymore. They want to stand on their own feet. They want to be self-sufficient. But they have certain asks. So the Gavi Leap was predicated and designed based on what the asks are from countries. Number one, they want more decision-making agency. So in our new framework, we are giving countries more decision-making agency on how they want Gavi resources deployed. Secondly, they want us to reduce administrative burden for them. They want to transact with us more simply. So we reflected, and we are now reducing our grant-making windows from eight to one envelope. They want turnaround time to be quicker. We are end-to-end digitizing. They want to be vaccine sovereign. So we structured what is called the African Vaccine Manufacturing Accelerator, which is a subsidy mechanism to catalyze sustainable vaccine manufacturing on the continent. They don't want aid anymore. It may be cliched, but as they say, they don't want fish, they want the fishing rod. So we are speaking to our colleagues at the World Bank and other multilateral development banks. And you would have noticed that we put in place what is called the MDB multiplier when Gavi had its replenishment this June. So not only were we fundraising in the traditional style for the next five-year period, which starts from January. We also put in place this new instrument, which is meant to unlock consensual lending for countries. And then we heard from them. It's extremely difficult for them to transact with each of us separately, Gavi, the Global Fund, the Global Polio Eradication Initiative, the various bilaterals. So we've accelerated our drive through joint board meetings, through joint operational work, through joint action plans to see how we can merge operations at the last mile. And I do believe this is an unprecedented effort of its kind. So in a nutshell, the Gavi Leap puts countries at the center. And as you would know, Gavi is quite a unique organization in terms of how sustainability is hardwired in our design because, and I say this with a lot of humility, we are the only international agency where contributions from countries come in terms of hard dollars into a bank account. So we're helping them further prepare for those transitions and for those exit strategies, and they're welcoming this. The other dimension of Gavi Leap is the changes in the ways of our working within the Secretariat. Because we are drastically changing our country operating model and how we interface with countries, this also has an impact on the ways we work. So with far more simplicity, with far more synergy, that will allow us to deploy a secretariat with 33% less human resource and 40% less non-human resource costs with effect from January 1, 2026, because we've changed our ways of working. We've become far simpler. We're using AI more. We're end-to-end digitizing our processes. So in a nutshell, there is a new reality, and we have to empower countries to be more self-sufficient in this environment of unprecedented resource constraints. You have to pivot. And of course, there's a wider conversation about reform of the global health architecture, reform of international development, reform of the UN. And we, as Gavi, will proactively engage in that discourse. But we don't want to sit at the margins. We want to be ahead of the curve, transform ourselves. So we define these four principles for our reform. Country centricity, country self-sustainability, focus mandates, and clear end dates for operational roles for international entities. So the entire reform is predicated on empowering countries, scaling back our role, and ultimately exiting ourselves out of business at a particular time point for operational roles, so that we as Gavi will focus on our core mandates, which are truly global, and where a global interplay really brings impact, which the regional and country level cannot.
Rachel Glennerster: I'm going to come back to this point about the collaboration with MDBs in a minute, but Japan is really focused on universal health coverage, and it launched this sort of work several years ago in a rather different environment. We've heard all about the need to prioritize and the cuts coming. Is it still a realistic goal in the new environment?
Hitoshi Hirata: Well, first, thank you very much for having me in this very important event. Yes, your question, advancing UHC is realistic. Well, I should as well change the question. The question is not whether UHC advancing is realistic, but how realistic an approach we can take to advance UHC. We are facing a very changing landscape, and as a previous fellow panelist pointed out, the reduction of ODA and also the increasing burden of debt in our partner countries, makes it very challenging for us to advance UHC. I was in Seville to attend Financing For Development conference, and at the meeting, the main discussion was how to mobilize domestic and private finance to scale impact. And it was fascinating to know that our partner countries were strengthening their commitment to expand their revenue, and to advance their efforts to collect the tax effectively by using, for example, health taxes. So we would like to support their health financing, and also we would like to link with existing public finance management efforts. And also, we would like to tap into domestic resources and also the private resources. We recently started the new function of de-risking, so we would like to explore the possibility to link the domestic and private finance and to the impactful projects that we would like to do. And to advance as a U.S.A., the key is how we can respect our partner countries' ownership. So how we can support their priority and how can we align our program with their initiative. And Japan has been supporting our partner countries in this principle, the self-help. And that is partly because of our history of development. We put emphasis on self-help. And I really hope we can further strengthen this principle by, well, by using our partnership with the partner countries and also the development partners and new partners, including emerging donors and also the private sector.
Rachel Glennerster: John-Arne, we're hearing a lot about the importance of country ownership from the panel. The Wellcome Trust did a lot of work and supported the work that led to the Lusaka Agenda, which obviously emphasized country ownership. But we've been talking about the importance of country ownership for decades. I mean, as long as I've been in development. So what's going to be different this time?
John-Arne Røttingen: So the Wellcome Trust is an organization supporting science, not an aid or development organization. So why are we at all engaged? And the reason is, of course, we have seen that the major advances in child survival, in life expectancy are all driven by scientifically based solutions. Vaccines, antiretrovirals, long-lasting antiretrovirals, and so forth. And we believe that that is also how life expectancy and well-being can be improved in the future. And of course we are very invested in improving health for everyone through science. We have priorities on the applied side, on infectious diseases, mental health, and also on the connections between climate change and health. But then we need a system that can deliver. So, yes, these debates have been ongoing for many years. They were reinforced during the pandemic and in the aftermath of the pandemic, and that was at the peak of international finance for global health because it was a strong and clear demand, and I think much more serious demand from countries and from leaders, particularly from Africa. And it is very much about independence and sovereignty, vaccine sovereignty, and so it's not only about being very clearly responsible for protecting, promoting, and improving health for citizens, but also about integrating health as a part of the economy. Of course, health is a big sector, an increasing sector in all countries, so the health workforce is important as such but so also are the commodities and technologies. So there's strong country ambitions and I think that is different. And then the abrupt changes to the international financing environment has just reinforced that. So of course we will lose many lives, we will lose health and I'm sure IHME will see it on the global burden of disease in a couple of years down the road that this dip in international finance has an impact on disease burden, but I really hope that in the long run this will have a positive impact. So I am optimistic, and the only positive impact can come from country leadership and countries demanding that they will need to be in charge. One country, one plan, one budget, one monitoring approach. And I'm hearing commitment now from almost all big external financers, the dedicated GHIs, Gavi, the Global Fund, the World Bank, and other multilateral development banks, the major bilateral donors, and in a way the signals that we see in the global health strategy of the United States are the same. It's sort of moving towards at least empowering and also making countries is responsible for delivery to a larger extent. I'm optimistic, definitely.
Rachel Glennerster: And I would just point out, I think the work that Wellcome Trust and others do on the generating new innovations that contractors can take up is absolutely critical. And as you say, it has been the major driver of improved health, but also improved incomes. I mean, there is a bit of a tension here as we move to country decisions about implementation. Where is the financing going to come for that innovation work? Because the bank can't lend money to Sierra Leone to develop a new malaria vaccine because it's a global public good and therefore we need global financing.
John-Arne Røttingen: And maybe that is a potential sort of impact of evolving to country-level decision-making – how do we maintain the benefits in the international system of market shaping, of innovation, on demand aggregation, but I think it's possible. And we are in a very different situation now than 30 years ago. There are much more capabilities in countries. We have much better data. At least we should be able to aggregate data and actually design this from the bottom up instead from the top down.
Rachel Glennerster: So slightly quicker this round, so we can get some audience questions in, but Mamta, the World Bank is launching health compacts with governments. Can you explain a little bit about why, what's different about a health compact than how you've worked before? I remember sort of the old days when the Bank was very involved in coordinating groups of donors. And whenever I ask about, “are you taking on that coordination role?” Again, people are a bit hesitant. Oh, it takes a lot of time to coordinate others. So explain a little bit about the health compacts and what's different from what you've done before.
Mamta Murthi: Let me just say that I agree with what was said about the optimism. And I think it's about how to get to UHC and not whether UHC is a goal that we should aspire to. This is a moment where, and I think Sania said it, where countries want to take leadership. And these compacts are country visions that the countries themselves are putting forward so that they can put an ask to all of us, the donor community, about what they want from us to reach the priority goals and targets that they have set for themselves. So these compacts are country compacts. They're not being signed with the World Bank. They're a vision statement for the country, some priority actions, some reforms, and some financing and, may I say, behavioral expectations of the donor community, very much in line with what Sania just said. So Gavi seems to be ahead of the game in thinking about approaching their support in this way. We were surprised to see the enthusiasm on the part of the countries to develop these compacts. Obviously, there are different countries that are at different levels of capacity, so some are turning more to WHO, the World Bank, and others for comments and suggestions on their compacts. Some are turning to us less. I just saw one from a well-known Caribbean nation and it's great. I don't know what we would comment on it. So there's no donor coordination that any of us would be doing. It's the country that is doing the donor coordination and I think this is what leadership means. And I don't think it's easy to do because we're all different beasts and we all have our different approaches, but I think this is also a part of countries taking ownership. We expect five countries later today to be presenting their compacts at a meeting that our president is chairing, and many of you on this panel will be there. And we are anticipating maybe 10 or 15, I mean, I want to be optimistic, maybe 20 countries will be presenting their compacts in Tokyo in December at the UHC summit that is being co-organized by the government of Japan, WHO, and ourselves. Another interesting thing about these compacts, and just to speak to the point that was made earlier, they're not just about public financing. They're also about the policy and the regulatory changes that need to occur to encourage private investment in health service delivery and supply chain and all the things that go toward making a health system function. Now, only time will tell. The proof of the pudding is in the eating. But I feel very encouraged by the leadership that the countries are showing because as all the panelists have said, I think this is the way to go. Ah, one last thing I forgot to say is that countries actually have goals and targets in terms of accessibility, affordability, job creation, that could ensue from the full implementation of these compacts, and I think that's very encouraging. And any monitoring that is done, I think, would be done by the country itself. I don't think it's donors who are monitoring. It's the country that's committing to do something, and I think civil society should be asking them to report back on how it’s going, and are you getting from the donor partners and others what you want from them? So hopefully we will also be held to account to support these compacts.
Rachel Glennerster: Sania, I want to come back to this point about the cooperation between you and the MDBs. And this came out of Gavi's Pledging Summit in June, and you put substantial funding towards this cooperation. So another way of seeing it is you could say, we both care about these overall health systems and prioritization, so we need to work together. Another way of thinking about it is division of labor. Gavi could focus on making vaccines affordable and a coordinated purchasing platform. So in some ways, cooperation is good but it can also lead to inefficiency because you're all involved in something, as opposed to saying, this is our core mission at Gavi, and we're going to leave the MDBs to get on with working with countries on delivery. So why convince me that it's a good thing to spend scarce concessional money subsidizing people's work with the MDBs, as opposed to spending that on bringing down the price and making vaccines more accessible, which is your core function?
Sania Nishtar: So there are global functions and then there are national functions. So let's classify them in transnational and national functions. The responsibility of delivery is with countries. And of course, ultimately they should be fully sustainable. They should utilize domestic resources. They should improve their tax to GDP ratios. They should overcome the central systemic constraints that stand in the way of effective delivery of social services. They should target their subsidies to the poorest. They should focus on economic growth and focus on accruing the benefits of growth equitably to populations. These are national responsibilities. And of course, overcoming systemic constraints is part of that. Now, the World Bank, IFIs, and multilateral development banks have the mandate to give the money, to give countries resources on budget to do that. So in a way, that's part of their domestic revenue as well. The role of us as entities is more catalytic. And we're talking about the health system space as you framed it. Our contributions within that space come more as grants for the purpose of enabling countries to overcome those systemic constraints and strengthening their systems. And the grants and the concessional lending is complementary in that sense. And as far as Gavi is concerned, we've always worked as an alliance. The World Bank is part of the alliance. We work very closely. And as part of this new MDB multiplier framework, we hope to further hone the collaboration. I think there's a lot of synergy and complementarity between what we're doing. It's music to my ears to hear about the country compacts. There's a huge synergy to be exploited vis-a-vis our focus on the Gavi Leap and country centricity. But just to bring to bear that the ultimate responsibility is that of countries. We are there just to help catalyze. But as far as the earlier part of your comment is concerned, there are certain global functions that are truly global functions, which cannot be divested. The articulation of norms and standards, the setting of rules, the global regulation of medicines, vaccines, devices. There are some functions around pandemic preparedness and global health emergencies, where each of the agencies have comparative advantages: the whole space of market shaping and pooled procurement, which is something that Gavi and the Global Fund does. So those things will need to continue to remain within the global space. Of course, going forward, we have to make sure that there's no mission creep and competitive behaviors, which sometimes is the case, which is why the third principle in the Gavi Leap is focused mandates. I think the challenge going forward will be how are we going to finance these. And, of course, already there's some very interesting ideas about how to more sustainably finance these global functions and incrementally divest the operational responsibilities to countries and to the MDBs going forward, so that at the global space, we are just responsible for a certain set of functions that are truly global.
Rachel Glennerster: I guess my challenge was to encourage you to focus on exactly those global functions that are absolutely critical and, there is a trade-off between putting more effort into those and more on the country side, which, as you say, is really the country responsibility. Hitoshi, we've heard Mamta talk about these country compacts. How much do you see that as being a driving force for your work at JICA?
Hitoshi Hirata: I understand the new compact emphasizes the core services that will be provided by countries using domestic resources, and the development cooperation will play a supplementary role. We totally agree with that policy, and that is very much in line with our policy to support country ownership, and also self-help efforts. And so we like to use this compact as a framework to improve our dialogue with partner countries, and also the development partners. We have developed a sector-specific strategy in the health sector, and we use such strategy to have good coordination with partner countries, but that strategy is a living document. So we would like to use this compact as a framework to ensure better prioritizing and also the effective use of resources. And so this will present a very good basis for improving the partnership and also supporting country ownership. And we would like to improve our partnership. I think we need to shift the next level of the partnership. We have said many times the partnership is very important, and under this very challenging situation, we have to work really closely. And this compact will give a very good framework to improve our partnership. And as I said, not only the conventional development partners, but also the new emerging partners and new emerging donor countries and the private sector. We would like to further strengthen our engagement with those new partners.
Rachel Glennerster: John-Arne, you've commissioned a five provocative think-pieces from regional experts. Can you pick one or two conclusions from those that you thought were particularly radical and made you think differently?
John-Arne Røttingen: In addition to those, we are also commissioning or supporting five regional convenings. And actually the first one is concluding today, and then the four next ones will conclude in a month. And we believe those sort of dialogues are very important and need to be rooted in country and community perspectives. So in a way, the thought pieces are a starting point. They're quite diverse, of course because they are written from different regions, but also diverse because they just have taken different starting points. Just to be clear, Wellcome has no position in sort of “this is a good recommendation, this is not a good one.” But I think there's a common theme here and that is very much aligned with what we have heard: devolving responsibility to countries. The other is regionalization, that we have not covered really, because we talk about global functions and national functions. So that's probably an emerging theme that is really key to understand, because regionalisation) can happen from the global level to devolving things to regions, but it can also happen from the national level up, in a way to collaborate and work on collective problem-solving and solutions. And the type of regionalization that is described in these papers is more of the latter. So in a way, their ownership in the regions for these solutions, and modelled after how other regions have done things in the past. On the drug market approval side, of course, the European Commission establishing EMA many years ago is one example that AMA is taking up now and other regions are also considering harmonization and joint mechanisms. On the procurement side, we have the revolving fund in PAHO and the Latin American region, other regions, thinking also similarly, how can we aggregate our resources? Because I think the big challenge is, if global functions are seen as global-global, they can also very easily crowd out capabilities at country and regional levels. And that is maybe not sustainable in the long run. I agree with the principle on focusing mandates and making sure that organizations are not competing and mission creep, but at the same time, you can divide up the way of thinking what is needed on health in very many different ways. So what is, let's say a challenge like malaria, it's a child health problem, so it's a global financing facility responsibility. It's a Global Fund problem because it's HIV, TB, and malaria. It's a vaccination solution, so that's Gavi. So because we have sort of established mechanism with different mandates, but that cuts across in just two, three different ways to conceptualize the same health challenge on the ground, and that is just one example. I think we also need to, in a way, rethink how we make sure that yes, we give the responsibility to countries, setting priorities, and then in a way, as you have said from CGD, what we do from the external side is marginal. In a way, it's either helping and improving so that things can be delivered more cost-effectively at scale, or additionally to what is already prioritized and decided in countries.
Rachel Glennerster: I mean, we have to be careful with the marginal if we continue to generate the support for aid in countries that we...
John-Arne Røttingen: Marginal can have different meanings. The margins versus marginal.
Rachel Glennerster: Additionally, there is a challenge there and my team knows that I challenge them on the PR side of that. Let's turn to audience questions now. By the way, we'll take three or four and then come back.
Audience question: Hello, good morning, everyone. Tamara Chikradze from International Rescue Committee. We hear a lot about cost-effectiveness being the driving force for prioritization in the changing aid landscape, which is good, but we also know that more and more people live in conflict or protracted crisis, at the so-called last mile, and getting to those people does require that extra investment, extra cost, is not always possible at scale. I think my question is to Ms. Murthi and Dr. Nishtar, with the reforms that you talked about, like the new health compacts and the Gavi Leap, what mechanisms are put in place to make sure that in a world of austerity and need to prioritize, the equity imperative of global health and our mission does not get left behind and these people continue to get reached?
Audience question: Hi. My name is Luisa Galveo with WaterAid. I had a question for Mamta about budget execution that you mentioned. I've heard this come up recently by the World Bank and across sectors, so this is clearly not just a health issue. This is also relevant to other sectors. And I'm wondering what you see as the solutions that are necessary to address this and what the role the World Bank is playing.
Audience question: Hi, good morning. My name is Aapta Garg. I'm with the International Center for Research on Women. Thank you so much for this conversation. I'm wondering as we're thinking about these transitions to locally driven models, in an era where there's lack of political will for SRHR funding, for reproductive funding, for investments in care, especially for long-term care and elderly care. How do we ensure that during these transitions that those services continue to be invested in? They're already under-resourced, already under-invested. How do we ensure that reproductive health, women's access to care for abortions, cervical cancer screenings, et cetera, and those for marginalized groups, including LGBTQI populations, which in some places are criminalized, do have safe access as we're thinking about these investments and expansions of care.
Rachel Glennerster: I think we have a common theme across these, which is how do we make sure marginalized people, marginalized topics don't get dropped in the process?
John-Arne Røttingen: I think that's actually a real dilemma because I talked about sovereignty and health sovereignty. We live in a world of sovereign states. We live in a world of more sovereign states in the sense of the pendulum has switched towards sort of a statist view of the world and away from a cosmopolitan view that we need to sort of support and help people irrespective of where they are. There is a danger that giving more responsibilities to country governments will then in a way reinforce the sort of the priorities and the policies and the norms that are decided by governments and the governments are democratically elected but we also know that there are not necessarily fully democratic processes across the world. So it's really just a big challenge on how to reconcile that. Whose norms are the right norms? Yes, we have the human rights and we have the global defined norms that all countries have committed to, but at the same time we are also challenged on that currently in the UN bodies and other organisations. My thinking around this is just to make sure that in any mechanisms of at least external finance, that there is very strong transparency and a clear voice from civil society and different groups. And it needs to be a part of a political struggle and a discussion. I don't think we have other solutions, and of course that political struggle and discussion needs to happen at the international level, but it also needs to be allowed at national levels. So we need strong civil society groups that are empowered to take a role in those debates in countries.
Hitoshi Hirata: Well, I think, if I may, I would like to respond to the budget execution. We also face the same problems. But what we can do is, well, back to basics. So we will have a very detailed monitoring process. For example, every three months, in principle, we have a portfolio review meeting not only in the health sector but also all sectors. So the framework encourages the executing agency and also the partner countries' government to implement and execute the budget as planned. And also, we send a monitoring mission to know the reality on the ground, that would facilitate the execution of the budget and implementation of the project. So, there is no magical stick, but we need to do such a very, well, on-the-ground monitoring process.
Sania Nishtar: Well, I'll take the pick on the question on fragility. It's very important to recognize that as we craft this new future of international development and cooperation and global health, that we are very conscious that we need to be mindful that in this new world order, fragility is going to be a norm. So conflicts and all kinds of displacements, internal and external, will unfortunately, continue to be a new norm. So in any planning, we have to factor for that, which is why at Gavi, despite the prioritization of our programs, we have protected the budget and, in fact, increased the budget for our response to fragile and humanitarian settings. In fact, we are creating a new fund that – with new standard operating procedures – will equip us with the operational agility which is required to operate in these environments. And this new approach and new fund builds on the very successful learnings we've had in what was called a zero-dose implementation program with IRC. And we will, in fact, be coming back to the CGD to talk about it tomorrow. So those learnings have been very important for us to shape this new approach to dealing with humanitarian and fragile settings. And it's not just displacements, and it's not just conflicts. It's also situations where governments are not operating. It's situations of disasters. And in addition to our funding mechanism, the new funding mechanism, it's our stockpiles that come into play in these situations as well. Because during disasters, in particular, during settings of conflict, disease outbreaks increase. So Gavi has a mechanism which kicks into place to mobilize our vaccine stockpiles. We have existing mechanisms in place to grant co-financing waivers. As I explained earlier, in response to your earlier question, Gavi works through a mechanism where countries co-finance the cost of their vaccines. And we have a policy in place to grant co-financing waivers for countries that are in fragile situations. So it is through our stockpiles, it is through our co-financing waiver mechanism, it is through our new instrument and mechanisms for fragility that we will be stepping up our support rather than downsizing given the unfortunate circumstances.
Rachel Glennerster: Okay, we seem to be doing extremely well in ticking off all my online questions, because one of them was about fragility, but just to kind of pull out the link with this question, that the issue is that the country ownership can sometimes fail, or it needs to be supported, particularly if you're talking about an area of the country a government isn't even in control of, then you really have to find alternative mechanisms.
Mamta Murthi: I'm so glad I came after all the others because there's very little for me to say, maybe just to respond to the question on budget execution. So we do have tools like the PETS, which is the Public Expenditure Tracking Survey and the PEPFAR. I'll have to think about what that acronym means, but something to do with accountability. That's the A. And this helps diagnose where the problem lies. And that's very helpful to countries to enhance budget execution. But I have to tell you that it's hard for countries as well. I was just with the Senegal delegation yesterday. As you're aware, they are in the midst of a huge fiscal consolidation. They have all this unreported spending that they have had to bring on budget. And in order to keep their debt in control, They are reducing spending across the board. And ultimately, that government is going to decide, is it more valuable for me to spend right now on getting these roads and bridges built, which are generating jobs and creating incomes for people, or do I give that little additional budget room that I have to the health sector to provide services? These are very difficult choices that governments have to make in the context of fiscal consolidation. And so I think we just also need to be aware of that. On the point on SRHR and women, I think John-Arne said it. I think our external assistance has to build in and does build in these safeguards to assure inclusive provision of services. Our IDA policy paper, for example, commits us to implement our gender strategy, which has a very strong SRHR element. Implement that in every IDA country. So there's no going around that, so to speak. We have a grievance redress mechanism. And so if it's observed that this is not using IDA funds, this is not happening, then there are various mechanisms to escalate that. And that allows us to bring it to the attention of national and regional authorities. So I think having those safeguards is actually quite helpful for the external assistance. But at the end of the day, in terms of the government's own resources, I think the democratic process has to play its role. And finally, what do you do in fragile contexts? I think we have a number of mechanisms to work in fragile contexts. Actually, I discovered this when I worked in the Africa region. We mostly work through government. And even when government doesn't have the ability to execute in certain areas, they may grant the right for the use of IDA or IBRD resources to third parties, and they can do that to IRC, to ICRC, to whoever might be on the ground. And there are exceptional circumstances in which we can say to government but these are very exceptional circumstances, that the resources will pass directly to a third party to execute the intention. And we have done this, actually, in South Sudan. I was in the Africa region at the time, so I discovered we actually have this proviso, and this can be done. But it's complicated, since we largely work through governments. But many governments are aware, especially when it comes to public health, that they are not able to operate in certain areas and need to work through other agencies. So it's not always a complicated discussion. It is a complicated discussion in the midst of a civil war.
Rachel Glennerster: And I can't resist coming in on that, fragility and so much of my work has been on it. You linked it to cost-effectiveness And most of the responses have been about whether governments are able to deliver or their incentives to deliver in a civil war. Actually, I'm really impressed by the work that the IRC has done. It shows that actually, it's not the main driver of cost effectiveness is reaching the marginal, that it's more the magnitude, the size of the program, you can actually get decent cost effectiveness even in fragile conditions, which is very encouraging. Okay, I'm going to ask a couple of online questions. As I say, you've already hit on two and then I'll get one more from the audience. So can you provide examples of countries that are successfully implementing innovative domestic financing mechanisms? So, what are some good examples that other countries could maybe mimic? And how would your organization support the use of more outcome-based financing to ensure more effective and equitable spending?
Audience question: Thanks so much. Leah Rosenzweig, senior fellow here at CGD and director of the market-shaping accelerator. So I want to return to this point about how we finance global public goods and innovation. You know, pessimism is abundant for all the reasons you all mentioned, but also I think living in DC and seeing the sort of war on science and science funding here in our country. Obviously we want high-income countries to come in and pay for these global public goods. Are you at all optimistic about the role of other country governments coming in? We've had success, for the pneumococcal advanced market commitment, five country governments, not including the U.S., UK, Canada, Italy, Russia, Norway coming in, and the Gates Foundation. So both the role of philanthropy coming in and funding these gaps, other high-income countries, and also the private sector. We've seen that recently in some climate space, $1 billion put up by Frontier, Stripe, Meta, others. And then I also want to push the Bank to ask, in this moment of transition, is it on the table for the World Bank and others to think about financing these global public goods rather than a country-by-country model at all?
Mamta Murthi: So let me give you an example of innovative domestic financing. We had a, and this might give me an opportunity to tell you that I also cover education, and gender, and social protection, and labor, and health. So I hope people are aware of the debt for development swap in Cote d'Ivoire. So Cote d'Ivoire used a World Bank guarantee to retire some expensive commercial debt. And they put the savings into getting more kids into secondary school. And the guarantee at the retiring of expensive commercial debt allowed them to put 30,000 more kids through secondary school. I think we would like to see more of this. Can't be done everywhere. It can't be when you're in the midst of restructuring your debt with your commercial creditors. But it works for many more countries than you think, and I think would be a great thing to do. There are lots of debt for development swaps out there, so I also have to give a warning. Many of them are not fiscally enhancing. And the really important thing is that it should expand the fiscal space and allow countries to put more money into things that matter for long-term growth and, actually, welfare. I agree with your point.
Sania Nishtar: So on the point about innovative domestic financing, I think the key point is about sustainability and scale. Because you can have these little, little, nice, shiny pilots, but if they're not operating at scale, then they don't create impact. I'd like to, once again, give the example of Gavi. Because in our model, what happens is that when we start introducing a vaccine in a country, the country starts paying 20 cents per dose. And then the contribution of the country increases as their economic situation improves. And they ultimately exit from our support at some point in time. So Gavi started with 78 countries. Nineteen of them have exited from Gavi support. Countries as large as Indonesia and India have graduated from support, and today they are fully underwriting the cost of that, their vaccines themselves. And this links clearly and squarely with your other point about outcome-based financing, because we can clearly link the amount of contributions we have made as an international entity and the quantum of the contribution the country has made, and you can exactly link it to the number of children vaccinated and translate that into life saved. So it's a very clear correlation with outcomes, which brings me to the third part of the question about are other countries paying? And that, I think, is where there is a success story, a silver lining in these times, because Gavi had its replenishment in June this year. India and Indonesia, that were once Gavi-supported countries, contributed. And even the current Gavi-supported countries contributed, the Central African Republic, Uganda, Rwanda, as a way of expressing their solidarity with this international mechanism and as a way of signaling its importance. So yes, innovative domestic financing can work, and our experience has shown that it does. But it has to be sustainable, and it has to be for scale. Because unfortunately, sometimes there's a tendency to have small little pilots, which cannot be deployed in a wider context.
Hitoshi Hirata: Well, regarding the innovative domestic finance, well, again, the FFD4 outcome documents highlight is to utilize public development banks. And we would like to explore the possibility to use more in-countries public-driven banks and financing institutions. And also, we would like to expand the capital market in that country. That might facilitate the circulation of the domestic financing. And that might support the public budget as supplementary financing resources. So that might be the one area we would like to explore.
John-Arne Røttingen: I would like to cover that, but maybe briefly on innovative finance, because I think actually the health sector is difficult when it comes to innovative finance and we have struggled and we're probably investing more in trying to find new models than actually we can demonstrate benefit. And to me, when it comes to provision and financing provision of care, the underlying challenge is that it is a risk-sharing approach. It's not something that... It cannot be privatized. Because if it's privatized, it's bought without the risk-sharing. So the refinance through either taxation or through payroll, insurance or other mechanisms, will in the end make it harder to come up with this innovative finance with blended, with private investments. But having said that, on the commodity side, on the technology side, I think there are a lot of innovative finance mechanisms, and that links to global public goods concern. And I am concerned related to the potential big shifts we see in the financing of technology development, pharmaceutical diagnostics, or diseases that disproportionately affect the developing countries. And of course, those will still first and foremost be infectious diseases, but there are other conditions as well. And it's hard to see where that landscape is evolving. So one is the public sector reduction in finance, and the two countries that have been the biggest funders, both the United States and the UK, are both systematically reducing support. Other countries have not indicated stepping up and private sector is also shying away. And part of the reason is the volatility in the pharmaceutical markets, the tariffs, the questions on where production plants should be and all of that has created a lot of uncertainty in that business and then high risk programs and projects are not taken on. So I am de facto concerned. I'm not sure about whether pull incentives as such, so AMCs, Advanced Market Commitments or others, and two total market-based solutions are the best solution because the only way that can deliver is that it's sufficiently competitive from a market point of view and the cost of capital. So it will be compared to a cancer programme or whatever. So I think we need to be innovative there. I think we need to find new partnership models. We need to ring-fence innovations, economies in a way, for the needs of those diseases affecting disproportionately the poorest. And I think then it's about creating that understanding that there is a collective responsibility also for industry. So maybe individual companies will not take that risk on, but how can we find models for actually also in a way socializing the solutions? And there have been models in the past and I think we need to find new models as well in the future.
Sania Nishtar: I cannot resist saying that Gavi has been very effective in another model of partnership with reference to domestic financing as well, and that is to bolster African vaccine manufacturing. There's an instrument called the African Vaccine Manufacturing Accelerator (AVMA), which is a subsidy mechanism. It makes milestone payments to bolster sustainable commercial vaccine manufacturing on the continent. And because your frame of reference was domestic, it's another example of how you can inject resources into the domestic setting to bolster a public outcome. And every African head of state today is using that as a way of furthering their dream of vaccine sovereignty on the continent. So yes, John-Arne, the partnerships are very critical, and structuring the right instrument for the right moment, for the right outcome in partnership with the country is the trick, because they have to own it. Because whenever I'm speaking to them about the AVMA, as we call it, they say, oh, that is our own instrument. So I think that it's very important, sustainability, scale, ownership.
Mamta Murthi: I'll just come in very briefly because of the market shaping question. And I just want to say that we support a lot of regional public goods. Your question was about global. And here I just want to say we've really innovated in the way we use our balance sheet. So we're not the World Bank of even two years ago. And I can give you a long list of things that we've done. So my response to that would be if there's an exciting proposition, we would take it on. We are using our balance sheet very differently now than we did before. I think the point that John-Arne made about needing a different model for some of these things which are largely demanded in, or would largely be used in poorer countries and where the commercial proposition is not always clear at the outset, I think that is where I think we struggle and that's the nut to crack. AVMA will help, but in the vaccine space, there's diagnostics, there's all kinds of things that we need to think about, especially as populations in low-income countries age, which is happening already, something we shouldn't miss.
Rachel Glennerster: Yeah, we've actually been doing some work in the market-shaping accelerator on diagnostics, which are, you know, where the needs are different in low- and middle-income countries. And I think the regional idea that has come out of this panel, I think is a very good one, because it's very hard to have any individual country support innovation. But a lot of the challenges are regional. You know, Zika in Latin America, Ebola is obviously could be global, but it's mainly an African challenge. So good to get some concrete ideas coming out of the panel. So I'm going to wrap up here. We're five minutes over. So thank you, everyone, for joining. and thanks to our panelists.
